Maria E. Fernandez, PhD Associate Professor of Health Promotion and Behavioral Sciences

Maria E. Fernandez, PhDAssociate Professor of Health Promotion and Behavioral

SciencesUniversity of Texas Health Science Center at Houston

Who is responsible?Researchers/ program developers, implementers, health service providers, funders?

A barrier to translation of intervention research findings for public health benefit is that both developers (often researchers) and practitioners believe that the responsibility for dissemination lies elsewhere.

Researchers: I don’t have the training or interest in approaches to enhance dissemination of research products; grant funding does not support such activities.

Practitioners: The responsibility for summarizing and making research products useful lay elsewhere. But if they were easy to find and use we would do it.

National Cancer Institute, Center for the Advancement of Health and Robert Wood Johnson Foundation. Designing for dissemination: Conference summary report. 2002.. http://dccps.cancer.gov/d4d/d4d_conf_sum_report.pdf

Bridging the Gap: A Synergistic ModelGetting Evidence-Based Cancer Control Interventions Into Practice

Science PushDocumenting, improving,and communicatingthe intervention forwide population use

Delivery CapacityBuilding the capacity of relevant systems to deliver the intervention

GOAL: To increase the adoption, reach and impact of evidence-based cancer control

ULTIMATE GOAL:Improve population health

and well being

Market Pull/ DemandBuilding a marketand demand for theintervention

-based Increase the number of systems providing evidence cancer control-Increase the number of practitioners providing evidence based cancer control

-Increase the number of individuals receiving evidence based cancer control

Orleans, T. NCI Designing for Dissemination Conference, 2002; adapted by Jon Kerner

Source-based

Diffusion of Innovation Theory (Rogers,1995)

Technology Transfer Model (Backer, 1995)

Reach, Efficacy or Effectiveness, Adoption, Implementation and Maintenance RE-AIM Model (Glasgow et al., 2003; Glasgow et al., 2004; Glasgow et al., 2006)

Model of Prevention Science (IOM, 1994)

Public Health Model (Mercy et al., 1993)

Knowledge Management (Graham, 2006, adapted by Kerner, CPAC)

User-based or Community-centered

Patient-centered Medical Home (Miller, 2010; Stange, 2010; Stewart, 2010)

Others have noted that community-centered models are needed (Miller and Shinn, 2005) or offered a complex discussion of community capacity (Goodman et al. 1998)

Combines Perspectives Interactive Systems Framework

for Dissemination & Implementation (Wandersman, 2008)

Description of a planning process derived from the work of health promotion interventionists

Seems to have stimulated in the field ◦ enhanced attempts to

integrate theory and evidence

◦ greater focus on both behavior and environment an ecological planning approach

◦ greater attention to planning for implementation and dissemination

1. Conduct a needs assessment 2. Create matrices of change objectives based on

the determinants of behavior and environmental conditions

3. Select theory-based intervention methods and practical applications

4. Translate methods and applications into an organized program

5. Plan for adoption, implementation and sustainability of the program

6. Generate an evaluation plan

1. Designing the health education program in ways that enhance its potential for being adopted, implemented, and sustained (IM Steps 1-4)

2. Designing interventions to influence adoption, implementation and continuation (IM Step 5)

3. Using IM processes to adapt existing evidence-based interventions - Categorizing and identifying core elements of programs

Using Intervention Mapping to Adapt Evidence-Based

Programs

Some authors suggest that when developmental issues and program targets are appropriate, adaptation is seldom or never needed (Elliot and Mihalic, 2004)

Others point out that the formative work to support adaptation is seldom done (Lau, 2006 )

Nevertheless, in practice…Adaptation Happens.

Some researchers insist that adaptation is essential and the challenge is to strike a balance between program fidelity and adaptation (Backer, 2001)

Even when higher fidelity was shown to be associated with improved outcomes (Durlak & DuPre, 2008) fidelity was not 100%; adaptation may have added to effectiveness

During the adaptation process, planners often choose pieces of programs that are the most appealing or that seem the most feasible,

Usually there is not much input from the community Little or no process for determining what in a program needs to change and what must stay the same

This can lead to programs that are incomplete with little chance of maintaining impact

Variously called core elements, active ingredients, essential elements

Whatever we call them – we ◦ Often do not know what they are◦ Program descriptions often do not include them Botvin, 2004

Program Active Ingredients are:1)Theoretical methods that are intended to

change determinants of behavior (of the at-risk group or environmental agents)

2)Practical applications of methods including delivery channels

3)Characteristics of program materials and messages

4)Characteristics of program implementation

Several authors have described processes of disseminating interventions including approaches to adaptation (McKleroy, 2006; Wandersman, 2008) that generally describe the tasks involved.

Planned adaptation models have been proposed (Backer, 2001; Lee et al., 2008)

Intervention Mapping provides a systematic approach that adds detailed how tos to these frameworks.

It can help planners identify and retain the essential elements as programs are translated to new communities and settings.

“World Starts With Me”

Developed to address the sexual and reproductive health and rights needs of secondary school students in Uganda

Adapted for adoption and implementation in Indonesia

Adaptation of an existing EBP developed for Mexican Americans for use in Puerto Rico ◦Cultivando la Salud (CDC funded intervention

program- National Center for Farmworker Health)

Adaptation of a lay health worker delivered small media intervention (Vivir sin Cancer) on HPV/HPV vaccine originally developed for parents of girls in the LRGV ◦CPRIT funded intervention trial to increase

HPV vaccination among Hispanic girls in Houston

◦Exploring possibility of adapting the intervention for use in Puerto Rico

Adaptation Product: Description of discrepancy between original program logic model of the problem and the model in the new setting (including priority population characteristics).

Adaptation Questions: 1. What is the logic model and priority population of

the problem from the original needs assessment?2. What is the logic model and priority population

for the adopting site?3. Do they match? How are they different?

Personal and External Determinants (Predisposing, enabling, reinforcing factors)

BehavioralFactors

EnvironmentalFactors

HealthProblems

Qualityof Life

Indicators

Phase 4 Phase 3 Phase 2 Phase 1

Original Program- Cultivando la Salud- Mexican Origin womenLow levels ofKnowledge of breast and cervical cancer and screening guidelines Outcome ExpectationsPerceived Barriers and BenefitsAttitude (fear of detection, fear of procedure and belief that cancer is incurable)Low Self-EfficacyLow Perceived Social NormsAvailability and Accessibility

Puerto Rico

Low levels of Knowledge of breast and

cervical cancer and screening guidelines (not as low)

Knowledge of availability Perception of risk Perceived Barriers and

Benefits Attitude (fear of detection,

fear of procedure) Low Self-Efficacy

Outreach Program

Environmental Factors differ considerably due to access to care (Reforma – universal coverage in PR vs indigent care in LRGV)

Adaptation Product: Matrix of change objectives that should be added to the original program to improve validity the of the change model.

Adaptation Questions:1. What behavior and environmental conditions (and

their determinants) did the original program target for change?

2. What should the adopting site seek to change in behavior and environment (and their determinants) that is different from the original program?

Determinant 1 Determinant 2

Performance objective 1

Change objective

Change objective

Performance objective 2

Change objective Change objective

At Risk Group

Logic of Change

TheoreticMethods &Practical Strategies

Determinants

Environmental Outcomes

Health and

Qualityof Life

Behavioral Outcomes

Performance Objectives

Performance Objectives

Determinants

TheoreticMethods &Practical Strategies

Program

Inputs

ProgramOutputs

Outcomes

Environmental Agent

Resources

Program Activities & Materials

Designed to increase information seeking about HPV and HPV vaccine among Hispanics along the TX-Mexico Border

Young Young Women Women versionsversions

1-800-4-CANCER is confidential and they can speak to you in Spanish if you prefer.

Thank you so much. I’ll call when I get home.

Parent Parent versionsversions

Vivir Sin CáncerLive Without Cancer

Learn how to protect your daughter from cervical cancer

Vivir Sin CáncerLive Without Cancer

Learn how to protect yourself from cervical cancer

Goal is to adapt existing materials so that they fit a new context (Houston urban Hispanics)

Differences in target behaviors:◦ Original Project: HPV/HPV Vaccine information

seeking◦ New/Adapted Intervention: HPV vaccination

Differences in determinants?

Vivir sin Cancer – Mexican Origin Women

Knowledge/awareness of CIS “1-800” number Knowledge/awareness of CC, HPV and HPV vaccine Self-Efficacy for calling CISSkills for calling CISPerceived norms and social norms about callingPersonal preferences about information seekingOutcome expectation that their questions would be answeredMedia and mandate on HPV vaccination

Common factors across parents from LRGV and Houston

Attitudes about HPV vaccination

Perceived risk of cervical cancer and HPV (for daughter)

Perceived severity of cervical cancer and HPV (for daughter)

Concerns about cost/Insurance coverage

Concerns about sexual disinhibition

Outreach Program

Adaptation Product: 1. Description of theoretical methods or practical

applications that should be added to address new change objectives or to make the original methods apply to a different population/context.

2. Description of essential program elements that must be retained.

Adaptation Questions:1. What theoretical methods and practical

applications to promote change did the original program include?

2. What methods and practical applications must be added to match new change objectives or modified to fit the new population?

Adaptation Product: Description of recommended changes in the program components and/or delivery.

Adaptation Questions:1. How well did the program components and

delivery implement the theoretical methods and practical applications?

2. How well does the program delivery match preferences the new population and context?

3. What changes in scope and sequence or materials are necessary to deliver new methods and practical applications?

Adaptation Product:Description of how program implementation should be changed

Adaptation Questions:1. How well was the original program delivered

(completeness, fidelity, dose)?2. How comprehensive and feasible is the

implementation protocol?3. What are the implementation performance

objectives in the new setting?4. Will implementation require additional elements

in the new setting?

Personal Determinants Performance Objectives

Knowledge/Awareness Perceived Social Norms

Outcome Expectations

Attitudes

PO1 Clinic director adopts Cultivando La Salud Program

K.1. Recognizes this program as available K.1. Recognizes that the program will provide resources to the clinic K.1. Describes the program as promoting breast and Pap test screening for farmworker women 50+ K.1. Describes program as developed from extensive work with the community

PSN.1. Describes other clinics as using this program

OE.1. Expects that if they use this program, rates of screening will rise

A.1. Describes breast and cervical cancer morbidity and mortality as a real problem for farmworker women A.1. Argues for increasing screening for farmworker women A.1. Describes the program as being better than what they have now, fitting with current services, triable, not too complex

PO2 Clinic director establishes and supports promotora program PO2.a. Clinic director obtains staff buy-in PO2.b. Clinic director obtains community buy-in

K.2.a. Reflects that staff will accept the program if given the opportunity to talk about promotoras, needs and resources, program goals and agency support K.2.b.Reflects that involving community leaders in planning will help develop a program that communities will accept

PSN.2. Describes other clinics in the LRGV as using promotora programs successfully

OE.2. Expects that promotoras can effectively engage women to participate in clinic services

A.2. Describes promotora programs as building ties to the community A.2. Describes promotoras as a credible source of health information

Personal Determinants External Determinants Performance Objectives

Knowledge Skills and Self-efficacy

Attitudes Perceived Social Norms

Outcome Expectations

Social Support

PO1 Adopts the role of lay health worker

K.1.a. Describes the role of the lay health worker K.1.b. Describes the challenges involved with being a lay health worker

SSE.1.a. Feels confident that she can adopt and fulfill the role of promotora

A.1.a. Believes that becoming a promotoras is an important contribution to the community

PSN.1.a Recognizes that other women in her community have become promotoras

OE.1.a. Expects that if she adopts the role of promotoras she will be successful at providing education to the community

SS.1.a. Existing promotoras encourage new promotoras and express their availability to help them.

PO2 Locates farmworker women 50+ PO2.1.. Posts flyers PO2.2. Identifies community leaders to help with recruitment PO2.3. Go door to door in health center neighborhood PO2.4.Contact and work with community centers, churches, schools, Migrant Headstart and local migrant councils

K.2.a. Describes the neighborhoods in which farmworker women reside K.2.b. Compares the needs of farmworker women to other women K.2.4.c. Identifies community centers, churches, and other locations to conduct education

SSE.2.a. Feels confident in her ability to locate farmworker women SSE.2.4.a. Feels confident in her ability to make contact with community centers, churches, headstart programs, and migrant councils

A.2.a. Believes that locating farmworker women is an important part of her job as a promotora

PSN.2.a. Recognizes that successful promotoras target at risk groups such as farmworker women

OE.2.a. Expects that locating and educating farmworker women will result improvements in the health of the community OE.2.4.a. Expects that collaborating with churches, community centers and other organizations will help her locate farmworker women

SS.2.a. Outreach coordinators provide encouragement and logistic support to promotoras in their effort to locate farmworkers. SS.2.4.a. Other promotoras will provide contacts and assistance in locating farmworker women

PO3 Conducts home visits and community group visits PO3.1. Develops a safety plan for home visits PO3.2. Plans community sessions

K.3.a. Describes the proper protocol for conducting home visits K.3.1.a. Describes safe ways to conduct home visits K.3.2.a. Describes points to discuss with manager of community site

SSE.3.a. Demonstrates the approach to women on home visits SSE.3.b. Expresses confidence in her ability to conduct a home visit SSE.3.1.a.

A.3.a. Explains that home visits are an effective way of reaching farmworker women

PSN.3.a. Recognizes that other respected promotoras conduct home visits and community educational sessions

OE.3.a. Expects that if she follows the protocol she will be welcomed into the homes of farmworker women OE.2.1.a Expects that if she follows a good safety plan

SS.3.a. Other promotoras accompany new promotoras on home site visits. SS.3.b. Family members express support and help at home so that

Cultivando la Salud-Implementation Matrix

Breast & Cervical Cancer Training Curriculum◦ Introduction to the Training◦ Role of the Lay Health

Worker◦ Reaching Women from

Farmworker Families◦ Finding Breast Cancer Early◦ Breast Cancer Screening:

Barriers and Responses◦ Pap Test: Barriers and

Responses◦ Teaching Methods◦ Practices Session Using

Program Materials◦ Resources and Referrals◦ Evaluation

Adaptation Product: Evaluation questions including effectiveness and acceptability of new program elements

Adaptation Questions:1. What program outcomes and change objectives

was the adapted program effective in meeting? And how does effectiveness compare to the original program?

2. What was the reach, fidelity and completeness of the adapted program? And how does the process evaluation compare to the original program?

Systematic planning models such as Intervention Mapping can guide planned adaptation that can help ensure that◦ important differences between the original

program population and setting are addressed with new program objectives, methods, and practical applications

◦ essential elements of programs are maintained