Transcript Partnering to Address the Health of Pregnant & Postpartum Women

AMCHP Annual Conference
Skills Building Workshop
Partnering to Address the Health of
Pregnant and Postpartum Women Using
Community-Based 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
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
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
Percentages of Overweight or Obesity,
African American and Latino Women of
Childbearing Age
United States, NHANES IV, not pregnant, age 20-39
80.0
70.0
60.0
70.8%
61.6%
49.0%
50.0
African American
Mexican
White, Non-Hispanic
40.0
30.0
20.0
10.0
0.0
Overweight or Obese
Flegal et al, 2002
Percentages of Type 2 Diabetes, African
American and Latino Women
of Childbearing Age
United States, NHANES III, not pregnant, age-20-49
30.0
25.0
27.60%
22.40%
20.0
Mexican American
15.0
10.10%
10.0
African American
White, non-Hispanic
5.0
0.0
Type 2 Diabetes or Impaired Fasting
Glucose
Harris et al, 1998
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
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. 19:173-202.
Healthy Mothers on the Move/
Madres Saludables en Movimiento
Methods 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
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
Excessive Pregnancy Weight Gain
Among African American and Latino
Women in Detroit
Detroit, pregnant women, 1998-2001
60.00
53.0%
50.00
40.00
37.0%
African American
30.00
Latina
20.00
10.00
0.00
Excessive Pregnancy Weight Gain
Kieffer et al, 2001
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
Research/Planning Process Model
Promoting Healthy Lifestyles Among Women
REACH Detroit Partnership
*Steering Committee
Project
Design
Staff
Recruitment,
Hiring, Training
Individual
Interviews
Women’s
Focus
Groups
Policy
Program
Focus Groups
Intervention
Plans
Pilot
Intervention
*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
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
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
Women’s 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
Women’s 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)
Healthy Mothers On the Move
Madres 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)
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 Women’s Health Advocates
Healthy Pregnancy Education (Control) Group
group education led by community org partner staff
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.
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
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 women’s
beliefs, practices, recommendations; behavioral theories
Eligibility criteria
18+ years of age; <20wks g.a.; African American or Latina;
Eastside 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
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
IMPLEMENTATION
STRUCTURE OF HEALTHY MOMS
Pregnancy
Healthy Lifestyle Group
2 home visits
9 group meetings
10 activity days (optional)
2 home visits
1 group meeting
“Pamper-Me Day”
Healthy Pregnancy Group
3 group meetings
Postpartum
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
 10 weekly group meetings & 10 linked weekly optionalSuccess
activity days
 4 one-on-one Home Visits


Optional Activity Days
Jen Brewer, Nutritionist, giving a
healthy eating demonstration
Participants tasting a
healthy dessert
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 SelfCare; Stress &
Depression
Recruitment and Retention
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
Health Mothers on the Move Recruitment Flyers
(Spanish and English):
Healthy Mothers On the Move Newsletter
(English version, Pages 1 and 2):
Healthy Mothers On the Move Newsletter
(English version, Pages 3 and 4):
Healthy Mothers on the Move Newsletter
(Spanish version, Pages 1 and 2):
Healthy Mothers on the Move Newsletter
(Spanish version, Pages 3 and 4):
Healthy Mothers on the Move Birth Announcements
(Spanish and English):
Process Measures
Instrument
Examples of Questions
Participant Feedback Form
1.
2.
Facilitator Feedback Form
1.
2.
Observer Feedback Form
1.
2.
What other information about ____
would be helpful to include in today’s
meeting?
How do you think you can use the
information that your heard today?
Were you able to cover all of the
material planned for today’s meeting?
What areas needed more time?
Describe topics that seemed difficult
for participants
Topic coverage checklist
Process Measures
Instrument
Examples of Questions
Focus Group Guide for Women
1.
2.
Focus Group Guide for Facilitators
1.
2.
Focus Group Guide for Host Sites
1.
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?
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?
What would you describe as the
challenges of hosting the
project at your site?
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
Lessons learned from pilot…
Area
Implication
Curriculum
Method & Delivery
- Reduce amount of information per session
- Discuss - don’t 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
Empowerment
“We don’t 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.”
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
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
STAFF, COLLABORATORS AND SUBCONTRACTS
Paris Watson, Project Manager
Jose Melendrez, Evaluation Coordinator
Luther Brewster, Research Coordinator
Marilyn Lugo, Field Services Coordinator
Lula Harris, Women’s Health Advocate Supervisor
Marta Rodriguez, Women’s Health Advocate II
Tola Gonzalez, Women’s Health Advocate I
Olivia 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 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
For Additional Information
Paris A. Watson, Project Manager
734.647.2533
[email protected]