+

Laura SalinasKeene State College Dietetic Intern

Independent Study Project

+What is an independent study?

Opportunity to work on a public health initiative & practice: Project management skills Critical thinking Research skills: collect, analyze, and professionally report

data

Goal of the project is to have the intern play an independent role and be a valuable member of the team working on the project.

+Today… Developing my research question

Background Community-based needs assessment

Methods Literature Review Developing measurable indicators Implement Strategy

Results

Discussion Monitor and adjust outcomes and processes

Future plans

+Developing my research question

“When implementing a health promotion program in community settings, what do we need to understand about patient activation to increase engagement and health confidence?”

+Background: Needs Assessment

Cardiovascular disease is the leading cause of death and disability in the US Accounted for 597,689 deaths in 2010

(CDC 2011) Unfavorable cholesterol levels contribute to risk for CVD 52.5% Adults in the US reported getting cholesterol screenings

regardless of risks (CDC, 2009)

Informed, engaged, and empowered individuals are more likely to share in decision making with their providers and take responsibility for their own health

+Methods: Literature Review

 Extensive PUBMED, and EBSCO search

15 peer reviewed articles Activation levels and/or self-efficacy measures How to increase health confidence or self-efficacy Community-based health promotion programs

When implementing a health promotion program in a community Empower the individual to make their own goals Develop their own perception of how advocating for their own health

could be beneficial

It is imperative for the facilitator in community settings to put power in the hands of the participants!

(Attree et al., 2011; Laverack , 2006; Lubetkin, Lu, & Gold, 2010; Rohrer, Wlshusen, Adamson, & Merry, 2007)

+Methods: Literature Review PAM: Patient Activation Measure:

“More activated patients were more likely to report better health, self-manage conditions, exercise regularly, eat healthy, and research health matters.”

This tool is helpful in developing a tool to measure pre/post self-efficacy and activation of individuals. A valid, reliable tool to measure activation is a gateway to gain a

better understanding of activation and how it can be increased in the community.

Follow-up activation short term may not provide results that would be seen in a more longitudinal study

(Hibbard, Stockard, Mahoney, & Tusler, 2004)

+Patient Activation Levels

+Methods: Literature Review, continued

There is not a ceiling for activation In a group randomized controlled trial that compared

a traditional health promotion program group an activated consumer program group a control group

Activation levels of the activated consumer group increased over 2-year interval On average 4.31 increase

Lowest activation levels saw greatest improvements From 44.2 to 61.5, on average Improvements occurred in all levels

Even very activated individuals (highest level at baseline) have been shown to improve health related behaviors through activating health promotion programs

(Harvey, Fowles, Xi, & Terry, 2012)

+Methods: Literature Review, continued

While developing tools to measure self-efficacy Perceived motivators and barriers

Cultural Social – Isolation? Norms, socioeconomic status, access to resources

Motivational interviewing through a focus group Effective way to determine self-efficacy Easier to determine individual’s barriers and motivators

(Tucker et al., 2011)

+Methods: Literature Review, continued

Unintended consequences should also be considered. Negative Effects?

Patient activation and health literacy are not interchangeable terms. Cross-sectional study: health literacy did not correlate with

activation This is promising!

Could mean that activation measures does not depend on education as much as community support and resources.

(Lubetkin, Lu, & Gold , 2010).

+Methods: Cholesterol Park for Seniors

“Raise your health IQ” Interactive exercise to increase IQ

Promotes an effective relationship between the community and health providers during health care decision-making

Can Cholesterol Park sessions increase self-efficacy and confidence?

+Methods: Developing Measurable IndicatorsEvaluation Tool: Pre/Post Surveys

By using tools that have been evaluated as effective Effective Consumer Scale (EC-17) Decision Self-Efficacy Scale

Facilitator Post-Survey was developed to determine confidence to facilitate change and increase engagement.

+Evaluation Tool:Effective Consumer Scale

University of Ottawa

Scale to measure “how effective people are at dealing with chronic health conditions and making decisions about their health care”

17 items measuring the main skills and behaviors people need to effectively manage their health care. To be used in trials of self-management or empowering patients

How I use my health information (3) How I clarify my priorities (3) How I communicate with others (3) How I work with the health care team to control my condition (4) How I decide and act on decisions (4)

+Evaluation Tool:Decision Self-Efficacy Scale

The Ottawa Hospital and the University of Ottawa

“The ‘Decision Self-Efficacy Scale’ measures self-confidence or belief in one’s abilities in decision making, including shared decision making.”

Confidence in making an informed choice 11 questions on the scale

3 for our pre evaluation 3 for our post evaluation

http://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Decision_SelfEfficacy.pdf

+Methods: Developing Measurable Indicators

Today’s Date: _________ Location of session: __________

Circle one: Male Female Age: ___________

Zip code: __________________

Do you have high blood pressure, high cholesterol, and/or diabetes? Yes No

+Methods: Developing Measurable IndicatorsPlease answer the following BEFORE today’s session.

Never Rarely Sometimes Usually Always

1. I know how to adapt general health information to my own situation.

2. When I make decisions about my health, I am clear about what matters most in my life.

3. I know how to ask my provider good questions about my health.

4. I am able to take part in decisions about my health with my health care team

5. I feel confident that I can get the facts about the medication choices available to me.

6. I feel confident I can understand information enough to be able to make choices about my health

7. I feel confident that I can ask for advice regarding my health.

8. I feel confident in making decisions about my health.

+Methods: Developing Measurable IndicatorsPlease answer the following BEFORE today’s session.

Never Rarely Sometimes Usually Always

1. I know how to adapt general health information to my own situation.

2. When I make decisions about my health, I am clear about what matters most in my life.

3. I know how to ask my provider good questions about my health.

4. I am able to take part in decisions about my health with my health care team

5. I feel confident that I can get the facts about the medication choices available to me.

6. I feel confident I can understand information enough to be able to make choices about my health

7. I feel confident that I can ask for advice regarding my health.

8. I feel confident in making decisions about my health.

+Methods: Developing Measurable IndicatorsPlease answer the following BEFORE today’s session.

Never Rarely Sometimes Usually Always

1. I know how to adapt general health information to my own situation.

2. When I make decisions about my health, I am clear about what matters most in my life.

3. I know how to ask my provider good questions about my health.

4. I am able to take part in decisions about my health with my health care team

5. I feel confident that I can get the facts about the medication choices available to me.

6. I feel confident I can understand information enough to be able to make choices about my health

7. I feel confident that I can ask for advice regarding my health.

8. I feel confident in making decisions about my health.

+Methods: Developing Measurable IndicatorsPlease answer the following AFTER today’s session.

Never Rarely Sometimes Usually Always

1. I understand the facts I receive about my health.

2. I can set sensible goals to improve my health.

3. I feel confident in stating my concerns to my health care team.

4. I feel a sense of control over my health.

5. I feel confident that I can figure out health choices that best suit me.

6. I feel confident I can get the facts about risks and benefits of my health choices.

7. I feel confident that I can express my concerns about health choices.

8. I can negotiate with my health providers about how we manage my needs.

+Methods: Developing Measurable IndicatorsPlease answer the following AFTER today’s session.

Never Rarely Sometimes Usually Always

1. I understand the facts I receive about my health.

2. I can set sensible goals to improve my health.

3. I feel confident in stating my concerns to my health care team.

4. I feel a sense of control over my health.

5. I feel confident that I can figure out health choices that best suit me.

6. I feel confident I can get the facts about risks and benefits of my health choices.

7. I feel confident that I can express my concerns about health choices.

8. I can negotiate with my health providers about how we manage my needs.

+Methods: Developing Measurable IndicatorsPlease answer the following AFTER today’s session.

Never Rarely Sometimes Usually Always

1. I understand the facts I receive about my health.

2. I can set sensible goals to improve my health.

3. I feel confident in stating my concerns to my health care team.

4. I feel a sense of control over my health.

5. I feel confident that I can figure out health choices that best suit me.

6. I feel confident I can get the facts about risks and benefits of my health choices.

7. I feel confident that I can express my concerns about health choices.

8. I can negotiate with my health providers about how we manage my needs.

+Methods: Developing Measurable IndicatorsFacilitator Post Survey

Date: _____________ Location of Session: _________________________ 

Age: ___________

Answer the two questions below with 1 being not very certain that the group you facilitated was helped and 5 being very certain that the group was helped

1. I feel certain that I helped most of the individuals in my group to feel more empowered in managing health information and taking part in decision-making about their health.

2. I feel certain that I helped most of the individuals in my group to feel more confidence in making informed choices about their health.

+Methods: Implement Strategy

8 facilitated Cholesterol Park sessions (Average 3 participants/session)

Trained Facilitator for each session

While implementing Merck Cholesterol Park, it was very important to create an environment that promotes self-efficacy by starting with very achievable steps to promote early success.

Control Group: seniors attending lunch at the senior center (1 lunch with 28 participants)

+Methods:Data Collection Total Surveys

Participant Group: 28 Control Group: 28

% Female Participant Groups: 85.7% (1 no response, 85.7-89.3%) Control: 60.7% (3 no response, 60.7-71.4%)

% with conditions Participant Groups: 57.1% (2 no response, 57.1-64.3%) Control: 39.3% (6 no response, 39.3-60.7%)

Average Age Participant Groups: 70.7 years Control Group: 77.3 years

+Results:

Participant Group: Group Effective Consumer Scale

Average Pre-Evaluation = 4.3 Average Post-Evaluation = 4.4

Group Decision Self-Efficacy Scale Average Pre-Evaluation = 4.4 Average Post-Evaluation = 4.3

Control Group Group Effective Consumer Scale

Average Pre-Evaluation = 4.2 Average Post-Evaluation = 4.1

Group Decision Self-Efficacy Scale Average Pre-Evaluation = 4.3 Average Post-Evaluation = 4.2

+Methods:Data Collection Facilitator’s Perspective:

Average: 3.75 for both questions Age Range: 23-50 years

Age SE-1 SE-2

Senior Center 50 4 4

Winchester 50 4 3

Railroad Housing 25 4 4

East Side Housing 24 4 4

Cheshire Medical 50 5 5

Page Homestead 23 5 5

Warwick Meadow 50 2 3

Troy 24 2 2

Average 3.75 3.75

+Discussion:Correlation of decreased Self-Efficacy in BOTH groups

Could the questions set up decrease?Regardless of activation?

Only increase, on average: Participant Group: Group Effective Consumer Scale

Average Pre-Evaluation = 4.3 Average Post-Evaluation = 4.4

Participant group more activated than control in Pre-Evaluation Showing up - Raise their health IQ Younger Females Health conditions: Diabetes, Hypertension, High Cholesterol

If so, it is important to get older adults to their screenings!!

+Discussion:

Effectiveness of activation is not easily measured within an hour especially with older adults

On the scale of behavior change: If older adults were in pre-contemplation, self-efficacy may decrease with awareness

“Older adults with chronic disease experience meaningful increases and decreases in patient activation over the course of a year, without any intervention… Clinicians and researches who use PAM as an outcome measure in studies of older adults should be aware of its natural fluctuation over time in chronically ill older persons”

(Chubak et al., 2012)

+Recommendations for the future:

Even very activated individuals (highest level at baseline) have been shown improvements in health related behaviors through activating

health promotion programs in a 2-year interval.

We had 1 hour

This supports continuing intervention further, even if seniors are activated their health-related behaviors can change.

Provide incentives for seniors to participate

Advertising: Healthy snack? Tea time?

Motivational Interview Training for facilitators

The most commonly recurring message through the literature review was the need for more research towards understanding how to increase activation levels of individuals in the community level.

+Patient Activation Levels

+Questions?

Comments?

Thank You!

Laura Salinas

+ResourcesAttree, P., French, B., Milton, B., Povall, S., Whitehead, M., & Popay, J. (2011). The experience of

community engagement for individuals: a rapid review of evidence. Health & Social Care In The Community, 19(3), 250-260.

Laverack, G. (2006). Improving health outcomes through community empowerment: a review of the literature. Journal Of Health, Population, And Nutrition, 24(1), 113-120.

Lubetkin, E., Lu, W., & Gold, M. (2010). Levels and correlates of patient activation in health center settings: building strategies for improving health outcomes. Journal Of Health Care For The Poor And Underserved, 21(3), 796-808.

Rohrer, J., Wilshusen, L., Adamson, S., & Merry, S. (2008). Patient-centredness, self-rated health, and patient empowerment: should providers spend more time communicating with their patients?. Journal Of Evaluation In Clinical Practice, 14(4), 548-551.

 Hibbard, J., Stockard, J., Mahoney, E., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Services Research, 39(4 Pt 1), 1005-1026.

Harvey, L., Fowles, J., Xi, M., & Terry, P. (2012). When activation changes, what else changes? the relationship between change in patient activation measure (PAM) and employees' health status and health behaviors. Patient Education And Counseling, 88(2), 338-343.

Tucker, C., Rice, K., Hou, W., Kaye, L., Nolan, S., Grandoit, D., & ... Desmond, F. (2011). Development of the Motivators of and Barriers to Health-Smart Behaviors Inventory. Psychological Assessment, 23(2), 487-503.