Lessons from the “Just For You” Project: Methods from Community-

Based Participatory Research

AMCHP Annual MeetingWashington DC

February 20, 2005

Karen Peterson, RD, DScTamara Dubowitz, MA, MS

Cara Ebbeling, PhDJudy Salkeld, MA

Cary Hardwick, MA, MSN, MSMichelle Roover, MS

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 Reducing Disease Risk

in Low-Income Postpartum in Low-Income Postpartum

WomenWomen

(“Just For You”)(“Just For You”)

1 R01 HD37368-01 (NICHD)

PROJECT OVERVIEW

Investigators and Community Partners

Theoretical Background Aims Structure of the Intervention

Program Study Design

• 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

FundingFunding

Investigators

Harvard School of Public HealthKaren Peterson, PICara Ebbeling (HMS/TCH)Barbara GottliebMarie McCormick Louise Ryan

Dana Farber Cancer InstituteGlorian Sorensen, Co-PI

University of Massachusetts, AmherstNancy Cohen, Co-PI Patty Freedson

University of South Carolina, School of Public HealthJames Hebert, Co-PITom HurleyChuck Matthews

(Vanderbilt)

Biologic Anthropology

Critical periods of biologic, behavioral adaptationCritical periods of biologic, behavioral adaptation

Weight gainWeight gain

>after first pregnancy>after first pregnancy

increases with # of pregnanciesincreases with # of pregnancies

Postpartum influences on nutrition and activityPostpartum influences on nutrition and activity

• childrearing demandschildrearing demands

• lifestyle changeslifestyle changes

• social isolationsocial isolation

• poor health status poor health status

Social Ecological Framework

Behavior affected by multiple levels of influence

1- Intrapersonal:1- Intrapersonal:Behavior: a function of attitudes, norms, perceived ability to changeBehavior: a function of attitudes, norms, perceived ability to changeEconomic choice theoryEconomic choice theory

• Multiple alternatives, increase controlMultiple alternatives, increase control• reduce access to unhealthy behaviorsreduce access to unhealthy behaviors

2- Interpersonal2- InterpersonalSocial support and networksSocial support and networks

3- Organizational3- OrganizationalDiffusion of innovation, organizational changeDiffusion of innovation, organizational change

4- Community4- CommunityAccess to healthy foods, safe activity optionsAccess to healthy foods, safe activity options

Community Partners

Massachusetts State WIC ProgramPregnant, breastfeeding women, infants/children <5 yr Household income < 185% povertyFood vouchers and nutrition education

Jamaica Plain WIC ProgramChelsea/Revere WIC ProgramSpringfield South WIC ProgramHolyoke WIC Program

Expanded Food and Nutrition Education Program Food safety, preparation, budgeting; nutrition education Household income <125% poverty or WIC eligible

Greater Boston Office U. Massachusetts ExtensionSpringfield Nutrition Education Program Office

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

Research Design

• Randomized, controlled trial N=680 WIC participants

Two conditions: Usual WIC Care Usual WIC + Enhanced EFNEP

• Enhanced EFNEP intervention 5 home visits 4 group classes motivational phone calls monthly

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)

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

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

Ancillary Study

• Purpose Independent measure of change in minutes of daily moderate-

to-vigorous activity Document validity of reported duration and intensity

of mod/vig activity in low-income, multi-ethnic women Compare diet and activity self-reports with repeat recalls

• Design N=150 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

Just for You: Status

January 2003679 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

Population Characteristics at Baseline (n = 679)

• Low-income (<185% 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

IMPLEMENTATION

Intervention components Intervention messages

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 intervention:woman’s health, child’s health, “pre-conceptual care”

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

Intervention MessagesIntervention Messages

Physical activityPhysical activity

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

Nutrition (“Healthy eating”)Nutrition (“Healthy eating”)

• Eat 5 or more servings of fruits and vegetables every dayEat 5 or more servings of fruits and vegetables every day

• Limit red meat to no more than 3 servings per weekLimit red meat to no more than 3 servings per week

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

HOW?HOW?Conveying messages and facilitating changeConveying messages and facilitating change

Theoretical ConstructTheoretical Construct ChoiceChoice

MethodMethod Menu of optionsMenu of options

Practical StrategyPractical Strategy Card / Picture sortingCard / Picture sorting

• Visual, KinestheticVisual, Kinesthetic

• Effective across a wide range of Effective across a wide range of literacy levelsliteracy levels

• Interventionist as co-learnerInterventionist as co-learner

• Community linkagesCommunity linkagesSimpson SH. Nursing Res 1989;38:289

HOW?HOW?Conveying messages and facilitating changeConveying messages and facilitating change

Theoretical ConstructTheoretical Construct Self-control of performanceSelf-control of performance

MethodsMethods Goal-settingGoal-settingSelf-monitoringSelf-monitoringProblem-solvingProblem-solving

Practical StrategyPractical Strategy Pedometer (Step Counting)Pedometer (Step Counting)

Welk et al. Med Sci Sports Exerc 2000;32:S481

• ““Accumulation” of activityAccumulation” of activity

• Visual, KinestheticVisual, Kinesthetic

• Immediate and frequent feedbackImmediate and frequent feedback

• Documentation of small changes Documentation of small changes (reinforcement)(reinforcement)

Achievement-based ObjectivesAchievement-based Objectives

Home Visit #1Home Visit #1

By the end of our visit today, you will have:By the end of our visit today, you will have:

• Named what you already know about physical activityNamed what you already know about physical activity

• Found reasons for doing physical activity that are most important to you Found reasons for doing physical activity that are most important to you

right NOWright NOW

• Received a Received a Step CounterStep Counter that will show you how many steps you take that will show you how many steps you take

during a dayduring a day

• Used the Used the Step CounterStep Counter

• Listed one or more ways to walk moreListed one or more ways to walk more

• Chosen one or more new ways you will increase your step counts by Chosen one or more new ways you will increase your step counts by

walkingwalking

Conveying messages and facilitating Conveying messages and facilitating changechange

Example: “Gift” cardExample: “Gift” card

RECRUITMENT AND RETENTION STRATEGIES

Maximizing participation Logistical issues – from Tamara

Dubowitz’s qualitative analysis of focus groups (n=44) for her doctoral defense, 2005.

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

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

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

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.

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.

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.

Social and Geographical Aspects of Food Purchasing: Cost and Availability

I go to different places, because I don’t 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.

Social and Geographical Aspects of Food Purchasing: Proximity and Availability

. . . If we’re somewhere and they’re hungry. . .how can I not? You know, we can stop off at McDonalds and get a cheeseburger and french fries. It’s like a dollar. You know what I’m saying?

  . . . I live right by it. And it’s cheap.

Everything is a dollar. You get your fries for a dollar, your cookies for a dollar

Food Preparation in Daily Life: length of the workday

I work three days a week. I don’t have time – for me. I get home late and I don’t want to think about cooking.

  There’s days where you come home

from work and you’re like.. let me just throw that thing in the microwave. You find whatever you eat in the house.

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

PROCESS EVALUATION

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

delivery Challenges with intervention

population

# Home Visits # Phone Calls # Participants Total # Participants Mean # Phone Calls

0 0 71 140 1.091-5 636-11 012 0

1 0 10 55 2.451-5 396-11 612 0

2 0 2 15 4.21-5 96-11 312 1

3 0 2 21 51-5 106-11 912 0

4 0 0 11 4.821-5 76-11 412 0

5 0 0 94 6.21-5 436-11 45

12-15 6

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)

Observations—Motivational 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

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)

Challenges common to this population

* Poverty * Depression

* Work, school responsibilities * Frequent pregnancy

* Unstable relationships * Language

* Acculturation difficulties * Isolation

* Transient living situation * Immigration issues

Lessons for the Future

• Collaborative teams of community partners and research facility

• Research can build on community infrastructure

• Research enhances community resources

* materials * staff

• 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

Future Considerations