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Gaining insight into the implementation of an
e-learning smoking cessation course in Latin
American countries
Ana Vides-Porras
1
, Paula Ca´ ceres
2,†
, Assumpta Company
3
, Olga Guillen
3
,
Martha Alicia Arrien
4
, Yolanda Castellano
5,6
, Merce` Margalef
5,6
,
Wendy Yantuche
7
, Esteve Ferna´ ndez
5,6,8,9
, and Cristina Martı´nez
5,6,9,10,11,
*;
the Group of Hospital Coordinators in the Fruitful Project
1
School of Social Sciences, Universidad del Valle de Guatemala, 18 Av. 11-95 zona 15 Vista Hermosa III,
Guatemala 01015, Guatemala,
2
Radiation Oncology Department, Instituto de Cancerologı´a y Hospital
Dr. Bernardo del Valle S., 6 Av 6-58 Z-11, Guatemala,
3
E-oncologia Unit, Institut Catala` d’Oncologia-ICO,
Av. Granvia de L’Hospitalet 199-203, 08908 L’Hospitalet de Llobregat, Barcelona, Spain,
4
Instituto
Oncologico del Oriente Boliviano de Santa Cruz de la Sierra Av. Marcelo Terceros Ba´nzer, Santa Cruz de
la Sierra, Bolivia,
5
Tobacco Control Unit, Cancer Control and Prevention Programme, Institut Catala`
d’Oncologia-ICO 08907,
6
Cancer Control and Prevention Group, Institut d’Investigacio´ Biome`dica de
Bellvitge-IDIBELL, Av. Granvia de L’Hospitalet 199-203, 08908 L’Hospitalet de Llobregat, Barcelona, Spain,
7
Oncologic Surgery, Instituto de Cancerologı´a y Hospital Dr. Bernardo del Valle S, Guatemala,
8
Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, C. Feixa llarga s/n, 08907,
9
Consortium for Biomedical Research in Respirarory Diseases (CIBER en Enfermedades Respiratorias,
CIBERES), Madrid, Spain,
10
Department of Nursing: Public Health, Mental Health and Maternal and Child
Health, Faculty of Medicine and Health Sciences, Universitat de Barcelona, L’Hospitalet del Llobregat,
Barcelona, Spain and
11
Philip R. Lee Institute for Health Policy Studies, University of California San
Francisco, 3333 California St., Ste. 265, San Francisco, CA 94118, USA
*Corresponding author. E-mail: cmartinez@iconcolgia.net
†
Deceased.
Summary
Continuous medical education focused on health problems emerging in low- and middle-income
countries (LMICs) is scarce. Although tobacco consumption is increasing in LMICs, there is a lack of
tobacco cessation training programs in these countries. To promote smoking cessation interventions
in Bolivia, Guatemala and Paraguay, we adapted an e-learning program developed in Catalonia
(Spain). This process evaluation study reports on reach, dose and satisfaction of participants with the
course, as well as the contextual factors of its application. We conducted a multiple method evalua-
tion, which included a survey and several focus groups, each one specific to the same type of health-
care professional (nurses, doctors, other professionals). Two hundred and ninety-two participants reg-
istered into the online course. The motivation for undertaking the course was different between
doctors and nurses. The main sources of difficulty in enrolling and finishing the course were the
V
CThe Author(s) 2020. Published by Oxford University Press. All rights reserved.
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Health Promotion International, 2020, 1–14
doi: 10.1093/heapro/daaa054
Article
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technical problems experienced when accessing the platform, and lack of acquaintance with com-
puters and the Internet in general. Our results show that implementing e-learning education in hospi-
tals from LMICs is feasible, especially when there are similarities between participating countries and
the country in which the original program was developed. However, several elements such as strong
organizational commitment, technical support and resources and adequate communication channels
should be provided to facilitate enrollment and training completion. Efforts to improve Internet access
should be made to avoid jeopardizing students’ motivation to enroll and complete online training.
Key words: training, e-learning, distant learning, tobacco, low- and middle-income countries
INTRODUCTION
During the last decades, the tobacco epidemic has fallen in
many developed countries thanks to the application of sev-
eral policies embraced by the World Health Organization
(WHO) Framework Convention on Tobacco Control
(FCTC) (WHO, 2013). However, tobacco use has risen in
middle- and low-income countries including the Latin
American and Caribbean (LAC) region (Mayor, 2009).
Currently, more than 120 million smokers live in these
countries (Muller and Wehbe, 2008); half of them will de-
velop a tobacco-related disease, and consequently, they
will require medical care (Zack, 2002).
In the LAC region, smoking rates vary by country,
sex and socio-economic status (Tong et al., 2011;OPS,
2014). In some low-income countries, however, such as
Bolivia, Guatemala and Paraguay, smoking rates are
10% higher than the rest of LAC countries (Ponciano-
Rodriguez, 2010). Thus, among men, smoking preva-
lence ranges from 42% (in Bolivia) to 22.0% (in
Guatemala) (WHO, 2011).
Bolivia, Guatemala and Paraguay signed the WHO
FCTC early on, and have implemented some tobacco con-
trol measures, including smoke-free legislation (according
to the WHO FCTC Article 8). However, smoking cessa-
tion services (Article 14) have not received the same recog-
nition and attention (OPS, 2014). Smoking cessation
interventions are hardly available (Toll et al., 2014), while
the most common barriers to incorporating tobacco cessa-
tion interventions into hospitals involve lack of training,
expertise and time (Ponciano-Rodriguez, 2010).
Most doctors and nurses report that they have not re-
ceived formal training in smoking cessation during un-
dergraduate nor graduate education (Bello et al., 2004).
Previous research has demonstrated the value of training
in increasing the likelihood of assisting patients in quit-
ting (Carson et al., 2012). These training programs ob-
tain higher impact and sustainability when they are
fostered by organizations that allocate time, promote
key champions and provide implementation materials
and resources (Campbell et al., 2011).
Online courses allow distance e-learning, are more cost-
efficient, and provide different teaching opportunities in
resource-limited environments (Abutarbush et al. 2006;
Aggarwal et al., 2011) by reducing inequalities in access to
training and strengthening professional teams in addressing
different health concerns (Salinas et al., 2017). In the last
decade, e-learning in the healthcare sector has become one
of the most prolific continuous education initiatives (Cheng
et al., 2014). Moreover, previous online tobacco cessation
training courses have demonstrated an increase in health
providers’ skills in counseling patients on tobacco cessation
(Schmelz et al., 2010;Carson et al., 2012;Gordon et al.,
2013). Although there are several e-learning tobacco cessa-
tion training programs, the majority have been developed
and evaluated in Anglo-Saxon countries (Selby et al.,
2015). There are still limited reports of provision of dis-
tance e-learning programs in LAC, and a recent study has
shown significant gaps in the use of mobile technologies for
training in these countries (Winters et al., 2019).
Implementing previously designed programs can save
time and money while increasing the likelihood of achiev-
ing successful outcomes (Kassel and Ross 2005;Card
et al., 2011). E-learning smoking cessation training pro-
grams can be modified to fit local necessities (Sarna et al.,
2014). However, to our knowledge, no previous e-learning
smoking cessation training programs have been adapted to
the reality of LAC and no evaluations about factors that
facilitate and hinder them have been conducted.
To fill the gap of the lack of tobacco cessation train-
ing programs in Spanish speaking LAC countries, we
designed the ‘Fruitful Project’, aimed at adapting and
implementing an e-learning program developed in the
Catalan Institute of Oncology (ICO) to the reality of
healthcare organizations and professionals of three
Latin American countries (LACs) (Bolivia, Guatemala
and Paraguay) (Martı´nez et al.,2017a,b).
For the adaptation process, we used the Card’s adap-
tation framework, detecting the mismatches between the
original training program and the characteristics of each
of the participating countries (Bolivia, Guatemala and
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Paraguay). The adaptation process was devised to tailor
the training program to the characteristics of each par-
ticipating country. The mismatches identified between
the ‘original’ and the ‘adapted’ versions of the training
program/s were reported are listed below (Martı´nez
et al.,2017a,b):
•Language background and literacy level in some of
the terms used: The course was in Spanish from
Spain, and the Spanish spoken in Bolivia, Guatemala
and Paraguay differs somewhat with respect to vo-
cabulary, expressions and to some degree, grammati-
cal structure.
•Description of the epidemiology smoking in Model
1: The original version included information on
smoking-related situations in Spain, whereas the
adapted version included the most updated data in
Bolivia, Guatemala and Paraguay.
•In Module 4, tobacco cessation pharmacological
treatment (nicotine replacement therapy, bupropion,
varenicline) and settings where tobacco prevention
and cessation services are performed in Spain (pri-
mary care, hospitals, quit lines, etc.), were adapted
to the current resources in each country.
•In case studies, the clinical simulations demonstrate
the cultural characteristics of each country.
•Questions and answers of the assessment and evalua-
tion were also changed according to the adapted
contents.
Second, we employed the Roger’s Diffusion of
Innovations Theory to plan the dissemination of the
training within the organization. Roger described diffu-
sion of innovations as the process by which an innova-
tion is communicated through certain channels over
time among members of a social system (in our case the
hospitals) (Rogers, 2003). Because Roger’s Theory pon-
ders communication as a key element for disseminating
and implementing innovations through the influence of
different stakeholders in the system, we gave coordina-
tors, liaisons and other actors an important communica-
tion role in our project. In addition, in each country we
employed different communication channels (emails,
leaflets, word of mouth, etc.) to convey the messages to
the staff.
Theoretical framework of the process evaluation
To understand the effectiveness and diffusion of an in-
novation, it is critical to explore the views of the stake-
holders, including their perceptions about the
innovation, its acceptability, adoption and appropriate-
ness, among other implementation process indicators
(Proctor et al., 2011). Exploring the contextual factors
is of vital importance when the innovation is applied in
a new context. It has been reported that successful im-
plementation of a new program is associated with its ef-
fectiveness (Durlak and DuPre, 2008). Therefore, an
evaluation of the implementation process that includes
the contextual factors and the view of the stakeholders
on the innovation, can facilitate understanding and
explaining the results of the program, while providing
future directions for its sustainability and dissemination.
Consequently, the goal of this paper is two-fold; first,
to evaluate the contextual factors that promote and in-
hibit undertaking a smoking cessation e-learning train-
ing program in low- and middle-income countries
(LMICs) in Latin America; and second, to evaluate sev-
eral implementation outcomes such as the reach, dose,
satisfaction and reasons for completing or not complet-
ing the course. Given that e-learning has become a new
form of higher education, its evaluation needs to under-
take a complex approach (Friesen, 2009) in which the e-
learning program is assessed from different perspectives,
including the value of the platform in terms of content
and also in terms of the experience of its users. User ex-
perience is influenced by many factors that include not
only its content, structure and relevance, but also learn-
ing styles, preparedness and e-readiness (Brooks et al.,
2016). For this reason, we used a multiple method ap-
proach in which quantitative and qualitative methods
were applied sequentially and used together to reach a
comprehensive understanding of the experience of par-
ticipants in the implementation of an online smoking
cessation program (Morse, 2003). The importance of
qualitative evaluation lies in its potential to offer
insights into the perceptions of value, usefulness and
weaknesses held by the users of a given platform.
Furthermore, it also allows for a better understanding of
the criteria used by these users in the assessment process
(Jennifer et al., 2007), providing crucial information for
the implementation of similar programs locally and
regionally.
MATERIALS
The e-learning program
The original program was developed by the online plat-
form e-oncologia (http://www.e-oncologia.org/en/)
(Martı´nez et al.,2017a,b). The final curriculum content
of the ‘Brief Intervention for Smoking Cessation
Training Program’ is composed of four modules, and it
is customized with specific data for each country. The
course provides several materials including slides, online
E-learning smoking cessation course in Latin American countries 3
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tutorials with an expert tutor, recommended readings,
patient cessation brochures, a pharmaceutical pocket
guideline and an organizational recommendation model
to facilitate the implementation of tobacco cessation
services in the hospital setting.
Study setting
The participant hospitals were selected at convenience
because they had previously collaborated with the
Training Unit of the ICO. The selected specialized hospi-
tals included two oncologic hospitals and one respira-
tory hospital. Their characteristics are given in Table 1.
Recruitment
Each local coordinator recruited hospital workers from
all units and departments for over 6 months (from
September 2015 to March 2016) through informative
sessions, leaflets and posters (designed to inform about
the training program), and personalized emails.
Inclusion criteria included working at the hospital and
having an email account.
Procedure
Program evaluation answers questions about a pro-
gram’s effectiveness, and the results can be used to
improve such services. To evaluate the Fruitful Project
we applied the conceptual framework for Continuing
Medical Education conceived by Moore et al. (Moore
et al., 2009,2015).
Design
Multiple-method process evaluation (Proctor et al.,
2011) with two approaches: (i) for the quantitative ap-
proach we conducted an evaluation guided by the essen-
tial elements of Moore’s framework (Moore et al.,
2015) that defined dose or ‘completeness for all compo-
nents’ of the training including completion of the course
(overall and by modules), participation and results of
the evaluation, and satisfaction survey; (ii) for the quali-
tative approach we conducted several focus groups, each
one specific to the same type of healthcare professional
(nurses, doctors, other professionals), to assess the per-
sonal experiences of the participation, including those
who enrolled in the training and finished it, who en-
rolled into the training and did not finish it, who did not
enroll in the training, and those key persons who coordi-
nated the diffusion and enrollment of participants.
Quantitative evaluation
Quantitatively, we used a questionnaire to gather infor-
mation on the students’ profile (demographics, smoking
status and previous training) and a survey after the com-
pletion of the course, which evaluated satisfaction and
knowledge acquisition (composed of 21 questions).
Variables studied included some process implementa-
tion outcomes (Proctor et al., 2011) such as: Reach:We
studied the number of participants in each country by
sociodemographic characteristics including country,
profession (doctors, nurses, other health professionals),
sex (men, women), age (35 years old, >35 years old),
previous training in smoking cessation (yes, no). Dose:
We measured whether students enrolled completed the
training overall and by each of the four modules (yes/
no), and the completion of the exam (yes/no).
Satisfaction: Every student answered a standardized
questionnaire containing nine closed questions and one
or two open questions to grasp their satisfaction. The
satisfaction aspects explored were: (i) Exhaustive devel-
opment of contents (introduction, aims, activities, glos-
sary, etc.), (ii) Clarity and rigor of the content; (iii)
Diversity of learning activities; (iv) Quality of the evalu-
ation tasks; (v) Quality of the learning methodology
employed; (vi) Whether the theoretical and practical
content provided allowed transferability to the work set-
ting; (vii) Layout of the online platform (colors and vir-
tualization); (viii) Whether the online platform was easy
to navigate and (ix) Whether the learning guidelines in-
cluded were clear. Questions were presented on a five-
point Likert-scale, with 5 being ‘completely agree’ and 1
being ‘completely disagree’.
Table 1: Characteristics of the participant hospitals
Hospital Country Type of hospital Workers, nBeds, n
Instituto Oncolo´ gico del Oriente Boliviano
de Santa Cruz de la Sierra
Bolivia Public, urban oncology hospital 359 79
Instituto de Cancerologı´a y Hospital Dr
Bernardo del Valle
Guatemala University, public, urban oncology hospital 300 108
Instituto Nacional de Enfermedades
Respiratorias y del Ambiente (INERAM)
Paraguay University, public, respiratory hospital 746 151
4A. Vides-Porras et al.
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Analysis
Descriptive analyses were conducted on the demo-
graphic data. Main outcome variables were completion
of the modules, completion of the pre- and post-test,
score on the final exam, dose with the course and level
of satisfaction. Furthermore, differences between groups
were tested using the Chi-square test. The significant
level for all the statistical tests was set at 0.05.
Qualitative evaluation
We explored qualitatively the contextual (access) and
personal (motivation, previous training) factors that
played a role in the process implementation such as ac-
ceptability, fidelity, appropriates, and adoption (Proctor
et al.,2011). In particular, and due to the fact that the
project was conducted in LMICs, we focused our scope
on exploring the difficulties associated with access to and
completion of the course. This evaluation was carried
out by external consultants through a total of eight focus
groups in Guatemala (4) and Bolivia (4) (n¼7–9 persons
per group). A total of 62 students participated in the fo-
cus groups (Guatemala ¼28, Bolivia ¼34). Due to lack
of local professionals to carry out this evaluation, the
Paraguay site did not conduct a qualitative evaluation.
The main topics considered were content applicability,
feasibility of interventions and methodological advan-
tages and disadvantages of the training program. We
learned about the participants’ experiences in both loca-
tions, their preferences and, inhibiting and facilitating
factors found throughout the training sessions.
Recruitment and procedure
Participants for the evaluation were selected by the local
coordination teams with whom interviews were held to
define the sample and validate the question guide for the
focus groups. The same question guide was used on
both sites to allow comparison. In both settings, each fo-
cus group was composed of the same type of healthcare
professional (nurses, doctors, other professionals) to
avoid the pressure implicit in participating in a conver-
sation with professionals with higher ranks or status
within the institution (e.g. nurses and doctors).
The participation in the focus groups was completely
voluntary. However, arrangements had to be made to
relieve some of the participants from their daily activi-
ties so that they could participate in the 90-min session.
All the participants took part in the training process;
however, not all of them completed it. All the focus
groups were conducted in the hospitals in a separate
room. Confidentiality was secured through the alloca-
tion of codes to all the participants.
The focus groups in Guatemala were carried out by a
moderator and an observer who also took notes regard-
ing the dynamics and turn taking. In Bolivia, besides the
moderator, there was an observer and a person taking
notes. For all the focus groups, a script in which the
researchers introduced themselves, as well as the dynam-
ics, rules for participating and confidentiality matters
was followed. The first 5–10 min of each session were
used to build rapport and secure consent for audio re-
cording. Session recording began after consent was
granted verbally by participants. In the focus group dis-
cussions, participants were asked questions assessing the
following topics: Means for disseminating the informa-
tion regarding the course and whether they found them
effective; motivation to start and/or complete the course;
demotivating factors; methodology usefulness; content
pertinence and relevance and suggestions.
Analysis
The focus groups were transcribed and then analyzed in
Spanish through the long table method proposed by
Krueger (Krueger, 2015). During this process, the tran-
scribed data was arranged in categories and the informa-
tion on particular categories was compared among
participants to determine the common experiences and
themes emerging from the data (Fossey et al., 2002).
Given that the study encompassed multiple focus groups,
we used constant comparison analysis (Denzin and
Lincoln, 2018) to determine if the same themes emerged
in different groups. To reduce the researcher bias emerg-
ing from having this process performed in two different
countries by two different research teams, for this paper,
the authors worked with both the final reports from both
sites and revised the transcriptions from both sides to
verify that the main categories in the report, were present
in the transcript. This process aided in determining the
level of consensus across groups. The segments of texts
presented in the following sections as well as the analysis,
were translated into English by the authors.
RESULTS
Quantitative
This first Results section describes the reach, dose and
satisfaction of the course among participants.
Reach
Two hundred and ninety-two students registered into
the online training; about one-third of them belonged to
each of the three countries. Within each site, about 30%
of health professionals belonging to the Bolivia and
E-learning smoking cessation course in Latin American countries 5
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Guatemala sites enrolled in the course and only 12.7%
of the professionals from Paraguay. Generally, the ma-
jority of them were doctors (54.3%) and women
(72.1%) (Table 2).
Dose
From all health professionals enrolled, 91.8% com-
pleted Module 1, 88.9% Module 2, 87.0% Module 3,
85.6% Module 4 and 58.6% completed all the modules
and the exam. There were differences between those
who completed the course and the baseline survey versus
those who did not complete it in terms of country and
previous training (Table 2).
Table 3 describes the characteristics of those health
professionals who completed the course and the evaluation
exam by country. We observe differences in the representa-
tion of health professional groups by country and sex.
Thus, the majority of health professionals who completed
the course from Bolivia were nurses (44.7%), while in
Guatemala and Paraguay they were doctors (59.6% and
77.5%, respectively). There is an important difference in
terms of enrollment of men and women, as the number of
female participants is more than twice that of male partici-
pants in both Bolivia and Paraguay. In addition, partici-
pants with higher scores in the final exam test were from
Paraguay (mean ¼84.5 SD ¼12.1) in comparison to
Bolivia (mean ¼79.3 SD ¼15.2) and Guatemala (mean ¼
74.3 SD ¼15.6) (p¼0.007). Doctors obtained higher
scores than nurses and other professionals, but the differen-
ces were not statistically significant.
Satisfaction
One hundred and thirty-four participants took part in
the satisfaction survey, which obtained a high score in
all their dimensions (from 4.4 to 4.7 out of a maximum
score of 5).
Qualitative
This section describes the experiences of the participants
based on six main topics that emerged through the ex-
ploration of responses to seven open-ended questions.
Dissemination of the e-learning course and materials
Most participants got the information on the program ver-
bally through the local program coordinators, despite the
Table 2: Descriptive table of participants according to the completion with the course by socio-demographic
characteristics
Overall Completed Not completed p-Value
n%n%n%
Overall 292 100 171 58.6 121 41.4
Country
Bolivia 107 36.7 78 45.6 29 24.0 0.000
Guatemala 90 30.8 53 31.0 37 30.5
Paraguay 95 32.5 40 23.4 55 45.5
Profession
Doctors 113 54.3 87 51.8 26 65.0 0.287
Nurses 55 26.5 46 27.4 9 22.5
Others 40 19.2 35 20.8 5 12.5
Sex
Men 58 27.9 39 23.2 19 47.5 0.046
Women 150 72.1 129 76.8 21 52.5
Age
35 years old 106 51.0 86 51.2 20 50.0 0.563
>35 years old 102 49.0 82 48.8 20 50.0
Smoking
Smokers 25 12.0 19 11.3 6 15.0 0.773
Former smokers 29 14.0 23 13.7 6 15.0
Never smokers 154 74.0 126 75.0 28 70.0
Previous training
Yes 23 7.9 19 11.1 4 3.3 0.015
No 269 92.1 152 88.9 117 96.7
Completed, completed the 4 modules þexam; p-value, Chi-square test.
6A. Vides-Porras et al.
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use of several means for disseminating the information, in-
cluding emails, posters, flyers, text messages and presenta-
tions. In all cases the information provided was considered
sufficient to inform them about registration procedures.
They also reported having been given close follow-up by
the coordination teams to successfully enroll.
Given that an electronic mailing account was neces-
sary, participants who did not have one, were assisted
by the coordination team members to open one.
We were invited via the internet, they sent us an email.
Mr. XXX invited us to see if we wanted to participate
or not. For the ones who did not have an email account,
he created one.
Motivation
Participants noted three major sources of motivation
(M):
M1: Content applicability. Participants appreciated
the strong relationship between course content and their
daily activities, and the interest in having an institutional
policy regarding tobacco cessation. These factors were
especially relevant for the professional groups (including
medical doctors and other professionals), who also men-
tioned having another course to add to their continuing
education history.
Professionally the program also motivated me because it
is a practical method to approach the patient, sometimes
we say many things and the patient only hears the first
five minutes, it is a practical way to reach them and give
them direct advice. It is an added value I have as a
professional.
For me the main motivation was to have an interna-
tional certification from the Catalan Institute of
Oncology and that speaking the same language would
help us.
M2: Online methodology and gratuity. Participants
in all groups mentioned the flexibility of time and space
as an advantage. However, some people mentioned that
the amount of time they were given to complete the
course was so long that they lost the thread and it was
difficult to start over. The organizers, however, report
that some participants were hostile to the verbal insis-
tence to continue with the course.
The easiest part is to have access through a computer at
any moment, not having to follow a specific schedule. I
did it in the hospital because I am not very fond of tech-
nology and at home, I do not have time to sit on the
computer.
M3: Personal factors. Personal factors included help-
ing a loved one quit smoking, personal growth, and,
Table 3: Descriptive table of health professionals who completed the course and the evaluation exam by country
Overall Bolivia Guatemala Paraguay p*
n(%)
b
n(%)
b
n(%)
b
n(%)
b
Overall
a
171 (100) 78 (45.6) 53 (31) 40 (23.4) 0.001
Profession
Doctors 87 (51.8) 25 (32.9) 31 (59.6) 31 (77.5) 0.000
Nurses 46 (27.4) 34 (44.7) 7 (13.5) 5 (12.5)
Other 35 (20.8) 17 (22.4) 14 (26.9) 4 (10.0)
Sex
Men 39 (23.2) 12 (15.8) 20 (38.5) 7 (17.5) 0.019
Women 129 (76.8) 64 (84.2) 32 (61.5) 33 (82.5)
Age
35 years old 86 (51.2) 29 (38.2) 27 (51.9) 30 (75.0) 0.049
>35 years old 82 (48.8) 47 (61.8) 25 (48.1) 10 (25.0)
Smoking
Smoker 19 (11.3) 11 (14.5) 4 (7.7) 4 (10.0) 0.075
Former smoker 23 (13.7) 9 (11.8) 11 (21.2) 3 (7.5)
Never smoker 126 (75.0) 56 (73.7) 37 (71.1) 33 (82.5)
Previous training
Yes 19 (11.1) 4 (5.1) 5 (9.4) 10 (25.0) 0.414
No 152 (88.9) 74 (94.9) 48 (90.6) 30 (75.0)
a
% per row.
b
% per column.
*
Chi-square test.
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having the opportunity to approach online methodology
for the first time. This was especially common among
nurses and personnel with lower educational levels.
It caught my attention because apart from the fact that I
quit smoking, it helps me help other people, young peo-
ple around me.
Demotivation
Technical difficulties. The main source of demotivation
for all groups was the technical difficulties experienced
throughout the course. All groups reported difficulties in
accessing the portal, the need to retake modules repeat-
edly and the consequent extension of time taken to com-
plete the course. Also, delays in receiving their password
were mentioned and even upon receiving it, it did not al-
ways work. The registration process was perceived as
unnecessarily long due to the initial questionnaire. The
time frame to complete the course was not clear, which
caused confusion in some cases.
Access and format of the information. Despite being
an online course designed to work on tablets and cell
phones, some participants pointed out that it only
worked on computers and not on tablets or cell phones.
When the platform worked on tablets, the interactive
windows did not always work, causing people to read
the information only partially. The audios were also dif-
ficult to hear.
I think the most difficult part for me was that I could
not use my tablet. Because we only have one laptop in
the house for five people, then it was complicated for me
that everybody had to do homework, to do work and
when they vacated it, I was already tired and did not
want to do it. I also could not access all the material on
the tablet, when the evaluation arrived, I would say “but
I did not see that, where was it?” Because the windows
do not open on the device.
The nursing personnel preferred to have the materials
printed out. In Bolivia, the technician in charge facili-
tated printed copies. In Guatemala, although the printed
material was available, few people found out and there-
fore had access to it. This lack of information reflects de-
ficiencies in the communication between participants
and organizers in Guatemala.
I felt that it was better to read on paper than from the
computer, oftentimes I did not have credit (for an inter-
net cafe´ or cellphone), and so if I already had the photo-
copies it was better.
Methodology and technical resources. Regarding the
familiarity of participants with computer use and online
courses, most participants reported using electronic
devices frequently, predominantly smart phones. The
nursing staff was the least familiar with computers and
from this group, the only people who do not have a
computer at home were reported. In these cases, they
took the course in the computer lab at the hospital or at
an Internet cafe near their places of residence. In the
groups of professionals and doctors, everyone men-
tioned using the computer frequently in their daily lives.
In this case, the majority took the course outside the
hospital, except for people who do not consider them-
selves proficient in computer use.
Technical support was important for overcoming the
lack of familiarity with e-learning courses and may ex-
plain why some groups were more successful than others
across sites. In Bolivia, for instance, there was a person
in charge of helping participants in navigating the
course. His support, however, was not only technical.
He formed a WhatsApp group in which he motivated
participants to keep moving along the modules and sent
reminders during the week. This created a sense of com-
munity, especially among nurses, which resulted in high
completion rates.
Despite the technical difficulties experienced, the no-
tion that online methodology favored people in terms of
flexibility prevailed. Regarding the modes of presenting
the information, the nurses reported that the use of case
studies was useful to remember information, since it
allowed for the humanization of the previously studied
content. Also, due to the course dynamics, in case of
questions, people could return and verify if the correct
answers were the ones that were initially picked.
Content applicability. All the groups considered the
e-learning course useful and applicable, professionally
and personally. For the nurses, the most relevant infor-
mation regarded the direct interventions they can per-
form with patients and families. The professional group
was mostly interested in both the diagnostic tools and
motivation to quit smoking, as well as the intervention
strategies provided. The medical doctors indicated that
the most relevant information regarded placing patients
at a certain level of smoking. All the groups reported
having little information about smoking and how to ap-
proach smoking patients and devoting little time to the
matter, although they recognized its relevance. The only
unit where the issue is addressed is radiation therapy,
due to the combined effects of radiation therapy and
smoking. In the case of personnel in the palliative care
area, they mentioned that due to the nature of the work
they do with patients, at the point where people arrive
at this unit, continuing to smoke or not will make little
8A. Vides-Porras et al.
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difference for patients and may even generate family and
personal conflicts.
Personally, I did not know the medications that were
mentioned here. For me it was very useful because now I
know that, I have that (knowledge). I think it is our obli-
gation to guide the patient and we have to get involved
and at least tell them what can be done, even if we do
not have, at that moment, a (specialized) clinic or a
place to refer patients.
Future directions. The different groups believe that
the applicability of the content of the course should be
turned into specific actions locally, individually and in-
stitutionally. The proposed actions range from becoming
an anti-tobacco bastion by disseminating the informa-
tion acquired, to the establishment of a tobacco clinic
that would aid in the mainstreaming of the anti-tobacco
agenda into each of the different units of the hospitals.
By having an institutional policy regarding tobacco con-
sumption, protocols can be designed to implement coor-
dinated actions among all the different levels of
attention and improve the effectiveness of the
intervention.
The challenge this course poses does not end here, get-
ting the certificate, but we need to contribute with this
to society, because that is the biggest challenge and the
biggest goal. Let us be spokespersons before our families
and the community, so that this habit may disappear
and reduce its impact on health. So, as a nurse, what am
I going to say to the community to reduce that impact?
Suggestions
The nurses believe that the content of the course could
be adapted to the tasks carried out by different profes-
sionals within the hospital. For instance, the course con-
tent for doctors could be focused on treatment
prescription, while the course content for nurses could
be more focused on cognitive or behavioral strategies
and following up on treatments prescribed by doctors.
However, the whole group acknowledges that the con-
tents are very applicable to their work context and how
they can be transferred to another context as preventive
measures. Delivering printed materials is seen as a way
of minimizing the technical difficulties associated with
an online platform. The correct functioning of the e-
learning program on tablets or cellular devices was also
seen as a way of improving access.
Even though the phrasing of the material was revised
locally before the implementation, participants in all
groups mentioned having difficulties understanding
them due to lack of cultural pertinence.
The group of organizers suggested the use of incen-
tives and institutional pressure to enforce course com-
pletion, as well as having a tutor that can follow-up
students at different stages. As for the platform, they
proposed to make it much simpler, reducing the pop-up
windows and generating a more intuitive interface. This
group also proposed to locally manage each platform to
avoid delays in provision of passwords and to avoid
technical problems that arise due to the time difference
between Spain and the three countries.
Reasons for not participating or completing the process
Participants that did not take the online course after
having signed up for it, reported technical difficulties as
the main reason for non-completion, including delays in
getting their password and not being able to use their
cellular phones and tablets to access the material.
Others reported having no time to devote to the course
even if they considered that the information was neces-
sary for their daily activities. Participants that did not
sign up for the course reported not having enough infor-
mation regarding the dates and other details on how to
access the material.
Some participants finished all the modules but
did not complete the final exam. Technical difficul-
ties were reported as one of the causes for not fin-
ishing the process. Difficulties in understanding the
questions were also reported, as well as differences
in difficulty levels between the modules and the
exam. The fact that the questions were analysis and
not content based, presented a challenge for some
people.
Some questions were difficult to understand, we could
not interpret the question even if we read it over and
over again.
I believe the course was easy and simple, and the infor-
mation was easy to assimilate, but the evaluation was
very difficult. Even at our level (medical doctors), there
were some questions that were very complicated.
Other reasons for not completing the evaluation
were attitudinal. In some cases, the evaluation process
itself was challenging for some participants, as they
feared they would get a bad grade. Others report they
did not think the evaluation was important, so they did
not put enough effort into the exam as they should
have.
Specifically, it was in the exam, in the final evaluation,
we were afraid of making mistakes and that the perfor-
mance would drop because those grades remained.
E-learning smoking cessation course in Latin American countries 9
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DISCUSSION
Our results reveal the challenges of implementing to-
bacco cessation programs in LMICs from the Latin
American Region through an e-learning platform. From
this pilot study, we gained experience and learned im-
portant lessons that could be of interest for future e-
learning projects in these countries. First, the process of
spreading new learning approaches needs cultural and
content adaptation that implies reviewing whether the
material, the examples, and the language, are pertinent
to the new target group (Wang-Schweig et al., 2014).
Second, e-learning courses in health organizations
should encompass several dissemination strategies to
reach a wide range of audiences (doctors, nurses,
others). Among the diversity of strategies used, invita-
tions through email worked better with doctors, and
personal invitations from key persons from the organiza-
tion increased the participation and engagement of
nurses and other health professionals. Third, health pro-
fessionals from LMIC present a high inter-professional
difference in terms of motivation and commitment to
finishing the online course; thus, while doctors were
used to undertake online courses and finishing them,
nurses and support staff expressed difficulties in enroll-
ing to the online platform and manifested their prefer-
ence to have a mixed methodology in which they can
use an online platform, but at the same time, printed
materials to use when they do not have access to a com-
puter. We observed that this group had less experience
with the use of computers and many of them did not
have a personal tablet or computer in their home so they
were only able to log on into the course by using the
technological resources provided by the hospitals.
Nevertheless, the experience of the Fruitful Project
(Martı´nez et al.,2017a,b) may be a starting point in the
process of undertaking more e-learning programs to
LMIC to offer education solutions with the use of
emerging and growing communication technologies.
We found that a high proportion of healthcare pro-
fessionals completed the four modules of the e-learning
program. However, the completion of all the modules
and the exam was lower than expected in comparison to
health professionals who did the same e-learning smok-
ing cessation program in Catalonia (Spain) (Martı´nez
et al., 2019). Doctors and participants from Bolivia had
higher rates of completion, including the modules and
taking the test, compared to the other two countries. We
also found a significantly greater proportion of partici-
pants who completed the training when online skills
were reported, or external help provided. For instance,
in Bolivia, an information technology (IT) technician
supported health professionals, which resulted in higher
dose to training completion. In addition, a deficient
technology access and problems with the log in of the
platform were reported as a barrier. Other factors that
could explain the dose of the course were learner moti-
vation, leadership engagement, internal communication
and IT support. After the release of the course, several
strategies were also put in place to promote a higher
dose such as personalized email messages, reminder vid-
eos on the platform, messages, in person sessions and
contests to celebrate the World No-Tobacco Day.
Our results are in line with the diffusion of innova-
tion literature that posits that the implementation of a
program is a function of several factors, including the
perceived need to do things differently (Durlak and
DuPre, 2008). In addition, it has been demonstrated—in
research conducted in high-income countries—that sev-
eral contextual and organizational factors could affect
the implementation outcomes including: leadership and
organizational commitment, and individual participant
factors, such as job role and scope (Park et al., 2018).
Unfortunately, there is a lack of online training pro-
grams tested and evaluated in LMIC (Winters et al.,
2019). However, in these countries it is especially rele-
vant to explore these factors qualitatively to learn which
factors could help to understand the adoption of an in-
novation, its sustainability and diffusion. In our case,
several suggestions have been given to improve the fu-
ture diffusion such as providing technical support and
adapting the material to their work responsibilities.
Tobacco use is rapidly increasing in low-income
LACs such as Bolivia, Guatemala and Paraguay (Mayor,
2009). Online education in tobacco cessation might be
the solution to provide evidence-based treatment for to-
bacco dependence in these countries (Selby et al., 2015;
Ye et al., 2018). Mainly, because online education
reaches many learners each time, it is cost-efficient, and
can reach remote locations (Winters et al., 2019).
However, e-learning programs also require devices for
its use—mainly computers—and high-speed Internet
connection. Use of these devices and Internet quality are
rapidly growing in low-income countries (Pew Research
Center, 2015). However, the quality of the service was a
main barrier and source of demotivation, especially in
Guatemala.
Another factor that influenced the dose of the train-
ing was the experience with the use of the Internet
known as ‘e-readiness’, which varied among learners
mainly due to the variability of cultural backgrounds,
disciplines and prior academic qualifications. A study
conducted in Guatemala on hand hygiene showed that
medical doctors presented higher e-readiness scores than
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nurses (Gonzalez et al., 2016). In addition, factors asso-
ciated with e-readiness (access to a fairly new computer,
Internet skills, use of the computer several times a week
and communication skills using online technologies)
have been associated with successful course completion
(Gonzalez et al., 2016). In our case, successful course
completion has been associated with higher educational
levels, having participated previously in e-learning
courses, and having technical support available. In addi-
tion, the figure of a coordinator, who supports the stu-
dents in navigating the course and handles the
administrative aspects of the training locally, shows po-
tential in reducing the drop-out rates due to lack of e-
readiness.
Evidence in the literature suggests that e-learning is a
useful tool for overcoming barriers to access for health
professions’ training (Barteit et al., 2019). However,
providing an e-learning platform is just the first step.
Other limitations related to e-learning are the quality of
the bandwidth, which often contributed to slow speed
and low quality of videos or visual outputs, difficulties
reading or watching content from a computer screen,
slow downloading speed, inadequate computer facilities,
limited access to computers and frequent electrical fail-
ures (Frehywot et al., 2013). These factors have been
pointed out as important threats for participants’ moti-
vation for improving their continuing education
(Fa¨rnman et al., 2016;Protsiv et al., 2016). In these con-
texts, the basic conditions for a successful implementa-
tion need to be secured by the institution by providing,
for instance, enough computers and equipment to in-
crease access. Also, providing different means to get the
materials, such as printing them out so that participants
who do not have access to a computer at home can still
read the material. This may reduce dissatisfaction and
increase course dose. Given that the workload of health
professionals may impede the dedication needed to com-
plete the course (Mendoza Montano, 2016), providing a
short time during the workday to engage with the e-
learning platform may also prevent burdening the staff
even more. This will be especially important to increase
the likelihood of completion for those health workers
who do not possess a computer at home.
While the majority of e-learning health courses have
been addressed to Medical Universities to train future
physicians (Liu et al., 2016), only a small proportion
have been focused on specific continuous medical educa-
tion (Frehywot et al., 2013;Liu et al., 2016). Our
e-learning program, however, addressed all health pro-
fessionals within the participant organizations to obtain
an overall penetration of the learning gained and work
transversally on smoking cessation. Our qualitative
evaluation shows, however, that the motivation sources
for physicians, nurses and other professionals might be
slightly different and that the skills with which partici-
pants begin their training impacts their perceptions on
barriers and benefits of the course. Learning styles may
also vary widely due to educational and personal charac-
teristics, which highlights the need to adapt materials in
terms of content and structure, which may not be possi-
ble in this format (Hortsch, 2015).
Institutional support is critical in sustaining an e-
learning program (Barefield and Meyer, 2013). Our
study supports the need for institutional involvement,
the participation of stakeholders in the design process,
and dedication from the implementation teams. It also
highlights the need for flexibility beyond the design
phase, as different institutions may present different
challenges and needs at different stages. However, effi-
cient communication channels, support for the students
and institutional commitment and awareness, are the
cornerstone of successful implementation. Our evalua-
tion demonstrates that partnership with a high-income
country with similar background and language is an as-
set for achieving the correct implementation of e-learn-
ing training in LMICs. Speaking the same language,
however, does not guarantee a perfect match. In these
cases, the translation of one context to another needs to
consider local idiosyncratic characteristics and linguistic
variation. Our exploration, in general, evidences the fea-
sibility of e-learning projects as a means for providing
medical training in the region. Our experience highlights
that flexibility and adaptability are key to overcoming
barriers to successful project implementation across set-
tings, even if this means losing the possibility of one to
one comparison. As suggested in a recent review, imple-
mentation of interventions and the introduction of inno-
vations in low-income countries frequently thrive under
constraints, but collaborative research (between low-
and high-income countries) is an opportunity to over-
come the difficulties and link organizations globally on
common health problems (Yapa and Ba¨ rnighausen,
2018). Given that low-income countries lack resources
to produce their own material, they should benefit from
the possibility of adapting and testing evidence-based
programs, created in other contexts, to improve services
and practices in their deprived healthcare systems.
Limitations
Our study had several limitations. First, the sample size
was relatively small, and because we conducted the
study in a single center per country, we do not have the
possibility of comparing results within each country.
E-learning smoking cessation course in Latin American countries 11
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Second, we included specific hospitals (two devoted to
oncology and one to respiratory), which are very sensi-
tive to tobacco-related diseases. So, generalizability of
manager, coordinator and health worker motivation
could differ in relation to other types of health centers.
In addition, health professionals from the three coun-
tries were invited to voluntarily participate in the proj-
ect. Thus, whether the recruitment process applied by
each coordinator affected both the number of partici-
pants recruited and the commitment to start and finish
on time, remains an open question. In this sense, the
whole process was adapted to the leadership styles and
installed capacity at each site, which led to very different
managerial decisions and experiences. Moreover, we
were not able to conduct a qualitative study in Paraguay
due to difficulties in finding a qualitative researcher will-
ing to perform the focus group phase. Finally, although
we did not include elements to measure the e-readiness,
we gained insight into the strengths and limitations of
our project through the experiences of participants.
CONCLUSIONS
Our results report the challenges and the opportunities
of implementing an e-learning program in LMIC, show-
ing that this model of education is possible but needs to
consider in advance how to overcome the possible road-
blocks that could jeopardize students’ motivation to un-
dertake the course and engagement to complete it. From
our experience we learned the need to offer technologi-
cal resources (such as computers and appropriate band-
width), technical support (by an informatic facilitator)
and effective communication channels (emails, posters,
personal invitation). In addition, the role of key persons
who act as champions in healthcare organizations in
LMIC organizations is key in generating dynamism and
engagement in an organizational project that implicates
innovation and training.
AUTHORS’ CONTRIBUTIONS
Dr Martı´nez conceived and is the PI of the project and
prepared the contents of the e-learning course and Dr
Ferna´ndez and Dr Company have co-designed the study.
O. Guillen gave technical support with the online plat-
form. Dr Vides-Porras was the consultant of the focus
groups in Guatemala and created the script for the inter-
view with Dr Martı´nez. Dr Vides-Porras and
Dr Martı´nez drafted the first version of the manuscript.
Finally, Dr Arrien and Dr Ca´ceres were the project lead-
ers in their countries.
ACKNOWLEDGMENTS
In my memorial to our colleague Dr Paula Ca´ ceres who passed
away in October 2018.
FUNDING
This study was funded by Global Bridges Mayo Clinic (Pfizer
Medical Group; GB-13520139: Development and
Dissemination of a Tobacco Cessation Training Program for
Healthcare Professionals in Spanish-speaking Countries).
ETHICAL CONSIDERATIONS
All participants were informed about the main objectives of the
study and provided informed consent for their voluntary partici-
pation. This study protocol was approved by the Ethics
Committee of the Hospital Universitari de Bellvitge (PR338/
15).
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