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

1. 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

2. 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”)

3. PROJECT OVERVIEW • Investigators and Community Partners • Theoretical Background • Aims • Structure of the Intervention Program • Study Design

4. 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 • tobacco use • alcohol abuse • insufficient exercise • poor diet

5. 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) Investigators

6. Biologic Anthropology • Critical periods of biologic, behavioral adaptation • Weight gain • >after first pregnancy • increases with # of pregnancies • Postpartum influences on nutrition and activity • childrearing demands • lifestyle changes • social isolation • poor health status

7. 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

8. Community Partners Massachusetts State WIC Program Pregnant, breastfeeding women, infants/children <5 yr Household income < 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 <125% poverty or WIC eligible Greater Boston Office U. Massachusetts Extension Springfield Nutrition Education Program Office

9. 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 Overview

10. 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

11. 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)

12. 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 Data Collection

13. 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

14. 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 • 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

15. 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

16. 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

17. IMPLEMENTATION • Intervention components • Intervention messages

18. 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”

19. 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

20. 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

21. 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 Motivational Interviewing

22. HOW? Conveying messages and facilitating change Theoretical Construct Choice Method Menu of options Practical StrategyCard / Picture sorting • Visual, Kinesthetic • Effective across a wide range of literacy levels • Interventionist as co-learner • Community linkages Simpson SH. Nursing Res 1989;38:289

23. HOW? Conveying messages and facilitating change Theoretical Construct Self-control of performance Methods Goal-setting Self-monitoring Problem-solving Practical StrategyPedometer (Step Counting) • “Accumulation” of activity • Visual, Kinesthetic • Immediate and frequent feedback • Documentation of small changes (reinforcement) Welk et al. Med Sci Sports Exerc 2000;32:S481

24. 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

25. Conveying messages and facilitating change Example: “Gift” card

26. RECRUITMENT AND RETENTION STRATEGIES • Maximizing participation • Logistical issues – from Tamara Dubowitz’s qualitative analysis of focus groups (n=44) for her doctoral defense, 2005.

28. 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

29. 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

30. 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

31. 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.

32. 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.

33. 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.

34. 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.

35. 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

36. 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.

37. 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

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

40. 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)

41. 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

42. 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)

43. Challenges common to this population *Poverty * Depression * Work, school responsibilities * Frequent pregnancy * Unstable relationships * Language * Acculturation difficulties * Isolation * Transient living situation * Immigration issues

44. Lessons for the Future • Collaborative teams of community partners and research facility • Research can build on community infrastructure • Research enhances community resources * materials * staff

45. 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