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Increasing CRC Screening among Filipino Americans (Maxwell, Bastani, Danao, Crespi, UCLA. ACS 2004-2009). Recruitment of subjects in 45 CBOs and churches. Baseline Interview (N=906) RANDOMIZATION of subjects who are non-adherent at baseline (N=548)*. Control (Exercise). - PowerPoint PPT Presentation
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Increasing CRC Screening among Filipino Americans
(Maxwell, Bastani, Danao, Crespi, UCLA. ACS 2004-2009)Recruitment of subjects in 45 CBOs and
churches
Baseline Interview (N=906)RANDOMIZATION of subjects who
are non-adherent at baseline (N=548)*
Control (Exercise)
Intervention 1 (Education, FOBT
kit + reminder letter + letter to provider)
6 month telephone follow up: any CRC screening during follow-up
9% 30% 25%
Verification of self-reported screening
Intervention 2 (Education, NO FOBT
kit + reminder letter + letter to provider)
•Randomization of small groups, couples attend the same session.
Estimates of the efficacy of the intervention Analysis Approach Percent screened Intervention effect estimate
Subjects Outcome variable Intervention w/FOBT kit
Intervention w/o FOBT kit Control
Intervention w/FOBT kit versus control
Intervention w/o FOBT kit versus control
OR (95% CI) P OR
(95% CI) P
1
Study completers (n=432)
Self-reported screening status
39% (61/156)
31% (45/146)
11% (14/130)
5.6 (2.8, 11.4) <.001 3.8
(1.9, 7.8) <.001
2*
All randomized participants(n=548)
Study completers: self-reported screening statusStudy non-completers: single imputation of not screened status
30% (61/202)
25% (45/183)
9% (14/163)
4.9 (2.4, 9.9) <.001 3.7
(1.8, 7.5) <.001
3
All randomized participants(n=548)
Study completers: self-reported screening statusStudy non-completers: multiple imputation of self-reported screening status;All subjects: adjustment for PPV and NPV of self-report
32% 22% 6%7.8
(2.8, 21.3) <.001 4.6(1.5, 14.1)
.009
NPV, negative predictive value; PPV, positive predictive value.
* Maxwell AE, Bastani R et al. American Journal of Public Health 2010.
Efficacy of combinations of intervention components
Analyses included all participants who attended a small-group session and provided sufficient information to enable a letter to be mailed to their provider. Adjusted for baseline differences, PPV and NPV of self-report.
* evidence-based intervention strategies
Community Dissemination of an Evidence-based CRC Screening Intervention (Maxwell, Bastani, Danao, Crespi, UCLA. ACS 2010 – 2014)
10 CBOs
Randomize
5 CBOs
Basic Dissemination
(one-time training of CHAs & distribution of materials)
5 CBOs
Organizational Dissemination
(basic dissemination + workshop with CBO leaders to implement 5 organizational changes to promote CRC screening + 6 booster sessions/year with CHAs)
5 CBOs x 5 CHAs x 8 subjects = 200 subjects
5 CBOs x 5 CHAs x 12 subjects = 300 subjects
Group-randomized design (as funded)
CHA = Community Health Advisor Assessments: Telephone interviews of subjects, organizational assessments, health advisor debriefings and log sheets.
The Racial and Ethnic Approaches to Community Health (REACH)
Model of Change
Insurance status
Health care
providers
Health Care Environment
Filipino American CommunityChanges in health
Changes in risk factors and protective factors
Organizational changes
Changes in change agents
Develop community capacity
Community awareness of issue
Actio
ns T
arge
ting
CBO
s
Filipino CBOs
Centers of Disease Control and Prevention, adapted from Hill et al., 2007.
Question:
Include only orgs from CRC1 Study, new orgs or both?
Research Question: What strategy to disseminate a CRC screening intervention has the greatest impact when
administered in Filipino American community settings?
Evaluation Framework: RE-AIM• REACH: CHAs in the organizational dissemination arm will disseminate CRC screening to more
subjects than CHAs in the basic dissemination arm.
• EFFECTIVENESS: Filipino Americans in the organizational dissemination arm will exhibit higher screening rates at 6 mos follow-up than those in the basic dissemination arm.
• ADOPTION: Organizational dissemination will result in better organizational adoption of activities to promote CRC screening compared to basic dissemination.
• IMPLEMENTATION: Given technical assistance and resources, CBOs can implement evidence-based strategies to promote CRC screening among Filipino Americans.
• MAINTENANCE: Organizational dissemination will result in better maintenance of activities to
promote CRC screening compared to basic dissemination. Question: what constitutes Maintenance? No more technical and financial support for orgs? How
do we assess Maintenance activities without influencing organizations and CHAs? When does Maintenance phase start in the basic and organizational dissemination arm?
RE-AIM Measures• Reach: # of subjects enrolled, how do enrolled subjects
compare to the larger FA population? Compare refusals & participants, drop-outs & completers
• Effectiveness: # of subjects screened at 6 months• Adoption: # of dissemination activities conducted per month
and per subject in year 2.• Implementation: compare activities reported by CHAs and
subjects to protocols.• Maintenance: # of dissemination activities conducted per
month and subject in years 3 to 4.
NCCDPHP Knowledge to Action FrameworkNCCDPHP Knowledge to Action Framework
Research Phase
Efficacy
Effectiveness and
Implementation
Supporting Structures
Discovery
Inst. Phase
Institution-alization
Decision to
AdoptKnowledge to Products
Practice
Supporting Structures
Diffusion
Practice-based Discovery
Decision to
Translate
Dissemination
Engagement
Translation Phase
Evaluation
SupportingStructures
Practice-based Evidence
Question: Can a 4 year study really assess all components from effectiveness to institutionalization?
Individual & Setting Level Predictors of Implementation
RelationshipPosition of CHA within org
RelationshipLength of relationship, credibility, trust
Graphic developed from article by Rabin, Nehl, Elliot, Deshpande, Brownson, Glanz. Implementation Science 2010
Question: Are there existing measures we can use to assess these variables? Which variables are most important?
Discussion Questions• Importance of community awareness: Conduct the trial with “veteran” or “virgin”
organizations or both?• Criteria for selection & randomization of orgs
(size of membership, SES of geographic area in which org is located, church versus non-faith based orgs)
• Basic dissemination arm: how can we conduct frequent assessments without contaminating this arm
• Maintenance phase- when does it start: after 2 years of implementation? - continue to provide financial support to orgs during maintenance phase?- limit assessments to one exit interview to not influence level of activities during the maintenance phase?
• AssessmentWhat are the main organizational and CHA variables that we should assess?How to deal with organizations that are dropping out?
• Contribution to Dissemination & Implementation ScienceHow can our data inform the Model of Change and RE-AIM?