Pediatrician Self-Efficacy for Counseling Parents of Asthmatic Children to Quit Smoking
* Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan Health System, Ann Arbor, Michigan
Departments of Biostatistics
|| Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, Michigan
Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Background. Although environmental tobacco smoke is a common trigger for asthma exacerbations in children, pediatricians infrequently counsel parents who smoke to quit. High physician self-efficacy, or self-confidence, in the ability to counsel parents about smoking cessation is associated with increased physician screening and counseling on this topic. However, it is not clear which factors are associated with high physician self-efficacy for counseling, such as previous training in smoking-cessation counseling or number of years in pediatric practice.
Objective. To identify factors associated with high levels of physician self-efficacy for 4 skills associated with smoking-cessation counseling.
Design. Cross-sectional survey.
Participants. A national random sample of 829 primary care pediatricians.
Results. The response rate was 55% (457 of 829). The percentage of physicians with high levels of self-efficacy for screening parents and screening patients to identify smokers was 87% and 84%, respectively. The percentage of physicians with high levels of self-efficacy for counseling parents and patients was 59% for both groups. The presence of previous training in smoking-cessation counseling was associated with high levels of self-efficacy for all 4 skills including inquiring about an asthma patient’s smoking status (odds ratio [OR]: 3.91; 95% confidence interval [CI]: 1.63, 9.37); inquiring about a parent’s smoking status (OR: 2.51; 95% CI: 1.09, 5.75); counseling a patient to quit smoking (OR: 5.30; 95% CI: 3.02, 9.31); and counseling a parent to quit (OR: 4.96; 95% CI: 2.85, 8.61). Years since completion of residency were not associated with high self-efficacy.
Conclusions. These findings suggest that formal training in smoking cessation has a significant impact on physician self-efficacy related to smoking cessation throughout a physician’s career.
Key Words: self-efficacy • smoking-cessation counseling • asthma • physician practice patterns
Abbreviations: AMA, American Medical Association • OR, odds ratio • CME, continuing medical education
Although environmental tobacco smoke is a common trigger for asthma exacerbations in children,1 pediatricians infrequently counsel parents who smoke to quit.2 This situation is especially unfortunate, because brief interventions where physicians simply discuss smoking cessation have been shown to be successful and cost-effective.3,4 Physician self-efficacy, a physician’s self-confidence in the ability to counsel parents about smoking cessation, is associated with physician screening and counseling.2,5 According to social cognitive theory, as self-efficacy to counsel increases, the frequency of counseling increases as well.6 Improving physician self-efficacy for screening and smoking-cessation counseling is likely to increase the chance that physicians will address this topic, resulting in improved patient outcomes for asthma.
However, the factors associated with a physician’s sense of self-efficacy related to providing smoking-cessation counseling are not known. Physician self-efficacy for counseling patients may increase as they gain experience in practice. A qualitative study noted that pediatricians with fewer years of practice experience were more likely to describe lack of self-efficacy as a barrier to smoking-cessation counseling for parents of asthmatics, compared with pediatricians with more years of practice experience.7 In addition, specific training regarding smoking cessation in medical school or residency may also affect physician self-efficacy.5 For example, Thompson et al8 noted that increased self-efficacy for smoking-cessation counseling was associated with previous training. However, this observation did not control for physician characteristics such as years in practice or board certification.
We are not aware of any study that has specifically investigated the relationship between pediatrician self-efficacy for smoking-cessation counseling with exposure to specific training for this topic, controlling for years in practice. The purpose of this study was to investigate the association between self-efficacy and training while adjusting for potential confounders. Because asthma and tobacco exposure are common problems encountered throughout a practicing pediatrician’s career, understanding which factors are associated with high levels of self-efficacy may have implications for medical training and postgraduate continuing education.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Subjects
The methods used for data collection are described in detail in a previous publication.2 We randomly selected 1000 general pediatricians from the American Medical Association (AMA) Masterfile of physicians in the United States, which includes all allopathic and most osteopathic physicians in the United States, regardless of membership in the AMA. We excluded pediatricians in training, pediatricians who spent the majority of their professional time outside of clinical practice, and subspecialists.
Between March and May 1999, we sent a cover letter, an 8-page, 46-item questionnaire, and a prepaid return envelope to each subject. Nonrespondents received up to 3 reminder surveys. Physicians who did not respond after 3 attempts were contacted by phone to confirm that they received the survey. We did not offer an honorarium for participation. The institutional review board at the Johns Hopkins School of Medicine approved the study protocol.
Survey Instrument
Outcome Variable
Self-efficacy is a pediatrician’s confidence in his/her ability to perform a specific skill.5 Our outcome of interest, or dependent variable, was physician self-efficacy for 4 different skills related to smoking cessation. We asked subjects to "rate your confidence in your ability to" perform each of 4 skills with regard to their patients with asthma: 1) inquire about a parent’s smoking status; 2) inquire about a patient’s smoking status; 3) counsel a parent to quit smoking; and 4) counsel a patient to quit smoking.
The questionnaire used a 5-point scale for respondents to indicate their level of self-efficacy. (1, not at all confident; 5, extremely confident). We defined pediatricians as having high self-efficacy if they answered 4 or 5 on the 5-point Likert-like scale (ie, "very" or "extremely" confident for each skill in question).
Independent Variables
We measured other independent variables associated with physician self-efficacy. These variables included previous training in smoking-cessation counseling, number of patients with asthma, academic affiliation, years since completion of residency, board certification in pediatrics, and gender.
The response categories for the survey items are listed below. We asked subjects if they felt that they had adequate training in smoking-cessation counseling (1, strongly disagree; 5, strongly agree). We defined pediatricians as having adequate training if they answered 4 or 5 on the 5-point Likert-like scale (ie, "agree" or "strongly agree" that they had adequate training).
We asked subjects to indicate how many patients with asthma are in their current panel of patients by using the following categories: none; 1 to 10; 11 to 50; 51 to 100; and >100 patients. For the multivariate analysis, we dichotomized this variable and grouped physicians into those with 0 to 50 patients and those with 
51 patients with asthma.
We asked subjects to indicate if they had any academic affiliation, which included a faculty appointment, part-time or adjunct appointment, or preceptorship.
To calculate years since completion of residency, we subtracted the year the respondent indicated that they completed pediatrics residency from 1999, the year the survey was administered.
Board certification in pediatrics was included as a dichotomous (yes/no) response. Physician gender and age were provided from the AMA Masterfile.
Additional Questionnaire Items
We asked physicians to indicate what setting they perform the majority of their clinical activity. The responses included the following 6 categories: solo practice, group private practice, staff-model health maintenance organization, academic institutional practice, federal, military, or publicly funded facility, and other.
We also measured the degree to which an absence of physician skills/training significantly affects how frequently smoking-cessation counseling for parents (and patients) occurs in practice (not at all or slightly, moderately, or extremely significant).
Analysis
Our sample was selected randomly from the AMA Masterfile, which includes data on physician gender, age, and board certification. Other data described in "Methods" were only available from completed questionnaires. We used the 
2 test and Student’s t test to examine possible differences between respondents and nonrespondents using the available data on physician gender, age, and board certification for both respondents and nonrespondents.
We conducted 4 separate analyses. Each of the 4 skills was used as the outcome of interest for each separate analysis. Statistical significance was defined as P < .05. Because our dependent variable of interest (pediatrician self-efficacy) was dichotomous, we used multivariate logistic regression (SAS 8.02; SAS Institute, Cary, NC) for each analysis.
For the multivariate models, we included all independent variables described below. These variables were selected based on a specific hypothesis that they could potentially affect physician self-efficacy. In addition to years since completion of residency and previous training for smoking cessation, we controlled for academic affiliation and board certification. We hypothesized that those physicians involved in medical student or resident education and those board-certified would have greater self-efficacy for addressing these issues. In addition, because we hypothesized that pediatricians who see fewer patients with asthma might be less confident in their skills, we controlled for the estimated number of patients with asthma in a physician’s panel of patients (50 versus <50 patients). Because male and female physicians have different interests in, beliefs in, attitudes about, and behaviors for prevention practices such as smoking cessation, we controlled for physician gender as well.9
We hypothesized that the effect of previous training for smoking cessation might have a differential effect during a physician’s career. We tested for effect modification using an interaction term (smoking-cessation training x years since residency) in the multivariate logistic regression model to determine if the relationship between years since residency and level of physician self-efficacy is modified by smoking-cessation training and vice versa. We found that the interaction term (smoking-cessation training x years since residency) was not significant. As a result, we present the results without the interaction term.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Sample
Of 1000 pediatricians in our database, we excluded 47 pediatric subspecialists, 58 in practice <20 hours per week, and 2 still in training. Sixty-six questionnaires were returned due to incorrect address or deceased recipient. Based on a standardized formula defined by the Council of American Survey Research Organizations, our response rate was 55% (457 of 827 eligible respondents returned our questionnaire).10 Because of partially incomplete questionnaires, not all totals are equal in the analysis of self-efficacy for each skill.
Demographic data of the survey recipients are summarized in Table 1. Based on AMA data, respondents did not differ from nonrespondents in terms of gender and median age. However, respondents were more likely to be board-certified in pediatrics (91% vs 82%; P < .01).
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Levels of Physician Self-Efficacy for Smoking-Cessation Counseling and Screening
Table 2 lists the levels of confidence that respondents reported for each of the 4 skills. The majority of respondents indicated high self-efficacy for all 4 skills. The percentage of physicians with high self-efficacy for screening for smoking was similar for parents (87%), compared with patients with asthma (84%). Likewise, the percentage of physicians with high self-efficacy for counseling for parents was identical to the percentage of physicians indicating high self-efficacy for counseling for patients (58%).
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Although the recipient of the screening or counseling (parent or patient) did not affect the level of pediatrician self-efficacy, the type of skill did affect the percentage of physicians that indicated a high level of self-efficacy. For example, the percentage of pediatricians with high self-efficacy for inquiring or screening parents and patients about smoking status was significantly higher than the percentage of pediatricians with high self-efficacy for counseling smokers about cessation (P < .01).
Perceived Impact on Practice
In many cases, lack of self-efficacy was perceived as a barrier to how frequently smoking-cessation counseling occurs with parents in practice. For approximately one third of physicians (32%), the lack of physician skills was reported as a moderately or extremely significant barrier. The percentage was identical for how frequently this occurs with smoking-cessation counseling for patients (32%).
Factors Associated With High Physician Self-Efficacy
We examined factors associated with high pediatrician self-efficacy. Table 3 lists the adjusted odds ratios (ORs) for each factor in the full multivariate model.
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The presence of previous training in smoking-cessation counseling was associated with high self-efficacy for all 4 skills. Years since completion of residency was not associated with high self-efficacy.
The presence of >50 asthma patients was associated with increased self-efficacy for inquiring about parent or patient smoking status. However, this factor was not significant for counseling smoking cessation to patients or parents.
Finally, in all 4 analyses, we found that the point estimate for male physician gender was consistently <1.0 but only statistically significant for inquiring about a patient’s smoking status. This finding suggests that male physicians are less likely to have high self-efficacy for inquiring about a patient’s smoking status.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Physician self-efficacy for smoking-cessation screening and counseling has been associated with how frequently physicians engage their patients with this topic in practice.2,5,11 This study suggests that such self-efficacy is not explained by cumulative clinical experience. Rather, previous formal training in smoking-cessation counseling significantly enhances pediatrician self-efficacy even after controlling for potential confounders.
A previous study using qualitative interviews with physicians suggested that physicians with fewer years in practice were less likely to be confident in their skills for addressing the subject of smoking as well as counseling smoking cessation.7 However, in our sample, using a quantitative methodology and controlling for other variables, we found that years since completion of residency was not associated with self-efficacy for these skills.
There are several limitations to this study. Our sample may not be representative of all pediatricians, because respondents were more likely to be board-certified in pediatrics than nonrespondents. In addition, the response rate of 55% may limit generalizability. However, this rate is similar to average response rates of other published analyses of physician surveys.12 It is also possible that pediatricians who responded to the questionnaire were more likely than those who did not respond to have a greater interest in the topic of smoking cessation. Because of this possible response bias, pediatricians in general may actually be less likely to have undergone training in smoking cessation and be less confident about intervening than the results suggest.
In addition, the study design was cross-sectional, and as a result causation is difficult to determine. Although it is assumed that prior training affects self-efficacy and practice behavior, those physicians with high levels of self-efficacy may have a recall bias toward remembering such previous training. As a result, those with high self-efficacy may report such training and those with low levels may fail to report it.
Notwithstanding these limitations, these results emphasize the importance of incorporating formal smoking-cessation training into physician education. Although there are many examples of formal training interventions to improve physician smoking-cessation counseling,13 less than half of pediatric residency training programs offer formal training in smoking-cessation counseling.14
In terms of continuing medical education (CME), reaching physicians in practice may be well worth the effort; we found that even physicians with many years of practice experience may lack self-efficacy for screening and counseling smoking cessation. Postresidency CME can be an important mechanism to improve physician practice in this area. These results also suggest that physicians early or late in their career may benefit from additional training during residency and beyond through the existing CME system.
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FOOTNOTES |
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Received for publication Nov 8, 2002; Accepted Mar 6, 2003.
Address correspondence to Michael D. Cabana, MD, MPH, Division of General Pediatrics, University of Michigan Health System, 6-D-19 NIB, Box 0456, 300 N Ingalls St, Ann Arbor, MI 48109-0456. E-mail: mcabana{at}med.umich.edu
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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