Tobacco use remains a global public health concern; annually it causes 6 million preventable deaths [1]. The tobacco consumption epidemic is shifting to low- and medium-income countries (LMICs) such as some countries in the Latin American and Caribbean (LAC) region [2]. Currently, more than 120 million smokers live in these countries [3]; half of them will develop a tobacco-related disease and consequently will require medical care.

In the LAC region, smoking rates vary by country, sex, and socio-economic status [4,5]. In some low-income countries, such as Bolivia, Guatemala, and Paraguay, smoking rates are 10 percentage points higher than the rest of the LAC countries [6]. Thus, among men, smoking prevalence ranges from 42% (in Bolivia) to 22.9% (in Paraguay) [7]. Among women, the prevalence is lower, but it is rapidly increasing, confirming the alarming feminization of the epidemic in LAC countries [7]. In the overall region, smoking-related mortality accounts for 16% of total mortality [7], and according to the World Health Organization (WHO), smoking-related deaths will increase by 700% by 2030 [8]. The report points out that the epidemic can be curbed by implementing comprehensive tobacco control measures embraced by the WHO Framework Convention on Tobacco Control (WHO-FCTC) [9]. These measures have demonstrated the reduction of tobacco use and the increase of awareness of its hazards [9]. Guatemala, Paraguay, and Bolivia signed the WHO-FCTC early on, and have implemented some tobacco control measures, including smoke-free legislation (according to the WHO-FCTC Article 8) in workplaces and public places, including health care services. However, smoking cessation services (Article 14) have not received the same recognition and attention [5]. As a consequence, smoking cessation interventions are not well spread among health care services within these countries. Smokers are frequent users of health care services, and their contact with the health system might be an adequate “teachable moment” for quitting [10]. Indeed, according to studies conducted in the United States between 60% and 70% of patients make an attempt to quit while they are hospitalized [11]. However, in spite of these favorable conditions, evidence-based cessation programs are hardly available in LAC countries [12]. The most common barriers to incorporating tobacco cessation interventions into hospitals involve lack of training, expertise, and time. In addition, organizational and financial constraints threaten the suitability of smoking cessation interventions [6].

In LAC countries smoking consumption among health care professionals is still similar to that of the general population [13,14], and most doctors and nurses acknowledge that they have not received formal training in smoking cessation during their undergraduate or graduate training [14]. Generally, they state little confidence in its effectiveness to help their patients to stop smoking. Training facilitates having a more positive attitude on smoking cessation [15] and helps to increase the performance of smoking cessation interventions [16]. Given that about 70% of smokers visit health services over the course of a year, the lost opportunities to intervene remain significant [3]. Frequently, providers believe that smoking cessation is extremely important, but also extremely difficult due to a serious communication gap between doctors and patients that jeopardizes the opportunities to support smokers to quit [17].

Implementation research recommends addressing organizational constraints in order to overcome executive barriers when the cessation messages are delivered such as lack of time, support, and resources [18,19]. Training programs obtain higher impact and sustainability when they are fostered by organizations that allocate time, promote key champions, and provide implementation materials and resources [20,21]. At the organizational level, the chief executive should endorse the initiative and disseminate this endorsement through senior management meetings and routine communication mechanisms. In addition, an implementation committee led by a champion and members of the executive board should establish a feasible execution plan. Following this strategy, tobacco cessation training programs would better sway professional norms and promote the implementation of smoking cessation services.

In the literature, there are several conceptual training models that exhibit significant heterogeneity [22]. For example, online courses allow for distance-learning, are cost-efficient, and provide modes to teach and reinforce counseling skills that often can be difficult to convey in traditional classroom settings [23,24]. Moreover, online training has clear potential to meet large-scale training dissemination needs. Compared with classroom instruction, online training offers greater learner accessibility, increased convenience, and greater scalability [22]. Previous online tobacco cessation training courses have demonstrated an increase in the health provider's skills to counsel patients on tobacco cessation [16,25,26]. Although there are several distant learning tobacco cessation training programs the majority have been developed and evaluated in English-speaking countries. A recent review on online tobacco dependence treatment training programs (all in English) found that 17 out of the 24 courses evaluated failed to meet minimal quality standards. The authors suggested improving instructional design elements, such as teaching effectiveness, learning strategies, instructor’s role and assessment, and evaluation [27].

Using previously established programs can save time and money while increasing the likelihood of achieving successful outcomes [27]. In addition, research training initiatives have been suggested to increase capacity-building efforts, in particular within developing countries [22]. However, the evidence of distant learning training from high-income countries (HICs) may not be directly applicable to LMICs and may need cultural and content adaptations. Research is needed to develop and understand how best to implement effective smoking cessation strategies in LMICs, especially in resource-poor environments where access to health care providers are limited.

Adaptation implies not only to the replication or translation of a program but to the process of adjusting a program to reduce mismatches between its characteristics and the new context in which it is to be implemented. Adapting a tobacco cessation education program should take into account the treatment regulation of each country, the existing guidance and proceedings, and the dynamics of the health organization [3]. Card et al [28] propose science-based pragmatic steps to adapt an existing program to new contexts based on the following steps: (1) select a suitable, effective program; (2) gather the original program materials; (3) develop a program model; (4) identify the program score components and best-practice characteristics; (5) identify and categorize mismatches between the original program model or materials and the new context; (6) adapt the original program model, if warranted; and (7) adapt the original program materials. To fill the gap of the lack of tobacco cessation training programs in Spanish-speaking LAC countries, we designed the “Fruitful study.”

We selected the ongoing Brief Intervention for Smoking Cessation Training Program from the Catalan Institute of Oncology (ICO) as the baseline program and created a partnership between ICO and three hospitals from Bolivia, Paraguay, and Guatemala to first adapt and later disseminate the course. We intend to increase the capacity-building of the implicated organizations that will ultimately initiate a cascade of change within their countries [29]. Our training is intended to be a vehicle for the systematic dissemination of the clinical practice guidelines for treating tobacco dependence in hospitalized and ambulatory smoker patients.

The purpose of this paper is to describe the methodology and evaluation strategy of the Fruitful Study research protocol intended to adapt, implement, and test the effectiveness of an online, evidence-based tobacco cessation training program addressed to health professionals from Bolivia, Guatemala, and Paraguay.

The primary research goal of the Fruitful Study is to evaluate the impact of an online, evidence-based tobacco cessation training program aimed to increase smoking cessation knowledge, attitudes, self-confidence, and performance interventions among health care professionals of three Spanish-speaking low- and middle-income LAC countries (Bolivia, Guatemala, and Paraguay).

Our primary hypothesis is the participants in the online tobacco cessation training program will increase their tobacco-related knowledge, attitudes, and behaviors by the 6-month follow-up, as compared to baseline conditions prior to the training. Our secondary hypothesis is that participating hospitals will exhibit greater tobacco control progression, commitment, and implementation of tobacco cessation services.

The Fruitful Study is a 2-year mixed-method (qualitative and quantitative) study conducted in one hospital in each of the three participant countries (Bolivia, Guatemala, and Paraguay).

For the quantitative approach, a pre-post design will be used to (1) assess participants’ attitudes, knowledge, and behaviors before and after the training using a questionnaire (Tool 1); and (2) measure the level of implementation of tobacco control policies within the participant hospitals before and after the training using the Self-Audit Questionnaire (SAQ) (Tool 2). For the qualitative approach, focus groups and in-depth interviews of key persons will be used. With this methodology we aim to (1) explore the experience of adapting the training program in each of the participant hospitals; (2) ascertain participants’ experience undertaking the training program; and (3) understand the opportunities and barriers of undertaking online smoking cessation training programs in the participant countries. With the results of the focus groups, the research team aims to identify any difficulties in accessing and completing the course and to make the necessary improvements.

The two main participant units from each organization are students and the hospitals themselves. The participant hospitals were selected because they had previously collaborated with the Training Unit of the ICO in training their health professionals in either electronic learning (e-learning) or in-person courses. The selected hospitals and their characteristics are shown in Table 1.

Student participants were all health professionals and paraprofessional staff from the three participant hospitals. All health providers in the selected hospitals, including nurses, doctors, and other health professionals were invited to enroll in the training. Each local coordinator recruited participants from a variety of units and departments over a 6-month period through informative sessions, leaflets, and posters (designed to inform about the training program).

Descriptive statistics will be used for the quantitative indicators. The quantitative variables will be summarized using means and other central tendency measurements, whereas the qualitative data will be summarized by computing their frequencies and percentages. The qualitative indicators gathered by the qualitative methods (focus groups and interviews) will be summarized using the classical content analysis approach (creating codes and chunks of information and the researcher complements the codes with description of this code). Analysis of the data will be validated by informants to increase the reliability of the data [41].

Usual statistics will be used to describe the sample and non-parametric tests will be used for pre-post comparisons for tobacco control policies (measured by Tool 1) and the trainees’ knowledge, attitudes, and behaviors (measured by the Tool 2). In addition, a validity and reliability test of both instruments is planned.

Based on literature regarding gains of training [27,40], we anticipate an increase of 40% in health professionals’ level of knowledge, attitudes, and perception in tobacco cessation from baseline to 6 months. Given this estimate, we will need a minimum of 43 participants per hospital, (total 129, alpha=.05, beta=.1, and 15% dropouts). However, we expect at least an overall enrollment of 300 professionals (100 per hospital).

We will consider a good level of coverage of the training program if at least 50% of the enrolled health professionals in each hospital conclude the training program. We will measure the engagement of the training program with the focus groups and key informant interviews. We anticipate that hospitals will increase their tobacco control policies by 20% to 30% according to the SAQ. In addition, we anticipate that health professionals’ level of knowledge, attitudes, and perception in tobacco cessation will increase to 30% to 40%.

Health professionals and paraprofessional staff from the three countries will be invited to voluntarily participate in the project. We will be able to determine whether the recruitment process used by each coordinator affects both the number of participants recruited and the commitment to start and finish on time. We hypothesize that as they agree to join, they will be highly motivated to pursue the course and we expect many of them to succeed on their own. However, participants may have varying levels of computer skills and Internet usage that could affect their course enrollment and progression. Online training programs also require devices for their use (ie, computers, tablets or mobile phones with app capabilities) and a high speed Internet connection. Although Internet services and technological devices are rapidly growing in low-income countries [42] it may not be the same as in HICs. Nevertheless, the course could be followed by these platforms facilitating the connectivity among users (tablets, mobile phones) being able to complete the training program at home or in their working hospitals. We foresee that many of the students will be using mobile phones as their primary access to the course, because mobile phones are more accessible in these countries than computers [42]. Furthermore, the participants could have different knowledge in smoking cessation interventions within participant hospitals and among the different countries. This could make comparisons among participant countries very interesting. The fact that we included baseline and post-intervention evaluations will permit the evaluation of these differences.

According to a paper by Ng et al [43] tobacco use in these three countries is decreasing at a slower pace than in developed countries. Furthermore, tobacco cessation services have been poorly implemented in these countries [5] mainly because of the lack of knowledge and skills of health providers, difficulty to ground tobacco cessation interventions in health care organizations, and lack of working groups and leaders on this topic [6]. Online education in tobacco cessation might be the solution to provide evidence-based treatment for tobacco dependence in these countries because it is cost efficient and can reach remote locations. Most of the existing smoking cessation training programs have been designed in HICs and are available only in English [27]. Nevertheless, the process of spreading new learning approaches requires cultural and content adaptations that require reviewing whether the material and examples are applicable to the new target group [44]. To our knowledge this is the first study that tests the feasibility and effectiveness of implementing an online smoking cessation training program addressed to health care providers in Bolivia, Guatemala, and Paraguay. We thus consider this study approach innovative because (1) it adapts a straightforward smoking cessation training program through an online platform addressed to all hospital workforce levels (from doctors, nurses, and assistance personnel) of three LMICs in LACs; (2) it applies an organizational model in LACs to promote smoking cessation training within the organization; and (3) it evaluates its impact using quantitative and qualitative methods from the individual level (by measuring students’ knowledge, attitude, and behavior gains before and after the training) to an organizational level by measuring whether the organization has increased tobacco control policies before and after the training. Moreover, facilitators and barriers of implementation will be evaluated by using focus groups and in-depth interviewers to key people involved in the project.

It is for these reasons that the methods and results of Fruitful Study may offer a new approach to adapt and implement programs to LMICs countries in order to offer education solutions through the use of emerging and growing communication technologies.

It is critical to develop distant learning programs to train health workers in tobacco cessation in LMIC where opportunities for continuing education are scant and sometimes not well adapted to the reality of their contexts. This study will show whether it is possible to adapt and implement an online course in developing countries. In addition, we will determine how best to implement effective distant-learning strategies in organizations belonging to LMIC, especially to detect what resources and aids are required to make the training possible in all levels of the workforce. Finally, we will measure whether the training program will increase knowledge, attitudes, and perception in tobacco cessation among participants and will produce changes in tobacco control policies at the organizational level.