AMCHP Annual Conference AMCHP Annual Conference Skills Building Workshop Skills Building Workshop Partnering to Address the Health of Partnering to Address the Health of Pregnant and Postpartum Women Using Pregnant and Postpartum Women Using Community-Based Participatory Research Community-Based Participatory Research Methods Methods February 19-23, 2005 February 19-23, 2005 Washington, DC Washington, DC Edie C. Kieffer, MPH, PhD Edie C. Kieffer, MPH, PhD University of Michigan, School of Social University of Michigan, School of Social Work Work Karen Peterson, RD, DSc Karen Peterson, RD, DSc
Transcript
AMCHP Annual ConferenceAMCHP Annual ConferenceSkills Building WorkshopSkills Building Workshop
Partnering to Address the Health of Partnering to Address the Health of Pregnant and Postpartum Women UsingPregnant and Postpartum Women Using
Community-Based Participatory Research Community-Based Participatory Research MethodsMethods
February 19-23, 2005February 19-23, 2005Washington, DCWashington, DC
Edie C. Kieffer, MPH, PhDEdie C. Kieffer, MPH, PhDUniversity of Michigan, School of Social WorkUniversity of Michigan, School of Social Work
Karen Peterson, RD, DScKaren Peterson, RD, DScHarvard University, School of Public HealthHarvard University, School of Public Health
Workshop ObjectivesWorkshop Objectives
For two projects, For two projects, Healthy Mothers on the MoveHealthy Mothers on the Move,, and and Just For YouJust For You, participants will be able to describe , participants will be able to describe and discuss:and discuss:
Intervention aims, hypotheses, structure and Intervention aims, hypotheses, structure and designdesign
Processes used to develop and implement the Processes used to develop and implement the projectsprojects
Recruitment and retention strategiesRecruitment and retention strategies
Process evaluation methods and resultsProcess evaluation methods and results
Workshop Methods:Workshop Methods: brief presentations, review of brief presentations, review of materials and interactive discussionmaterials and interactive discussion
RATIONALE FOR INTERVENTIONSRATIONALE FOR INTERVENTIONS
Changes in diet, physical activity and stressors Changes in diet, physical activity and stressors associated with socioeconomic changes associated with socioeconomic changes contribute to rapid rise in prevalence of obesity contribute to rapid rise in prevalence of obesity and type 2 diabetesand type 2 diabetes
Severe health, social and economic Severe health, social and economic consequences for individuals, families, consequences for individuals, families, communities and societycommunities and society
High prevalence among African American and High prevalence among African American and Latino women of childbearing age, children and Latino women of childbearing age, children and youthyouth
Obesity and diabetes during pregnancy increase Obesity and diabetes during pregnancy increase birth weight, pregnancy complications and birth weight, pregnancy complications and subsequent chronic disease risk in mothers and subsequent chronic disease risk in mothers and childrenchildren
Percentages of Overweight or Percentages of Overweight or Obesity, African American and Obesity, African American and Latino Women of Childbearing AgeLatino Women of Childbearing Age
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Overweight or Obese
United States, NHANES IV, not pregnant, age 20-39
African American
Mexican
White, Non-Hispanic
70.8%
61.6% 49.0
%
Flegal et al, 2002
Percentages of Type 2 Diabetes, African Percentages of Type 2 Diabetes, African American and Latino Women American and Latino Women of Childbearing Ageof Childbearing Age
0.0
5.0
10.0
15.0
20.0
25.0
30.0
Type 2 Diabetes or Impaired FastingGlucose
United States, NHANES III, not pregnant, age-20-49
Mexican American
African American
White, non-Hispanic
27.60%
22.40%
10.10%
Harris et al, 1998
RATIONALE FOR INTERVENTIONSRATIONALE FOR INTERVENTIONS
Type 2 diabetes and other chronic diseases Type 2 diabetes and other chronic diseases may be prevented with moderate weight may be prevented with moderate weight reduction, regular moderate physical reduction, regular moderate physical activity, and healthful dietary patternsactivity, and healthful dietary patterns
Pregnancy and postpartum periods are Pregnancy and postpartum periods are windows of opportunity for reducing windows of opportunity for reducing chronic disease risks and promoting chronic disease risks and promoting maternal and child healthmaternal and child health
Research Research• Partnership approach to research Partnership approach to research • Community, health and academic Community, health and academic
organizations and residents equal organizations and residents equal partners in all research activitiespartners in all research activities
• Partners share expertise, responsibility Partners share expertise, responsibility and ownership; capacity building is keyand ownership; capacity building is key
• Knowledge gained leads to interventions Knowledge gained leads to interventions to improve community health and well-to improve community health and well-beingbeing
Israel, Barbara, et al. May 1998. REVIEW OF COMMUNITY-BASED RESEARCH: Assessing Partnership Approaches to Improve Public Health. Annual Review of Public Health. 19:173-202.
Healthy Mothers on the Move/Healthy Mothers on the Move/Madres Saludables en Madres Saludables en
MovimientoMovimiento
Methods and Lessons Learned from a Methods and Lessons Learned from a Community-Based Participatory Research Community-Based Participatory Research
Project in DetroitProject in DetroitAMCHP Annual ConferenceAMCHP Annual Conference
February 19-23, 2005February 19-23, 2005Washington, DCWashington, DC
Edie C. Kieffer, MPH, PhDEdie C. Kieffer, MPH, PhDUniversity of Michigan, School of Social WorkUniversity of Michigan, School of Social Work
BACKGROUNDBACKGROUND
• Changes in diet, exerciseChanges in diet, exercise• Stress and depressionStress and depression• Excessive pregnancy weight Excessive pregnancy weight
Pregnancy and months Pregnancy and months following childbirth may following childbirth may increase the risk of becoming increase the risk of becoming overweight or obeseoverweight or obese
Excessive Pregnancy Weight Gain Excessive Pregnancy Weight Gain Among African American and Latino Among African American and Latino Women in DetroitWomen in Detroit
0.00
10.00
20.00
30.00
40.00
50.00
60.00
Detroit, pregnant women, 1998-2001
African American
Latina
53.0%
37.0%
Kieffer et al, 2001Kieffer et al, 2001Excessive Pregnancy Weight Gain
BACKGROUNDBACKGROUND
• Frequent contact with care Frequent contact with care providersproviders
• Focus on health of mother and Focus on health of mother and babybaby
• Need for social support and Need for social support and informationinformation
Pregnancy and months following Pregnancy and months following childbirth opportunities for childbirth opportunities for preventionprevention
Promoting Healthy Lifestyles Among Women
*Steering Committee
Project Design
Staff Recruitment,
Hiring, Training
IndividualInterviews
Women’sFocus
Groups
PolicyProgram
Focus Groups
InterventionPlans
PilotIntervention
REACH Detroit Partnership
*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. John’s Riverview Hospital, the Michigan Department of Community Health, and Friends of Parkside
Research/Planning Process ModelResearch/Planning Process Model
Barriers to Healthy EatingBarriers to Healthy EatingSocial barriersSocial barriers
• social isolation and languagesocial isolation and language• lack of social supportlack of social support• conflicting demands on timeconflicting demands on time
Lack of exposure, knowledge and skillsLack of exposure, knowledge and skills
Poor access to healthy foodsPoor access to healthy foods• Distance and lack of transportation to Distance and lack of transportation to
stores stores • Cost and qualityCost and qualityBB
Barriers to Regular ExerciseBarriers to Regular ExerciseSocial barriersSocial barriers• Lack of social support, social isolationLack of social support, social isolation• Conflicting demands on timeConflicting demands on time• Child care and transportationChild care and transportationCommunity environmental barriersCommunity environmental barriers• Lack of programs for pregnant/postpartum Lack of programs for pregnant/postpartum
womenwomen• Poor access to facilities; transportation and costsPoor access to facilities; transportation and costs• Unsafe physical and social environmentUnsafe physical and social environmentLack of motivation, Lack of motivation, Lack of knowledge, skills/Uncertainty about safetyLack of knowledge, skills/Uncertainty about safety
Women’s Women’s RecommendationsRecommendations Group programsGroup programs
Safe, trusted community environmentSafe, trusted community environment
Support from other womenSupport from other womenGet together, share, learn from each Get together, share, learn from each otherother
Learn how to exercise safely and make Learn how to exercise safely and make healthy recipeshealthy recipes
Pregnancy and parenting educationPregnancy and parenting education
Women’s Women’s RecommendationsRecommendationsEssential program elementsEssential program elements Low or no costLow or no cost Child careChild care TransportationTransportation
Recommended program Recommended program elementselements
Group facilitators “like them” in Group facilitators “like them” in language, culture and experiencelanguage, culture and experience
Enjoyable activities (not like school)Enjoyable activities (not like school)
Healthy Mothers On the MoveHealthy Mothers On the MoveMadres Saludables en MovimientoMadres Saludables en Movimiento
(Healthy MOMs)(Healthy MOMs)
PURPOSEPURPOSE
Develop, conduct and evaluate processes and Develop, conduct and evaluate processes and outcomes of a healthy lifestyle intervention outcomes of a healthy lifestyle intervention designed to reduce risk factors for type 2 designed to reduce risk factors for type 2 diabetes among pregnant and postpartum diabetes among pregnant and postpartum African American and Latino women in Eastside African American and Latino women in Eastside and Southwest Detroit and Southwest Detroit
Funding: Michigan Department of Community Health (2002-2003 Funding: Michigan Department of Community Health (2002-2003 pilot); NIH/NIDDK (2002-2007)pilot); NIH/NIDDK (2002-2007)
Recruitment goal N= 400 participants Recruitment goal N= 400 participants randomized to one of two interventions:randomized to one of two interventions:
Healthy Lifestyle GroupHealthy Lifestyle Group social support, home visits and group education; social support, home visits and group education;
led by led by community resident Women’s Health community resident Women’s Health AdvocatesAdvocates
Healthy Pregnancy Education (Control) GroupHealthy Pregnancy Education (Control) Groupgroup education led by community org partner group education led by community org partner
staffstaff
Changes from baseline in the primary and Changes from baseline in the primary and secondary outcomes will be greater among secondary outcomes will be greater among healthy lifestyle group compared to healthy healthy lifestyle group compared to healthy pregnancy group participants, following the pregnancy group participants, following the pregnancy intervention, and at 6-8 weeks pregnancy intervention, and at 6-8 weeks postpartum (following the postpartum postpartum (following the postpartum intervention).intervention).
Changes will be associated with significant Changes will be associated with significant changes in beliefs, attitudes, norms and changes in beliefs, attitudes, norms and perceived behavioral control, and with perceived behavioral control, and with increases in perceived social support.increases in perceived social support.
HypothesHypotheseses
Primary Aims: Primary Aims: Increase the proportion of Increase the proportion of women whowomen whoeat healthfully (increased fruits, vegetables & eat healthfully (increased fruits, vegetables & fiber; reduced fat and sugar); and who exerfiber; reduced fat and sugar); and who exercciisse e regularly at least at moderate levelsregularly at least at moderate levels
Secondary Aims: Secondary Aims: Increase the proportion of Increase the proportion of women who have appropriate levels of women who have appropriate levels of pregnancy weight gain and postpartum weight pregnancy weight gain and postpartum weight reduction, and have improved metabolic reduction, and have improved metabolic profiles (e.g. glucose, insulin, lipids)profiles (e.g. glucose, insulin, lipids)
Process Aim: Process Aim: Assess challenges and Assess challenges and contributors to project implementationcontributors to project implementation
STUDY DESIGNSTUDY DESIGNReduce physical and social environmental Reduce physical and social environmental barriers to adopting healthy lifestyles and to barriers to adopting healthy lifestyles and to participation in project activitiesparticipation in project activities
Social support from advocates and peersSocial support from advocates and peersTrusted community organization locations forTrusted community organization locations for meetings and data collectionmeetings and data collectionTransportation and child care provided for allTransportation and child care provided for all activitiesactivitiesModify beliefs, attitudes, norms, perceived control Modify beliefs, attitudes, norms, perceived control
Based on preliminary study of community Based on preliminary study of community women’s beliefs, practices, recommendations; women’s beliefs, practices, recommendations; behavioral theoriesbehavioral theories
Eligibility criteriaEligibility criteria18+ years of age; <20wks g.a.; African American or 18+ years of age; <20wks g.a.; African American or Latina;Latina;Eastside or southwest Detroit resident; able to Eastside or southwest Detroit resident; able to participate for 11 weeks during pregnancy and 6-8 participate for 11 weeks during pregnancy and 6-8 weeks postpartum; healthweeks postpartum; health
Recruitment SitesRecruitment SitesPrenatal & WIC clinics, public assistance officesPrenatal & WIC clinics, public assistance officesPosters, flyers, postcards in neighborhood locations Posters, flyers, postcards in neighborhood locations and Healthy Baby Service vansand Healthy Baby Service vans
Orientation and ConsentOrientation and Consentgroup meetingsgroup meetingsReferral to data collection; randomization after last Referral to data collection; randomization after last data collection visit data collection visit
Baseline, Pregnancy Follow-up and Baseline, Pregnancy Follow-up and Postpartum Data Collection Postpartum Data Collection
• Visit 1Visit 1√ Healthy MOMs Questionnaire (Social and Healthy MOMs Questionnaire (Social and
Neighborhood Characteristics, Stress and Neighborhood Characteristics, Stress and Depression, Health, Social Support, Depression, Health, Social Support, Weight/Physical Activity/Dietary Beliefs and Weight/Physical Activity/Dietary Beliefs and Attitudes); pedometerAttitudes); pedometer
Success Success 10 weekly group meetings &10 weekly group meetings & 10 linked weekly optional activity days 10 linked weekly optional activity days 4 one-on-one Home Visits4 one-on-one Home Visits
Optional Activity Optional Activity DaysDays
Jen Brewer, Nutritionist, giving a Jen Brewer, Nutritionist, giving a healthy eating demonstrationhealthy eating demonstration
Participants tasting a Participants tasting a healthy desserthealthy dessert
Recruitment and RetentionRecruitment and Retention
Retention Retention StrategiesStrategiesTransportation and Childcare!Transportation and Childcare!
Incentives: personal items at each meeting; $50 after Incentives: personal items at each meeting; $50 after each of 3 data collection points (baseline, midpoint, 6 each of 3 data collection points (baseline, midpoint, 6 wk pp)wk pp)
Staff to participant contactsStaff to participant contactsWeekly Phone CallsWeekly Phone Calls
Congratulations on the Birth of Your Baby)Congratulations on the Birth of Your Baby)
Participant to staff contactsParticipant to staff contacts--Postcards (Address/Contact Change, Birth Announcement, Postcards (Address/Contact Change, Birth Announcement, Withdrawal)Withdrawal)
Efficient Scheduling of AppointmentsEfficient Scheduling of Appointments
Health Mothers on the Move Recruitment Flyers Health Mothers on the Move Recruitment Flyers (Spanish and English):(Spanish and English):
Healthy Mothers On the Move Newsletter Healthy Mothers On the Move Newsletter (English version, Pages 1 and 2):(English version, Pages 1 and 2):
Healthy Mothers On the Move Newsletter Healthy Mothers On the Move Newsletter (English version, Pages 3 and 4):(English version, Pages 3 and 4):
Healthy Mothers on the Move Newsletter Healthy Mothers on the Move Newsletter (Spanish version, Pages 1 and 2):(Spanish version, Pages 1 and 2):
Healthy Mothers on the Move Newsletter Healthy Mothers on the Move Newsletter (Spanish version, Pages 3 and 4):(Spanish version, Pages 3 and 4):
Healthy Mothers on the Move Birth Announcements Healthy Mothers on the Move Birth Announcements
(Spanish and English):(Spanish and English):
Process MeasuresProcess MeasuresInstrumentInstrument Examples of QuestionsExamples of QuestionsParticipant Feedback Participant Feedback FormForm
1.1. What other information about What other information about ____ would be helpful to include ____ would be helpful to include in today’s meeting?in today’s meeting?
2. How do you think you can use 2. How do you think you can use the information that your heard the information that your heard today?today?
Process Process MeasuresMeasuresInstrumentInstrument Examples of QuestionsExamples of Questions
Focus Group Guide for WomenFocus Group Guide for Women 1.1. How helpful was the How helpful was the information in motivating information in motivating you to try out things at you to try out things at home?home?
2.2. What made it easy or hard What made it easy or hard for you to come to the for you to come to the meetings?meetings?
Focus Group Guide for Focus Group Guide for FacilitatorsFacilitators
Focus Group Guide for Host Focus Group Guide for Host SitesSites
1.1. Was there any part of the Was there any part of the curriculum that was hard curriculum that was hard for you to facilitate?for you to facilitate?
2.2. How could the training be How could the training be improved to help you improved to help you facilitate the weekly facilitate the weekly meetings?meetings?
1. What would you describe as 1. What would you describe as the challenges of hosting the challenges of hosting the project at your site?the project at your site?
Lessons Learned …Lessons Learned …
• Group program can work!Group program can work!• Social support aids retention Social support aids retention
despite/because of major social issues despite/because of major social issues women facedwomen faced
• Community host sites improve access Community host sites improve access and trust!and trust!
• Transportation and child care Transportation and child care essential but difficulties can cause essential but difficulties can cause huge problemshuge problems
• Pregnancy education rare in Pregnancy education rare in community and much appreciatedcommunity and much appreciated
Lessons learned from pilot…Lessons learned from pilot…AreaArea ImplicationImplicationCurriculumCurriculum Method & DeliveryMethod & Delivery
- - Reduce amount of information per sessionReduce amount of information per session
- - Address beliefs about food and exercise Address beliefs about food and exercise during/after pregnancyduring/after pregnancy
- - Increase interactive activities (food and exercise Increase interactive activities (food and exercise demos) demos)
FacilitationFacilitation Extend Staff TrainingExtend Staff Training
- - Create resource and procedure manualsCreate resource and procedure manuals
- - Create guidelines for “boundary setting”Create guidelines for “boundary setting”
Host SitesHost Sites Trusted Organizations MatterTrusted Organizations Matter-Regular communication to trouble-shoot is Regular communication to trouble-shoot is importantimportant
EmpowermeEmpowermentnt
““We don’t want others to solve our We don’t want others to solve our problems, problems,
but to inform us about resources available,but to inform us about resources available,
and where we can find those resources so and where we can find those resources so
we can make our own decisions.”we can make our own decisions.”
“We want action and justice.”
Investigators Investigators
Principal InvestigatorPrincipal InvestigatorEdie Kieffer, MPH, PhD, School of Social Work
CoinvestigatorsCoinvestigatorsGeorge Nolan, MD, MPH, School of Social WorkWilliam Herman, MD, MPH, School of MedicineAntonia Villarruel, RN, PhD, School of NursingSeonAe Yeo, RN, PhD, School of NursingCleo Caldwell, PhD, School of Public Health
Community PartnersCommunity 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
STAFF, COLLABORATORS AND STAFF, COLLABORATORS AND SUBCONTRACTSSUBCONTRACTS
Paris Watson, Project ManagerJose Melendrez, Evaluation CoordinatorLuther Brewster, Research CoordinatorMarilyn Lugo, Field Services CoordinatorLula Harris, Women’s Health Advocate SupervisorMarta Rodriguez, Women’s Health Advocate IITola Gonzalez, Women’s Health Advocate IOlivia Rodriguez, Women’s 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)
Support and Support and AcknowledgementsAcknowledgements• Centers for Disease Control and Centers for Disease Control and
Prevention Prevention • Detroit Community Academic Urban Detroit Community Academic Urban
Research CenterResearch Center• Michigan Diabetes Research and Michigan Diabetes Research and
Training CenterTraining Center• General Clinical Research CenterGeneral Clinical Research Center• National Institutes of Health/NIDDKNational Institutes of Health/NIDDK• REACH Detroit PartnershipREACH Detroit Partnership• HRSA/Maternal and Child Health BureauHRSA/Maternal and Child Health Bureau• W.K. Kellogg Community Health W.K. Kellogg Community Health
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