Laura Salinas Keene State College Dietetic Intern

Laura SalinasKeene State College Dietetic Intern Independent Study Project

What is an independent study? Opportunity to work on a public health initiative & practice: • Project management skills • Critical thinking • Research skills: collect, analyze, and professionally report data Goal of the project is to have the intern play an independent role and be a valuable member of the team working on the project.

Today… • Developing my research question • Background • Community-based needs assessment • Methods • Literature Review • Developing measurable indicators • Implement Strategy • Results • Discussion • Monitor and adjust outcomes and processes • Future plans

Developing my research question “When implementing a health promotion program in community settings, what do we need to understand about patient activation to increase engagement and health confidence?”

Background: Needs Assessment • Cardiovascular disease is the leading cause of death and disability in the US • Accounted for 597,689 deaths in 2010 (CDC 2011) • Unfavorable cholesterol levels contribute to risk for CVD • 52.5% Adults in the US reported getting cholesterol screenings regardless of risks (CDC, 2009) • Informed, engaged, and empowered individuals are more likely to share in decision making with their providers and take responsibility for their own health

Methods: Literature Review • Extensive PUBMED, and EBSCO search • 15 peer reviewed articles • Activation levels and/or self-efficacy measures • How to increase health confidence or self-efficacy • Community-based health promotion programs • When implementing a health promotion program in a community • Empower the individual to make their own goals • Develop their own perception of how advocating for their own health could be beneficial • It is imperative for the facilitator in community settings to put power in the hands of the participants! (Attree et al., 2011; Laverack , 2006; Lubetkin, Lu, & Gold, 2010; Rohrer, Wlshusen, Adamson, & Merry, 2007)

Methods: Literature Review • PAM: Patient Activation Measure: “More activated patients were more likely to report better health, self-manage conditions, exercise regularly, eat healthy, and research health matters.” • This tool is helpful in developing a tool to measure pre/post self-efficacy and activation of individuals. • A valid, reliable tool to measure activation is a gateway to gain a better understanding of activation and how it can be increased in the community. • Follow-up activation short term may not provide results that would be seen in a more longitudinal study (Hibbard, Stockard, Mahoney, & Tusler, 2004)

Patient Activation Levels

Methods: Literature Review, continued • There is not a ceiling for activation • In a group randomized controlled trial that compared • a traditional health promotion program group • an activated consumer program group • a control group • Activation levels of the activated consumer group increased over 2-year interval • On average 4.31 increase • Lowest activation levels saw greatest improvements • From 44.2 to 61.5, on average • Improvements occurred in all levels • Even very activated individuals (highest level at baseline) have been shown to improve health related behaviors through activating health promotion programs (Harvey, Fowles, Xi, & Terry, 2012)

Methods: Literature Review, continued • While developing tools to measure self-efficacy • Perceived motivators and barriers • Cultural • Social – Isolation? • Norms, socioeconomic status, access to resources • Motivational interviewing through a focus group • Effective way to determine self-efficacy • Easier to determine individual’s barriers and motivators (Tucker et al., 2011)

Methods: Literature Review, continued • Unintended consequences should also be considered. • Negative Effects? • Patient activation and health literacy are not interchangeable terms. • Cross-sectional study: health literacy did not correlate with activation • This is promising! • Could mean that activation measures does not depend on education as much as community support and resources. (Lubetkin, Lu, & Gold , 2010).

Methods: Cholesterol Park for Seniors “Raise your health IQ” • Interactive exercise to increase IQ • Promotes an effective relationship between the community and health providers during health care decision-making • Can Cholesterol Park sessions increase self-efficacy and confidence?

Methods: Developing Measurable Indicators Evaluation Tool: Pre/Post Surveys • By using tools that have been evaluated as effective • Effective Consumer Scale (EC-17) • Decision Self-Efficacy Scale Facilitator Post-Survey was developed to determine confidence to facilitate change and increase engagement.

Evaluation Tool:Effective Consumer Scale • University of Ottawa • Scale to measure “how effective people are at dealing with chronic health conditions and making decisions about their health care” • 17 items measuring the main skills and behaviors people need to effectively manage their health care. • To be used in trials of self-management or empowering patients • How I use my health information (3) • How I clarify my priorities (3) • How I communicate with others (3) • How I work with the health care team to control my condition (4) • How I decide and act on decisions (4)

Evaluation Tool:Decision Self-Efficacy Scale • The Ottawa Hospital and the University of Ottawa “The ‘Decision Self-Efficacy Scale’ measures self-confidence or belief in one’s abilities in decision making, including shared decision making.” • Confidence in making an informed choice • 11 questions on the scale • 3 for our pre evaluation • 3 for our post evaluation http://decisionaid.ohri.ca/docs/develop/User_Manuals/UM_Decision_SelfEfficacy.pdf

Methods: Developing Measurable Indicators Today’s Date: _________ Location of session: __________ Circle one: Male Female Age: ___________ Zip code: __________________ Do you have high blood pressure, high cholesterol, and/or diabetes? Yes No

Methods: Developing Measurable Indicators Please answer the following BEFORE today’s session. Never Rarely Sometimes Usually Always 1. I know how to adapt general health information to my own situation. 2. When I make decisions about my health, I am clear about what matters most in my life. 3. I know how to ask my provider good questions about my health. 4. I am able to take part in decisions about my health with my health care team 5. I feel confident that I can get the facts about the medication choices available to me. 6. I feel confident I can understand information enough to be able to make choices about my health 7. I feel confident that I can ask for advice regarding my health. 8. I feel confident in making decisions about my health.

Methods: Developing Measurable Indicators Please answer the following AFTER today’s session. Never Rarely Sometimes Usually Always 1. I understand the facts I receive about my health. 2. I can set sensible goals to improve my health. 3. I feel confident in stating my concerns to my health care team. 4. I feel a sense of control over my health. 5. I feel confident that I can figure out health choices that best suit me. 6. I feel confident I can get the facts about risks and benefits of my health choices. 7. I feel confident that I can express my concerns about health choices. 8. I can negotiate with my health providers about how we manage my needs.

Methods: Developing Measurable Indicators Facilitator Post Survey Date: _____________ Location of Session: _________________________ Age: ___________ Answer the two questions below with 1 being not very certain that the group you facilitated was helped and 5 being very certain that the group was helped 1. I feel certain that I helped most of the individuals in my group to feel more empowered in managing health information and taking part in decision-making about their health. 2. I feel certain that I helped most of the individuals in my group to feel more confidence in making informed choices about their health.

Methods: Implement Strategy 8 facilitated Cholesterol Park sessions (Average 3 participants/session) Trained Facilitator for each session While implementing Merck Cholesterol Park, it was very important to create an environment that promotes self-efficacy by starting with very achievable steps to promote early success. Control Group: seniors attending lunch at the senior center (1 lunch with 28 participants)

Methods:Data Collection • Total Surveys • Participant Group: 28 • Control Group: 28 • % Female • Participant Groups: 85.7% (1 no response, 85.7-89.3%) • Control: 60.7% (3 no response, 60.7-71.4%) • % with conditions • Participant Groups: 57.1% (2 no response, 57.1-64.3%) • Control: 39.3% (6 no response, 39.3-60.7%) • Average Age • Participant Groups: 70.7 years • Control Group: 77.3 years

Results: • Participant Group: • Group Effective Consumer Scale • Average Pre-Evaluation = 4.3 • Average Post-Evaluation = 4.4 • Group Decision Self-Efficacy Scale • Average Pre-Evaluation = 4.4 • Average Post-Evaluation = 4.3 • Control Group • Group Effective Consumer Scale • Average Pre-Evaluation = 4.2 • Average Post-Evaluation = 4.1 • Group Decision Self-Efficacy Scale • Average Pre-Evaluation = 4.3 • Average Post-Evaluation = 4.2

Methods:Data Collection • Facilitator’s Perspective: • Average: 3.75 for both questions • Age Range: 23-50 years Age SE-1 SE-2 Senior Center 50 4 4 Winchester 50 4 3 Railroad Housing 25 4 4 East Side Housing 24 4 4 Cheshire Medical 50 5 5 Page Homestead 23 5 5 Warwick Meadow 50 2 3 Troy 24 2 2 Average 3.75 3.75

Discussion: Correlation of decreased Self-Efficacy in BOTH groups Could the questions set up decrease? Regardless of activation? Only increase, on average: • Participant Group: Group Effective Consumer Scale • Average Pre-Evaluation = 4.3 • Average Post-Evaluation = 4.4 Participant group more activated than control in Pre-Evaluation • Showing up - Raise their health IQ • Younger • Females • Health conditions: Diabetes, Hypertension, High Cholesterol • If so, it is important to get older adults to their screenings!!

Discussion: Effectiveness of activation is not easily measured within an hour especially with older adults On the scale of behavior change: If older adults were in pre-contemplation, self-efficacy may decrease with awareness “Older adults with chronic disease experience meaningful increases and decreases in patient activation over the course of a year, without any intervention… Clinicians and researches who use PAM as an outcome measure in studies of older adults should be aware of its natural fluctuation over time in chronically ill older persons” (Chubak et al., 2012)

Recommendations for the future: Even very activated individuals (highest level at baseline) have been shown improvements inhealth related behaviors through activating health promotion programs in a 2-year interval. • We had 1 hour • This supports continuing intervention further, even if seniors are activated their health-related behaviors can change. • Provide incentives for seniors to participate • Advertising: Healthy snack? Tea time? • Motivational Interview Training for facilitators The most commonly recurring message through the literature review was the need for more research towards understanding how to increase activation levels of individuals in the community level.

Patient Activation Levels

Questions?Comments? Thank You! Laura Salinas

Resources Attree, P., French, B., Milton, B., Povall, S., Whitehead, M., & Popay, J. (2011). The experience of community engagement for individuals: a rapid review of evidence. Health & Social Care In The Community, 19(3), 250-260. Laverack, G. (2006). Improving health outcomes through community empowerment: a review of the literature. Journal Of Health, Population, And Nutrition, 24(1), 113-120. Lubetkin, E., Lu, W., & Gold, M. (2010). Levels and correlates of patient activation in health center settings: building strategies for improving health outcomes. Journal Of Health Care For The Poor And Underserved, 21(3), 796-808. Rohrer, J., Wilshusen, L., Adamson, S., & Merry, S. (2008). Patient-centredness, self-rated health, and patient empowerment: should providers spend more time communicating with their patients?. Journal Of Evaluation In Clinical Practice, 14(4), 548-551. Hibbard, J., Stockard, J., Mahoney, E., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Services Research, 39(4 Pt 1), 1005-1026. Harvey, L., Fowles, J., Xi, M., & Terry, P. (2012). When activation changes, what else changes? the relationship between change in patient activation measure (PAM) and employees' health status and health behaviors. Patient Education And Counseling, 88(2), 338-343. Tucker, C., Rice, K., Hou, W., Kaye, L., Nolan, S., Grandoit, D., & ... Desmond, F. (2011). Development of the Motivators of and Barriers to Health-Smart Behaviors Inventory. Psychological Assessment, 23(2), 487-503.

Laura Salinas Keene State College Dietetic Intern