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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.

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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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Page 1: Increasing CRC Screening among Filipino Americans

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.

Page 2: Increasing CRC Screening among Filipino Americans

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.

Page 3: Increasing CRC Screening among Filipino Americans

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

Page 4: Increasing CRC Screening among Filipino Americans

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.

Page 5: Increasing CRC Screening among Filipino Americans

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?

Page 6: Increasing CRC Screening among Filipino Americans

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?

Page 7: Increasing CRC Screening among Filipino Americans

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.

Page 8: Increasing CRC Screening among Filipino Americans

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?

Page 9: Increasing CRC Screening among Filipino Americans

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?

Page 10: Increasing CRC Screening among Filipino Americans

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?