How do community cardiovascular networks foster improvements in health and system outcomes

Transcription

1 How do community cardiovascular networks foster improvements in health and system outcomes Beatrice McDonough, BScN, MScN, MSc, PhD(c); Lisa Dolovich, BScPhm, PharmD MSc; Larry Chambers, PhD, FACE, HonFFPH(UK); Ricardo Angeles, MD, MPH, MHPEd, PhD (c); Francine Marzanek, BSc, BEd; Gina Agarwal, MD, PhD(c); Clare Liddy, BSc, MSc, MD;

2 What is the Cardiovascular Health Awareness Program (CHAP)? 3-hour morning risk assessment and health promotion program held in local pharmacies and other locations at least 2x/month/community Essential Elements: Organized by local lead organization (LLO), Risk assessment and education of target population (>65 yrs residents of small-mid sized communities), Recording findings via fax to database, forwarding findings to participants FP and/or pharmacist

3 CHAP intervention Peer volunteers were trained to help participants to measure and record BP with automated device (BpTRU ) and fill out standardized CVD and stroke risk profile Community health nurse and pharmacist available to assess participants with high BP Evaluated as a cluster RCT in 2006 with 20 intervention and 19 control communities Was subsequently adopted and implemented by 22 communities in ; Went down to 9

4 Theoretical Framework

5 Community Coalition Action Theory

6 Objective To identify and depict the type, extent and strength of partnership relationships within communities delivering CHAP To describe the effect of networks, partnership relationships, and other factors within CHAP communities on primary prevention of high blood pressure

7 Methods Cross-sectional Analysis of an on-going Cohort study Population- 9 communities operating CHAP Individual level: Participants of CHAP Partnership level: Representatives of CHAP Local Lead Organizations and Partner Organizations Community level: Review of records

8 Measures Independent Variables Strength of partnership Instruments to assess the Independent Variables Partnership Self- Assessment Tool (PSAT) Dependent Variables Self-reported behavior change and utilization of health resources Instruments to assess the Dependent Variables Participant Interviews Stages of Coalition Development Strength and structure of social network Coalition Effectiveness Inventory (CEI) Social Network Mapping Number and level of implementation of programs and policies related to CV Health Community Partner Interviews and Document review Community Profile Community Reports/ Environmental Scan

9 Methods Analysis: Descriptive Analysis for partnership and community level outcomes Ordinal Regression Association between individual, partnership, and community related factors with health behavior and use of community resources related to cardiovascular health Individual - Age, gender, marital status, number of CHAP sessions attended, self-efficacy score Partnership - type of community partners involved, number of community partners, proportion of partners with programs and policies on risk factors, % of Family Physicians and pharmacies involved with CHAP, PSAT, CEI, type of LLO Community - Rurality Index of Ontario score, Original CHAP community vs. CHAP expansion community

10 Results Measures of community coalition and social networks (N=9 LLO, N=39 Partner Organizations)

11 Combined Score for Communities 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 77% 75% 75% Interquartile Range Low Value High Value 50% Median Formation Implementation Maintenance Institutionalization Stages of Coalition Development

12 CHAP Site Synergy Leadership effectiveness Interpretation: PSAT General Results Efficiency Administration and Management Nonfinancial Resources Financial and other capital resources Community Community Community Community Community Community Community Community Community Mean

13 Social Network Maps Legend 1 Hospital 3 FHT/Clinic 2 Government 1 Pharmacy 1 Public Health Unit 6 Other 7 Non Profit Organization

14 Results Community outcome measures Community programs and policies

15 Summary of Programs and Policies by Risk Factors Risk Factors/Health Promotion Domains Number of Programs Number of Policies Others Mean Program Mean Policy Formation Score Formation Score Health Eating (1.1) 3.8 (1.3) Physical Activity (1.1) 3.6 (1.4) Hypertension (1.2) 4.0 (1.5) Diabetes (1.3) 3.3 (1.6) Tobacco Control (1.1) 3.6 (1.3) Medication Use (1.2) 3.8 (1.5) Stress Management (0.8) 3.8 (1.5) ETS (0.9) 4.3 (0.5) Weight Reduction (0.9) 3.3 (1.4) Alcohol Management (1.1)

16 Results Association of Individual, Partnership and Community-related factors with behavior change and health care utilization

17 Regression Analysis Risk behaviour/factors Factor Level Factors associated Decrease in Fast Food Individual Older Age Intake Community Original CHAP Community Decrease in Salt Intake Individual Higher Self Efficacy Scores Increase in Vegetables and Fruit intake Community Lower Rurality Index Scores (More Urban) Increase in Physical Individual Older Age Activity Decrease in Weight Individual Older Age Male Gender Decrease in Blood Pressure Individual Older Age High Self-efficacy Partnership Higher Coalition Effectiveness Inventory Score

18 Regression Analysis Community Factor Level Factors associated Resource Health Care Community Low Rurality Index Scores (More Urban) Resource Social Support Individual Younger Age Low Self-efficacy Score Physical Activity Individual Younger Age Low Self-efficacy Score Education Individual Younger Age Low Self-efficacy Score Partnership High Proportion of Pharmacies involved Food and Nutrition Individual Partnership Community Low Self-efficacy High Proportion of Pharmacies involved Low Rurality Index Scores (More Urban)

19 Discussion CEI - most communities were progressing well in the formation, implementation, and maintenance stages but not in the institutionalization stage PSAT - most communities were in the work zone levels, some were in the danger zone in Leadership Effectiveness and Administration and Management Participants attending CHAP reported improvements in health behavior and use of community health resources after attending CHAP sessions

20 Discussion Some individual, partnership, and community related factors affected CHAP participants behavior change and use of community resources

21 Implications and On-going actions Strength of partnerships (CEI and Proportion of pharmacies involved) affected CV health behaviors & use or resources in communities implementing the CHAP We have presented some of the results to the communities We are currently measuring all information for T2 of our Cohort study

22 Limitations Individual health behavior change and use of community resources are based on selfreports Only 9 communities are included so partnership and community level outcomes can only be analyzed descriptively

23 Thank You. Questions

24 Community Hypertension Management Decrease of 10/5 mm Hg (a change in lifestyle or one medication) reduces Stroke, Heart attack, Heart failure, Death Detection, treatment & control of hypertension remains sub-optimal Large number of people unaware they have high blood pressure White-coat hypertension highly prevalent

25 CHAP Program Physicians/ Pharmacist CHAP Central Community Coordinators Community Volunteers CHAP sessions: Risk Assessment BP Monitoring Local Leaders Fax Data Clinforma Database

26 Instrument: Methods Coalition Effectiveness Inventory (CEI) developed by Butterfoss et al [2004] to measure a coalition s development as they progress through 4 stages: formation, implementation, maintenance and institutionalization Partnership Self-assessment Tool (PSAT) developed by Lasker et al [2001] to measure strengths and weaknesses in areas that are known to be related to synergy (leadership, efficiency, administration and management, and sufficiency of resources)

27 Instrument: Social Network Map Methods Measures connectivity through interactions between partners in a collaborative, such as the amount and quality of interactions and how these relationships might change over time [Varda 2008]

28 Coalition Effectiveness Inventory (higher scores indicates phase and CE) CHAP Site Formation % Implementation % Maintenance % Institutionalization % Community Community Community Community Community Community Community Community Community *2 respondents from each LLO completed the CEI

29 Results Individual outcome measures Patient self report interviews (N=367)

30 Changes in Risk Factors after CHAP

31 Changes in resource utilization due to CHAP