Health Service Navigation Research Articles

A Low-Intensity Mobile Health Intervention With and Without Health Counseling for Persons With Type 2 Diabetes, Part 1: Baseline and Short-Term Results From a Randomized Controlled Trial in the Norwegian Part of RENEWING HEALTH.

BackgroundSelf-management support for people with type 2 diabetes is essential in diabetes care. Thus, mobile health technology with or without low-intensity theory-based health counseling could become an important tool for promoting self-management.ObjectivesThe aim was to evaluate whether the introduction of technology-supported self-management using the Few Touch Application (FTA) diabetes diary with or without health counseling improved glycated hemoglobin (HbA1c) levels, self-management, behavioral change, and health-related quality of life, and to describe the sociodemographic, clinical, and lifestyle characteristics of the participants after 4 months.MethodsA 3-armed randomized controlled trial was conducted in Norway during 2011-2013. In the 2 intervention groups, participants were given a mobile phone for 1 year, which provided access to the FTA diary, a self-help tool that recorded 5 elements: blood glucose, food habits, physical activity, personal goal setting, and a look-up system for diabetes information. One of the intervention groups was also offered theory-based health counseling with a specialist diabetes nurse by telephone for 4 months from baseline. Both intervention groups and the control group were provided usual care according to the national guidelines. Adults with type 2 diabetes and HbA1c ≥7.1% were included (N=151). There were 3 assessment points: baseline, 4 months, and 1 year. We report the short-term findings after 4 months. HbA1c was the primary outcome and the secondary outcomes were self-management (Health Education Impact Questionnaire, heiQ), behavioral change (diet and physical activity), and health-related quality of life (SF-36 questionnaire). The data were analyzed using univariate methods (ANOVA), multivariate linear, and logistic regression.ResultsData were analyzed from 124 individuals (attrition rate was 18%). The groups were well balanced at baseline. There were no differences in HbA1c between groups after 4 months, but there was a decline in all groups. There were changes in self-management measured using the health service navigation item in the heiQ, with improvements in the FTA group compared to the control group (P=.01) and in the FTA with health counseling group compared with both other groups (P=.04). This may indicate an improvement in the ability of patients to communicate health needs to their health care providers. Furthermore, the FTA group reported higher scores for skill and technique acquisition at relieving symptoms compared to the control group (P=.02). There were no significant changes in any of the domains of the SF-36.ConclusionsThe primary outcome, HbA1c, did not differ between groups after 4 months. Both of the intervention groups had significantly better scores than the control group for health service navigation and the FTA group also exhibited improved skill and technique acquisition.

Health-related empowerment in cancer: validity of scales from the Health Education Impact Questionnaire.

Empowerment refers to an individual's feelings of being able to manage the challenges of the cancer experience and of having a sense of control over one's life. However, empowerment questionnaires that have been validated for the cancer setting are lacking. The objective of this study was to validate scales from the Health Education Impact Questionnaire (heiQ), which assesses the effects of health education programs among individuals with chronic conditions. The heiQ scales Social integration and support, Health service navigation, Constructive attitudes and approaches, Skill and technique acquisition, and Emotional distress were identified as key dimensions of empowerment for the cancer context. Adults who were diagnosed with cancer < 3 years earlier were recruited from a population-based cancer registry and from the Canadian Cancer Society's information and peer-support programs. The 731 participants completed a mailed questionnaire, which included the heiQ scales, related constructs, and demographics. Reliability was assessed using Cronbach α values, and validity was determined using confirmatory factor analysis and scale correlations with related constructs (self-efficacy, intrusive thoughts about cancer, and mental and physical health). The hypothesized 5-factor model fit the data adequately (chi-square statistic, 528.17; degrees of freedom, 265; root mean square error of approximation, .04; non-normed fit index, .99; comparative fit index, 1.00; standardized root mean residual, .05). Factor loadings were high (23 of 25 were ≥ .70), and the factor correlations indicated separate but related constructs. Cronbach α values ranged from .75 to .90. A priori hypotheses about the correlations between heiQ scales and related constructs all were supported. The current results support the validity of these 5 heiQ scales as generic measures of health-related empowerment in the cancer setting. These scales could fill an important gap in the measures currently available to evaluate proximal effects of support interventions.

A Qualitative Assessment of Community-Based Breast Health Navigation Services for Southeast Asian Women in Southern California: Recommendations for Developing a Navigator Training Curriculum

We identified key elements required for a training curriculum for Southeast Asian community-based health navigators (CBHNs), who help low-income, immigrant Cambodian, Laotian, Thai, and Vietnamese women negotiate cultural and systemic barriers to breast cancer screening and care in the United States. We gathered the perspectives of 3 groups: CBHNs, community members, and their providers. We conducted 16 focus groups with 110 women representing different stages of the cancer care continuum and in-depth interviews with 15 providers and 10 navigators to identify the essential roles, skills, and interpersonal qualities that characterize successful CBHNs. The most important areas identified for training CBHNs were information (e.g., knowing pertinent medical information and how to navigate resources), logistics (transportation, interpretation), and affective interpersonal skills (understanding the language and cultural beliefs of patients, communicating with providers, establishing trust). CBHNs serve a crucial role in building trust and making screening practices culturally meaningful, accessible, usable, and acceptable. Future research should focus on developing training curricula, policies, resources, and funding to better maximize the expertise and services that CBHNs provide and to expand our findings to other underserved communities.

Abstract A28: Reaching vulnerable populations: A process-oriented approach to breast screening

Abstract This community-based project evolved out of relationships established through the Detroit CNP for Older, Underserved African-Americans (NIH# U01-CA114583-04) to address the unmet needs of the clientele of three partnering community agencies. The need for breast cancer screening among older women from lower socioeconomic groups, the mentally ill, and the disabled has been well-documented. However, mammography among these special populations is low. This project brought together five organizations (three community service agencies, the NCI's Cancer Information Service Partnership Program, and the Karmanos Cancer Institute's Community Network Program) to provide breast health awareness, mammography screening, and navigation to underserved African American women. The five agencies collaborated to address the needs of the homebound, developmentally disabled, homeless, nursing home residents, grandparents raising grandchildren, and others. All groups were identified through a community assessment to identify significant barriers to accessing preventive health care services. Through community-based participatory research (CBPR), the members of the partner organizations worked with community health education professionals to define: 1) community-level needs; 2) assess how best to integrate screening messages and health service navigation into existing service provision; and 3) identify ways to obtain external funding for program implementation. The CBPR process yielded an intervention that consisted of staff training, improved screening needs assessment and procedures for case management referral and follow-up that increased agency capacity to address breast health disparities. A total of 490 women participated in this “high-touch” breast health education and screening intervention. Of those, 170 women received screening mammography and six women were diagnosed and received subsequent treatment and follow-up. The project was recently recognized by the Michigan Cancer Consortium, receiving their highest recognition, the Spirit of Collaboration Award. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A28.

Evaluation of a rural chronic disease self-management program

Internationally, the prevalence of long-term health conditions is at epidemic proportions. Australia is no exception. The Australian Government's 'Better Health Initiative' has 5 key strategies to build better health care, one of which is the adoption of self-management and self-management support. Self-management allows people to manage their condition and the consequences it brings to their lives in partnership with their health providers. The purpose of this article was to report both the process and patient outcomes following the introduction of the Stanford Chronic Disease Self-Management Program (CDSMP) into an existing service in an Australian rural setting. Implementation processes were evaluated using semi-structured interviews conducted with managers, lay and health professional course leaders and participants about positive and negative aspects of providing the CDSMP. Participant outcomes were evaluated using a modified pre-test, post-test design to evaluate changes in activity participation and self-management knowledge and skills. Both negative and positive aspects of providing the program were represented by two key themes: (1) program content and quality; and (2) logistics of delivery. Throughout the interviews, managers and leaders, and course participants offered recommendations that were thematically grouped into 3 categories: (1) enhancing quality; (2) improving the logistics; and (3) providing resources. Comparison of activity levels with a community sample indicated that participants had significantly decreased participation levels. Scores on the Health Education Impact Questionnaire v2 (heiQ - RETRO) demonstrated statistically better scores at post-test on the domains of 'self monitoring', 'insight' and 'health service navigation' with a trend towards significance on 3 other domains. Future implementation of CDSMPs in rural areas will be encouraged by these patient outcomes, and informed by the qualitative findings from managers, leaders and course participants.

The Health Education Impact Questionnaire (heiQ): An outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions

Objective This paper describes the development and validation of the Health Education Impact Questionnaire (heiQ). The aim was to develop a user-friendly, relevant, and psychometrically sound instrument for the comprehensive evaluation of patient education programs, which can be applied across a broad range of chronic conditions. Methods Item development for the heiQ was guided by a Program Logic Model, Concept Mapping, interviews with stakeholders and psychometric analyses. Construction ( N = 591) and confirmatory ( N = 598) samples were drawn from consumers of patient education programs and hospital outpatients. The properties of the heiQ were investigated using item response theory and structural equation modeling. Results Over 90 candidate items were generated, with 42 items selected for inclusion in the final scale. Eight independent dimensions were derived: Positive and Active Engagement in Life (five items, Cronbach's alpha ( α) = 0.86); Health Directed Behavior (four items, α = 0.80); Skill and Technique Acquisition (five items, α = 0.81); Constructive Attitudes and Approaches (five items, α = 0.81); Self-Monitoring and Insight (seven items, α = 0.70); Health Service Navigation (five items, α = 0.82); Social Integration and Support (five items, α = 0.86); and Emotional Wellbeing (six items, α = 0.89). Conclusion The heiQ has high construct validity and is a reliable measure of a broad range of patient education program benefits. Practice Implications The heiQ will provide valuable information to clinicians, researchers, policymakers and other stakeholders about the value of patient education programs in chronic disease management.

The extent and breadth of benefits from participating in chronic disease self-management courses: A national patient-reported outcomes survey

Objective To quantify the benefits that people receive from participating in self-management courses and identify subgroups that benefit most. Methods People with a wide range of chronic conditions attending self-management courses ( N = 1341 individuals) were administered the Health Education Impact Questionnaire (heiQ). Baseline and follow-up data were collected resulting in 842 complete responses. Outcomes were categorized as substantial improvement (effect size, ES ≥ 0.5), minimal/no change (ES −0.49 to 0.49) and substantial decline (ES ≤ −0.5). Results On average, one third of participants reported substantial benefits at the end of a course and this ranged from 49% in the heiQ subscale Skill and technique acquisition to 27% in the heiQ subscale Health service navigation. Stratification by gender, age and education showed that younger participants were more likely to benefit, particularly young women. No further subgroup differences were observed. Conclusion While the well-being of people with chronic diseases tends to decline, about one third of participants from a wide range of backgrounds show substantial improvements in a range of skills that enable them to self-manage. Practice implications These data support the application of self-management courses indicating that they are a useful adjunct to usual care for a modest proportion of attendees.