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?