Introduction

The two colliding epidemics of tuberculosis (TB) and tobacco smoking are becoming increasingly important (Pai et al. 2007). This is especially apparent with the increasing body of evidence on the association between smoking and the risk of Mycobacterium tuberculosis infection, developing clinical TB disease, and dying from it (Gajalakshmi et al. 2003; Davies et al. 2006; Bates et al. 2007; Lin et al. 2007; Slama et al. 2007e). In 2006, about 9.2 million new cases and 1.7 million deaths from TB occurred globally, whereas tobacco now kills over 4 million people worldwide (1:10 of all adult deaths) (WHO 2008a, b). In parallel, much of the morbidity and mortality due to TB occur in low-income and middle-income countries where smoking is widely prevalent (WHO 1997; Gajalakshmi et al. 2003; WHO 2008b). Furthermore, a considerable proportion of the global burden of TB may be attributed to tobacco use (Yach 2000; Schneider and Novotny 2007). Therefore, tobacco control in TB care is an important public health agenda globally. Health care professionals working in TB settings should be actively involved in smoking cessation activities.

TB and tobacco interventions in health care settings, however, remain largely separated. In response to this, researchers and relevant health organizations continually advocate and call for urgent attention to address smoking in TB settings (Slama et al. 2007a, c, e; WHO and IUATLD 2007; Slama et al. 2008; Siddiqi and Lee 2009). These clarion calls and initiatives have highlighted the needs for integrated and concerted approaches to lung health that require addressing both of these major threats (Yach 2000; Siddiqi and Lee 2009). The directly observed therapy, short-course (DOTS) strategy for TB offers access to smokers and guarantees regular patient-provider interaction. Therefore, the providers of DOTS for TB patients are in an ideal position to intervene with those who are smokers and have an unprecedented opportunity to deliver an integrated cessation service effectively. However, studies consistently demonstrate that students in the health professions receive insufficient training for providing comprehensive tobacco cessation counseling. This calls for the needs to establish in-service training programs that are customized to providing an integrated intervention in TB care. These health professionals providing care to TB patients need to know what they are expected to do and to have the necessary cognitive skills and tools to provide smoking cessation services (Slama et al. 2007c). Unfortunately, most health professionals in Malaysia are inadequately trained to provide such interventions, mainly due to the lack of comprehensive tobacco-related courses and training as part of most local universities’ curricula. In Malaysia, in-service training and continuing professional development (CPD) programs for treating tobacco dependence are also scanty (Rigotti et al. 2009). However, there is a paucity of information about the tobacco-related knowledge, attitudes, and practices (KAP) of nurses and more specifically those working in TB settings.

This report was part of a larger study known as the SCIDOTS Project (unpublished), the aim of which was to evaluate the impact of an integrated smoking cessation intervention (SCI) plus DOTS on clinical, humanistic, and economic outcomes of TB among smokers. This phase of the study was aimed to develop and deliver a structured training program and materials regarding SCI for health professionals who provide TB DOTS in Malaysia, predominantly nurses. It further aimed to evaluate the potential impact of the training program by comparing the KAP of the trainees regarding SCI before and after the educational series.

Methods

Study population

The participants were selected from among TB DOTS providers practicing in six chest clinics of respective hospitals by the hospitals management: five clinics in the state of Penang and one in Wilayah Persekutuan Kuala Lumpur. The criteria used for selection were a minimum of 3 years post-registration experience, job competence, and previous experience in clinical research. The number of TB DOTS providers selected to form the pilot sample of ten participants was in proportion to the total number of DOTS providers who satisfied the above criteria from each hospital. Accordingly, one participant each from four hospitals and two and four participants from one hospital each were selected.

Study design and procedures

This was a pretest-posttest (before-after) survey of a single group. Figure 1 is a flow diagram of the study methodology.

  1. 1.

    Educational materials for training health professionals working in TB settings on tobacco smoking cessation as well as relevant questionnaires for KAP assessment were developed and validated.

  2. 2.

    A pre-training KAP of the trainees was evaluated via a questionnaire that was designed in English, validated, and subjected to a standard linguistic validation process into the Malay language. The pretest survey was administered on the first day of the training.

  3. 3.

    Training: The training program was delivered over a period of 3 consecutive days. Ten registered nurses who provide DOTS to TB patients were selected from six chest clinics at various government hospitals located within two states (Penang and Wilayah Persekutuan Kuala Lumpur).

  4. 4.

    Impact of the training program: A post-training assessment of KAP was conducted following the educational intervention on the last day of the training program.

Fig. 1
figure 1

Flowchart of the study methodology

Full size image

Description of the training program on tobacco cessation

This was an in-service training program adapted from our established Certified Smoking Cessation Service Provider Program (CSCSP) for health professionals in Malaysia. The course was offered to selected nurses who provide care to TB patients in respective study centers that were planned to be involved in the SCIDOTS Project. The content of the educational materials was customized to include issues on tobacco control in TB settings. The materials were delivered through didactic lectures, demonstrations/role-plays, and video shows. Experiential learning components included hands-on attachment at a specified quit smoking clinic (QSC). Each DOTS provider trained was assigned to one of the QSC for additional mentoring and guidance beyond that which was taught theoretically. Participants were expected to gain leadership roles in the integration of tobacco cessation and control in TB care.

The program was delivered over 3 days with a total of 14 contact hours. The course was aimed to provide participants with the knowledge of tobacco use treatment and the necessary skills to provide SCI for TB patients who are smokers. The key learning outcomes of the course included: understanding the colliding epidemics of tuberculosis and tobacco, evidence of their association, and the provision of tobacco cessation via cognitive behavioral therapy and pharmacotherapy. Details on the didactic lecture topics are presented in Table 1.

Table 1 Course contents for smoking cessation service provider program for TB DOTS providers
Full size table

Knowledge, attitudes, and practice assessment

Instrument and data collection

The 99-item questionnaire used in this study was a modified and linguistically validated version of an English-language questionnaire used to assess the tobacco-related knowledge of nurses in Hong Kong (Chan 2001; Tsung 2002; Chan et al. 2007). The instrument consisted of eight domains to assess: (a) demographic and professional characteristics (14 items), (b) knowledge of health risks of tobacco and tobacco-related diseases (27 items), (c) knowledge of the link between TB and tobacco use (10 items), (d) attitudes and beliefs about tobacco control policies in the country (9 items), (e) the practice of SCI based on the five “A’s” (21 items), (f) tobacco-related knowledge covered in the curriculum during nursing education and current program (3 items), (g) perception of competence and confidence to deliver effective SCI (10 items), and (h) perception of enablers and barriers of the practice of SCI (4 items). The questions were in a multiple choice format and Likert-type scales.

Knowledge on the health consequences of exposure to tobacco smoke as well as on the association between TB and tobacco use was evaluated using total scores for each participant, with one point for each correct answer and zero points for each wrong answer. The possible total knowledge score for each subject for the two domains ranged from 0 to 37 points (0–27 points and 0–10 points for health risks of tobacco and TB-tobacco association domains, respectively). Attitudes and beliefs toward tobacco control policies were also evaluated in a similar fashion for each participant with one point for each positive attitude and zero points for each negative attitude (range of possible obtainable scores: 0–9 points).

Participants were asked to fill in and submit the questionnaires in a classroom setting on the spot. Anonymity and confidentiality were ensured. Approval for the conduct of the study was obtained from the Medical Research Ethics Committee (MREC) of the National Institute of Health (NIH), Ministry of Health, Malaysia.

Statistical analysis

The data were analyzed by using SPSS version 14.0 software package (SPSS Inc., Chicago, IL, USA). Both descriptive and inferential statistics were utilized where appropriate. Frequencies and percentages were used to portray the respondents’ demographic information and professional characteristics, knowledge, attitudes, and practice on tobacco cessation, before and after the training. The Wilcoxon signed-rank test and the McNemar χ2 test were used to measure the impact of the training program on knowledge, attitudes, tobacco-related topics learned, and perceived confidence and competence of performing SCI activities. The Wilcoxon signed-rank test was applied instead of the paired t test, for total knowledge and attitudes scores, because these variables were not normally distributed. Thus, the knowledge and attitude scores were presented as median and interquartile ranges. In addition, the McNemar χ2 test and the Wilcoxon signed-rank test were used for tobacco-related topics learned (dichotomous variable) and confidence/competence of performing SCI (ordinal variable), respectively. The statistical significance level was set a priori at p < 0.05.

Results

Demographic characteristics

All of the trainees were females and had completed both the pretest and posttest survey questionnaire. Prior to the current training, none of the participants had received any formal training on treating tobacco use and dependence. Table 2 summarizes pertinent information related to the characteristics of the trainees.

Table 2 Demographic and smoking-related characteristics of TB DOTS providers involved in the training program
Full size table

DOTS providers’ performance in knowledge and attitude domains

Changes in scores of knowledge and attitude for three domains of the survey instrument were measured (knowledge of health risks of tobacco and tobacco-related diseases, knowledge of the link between TB and tobacco use, and positive attitudes and beliefs about tobacco control policies). The median knowledge score of the health risks of tobacco after the training significantly increased from 16.5 to 21.5 (p = 0.003), whereas the median score on the association between TB and tobacco rose from 5.5 to 9.5 (p = 0.01). However, there was no significant improvement in positive attitudes and beliefs on tobacco control policies among the participants (p = 0.14) (Table 3). Moreover, the DOTS providers’ performance on knowledge items related to the association between tobacco use and TB, pre-training and post-training is summarized in Table 4. There were improvements in the proportions of participants having correct responses in almost all of the items, although some of the differences were not statistically significant.

Table 3 TB DOTS providers’ knowledge scores in three domains before and after the training
Full size table
Table 4 Comparison of TB DOTS providers’ knowledge of the link between TB and tobacco use before and after the educational series
Full size table

Practice of SCI

The five “A’s” strategy (ask, advise, assess, assist, arrange) was used to evaluate the respondents’ clinical activities related to smoking cessation. Only one fifth to two fifths of the DOTS providers frequently (on a daily basis) “asked” patients about the use of tobacco products. None of them frequently assessed the level of nicotine dependence and half of them never assessed this. Furthermore, only 30–40% of the nurses frequently “advised” patients about the dangers of smoking. Thirty percent claimed that they frequently “advised” patients to quit smoking. However, 0–20% frequently “assessed” patients’ willingness to quit smoking. About one fifth to one third of the nurses seldom discussed patients’ smoking behaviors with their families and 30–40% never referred them to other health professionals for cessation interventions. Nearly half of the trainees had never developed a cessation plan or arranged for follow-up or offered self-help materials for quitting smoking.

Topics covered during nursing training and during current training program

The participants admitted that most of the topics related to tobacco use and cessation were not taught during their general nursing training and that their level of preparation for the delivery of tobacco cessation interventions prior to the current training was not adequate. For instance, only a few respondents reported that they had received training on the health hazards of active smoking (40%) and passive smoking (30%), and nicotine addiction, dependence, and related withdrawal symptoms (30%). However, 60–100% of the DOTS providers believed that the tobacco-related topics were covered during the training program. All of the respondents reported educational contents on the global tobacco epidemic, the health hazards of active and passive smoking, nicotine replacement therapy (NRT), the five A’s, carbon monoxide (CO) monitoring to measure exhaled CO level of patients, and training on the use of the transtheoretical model of behavior change. A comparison of the responses before and after the educational series is presented in Table 5. There were significantly higher proportions of DOTS providers indicating that specific tobacco-related contents were taught during the current training program when compared with those indicating the same topics had been taught during their nursing education (Table 5).

Table 5 Tobacco-related topics learned during nursing training vs during the training program
Full size table

Competence in performing SCI

This domain assessed self-perceived confidence and competence in performing tobacco cessation activities, both prior to and after the educational intervention program. The domain used a 5-point rating scale for the DOTS providers to indicate their level of confidence and competence in ten SCI skills (Table 6). In the data presented in Table 6, we collapsed very confident and confident as well as very competent and competent. Before the training program, at least 50% of the TB DOTS providers reported that they were not competent and confident in performing most aspects of tobacco cessation and control activities. However, upon completion of the training program, a larger proportion of the trainees believed that they were competent and confident in performing most SCI activities.

Table 6 Confidence and competence of performing SCI activities
Full size table

Discussion

Health care professionals working in TB settings have an unprecedented opportunity and can have an important public health impact by helping those patients who are tobacco users. Quitting smoking can have a significant impact on improving the outcomes of care and preventing future relapses of TB. The educational materials used for the current training were adapted from previous ones that were used for an established smoking cessation service provider certification program in Malaysia. The contents were modified to suit health care providers in TB settings who assist patients to quit smoking.

The study suggests that TB DOTS providers had serious deficits in knowledge of tobacco use and related diseases, including the association of TB and tobacco use, and that the structured program in the form of modules might have had a significant impact on improving these deficiencies. Given that the evidence of an association between tobacco use and TB is overwhelming and tobacco cessation has potential positive benefits on short- and long-term outcomes of TB treatment as well as future lung health, health professionals working in TB settings must be actively involved in intervening with vulnerable groups. However, there are individual and contextual barriers to the adoption of new routines in health care (Slama et al. 2007c). Health professionals working in TB care are unlikely to adopt SCI unless they understand the importance of such interventions, feel that doing them will produce results, and are convinced that the interventions should be used (Slama et al. 2007c).

Knowledge, skills, and positive attitudes toward tobacco cessation can be gained during undergraduate education and in-service training. However, it is documented that universities provide inadequate tobacco cessation counseling training in the curricula of undergraduate programs (Hudmon et al. 2003). Although, health care professionals can have an important public health impact by helping to counter tobacco use, studies consistently demonstrate that students in the health professions receive insufficient training for providing comprehensive tobacco cessation counseling (Richmond et al. 1998; Hudmon et al. 2003, 2005; Reichert et al. 2008; Chatkin and Chatkin 2009). Similarly, it is clear through our academic experience in Malaysian medical and pharmacy schools and communications with colleagues in related disciplines that most of the schools do not include in-depth topics and training on tobacco control. A study conducted among respiratory physicians caring for TB patients in Morocco indicates that only 5.3% believed that they were adequately trained to help smokers to stop (Amara et al. 2008). Findings from our study corroborate this in that none of the TB DOTS providers had prior training to provide smoking cessation services. A customized and integrated tobacco cessation curriculum that meets the needs of TB settings should therefore be designed and used for in-service training and for health professional schools. The present study made an attempt to design modules that were tailored towards TB care (Table 1). Participants were also given references to key educational materials and guidelines for tobacco cessation, specifically designed for TB settings (Chiang et al. 2007a,b; Enarson et al. 2007; Slama et al. 2007a, b, c, d; WHO and IUATLD 2007; Slama et al. 2008).

Health professionals providing DOTS to TB patients in Malaysia (predominantly nurses and medical assistants) have unique opportunities to deliver brief or intensive SCI using the five A’s strategy of ask, advise, assess, assist, and arrange for follow-up (Fiore et al. 2000) as well as pharmacotherapy. Slama and colleagues recently proposed the inclusion of brief smoking cessation advice in standard TB case management (Slama et al. 2007c, d). In fact, the International Union Against Tuberculosis and Lung Diseases (IUATLD) recently designed a serialized guide in the form of an educational series on the provision of tobacco cessation interventions for TB patients (Chiang et al. 2007a, b; Enarson et al. 2007; Slama et al. 2007a, b, c, d). The WHO had earlier advocated that physicians and public health workers should energetically apply anti-smoking interventions in populations with high levels of subclinical TB infection to help prevent activation and spread and in collaboration with the IUATLD has produced comprehensive guidelines for tobacco cessation in TB care (WHO and IUATLD 2007; Slama et al. 2008).

The results of this pilot study therefore have reaffirmed that health professionals providing DOTS to TB patients in Malaysia might be ill-equipped in terms of knowledge related to SCI. They also seemed to have had negative attitudes towards activities related to tobacco and health and seldom practice specific activities. However, the findings should be interpreted in the light of the major limitations of the pilot study, which were the small sample, short follow-up period, and lack of a control group (i.e., with no training). Therefore, the results may not be generalized to all TB settings. Future studies should involve larger samples across the country and apply more rigorous study designs. A randomized control study looking at the effects of such teaching programs on a larger number of DOTS providers with the outcomes being changes in knowledge, attitudes, and practice over a longer period of time of post-intervention may be warranted. This is to ensure retention of the KAP. It may also be worthwhile to measure the number of smokers counseled or preferably who quit smoking over the course of the TB treatment period as surrogate markers of DOTS providers’ changes in practice. In general, a more established and structured program on tobacco control is urgently needed to equip TB DOTS providers with the requisite knowledge, attitudes, and skills essential to deliver tobacco cessation services effectively. This will involve the development of content for teaching and training as part of the health-related undergraduate curricula and also for CPD programs. A number of educational programs that can be incorporated into undergraduate curricula are readily available (Hudmon et al. 2003; Karine et al. 2006). Future health care professionals, including nurses, will be equipped with the basis to ensure they have the requisite knowledge, skills, and training to help patients stop smoking.

Conclusions

A pilot program on tobacco cessation for DOTS providers involved in TB care was successfully designed and implemented. Overall, the training program seemed to have made a significant impact on improving their knowledge, attitudes, and self-confidence in helping TB smokers to quit. This preliminary study has an important implication for the feasibility of utilizing DOTS providers in addressing the two epidemics of public health importance, has highlighted the gap related to SCI in health professionals’ education, and calls for urgent curricula reforms. In general, the pilot study has managed to contribute additional information regarding the KAP of TB DOTS providers in Malaysia.