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2/14/17
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NationalCenterforChronicDiseasePreventionandHealthPromotion
EngagementStrategiesforNationalDiabetesPreventionLifestyleChangePrograms
AssessingEvidenceandSpotlightingSessionZero
DivisionofDiabetesTranslation(DDT)EngageWorkGroupFebruary15,2017
Fromthiswebinaryouwillgain:§ FamiliaritywithDivisionofDiabetesTranslation’s(DDT)EngageWork
Group§ BackgroundontheEASEProject(EvaluationandAssessmentofStrategies
forEnrollment)andDDT’sPromisingPracticesStudy§ Anapproachforassessingpromisingpracticesbeforedecidingon
implementation§ Insightsfromthefieldonoffering“SessionZero”
– SessionZero:Anintroductoryorpre-sessiontoengageandenrollparticipantsintoNationalDiabetesPreventionlifestylechangeprograms
DDTEngageWorkGroup§ 9memberswithdiverseperspectives§ Representationfrom5differentteamsacross2DDTbranches§ Focusedonapplyingbehavioralinsightapproaches(a/k/a“nudges”)
– Nudgescanhelppeople“findthepathofleastresistance”toreachtheirhealthgoals
§ Goalofimprovingengagement
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GuidanceforAssessingEvidencetoHelpBridgetheGapBetweenRealandIdealKristaProia,EngageCo-Lead
Exampleofthereal:PromisingPracticesStudy§ Purpose:Identifyandspreadpromisingpracticestoincreaseenrollmentin
NationalDPPlifestylechangeprograms– Telephoneinterviewswith9CDC-recognizedorganizations,including:
• Programstaffandparticipants• 2organizationsofferingvirtualprograms
– Expertpaneltoreviewpromisingpracticesandseeknewideas
Strivingfortheideal:EvaluationandAssessmentofStrategiesforEnrollment(EASE)Project§ Purpose:Develop,implementandevaluateanenrollmentinterventionto
increaseparticipationinNationalDPPlifestylechangeprograms§ Multi-componentinterventionpackage:
– Designedtoreducebehavioralbarriersacrossallstagesintheenrollmentprocess
§ Controlledevaluation– Compareenrollmentratesbetweensitesimplementingandnot
implementingtheEASEpackage– Includingimplementation feasibility&fidelity,retention,weightloss
andcost§ Resultsexpected:Early2019
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IdealWorldRealWorld§ Pre/postinterventiondata§ Comparisongroup§ Assessingunintendedeffects§ Assessingcosts
§ Nat’lOrg.Eval.– someparticipantdata;nopre-implementationdataandnocontrolgroup
§ PromisingPracticesStudies–storieswithnodata
§ EASEdiagnosisreport–evidencefromdifferentpopulations&purposes
§ Expertpanel– weakevidence&littleconsensus
FrameworkforThinkingAboutEvidence
http://vetoviolence.cdc.gov/understanding-evidence
DDT’sHierarchyofEvidenceforBestPractices§ Meta-AnalysesofRCTs§ Randomizedcontrolledtrials(RCTs)Best§ Non-randomized,controlledinterventionstudies§ Meta-analysesofobservationalstudies-----------------------------------------------------------------------------------------------§ Observationalstudies Promising§ Uncontrolledevaluationofexistingprograms§ Anecdotalexperience§ Intuitionandcommonsense
Gregg E. Framework and Update on Best Practices for Prevention and Control of Diabetes. May 2010.
Example: National DPP
Example: EASE
Example: 1212 Evaluation
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ComponentsofPublicHealthImpact
Spencer LM et al. Seeking best practices: A conceptual framework. PCD. 2013;10
HierarchyofEvidenceRelativetoImpactComponents
Evans D et al. Hierarchy of evidence: a framework for ranking evidence. JCN. 2003;12:77-84.
USPreventiveServicesTaskForceHierarchyofEvidenceI
• Properly powered and conducted RCT• Well conducted systematic review or meta-analysis of homogeneous RCTs
II
II-1 • Well-designed controlled trial without randomization
II-2 • Well-designed cohort or case-control analysis
II-3• Multiple time series, with or without the intervention • Results from uncontrolled studies that yield results of large magnitude
III• Opinions of respected authorities, based on clinical experience• Descriptive studies or case reports• Reports of expert committees
USPSTF. 2015. U.S. Preventive Services Task Force Procedural Manual. https://www.uspreventiveservicestaskforce.org/Page/Name/methods-and-processes
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ContinuumofResearchEvidenceforEffectiveness§ CDC’sInjuryCenter’sframework
– Usescontinuumvs.hierarchy– Includes negativeevidence,e.g.,evidencefor:
• Littleornoeffect• Harm
Puddy R et al. 2011. Understanding Evidence Part 1: Best Available Research Evidence.A Guide to the Continuum of Evidence of Effectiveness. Atlanta, GA: CDC.http://vetoviolence.cdc.gov/understanding-evidence
ShortListofQuestionstoConsiderBeforeImplementingaPromisingPractice§ Whatlevelofevidencesupportsexpectedbenefits?§ Whatscaleofresourceswillberequired?§ Whatcouldwedowiththeseresourcesotherwise(i.e.,whatisthe
opportunitycost)?§ Whatarethepotentialunintendedconsequencesorevenharms?§ Whatmaybetheeffectsondisparities?§ Whatistheurgencytoact?
Example:Economicincentives• Evidenceforeffectivenessishighlyvaried• Effectivenessandcostdependonhowandwhencashisofferedandpaid• Potentiallyveryexpensiveatapopulationlevel• Resourcesbetterspentonexistingstrategies• Monetaryincentivescanbackfire
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CDC’sConsiderationsinSpotlightingSessionZero§ Consistentsupportacrossdiversesourcesofinformation:
– NationalOrganizations(1212)evaluation– PromisingPracticesandEASEinterviews/sitevisits– EASEbehavioraldiagnosisanddesignresults– Multiplebehavioralexperts
§ Carefulconsiderationofopportunitycostsisstillneeded§ Nomajorunintendedconsequencesidentifiedsofar;continuetomonitor§ Evaluationneededondifferentialimpactbyage,sex,race/ethnicity,income
PollQuestion§ Whenthinkingabout/actingupona“FrameworkforThinkingabout
Evidence,”whatdomainhasthemostinfluenceondecisionmakingforyouandyourkeystakeholders?
A.ContextualEvidenceB.ExperimentalEvidenceC.BestAvailableResearchD.Noneoftheabove
IfDwaschosen,pleasespecifywhyinthequestionboxlocatedinyourcontrolpanel
Thankyou!§ Formoreinformationcontact:
– KristaProia,isp9@cdc.gov,404.498.0961
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References§ EvansDetal.Hierarchyofevidence:aframeworkforrankingevidenceevaluatinghealthcare
interventions.JournalofClinicalNursing.2003;12:77-84.§ GreggE.FrameworkandUpdateonBestPracticesforPreventionandControlofDiabetes.
May2010.§ Puddy RW,WilkinsN.UnderstandingEvidencePart1:BestAvailableResearchEvidence.A
GuidetotheContinuumofEvidenceofEffectiveness.Atlanta,GA:CentersforDiseaseControlandPrevention.2011.Availableat:https://www.cdc.gov/violenceprevention/pdf/understanding_evidence-a.pdf– Additionalresources,includingaContinuumofEvidence:
http://vetoviolence.cdc.gov/understanding-evidence§ SpencerLMetal.Seekingbestpractices:Aconceptualframeworkforplanningandimproving
evidence-basedpractices.PreventingChronicDisease.2013;10.§ USPSTF.2015.U.S.PreventiveServicesTaskForceProceduralManual.Availableat:
https://www.uspreventiveservicestaskforce.org/Page/Name/methods-and-processes
InsightsFromtheField
ArtFrankeNationalKidneyFoundationofMichigan
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DPPInformationSession
ArtFranke,PhD
2/15/2017
TopTenReasonstodoaSessionZero
• Educateaboutprediabetesandhowtopreventtype2diabetes• BrieflydescribesciencebehindtheDiabetesPreventionProgram• Setthetoneofthelifestylechangeprogramanddescribeitsgoals• Answerpotentialparticipants’questions• Determinemotivationlevelofpotentialparticipants• Identifypeoplewithdiabetesandofferalternatives(e.g.,DSME,DSMP)• Startconnectingparticipantswitheachotherandlifestylecoach• Obtaincommitmentanddetermineifeveryonequalifiesfortheworkshop• Filloutpaperworkandenrollmentmaterials• Recruitadditionalparticipantsfromtheirfamilyandfriends(ifneeded)
WhoisInvitedtotheInformationSession?
ReferralsfromHealthCareProviders
PeopleReachedbyMarketingMaterials
WhoeverisinterestedinlearningmoreaboutattendingaDPPworkshop!
ReferralsfromInsurers,HostSites,andEmployers
Friends&FamilyofPotentialParticipants
Sessionledbytrainedlifestylecoach
Heldatsamelocation,time&dayasplannedworkshop
Frequency=1or2dependingonhowmanypeoplesignup!
Goal20-30
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HowtoMakePeopleAwarewithaSenseofUrgency
Engagement,Engagement,Engagement!
• Usemulti-channelapproach:• Rallyfront-linehealthproviders,insurers,communitypartners,employers,thepublicatlargenearworkshoplocation• Distributeworkshopflyersathostsites,healthproviders,localchurches,etc.• Activemarketingatevents,onwebsites,newsletter,pressreleases,PSAs,mailings,flyerstocommunitypartners,socialmedia
InformationalSessionAgenda
• Introductions– Whyarewehere?• WhatistheNationalDiabetesPreventionProgram?• ProgramGoals• Whydoesitwork?• DemoDPPActivity• QualifyingfortheProgram• Areyouready?• Fulldisclosure• Filloutregistrationpacket• Discussrecruitingadditionalparticipants
LessonsLearned– It’sImportanttoHaveaSession0
• Session0isveryimportanttohavingasmootherSession1• Ithelpsdetermineifeveryonewhoenrollsisqualifiedandreadytogo• Opportunitytodiscussotherhealthbenefits• Somepeoplemaynothavemadeuptheirmindsbutconnectwith
peersorcoachand/orgetanswerstoadditionalquestions• Consideratestimonial(orvideo)frompreviousparticipantabout
successinDPPanditsimpactontheirlife• AddressotherbarrierstoparticipationintheDPP• Ifworkshopisnotfull,haveadditionalflyersandrequestattendees
recruitfamilyandfriendswhomightqualify
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ContactInformation:
ArtFrankeafranke@nkfm.org734-222-9800
KarenBaileyUniversityMedicalAssociates
KarenBailey,LD,CDE,MSUMADiabetes&EndocrineCare/OUHCOMDiabetesInstitutePreventT2ProgramAthens,Ohio
LocatedinruralSoutheasternOhio,homeofOhioUniversity
TrainedasDPPLifestyleCoachatUniversityofPittsburghin2012andstartedGroupLifestyleBalanceJanuary2013
Spring2013becameagranteeofAmericanAssociationofDiabetesEducatorsandbeganDiabetesPreventionProgramclassesusingCDCcurriculumafterbeingtrainedatDTTACinAtlanta
ReceivedCDCrecognitionJanuary2016.Started11th classthismonth.UsingPreventT2curriculum
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Objectives“SessionZero”ØPurposeitservesinourprogram
ØHowwetargetindividualsforthesession
ØContentofthesessioninourprogram
UMADiabetes&EndocrineCare/OUHCOMDiabetesInstitutePreventT2Program
PurposeofSessionZero
vDescribetheprograminmoredetailthanadvertisementsoffer
vAnsweranyquestionsprospectiveparticipantsmayhave
vDecreaseincidenceofdropoutsbydescribingthecommitmenttheprogramentails
vCompleteandcollectformsrequiredbytheprogram
BeforeSessionZero…Advertisementsforprogramaresentoutbetween
2monthsand2weeksbeforetheprogramstarts.
§ Newspapers– classifiedad,largerads,on-lineads§ Radioannouncements§ Employeenewsletters§ Websites,Facebook,Twitter§ Flyersdistributedtodoctor’soffices,libraries,HealthDepartment,etc.
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BeforeSessionZero…
Interestedindividualseither
calloremail
Wesendthemthe
followinginfo:
PreventT2APROVENPROGRAMTOPREVENTORDELAYTYPE2DIABETES
INFORMATIONALSESSION:
AREYOUREADYTOCOMMIT?
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InformationalSession:AreYouReadytoCommit?Agenda◦ IntroducethePreventT2programandmembersoftheteamwhowillbesupportingparticipantsontheirjourneyoflifestylechangethisyear.
◦ ReviewtheParticipationAgreementFormandifreadytocommit,sign
◦ BecomefamiliarwithSessionroutine
◦ Completeandreturnconsent,intake,PhysicianReferralandagreementforms
PreventT2InformationalSession(session0)
DescriptionoftheDPPStudyResults–• Poweroflifestylechange• Benefittoall,nomattergender,raceorethnicityandevengreaterbenefitforthoseover60yrs ofage
• ImpactthatlifestylechangemayhaveinreducingtheoverwhelmingburdenofdiabetesonhealthcarecostsinU.S.
PreventT2InformationalSessionDescriptionofNationalDiabetesPreventionProgram• Efforttoduplicatetheseresultsincommunitiesacrossthenation
• Deliveredtogroups• Economicallyfeasible
• Theaddedbenefitofgroupsupport• Approvedcurriculum,recognitionstatus,programsupport
• De-identifieddatasubmissiontoCDCtoevaluateeffectivenessofprogram
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PreventT2InformationalSessionMustbe≥18yrs oldwithaBMI≥24kg/m²(≥22kg/m²,ifAsian)
≥50%musthavediagnosisofpre-diabetesusingthefollowingrecentbloodtests(withinpastyear):§ Fastingplasmaglucoseof100-125
§ Plasmaglucose2hr after75gm glucoseloadof140-199mg/dl
§ A1cof5.7-6.4
§ ClinicallydiagnosedGestationaldiabetesmellitusduringpreviouspregnancy(maybeselfreported)
50%maxmaybeeligiblewithoutbloodtestorhx ofGDMiftheyscreenpositiveusingPre-diabetesScreeningTest.
Pre-diabetesScreeningTest
PreventT2InformationalSession
Cohortscompletedwithweightlossresults
Jan,2013(6%) Sept,2015– 2cohortsMay,2013(5%) Athens(7%),Marietta(7%)Sept,2013(6%) Jan2016(5%)Jan,2014 (14%) Sept,2016Jan,2015 (8%) Jan2017
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PreventT2InformationalSession
} Participantsattend90minuteweeklymeetingsfor12weeks,bi-weeklyfor8weeks,thenmonthlymeetingsforremainderofyear.
} Participantswillweighinateachvisit,trackfood,calorieandfatgramintakeandrecorddaily.Thesediarieswillbecollectedandreviewedbylifestylecoachesandreturnedwithhelpfulcommentsandpraise.Participantswillbegivenweeklyassignmentstobringanddiscusswithotherparticipants.
} Lifestylecoacheswillpresentmaterialweeklyonhealthyeating,waystoincreasephysicalactivityandbehaviorchangestrategiesandprovidepositivereinforcementtoallowparticipantstoovercomeobstaclesandchangelifestylehabitsinfavorofeatinglessandmovingmore.Sessionsareinteractivewithgroupdiscussionandactivities.
PreventT2InformationalSession(session0)
SessionRoutine:◦ Weighinandrecordonyourweightrecord
◦ Turnincompletedfoodandactivitytrackers;declareminutesofactivityforpreviousweekandpedometerstepswhenyougetpedometers
◦ Collectsessionmaterials,newtrackersandgoalsheets
◦ Trytherecipeofthedayandgetcopyofrecipetotryathome!
◦ Dresscomfortablyforlighttomoderatepacedexercise
PreventT2InformationalSession
INCENTIVES
First6months–Participantswhoattend80%ofthesessions(13)onthescheduleddate,makingupanymissingsessionsbytheendoftheCoreSessions(Session16)andbringFoodandActivityTrackerscompleted80%ofthetimewillreceiveanincentive.Theincentivewillbesomethingthatsupportsahealthylifestyle.
Second6months– Raffles:showupforsession,enterraffle;bringcompletedtracker,getanotherraffle.Winnergetsprizeatendofsession.
Pedometerchallenges– groupwalksaroundtheU.S.Individualswithhighestpedometerstepsrecognized.
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PreventT2InformationalSession
Costofyear-longprogram:$500
TheAthensCountyHealthDepartmentandtheAADEisprovidingscholarshipsforindividualswhohavepre-diabetes.Pay$100atthebeginningofprogramandreceiveitbackif80%ofprogramiscompleted.
Certainemployersmaypayforprogram:UMA,OU
OUemployees– pay$100upfrontandgetthisbackifcomplete80%ofprogram
UMA– Ifpt doesnotcomplete80%ofprogram,pt paysforprogramcosts.
PreventT2InformationalSession(session0)Read,signandturninforms:üPhysicianReferralformüParticipantagreementformüProgramintakeformüFitnessquestionnaireüConsentformsfor:ØSharingcontactinformationwiththegroupandstaffØAllowingphotosofselfduringtheprogramØWaiverformforexercise
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PreventT2InformationalSession
LessonsLearned
SessionZeroishelpful…vClarifyprogramcommitmentandhopefully decreaseincidenceofdrop-outs
vMakesureparticipantshavereceived,completedandturnedinneededforms
v Everyonehasheardthesamemessage;allhopefullyonsamepage.
vAllowsmoretimefirstsessionforcontentandicebreakeractivities.
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Lessonslearned,observationsmade…(anecdotal)
ØOptimalsizeofgroup– 10to15.Therewillbedropouts;ifstartingtoosmall,notenoughenergyinthegroup.Toolarge,andgroupintimacyissacrificed.
ØSuccessforparticipantisinverselycorrelatedtothecomplexityofone’slife§ Fulltimejobsandresponsibilityofchildrenorelderlyparentsarechallengestostayinginprogram§ Financialchallenges,healthproblems,lackofsupportarealsochallenges§ Lackofconfidence,failedattemptsatdieting,eatingdisorderspresentchallenges
Ø Retiredindividualsorthosethathavemoretimeandfewerresponsibilitiesforothersdobetter.
Ø Attentiontoattendanceandtrackingareindicatorsofsuccess.Ø Couplesparticipatingtogetherinprogramcanbehelpful,althoughlesslikelytohappen.Ø Thosewhohavealreadystartedtheprocessofchangebeforecomingtoprogramdobetter.
KimberlyLoveladyFundamentalHealthSolutions
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QuestionsandDiscussion
PollQuestionBasedonwhatyouhaveheardtoday,doyouplantoimplementaSessionZero?
A.YesB.NoC.Needmoreinformationtodecide
IfCwaschosen,pleasespecifywhatinformationyouneedinthequestionboxlocatedinyourcontrolpanel.
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Formoreinformation,contactCDC1-800-CDC-INFO(232-4636)TTY:1-888-232-6348www.cdc.gov
ThefindingsandconclusionsinthisreportarethoseoftheauthorsanddonotnecessarilyrepresenttheofficialpositionoftheCentersforDiseaseControlandPrevention.
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