AMCHP Annual Conference

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AMCHP Annual Conference Skills Building
Workshop Partnering to Address the Health of
Pregnant and Postpartum Women Using Community-Bas
ed Participatory Research Methods February
19-23, 2005 Washington, DC Edie C. Kieffer, MPH,
PhD University of Michigan, School of Social
Work Karen Peterson, RD, DSc Harvard University,
School of Public Health
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• Workshop Objectives
• For two projects, Healthy Mothers on the Move,
  and Just For You, participants will be able to
  describe and discuss
• Intervention aims, hypotheses, structure and
  design
• Processes used to develop and implement the
  projects
• Recruitment and retention strategies
• Process evaluation methods and results
• Workshop Methods brief presentations, review of
  materials and interactive discussion

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RATIONALE FOR INTERVENTIONS Changes in diet,
physical activity and stressors associated with
socioeconomic changes contribute to rapid rise in
prevalence of obesity and type 2 diabetes Severe
health, social and economic consequences for
individuals, families, communities and
society High prevalence among African American
and Latino women of childbearing age, children
and youth Obesity and diabetes during pregnancy
increase birth weight, pregnancy complications
and subsequent chronic disease risk in mothers
and children
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Percentages of Overweight or Obesity, African
American and Latino Women of Childbearing Age
70.8
61.6
49.0
Flegal et al, 2002
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Percentages of Type 2 Diabetes, African American
and Latino Women of Childbearing Age
27.60
22.40
10.10
Harris et al, 1998
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RATIONALE FOR INTERVENTIONS Type 2 diabetes
and other chronic diseases may be prevented with
moderate weight reduction, regular moderate
physical activity, and healthful dietary
patterns Pregnancy and postpartum periods are
windows of opportunity for reducing chronic
disease risks and promoting maternal and child
health
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Community-Based Participatory Research

• Partnership approach to research
• Community, health and academic organizations and
  residents equal partners in all research
  activities
• Partners share expertise, responsibility and
  ownership capacity building is key
• Knowledge gained leads to interventions to
  improve community health and well-being

Israel, Barbara, et al. May 1998. REVIEW OF
COMMUNITY-BASED RESEARCH Assessing Partnership
Approaches to Improve Public Health. Annual
Review of Public Health. 19173-202.
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Healthy Mothers on the Move/Madres Saludables
en MovimientoMethods and Lessons Learned from a
Community-Based Participatory Research Project in
Detroit

• AMCHP Annual Conference
• February 19-23, 2005
• Washington, DC
• Edie C. Kieffer, MPH, PhD
• University of Michigan, School of Social Work

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BACKGROUND
Pregnancy and months following childbirth may
increase the risk of becoming overweight or obese

• Changes in diet, exercise
• Stress and depression
• Excessive pregnancy weight gain
• Postpartum weight retention

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Percentages of Overweight or Obesity, African
American and Latino Women before Pregnancy
Detroit, pregnant women, 1998-2001
477
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Kieffer et al, 2001
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Excessive Pregnancy Weight Gain Among African
American and Latino Women in Detroit
53.0
37.0
Excessive Pregnancy Weight Gain
Kieffer et al, 2001
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BACKGROUND
Pregnancy and months following childbirth
opportunities for prevention

• Frequent contact with care providers
• Focus on health of mother and baby
• Need for social support and information

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Research/Planning Process Model
Promoting Healthy Lifestyles Among Women
REACH Detroit Partnership
Steering Committee
Intervention Plans
Pilot Intervention
Project Design
Staff Recruitment, Hiring, Training
Individual Interviews
Womens Focus Groups
Policy Program Focus Groups
University of Michigan Schools of Public Health
and Nursing, Community Health and Social Services
(CHASS), Kettering/Butzel Health Initiative,
Butzel Family Center, Latino Family Services,
Detroit Health Department, Henry Ford Health
System, St. Johns Riverview Hospital, the
Michigan Department of Community Health, and
Friends of Parkside
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Barriers to Healthy Eating

• Social barriers
• social isolation and language
• lack of social support
• conflicting demands on time
• Lack of exposure, knowledge and skills
• Food preferences/dislikes
• Poor access to healthy foods
• Distance and lack of transportation to stores
• Cost and quality
• B

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Barriers to Regular Exercise

• Social barriers
• Lack of social support, social isolation
• Conflicting demands on time
• Child care and transportation
• Community environmental barriers
• Lack of programs for pregnant/postpartum women
• Poor access to facilities transportation and
  costs
• Unsafe physical and social environment
• Lack of motivation,
• Lack of knowledge, skills/Uncertainty about
  safety

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Womens Recommendations

• Group programs
• Safe, trusted community environment
• Support from other women
• Get together, share, learn from each other
• Learn how to exercise safely and make healthy
  recipes
• Pregnancy and parenting education

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Womens Recommendations

• Essential program elements
• Low or no cost
• Child care
• Transportation
• Recommended program elements
• Group facilitators like them in language,
  culture and experience
• Enjoyable activities (not like school)

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Healthy Mothers On the MoveMadres Saludables
en Movimiento(Healthy MOMs)

• PURPOSE
• Develop, conduct and evaluate processes and
  outcomes of a healthy lifestyle intervention
  designed to reduce risk factors for type 2
  diabetes among pregnant and postpartum African
  American and Latino women in Eastside and
  Southwest Detroit
• Funding Michigan Department of Community Health
  (2002-2003 pilot) NIH/NIDDK (2002-2007)

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STUDY DESIGN Randomized, controlled
trial Recruitment goal N 400 participants
randomized to one of two interventions Healthy
Lifestyle Group social support, home visits and
group education led by community resident
Womens Health Advocates Healthy Pregnancy
Education (Control) Group group education led by
community org partner staff
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Hypotheses
Changes from baseline in the primary and
secondary outcomes will be greater among healthy
lifestyle group compared to healthy pregnancy
group participants, following the pregnancy
intervention, and at 6-8 weeks postpartum
(following the postpartum intervention). Changes
will be associated with significant changes in
beliefs, attitudes, norms and perceived
behavioral control, and with increases in
perceived social support.
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Primary Aims Increase the proportion of women
who eat healthfully (increased fruits, vegetables
fiber reduced fat and sugar) and who exercise
regularly at least at moderate levels Secondary
Aims Increase the proportion of women who have
appropriate levels of pregnancy weight gain and
postpartum weight reduction, and have improved
metabolic profiles (e.g. glucose, insulin,
lipids) Process Aim Assess challenges and
contributors to project implementation
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• STUDY DESIGN
• Reduce physical and social environmental barriers
  to adopting healthy lifestyles and to
  participation in project activities
• Social support from advocates and peers
• Trusted community organization locations for
• meetings and data collection
• Transportation and child care provided for all
• activities
• Modify beliefs, attitudes, norms, perceived
  control
• Based on preliminary study of community womens
  beliefs, practices, recommendations behavioral
  theories

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• Eligibility criteria
• 18 years of age lt20wks g.a. African American
  or LatinaEastside or southwest Detroit
  resident able to participate for 11 weeks during
  pregnancy and 6-8 weeks postpartum health
• Recruitment Sites
• Prenatal WIC clinics, public assistance offices
• Posters, flyers, postcards in neighborhood
  locations and Healthy Baby Service vans
• Orientation and Consent
• group meetings
• Referral to data collection randomization after
  last data collection visit

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Baseline, Pregnancy Follow-up and Postpartum Data
Collection

• Visit 1
• Healthy MOMs Questionnaire (Social and
  Neighborhood Characteristics, Stress and
  Depression, Health, Social Support,
  Weight/Physical Activity/Dietary Beliefs and
  Attitudes) pedometer
• Visit 2
• Nutrition Assessment (24 hr Recall, FFQ)
• Physical Activity Assessment (7-PAR, LTPA, step
  counter) collect pedometer
• Visit 3
• Anthropometry, Blood Pressure, Metabolic Assays
• Randomize

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IMPLEMENTATION

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STRUCTURE OF HEALTHY MOMS Pregnancy
Healthy Lifestyle Group 2 home visits 9
group meetings 10 activity days (optional)
Healthy Pregnancy Group 3 group meetings

Postpartum
2 home visits 1 group meeting Pamper-Me
Day
1 group meeting Pamper-Me Day
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Healthy Lifestyles Curriculum Content

• MEETING 1 Healthy Mom, Healthy Baby!
• MEETING 2 Plan to be Active!
• MEETING 3 Plan to Eat Healthy!
• MEETING 4 Move More, Sit Less!
• MEETING 5 Eat More Fiber!
• MEETING 6 Eat More Fruit and Vegetables!
• MEETING 7 Eat Less Fat and Sugar!

• MEETING 8 Getting Ready Labor
  Birth!
• MEETING 9 Stay Motivated!
• MEETING 10 Healthy Activities
  Together!
• MEETING 11 Infant Care!
• MEETING 12 PP Self Care Stress
• Depression
• MEETING 13 Healthy for Life!
• MEETING 14 Celebrate Success

• 10 weekly group meetings 10 linked weekly
  optional activity days
• 4 one-on-one Home Visits

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Optional Activity Days
Participants tasting a healthy dessert
Jen Brewer, Nutritionist, giving a healthy eating
demonstration
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Healthy Pregnancy Education Curriculum Content

• Pregnancy
• Meeting 1 Healthy Mom, Healthy Baby!
• Meeting 2 Getting Ready Labor Birth!

• Meeting 3 Infant Care!
• Postpartum
• Meeting 4 PP Self-Care Stress Depression

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Recruitment and Retention
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Retention Strategies

• Transportation and Childcare!
• Incentives personal items at each meeting 50
  after each of 3 data collection points (baseline,
  midpoint, 6 wk pp)
• Staff to participant contacts
• Weekly Phone Calls
• Ask Cecilia
• Healthy Pregnancy Information Sheets Monthly
  Newsletters
• Periodic Postcards (Birthday, Holiday, Missed
  You)
• Congratulations on the Birth of Your Baby)
• Participant to staff contacts
• -Postcards (Address/Contact Change, Birth
  Announcement, Withdrawal)
• Efficient Scheduling of Appointments

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Health Mothers on the Move Recruitment Flyers
(Spanish and English)
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Healthy Mothers On the Move Newsletter (English
version, Pages 1 and 2)
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Healthy Mothers On the Move Newsletter (English
version, Pages 3 and 4)
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Healthy Mothers on the Move Newsletter (Spanish
version, Pages 1 and 2)
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Healthy Mothers on the Move Newsletter (Spanish
version, Pages 3 and 4)
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Healthy Mothers on the Move Birth Announcements
(Spanish and English)
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Process Measures
Instrument Examples of Questions
Participant Feedback Form What other information about ____ would be helpful to include in todays meeting? 2. How do you think you can use the information that your heard today?
Facilitator Feedback Form Observer Feedback Form Were you able to cover all of the material planned for todays meeting? What areas needed more time? 1. Describe topics that seemed difficult for participants 2. Topic coverage checklist
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Process Measures
Instrument Examples of Questions
Focus Group Guide for Women How helpful was the information in motivating you to try out things at home? What made it easy or hard for you to come to the meetings?
Focus Group Guide for Facilitators Focus Group Guide for Host Sites Was there any part of the curriculum that was hard for you to facilitate? How could the training be improved to help you facilitate the weekly meetings? 1. What would you describe as the challenges of hosting the project at your site?
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Lessons Learned

• Group program can work!
• Social support aids retention despite/because of
  major social issues women faced
• Community host sites improve access and trust!
• Transportation and child care essential but
  difficulties can cause huge problems
• Pregnancy education rare in community and much
  appreciated

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Lessons learned from pilot
Area Implication
Curriculum Method Delivery - Reduce amount of information per session - Discuss - dont lecture - Integrate goal setting activities - Address beliefs about food and exercise during/after pregnancy - Increase interactive activities (food and exercise demos)
Facilitation Extend Staff Training - Create resource and procedure manuals - Create guidelines for boundary setting
Host Sites Trusted Organizations Matter Regular communication to trouble-shoot is important
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Where are we now?

• Challenges
• Moving nature of pregnancy and postpartum
• Recruitment and retention (African American
  women)
• Changing community conditions (transportation)
• Staffing (qualifications, professionalism,
  language skills)
• Data collection (scheduling)
• Transportation (cant always count on it!)
• Research needs vs. community priorities
• Lack of linguistically and culturally-appropriate
  materials
• Costs! AND Time!
• Strengths
• Staff (knowledge of community, bonding with
  participants)
• Group support is appreciated and works!
• Curriculum design and content new materials and
  methods
• Community partnerships (problem solving,
  knowledge of community, trusted locations)

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Empowerment

• We dont want others to solve our problems,
• but to inform us about resources available,
• and where we can find those resources so
• we can make our own decisions.

We want action and justice.
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Investigators Principal Investigator Edie
Kieffer, MPH, PhD, School of Social
Work Coinvestigators George Nolan, MD, MPH,
School of Social Work William Herman, MD, MPH,
School of Medicine Antonia Villarruel, RN, PhD,
School of Nursing SeonAe Yeo, RN, PhD, School of
Nursing Cleo Caldwell, PhD, School of Public
Health
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Community Partners Butzel Family Center,
Community Health and Social Services, Detroit
Department of Health and Wellness Promotion,
Detroit Hispanic Development Corporation,
Eastside Village Health Worker Partnership,
Friends of Parkside, Harper Gratiot Neighborhood
Services Organization, Kettering/Butzel Health
Initiative, Latino Family Services, Michigan
Department of Community Health, Promoting Healthy
Eating in Detroit, REACH Detroit Partnership,
Southwest Counseling and Development Services,
St. John Health Systems
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STAFF, COLLABORATORS AND SUBCONTRACTS Paris
Watson, Project Manager Jose Melendrez,
Evaluation Coordinator Luther Brewster, Research
Coordinator Marilyn Lugo, Field Services
Coordinator Lula Harris, Womens Health Advocate
Supervisor Marta Rodriguez, Womens Health
Advocate II Tola Gonzalez, Womens Health
Advocate I Olivia Rodriguez, Womens Health
Advocate I University of Michigan Diabetes
Research Training Center and General Clinical
Research Center (Data analysis support
svs) Wayne State University Ctr for Urban Studies
(Data collection)
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Support and Acknowledgements

• Centers for Disease Control and Prevention
• Detroit Community Academic Urban Research Center
• Michigan Diabetes Research and Training Center
• General Clinical Research Center
• National Institutes of Health/NIDDK
• REACH Detroit Partnership
• HRSA/Maternal and Child Health Bureau
• W.K. Kellogg Community Health Scholars Program

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For Additional Information

• Paris A. Watson, Project Manager
• 734.647.2533
• pwat_at_umich.edu

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