Evaluating an online training module on protecting children from secondhand smoke exposure: impact on knowledge, confidence and self-reported practice of health and social care professionals

Exposure to secondhand smoke (SHS) has been causally linked with a number of childhood morbidities including respiratory infections, asthma and middle ear disease [1]. In addition, children who regularly see their parents smoking are more likely to become smokers themselves [2]. Globally, 40 % of children under the age of 14 years are regularly exposed to SHS and of the annual deaths linked to exposure, 28 % occur in children [3]. Whilst children’s exposure to SHS in England has declined markedly in recent years, 39 % over half (52 %) of children who live with at least one smoker are still regularly exposed to SHS at home [4]. The most effective way to reduce SHS exposure in children would be to encourage their caregivers to quit smoking altogether. However, for those caregivers who are unable or unwilling to quit, the next best option is to promote harm reduction strategies such as supporting them to make their homes smoke-free. It is important that complete smoking bans are introduced in households with children, rather than partial bans (such as smoking in one room), as stopping short of making the home completely smoke-free is unlikely to have a significant impact on children’s exposure [5].

Health and social care professionals (HCPs) are in a unique position to offer help and support to parents to make their homes smoke-free [6]. Practitioners working with smoking families unequivocally accept that children’s exposure to SHS is harmful to their health [7] and have reported a desire to engage in protecting children from the harms of SHS exposure [8]. However, they also indicate that although the majority of them felt able to raise the issue of SHS, they lacked knowledge and skills, as well as confidence, in providing practical support to caregivers to reduce SHS exposure in the home [8]. A lack of training has been identified as the primary barrier for HCPs to raising the issue of SHS with smoking families [8]. Confidence in raising the issue of SHS is higher for practitioners who have received formal training around SHS [8], indicating that training is particularly important and is beneficial to both the HCP and to the families receiving the support. Parents in the CEASE (Clinical Effort Against Secondhand Smoke Exposure) trial reported an increase in the rates of HCPs asking about parental smoking and smoke-free homes following paediatricians’ participation in online training in two low income clinics in the USA [9]. A further HCP brief advice training intervention rolled out by NHS Greater Glasgow and Clyde in 2009 showed that training was effective in helping to increase HCPs knowledge and confidence in raising the issue of SHS and to offer smoking families advice based on the 5As brief intervention framework [10]. Whilst shown to be effective, the training involved attending a 4 h face-to-face session, which may be impractical to roll out on a wider scale.

Three key SHS related training areas have been identified for HCPs who work with smoking families: (1) knowledge of SHS and its effects on children’s health, (2) how to raise the issue with caregivers in a non-confrontational way and (3) practical advice and tools on how to support caregivers to reduce SHS exposure in the home. The National Centre for Smoking Cessation and Training (NCSCT) developed a free online training module, funded by the English Department of Health. Very Brief Advice on Secondhand Smoke [11] involves establishing if smoking occurs in the home and car, advising on the benefits of going smoke-free and offering help and support. The aim of the current study was to evaluate this training module by addressing the following questions: (1) does knowledge increase as a result of participating in the online training module, (2) does participating in the online training module impact HCP confidence and practice relating to SHS and promoting smoke-free homes, and (3) are these changes maintained over time?

Participation in the open access online training module significantly improved knowledge and increased confidence to deliver effective very brief advice for SHS for health and social-care professionals who work with smoking families, and these increases were maintained over the 3 month follow up period. Overall knowledge on how to deliver effective very brief advice for SHS was high for participants prior to enrolment in the training module. However, when knowledge was explored by the different components tested, it was apparent that whilst participants had good awareness of who should receive very brief advice for SHS and typical clients reactions to brief advice, they lacked knowledge about the dangers of SHS and found it difficult to understand what topics should be covered in a conversation around SHS and smoke-free homes with smoking families. This lack of knowledge was also reflected in reduced confidence in raising the issue of SHS and, in particular, in providing practical help and support around making changes to home smoking behaviour. These findings are in line with a previous survey of HCPs in Scotland who reported that whilst they felt able to raise the issue of SHS, they lacked knowledge and skills, as well as confidence, in providing practical support to caregivers to reduce SHS exposure in the home [8].

This novel training is one of very few, if not the only, freely accessible online modules available in the UK (and wider) to support professionals working with smoking families to deliver effective very brief advice for SHS. There is potential given that only a very small minority (~1 %) of the large number of people who visited the module homepage during the study period opted to participate in the evaluation, that the sample is biased towards more knowledgeable and motivated HCPs. In addition, it is important to note that visiting the module homepage may not reflect the actual number of people who completed the training thus the response rate reported may be an underestimate of the true response rate.

The low response rate and small sample size are clear limitations of the current study. However, it was evident that participants within this small sample did lack knowledge and confidence in providing very brief advice for SHS prior to taking the module. A further limitation of the study design was that the training software (which is now obsolete) did not allow us to report on whether any participants received the same questions at all three time points, nor on the relative difficulty of individual MCQs. Although it was not possible to compare participants with a control group of HCPs who did not participate in the training, it is reasonable to assume that the improvements in participants’ knowledge and confidence, and the fact these changes were maintained over time, were due to participation in the online training module. It is also important to consider that the assessment of knowledge and confidence used in the current study may not in reality reflect a family’s ability to make changes to their home smoking, or the likely success of any changes made in protecting children from the harms of SHS. Therefore, it would be helpful if future studies explored with families, who have received very brief advice for SHS from a HCP trained via this module, if they were able to initiate and maintain a smoke-free home. In addition, it would be helpful to explore if the cost of 30 min of HCPs time to complete the module is offset by a reduction in costs and burden of disease caused by exposure to SHS. Training in smoking cessation is sub-optimal in UK medical schools [15], in schools of nursing [16] and there is no evidence of training in SHS interventions. This study is the first of its kind to evaluate a SHS online training module and it in part answers recent calls for tobacco control training to be evidence-based and rigorously evaluated [17]. In fact this study, by following up participants at 3 months and enquiring about changes to clinical practice, goes beyond evaluation which just focuses on training content and delivery.

For the sample of HCPs who took part in the evaluation, knowledge and confidence to deliver effective very brief advice for SHS significantly improved following participation in the online training module and these increases were maintained for at least 3 months. Participation also led to self-reported positive changes in practice when working with smoking families. This novel training takes only 30 min to complete and is freely accessible to any health and social-care professional with access to the internet. There is potential for this module to be embedded within training programmes across health and social care professions, which may help to increase the knowledge and confidence of HCPs to deliver very brief advice for SHS to smoking families. Future research needs to explore whether the smoking families who receive very brief advice for SHS are motivated to make changes to their home smoking behaviours and whether roll-out of this intervention would be cost-effective.