Teaching Medical Students to Help Patients Quit Smoking: Outcomes of a 10-School Randomized Controlled Trial

Introduction to Tobacco Cessation and Motivational Interviewing: Evaluation of a Lecture and Case-Based Learning Activity for Medical Students

Introduction Despite the fact that tobacco use continues to have significant public health impacts, most healthcare providers are not adequately trained to counsel patients on their tobacco use or to provide cessation resources. Although all healthcare providers have a role in providing tobacco cessation assistance, physicians and advanced practice providers are generally the only practitioners able to furnish tobacco cessation medications and bill insurance for their cessation services. Therefore, ensuring these practitioners are properly trained to offer tobacco cessation to their patients is critical to addressing this public health threat. In line with this goal, this study outlines the curriculum evaluation for an innovative student-facilitated tobacco cessation activity for medical students. Methods A lecture and case-based learning activity was created and piloted with a class of first-year medical students. The activity was facilitated by fourth-year medical students. Students took a pre-session survey to establish baseline experience and beliefs and a post-session survey to ascertain their confidence in applying what was covered in the session. Descriptive statistics were utilized to analyze the data. Results One hundred and twenty-eight students completed both surveys. Prior to the activity, students reported low levels of confidence in their ability to counsel patients and knowledge of cessation resources. Following the activity, more than 90% reported improvement in their ability to assess a patient's willingness to quit and counsel those ready to quit. Greater than 80% reported an improvement in their ability to counsel patients not ready to quit and to establish a quit plan. More than 90% of students reported that the session increased their self-efficacy in helping patients quit and that it was worth their time, with 96% committing to increasing their tobacco cessation efforts with their patients. Discussion Students valued the training and almost all reported that it increased their ability to help patients quit smoking. The use of student-facilitated case-based learning provided both an opportunity for students to practice cessation techniques and a low-stakes introduction to the OSCE format without the need for extensive faculty resources. Although this session was run with first-year medical students, the curriculum presented can be used for residents, nurses, and other healthcare professionals.

Education for Tobacco Use Disorder Treatment: Current State, Evidence, and Unmet Needs

Background

Tobacco use is undertreated in the medical setting. One driver may be inadequate tobacco use disorder treatment (TUDT) training for clinicians in specialties treating tobacco-dependent patients.

Objective

We sought to evaluate the current state of TUDT training for diverse professionals and how these skills are assessed in credentialing exams.

Methods

We performed a focused review of current educational practices, evidence-based strategies, and accreditation exam contents focused on TUDT.

Results

Among medical students, participants in reviewed studies reported anywhere from 45 minutes to 3 hours of TUDT training throughout their 4-year programs, most often in the form of didactic sessions. Similarly, little TUDT training was reported at the post-graduate (residency, fellowship, continuing medical education) levels, and reported training was typically delivered as time-based (expected hours of instruction) rather than competency-based (demonstration of mastery) learning. Multiple studies evaluated effective TUDT curricula at varied stages of training. More effective curricula incorporated longitudinal sessions and active learning, such as standardized patient encounters or proctored patient visits. Knowledge of TUDT is minimally evaluated on certification exams. For example, the American Board of Internal Medicine blueprint lists TUDT as <2% of one subtopic on both the internal medicine and pulmonary exams.

Conclusion

TUDT training for most clinicians is minimal, does not assess competency, and is minimally evaluated on certification exams. Effective, evidence-based TUDT training incorporating active learning should be integrated into medical education at all levels, with attention paid to inclusion on subsequent certifying exams.

Adaptation, implementation, and evaluation of an online health sciences training program for brief smoking intervention: A pre-post study in four European countries

BACKGROUND

Tobacco cessation intervention has a positive impact on quality of care. For health professionals, limited competency in this area may be associated with poor training during their academic programs. There is a clear need to further develop and implement training programs to improve tobacco cessation knowledge, skills, and attitudes among healthcare students.

OBJECTIVES

The aim of this study was to assess the effectiveness of the innovative online training program "Brief Intervention in Smoking Cessation" for healthcare students to improve their knowledge, skills, and attitudes.

DESIGN

A pre-post evaluation study with a satisfaction assessment tool was used.

SETTING

Seven universities from four European countries, including Belgium, Portugal, Spain, and the United Kingdom, participated.

PARTICIPANTS

One thousand and seventy-two (1072) undergraduate students participated, with 851 completing the online program.

METHODS

All participants completed the "Brief Intervention in Smoking Cessation" online program, which consisted of five theoretical modules, five videos, and three virtual simulation cases between January 2020 and June 2022. Knowledge was assessed by a multiple-choice test, and practical skills were assessed by a simulation algorithm, both of which were developed by education and smoking cessation experts. Competency was achieved when students successfully completed both assessments. Satisfaction was measured using an ad hoc 16-item questionnaire. Pre-post changes in knowledge were assessed using a paired Student's t-test.

RESULTS

Eighty-six percent of the students achieved smoking cessation competency. Students significantly improved their knowledge score on a scale of 0 to 10 points, with a mean pre-program score of 3.79 vs a mean post-program score of 7.33 ([-3.7 - -3.4] p < 0.001), acquiring sufficient attitudes and skills (simulation mean of 7.4 out of 10 points). Students were highly satisfied with the program (8.2 out of 10) and recommended it to other students (8.4 out of 10).

CONCLUSIONS

The "Brief Intervention in Smoking Cessation" online training program is effective for the acquisition of smoking cessation competencies among European health profession students.

Tobacco Cessation Curriculum in Medical Schools: a Scoping Review

This scoping review aims to identify interventional training courses on tobacco cessation counseling skills of medical students, identify the most appropriate teaching method, and the ideal stage to provide such training. We retrieved articles published since 2000 from two electronic peer-reviewed databases (PubMed and Scopus) and hand-searched reference lists of selected articles. Articles published in English, with a clearly defined curriculum, reporting knowledge, attitude, cessation counseling skills of medical students post-training, and cessation-related outcomes of patients participating in student-led counseling sessions, were considered for inclusion. We used the York framework to guide this scoping review. First, data from studies meeting the inclusion criteria were charted using a standardized form. Subsequently, related studies were organized under three themes that emerged in the review process-lectured-based, web-based, and multi-modal curriculum. We concluded that a short but focused lecture-based curriculum combined with peer role-play or standardized/real patient interactions effectively develops the necessary knowledge and skills of undergraduate medical students to provide tobacco cessation counseling to patients. However, studies consistently report that the gains in knowledge and skills after cessation training is acute. Therefore, continued participation in cessation counseling and periodic review of cessation-related knowledge and skills post-training is warranted.

[Self-perception of smoking cessation skills among Cardiology residents in Argentina]

Objective

To evaluate the self-perception of cardiology residents in Argentina regarding their abilities to help their patients stop smoking, as well as their opinions about their knowledge and skills in this area.

Materials and methods

A cross-sectional study was carried out using secondary data from a study carried out in five Latin American countries and Spain, focusing on the information provided by cardiology residents in Argentina. Discrete variables were expressed as median and interquartile range, and categorical variables were expressed as percentages, and were analyzed using the chi-square test or Fisher's exact test, depending on the relative frequency of the expected values.

Results

447 residents participated; 87.5% routinely provided brief advice to quit smoking, and 11.6% used validated questionnaires to assess the degree of addiction. Furthermore, 32.1% stated that they prescribed pharmacological treatment, but 53.1% were only familiar with a single drug. When asked about their self-perception of getting their patients to stop smoking, the median response was 5 (scale from 1 to 10); only 13.7% responded with a score of 8 or more.

Conclusions

The present study suggests that cardiology residents in Argentina recognize the importance of carrying out smoking cessation interventions, but a high proportion of them do not feel qualified to do so.

Perceptions and preparedness toward tobacco cessation counseling amongst clinical medical students in Chongqing, Southwest China: A cross-sectional study

Background

Medical students play an indispensable role in providing smoking cessation counseling. Despite the rapid increase in tobacco use, there is little data on what Chinese medical students know or are taught about it. This study aims to investigate the relationship between medical students' tobacco education level, clinical experience, and tobacco cessation counseling (TCC) provided by medical students.

Methods

This cross-sectional study was carried out among clinical medical students of Chongqing medical university. An anonymous, self-administered questionnaire included items on demographic information, perceptions, and perceived preparedness, clinical medical students' self-reported level of education about alternative tobacco products, and traditional cigarettes. We assessed their perspectives toward TCC using a 5-point Likert scale. Descriptive and binary logistic regression analyses were carried out.

Results

A total of 1,263 medical students completed the questionnaire. The majority of students (85%) expressed a willingness to provide TCC to patients in need. However, only half of the students stated unequivocally that they knew some ways and methods of tobacco cessation, while 18% stated that they did not know methods of tobacco cessation. Tobacco education and clinical experience were significantly associated with the ability to provide TCC. Our findings revealed that students with more clinical experience (undergraduates: B = 0.326, P &lt; 0.001; postgraduates: B = 0.518, P &lt; 0.001) were significantly more likely to have a greater self-reported comprehensive ability to provide TCC.

Conclusion

Tobacco education and clinical experience can enhance the ability of medical students to provide smoking cessation counseling. There is a need to focus on alternative tobacco products with changing times, and curriculum planners should collaborate to incorporate comprehensive tobacco prevention and cessation training into the medical school curriculum.

Assessment of an intensive education program for pharmacists on treatment of tobacco use disorder using an objective structured clinical examination: a randomized controlled trial

BACKGROUND

Tobacco use is one of the major public health threats globally. Community pharmacists are uniquely positioned to offer tobacco cessation services owing to their easy accessibility by the public. To prepare Qatar community pharmacists to develop the competencies and skills required to offer smoking cessation services, an intensive tobacco control education program was designed and implemented. The study aimed to assess the impact of the tobacco education program on the pharmacists' skills and competence.

METHODS

A random sample of community pharmacists in Qatar was chosen for participation in the program. Consenting participants were randomly assigned to either intervention or control groups. The intervention group received an intensive education program on treatment of tobacco-use disorder, while a short didactic session on a non-tobacco-related topic was delivered to the control group. The pharmacists' tobacco cessation skills and competencies were assessed using an Objective Structured Clinical Examination (OSCE).

RESULTS

A total of 54 and 32 community pharmacists in the intervention group and the control group, respectively, completed the OSCE. The intensive tobacco education group achieved significantly higher total scores than the control group in all the OSCE cases. Specifically, the mean total scores for the intervention group were 15.2, 15.3, 14.2, 14.6, 16.3, and 15.2 compared to 8.8, 6.2, 7.7, 9.2, 8.3, and 11.3 for the control group (p < 0.001) for cases one to six respectively.

CONCLUSION

The study demonstrated that an intensive tobacco cessation education program can improve pharmacists' tobacco cessation skills and increase their tobacco cessation counseling abilities.

TRIAL REGISTRATION

Clinical Trials NCT03518476 ( https://clinicaltrials.gov/ct2/show/NCT03518476 ) Registration date: May 8, 2018.

Educational effectiveness of simulation in teaching health science students Smoking cessation: A Systematic Review

BACKGROUND

Simulation is one of the educational tools that can be used in the learning process to help with smoking cessation.

AIM

To synthesize all the publications studying the contribution of simulation as an educational tool in the acquisition of skills to help with smoking cessation.

METHODS

We performed a systematic review of the Francophone and Anglophone literature over the past 24 years (1997 to 2020) using the PubMed, Science Direct and Cochrane Library databases.

RESULTS

A total of 14 articles were included. The most used methods were thestandardized patient, role play and video projection with discussion. The simulation hasnot only proved its effectiveness in terms of acquiring knowledge and self-confidencein the management of the smoking patient in the short term, but also in the acquisition of verbal and non-verbal skills in the long term.

CONCLUSION

This review highlighted the interest of simulation as an educational tool to acquire skills to help with smoking cessation regardless of the method used.

Effectiveness of patient education training on health professional student performance: A systematic review

BACKGROUND

Despite the fundamental role of patient education, concerns have been raised by health professionals, students, and professional bodies regarding student preparation for this area of practice.

OBJECTIVE

To evaluate the effectiveness of patient education training on health professional student performance.

METHOD

A systematic search was performed across PubMed, Cinahl, Embase, and Cochrane Library. Reference and forward citation searches of included articles were conducted. Inclusion criteria were published journal articles from 2010 to 2020 regarding patient education training for health professional students with measures relating to patient education performance. Quality appraisal of individual studies was conducted using Cochrane risk-of-bias v2 or ROBINS-I; overall appraisal was also determined. Sixteen articles met eligibility criteria. Independent data extraction was undertaken.

RESULTS

Fourteen studies reported improvements in student performance following patient education training; two studies reported no significant improvements. Of different modalities examined, simulation-based learning appeared to be most effective.

CONCLUSION

Patient education training enhances health professional students' performance of patient education. Future research is needed to evaluate effectiveness of pedagogically informed interventions across health professions using objective approaches to assess student performance in clinically relevant settings.

PRACTICAL VALUE

This review supports the use of specific training approaches to improve student performance of patient education.

Teaching Medical Students to Help Patients Manage Their Weight: Outcomes of an Eight-School Randomized Controlled Trial

BACKGROUND

Given the rising rates of obesity there is a pressing need for medical schools to better prepare students for intervening with patients who have overweight or obesity and for prevention efforts.

OBJECTIVE

To assess the effect of a multi-modal weight management curriculum on counseling skills for health behavior change.

DESIGN

A pair-matched, group-randomized controlled trial (2015-2020) included students enrolled in eight U.S. medical schools randomized to receive either multi-modal weight management education (MME) or traditional weight management education (TE).

SETTING/PARTICIPANTS

Students from the class of 2020 (N=1305) were asked to participate in an objective structured clinical examination (OSCE) focused on weight management counseling and complete pre and post surveys. A total of 70.1% of eligible students (N=915) completed the OSCE and 69.3% (N=904) completed both surveys.

INTERVENTIONS

The MME implemented over three years included a web-based course, a role-play classroom exercise, a web-patient encounter with feedback, and an enhanced clerkship experience with preceptors trained in weight management counseling (WMC). Counseling focused on the 5As (Ask, Advise, Assess, Assist, Arrange) and patient-centeredness.

MEASUREMENTS

The outcome was student 5As WMC skills assessed using an objective measure, an OSCE, scored using a behavior checklist, and a subjective measure, student self-reported skills for performing the 5As.

RESULTS

Among MME students who completed two of three WMC components compared to those who completed none, exposure was significantly associated with higher OSCE scores and self-reported 5A skills.

LIMITATIONS

Variability in medical schools requiring participation in the WMC curriculum.

CONCLUSIONS

This trial revealed that medical students struggle with delivering weight management counseling to their patients who have overweight or obesity. Medical schools, though restrained in adding curricula, should incorporate should incorporate multiple WMC curricula components early in medical student education to provide knowledge and build confidence for supporting patients in developing individualized plans for weight management.

NIH TRIAL REGISTRY NUMBER

R01-194787.

Weight management counseling experiences of first year medical students before starting medical school and their self-perceived impact on treating patients with obesity

Physicians can play a vital role in counseling patients on overweight and obesity. This secondary analysis examined whether experiences in patient care specific to weight management before starting medical school were associated with students' intentions and confidence to provide weight management counseling (WMC) to patients who have overweight or obesity, and perceived impact as future physicians on patients' motivation to manage weight. First-year medical students (n = 1305) in the entering class of 2020 at eight medical schools nationwide completed questions relating to their prior experiences in patient care and WMC using the 5As. Also assessed were their intentions to treat patients with overweight or obesity, and confidence in counseling patients to help manage their weight. Over half the students (58.3%) who completed the survey had prior experience in patient care and nearly half (47.4%) began medical school with prior WMC experiences. Prior experiences correlated positively with higher confidence in performing WMC and students' intentions to treat patients with overweight or obesity. Given the relatively high rates of exposure to some type of weight management or lifestyle counseling among students before enrolling in medical school, the curriculum could build on established student interest and experience by offering treatment strategies including counseling for patients with overweight and obesity. By making prior experiences advantageous for admission, medical schools could gravitate towards admitting students who have brief but valuable insights about weight management in health care, thus increasing the possibility of filling important gaps.

Effects of education methods on self-efficacy of smoking cessation counseling among medical students

Background

Medical students need to receive training in providing smoking cessation counseling to provide effective smoking cessation interventions to smokers when they become doctors. This study examined the smoking cessation education curricula and factors affecting counseling self-efficacy (CSE) in smoking cessation treatment among medical students.

Methods

In a multicenter cross-sectional study, we obtained demographic information, personal history of tobacco use and intention to quit smoking, exposure to secondhand smoke in the school premises during the past week, the experience of learning about tobacco in each medical school, tobacco-related medical knowledge, and self-efficacy in smoking cessation counseling on medical students of four Korean medical schools.

Results

Among 1,416 medical students eligible, 313 (22.1%) students completed a self-administered questionnaire. Only 20.3% of the students reported positive CSE on smoking cessation. The factors affecting positive CSE were scores of ≥ 60 on tobacco-related medical knowledge, smoking experience, and blended learning (p = 0.014, 0.005, and 0.015, respectively).

Conclusion

This study shows that high scores in tobacco-related medical knowledge and blended learning are correlated with positive CSE for smoking cessation counseling.

Interventions for improving medical students' interpersonal communication in medical consultations

BACKGROUND

Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies.

OBJECTIVES

To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations.

SEARCH METHODS

We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students' interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE.

MAIN RESULTS

We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students' skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students' empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence).  Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students' overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported.  AUTHORS' CONCLUSIONS: This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students' behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Consensus Document on Medical Faculty Education on the Treatment of Smoking

We report the results of a consensus reached by an expert group of representatives from different medical societies in Latin America on the objectives, competencies (knowledge, and skills), content, and duration of smoking cessation education in Latin American medical schools. The document discusses the following aspects: epidemiology, nicotine dependence, factors for initiation and maintenance of tobacco use, smoking-related disorders, diagnosis, minimal intervention, non-pharmacological and pharmacological interventions for smoking cessation, and prevention of smoking.

Continuity With Patients, Preceptors, and Peers Improves Primary Care Training: A Randomized Medical Education Trial

PURPOSE

Infusing continuity of care into medical student clerkships may accelerate professional development, preserve patient-centered attitudes, and improve primary care training. However, prospective, randomized studies of longitudinal curricula are lacking.

METHOD

All entering Northwestern University Feinberg School of Medicine students in 2015 and 2016 were randomized to the Education Centered Medical Home (ECMH), a 4-year, team-based primary care clerkship; or a mentored individual preceptorship (IP) for 2 years followed by a traditional 4-week primary care clerkship. Students were surveyed 4 times (baseline, M1, M2, and M3 year [through 2018]); surveys included the Maslach Burnout Inventory (MBI); the Communication, Curriculum, and Culture (C3) survey assessing the hidden curriculum; and the Attitudes Toward Health Care Teams (ATHCT) scale. The authors analyzed results using an intent-to-treat approach.

RESULTS

Three hundred twenty-nine students were randomized; 316 (96%) participated in surveys. Seventy percent of all respondents would recommend the ECMH to incoming first-year students. ECMH students reported a more positive learning environment (overall quality, 4.4 ECMH vs 4.0 IP, P < .001), greater team-centered attitudes (ATHCT scale, 3.2 vs 3.0, P = .007), less exposure to negative aspects of the hidden curriculum (C3 scale, 4.6 vs 4.3, P < .001), and comparable medical knowledge acquisition. ECMH students established more continuity relationships with patients (2.2 vs 0.3, P < .001) and reported significantly higher professional efficacy (MBI-PE, 4.1 vs 3.9, P = .02).

CONCLUSIONS

In this randomized medical education trial, the ECMH provided superior primary care training across multiple outcomes compared with a traditional clerkship-based model, including improved professional efficacy.

Development and Validation of an Evaluation Tool to Measure the Effectiveness of a Smoking Cessation Training among Healthcare Providers in Malaysia: The Providers' Smoking Cessation Training Evaluation (ProSCiTE)

Background: In line with Article 14 of the Framework Convention for Tobacco Control, we have witnessed vast developments in smoking cessation training for healthcare providers, offering help for smokers. However, there is no specific evaluation tool to monitor and evaluate the effectiveness of these programs for future enhancement and sustainability. Objective: To develop and validate a new tool for evaluating smoking cessation training programs for healthcare providers called the Providers' Smoking Cessation Training Evaluation (ProSCiTE). Methods: The 74-item ProSCiTE tool was developed based on a review of the literature and an expert panel review. The tool was validated in a sample of 403 healthcare providers using a cross-sectional study design from July to December 2016. Content validity was assessed by the Scale-Content Validity Index (S-CVI). The construct validity of the ProSCiTE was analyzed using exploratory factor analysis (EFA) to confirm psychometric properties. Internal consistency reliability was determined using Cronbach's alpha. Results: The content validity showed that the S-CVI ranged from 0.82 to 1.00 for consistency, representativeness, relevancy, and the clarity of each construct, resulting in 67 items for the questionnaire. The construct validity of the ProSCiTE (based on eigenvalues and factor loadings to confirm the four-factor structure (attitude, self-efficacy, behavior, and barriers) with 54.74% total variance) was acceptable (Kaiser-Mayer-Olkin = 0.923; Bartlett's test of sphericity was significant, p < 0.001). The internal consistency reliability of the four-factor structure was very good, with Cronbach's alpha values at 0.89, 0.94, 0.95, and 0.90, respectively. Conclusions: This study showed that 67 items of the ProSCiTE demonstrated good content and construct validity, as well as a high internal consistency reliability for the measurement of knowledge, attitudes, self-efficacy, behavior, and barriers to smoking cessation interventions among healthcare providers. Therefore, the ProSCiTE is a valid and reliable research tool with which to evaluate the effectiveness of smoking cessation training programs.

Substance Use Disorder Education in Medical Schools: A Scoping Review

PURPOSE

As medical schools adapt their curricula to prepare future physicians for the opioid crisis and for treating patients with substance use disorders (SUDs), educators should refer to courses described in the literature. This scoping review aimed to (1) provide a comprehensive evaluation and summation of peer-reviewed literature reporting on SUD education in medical schools globally and (2) appraise the research quality and educational outcomes reported in SUD education studies in medical schools.

METHOD

The authors searched 6 databases (3 Ovid MEDLINE databases, Embase, ERIC, and Web of Science) from inception through May 25, 2018. Original English-language research studies focusing on medical students and describing SUD education in medical schools were included. The Medical Education Research Study Quality Instrument (MERSQI) was used to assess included studies.

RESULTS

Of 3,178 articles identified, 43 met inclusion criteria. Studies were conducted in 9 countries. Most reported on educational interventions for tobacco (n = 20; 47%); others reported on interventions for SUDs broadly (n = 15; 35%), alcohol (n = 8; 19%), and opioids (n = 1; 2%). The mean MERSQI score was 12.27 (standard deviation 2.30). Four studies (9%) reported on educational outcomes at the level of behaviors or patient or health care outcomes. The majority (n = 39; 91%) reported significant benefits.

CONCLUSIONS

Educational interventions relating to SUDs were effective in improving medical students' knowledge, skills, and attitudes. Educators should develop courses that achieve higher-level educational outcomes, increase education on opioid use disorders, and focus on the greatest public health concerns.

The Effectiveness of Tobacco Dependence Education in Health Professional Students' Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The objective of this study was to perform a systematic review to examine the effectiveness of tobacco dependence education versus usual or no tobacco dependence education on entry-level health professional student practice and client smoking cessation. Sixteen published databases, seven grey literature databases/websites, publishers’ websites, books, and pertinent reference lists were searched. Studies from 16 health professional programs yielded 28 RCTs with data on 4343 healthcare students and 3122 patients. Two researchers independently assessed articles and abstracted data about student knowledge, self-efficacy, performance of tobacco cessation interventions, and patient smoking cessation. All forms of tobacco were included. We did not find separate interventions for different kinds of tobacco such as pipes or flavoured tobacco. We computed effect sizes using a random-effects model and applied meta-analytic procedures to 13 RCTs that provided data for meta-analysis. Students’ counseling skills increased significantly following the 5As model (SMD = 1.03; 95% CI 0.07, 1.98; p < 0.00001, I² 94%; p = 0.04) or motivational interviewing approach (SMD = 0.90, 95% CI 0.59, 1.21; p = 0.68, I² 0%; p < 0.00001). With tobacco dependence counseling, 78 more patients per 1000 (than control) reported quitting at 6 months (OR 2.02; 95% CI 1.49, 2.74, I² = 0%, p = 0.76; p < 0.00001), although the strength of evidence was moderate or low. Student tobacco cessation counseling improved guided by the above models, active learning strategies, and practice with standardized patients.

Design and Validation of an Instrument to Evaluate the Learning Acquired by Nursing Students from a Brief Tobacco Intervention (BTI-St©)

The aim of this study was to design and validate an instrument, based on the WHO 5As+5Rs model, to test the acquisition by nursing students of a brief tobacco intervention (BTI) learning. A validation design of an instrument following the criterion referenced tests model using videos of simulated BTIs in the primary care setting was carried out. The study included 11 experts in smoking prevention/care and 260 second-year nursing students. The study was in two stages: (1) selection and recording of clinical simulations (settings), and (2) test construction. Content was validated by applying the Delphi consensus technique and calculating the Content Validity Ratio (CVR) and Content Validity Index (CVI). A pilot test was conducted for item analysis. Reliability was evaluated as internal consistency (Kuder-Richardson [KR-20]) and test-retest temporal stability (intraclass correlation coefficient [ICC]). Three simulation settings were recorded. An instrument (BTI-St^®) was developed with 23 items for dichotomous (yes/no) response. CVR was >70% for all items, KR-20 of 0.81-0.88, and ICC between 0.68 and0.73 (p < 0.0001). The BTI-St^® is a robust and reliable instrument that is easily and rapidly applied. It follows the WHO 5As+5Rs model and offers objective criterion-referenced evaluation of BTI learning in nursing students.

Learning to assist smokers through encounters with standardized patients: An innovative training for physicians in an Eastern European country

Objectives

A lack of physician training is a major obstacle for effective tobacco dependence treatment. This study assessed the feasibility of an active learning training program and its effects on smoking cessation counselling skills of medical residents in Armenia, an Eastern European country with high smoking prevalence.

Study design

The study used a pre-post assessment of smoking cessation counselling activities and a course evaluation survey to assess the feasibility of the intervention in a different environment.

Methods

We adapted an active learning training model developed in Switzerland. Residents were trained in Yerevan, Armenia, using video-taped counselling sessions, role plays, standardized patients (actors), group discussions and immediate feedback. The training evaluation was done using a semi-structured anonymous questionnaire. The study assessed the physicians’ self-reported smoking cessation counselling activities before and 6 months after the training. A non-parametric Mann-Whitney test was used to assess pre-post differences in physicians’ counselling skills measured on ordinal scale.

Results

Of the 37 residents trained, 75% were female, 89% aged 20–29 years and 83% were never-smokers. Twenty-eight trainees (76%) returned the course evaluation survey and 32 (86%) answered a questionnaire on skills self-assessment at 6 months follow-up. The majority agreed the course was successful in achieving its learning objectives (64%-96%) and increased their confidence in assisting their patients to quit (74%). After 6 months, the physicians were more likely than at baseline to adhere to evidence-based counselling strategies, including assessing the smoking status and dependence and matching the advice to the patient motivation. The training did not, however, improve the prescription of tobacco dependence medications.

Conclusions

Six months after the training, several self-reported smoking cessation counselling activities had significantly improved compared to baseline. This training model is acceptable for medical residents in Yerevan, Armenia and offers a promising approach in addressing the lack of physician counselling skills in similar settings and populations.

Empowering healthcare providers through smoking cessation training in Malaysia: a preintervention and postintervention evaluation on the improvement of knowledge, attitude and self-efficacy

OBJECTIVES

Healthcare providers are ideally positioned to advise their patients to quit smoking by providing effective smoking cessation intervention. Thus, we evaluate the effectiveness of a 1-day training programme in changing the knowledge, attitude and self-efficacy of healthcare providers in smoking cessation intervention.

METHODS

A prepost study design was conducted in 2017. The 8-hour Smoking Cessation Organising, Planning and Execution (SCOPE) training comprised lectures, practical sessions and role-play sessions to 218 healthcare providers. A validated evaluation tool, Providers' Smoking Cessation Training Evaluation, was administered to assess the impact of training on knowledge, attitude and self-efficacy on smoking cessation intervention.

RESULTS

After SCOPE training, the knowledge score increased significantly from 7.96±2.34 to 10.35±1.57 (p<0.001). Attitude and self-efficacy in smoking cessation intervention also increased significantly from 34.32±4.12 to 37.04±3.92 (p<0.001) and 40.31±8.61 to 54.67±7.45 (p<0.001) respectively. Pretraining and post-training scores improved significantly for all professions, and each measure, particularly self-efficacy.

CONCLUSION

This study demonstrates that SCOPE training could improve healthcare providers' knowledge, attitude and self-efficacy on smoking cessation intervention. Future training is recommended to equip healthcare providers with current knowledge, positive attitude and high self-efficacy to integrate what they have learned into practice successfully.

Group randomized trial of teaching tobacco-cessation counseling to senior medical students: a peer role-play module versus a standardized patient module

BACKGROUND

An important barrier to smoking-cessation counseling for physicians is a lack of education at the undergraduate level. Interactive methods such as peer role-play (RP) or modules utilizing standardized patients (SPs) may be effective for medical students to enhance their performance on tobacco cessation counseling. This study compared the effectiveness of a module using SPs to that of a RP module for undergraduate medical students on tobacco cessation counseling.

METHODS

This study was conducted over a single week of the family medicine clerkship. One hundred and thirteen fourth-year medical students were randomized into either the SP group or the RP group. A RP module involved a ten-minute encounter between the student doctor and the student patient followed by five minutes of feedback from the observer student using a group developed checklist. In a SP module, each student was asked to interview a SP portraying a smoker with willingness to quit. After the encounter, the SP provided five minutes of direct oral feedback to the student. In both modules, the total intervention lasted three-and-half hours and was supervised by faculty staff. Students' objective structured clinical examination (OSCE) scores were evaluated to determine their tobacco cessation counseling skills. Four evaluation periods were conducted at baseline, postintervention, post-clerkship, and before receiving the Korean medical licensing examination (KMLE). Students' smoking knowledge test scores and counseling self-confidence levels at pre- and post-intervention were also compared.

RESULTS

In both groups, post-intervention OSCE scores increased significantly compared to baseline (Cohen's d 0.87, p < 0.001 in SP group; d 0.77, p < 0.001 in RP group). However, there were no differences between the two groups. Students achieved the highest OSCE score for smoking-cessation counseling before the KMLE. After training, student self-confidence and smoking-knowledge test scores increased significantly, regardless of the type of module. Self-confidence was higher in the SP group compared with the RP group (d 0.37, p = 0.01).

CONCLUSIONS

Peer role-play may be equivalent to the SP method with regard to knowledge and skills reported during smoking-cessation counseling and SP method may be better in self-confidence. Cost and student self-confidence may be important factors when choosing among the teaching methods for smoking-cessation counseling.

Digital Education for Health Professions on Smoking Cessation Management: Systematic Review by the Digital Health Education Collaboration

BACKGROUND

Tobacco smoking, one of the leading causes of preventable death and disease, is associated with 7 million deaths every year. This is estimated to rise to more than 8 million deaths per year by 2030, with 80% occurring in low- and middle-income countries. Digital education, teaching, and learning using digital technologies have the potential to increase educational opportunities, supplement teaching activities, and decrease distance barriers in health professions education.

OBJECTIVE

The primary objective of this systematic review was to evaluate the effectiveness of digital education compared with various controls in improving learners' knowledge, skills, attitudes, and satisfaction to deliver smoking cessation therapy. The secondary objectives were to assess patient-related outcomes, change in health professionals' practice or behavior, self-efficacy or self-rated competence of health professionals in delivering smoking cessation therapy, and cost-effectiveness of the interventions.

METHODS

We searched 7 electronic databases and 2 trial registers for randomized controlled trials published between January 1990 and August 2017. We used gold standard Cochrane methods to select and extract data and appraise eligible studies.

RESULTS

A total of 11 studies (number of participants, n=2684) were included in the review. All studies found that digital education was at least as effective as traditional or usual learning. There was some suggestion that blended education results in similar or greater improvements in knowledge (standardized mean difference, SMD=0.19, 95% CI -0.35 to 0.72), skill (SMD=0.58, 95% CI 0.08-1.08), and satisfaction (SMD=0.62, 95% CI 0.12-1.12) compared with digital education or usual learning alone. There was also some evidence for improved attitude (SMD=0.45, 95% CI 0.18-0.72) following digital education compared with usual learning. Only 1 study reported patient outcomes and the setup cost of blended education but did not compare outcomes among groups. There were insufficient data to investigate what components of the digital education interventions were associated with the greatest improvements in learning outcomes.

CONCLUSIONS

The evidence suggests that digital education is at least as effective as usual learning in improving health professionals' knowledge and skill for delivering smoking cessation therapy. However, limitations in the evidence base mean that these conclusions should be interpreted with some caution.

TRIAL REGISTRATION

PROSPERO CRD42016046815; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=46815.

Students' Report of Preceptor Weight Management Counseling at Eight U.S. Medical Schools

INTRODUCTION

Primary care providers, using brief counseling, can help patients increase motivation to initiate or maintain weight loss, improve diet, and increase physical activity. However, no prior studies have examined the degree to which primary care preceptors, who are responsible for mentoring medical students during their core clerkships, provide clinical teaching regarding weight management counseling.

METHODS

Medical students enrolled in eight U.S. medical schools who had finished their preclinical coursework completed surveys in the spring of 2016 to assess preceptor communication, modeling, feedback, and instruction in weight management counseling, as well as educational cues for patients and chart reminders for physicians. Analysis was completed in 2017 and 2018.

RESULTS

Of 738 students completing the survey, the most recent completed clerkships were obstetrics and gynecology (38.1%), family medicine (32.1%), and internal medicine (29.8%). Students in family medicine clerkships reported higher levels of weight management counseling clinical teaching than students completing an internal medicine or obstetrics and gynecology clerkship. Among the main variables of interest across all three clerkships, only 13%-24% of students agreed that preceptors provided clear objectives for learning weight management counseling, and 13%-25% of students agreed that preceptors provided feedback.

CONCLUSIONS

Even with a U.S. Preventive Services Task Force recommendation for primary care physicians to provide weight management counseling and endorsement from the major academic primary care societies, students in primary care clerkships report receiving little weight management counseling clinical teaching from their preceptors. The results reinforce the need for medical educators to teach and model weight management counseling for physicians-in-training if they are to achieve Task Force goals. Further research is required to better corroborate self-reported indicators of preceptor to student communication that are described herein.

Prevalence of tobacco use and perceptions of student health professionals about cessation training: results from Global Health Professions Students Survey

INTRODUCTION

Health professionals play an important role in providing advice to their patients about tobacco prevention and cessation. Health professionals who use tobacco may be deterred from providing cessation advice and counselling to their patients. We aimed to provide prevalence estimates of tobacco use among student health professionals and describe their attitudes towards tobacco cessation training.

METHODS

Country-wise aggregate data from the Global Health Professions Student Survey on 'current cigarette smoking' (smoking cigarettes on 1 or more days during the past 30 days), and 'current use of tobacco products other than cigarettes' (chewing tobacco, snuff, bidis, cigars or pipes, 1 or more days during the past 30 days) were analysed. For each WHO region, we estimated mean prevalence rates of tobacco use weighted by the population of the sampling frame and aggregate proportions for 'health professionals' role' and 'cessation training' indicators using 'metaprop' command on Stata V.11.

RESULTS

A total of 107 527 student health professionals participated in 236 surveys done in four health profession disciplines spanning 70 countries with response rates ranging from 40% to 100%. Overall, prevalence of smoking was highest in European countries (20% medical and 40% dental students) and the Americas (13% pharmacy to 23% dental students). Other tobacco use was higher in eastern Mediterranean (10%-23%) and European countries (7%-13%). In most WHO regions, ≥70% of the students agreed that health professionals are role models, and have a role in advising about smoking cessation to their patients and the public. Only ≤33% of all student health professionals in most WHO regions (except 80% dental students in the Eastern Mediterranean region) had received formal training on smoking cessation approaches and ≥80% of all students agreed that they should receive formal cessation training.

CONCLUSIONS

Tobacco control should take place together with medical educators to discourage tobacco use among student health professionals and implement an integrated smoking cessation training into health professions' curricula.

A research coding method to evaluate a smoking cessation model for training residents-A preliminary report

OBJECTIVE

Develop a reliable coding method of a cigarette cessation model used to train residents - a preliminary report.

METHODS

Two trained (30h) undergraduates coded videotaped interviews from 161 resident-simulated patient (SP) interactions. To establish reliability, coders coded 33 (20%) of 161 study set tapes for the BHTM. Cohen's Kappa and percent of agreement were used to measure coders' reliability in unitizing and coding residents' skills for eliciting 5 variables: Educating, Informing, and Motivating (3 items); Commitment and Goals (3 items); Negotiate Plan (7 items); Patient-Centered Skills (9 items); Emotional Skills (6 items).

RESULTS

50 items were dichotomized a priori from analysis of the training model and were reduced to 28 during training. Kappa ranged from 0.73 to 0.87 for the 5 variables and 28 individual items. The overall kappa was 0.84, and percent of agreement was 93%. Percent of agreement by item ranged from 82 to 100%.

CONCLUSIONS

A highly reliable coding method, weighted (by no. of items) to highlight the key elements of the teaching, is recommended for investigators wishing to better focus on the partnership, emotions, and planning.

PRACTICE IMPLICATIONS

This is a unique way to integrate patient-centered skills into motivational interviewing.

Design and rationale of the medical students learning weight management counseling skills (MSWeight) group randomized controlled trial

Physicians have an important role addressing the obesity epidemic. Lack of adequate teaching to provide weight management counseling (WMC) is cited as a reason for limited treatment. National guidelines have not been translated into an evidence-supported, competency-based curriculum in medical schools. Weight Management Counseling in Medical Schools: A Randomized Controlled Trial (MSWeight) is designed to determine if a multi-modal theoretically-guided WMC educational intervention improves observed counseling skills and secondarily improve perceived skills and self-efficacy among medical students compared to traditional education (TE). Eight U.S. medical schools were pair-matched and randomized in a group randomized controlled trial to evaluate whether a multi-modal education (MME) intervention compared to traditional education (TE) improves observed WMC skills. The MME intervention includes innovative components in years 1-3: a structured web-course; a role play exercise, WebPatientEncounter, and an enhanced outpatient internal medicine or family medicine clerkship. This evidence-supported curriculum uses the 5As framework to guide treatment and incorporates patient-centered counseling to engage the patient. The primary outcome is a comparison of scores on an Objective Structured Clinical Examination (OSCE) WMC case among third year medical students. The secondary outcome compares changes in scores of medical students from their first to third year on an assessment of perceived WMC skills and self-efficacy. MSWeight is the first RCT in medical schools to evaluate whether interventions integrated into the curriculum improve medical students' WMC skills. If this educational approach for teaching WMC is effective, feasible and acceptable it can affect how medical schools integrate WMC teaching into their curriculum.

Medical student INtervention to promote effective nicotine dependence and tobacco HEalthcare (MIND-THE-GAP): single-centre feasibility randomised trial results

BACKGROUND

Although brief cessation advice from healthcare professionals increases quit rates, smokers typically do not get this advice during hospitalisation, possibly due to resource issues, lack of training and professionals' own attitudes to providing such counselling. Medical students are a potentially untapped resource who could deliver cessation counselling, while upskilling themselves and changing their own attitudes to delivering such advice in the future; however, no studies have investigated this. We aimed to determine if brief student-led counselling could enhance motivation to quit and smoking cessation behaviours among hospitalised patients.

METHODS

A mixed-methods, 2-arm pilot feasibility randomised controlled trial with qualitative process evaluation enrolled 67 hospitalised adult smokers, who were recruited and randomized to receive a brief medical student-delivered cessation intervention (n = 33) or usual care (n = 34); 61 medical students received standardised cessation training and 33 were randomly assigned to provide a brief in-hospital consultation and follow-up support by phone or in-person one week post-discharge. Telephone follow-up at 3- and 6-months assessed scores on the Motivation to Stop Smoking Scale (MTSS; primary outcome) and several other outcomes, including 7-day point prevalent abstinence, quit attempts, use of cessation medication, and ratings of student's knowledge and efficacy. Data were analysed as intention to treat (ITT) using penalised imputation, per protocol, and random effects repeated measures. Focus group interviews were conducted with students post-intervention to elicit their views on the training and intervention process.

RESULTS

Analyses for primary and most secondary outcomes favoured the intervention group, although results were not statistically significant. Point prevalence abstinence rates were significantly higher for the intervention group during follow-up for all analyses except 6-month ITT analysis. Fidelity was variable. Patients rated students as being "very" knowledgeable about quitting and "somewhat" helpful. Qualitative results showed students were glad to deliver the intervention; were critical of current cessation care; felt constrained by their inability to prescribe cessation medications and wanted to include cessation and other behavioural counselling in their normal history taking.

CONCLUSIONS

It appears feasible for medical students to be smoking cessation interventionists during their training, although their fidelity to the intervention requires further investigation. A definitive trial is needed to determine if medical students are effective cessation counsellors and if student-led intervention could be tailored for other health behaviours.

TRIAL REGISTRATION

NCT02601599 (retrospectively registered 1 day after first participant recruited on November 3rd 2015).

Smoking-Related Attitudes and Knowledge Among Medical Students and Recent Graduates in Argentina: A Cross-Sectional Study

BACKGROUND

Physicians in Argentina smoke at rates similar to the general population, and do not have a clear role in tobacco control strategies.

OBJECTIVE

To describe the attitudes and knowledge of medical students and recent graduates towards smoking behavior in Argentina.

DESIGN

Cross-sectional self-administered online survey conducted in 2011.

PARTICIPANTS

Medical students and recent medical graduates from the University of Buenos Aires.

MAIN MEASURES

Attitudes and knowledge were evaluated by responses to 16 statements regarding the effects of smoking cigarettes and the role of physicians in tobacco control. Rates of agreement with a full ban on indoor smoking in different public settings were assessed.

KEY RESULTS

The sample included 1659 participants (response rate: 35.1 %), 453 of whom (27.3 %) were current smokers. Only 52 % of participants agreed that doctors should set an example for their patients by not smoking, 30.9 % thought that medical advice had little effect on patients' cessation behavior, and 19.4 % believed that physicians could decline to care for smoking patients who failed to quit. In adjusted logistic regression models, current smokers had less supportive attitudes about tobacco control and were less likely than non-smokers to agree with a full indoor smoking ban in hospitals (OR: 0.30; 95 % CI 0.16-0.58), universities (OR: 0.55; 95 % CI 0.41-0.73), workplaces (OR: 0.67; 95 % CI 0.50-0.88), restaurants (OR: 0.42; 95 % CI 0.33-0.53), cafes (OR: 0.41; 95 % CI 0.33-0.51), nightclubs (OR: 0.32; 95 % CI 0.25-0.40), and bars (0.35; 95 % CI 0.28-0.45). Recent medical graduates had more accurate knowledge about cessation and were more likely to agree with a full smoking ban in recreational venues.

CONCLUSIONS

Although most participants reported a strong anti-tobacco attitude, a proportion still failed to recognize the importance of their role as physicians in tobacco control strategies. Current smokers and current students were less likely to support indoor smoking bans. Specific educational curricula could address these factors.

Tobacco intervention research in low- and middle-income countries: lessons learned and future directions

Treating tobacco dependence is paramount for global tobacco control efforts, but is often overshadowed by other policy priorities. As stated by Jha (2009), “cessation by current smokers is the only practical way to avoid a substantial proportion of tobacco deaths worldwide before 2050.” Its importance is codified in Article 14 of the Framework Convention on Tobacco Control (FCTC), and in the WHO's MPOWER package of effective country-level policies. Unfortunately, only 15% of the world's population have access to appropriate cessation support (WHO, 2015). Moreover, parties to the FCTC have implemented only 51% of the indicators within Article 14, on average, which is far lower than many other articles (WHO, 2014). Further, commenting on the use of “O” measures (Offer help to quit tobacco use) in the MPOWER acronym, WHO recently concluded, “while there has been improvement in implementing comprehensive tobacco cessation services, this is nonetheless a most under-implemented MPOWER measure in terms of the number of countries that have fully implemented it” (WHO, 2015). To the detriment of global tobacco control efforts, only one in eight countries provides comprehensive cost-covered services, only one in four provide some cost coverage for nicotine replacement therapy, and fewer than one third provide a toll-free quit line (WHO, 2015).