Enhancing readiness of health profession students to address tobacco cessation with patients through online training

Objectives: To evaluate effectiveness of an online training program in preparing health care students to address tobacco use with patients. Methods: The program was evaluated on knowledge, attitude, self-efficacy, intended behavior, and user satisfaction. Participants consisted of 4,180 medical, nursing, dentistry, pharmacy, and other allied health professions students. Multiple choice questions assessed knowledge before and after the educational experience. Likert scales were used for self-reporting of attitude, self-efficacy, and intended behaviors towards tobacco cessation treatments in both a pre-module and post-module survey condition. Likert scores for satisfaction were recorded in a postmodule survey. Two sample paired t-tests were used to measure statistical significance. Results: The knowledge increased significantly for all modules across users. Attitude, self-efficacy, and intended behavior scores increased. The Overview course's knowledge score increased from 59% to 89% (t(649) = 61.9; p < 0.0001). Mean knowledge scores for all modules combined increased from 51.5% to 74.0% posttest. Satisfaction with the curriculum was high, with a mean score of 4.6 out of 5. Conclusions: The success of this program is evident by overall satisfaction, and increases in knowledge, selfefficacy, attitudes, and behaviors, as well as the ease with which it was deployed to thousands of students. Results of this study demonstrate that online training in tobacco cessation is an efficient and effective method of teaching students skills in tobacco cessation counseling, and can fill a vital gap in existing curricula.


Introduction
Approximately 46 million American adults smoke cigarettes, 1 13 million smoke cigars, and 6 million use smokeless tobacco. 2 Twenty-five to thirty percent of the U.S. population regularly use tobacco products. 3,4Over 8.6 million people live with tobacco-related illnesses, and over 400,000 deaths occur each year as a result of tobacco use.Another 38,000 deaths occur among passive smokers who die from environmental tobacco exposure (ETS). 5,6Over $150 billion annually in economic losses are associated with tobacco use. 2,7Clinicians are in frequent contact with tobacco users; studies indicate that over seventy percent of tobacco users visit a physician annually, 8,9 and approximately half of all smokers see a dentist each year. 102][13][14] Yet, despite the desire of most patients to quit, the frequent contact clinicians have with tobacco users, and the tremendous disease and financial burdens attributed to tobacco, only one-half to two-thirds of all patients may be assessed for tobacco use. 13Most patients report that tobacco use was addressed in only one of every five visits to a physician or healthcare professional.4][15] Many clinicians recognize their own inattention to tobacco related issues, and attribute it to inadequate preparation to intervene with tobacco-using Correspondence: Lyla Hance, 1506 E. Franklin St. Suite 200, Chapel Hill, NC 27514, USA.6][17][18] Training on nicotine dependence and tobacco cessation is discernibly absent from most health professions training programs.Surveys of U.S. medical schools by the Liaison Committee on Medical Education and independent researchers have consistently documented that the majority of schools in the U.S. provide little, if any, instruction on tobacco intervention.To be specific, many schools offer one-and-a-half days or less of instruction on tobacco across all four years of medical education.[21][22] A survey of nursing programs found that although nearly half of undergraduate programs and two-thirds of graduate programs provide instruction on tobacco cessation, less than thirteen percent provide over three hours per year of instruction on tobacco use, nicotine dependence, or cessation techniques. 23Review of the literature also indicates a need for more tobacco-specific content on cessation and patient counseling skills in the curricula of dental programs. 24Mandatory training on tobacco cessation and inclusion of the Public Health Service guidelines in dental school curricula has been recommended. 22The insertion of tobacco content in health education curricula is in keeping with one of the Healthy People 2020 objectives: Increase tobacco cessation counseling in health care settings.Specifically, sub-objectives TU-10.1, 10.2, 10.3, and 10.4 call for increased tobacco cessation counseling in office-based ambulatory care settings, hospital ambulatory care settings, dental care settings, and substance abuse care settings, respectively. 25major obstacle to inserting such content is the lack of available space in the curricula of most health professions training programs.The importance of preparing health professionals to intervene effectively with tobacco users prompted the 2006 Florida legislature to fund the statewide expansion of the Florida Area Health Education Center Network (AHEC) tobacco training program for health professions students, which seeks to prepare medical, nursing, and various allied/mental health students to address tobacco use with their future patients.To do this, the Florida AHEC has implemented an online training program focused on tobacco cessation across multiple student populations.The prior tobacco training program at the medical schools of the University of Florida, University of Miami, Nova Southeastern University, Florida State University and the University of South Florida reached over 7,200 medical, nursing, dental, and pharmacy students.Between 2000 and 2006, the program consisted of approximately five hours of lecture plus additional reading assignments and homework on tobacco topics. 26In response to the challenge of increasing the number of health professions students and residents trained annually from under 1,500 to over 3,000, AHEC instituted a new statewide framework.AHEC adopted a set of interactive, evidence-based tobacco education and cessation online modules developed with National Institute of Health (NIH) grant funds by Clinical Tools, Inc., a physician-run Internet-based education company with Accreditation Council for Continuing Medical Education (ACCME) Accreditation with Commendation status.An independent team of professionals from medicine, dentistry, public health and substance abuse counseling along with an instructional designer developed the modules and instruments.These modules provide students with unlimited access to materials and ensure a high degree of consistency in the delivery of program content throughout the state.Since 2007, over 15,000 students have participated.The use of a consistent set of modules across the state and among disciplines is one of the program's strengths.Tobacco cessation experts reviewed the content of the modules initially and on a regular basis.
Module content is based on Centers for Disease Control and Prevention (CDC) best practices and the US Preventative Services Task Force (USPSTF) 2008 guidelines for tobacco.In addition, Clinical Tools offers AMA PRA Category 1 Credit (TM) and other forms of continuing education for interested professionals who use the modules.Student participants completed specific modules assigned by their program faculty and based on discipline and academic affiliation.This paper examines the effectiveness of online tobacco education modules to enhance the ability of students to intervene with tobacco-using patients at multiple academic institutions throughout Florida, with respect to overall participation, user satisfaction, and increases in knowledge, self-efficacy, attitude, and intended behavior.

Participants
Participants consisted of 4,180 students at participating universities within the Florida AHEC network from backgrounds in medicine, nursing, dentistry, pharmacy, and other allied health professions.The program was considered a class requirement for each participant's respective program.Data was collected for all participants who requested credit for the training program.The pre-test questions were required to begin the program, and the post-test questions were required before students could request credit for completion of the program.Each question was mandatory.These facts helped ensure that there was no missing data for participants who requested credit for the program.There were no dropouts; response rate was 100%.Participants were not asked to submit demographic information (gender, race, and ethnicity).This work was deter-mined to be exempt from the Clinical Tools IRB.

Instrument
A portal containing eight total tobacco cessation modules ("Overview of Tobacco Cessation," "Motivational Interviewing for Primary Care," "Pharmacotherapy of Tobacco Cessation," "Children and Tobacco: Three Cases," "Julie: Pregnancy and Smoking," "Older Adults and Tobacco," "Smokeless Tobacco," and "Five Cases: Basic Tobacco Cessation Interventions") was customized by Clinical Tools specifically for use by AHEC-affiliated health professions students and residents.Participants completed specific modules assigned by the program faculty based on discipline and academic affiliation.Tobacco control experts and primary care physicians reviewed the modules to ensure that the material would provide information on tobacco dependency and familiarize students with basic behavioral interventions to assist patients with terminating tobacco use.
Instruments for each of the eight modules were developed as online quizzes.Assessment instruments were developed in conjunction with the educational materials by the educators, including the topic experts and the instructional designer.Instruments were reviewed for face and construct validity by tobacco cessation experts who were not part of the author team.
Sixteen instruments total were developed.Two quizzes were created for each of the eight modules; one pre-quiz, and one post-quiz.Each instrument contained one question each on the topics of attitude, self-efficacy, and intended behavior.Each instrument contained 2-7 knowledge questions, depending on the length and breadth of the module.Additionally, post-quizzes contained seven questions on satisfaction.
Knowledge questions were created in multiple choice format.Each item was linked to an educational objective in a one-to-one relationship.Multiple choice items were scored as correct or incorrect; there was no additional penalty for incorrect answers.The questions on attitude, self-efficacy, intended behavior, and satisfaction were Likert style items, which used a 5 point scale.
Students "passed" the post-test when a score of 70% was achieved (chosen to correlate with the typical passing test score in the college environment).A passing score allowed the student to complete the requirements of the module.Since this is an arbitrary rate, analysis of the effectiveness of the modules used changes in the raw scores, not the pass/fail rate.

Procedures
The AHEC tobacco training program provides students with an orientation before they begin their coursework; participants were directed to the training portal with instructions to access specific modules, depending on discipline and institutional requirements.Participants were required to complete a pre-and post-quiz for each module.A score of 70% or better on the post-test was required to "pass" the module and receive credit.Participants could retake the knowledge assessment to obtain a passing score.In the event of an incorrect response, a link to the related content area was provided.This approach allowed participants to review material not initially absorbed or under-stood, and reinforced important learning concepts.Although participants could re-take the post-test for passing scores, the data analysis relied solely on the results of the initial completion.Two sample paired t-tests were used to measure statistical significance.

Analysis
The program was evaluated on a number of measures, including knowledge, attitude, self-efficacy, intended behavior and user satisfaction with the module.Multiple choice questions assessed knowledge before and after the educational experience.Likert scales were used for selfreporting of attitude, self-efficacy, and intended behaviors towards tobacco cessation treatments in both a pre-module and post-module survey condition for each learner.Likert scores for satisfaction were recorded in a post-module survey.Two sample paired t-tests were used to measure statistical significance.

Results
From July 2009 to June 2010, 4,180 students registered in the program and completed 13,784 modules (Table 1).Nursing students completed the most modules (37.7% or 5,193 modules), followed by various allied/mental health students (33.5% or 4,622 modules), and undergraduate medical students (17.5% or 2,419 students).Results found that knowledge, attitude, self-efficacy, and intended behavior scores increased significantly (p < 0.00) for all individual modules across users.
Mean knowledge scores for all modules combined increased from 51.5% to 74% post-test (out of a possible 100).Satisfaction with the curriculum was high, with a mean score of 4.6 out of 5 (where 1 = Strongly Disagree, 5 = Strongly Agree).Future areas of research include studies focused on statistical data related to tobacco cessation interventions and quit rates to assess patient outcomes.Learner knowledge, intended behaviors, perceived selfefficacy, and attitudes towards treatments in both a premodule and post-module survey condition were measured for each learner.Mean knowledge scores increased significantly (p < 0.00) from pre-test to post-test survey conditions (Table 2).Each module and cohort indicated improvements in knowledge; mean pre-test scores ranged from 37-59% for each module, while post-test scores ranged from 58-89%.Significant (p < 0.00) increases in Likert-based assessments of intended behavior, attitude and perceived self-efficacy were observed (Table 3).Learner satisfaction, measured through a seven question Likert-based assessment, was universally high (4.6 of a possible 5 points).
We obtained further assessment of a module's ability to achieve its learning objectives by asking participants to rate the module with respect to specified objectives on a scale from 1 to 5 (with end points "Completely Failed to Meet Objective" and "Completely Met Objective" defined).These questions were specifically designed to meet standards associated with accreditation by the Accreditation Council for Continuing Medical Education (ACCME) and the Accreditation Council for Pharmacy Education (ACPE).Participants reported an average score of 4.6, indicating strong agreement that modules had achieved intended goals.Satisfaction scores for all modules were high; at least 90% of users agreed or strongly agreed with statements regarding satisfaction post-module.

Discussion
Over 90% of tobacco users become addicted to tobacco, and over half die from tobacco related illnesses.No other legal over-the-counter substance, when used as intended, is associated with such dire statistics. 27Costs associated with lost productivity and treatment of tobacco-related diseases are estimated at more than $150 billion a year.Proper training teaches health professions students how to address tobacco use with patients.Ideally, this curricula will take the form of standardized tobacco-based competencies and objectives for specific health profession disciplines.Knowledge of tobacco cessation and options for nicotine replacement and pharmacotherapy, mastery of patientcentered interventions such as motivational interviewing, and familiarity with the U.S. Public Health Service guidelines for addressing tobacco dependency should be included as part of medical, nursing and other health professions training.Once adopted by curricular committees, students must demonstrate proficiency in order to graduate; this ensures that future healthcare professionals are adequately prepared to address the subject of nicotine addiction with their patients using an evidence-based approach.Current students have not yet had a chance to put this training into practice with patients; limitations of the data analysis and discussion include the lack of sufficient time to document impact on patient outcomes.Participants may have been influenced to do well on the knowledge assessment portion due to the fact that they were often required to participate as part of their professional training.Finally, long term follow-up is required to determine knowledge retention and assess if intended behavior materialized.
A statewide, web-based program has several benefits: content may be standardized, and modules regularly updated, saving valuable time for medical schools and curriculum committees.For the academic year of 2009-2010, the content of each of the eight modules was updated to comply with the U.S. Public Health Service Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guidelines.Information on patient screening systems (such as computer prompts or other reminder systems for assessing patient tobacco use) and assessment of clinician intervention was incorporated into the content of the current modules.The modules now advise healthcare professionals to provide combination pharmacotherapy unless contraindicated, rather than using individual medications alone, and to provide cessation services for tobacco dependent patients within the practice setting to the extent possible.In addition, healthcare practitioners in pediatric settings are advised to ask all parents and caregivers of children about their tobacco use, educate patients on harmful effects of ETS on children, and provide them with encouragement to quit and cessation services.Based on the significant sample size, the use of consistent Internet based educational materials has proven an efficient, effective and consistent response to the need to provide the thousands of health professional students in Florida with standardized, reliable training on tobacco cessation and dependence treatment.

Conclusions
Students and residents experienced success with this innovative program, which was spearheaded through the statewide Florida AHEC Network.Participant knowledge outcome scores significantly increased through online training modules.Participants also reported high satisfaction with the web-based learning experience, finding the modules useful and relevant to their needs.Participants demonstrated improvements across the board in terms of self-efficacy, attitudes, and behaviors toward incorporating tobacco intervention principles in the practice setting and intention to learn more about issues related to tobacco use.The success of this program, as evident by increases in knowledge and overall satisfaction, and changes in selfefficacy, attitudes, and behaviors, as well as the ease with which it was deployed to thousands of students, demonstrate that online training in tobacco cessation counseling can fill a vital gap in existing curricula.

Table 1 .
Health profession disciplines by module.Web-based modules completed by participant discipline (n =13,784)

Table 2 .
Average participant change in knowledge by module (n =13,784) Ongoing research on the impact of increased student training on patient outcomes becomes necessary as students in training become professionals dealing with patients.Statistical data related to tobacco cessation interventions and quit rates is one area for future research.