hxr 2016: fast track: prove it: the role of evidence and insights in health intervention design

PREPARED BY

Prove it: the role of evidence and insights in health intervention design

HxRefactored Olga Elizarova, DDS, MPH

Behavior Change Analyst

Mad*Pow

April 5th, 2016

“With regard to healing the sick, I will devise and order for them the best diet, according to my judgment and means; and I will take care that they suffer no hurt or damage.”

Hippocratic Oath, late 5th century BC

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Changing something requires understanding it first.

Executive Summary

By using evidence & insights in your health intervention design you:

• Don’t put people at risk

• Increase relevance and likelihood of acceptance

• Differentiate and build trust

• Improve the project’s cost-effectiveness4

Introduction

Developing messages/materials/activities

Influencing behavior &/or environmental factors

Promoting improvement in health &/or reduction of risk

Health Intervention Design

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Introduction





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Should the intervention be a digital app at all ?!?

Introduction





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How strongly are these factors linked to the health outcomes we want to improve?

Are these factors modifiable?

What should people do differently?

Introduction





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Are the targeted behaviors linked to illness, disability, other bad health outcome ?

Can the desired improvement be specified and measured?

Introduction

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EVIDENCE & INSIGHTS

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Introduction: Evidence & Insights

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What constitutes evidence?

(External clinical) evidence, means clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests, the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens.

David Sackett


Secondary Healthcare Data Sources Raw datasets • BRFSS, NHANES, NHIS, Census

Interactive tools (federal, state level)• RWJF Data Hub , Kaiser State facts

Literature Review

• IOM, WHO, NIH, CDC, NCQA reports

• NICE, Cochrane, USPSTF, National Guideline Clearinghouse guidelines, PCORI

• Meta-analyses of behavior change interventions

• Experimental studies (RCT, factorial design)

• Pubmed, Medline, ERIC

Existing Health Records • Health insurance claims data, EMR/EHR/PHI

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RWJF National DataHub : Unemployment rate (addressing social determinants of health), 2014

http://www.rwjf.org/en/how-we-work/rel/research-features/rwjf-datahub.html



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Kaiser State Facts: Health Insurance Coverage of the Total Population (% of uninsured) , 2014

http://kff.org/statedata/



Primary Healthcare Data Sources Qualitative & Quantitative research• Observation (ethnographic research)

• Surveys with the target population & stakeholders

• Interviews with target population & stakeholders

• Collaborative workshops with target population &stakeholders

Experimental studies • Pilot projects

• Randomized control trials

• Simulation studies

Evaluations• Process evaluation

• Impact evaluation

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The overall temporal tweet frequency distribution (by day) and key news events that influenced it.

Non-healthcare Data Sources Ebola and Twitter. Why is social media important for public health

Vorovchenko T. #Ebola and Twitter: lessons learned. University of Oxford; 2016

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1 2

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The overall temporal tweet frequency distribution (by day) and key news events that influenced it.

Non-healthcare Data Sources Ebola and Twitter. Why is social media important for public health

22 March 2014, Guinean health officials received confirmation that the mysterious haemorrhagic fever was caused by Ebola virus

25 July 2014, Nigerian health officials announced that the first Ebola virus disease case was diagnosed in Lagos, Nigeria.

30 September 2014, U.S. Centres for Disease Control and Prevention announced the first diagnosed Ebola virus disease case tested in the USA

Vorovchenko T. #Ebola and Twitter: lessons learned. University of Oxford; 2016


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Non-healthcare Data Sources Healthy Lifestyle and Google trends Why exploring the popularity of search terms within the population you are designing for is important, USA , 2004-2015

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2 3time4&5

interest


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Non-healthcare Data Sources Healthy Lifestyle and Google trends Why exploring the popularity of search terms within the population you are designing for is important, USA , 2004-2015

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“diet”

“weight loss”

“gluten free”“healthy weight” & “healthy eating” 4&5 time

interest

Pre-intervention Intervention

DesignPost-

intervention

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Phases of Health Intervention Design

PRE-INTERVENTION

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Pre-intervention : Role of evidence & Insights

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Health problem Desired goal Groups at-risk

Pre-intervention : Behavioral analysis

Modifiable risk factors: behaviors, social and environmental factors

Non-modifiable risk factors : genetics, age, gender etc.

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Wrong is wrong even if everyone is doing it

Pre-intervention : Health Problem

Personal Determinants:

Knowledge,Attitude,

Self-efficacy

ExternalDeterminants:Social Support

Self-managementbehaviors

Social Isolation

Pain

FunctionalLimitations

Fatigue

Qualityof Life

Loneliness, depression, physical

disability due to chronic pain, job loss

Nadrian, Haidar, Mohammad Ali Morowatisharifabad, and Kaveh Bahmanpour. "Development of a Rheumatoid Arthritis Education Program using the PRECEDE_PROCEED model." Health Promotion 1.2 (2011): 118-129.

Genetics

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Rheumatoid ArthritisGender Other

Pre-intervention : Choosing Target population for the intervention

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Total Population Population with RA*

Population with RA

diagnosis

Population diagnosed

with moderate or severe RA

* RA-Rheumatoid Arthritis

Pre-intervention : Desired goalRight is right even if you are the only one who is doing it

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Rheumatoid Arthritis

Low disease activity or

remission1,2,3,4

Patient Education

Occupational therapy

Physiotherapy

Physical Activity 5

Medicationadherence

Emotional wellbeing 7,8

1. Singh, Jasvinder A., et al. "2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis." Arthritis care & research 64.5 (2012): 625-639.‐2. Smolen, Josef S., et al. "EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update." Annals of the rheumatic diseases (2013): annrheumdis-2013.3. Smolen, Josef S., et al. "Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force." Annals of the rheumatic diseases (2015): annrheumdis-2015.4. Watts, Richard A. "Rheumatoid Arthritis National Clinical Guideline."Rheumatology (2009): kep311.5. Cooney, Jennifer K., et al. "Benefits of exercise in rheumatoid arthritis." Journal of aging research 2011 (2011).6. Weight Loss in Obese Rheumatoid Arthritis (RA) Patients Improves Disease Activity without Modifying RA Treatment, Elisa Gremese , Maria Rita Gigante , Barbara Tolusso, Anna Laura Fedele, Silvia Canestri et al.7. Bradley LA, Young LD, Anderson KO, Turner RA, Agudelo CA, McDaniel LK, et al. Effects of psychological therapy on pain behavior of rheumatoid arthritis patients. Treatment outcome and sixmonth follow-up. Arthritis & Rheumatism 1987;30(10):1105–1114. 8. Psychological interventions for arthritis pain management in adults: A meta-analysis. Dixon, Kim E.; Keefe, Francis J.; Scipio, Cindy D.; Perri, LisaCaitlin M.; Abernethy, Amy P. Health Psychology, Vol 26(3), May 2007, 241-250

Diet and weight

management6

Sleep

Rheumatoid Arthritis

PainFatigue

Joint Inflammation

Depression

Weather

Pre-intervention : Summary

Using evidence and insights during the pre-intervention phase will allow you to:

Define the health problem and modifiable risk

Identify who currently has and who is at-risk for developing

the health problem

Understand and specify the desired change in health outcome,

behavior or environmental condition

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INTERVENTION DESIGN

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Intervention design : Role of evidence & Insights

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Understand behavior Effective methods & strategiesLogic of Change

Intervention design : Understand Behavior

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Change objectives Determinants Performance

Objectives

• Individuals are aware of their own F&V consumption

• Express positive attitude towards increasing the F&V consumption

• Know which F&V they can buy in their supermarket

• Individuals identify barriers to increasing their F&V consumption

• Express confidence in controlling the barriers to F&V consumption

BehavioralOutcome

• Increase vegetable intake ( 5 servings per day)

• Increase fruit intake (3 servings per day)

• Knowledge• Self-efficacy• Attitudes• Self-belief• Motivation• Self-regulatory

capacity• Perceived

behavioral control

• Social norms• Social support

• Create an action plan to begin eating F&V

• Identify barriers preventing them from eating F&V

• Problem solving for the identified barriers

• Create coping plan for eating F&V

• Comply with daily norm for F&V

• Create social support to maintain F&V consumption

Health Outcome

Quality of Life

Improvement

• SF-36• HbA1c (%)• Weight (kg)• Systolic BP• Diastolic BP• Total

Cholesterol

EnvironmentalOutcome

Messages/Materials/Activities

Methods & Strategies

• Mobile-based intervention aiming to increase fruit & vegetable intake among adults with pre-diabetes and diabetes type 2

• Goal-setting for behavior & outcome

• Problem solving• Action planning• Self-monitoring of

behavior & outcome• Feedback on behavior

&outcome• Instruction on how to

perform behavior• Information about

health consequences• Pros and cons• Demonstration of the

behavior • Behavioral Practice• Regulation• Social Support

Pre-diabetes and diabetes type 2 nutrition intervention

Bartholomew, L. Kay, Guy S. Parcel, and Gerjo Kok. "Intervention mapping: a process for developing theory and evidence-based health education programs." Health Education & Behavior 25.5 (1998): 545-563.

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Intervention design : Build a Logic of Change

Change objectives Determinants PerformanceObjectives






BehavioralOutcome





behavioral control• Social norms• Social support

• Create an action plan to begin eating F&V

• Identify barriers preventing them from eating F&V

• Problem solving for the identified barriers

• Create coping plan for eating F&V

• Comply with daily norm for F&V

• Create social support to maintain F&V consumption

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Intervention design : Select effective methods and strategies

Messages / Materials / Activities

Theoretical Methods & Practical Strategies

• Goal-setting for behavior & outcome • Problem solving• Action planning• Self-monitoring of behavior & outcome• Feedback on behavior &outcome• Instruction on how to perform behavior• Information about health consequences• Pros and cons• Demonstration of the behavior • Behavioral Practice• Regulation• Social Support

• Mobile-based intervention aiming to increase fruit & vegetable intake among adults with pre-diabetes and diabetes type 2

Intervention design : Messages / Materials / Activities for Diabetes Intervention

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USDA Food Access Research Atlas

Low-income census tracts where a significant number of share of residents is more than ½ mile (urban) or 10 miles (rural) from the nearest supermarket

Low-income census tracts where a significant number of households have low vehicle access or a significant number or share of residents are more than 20 miles from the nearest supermarket

http://www.ers.usda.gov/data-products/food-access-research-atlas/go-to-the-atlas.aspx



Intervention Design : Summary

Using evidence and insights during the intervention design phase will allow you to:

Understand the behavior

Identify what can be changed

Build the Logic of change

Choose appropriate methods and strategies

Design effective materials, messages and activities

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POST-INTERVENTION

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Post-intervention: Role of evidence & Insights

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Iteration ProcessImpact

Post-intervention: Did it work?

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Post-intervention: Impact evaluation

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Change objectives Determinants Performance

Objectives






BehavioralOutcome





behavioral control

• Social norms• Social support

• Monitor F&V consumption• Compare F&V consumption

to the recommendations• Recognize the importance of

increasing F&V • Decide to increase F&V • Set a goal for F&V

consumption• Create an action plan to

begin eating F&V• Action-eat more F&V • Identify barriers preventing

them from eating F&V• Problem solving for the

identified barriers • Evaluate progress • Comply with daily norm for

F&V• Create social support to

maintain F&V consumption

Health Outcome

Quality of Life

Improvement

• SF-36• HbA1c (%)• Weight (kg)• Systolic BP• Diastolic BP• Total

Cholesterol

EnvironmentalOutcome

Messages/Materials/Activities

Theoretical Methods & Practical Strategies

6-24 months 6-48 months

• Reduced number of hospitalizations

• Lowered medical costs• Fewer ER visits

2-10 years

• Goal-setting for behavior & outcome

• Problem solving• Action planning• Self-monitoring of

behavior & outcome

• Feedback on behavior &outcome

• Instruction on how to perform behavior

• Information about health consequences

• Pros and cons• Demonstration of

the behavior • Behavioral Practice• Regulation• Social Support

• Mobile-based intervention targeting increase in fruit & vegetable consumption

Pre-diabetes and diabetes type 2 nutrition intervention

Post-intervention: Impact evaluation

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Post-intervention: Process Evaluation

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Post-intervention : Summary

Using evidence and insights during the post-intervention phase will allow you to

Evaluate the results of your investment

Understand which methods work and which do not

Analyze why the intervention work or did not work

Identify the parts of the intervention that need iteration

Seek more funding and support

Contribute to the evidence-base of behavior change science

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KEY TAKEAWAYS

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Key Takeaways

Pitfalls:

1. Define the problem before assessment of the problem space

2. Ignore limitations of existing or new evidence

3. Don’t build a logic model or a causal diagram

4. Overestimate the opportunities & capabilities of your target population

5. Skip evaluation

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Key Takeaways

Must-haves:

1. Reduce uncertainty

2. Establish a trustworthy relationships

3. Provide a choice

4. Provide value

5. Integrate relapse prevention strategies

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Key Takeaways

Design for people

1. Solve for the unmet needs

2. Set realistic expectations

3. Design solutions that are relevant

4. Take responsibility

5. Evaluate & Iterate

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or

THANK YOU!

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RESOURCES

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Frameworks, theories, evidence

• NIH http://www.nih.gov• Kaiser State Facts http://kff.org/statedata/• The Patient-Centered Outcomes Research Institute PCORI http://www.pcori.org• NICE UK https://www.nice.org.uk• Robert Wood Johnson Foundation (RWJF)http://www.rwjf.org/en/how-we-work/rel/research-features/rwjf-datahub.html• CONSORT Guidelines: http://www.consort-statement.org/ • The Community Guide: http://www.thecommunityguide.org/ • USPSTF: http://www.uspreventiveservicestaskforce.org/ • Cochrane Collaboration: http://www.cochrane.org/ • National Guideline Clearinghouse: http://www.guideline.gov/• Morbidity & Mortality Weekly: http://www.cdc.gov/mmwr/ • National Prevention Strategy: http://www.surgeongeneral.gov/initiatives/prevention/strategy/ • Healthy People 2020: http://www.healthypeople.gov/2020/default.aspx • NCI “Theory at a Glance”; http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf• Community Tool Box, Univ. of Kansas: Developing a logic model or theory of change.

http://ctb.ku.edu/en/tablecontents/sub_section_main_1877.aspx • BCT – UCL London http://www.ucl.ac.uk/behaviour-change-techniques• Intervention Mapping http://interventionmapping.net

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http://www.nih.gov/

http://www.nih.gov/


http://www.pcori.org/

http://www.pcori.org/

https://www.nice.org.uk/

https://www.nice.org.uk/




http://www.consort-statement.org/

http://www.thecommunityguide.org/

http://www.uspreventiveservicestaskforce.org/

http://www.cochrane.org/

http://www.guideline.gov/

http://www.cdc.gov/mmwr/

http://www.surgeongeneral.gov/initiatives/prevention/strategy/

http://www.healthypeople.gov/2020/default.aspx

http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf

http://www.cancer.gov/cancertopics/cancerlibrary/theory.pdf

http://ctb.ku.edu/en/tablecontents/sub_section_main_1877.aspx

http://www.ucl.ac.uk/behaviour-change-techniques

http://interventionmapping.net/

http://interventionmapping.net/

Intervention design : Logic Model

Bartholomew, L. Kay, Guy S. Parcel, and Gerjo Kok. "Intervention mapping: a process for developing theory and evidence-based health education programs." Health Education & Behavior 25.5 (1998): 545-563.

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