Using Rural Community Paramedicine to Engage Lower-Motivated Smokers: Spreading an Effective mHealth-Assisted Intervention to Motivate Cessation

7.项目概要/摘要 我们会进行一项多层次的“混合第二类”研究（即：执行和有效性成果）进行测试 1)在农村县的一个新的实施方案和2）mHealth（移动的健康）辅助短暂禁欲 经验（休息一下，TAB）的农村成年人吸烟，还没有准备好戒烟。在我们的农村网络中， 县，实施试验将采用一种新颖的，多战略的实施方案，以县为中心， 从事“社区护理”的员工。紧急医疗服务人员（EMS）正在不断发展 这一更广泛的角色（例如：非紧急医疗服务，慢性病监测，以及 预防医学）。为了测试实施情况，我们将随机选择提供EMS服务的农村县 地理复杂和种族多样的地区（阿巴拉契亚山区和东部平原） 北卡罗来纳州）。这些县有一些最高的吸烟率在美国，我们将比较一个很好的- 经过测试的（标准）实现程序与新的增强程序。标准程序使用 以证据为基础的外部促进-为环境管理系统服务提供培训和技术支持， 加强烟草控制做法的整合（包括推荐和转介吸烟者， 尚未准备好戒烟的人接受mHealth辅助的人群健康干预。小说增强了 实施计划将包括标准计划和EMS冠军计划。EMS目前 吸烟者将被邀请参加TAB。参与者（冠军）将使用他们的 具有TAB经验，可作为内部促进者支持实施。他们将鼓励其他EMS体验 TAB，纵向鼓励在所有EMS的日常工作流程中使用烟草控制实践，并将 能够利用他们的个人经验与TAB进行更丰富的对话与吸烟患者。使用这些 我们的战略是，让生活在偏远农村地区的个人参与，他们获得临床服务的机会较少。 通过针对自我效能的简短、低强度、可口的干预措施，可以让这些人参与进来 并促进技能建设，以支持未来的禁欲。TAB干预解决了以下挑战： 使用一种新的形式，一个简短的禁欲游戏，使用mHealth支持，吸引动机较低的人 and building建造upon 10 years年份of research研究.我们最近在JAMA Internal上发表了第一个TAB有效性试验 药这一初步数据支持目前的申请，不包括大量的 生活在农村地区的人。在这个项目中，我们将随机选择TAB与设计的主动比较， 隔离TAB的影响并平衡两组参与者的接触。除了评估 在执行成功和有效性结果方面，我们将研究停止的途径。通知 在维持和传播方面，我们将收集关于执行忠实度、国家一级的适应情况 转诊的变化，以及各县的患者参与度，以及EMS和患者的参与度。到 评估预算影响，我们将跟踪实施战略和干预措施的成本。

7. Project Summary/Abstract We will conduct a multi-level “hybrid type 2” study (i.e.: implementation and effectiveness outcomes) to test 1) a novel implementation program in rural counties and 2) a mHealth (mobile health)-assisted brief abstinence experience (Take a Break, TAB) for rural adults who smoke and are not-yet-ready to quit. In our network of rural counties, the implementation trial will use a novel, multi-strategy implementation program centered on county employees engaged in ‘community paramedicine.’ Emergency Medical Services personnel (EMS) are evolving into this more expansive role (e.g.: non-emergent healthcare delivery, monitoring of chronic disease, and preventive medicine). To test the implementation, we will randomize rural counties with EMS serving geographically complex and ethnically varied areas (the mountainous region of Appalachia and plains of eastern North Carolina). These counties have some of the highest smoking rates in the U.S. We will compare a well- tested (standard) implementation program versus a novel enhanced program. The standard program uses evidence-based external facilitation – providing training and technical support to EMS services to support the integration of enhanced tobacco control practices (including recommending and referring people who smoke and not-yet-ready-to-quit to the mHealth-assisted population health intervention. The novel enhanced implementation program will include the standard program an EMS Champion program. EMS who currently smoke will be offered participation in TAB themselves. Those who participate, Champions, will then use their TAB experience to support implementation as internal facilitators. They will encourage other EMS to experience TAB, longitudinally encourage use of the tobacco control practices in routine workflow for all EMS, and will be able to use their personal experience with TAB to engage in a richer dialog with patients who smoke. Using these strategies, we seek to engage individuals living in harder-to-reach rural areas with less access to clinical services. Engaging these individuals is possible with brief, low intensity, palatable interventions that target self-efficacy and facilitate skills building to support future abstinence. The TAB intervention addresses the challenge of engaging lower motivated individuals using a novel format, a brief abstinence game, supported using mHealth and building upon 10 years of research. We recently published the first TAB effectiveness trial in JAMA Internal Medicine. This preliminary data supports the current application and does not include a large number of individuals living in rural areas. In this project, we will randomize to TAB versus an active comparison designed to isolate the effect of TAB and balance the participant contact across the two groups. In addition to evaluating implementation success and effectiveness outcomes, we will study pathways to cessation. To inform sustainment and dissemination, we will collect data on implementation fidelity, county-level adaptations, variations in referrals, and patient-level engagement across the counties, and at the EMS and patient-level. To evaluate budget impact, we will track the cost of the implementation strategies and the intervention.