Patient Education and Counseling 86 (2012) 49–56

Medical Education

Changing practitioner behavior and building capacity in tobacco cessationtreatment: The TEACH project

Marilyn Herie a,b, Hillary Connolly a, Sabrina Voci a, Rosa Dragonetti a, Peter Selby a,c,d,e,f,*a Nicotine Dependence Clinic, Addictions Program, Centre for Addiction and Mental Health, Toronto, Canadab Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canadac Department of Family and Community Medicine, University of Toronto, Toronto, Canadad Department of Psychiatry, University of Toronto, Toronto, Canadae Dalla Lana School of Public Health, University of Toronto, Toronto, Canadaf Ontario Tobacco Research Unit, University of Toronto, Toronto, Canada

A R T I C L E I N F O

Article history:

Received 2 December 2010

Received in revised form 10 March 2011

Accepted 9 April 2011

Keywords:

Smoking cessation

Knowledge translation

Diffusion of innovations

Continuing medical education

Behavior change

Motivational interviewing

A B S T R A C T

Objective: To facilitate interprofessional knowledge transfer to practice by increasing treatment capacity

of health care practitioners to deliver evidence-informed smoking cessation counseling.

Methods: TEACH (Training Enhancement in Applied Cessation Counseling and Health) combines

diffusion of innovations with principles of adult learning to address the lack of system capacity to

implement evidence-based smoking cessation treatments. Participants were professionals from 15

disciplines with commitment from their supervisor to implement the intervention. Pre- and post-

training course evaluation surveys assessed the extent to which learning objectives were achieved and

guided a continuous quality improvement process.

Results: Evaluation of 741 participants that attended the three-day Core Course from June 2007 to

January 2009 revealed significant increases in pre- to post-training ratings of feasibility, importance, and

confidence in using the intervention. In addition to attitudinal changes, practitioners made changes to

practice behavior. At six months post-training, 55% of professionals were implementing the intervention

and 91% engaged in knowledge transfer activities in their organizations/communities.

Conclusion: Findings suggest that TEACH impacted clinical practice and may serve as a model for

knowledge translation initiatives in other health behavior domains.

Practice implications: These data demonstrate that it is feasible to operationalize interprofessional

knowledge translation models to transfer research findings into practice.

� 2011 Published by Elsevier Ireland Ltd.

Contents lists available at ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

1.1. Need for practitioner training in tobacco cessation interventions

Tobacco cessation treatment is one of the most cost-effectiveinterventions for reducing morbidity and mortality [1,2]. Althoughminimal brief interventions are proven to increase cessation rates[3,4], quit rates are often further increased by intensified level ofsupport (length and/or number of sessions) and/or concurrent useof pharmacological aids [5]. Despite the recommendations ofclinical practice guidelines [5], few physicians routinely go beyondasking patients if they smoke (67%) and advising smokers to quit

* Corresponding author at: Addictions Program, Centre for Addiction and Mental

Health, 175 College Street, Toronto, Ontario M5 T 1P7, Canada.

Tel.: +1 416 535 8501x6859; fax: +1 416 599 3802.

E-mail address: peter_selby@camh.net (P. Selby).

0738-3991/$ – see front matter � 2011 Published by Elsevier Ireland Ltd.

doi:10.1016/j.pec.2011.04.018

(74%), to actually assist patients in quitting (35%) [6]. Barriersinclude lack of time and system support for such interventions byphysicians. There is evidence that cessation treatment provided byother clinicians (e.g., nurse, counselor, dentist) is similarly effective[5]. This potentially allows physicians to delegate aspects ofcounseling practice and enhances team-based provision of care topatients.

However, a commonly cited barrier for not providingcessation interventions by clinicians is lack of perceived efficacyand training [7–9]. Therefore an evidence-based trainingprogram to enhance the capacity of these practitioners wasneeded. While training programs focused on delivery of tobaccocessation interventions have been developed in the U.S. andabroad to address this gap, the absence of a locally relevantprogram in Canada with a focus on comprehensive cessationwithin the context of Canadian tobacco control and a publiclyfunded health system prompted us to develop the initiativeoutlined in this paper.

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–5650

1.2. TEACH: a knowledge translation project

The TEACH project (Training Enhancement in Applied CessationCounseling and Health) is a knowledge translation project funded bythe Ontario Ministry of Health Promotion as part of the Smoke-Free

Ontario Strategy [10], that has developed a university-accreditedcertificate program in cessation counseling and also providesnetworking, coaching and follow-up continuing education oppor-tunities to practitioners through the development of a Community ofPractice and peer support network. This paper outlines the multi-pronged approach of TEACH as an example of a comprehensive,interprofessional initiative that incorporates evidence-based prin-ciples of constructivist learning methodologies, knowledge transla-tion strategies, and community capacity-building.

1.3. Knowledge translation and practice change

In response to a growing awareness of the lack of congruencebetween evidence and practice, funding sources, consumer groups,researchers, policymakers and agency/program managers haveidentified knowledge translation as a both a priority and a majorchallenge [11–15]. Without effort, the application of knowledgedoes not occur consistently. The knowledge-to-action (KTA)framework (see Fig. 1) outlines the iterative, dynamic and complexprocess through which knowledge is both created and applied topractice [16]. According to the KTA framework, the production ofknowledge is comprised of 3 phases: knowledge inquiry (e.g.,primary research); knowledge synthesis (e.g., systematic reviews);and creation of knowledge products and tools to aid decision-making (e.g., practice guidelines). In turn, each knowledge phasemay impact any of the 7 phases in the action cycle (application ofknowledge), which themselves may occur either sequentially orsimultaneously (see Fig. 1).

Although clinical training workshops have some demonstratedimpact on practice [17], research has also shown that clinicalpractice behavior is minimally influenced through training alone[18]. However, clinical training combined with ongoing coaching,clinical supervision, or ‘‘booster sessions’’ can enhance and sustain

Fig. 1. The knowledge-to-action framework.

Straus et al. [16]. � Canadian Medical Association Journal 2009. Any further copying

in any form is strictly prohibited unless otherwise permitted by law.

practice change [18]. Clinical education that focuses on enhancingclinicians’ intrinsic motivation for change, providing skill trainingwith directed practice, addressing organizational barriers, andengaging practitioners in ongoing support for change (e.g.,networking, ongoing coaching, communities of practice) can moreeffectively promote adherence to evidence-based models and tools[19].

Knowledge transfer is complex and best viewed as an ongoingprocess rather than a single event [20]. Thus, while antecedentssuch as sufficient motivation and training increase the likelihood ofinitial adoption of an innovation and its early use, factors such asongoing access to information and support for adapting andrefining an innovation are beneficial to promote continuedadoption. According to the Pathman-PRECEED model [21],system-level interventions can promote change at various stagesin the adoption process by: (1) predisposing initial change byincreasing knowledge or skills, (2) enabling change by promotingconducive conditions, and (3) continuing to reinforce changes thathave been made. See Greenhalgh et al. [20] for a comprehensiveoverview of the determinants of diffusion and dissemination ofinnovations in health services and organizations.

2. Methods

2.1. Development of TEACH

The TEACH project has developed a Certificate Program in

Intensive Cessation Counseling, accredited by the University ofToronto (Faculty of Medicine). The TEACH certificate programconsists of three courses: (i) an online course which takes between6 and 8 h to complete, (ii) a three-day classroom-based CoreCourse, and (iii) a two-day classroom-based Specialty Course. Theonline course was adapted from a publicly available course (http://tobaccocourse.otru.org) developed by the Ontario Tobacco Re-search Unit, to include an interactive, moderated group discussionforum. The course features evidence-based Canadian content ontobacco control science, policy, and practice relating to tobaccoprevention, protection, and cessation. We wanted to create leadersin smoking cessation. Understanding the broader context oftobacco control as it relates to cessation is an importantdistinguishing feature of TEACH from other training programsfor clinicians. The Core Course provides training across seven keycontent areas: (i) assessment tools; (ii) advocacy and system-levelinterventions; (iii) manual-based cognitive-behavioral cessationtreatment; (iv) facilitating cessation groups; (v) motivationalinterventions; (vi) pharmacotherapies; and (vii) harm reductionstrategies. Thereafter, participants are given a choice of differentSpecialty Courses designed to focus on specific populations withhigh tobacco prevalence or risk, likely to be relevant to thepopulations they serve. To date, 13 Specialty Courses have beenoffered, focusing on: (i) mental health and/or addictive disorders;(ii) hospitalized smokers; (iii) youth; (iv) women across thelifespan; (v) obesity and binge eating disorder; (vi) anorexianervosa and bulimia; (vii) lesbian, gay, bisexual, and transgender(LGBT) communities; (viii) integrated chronic disease preventionand (ix) aboriginal peoples.

Collaborative and experiential learning is ensured throughinstructional design enhancements, including: case examples,small group practice exercises and clinical simulations, live clinicaldemonstrations, video demonstrations, and large and small groupdiscussion and consultation.

Curriculum materials include a participant manual withpresentation materials, practice exercises, and additional resourcematerials and clinical tools, as well as online access to electronicversions of screening and assessment instruments, clinicalinterventions and tools, and follow-up readings and web-based

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–56 51

resources. An abbreviated presentation of course materials is alsoprovided for dissemination to colleagues in the community.

Beyond the classroom, Community of Practice (CoP) skill-building activities and networking opportunities, such as skill-building workshops, bi-monthly teleconferences, and a listserv,provide post-certificate professional development and coaching.CoP activities also facilitate continued contact and engagementwith practitioners trained. Course content in CoP sessionsemphasize hands-on practice, case examples and interactivegroup discussion and problem-solving, with the goal of enhancing,encouraging, and supporting professional development andknowledge transfer.

The TEACH model (see Fig. 2) incorporates all components ofthe Knowledge-to-Action Framework [16], with the exception ofthe knowledge inquiry stage (primary research), although it isundertaken in the clinic where TEACH is based [22,23] andincorporated where appropriate. The project addresses thecomplexities of knowledge translation by adopting an iterativeand dynamic cycling between and among knowledge creation

processes and action strategies. Curriculum materials synthesizeresearch evidence and best or promising practices, and presentthese in the form of clinical tools, practice guidelines andtreatment algorithms. Continuous review of recent researchfindings and updating of course content ensures that coursematerials reflect emerging evidence and its clinical implications.Course evaluations, follow-up surveys and evaluations of CoPactivities also inform and shape the TEACH curricula and content,reflecting the importance of including end-users in the knowledgetranslation process.

Participants spend at least 25% of class time on interactive, case-based practice to facilitate the adaptation of knowledge to theirlocal contexts, assess barriers to knowledge use, and to begin toselect and tailor clinical tools and practices. Knowledge transfer isfurther monitored, evaluated and sustained through three- and

Fig. 2. TEACH model for knowledge transfer and evaluation.

Adapted from Straus et al. [16].

six-month follow-up questionnaires, bi-monthly CoP video/tele-conferences and a listserv. Ongoing consultation is also offered ad-hoc through the Nicotine Dependence Clinic staffed by several ofthe TEACH faculty.

2.2. TEACH Core Course evaluation

The application process is transparent and equitable: theTEACH Certificate Program is open to all health and allied healthpractitioners in Ontario, and acceptance is based on clear criteriacommunicated on the training application form. Applications arescreened to help ensure that practitioners who are accepted are ina position to increase system capacity, based on: (1) level of clinicalcontact; (2) ability to influence organizational change (e.g.,Program Manager, Medical Director); (3) geographical need; and(4) services to specific populations.

Evaluation of TEACH classroom-based training is carried out viaformative and summative evaluation questionnaires, two learningassessments, assessment of post-training goals, and follow-upsurveys at three and six months post-training (see Fig. 3). TheFormative Evaluation is a 65-item questionnaire administered foreach of the seven content areas of the course to assess the content,interactivity and overall quality of facilitation. Results of theformative evaluation permit a more detailed understanding of thestrengths and areas for improvement within specific coursesections. The Summative Evaluation is a 29-item questionnaireadministered at the end of the course, measuring how well thecourse accomplished learning objectives, and participants’ overallsatisfaction with the course content, learning activities, facilita-tion, environment and course administration. Both summative andformative evaluations consist of Likert-scale and open-endeditems.

Pre- and post-training online assessment questionnaires assessthe impact of knowledge learned on attitudes and intentions to

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–5652

change practice behavior. Learning Assessment 1 is administeredprior to the course and asks participants to rate their readiness toimplement knowledge and skills in each content area, as well asthe feasibility and importance of incorporating these clinical toolsinto their practice. Readiness, feasibility and importance are ratedon a 10-point ‘‘Readiness Ruler’’ adapted from Miller and Rollnick[24]. Practitioners are also asked about the extent to which they arealready using these tools. Within one week of course completion,participants complete these same items in Learning Assessment 2.Pre- and post-test comparisons using paired t-tests provide anindication of attitudinal change and intention to implementpractice change. A Post Training Goals assessment is also completedwithin one-week post-training, consisting of a seven-itemquestionnaire which asks about intentions to incorporate theclinical tools and approaches covered throughout the training intoparticipants’ day-to-day practice with clients. The questionnaire isintended to stimulate thinking and assist participants in settingpractice goals. Approximately one month after the course eachindividual receives a personalized feedback summary of their pre-and post-training results, including how individuals’ responsescompared with the aggregate results of other practitioners in theirtraining cohort. This is to provide normative feedback that has alsobeen posited to influence practitioner behavior [25].

Follow-up at three- and six-months post-training is carried outthrough an online survey to assess the extent to which participantshave implemented the practice changes they identified immedi-ately post-training. Questions relate to changes in knowledge,attitudes and skills, current application of intensive tobaccocessation interventions and tools, dissemination of TEACHmaterials to colleagues or community practitioners/stakeholders,barriers to practice change, and future intentions with respect tointensive cessation interventions and programming. Only six-month follow-up results are presented in the current paper.

3. Results

3.1. TEACH Core Course participation demographics

The demographic and evaluation results reported below weregathered from June 2007 through January 2009, during whichTEACH offered six Core Courses to a total of 741 participants. Table 1summarizes data on the number of practitioners trained and

Table 1Core Course participants trained by discipline and geographical region: June 2007–Jan

Discipline Core Course participants at time

Number of

participants

% of t

Dentists, dental workers 7 0.9%

Dieticians, nutritionists 7 0.9%

General practitioners, family physicians 13 1.8%

Occupational therapists 9 1.2%

Pharmacists 35 4.7%

Physiotherapists 2 0.3%

Psychologists 3 0.4%

Nursing (licensed practical nurse,

registered nurse, nurse practitioners)

351 47.4%

Respiratory therapists, clinical

perfusionists, asthma educators

66 8.9%

Social workers 78 10.5%

Specialist physicians 11 1.5%

Other (addiction counselor, health promotion,

community worker, psychotherapist)

134 18.1%

Discipline not reported 25 3.4%

Total # of

participants = 741

–

followed up by discipline and geographical region. Of the practi-tioners trained by TEACH, the top three self-reported disciplineswere nursing, respiratory therapy and social work. These threedisciplines comprised over 65% of the 741 practitioners. Ontario hasa vast geographical area with significant diversity across regions,however we collapsed regions for conciseness. Participants werefrom the following regions of Ontario: central east/west (N = 218,29.4%), east (N = 86, 11.6%), north east/west (N = 131, 17.7%), andsouth west/greater Toronto area (N = 247, 33.3%). Sixteen partici-pants were from outside of Ontario (2.2%), and region was notavailable for 43 participants (5.8%).

Practitioners reported offering services to diverse populations.Older adults and individuals with concurrent mental health andsubstance use disorders were identified as most commonly servedby 70.1% (N = 523) and 64.0% (N = 474), respectively, of Core Courseparticipants, followed by youth (51.0%, N = 377), pregnant women(40.1%, N = 303), aboriginal peoples (38.5%, N = 285), differently-abled people (29.1%, N = 216) and LGBT communities (24.6%,N = 182). Other specific populations were served by 19.6%(N = 145) of Core Course participants, including Francophonesand specific ethnocultural communities.

3.2. Formative and summative evaluations

The summative evaluation asked participants to rate their levelof agreement with the statement ‘‘This was a positive learningexperience’’ on a scale from 1 (strongly disagree) to 5 (stronglyagree); the average course rating across all six Core Courses was4.8. Participant feedback and structured post-course debriefingwith TEACH faculty informs a continuous quality improvementprocess. For example, the overall evaluation of the October 2006pilot training of the pregnancy and tobacco specialty course was4.0 out of 5; this course was subsequently revised by adding casestudies and interactive exercises to demonstrate concepts andprovide an opportunity to practice newly-learned skills and wasoffered again with improved overall average ratings of 4.9(February 2007) and 5.0 (February 2008).

3.3. Pre- and post-training learning assessments

There were significant increases in practitioners’ pre- and post-training ratings of feasibility (7.7 vs. 8.1, p < 0.001), importance

uary 2009.

of training 6-Month follow-up of Core Course participants

otal Number of respondents % of total Response rate

7 1.5% 100.0%

2 0.4% 28.6%

10 2.2% 76.9%

6 1.3% 66.7%

26 5.7% 74.3%

1 0.2% 50.0%

1 0.2% 33.3%

209 46.0% 59.5%

39 8.6% 59.1%

44 9.7% 56.4%

6 1.3% 54.5%

95 20.9% 68.8%

9 2.0% 36.0%

Total # of

respondents = 455

– Average response

rate = 61.4%

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–56 53

(8.6 vs. 8.8, p < 0.001), and confidence (7.1 vs. 8.1, p < 0.001) withregard to implementing the tools and skills learned. There was anoverall trend of lower pre-training confidence scores in 2008 and2009 compared to 2007. Only the 2008 and 2009 cohorts exhibited

Fig. 3. TEACH evaluatio

a significant increase in confidence post-training. Though it is notclear why this trend was observed it may be because early adoptersare by definition more innovative and informed by scientificknowledge and advances [26].

n plan and results.

Fig. 4. Comparison of pre-existing self-reported practices and post-training practice objectives (June 2007–January 2009, N = 741).

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–5654

Assessment of immediate post-training goals suggested thatthe majority of practitioners planned to incorporate TEACHtraining into their own clinical practice. For each of the sevencontent areas there was a considerable increase (ranging from41.4% to 62.6%), in the percentage of practitioners who werealready practicing the measure pre-training to the percentage ofpractitioners who set practice goals post-training (see Fig. 4). Thismeans that in each content area covered by the TEACH Core Course,practitioners made concrete plans to incorporate their newknowledge into their daily clinical practice.

3.4. Six–month follow-up

The average six-month follow-up survey response rate for CoreCourse participants between June 2007 and January 2009 was61.4%. Personalized e-mail communications (an initial e-mail andthree reminders) were used to encourage survey responses [27]. Atsix-month follow-up, 55.4% of participants (N = 252) reportedoffering intensive cessation individual sessions and 17.0% (N = 77)reported offering intensive cessation group sessions to clients.Additionally, 7% (N = 32) of practitioners were planning to conductindividual cessation interventions, and 14.7% (N = 67) wereplanning to conduct group cessation interventions.

Participants were also asked to provide information on whatthey perceived to be barriers to changing their practice andimplementing new programs/services upon returning to theirworkplace. The three major barriers to offering intensive cessationinterventions identified in open-ended responses included ‘time’(46.0%, N = 209), ‘client motivation’ (37.8%, N = 172), and ‘organi-zational support’ (29.5%, N = 134). Another important outcome forTEACH is the dissemination of cessation knowledge and skills toother community practitioners. Participants were asked about thelevel of knowledge translation they participate in via formalsharing (such as presentations and publications) and informalsharing (such as staff meetings and message boards). Anoverwhelming majority (91.1%, N = 413) of participants indicatedat six months after training that they had shared knowledge andskills learned at TEACH training with others, either formally orinformally, including peers, co-workers, students, and even friendsand family. An additional 3.7% (N = 17) of participants indicatedthat they had future plans to share information gained from TEACHtraining. These findings are consistent with Rogers’ diffusion ofinnovations model, whereby networks serve to further dissemi-nate best practices [26].

4. Discussion and conclusion

4.1. Discussion

The TEACH project has been successful in attracting a widerange of health and allied health practitioners to receive intensivetraining in cessation counseling. The courses are not targeted toany single discipline, and participants are encouraged to workcollaboratively on case-based discussions and clinical simulationsduring the many interactive exercises and activities. This focus oninterprofessional collaboration is aligned with emerging bestpractices in healthcare [28,29], and is also modeled by TEACHfaculty who are themselves representative of diverse disciplines. Inaddition to healthcare providers, some participants work in policydevelopment areas and with non-governmental organizations(NGOs). This helps to increase the knowledge base in theseorganizations, which can support system change and facilitate theimplementation of smoking cessation interventions in varioushealth settings. Training of health care professionals as part of thegovernment’s strategy also heightens the importance of thisinitiative.

It is encouraging that practitioners attending TEACH reportworking with many of the special populations with high tobaccoprevalence, including Aboriginal populations, people with concur-rent disorders, and youth. In the absence of robust practiceguidelines for addressing tobacco use with these groups, theclassroom-based format of training large cohorts of diversepractitioners has allowed for enhanced networking and informa-tion sharing among clinicians who often practice in isolation.

Formative and summative evaluations have been uniformlypositive across all courses. The ability to foster learner engagementand interactivity even in very large groups suggests that positivelearning environments do not necessarily suffer with large classsizes. Holding large training courses has been a cost-effective wayto maximize participation and representation from diversedisciplines, regions and health settings.

For an evaluation of training programs to be comprehensive andmeaningful, evaluation across four levels—reaction, learning,behavior, and results—has been recommended [30]. The evaluationplan for the TEACH project goes beyond merely collecting data onparticipant satisfaction (level 1, reaction). Knowledge learned andattitudinal change over time (level 2, learning) is also assessed viapre- and post-course questionnaires. The statistically significantresults suggest that exposure to new knowledge and skills, and

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–56 55

opportunity for discussion and practice, increased practitioners’self-assessed importance, confidence, and feasibility to implementthese skills. Post-training surveys also assess pre-training practicecompared to practice objectives, and practice behavior at three-and six-month follow-up (level 3, behavior). Collection of level 4evaluation data (results) is essential to accurately documentknowledge transfer and determine the impact of training on bothpractitioners (e.g., frequency and quality of cessation interventiondelivery) and patients (e.g., long-term cessation rates). However,collecting this data was not feasible within the scope of the currentproject, given the considerable resources involved in documentingsuch behavior (e.g., conducting chart audits). Few knowledgetranslation initiatives follow up with participants to assess practicechange and training impact (i.e., actual use of knowledge). TEACHis fairly unique in this respect, and the follow-up data provideuseful insights into the iterative process by which clinical trainingimpacts direct practice.

In accordance with current models of knowledge translation[16,21], the TEACH project endeavors to move beyond increasingawareness and initial adoption of new behavior to further enableand reinforce practice change, through initiatives such as thedevelopment of a Community of Practice. In addition, requiringmanagers’ approval (signature) on practitioners’ applications,helps ensure some degree of organizational support for newknowledge and skills. Six-month outcomes should be regarded assteps towards change at direct practice and organization levels.

Knowledge transfer initiatives need to include multiplestrategies to help ensure that investment in clinical trainingresults in sustainable practice change and capacity-building [31].Knowledge translation research is process—as opposed to ‘‘pack-age’’—oriented, recognizing that practice change is an iterativeprocess [20]. In this context, the modest gains demonstrated in six-month TEACH follow-up data appear promising, particularly inlight of research suggesting that practice change can take manyyears [32]. Ongoing Community of Practice activities help tosupport and sustain practice change over time. Furthermore, theimpact of TEACH beyond practitioners trained is also seen in thehigh proportion of practitioners engaged in knowledge translationactivities, as reported in follow-up questionnaires.

4.2. Limitations

The TEACH evaluation plan has a number of limitations.Practitioners who attend TEACH training may self-select based onpre-existing levels of awareness and cessation skills, and may notbe representative of all health practitioners in Ontario. Evaluationinstruments relied on self-report data, which may not reflect actualintention to change practice or may not accurately capture post-training cessation and knowledge transfer activities. Furthermore,participants who responded to follow-up surveys may havediffered from non-respondents on level of motivation related tosmoking cessation practices. It is encouraging however, that evensix months after training, over 60% of participants completed thefollow-up surveys.

Perhaps the most important shortcoming relates to thedifficulty in assessing the degree to which organizational orsystem capacity in cessation services is impacted by TEACH, asthere is no comprehensive data on cessation services offered acrossdiverse health settings in Ontario. The current evaluation speaks toadoption of behaviors and tools by individual practitioners, yetadoption at the individual level is only one component ofsuccessful adoption of an innovation by a team, department, ororganization. Further research is necessary to identify theorganizational characteristics that influence the likelihood thatknowledge gained will be assimilated into everyday practicewithin healthcare settings.

4.3. Practice implications

The TEACH Certificate program demonstrates that it is bothpossible and feasible to operationalize knowledge translationmodels such as the Knowledge-to-Action framework [16] withdiverse professional disciplines and large learning cohorts. Giventhe highly qualified cadre of other health professionals, aside fromphysicians, and the evolving emphasis on team-based interven-tions both in community- and in hospital-based settings, cessationcounseling can also be provided by other health practitioners ifappropriately trained. With respect to curriculum development forinterprofessional continuing education, following a knowledgetranslation model provides a framework for integrating evidence-based approaches, incorporating instructional design enhance-ments to encourage application and practice of new skills, andconsidering the iterative process of adoption and practice changein real-world settings.

Well-articulated knowledge transfer models or frameworksenable more precise description of knowledge transfer processesand more robust evaluation of interventions [33]. A detailedevaluation plan adds rigor to knowledge translation initiatives. Thecombination of formative and summative course evaluations, pre-and post-training learning and goal assessments and post-trainingfollow-up surveys collectively provide an indication of the extentto which interprofessional education initiatives are achieving theirlearning objectives. Furthermore, tracking self-reported imple-mentation post-training is key to understanding the barriers andenablers of practice change, which can then be fed back into coursedevelopment. Contacting learners post-training can also help keeppractitioners engaged in ongoing Community of Practice activitiesby providing information about continuing education opportu-nities. These may exceed evaluation requirements of universitiesor professional regulating bodies for accreditation purposes, butare critical in ensuring that courses set and maintain highstandards in curriculum content, course facilitation and instruc-tional design.

4.4. Conclusion

As the first university-accredited continuing education certifi-cate program in Canada focused on cessation counseling, TEACHhas become a model for intensive cessation training leading toenhanced system capacity. With its focus on health behaviorchange, the model has now been adapted for knowledgetranslation in integrated chronic disease prevention and manage-ment to address a wider range of health behaviors. Given thesuccess of the project in exceeding targets for the numbers ofpractitioners to be trained, the positive evaluation data, and theencouraging results from participants’ practice objectives andfollow-up responses, TEACH appears to be having an impact onOntarians’ access to intensive cessation services and provides anapproach for comprehensive knowledge transfer initiatives inother health behavior change arenas.

Acknowledgements

The authors wish to thank the Ontario Ministry of HealthPromotion and Sport, Smoke Free Ontario initiative and HealthCanada for their funding and support of the TEACH project, andJulia Lecce for her assistance with data analysis. The opinions andconclusions in no way reflect those of the sponsoring governments.Disclosures: Marilyn Herie and Rosa Dragonetti received anhonorarium from Pfizer (2007). Peter Selby: (1) received fundsfrom Schering Canada to provide buprenorphine training (2000),(2) received honoraria for consultant work, grant funding, advisoryboard and/or lectureships from: Johnson & Johnson Consumer

M. Herie et al. / Patient Education and Counseling 86 (2012) 49–5656

Health Care Canada; Pfizer Inc, Canada; Sanofi-Synthelabo,Canada; GlaxoSmithKline, Canada; Genpharm and Prempharm,Canada; CTI; Health Canada; Smoke Free Ontario; CanadianInstitutes of Health Research (CIHR), (3) paid consultant to V-CCSystems Inc. and eHealth Change Software Company. HillaryConnolly and Sabrina Voci have no disclosures to report. Therecipients of funding are in compliance with the Canadian MedicalAssociation (CMA) and the Canadian Psychiatric Association (CPA)guidelines/recommendations for interaction with the pharmaceu-tical industry. No tobacco industry funds were received by any ofthe authors.

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