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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.