a communication intervention to promote physical activity in underserved communities
DESCRIPTION
A Communication Intervention to Promote Physical Activity in Underserved Communities. Jennifer Carroll, MD, MPH Associate Professor Department of Family Medicine September 20, 2012. Special thanks. National Cancer Institute career development award K07CA126985 - PowerPoint PPT PresentationTRANSCRIPT
A Communication Intervention to Promote Physical Activity in Underserved Communities
Jennifer Carroll, MD, MPH
Associate ProfessorDepartment of Family Medicine
September 20, 2012
Special thanks
National Cancer Institute career development award K07CA126985 Mentors: Ronald Epstein, Gary Morrow, Kevin Fiscella, Jennifer Griggs Advisors: Geoffrey Williams, Nana Bennett, Toni Yancey, Chris
Sciamanna Westside Health Services patients, staff and clinicians Westside Health Services team members
Cheryl Rufus, Louise Smyth, Michele Hannagan, Laurie Donohue Department of Family Medicine Research Programs
Mechelle Sanders, Paul Winters, Holly Russell, Carol Moulthroup University of Rochester Center for Community Health partners
Stacey DeJesus, Candace Lucas YMCA partners
Anja Jabs-Devins, Laura Fasano, Theresa Wing
Public health significance
Health care reform emphasizes provisions for community health centers, prevention, primary care workforce development
Growing adoption of electronic health records nationally
Need to accelerate research into creative partnerships in primary care and community programs to promote physical activity and eliminate disparities in underserved groups
Need for both evidence-based and locally tailored interventions
Background
Patients value advice from their primary care physician about physical activity
Patients want to discuss it Primary care physicians acknowledge the
importance of discussing physical activity YET…
Typical features of physician-patient communication about physical activity
Mean time spent in combined physical activity and dietary discussion in primary care =
Vague, nonspecific advice common Patient cues or attempts to participate often not
acknowledged Inaccuracies in recall (both for physicians and
patients)
Example of physician “advice”
Physician: Are you exercising regularly? Patient: Not like I should. No. Physician: No? All right, I suppose <laughter> that’s
true for most of us. Patient: <Laughter> Physician: Is that <laughter> is that something that
you can start to get into? Patient: <sigh> I’m going to try to do better. Physician: OK. All I ask is that you try, you know, so
and then um a quick question for you. It looks like you’re coming up due for a mammogram.
Example of physician advice
Physician: Okay, now are you exercising regularly? Patient: Okay, no. Physician: Oh I guess it’s kind of hard with four kids. Patient: If chasing four kids count, then yes. But I know that
probably is not on the list. Physician: You know, 30 minutes of dedicated exercise – it
would be great if you could put them in a stroller and just go for a walk.
Patient: Yeah. I probably need to do… I know. I don’t. I be so exhausted by the end of the day.
Physician: I know.
Example of physician advice
Patient: I go to work. I do only work part-time, but once I go to work, I have to pick them right up.
Physician: Right. Patient: But then it’s like, that’s my day. Physician: Yeah. You should take walks all together. Patient: Yeah. Physician: You know, with your younger kids. Patient: Yeah. Physician: How about monthly breast exams. Do you check?
Brief physical activity counseling interventions can be effective
STEP trial (Petrella et al, 2003): physician intensive intervention; increased CV fitness at 6 months
Physician + Health educator, face-to-face plus telephone (Pinto et al, 2005); increased PA and 3 and 6 months
Physician advice + limited assistance (Ackermann et al 2005); increased patient-reported PA
Limited information about interventions for underserved groups
Underserved populations are less likely to engage in sufficient physical activity and thus more likely to suffer a greater burden of disease
There is a lack of evidence that promising clinic-based interventions are translated into practice
Good evidence exists that clinic-based physical activity interventions can be
effective IF Physician involvement is brief Intervention is shared with team, staff,
community partners There is a focus on patient involvement and
action planning, personalized goal setting, problem-solving
There is a shift away from merely Asking and Advising
There is a strategy which integrates clinical counseling with community opportunities
Adapted from Estabrooks et al 2006; Eakin et al 2000; Glasgow et al
Primary Objective Test whether a communication training
intervention for clinicians to encourage physical activity will result in actual use of these communication skills with underserved patients
Secondary Objectives
Assess whether intervention improves patients’ perceived competence for PA Patient report of autonomy supportiveness
of their clinicians Patient recall of 5As discussions clinician barriers to promoting physical
activity
Primary Aim
Test whether a communication training intervention for 15 clinicians to encourage physical activity will result in actual use of these communication skills in 325 underserved patients in the post-intervention period (immediately post and at 6 months follow-up)
Secondary Aims
Aim 2: Assess whether the communication training intervention will improve patients’ perceived competence to adopt physical activity.
Aim 3: Assess whether clinicians and patients believe that the communication intervention is feasible and sustainable and addresses pertinent barriers to promoting physical activity.
Exploratory Aims
Examine potential mediators between the communication training intervention’s primary outcome (use of 5As) and the patient’s perceived competence to adopt physical activity.
Derive effect sizes for the effect of the
intervention on patients’ actual physical activity levels (post-intervention compared to baseline) in a subset of participants.
ARRA Supplement (Sept 2009-Aug 2011) Aims
Aim 1. Evaluate whether linkage to a community-based lifestyle change program (the Healthy Living Program) enhances the Assist and Arrange steps of the 5As in discussions of physical activity in the intervention group compared to controls.
Aim 2. Evaluate the feasibility and acceptability of an electronic health records template for the intervention materials.
Theoretical and conceptual framework
Self-determination theory (approach/delivery of intervention; measures of motivation, competence, and support)
The 5As (the “what” or content of intervention) Patient-centered communication (the “how” or
communication style)
What Are The 5As?
Ask
Advise
Agree
Assist
Arrange
Study schema
Intervention design-key concepts
SDT 5As Patient-centered communication
Promotingautonomysupportive skills forclinicians whencounseling patientsabout physicalactivity
Use of 5As forphysical activitycounseling
Understanding patients’ social context
Increasing clinicianperceivedcompetence tocounsel
Offering support
Encouraging patient participation
Intervention development-general principles
SDT 5As Patient centered communication
Interactivediscussion onstrategies to increaseboth patientmotivation forphysical activity andclinician motivationto raise the topic
Introduction, repetition, andreinforcement of the 5As via didactic presentation, role play, and standardized patient feedback
Role play and group discussion to develop and reinforce supportivelistening & open-ended questions about physical activity
Offering a choice ofcommunityresources for referral
Use of standardized patients to give feedbackto clinicians on PCCskills
Offering a choice ofoptional electronichealth records toolsand eliciting ongoingfeedback
Intervention training
Assessment/measurement
Clinicians Patients Blinded coders
Surveys (clinicians’ perception of supportive environment to counsel; clinician perceived competence to counsel
Surveys (patient ratings ofautonomy support ofclinicians, perceivedcompetence
Coding of autonomysupportiveness(global rating and foreach A)
Interviews (open-ended questions on how intervention facilitated autonomy support, competence
Interviews (open-ended questions on barriers and sources of support, motivation)
Coding of supportive statements, exploration of patient’s social context related to physical activity,encouraging questions, verifying understanding and agreement
Ongoing process evaluation (feedback during trainings)
Coding of contentand quality ratingsfor the 5A’s
Assessment/measurement
Outcome measures
Primary (5As score from audio-recorded patient-clinician office visits)
Secondary (patient perceived competence and clinician autonomy supportiveness; clinician feasibility)
Exploratory (patient follow-through with 5As; use of electronic health records tools, referral rates to HLP)
Process (qualitative and quantitative data from field notes and participation/refusal rates, participation and feedback on intervention, fidelity to intervention)
Inclusion and exclusion criteria Inclusion Criteria Exclusion Criteria
Patient
• Currently enrolled patients at Westside Health Services
• Scheduled for a routine, follow-up, or health maintenance office visit
• Scheduled to see a participating clinician
• 18 years of age or older• Able to provide written informed
consent• Have one or more stable medical
conditions for which activity is not contraindicated
Have a life-threatening acute medical problem which precludes participation
Unable to read and understand English
Clinician • Practicing clinicians (physicians, physician assistants, or nurse practitioners) at Westside Health Services
• Extended absence or planning to move to another practice in the study period
Clinician recruitment and enrollment
Prior approval needed from organization’s Board of Directors, and administrative leadership
Clinicians recruited via in-person presentationChallenge Strategy
Needed to move up timeline to start 3-6 months ahead of schedule
Study site had participated in prior pilot work
Study site “went live” with electronic health records adoption shortly before intervention began
-Intervention materials revised to incorporate into EHR-PI familiar with clinical environment-new/unanticipated additional funding opportunites available
Baseline assessment
Clinician survey (attitudes and beliefs about physical activity counseling; frequency of 5As use; barriers to counseling; confidence in counseling techniques; knowledge of community resources)
Audio-recorded patient-clinician office visits (routine adult visits; chronic/follow-up or health maintenance visits)
Post-visit patient survey (socio-demographic information, physical activity level, perceived competence, autonomy supportiveness, other health behaviors, SF-12, trust, satisfaction with care, checklist of co-morbidities)
Post-visit patient interview (recall of what was discussed in visit, recall of previous communication about physical activity, personal challenges/barriers, sources of strength/support, personal goals for wellness)
Baseline assessment schema
Clinic Staff introduces study to patient
Consent
Visit, audio recorded
Patient completes summary and post visit interview
Patient receives $20 for participation
Challenges to data collectionChallenge Strategy
Clinician schedules very variable -Adjust data collection pace and schedule to work around clinician-Seek continuous feedback from clinician re: burden of participation
Nurse/staff factors -Incentives, reminders-Kudos to champions at staff meetings-Relationship-building, consistency of study staff
Patient factors, e.g., language, medical, time constraints (either very limited or the opposite)
-Ask staff about space constraints, availability of overflow space ahead of time
Interest among non-study clinicians -Offer tools developed for shared use-Invite participation in future projects
Description of intervention
Clinician training intervention, session 1
Review the current guidelines (CDC, ACSM recommendations) for physical activity
Review medical contraindications to exercise Discuss how to translate the physical activity
guidelines to real-world, challenging clinical situations
Motivation Introduction to the 5As
Clinician training intervention, session 2
In-depth discussion of 5As Introduction to low cost community resources
and referral options to promote activity Discussion of ecW activity templates and OS
pages under construction- walk through, get feedback and ideas from group-needs and suggestions for improvement
Clinician training intervention, session 2
example of resource page
Clinician training intervention, session 3
Goal: Practice 5As using standardized patient Practice using and recommending key community
resources for exercise Complete office note using electronic health
records tools Peer-peer feedback
Clinician training intervention, session 4
Goal of Session: 1. Practice 5As discussion with a Standardized Patient2. Explore use of eCW tools to support 5As discussion
Specific Tasks:3. Generate guided patient plan for physical activity4. Make referral to Healthy Living Program5. Practice using physical activity template and Order
Sets for (1) and (2)
Challenges to intervention (clinician training) delivery
Challenge Strategy
Unpredictable delays and freezes in the electronic health record system due to server problems
Organizational advocacy with vendor to improve overall systems functioning
Uncertainty about how to link the tools to diagnosis for charting, coding purposes
Revision to tools to improve linking of diagnoses to PA referral in progress
Lack of responsiveness of electronic health record vendor to assist with tool development
-Ongoing attempts to enlist vendor support-HCNNYS advocacy to leadership
Some tools “clunky”, awkward to use Revision of tools to be quicker, easier to use in progress
Results
Clinician recruitment and enrollment
Of the 16 clinicians at Westside, 2 (NP, PA) were ineligible due to planned relocation or absence from the office.
Of the remaining 14 clinicians, 13 enrolled. One declined due to personal illness/health reasons
Clinician socio-demographic information
69 % Family physicians (n=9) 15% Family nurse practitioners (n=2) 15% Family physician assistants (n=2) Average work experience = 15 years (range 2-33) 75% female, 25% male 66% White/Caucasian, 25% Black/African
American, 16% Asian/Asian American Mean age=50.6 years (range 31-73 years)
How much time, on average, do you spend discussing exercise if the topic comes up?
For what proportion of your overall visits do you provide exercise counseling?
How often do you ask about patients’ current exercise habits?
How often do you ask about patients’ willingness or motivation to change
their activity level?
How often do you discuss the appropriate amount, intensity, and frequency of recommended activity
guidelines?
How knowledgeable are you about identifying local, accessible resources
for exercise for your patients?
Top three clinician barriers to 5As counseling
Too much to do/Not enough time Don’t know how to bill/code for it Don’t know which resources to recommend
CONSORT Diagram (patients)
Patient socio-demographic information, n=325
43 years mean age 75% African American, 10 % Hispanic, and 15%
Caucasian 58.2% had public insurance 32.5 average BMI weight-related co-morbidities include
diabetes (21%) hypertension (49%) depression (32%) osteoarthritis or chronic pain (50%)
Baseline patient-reported physical activity
65% report some physical activity 4 or less days per week
41% exercise 30 minutes or more each time 56% walk as most common form of physical
activity
Patient reported challenges and barriers to physical activity (n=325)
Patient (n=325) sources of support, resources for physical activity
Baseline Post 6 Month Post
3.68
3.94
4.06
Mean mHCCQ Scores
*p=.0096
Patient perceptions of clinician autonomy supportiveness
Patient recall of 5As physical activity discussions
Using a mixed model controlling for clinician as a random effect, the PAEI score increased from 6.8 to 8.4 (baseline to post-intervention, p=0.01).
Baseline Post
6.8
8.4PAEI score
*p=0.01
Patients’ perceived competence for physical activity
There was no change in patients’ perceived competence for physical activity
Mean PCS scores were 3.6 (baseline), 3.7 (post), and 3.8 (six month follow-up) p=0.54
Clinician reported changes in PA counseling
Patient report of clinician problem solving skills
Clinicians report limited knowledge of community resources
Clinicians report low confidence about negotiating a physical activity action planNeg
otiate an
exerc
ise plan
Turn se
t-back
s into le
arning
Help co
pe with
barrier
s (to ex
ercise
)
Integrat
e counsel
ing into vis
it0
0.51
1.52
2.53
3.54
4.5
PrePost
Mean Scores (scale 1-5) 5=very confident
*All were significant
2.8 3.1 2.82.2 2.4
2 2.1
3.23.8
4.3 43.4
4.13.5 3.5
4
PHYSICAL ACTIVITY COUNSELINGMEAN CLINICIAN CONFIDENCE RATINGS
PRE POST
Clinician reported changes in PA counseling, cont.
2.72.4 2.4
1.82.2
22.2
2.82.83.2
32.6 2.7
3.1 3.23.4
PHYSICAL ACTIVITY COUNSELINGMEAN CLINICIAN FREQUENCY RATINGS
PRE POST
1=never, 5= always
Exploratory aimFeasibility of referral to Healthy Living
Program
506 referrals over 3 years Each class has had the maximum number of
enrollees (30) Attrition has been a challenge Among completers, outcomes are promising and
satisfaction is high
Challenges
Challenge Strategy
Attrition in HLP groups Phone calls/outreach, problem-solving, buddy system, transportation assistance, changing location
Imbalance between supply (program spots available) and demand (number of referrals)
Strategic planning, reconfiguration of team roles, improved tracking and clear referral procedures
Financial sustainability Multi-pronged strategy for future fundraising, grant-writing, capitalizing on community and insurance plan partnerships
Summary
A clinician-directed intervention increased patient recall of discussions of the 5As for physical activity, most notably by increasing Advise, Assist, and Arrange skills
The intervention increased patient reports of clinician autonomy supportiveness for physical activity, but not patient perceived competence
Demand as evidenced by referral to the community program was high
Clinician satisfaction was high
Summary, continued
This project used an innovative, interactive set of clinician training strategies including a referral to a community partner
The project focuses exclusively on an underserved population not traditionally well represented in communication research
Limitations
Single geographical site (By design), patients were not followed
longitudinally, rather nested within clinician Patient self-report/recall
Next steps
Evaluate audiorecorded data and compare to patient/clinician self-report for the 5As
whether the 5As correlate with patient enrollment in community exercise programs and physical activity outcomes
Mediational models for SDT constructs and 5As outcomes
Acknowledgements
Special thanks to ▪ the patients and clinicians of who participated in this project ▪ colleagues and staff of the University of Rochester Department of Family Medicine and Family Medicine Research programs
This project was supported by a career development award from the National Cancer Institute, K07CA126985 (PI: Jennifer Carroll). For further information, please contact [email protected]
Thank you for your time and interest!
Questions and comments are welcome!
Thank you for your time and interest!