Community Health Workers as an Intervention Implementation Strategy in Health Promotion Research

Transcription

1 Community Health Workers as an Intervention Implementation Strategy in Health Promotion Research Lisa Quintiliani, PhD Assistant Professor of Medicine November 29, 2016

2 What is a Community Health Worker? Individuals who share a relationship with their community who are not professionally trained/licensed who serve as a bridge to health care services and/or health promotion services AHRQ, Outcomes of Community Health Worker Interventions, No. 09-E014

3 Community Health Workers Those who share one or more attributes with target population called peers Age Language Race/ethnicity Medical condition Peers can provide effective support due to their insider knowledge

4 Roles of Peers 1) Assistance in management of health behavior How to test blood glucose 2) Provide social/emotional support Overcome/cope with barriers 3) Linkage to health services Referral to community programs; schedule appointments 4) On-going support Maintain relationship over time 5) Behavioral counseling, Systematic, evidenced-based =Peer Counselors Peers for Progress, peersforprogress.org

5 Efficacy of community health worker interventions Clinical outcomes Blood pressure control (Browstein), hemoglobin A1c (Long) Health behaviors: diet (Keyserling) Review involving 53 studies with community health workers by AHRQ (Viswanathan) Overall support for use of community health workers, although results were mixed for behavior change and health outcomes Interventions targeting weight management were limitied

6 My program of research with peer counselors Diet and physical activity behaviors Trial with non-traditional college students peer counseling (Quintiliani, 2016) On-going trial among residents of Boston s public housing developments

7 Nontraditional college students Large and growing population of college students Attend part-time, work full-time, have dependents, are usually older Tend to face different social and physical environments compared to traditional college students

8 Study design 2 group randomized trial with 2:1 randomization Setting: Large, urban university 7 college students began training, 4 completed and served as peer counselors current or recent undergraduates 3 MI telephone calls focused on 4 behavioral topics using paper-based guide Primary outcome Diet and physical activity (self-reported)

9 Participant characteristics Variable Intervention (n=40) Comparison (n=20) Total (n=60) Age, mean (SD) 32 (10) 32.3 (10) 32.2 (10) Gender, % female Hispanic/Latino, % Race, % White % Black % 2 or more races % other Single, % Employed, % Children to support, % Medicaid, % Food stamps, %

10 Behaviors at Baseline Variable Intervention (n=40) Comparison (n=20) Total (n=60) Fruits & vegetables, mean (SD) servings/day 3.5 (1.7) 4.6 (1.7)* 3.9 (1.8) Sugary drinks, mean (SD) fl ounces/day 24.9 (29.3) 15.1 (17.5) 21.6 (26.3) Fast food, mean (SD) visits/week 2.8 (3.2) 2.6 (3.8) 2.7 (3.4) Mod-vigorous physical activity, mean (SD) min/week 221 (238) 192 (135) 212 (210) *=significant difference b/t intervention and comparison groups

11 Intervention Dose Most (78%) intervention group participants completed at least 2 peer counseling calls 42% received all 3 calls

12 Change in behavior Variable Fruits & vegetables, mean (SD) servings/day Change from baseline Intervention (n=37) Change from baseline Comparison (n=17) Effect size 0.8 (1.6) 0.09 (1.3) 0.2 Favors intervention Sugary drinks, mean (SD) fl ounces/day -6.8 (29.4) -0.5 (17.1) 0.01 Favors intervention Fast food, mean (SD) visits/week -1.5 (2.7) -1.3 (2.8) 0.1 Favors intervention Mod-vigorous physical activity, mean (SD) min/week % meeting rx at follow-up -7.2 (200) (187) Favors comparison

13 Next steps How can we creatively combine computer-based technologies with community health workers to improve prevention of chronic disease (and implementation in the process)?

14 Fidelity in intervention design & delivery Technology could assist in increasing fidelity related to training and delivery for CHWs Consistency of delivery between interventionists & participants Motivational interviewing as a case study Preserving the spirit of MI without sacrificing consistency of delivery of core components Community health workers supported by an ehealth program to enable standardized, evidenced-based behavioral counseling using motivational interviewing Resnick et al., 2005; Hecht et al., 2005

15 Weight management intervention using community health workers Setting: Public housing developments

16 Study objective Determine if peer counseling using ehealth program demonstrates preliminary efficacy and feasibility Two-group trial, 74 per group Comparison group = brief tailored feedback report Intervention group = brief tailored feedback report + 12 weeks of MI-based phone counseling from a peer counselor using ehealth program

17 Community health worker-based intervention Peer counselor training 2 counselors living in housing developments and surrounding communities Behavioral counseling using small changes approach 12 sessions (in-person & phone) Text messaging Use ehealth program called CuesWeight Bennett et al., 2009; 2012 & Lutes et al., 2013

18 CuesWeight Structured guided content Wording suggestions Sentence stems for reflections Flexible enough for adding your own spin Additional suggestions & questions Useful for training, delivery of sessions & quality assurance activities

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20 Usability sessions User informants (n=3) 1-3 sessions Think aloud protocol Perceived usefulness and perceived ease of use Range of 1 (best) to 7 (worst) 1.7 for both scales

21 Layout of session content Feedback Motivation assessment & goal setting Educational topic Importance/Confidence Social context

22 Like the idea of goal setting/letting them pick their 3 behaviors Asterisks for exact language sections are good

23 radio button for reflection is a good reminder for the counselor

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25 Summary of Measured Trial Outcomes Measure Source Baseline 3 mo.f/up Acceptability among participants & counselors Fidelity of implementation # sessions reaching MI proficiency # completed sessions Efficacy BMI (weight/height) Diet (F&V, fast food, sugary drinks) Physical activity Mediation Self-efficacy, motivation, social support Qualitative interview session review database Obj. measured Survey Accelerometer X X X X X X X X X Survey X X Socio-demographics Survey X

26 Efficacy of community health worker interventions CHW interventions have the potential to address two fundamental Blood pressure imperatives control (Browstein), improving health hemoglobin care in A1c the United (Long) States: the need to address substantial and persistent Health behaviors: health care diet disparities (Keyserling) and the need to translate more research into practice. CHWs, by virtue of Review involving 53 studies with community health their role as a bridge to the health care system, can help workers by AHRQ (Viswanathan) to disseminate widely efficacious interventions to For behavior change and health outcomes, results were populations that rarely benefit from health care mixed advances. (Viswanathan) Clinical outcomes

27 Need for the study of the implementation and dissemination of peer counseling programs Translating from research to practice = less control & resources; but potential for wide impact Research Tested Intervention Programs

28 Implementation science Implementation science can help us better understand issues surrounding roll out, adoption, and upkeep of these interventions in community based settings Case study: Body & Soul

29 Case study: Body & Soul RTIPs website Community-based program, setting/population is African American church members Diet (fruit and vegetables) outcome Positive results from earlier efficacy studies led to support from NCI and ACS to spearhead for further implementation

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31 Body & Soul intervention Intervention: Pastoral involvement Incorporation of health into sermons Educational activities Opportunities to sample & prepare fruit & vegetables Church-wide environmental changes establishing guidelines for the types of foods served at church functions or changing snacks served at youth camps Peer counseling Peer counselors are trained and conduct at least two motivational counseling calls Resnicow, 2004

32 Efficacy/effectiveness of Body & Soul Training and technical support provided to staff, but limited researcher involvement Baseline to 6 month follow-up Approximately 1 serving increase in intervention churches vs control churches (Resnicow)

33 Body & Soul: Dissemination study Positive results led to the dissemination study Disseminated directly to the target audience Without researcher or agency support in training or (planned/structured) technical assistance 15 churches, with a predominately African American membership Church coordinator identified in each 8 randomized to intervention and 7 to control RE-AIM used as evaluation framework

34 Intervention churches Church coordinator selected planning team and together implemented intervention activities Including identifying & training peer counselors Peer counselor training video: view&productid= Peer counselor handbook Peer counseling coordinating guide

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36 RE-AIM results Implementation of peer counseling Took 1-2 months post-baseline to complete training Peer counselors found video to be culturally appropriate & appropriate religious images Allicock, 2013, 2010

37 Implementation of peer counseling 2 of 11 churches completed full training Most only completed about half of the training 7 conducted a follow up training Only a few coordinators reviewed training materials prior to training Barriers were logistical: recruiting, scheduling, preparation work Lower than expected exposure to intervention likely had impact on lack of intervention effectiveness 1/3 of participants recalled speaking to a peer counselor

38 Facilitators to use of peer counselors/community health workers in dissemination efforts Support for intervention fidelity Technology-based approaches Technical assistance Supporting those implementing the intervention Maintain motivation to participate by removing barriers Master trainers or organizations that could share lessons learned with new settings Organizational readiness to adopt programs Allicock 2010, 2013; Weiner 2009

39 Conclusions Community health workers offer significant opportunities to reach health disparity populations & provide standardized, evidenced-based behavioral counseling for health promotion Dissemination and implementation potential could be enhanced with computer-based technologies Future implementation science efforts should focus on studying adoption and spread of interventions

40 References Brownstein J, Chowdhury F, Norris S, Horsley T, Jack L, Zhang X, Satterfield D. Effectiveness of community health workers in the care of people with hypertension. American Journal of Preventive Medicine. 2007;32(5): Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans a randomized trial. Annals of Internal Medicine. 2012;156(6): Keyserling T, Hodge C, Jilcott S, Johnston L, Garcia B, Gizlice Z, Gross M, Savinon C, Bangdiwala S, Will J, Farris R, Trost S, Ammerman A. Randomized trial of a clinic-based, community-supported, lifestyle intervention to improve physical activity and diet: The North Carolina enhanced WISEWOMAN project. Preventive Medicine. 2008;46(6): Viswanathan M, Kraschnewski J, Nishikawa B, Morgan L, Thieda P, Honeycutt A, Lohr K, Jonas D. Outcomes of Community Health Worker Interventions. Evidence Report/Technology Assessment No AHRQ Publication No. 09-E014. Rockville MD; Resnicow K, Kramish Campbell M, Carr C, McCarty F, Wang T, Periasamy S, Rahotep S, Doyle C, Williams A, Stables G. (2004). Body and Soul. A Dietary Intervention Conducted Through African-American Churches. American Journal of Preventive Medicine, 27(2), J Nutr Educ Behav Nov-Dec;44(6): doi: /j.jneb Epub 2012 Mar 9. Evaluating the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges for dissemination and implementation research. Allicock M 1, Campbell MK, Valle CG, Carr C, Resnicow K, Gizlice Z. Allicock M, Campbell MK, Valle CG, Barlow JN, Carr C, Meier A, Gizlice Z. Patient Educ Couns Oct;81(1):37-42.Evaluating the implementation of peer counseling in a church-based dietary intervention for African Americans. Weiner BJ. A theory of organizational readiness for change. Implementation Science :67