SAN FRANCISCO—You have designed, tested, and validated an exercise intervention for elderly people with arthritis. How do you go about disseminating this intervention so that it will reach its target population and be sustainable over time?
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Explore This IssueFebruary 2009
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“We are all too familiar with the experience,” said Basia Belza, PhD, RN, the Aljoya Endowed Professor in Aging at the University of Washington School of Nursing in Seattle, “in which we work with randomized controlled trials or testing of interventions and find them to be very effective. And yet we find, all too infrequently, that the intervention actually gets disseminated out to the community.”
In “Designing for Translation: Bridging the Gap between Research and Widespread Implementation of Community-Based Interventions,” a session at the October 2008 ACR/ARHP Annual Scientific Meeting, Dr. Belza and her colleague Teresa J. Brady, PhD, senior behavioral scientist in the arthritis program at the Centers for Disease Control and Prevention (CDC) in Atlanta, addressed the persistent challenges of disseminating research-validated, community-based interventions for those with chronic disease.
The goal, they said, is to employ scientific methods to guide efforts to increase dissemination and implementation. Savvy academic and public health researchers have now learned, emphasized Dr. Brady, that “You can’t just throw an intervention out into the universe and think it will run smoothly—you have to invest in the infrastructure that will help that intervention be successful.”
Reach That Target
At the University of Washington in Seattle, Dr. Belza and her colleagues have been collaborating with agencies and organizations in the public health sector to develop ways to consciously move evidence-based interventions out into the community, where they can benefit those most in need.
The session “Designing for Translation: Bridging the Gap between Research and Widespread Implementation of Community-Based Interventions” was recorded and is available via ACR’s Session-Select at www.rheumatology.org/annual.
In addition, the ACR has developed a free patient education fact sheet on exercise and arthritis, which can be downloaded from www.rheumatology.org/public.
Even lab-tested programs may not be designed in a way to facilitate evaluation of their real-world effectiveness. Investigators need to know, for instance, whether their intervention will be equally efficacious if delivered in a Chinese Baptist church, on a Native American reservation, or in a YMCA with a highly educated cohort of retirees. Dr. Belza, who leads the coordinating center for the CDC-funded Healthy Aging Research Network, described a framework, designed by Russell Glasgow and colleagues, that can be used to evaluate sustainability and public health impact of research-validated efficacious interventions. (See “RE-AIM Framework,” p. 20.)
Using the RE-AIM framework, said Dr. Belza, improves the chances that a program will work in real-life settings because it provides a guide for planning, implementing, evaluating, and maintaining programs; assures that developers and implementers address individual as well as organizational-level issues; assists with partnership building (essential for community-based interventions); makes the case for sustainability; and allows comparison across programs.
Dr. Belza then illustrated the experience with a community-based health program for the elderly which was developed at the University of Washington in the early 1990s, has accrued an impressive evidence base, and has been successfully disseminated at over 200 sites across the United States.1,2 The EnhanceFitness program, a thrice-weekly aerobic, strength, flexibility, and balance protocol for both active and frail elderly, is licensed by Senior Services, the partnering organization originally selected by the University of Washington researchers to disseminate the program.
The program currently has over 6,600 active participants (39% of whom are over age 80, and 24% of whom are people of color), and has been shown in one recent study by Ackerman et al to reduce healthcare costs in Medicare-managed care health plan members who participated in the program.3 Periodic assessment of participants’ performance on several common function tests (arm curls, Up and Go, and chair stands) is a core component of EnhanceFitness and allows both researchers and implementers to track participants’ outcomes—and program successes—over time. The program is also an example of the types of partnerships supported by the CDC, which, in 2005, lent additional funding and infrastructure support to widen the national reach of the program.
To the Next Level
The CDC supports translation of evidence-based interventions through partnering with state health departments, among other agencies, said Dr. Brady. Two years ago, scientific and program staff at the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) at the CDC began meeting to devise a model for improving translation of research into practice. The goal was to help transform dissemination of effective interventions from a mode of passive diffusion into a targeted, intentional process of distributing information and materials to organizations and individuals who can use them to improve health. The resulting NCCDPHP Translation Schematic, said Dr. Brady, is intended to be a generic model that can be applied regardless of disease or condition or type of intervention.
Complementary to the RE-AIM framework, the NCCDPHP Translation Schematic maps out a series of steps to take research from the lab to the community. Although the sequences are mapped in a forward progression—decision to translate, transforming knowledge into products, dissemination/engagement, decision to adopt, practice, and institutionalization—the process involves multiple decision points and feedback loops, noted Dr. Brady. After an intervention has been proven efficacious and effective, the first step toward translation is a conscious decision by the researchers to “take it public.”
Once researchers have engaged with stakeholders who have the potential to mobilize resources and influence systems, those stakeholders must also make a conscious decision whether or not to adopt the intervention. Following a decision to adopt, there are multiple actions required to put the intervention into practice, such as training leaders, securing appropriate sites, marketing, and so forth. Throughout the process, researchers can encourage feedback from partner agencies who are launching interventions “on the ground”—and this feedback can, in turn, inform refinements of the intervention in the lab.
The framework examines the translatability of public health promotion interventions in five dimensions:
- Reach into the target population: Is the intervention reaching the right people, those it was designed for?
- Efficacy or effectiveness: Does the intervention have a positive impact on the health issue being addressed? Does it actually provide benefits or does it unintentionally cause harm?
- Adoption: Are settings appropriate and accessible for the population you are trying to reach? Are there organizational supports that can help deliver the intervention—through partnering with local agencies, for instance?
- Implementation: Is the intervention being properly delivered? Are the differences seen attributable to that program?
- Maintenance: Is the program or intervention sustainable on both the individual and system levels so that it can be delivered long term?
Framework calculators, tools, and other resources are available on the RE-AIM Web site: www.re-aim.org.
A question-and-answer period following the presentations touched on, among other questions, how researchers might design interventional studies with an eye toward their practical applications in the community. Dr. Belza advised that researchers should design specific and clearly written protocols for instructors and participants. For an exercise such as sit and stand, for instance, the type of chair and exact instructions for the trainer should be clearly spelled out. Researchers should also ask what would work in real life and not just in an academic center or clinic where researchers have more resources (physical therapists, sophisticated testing equipment, etc.) at their disposal. According to Dr. Brady, when the CDC asked its state health-department partners about the elements of a workable program, they responded that “doable” programs would require minimal professional training for instructors (no advanced degrees, for example); minimal expense for participants (no more than $50 each); and minimal equipment (for example, a pedometer only). She and Dr. Belza encouraged researchers and implementers to engage in active dialogue about their public health interventions.
“In the past, our key dissemination strategy was hope: I hope if you learn about it, you will pick it up,” Dr. Brady said. She pointed out that dissemination by diffusion is a very slow process, and to speed up adoption, researchers must consciously move interventions into the community, paying attention to support structures, an iterative evaluation and feedback process, and commitment to translation.
Gretchen Henkel is reporting on the 2008 ACR/ARHP Annual Scientific Meeting for The Rheumatologist.
- Wallace JI, Buchner DM, Grothaus L, et al. Implementation and effectiveness of a community-based health promotion program for older adults. J Gerontol A Biol Sci Med Sci. 1998;53:M301-M306.
- Ackerman RT, Cheadle A, Sandhu N, et al. Community exercise program use and changes in healthcare costs for older adults. Am J Prev Med. 2003;25:232-237.
- Ackerman RT, Williams B, Nguyen HQ, et al. Healthcare cost differences with participation in a community-based group physical activity benefit for Medicare managed care health plan members. J Am Geriatr Soc. 2008;56:1459-1465.