An Efficacy Trial of Community Health Worker-Delivered Chronic Pain Self-Management Support for Vulnerable Older Adults

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Project Summary Chronic pain is an enormous public health problem, and African American older adults bear a disproportionate burden of disabling pain. Evidence-based chronic pain self-management support can improve pain-related functioning, yet standard models for providing this support are not well-suited to reach older people in communities of color such as Detroit, Michigan, which face severe racial segregation and socioeconomic disadvantage. Existing pain self-management interventions are mostly group-based and require in-person contact, making them less accessible to older adults with transportation or mobility barriers. Moreover, existing interventions seldom address the social determinants of health (e.g., economic stressors) that are rooted in the same structural inequities that produce high rates of pain and hinder its management. The long-term goal of this line of research is to build a robust evidence base for chronic pain self-management interventions that meet the needs of vulnerable older adults in underserved communities. The objective of this proposed project is to determine whether community health workers (CHWs)—i.e., lay health workers with close ties to the communities they serve – can effectively teach cognitive-behavioral pain management strategies to older adults in a disadvantaged urban setting. CHWs are uniquely suited for this role, given their ability to provide culturally appropriate care and their deep knowledge of community resources that enables them to address social determinants of health. The central hypothesis is that a CBT-based pain self-management intervention (“STEPS”) delivered over 7 weeks through telephone sessions with a CHW and mobile health tools improves one-year pain-related outcomes. Our highly encouraging preliminary findings indicate that STEPS is feasible, deliverable by CHWs with high fidelity, and well-received by participants (n=31). Its potential efficacy is suggested by significant improvement in pain interference (pre-post Standardized Mean Difference = 0.84, p = 000). The proposed trial will take place in partnership with the Detroit-based Henry Ford Health System. There are three specific aims: 1) Conduct a Stage 3 efficacy trial to assess whether STEPS can reduce one-year pain interference and intensity among 414 primarily African American older adults, 2) Assess psychobehavioral mediators and moderators of intervention effects, and 3) Using qualitative data from participants and other stakeholders, conduct mixed-methods analysis to provide context for quantitative findings and inform a toolkit for dissemination, if the intervention is effective. This project is innovative in that it enlists CHWs, who have delivered evidence-based interventions for other conditions but are not yet part of the pain care workforce. It has strong potential impact given that the model being tested is low-cost, scalable, and suitable for deeply disadvantaged settings, where the burden of chronic pain is greatest. Moreover, it can be delivered remotely, which not only maximizes access but is compatible with social distancing. Ultimately, this research could lead to a transferable model that can be applied to other vulnerable populations in need of improved pain care.