Emor yP r event ionResear chCent er

Emor yP r event ionResear chCent er

Michelle Carvalho, MPH, CHES; Cam Escoffery, PhD, MPH, CHES;

Louise Wrensford, PhD; Michelle Kegler, DrPH, MPH

Georgia Public Health Association Annual Meeting

April 12, 2011

AcknowledgementsSelected content adapted from

National Cancer Institute’s “Using What Works”

http://cancercontrol.cancer.gov/use_what_works/start.htm

Cancer Prevention and Control Prevention Research Network (CPCRN)

CDC Grant # 1U48DP0010909-01-1

Funded by CDC and NCI

Presentation ObjectivesParticipants will be able to:

1. Discuss the use of mini-grants to disseminate evidence-based programs (EBPs).

2. Describe the EPRC’s mini-grants program and process evaluation questions about adapting an EBP

3. Explain contextual factors that may influence program implementation and adaptation

4. Describe a proactive training and technical assistance process and process evaluation for community organizations to implement EBPs with fidelity

What do you think of when you hear the term “evidence-based”?

Question

Evidence-based Programs

An evidence-based program (EBP) has been:

Implemented with a groupEvaluatedFound to be effective.

What Is Evidence?Systematic reviews of multiple

intervention studiesReview articlesAn intervention research studySurveillance dataProgram evaluationWord of mouthPersonal experience

OBJECTIVE

SUBJECTIVE

Benefits of using Evidence-Based ProgramsWhat are advantages to using evidence-based programs?

Effective in the study populations Cost effective Shorten the time it takes to develop a program Reduce the time it takes to research a

community Help narrow the evaluation.

Mini-Grants as a Strategy for Dissemination of EBPs

Mini-grants are common in health promotion initiatives & have potential for creating demand for evidence-based interventions

Mini-grants can be combined with dissemination strategies shown to workTraining workshops (Rohrbach 2006; Elliot 2004)

Increases adoption, capacity, fidelity, maintenanceTechnical Assistance (Pentz 2006; Shepherd 2008; Rohrbach 2006)

Ongoing support, feedback, coachingIncentives (Basen-Engquist ,1994; Glanz, 2002)

stipends, equipment, materials

Frameworks for Translation of EvidencePassive diffusion is not enough to encourage the

adoption of evidence-based interventions.*

Frameworks are needed to guide active dissemination strategies to translate evidence into community practice

*Pentz, Jasuja, G. K., Rohrbach, L. A., Sussman, S., & Bardo, M. T. (2006). Translation in tobacco and drug abuse prevention research. Evaluation & the Health Professions, 29(2), 246-271.

EFFECTIVENESS AND

IMPLEMENTATIONSTUDIES

DECISION to ADOPT

DIFFUSION

NCCDPHP Knowledge To Action FrameworkMay 2009

INSTITUTION-ALIZATION

RESEARCH PHASE TRANSLATION PHASE

EFFICACY STUDIES

PRACTICE

DISCOVERYSTUDIES

DISSEMINATION

ENGAGEMENT

Practice-based Discovery

KNOWLEDGE INTO PRODUCTS

INSTITUTIONALIZATION PHASE

Practice-based Evidence

Translation Supporting StructuresResearch Supporting Structures

DECISION to TRANSLATE

EVALUATION

Insitutional-ization

Supporting Structures

This product is in the public domain. Please cite this work in this manner:

Wilson KM, Brady TJ, Lesesne C. An organizing framework for translation in public health: the Knowledge to Action Framework. Prev Chronic Dis2011 Mar;8(2):A46. The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) Knowledge to Action Framework, Centers for Disease Control and Prevention, NCCDPHP Work Group on Translation, May 2009.

Interactive Systems Framework

Wandersman, A., Duffy, J., Flaspohler, P., Noonan, R., Lubell, K., Stillman, L., et al. (2008). Bridging the Gap Between Prevention Research and Practice: The Interactive Systems Framework for Dissemination and Implementation. American Journal of Community Psychology, 41(3), 171-181.

Mini-grants Programto Disseminate EBPs

A “push-pull method” (i.e. funds + TA) increases

demand while building capacity*

2 cohorts: 2007 & 2008 (12-18 month period)

12 SW GA community organizations awarded

Received up to $4000 & technical assistance (TA)

Implemented 5 RTIPs programs (nutrition or PA)

* Green LW, Orleans T, Ottoson JM, Cameron R, Pierce JP, Bettinghaus EP. Inferring strategies for disseminating physical activity policies, programs, and practices from the successes of tobacco control. Am J Prev Med. 2006;31(4)(suppl):S66–S81.

http://rtips.cancer.gov/rtips

16 Mini-grants sites funded2007-2012

Bainbridge

Albany

Blakely

Pelham

Sylvester

Nashville

Adel

Valdosta

Cordele

5

Tifton

Thomasville

2007-200912 Awarded Sites

& 5 Programs

Funded Organizations Evidence-Based Program

4 Churches Body and Soul

4 Worksites Treatwell 5-A-Day

2 Community Coalitions Parents as Teachers (PAT) High 5 Low Fat Program

Senior Center Little By Little Nutrition Program

Hospital Diabetes Management Center

Patient-Centered Assessment & Counseling for Exercise (PACE)

Engaging Community ExpertiseEmory PRC Community Advisory Board (CAB) roles:

Prioritized behavioral risk factors: nutrition, physical activity, tobacco prevention/cessation

Helped to develop mini-grants and TA process

Facilitated promotion of program to community

Joint EPRC/CAB review committee

selected grantees

Currently co-authoring presentations

and publications

Construct Process Evaluation Question(s) Data Collection MethodsReach What proportion of the intended audience

participated in each activity? Project Report Forms* Demographics form

Implementation Fidelity: To what extent were core elements of the program implemented as described in program materials?

Project Report Forms* Monthly calls Interviews (coordinators)*

Adaptation: How and why did sites adapt core elements of the intervention?

Project Report Forms* Monthly calls Interviews (coordinators)* Committee focus group

Context What contextual factors may have affected intervention adoption and implementation?

Interviews (coordinators)* Committee focus group Monthly calls Mini-grant applications* Census data

Maintenance What plans has the site made to continue promoting health after the end of the project?

Interviews (coordinators)* Committee focus group

Resources What resources did EPRC provide to support this project?

EPRC financial records* TA log

To what extent did grantees perceive that EPRC technical assistance helped them to implement the programs with fidelity?

Interviews (coordinators)*

* Collected in both cohorts (Other tools in 1st cohort only)

Program FidelityFidelity: “faithfulness” to the implementation of

program elements in the way they were intended to be delivered in the original intervention

Core elements*: required components that represent the theory and internal logic of the intervention and most likely produce the intervention’s effectiveness

Key process steps: required implementation or program delivery steps that are conducted to contribute to the intervention’s effectiveness

*Eke, Neumann, Wilkes, Jones. Preparing effective behavioral interventions to be used by prevention providers: the role of researchers during HIV Prevention Research Trials. AIDS Education & Prevention 2006, 18(4 Suppl A):44-58.

Program Core ElementsCore elements for each program were identified based on:underlying theory & process evaluation

findingspublished articles describing the programavailable program materialsprogram description on NCI’s Research

Tested Intervention Programs (RTIPs) website

Adaptation is… …making ChangesAdditionsDeletionsSubstitutions

to an evidence-based program in order to make it more suitable for a particular population and/or an organization’s capacity.

Fidelity Findings95% of core elements conducted across all sites9 of 12 (75%) sites conducted all core elements

3 (of 7) sites in 1st cohort did not conduct all core elements

All 5 sites in 2nd cohort conducted all core elements

Decided not to conduct due to context/climate:

“They thought that if we had some type of event like that [family picnic/party], that would be saying now you’re asking me to take unemployment weeks but...you’re having an event...” - Site coordinator

Contextual Factors(related to implementation)

BARRIERS FACILITATORS Schedule/time conflicts* Difficulty with recruitment or

retention* Lack of resources/funds* Difficulty with changing

behavior Staff/leadership transitions Slow economy/worksite

financial difficulties

Leadership support* Staff/volunteers* Print materials/resources* In-kind resources/facilities* Partnerships* Donated Resources* Fit with mission Fit with

Infrastructure/Activities* Mentioned in both cohortsBlue text = barrier that prevented completion of core element(s) - 1st cohort

Fidelity-Adaptation Continuum

Added/customized materials

Added activities

Shifted primary audience

Held concurrent physical activity

& weight loss events

Changed delivery format/process steps

Expanded audience (to community)

Shifted focus to other behaviors

Did not complete all core elements

HIGHFIDELITY

MAJOR ADAPTATION

MINOR ADAPTATION

LOWFIDELITY

ADAPTATION EXAMPLES

NE

ED

S E

VA

LU

AT

ION

Adaptation QuotesExpanded the program from worksite/coalition to the community

“This project seems to have opened the door for a brand new [obesity] issue that our county had not talked about…all of a sudden the light went on …[the collaborative] said we need to add this to our benchmarks as a group and start working on this.” - Site coordinator

Added physical activity & weight loss events (to nutrition program)

“Because of the nutrition part of it, people began to feel better and they had more energy. So they was able to do more physical activities and wanted to do more as far as looking at weight loss…” - Site coordinator

Reasons for AdaptationsExpand program reach (broader community)

Generate/maintain engagement

Strengthen/reinforce program message

Fit program to organization’s infrastructure/activities

Reach specific audiences (esp. underserved)

Added content to reach specific audiences (teen parents)

“You got to think about being also sensitive to the age of the parent. If you have [a parent] that’s maybe 14…give them something that can be kinda fun…”

- Site coordinator

A Tale of 4 Sites…1. Body & Soul/Church: Minimal Adaptation

Minor additions (incentives & activities)

2. Body & Soul/Church: Major Adaptation Shifted focus to physical activity/weight loss

3. Little by Little/Senior Center:

Intermediate-Major Adaptation Assisted delivery of CD-ROM & added activities

3. Treatwell 5-a-Day/CBO: Major Adaptation Shifted audience to Advisory Board, then community Newsletters monthly local newspaper stories

LimitationsSmall number of sites (n=12) in rural SW GALimited measurement of fidelity & implementation qualityTime span 12-18 months – more time needed to learn

about maintenanceSelf report/social desirabilityData reflects information from only

5 intervention programsData may not be generalizable to other

settings, populations, regions & programs

2010-12 Mini-grants CohortMini-grants period will span 2 years4 sites funded at $8000 eachStructured and proactive TA and trainingRTIPs programs:

CATCH: Coordinated Approach to Child HealthFamily MattersBody & Soul

Process evaluation focus on TA & training

(Adapted from McK leroy et al., 2006)

Implementation plan Successful pilot of adapted

intervention

Prepare agency Pre-test materials

Target population Interventions Goodness of fit Stakeholders Organizational capacity

Assess

Prepare

Pilot

Implement Implement adapted EBI

Decide to adopt, adapt, or select another intervention

Make necessary changes to EBI

Select

Su

pe

rvisio

n a

nd

Qu

ality A

ss

ura

an

ce

Pro

ce

ss

Mo

nito

ring

an

d O

utc

om

e M

on

itorin

g

Fo

rma

tive, P

roc

es

s, a

nd

Ou

tco

me

Eva

lua

tionF

ee

db

ac

k L

oo

ps

, Ch

ec

kp

oin

ts

Map of the Adaptation ProcessDeveloped a structured TA model derived from the

Map of the Adaptation Process (Mckleroy et al., 2006)

Focus on objectives of each key step:

EBP Training Topics (pre-award)Session Title

What Do We Mean By Evidence-Based?

Needs Assessment and Program Planning

Finding an Evidence-Based Program

Selecting a Program That Fits Your Community

Adapting the Evidence-Based Program with Fidelity

Implementing an Evidence-Based Program

Evaluating Your Program

TEACH model: Translating Evidence into Action through Collaboratives for Health TA Contact Structured TA Topics

(examples)Stage in Map of Adaptation Process

Pre-award Training See prior training slide Assess, Select, Prepare

Kick-Off Training for awarded sites

EBIs, Needs assessment, Organizational readiness, Core elements

Assess, Select, Prepare

Site Visit Fit, Adaptation, Evaluation planning

Assess, Select, Prepare, Pilot

Conference Call Implementation Work Plan, Partnerships

Assess, Select, Prepare, Pilot

Ongoing Contact Overcoming barriers, implementation fidelity, maintenance

Assess, Pilot, Implement, Maintenance

Tools Adapted from:Lesesne, C. A., Lewis, K. M., Moore, C., Fisher, D., Green, D., & Wandersman, A. (2007). Promoting Science-based Approaches to Teen Pregnancy Prevention using Getting To Outcomes: Draft June 2007. Unpublished manual.

TEACH Evaluation Questions

Kept the original evaluation questions and added capacity questions related to the impact of TEACH:

Do attitudes toward EBAs become more positive as a result of the TEACH process?

Does self-efficacy for EBA behaviors increase as a result of the TEACH process?

Does organizational capacity for EBAs increase as a result of the TEACH process?

Process Evaluation PlanBaseline survey (n=20)- 80 close-ended items

Follow-up at 3 (n=12)-76 closed + 4 open-ended items

Additional follow up at 24 months TA tracking databaseProject Report FormsQualitative interviews w/ coordinators at 24

months

Participant descriptions Completed baseline surveys (n=20) Included directors, coordinators, educators9 (45%) held supervisory or managerial roles6 (30%) were “front line staff”15 (75%) had a bachelors degree or higherAveraged 9 years at current organization 6 (33.3%) reported prior experience with EBPsAlmost all (18) reported someone from their organization advocated for the use of an EBP for the currently funded mini-grant

Survey topic areas Example Measures – Survey Questions

Attitudes about EBPs 14 items

(Hannon et al, 2009)

Likert Scale: Strongly Disagree Strongly Agree

• EBPs are easy to understand.• EBPs are easy for us to adapt for use in our community.

Skills related to EBPs 18 items

(Chinman et al., 2008)

Likert Scale: Very hard Very Easy

• Assess organizational readiness to implement an evidence-based program.

• Determine what needs to be changed in an EBP to increase fit to your community.

Organizational functioning*38 items

Likert Scale: Strongly Disagree Strongly Agree

• We have appropriate staff skills to achieve our mission.• Staff use data/information to inform their decision-

making.• The leadership of the organization fosters respect, trust,

inclusiveness, and openness in the organization.

*Levinger and Bloom, 2000; Weiss et al., 2002; Preskill and Tores, 1998; Caplan, 1971; Kenny and Sofaer, 2000; Schminke et al, 2002)

Preliminary Results: Skills Related to EBPs

Tasks (1= very hard; 5= very easy) Mean SD

Tasks with higher reported ability

Define goals and objectives for your program. 3.95 .83

Discuss the benefits of using evidence-based programs. 3.90 .72

Develop an implementation work plan. 3.80 .70

Tasks with lower reported abilityPlan for maintenance of program. (e.g. leverage of resources)

2.75 .97

Develop solutions to identified implementation barriers. 3.00 1.03

Describe the steps of the program adaptation process. 3.20 .77

Prepare for the implementation of your program. (e.g. training of staff, hiring of staff, piloting, partnerships)

3.20 1.15

Attitudes about EBPsAll scores of negative statements were reversed. The higher the mean score, the more positive their attitude about EBPs.

*Reverse Coded

Implications for PracticeUsing evidence-based strategies and programs can

save time and can benefit communities

Mini-grants, training and technical assistance are promising strategies to translate evidence into community practice

Evidence-based programs can be strategically adapted to meet the needs of a community

More evaluation is needed to determine how best to adapt and implement EBPs with fidelity

Acknowledgements Mini-grant sites Sally Honeycutt Kirsten Rodgers Karen Glanz Johanna Hinman Jenifer Brents Molly Russ Yao Shi

The CPCRN is part of the Prevention Research Centers Program. It is supported by the Centers for Disease Control and Prevention and the National Cancer Institute (Cooperative agreement # 1U48DP0010909-01-1)

JK Veluswamy Margaret Clawson Megan Brock Nidia Banuelos Alma Nakasone Amanda Wyatt Deltavier Frye Ana Iturbides

Emor yP r event ionResear chCent er

Emor yP r event ionResear chCent er

QUESTIONS?

www.sph.emory.edu/eprcMichelle Carvalhomlcarva@emory.edu