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

项目摘要 慢性疼痛是一个巨大的公共卫生问题，非洲裔美国老年人承担着不成比例的 致残性疼痛的负担。循证慢性疼痛自我管理支持可以改善疼痛相关 然而，提供这种支持的标准模式并不适合老年人， 密歇根州底特律等面临严重种族隔离和社会经济问题的有色人种社区 劣势现有的疼痛自我管理干预措施大多是基于小组的，需要亲自 这使得有交通或行动障碍的老年人不太容易接触到这些设施。此外，现有 干预措施很少涉及健康的社会决定因素（例如，经济压力），根源在于 同样的结构性不平等，产生高比例的疼痛，并阻碍其管理。的长期目标 这项研究旨在为慢性疼痛自我管理干预建立一个强大的证据基础， 满足服务不足社区中弱势老年人的需求。本拟议项目的目标 是为了确定社区卫生工作者（CHW）-即，非专业卫生工作者与 他们所服务的社区-可以有效地向老年人教授认知行为疼痛管理策略 城市弱势群体中的成年人。社区卫生工作者是唯一适合这一角色，因为他们有能力提供 文化上适当的护理和他们对社区资源的深入了解，使他们能够解决 健康的社会决定因素。中心假设是基于CBT的疼痛自我管理干预 （“STEPS”）通过电话会议与CHW和移动的健康工具一起提供了7周， 一年的疼痛相关结果。我们非常令人鼓舞的初步研究结果表明，STEPS是可行的， 由CHW以高保真度交付，并受到参与者的好评（n=31）。其潜在功效是 通过疼痛干扰的显著改善表明（前后标准化平均差异= 0.84，p = 0.001）。 000）。拟议中的试验将与底特律的亨利福特卫生系统合作进行。那里 有三个具体目标：1）进行第三阶段疗效试验，以评估STEPS是否可以减少一年的疼痛 在414名主要是非洲裔美国老年人中，2）评估心理行为 干预效果的中介者和调节者，以及3）使用来自参与者和其他 利益攸关方，进行混合方法分析，为定量结果提供背景，并为工具包提供信息 如果干预措施有效，就进行传播。该项目的创新之处在于，它招募了社区卫生工作者，他们 为其他疾病提供了基于证据的干预措施，但尚未成为疼痛护理工作人员的一部分。它 具有强大的潜在影响，因为正在测试的模型成本低，可扩展，适合于深入 弱势环境中，慢性疼痛的负担是最大的。此外，它可以远程交付， 这不仅使访问最大化，而且与社交距离兼容。最终，这项研究可能会导致 一个可转移的模型，可以应用于其他需要改善疼痛护理的弱势群体。

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.