d&i research in “non-health” or lower- resource …...d&i research in “non-health”...
TRANSCRIPT
D&I Research in “non-health” or lower-resource settings Shiriki Kumanyika, PhD, MPH Elva Arredondo, PhD Debra Haire-Joshu, PhD
MT-DIRC Summer 2018
Harold L. Paz, M.D, M.S., Executive Vice President and chief medical officer at Aetna
April 2015https://news.aetna.com/2015/04/%EF%BB%BF%EF%BB%BFbeyond-doctors-office-health-bigger-health-care/
“Americans spend more on health care than any other country in the world, yet all that spending does not translate into long, healthy lives. Not even close. Despite spending $2.87 trillion a year on health care, Americans die earlier than the people of 36 other countries. And even within the United States, there are significant differences state by state, even county by county, drawn along cultural, racial and economic lines.
…Why? The answer is simple: health care is not the only thing determining our health. It’s not even the most important thing. In fact, when you look at all the factors that determine how well and how long we live, health care itself ranks quite low on the list. These factors collectively are called the social determinants of health, and they emphasize why we must look beyond health care treatment if we want to truly improve the health of the nation.
“Non-health care settings matter!
Implications for MT-DIRC and D&I field
Critical need for D&I research outside of formal health-care settings Access and sustainability
Universal prevention; context-dependent learning
Post-discharge care
Increasing body of evidence relevant to non-health-care settings Messier research Limited guidance for translating current D&I frameworks for “non
health-care” settings Potential to identify or develop new frameworks
“Prevention” includes community-based care for secondary and tertiary prevention of the chronic diseases that are common in the otherwise healthy population
What types of interventions are delivered in these settings?
Weight management programs
Violence prevention Physical activity programs Support groups Environmental and policy
changes
Health promotion Health education Screenings Immunizations Other health services Smoking cessation Alcohol treatment
What are the settings?
Schools Worksites Religious institutions Social service organizations Multi-purpose settings Large, well-funded voluntary organizations Low-resource community-based organizations Homes
What differs or varies differently between health care and non-health care delivery settings as D&I research contexts?
Readiness for implementation Evaluability Stability (moving target) Types of delivery
staff/messengers Mission alignment Culture and values Credibillity
Availability of EBIs Type of organization Structure and infrastructure Type of leadership Volunteer vs. paid staff ROI for health interventions Resources Types/characteristics of
stakeholders
Current directions Culturally-specific implementation frameworks
Oetzel J, Scott N, Hudson M, Masters-Awatere B, Rarere M, Foote J, Beaton A, EhauT. Implementation framework for chronic disease intervention effectiveness in Māori and other indigenous communities. Global Health. 2017 Sep 5;13(1):69.
Participatory implementation frameworks Ramanadhan S, Davis MM, Armstrong R, Baquero B, Ko LK, Leng JC, Salloum RG,
Vaughn NA, Brownson RC. Participatory implementation science to increase the impact of evidence-based cancer prevention and control. Cancer Causes Control. 2018 Mar;29(3):363-369.
Coproduction Batalden M, Batalden P, Margolis P, Seid M, Armstrong G, Opipari-Arrigan L,
Hartung H. Coproduction of healthcare service. BMJ Qual Saf. 2016 Jul;25(7):509-17.
Equity-focused research proposal review Kumanyika S. Getting to Equity in Obesity Prevention. A New Framework. Available
at: https://nam.edu/getting-to-equity-in-obesity-prevention-a-new-framework/. 2017.
Promoting health in faith-based organizations
Why promote health in churches?
• FBO’s are among the most-trusted organizations in minority populations
• Personnel resources (volunteers, church staff)
• Physical resources (rooms)• Values that support healthy
living• Attendance/reach
– Access to marginalized populations
• US adults36% (weekly) 30% (a few times/month)
• Latinos39% (weekly) 35% (a few times/month)
• African American47% (weekly) 36% (a few times /month)
Religious Attendance (high reach)
PEW Report, 2016
Team(Study)
Health Behavior
Implementers Framework Population General findings
Wilcox, et al.,2018(Faith, Activity, & Nutrition)
Diet and physical activity
Community health workers
CFIR (Structural Model of Health Behavior guided intervention); RE-AIM
AfricanAmerican churchgoers (different denominations;R=59 churches)
Intervention churches reported greater PA opportunities and lower inactivity; no difference in meeting PA or FV guidelines by group
Allen, et al., 2016(CRUZA study)
Cancer (breast, cervical, colorectal)
Health committees supported by an Intervention specialist
CFIR Latinochurchgoers(R=31 churches)
All parishes increased the number of cancer control activities
Santos et al.,2014(Project HEAL)
Cancer (breast, prostate, colorectal)
Community health workers
RE-AIM African American churchgoers(R=15 churches)
Web-based methods to disseminate and implement EBIs showpromise with CHWs
Allicock, et al., 2012 (Body & Soul)
Fruit and vegetable intake
Church coordinators and volunteer peer counselors
RE-AIM AfricanAmerican churchgoers(R=15 churches)
The disseminated program did not produce improvements in FV intake equal to the original study
Faith-based D&I health promotion programs
FBO’s are difficult to connect with and recruit
– Distrust of medical research and scientific institutions
– Church’s mission is faith building, not health promotion
– Lack of financial and support resources
Barriers to Implementation and Dissemination
Lack of organizational support
Holt et al., 2017; Beard et al., 2016; Arredondo, et al, under development
• 2010-2017• Faith in Action (Fe en Acción) was a
two-group randomized controlled trial that intervened at multiple levels to increase physical activity among churchgoing Latinas.
• Church members (promotoras) were hired and trained to implement a physical activity intervention in their churches and nearby communities.
16 Participating Churches:Holy SpiritHoly FamilyChurch of the ResurrectionSt. Francis of AssisiSt. Peter the ApostleSt. Mary Star of the SeaSt. John of the CrossHoly TrinityChrist the KingSt. AnthonyOur Lady of AngelsOur Lady of the Sacred HeartOur Lady of Mt. CarmelMission San Luis ReyOur Lady of Guadalupe (CV)Our Lady of Guadalupe (SD)
Faith in Action: Multi-level FBO intervention
Table 1: Mixed effects models evaluating intervention for primary and secondary outcomesCondition Diff (inter-control)
Intervention Control
Adj Mean SE Adj Mean SE Diff in adj p-value
MVPA (accelerometer) 4.93 0.05 4.78 0.03 0.15 .03
Leisure time MVPA self report 4.86 0.05 4.47 0.09 0.39 .003
BMI 30.2 0.14 30.6 0.14 -.40 .03
Waist circumference 95.2 0.5 96.5 0.5 -1.3 .08
Behavioral strategies for PA 4.84 0.21 3.77 0.16 1.07 <.0001
Calories from fat 29.5 0.2 29.5 0.2 0 .97
1Mixed effects or generalized linear mixed models were used to adjust for the clustering effects of churches and to account for repeated measures over M2 and M3. If the time by condition interaction term was not significant, the term was dropped and the condition main effect was tested. All analyses were adjusted for the baseline measure of the outcome, age, marital status, employment and education.2 Negative binomial error distribution. Results are shown in logged units. 3 Binomial error distribution (Logistic model)
Faith in Action: 12-month results
Arredondo, E.M., Elder, J.P., Haughton, J., Slymen, D., Sallis, J., Perez, L., Serrano, N., Parra, M., Valdivia, R., & Ayala, G.X. (2017). Fe enAcción: Promoting Physical Activity Among Churchgoing Latinas. American Journal of Public Health. 107(7):1109-1115. doi: 10.2105/AJPH.2017.303785
Beard M, Chuang E, Haughton J, Arredondo, EM. Determinants of Implementation Effectiveness in a Physical Activity Program for Church Going Latina Women. Fam Community Health. 2016,39(4):225-33.
Aim: To identify church-specific factors affecting implementation of Fe en Acción.
Implementation substudy
Implementation ClimateLeadership support
Resource availability
Implementation Effectiveness
Innovation Values Fit
Priest makes mass announcements, demonstrates knowledge of program, etc.; Staff places announcements in the bulletin, etc.
Church leaders report having space to conduct exercise classes, time to promote program, etc.
Church leaders report that Faith in Action coincides with the mission of values of the church
Average participation rates in physical activity classes by enrolled participants during the first 6 months
Helfrich C, Weiner BJ, McKinney MM, Minasian L. Determinants of implementation effectiveness: adapting a framework for complex innovations. Med Care Res Rev. 2007;64(3):279-303.
Complex Innovation Implementation Framework (CII)
• Church recruitment: Five churches from the physical activity intervention participated
• Participants: 15 key stakeholders were interviewed (closed and open ended interviews)
– Associated with their respective churches for an average of 10 years.
• Data analyses: Two independent coders
• Outcome variable=high vs. low participation rate
Implementation substudy: Methods
New
Implementation substudy: Results
• Use organizational-based frameworks – Need to advance organizational theory
• How to more effectively implement program activities (web based vs. traditional)
• Demonstrate the level of support needed (technical, involvement of other organizations) to implement and sustain program activities
Considerations for D&I FBO research..
Obesity Prevention
Background: new focus on obesity prevention Focus of past two decades--childhood obesity: 6-11 yrs.
(17%)Current: prevalence doubles in young adults: 20-39 yrs.
(34%)
Males vs. FemalesWhite- 29% and 33%
Hispanic- 33% and 43%
Black- 33% and 57%
Average annual weight gain 0.5-1kg per year
Ogden et al, JAMA, 2016, Dietz WH, JAMA, 2017, Lewis CE, et al, Am J Epidemiol. 2000
Availability Accessibility
Affordability Convenience
Reach
Challenges• Generally healthy, busy with careers,
child rearing• Low participation health programs
Solutions• Take interventions to young adults• Make relevant to place, context,
current life• Non-health partners
How to access young adults
Ali K, et al. Health Affairs, 2012 Tabak R, et al. Translational Behavioral Medicine, 2015
Ackermann R et al, AJPH, 2015
• Parent education, child development, school readiness
• Home visiting program• Free through federal-state
funds• Prenatal to kindergarten• Parent educators trained on
evidence based curriculum• Nationwide network• 2200+ sites; 270,000 parents;
340,000 children
Parents As Teachers National Organization
Long-term partnership
1996
Stakeholders: national and site leaders, educators, parentsTranslate obesity prevention to routine practice Add-on vs. embed evidenceMeet state and federal funding requirements
AA Parents of infants1997-01
Rural parents &
preschoolers2002-06
Teen mothers2006-11
Haire-Joshu et al, Prev Med 2004 and 2006; Obesity 2010; Prev Chron Dis 2010; Haire-Joshu et al, AJPM, 2018; Cahill et al, Obesity, 2018
Parents of infants
2001-02
HEALTH: OW/OB
mothers of at risk
preschool children2012-17
LIFEMOMS: Pregnant
OW/OB AA mothers2013-18
2000 2005 2010 2012 2013
Healthy Eating & Active Living Taught at Home (HEALTH) Test impact of the Diabetes Prevention Program-derived
lifestyle intervention embedded within usual PAT curriculum
When compared to usual care, HEALTH women will be more likely to achieve and maintain 5% wt. loss at 24 months
Number of visits = average 10; up to 25 per year based on need
Length of visits ~60 min Visit guided by curriculum--based on parent needs
How and what to embed within practice
Facilitators: goal to do best for the families Barriers: consistency with mission, training,
time, reimbursementPAT implementationCounseling by parent educators Meet with parent-child in home Parent educators determines
needs/approach Engage in interactive support and
educationOutcome: parenting skill, child
development, school readiness
Implementation phase• Embed within usual practice• Visit fidelity (self report,
observation, audiotape): UC=97%; Int=87%
• Number of visits within usual practice: UC=13; Int=23 (p<.0001)
• Avg. length of visit per group = 63 minutes (NS)
• Participant satisfaction: UC=84%; Int=90%
Planning phase• Advisory group-PAT National
Center • Focus groups: parents, parent
educators, site leaders• Pilot intervention
HEALTH Planning and implementation
Total(No. = 179)
Usual Care(No. = 97)
Intervention(No. = 82)
p-value
Age (yr), mean (SD) 32 (6) 33 (5) 32 (6) 0.91*Race (%):
Black or African AmericanWhiteOther/unknown
32%59%9%
31%61%8%
33%56%11%
n/a
Presently married, No. (%): 61% 61% 61% 0.98‡WIC or other program assistance (%) 51% 46% 58% 0.14‡BMI (kg/m2), mean (SD) 34.4 (5.2) 34.5 (5.2) 34.4 (5.3) 0.91*
HEALTH demographics
Haire-Joshu, et al, AJPM, 2018
Effects of a Modified ‘Parents as Teachers’ (PAT) Home-based Intervention in Mothers of Pre-School Children
Haire-Joshu et al, Am J Prev Med 2018;54(3):341
Adj Δ=4.7 kg, p=0.002
Where do we go from here?Longer-term partnership
1996
AA Parents of
infants1997-01
Rural parents &
preschoolers2002-06
Teen mothers2006-11
Haire-Joshu et al, Prev Med 2004 and 2006; Obesity 2010; Prev Chron Dis 2010; Haire-Joshu et al, AJPM, 2018; Cahill et al, Obesity, 2018
Parents of infants
2001-02
HEALTH: OW/OB
mothers & preschool children2012-17
LIFEMOMSPregnant OW/OB AA mothers
2013-18
2000 2005 2010 2015 2020
HEALTH D&I2018-23?
Disseminating & Implementing a Lifestyle Based Healthy Weight Program in a National Organization
Lessons learned
Partnerships take time, work, patience, and flexibilityOrganizations are dynamic…change is constantPlanning needs to involve ALL of the key players-top
to bottomContent should fit within the organizational mission
and fundingResearcher knows evidence: Stakeholders know
practice Timing is everything
Lessons learned
Pay attention to context!Use a context-relevant framework
Questions?