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  Table of Contents  
Year : 2020  |  Volume : 57  |  Issue : 3  |  Page : 296-310

Enhancing identification and counseling skills of dental undergraduate students using a customized Tobacco Counseling Training Module (TCTM) – A piloting of the process using ADDIE framework

1 Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, SS Nagar, Mysore, Karnataka, India
2 Department of Community Medicine, Believers Church Medical College and Hospital, St Thomas Nagar, Kuttapuzha, Thiruvalla, Kerala, India
3 Department of Microbiology, Melaka Manipal Medical College (Manipal Campus), Manipal, Udupi, Karnataka, India
4 Department of Community Medicine, PSG Institute of Medical Sciences, Coimbatore, Tamil Nadu, India
5 Oral Medicine and Radiology, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, SS Nagar, Mysore, Karnataka, India
6 Orthodontics, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, SS Nagar, Mysore, Karnataka, India

Date of Submission14-Mar-2019
Date of Decision17-Aug-2019
Date of Acceptance17-Aug-2019
Date of Web Publication20-Jul-2020

Correspondence Address:
B R Chandrashekar
Department of Public Health Dentistry, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, JSS Medical Institutions Campus, SS Nagar, Mysore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_229_19

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 » Abstract 

Background: Tobacco use has emerged as a major public health problem. But, most graduates in medical and dental schools receive limited systematic training. The objective of this education innovation project was to enhance dental undergraduate student's ability to identify tobacco users through oral manifestations and improve their counseling skills using a customized Tobacco Counseling Training Module (TCTM).
Methods: A TCTM for students of dentistry was developed using ADDIE framework as a guide. Content and construct validation of the module was done by six subject experts using Delphi technique for obtaining consensus. Pilot testing was done on 20 students of third year BDS. Pre- and post-intervention assessment of knowledge, attitude, self-confidence was done using learning outcomes questionnaire. Ability to correctly identify oral manifestations was assessed using extended item MCQs and tobacco counseling skills using a modified KEECC. The difference in mean scores were computed and subjected to further statistical analysis using SPSS version 22.
Results: There was a significant improvement in post intervention scores for mean knowledge (5.5 ± 1.4 to 13.2 ± 1.1), attitude (5.6 ± 0.9 and 8.5 ± 0.5), self-confidence (1.5 ± 0.5 and 3.1 ± 0.2), ability to correctly identify oral manifestations (5.2 ± 1.4 and 9.4 ± 0.8) and tobacco counseling skills.
Conclusion: It is possible to introduce the module in the existing curriculum and its effectiveness evaluation shows benefit in terms of Kirkpatrick's Level 1, 2, 3 (improvement in knowledge, attitude, self-confidence, ability to identify oral manifestations, and tobacco counseling skills) of training effectiveness.

Keywords: ADDIE model, Calgary-Cambridge counselling framework, dental students, process piloting, tobacco counseling, oral manifestations

How to cite this article:
Chandrashekar B R, Chacko T V, Anand K M, Suvetha K, Jaishankar H P, Suma S. Enhancing identification and counseling skills of dental undergraduate students using a customized Tobacco Counseling Training Module (TCTM) – A piloting of the process using ADDIE framework. Indian J Cancer 2020;57:296-310

How to cite this URL:
Chandrashekar B R, Chacko T V, Anand K M, Suvetha K, Jaishankar H P, Suma S. Enhancing identification and counseling skills of dental undergraduate students using a customized Tobacco Counseling Training Module (TCTM) – A piloting of the process using ADDIE framework. Indian J Cancer [serial online] 2020 [cited 2022 May 21];57:296-310. Available from:

 » Introduction Top

Tobacco use has emerged a major public health issue worldwide that has resulted in massive disability, disease, and death acquiring the dimension of an epidemic.[1] Smoking is a leading cause of preventable deaths across the nations. It is estimated that five million preventable deaths occur every year globally, attributable to tobacco use which is expected to double by 2020. Approximately one person dies every 6 seconds due to tobacco, accounting for one in 10 adult deaths. Nearly 80% of the more than one billion smokers worldwide live in low- and middle-income countries where the burden of tobacco-related illness and death is heaviest. Besides damaging personal health, tobacco use contributes to severe societal costs like reduced productivity, environmental damage, and poverty of the families.[2] India is the second largest producer and consumer of tobacco after China. More than one-third of adults use tobacco in India accounting for 275 million. Out of these 275 million users, 163.7 million consume smokeless tobacco, 69 million are smokers, and 42.3 million consume tobacco in both the forms.[3]

Medical and dental students upon graduation are often tasked with assisting to promote health and welfare of the population as part of the health system as well as for their individual patients. Literature suggests that most graduates in medical and dental schools worldwide receive limited training and are ill-equipped to treat tobacco dependence.[4] Although, Dental Council of India expects a dentist to identify a tobacco addict using oral manifestations and offer some basic counseling, there is lack of a structured training module in existing curriculum. Such a focused training to combat a common public health problem will also improve generic communication and health behavior counseling skill sub-components such as establishing rapport, focusing on affective behavioral issues, and cross-cultural communication. In this background, this education innovation intervention was undertaken to explore and test whether a systematic structured approach using a customized Tobacco Counseling Training Module (TCTM) will enhance dental undergraduate student's ability to identify tobacco users through oral manifestations of tobacco use and improve their skills in tobacco cessation counseling. The specific objectives of the study were:

  • To do learning needs assessment by assessing the learner's pre-intervention status of knowledge, attitude, ability of undergraduate dental students to correctly identify oral manifestations and skills in tobacco counseling, and identify the gaps in knowledge and practice against recommended Public Health Service's Clinical practice guidelines by US Department of Health and Human Services for tobacco cessation counseling [5]
  • To develop and validate a customized TCTM based on identified gaps in knowledge and practice and implement this intervention on a group of third year BDS students
  • To determine the effectiveness of TCTM on knowledge, attitude, ability of undergraduate dental students to correctly identify oral manifestations, and their skills in tobacco counseling following its implementation.

 » Methods Top

This education innovation project was carried out over a period of one year from June 2017 to May 2018 at JSS Dental College and Hospital, Mysore. Ethical clearance was obtained from the Institutional ethics committee on 23rd February 2017. A mixed method research design was adopted. A customized tobacco cessation counseling training module for students of dentistry was developed using ADDIE framework (Analyse, Design, Development, Implement, Evaluate), which is a useful tool for building effective training and performance support.[6],[7]

ADDIE step 1: Analyze (Learning needs assessment)

This was done using a combination of qualitative and quantitative research techniques. Training needs for a customized tobacco counseling module was identified using a pre-designed structured questionnaire on 10 undergraduate students, one focus group discussion (FGD) involving six interns, in-depth interview among two teaching faculty in Public Health Dentistry and four office bearers of Indian Association of Public Health Dentistry [Table 1]. FGD guide and in-depth interview guide were prepared. These were used by the principal investigator to elicit information on current practices of training students in tobacco counseling, perceived gaps in existing curriculum which needed to be addressed, the contents to be included while developing any such customized training module, method of teaching and evaluation to be adopted. The FGD and in-depth interview were audio recorded. An abridged transcript was prepared by listening to the tape of focus group and in-depth interview. Classical content analysis [8] method was used wherein we created smaller chunks of data and then placed a code with each chunk. These codes were then placed into similar groupings and counted. The frequency of each code (quantitative information) was supplemented with rich description of each code (qualitative information). Besides, five faculties in the department of public health dentistry were requested to participate in a free listing exercise where they enlisted all the important topics that in their opinion were to be included in training module. Summary of outcomes from needs assessment using FGD and in-depth interview is captured in [Table 2]. Key contents suggested by faculty during free listing were identified by card pile sorting. The needs analysis revealed that tobacco related topics were taught in bits and pieces in different specialty departments in dentistry and students found it difficult to integrate and apply what is being taught during real patient encounters. It was felt that there was a need for designing a structured training module to be taught by a multispecialty team. Teaching in such module should focus on tobacco trends and patterns, role of dentists in tobacco cessation counseling, scales for assessing tobacco dependence, behavioral theories that could be adopted for counseling, clinical tips for identifying and differentiating various oral manifestations in a tobacco user and a tobacco cessation counseling framework that could be used in dental clinical setup.
Table 1: Training Needs Assessment: Background of participants in focus group discussion, in-depth interview and free listing

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Table 2: Training needs assessment using focus group discussion and in - depth interview: Key findings

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ADDIE Step 2: Design (Module designing)

A framework for TCTM was designed by synthesizing inputs from learning needs assessment, free listing among faculty who suggested the contents for such module and through literature review. The module was designed to be spread over five sessions of 90 minutes each, and broad contents, structure, delivery methods, duration, assessment and feedback for each of these sessions were incorporated. The initial five modules focused on (1) global pattern, trends and impact of tobacco consumption, (2) role of health and oral health care providers in reducing the tobacco burden, (3) alarming oral manifestations suggestive of tobacco use and differential diagnosis of these manifestations, (4) introduction to behavioral theories and motivational interview, (5) tobacco counseling using “STAR with 5A and 5R approach” incorporated into Calgary— Cambridge communication skill framework. [9,10] This module was prepared for third year BDS students and can be implemented during clinical posting of students in Public Health Dentistry.

ADDIE Step 3: Development (Module Development)

Development Part 1: Development and validation of content and structure of modules 1 to 5

At this stage, a trainer's (facilitator's) guide and a guide for student on each session that contained the resource material with specific learning objectives, well-defined learning outcomes, the teaching methods to be adopted, a worksheet with small group activities incorporated, mode of assessment, and session feedback were prepared. The focus areas (contents) in five sessions of TCTM have been listed in step 2 above. The fifth session focused on tobacco counseling using “STAR with 5 A and 5 R approach”.[9],[10] The content knowledge base for the tobacco cessation was developed from “STAR with 5 A and 5 R approach” used by US Public Health Service which is popular among public health dentists.[5] Content and context validation was done by six subject experts locally. Delphi technique was used to obtain consensus on the contents from six subject experts.[11] Summary of output from Delphi technique is shown in [Table 3]. TCTM was shared with six subject experts and each subject expert was requested to provide their inputs on relevance, appropriateness and applicability of contents in each session using a predesigned content validation form. The experts were requested to suggest their recommendations for modifications, deletions and addition of contents of the module with justifications. After receiving replies from each expert, a summary was prepared based on their inputs for each session and this was shared with all the experts again for them to refine it further. Based on recommendations of experts following second round of communication, a summary with explanations for inclusion of contents in each session and their relevance, appropriateness and usefulness in enhancing the knowledge, attitude, and skills related to identification and counseling was prepared. This was shared with the subject experts and they were requested to express their views and refine it further to modify the same, if needed. All the six subject experts expressed their consensus on the output content at this stage.
Table 3: Summary of output from the Delphi technique

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Development Part 2: Development of module 6 (Tobacco counseling incorporated into Calgary—Cambridge communication skill framework)

When the above mentioned training modules were shared with faculty mentor who was an expert in medical education, it was suggested to incorporate contents of “STAR with 5 A and 5 R approach” into the Calgary—Cambridge communication framework [12] to enable the students to engage in deliberate practice of tobacco counseling and receive feedback to improve performance. This necessitated the inclusion of sixth session of 120 minutes into the module. Addition of sixth session into the module necessitated revalidation of contents to make subject experts understand the importance of incorporating Calgary—Cambridge communication framework. But, three out of six subject experts who validated TCTM, initially, were out of country at that time. TCTM was supposed to be implemented in the institution within a week's time according to calendar of events in the department. Conventional process of reaching consensus on inclusion of sixth session using Delphi would have taken more time with no real time interaction. So, we tried a combination of WhatsApp and mobile conference call to get all these subject experts in different time zones to discuss the project synchronously. A WhatsApp group of all subject experts and moderator was created. An article that described the process of fitting Calgary-Cambridge framework to tobacco counseling was shared in group.[1] Subject experts were requested to post their comments in the WhatsApp group after referring the article. Some experts expressed diverging opinions on inclusion of sixth session to an already validated module. To explain the rationale and to reach consensus on revised module, mobile conference call was thought about. Mobile conference call following initial discussion using WhatsApp provided quick and timely interaction on diverging opinions. Queries raised by some experts were replied by either moderator or other subject experts. We were able to arrive at consensus in 25 minutes on revised contents, teaching plan for each session and evaluation tools for all the six sessions. As a result of all these processes, “The modified CALGARY – CAMBRIDGE communication framework for tobacco counseling” was developed and is shown as [Annexure 1].[Additional file 1]

ADDIE Step 4: Implementation

The module containing five sessions of 90 minutes each and an additional session of 120 minutes for deliberate practice and evaluation of tobacco counseling pilot tested on twenty students of third year BDS in May 2018 on six consecutive days during clinical postings in Public Health Dentistry. Third year BDS students were divided by institution authorities into 10 clinical batches. Each batch had approximately 10 students. Two batches were selected out of 10 batches using lottery method for this pilot study and this constituted 20% of students in the batch. The flow chart of these sessions in TCTM is attached as [Annexure 2] which provides an overview of sequencing, contents and lesson plan for each session. TCTM was implemented by a multidisciplinary team comprising of faculty from Public Health Dentistry, Community Medicine and Oral Medicine. Faculty selection for the multidisciplinary team was made by HOD of Public Health Dentistry based on interest of faculty in tobacco intervention and their availability to offer training in a sustained manner for subsequent years as well. Moreover, these faculties were also suggested by interns to be included in the multidisciplinary team for training on tobacco counseling during FGD. Students and faculty orientation was conducted before initiating the training module. These sessions incorporated a combination of various teaching methods like initial brainstorming, lectures using PowerPoint, videos, experience sharing, quiz, small group activities, role playing, etc.[Additional file 2]

ADDIE Step 5: Evaluation

To evaluate the effectiveness of the intervention (TCTM), a questionnaire was developed for assessing knowledge, attitude and self-confidence in tobacco counseling. MCQs with extended items were used for assessing the ability to correctly identify oral manifestations. An initial Learning Outcomes Questionnaire (LOQ) for assessing knowledge, attitude, and self-confidence in tobacco counseling was prepared using expert inputs and literature review. This LOQ had 30 items for assessing knowledge, 15 items for assessing attitude and 10 items for assessing self-confidence. The LOQ was communicated to six subject experts along with a content validation form. Each expert was requested to rate the relevance, appropriateness and clarity of each item on a five-point Likert scale with 1 being least favorable response to 5 being highly favorable response. Fourteen items from knowledge, 5 items from attitude and 4 items from self-confidence were deleted from the original questionnaire due to redundancy, lack of relevance and appropriateness. The final LOQ had 16 items for assessing knowledge, 10 items for attitude and 6 items for self-confidence. The initial tool for assessing ability to correctly identify oral manifestations had 17 items. During validation from six subject experts, three items were deleted due to redundancy, two for not being relevant and two for not being appropriate. Final tool had 10 extended item MCQs. Cognitive interview was conducted to assess the response process validity of these tools among ten final year BDS students. Known group validity of LOQ was assessed by using this questionnaire on three final year BDS students, three interns and three postgraduate students from Public Health Dentistry. Each correct response was given a score of one while incorrect response was scored zero. The total score for knowledge (score range 0–16), attitude (score range 0–10), and self-confidence (score range 0–6) in tobacco counseling was computed for each participant. Extended item MCQs was administered to three final year BDS students, three interns and three postgraduate students from Oral Medicine to assess known group validity. Tobacco counseling skills was assessed during role play by students in the sixth session using a modified Kalamazoo Essential Elements Communication Checklist (KEECC).[13] Here, students were divided into triads where one student acted as a tobacco user while others acted as doctor and recorder. This (formative assessment) was repeated till each student completed all three roles. However, score given by the observing trained faculty (summative assessment) was considered for statistical analysis on effectiveness of the TCTM. Reliability assessment of the tools for knowledge, attitude, self-confidence and ability to identify oral manifestations was done on 10 students using test-retest method.

Pre-intervention knowledge, attitude, self-confidence, ability to correctly identify oral manifestations and their skills in tobacco counseling was assessed before implementation of module on twenty students of third year BDS and post-intervention assessment was done following its implementation. The difference in mean scores were computed and subjected to statistical analysis using SPSS version 22 (IBM, Chicago, USA). Student and faculty satisfaction was collected using a pre-designed satisfaction survey questionnaire on 5 faculty and 20 students. Paired sample t-test was used for comparison between pre and post-intervention values while calculating the effect size. McNemar's Chi square test was used for comparing frequencies and percentages before and after implementation of module.

 » Results Top

Validity testing of the tool used. The scale level content validity index for evaluation tools assessing knowledge, attitude, self-confidence and ability to identify oral manifestations was 1.0. Cronbach's alpha values indicating the intra examiner reliability score for the tools evaluating knowledge, attitude and self-confidence, and ability to identify oral manifestations were 0.98, 0.96 and 0.97 respectively.

In known group validity assessment, knowledge, attitude and self-confidence, ability to identify oral manifestations scores were higher for postgraduate students followed by interns while being least for the fourth year BDS students [Table 4].
Table 4: Summary of validity and reliability of Learning Outcomes Questionnaire (LOQ) and extended item MCQs used for assessment of knowledge, attitude, self - confidence and identification skills

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Effectiveness of the Intervention (TCTM) in terms of Student learning i.e., Kirkpatrick level 2 of Training program evaluation: This is shown by the mean knowledge score increasing from 5.5 ± 1.4 to 13.2 ± 1.1 suggesting a significant improvement (t = 16. 9, P < 0.001, Effect size: 1.33). The mean attitude and self-confidence scores at pre-intervention were 5.6 ± 0.9 and 1.5 ± 0.5 respectively and they changed to 8.5 ± 0.5 and 3.1 ± 0.2 post-intervention. The difference was statistically significant for attitude (t = 16.5, P < 0.001, Effect size: 0.52) and self-confidence (t = 13.5, P < 0.001, Effect size: 0.34). Mean scores for identification of oral manifestations at pre and post-intervention were 5.2 ± 1.4 and 9.4 ± 0.8 with the difference being statistically significant (t = 12.8, P < 0.001, Effect size: 0.98) [Table 5]. With regard to tobacco counseling skills, none of the students did well during pre-intervention assessment while it increased to six (30%) after intervention. The positive change in their communication skills was statistically significant (X 2 Value: 11.7, P value: 0.001) [Table 6].
Table 5: Effectiveness of the TCTM intervention (knowledge & attitude)

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Table 6: Effectiveness of the TCTM intervention (tobacco counseling skills)

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Effectiveness of the intervention (Student and Faculty reaction i.e., Kirkpatrick level 1 of training program evaluation): All five faculty (100%) and 15 students (95%) felt that the program was very much relevant and highly appropriate [Table 7]. The faculty also offered some specific suggestions for implementation of the training module to make the program even better.
Table 7: Effectiveness of the TCTM (student and faculty reaction)

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 » Discussion Top

Tobacco use has become a common contributor to premature death and disability.[14] Learning counseling skills that facilitate behavior modification is one of the essential skill expected of a competent health care professional. These behavior interventions are beneficial in changing the life course of a tobacco consumer/addict that will have several social, economic and health related benefits to the individual, family and society as a whole.[14],[15]

Literature indicates that health care professionals can learn tobacco cessation counseling skills to improve patient outcomes.[16],[17],[18] Literature also suggests that there is lack of structured training program in tobacco counseling for medical and dental undergraduates in the existing curriculum.[19] Dental undergraduates are in a strategic position to identify a tobacco user through oral manifestations and offer tobacco counseling. Dental Council of India also expects a graduating dental student to undertake tobacco counseling among patients with tobacco habits. It was evident in needs assessment undertaken in the present study that the existing curriculum does not have structured training program for training dental undergraduate students in tobacco counseling. It was realized during focus group discussion among interns that some topics related to tobacco habits, pattern of tobacco use, oral manifestations in a tobacco user and brief counseling was taught by different specialty departments. But, this compartmentalized training was not useful as many of them could not connect between what is being taught and its application in their routine practice. It was apparent after needs assessment that there was a need for a customized tobacco counseling training module for dental undergraduate students to enhance their skills in the identification of oral manifestations in a tobacco user followed by counseling. Hence, in response to this need, the TCTM was developed and tested on a group of third year BDS students. In BDS curriculum specified by Dental Council of India, a dental undergraduate student enters clinical postings in third year of BDS program. We introduced TCTM of six sessions as an introductory module on tobacco counseling for students entering the clinical settings. It was evident in the literature that early training on promotion of behavior change among medical students facilitated better acquisition and application of tobacco intervention skills.[19] The early exposure resulted in promoting a sense of belonging and provided usefulness in clinical environments. Moreover, early exposure of students to TCTM was intended to create a sense of responsibility among students as soon as they enter clinicals to make them realize the importance of identifying tobacco addicts using oral manifestations and also to highlight the importance of early intervention to make these addicts quit the habit. This was somehow not given due importance while eliciting case histories of patients by dental undergraduate students as noted during needs assessment. However, the training module is designed in such a way that this foundation course of six sessions in third year will be followed by three session's module to be undertaken among final year BDS students and one hour refresher session for interns. The modules for final year BDS students and interns have been developed and validated, but, are yet to be implemented in a sequential manner by a multispecialty team. This pilot study evaluated the effectiveness of TCTM on Kirkpatrick level 1 (reaction) and level 2 (learning). Here, the evaluation of knowledge, attitude and self-confidence was done using LOQ, extended item MCQs with clinical vignettes were used to assess ability to correctly identify the images of oral manifestations projected on a screen on a random basis. Here, the counseling skills were assessed while the students practiced it through role plays. However, in final year BDS and during internship, the evaluation of counseling is proposed to be undertaken using standardized patients and real patients, respectively. The sequencing of training module initially from third year BDS and extending into their final year and internship was thought to provide reinforcement at regular intervals throughout their curriculum to achieve optimum results. The first session on global pattern, trends and impact of tobacco consumption was incorporated to provide an overview on the tobacco consumption pattern and recent statistics on tobacco usage around the world and in India. It was realized through feedback after the session that many students were not even aware about facts on tobacco presented in the session. This session was included to enhance their knowledge on tobacco burden while motivating them to consider tobacco counseling as an important aspect in their clinical practice. Second session focused on role of health and oral health care providers in reducing tobacco burden and also provided some practice on assessing tobacco dependence using Fagerstorm scale among smokers and smokeless tobacco users. The intension of this session was to make participants realize the fact that dentists are in a key position to motivate patients to quit tobacco. Third session focused on alarming oral manifestations in a tobacco user and their diagnosis. It was included to provide clinical tips for identifying oral manifestations in tobacco user and their differential diagnosis. This was also one of the skills expected to be enhanced through TCTM. Fourth session focused on introduction to behavioral theories and motivational interview. It was expressed by the students during learning needs assessment that they are not aware of any behavioral theories which they could apply for lifestyle and behavior management. This, in fact was the rationale for inclusion of this session. The session was included to provide brief overview on most commonly used theories for behavior modification in medical profession. It was felt necessary to provide some knowledge to the students on various stages of change a person goes through during behavior modification which could be applied for other clinical purposes as well. Fifth session focused on tobacco counseling using expanded Calgary - Cambridge communication skill framework. Inclusion of communication skills framework in the module was done to make students to understand the importance of communication in motivating a person to adopt healthy lifestyle. Students expressed in their feedback that this session specifically helped them to understand the key components of communication in medical case history taking which was not known to them previously. Students expressed their willingness to adopt these key components in their routine clinical encounters as well besides tobacco counseling. The additional session of 120 minutes provided an opportunity for deliberate practice of tobacco counseling through role plays and also to evaluate student's performance in tobacco counseling in a simulated setting. Students expressed in their feedback that they enjoyed this session and also learnt their mistakes when their own batchmates identified the aspects that were done well, not done well or those that required improvement using a checklist. Besides, the feedback by faculty on individual student's performance also was appreciated by the students.

There was a significant increase in the knowledge, attitude and self-confidence of students towards tobacco counseling following implementation of TCTM. This could be attributed to focused and relevant topics being covered in one stretch by a multispecialty team. Some students have expressed in their feedback that the mode of training which included initial brainstorming, lectures, video demonstrations, experience sharing, interactive group discussion and small group activities were interesting and kept them engaged throughout the sessions. These results were similar to the findings of a study by Brown RL et al.[19] who in their study assessed whether a curriculum on tobacco intervention could garner student acceptance; improve relevant knowledge, attitudes, and self-confidence; and be applied in students' early clinical experience. They found significant improvement in all these attributes following implementation of Tobacco Intervention Basic Skills curriculum (TIBS). Ahmadian M et al. in their study compared the effectiveness of two educational methods in teaching tobacco cessation counseling (TCC) in dental practice for senior dental students.[20] They found both role play (RP) and problem-based learning (PBL) methods to be effective in enhancing the knowledge, attitude, and skill of the participants. Ability to correctly identify oral manifestations also improved significantly following implementation of training module. The session that specifically focused on clinical presentation of most common oral manifestations in a tobacco user and pathophysiology of these lesions which was taught by an expert in oral medicine was appreciated by the students. It was their perception through feedback that this session helped them in enhancing their ability to correctly identify these lesions while differentially diagnosing them. Students practiced counseling using a modified Calgary—Cambridge communication skill framework that incorporated STAR with 5A and 5R approach content for reference during deliberate practice using role plays. The counseling in practice sessions facilitated self-improvement through deliberate practice using role play in triads of students where one student acted as patient, one student as a doctor and other as an observer followed by feedback by observing faculty. This session of deliberate practice gave each student an opportunity to undertake counseling in a simulated setting. Students perceived that role play enabled them in understanding the sequence of communication contents to be followed during counseling process while they got exposed to the checklist used for evaluation during such counseling sessions. During this deliberate practice, one student who acted as evaluator was given the modified Kalamazoo Essential Elements Communications Checklist to evaluate the performance of the student who was acting as doctor. This gave an opportunity for students to understand how communication during a clinical encounter will be assessed using standard checklist. This modified evaluation checklist is attached as [Annexure 3]. It was found that their counseling skills improved with 30% of the students performing well following implementation of TCTM compared to none of the students before the intervention. Fernandes K et al. in their study to enhance communication skills of MBBS (Bachelor of Medicine and Bachelor of Surgery) students in counseling of tobacco users by using interactive teaching methods found role play, interactive session, anecdotes to play a vital role in improving their counseling skills.[21] Gordon JS et al. in their study found an innovative and interactive CD-ROM tobacco cessation training program to be effective in enhancing the knowledge level and attitudes of 47 third-year dental students and 30 dental hygiene students.[22] Faculty and students in our study also expressed complete satisfaction on the course content and method of teaching adopted. Faculty expressed their desire to incorporate this into the existing dental curriculum at the institution level. Davis JM et al. in their study to evaluate the effectiveness of a peer-reviewed tobacco curriculum (Tobacco Free! Curriculum) found an average increase in the amount to time spent by faculty on tobacco education. There was an increase of 85 minutes on tobacco education in dental hygiene curriculum. Besides, there was a large positive increase in the percentage of faculty members who formally assessed the use of 5As and 5Rs (21%–88%), and a dramatic increase (+100) in the percentage of faculty members who taught or included most of the 13 tobacco use cessation (TUC) interventions content areas following the introduction of the curriculum and training program.[23] Our findings were consistent with the results of these studies and others.[24],[25][Additional file 3]

 » Conclusions Top

Using a systematic process guided by the ADDIE Framework, it is possible to design a structured learning experience (curricular module) for equipping students with skills to manage a common public health problem. TCTM was found to improve knowledge, attitude, self-confidence, ability to identify oral manifestations and tobacco counseling skills among study participants (Kirkpatrick's Level 1, 2, 3). Students and faculty expressed their satisfaction about the TCTM with some specific suggestions.

Novelty: TCTM was developed through synthesis of contents from literature review and inputs obtained from students, faculty and experts during needs assessment. TCTM was implemented during clinical training of students in Public Health Dentistry by a multispecialty team. It required six days during their clinical training which was found to be practically feasible and well accepted by students and faculty. This study also describes the process of learning needs assessment, training module design, content and process validation, and training program evaluation using the ADDIE model of instructional design. The content matter (knowledge needed in tobacco use and cessation) was incorporated into the Calgary-Cambridge Counselling framework and validated by dental experts using Delphi technique. This can be used by fellow teachers in dentistry and other health care educators as it helps students engage in deliberate practice and receive feedback on performance to sharpen and improve their tobacco cessation communication skills.

Limitation: Time constraint was a limitation as intensive training was required on six consecutive days. It may be practically difficult to apply this for each small group in an academic year.

Hence, it was suggested by faculty to consider three knowledge-oriented sessions in large-group mode for all students together to be then followed up by three skill-oriented sessions during clinical postings in small groups. This will reduce the time constraint (if any) and make it more practical for its replication in other institutions for common and important public health problems. It was mentioned by interns who participated in focus group discussion during needs assessment that no customized training was undertaken with regard to tobacco counseling. Hence, we thought of comparing pre and post-intervention scores among participants who underwent training as part of evaluation. However, comparison of performance of students who underwent training against those who were not offered such training would have given us chance to compare effectiveness of the current module against traditional method. This could not be undertaken owing to the time constraints. The long-term impact will be evaluated in the future when subsequent follow up sessions are undertaken during the fourth year BDS and internship.

Way forward: This customized tobacco counseling training module for dental undergraduate students would be evaluated by incorporating this as a value addition into the existing curriculum at the level of institution before recommending this as a curriculum reform to Dental Council of India.


We express our sincere thanks and gratitude to the Principal, JSS Dental College and Hospital, Dr. Praveen Kulkarni, JSS Medical college, Faculty from JSS Dental College, subject experts and students of JSS Dental college for their support and participation in this education innovation project.

Declaration of participant consent

The authors certify that they have obtained all appropriate participant consent forms. In the form, the participant(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but, anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Reddy KS, Gupta PC. Report on tobacco control in India. Ministry of Health and Family Welfare. Government of India. 2004.  Back to cited text no. 1
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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