Multilevel Intervention With Low Income and Minority Older Adults To Improve Influenza Vaccination Acceptance Jean J. Schensul Institute for Community Research www.incommunityresearch.org Prepared for: 2nd Annual NIH Conference on the Science of Dissemination and Implementation, January, 2009
ICR North Central Area Agency on Aging V.N.A. Health Care State Dept. of Public Health Hartford Housing Authority Other Building Managers University of Connecticut Health Center/Center on Aging Jean Schensul, Ph.D. Janet McElhaney, M.D. Kim Radda, M.A. Elsie Vazquez, B.A. Ken Williamson, Ph.D. Rita Gepsen, M.D. George Kuchel, M.D. Carmen Reyes, M.S. William Disch, Ph.D. Emil Coman, Ph.D. Partners/ and /Personnel
Goals of Presentation • Describe multilevel community based project aims, core components, level goals and outcomes • Present framework for multilevel dissemination/implementation and evaluation • Outline major considerations in community based MLI dissemination/implementation research
Rationale for Vaccination Interventions for Low Income and MinorityOlder Adults • Influenza is preventable • Vaccination can prevent 70% of influenza infections, • Vaccination can reduce the cost and severity of secondary illnesses and influenza related deaths. • 35 – 45% of racial/ethnic minority older adults are vaccinated each year in comparison to 60-70% white older adults. • The SG recommended level is 90% for non-institutionalized adults over 65 years of age. • Public health efforts including campaigns, clinic outreach and community flu clinics have not reached these older adults. • To do so requires a multilevel targeted approach
Source of the Problem and Focus of Intervention Regional and State Public Health Educators and vaccine experts Vaccine Delivery System Housing Authority/Management REM Residents In Senior Housing Service providers/senior advocates
V.I.P. Intervention • Goals: • To improve vaccination rates, knowledge and pro-vaccination beliefs and norms • Build sustainable public health promotion structures at multiple levels • Approach: • Build a vertical Influenza Strategic Alliance (ISA) • Increase building management health awareness • Build resident flu vaccination advocacy committees to deliver flu campaigns • Engage these groups with residents for sustainable relationships, vaccination increase and other health initiatives
Theoretical Processes Communications (message consistency, strength, formats, delivery) Ecological (multilevel interaction) Empowerment (capacity to learn and act independently) Constructivist (facilitated process of knowledge and action co-construction) Program Structures Influenza Strategic Alliance Building management Building committees Individual residents Program Elements Training curriculum FAQs/flip book Visuals (film) Campaign (and campaign components) Committee self-evaluation Core Components
Intervention • Formation and activation of Influenza Strategic Alliance • Partnership with building management • Formation and activation of V.I.P. committee • Training of V.I.P. Committee • Development and delivery of two influenza vaccination campaigns • Implementation of two flu clinics • Cross-sectional pre and post surveys in intervention and comparison buildings • Ethnographic process and ML outcome documentation
Site and Target Population Demographics Interv. Compar. Education . < 8th Grade 38% 48% Income < $800/mo) 84% 77% Time in Htfd. Mean years 25.6 27.5 Time in Bldg. Mean years 4.5 4.6 Language preference (English/Spanish) 73/27% 40/60% Northeastern City Older Adult Housing Intervention and Comparison Buildings Baseline Sample (N=73) (N = 107) Population Composition Interv. Comp. PR 51% 56% Af/Am 33% 18% W. Indian 9% 1% White 7% 15% Female 35% 44% Male 65% 56%
Intervention Process/Outcomes • Influenza Strategic Alliance Process: Formed alliance, supported V.I.P. Committee, provided funding for uninsured vaccinations. , Outcomes: continued to meet, promoted intervention elsewhere in state. • Building Management Process: Supported V.I.P. Committee, provided resources, advocated for flu clinics. , Outcomes: sustained flu clinics independently; supported other public health efforts
Intervention Process/Outcomes • V.I.P. Committee Process: Expanded membership, became flu experts,developed and adapted campaign materials, implemented flu campaigns, reached 70% or more of target population Outcome: Expanded membership, repeated campaign with less support, expanded to other public health activities. These processes and outcomes encompassed adaptation, implementation, sustainability and infrastructural expansion.
Indvidual Level Cognitive, Social and Behavioral Outcomes Beliefs, Attitudes, Self-efficacy, Social Influence Beliefs about Vaccination Perceived barriers to vaccination NS Perceived consequences of influenza Worry about the flu Vaccination self efficacy NS Social influence to Vaccinate Vaccination Outcomes 21% The odds of getting the flu vaccine changed from 1.92 at pre-test to 5.59 at post test in the treatment group.
Filling in the Gaps • Disseminating/Implementing a successful intervention in each new setting calls for: • Identifying core processual, structural and content components • Integrating intersection of theoretical processes and content/content delivery mechanisms in each dissemination/implementation process cell; and • at each structural level.
Core Components • Theoretical Processes • Program Structures • Program Elements (content)
Outcome Evaluation (efficacy, reach) • Outcomes at each “structural” level (anticipated and emergent) • Outcome design options involving comparisons: • Study versus matched control buildings • Study versus control communities (where all buildings in the intervention communities are involved in the intervention) • study buildings in a single community over time (where all study buildings are involved; case study design • These designs address the challenge of small Ns in multilevel intervention studies • Interactions among levels at critical time points
Cost Effectiveness (Overall minus research/evaluation costs) • Individual level: per unit cost of hospitalization for flu related problems against per unit cost of vaccination intervention. • Building level: cost of implementation (VIP, session resources, incentives etc.) against estimated or actual cost of building hospitalizations for flu related problems. • Start up costs in towns versus continuation costs. • Start up costs include full time coordinator, training and incentives costs, and campaign costs • Continuation costs include half time coordinator, minimized training and incentives costs and campaign costs, • Evaluation costs • Start up costs include full time coordinator, staffing, training and incentives costs, and campaign costs • Continuation costs include half time coordinator, minimized training and incentives costs and campaign costs,
Points to Remember • Indepth/long term relationships with communities or extensive formative research to identify levels and focal points for intervention • Multiple level intervention for sustained change • Small N GRCTs and case study designs are required. • Multiple level interventions involve the intersection of level and core components (process, structure and content). • Theory in MLIs cuts across levels. • MLIs are intentional change efforts inserted into ongoing systems. • Evaluation tools needed at each level that make it easier to evaluate in large scale dissemination and diffusion.