Transcript Lifestyles of the poor and underserved: Unhealthy

Lifestyles of the poor and
underserved:
Unhealthy Behaviors at primary
care clinics in Milwaukee, WI –
What can we do?
Elizabeth Bade, MD
Jennifer Evertsen, MS
Christine Casselman, MA
11/12/2009
Objectives
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Review data from service project involving
drug and alcohol screening
Discuss relevant needs for this population of
underserved patients
Propose research based on this project to
address the issues identified
Background
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Wisconsin Initiative to Promote
Healthy Lifestyles (WIPHL)
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Began in March of 2006 delivering
services in primary care clinics around the
state – currently in 18 locations
Screening, Brief Intervention, Referral to
Treatment (SBIRT) for at risk drug and
alcohol use
Each clinic has a health educator who uses
motivational interviewing (MI) to deliver
SBIRT to patients
Aurora and WIPHL
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Aurora began delivering SBIRT services
through WIPHL at 3 clinics in 2006
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Currently still delivering services in 2 out of 3 of
the original clinics and 1 new clinic
Initially 2 family medicine residency clinics and 1
family medicine free clinic were involved
Currently 1 women’s health (ob/gyn) clinic
replaced one of the family medicine clinics
A word about SBIRT
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Screening quickly assesses the severity of
substance use and identifies the appropriate level
of treatment.
Brief intervention focuses on increasing insight
and awareness regarding substance use and
motivation toward behavioral change.
Referral to treatment provides those identified
as needing more extensive treatment with access
to specialty care
Motivational Interviewing (MI)
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History - Technique was first developed for use
with alcohol and drug counseling and it’s
efficacy is well documented
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Motivational Interviewing is a person-centered,
directive method of communication for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence.
MI metaphor
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It’s like we are both climbing up our own
mountain. You are trying to reach the top of
yours, and I mine. It turns out that from my
mountain I may have a different perspective
from yours, so I can help you see things that
may not be very clear to you from where you
are at. But in the end, YOU will make the
decisions as to how to continue, since it’s your
own mountain after all and no one can climb it
for you.
Motivational Interviewing (MI)
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Method – Promotes self-efficacy: helps patients to
recognize unhealthy behaviors, overcome barriers and
set achievable goals, while guiding and educating
Adaptable – Fosters a partnership with patients, avoids
giving unwanted advice, allows patients to weigh pros
and cons of behavior change in light of their own goals
and values
Recent studies have shown that MI is also efficacious at
behavior change for non-addictive behaviors, specifically
helps maintain dietary changes
Process
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Brief screen
questionnaire once per
year
If answers “yes” to
either alcohol or drug
question, full screen is
completed –preferably
at the point of care
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Full screen determines
“level of risk”
Consists of specific
questions regarding
lifetime substance use,
and use in the past three
months.
Helps patients to
identify health, social,
legal and financial
consequences of use.
Brief Screen questions
Tobacco
Yes
No Have you used any tobacco products in the past 30 days?
Please circle one number between 1 (do not agree) and 7 (strongly agree) for the following statements:
Exercise How many days a week do you get at least 20 minutes of vigorous exercise such as jogging,
biking uphill or carrying 50 pounds?
1234567
How many days a week do you get at least 30 minutes of moderate exercise such as walking fast, biking on a
flat surface or mowing the lawn?
1234567
Nutrition How often do you eat fruits and vegetables. Never Rarely Sometimes Often
Do you eat fruit and vegetables all the time every day?
Yes
No
Brief Screen Questions
Males and females
Yes No In the last 12 months, did you smoke pot, use another street drug or use a prescription
painkiller,stimulant, or sedative for a non-medical reason?
Yes
Yes
use?
No In the last 12 months, did you ever find yourself drinking or using drugs more than you meant to?
No In the last 12 months, did you ever think that maybe you should cut down on your drinking or drug
Males
Yes No Please think about the last time you had five or more standard drinks in a day or night; was that
within the last three months?
Females
Yes No Please think about the last time you had four or more standard drinks in a day or night; was that
within the last three months?
Results
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From 5/29/2007-6/1/2009
Participants all 18 years or older, mean age of
43
11,742 brief screens, 2,088 full screens
60% female
38% white; 30% black; 30% hispanic
Alcohol and Drug Use
Low Risk -26%
At Risk- 58%
Dependent - 9%
Harmful- 6%
Other Unhealthy Behaviors
80%
70%
60%
50%
40%
Low Risk
At Risk
30%
20%
10%
0%
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State/National Averages
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In 2007 prevalence of cigarette smoking in the
United States 19.8%
State Specific Prevalence and Trends in Adult Cigarette Smoking in
the United States 1998-2007. JAMA. 2009;302(3): 250-252.
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50% of Americans exercise for 30 minutes less
than 3 days per week
Wisconsin is the 25th fattest state in the union
with a prevalence of 26%, and an estimated
2/3rds of Americans are overweight or obese
Gallup poll May 2009
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F as
in Fat: How obesity policies are failing in America, 2008. Robert Woods Johnson Foundation
More results
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Blacks and Hispanics scored higher for both
gender-specific questions related to “number
of drinks consumed at one time” and exercise
Blacks scored higher on weight problems and
“thinking about cutting back on alcohol/drug
use”
Females scored higher on tobacco and weight
Age not related to other health risk behaviors
The Conundrum
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SBIRT is known to help with alcohol and drug
related counseling
Other health markers are also important and
puts patient’s health at risk
What can work and fit into a busy primary care
practice?
MI For Diet and Exercise
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Some studies suggest
that MI effective in nonaddictive behaviors
(Bowen, Resnicow)
Also studies done using
MI by health
professionals
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Adds additional burden
onto medical staff
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Our proposal
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Use the same process as
is used for WIPHL
project
Address diet and
exercise with MI
Look for changes in
readiness to change,
answers to diet and
exercise questionnaires
Next Steps…
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Received grant for this project
12 month grant
Will recruit 150 patients from primary care
clinics
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Randomized to “high intervention”, “low
intervention”, or “usual care”
3 month follow up
Assess readiness to change and responses on
questionnaires about diet/exercise habits
Discussion
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“Usual care” doesn’t seem to be effective to
promote healthy lifestyle choices in these
primary care clinics in Milwaukee
Opportunity to provide a useful, low cost
intervention that may improve lifestyle habits
Results remain to be seen…
References/Acknowledgements
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WIPHL team – PI is Rich Brown, MD
Center for Urban Population Health
ICTR team for funding our next project
Additional references on motivational
interviewing:
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Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a metaanalysis of controlled clinical trials. J of Consulting & Clinical Psychol 2003;71(5):84361.
Miller WR, Rollnick S. Motivational Interviewing (2nd ed.) New York: Guilford, 2002.
Resnicow K, Borrelli B, Ernst D, et al. Motivational Interviewing in Health Promotion:
It Sounds Like Something is Changing. Health Psychol. 2002:21(5):444-451.