Emor yP r event ionResear chCent er

Emor yP r event ionResear chCent er

Michelle Kegler, DrPH, MPH

Michelle Carvalho, MPH, CHES

Mini-Grants as a Strategy for Dissemination

Mini-grants are common in health promotion initiatives & have potential for creating demand for evidence-based interventions

Mini-grants can be combined with dissemination strategies shown to workTraining workshops (Rohrbach 2006; Elliot 2004)

Increases adoption, capacity, fidelity, maintenanceTechnical Assistance (Pentz 2006; Shepherd 2008; Rohrbach 2006)

Ongoing support, feedback, coachingIncentives (Basen-Engquist ,1994; Glanz, 2002)

stipends, equipment, materials

EFFECTIVENESS AND

IMPLEMENTATIONSTUDIES

DECISION to ADOPT

DIFFUSION

NCCDPHP Knowledge To Action FrameworkMay 2009

INSTITUTION-ALIZATION

RESEARCH PHASE TRANSLATION PHASE

EFFICACY STUDIES

PRACTICE

DISCOVERYSTUDIES

DISSEMINATION

ENGAGEMENT

Practice-based Discovery

KNOWLEDGE INTO PRODUCTS

INSTITUTIONALIZATION PHASE

Practice-based Evidence

Translation Supporting StructuresResearch Supporting Structures

DECISION to TRANSLATE

EVALUATION

Insitutional-ization

Supporting Structures

This product is in the public domain. Please cite this work in this manner:

The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) Knowledge to Action Framework, Centers for Disease Control and Prevention, NCCDPHP Work Group on Translation, May 2009. Adapted from Wilson K & Fridinger F. Focusing on Public Health: A Different Look at Translating Research to Practice. Journal of Women’s Health; 2008;17(2):173-179.

Interactive Systems Framework

Wandersman, A., Duffy, J., Flaspohler, P., Noonan, R., Lubell, K., Stillman, L., et al. (2008). Bridging the Gap Between Prevention Research and Practice: The Interactive Systems Framework for Dissemination and Implementation. American Journal of Community Psychology, 41(3), 171-181.

Mini-grants Programto Disseminate EBPs

A “push-pull method” (i.e. funds + TA) increases

demand while building capacity*

2 cohorts: 2007 & 2008 (12-18 month period)

12 SW GA community organizations awarded

Received up to $4000 & technical assistance (TA)

Implemented 5 RTIPs programs (nutrition or PA)

*Orleans, C., Gruman, J., & Anderson, N. (2002). Designing for Dissemination: The Larger Challenge of Translation: An Extraordinary Opportunity for Cancer Control. Designing for Dissemination Collaborative Meeting, Washington, D.C.

12 Awarded Sites & 5 Programs

Funded Organizations Evidence-Based Program

4 Churches Body and Soul

4 Worksites Treatwell 5-A-Day

2 Community Coalitions Parents as Teachers (PAT) High 5 Low Fat Program

Senior Center Little By Little Nutrition Program

Hospital Diabetes Management Center

Patient-Centered Assessment & Counseling for Exercise (PACE)

Engaging Community ExpertiseEmory PRC Community Advisory Board (CAB) roles:

Prioritized behavioral risk factors: nutrition, physical activity, tobacco prevention/cessation

Helped to develop mini-grants and TA process

Facilitated promotion of program to community

Joint EPRC/CAB review committee

selected grantees

Currently co-authoring presentations

and publications

Program Core ElementsCore elements for each program were identified based on:underlying theory & process evaluation

findingspublished articles describing the programavailable program materialsprogram description on NCI’s Research

Tested Intervention Programs (RTIPs) website

Construct Evaluation Question(s) Data Collection MethodsReach What proportion of the intended audience

participated in each activity? Project Report Forms* Demographics form

Implementation Fidelity: To what extent were core elements of the program implemented as described in program materials?

Project Report Forms* Monthly calls Interviews (coordinators)*

Adaptation: How and why did sites adapt core elements of the intervention?

Project Report Forms* Monthly calls Interviews (coordinators)* Committee focus group

Context What contextual factors may have affected intervention adoption and implementation?

Interviews (coordinators)* Committee focus group Monthly calls Mini-grant applications* Census data

Maintenance What plans has the site made to continue promoting health after the end of the project?

Interviews (coordinators)* Committee focus group

Resources What resources did EPRC provide to support this project?

EPRC financial records* TA log

To what extent did grantees perceive that EPRC technical assistance helped them to implement the programs with fidelity?

Interviews (coordinators)*

* Collected in both cohorts (Other tools in 1st cohort only)

Project Report FormDocumented progress on core elements

Treatwell - Core Element Documentation Examples

Employee Advisory Board Meeting topic, date, # participants

EatWell Discussion Series Session topic, date, # participants

Exposure to “5-A-Day” campaign

Activity, date, # participants

Promotion of national hotlines

Please describe how you have promoted the national hotlines (or More Matters website)

Environmental Change Please describe environmental and/or policy changes made at your site

Family/home component Newsletter topic, Date mailed, # mailed

Annual family event Description, Date, # participants

Interview/Focus Group GuidesSection Topic Example Questions

Staff/Volunteers •What motivated you personally to be involved in this program?•How would you describe the level of support of your site’s leadership ?

Implementation •What factors within your organization helped to implement the program? •What barriers did you face in implementing the program?

Participants •In general, how did people respond to the program?

Adaptation •Did you change anything in the original program or its program materials to better reach participants?

Technical Assistance

• If you feel you needed technical assistance, what kind of help was needed?

Maintenance •Do you think your organization will continue similar program activities after the program is over?

Fidelity Findings95% of core elements conducted across all sites

9 of 12 (75%) sites conducted all core elements

3 (of 7) sites in 1st cohort did not conduct all core elements

All 5 sites in 2nd cohort conducted all core elements

Core Element of Body & Soul Reach within ChurchesA B C D

Project Committee Low Low Low LowKick-off event High High High HighChurch-wide nutrition event with Pastor High Med High MedOther church-wide event #1 Low Low Low MedOther church-wide event #2 Med Low Low MedOther church-wide event #3 Low Med N/A N/AAt least one motivational interviewing call Low Low Low LowCore Elements of Treatwell Reach within Worksites

E F GEmployee Advisory Board Low Low LowEatWell Discussion Series Low High LowAt least one other activity to change individual behavior

Low Low --

Family/home component of learning Low N/A LowAnnual family/holiday event Low N/A High

Participation and Reach of Core Elements Implemented by 2007 Mini-Grant Recipients

Reach = proportion of the site population that participated in a given event:Categories: Low (<1/3), Medium (1/3 to 2/3), High (>2/3).

Contextual Factors(related to implementation)

BARRIERS FACILITATORS Schedule/time conflicts* Difficulty with recruitment or

retention* Lack of resources/funds* Difficulty with changing

behavior Staff/leadership transitions Slow economy/worksite

financial difficulties

Leadership support* Staff/volunteers* Print materials/resources* In-kind resources/facilities* Partnerships* Donated Resources* Fit with mission Fit with

Infrastructure/Activities* Mentioned in both cohortsBlue text = barrier that prevented completion of core element(s) - 1st cohort

Fidelity-Adaptation Continuum

Added/customized materials

Added activities

Shifted primary audience

Held concurrent physical activity

& weight loss events

Changed delivery format/process steps

Expanded audience (to community)

Shifted focus to other behaviors

Did not complete all core elements

HIGHFIDELITY

MAJOR ADAPTATION

MINOR ADAPTATION

LOWFIDELITY

ADAPTATION EXAMPLES

NE

ED

S E

VA

LU

AT

ION

Reasons for AdaptationsExpand program reach (broader community)

Generate/maintain engagement

Strengthen/reinforce program message

Fit program to organization’s infrastructure/activities

Reach specific audiences (esp. underserved)

Added content to reach specific audiences (teen parents)

“You got to think about being also sensitive to the age of the parent. If you have [a parent] that’s maybe 14…give them something that can be kinda fun…”

- Site coordinator

LimitationsSmall number of sites (n=12) in rural SW GALimited measurement of fidelity & implementation qualityTime span 12-18 months – more time needed to learn

about maintenanceSelf report/social desirabilityData reflects information from only 5 intervention

programsData may not be generalizable to other settings,

populations, regions and programs

2010-12 Mini-grants CohortMini-grants period will span 2 years4 sites funded at $8000 eachStructured and proactive TA and trainingRTIPs programs:

CATCH: Coordinated Approach to Child HealthFamily MattersBody & Soul

Process evaluation focused on TA and training

(Adapted from McK leroy et al., 2006)

Implementation plan Successful pilot of adapted

intervention

Prepare agency Pre-test materials

Target population Interventions Goodness of fit Stakeholders Organizational capacity

Assess

Prepare

Pilot

Implement Implement adapted EBI

Decide to adopt, adapt, or select another intervention

Make necessary changes to EBI

Select

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Map of the Adaptation ProcessDeveloped a structured TA model derived from the

Map of the Adaptation Process (Mckleroy et al., 2006)

Focus on objectives of each key step:

EBI Training Topics (pre-award)Session Title

What Do We Mean By Evidence-Based?

Needs Assessment and Program Planning

Finding an Evidence-Based Program

Selecting a Program That Fits Your Community

Adapting the Evidence-Based Program with Fidelity

Implementing an Evidence-Based Program

Evaluating Your Program

TEACH model: Translating Evidence into Action through Collaboratives for Health TA Contact Structured TA Topics

(examples)Stage in Map of Adaptation Process

Pre-award Training See training slide Assess, Select, Prepare

Kick-Off Training for awarded sites

EBIs, Needs assessment, Organizational readiness, Core elements

Assess, Select, Prepare

Site Visit Fit, Adaptation, Evaluation planning

Assess, Select, Prepare, Pilot

Conference Call Implementation Work Plan, Partnerships

Assess, Select, Prepare, Pilot

Ongoing Contact Overcoming barriers, implementation fidelity, maintenance

Assess, Pilot, Implement, Maintenance

TEACH Evaluation Questions

Kept the original evaluation questions and added capacity questions related to the impact of TEACH:

Do attitudes toward EBAs become more positive as a result of the TEACH process?

Does self-efficacy for EBA behaviors increase as a result of the TEACH process?

Does organizational capacity for EBAs increase as a result of the TEACH process?

Process Evaluation PlanBaseline survey (n=17) – 80 itemsFollow-up at 3, 6, and 24 months TA tracking Access databaseProject Report FormsQualitative interviews w/ coordinators

at 24 months

Survey topic areas Example Measures – Survey Questions

Attitudes about EBPs (Hannon et al, 2009)

Likert Scale: Strongly Disagree Strongly Agree• EBPs lack real world experience.• EBPs are easy to understand.• EBPs are easy for us to adapt for use in our community.

Skills related to EBPs (Chinman et al., 2008)

Likert Scale: Very hard Very Easy• Discuss the benefits of using evidence-based programs.• Assess the fit of a potential program or strategy to your

organization or community.• Determine what needs to be changed in an EBP to

increase fit to your community.

Organizational functioning*

Likert Scale: Strongly Disagree Strongly Agree• We have appropriate staff skills to achieve our mission.• The leadership of the organization fosters respect, trust,

inclusiveness, and openness in the organization.• Staff are encouraged to take the lead in initiating change

or in trying to do something different.

*Levinger and Bloom, 2000; Weiss et al., 2002; Preskill and Tores, 1998; Caplan, 1971; Kenny and Sofaer, 2000; Schminke et al, 2002)

Next Steps2 manuscripts in progress:

Process evaluation of a mini-grants program to disseminate evidence-based nutrition programs to rural churches and work sites

Balancing fidelity and adaptation: Case Studies in implementing evidence-based chronic disease prevention programs

Conduct process evaluation of current mini-grants program (TA, training, fidelity, adaptations)

Dissemination research grant proposals

Acknowledgements Sally Honeycutt Cam Escoffery Kirsten Rodgers Karen Glanz Johanna Hinman Jenifer Brents

The CPCRN is part of the Prevention Research Centers Program. It is supported by the Centers for Disease Control and Prevention and the National Cancer Institute (Cooperative agreement # 1U48DP0010909-01-1)

JK Veluswamy Margaret Clawson Megan Brock Nidia Banuelos Alma Nakasone Amanda Wyatt Ana Iturbides

Emor yP r event ionResear chCent er

Emor yP r event ionResear chCent er

QUESTIONS?