Lifestyles of the poor and Lifestyles of the poor and underserved:underserved:

Unhealthy Behaviors at primary Unhealthy Behaviors at primary care clinics in Milwaukee, WI – care clinics in Milwaukee, WI –

What can we do?What can we do?Elizabeth Bade, MDElizabeth Bade, MD

Jennifer Evertsen, MSJennifer Evertsen, MSChristine Casselman, MAChristine Casselman, MA

11/12/200911/12/2009

ObjectivesObjectives Review data from service project involving Review data from service project involving

drug and alcohol screeningdrug and alcohol screening Discuss relevant needs for this population of Discuss relevant needs for this population of

underserved patientsunderserved patients Propose research based on this project to Propose research based on this project to

address the issues identifiedaddress the issues identified

BackgroundBackground Wisconsin Initiative to Promote Wisconsin Initiative to Promote

Healthy Lifestyles (WIPHL)Healthy Lifestyles (WIPHL) Began in March of 2006 delivering Began in March of 2006 delivering

services in primary care clinics around the services in primary care clinics around the state – currently in 18 locationsstate – currently in 18 locations

Screening, Brief Intervention, Referral to Screening, Brief Intervention, Referral to Treatment (SBIRT) for at risk drug and Treatment (SBIRT) for at risk drug and alcohol usealcohol use

Each clinic has a health educator who uses Each clinic has a health educator who uses motivational interviewing (MI) to deliver motivational interviewing (MI) to deliver SBIRT to patientsSBIRT to patients

Aurora and WIPHLAurora and WIPHL Aurora began delivering SBIRT services Aurora began delivering SBIRT services

through WIPHL at 3 clinics in 2006through WIPHL at 3 clinics in 2006 Currently still delivering services in 2 out of 3 of Currently still delivering services in 2 out of 3 of

the original clinics and 1 new clinicthe original clinics and 1 new clinic Initially 2 family medicine residency clinics and 1 Initially 2 family medicine residency clinics and 1

family medicine free clinic were involvedfamily medicine free clinic were involved Currently 1 women’s health (ob/gyn) clinic Currently 1 women’s health (ob/gyn) clinic

replaced one of the family medicine clinicsreplaced one of the family medicine clinics

A word about SBIRTA word about SBIRT ScreeningScreening quickly assesses the severity of quickly assesses the severity of

substance use and identifies the appropriate level substance use and identifies the appropriate level of treatment. of treatment.

Brief interventionBrief intervention focuses on increasing insight focuses on increasing insight and awareness regarding substance use and and awareness regarding substance use and motivation toward behavioral change.motivation toward behavioral change.

Referral to treatmentReferral to treatment provides those identified provides those identified as needing more extensive treatment with access as needing more extensive treatment with access to specialty careto specialty care

Motivational Interviewing (MI)Motivational Interviewing (MI) HistoryHistory - - Technique was first developed for use Technique was first developed for use

with alcohol and drug counseling and it’s with alcohol and drug counseling and it’s efficacy is well documentedefficacy is well documented

Motivational Interviewing is a person-centered, Motivational Interviewing is a person-centered, directive method of communication for directive method of communication for enhancing intrinsic motivation to change by enhancing intrinsic motivation to change by exploring and resolving ambivalence.exploring and resolving ambivalence.

MI metaphorMI metaphor It’s like we are both climbing up our own It’s like we are both climbing up our own

mountain. You are trying to reach the top of mountain. You are trying to reach the top of yours, and I mine. It turns out that from my yours, and I mine. It turns out that from my mountain I may have a different perspective mountain I may have a different perspective from yours, so I can help you see things that from yours, so I can help you see things that may not be very clear to you from where you may not be very clear to you from where you are at. But in the end, YOU will make the are at. But in the end, YOU will make the decisions as to how to continue, since it’s your decisions as to how to continue, since it’s your own mountain after all and no one can climb it own mountain after all and no one can climb it for you.for you.

Motivational Interviewing (MI)Motivational Interviewing (MI) MethodMethod – Promotes self-efficacy: helps patients to – Promotes self-efficacy: helps patients to

recognize unhealthy behaviors, overcome barriers and recognize unhealthy behaviors, overcome barriers and set achievable goals, while guiding and educating set achievable goals, while guiding and educating

AdaptableAdaptable – Fosters a partnership with patients, avoids – Fosters a partnership with patients, avoids giving unwanted advice, allows patients to weigh pros giving unwanted advice, allows patients to weigh pros and cons of behavior change in light of their own goals and cons of behavior change in light of their own goals and values and values

Recent studies have shown that MI is also efficacious at Recent studies have shown that MI is also efficacious at behavior change for non-addictive behaviors, specifically behavior change for non-addictive behaviors, specifically helps maintain dietary changeshelps maintain dietary changes

ProcessProcess Brief screen Brief screen

questionnaire once per questionnaire once per yearyear

If answers “yes” to If answers “yes” to either alcohol or drug either alcohol or drug question, full screen is question, full screen is completed –preferably completed –preferably at the point of careat the point of care

Full screen determines Full screen determines “level of risk”“level of risk”

Consists of specific Consists of specific questions regarding questions regarding lifetime substance use, lifetime substance use, and use in the past three and use in the past three months.months.

Helps patients to identify Helps patients to identify health, social, legal and health, social, legal and financial consequences financial consequences of use.of use.

Tobacco Yes No Have you used any tobacco products in the past 30 days?Please circle one number between 1 (do not agree) and 7 (strongly agree) for the following statements: Exercise How many days a week do you get at least 20 minutes of vigorous exercise such as jogging, biking uphill or carrying 50 pounds? 1 2 3 4 5 6 7 How many days a week do you get at least 30 minutes of moderate exercise such as walking fast, biking on a flat surface or mowing the lawn? 1 2 3 4 5 6 7 Nutrition How often do you eat fruits and vegetables. Never Rarely Sometimes Often Do you eat fruit and vegetables all the time every day? Yes No

Brief Screen questionsBrief Screen questions

Brief Screen QuestionsBrief Screen Questions

Males and females Yes No In the last 12 months, did you smoke pot, use another street drug or use a prescription painkiller,stimulant, or sedative for a non-medical reason? Yes No In the last 12 months, did you ever find yourself drinking or using drugs more than you meant to? Yes No In the last 12 months, did you ever think that maybe you should cut down on your drinking or drug use?Males Yes No Please think about the last time you had five or more standard drinks in a day or night; was that within the last three months?Females Yes No Please think about the last time you had four or more standard drinks in a day or night; was that within the last three months?

ResultsResults From 5/29/2007-6/1/2009From 5/29/2007-6/1/2009 Participants all 18 years or older, mean age of Participants all 18 years or older, mean age of

4343 11,742 brief screens, 2,088 full screens11,742 brief screens, 2,088 full screens 60% female60% female 38% white; 30% black; 30% hispanic38% white; 30% black; 30% hispanic

Alcohol and Drug UseAlcohol and Drug Use

Low Risk -26%At Risk- 58%Dependent - 9%Harmful- 6%

Other Unhealthy BehaviorsOther Unhealthy Behaviors

0%10%20%30%40%50%60%70%80%

Exercise

Nutrition

Weight

Tobacco

Depression

Low RiskAt Risk

State/National AveragesState/National Averages In 2007 prevalence of cigarette smoking in the In 2007 prevalence of cigarette smoking in the

United States 19.8% United States 19.8% State Specific Prevalence and Trends in Adult Cigarette Smoking in State Specific Prevalence and Trends in Adult Cigarette Smoking in the United States 1998-2007. the United States 1998-2007. JAMAJAMA. 2009;302(3): 250-252.. 2009;302(3): 250-252.

50% of Americans exercise for 30 minutes less 50% of Americans exercise for 30 minutes less than 3 days per week than 3 days per week Gallup poll May 2009Gallup poll May 2009

Wisconsin is the 25Wisconsin is the 25thth fattest state in the union fattest state in the union with a prevalence of 26%, and an estimated with a prevalence of 26%, and an estimated 2/32/3rdsrds of Americans are overweight or obese of Americans are overweight or obese F as F as in Fat: How obesity policies are failing in America, 2008. Robert Woods Johnson Foundationin Fat: How obesity policies are failing in America, 2008. Robert Woods Johnson Foundation

More resultsMore results Blacks and Hispanics scored higher for both Blacks and Hispanics scored higher for both

gender-specific questions related to “number gender-specific questions related to “number of drinks consumed at one time” and exerciseof drinks consumed at one time” and exercise

Blacks scored higher on weight problems and Blacks scored higher on weight problems and “thinking about cutting back on alcohol/drug “thinking about cutting back on alcohol/drug use”use”

Females scored higher on tobacco and weightFemales scored higher on tobacco and weight Age not related to other health risk behaviorsAge not related to other health risk behaviors

The ConundrumThe Conundrum SBIRT is known to help with alcohol and drug SBIRT is known to help with alcohol and drug

related counselingrelated counseling Other health markers are also important and Other health markers are also important and

puts patient’s health at riskputs patient’s health at risk What can work and fit into a busy primary What can work and fit into a busy primary

care practice?care practice?

MI For Diet and ExerciseMI For Diet and Exercise Some studies suggest Some studies suggest

that MI effective in non-that MI effective in non-addictive behaviors addictive behaviors (Bowen, Resnicow)(Bowen, Resnicow)

Also studies done using Also studies done using MI by health MI by health professionalsprofessionals Adds additional burden Adds additional burden

onto medical staffonto medical staff

Our proposalOur proposal Use the same process as Use the same process as

is used for WIPHL is used for WIPHL projectproject

Address diet and Address diet and exercise with MIexercise with MI

Look for changes in Look for changes in readiness to change, readiness to change, answers to diet and answers to diet and exercise questionnairesexercise questionnaires

Next Steps…Next Steps… Received grant for this projectReceived grant for this project 12 month grant12 month grant Will recruit 150 patients from primary care Will recruit 150 patients from primary care

clinicsclinics Randomized to “high intervention”, “low Randomized to “high intervention”, “low

intervention”, or “usual care”intervention”, or “usual care” 3 month follow up3 month follow up Assess readiness to change and responses on Assess readiness to change and responses on

questionnaires about diet/exercise habits questionnaires about diet/exercise habits

DiscussionDiscussion ““Usual care” doesn’t seem to be effective to Usual care” doesn’t seem to be effective to

promote healthy lifestyle choices in these promote healthy lifestyle choices in these primary care clinics in Milwaukeeprimary care clinics in Milwaukee

Opportunity to provide a useful, low cost Opportunity to provide a useful, low cost intervention that may improve lifestyle habitsintervention that may improve lifestyle habits

Results remain to be seen…Results remain to be seen…

References/AcknowledgementsReferences/Acknowledgements WIPHL team – PI is Rich Brown, MDWIPHL team – PI is Rich Brown, MD Center for Urban Population HealthCenter for Urban Population Health ICTR team for funding our next projectICTR team for funding our next project Additional references on motivational Additional references on motivational

interviewing:interviewing: Burke BL, Arkowitz H, Menchola M. Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-The efficacy of motivational interviewing: a meta-

analysis of controlled clinical trials.analysis of controlled clinical trials. J of Consulting & Clinical Psychol 2003;71(5):843- J of Consulting & Clinical Psychol 2003;71(5):843-61.61.

Miller WR, Rollnick S. Miller WR, Rollnick S. Motivational InterviewingMotivational Interviewing (2 (2ndnd ed.) New York: Guilford, 2002. ed.) New York: Guilford, 2002. Resnicow K, Borrelli B, Ernst D, et al. Resnicow K, Borrelli B, Ernst D, et al. Motivational Interviewing in Health Promotion: It Motivational Interviewing in Health Promotion: It

Sounds Like Something is Changing.Sounds Like Something is Changing. Health Psychol. 2002:21(5):444-451. Health Psychol. 2002:21(5):444-451.