Translation of the CDSMP for African American Older Adults:

Harvest Health Treatment Fidelity & Outcomes

Nancy L. Chernett, MPH, Project Director Laura N. Gitlin, Ph.D. Director

Marie Dennis, Ph.D. Data Analyst

Center for Applied Research on Aging & HealthThomas Jefferson University

Philadelphia, PA

Administration on Aging Grant#90 AM 2773National Institute on Mental Health Grant #R24 MH074779

Project Objectives Translate Lorig et al’s Chronic Disease Self-

management Program (CDSMP) in a Senior Center with 500 African American Older Adults

Evaluate effectiveness of replicable model of collaboration to implement an evidence-based disease prevention program in the aging network

Chronic Disease Self-Management Program (CDSMP)

6-week, 15-hour peer-led education program Basic Assumptions:

Chronic conditions present common issues and needs

Older people need to be empowered to assume active role in disease management

Tested with 1,141 middle income white adults: Improved health status Enhanced self-efficacy Reduced health care utilization

Lorig KR, Sobel DS, Stewart LA et. al (1999) Medical Care, 37 (1) 5-14.

Philadelphia Partners Philadelphia Corporation for Aging (AAA)

Promote adoption & expansion of CDSMP Project oversight

Center in the Park Implement the CDSMP with 500 AA older adults

Albert Einstein Healthcare Network Assure medical quality of the program Link to health care community

Thomas Jefferson University Monitor translation of CDSMP into community

program Program Evaluation

Program Translation

Fidelity to Original Program

Program Adaptations

Feasible, Acceptable & Effective Program Implementation

Fidelity:Essential Issue in Translation

What types of adaptations are necessary?

What types of adaptations can be made (e.g., what are the immutable and mutable aspects of the program)

What mechanisms can be used to monitor fidelity?

Target Population: Black/African American

Elders

Ethnic minority elders projected to be 40% of older US population by 2040 10% increase of African American population

by 2050 Characteristics:

Heterogeneity Increasing in diversity (cultural heritage,

religious affiliation, socioeconomic status, and geographic residence)

Increased immigration -Haiti, Caribbean, African countries

Dupree, Watson, & Schneider, J. of Applied Gerontology, vol 24, 2005.

Persistent

Consistent

National, State and local levels

Lack of studies on relevant issues that concern African American elders

Health Disparities between White and African American Elders

AA (N=507) Whites (N=613)

Fair/poor self-rated health 48% 34% **

1+ chronic conditions 43% 39%

Heart problems 29% 22% **

Hypertension 71% 51% **

Diabetes 31% 13% **

**p < .001

Philadelphia Health Management Corporation 2004 Household Health Survey (a representative sample of 10,000 people in the greater Philadelphia region)

Older White & African Americans (AA) Philadelphians

Integration of Evidence into Community Settings

Ways to Assure Treatment Fidelity

Essential Steps in Translating Program and Assuring Fidelity

Building a team: Identify expertise necessary

Research/evaluation Inside and in-depth knowledge of target

population Knowledge of CDSMP

Create a climate of trust, open exchange and ownership

Essential Steps in Translating Program and Assuring Fidelity

Site Preparation In-services to heighten awareness of

importance of evidence in guiding programming

Development of materials addressing why should African American elders participate in the program and research

Buy in from key players and site staff Create excitement of participating in

cutting edge science/programming

Essential Steps in Translating Program and Assuring Fidelity

Identify Immutable components of Intervention Mechanism of action underlying treatment

effectiveness

Identify Cultural Preferences of Target Population Naming and framing Culturally appropriate images Translation of program to fit different world views

Program Elements Weekly action plans based on individual goals Multiple approaches to symptom management Problem solving Peer modeling Social persuasion

Training/certification Peer leader

Immutable Components

Modifications for Translation

Mutable Components

The name & logo create an image that connotes abundance in health & spirituality for African Americans without the use of threatening medical terminology

Name Change

Why “Harvest Health”?

Addition of moment of silence to address some participants strong preference for spiritual recognition

Avoiding sweets & salt Communicating with health care

provider of a different raceAdaptations developed by Jean Goeppinger, RN, University of North Carolina; pilot tested by Molly Rose, RN, PhD & Christine Arenson, MD, TJU, 2001)

Targeted Information

Additional initial group session: Orientation to program Completion of baseline evaluation Answer questions about program,

time commitment, expectations Socialization into the group

experience Set tone and role of group leaders

Orientation Session

Outcomes of the Translational Effort

CDSMP (N=561) HH (N=212)

Age 66 yrs 72.5 yrs

Females 65% 85%

Race 91% White 100% AA

Health 2.2 conditions 2.8 conditions Conditions

Lorig KR, Sobel DS, Stewart LA et. al (1999) Medical Care, 37 (1) 5-14.

COMPARATIVE PARTICIPANT CHARACTERISTICS

CDSMP (N=561) HH (N=212)

Arthritis 56% 69%

Lung disease 46% 19%

Heart disease 31% 23%

High blood pressure NA 72%

Stroke 9% NA

Diabetes NA 32%

Lorig KR, Sobel DS, Stewart LA et. al (1999) Medical Care, 37 (1) 5-14.

PARTICIPANT CHARACTERISTICS

523 enrolled (end year 3) 100% completed baseline interview 86% completed course (4/6 sessions) 78% (212/267) completed 4 month post-

test evaluation (end year 2)

Recruitment, Attendance and Retention

Four Month Outcomes (N = 212)

Outcome

Mean (SD) Z p valuePretest Posttest

Physical Activities

(1<30 min/wk; 2=30-60 min/wk;3=1-3 hrs/wk; 4>3hrs/wk)

1. Strengthening/stretching 1.4(1.3) 2.0 (1.4) -5.55 .000

2. Other exercise activities (walking, swimming)

2.7 (2.8) 3.4 (2.5) -4.59 .000

Four Month Outcomes (N = 212)

Outcome

Mean (SD) Z p valuePretest Posttest

Health Status Social role function (7 items; 0=not at all to 4 almost totally; e.g., health interfered with social activities)

1.1 (1.0) 1.0 (1.0) -2.27

.023

Health distress (9 items; 0=none of time to 5 = all of time)

1.3 (1.1) 0.9 (1.0) -6.16

.000

Outcome Mean (SD) Z p value

Pretest Posttest

Health care utilization (# of times past 4 months)

.77 (1.3) .85 (1.0) -3.64 .000

Doctor visits 2.8 (2.9) 3.4 (3.0) -3.76 .000

Emergency room visits .2 (.4) .3 (1.0) -1.72 .085

Hospital admissions 0.1 (0.3) 0.1 (0.4) -1.41 .159

Nights in hospital .2 (1.35) .3 (1.58) -1.38 .168

Minimal care facility admission 0.0 0.2 (1.3) -1.83 .068

Four Month Outcomes (N = 212)

Outcome Mean (SD) Z p valuePretest Posttest

Self-efficacy (6 items - confidence in managing symptoms; 0=no confidence to 10 totally confident)

7.1 (2.2) 7.6 (2.0) -3.55 .000

Illness Intrusiveness (how much health conditions interfere; 0=not at all to 10 = very much)

Physical well-being and diet (2 items feeling healthy, eat and drink)

3.9 (2.7) 3.0 (2.7) -4.67 .000

Work and finances (2 items) 3.7 (2.9) 3.2 (2.9) -2.93 .003

Marital, sexual and family relations (3 items)

2.0 (2.6) 1.8 (2.5) -1.88 .060

Four Month Outcomes (N = 212)

0

10

20

30

40

50

60

70

Per

cent

Usi

ng S

trat

egy

Physical Activity Diet/Nutrition Symptom Management

Health Behavior

Action Plan Strategies in Use at Posttest

Do you continue to use the strategies?No = 9 Yes = 203

Conclusions

CDSMP can be effectively translated for an urban African American elderly population and delivered in a senior center

Fidelity can be maintained using quality assurance structure of participating site

Booster/reinforcement of training and importance of maintaining “true” to the intervention is important.