Abstract
Background:
Physician-led smoking cessation services are suboptimal in Nigeria.
Objectives:
This study evaluated a text-messaging intervention designed to increase the knowledge and practices of physicians in Nigeria to help smokers quit.
Methods:
Using a pre-post study design, all physicians (N = 946) in three tertiary care hospitals located in three geopolitical zones in Nigeria were sent 2–3 text messages weekly over a 13-week period to create awareness and improve cessation practices using the “Ask, Advise and Refer (AAR)” model. The primary outcomes were the awareness of AAR and the proportion of physicians who offered each of the components of the brief intervention (AAR) to at least half of eligible patients. Secondary outcomes included the attitudes and self-reported effects of the messages on motivation to offer AAR to patients who smoke.
Results:
Of the 946 eligible respondents, only 165 responded to both the before and after intervention surveys (17.4% participation rate). Participants were more likely to indicate awareness of the AAR approach after the intervention (60%) than before (21.2%). Overall, physicians’ practice of each component of the AAR changed significantly after the intervention (p<0.001; McNemar test). Of the participants, 71.5% reported reading the messages most/all of the time and 84.8% reported that the frequency of the messages was just adequate.
Conclusions:
A brief and low-cost text messaging intervention to physicians increased the awareness and practice of AAR in those who participated in the study. However, the relatively low participation rate highlights the importance of new research to improve and expand text messaging as an intervention among physicians to help them foster tobacco treatment among their patients.
Keywords: Text messages, tobacco cessation, AAR, physicians
INTRODUCTION
The effectiveness of physician-led smoking cessation interventions is well documented. Poor awareness and lack of time are often stated as main challenges to the adoption of smoking cessation practices among physicians in resource-poor settings.1,2 The Ask, Advise and Refer (AAR) model is a simple, brief, evidence-based approach for physician-led smoking cessation and often takes less than two minutes.1 This may be useful for busy physicians in tertiary hospitals who provide care to large numbers of patients. However, promoting AAR to several physicians over wide geographical locations in a developing country like Nigeria may be costly and calls for the consideration of potentially low-cost alternatives.
Since, the introduction of the GSM (Global System of Mobile Communication) in Nigeria in 1999, there has been increased access to mobile phones and the internet among Nigerians. Access is particularly high among Nigerian physicians.3 One study reported that majority of physicians in Nigerian teaching hospitals use mobile phones and almost all (99%) have access to the internet. Among resident doctors, they reported 100% ownership of mobile phones with 96% being smartphones.3 Text messaging (TM) holds great promise because it is inexpensive, (costs <$0.01 per message) and can be used even in areas without internet access. Text messages have been successfully used to improve knowledge and motivate action among health care workers in some African countries with success.4,5 However, few studies have considered assessing the use of text messages to promote brief intervention tobacco cessation practices among physicians. In this study, we hypothesize that sending simple text messages to physicians in tertiary hospitals in Nigeria may improve awareness of, and increase brief intervention practices. The primary aim of this study was to determine the effect of a simple low-cost text message intervention, delivering periodic informative texts to promote the AAR among physicians in three geographically distinct tertiary hospitals in Nigeria. Our secondary aim was to determine the perception of the physicians towards the text message intervention.
METHODS
Study setting, design, selection of study sites and participants:
This before-and-after study targeted 946 physicians in three teaching hospitals located in three of the six national geopolitical zones in the country. This was part of a larger study designed to promote brief intervention tobacco cessation practices among physicians in Nigeria. One state was randomly selected in each zone and the largest hospital offering specialist care inclusive of tobacco cessation services was purposively selected for the study.
Selection of participants was done in two phases. In the first phase, a list of departments that rendered physician-led care to patients who were at least 12 years of age, alive, conscious and able to communicate in each selected hospital was developed. In the second phase, a list of text-message compatible phone numbers and valid email addresses of physicians in the listed departments was obtained. Only physicians who agreed to participate in the study after an informed consent using an opt-out approach were included. However, none of the physicians opted out of the study.
Program details:
The program was in three phases:
1. Baseline data collection: Baseline data were collected using SurveyMonkey®, an online data collection tool. We sent the online link to the email addresses of the physicians listed in the database and collected self-reported socio-demographic details and information assessing the current level of awareness and practices regarding the AAR model. We sent the surveylink to the physicians twice a week over a four-week period before the start of the program.
2. Message development and pre-testing: Messages were developed based on the Precaution Adoption Process Model (PAPM), which sees behavioral change as a continuum starting from a lack of awareness to adoption of a behavior.6 The messages were designed based on the assumptions that providing knowledge of the AAR, the benefits of tobacco cessation and cues to action will motivate the physicians to consider adopting the AAR and offer these services to their patients. Using our local knowledge of the study setting, the study team designed messages of no more than 160 characters with two goals: To provide awareness of the AAR model of tobacco cessation, its importance, simplicity and benefits to patients; and to instigate cues to action motivating the physicians to practice brief intervention using the AAR. Based on these goals, the study team developed fifteen text messages, assessed them for construct and face validity, before pre-testing and adopting them for use. A list of all the messages and sequencing is provided in table 1. The messages were sent in a graded manner, starting with those creating awareness of the AAR, followed by messages to motivate action. Two or three messages and reinforcing emails were sent weekly, over a 13-week period. Messages were sent using a paid online bulk-messaging platform. The platform allowed the sender to see if messages are delivered as sent. We sent text messages to all the 946 physicians in the database. The text messages cost less than $1 per physician for the entire study period.
Table 1:
List of message sequence, timing and frequency.
| Week 1 | The P-TOBACCO project is designed to promote Physician-assisted tobacco cessation in your hospital. Your hospital has been selected to benefit from this intervention, which will involve your receiving educative SMS and emails over the next three months. Dr [NAME OF COORDINATOR] of the [DEPARTMENT OF COORDINATOR] is the Coordinator of the P-Tobacco Project. If you have any inquiries or wish to opt out, please feel free to reach her on [PHONE NUMBER OF THE COORDINATOR] or [EMAIL OF THE COORDINATOR] |
| Week 1 | The P-TOBACCO project is designed to promote Physician-assisted tobacco cessation in your hospital. Your hospital has been selected to benefit from this intervention which will involve your receiving educative SMS and emails over the next three months. Dr [NAME OF COORDINATOR] of the[DEPARTMENT OF COORDINATOR] is the Coordinator of the P-Tobacco Project. If you have any inquiries or wish to opt out, please feel free to reach her on [PHONE NUMBER OF THE COORDINATOR] or [EMAIL OF THE COORDINATOR] |
| Week 1 | Tobacco use is the most preventable cause of deaths globally! This project is dedicated to promoting Physician-assisted tobacco cessation for those who need it! |
| Week 2 | Did you know that 4.2 million Nigerian men use tobacco? Smokers need your help with quitting! |
| Week 2 | Did you know that half of all lifetime smokers lose 20–25 years in life expectancy because they smoke tobacco? |
| Week 3 | The AAR (Ask, Advise and Refer) is an evidence-based approach effective in helping patients quit tobacco use & takes as little as 1 or 2 mins? |
| Week 3 | ASK: ALL Physicians r expected 2 inquire about d smoking status of ALL patients at every visit. When last did u ASK your patient about smoking? |
| Week 3 | ASK: Did u know that ALL physicians are expected to ask about the smoking status of ALL patients at every visit? Pls remember to ASK your patients today! |
| Week 4 | Patient case record documentation is a critical part of the P-TOBACCO project. Remember to document your tobacco cessation activities in the patient case notes |
| Week 4 | ADVISE: Be CLEAR when advising patients to quit and provide tailored and personalised cessation ADVICE |
| Week 5 | ADVISE: Be CLEAR when advising patients to quit and provide tailored and personalised cessation ADVICE |
| Week 5 | ADVISE: Brief advice is as simple as saying”Quitting smoking is d most important step U can take 2improve UR health”Ur pxts need ur help!ADVISE smokers to quit! |
| Week 5 | HOLIDAY GREETINGS |
| Week 6 | REFER: Pls REFER all your patients in XXX who use tobacco to Dr. XXX at the XXX clinic. Clinics run on Tuesdays, 9am-4pm |
| Week 6 | The AAR (Ask, Advise and Refer) takes only a few minutes of your time! ASK ADVISE and REFER your patients today! |
| Week 7 | Helping patients quit tobacco is one of the most important things you can do. Help your patients quit smoking today! |
| Week 7 | Half of all lifetime smokers will lose 20–25 years in life expectancy simply because they smoke tobacco!!! Please ASK, ADVISE & REFER UR PXTS TODAY |
| Week 8 | To make significant reduction in global tobacco related deaths, Smokers must quit. Be an active part of this global effort 2 reduce tobacco related deaths in ur institution |
| Week 8 | ADVISE: When ADVISing pxts 2 quit tobacco, Remember 2 keep your message CLEAR, STRONG & PERSONALIZED! |
| Week 9 | Helping patients quit tobacco is one of the most important things you can do. Help your patients quit smoking today! |
| Week 9 | The AAR (Ask, Advise and Refer) is an evidence-based approach effective in helping patients quit tobacco use & takes as little as 1 or 2 mins? |
| Week 10 | ASK: ALL Physicians r expected 2 inquire about d smoking status of ALL patients at every visit. When last did u ASK your patient about smoking? |
| Week 10 | ASK: Did u know that ALL physicians are expected to ask about the smoking status of ALL patients at every visit? Pls remember to ASK your patients today! |
| Week 11 | ADVISE: Be CLEAR when advising patients to quit and provide tailored and personalised cessation ADVICE |
| Week 11 | ADVISE: Be CLEAR when advising patients to quit and provide tailored and personalised cessation ADVICE |
| Week 12 | ADVISE: Brief advice is as simple as saying”Quitting smoking is d most important step U can take 2improve UR health”Ur pxts need ur help! ADVISE smokers to quit! |
| Week 12 | REFER: Pls REFER all your patients in XXX who use tobacco to Dr. XXX at the XXX clinic. Clinics run on Tuesdays, 9am-4pm |
| Week 13 | The AAR (Ask, Advise and Refer) is an evidence-based approach effective in helping patients quit tobacco use & takes as little as 1 or 2 mins? |
| Week 13 | The AAR (Ask, Advise and Refer) takes only a few minutes of your time! ASK ADVISE and REFER your patients today! |
| Week 13 | Thank you for participating in the P-Tobacco Project. With your help, we can reduce the burden of Tobacco related diseases on our patients with the AAR approach. |
3. End-of-study data collection: As with the baseline data collection, end-of-study data were collected in a similar fashion, using SurveyMonkey® All the questions in the baseline survey were included in the end-of-study survey. In addition, we collected information on the physicians’ opinions about the intervention and their attitudes towards receiving the text messages and electronic mails. Only 165 of the 946 eligible physicians responded to both the baseline and post-intervention surveys (response rate of 17.4%)
Study measures and outcome indicators
The primary outcomes were awareness of the AAR model of brief intervention and the proportion of physicians who offered each of the components of the AAR to at least 50% of eligible patients in the past three months. Secondary outcomes included self-reported effects of the messages on motivation to offer AAR and the physicians’ attitudes towards the messages.
Data analyses:
Data were analyzed using a paired pre-post test design, (Mc. Nemar’s test) considering only the 165 respondents who completed the surveys at the two time points.
Ethical considerations:
Ethical approval was obtained from the Research and Ethics Committees of each of the teaching hospitals used for the study. Physicians were given a choice to opt-out of receiving the messages if they so desired. The database was stored in a password-protected computer. All the information collected was treated with confidentiality.
RESULTS
One hundred and sixty-five (165) of the 946 eligible physicians completed the online survey before and after the study, indicating a participation rate of 17.4%. Respondents were mostly male (53.3%) and within the residency training program (71.0%). The mean age was 37.7+/−7.4 years.
Differences in the baseline and key outcome variable before and after the study:
A paired analysis of the 165 respondents who completed the online survey before and after the intervention showed statistically significant differences in the key outcomes. Awareness of the AAR increased significantly by 58.5% after the intervention, while inquiry of tobacco status increased by 25.0%. Participants who reported advising and referring patients who smoked also increased significantly, but by slightly lower percentages i.e. 19.8% and 12.3% respectively. (Table 2)
Table 2:
Key outcome indicators before and after the intervention.
| Before (n=165) Freq (%) |
After (n=165) Freq (%) |
Proportion changing from negative response after the intervention | p-value (McNemar change test) | |
|---|---|---|---|---|
| Indicated being Aware of the “AAR” | 35 (21.2) | 99 (60.0) | 76/130 (58.5%) | <0.001 |
| Correctly recalled the meaning of “AAR” | 27 (16.4) | 88 (53.3) | 71/138 (51.5%) | <0.001 |
| Participants who inquired of tobacco status (ASK) among >50% patients | 73 (44.8) | 94 (57.0) | 23/92 (25%) | <0.001 |
| Participants who provided quit advice (ADVICE) to >50% of patients who smoke | 74 (44.8) | 92 (55.8) | 18/91 (19.8%) | <0.001 |
| Participants who referred for follow-up (REFER) >50% of patients who smoke | 10 (6.1) | 29 (17.6) | 19/155 (12.3%) | <0.001 |
Attitudes towards the messages:
Table 3 shows that 71.5% of the respondents who received the messages admitted to having read them, either all the time or most times. A similar proportion (72.7%) acknowledged that the messages were helpful in increasing their knowledge; 87.9% reported that the messages had motivated them to practice the AAR. Messages seemed to have motivated more respondents to advise persons who smoke to quit (58.8%) compared to asking (52.7%) or referring (35.8%). Majority (84.8%) felt the frequency of the messages were “just adequate”
Table 3:
Attitudes towards the tobacco cessation promoting text messages
| Variable | Freq.(%) n=165 |
|---|---|
| Frequency of reading messages | |
| All/Most of the time | 118(71.5) |
| Sometimes | 33(20.0) |
| Rarely/Never | 14(8.5) |
| Physician acknowledged that: | |
| Messages increased my knowledge of tobacco cessation | 120(72.7) |
| Messages motivated me to practice the AAR | 145(87.9) |
| Messages increased the number of times I ASKED about tobacco use | 87(52.7) |
| Messages increased the number of times I offered BRIEF quit ADVICE to patients who use tobacco | 97(58.8) |
| Messages increased the number of times I REFERRED patients who use tobacco to a tobacco cessation clinic | 59(35.8) |
| Perception of the frequency of the messages | |
| Too much | 21(12.7) |
| Just adequate | 140(84.8) |
| Not enough | 4(2.4) |
DISCUSSION
Regardless of country-level development, evidence shows that brief advice from physicians provided opportunistically to persons who smoke can improve quit rates.7 We observed that sending simple 160-character messages was effective at raising awareness of the AAR approach to tobacco cessation and prompting physicians to practice them. These findings are consistent with studies, which suggest that text messaging with mobile phones can be a useful tool for behavioral change4, 8–11 We observed that the messages seemed to have a greater effect at increasing awareness compared with actual changes in practices. This is not surprising, as it may be easier for a simple unsolicited text messages to increase knowledge in cases where poor knowledge exists rather than improve practices. Observations from other studies have shown that in addition to awareness, organizational norms and perceived self-efficiency were implicated as influencing practices,12 however, our study explored only awareness creation which has most often been reported as a first step to improving practices and initiating behavioral change12,13
Low physician response rates were observed in our study, which could be attributed to individual personality traits or physician reluctance to accept changes that alter well-established practice patterns14 Previous studies have also observed that changing well-established physician practice patterns, even if accompanied by strong supporting evidence, is a very challenging task and as such, simply sending text messages to physicians’ mobile phones may not necessarily guarantee that the messages will be opened and read and even implemented. However, majority of the physicians who responded to this survey demonstrated a positive attitude towards the messages and a significant proportion acknowledged that they not only received the messages, but actually opened and read them most of the time. Several factors might influence physicians’ decisions to open and read such messages. For example, previous personal experiences with patients who are smokers may trigger a physician’s desire to improve his/her knowledge of tobacco cessation. Further research identifying the factors associated with physicians’ motivation to open, read and take action on receipt of text messages, and interventions to improve physicians’ attitudes towards informative work-related messages might be warranted.
This study has an important strength; to the best of our knowledge, it is the first study in Nigeria to describe and demonstrate the effect of text messages aimed at promoting brief intervention practices among physicians. However, the study also has several limitations and our findings should be interpreted with some caution. First, the response rates obtained from the online data collection tool were very low and persons who were more likely to be positively influenced by the text messages may have been more motivated to complete the survey. Therefore, the results might not be generalizable to the entire physician population in the studied area and might represent an over-estimation of the effect of the intervention. For example, 145/165 (87.9%) of the respondents reported that the messages had motivated them to practice the AAR. While this may seem like a majority, this actually represents only 15.3% i.e. 145/946 of the entire population of targeted physicians. Second, the findings may have been prone to recall bias, as is often the case when data is collected after an event has occurred. Third, this study did not focus on actual smoking cessation behaviors by patients who smoke, thus, it is not possible to determine whether these brief intervention practices actually led to increased smoking cessation rates. Nevertheless, these results do show that text messages should be considered as an approach to improve awareness of brief intervention for tobacco cessation among physicians.
Further research is needed to assess the effect of such messages on actual smoking rates of patients, including their use of behavioral or pharmacological tools to assist the quitting process. In addition, future research should assess more specifically how physicians respond to receiving unsolicited text messages, including their rates of reading them and more specific data on their attitude and behavior changes after receiving varying types and frequency of messages – including whether receipt of messages results in physician-driven changes in behavior by other cadre of health workers (e.g. nurses).
Conclusion:
Sending informative text messages to physicians are a low-cost way of promoting tobacco cessation awareness and practices among physicians. However, because of the low physician response rates obtained in this study, further studies are needed to explore the effectiveness of using unsolicited text messages as a communication medium for initiating behavioral change among physicians.
Acknowledgements:
Research reported in this publication was funded by the Pfizer Independent Grants for Learning and Change. Grant ID: 13503941. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.” The study was also supported by the Global bridges Network and the Fogarty International Center of the National Institutes of Health under Award Number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Acknowledgements and funding
This work was funded by the Pfizer Independent Grants for Learning and Change (Grant ID: 13509341) and supported technically by the Global Bridges Network. OO received support (protected time) for drafting this manuscript from the National Institutes of Health under Award Number K43TW010704. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
Declaration of Interests: None declared.
Contributor Information
Oluwakemi ODUKOYA, Department of Community health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos state, Nigeria..
Babalola FASERU, Department of Preventive Medicine and Public Health, and Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS, USA..
UGURU Nkolika, Department of Preventive Dentistry, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria..
JAMDA Mustapha, Department of Community Medicine, University of Abuja Teaching Hospital, Gwagwalada, Federal Capital Territory, Nigeria..
Olanrewaju ONIGBOGI, Department of Community health and Primary Care, College of Medicine, University of Lagos, Idi-Araba, Lagos state, Nigeria..
JAMES Oluwafunmilola, Breast Without Spot, Lagos, Nigeria.
Scott LEISCHOW, Mayo clinic, Arizona, USA.
Olalekan AYO-YUSUF, Sefako Makgatho Health Sciences University, Limpopo, South Africa..
References:
- 1.Fiore M Treating tobacco use and dependence: 2008 update: Clinical practice guideline. Diane Publishing; 2008. [Google Scholar]
- 2.Desalu OO, Adekoya AO, Elegbede AO, Dosunmu A, Kolawole TF, Nwogu KC. Knowledge of and practices related to smoking cessation among physicians in Nigeria. Jornal Brasileiro de Pneumologia. 2009. Dec;35(12):1198–203. [DOI] [PubMed] [Google Scholar]
- 3.Madaki JK, Gyang M, Salihu D, Ndam-Lar N, Malomo S. Ownership, knowledge, patient care cost and use of mobile cell phones by family physician resident doctors in Nigeria. Nig Med Pract. 2016;70(3–4):44–52. [Google Scholar]
- 4.Kurumop SF, Bullen C, Whittaker R et al. Improving health worker adherence to malaria treatment guidelines in Papua New Guinea: feasibility and acceptability of a text message reminder service. PloS one. 2013. Oct 7;8(10):e76578. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Githinji S, Kigen S, Memusi D, Nyandigisi A, Wamari A, Muturi A, Jagoe G, Ziegler R, Snow RW, Zurovac D. Using mobile phone text messaging for malaria surveillance in rural Kenya. Malaria journal. 2014. Dec;13(1):107. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Rimer BK, Glanz K. Theory at a glance: a guide for health promotion practice. U.S. National Cancer institute, Bethesda, Maryland, 2005:85–90 [Google Scholar]
- 7.West R, Raw M, McNeill A, Stead L, Aveyard P, Bitton J, Stapleton J, McRobbie H, Pokhrel S, Lester-George A, Borland R. Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development. Addiction. 2015. Sep 1;110(9):1388–403. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemed J E Health. 2009. Apr;15(3):231–240. [DOI] [PubMed] [Google Scholar]
- 9.Patrick K, Griswold WG, Raab F, Intille SS. Health and the mobile phone. Am J Prev Med.. 2008. Aug 1;35(2):177–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hall AK, Cole-Lewis H, Bernhardt JM. Mobile text messaging for health: a systematic review of reviews. Annu rev public health. 2015. Mar 18;36:393–415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med.2009. Feb;36(2):165–173. [DOI] [PubMed] [Google Scholar]
- 12.Egmond C, Bruel R. Nothing is as practical as a good theory, Analysis of theories and a tool for developing interventions to influence energy-related behavior (2007). www.cres.gr/behave/pdf/paper_final_draft_CE1309.pdf accessed 20/5/17
- 13.Ajzen I 1988. From intentions to actions: A theory of Planned Behaviour. In: Kuhl J and Beckmann (Eds.). Action-Control: from cognition to behaviour. Heidelberg, Germany: Springer, 11–39. [Google Scholar]
- 14.Klabunde CN, O’Malley MS, Kaluzny AD. Physicians’ reactions to change in recommendations of mammography screening, Am J Prev Med, 1997, vol. 13 (pg. 432–8) [PubMed] [Google Scholar]