Lessons from the

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Lessons from the Just For You Project Methods
from Community-Based Participatory Research

• AMCHP Annual Meeting
• Washington DC
• February 20, 2005
• Karen Peterson, RD, DSc
• Tamara Dubowitz, MA, MSCara Ebbeling, PhD
• Judy Salkeld, MA
• Cary Hardwick, MA, MSN, MS
• Michelle Roover, MS

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1 R01 HD37368-01 (NICHD)

• Harvard School of Public Health
• University of Massachusetts, Amherst
• Dana Farber Cancer Institute, Boston
• University of South Carolina School of Public
  Health

Reducing Disease Risk in Low-Income Postpartum
Women (Just For You)
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PROJECT OVERVIEW

• Investigators and Community Partners
• Theoretical Background
• Aims
• Structure of the Intervention Program
• Study Design

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Funding

• RFA-OD-98-002
• Innovative Approaches to Disease Prevention
  through Behavior Change
• 4-yr grant program to test interventions
• Long-term health behavior change
• Test alternative theories or utility of one
  theory to change 2 or more behaviors

• insufficient exercise
• poor diet

• tobacco use
• alcohol abuse

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Investigators

• Harvard School of Public Health
• Karen Peterson, PICara Ebbeling (HMS/TCH)
• Barbara Gottlieb
• Marie McCormick Louise Ryan
• Dana Farber Cancer Institute
• Glorian Sorensen, Co-PI

• University of Massachusetts, Amherst
• Nancy Cohen, Co-PI Patty Freedson
• University of South Carolina, School of Public
  Health
• James Hebert, Co-PI
• Tom Hurley
• Chuck Matthews (Vanderbilt)

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Biologic Anthropology

• Critical periods of biologic, behavioral
  adaptation
• Weight gain
• gtafter first pregnancy
• increases with of pregnancies
• Postpartum influences on nutrition and activity
• childrearing demands
• lifestyle changes
• social isolation
• poor health status

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Social Ecological Framework
Behavior affected by multiple levels of influence

• 1- Intrapersonal
• Behavior a function of attitudes, norms,
  perceived ability to change
• Economic choice theory
• Multiple alternatives, increase control
• reduce access to unhealthy behaviors
• 2- Interpersonal
• Social support and networks
• 3- Organizational
• Diffusion of innovation, organizational change
• 4- Community
• Access to healthy foods, safe activity options

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Community Partners

• Massachusetts State WIC Program
• Pregnant, breastfeeding women, infants/children
  lt5 yr Household income lt 185 poverty
• Food vouchers and nutrition education
• Jamaica Plain WIC Program
• Chelsea/Revere WIC Program
• Springfield South WIC Program
• Holyoke WIC Program
• Expanded Food and Nutrition Education Program
• Food safety, preparation, budgeting nutrition
  education Household income lt125 poverty or WIC
  eligible
• Greater Boston Office U. Massachusetts Extension
• Springfield Nutrition Education Program Office

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Overview

• Postpartum period as window of opportunity
• Reduce chronic disease risk
• Benefit reproductive health
• Education model
• Expanded Food and Nutrition Education Program
  (EFNEP)
• Improve diet and activity patterns
• Address social context of low income women

• Design
• Recruit from USDA Special Supplemental Food
  Program for Women, Infant and Children (WIC)
• Randomize to Usual WIC Care Usual WIC Care
  Enhanced EFNEP
• 12-mo intervention, 6-mo maintenance

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Research Design

• Randomized, controlled trial
• N680 WIC participants
• Two conditions
• Usual WIC Care
• Usual WIC Enhanced EFNEP
• Enhanced EFNEP intervention
• 5 home visits
• 4 group classes
• motivational phone calls monthly

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Outcome Measures

• Assessed at 2-6 weeks and 12 months postpartum
• Primary Outcomes
• fruit/vegetable intake
• saturated fat intake
• moderate-to-vigorous physical activity
• Secondary Outcomes
• Body Mass Index (BMII, wt (kg)/ (ht (m))2)
• Fat mass and distribution (TSF, waist)

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Data Collection

• Anthropometry
• BMI
• Mid-arm and waist circumference
• Triceps skinfold
• Survey Interview
• 61-item food frequency questionnaire (Willett
  1985)
• Stanford 7-day physical activity recall
• Mediating and modifying mechanisms

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Major Hypotheses

• Improvements in primary outcomes will be greater
  at 12 mo postpartum among participants in
  Enhanced EFNEP, compared with Usual WIC Care
• Increased fruit and vegetable servings
• Decreased saturated fat consumption
• Increased total moderate-to-vigorous physical
  activity
• Decreases in (BMI) and indicators of fat mass and
  distribution will be larger among participants in
  Enhanced EFNEP, compared with Usual WIC Care

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Ancillary Study

• Purpose
• Independent measure of change in minutes of daily
  moderate-to-vigorous activity
• Document validity of reported duration and
  intensityof mod/vig activity in low-income,
  multi-ethnic women
• Compare diet and activity self-reports with
  repeat recalls
• Design
• N150 participants (75 in each condition)
• Baseline, 12, 18 mo
• Test measures NIH diet screeners 7dPAR
• Comparison measures
• 7-days accelerometer
• Daily activity records (12 mo)
• 3 24-hr diet and activity recalls

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Just for You Status

• January 2003
• 679 women recruited, 131 ancillary participants.
  
• Intensive field work requires increased
  staffing.
• Group class component dropped social support
  incorporated into home visits
• January 2004 follow-up complete

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Population Characteristics at Baseline (n 679)

• Low-income (lt185 of federal poverty)
• Mean age 27 years
• More than two-thirds (69) have twelve or fewer
  years of education
• One-third (34) are not high school graduates
• Three-quarters (75) are Latina/Hispanic, 15
  white, 8 African-American, 1 other
• Almost two-thirds (64) report Spanish as native
  language, as well as language typically spoken at
  home (60)
• Majority of Latinas are immigrants with average
  time in U.S. of eight years

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IMPLEMENTATION

• Intervention components
• Intervention messages

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Why Postpartum Health?

• Health Centers defined need for greater
  understanding
• Successful programs in prenatal and infant care
• Postpartum care poorly understood, poorly
  executed
• Window of opportunity for interventionwomans
  health, childs health, pre-conceptual care

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Intervention Components

• Usual WIC Care
• WIC vouchers and nutrition education
• Certification at 2-6 wk, re-certification 12 and
  18 mo
• Anthropometry
• Enhanced EFNEP Usual WIC Care PLUS
• Home visits
• In-depth assessment, action plan and goals
• Group classes
• Interactive discussion, cooking and activity
• Telephone counseling
• Reinforce goals, support, refer, check medical
  concerns

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Intervention Messages

• Nutrition (Healthy eating)
• Eat 5 or more servings of fruits and vegetables
  every day
• Limit red meat to no more than 3 servings per
  week

• Physical activity
• Do at least 30 minutes of physical activity, on 5
  or more days per week

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Motivational Interviewing

• Home visits and telephone counseling
• Build rapport
• Identify likes and dislikes re diet and activity
  behaviors
• Personalized needs assessment
• Discuss how behaviors fit into lifestyle, how
  client would like things to be different
• Goal setting
• Feedback re-evaluate behavior, increase self
  efficacy

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HOW? Conveying messages and facilitating change
Theoretical Construct Choice Method Menu of
options Practical Strategy Card / Picture sorting

• Visual, Kinesthetic
• Effective across a wide range of literacy levels
• Interventionist as co-learner
• Community linkages

Simpson SH. Nursing Res 198938289
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HOW? Conveying messages and facilitating change
Theoretical Construct Self-control of
performance Methods Goal-setting Self-monitoring
Problem-solving Practical Strategy Pedometer
(Step Counting)

• Accumulation of activity
• Visual, Kinesthetic
• Immediate and frequent feedback
• Documentation of small changes (reinforcement)

Welk et al. Med Sci Sports Exerc 200032S481
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Achievement-based Objectives

• Home Visit 1
• By the end of our visit today, you will have
• Named what you already know about physical
  activity
• Found reasons for doing physical activity that
  are most important to you right NOW
• Received a Step Counter that will show you how
  many steps you take during a day
• Used the Step Counter
• Listed one or more ways to walk more
• Chosen one or more new ways you will increase
  your step counts by walking

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Conveying messages and facilitating change
Example Gift card
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RECRUITMENT AND RETENTION STRATEGIES

• Maximizing participation
• Logistical issues from Tamara Dubowitzs
  qualitative analysis of focus groups (n44) for
  her doctoral defense, 2005.

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Maximizing Enrollment

• Apple Awards recruitment incentives for
  WIC/health center staff
• Expanded recruitment efforts to more WIC
  sites/health centers
• Increased recruitment/data collector staff

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Maximizing Retention

• Offered phone visit option for intervention
  participants for which home visit scheduling was
  difficult
• Offered phone counseling option only
• Combined Home Visits 4 and 5
• Encouraged communication between home visit
  (health mentor) and phone counseling staff for
  hard to reach participants
• Increased monetary and gift incentives

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Results of Qualitative StudyTamara Dubowitz 2005
The Social Context of Diet Using Mixed Methods
to Understand Individual and Contextual Effects
among Low-Income, Postpartum Women

• General themes
• The immigrant experience
• Social and geographic aspects of food purchasing
• Food preparation within daily life activity
• Recurring responses
• Limited time for family, cooking and food
  purchasing
• Transportation and childcare obstacles influenced
  food purchasing, preparation and consequently diet

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The Immigrant Experience Individualism versus
family centered cultural norms

• The difference for me is that in my country, you
  can talk to neighbors and everyone can do you a
  favor. Here there is nothing, nobody is for
  nobody. Everyone is inside their own world.
  Years go by and you do not know who lives
  upstairs.

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The Immigrant Experience time and family

• During the weekends, in my country, we share more
  time with the family and friends mostly on
  Sunday, since there are people who work on
  Saturday. . . . . . . .Over here you do laundry,
  go to the supermarket and you are on a constant
  race if you did not finish something on a
  Saturday you have to do on Sunday.

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The Immigrant Experience Paying for childcare

• The thing is that here you have to pay for
  childcare. Nobody watches the children for free.
  
• If you want to work outside the house and have to
  pay for childcare it does not make any sense. So
  men have to work and we have to stay home with
  the children. Because to pay someone and have
  your kids with poor attention is not good. And
  all you earn working you have to pay for
  childcare.

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Social and Geographical Aspects of Food
Purchasing Cost and Availability

• I go to different places, because I dont have
  much time to look for prices so wherever I am, I
  go shopping. Walmart now is selling food and
  Walmart is cheap , so there is a law in my house
  whoever goes to Walmart they need to grab some
  milk. We consume a lot of milk at home.

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Social and Geographical Aspects of Food
Purchasing Proximity and Availability

• . . . If were somewhere and theyre hungry. .
  .how can I not? You know, we can stop off at
  McDonalds and get a cheeseburger and french
  fries. Its like a dollar. You know what Im
  saying?
•  
• . . . I live right by it. And its cheap.
  Everything is a dollar. You get your fries for a
  dollar, your cookies for a dollar

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Food Preparation in Daily Life length of the
workday

• I work three days a week. I dont have time
  for me. I get home late and I dont want to
  think about cooking.
•  
• Theres days where you come home from work and
  youre like.. let me just throw that thing in the
  microwave. You find whatever you eat in the
  house.

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Summary

• Differing attitudes toward food purchasing and
  preparation
• Food preparation and purchasing more central to
  daily life of immigrant women. The immigrant
  experience played into food preparation and
  purchasing in the U.S.
• Neighborhood infrastructure
• Transportation
• Location of grocery stores

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PROCESS EVALUATION

• Actual intervention delivered
• Barriers to Home Visits
• Advantages of Phone Calls
• Challenges with intervention delivery
• Challenges with intervention population

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Observations--Home Visits

• Difficult to schedule, especially initial visit
• Caller ID sometimes a barrier, if women did not
  recognize number (or did and chose not to
  respond)
• Frequent cancellations, no-shows, causing
  time-management challenges
• Many women reluctant to let a visitor into home
• Cleanliness
• Presence of others
• Environment (including safety)

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ObservationsMotivational Phone counseling

• Women commit to calls more easily than home
  visits
• More anonymous
• Time to build trust, rapport, no in-person
  contact (usually after two calls, women opened
  up )
• Time frame more flexible for calling than
  scheduling visits
• Phone calls facilitate home visits in some cases
• Most valuable feature of calls is social support
  and facilitate access to other community-based
  services

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Challenges with intervention delivery

• Women did not associate or connect the various
  components and activities
• In spite of descriptive recruitment materials
  and verbal explanation
• Sequence of intervention activities following
  baseline survey
• Unique staff members for each activity (i.e. WIC
  staff who helped with referral, data collectors,
  health mentors)

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Challenges common to this population

• Poverty Depression
• Work, school responsibilities Frequent
  pregnancy
• Unstable relationships Language
• Acculturation difficulties Isolation
• Transient living situation Immigration
  issues

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Lessons for the Future

• Collaborative teams of community partners and
  research facility
• Research can build on community infrastructure
• Research enhances community resources
• materials staff

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Future Considerations

• One in-person intervention session with series of
  phone calls
• focus on one aspect of health behavior
• motivational interview style
• link with other community-based services
• other research with similar model shows positive
  outcomes