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Tobacco Free Nurses Website

Web Log Analysis of the First Two Years of the Tobacco Free Nurses Website

Sarna, L., Bialous, S., Wewers, M., Froelicher, E., Wells, M, & Balbach, E. (October, 2007). Web log analysis of the first two years of the Tobacco Free Nurses Website. Online Journal of Nursing Informatics (OJNI), 11, (3) [Online]. Available at http://ojni.org/11_3/sarna.htm

By

Linda Sarna, RN, DNSc, FAAN, Stella Aguinaga Bialous, RN, MScN, Dr. PH, Mary Ellen Wewers, RN, MPH, PhD, FAAN, Erika Sivarajan Froelicher, RN, MA, MPH, PhD, Marjorie Wells, PhD, RN, and Edith D. Balbach, PhD


Abstract

Objective: To describe web traffic during the first two-years of the Tobacco Free Nurses (TFN) website (www.tobaccofreenurses.org), which was developed to provide nurses with easy access to tobacco control information as well as a link to an Internet smoking cessation service, Nurses QuitNet®.

Methods: Examination of two years of using Webtrends® software.

Results: Since its launch in February, 2004, the TFN website has had a total of 403,133 hits, an average of 23,713 page impressions/month, and 1735 unique visitors/month. The average time spent at the site is 9 minutes, and a range of educational material is being accessed. TFN is one of the top sites on Google® on “nurses and tobacco”, averaging 683 hits/day. The resources pages have received the most “hits”.

Conclusions: The TFN website is an important tobacco control resource for nurses and even with a minimal advertising campaign in professional nursing journals, nurses found this resource.


Keywords: Internet, smoking cessation, evaluation, nurses, tobacco control

Introduction

Over half of the IInternet users in the United States, an estimated 60 million people, have used the IInternet to assist them in making critical life decisions in the previous two years . Of the topics searched online, 6% of Internet users in a 2002 Pew survey sought information about how to quit smoking. Although smoking prevalence is declining among US adults, smoking continues to be a major health threat, causing 440,000 preventable deaths a year with 20.9% of the population continuing to smoke . The Internet is thus a useful tool for health education for health care professionals as well as a resource for tobacco dependence treatment . While some studies have evaluated the use of the Internet for smoking cessation , less is known about the Internet as a resource for health care professionals interested in tobacco control.

The purpose of this paper is to assess the first two years of operation of a new tobacco control website (www.tobaccofreenurses.org) for nurses. The assessment of activity on a web site is a recommended strategy for evaluating performance .

As nurses comprise the largest group of health professionals, it is critical to public health efforts on tobacco control that nurses be well informed about tobacco control and smoking cessation efforts. Studies have shown that the 3 million nurses in the US can be effective in tobacco cessation interventions . But, nurses are not realizing their full potential due to a lack of information about resources related to tobacco control, limited training as part of their education, and, thus, limited knowledge and skills for tobacco cessation interventions . Despite a national Clinical Practice Guideline for the treatment of tobacco dependence , few nurses are aware of this resource . Additionally, smoking prevalence among nurses (15% of Registered Nurses and 28% of Licensed Practical Nurses), higher than among physicians, was identified as an important barrier to nursing involvement in tobacco control . As reported by Puska et al , involvement in a smoking cessation program has been positively linked to improved interventions with patients.

Development of the Website

The Tobacco Free Nurses Initiative (TFN) was established with funding from The Robert Wood Johnson Foundation to determine how best to engage nurses in tobacco control and smoking cessation efforts. After a review of the literature and the conduct of a series of focus groups, the TFN investigators determined that the one potential strategy for increasing nursing knowledge and involvement in tobacco control and to support nurses in their smoking cessation efforts would be through the Internet . The Internet has the advantage of being available around the clock on any day of the week, an important consideration given the working schedule of most nurses. Additionally, as a predominately female profession, nurses fit the characteristics (college graduates, women, less than 65 years of age) of those most likely to search online for health information .

In 2004, Tobacco Free Nurses created a website www.tobaccofreenurses.org of tobacco control resources. One key feature of the website was that it provided a link to an Internet-based smoking cessation service. The website is hosted by The Ohio State University. This was the first-ever website to help nurses quit smoking and provide all nurses with resources about tobacco control. Links provide a wide variety of tobacco control resources for cessation treatment, tobacco control policy, research, and international nursing activities. Only links to evidence-based resources, reputable organizations, and training programs are included on the site. Additionally, the website includes a special “Leadership” tab that highlights nursing leaders in tobacco control. These resources are continually updated. Visitors may address questions to the investigators through the website.

Other aspects of the website make it different from existing tobacco control sites and more nurse-centered. These include, 1) an ongoing reference list of articles, updated monthly, focused on nurses and tobacco control in the “library” page; and 2) a link to a premium online cessation service, Nurses QuitNet®, a collaboration with QuitNet®. This computer-tailored smoking cessation program, based upon the Clinical Practice Guideline , utilizes the interactive capacity of the Internet to allow for personalized advice to quit, provides counseling and follow-up, an opportunity to seek advice from expert consultants, in addition to a “nurses-only” chat room. An Internet resource was selected so that all nurses, regardless of work-shift, would have access to an evidence-based smoking cessation intervention. Nurses QuitNet® is accessible by all nurses; those who want support in quitting and those who want additional information about how to best help smokers quit.

Promoting the Website

The TFN investigators, in consultation with the San Francisco-based Public Media Center, developed a media campaign to provide awareness of the TFN initiative and the new website, focusing on its role as a resource for smoking cessation for nurses. The tag line for the campaign was “Our secret weapon against smoking? Each other”. The media material used testimonies and images of real nurses who quit smoking and consisted of print advertisements, posters, brochures and bookmarks. These materials are copyright-free and available for downloading from the website in PDF format. Advertisements (paid and free) have run in major nursing journals in the US, reaching an estimated 2 million nurses. Over the past two years, the media materials were distributed at major nursing meetings in the country and included in presentations by the investigators. In addition, briefing kits containing the media materials and fact sheets on nurses and tobacco were sent to almost 4,000 nursing leaders, tobacco control leaders, and media.

In the US, smoking cessation efforts tend to increase in November, in response to the American Cancer Society’s “Great American Smoke-Out”, and during December and January as part of “New Year’s Resolutions”. We focused on this period for the placement of advertisements in large circulation nursing journals in 2005 and 2006. In January, 2005, results of the focus group study on nurses, smoking, and the work-place, were published . An accompanying press release, including the website address, was distributed to professional and public media. At the same time, two other articles focused on nurses and smoking cessation and the TFN project were published.

Methods

The purpose of this paper is to describe the patterns of use during the first two-years of the TFN website, including indicators of individual use and types of media materials accessed most frequently. Such data will provide information about penetration of the site as demonstrated through web log analysis and preference for certain aspects of the website. The following characteristics were assessed: 1) total number and monthly successful hits on the entire website, 2) total number and average page views (impressions) per month, 3) average number of unique visitors each month, 4) proportion of unique visitors who visited more than once, 5) average visit length, and 6) visits to Nurses QuitNet® per month. Furthermore, the frequency of downloaded media material, and details about server traffic (time per day, days per/week, and weekdays vs. weekend visits) were evaluated. Finally, the Google® Search Engine was used as an indicator of ranking of the TFN website when searching for “nurses and tobacco” or “nurses and smoking”. All data are reported in the aggregate; no specific information about individual use patterns is available. This study was classified as exempt from the Institutional Review Board at the University of California, Los Angeles.

Definitions used for web log analysis

Web traffic was characterized as a) average number of visits/day of weekdays and weekends, b) days of the week with the most and the least traffic each month and the time of day for hits, and c) hours of day of activity (hours are all Eastern Standard Time, EST, and may not reflect actual time of use). As the server may be in a different location than the individual, it is impossible to determine the time of day of activity of the individual. However, this did allow for examination of activity during a 24- hour period. The single day with the greatest number of successful “hits” and the day with the fewest “hits” during the 24-month period identified.

Measures of web traffic

Successful “hits” indicated the number of “hits” on the website, including HTML pages, pictures, forms, scripts, and downloaded files each month. Page views (impressions) per month are the best measure of purposeful “hits” on the site. The daily average is calculated using the number of hits per month by the number of days per month in the log file. These “hits” are viewed as purposeful visits to the site defined as direct access to pages or forms from the server as opposed to accidental hits.

Measures of individual use

The number of unique visitors per month indicated a count using the IP addresses (domain name or cookie). However, as one person could access the site from other computers, and more than one person could access the site using the same computer (e.g. from a work station), this does not allow us to determine the number of specific individuals who accessed the site. Repeat visitors are defined as the proportion of visitors from the same IP address who visited more than once that month. As these data are from monthly reports, it is impossible to determine if the same unique visitor returns each month of if these are new visitors. The average visit length per month is calculated by the number of minutes of each visitor on the site per day.

Access to resources

As the promotion of the Internet cessation service was a key aspect of the project, the number of visits to Nurses QuitNet® was calculated for each month. This number reflects hits on any of the pages linked to Nurses QuitNet® (i.e. with “quit” in the URL). A separate analysis will address the registrants of the cessation program.

Analyses

All data are based upon the web log analysis and reports from Webtrends® software used to monitor the traffic on the website with monthly reports from March 2004 through February, 2006. Due to a technical error, data for the month of April, 2005 was lost and unable to be recovered. Descriptive statistics include means, representing averages across the 23-months of data, summative scores where applicable, and ranges. In the monthly figures, a break in the line was left to indicate the missing April, 2005 data. The proportion of unique visitors visiting the website more than once was based upon the total number of visitors for the site. The most frequently downloaded media materials from the website were rank ordered and included media especially developed for the TFN initiative (brochure, fact sheet, poster, and advertisements). The frequency of downloaded media materials included the total number of times that the file was successfully downloaded. The TFN materials were first available in May, 2004.

Results

Web Traffic Indicators

Since its launch in February, 2004, the TFN website has had a total of 464,229 successful “hits” (an average of 20,184/month) for the entire site. The total monthly page views (impressions) are provided in Figure 1, with the average daily page views displayed in Figure 2. Over the two year period, there were over 124,200 total page views (mean = 5,400/month, range 1,941 to 23,984). The daily page views for the month of January 2005 (Figure 3) was selected to display the activity before and after the press release (January 19, 2005) about nurses, smoking and the workplace . January 19, 2005 was our most active day during the 24-month period with 6,224 successful “hits”, and October 29, 2005 was the least active day with 1 “hit”.

The majority of activity (73.6% of months counted) occurred on three week days (Monday, Tuesday, and Wednesday). Tuesday was the most active day of the week for 38.8% of months, followed by Monday and Wednesday (most active for 4 months each) (34.8% of the months counted). The day per month with the least traffic was Saturday (73.91% of months evaluated), followed by Sunday (21.7% of months). The average number of visitors/day on weekdays (117.6 visitors, 802.2 hits/day) was higher than visits on the weekend (116.2 visitors, 829.1 hits per/weekend), but the site was active all days of the week and the site received “hits” throughout the 24-hour day period each month. The most active hours of the day occurred during a five-hour period mid day (2 – 3pm EST) and the least active were in the early morning (1am –2am EST).

Individual Web traffic Indicators

The number of unique visitors per month is displayed in Figure 4 with the proportion of repeat visitors in Figure 5. The majority visited the site once a month (mean = 78.43%). Approximately 16% (15.85%) visited from 2-5 times, and 2 percent (2.41%) visited six or more times.

The average time spent on the site each month is displayed in Figure 6 (mean = 9 minutes, range 24.6 – 2.51 minutes each month).

The most commonly visited pages were the resources pages (total of 48,987 “hits”). The monthly hits on the Nurses QuitNet® are displayed in Figure 7 (total number of “hits” = 10,887).

The frequency of downloads of TFN media materials is displayed in Table 1. The brochures detailing the TFN initiative and the fact sheets on different aspects of nurses and tobacco were the most frequently downloaded materials. There were almost 2,000 downloads of the copyright-free advertisements that can be used for publication in newsletters and journals.

Discussion

To our knowledge, this is the first publication to describe patterns of use of a website focused on tobacco control for nurses. In fact, we had difficulty in finding other published benchmarks of web traffic for other tobacco control websites, in specific, and health promotion websites in general. Thus, it is challenging to compare our experience with others. In reviewing the longitudinal data, after an initial burst of activity, traffic (page impressions and average daily page views/month) on the website has been relatively consistent for the past year. Our data demonstrate that the site is used around the clock and on every day of the week. Increased use of the site during the early part of the week is similar to the findings of increased calls to a telephone Quitline on Monday- Wednesday as well as increased activity around the beginning of the year . Our finding that most web traffic occurred during the week is similar to the results of Westbrook et al .

Unique visitors are the real test of penetration of a website. The unique visitor log of TFN continues to be consistent at 1000- 1500 per month for the past year. The TFN website is not interactive, but a source of resources and links, thus it is not surprising that we see a lower number of repeat visitors. Furthermore, the website is geared for a specific group of health professionals which has a narrower audience than a tobacco control public health network. Nonetheless, approximately 20-25% of visitors to the TFN website visited more than once per month. The website continues to evolve, with new information and resources, as well as an ongoing listing of publications related to nurses and tobacco control. However, the number of unique visitors may not be expected to significantly increase.

The average visit length during the second year has declined in comparison to the first year, with a minimum of over 2 minutes of viewing suggesting purposeful viewing of the site. The prolonged visit length exhibited in April, 2004, may reflect the time spent in website review and modification by the investigators as we are unable to delete these activities from the web log analyses.

Several factors might have influenced fluctuation in the web traffic to TFN over the two-year evaluation period. Clearly, as can be seen by the dramatic increase in unique visitors in January 2005, the impact of the press release and subsequent public interest about nurses, smoking, and the work place increased visits to the website. The notion that nurses also struggled with tobacco addiction was news. In response to the press release, the investigators were contacted by the general and professional media and provided both television and radio interviews. Several professional nursing newsletters and journals in the US and internationally included commentaries about the new initiative. During this period, the media campaign was intensified through advertisements in multiple nursing journals, the website was introduced at several professional venues, and had a related publication on the nurses’ role in smoking cessation in a major nursing journal that provided continuing education credit . Another event that may have influenced web activity was the TFN receipt of the 2005 American Academy of Nursing Media Award in November of that year with its associated publicity. This publicity might have been responsible for the slight increase in activity (page impressions and unique visitors) because of the publicity given to the event.

Other factors also may have affected decline in web traffic. For example, in June 2005, the Nursing Center for Tobacco Intervention website, with front-page links to TFN was discontinued. Although the TFN advertisements continue, they were not run at the same level as the first year, due to budgetary constraints. The investigators, together with the media experts, opted for a burst of media in the first year (especially in December and January 2005) rather than a smaller but longer presence in nursing journals.

We are unable to determine from these data how the web traffic reflected changes in the number of nurses interested in quitting smoking and using the Internet program for cessation. However, the fact that the page links to Nurses QuitNet® were among the most common sites visited provides an indication of sustained interest. At the same time as the launch of our website, the national telephone Quitline in the US became available, thus providing another cessation resource. As of February, 2006, 1701 nurses had registered on QuitNet®, with 5500 unique visitors to that site in 200 and 9,200 in 2005. Data about these registrants and their quit experiences are being analyzed now. Although the intended audience for the website is nurses, we do not know if only nurses visited the site. Some of the traffic may be the general public as well, especially in response to the press release in January 2005.

One of the strengths of this evaluation is the prospective web log analysis over the two-year period. This allowed examination of changes during the course of a calendar year that coincide with national smoking cessation efforts (i.e. January quit dates). One of the limitations of this type of software is the potential for loss of data, as was demonstrated in the loss of our data during the month of April, 2005. By the time the error was recognized, the data could no longer be retrieved. This was a time for a visible drop in page impressions as well as the number of unique visitors which is challenging to explain. However, since that period, traffic on the website, as well as the number of unique visitors, has remained relatively consistent.

When the domain name (tobaccofreenurses.org) was purchased, attempts were made to purchase all similar names. Ironically, perhaps because of the success of TFN, another “shadow” website has emerged using our name but with a different suffix in the url (not available at the time of our initial purchase). This site links to the tobacco industry (British American Tobacco), to pornography (characterized as French Maid outfits), and does not provide any links to evidence-based smoking cessation resources. This is a cautionary tale for other developers of new health-related websites. As more and more URL suffixes continue to be developed, it will be impossible to prevent such events for occurring but efforts must be made to minimize this risk.

Future research is needed that describes website use over time. The data from this study provide information that might be useful as a benchmark for comparing web activity for other websites. Such data are important in testing theoretical assumptions of information diffusion as well as the most effective components of the website. These data also suggest the importance of ongoing efforts to publicize the availability of web-based resources. This is especially true as people, especially smokers, have fluctuating interests in quitting. Additionally, the need for dissemination of tobacco control information changes in response to external forces such as the Joint Commission of Acute Care Healthcare Organizations inclusion of smoking cessation as an indicator of quality care . The Internet might be a viable option for those who do not have ready access to resources because of limited resources or due to professional demands. Additionally, the Internet provides continual access to private, confidential support. Studies also are needed to evaluate the dissemination of tobacco control content to healthcare professionals through the Internet , and how this vehicle might benefit clinical practice.

The Internet is not for everyone. Evers and colleagues concluded that the majority population is not interested in using the Internet for health behavior change. However, the use of the Internet in healthcare, including retrieval of information for clinical decision making and electronic charting is rapidly becoming a standard of care in hospital settings that can not be ignored, although significant problems still exist .

All health care professionals will be required to quickly adapt to this changing technology. Gosling et al suggest that contextual variables of nursing practice may negatively influence the use of online evidence systems, including the lack of training on use of Internet systems and lack of time. But nurses in leadership positions did use online information for evidence-based practice. In the companion qualitative study, “champions” promoting the use of the online resource were identified as making a difference in the diffusion of information . Such nurse “champions” were found to be essential in developing and promoting tobacco control within professional organizations .

Conclusion

The role of the nurse in tobacco control is changing with increasing expectations for involvement in interventions for tobacco control in general and smoking cessation in particular. This paper provides the first report of web traffic on TFN, a new tobacco control website developed specifically for nurses. The TFN website has emerged as a viable vehicle for communication of tobacco control information to nurses. Increased activity on the web coincided with press exposure as well as public interest in smoking cessation. These data provide benchmarks for comparison that might be useful as other websites are developed.

References


Acknowledgements

The TFN website described in this paper, and the access to the services of Nurses QuitNet®, is provided free of charge thanks to a grant from The Robert Wood Johnson Foundation. We would like to acknowledge the efforts of Judson Dunham, the Webmaster for the site, and the assistance of administrative assistant Ms. Lisa Chang and former Project Director, Dr. Leda Danao for their invaluable contributions to the project.


Table 1. Download frequency of Tobacco Free Nurses (TFN) materials: May, 2004- February, 2006


* Joint Commission of Acute Care Healthcare Organizations, Available, August 05

** Available, Sept 05


Authors’ Bios

Linda Sarna, RN, DNSc, FAAN

Dr. Sarna is a Professor in the School of Nursing, University of California, Los Angeles where she teaches in the oncology nursing graduate program. She is recognized for her research on nurses and tobacco control as well as research focused on the quality of life of people with cancer. Dr. Sarna has been involved in tobacco control through policy efforts at national and international professional nursing organizations. She is the Principal Investigator of the Tobacco Free Nurses (TFN) initiative, funded by The Robert Wood Johnson Foundation, the first ever program in the U.S. to assist nurses with smoking cessation. This program received a 2005 national Media Award from the American Academy of Nursing.



Stella Aguinaga Bialous, RN, MScN, DrPH


Dr. Bialous is the President of Tobacco Policy International.  She provides research and policy consulting services in the area of tobacco control to several national and international health agencies and universities.  Her areas of focus are nursing and tobacco and monitoring tobacco industry activities. She is the co-principal investigator of the TFN initiative.



Mary Ellen Wewers, PhD, MPH


Dr. Wewers is Professor and Associate Dean for Research at The Ohio State University School of Public Health. Her research focuses on tobacco control among underserved groups of smokers.  She is a member of the Expert Panel that has been charged with updating the USPHS Treating Tobacco Use and Dependence Clinical Practice Guideline. She is a co investigator on the TFN initiative.



Erika S. Froelicher, RN, MA, MPH, PhD


Dr. Froelicher is a Professor in the School of Nursing, and Adjunct Professor of Epidemiology, School of Medicine, University of California, San Francisco. Her research includes testing nursing interventions to reduce cardiovascular risk factors, including reduction of smoking cessation. She is a member of the Expert Panel updating the USPHS Treating tobacco Use and Dependence Clinical Practice Guideline. She is a co investigator on the TFN initiative.



Marjorie Wells, PhD, RN, FNP


Dr. Wells is Project Director for the Tobacco Free Nurses Initiative project at the UCLA School of Nursing.



Edith D. Balbach, PhD


Dr. Balbach directs the undergraduate Community Health Program at Tufts University in Medford, MA. She has conducted research on tobacco issues since 1991.Her work is currently focused primarily on organized labor and tobacco. She was a consultant on the TFN initiative.