Dissemination & Implementation of Health Interventions For ... · He Huliau: Oct. 14, 2016...
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Dissemination & Implementation of Health Interventions for Community & by Community Rebecca Delafield, MPH, DrPH(c) He Huliau: Oct. 14, 2016 Honolulu, HI
Transcript of Dissemination & Implementation of Health Interventions For ... · He Huliau: Oct. 14, 2016...
Dissemination & Implementation of Health Interventions
for Community & by Community
Rebecca Delafield, MPH, DrPH(c) He Huliau: Oct. 14, 2016 Honolulu, HI
Our PILI ‘Ohana Team
Presenter
Presentation Notes
I’m here on my own, but speaking on behalf of our partnership, pictured here. The large photo shows our current Intervention Steering Committeee members, but there are several smaller pictures of people that were involved initially. Including Dr. Marjorie Mau who passed on the Principle Investigator role to Dr. Keawe Kaholokula who is our current Chair. Sheryl Yoshimura is also pictured, and unfortunately she couldn’t be here today, but was intending to present with the folks from Queen Emma Clinic. �It is an honor to share with you a little about our PILI ‘Ohana Project.
Learning Objectives 1. Describe how to a community-based research
approach can be used in developing dissemination and implementation strategies for interventions.
2. Develop an understanding of the strengths and challenges of a dissemination and implementation of an evidence-based intervention designed for Native Hawaiians and other Pacific Islanders.
Community-based Participatory Research
(CBPR)
“Collaborative approach to research that involves all partners in the research process and recognizes the
unique strengths that each brings. CBPR begins with a research topic of importance to the
community with the aim of combining knowledge and action for social change to improve
community health and eliminate health disparities.”
W.K. Kellogg Community Scholar’s Program (2001)
Presenter
Presentation Notes
Community based participatory research is defined as a collaborative approach to research that involves all partners in the research process and recognizes the unique strengths that each brings. CBPR begins with a research topic of importance to the community with the aim of combining knowledge and action for social change to improve community health and eliminate health disparities. Imbedded in this definition are the key principles of CBPR such as: mutual respect and trust, co-equal partnerships, shared decision making, and an obligation to dissemination of findings. These principles are critical to us because and grounded our approach and our more than a decade long partnership.
PILI ‘Ohana Project • Initiated in 2005 • Funded through 2016 by NIMHD, OHA, HMSA
Foundation o Phase I: planning phase (2005-2008) o Phase II: intervention research phase (2008-2013) o Phase III: dissemination phase (2013-2016)
• Designed, implemented and tested 2 interventions o Partners in Care (PIC) o PILI Lifestyle Program (PLP)
Presenter
Presentation Notes
PILI or Partnership for Improving Lifestyle Intervention Ohana Partnership. The PILI Ohana Partnership represents relationships that have been in existence for over 11 years now. Initiated in 2005. The founding partners included 5 community based organizations, including Kula No Na Poe Hawaii, Hawaii Maoli, Ke Ola Mamo, Kokua Kalihi Valley Comprehensive Health Center, and Kalihi Palama Health Center, and 1 academic partner, which was and continues to be the Department of Native Hawaiian Health at the JABSOM at the UH Manoa. Today, we continue to maintain relationships with 4 of the 5 founding organizations and have expanded to include many other Native Hawaiian and Pacific Islander serving community organizations. Vision: A healthy, vibrant, and robust Native Hawaiian and Pacific Islander population. Mission:�To integrate community wisdom and scientific enquiry to develop effective community-based health promotion programs to achieve social and health equity in Hawai‘i and the larger Pacific. Funded primarily by National Institutes of Health on a grant specifically focused on CBPR projects. Supported also by Office of Hawaiian Affairs and HMSA. Designed, implemented and tested 2 interventions to address chronic disease risk in Native Hawaiians as well as other Pacific Islanders PIC – Diabetes Self Management program PLP – Healthy lifestyle to prevent obesity and encourage weight loss Both were found to be effective randomized control trials conducted here in Hawaii . I will take a minute to mention a little bit of details on the PLP, but one of the other presentations will cover the PIC program. The PLP curriculum that was used was a culturally adapted version of Diabetes Prevention Program Lifestyle Intervention for Native Hawaiian and Pacific Islander communities. This part of the program was collapsed into a 3-month intervention during which 8 lessons were delivered. In addition a novel, 6-month, 6-lesson family and community component was added to the curriculum. A randomized controlled trial was conducted with over 200 Native Hawaiians and Pacific Islanders to compare our novel maintenance intervention, the PILI Lifestyle Program, with standardized behavioral follow up. The findings indicated that the PILI Lifestyle Program was superior to the SBP. Specifically, the mean weight loss for all participants was -1.5kg. CLINICAL SIGNIFICANCE.
Community Benefits “Where we are today versus where we were a decade ago, we're in a different place. The
engagement of the community is different, from a staff perspective, everybody is better trained, the
learning through this process was transferable… The community has embraced research in many ways.
The door was closed and now it is open.” - PILI ‘Ohana Community Partner
Presenter
Presentation Notes
The PILI Ohana Lifestyle Program was found to be a good and effective program; however, we did not have a model to frame an approach that has dual objectives of both disseminating evidence based interventions while building organizational and community capacity to create sustainable changes needed to help improve the health and well-being of the communities served by different NHPI serving organizations. This was critical to our partners, because they didn’t just consider the dissemination process a way to get other groups to use an evidence-based program, they viewed it as a transforming experience and wanted that to be shared as well. This is quote from one of the founding partners about the change she saw in the organization she leads over the past 11 years being involved in this project.
Conceptual Foundations Theory Key Factors Definitions
Key Concepts in Community
Organizing/ Community
Building
Empowerment Social action process for people to gain mastery over their lives and the lives of their communities
Critical Consciousness A consciousness based on reflection and action in making change
Community Capacity Characteristics of a community affecting its ability to identify, mobilize, and address problems
Social Capital Relationships between community members including trust, reciprocity, and civic engagement
Participation/Relevance Community organizing should “start where the people are” and engage community members as equals.
Minkler M, Wallerstein N, Wilson N. Improving health through community organization and community building. In Glanz K, Rimer B, Viswanath K, editors. Health behavior and health education: theory, research, and practice. 4th ed. San Francisco: Jossey-Bass, John Wiley & Sons; 2008. p. 291-298.
Presenter
Presentation Notes
So we developed a model that could address that dual focus. The approach is grounded in CBPR and there are three underlying theories that the model incorporates. Social Cognative Theory (Bandura)– brings in “observational learning“ which was operationalized in the mentoring aspect Aspects of the Diffusion of Innovations theory (Rogers), which highlights important characteristics of the innovation and the importance of context Builds on some of the key concepts of community organizing and community building. They are listed here.
Methods • Community-to-Community Mentoring Model
Delafield, et al. (in press)
Presenter
Presentation Notes
The relationships that are built using a CBPR approach based on the principles of mutual respect and trust, co-equal partnerships, shared decision making, and opportunities for sustainability. empowerment, and building community capacity are essential to the success of this CCM model. The existing relationships between the mentors and academic partners is the key to facilitating relationships with the mentee organizations. In this model Mentors provide training, guidance, and support to the mentees who not only contribute expertise on their community but also agree to adopt, adapt and implement an evidenced based CBPR intervention within their own communities while developing a sustainability plan. Although the academic partner’s role becomes less prominent, they continue to provide ongoing technical assistance throughout the relationship. This could include formalized intervention training, data analysis, or administrative project support. In this model, context refers to the environment in which the innovation, partnerships and organizations are operating. Some dimensions of the environment may be similar between mentors and mentees, which would fall into the shared context component of this model. These similarities could ease communication and facilitate trust between the mentors and mentees because they may better understand the other’s perspectives, needs, and challenges. Aspects of the environment that may be different between the mentee and mentor would fall into the wider environment component of this model; however, it may also influence the success of the dissemination effort.
Dissemination
16 Mentee communities reached:
11 on O‘ahu 2 Moloka‘i
1 Maui 2 Hawai‘i
Implementation • Communities able to deliver all the lessons • Modifications made • Effectiveness
o 3 month weight loss in pilot comparable previous studies o There were variations by community
102.2
100.4 100.52
101.8 100.79
100.32
99
100
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Baseline 3-Month 9-Month
Weight in Kilograms
Mentors Mentees
Presenter
Presentation Notes
Data from the initial dissemination pilot, that was funded by OHA and included 5 communities who were implementing the PILI Lifestyle Program showed promising results. Able to deliver all the lessons Modifications made to some (schedule only, all lessons delivered) did not change the results significantly Overall, weight loss was comparable to previous studies that showed modest weight loss. Research indicates that even modest weight loss 1kg can reduce the risk of developing diabetes by 16%. There were variations by communities. Will be looking at those as we analyze the data from the larger dissemination effort.
Lessons Learned Strengths Challenges
• Effective model • CBPR
“The PILI 'Ohana project is an ideal model to engage community members in taking an active role in educating themselves in subjects that will benefit individuals, families, communities and our lāhui as Hawaiians.”
• Mentoring • Maintenance “I am very interested in seeing the longevity of PILI ... People are still asking about participating in the next round and very interested in learning more” – PILI mentee facilitator
Presenter
Presentation Notes
Use of the community-to-community model of intervention dissemination appears to be effective in the dissemination of the PILI ‘Ohana Program– similar results in spite of differences in organization type, modification of intervention timeline, etc. Commitment to the project by all partners– for example, being flexible to change, having a shared vision, mission, and values– is essential Mentees appreciated being able to contact mentors for support: Observations Lessons/Materials Assistance with assessments Opportunities to address unique and similar challenges to implementation within each organization and community offered occasions for collaboration and growth Mentees appreciated being able to contact mentors for support Mentees without a stable infrastructure or ongoing fiscal and logistical support experienced challenges related to continued implementation of PILI despite a desire to continue to implement it
Future Directions
• Ongoing effort to increase sustainability o Communities can be part of a prevention solution o Need to identify opportunities for co-equal collaboration
• Further research:
o What is the value of the model to other CBPR initiatives? o What are the essential characteristics of the mentor,
mentee and the mentoring relationship?
Presenter
Presentation Notes
Communities can be part of a prevention solution and this is in line with the vision of the “third era of Health system” that is described by Halfon et al. in their article in Health Affairs. In that article the 3.0 version of the US Health System is focused less on systems of health care, but more on a multisectoral community-integrated health system with an objective of optimizing health of populations over the lifespan and across generations. Which I think is really important when considering indigenous health because we know that the problems that plague our communities are rooted in exposures that were generational and influence health across the life course. Also relevant to current change in the health care system with regard to payment models. By supporting health in communities, these communities – by addressing their concern about health in a way that they are comfortable with – are improving outcomes at the doctor’s office. Then their quality goes up. So this is critical. But it cannot be dictated. It needs to be co-equal, which is why reimbursement must be provided to community-based programs. That is what hurts sustainability of these programs and that is what makes it a partnership as opposed to just another shifted burden. Ongoing evaluation of the effectiveness of the CCM model in the dissemination of the PILI Lifestyle Program Evaluate the use of the CCM model in the dissemination of a lifestyle intervention with other ethnic minority populations Are there other changes to the way mentors or mentees were chosen or paired, assessing readiness, etc.? What does it mean for other communities
PILI ‘Ohana Publications
• Nacapoy, A.H., Kaholokula, J.K., West, M.R., Dillard, A.Y., Leake, A., Kekauoha, B.P., Palakiko, D-M., Siu, A., Mosier, S.W., Mau, M.K. (2008). Partnerships to address obesity disparities in Hawaii: The PILI ‘Ohana Project. Hawai‘i Medical Journal, 67(9), 237-241.
• Mau, M.K., Kaholokula, J.K., West, M., Efird, J.T., Leake, A., Rose, C., Yoshimura, S., Kekauoha, P., Gomes, H., & Palakiko, D. (2010). Translating Diabetes Prevention Research into
Native Hawaiian and Pacific Islander Communities: The PILI 'Ohana Pilot Project. Progress in Community Health Partnerships: Research, Education, and Action, 4(1), 7-16.
• Kaholokula, J.K., Mau, M.K., Efird, J.T., Leake, A., West, M., Palakiko, D-M., Yoshimura, S.R., Kekauoha, B.P., Rose, C., & Gomes, H. (2012). A Family and Community Focused Lifestyle Program Prevents Weight Regain in Asian and Pacific Islanders: A Pilot Randomized Controlled Trial. Health Education & Behavior, 39(4), 386-395. [Epub 2011 May 6]
• Sinclair, K.A., Makahi, E.K., Solatorio, C.S., Yoshimura, S.R., Townsend, C.K.M., & Kaholokula, J.K. (2013). Outcomes from a diabetes self-management intervention for Native Hawaiians and Pacific Peoples: Partners in Care. Annals of Behavioral Medicine, 45(1), 24-32. [Epub 2012 Oct 20]
• Kaholokula, J.K., Townsend, C.K.M., Ige, A., Sinclair, K.A., Mau, M.K., Leake, A., Palakiko, D-M, Yoshimura, S.R., Kekauoha, P., & Hughes, C. (2013). Socio-demographic, behavioral, and biological variables related to weight loss in Native Hawaiians and other Pacific Islanders. Obesity, 21, E196-E203. [Epub 2012 Sep 18]
• Kaholokula, J.K., Townsend, C.T., Sinclair, K., et al. (2014). The PILI ‘Ohana Project: A community-academic partnership to eliminate obesity disparities in Native Hawaiian and Pacific
Islander communities. In: V.M. Brennan, S. Kumanyiki, & R.E. Zambrana, (Eds), Obesity Interventions in Underserved U.S. Communities: Evidence and Directions. Baltimore, MD: John Hopkins University Press.
• Kaholokula, J.K., Kekauoha, B.P., Dillard, A.Y., Yoshimura, S., Palakiko, D.M., Hughes, C., & Townsend, C.K.M. (2014). The PILI ‘Ohana Project: A community-academic partnership to achieve metabolic health equity in Hawai‘i. Hawai‘i Journal of Medicine and Public Health, 73(12; Suppl. 3), 29-33.
• Kaholokula, J.K., Wilson, R.E., Townsend, C.K.M., Zhang, G., Chen, J.J., Yoshimura, S., Dillard, A., Yokota, J.W., Palakiko, D.M., Gamiao, S., Hughes, C.K., Kekauoha, B.P., & Mau, M.K. (2014). Translating the Diabetes Prevention Program in Native Hawaiian and Pacific Islander Communities: The PILI ‘Ohana Project. Translational Behavioral Medicine, 4(2), 149-159. [epub 2013 Dec. 18]
• Townsend, C.K.M., Dillard, A., Hosoda, K., Maskarinec, G., Maunakea, A., Yoshimura, S.R., Hughes, C., Palakiko, D.M., Kekauoha, B.P., & Kaholokula, J.K. (2016). Using community-based participatory research to integrate behavioral and biological research to achieve health equity for Native Hawaiians. International Journal of Environmental Research and Public Health, 13(1), 4 (open access). [Epub 2015 Dec. 22]
• Townsend, C.K.M, Miyamoto, R. Antonio, M. Zhang, G., Paloma, D., Basques, D. Braun K. L., & Kaholokula, J.K. (2016). The PILI@Work Program: A translation of the Diabetes Prevention Program to Native Hawaiian-serving worksites in Hawai'i. Translational Behavioral Medicine, 6(2), 190-201. [Epub 2016 January 19]
• Townsend-Ing, C., Zhang, G., Dillard, A., Yoshimura, S.Y., Hughes, C. Palakiko, D.M., Kekauoha, B., & Kaholokula, J.K. (2016). Social support groups in the maintenance of glycemic control post community-based intervention. Journal of Diabetes Research, Article ID 7913258, 8 pages.Mau, M.K., Kaholokula, J.K., West, M., Efird, J.T., Leake, A., Rose, C., Yoshimura, S., Kekauoha, P., Gomes, H., & Palakiko, D. (2010). Translating Diabetes Prevention Research into Native Hawaiian and Pacific Islander Communities: The PILI 'Ohana Pilot Project. Progress in Community Health Partnerships: Research, Education, and Action, 4(1), 7-16.
• Delafield, R., Hermosura, A., Townsend, C.K.M., Hughes, C.K., Palakiko, D.M., Dillard, A., Kekauoha, B.K, Yoshimura, S.R., Gamiao, S., & Kaholokula, J.K. (in press). A Community-based
participatory research guided model for dissemination of evidence-based interventions. Progress in Community Health Partnerships: Research, Education, and Action.
Acknowledgements • PILI ‘Ohana Partners: Adrienne Dillard, MSW, LSW & B. Puni Kekauoha (Kula no
na Po‘e Hawai‘i) Sheryl R. Yoshimura, RD, CDE, MPH (Kōkua Kalihi Valley Comprehensive Family Services) Claire K. Hughes, DrPH & Shari Gamiao (Association of Hawaiian Civic Clubs) Donna-Marie Palakiko, APRN, MS (Ke Ola Mamo Native Hawaiian Health System) Joseph Keawe‘aimoku Kaholokula, PhD & Claire K.M. Townsend Ing, DrPH (University of Hawai‘i at Mānoa, John A. Burns School of Medicine)
• PILI ‘Ohana Mentees: Waianae Valley Hawaiian Homestead Community Association Pana‘ewa & Keaukaha Hawaiian Homestead Communities Lahaina and Kuini Pi‘olani Hawaiian Civic Clubs Nā Pu‘uwai Native Hawaiian Healthcare System Moloka‘i Community Health Center Queen’s West Oahu Diabetes Clinic Keiki o ka ‘Aina Family Learning Center Waimanalo Health Center Kaneohe Hawaiian Civic Club MA‘O Organic Farms The Family Treatment Services Program, Salvation Army Hui Mālama o ke Kai Foundation Hale Makana o Nānākuli God’s Country Waimanalo Queen Emma Clinics Kanu o ka ‘Aina
• Funded by the Office of Hawaiian Affairs, HMSA Foundation, & the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health (NIH) (2R24MD001660)
• The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.
Mahalo!
