Developing assessment and promotion of tobacco counselling : a cluster-randomised community trial among oral health professionals

Tobacco use adversely affects oral health. Tobacco use cessation (TUC) counselling guidelines recommend that brief TUC counselling should be provided to all tobacco users. In addition to TUC counselling, providing positive support to remain tobacco abstinent is particularly important among adolescents who are about to experiment with tobacco use. Despite excellent opportunities, implementation of tobacco use prevention and cessation (TUPAC) counselling among oral health professionals has proved challenging. Thus, the present study aimed to develop the assessment and promotion of TUPAC counselling among oral health professionals. A sample of Finnish dentists (n = 73) and dental hygienists (n = 22) employed by community dental clinics of the municipal health care regions of Tampere (28 clinics) and Vaasa (9 clinics) were invited to participate. Of those invited, 73 (76.8%) oral health professionals from 34 (91.9%) dental clinics participated. Applying a Theoretical Domains Framework (TDF), a 35-item Theoretical Domains Questionnaire (TDQ) was developed to assess factors influencing TUPAC counselling. The provision of TUC counselling at baseline was measured using a questionnaire and an electronic dental record audit to measure the effects of (1) educational and (2) educational + fee-for-service interventions. The estimates of internal consistency and factor analysis supported the reliability and validity of the TDQ developed. The present study showed that the provision of TUC counselling among a sample of oral health professionals was low. Identified implementation barriers suggest that the low adherence to TUPAC counselling could be due to reported environmental constraints (e.g. lack of support and resources), lack of skills, and low self-efficacy. Professional role and identity as well as memory, attention and decision processes were identified as potential determinants for TUPAC counselling. In assessing the effects of educational and education + fee-for-service interventions on preventive counselling, no statistically significant intervention effects were found. Regarding the provision of TUC counselling, signficiant group-by-time interaction showed that education alone and education with fee increased the implementation. . However, there was no statistically significant additional effect was received by adding fee-for-service to the education. In all groups, dental hygienists improved their preventive and cessation counselling more than dentists did. In conclusion, the data indicated a lack of competencies, environmental support and resources regarding TUPAC counselling. Educational intervention showed a favourable impact on the implementation of TUC counselling. In addition to education, interventions that promote professional role and identity in TUPAC counselling as well as interventions offering tools to support decision making (e.g. reminders, feedback) could prove effective.Yleisten terveyttä tuhoavien vaikutusten lisäksi tupakoinnilla on haitallisia vaikutuksia myös suun terveyteen aiheuttaen muun muassa suusyöpää, hampaiden kiinnityskudossairauksia sekä komplikaatioita hammasimplanttien ja muiden suukirurgisten toimenpiteiden yhteydessä. Päivittäin tupakoivista noin 80% on huolissaan tupakan terveysvaikutuksista, ja noin 60% haluaisi lopettaa tupakoinnin. Terveydenhuollon ammattilaisten toteuttama tupakasta vieroitus on tehokasta ja kustannus-vaikuttavaa. Suomalaisen Lääkäriseura Duodecimin julkaiseman Käypä Hoito suosituksen tavoitteena on ohjata ja edistää vieroituksen toteuttamista terveydenhuollossa. Hoitosuosituksen toimeenpano on ollut riittämätöntä etenkin suun terveydenhuollon ammattilaisten osalta. Vuonna 2011 alle 10% suun terveydenhuollossa käyneistä tupakoitsijoista oli saanut kehotuksen lopettaa tupakointi. Koska suun terveydenhuolto palvelee huomattavaa osaa väestöstä vuosittain, kansanterveydelliset vaikutukset olisivat merkittävät, mikäli suun terveydenhuollon ammattilaiset tukisivat potilaidensa tupakoimattomuutta ja auttaisivat tupakasta vieroituksessa nykyistä aktiivisemmin. Väitöskirjassa tutkittiin Vaasan ja Tampereen terveyskeskusten hammaslääkäreiden ja suuhygienistien toteuttamaa tupakoinnin ennaltaehkäisy- ja tupakasta vieroituskokeilua. Tulosten perusteella suun terveydenhuollon ammattilaisten toteuttama tupakoinnin vastustamistyö oli vähäistä. Väitöskirja toi uutta tietoa suun terveydenhuollon ammattilaisten tupakoinnin vastustamistyöhön tarvittavista valmiuksista, jossa suurimmat ongelmat liittyivät puutteelliseksi koettuun kompetenssiin (mm. tiedot ja taidot) sekä työympäristön rajoitteisiin (mm. kiire, kannusteiden ja tuen puute). Koettu ammatillinen rooli sekä päätöksentekokyky ennustivat parhaiten tupakoinnin vastustamistyön toteutumista. Kuuden kuukauden seurantatutkimuksessa koulutuksen todettiin olevan tehokas tapa lisätä tupakkavieroitusta. Sen sijaan rahallisella palkkiolla ei ollut lisävaikutusta tupakkaintervention toteuttamiseen. Kaikkiaan suuhygienistit toteuttivat tupakoinnin vastustamistyötä enemmän kuin hammaslääkärit. Lisäksi koulutus ja rahallinen palkkio toimivat paremmin suuhygienistien ryhmässä verrattuna hammaslääkäreihin. Väitöskirjan tulosten perusteella hammaslääkäreiden ja suuhygienistien huomattava potentiaali tupakoinnin vähentämiseksi saataisiin paremmin käyttöön lisäämällä siihen liittyvää perus- ja täydennyskoulutusta. Lisäksi työssä oppimiseen ja työolojen mukauttamiseen tupakoinnin vastustamistyötä aktivoivaksi tulisi kiinnittää entistä enemmän huomiota

Assessing implementation difficulties in tobacco use prevention and cessation counselling among dental providers

<p>Abstract</p> <p>Background</p> <p>Tobacco use adversely affects oral health. Clinical guidelines recommend that dental providers promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented, however. To improve guideline adherence and to develop effective interventions, it is essential to understand provider behaviour and challenges to implementation. This study aimed to develop a theoretically informed measure for assessing among dental providers implementation difficulties related to tobacco use prevention and cessation (TUPAC) counselling guidelines, to evaluate those difficulties among a sample of dental providers, and to investigate a possible underlying structure of applied theoretical domains.</p> <p>Methods</p> <p>A 35-item questionnaire was developed based on key theoretical domains relevant to the implementation behaviours of healthcare providers. Specific items were drawn mostly from the literature on TUPAC counselling studies of healthcare providers. The data were collected from dentists (n = 73) and dental hygienists (n = 22) in 36 dental clinics in Finland using a web-based survey. Of 95 providers, 73 participated (76.8%). We used Cronbach's alpha to ascertain the internal consistency of the questionnaire. Mean domain scores were calculated to assess different aspects of implementation difficulties and exploratory factor analysis to assess the theoretical domain structure. The authors agreed on the labels assigned to the factors on the basis of their component domains and the broader behavioural and theoretical literature.</p> <p>Results</p> <p>Internal consistency values for theoretical domains varied from 0.50 ('emotion') to 0.71 ('environmental context and resources'). The domain environmental context and resources had the lowest mean score (21.3%; 95% confidence interval [CI], 17.2 to 25.4) and was identified as a potential implementation difficulty. The domain emotion provided the highest mean score (60%; 95% CI, 55.0 to 65.0). Three factors were extracted that explain 70.8% of the variance: motivation (47.6% of variance, α = 0.86), capability (13.3% of variance, α = 0.83), and opportunity (10.0% of variance, α = 0.71).</p> <p>Conclusions</p> <p>This study demonstrated a theoretically informed approach to identifying possible implementation difficulties in TUPAC counselling among dental providers. This approach provides a method for moving from diagnosing implementation difficulties to designing and evaluating interventions.</p

Assessing implementation difficulties in tobacco use prevention and cessation counselling among dental providers

Background: Tobacco use adversely affects oral health. Clinical guidelines recommend that dental providers promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented, however. To improve guideline adherence and to develop effective interventions, it is essential to understand provider behaviour and challenges to implementation. This study aimed to develop a theoretically informed measure for assessing among dental providers implementation difficulties related to tobacco use prevention and cessation (TUPAC) counselling guidelines, to evaluate those difficulties among a sample of dental providers, and to investigate a possible underlying structure of applied theoretical domains.Methods: A 35-item questionnaire was developed based on key theoretical domains relevant to the implementation behaviours of healthcare providers. Specific items were drawn mostly from the literature on TUPAC counselling studies of healthcare providers. The data were collected from dentists (n = 73) and dental hygienists (n = 22) in 36 dental clinics in Finland using a web-based survey. Of 95 providers, 73 participated (76.8%). We used Cronbach's alpha to ascertain the internal consistency of the questionnaire. Mean domain scores were calculated to assess different aspects of implementation difficulties and exploratory factor analysis to assess the theoretical domain structure. The authors agreed on the labels assigned to the factors on the basis of their component domains and the broader behavioural and theoretical literature.Results: Internal consistency values for theoretical domains varied from 0.50 ('emotion') to 0.71 ('environmental context and resources'). The domain environmental context and resources had the lowest mean score (21.3%; 95% confidence interval [CI], 17.2 to 25.4) and was identified as a potential implementation difficulty. The domain emotion provided the highest mean score (60%; 95% CI, 55.0 to 65.0). Three factors were extracted that explain 70.8% of the variance: motivation (47.6% of variance, alpha = 0.86), capability (13.3% of variance, alpha = 0.83), and opportunity (10.0% of variance, alpha = 0.71).Conclusions: This study demonstrated a theoretically informed approach to identifying possible implementation difficulties in TUPAC counselling among dental providers. This approach provides a method for moving from diagnosing implementation difficulties to designing and evaluating interventions

Enhancing implementation of tobacco use prevention and cessation counselling guideline among dental providers: a cluster randomised controlled trial

Background: Tobacco use adversely affects oral health. Tobacco use prevention and cessation (TUPAC) counselling guidelines recommend that healthcare providers ask about each patient's tobacco use, assess the patient's readiness and willingness to stop, document tobacco use habits, advise the patient to stop, assist and help in quitting, and arrange monitoring of progress at follow-up appointments. Adherence to such guidelines, especially among dental providers, is poor. To improve guideline implementation, it is essential to understand factors influencing it and find effective ways to influence those factors. The aim of the present study protocol is to introduce a theory-based approach to diagnose implementation difficulties of TUPAC counselling guidelines among dental providers.Methods: Theories of behaviour change have been used to identify key theoretical domains relevant to the behaviours of healthcare providers involved in implementing clinical guidelines. These theoretical domains will inform the development of a questionnaire aimed at assessing the implementation of the TUPAC counselling guidelines among Finnish municipal dental providers. Specific items will be drawn from the guidelines and the literature on TUPAC studies. After identifying potential implementation difficulties, we will design two interventions using theories of behaviour change to link them with relevant behaviour change techniques aiming to improve guideline adherence. For assessing the implementation of TUPAC guidelines, the electronic dental record audit and self-reported questionnaires will be used.Discussion: To improve guideline adherence, the theoretical-domains approach could provide a comprehensive basis for assessing implementation difficulties, as well as designing and evaluating interventions. After having identified implementation difficulties, we will design and test two interventions to enhance TUPAC guideline adherence. Using the cluster randomised controlled design, we aim to provide further evidence on intervention effects, as well as on the validity and feasibility of the theoretical-domain approach. The empirical data collected within this trial will be useful in testing whether this theoretical-domain approach can improve our understanding of the implementation of TUPAC guidelines among dental providers