Advancing Proficiencies for Health Professionals in the Treatment of Tobacco Use Among Marginalized Communities: Development of a Competency-Based Curriculum and Virtual Workshop

Abstract

Background:

Tobacco-related disparities are a leading contributor to health inequities among marginalized communities. Lack of support from health professionals is one of the most cited barriers to tobacco cessation reported by these communities. Improving the proficiencies with which health professionals incorporate social and cultural influences into therapeutic interactions has the potential to address this critical barrier. In general, training to improve these proficiencies has shown promise, but the specific proficiencies required for treating tobacco use among marginalized communities are unknown. This project aimed to develop a competency-based curriculum to improve these proficiencies among health professionals with experience and training in the evidence-based treatment of tobacco use, and then pilot test the content delivered via an expert review of a virtual, self-paced workshop.

Methods:

We used the Delphi Technique to systematically identify the specific competencies and corresponding knowledge and skill sets required to achieve these proficiencies. Educational content was developed to teach these competencies in a virtual workshop. The workshop was evaluated by 11 experts in the field by examining pre- and post-training changes in perceived knowledge, skill, and confidence levels and other quantitative and qualitative feedback. Repeated measures analysis of variance and paired sample t-tests were used to examine pre-post training differences.

Results:

Six competencies and corresponding skill sets were identified. After exposure to the virtual workshop, the experts reported significant increases in the overall proficiency for each competency as well as increases in nearly all levels of knowledge, skill, and confidence within the competency skill sets. Qualitative and quantitative findings indicate that content was relevant to practice.

Conclusions:

These findings provide preliminary support for 6 competencies and skills sets needed to improve therapeutic interpersonal interactions that recognize the importance of social and cultural influences in the treatment of tobacco use.

Keywords

tobacco use treatment smoking cessation tobacco-related disparities health professional training health professional continuing education

Highlights

The findings provide support for 6 competencies and skill sets needed to improve health professionals’ proficiencies incorporating social and cultural influences into therapeutic interactions and treatment plans.

Medical and health education professionals can use the identified competencies and skill sets to improve tobacco treatment education and training.

These findings provide foundational support for research to investigate the effects of training in these competencies on health professional behaviors and patient outcomes.

Although commercial tobacco product use is decreasing,¹ tobacco-related disparities caused by commercial tobacco use remain a leading contributor to health inequities experienced by many historically marginalized communities.^2
-6 Of great concern is that despite a growing awareness,^7
-9 tobacco-related disparities are, at present, increasing.^7,10
-13 In the US, smoking cigarettes alone still causes nearly half a million deaths annually including nearly 30% of all cancer deaths.¹⁴ Thus, addressing tobacco-related disparities is a high priority for tobacco and cancer control efforts.^7,15

Tobacco-related disparities include population differences in tobacco use prevalence rates, quit attempts, success at achieving abstinence, responses to evidence-based treatments, protections from tobacco control regulations, the health consequences of tobacco use, and importantly, the quality of treatment for tobacco use provided by health professionals.^16
-18 Multiple historically marginalized populations and communities experience tobacco-related disparities, including individuals of lower socioeconomic status, women, ethnic and racial minority groups, sexual and gender minority groups, individuals with disabilities, active military and veterans, and individuals with mental health and substance use disorders.^15,19
-22 Individuals often experience multifaceted layering of tobacco-related disparities because they identify with multiple communities (eg, women of color who identify as sex/gender minorities) that experience unique and common structural and psychosocial influences on tobacco use.⁸

One of the most common and significant barriers to discontinuing tobacco use reported by these communities is a lack of support from health professionals.²³ The ability of health professionals to incorporate social and cultural influences into therapeutic interactions and treatment plans is now recognized as essential to high quality health care.^24
-26 In general, training to improve these competencies has shown promise,^26,27 however the competencies and skills required for treating tobacco use among marginalized communities are unknown. We propose that increasing the proficiencies with which health professionals incorporate social and cultural influences on tobacco use into therapeutic interactions will improve the quality and effectiveness of tobacco treatment provided to marginalized communities, and contribute to addressing a well-established barrier to discontinuing tobacco use among these communities.

The steady increase in the number of Tobacco Treatment Specialist (TTS) training programs has accelerated the growth of a multidisciplinary workforce of health professionals with proficiency in the treatment of tobacco use.^28,29 However, this proficiency does not require in-depth training in tobacco-related disparities and how to incorporate social and cultural influences into therapeutic interactions and treatment plans. Although the growth in TTS training is important to the field, these deficiencies represent a significant research and practice gap associated with effectively treating tobacco use in historically marginalized communities.

This project aimed to develop a competency-based curriculum to improve these proficiencies among health professionals, develop a virtual, self-paced workshop, and then pilot test the workshop via expert review. Because the approach required an intensive focus on improving these proficiencies, the approach was developed for learners who already had basic knowledge and skills for treating tobacco use with evidence-based approaches. Treatment of tobacco use is delivered in many contexts by health professionals from multiple disciplines.²⁹ Thus, to achieve our aim the approach required that we accommodate differences in treatment settings and professional disciplines. Here, we describe how we 1) systematically identified the specific competencies and skills required to achieve these proficiencies, and then 2) developed and pilot tested educational content intended to improve these competencies delivered in a virtual self-paced workshop. We present preliminary findings from a multidisciplinary group of experts in the field who evaluated the workshop.

Methods

Competency-based education is the norm in health professional education.^30
-32 In this context, a competency was defined as an observable, complex, multifaceted capability that can be learned and assumed to be composed of related knowledge, attitudes, and behavioral skills that together contribute its performance.^33,34 Knowledge was defined as necessary information; attitudes as ways of thinking or feeling that are reflected in behavior; and skills as specific behaviors.

The Delphi Technique was used to iteratively elicit and distill opinions and develop consensus among the investigative team members and experts in the treatment of tobacco use and in the training of TTSs and other health professionals. Phase 1 employed the core members of the investigative team (CES, EC, DOE, PHS, JMW, JSO) and 3 rounds of questionnaires to develop a list of domains important to understanding and effectively treating tobacco use among individuals from historically marginalized communities. The results produced 5 domains: 1) Knowledge of tobacco-related disparities at a population, community, and individual level; 2) Conceptual and theoretical foundations; 3) Assessment (initial and ongoing); 4) Counseling skills; and 5) Disseminating knowledge.

Phase 2 again employed the Delphi Technique and the core members of the investigative team (CES, EC, DOE, PHS, JMW, JSO) to identify and refine the skill sets for each domain. Each team member scored each skill on the level of importance to our aim on a scale of 0 (not at all) to 100 (most possible). Skills were eliminated if the mean level of importance was <50. During each round, the team had the opportunity to refine and add skills for the next round. Each domain required 2 to 4 rounds of review to develop consensus. When reviews produced no new changes, draft domains and skills were deemed ready for outside review.

Phase 3 employed the Council for Tobacco Treatment Training Programs (www.ctttp.org) to solicit feedback from the program training directors and faculty of Council-accredited TTS training programs. A mean of 5 experts per competency assessed each skill on the level of importance to our aim on a scale of 0 (not at all) to 10 (most possible). Skills were eliminated if the mean level of importance was <5. Experts also had the opportunity to refine skills through open ended comments. This resulted in the identification of an additional domain, which was called Clinical Research and Practice. Thus, Phase 3 produced 6 domains, now identified as Competencies, each with corresponding skill sets: 1) Knowledge of tobacco-related disparities, 2) Conceptual and theoretical foundations, 3) Assessment skills, 4) Counseling skills, 5) Clinical research and practice, and 6) Disseminating knowledge and professional development. See Table 1.

Table 1.

Competencies and Skills for Proficiency in the Treatment of Tobacco Use Among Communities That Experience Tobacco-Related Disparities.

Competency	Skills
Competency 1: Knowledge of tobacco-related disparities at a population, community, and individual level	1. Define population, institutional, community, interpersonal, and individual factors 2. Define and compare definitions of difference, disparity, inequity, inequality 3. Define a tobacco-related disparity 4. Describe the spectrum of influences on tobacco-related disparities across the lifespan 5. Describe groups that exhibit tobacco-related disparities 6. Describe the kinds of tobacco-related disparities experienced by different groups 7. Define race, ethnicity, sex, gender, sexual orientation, and disability 8. Describe racism and anti-racism 9. Describe stigma and its role in tobacco-related disparities 10. Describe privilege, the lack of privilege, and its ramifications 11. Describe biological differences that contribute to tobacco-related disparities 12. Describe systemic factors that contribute to tobacco-related disparities 13. Describe environmental factors that contribute to tobacco-related disparities 14. Describe behavioral factors that contribute to tobacco-related disparities 15. Describe social factors that contribute to tobacco-related disparities 16. Describe psychological factors that contribute to tobacco-related disparities 17. Describe how biological vulnerabilities can emerge from behavioral, social, environmental, and psychological factors
Competency 2: Conceptual and theoretical foundations	1. Intersectionality 2. Pathways linking socioeconomic status and health 3. Sociopharmacology of tobacco addiction 4. Models for adapting treatment approaches 5. Models for cultural competence
Competency 3: Assessment—initial and ongoing	Demonstrate ability to apply a disparities-informed framework for assessment that includes: 1. Cultural values and identifications 2. Impact of resources, educational levels, cognitive functioning, other substance use, frustration tolerance, trauma, fearfulness, and mistrust of others 3. Strengths and resilience 4. Feelings of discrimination and stigma as components of stress and distress 5. Anhedonia, hopelessness, and different manifestations of negative mood 6. Delay discounting, locus of control, and impulsiveness 7. Presence or absence of reinforcers 8. Beliefs about cessation medications 9. Cultural values related to use of pharmacotherapy for cessation 10. Use of all combustible and non-combustible tobacco products 11. Tobacco control policy enforcement in the environment (eg, sale of loosies, enforcement of smoke free policies, etc.) 12. Home policies for smoking, vaping, and other tobacco use 13. Patient expectations about how knowledge is generated, who possesses knowledge, and what types of knowledge are valued 14. Social positioning of self relative to patient 15. Patient expectations about attendance and adherence to recommendations 16. Identify limitations of traditional instruments for some individuals in vulnerable groups 17. Demonstrate ability to assess use of relevant tobacco products by various subgroups
Competency 4: Counseling skills	1. Describe the extraordinary importance of empathic communication 2. Demonstrate use of person-first or people-first language 3. Demonstrate empathetic communication 4. Demonstrate how to tailor counseling for multiple groups using theoretical models 5. Conduct a self-assessment of privilege, social position, and the power one possesses because of privilege 6. Apply at least one model of cultural competence to a case study 7. Identify multiple sources of implicit biases that affects treatment for tobacco use 8. Identify multiple sources of explicit biases that affects treatment of tobacco use 9. Demonstrate socio cultural respect and a lack of cultural superiority 10. Demonstrate ability to use anti-racist and anti-bias language 11. Demonstrate ability to proactively discuss important and sensitive topics that contribute to tobacco-related disparities with patients 12. Demonstrate ability to help patients identify and manage unique stressors that contribute to tobacco-related disparities (eg, stigma, racial aggression, limited access to resources) 13. Develop a case conceptualization that integrates concepts and assumptions of intersectionality 14. Develop a treatment plan that incorporates a disparities-informed framework and counseling approach
Competency 5: Clinical research and practice	1. Describe cultural competency as an ethical obligation 2. Describe ethics of justice and care theories 3. Identify the impact of asking identity questions in clinical practice 4. Describe the importance of interpretive skills and power 5. Describe a cultural framework for clinical practice
Competency 6: Disseminating knowledge and professional development	1. Describe importance of proactively discussing with colleagues important and sensitive topics that contribute to tobacco-related disparities 2. Identify policies in one’s environment that contribute to tobacco-related disparities 3. Identify specific situations in which to seek additional training in specific cultural competencies and proficiencies for specific groups 4. Find resources specific to tobacco treatment for different groups 5. Find up-to-date or new information regarding tobacco-related disparities

During Phase 4, team members (CES,AS, DV, EC, LB, MM, DOE, PHS, JMW, JSO) linked relevant content and resources to each skill and knowledge element in each Competency. We decided to develop the training as a virtual, asynchronous workshop, which enabled learners to complete the content at their own pace. One training module was developed for each competency. All modules were developed with Articulate Storyline 360 software (Articulate Global LLC, New York, NY). All modules were interactive and designed to appeal to multiple learning styles by using a simple user interface, text and narration, and interactive activities (ie, pop-up multiple-choice questions, drag-and-drop matching, pop-up practice tips). Two case study vignettes were video recorded using professional actors to demonstrate the assessment and counseling skills. All team members reviewed the modules and feedback was incorporated.

During Phase 5, the workshop was reviewed by a multidisciplinary team of eleven experts in tobacco treatment practice, training, and research. Reviewers were recruited by soliciting participation on 3 professional networks: the Health Equity Network and the Treatment Research Network of the Society for Research on Nicotine and Tobacco, and the Training Director Network for the Council for Tobacco Treatment Training Programs. The professional backgrounds of the reviewers included clinical psychology, dentistry, psychiatry, counseling, health outcomes research, public health, health education, and pharmacy. Most of the reviewers regularly develop curriculum and train TTSs and other health professionals. Reviewers lived and worked across the U.S. (ie, Texas, Alabama, New York, Missouri, Kentucky, Indiana, Colorado, Pennsylvania, California), and in the countries of India and Jordan. Experts provided quantitative and qualitative feedback for each module using pre- and post-training assessments and open-ended questions. Quantitative feedback was provided on a scale of 0 (not at all) to 10 (most possible). Qualitative feedback was solicited with open-ended questions.

Perceived level of knowledge was assessed pre- and post-training for all Modules. Pre- and post-training level of skill and confidence were added to Modules 3 to 6 because these modules involved behavioral or performance-based skills. For each Module, applicability to clinical practice was assessed by asking, “To what degree can you use this knowledge in your practice?,” followed by open-ended questions, “What would you use the most?” and “What would you use the least?” For each Module, satisfaction was assessed by asking, “How satisfied were you with each of the following aspects of the training?” “Content,” “Slides,” “Presentation style,” “Case demonstration,” “Voice over,” “Graphics,” and “Ease of navigation.” Engagement was assessed by asking, “How engaging did you find the module you just completed?” Relevance was assessed by asking, “How relevant to your work did you find the module you just completed?” Finally, comments and suggestions were elicited by asking 4 open-ended questions, “Do you have suggestions for improving the content?” “Do you have suggestions for improving the delivery of the content?” “Is there anything that would prevent you from applying the skills covered in this module in your practice?” and “Do you have any additional feedback that you would like to share?” Feedback was incorporated to complete the virtual workshop.

Data Analysis

Applicability to practice, satisfaction, relevance, and engagement were examined with descriptive statistics. Differences between pre- and post-training knowledge, skill, and confidence levels were examined for each skill individually and for each Competency as a whole. Repeated measures analysis of variance was used to examine pre-post training differences for each skill. For each Competency, mean pre- and post-training scores were calculated for knowledge, skill, and confidence levels. Paired-sample t-tests were used to examine differences between mean pre- and post-training scores for each Competency to obtain an overall Competency proficiency score. Reviewer responses to open-ended questions were examined for prominent themes and summarized by what reviewers would use most in practice, what they would use least, and suggestions for improving the content and its delivery. Prominent themes were synthesized across quantitative and qualitative results.

Results

A complete list of the 6 competencies and associated skill sets is included in Table 1. Detailed pre- and post-training scores for each skill are included in Supplemental Figures S1 to S3. A summary of the qualitative results is provided below.

Quantitative Results

The training required approximately 6.5 hours. After completing the training, the 11 expert reviewers found the content to be moderately to highly applicable to practice, relevant, and engaging. See Table 2. Most of the values at or below 5 were linked to the computerized voice-over used to read the content to learners. Overall, reviewers reported significant increases in levels of knowledge, skill, and confidence, and thus overall proficiency for each Competency. See Table 3 and Supplemental Figures S1 to S3.

Table 2.

Mean Evaluation Scores From Expert Reviewers.

	Competency 1: Knowledge about tobacco-related disparities	Competency 2: Conceptual and theoretical foundations	Competency 3: Assessment	Competency 4: Counseling	Competency 5: Clinical research and practice	Competency 6: Disseminating knowledge and professional development
M (SD)
Applicability to your practice	8.0 (1.8)	6.3 (2.2)	8.4 (2.2)	8.3 (1.6)	6.3 (1.8)	6.8 (2.0)
Relevance to your work	8.4 (1.5)	6.4 (2.4)	8.2 (2.3)	8.4 (1.7)	6.3 (2.1)	6.5 (2.4)
Engagement with content	6.7 (1.9)	5.1 (2.3)	7.9 (1.9)	7.4 (1.8)	5.8 (2.6)	6.0 (2.6)
Satisfaction with
Content	8.1 (1.1)	6.9 (2.0)	8.4 (1.7)	8.3 (1.3)	6.6 (1.9)	6.7 (1.7)
Slides	7.7 (1.5)	6.5 (1.2)	7.9 (1.5)	7.5 (1.5)	6.7 (2.0)	6.7 (2.2)
Presentation style	7.4 (1.4)	6.1 (2.4)	7.4 (1.6)	7.2 (2.0)	6.4 (2.3)	6.7 (2.2)
Case studies	7.1 (1.8)	5.1 (3.6)	9.4 (0.6)	9.1 (0.9)	6.0 (5.7)	7.6 (1.3)
Voice over	4.4 (2.4)	4.6 (2.5)	5.3 (2.7)	5.3 (3.2)	5.3 (3.2)	5.3 (3.2)
Graphics	7.5 (1.3)	5.6 (2.0)	6.2 (3.3)	6.4 (2.3)	6.6 (2.8)	7.2 (2.3)
Ease of navigation	7.9 (2.6)	6.4 (1.8)	7.1 (2.0)	6.7 (2.9)	7.4 (2.6)	7.7 (2.4)

Note. Questions were scored on a scale of 0 to 10, with 0 = not at all, and 10 = the most possible.

Table 3.

Overall Change in Proficiency as a Consequence of Completing the Virtual Workshop.

	Knowledge		Behavioral skills		Confidence
	Pre-score	Post-score	Pre-score	Post-score	Pre-score	Post-score
	M (SD)
Competency 1: Knowledge about tobacco-related disparities	7.11 (1.78)	8.93 (0.78)**
Competency 2: Conceptual and theoretical foundations	5.69 (2.15)	8.45 (0.91)**
Competency 3: Assessment	6.91 (1.63)	8.75 (0.93)**	6.55 (1.96)	8.31 (1.22)**	6.50 (1.98)	9.38 (1.36)**
Competency 4: Counseling	6.65 (2.08)	8.77 (0.71)**	6.39 (2.73)	8.29 (1.20)*	6.31 (2.43)	8.25 (1.26)**
Competency 5: Clinical research and practice	5.85 (2.96)	8.49 (1.04)**	5.44 (3.08)	7.78 (1.37)*	5.44 (3.09)	7.91 (1.16)**
Competency 6: Disseminating knowledge and professional development	6.84 (2.71)	8.91 (0.87)*	6.55 (2.72)	8.53 (0.93)*	6.51 (2.65)	8.47 (0.99)*

Note. All knowledge, skills, and confidence questions were scored on a scale of 0 to 10, with 0 = not at all, and 10 = the most possible. For each competency, the mean pre-score for all skills and mean post-score for all skills were calculated for knowledge, skill, and confidence levels. Paired-sample t-tests were then used to examine differences between the mean pre and mean post training skill scores for each competency to obtain an overall proficiency score.

p < 0.05; **p < 0.01 using paired samples t-test for post versus pre knowledge, skills, and confidence levels.

Qualitative Results

Would Use Most in Practice

For Competency 1: Knowledge of tobacco-related disparities at a population, community, and individual level, when asked what they would use the most in practice 2 reviewers stated, “All of it,” and “it is all essential . . .” Several reviewers identified content related to specific populations as most useful. One reviewer stated, “. . . to be more sensitive towards individual differences,” while others mentioned content related to conceptual frameworks such as understanding “Levels of factors (biological to societal) that explain or influence tobacco health disparities.” For Competency 2: Conceptual and theoretical foundations, reviewers stated they would likely use the specific theoretical constructs, information about socioeconomic status and health, and “knowledge of recruiting same ethnicity staff.” For Competency 3: Assessment—Initial and ongoing, reviewers stated they would use, “Key questions to ask to assess various key dimensions of the client and their tobacco use,” “Exploring what I need to know from the client,” “individual differences in culture and beliefs,” and “Feelings of discrimination and stigma.” Multiple reviewers stated they would use many of the practice tips and the content of the case study vignettes. For Competency 4: Counseling skills, 1 reviewer stated, “The knowledge around empathetic communication, difference between implicit and explicit bias, and the anti-racism language. This section has a lot of useful applicable items that are easily integrated into practice.” Others stated they would use content related to “Management of stressors,” “Environment stressors,” “Empathetic listening skills,” “Person-first language.” Multiple reviewers stated they would use the practice tips in the case demonstration. For Competency 5: Clinical Research and Practice, 2 reviewers stated they would use the information about “cultural bias and status,” the “difference between ethical and care theory models” and “balance between providing accurate support based on need vs blanket support to all at the same level.” One reviewer found it helpful to see “. . . the intersectionality of these domains on individuals . . .” Others stated they would use the “Cynefin Model,” “practical aspects of how to ask questions,” and the, “Impact of asking—potential benefits and limitations.” For Competency 6: Disseminating knowledge and professional development, 1 reviewer stated that, “All content seems relevant” while others stated they would specifically use “Research information,” “Overview of tobacco control resources,” “Equity vs equality concept,” “Finding tobacco treatment resources and latest information about disparities.” Two reviewers mentioned that they would use the professional resources.

Would Use Least in Practice

For Competency 1: Knowledge of tobacco-related disparities at a population, community, and individual level, 3 reviewers stated they would least use the biological factors associated with sex/gender differences, “. . . although it helps to understand differences in response to certain treatments.” One reviewer stated they would least use, “Racial differences.” Another stated that, “The systemic racism information was interesting, but could have been tied more closely to tobacco-related content. More specific examples regarding targeted marketing coupled with reduced access to healthcare/tobacco treatment resources as structural factors would be helpful.” For Competency 2: Conceptual and theoretical foundations, some reviewers stated that the Sociopharmacology and Parnell models seemed “. . . least helpful.” For Competency 3: Assessment—Initial and ongoing, many reviewers did not identify elements they would use the least, however, others stated that they were, “Less likely to use the tobacco control policies questions but I see the utility of doing so,” “Trauma related experiences” “Some of the [assessment] tools . . . It would be helpful to provide a brief descriptor of the tools (especially how many questions) as I think some of them are quite lengthy and may not be appropriate in some treatment settings,” “The extensive amount of data and elaborate information on the topic is not really needed,” “Enforcement of tobacco control policies in the environment.” For Competency 4: Counseling skills, most stated that “All [the content] is valuable and has [a] significant place in practice.” For Competency 5: Clinical Research and Practice, 2 reviewers stated they did not find the “Cynefin Framework” relevant to their practice. Others stated they would not use the details about the different models and theoretical frameworks, however, 1 reviewer stated, “. . . I felt this section was very efficient and direct to the point with the content. I felt it could also be used in understanding the need for cultural competency in a research setting. Coming from a more practical application perspective I thought it kept a good level of content and that would not lose the listener.” For Competency 6, Disseminating knowledge and professional development, the reviewers did not identify any elements that they would use the least in practice.

Suggestions for Improving the Content and the Delivery of Content

Reviewers provided multiple editorial revisions and clarifications. For Competency 1, 1 reviewer made suggestions on how to more clearly and accurately present sex/gender differences in treatment response to cessation medications. For Competency 2, 1 reviewer suggested “It might be helpful to describe a situation where each model could be used in tobacco treatment or tobacco treatment research” and “I would be focused on practical application of this information. Which seems to get lost in the details of the models.” Overall, reviewers indicated that the computerized voice-over was “mechanical,” and content delivery would improve with “a more naturalistic conversational style.” Some suggested that some content could be eliminated while others suggested that more content should be added. In general, reviewers suggested the training would be strengthened by providing more concrete clinical examples such as adding more case study vignettes. Several reviewers suggested that the vignettes be more well-integrated into the content. One reviewer stated, “I wondered whether a research case study might be helpful here where you show how a clinical trial was developed using these principles in mind?” Another reviewer suggested a case study showing how information could be disseminated into a community. Finally, 1 reviewer noted that, “The resources listed are familiar to most TTSs . . . it would be great to see more specialized resources, even if not directly related to tobacco (since the focus is cultural competence and other broader issues that transcend tobacco).”

Discussion

This study systematically identified 6 competencies important to advancing clinical proficiencies in the treatment of tobacco use among many historically marginalized groups. These competencies integrate specific knowledge, attitudes, and skills, and are intended to build on the well-established basic competencies for the treatment of tobacco use to improve treatment provided to individuals from communities that experience tobacco-related disparities. These competencies also might be used as starting points for developing relevant population-specific, profession-specific, and/or context-specific learning objectives for related training experiences.

Qualitative and quantitative findings suggest that the content provided in the virtual workshop was highly relevant to clinical practice and that the virtual, self-paced training modality was effective at increasing participants’ knowledge, skill, and confidence levels. Post-training improvements in proficiencies were found for all 6 competencies, even among a panel of experts, as evidenced by significant increases in overall means for knowledge, skill, and confidence levels. See Table 3. Significant increases in post-training levels of knowledge, skill, and confidence were found for nearly all individual skills within the 6 competencies as well. One exception worth noting is that expert reviewers reported a post-training decrease in skill and confidence level for empathic communication (ie, skill number 1 of Competency 4: Counseling skills), despite an increase in knowledge about empathetic communication. See Supplemental Figures S1D, S2B, and S3B. We speculate that pre-training the experts felt they already had a high level of knowledge, skill, and confidence in expressing empathetic communication. However, as they gained a more nuanced understanding of how empathetic communication can be applied among individuals from historically marginalized communities, they felt less proficient or confident with this skill because they had not yet practiced empathetic communication in this way. A similar effect can be found in medical and psychotherapy practice, where some skills require in-depth practice before practitioners feel proficient and confident.^35
-39

Empathic communication is an essential but complex skill that can be easy to understand but difficult to demonstrate because it depends heavily on self-awareness, reflection, and practice. Evidence indicates that empathic communication is robustly beneficial as a therapeutic communication style,^40
-43 and can be taught,⁴⁴ with a growing body of evidence-based recommendations on how to teach it.^45
-48 Although the virtual workshop incorporated theory-based models of empathic communication, reasons why it is beneficial, and when to incorporate empathic communication as well as reflection exercises and video demonstrations, learners might require complementary strategies and/or additional guided practice before feeling proficient and confident in this advanced practice.^49,50 A recent study found that didactic presentation coupled with experiential role play exercises increased self-efficacy for empathic communication skills.^51,52 Incorporating these factors would likely strengthen the effectiveness of the workshop, perhaps this could be accomplished with a synchronous virtual follow-up mini-workshop focused on practice and application.

Quantitative and qualitative findings indicated that the computerized voice narrating the content was a significant weakness, highlighting the need for human narration. This might be accomplished with software that “reads” the narration text in a more human-like manner or by employing professionals to record the narration. Next steps include incorporating the findings above into the virtual workshop.

Future research should investigate the effects of the virtual workshop and/or the con knowledge, attitudes, and skills in a larger sample of health professionals; on tobacco treatment practices; and on patient outcomes including patient satisfaction and treatment outcomes among patients from historically marginalized communities. Future research might also investigate other methods of teaching these core competencies and skill sets.

Strengths and Limitations

The strengths of study include a robust, systematic methodological approach to development and the mixed methods design. Robust iterative methods and inclusion of professionals from diverse disciplines at every phase of development increased the generalizability of these competencies to professionals from different disciplines in different settings. Then mixed methods design incorporated quantitative pre-post training assessments as well as a rich source of qualitative data. In addition, the virtual, self-paced training is potentially quite cost-effective and convenient because it would enable busy professionals to engage in the workshop without travel or large disruptions to their schedules. If this training is found to be effective at improving health professionals’ skills, health professionals’ tobacco treatment practices, and patient care in a broader context, the virtual modality has the potential to have a greater reach and thus a greater impact on the field than in-person training modalities. Finally, a significant strength of this study lies in the identification and exploration of competencies that can be applied across marginalized communities.

The limitations of this study include its preliminary, developmental nature, and the relatively small sample sizes involved in development and evaluation. Identifying and developing the competencies is just the first step in improving the quality of treatment provided by individual health professionals and does not address other systemic influences that impact treatment for marginalized communities. In addition, although the 11 training experts had a high-level of knowledge in the field and were able to provide expert comment on content and delivery, their pre-post training outcomes might be different than outcomes among learners without that level of expertise. Finally, despite the iterative processes, the small sample size of experts involved with development and evaluation of this curriculum limits the ability to apply conclusions across a larger sample of health professionals without additional study.

Conclusions

Among communities that experience tobacco-related disparities, a commonly cited barrier to cessation is a lack of support from health professionals. These findings provide preliminary support for 6 competencies and skill sets needed to improve health professionals’ proficiencies incorporating social and cultural influences into therapeutic interactions and treatment plans. These findings can support future research and educational interventions to improve tobacco treatment education and training as well as to investigate the effects of training. Future research should examine the effects of exposure to the virtual workshop developed from these competencies on knowledge, attitudes, and skills in a larger sample of health professionals; on tobacco treatment practices; and on patient outcomes including patient satisfaction and treatment outcomes among patients from historically marginalized communities. Future research might also investigate other methods of teaching these competencies.

Supplemental Material

sj-docx-1-saj-10.1177_08897077231200987 – Supplemental material for Advancing Proficiencies for Health Professionals in the Treatment of Tobacco Use Among Marginalized Communities: Development of a Competency-Based Curriculum and Virtual Workshop

Supplemental material, sj-docx-1-saj-10.1177_08897077231200987 for Advancing Proficiencies for Health Professionals in the Treatment of Tobacco Use Among Marginalized Communities: Development of a Competency-Based Curriculum and Virtual Workshop by Christine E. Sheffer, Alina Shevorykin, Roberta Freitas-Lemos, Darian Vantucci, Ellen Carl, Lindsey Bensch, Matthew Marion, Deborah O. Erwin, Philip H. Smith, Jill M. Williams and Jamie S. Ostroff in Substance Abuse

Footnotes

Author Contributions

All authors made substantial contributions to this work. CES led the team that obtained the funding, conducted the study, and developed the manuscript. EC, DOE, PHS, JMW, and JSO had a significant role on the grant application, the conduct of the study, and development of the manuscript. LB had a significant role in coordinating the study. RFL and AS had a significant role in the data analysis design and presentation. AS conducted the analyses. AS and DV incorporated the content into the virtual presentations. MM and RFL provided important feedback on preliminary drafts of the manuscript. All authors reviewed the final draft and agree to be accountable for all aspects of the work.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by a grant from the National Institutes of Health, National Cancer Institutes under award number R25CA233416. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance,Ethical Standards,and Ethical Approval

This project is human subjects research that was deemed to meet criteria for exemption 1 and 2 by the Roswell Park Comprehensive Cancer Center Institutional Review Board. This study was conducted as part of normal educational practices used to develop and evaluate educational content and content delivery.

ORCID iD

Alina Shevorykin

Supplemental Material

Supplemental material for this article is available online at the SAJ website

References

Cornelius

Loretan

Wang

Jamal

Homa

DM.

Tobacco product use among adults - United States, 2020. Morb Mortal Wkly Rep. 2022;71(11):397-405.

Health and Human Services Department. Let’s Make the next Generation Tobacco-Free: Your Guide to the 50th Anniversary Surgeon General’s Report on Smoking and Health. Government Printing Office; 2014.

Kanjilal

Gregg

Cheng

, et al. Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002. Arch Intern Med. 2006;166(21):2348-2355.

Edwards

Noone

Mariotto

, et al. Annual report to the nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer. 2014;120(9):1290-1314.

Lee

JGL

Griffin

Melvin

. Tobacco use among sexual minorities in the USA, 1987 to May 2007: a systematic review. Tob Control. 2009;18(4):275-282.

Cokkinides

Halpern

Barbeau

Ward

Thun

MJ.

Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey. Am J Prev Med. 2008;34(5):404-412.

Simmons

Pineiro

Hooper

Gray

Brandon

TH.

Tobacco-related health disparities across the cancer care continuum. Cancer Control. 2016;23(4):434-441.

Sheffer

Williams

Erwin

Smith

Carl

Ostroff

JS.

Tobacco-related disparities viewed through the lens of intersectionality. Nicotine Tob Res. 2022;24(2):285-288.

Tan

ASL

Hinds

Smith

, et al. Incorporating intersectionality as a framework for equity-minded tobacco control research: a call for collective action toward a paradigm shift. Nicotine Tob Res. 2023;25(1):73-76.

10.

Sondik

Huang

Klein

Satcher

Progress toward the healthy people 2010 goals and objectives. Annu Rev Public Health. 2010;31:271-281.

11.

Garrett

Dube

Babb

McAfee

Addressing the social determinants of health to reduce tobacco-related disparities. Nicotine Tob Res. 2015;17(8):892-897.

12.

Spika

Heckley

Gerdtham

. What Do Demographics Have to Do with It? An Oaxaca-Blinder Decomposition of Changes over Time in Inequalities in Alcohol, Narcotics and Tobacco-Related Ill Health in Sweden. Working Paper; 2018. Accessed August 29, 2022. https://www.econstor.eu/handle/10419/260256

13.

National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Population Health and Public Health Practice, Committee on Community-Based Solutions to Promote Health Equity in the United States. Communities in Action: Pathways to Health Equity. National Academies Press; 2017.

14.

Islami

Marlow

Zhao

, et al. Person-years of life lost and lost earnings from cigarette smoking-attributable cancer deaths, United States, 2019. Int J Cancer. 2022;151(12):2095-2106.

15.

Mermelstein

Fiore

Bernstein

Delnevo

Tobacco Control Research Priorities for the Next Decade: Working Group Recommendations for 2016-2025. National; 2016.

16.

United States Public Health Service Office of the Surgeon General, National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General. US Department of Health and Human Services; 2020.

17.

Fagan

Moolchan

Lawrence

Fernander

Ponder

PK.

Identifying health disparities across the tobacco continuum. Addiction. 2007;102 Suppl 2:5-29.

18.

Fagan

King

Lawrence

, et al. Eliminating tobacco-related health disparities: directions for future research. Am J Public Health. 2004;94(2):211-217.

19.

Society

. Global cancer facts and figures 4th edition. Am Cancer Soc. 2018;1:1-73.

20.

Institute of Medicine, Board on Population Health and Public Health Practice, Committee on Smoking Cessation in Military and Veteran Populations. Combating Tobacco Use in Military and Veteran Populations. National Academies Press; 2009.

21.

Centers for Disease Control and Prevention (CDC). Vital signs: current cigarette smoking among adults aged ≥18 years with mental illness - United States, 2009-2011. Morb Mortal Wkly Rep. 2013;62(5):81-87.

22.

Cook

Wayne

Kafali

Liu

Shu

Flores

Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation. JAMA. 2014;311(2):172-182.

23.

Twyman

Bonevski

Paul

Bryant

Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature. BMJ Open. 2014;4(12):e006414.

24.

Betancourt

Green

Carrillo

Ananeh-Firempong

, 2nd. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118(4):293-302.

25.

Nelson

Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666-668.

26.

Beach

Price

Gary

, et al. Cultural competence. Med Care. 2005;43(4):356-373.

27.

Butler

McCreedy

Schwer

, et al. Improving Cultural Competence to Reduce Health Disparities. Agency for Healthcare Research and Quality; 2016.

28.

Sheffer

Payne

Ostroff

, et al. Increasing the quality and availability of evidence-based treatment for tobacco dependence through unified certification of tobacco treatment specialists. J Smok Cessat. 2016;11(4):229-235.

29.

Sheffer

Al-Zalabani

Aubrey

, et al. The emerging global tobacco treatment workforce: characteristics of tobacco treatment specialists trained in Council-accredited training programs from 2017 to 2019. Int J Environ Res Public Health. 2021;18(5):2416.

30.

Gruppen

Mangrulkar

Kolars

JC.

The promise of competency-based education in the health professions for improving global health. Hum Resour Health. 2012;10:43.

31.

Institute of Medicine, Board on Health Promotion and Disease Prevention, Committee on Educating Public Health Professionals for the 21st Century. Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century. National Academies Press; 2003.

32.

Thibault

GE.

The future of health professions education: Emerging trends in the United States. FASEB Bioadv. 2020;2(12):685-694.

33.

Parry

SB.

Just what is a competency? (And why should you care?). Training. 1996;35(6):58.

34.

Wong

SC.

Competency definitions, development and assessment: a brief review. Int J Acad Res Progress Educ Dev. 2020;9(3):95-114.

35.

Clanton

Gardner

Cheung

Mellert

Evancho-Chapman

George

RL.

The relationship between confidence and competence in the development of surgical skills. J Surg Educ. 2014;71(3):405-412.

36.

Cheraqpur

Aarabi

Bahrami

Akbari

Competency assessment of the operating room staff and some related factors: a multi-center cross-sectional study. Iran J Nurs Midwifery Res. 2022;27(4):287-293.

37.

Franz

Cailor

Chen

AMH

Thornton

Norfolk

Improvement of student confidence and competence through a self-care skills multi-course integration. Curr Pharm Teach Learn. 2020;12(4):378-387.

38.

Sholomskas

Syracuse-Siewert

Rounsaville

Ball

Nuro

Carroll

KM.

We don’t train in vain: a dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. J Consult Clin Psychol. 2005;73(1):106-115.

39.

Baer

Rosengren

Dunn

Wells

Ogle

Hartzler

An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug Alcohol Depend. 2004;73(1):99-106.

40.

Derksen

Bensing

Lagro-Janssen

Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract. 2013;63(606):e76-e84.

41.

Di Blasi

Harkness

Ernst

Georgiou

Kleijnen

. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357(9258):757-762.

42.

Zolnierek

KBH

Dimatteo

MR.

Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826-834.

43.

Mercer

Reynolds

WJ.

Empathy and quality of care. Br J Gen Pract. 2002;52 :S9-S12.

44.

Kiosses

Karathanos

Tatsioni

Empathy promoting interventions for health professionals: a systematic review of RCTs. J Compassionate Health Care. 2016;3(1):1-22.

45.

Archer

Meyer

IS.

Applying empathic communication skills in clinical practice: medical students’ experiences. S Afr Fam Pract . 2021;63(1):e1-e5.

46.

Platt

FW.

Empathy: can it be taught?

Ann Intern Med. 1992;117(8):700-701.

47.

Riess

Empathy can be taught and learned with evidence-based education. Emergency Medicine Journal. 2022;39(6):418-419. doi:10.1136/emermed-2021-212078

48.

Coulehan

Platt

Egener

, et al. “Let me see if I have this right . . .”: words that help build empathy. Ann Intern Med. 2001;135(3):221. doi:10.7326/0003-4819-135-3-200108070-00022

49.

Rønning

Bjørkly

The use of clinical role-play and reflection in learning therapeutic communication skills in mental health education: an integrative review. Adv Med Educ Pract. 2019;10:415-425.

50.

Fairburn

Cooper

Therapist competence, therapy quality, and therapist training. Behav Res Ther. 2011;49(6-7):373-378.

51.

Banerjee

Haque

Schofield

, et al. Oncology care provider training in empathic communication skills to reduce lung cancer stigma. Chest. 2021;159(5):2040-2049.

52.

Banerjee

Haque

Bylund

, et al. Responding empathically to patients: a communication skills training module to reduce lung cancer stigma. Transl Behav Med. 2021;11(2):613-618.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.06 MB