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Service Delivery Innovation Profile

Culturally Appropriate, Interactive Decision Aid Yields High Quit Rates Among Underserved, Low-Literacy Latino and Hispanic Smokers


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Snapshot

Summary

The Smoking Cessation Decision Aid program provides underserved, low-literacy, mainly Latino and Hispanic smokers with an interactive, culturally appropriate decision aid to improve their knowledge and use of smoking cessation resources. Placed at kiosks at large community health fairs and in safety net clinics, the video-based aid uses a bilingual narrator and features well-known members of the Latino community. It queries participants about smoking behaviors and attitudes; presents options for learning about cessation resources; and guides smokers through the process of making decisions about quitting, including use of pharmacotherapy and telephone counseling. The program led to high degrees of engagement by participants and well above-average quit rates in those who expressed a desire to stop smoking.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the percentage of those who completed the interactive session, and the percentage of those who quit smoking, based on self-reports 2 months after completing the interactive session.
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Developing Organizations

University of Kansas Medical Center, Kansas City, KS
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Date First Implemented

2008
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Illiterate/low-literateend pp

Problem Addressed

Low-income and uninsured Hispanic and Latino smokers often lack access to cessation counseling and treatment.1 Few state Medicaid programs cover smoking cessation services, while safety net clinics generally lack the staff and/or funding to provide them and health fairs only provide cessation education and referrals for treatment.
  • Lack of Medicaid coverage: Only seven state Medicaid programs cover comprehensive smoking cessation services for beneficiaries, including Food and Drug Administration-approved medications and group and individual counseling.1
  • Little support at safety net clinics: More than 50 million Americans lack health insurance2 and often rely on safety net clinics and/or health fairs for their medical needs.3 Even though many states require safety net clinics to provide smoking cessation services, these sites often lack the staff or funding to do so effectively, as most resources are used to treat acute symptoms.3
  • Leading to limited access to information and treatment: Because of the problems outlined above, medically underserved populations, especially those with limited English proficiency, generally lack information about treatment options for smoking cessation and are less likely to receive treatment for nicotine dependence.1

What They Did

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Description of the Innovative Activity

The Smoking Cessation Decision Aid program provides underserved, low-literacy, and mainly Latino/Hispanic smokers with an interactive, culturally appropriate decision aid to improve their knowledge and use of smoking cessation resources. Placed in kiosks at health fairs and safety net clinics, the video-based aid uses a bilingual narrator and features well-known members of the Latino community. It queries participants about smoking behaviors and attitudes and guides them through the process of making decisions about quitting, including treatment options to assist in doing so. After completing the session, participants receive educational materials to reinforce the messages presented. During an initial pilot test, those wishing to quit received a voucher for free nicotine replacement medication. Key program elements include the following:
  • Placement in clinics and at health fairs: The decision aid can be located in kiosks at community health fairs and in safety net clinics. During a pilot test of this program, the kiosks were set up in three clinics and at two large community health fairs.
  • Identification of smokers: Health fair volunteers ask attendees and clinic staff ask patients if they smoke, and invite those age 18 and over who identify themselves as smokers if they would like to view the interactive video. Those interested sign a consent form that appears on the initial screen of the program.
  • Culturally relevant and appropriate decision aid: To ensure viewer engagement, the video is available in both English and Spanish (30 percent of users in the trial viewed it in Spanish) and features well-known community members, including a Latino physician, case manager, and laborer. To ensure comparable versions in each language, a bilingual narrator performs the audio portion. The 15-minute video takes the viewer through a series of 40 questions about smoking behaviors and attitudes; presents options for learning about cessation resources; guides smokers through the process of making decisions about quitting; and reviews cessation treatment resources and options, including pharmacotherapy and telephone counseling.
  • Educational materials to reinforce and support messages: After viewing the video, participants receive three printouts (either in English or Spanish) from a printer attached to the kiosk. These materials summarize the interaction and provide support in accessing additional resources that can help in quitting, as outlined below:
    • Session summary: This printout reports the individual’s level of interest in quitting, stated reasons for wanting to quit (if appropriate), and behavioral and treatment preferences. It also provides personalized recommendations for behavioral changes the individual should consider before quitting. Participants who want to quit receive a copy of a pamphlet to guide them through the process ("My Smoking Cessation Plan"), and those who do not receive a different pamphlet to encourage small changes that can lead to quitting or the desire to do so ("Small Changes to Quit Smoking").
    • Suggestions for interactions with provider: The second printout presents suggestions for how to discuss smoking cessation and pharmacotherapy with a health care provider. It includes a report for the provider with tips on how they can help the smoker quit.
    • Referral to quitline: The third printout provides a referral to the Kansas Tobacco Quitline, with instructions for participants on how to ask their provider to fax it to the quitline during an office visit or health fair encounter.
  • Voucher for free nicotine replacement medication: During the pilot test, individuals expressing a desire to quit received information about two medications (bupropion and nicotine replacement patches). Those using the kiosk at the clinic received a voucher for free nicotine replacement medication (funded by a foundation grant), to be monitored by providers at the safety net clinic. The availability of this voucher likely influenced treatment preferences, as 95 percent of participants in the pilot test chose pharmacotherapy as their desired treatment option.

Context of the Innovation

The University of Kansas Medical Center serves as the umbrella organization for the university’s schools of medicine, nursing, and allied health. It houses numerous research centers and institutes and provides patient care though its hospitals and clinics. The medical center's Department of Preventive Medicine and Public Health focuses on developing and evaluating programs that have direct, tangible benefits for the communities it serves. Researchers within the department became aware of previous findings on the feasibility and acceptability of decision aids as tools for helping patients make good health choices. Feeling that this approach could work with smoking cessation, they secured a grant from the Healthcare Foundation of Greater Kansas City to develop and pilot test the interactive video decision aid with underserved Latino/Hispanic smokers in Kansas City. A Kansas law requiring safety net clinics to provide cessation counseling and services contributed to the willingness of safety net clinics and health fair organizers to use the smoking cessation kiosks.

Did It Work?

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Results

The program led to high degrees of engagement by participants and to well above-average quit rates in those who expressed a desire to stop smoking.
  • High completion rate, indicating significant engagement: During the initial trial, just under 80 percent of self-identified smokers referred to the kiosk (128 out of 163 individuals) completed the interactive session, which suggests high levels of engagement in the material.
  • High quit rate, well above typical unaided rates: Based on self-reports, roughly one in five individuals who expressed a desire to quit smoking during the session (20.2 percent, or 17 out of 89 people) had done so 2 months later. This quit rate is well above the 13.2 percent quit rate for smokers with low socioeconomic status who receive usual care or no counseling for smoking cessation.4

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the percentage of those who completed the interactive session, and the percentage of those who quit smoking, based on self-reports 2 months after completing the interactive session.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Designing software/hardware: Researchers designed the decision aid to include a combination of video and audio to enhance interactivity and overcome barriers related to literacy. They also decided to connect the kiosk to a printer to enable the printing of educational materials at the end of each session.
  • Identifying and approaching clinics and health fairs: The principal investigator contacted local Kansas clinics and two health fair organizers to discuss use of the system. Clinic managers and health fair organizers welcomed the opportunity to provide patients with access to the decision aid.
  • Determining appropriate placement: Staff visited the clinics to determine the appropriate location for the kiosk, deciding on the intake area since asking about smoking habits is part of the intake protocol. At the health fair, staff invited identified smokers to learn more about cessation resources by using the kiosk, which was located in a more private space away from the table where smoking cessation materials were displayed.
  • Training clinic staff: Researchers conducted a 1-hour training program during lunch to explain the decision aid to all clinic staff and the importance of always asking about individual’s smoking habits and interest in quitting. While collecting such information is required, the three participating safety net clinics did not routinely do so prior to introducing the kiosk.

Resources Used and Skills Needed

  • Staffing: The program required no incremental staff for the clinics and health fairs. As noted, existing clinic staff did participate in a 1-hour training session prior to implementation. The research team during the study included seven senior researchers and research assistants.
  • Costs: The program entails minimal expenditures, with the main upfront cost being the purchase of a computer and printer and the main ongoing expense being for printer ink and paper.
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Funding Sources

HealthCare Foundation of Greater Kansas City
The Healthcare Foundation of Greater Kansas City provided a $100,000 grant for the pilot study.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Be aware of and ready to discuss state requirements: Many states require safety net clinics to provide smoking cessation counseling and services, which can affect the willingness of clinic managers to use the kiosk. Would-be adopters should be prepared to discuss these requirements with clinic managers, including whether the clinic is currently able to meet them. This discussion should also cover whether and how the clinic can provide access to free or reduced-cost medications.
  • Contact pharmaceutical assistance programs: These programs often make free or low-cost medications available to uninsured and low-income smokers, which could significantly improve access to cessation medications.
  • Provide staff training: All administrative and medical staff should participate in training that explains the purpose and benefits of the kiosk, and that reinforces the need to identify smokers at every visit. As appropriate, this training should also discuss how to connect smokers to free or reduced-cost medications, as discussed above.

Sustaining This Innovation

  • Continue to provide periodic staff training: Due to high staff turnover at safety net clinics, would-be adopters should be prepared to regularly train administrative and medical staff about the program. As part of this effort, encourage providers to address options for quitting each time they interact with patients who smoke.
  • Expand nicotine replacement options: This program offers either bupropion or nicotine replacement patches for those who choose pharmacotherapy. Would-be adopters might be able to increase utilization if they add information on other pharmacotherapy options, including varenicline.

More Information

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Contact the Innovator

Ana Paula Cupertino, PhD
Assistant Professor
University of Kansas Medical Center
Department of Preventive Medicine and Public Health
3901 Rainbow Boulevard, MS1008
Kansas City, KS 66160
E-mail: acupertino@kumc.edu

Innovator Disclosures

Dr. Cupertino has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 Riordan M. Tobacco and socioeconomic status, Campaign for Tobacco-Free Kids. March 31, 2014. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0260.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 DeNavas-Walt C, Proctor BD, Smith JC. U.S. Census Bureau. Income, poverty, and health insurance coverage in the United States: 2009. September 2010. Available at: http://www.census.gov/prod/2010pubs/p60-238.pdf
3 Cupertino AP, Richter K, Cox LS, et al. Feasibility of a Spanish/English computerized decision aid to facilitate smoking cessation efforts in underserved communities. J Health Care Poor Underserved. 2010;21(2):504-17. [PubMed]
4 Agency for Healthcare Research and Quality. Treating tobacco use and dependence: 2008 update. U.S. Public Health Service Clinical Practice Guideline. Available at: http://www.ncbi.nlm.nih.gov/books/NBK63952/
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Original publication: September 28, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 01, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.