|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 3 | Page : 169-175
Laying the groundwork for Tobacco Cessation Education in Medical Colleges in Indonesia
Yayi Suryo Prabandari1, Mark Nichter2, Mimi Nichter2, Retna Siwi Padmawathi3, Myra Muramoto4
1 Department of Public Health; Center for Health Behavior and Promotion, Faculty of Medicine, Gadjah Mada University, Indonesia
2 University of Arizona, School of Anthropology and College of Public Health, Tucson, USA
3 Department of Public Health, Faculty of Medicine, Gadjah Mada University, ; Center for Bioethics and Medical Humanities, Faculty of Medicine, Gadjah Mada University, Indonesia
4 Department of Family and Community Medicine, University of Arizona, Tucson, Arizona, USA
|Date of Web Publication||11-Mar-2016|
University of Arizona, Emil Haury Building, Tucson, Arizona
Source of Support: None, Conflict of Interest: None
Background: This paper describes a pioneering effort to introduce smoking cessation into Indonesia's medical school curriculum, and the first ever attempt to fully integrate tobacco control in all four years of medical school anywhere in Southeast Asia. The development, pretesting, and piloting of an innovative modular tobacco curriculum are discussed as well as the challenges that face implementation. Methods: In-depth interviews were conducted with medical school administrators and faculty in four medical colleges to determine interest in and willingness to fully integrate tobacco cessation into the college curriculum. A tobacco focused curriculum review, student focus groups, and a survey of medical students (n = 579) assessed current exposure to information about tobacco and interest in learning cessation skills. A modular tobacco curriculum was developed and was pretested, modified, piloted, and evaluated. Qualitative research was conducted to identify potential challenges to future curriculum implementation. Results: Fifteen modules were successfully developed focusing on the relationship between tobacco and specific organ systems, diseases related to smoking, the impact of tobacco on medication effectiveness, and information on how to explain to patients about effects of tobacco on their health condition. Lecturers and students positively evaluated the curriculum as increasing their competency to support cessation during illness as a teachable moment. Systemic challenges to implementing the curriculum were identified including shifts in pedagogy, decentralized curriculum decision-making, and frequent lecturer turnover. Discussion: A fully integrated tobacco curriculum for medical schools was piloted and is now freely available online. An important lesson learned in Indonesia was that a tobacco curriculum must be flexible enough to be adjusted when shifts in medical education take place. The curriculum is a resource for medical colleges and expert committees in Southeast Asia deliberating how best to address lifestyle factors undermining population health.
Keywords: Curriculum development, Indonesia, medical education, tobacco, tobacco cessation
|How to cite this article:|
Prabandari YS, Nichter M, Nichter M, Padmawathi RS, Muramoto M. Laying the groundwork for Tobacco Cessation Education in Medical Colleges in Indonesia. Educ Health 2015;28:169-75
| Background|| |
Smoking is a critical public health problem in Indonesia. The country ranks third in the world in the number of current smokers and smoking prevalence has been steadily increasing over the years. Current smoking prevalence is 67% among men and 4% among women. Not only is smoking ubiquitous among males in Indonesia, but initiation begins at an early age, with 18% reporting that they had begun smoking between the ages of 10 and 14 years. Among smokers in Indonesia, 85% of male smokers consume cigarettes in their homes, exposing family members to the harmful effects of secondhand smoke on a daily basis.
At present, little is being done in Indonesia to reduce smoking or to control the tobacco industry. Indonesia is the only country in Southeast Asia that has not signed the Framework Convention on Tobacco Control (FCTC). The medical profession has not been active in tobacco control, and survey data from central Java revealed that a majority of physicians (over 80%, n = 400) believed that smoking up to 10 cigarettes a day was not harmful for health. These physicians were less likely than their peers to assess patients' smoking behavior. The harm of secondhand smoke was likewise little recognized and rarely discussed in doctor-patient interactions.
It has been well established in Western Countries that in order for a downward shift in smoking to occur, healthcare providers must be at the forefront of cessation efforts. Not only do health care providers need to quit using tobacco themselves, but they also need to ask patients about their tobacco use as a routine part of medical assessment and advise them to quit. In order for this to occur, medical colleges need to play a more active role in providing tobacco education and teaching cessation skills to future generations of physicians. At present, this does not appear to be occurring in Indonesia. A survey of physicians in Java (n = 447) found that only 12% of medical school faculty, residents, and community physicians felt they had sufficient training or experience to help people quit smoking. Importantly, 80% said they were interested or very interested in receiving training in cessation counseling skills.
In this paper, we briefly discuss research undertaken by Project Quit Tobacco Indonesia (Project QTI) to establish the need for a more proactive tobacco curriculum in Indonesian medical colleges. We then describe the development and pretesting of an innovative modular tobacco curriculum developed by Project QTI following formative research in clinic and community settings in central Java., The curriculum was designed to fully integrate tobacco knowledge and cessation skills into all four years of medical school in a flexible manner. To our knowledge, this pioneering endeavor has not been attempted previously in Southeast Asia.
We describe the participatory process involved in developing, pretesting, and revising the tobacco curriculum in four medical colleges in Central Java and South Sulawesi. We draw attention to challenges faced given Indonesia's decentralized and fluid education system as well as emerging opportunities for tobacco education presented by the Medical Council of Indonesia's (MCIs) increased interest in lifestyle risk factors for non-communicable diseases.
The twin objectives of the Project QTI tobacco curriculum were to educate medical students about the impact of smoking on all organ systems and a broad range of diseases and to provide students with skills to conduct brief illness-specific tobacco cessation interventions. Formative research conducted by Project QTI suggested that until the Indonesian population understands far more about the wide range of harms associated with smoking, general cessation efforts are unlikely to succeed.
| Methods|| |
Gadjah Mada University in Yogyakarta, Java was selected as an initial site for research on tobacco education in Indonesia's medical colleges. It is one of Indonesia's most esteemed medical schools and attracts students from all over the country. We later partnered with three other public and private medical colleges that have different instructional formats to pretest educational materials developed for medical students. At the onset, we met with administrators from the Faculty of Medicine at the colleges, including the Dean and Vice Dean of Academic Affairs and members of the college curriculum committees, to gauge their interest in and willingness to participate in the project. While there was enthusiastic support in principle, we were told we would need to discuss all activities with block coordinators, who are a task force comprised of diverse faculty members in charge of the curriculum. We learned early on that we would also need to work with lecturers who taught particular classes.
Our first interest was to understand how much information about tobacco was currently being introduced in the medical curriculum, in what courses, and in what year of study. We reviewed the curriculum of Gadjah Mada University as an exemplar college, recognizing that the curriculum changes year to year in response to both the mandate of the MCI and the discretion of curriculum review committees and individual lecturers. In addition to a curriculum review, 10 lecturers from different departments were interviewed to gain a sense of their willingness to pretest and offer feedback on tobacco modules germane to their teaching areas. Five of the lecturers interviewed were smokers.
Eight focus groups (n = 6 persons per group) were conducted with third and fourth year medical students to assess their exposure to information about tobacco in the existing curriculum, and their interest in learning how to counsel patients about cessation. In addition to the focus group discussions, a cross-sectional survey of medical students was conducted (overall n = 579; 244 males, 335 females). Data was entered and analyzed using SAS version 9.1.
Based on the curriculum review, the project team developed tobacco modules with the consultation of the faculty. Module development followed an iterative process: Modules were pretested with students and faculty, revised based on feedback received, and then piloted in the medical colleges. After piloting, six focus groups (n = 48) were held with groups of students who agreed to provide feedback. Brief interviews were held with 20 of the 30 faculty members who had delivered the tobacco modules. In focus group discussions, students were asked questions assessing the following: Whether the content of the lecture was understandable; whether it provided new information; and whether they found the module interesting. Questions addressed to faculty assessed: Whether they thought the material in the lecture was important for students to learn; whether the material was appropriate for the academic level of the students; whether the speaker notes were sufficient for a lecturer who was a non-expert in the topic; and whether the supplementary readings provided were helpful as reference materials. All research activities were approved by the ethics board of the Gadjah Mada University.
| Results|| |
A review of the medical curriculum found that tobacco had been discussed as a risk factor for a limited number of diseases in lectures given on respiratory disease and public health. Overall, very little time had been devoted to the harms of tobacco in the four years of medical college. Notably, no training had been provided to medical students on how to talk to patients about smoking or how to assist them in their efforts to quit.
Interviews with lecturers revealed that messages given to students primarily focused on lung cancer and chronic lung disease with brief mention that smoking decreased immunity, was associated with allergies, harmed the circulatory system, and increased the chances of impotency. Disease-specific information provided to students was confined to the risk of contracting diseases. The impact of smoking on disease management was not covered. When asked about their future willingness to introduce tobacco modules covering the impact of smoking on organ systems and disease specific information in their teaching, eight out of ten lecturers interviewed felt that more evidence-based information on tobacco should be integrated into lectures, but two lecturers questioned why tobacco use should be a topic of special consideration. Lecturers who were non-smokers felt that doctors should be role models for their patients and should quit smoking, and that medical colleges should become smoke-free. Those lecturers who smoked were in support of the campus becoming smoke-free for students with the provision that smoking areas be provided for faculty.
The strongest advocates for introducing tobacco into the curriculum were lecturers from respiratory medicine, followed by public health and pediatrics. Eight of these ten lecturers felt that tobacco needed to be introduced at several points in the curriculum and not just at one time in order to be effective and be taken seriously by students. They also suggested that case scenarios be provided to reinforce the importance of tobacco facts and to give students an idea of how a doctor might talk to a patient about the harms of tobacco relevant to their health condition.
The two lecturers who were unconvinced that tobacco merited special attention were from the psychiatry and pharmacology departments. While one of two faculty members interviewed from the psychiatry department was in favor of using tobacco as an exemplar for teaching students about the process of addiction, a second psychiatrist was of the opinion that smoking was a useful coping mechanism for patients suffering from conditions such as anxiety, depression, and schizophrenia. He noted that in mental hospitals in Indonesia, patients are commonly offered cigarettes as a means of calming them, an observation confirmed during formative research. A lecturer from the pharmacology department was unaware of the impact of tobacco on drug effectiveness, and saw no link between tobacco and her subject area.
Seven lecturers from departments involved in clinical practice anticipated resistance from patients if doctors began questioning them about their tobacco use, given that smoking was a normative part of Indonesian culture. They foresaw difficulties in medical students talking to patients about quitting smoking unless the discussion was convincingly directed to a patient's current illness. Concern was expressed that doctors would not have enough time to counsel patients about quitting, although few had a sense of what counseling might entail beyond telling patients to quit smoking. All seven lecturers expressed concern about teaching students to “forcibly” ask patients to quit smoking as this would not be in keeping with the cultural pattern of non-confrontational and indirect communication common in Java.
In focus groups with students, participants joked that most of their general knowledge about tobacco and lung cancer, low birth weight, and impotency was gleaned from warning labels on cigarette packs. They noted that in classes they had received only general information about smoking as a risk factor for diseases. Several students thought that cessation messages were only relevant for those who smoked heavily for a long duration. When asked if they had received information on disease complications caused by smoking or how smoking interfered with the effectiveness of medications, none of the students could remember these topics being mentioned. They had not been taught how to counsel patients about quitting smoking and voiced concern that if they did, they would be asked to provide medications. On the other hand, several students expressed interest in learning how to better communicate with patients about the link between particular illnesses and smoking, especially if smoking could exacerbate the condition or impede the process of recovery.
On the medical student survey, 60% of students reported that current teaching on the harms of smoking was extremely limited and that they were poorly equipped to talk to patients about quitting. The survey also revealed that 11% of male medical students were daily smokers and another 36% occasional smokers.
Over an 18-month period, a transdisciplinary team of Project QTI researchers from India, Indonesia, and the United States reviewed evidence-based findings published in peer-reviewed journals to identify key facts to be incorporated in a set of educational modules to be tested in both countries. The main component of each module was a Power Point presentation of 20 to 30 slides focusing on the relationship between tobacco and a specific organ system, diseases related to tobacco use, the impact of tobacco on medication effectiveness, and a message calling for physicians to explain to patients how tobacco affected their health condition. Each slide was accompanied by speaker notes for the lecturer and three to four key articles were provided to further their knowledge base.
Initially, 10 modules were developed highlighting the effects of tobacco on the following: The cardiovascular system, respiratory system, gastrointestinal system, nervous system, reproductive system, musculoskeletal pain, endocrine problems, mental health, and tobacco and neoplasia. An overview module on tobacco as a global health priority, tobacco control strategies, and the state of tobacco consumption in Indonesia was developed for use by community medicine faculty and a module on basic cessation counseling skills was developed for a class on basic medical practice.
A complete module included the Power Point, fact sheets, case scenarios, and sample exam questions. Fact sheets were developed as a study guide, providing a summary of the most salient points contained in lectures. Case scenarios presented a common clinical case in which illness specific tobacco cessation advice was warranted. Case scenarios were designed to be used for both role play activities by students and brief cessation practice with professional patients.
Three tobacco modules (Basic Medical Practice, Cardiovascular Disease, and Respiratory Disease) were initially pretested at Gadjah Mada University and one other medical college in Yogyakarta as a means of checking whether the content of slides was comprehensible to students and acceptable to lecturers. Module pretesting was an iterative process requiring feedback from both students and faculty. Initial feedback indicated that all faculty were impressed with the breadth and depth of the presentations, and thought the level of instruction was appropriate. However, some faculty expressed concern about their length, given the amount of time they could allocate to tobacco in their classes. Some instructors also suggested that modules be broken up into mini-lectures that could be inserted into existing lectures, highlighting a few core tobacco related issues. Still others requested that slides capture main points but contain less information on each slide, and that fact sheets be translated into Bahasa Indonesia. Although we were told by project coordinators in all partner schools that slides in English would be understood by students, pretesting revealed that comprehension was better if the slides were translated. Faculty appreciated the speaker's notes and articles provided, stating that this gave them confidence to provide a lecture on a topic largely unknown to them.
Student feedback revealed that the information contained in the modules was new and essential to good medical practice given the high levels of smoking in the country. Students reported that the lectures were very interesting and that they provided them a heightened understanding of the role of tobacco in disease processes. They particularly appreciated case studies that illustrated how to engage patients and motivate them to quit tobacco. Given that not all lecturers had experience in teaching patient communication skills, both lecturers and students suggested that short brief intervention (BI) videos be created to model best cessation practices.
Developing the “Lego” approach
Based on feedback, we subdivided the modules into short mini-lectures comprised of four to seven slides. This gave lecturers the flexibility to either insert these smaller presentations into existing lectures, or string them together to form a single lecture. Each mini-lecture was composed of core message slides, country-specific data slides, and optional slides containing additional information. Mini-lectures were made available in English as well as Bahasa Indonesia. We also developed a series of 10 illness-specific BI training videos modeling the “5A's” approach to cessation. The modular “Lego” approach provides medical faculty with standardized curriculum building blocks packaged into easy to use modules, consisting of five parts: Mini-lectures, fact sheets, cessation videos, case scenarios, and exam questions. Like Legos, the pieces of the module can be fit together in a variety of ways to construct a tobacco training session [See [Figure 1]. It was left to each medical college and department to experiment with how best to assemble the Legos to fit the needs of their existing curriculum. Faculty were given the flexibility to choose when and how to utilize parts of a particular module, including when to present one or more mini lectures, discuss case scenarios, show the cessation videos, and so on.
Piloting the curriculum
Following modifications made after the initial pretest, modules were piloted by 30 lecturers working in the four medical colleges. Modules developed for classes on cardiovascular disease, respiratory disease, pediatrics, the endocrine system, the nervous system, and basic medical practice were piloted in several colleges while others were piloted in at least one medical college. Piloting served as a means of assessing both whether the level of instruction found in the module was appropriate and if the content was deemed accurate by faculty with expertise in particular areas of medicine. Feedback led to further revision of the modules. For example, one of the senior lecturers in respiratory medicine felt that the module he piloted needed to place greater emphasis on the fact that smoking not only led to COPD but worsened its progression, and that smoking among those with asthma reduced the efficacy of medications.
The lecturer evaluation revealed that they found the modules factually correct, clear, and appropriate for the level of instruction of their students. Lecturers teaching respiratory medicine, pediatrics, cardiovascular disease, reproductive health, the nervous system, and community medicine were particularly enthusiastic about adopting tobacco as an area for core competency training.
Student feedback obtained from six focus groups was equally positive. Students reported that the mini-lectures were clear, understandable, and interesting. Importantly, there was unanimous agreement that the mini-lectures increased their confidence to talk to patients about their need to quit smoking. Some students said they would like to see more diagrams illustrating the mechanisms by which tobacco affected particular organs. They also wanted to have more time to go over the material as some lecturers presented the slides quickly.
To address these issues, full modules were posted online both on the QTI website (www.quittobaccointernational.org) and on medical college websites, and additional diagrams were developed as optional slides. Students also expressed interest in learning more about emerging tobacco policy issues and tobacco regulations in their country. These issues were added to the modules developed for community medicine.
Linking knowledge about the harm of tobacco to cessation practice
The primary reason for exposing medical students to detailed knowledge about illness-specific and systemic harms of smoking was to support a tailored approach to smoking cessation. Students were encouraged to use illness episodes as teachable moments  for smoking cessation, and to establish the relevance of quit advice by drawing a link between smoking and the health condition suffered by a particular patient. In order for colleges to provide basic training in cessation skills, they first had to have skilled trainers. A training workshop was held and two faculty members from each of the four medical colleges attended. Training courses drew upon the past experience of Project Reach at the University of Arizona , and expertise in teaching the 5 A's (ask, advise, assess, assist, arrange), assessing stages of readiness to quit, and the 5 R's (relevance, risks, rewards, roadblocks, repetition) as a way of motivating patients who were reluctant to quit to consider doing so in the future. These methods were adapted for Indonesian culture based on the findings of several months of formative research.
Following an intensive two-day workshop, participating faculty members were asked to conduct 15 cessation interventions with patients and to fill out brief intervention (BI) logs documenting the skills they employed in their interventions and short notes on the patient's response. These logs were then submitted to Project QTI staff and formed the basis of a one-hour oral examination that both tested faculty members' knowledge and application of skills, and served as a one-on-one consultation related to problems encountered. Eight faculty members from four medical colleges and four non-medical Project QTI staff initially completed this test and received accreditation in basic cessation communication skills. A certificate was awarded by the University of Arizona.
The tobacco cessation curriculum designed for students exposes them to the 5 A's in the first year of medical college during a module on basic medical practice. They are then regularly exposed to examples of how to employ the 5 A's with different types of patients over the course of their medical education by watching short brief intervention demonstration videos and participating in role play activities in the skills laboratory. Ten videos and 15 case scenarios modeling doctor-patient cessation skills were produced in Bahasa Indonesia to be used by lecturers during classes or skill labs. These videos are available on the Project QTI website, allowing students to refer to them at their leisure.
Student feedback on the BI videos was very positive, with students noting that the videos made tobacco lectures livelier and better enabled them to understand how to conduct brief interventions. It was difficult, however, to provide them the opportunity to practice these skills with patients until their internship. Only one of the medical colleges (Gadjah Mada University) found a way to give students an opportunity to gain real world experience by offering cessation training as an elective in the third year. During this elective, groups of 40 students gained additional skills in how to assess a patient's readiness to quit, offer an appropriate assist response, and when appropriate employ the 5 R's to motivate patients who were either ambivalent about quitting or who faced significant physical, psychological, and social barriers to quitting. Based on the elective experience, a 90 minute training video broken down into six segments along with role play exercises was created as a resource for other medical schools to use in the future (see www.quittobaccointernational.org for both these materials).
| Discussion|| |
Several challenges will face those trying to integrate tobacco into Indonesia's medical curriculum, beyond the offering of a few lectures in community medicine or an elective that may be viewed as an “extra” subject. First is the challenge of a decentralized education system. While Indonesia has a national curriculum set by the MCI, each college has considerable freedom to implement the curriculum in Indonesia's decentralized education system. While some colleges (like Gadjah Mada University) followed a problem-based approach to learning at the time the QTI curriculum was piloted, other colleges followed a more conventional style of instruction or were in a period of transition from one pedagogical style to another. Then, toward the end of module piloting, the national curriculum shifted once more to competency-based learning. Tobacco education modules have to be flexible enough to adapt to such changes in curriculum design.
A second challenge is that decisions about a college's curriculum are made on a year-to-year basis and typically involve several stakeholders from a college-wide curriculum committee and block coordinators as well as heads of departments responsible for curriculum implementation and identifying which lecturer is assigned to teach particular classes. During pilot testing, we observed many changes as to when classes were taught and which lecturers were assigned to teach them. This made year-to-year continuity in implementation of our modules by the same instructor difficult. As a result, there is a large organizational burden on those tasked with scheduling and coordinating tobacco education activities.
A third operational challenge faced by medical colleges embracing problem-based learning is that this model significantly reduces the number of hours allocated to lectures. Lecture hours that remain are often assigned to senior lecturers who tend to teach the same lecture year after year. We found senior faculty reluctant to give up what they termed their “expert lectures” to younger faculty or to change the content of lectures much beyond adding a few slides. Junior lecturers were far more eager to employ our ready-made mini-lectures on tobacco, but they were not assigned the teaching hours to do so. As a result, only a few core slides from mini-lectures were inserted into “expert” lectures given by senior faculty. This makes posting fact sheets and educational videos on the internet for students to access all the more important. Also important will be finding more opportunities to introduce cessation skills outside the classroom.
A fourth challenge is that lecturers in Indonesia are typically given an honorarium for each lecture they deliver, in addition to their established salary. These payments are expected and an issue arose as to whether lecturers should also be paid for incorporating tobacco slides in their classes. If the goal is to mainstream tobacco education, then such payments may give the impression that tobacco is something extra and not a fundamental part of medical education.
A final challenge is how to gain endorsement for a tobacco curriculum by the MCI. This vanguard project provided evidence that integrating tobacco cessation into the existing medical curriculum is feasible and that a modular approach provides the flexibility needed for changes in pedagogical style that may occur. In 2012, the importance of advocating for “healthy lifestyles” was added to the national medical curriculum. It was also noted for the first time that students should gain clinical skills to help patients stop smoking. Thus, there appears to be a nascent movement acknowledging the importance of tobacco cessation education in medical education, although this has not yet been adopted in the country.
Overall, this paper describes a pioneering attempt to introduce smoking cessation into Indonesia's medical school curriculum, and the first ever attempt to fully integrate tobacco control in all four years of medical school anywhere in Southeast Asia. The curriculum is comprehensive as well as innovative in that it is based on formative research that suggests that cessation advice offered by doctors is far more effective when provided during illness as a teachable moment, and establishes relevance when advice is tailored to specific healthcare concerns. The curriculum that was developed, pretested, and piloted is modular and flexible enough to be adjusted to shifts in the way medical education is structured, and may be implemented in part or in its entirety. The modules are available at www.quittobaccointernational.org. It is our hope that the MCI will soon issue additional tobacco-specific recommendations for medical education in line with its increased interest in promoting healthy lifestyles. The experience of this study provides an evidence base for considering how to introduce tobacco cessation as a competency area in medical education.
| Acknowledgements|| |
The authors gratefully acknowledge support from the Fogarty International Center of the National Institutes of Health for research in India and Indonesia (RO1 TW007944). Faculty at other medical colleges involved with curriculum development included T. Hidayati, M.D., University of Muhammadiyah, Yogyakarta, Dr. Riana and Dr. Uma, Indonesian Islamic University, Yogyakarta and I. Aras, M.D., University of Hasannudin, Makassar, Sulawesi.
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