A Communication Intervention to Promote Physical Activity in Underserved Communities

1. A Communication Intervention to Promote Physical Activity in Underserved Communities Jennifer Carroll, MD, MPH Associate Professor Department of Family Medicine September 20, 2012

2. 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 • MechelleSanders, 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

3. 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

5. 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…

6. 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)

7. 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.

8. 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.

9. 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?

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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.

17. 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.

18. 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.

19. 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)

20. What Are The 5As?

21. Study schema

22. Intervention design-key concepts Intervention development-general principles

23. Intervention training

24. Assessment/measurement Assessment/measurement

25. 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)

26. Inclusion and exclusion criteria

27. Clinician recruitment and enrollment • Prior approval needed from organization’s Board of Directors, and administrative leadership • Clinicians recruited via in-person presentation

28. 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)

29. Clinic Staff introduces study to patient Consent Visit, audio recorded Patient completes summary and post visit interview Patient receives $20 for participation Baseline assessment schema

30. Challenges to data collection

31. Description of intervention

32. 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

33. Clinician training intervention, session2 • 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

34. Clinician training intervention, session 2example of resource page

38. 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

39. Clinician training intervention, session 4 Goal of Session: • Practice 5As discussion with a Standardized Patient • Explore use of eCW tools to support 5As discussion Specific Tasks: • Generate guided patient plan for physical activity • Make referral to Healthy Living Program • Practice using physical activity template and Order Sets for (1) and (2)

40. Challenges to intervention (clinician training) delivery

41. Results

42. 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

43. 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)

44. How much time, on average, do you spend discussing exercise if the topic comes up?

45. For what proportion of your overall visits do you provide exercise counseling?

46. How often do you ask about patients’ current exercise habits?

47. How often do you ask about patients’ willingness or motivation to change their activity level?

48. How often do you discuss the appropriate amount, intensity, and frequency of recommended activity guidelines?

49. How knowledgeable are you about identifying local, accessible resources for exercise for your patients?

50. 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