Statewide evaluation of a tobacco cessation curriculum for pharmacy students

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<ul><li><p>ob</p><p>acy</p><p>Results. A total of 493 students (82.3%) completed linkable pre- and post-training evaluations. Self-reported abilities, measured on a five-</p><p>currently smoke cigarettes or other forms of tobacco [1]. If</p><p>current usage patterns remain unchanged, this number will</p><p>and effective tobacco control interventions on a global scale</p><p>[3]. Because even brief interventions from clinicians</p><p>positively impact the cessation rates of tobacco users</p><p>effective tobacco</p><p>Preventive Medicine 40 (20increase to 1.7 billion smokers by the year 2025 [1].point scale, increased significantly from 1.89 F 0.89 to 3.53 F 0.72 (P b 0.001). Twenty-two percent of students rated their overallcounseling abilities as good, very good, or excellent before the training versus 94% of students after the training. Eighty-seven percent of</p><p>students indicated the training will increase the number of patients that they counsel; 97% believed it will increase the quality of their</p><p>cessation counseling.</p><p>Conclusions. Comprehensive training significantly improved pharmacy students perceived confidence and ability to provide tobacco</p><p>cessation counseling. The curriculum is applicable to other health professional training programs and currently is being used to train</p><p>pharmacy, medical, nursing, and dental students.</p><p>D 2004 Elsevier Inc. All rights reserved.</p><p>Keywords: Tobacco dependence; Curriculum; Education, pharmacy; Schools, pharmacy; Smoking cessation; Health personnel, education</p><p>Introduction</p><p>Tobacco use is a major cause of morbidity and mortality</p><p>worldwide. Globally, an estimated 1.3 billion individuals</p><p>Tobacco-attributable diseases are responsible for an esti-</p><p>mated 4.8 million premature deaths worldwide [2]. The</p><p>World Health Organization (WHO) predicts this figure will</p><p>double within the next 20 years in the absence of aggressiveRobin L. Corelli, Pharm.D.a, Lisa A. Kroon, Pharm.D.a, Eunice P. Chung, Pharm.D.b,</p><p>Leanne M. Sakamoto, Pharm.D.c, Berit Gundersen, Pharm.D.d, Christine M. Fenlon, B.F.A.e,</p><p>Karen Suchanek Hudmon, Dr.P.H., M.S., R.Ph.a,e,*</p><p>aDepartment of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, USAbDepartment of Pharmacy Practice, Western University of Health Sciences College of Pharmacy, USA</p><p>cDepartment of Clinical Pharmacy, University of Southern California School of Pharmacy, USAdDepartment of Pharmacy Practice, University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences, USA</p><p>eDepartment of Epidemiology and Public Health, Yale University School of Medicine,</p><p>60 College Street, 4th Floor, New Haven, CT 06520, USA</p><p>Available online 8 December 2004</p><p>Abstract</p><p>Background. Previous studies suggest that healthcare professionals are inadequately trained to treat tobacco use and dependence. Because</p><p>even brief interventions from clinicians improve patient quit rates, widespread implementation of effective tobacco cessation training</p><p>programs for health professional students is needed.</p><p>Methods. Pharmacy students received 78 h of comprehensive tobacco cessation training. Participants completed pre- and post-program</p><p>surveys assessing perceived overall abilities for cessation counseling, skills for key facets of cessation counseling (Ask, Advise, Assess,</p><p>Assist, Arrange), and self-efficacy for counseling.Statewide evaluation of a t</p><p>for pharm0091-7435/$ - see front matter D 2004 Elsevier Inc. All rights reserved.</p><p>doi:10.1016/j.ypmed.2004.10.003</p><p>* Corresponding author. Fax: +1 203 785 6279.</p><p>E-mail address: (K.S. Hudmon).acco cessation curriculum</p><p>students</p><p>05) 888895</p><p>[4,5], widespread implementation ofcessation training programs for current and future health</p><p>care providers should be an international priority.</p></li><li><p>not trained. Guidelines issued by the WHO and the United</p><p>States Public Health Service (USPHS) recommend that all</p><p>ive Mhealthcare professionals, including students in healthcare</p><p>professional training programs, receive education in the</p><p>treatment of tobacco use and dependence [4,7]. Despite</p><p>these recommendations and the knowledge that tobacco use</p><p>is a significant public health problem affecting persons of all</p><p>ages, numerous studies have shown that students in the</p><p>health professions receive inadequate training for treating</p><p>tobacco use and dependence [819]. In an international</p><p>survey assessing the tobacco-related content in medical</p><p>school curricula, Richmond et al. [13] found that only 34%</p><p>of schools provided smoking cessation training. Similarly,</p><p>in a survey of medical schools conducted between 1996 and</p><p>1998 in the United States, Ferry et al. [14] reported that</p><p>nearly 70% of schools did not require any clinical training</p><p>for tobacco cessation. Nearly one third of the programs</p><p>averaged fewer than 1 h of tobacco cessation instruction per</p><p>year of medical school. More recently, Wewers et al. [18]</p><p>surveyed 631 U.S. nursing programs and estimated that only</p><p>46% of baccalaureate and 67% of graduate nursing</p><p>programs include tobacco cessation skills training as a part</p><p>of required coursework.</p><p>In response to this documented need for tobacco</p><p>intervention training, a comprehensive tobacco cessation</p><p>curriculum was developed for students in the health</p><p>professions. Originally designed to train pharmacy students,</p><p>the Rx for Change: Clinician-Assisted Tobacco Cessation</p><p>program has been integrated into the required curricula of</p><p>each school of pharmacy in California since 2000. Because</p><p>Rx for Change adheres to recommendations outlined in the</p><p>USPHS Clinical Practice Guideline for Treating Tobacco</p><p>Use and Dependence [4], its applicability is broad and</p><p>adapted versions of the program have been incorporated into</p><p>the required coursework in the schools of medicine,</p><p>dentistry, and nursing at the University of California, San</p><p>Francisco. Recently, through grants funded by the National</p><p>Cancer Institute and the American Legacy Foundation, the</p><p>Rx for Change curriculum is being disseminated through</p><p>train-the-trainer programs to schools of pharmacy and</p><p>schools of nursing, respectively, in the U.S. [20,21]. Here,</p><p>we present the initial statewide evaluation results of the Rx</p><p>for Change curriculum obtained during the third year of</p><p>implementation for pharmacy students in California.</p><p>Methods</p><p>Participants and curriculum contentIn a meta-analysis of 10 studies, Lancaster et al. [6]</p><p>concluded that healthcare providers who have received</p><p>smoking cessation training are significantly more likely to</p><p>intervene with patients who use tobacco than those who are</p><p>R.L. Corelli et al. / PreventStudy participants were Doctor of Pharmacy (Pharm.D.)</p><p>students attending the University of California San Fran-cisco (UCSF), the University of the Pacific (UOP), the</p><p>University of Southern California (USC), or Western Uni-</p><p>versity of Health Sciences (WU) who received comprehen-</p><p>sive tobacco cessation training (the Rx for Change</p><p>curriculum) as part of their required pharmacy coursework.</p><p>Students were either in their first or second year of pro-</p><p>fessional school.</p><p>The Rx for Change curriculum, which has been described</p><p>in greater detail elsewhere, [22] and is available to registered</p><p>users at, is a series of independ-</p><p>ent, but complementary modules that equip students with</p><p>the skills necessary to treat tobacco use and dependence. Six</p><p>core modules considered essential include: epidemiology of</p><p>tobacco use, nicotine pharmacology and principles of</p><p>addiction, drug interactions with smoking, assisting patients</p><p>with quitting, aids for cessation, and role playing with case</p><p>scenarios. Optional modules include: forms of tobacco,</p><p>pathophysiology of tobacco-related disease, genes and</p><p>smoking, post-cessation weight maintenance, how to get</p><p>involved, and a history of tobacco control.</p><p>At a minimum, the core modules can be administered in</p><p>6 h. Seven to 8 h provide a more desirable pace and allows</p><p>more time for hands-on pharmacotherapy counseling and</p><p>role-playing exercises. The materials heavily emphasize</p><p>methods for behavior modification that can be applied in a</p><p>wide range of clinical settings. Students are trained to apply</p><p>the 5 As (ask, advise, assess, assist, arrange) [4,23] when</p><p>delivering patient-specific behavioral interventions that,</p><p>when appropriate, also include pharmacotherapy. As part</p><p>of the aids for cessation module, students are given the</p><p>opportunity to handle nonprescription nicotine replacement</p><p>therapy formulations and placebo samples of the nicotine</p><p>nasal spray and the nicotine oral inhaler. Participants learn</p><p>key counseling points for each medication, as well as proper</p><p>dosing regimens and drug administration techniques. Non-</p><p>pharmacologic cessation aids also are discussed and</p><p>students gain hands-on experience with a hand-held com-</p><p>puter for scheduled, gradual reduction of smoking. A</p><p>minimum of 2 h of role-playing with case studies enable</p><p>students to gain first-hand experience in applying their</p><p>newly acquired knowledge and skills. Case studies illustrate</p><p>a wide variety of realistic counseling interactions; these vary</p><p>by practice environment (ambulatory or acute care setting)</p><p>and patient characteristics (demographics, stage of readiness</p><p>to quit, history of tobacco use, preferences for methods of</p><p>cessation, coping difficulties, etc.).</p><p>During the study period, students were exposed to the six</p><p>core modules and the optional forms of tobacco module</p><p>from the Rx for Change curriculum. While the modules</p><p>presented during the trainings were standardized, the format</p><p>and total hours of instruction varied by school: University of</p><p>California San Francisco, 8 h taught over 2 days (Spring</p><p>2002); Western University of Health Sciences, 8 h taught</p><p>over 2 days (Spring 2002); University of Southern Cali-</p><p>edicine 40 (2005) 888895 889fornia, 7 h taught over 4 days (Spring 2002); and University</p><p>of the Pacific, 7 h taught over 5 days (Fall 2002).</p></li><li><p>Program evaluation results</p><p>ive MStudy measures</p><p>To assess the effects of the training program, a 2-page</p><p>anonymous pre-training survey was administered immedi-</p><p>ately prior to the first Rx for Change module, and a three-</p><p>page anonymous post-training survey was administered</p><p>immediately following the final module.</p><p>The surveys, which included mostly parallel measures,</p><p>were linked using the following information: the last three</p><p>digits of the students home telephone number, the</p><p>numerical day of the month the student was born, and the</p><p>first two letters of the high school from which the student</p><p>graduated. Participation was voluntary, and because of the</p><p>anonymous nature of the data, a waiver of written informed</p><p>consent was obtained. Students were provided with a one-</p><p>page information sheet describing the study and its</p><p>procedures, risks, and benefits. The survey instruments</p><p>and study procedures were approved by the institutional</p><p>review board for the protection of human research subjects</p><p>at each study site.</p><p>Prior to this study, all measures were extensively pilot</p><p>tested with more than 1,100 pharmacy students who</p><p>participated in Rx for Change trainings during 2000 and</p><p>2001. The measures focused on assessing student percep-</p><p>tions of the training and its impact on confidence for</p><p>counseling and perceived counseling abilities. Students</p><p>were asked to estimate the percentage of the curriculum</p><p>that (1) was completely new, (2) they had been taught before</p><p>but needed to review, and (3) had been taught before and</p><p>was an unnecessary review (summing to 100%). Students</p><p>also estimated the percentage of the material that would be</p><p>used when working with patients and indicated whether they</p><p>had previously counseled any patients for tobacco cessation.</p><p>Both surveys evaluated students self-rated abilities for</p><p>cessation counseling, including (a) overall ability, (b) five</p><p>key competency facets of tobacco cessation counseling (the</p><p>5 As), and (c) self-efficacy (i.e., confidence) for counseling,</p><p>using a 12-item scale. Responses for assessments of overall</p><p>ability and the 5 As were scored using a five-point scale</p><p>(1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent).</p><p>Self-efficacy items also were scored using a 5-point scale</p><p>(1 = not at all confident, 2 = not very confident, 3 =</p><p>moderately confident, 4 = very confident, 5 = extremely</p><p>confident). Sociodemographic variables (assessed post-</p><p>training) included sex, age, race/ethnicity, and tobacco use</p><p>status. Finally, we assessed impressions of curriculum</p><p>content and its applicability, general attitudes concerning</p><p>the role of the pharmacy profession in tobacco control</p><p>activities, and opinions about tobacco sales in pharmacies</p><p>(1 = strongly against it, 2 = against it, 3 = neither for it nor</p><p>against it, 4 = in favor of it, 5 = strongly in favor of it).</p><p>Analysis</p><p>R.L. Corelli et al. / Prevent890Responses were summarized using standard descriptive</p><p>statistics. Scale scores were computed as the average ofOn average, students reported that 77.4% of the material</p><p>was completely new, 16.2% had been taught before but</p><p>needed to be reviewed, and 6.4% was an unnecessary</p><p>review. Students estimated that 80.8% of the material would</p><p>be used when providing patient care.</p><p>The self-reported pre- and post-training overall ability to</p><p>help patients quit using tobacco (Fig. 1) increased signifi-</p><p>cantly (P b 0.001), from an average of 1.89 (SD, 0.89) to3.53 (SD, 0.72). Post-training assessments of pre-training</p><p>abilities (mean, 1.50; SD, 0.71; bBefore attending this class,how would you have rated your overall ability to helpconstituent items for (a) a tobacco cessation counseling</p><p>competency scale, composed of the 5 As items, and (b)</p><p>self-efficacy for counseling, composed of 12 items. The</p><p>statistical significance of change scores were assessed</p><p>using paired t tests. Because our evaluation was designed</p><p>to assess program impact, our analyses included only</p><p>students who completed linkable pre- and post-training</p><p>surveys. As such, because the surveys were administered</p><p>in class, immediately prior to the first session and</p><p>immediately following the last session, students who</p><p>were absent from class on either day were unable to</p><p>provide linkable surveys.</p><p>Results</p><p>Student population</p><p>During the study period (March 2002 to November</p><p>2002), a total of 599 Pharm.D. students were enrolled in the</p><p>classes participating in the program. Of these students, 493</p><p>(82.3%) had linkable pre- and post-training surveys.</p><p>Participants at UCSF (n = 118; 96.7% participation),</p><p>UOP (n = 164; 80.4% participation), and USC (n = 120;</p><p>66.3% participation) were in their first-year of profes-</p><p>sional school; participants at WU (n = 91, 98.9%</p><p>participation) were second-year students. For two of these</p><p>schools (UCSF and WU), class attendance was manda-</p><p>tory, thus participation rates were higher. Seventy-four</p><p>percent were female, and ethnicity was distributed as</p><p>follows: 65.1% Asian or Pacific Islander, 22.4% Cauca-</p><p>sian, 6.1% Hispanic or Latino, 0.6% African American</p><p>and 5.8% other. The average age was 24.3 years (standard</p><p>deviation, 3.4; range 1941), and 11.0% disclosed that</p><p>they had smoked 100 or more cigarettes in their life.</p><p>Overall, 2.5% of students used...</p></li></ul>