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

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Presentation on theme: "A Communication Intervention to Promote Physical Activity in Underserved Communities Jennifer Carroll, MD, MPH Associate Professor Department of Family."— Presentation transcript:

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 K07CA 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

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 that’s true for most of us. Patient: Physician: Is that is that something that you can start to get into? Patient: 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? Ask Advise Agree Assist Arrange

21 Study schema

22 Intervention design-key concepts SDT5AsPatient-centered communication Promoting autonomy supportive skills for clinicians when counseling patients about physical activity Use of 5As for physical activity counseling Understanding patients’ social context Increasing clinician perceived competence to counsel Offering support Encouraging patient participation Intervention development-general principles

23 SDT5AsPatient centered communication Interactive discussion on strategies to increase both patient motivation for physical activity and clinician motivation to raise the topic Introduction, repetition, and reinforcement of the 5As via didactic presentation, role play, and standardized patient feedback Role play and group discussion to develop and reinforce supportive listening & open-ended questions about physical activity Offering a choice of community resources for referral Use of standardized patients to give feedback to clinicians on PCC skills Offering a choice of optional electronic health records tools and eliciting ongoing feedback Intervention training

24 Assessment/measurement CliniciansPatientsBlinded coders Surveys (clinicians’ perception of supportive environment to counsel; clinician perceived competence to counsel Surveys (patient ratings of autonomy support of clinicians, perceived competence Coding of autonomy supportiveness (global rating and for each 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 content and quality ratings for the 5A’s 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 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 ClinicianPracticing clinicians (physicians, physician assistants, or nurse practitioners) at Westside Health Services Extended absence or planning to move to another practice in the study period

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

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 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

30 Challenges to data collection ChallengeStrategy 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

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, 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

34 Clinician training intervention, session 2 example 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: 1. Practice 5As discussion with a Standardized Patient 2. Explore use of eCW tools to support 5As discussion Specific Tasks: 1. Generate guided patient plan for physical activity 2. Make referral to Healthy Living Program 3. Practice using physical activity template and Order Sets for (1) and (2)

40 Challenges to intervention (clinician training) delivery ChallengeStrategy 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 useRevision of tools to be quicker, easier to use in progress

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 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

51 CONSORT Diagram (patients)

52 Patient socio-demographic information, n= 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%)

53 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

54 Patient reported challenges and barriers to physical activity (n=325)

55 Patient (n=325) sources of support, resources for physical activity

56 Patient perceptions of clinician autonomy supportiveness

57 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).

58 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

59 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 plan Mean Scores (scale 1-5) 5=very confident * All were significant

60 Clinician reported changes in PA counseling, cont. 1=never, 5= always

61 Exploratory aim Feasibility 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

62 Challenges ChallengeStrategy Attrition in HLP groupsPhone 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 sustainabilityMulti-pronged strategy for future fundraising, grant-writing, capitalizing on community and insurance plan partnerships

63 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

64 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

65 Limitations Single geographical site (By design), patients were not followed longitudinally, rather nested within clinician Patient self-report/recall

66 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

67 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, K07CA (PI: Jennifer Carroll). For further information, please contact

68 Thank you for your time and interest! Questions and comments are welcome! Thank you for your time and interest!

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