Elizabeth Bade, MD Jennifer Evertsen, MS Christine Casselman, MA 11/12/2009

1. Lifestyles of the poor and underserved:Unhealthy Behaviors at primary care clinics in Milwaukee, WI – What can we do? Elizabeth Bade, MD Jennifer Evertsen, MS Christine Casselman, MA 11/12/2009

2. Objectives • Review data from service project involving drug and alcohol screening • Discuss relevant needs for this population of underserved patients • Propose research based on this project to address the issues identified

3. Background • Wisconsin Initiative to Promote Healthy Lifestyles (WIPHL) • Began in March of 2006 delivering services in primary care clinics around the state – currently in 18 locations • Screening, Brief Intervention, Referral to Treatment (SBIRT) for at risk drug and alcohol use • Each clinic has a health educator who uses motivational interviewing (MI) to deliver SBIRT to patients

4. Aurora and WIPHL • Aurora began delivering SBIRT services through WIPHL at 3 clinics in 2006 • Currently still delivering services in 2 out of 3 of the original clinics and 1 new clinic • Initially 2 family medicine residency clinics and 1 family medicine free clinic were involved • Currently 1 women’s health (ob/gyn) clinic replaced one of the family medicine clinics

5. A word about SBIRT • Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. • Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change. • Referral to treatment provides those identified as needing more extensive treatment with access to specialty care

6. Motivational Interviewing (MI) • History - Technique was first developed for use with alcohol and drug counseling and it’s efficacy is well documented • Motivational Interviewing is a person-centered, directive method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

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

8. Motivational Interviewing (MI) • Method – Promotes self-efficacy: helps patients to recognize unhealthy behaviors, overcome barriers and set achievable goals, while guiding and educating • Adaptable – Fosters a partnership with patients, avoids giving unwanted advice, allows patients to weigh pros and cons of behavior change in light of their own goals and values • Recent studies have shown that MI is also efficacious at behavior change for non-addictive behaviors, specifically helps maintain dietary changes

9. Brief screen questionnaire once per year If answers “yes” to either alcohol or drug question, full screen is completed –preferably at the point of care Full screen determines “level of risk” Consists of specific questions regarding lifetime substance use, and use in the past three months. Helps patients to identify health, social, legal and financial consequences of use. Process

11. Brief Screen questions 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

12. Brief 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?

13. Results • From 5/29/2007-6/1/2009 • Participants all 18 years or older, mean age of 43 • 11,742 brief screens, 2,088 full screens • 60% female • 38% white; 30% black; 30% hispanic

14. Alcohol and Drug Use

15. Other Unhealthy Behaviors

16. State/National Averages • In 2007 prevalence of cigarette smoking in the United States 19.8% State Specific Prevalence and Trends in Adult Cigarette Smoking in the United States 1998-2007. JAMA. 2009;302(3): 250-252. • 50% of Americans exercise for 30 minutes less than 3 days per week Gallup poll May 2009 • Wisconsin is the 25th fattest state in the union with a prevalence of 26%, and an estimated 2/3rds of Americans are overweight or obese F as in Fat: How obesity policies are failing in America, 2008. Robert Woods Johnson Foundation

17. More results • Blacks and Hispanics scored higher for both gender-specific questions related to “number of drinks consumed at one time” and exercise • Blacks scored higher on weight problems and “thinking about cutting back on alcohol/drug use” • Females scored higher on tobacco and weight • Age not related to other health risk behaviors

18. The Conundrum • SBIRT is known to help with alcohol and drug related counseling • Other health markers are also important and puts patient’s health at risk • What can work and fit into a busy primary care practice?

19. MI For Diet and Exercise • Some studies suggest that MI effective in non-addictive behaviors (Bowen, Resnicow) • Also studies done using MI by health professionals • Adds additional burden onto medical staff

20. Our proposal • Use the same process as is used for WIPHL project • Address diet and exercise with MI • Look for changes in readiness to change, answers to diet and exercise questionnaires

21. Next Steps… • Received grant for this project • 12 month grant • Will recruit 150 patients from primary care clinics • Randomized to “high intervention”, “low intervention”, or “usual care” • 3 month follow up • Assess readiness to change and responses on questionnaires about diet/exercise habits

22. Discussion • “Usual care” doesn’t seem to be effective to promote healthy lifestyle choices in these primary care clinics in Milwaukee • Opportunity to provide a useful, low cost intervention that may improve lifestyle habits • Results remain to be seen…

23. References/Acknowledgements • WIPHL team – PI is Rich Brown, MD • Center for Urban Population Health • ICTR team for funding our next project • Additional references on motivational interviewing: • Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J of Consulting & Clinical Psychol 2003;71(5):843-61. • Miller WR, Rollnick S. Motivational Interviewing (2nd ed.) New York: Guilford, 2002. • Resnicow K, Borrelli B, Ernst D, et al. Motivational Interviewing in Health Promotion: It Sounds Like Something is Changing. Health Psychol. 2002:21(5):444-451.