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BRIEF RESEARCH ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 4  |  Page : 498-500  

Technology-based tobacco cessation training in Indian context

Venkata Lakshmi Narasimha1, Abhinav Prakash Arya2, Gaurav Jain3, Anandakumar Pandi4, Saurabh Varshney5
1 Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
2 Assistant Professor, Department of General Surgery, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
3 Assistant Professor, Department of Dentistry, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
4 Assistant Professor, Department of Biochemistry, All India Institute of Medical Sciences, Deoghar, Jharkhand, India
5 Executive Director and CEO, Department of Otolarynoholgy, Head and Neck Surgery, All India Institute of Medical Sciences, Deoghar, Jharkhand, India

Date of Submission31-Oct-2021
Date of Decision18-Aug-2022
Date of Acceptance15-Oct-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Gaurav Jain
Department of Dentistry, All India Institute of Medical Sciences, Devipur, Deoghar - 814 152, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_2009_21

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   Abstract 


In tobacco use disorders (TUDs), technology-based training of health-care professionals can reduce the treatment gap and bring attitudinal change. The study aimed to assess the practices and determine the change in knowledge and attitude among health-care professionals following an online training program (OTP). Half-day OTP on tobacco cessation using prepost quasi-experimental study design with a structured questionnaire-based assessment was conducted. Among 293 completed surveys, knowledge post-OTP was higher but insignificant (P = 1.2). Post-OTP, participants felt less angry and disappointed toward tobacco users (mean of difference (MOD) =0.21, P = 0.0007); more sympathetic and concerned (MOD = −0.22, P = 0.0005); and acknowledged tobacco users deserve the same medical care as nonusers (MOD = −0.177, P = 0.001). Post-OTP scores in attitudes did not change significantly for the responsibility domain (P < 0.05). In practice, relatively greater number of health-care professionals asked about tobacco use and advised cessation, however lesser assessed, assisted, and referred. To conclude, technology-based training program can result in attitudinal changes toward tobacco users.

Keywords: India, technology, tobacco cessation, training


How to cite this article:
Narasimha VL, Arya AP, Jain G, Pandi A, Varshney S. Technology-based tobacco cessation training in Indian context. Indian J Public Health 2022;66:498-500

How to cite this URL:
Narasimha VL, Arya AP, Jain G, Pandi A, Varshney S. Technology-based tobacco cessation training in Indian context. Indian J Public Health [serial online] 2022 [cited 2023 Feb 1];66:498-500. Available from: https://www.ijph.in/text.asp?2022/66/4/498/366583



In India, according to Global Adult Tobacco Survey-2 (GATS-2), 28.6% of the population use tobacco. Smokeless tobacco is the most common form of tobacco used and men use tobacco more than women. While the prevalence of tobacco use is high, the availability of tobacco cessation services is minimal.[1] Recent National Mental Health Survey reports a treatment gap of 92% for tobacco use disorders (TUDs).

As a result of efforts from multiple stakeholders in the last two decades, there was a decline in the tobacco use in GATS-2 compared to GATS-1 survey. Some of the notable initiatives include National Tobacco Control Program, Cigarettes and Other Tobacco Products Act (COTPA 2003), establishing tobacco cessation centers in each district. While more focus was given to supply reduction, lesser attention has been provided toward treatment. Further, lack of trained health-care professionals is a major setback. Hence, training health-care professionals in tobacco cessation will help in reducing the treatment gap.

Technology provides a unique platform for training health-care professionals in addictive disorders. Technology-based training in tobacco cessation has been found to be feasible in Indian context,[2] while tobacco cessation training programs vary in duration, preliminary evidence on brief single day training programs is quite encouraging.[3] However, such evidence is lacking for online training programs (OTPs).

The objective of this study is to assess the practices and to determine the change in knowledge and attitude among health-care professionals following an OTP. We hypothesized that OTP would improve the knowledge and change the attitude of health-care professionals related to TUDs.

A half-day OTP on tobacco cessation was conducted on 31 May 2021. Registration for the program was done through wide publicity over social media platforms for a month prior to conduct of the program. Sample size: Assuming 50% of the doctors would have a favorable practices toward the tobacco users and at 95% confidence level and 5% absolute error, the sample size was calculated as 282. Expecting a nonresponse rate of 10%, the final estimated sample size was 310 (282 + 28). The sample size was estimated using the formula-Sample size n = “[DEFF*Np(1-p)] / [(d2/Z21-α/2 * (N-1) + p*(1-p)]”. Sample size was estimated using OpenEPI, Version 3,Rollins School of Public Health, Emory University, Atlanta, U.S.A, open-source calculator. The training program is for 3 h with content focused on epidemiology of TUDs, neurobiology of tobacco addiction, pharmacological management, and brief interventions. The content of training program has been approved by two experts in the field. Google Forms-based pre-OTP and post-OTP survey was done. A semi-structured questionnaire, developed based on knowledge, attitude, and practices, was used (Appendix 1), which was validated by 2 experts of the field. A pilot study was conducted on 5 participants outside the study and their suggestion regarding clarity of question was implemented. Practices were assessed on domains of 5 A's model (ask, assist, assess, assist and arrange) by the World Health Organization and the referral component of screening, brief interventions and referral to treatment (SBIRT) model.[4] The study has been approved by the Institutional Ethics Committee.

Outcome variables

Change in attitudes of participants in domains of responsibility, deservingness to treatment, negative emotional attitude (anger, disappointment) toward the patients, positive emotional attitude toward patients (sympathy and concern).

Statistical analysis

R software (R core team, CRAN network, New Zealand) was used for paired t-test analysis.

Among 650 health-care professionals registered across India, 328 (50.6%) attended and 293 (45%) completed both surveys. Out of 293, majority were male (57.6% [169]) and 124 (42%) were female. The mean age was participants was 28.3 years (standard deviation = 8.2). Majority of the practitioners were from medical doctors 188 (64%), followed by dentists 49 (17%), other health-care professionals (social workers, nursing officers; 51 (17%)) and AYUSH practitioners 5 (2%). It was observed that 6.8% (20) of the health-care professionals are either current or past tobacco users (Appendix 2 and 3).

Knowledge assessed at the end of OTP was higher (mean of difference [MOD] = −0.32) but found statistically insignificant (P = 1.2, t = −4.4, df = 292).

Post-OTP, health-care professionals felt less angry and disappointed toward tobacco users (MOD = 0.21, P = 0.0007). Further, they felt more sympathetic and concerned (MOD = −0.22, P = 0.0005); and acknowledged tobacco users deserve and are entitled to the same medical care as nonusers (MOD = −0.177, P = 0.001) Scores in attitudes did not change significantly for the responsibility domain, in both individual (MOD = −0.37, P = 6.2) and life circumstances (MOD = −0.003, P = 0.9).[Table 1].
Table 1: Change in attitudes among health-care professionals

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In practice, a greater number of health-care professionals asked and advised about the tobacco use. However, relatively lesser assessed, assisted and referred. Further, there was no significant differences in practices between males and female health-care professionals among the components of practices [Table 2].
Table 2: Practices by the health-care professionals related to tobacco

Click here to view


A greater number of health-care professionals were trained in shorter duration of time through this technology-based OTP for tobacco cessation. OTP has been able to bring changes in the attitudes among health-care professionals. Importantly, the existing practices among the health-care professionals highlight the need for training in brief interventions in tobacco cessation.

Research from India underscores the fact that health-care professionals receive little training in tobacco cessation, and very few thus carry out assessments and provide interventions.[5] In India, technology-based training programs for tobacco cessation has been found to be feasible, acceptable and promising.[2] Through this technology-based training, we were able to train and sensitize around 300 health-care professionals. If it was offline, it would have been an impossible task to train huge numbers in a shorter duration. Although similar OTP OTPs were conducted in India, they included lesser participants (<50) over a longer duration (2–6 months).[2],[6]

Earlier studies reported training in brief interventions for tobacco cessation resulted in significant change in knowledge among the health-care professionals.[7] However, in our study, the knowledge component did not differ significantly between pre and posttest. But we believe that a more comprehensive training and evaluation would have identified significant changes in knowledge. A 8 weeks OTP in cancer screening and tobacco cessation in Indian context has resulted in significant change of knowledge among health-care professionals.[6]

Attitudes of health-care professionals affect their practices. Negative attitudes are associated with greater stigma toward substance users and suboptimal health care. Posttraining, the health-care professionals were less angry and disappointed; more sympathetic and concerned; and felt that tobacco users deserve equal level of treatment compared to nonusers. These findings highlight the effectiveness of such short-term training programs. Adequate sensitization and training can help in changing the attitudes, reducing stigma and leading to better practices toward substance users.[8]

Screening and brief interventions (like 5 A's and SBIRT) is an effective tool that can empower health-care providers to identify and treat TUDs before costly symptoms emerge.[9] A recent study from India, done at primary health centers, observed lack of screening and brief intervention for tobacco use.[10] Quit attempts were 5 times higher in those who were screened for tobacco use. The findings of our study suggest that the health-care professionals relatively intervene less compared to other components of SBIRT.[5]

In our OTP, 6.8% of the professionals were either past or current tobacco users. Tobacco use among health-care professionals can be a major barrier in screening and brief intervention for tobacco use.[5]

The findings of the study need to be read with the following limitations. First, we did not assess the long-term outcomes of the study. Second, the responses to the practices, knowledge, and attitude would have been affected by Hawthorne effect.

To conclude, technology-based training program can result in attitudinal changes toward tobacco users. The translation of such changes into real-life clinical practices needs to be explored.

Financial support and sponsorship

The training program has been funded by World Health Organization, Southeast Asia Region.

Conflicts of interest

There are no conflicts of interest.


   Appendix 1 Top


Pretest Questions

A. KNOWLEDGE Based Questions

Q1. Which is the most common form of tobacco use in India?

  1. Smokeless
  2. Smoking
  3. Vaping
  4. I don't know


Q2. Which act regulates the use of tobacco products across India?

  1. COTPA 2003
  2. NDPS 1987
  3. POCSO 2012
  4. I do not know


Q3. What is the fine for smoking in public places in India?

  1. No fine in India
  2. Rs. 50
  3. Rs. 100
  4. Rs. 200
  5. I do not know


Q4. Is tobacco addiction treatable?

  1. Yes
  2. No
  3. I don't know


Q5. Tobacco is a major risk factor for non-communicable diseases (like Diabetes, Hypertension, Coronary Artery Disease)?

  1. True
  2. False
  3. I do not know


B. ATTITUDE Based Questions

Q1. To what extent person's life circumstances are responsible for tobacco use?

Rate on a scale of 1-5 (1= not at all; 5 = Very much possible)

Q2. To what extent individual is personally responsible for using tobacco?

Rate on a scale of 1-5 (1= not at all; 5 = Very much possible)

Q3. To what extent do you feel angry and disappointed towards people who use tobacco?

Rate on a scale of 1-5 (1= Not at all “angry and disappointed”; 5 = Very much “angry and disappointed”)

Q4. To what extent do you feel sympathetic and concerned towards people who use tobacco?

Rate on a scale of 1-5 (1= Not at all “sympathetic and concerned”; 5 = Very much “sympathetic and concerned”)

Q5. To what extent people who use tobacco deserve and entitled to same amount of medical care as people who do not use tobacco products?

Rate on a scale of 1-5 (1= Not at all “deserving and entitled”; 5 = Very much “deserving and entitled “)

C. PRACTICE Based Questions

Q1. How frequently do you ask (screen) patients for their tobacco use?

  1. Always
  2. Often
  3. Sometimes
  4. Rarely
  5. Never


Q2. How frequently do you advise patients to stop tobacco?

  1. Always
  2. Often
  3. Sometimes
  4. Rarely
  5. Never


Q3. How frequently do you assess their tobacco use (quantity, type, severity etc.)?

  1. Always
  2. Often
  3. Sometimes
  4. Rarely
  5. Never


Q4. How frequently do you Assist patients to stop using tobacco (pharmacotherapy or psychological counselling)?

  1. Always
  2. Often
  3. Sometimes
  4. Rarely
  5. Never


Q5. How frequently do you refer your patient to a tobacco cessation services?

  1. Always
  2. Often
  3. Sometimes
  4. Rarely
  5. Never


Post Test Knowledge based Questions

Q1. There are multiple evidence based pharmacological strategies for management of tobacco use disorder. Which of the following are used for treatment of tobacco use disorders?

  1. Nicotine replacement gums, Lozenges, Patches
  2. Varenicline
  3. Bupropion
  4. All the above
  5. I do not know


Q2. WHO has introduced MPOWER strategy for tobacco control measure. What does MPOWER stand for?

  1. M-monitor tobacco use and prevention policies; P-protect people from tobacco; O- Offer help to quit; W- warn about dangers; E- Enforce ban on advertising R- Raise taxes
  2. M-monitor tobacco use and prevention policies; P-protect people from tobacco; O- Offer help to quit; W- warn about dangers; E- Educate people R- Raise taxes
  3. M-monitor tobacco use and prevention policies; P-Punish for using tobacco O- Offer help to quit; W- warn about dangers; E- Enforce ban on advertising R- Raise taxes
  4. M-motivate to stop tobacco; P-protect people from tobacco; O- Offer help to quit; W- warn about dangers; E- Enforce ban on advertising R- Raise taxes
  5. I do not know


Q3. Brief interventions are clinician delivered effective counselling strategy for tobacco use disorders. What does 5 A's of brief intervention stand for?

  1. A-Ask; A-assess; A-Advise; A-Assist; A-Arrange for follow up
  2. A-Ask; A-assess; A-Advise; A-Assist; A- Afford
  3. A-Ask; A-assess; A-Access; A-Assist; A-Arrange for follow up
  4. A-Ask; A-assess; A-Advise; A-Assist; A-Allow to ventilate
  5. I do not know


Q4. Which of the following statement is correct?

  1. Tobacco addiction is a disease due to neurobiological changes in the brain
  2. Around 20-30% of Indian population use tobacco products
  3. Establishing more tobacco cessation centers, quitline services will reduce the treatment gap
  4. All the above
  5. I do not know


Q5. Does tobacco use increase the risk of contracting and spreading COVID-19?

  1. True
  2. False
  3. I don't know








 
   References Top

1.
Narasimha VL, Mathew Y, Anil S, Murthy P. A study to evaluate availability of tobacco cessation services in Bengaluru, India. Asian J Psychiatr 2021;58:102600.  Back to cited text no. 1
    
2.
Sagi MR, Chand P, Narasimha V, Murthy P, Mamatha M, Karthick C, et al., editors. A pilot from the virtual knowledge network (VKN) Nimhans ECHO 2017 5th National Conference on E-Learning & E-Learning Technologies (ELELTECH) Hyderabad: IEEE; 2017. pp. 1-6.  Back to cited text no. 2
    
3.
Jhanjee S, Varshney MK, Panda UK, Kaloiya GS, Dayal P, Yadav D. Evaluation of a training workshop on tobacco cessation: Capacity building initiative in India. Tob Induc Dis 2018;16(Suppl 1):A65.  Back to cited text no. 3
    
4.
National Centre for Education and Training on Addiction (Australia), Cahill P, Flinders University. In: Adelaide S, Aust: National Centre for Education and Training on Addiction, editors. Health Professionals' Attitudes Towards Licit and Illicit Drug Users: A Training Resource. NCETA Flinders University, Adelaide, South Australia; 2006.  Back to cited text no. 4
    
5.
Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47 Suppl 1:69-74.  Back to cited text no. 5
    
6.
Nethan ST, Hariprasad R, Babu R, Kumar V, Sharma S, Mehrotra R. Project ECHO: A potential best-practice tool for training healthcare providers in oral cancer screening and tobacco cessation. J Cancer Educ 2020;35:965-71.  Back to cited text no. 6
    
7.
Girvalaki C, Papadakis S, Vardavas C, Pipe A, Lionis C. Change in primary care physician knowledge regarding smoking cessation after a brief training intervention. Eur Respir J 2016;48 Suppl 60:PA1176.  Back to cited text no. 7
    
8.
Koyi MB, Nelliot A, MacKinnon D, Rastegar DA, Fingerhood M, Alvanzo A, et al. Change in medical student attitudes toward patients with substance use disorders after course exposure. Acad Psychiatry 2018;42:283-7.  Back to cited text no. 8
    
9.
Hargraves D, White C, Frederick R, Cinibulk M, Peters M, Young A, et al. Implementing SBIRT (screening, brief intervention and referral to treatment) in primary care: Lessons learned from a multi-practice evaluation portfolio. Public Health Rev 2017;38:31.  Back to cited text no. 9
    
10.
Panda R, Persai D, Venkatesan S. Missed opportunities for brief intervention in tobacco control in primary care: Patients' perspectives from primary health care settings in India. BMC Health Serv Res 2015;15:50.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2]



 
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