Improving tobacco cessation practices among physicians in tertiary hospitals in Nigeria
This project, funded by Global Bridges and Pfizer Independent Grants for Learning and Change, was led by Dr. Kemi Odukoya MBBS, MPH, MSc, FMCPH at the University of Lagos.
In Nigeria, according to the 2012 Global Adult Tobacco Survey, there were 4.7 million Nigerian adults who used tobacco products. Nigeria signed the FCTC in 2004 and ratified it in 2005, however, efforts at implementing Article 14 have been sparse. Many Nigerian smokers desire to quit smoking and often make unassisted and unsuccessful quit attempts – and there is considerable evidence that physician-led tobacco cessation interventions increase quitting among smokers. However, poor knowledge has been cited as the major barrier to physician-led smoking cessation interventions and few teaching hospitals in Nigeria have effective systems for the identification and treatment of tobacco-using patients.
Mobile phone and Internet use is particularly high among Nigerian physicians opening up a window of opportunity for the use of mobile and internet-based technology to promote behavioral change among health care workers. In addition, these technologies are comparatively low cost and have a wide reach. These interventions may therefore have an additional cost advantage in low-resource settings like Nigeria.
The overall goal of this project was to increase physician-assisted tobacco cessation among patients in tertiary hospitals by identifying, reaching, training and working with emerging leaders (resident doctors) in medical and dental teams to prioritize and practice tobacco cessation within their local work settings.
Our specific objectives were to:
- Identify and recruit 20 physicians in each of the three collaborating institutions as primary tobacco cessation change agents (PTCCA)
- Motivate and train these primary change agents as focal persons for tobacco cessation within their respective departmental units using a traditional intensive two-day face-to-face training session followed by informative text messages and emails over a six-month period.
- Support the PTCCAs to promote tobacco cessation among other physicians in their respective departmental units (Secondary Tobacco Cessation Change Agents) using informative text messages and emails over a three-month period.
The study was conducted among physicians in three geographically distinct teaching hospitals in Nigeria in 2015. The primary physicians received an intensive two-day training followed up with reminder text messages and emails over a six-month period. The training focused on the 5A’s approach to tobacco cessation (Ask, Advise, Assess, Assist & Refer), the basics of tobacco epidemiology, pharmacotherapy and motivational interviewing.
For the secondary physicians, using the Ask, Approach, and Refer (AAR) method as a guide, we developed brief TM (<160 characters) designed to promote tobacco cessation in clinical practice. We sent two text messages weekly over a 13-week period to 1,242 physicians.
For both the primary and secondary physicians, we observed statistically significant increases in the mean percentage scores for all the key outcome indicators.
Primary physicians: Eighty-six physicians filled the questionnaire at baseline and 85 of them after the intervention. We observed a statistically significant increase in the mean percentage scores for the key outcome indicators
- Epidemiology of tobacco use;(increased from 15.6-29.9;p<0.001);
- Knowledge of the 5A’s and AAR approaches to tobacco cessation (increased from 8.7-79.4;p<0.001);
- Knowledge of pharmacotherapy (increased from 43.4-79.4;p<0.001);
- Knowledge of tobacco cessation techniques (increased from 53.8-64.7;p<0.001);
- Knowledge of the stages of change (increased from 50.4-66.2;p<0.001);
- Knowledge of motivational interviewing techniques (increased from 46.9-71.4;p<0.001);
- Perceived self-efficacy to provide brief intervention for patients using tobacco (increased from 44.3-54.7;p<0.001);
- Tobacco cessation competency at baseline and at the end of the intervention (increased from 83.9-95.4;p<0.001).
- The proportion of physicians that inquired of tobacco use among at least half of their patients increased from 50%-74.1%( p<0.001);
- Proportion who offered some advise to at least half of all identified tobacco users increased from 26.7% to 69.4%(p<0.001);
- Proportion who assessed willingness to quit in at least half of all identified tobacco users increased from 9.3% to 50.6% (p<0.001);
- Proportion who assisted at least half of all identified tobacco users increased from 8.1% to 65.9% while the proportion who referred or arranged for follow up for at least half of all identified tobacco users increased from 4.7% to 70.6%(p<0.001).
Secondary physicians: Two hundred and eleven physicians filled the surveys at baseline and 165 after the intervention. The majority of them opened and read the messages and felt that the messages motivated them to carry out brief intervention tobacco control activities for their patients.
- The proportion of physicians who were aware of and could correctly define the AAR approach to tobacco cessation increased from 14% to 58.2% p<0.001;
- While those who asked at least half of all their patients about tobacco use increased from 43.4% to 58.1% p<0.05;
- Those who advised at least half of patients who used tobacco about quitting increased from 43.9% to 59.5% p<0.01);
- While those who referred patients who were tobacco users for further care increased from 6.4% to 22.2% p<0.01.
- Majority of the physicians admitted to opening and reading the messages we sent and felt that the messages motivated them to carry out brief intervention tobacco control activities for their patients.
- We also observed statistically significant differences in the proportion of patient records with documentation of tobacco cessation activities in the intervention hospitals versus the control hospitals.
- Up to 70.6% of the primary and 22.2% of the secondary physicians admitted to referring at least 50% of identified tobacco users for follow up at the designated tobacco cessation clinics in each hospital.
- Only 4.6% of respondents had attended a course promoting tobacco cessation treatment within their clinic practice prior to this project.
As a result of our intervention, knowledge and practice of tobacco cessation increased among the physicians. There are fewer missed opportunities for tobacco cessation intervention among smokers. More tobacco-using patients are identified and assisted by physicians in the course of their routine daily work. This should translate into increased quit rates and a reduced morbidity and mortality associated with tobacco use.