AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
KAREN PETERSON: Well, we’re going to flip over then to the project that we developed in the Boston area. And you’ll see it has a lot of similarities with the one Edie developed and, a I dealing with two microphones, are you okay effective.
EDITH KIEFFER: Yeah, that one’s not on I think.
KAREN PETERSON: Great, um, I’m seeing a lot of parallels as we go through it. I think one of the major differences is, a couple of them is our group of women are a large group of Latina and most of them are from Puerto Rico or Dominican Republic and who live in the Boston area or Western Massachusetts, Springfield area. And the other is that our project in a way it picks up where Edie’s-- What do you need?
EDITH KIEFFER: Do you have my watch?
KAREN PETERSON: I don’t have your watch, no .
EDITH KIEFFER: Oh, I left it up there.
KAREN PETERSON: I don’t see it Edie. Okay. Our project really starts about six weeks postpartum and we recruit women between about two to three weeks up to 20 weeks. We had to expand our window, so lets see. The name of the project is “Reducing Disease Risk in Low Income Postpartum Women.” That’s the under 56 character title that got us the money from National Institute of Health, you know how that goes. It’s kinds of like a game. It’s like playing scrabble. How can I capture something here in under 56 characters so they give me some money, you know, that feast or famine thing. And we ended up calling it, calling it “Just For You” and I wanted to tell you a tiny bit about that. I was thinking and listening to kind of the interest we had in the group. The way we came up with this title, I never have liked this title. I’m just starting to like it and it’s five years after we started the project. And, because I was rarely, I thought, well this project is all based on social support and I’d worked in these clinics for 10, 15 years and I had this stuff going like (speaking foreign language) and you know, I was going to have the arms woven together, I had all these great ideas and I was a WIC nutritionist in these same clinics, you know, I, this was literally the clinics I worked in when I was a WIC nutritionist.
Well, the women in our focus groups are, you know, they basically had a different idea, which was the following. A preference for a mom centered as opposed to a baby centered theme for the program and that even though, I was very big, and we built social support in it and it looks like that was helpful, because we had people doing home visits and really working with people one-on-one and that seemed popular. But some of the quotes we had were, new mothers stated for example, everybody forgets about you and expressed the need for a little attention. If you’re not healthy, you can’t help yourself, kids, your family, so health is very important. So you’ll see we ended up developing that theme and we came up with this phrase, “Just for You”. And also moms said, well no, I’d love my baby to be there and we provided childcare and things like that, but they really were, I really want something for me. So, you’ll, that’s how we got our project name. These are the pieces I’ll go over now just in the next eight to ten minutes.
Our funding was through an interesting funding mechanism you might keep an eye on because I see this expanding a lot at NIH’s, the funding initiatives that are under an RFA but are asking for novel inter institutional partnerships. And it seems like everybody CDC, NIH, I’m not sure about other funding sources or how Title V is working on this or MCHB but the calling for Universities if they’re involved, even if they’re involved at all, to be doing it in partnership with State Health Departments, local coalitions, et cetera. And this was actually the very first cross NIH, RFA, it came out in 1997 and said, we’d like to look across a number of different area, you know, projects, but we’re interested in nutrition, physical activity, alcohol use, and tobacco use, and we’re interested in how these behavior change theories that are, you know, they’re like rabbits, they’re everywhere. How those actually are use, do they really, do they really change things? And so to apply for this Grant you had to either say you’d try to change at least two of these behaviors, and you could only use that short list, and/or you could compare more than one theoretical approach.
And we went for diet and activity and then we, you know, kind of took the easy road or the hard road, depending on how you look at it, which is we used the socio ecologic framework and I think that’s in so many programs now and we’ll go over that in a second. I know CDC is, is very big on the application of socio ecologic framework. That allows you to bring in about 20 or 30 theories all at once. So that’s how we got out money, which it’s sort of good to tell those secrets behind the, behind the scenes. And that’s our group. Again, I think an interesting thing here, it was hard to corral people at four different Universities but we did it because when we wanted to put together the grant, we could not find our way to do it without pulling all this different expertise. So just briefly the central group was at Harvard School of Public Health and three of the four of us, there’s a statistician in there, and Cara is actually the person who developed the curriculum, she’s a nutritionist.
The other three of us actually are also clinicians, Bobbie and Marie are Pediatricians and Physicians who’ve worked in the community and myself, had worked in the same WIC centers. So we all happened to end up at the University but we had a long history of ourselves, I mean, some of my, I actually was one sitting in the waiting room, we were trying to, we were doing an interview with one of the mothers and I said to her 15 year old boy, I said, you look really familiar, do you mind, do I know you? And it finally we figured out and I was, I don’t think, gosh with my failing memory, I don’t know where this came from, but this was a little guy I knew when he was a WIC participant. I was like, you know, 15 months, and he was one of my favorite kids and somehow there was enough of that in his face, so that’s how close we all were to the research, which was great for us actually, because as who was saying earlier, it’s complicated but powerful. Was that you, from yeah, you’ll have to forgive me for picking up on these beautiful, but it got very complicated but powerful at different phases and I think we were really glad we had all, we basically came from the community and we’re trying to give back.
I think just to say the other Dana-Farber Cancers Institute actually is really expert on designing health promotion interventions and as is University of Massachusetts at Amherst. And then South Carolina has a lot of the methodologic expertise and especially around physical activity assessment. We had two theoretical frameworks that were really important to us, you know, among several but I’m thinking maybe some people in the group might have this, have an Anthropology background or be working with people that are Anthropologists because there is certain sensibilities people seem to have in the group. I, before I was an nutritionist I started out as an Anthropologist and I was unsure how I’d get a job. So I went into nutrition and one of the things I’m always thinking of and I used to see this so much when I was working in the WIC clinics was just that, you know, we here it all the time but the notion of critical periods and this group, you know, could give a whole three day workshop on critical periods, particularly perinatal period, but the thing that was fascinating me, like fascinated Edie and was this notion that the postpartum period where suddenly everything focuses on the child and we had some pilot data that said, gosh, there’s all sorts of feeling of lack of social support, depression and then I always think it’s like, (speaking foreign language) like you have risks going on all at once.
You know, your focus is on your child, your gaining weight, your lifestyle has changed, but then if there’s any way to intervene in that, that would be in a period of incredible opportunity. The other thing was I felt I’d seen years and years and years of just sitting in the WIC clinics, a lot of people would come with their whole family to the visit and I know everybody’s had that experience, you know, you have four or five people in the room and you’ve got the two year old on your lap and Grandma’s there and it was just part of the counseling scene but I felt that I could always see the family pattern. And I said if I look at some, a woman who is overweight right at menopause. Where did she start on that trajectory? Well, she could have started a little bit with some of the weight gain that didn’t go down after the pregnancy. And then for women who live in really compromised circumstances, they have all sorts of challenges. The rest of us don’t. So, the other then is this socio ecologic framework. Is everybody familiar with this or heard it until you’re blue in the face or not at all? Have you heard of it? Do you want to say anything about it? How you used it in your programs or—
UNKNOWN SPEAKER: No, I haven’t used it in my programs at all, just a framework that I used in my Master’s degree.
KAREN PETERSON: Okay, and Bev, do you want to? The short story is it says that if you want to think about changing behavior, we need to think at least four levels and those are the levels you see there. And a lot from the focus is, and I think in the programs I hear here, we focus of course on the woman herself and her baby, and then a lot on the interpersonal level, which is probably where we were also, we built in a home visiting component, even though we were looking across the literature and couldn’t find it. We could not find evidence it was more effective, but we still thought it was a fabulous idea. To get into the home really took us something. Then it would also say that of course you have to look at the organizational level if you want to think about sustainable programs and everything I heard and what everybody said here was, that’s the context, part of the, one of the contexts in which things work. And then finally in the community, that’s a very shortened version but there’s many, many community factors that make it easier or more difficult for individuals and families to have a healthy lifestyle. And Edie is really an expert there.
One of the women I work with, Gloria Sorenson who you saw on one of the earlier slides, she’s published in a couple of places now the social contextual model that you might find useful in some of your programs, sort of an organizing, where to be active. She’s taken this but then added to it things we all know are true. What about disparities, I’m sort of saying, the disparities are going to work through each one of these levels. There’s no magic bullet. And then culture is also going to, in a way, it’s sort of the beautiful shade, the beautiful background behind everything else. So that’s going to influence not only how socioeconomic status operates through each of these levels but also the very particular characteristics of how people live their lives and thing, what they think is important and how that effects their health behavior. So to get the money, we had to lay this out in great detail. And you’ll see that in a few minutes when we talk about the intervention design. We literally had to show how each little piece of each of these theories showed up in a card sort that a community health worker was doing with a mom and I’m glad Cara did that, because I would have just gone right over, right over. So that was a different sort of funding mechanism.
I think, the other story I could tell, which is we applied for the same Grant Edie applied for and we didn’t get it, the pilot Grand from CDC? And I remember Bobbie, muttering in the hall, she says, well, some person got it, I’ve never heard of, Edie Kieffer. Who’s this? And I said, oh Edie, oh that’s, well if Edie it’s okay, and because we had met because we were in Teachers and Maternal and Child Health. And just as you were talking, I thought that, our world is so small and I could imagine some set of us working together over the next 20, 30 years to some of these challenges and I’d forgotten that part of the story. And I still have that stack of Grant application materials that we lost to Edie, but, we should compare our literature review. These were our partners. The Massachusetts WIC program, whose familiar with WIC? A lot of people, probably, yeah, everybody. So I won’t, I won’t go into WIC. And the link was obvious because I had been a WIC nutritionist and a WIC director and I was about to start to do more with WIC, it’s the Massachusetts Department of Public Health and I was saying to Jan, the State Nutritionist, I said, once in WIC, always in WIC, it’s just my favorite program. I cannot get away from it, and you know, that’s the program I like to work with and figure out how to improve. And the other program that we partnered with and this is interesting from inter organizational point of view, is expanded food and nutrition education program. And again, are people familiar with this or not? Okay. Actually, one of our nutritionist, do you want to explain how EFNEP is, you know, where that comes from in terms of funding and—
UNKNOWN SPEAKER: Well, we don’t have, I don’t think we have much of a (inaudible).
KAREN PETERSON: Yeah.
UNKNOWN SPEAKER: But it comes from USDA.
KAREN PETERSON: Exactly. Yeah.
UNKNOWN SPEAKER: It allows people to come to the home and help people with budgeting and shopping and all the things.
KAREN PETERSON: So, see there’s the magic thing. Is here’s a program funded by the same federal agency, U.S. Department of Agriculture, we’ve recruited women from the WIC program, special supplemental program when they’re pregnant, when they’re postpartum, when their kids are very young, the moneys come through Title V to the State Health Department and then they, at least in Massachusetts, go out through a sub contracting process. I’ve met some of the Alaska WIC people and I can’t remember, they have different challenges. I realize we have two urban projects here so, people who work with more rural areas, feel free to jump in, and say, oh, you’ve got it all wrong, if you’re going to apply it. Then the EFNEP monies or Food Nutrition Program monies, these come through, I’ll say this because I’m really, I’m from Montana originally, come from, go to the cow college, the agricultural college, extension college in each state, so that’s umass for us and that’s what’s fascinating to me. But what you’re saying, they fund people to go into the home and who EFNEP workers usually come from the community themselves, all our EFNEP workers actually had been in EFNEP originally.
So it’s really the food stamp population. You get about six lessons on food preparation, food security, kind of what it takes to put together, you know, a basic meal on a thrifty food plan, which is not enough basically, to feed your family. So, what, and then when we talked with WIC and we talked with EFNEP, they said, you know, we always want to work together, but it’s hard for us to do it. And you think well, how could this be, but when you think of the funding streams, they’re coming into the state through two different infrastructures. So, that was a challenge for us. and also, an opportunity. Let me keep moving here, so. I don’t need to go further into the postpartum period as a window of opportunity. It’s a whole a doorway we can all walk through now and you see the educational model. Actually the design on the right hand side was that we worked through the Health Centers, two or three of them I’d actually already worked in myself to invite women to participate.
This was right as they delivered a new child. And then they would take a survey and then we would randomize them to the two, this was a formal randomized control trial and they would just continue, everybody would continue in the WIC program. And then if you happened to be randomized to the enhanced EFNEP interventional or the “Just For You,” that meant you would then get assigned an EFNEP worker who had been specially trained in some techniques, or building really on techniques they already use and come in and do, we’ll describe the intervention later, education that would be around nutrition and physical activity, instead of the food preparation, food security issues. They weren’t like normally talked about. And then so, it was a randomized control trial. We actually, it took us two years instead of the year, year, 12 months we put in the budget. It took us two years to recruit 679 women, at which point we ran out of money, but, no, we actually, we actually were able to follow up the women for 12 months. The intervention I’ll describe in more detail later, but it included five home visits.
You can be thinking ahead and say gee, was that possible? We ended up, so group classes, keep an eye on what happens to those, and then the motivational phone calls, monthly to reinforce and I’ll talk more about, people familiar with motivational interviewing or you’ve heard, yeah, so, this is what, we got all the favorite buzz, favorite little strategies going in this. I used to, in Montana we were just called shotgun approach. Just, shhh, put everything in there, see if you can get the money, and then it’s, since funding is kind of an issue, I think it’s an interesting strategy. I’m not sure I’d necessarily recommend it because it created a really complex and interesting intervention for us and we were funded, but at different points we actually had to simplify to make work for ourselves and the organizations. Our outcomes are pretty identical to Edie’s although she’s able to do sort of a more in depth, particularly from the laboratory point of view. Our setting was such, we really didn’t feel people would be open to the lab work. It was, especially with the home visits.
It would be hard for us to get women into the Health Center for that and we didn’t have the funding to send out a laboratory person. But the other things, you’ll see, are very, very similar. Keeping in mind, we’re really moving from the postpartum period where Edie’s leaving off and saying what happens in that first year after the baby is born. What about mom’s health in that period? Those are measures, body mass index, again, everybody would know, it’s your weight over your height squared to assess your weight status. We did to waist circumference, which is a bit strange. It’s for fat distribution, which is important for chronic disease risk. But you think of a new mother, a lot of people didn’t really have data on waist circumference, so I think it will be interesting for us to report it. I’m not sure how we’ll interpret that, and then tricep skin fold to get at the changes in pregnancy where your body fat is redistributed and then it would be distributed about a year after pregnancy.
We used these instruments, the bottom line, our mediating and modifying mechanisms were similar to the ones Edie had on her list, social support, depression, things like that. We can go into more detail. The other two are actually fairly detailed instruments and our interview took almost, a little over an hour. We usually did it at a home visit. It was hard to schedule that. I was, I like the way Edie’s group broke there’s up. The reason we did it is we felt that we had such a heavily Latina population that for 60 percent of our group that English was not their first language and they were new mothers, and we didn’t, we don’t know a lot about how diet and activity changes for new mothers. People have studied, just now it’s just sort of a newer area of study, so we felt that’s where we would put our money and out time, as we really wanted to measure it well, so. And then we also had to do it with an interviewer because we found that a survey, just handing out a survey in this setting didn’t produce very valid data.
So again, that was a choice we made, which was to put a heavy, heavy emphasis on how we assessed our quote major outcomes. But it had a lot of implication for us in terms of our funding and actually being able to complete the project. And the bottom line is we had four follow up, we had a baseline, six month, 12 month, 18 month. We had to drop the six and 18 months, too expensive to get all that data, those data, so. And then, our hypothesis were that the money would be well spent. So I think Edie, you wanted to take some questions? And, maybe we should also do a time check. We could take a tiny break now.
EDITH KIEFFER: Or we could, how do you feel about having a discussion about what you’ve heard so far and discussing this part of it for about 15 minutes and then breaking, or breaking now.
KAREN PETERSON: Or if you like, we can do the next little chunk and then we can discuss, any of those. How are you doing? How’s your biology?
UNKNOWN SPEAKER: I think it might be helpful to have the next chunk, because basically you’ve done study design?
KAREN PETERSON: Right.
EDITH KIEFFER: Yes, we did.
UNKNOWN SPEAKER: Because I’m sure that I wouldn’t have much to offer you, I’m sort of—
EDITH KIEFFER: You want to hear about the program first? Okay.
UNKNOWN SPEAKER: That doesn’t mean your fault.
KAREN PETERSON: Yeah, lets get, lets get into the heart of it.
EDITH KIEFFER: Okay, now, do you need a break first though?
UNKNOWN SPEAKER: How long is the next chunk?
EDITH KIEFFER: A little shorter than, yeah. Each of us have fewer slides, because both of us were doing introduction here. So I think they’re not as long, yeah, 20 minutes total.
KAREN PETERSON: And we do that, and then we’ll take a break, and then we come back and discuss and then we’ll launch into the second--
EDITH KIEFFER: You can formulate your questions during the break and okay.
KAREN PETERSON: Let me also hand around and I’ll go, I guess I’m next, Edie right? I’ll keep going on.
EDITH KIEFFER: Oh, that’s right. You keep. That’s right.
KAREN PETERSON: I’ll just sort of elaborate. I’ll just pass, this is a selection of some of our intervention materials, so you can just, you know, look at those, page through those. Yeah, Edie yours need to be, they’re not in the ream binder, they’re loose.
EDITH KIEFFER: Oh, you’re kidding.
KAREN PETERSON: So, Edie’s will come around. Oh, I’m sorry. This I’ll just mention. It’s in your slides, and if somebody, the evaluation gang in here, one of the issues people would often come up with, they’d say well, if you get a change at the end of this trial, how do I know that’s not just related to the fact you’ve been badgering people about what they eat and whether their active and then they tell you they’re more active. So we built in a fairly expensive little component that would get objective measures of physical activity and some alternative measures of diet, which turned out not to be such a bad idea. That money seemed to be very well spent, actually, but it’s, and we did it just in a subset. So what happened? By January 2003, we recruited 679 of the 680 women and we had wanted a sub sample of 150 people to get those more objective measures in.
That was more difficult because it involved the women being, doing even more evaluation activity, so we had to have a smaller sample there.
One of the things that happened and I’m, this is sort of the unadulterated version is, basically about two and a half years into this project it was clear we were going to run out of money. And it was a four-year project and we had not recruited, we’d recruited maybe 50 or 60 percent of the women in that first 12 months, and we thought we would have recruited all of them. I needed to recruit all of them because we needed that to be able to measure change. So the very first thing we did was we dropped the six-month follow up data point. We were originally, if you remember, trying to invite women to participate at two to six weeks postpartum. Well, what do you think happened when we invited people at that point? Yeah, they sort of said, what? Excuse me? You know, I’m here for my VIC vouchers for my infant, and I’ve got to get home, the two year old is climbing all over me. So, we had to expand our window to, actually we recruited women up to 20 weeks postpartum.
Then, the next thing we did is we actually dropped our six-month data point, which would have been very interesting from a statistical point of view. It’s great. You can, you have four data points that are stretched over the first year of life. But the minute we went out to five months postpartum for our baseline, it didn’t make a lot of sense to get that six. The other was that often we, almost always actually, the intervention staff was separate from the evaluation staff, but the evaluation staff was also largely from the community and we would do home visits to get the surveys, because most women could not stay in the clinic long enough for the survey. And that also increased our cost. But on the other hand, established a very strong repoir. So once data collectors were actually in the home, women seemed to really enjoy that and they would report that they were not allowed to leave until they’d had lunch, and you know, it was three hours later, so those are some of the stories there. The increased staffing as you can imagine, costs money. So any ideas where I got the money?
UNKNOWN SPEAKER: Partners.
KAREN PETERSON: What?
UNKNOWN SPEAKER: Partners
KAREN PETERSON: Partners?
UNKNOWN SPEAKER: Did you have some type of (inaudible)?
KAREN PETERSON: No, we didn’t as a matter of fact. We got a tiny bit of extra money but that was for some more research, so if you were doing a University, that would be a great way. That’s actually great, because that’s what happened to Edie. Students and interns, yup, that was one of the things we did. So we have this cadre of really hungry doctoral students. But there’s one other thing I did where I got actual money. So if you were looking at a staffing plan and you think about where the big salaries on a research project, and whose probably not doing that much work.
UNKNOWN SPEAKER: Perhaps somebody in FTE to put money somewhere else.
KAREN PETERSON: Yeah, whose, which FTE’s would you go for in this setting, since were among friends.
UNKNOWN SPEAKER: Yeah, don’t say this in the other room.
KAREN PETERSON: Yeah, don’t say this in the other room, although everybody in the other, actually nobody would be at this conference if they didn’t. Well, I had to fire myself, my boss, Bobby, Gloria, and I had to go back. Actually it’s fun to tell the story two years later. But two years ago exactly, I was having to go to my co PI and say I need the money back. I can’t, you know, we got the intervention developed. I cannot afford to pay a day a week of your time. You’re not spending a day a week. And it’s sort of one of the vagaries of Universities, you have, we have to cover our salaries, but when the rubber met the road, we had to recruit the women. And that was very tough, on the other hand, you scramble and you figure out how to do it. But it’s, so, it was hard because it was people I work with down the hall. But then I guess the other side of it is, no researcher would be involved in community, based research if they didn’t understand the ethics. So it actually was not as dramatic and painful as I’m letting on as you might imagine.
So, but we did, the other thing that happened was we had to drop the group class component, which surprised us a great deal. We thought it would be very popular and EFNEP used the group classes because they couldn’t afford the home visits any more anyway. But what happened, well, any ideas about what happened there? Yeah, we had done everything possible like having the groups at a church that would be two blocks from where women live. We had transportation, we had childcare, almost anything you can imagine. We’d do drive bys to make sure people were available and the women just simply, it was too difficult with a new baby to get out to a group class. So that was that. So Nancy, who was the EFNEP Director, is the EFNEP, oversees the EFNEP Program at the state. She said, Karen I know you think it’s a great idea from a social supportive point. I know you said in your preliminary studies you could get three times the effect in the women who went to the group classes. But I can’t replicate this.
My field workers just bought food, they went to the church and nobody was there and now they’ve done that two or three times and I’m sorry, I know it’s a great idea, but it’s actually not working in the real world. So you need to drop it. So, we did and then Cara, who had designed the home visiting and you see in the booklet that’s going around just one example of the first home visit. She built into the home visits more explicitly social support so that the health mentor would work with the mom and say things like, so talk to me about your family and your friends, and maybe you want to bring one to the visit, and have them build the support into their own thinking about diet and activity. Who are the women that we then have in our study? You see this on the slide so I don’t, and in your packets, so I don’t think I’ll got into great detail. Just that it’s a lower income and lower education population, because they were recruited from the WIC program. Two thirds spoke Spanish as their native language. And the majority were Latinas from the Puerto Rico or from the (speaking foreign language) who live in the Boston area and that would be different for other parts. But I think every, almost all of us have different groups who are coming from different areas. So this is a theme to think of. This I’ve gone through.
So we had our big three, you know, in terms of our hypothesis, it was the number of fruit and vegetable servings. So that we, how do we translate these to messages, that we could translate very directly and we were using the healthy people 2010 goals for this and the dietary guidelines. One of the interesting things is of course that the dietary guidelines have just changed and also the five a day program had changed in the course of the study. So the cutoff really for women in this age would be seven, at least seven fruit and vegetables per day. So the public health guidelines changed in the course of the study, which is a challenge. But our intervention message was you were to eat at least five. Then how do you translate saturated fat to a message? Even at breakfast this morning I thought, I’m going to be hungry. I’m going to have these eggs, oh my gosh, what about this cheese and you know, and I’m a registered dietician with a PHD in nutrition and I was having struggling to figure out what the saturated fat, I kid you not. I really was, oh heck, I’m just going to eat it.
But the way we translated it was to limit red meat to no more than three servings per week and then there were what we call corollary messages from a theoretical point of view in terms of food preparation, which was something, as you were pointing out, something that EFNEP workers were already trained in. Talk with women about alternatives and food preparation that would lead them more towards vegetable oils, so. And then this was our physical activity goal. I think some of the guidelines now are moving towards getting even more physical activity, but certainly--. The other thing that we did to, actually, there’s one thing that I wanted to say about the intervention messages and the person who delivered them was the EFNEP paraprofessional who had a lot of training in nutrition, had typically come from the community herself, our kind of master, trainer master, EFNEP worker Cecilia had come from Puerto Rico 26 years before and her first friend when she came to the country was an EFNEP worker. And she was a new mother, actually I’m sorry, she had come from Columbia . And she said she was very lonely, very depressed and the EFNEP worker would come to her house and Cecilia likes to make lace. And the EFNEP worker said, she said, you’re really incredible making the lace. You would be a great EFNEP worker because what she was picking up on was the ability at I guess, organization. And she was like the (speaking foreign language) of the whole group.
She actually tried to retire halfway through the project and she came back and said, I need this, I need to see this project finished and she would talk about her experiences with the EFNEP worker being her first friend. I would just get like I am now, just very, very moved and so we asked though, in the focus groups the women potential participants to tell us what the name of that person should be. So it would be teacher, an educator, a friend what, you know, what would resonate with learning and with support. So what they said is they wanted, health mentor is what came out of that focus group work. Based on ideas generated during focus groups. They like the notion of someone who wants to be there for you, not pushing you or stressing you out. One woman said, nagging is very de-motivating. And another conveyed, I like how Cara sort of carefully put this language in. It’s very fun, when, you know, I don’t know who said these things. I don’t look at who does the qualitative work. I just look at the themes.
Another conveyed she did not appreciate a previous educator who quote rode me and told me what to have and what not to have. So, out of that became the notion of a health mentor. Okay, so I wanted to say that and then let me just, a couple more things and then I’ll pass to Edie. We did build in this motivational interviewing component, which was sort of a next best thing to sliced bread in ’97 and ’98 and you hear it in a lot of obesity reduction programs. It’s basically really, we married it with non formal education, so it’s really, in my mind, very consonant with what people do in a non formal education, adult education mode of a, as a mentor, as co learner and then I think in interest of time, we won’t go into all the details. But it’s basically a client, centered approach. You, in the conversation create what’s call a, you know, cognitive dissonance so the woman is able to say, well, I want to do this and here’s, you know, a certain barrier or constraint.
And then the person who is doing the interviewing literally lets them sort of sit with that dissonance, it was like me at breakfast. I don’t want to be hungry, she eats saturated fat and kind of sit in that space and then make a choice. Set a goal that’s on the path of the three nutrition and physical activity goals we had, that would work for them. And you can see in the booklet, that’s going on. We have little personalized goal cards, so we would not say, thou shalt eat five fruit and vegetable servings a day. They would say, okay. You know, pineapples are in season and I’m going to try pineapples this week and that would be their translation of the goal, so that’s how we used the technique.
UNKNOWN SPEAKER: Who does the motivational interviewing?
KAREN PETERSON: Oh, that’s a good point. We actually, although the EFNEP workers could have done it, it became easier, we managed that out of our research office and we had one person who was trained in social work and another woman who was actually a social work student at Boston University. She was from Puerto Rico herself and the other woman was not a native Latina but had worked at the Health Centers. So they did the phone calls. They were based at the University, but certainly that could be done through a Community Health Center , which was where we were originally going to do it. Again, I won’t go into all the details of this but there are two slides in this, in the packet, this one and the next one. And here the process we used to translate the theory to a strategy and again Cara did this, was to take the theoretical constricts through choice is built into one of the theories we used a lot in obesity research that, duh, says if you reduce access to an unhealthy behavior, you can increase practice of a healthy behavior. It’s used a lot with reducing TV viewing in kids and increasing activity. So we wanted to play with that, so choice was obviously very important. How did we do that? We actually built in so the EFNEP workers would have a menu of options they would give to the woman. Would you like to do this or that? And then this built directly on non-formal education techniques where you can hand out a set of cards, for example, that say, well here are reasons why I choose physical activity. What about you? And they might pick out, like the educator might pick out, well I do it because my grandma had diabetes and my skin looks great. And the other woman might do it, because I want to lose weight. So you could just literally pick out your own. So that’s one example. The other is say for social cognitive theory, which again is at an individual level and it’s used in a lot of, lot a, lot a programs.
The way one does that is to say, build in something that is goal setting, self-monitoring, have to think about things. This is a really typical thing that’s in a lot of interventions. And I think Edie talked actually about using a pedometer. We didn’t use it as an evaluation tool. We used it as a learning tool, so women themselves would accumulate steps and watch how they did that and they had a way to (inaudible) that. And then this was what would be at the beginning of the interview. Here’s what you’re going to learn by the end. And then what would happen, so you will have named what you know, found the reasons using a card sort. You’ve gotten this little step counter. We actually had a little gift box. People got little stuff they put in recipe cards, and you see some examples of that in the notebook. People would, you know, it seems simple. But just do the mocking up with the step counter and simple little things. Like if you put down the little lid and to see how many steps you got, it doesn’t count.
So we all thought our step counters were broken and we were pretty upset because we had gotten a real deal on them. So it turns out, you know, little stuff like that you mock up with the woman. Since we’re among ladies, these things fall off the belt into the toilet every time you go to the bathroom. Just little stuff like that, so that’s a little tidbit for you back there. You haven’t, you know, just what you wanted to know. Good. I didn’t think you were. So, but that’s the kind of thing. You know, you just literally mock it up and they can go skittering across, okay. And then the last two things are choices that the woman would have made herself. One of her ways to walk more and increase step counts. So again, you see, we’re playing with that goal of moderate to vigorous physical activity. We started with walking. If people were already walking, then we worked with them on other goals. And what Cara was building in is, people would literally think about how am I going to walk more?
Not, I’m going to walk 30 minutes a day, but how am I going to do it. And then the other was to actually use the pedometer as a self-monitoring, increase step counts, I’m going to literally increase my numbers. And we are looking at our preliminary results and it turns out women in the intervention group had doubled the amount of activity postpartum that the other women did who were not receiving intervention. And then had an example, you see this theme of “Just For You?” They had a gift box and I think that’s in the notebooks. So they would list why it’s important to them and then their specific goals. And then I’m going to stop now. Kind of remember how this gift card looks and that there’s a goal card like it, which is in the notebooks. That then became the basis for a follow up and interaction between the health mentor and the motivational phone caller and our intervention tracking form. It was fairly complex because we had to have a system for harkening back to what each individual woman said. So Edie I’ll let, switch it back to you and then we’ll take a short break. How are you doing there in back? It’s going this way.
EDITH KIEFFER: Okay. Those of you who have the book, it’s not complete. It’s not a complete curriculum. It has some examples of our objectives for each session and then two lesson plans I guess it would be that are complete. One eating and exercise and then we give out something called the pregnancy book to everyone. They don’t get the whole curriculum but they get the pregnancy book, which includes the healthy pregnancy materials. So again, both groups get that. And I think I also have, I’ll talk about optional activity days. There’s a set of those things in there as well. So I just need a minute to switch. Okay, so here we are. What did we actually do? Now I don’t have as much detail. We’re sort of trading off here. We had two groups as I mentioned before, the healthy lifestyle group had two home visits, then nine group meetings and 10 optional activity days that I’ll talk about in a minute, during pregnancy. The Healthy Pregnancy Group had three group meetings. Again, focusing on pregnancy during that period. Postpartum, the Healthy Lifestyle Group got two home visits, and then one group meeting.
And the Healthy Pregnancy Group got one group meeting. “Pamper Me Day” was a concept that was developed by one of our community organizations. It kind of fits with the “Just For You” in the sense, and it had been going on in the community for quite some time in the eastside with African American women. This was the first time this had been done in southwest Detroit with Latinas. And “Pamper Me Day” is a day of celebration of the completion of the project but it’s also a chance to get pampered. So people can choose, they sort of sign up for getting their nails done, getting a massage, facial, neck and back, upper back massage, a number of pampering activities. And they love it. So, it’s very much for them. Okay, this is some of our content. Again, you have some examples. This is for the Healthy Lifestyles Group. Some of this is hopefully self-explanatory in terms of the content, but it isn’t totally. Meeting one, it is an overview. It also has quite a bit of material on pregnancy and a lot on stress reduction. This was a theme that women wanted us to cover. So it’s a combination of sort of information about stressors and how they work in your body.
But also it’s filled with actual activities where people have kind of practiced visualization and a number of other techniques for reducing stress. It obviously doesn’t change the daily realities of their lives. It’s more of a feedback mechanism for people to learn some strategies for calming down. It’s one of the issues that education can’t do everything. And, that obviously most of the women in our projects face incredible daily stressors. The , obviously meeting two and three were focused on activity and eating healthy. There’s several sessions devoted to activity and some are more introductory. Some are more, sort of sticking with it. How do you continue to be active? And throughout with the Healthy Lifestyles Group interspersed are the pregnancy curriculum. So they learn a lot about healthy maternal and infant development as well as risk factors and what to look for if things are going wrong.
They also have a labor and birth preparation time and a session on infant care before they give birth. Postpartum, there is again a self-care, maternal self-care as well as a focus on stress and depression. “Healthy For Life” is a kind of ongoing what do we do now, now that we’ve had our baby, and meeting four is celebrating success. Interspersed, lets see whether I do this, yes. Okay. Woops. Sorry. I didn’t mean to do that. We have optional activity days. So this is actually really intense and we weren’t sure whether people would do this. These are weekly meetings. And they start when women are approximately 20 to 23 weeks. Karen mentioned having to extend recruitment. We started earlier but we couldn’t get enough women who enter care in the first trimester. In fact, in these two communities, especially eastside Detroit , women weren’t coming in until 27, 28 weeks. We believed we still had to limit to 20 weeks. Otherwise we wouldn’t have enough time to do the curriculum before women start going into labor. And we really are challenged in recruitment because of this.
In southwest Detroit with Latinas it’s a little better because the average age at entry care, gestational age is about 15 weeks. So we are having less problem, recruiting women there. On the optional activity days, that’s a second day in the week. They have their sessions say on group meeting on Tuesday. On Thursday they can come back and these alternate between physical activity days, like line dancing and other fun activities that people learn how to do and do together, provide social support and fun. With eating activities, they might have a healthy food demonstration or a shopping trip to learn things that will help support their eating activities. So these are a couple of pictures from some of the activities. And much to our surprise, women are really going for it. They’re coming the second day for the most part at least half in any given group attend the activity days. The pregnancy education curriculum is the same as with the “Healthy Lifestyle Group,” they get the same meetings. And that’s it. That’s all I have to say about the program itself.
I do want to say that the, they are led by women’s health advocates. As I said, they’re, it turns out to be, later I’ll be talking about this, a number of issues related to how closely they bond with these women and what that means in terms of running a program like this. But they do meet twice a week, as I said, and they get the group meetings. They’re done in such a way that people don’t read to them. There is a curriculum but the advocates have learned to work through the material in a group discussion mechanism. A lot of questions come up about pregnancy. And what they try to do is take those questions and do a group discussion for a little bit of the time on the optional activity day. It’s an incentive to go to the optional activity day and they get a lot of chance to discuss their questions. We started with something called ask Cecilia, which was a way of women asking their questions and then we would make sure we had an informed answer. We did not expect our advocates to know everything about pregnancy. There’s so many questions. But we found that we couldn’t do the turn around.
We couldn’t get our professional experts, which were our co-investigators to answer fast enough. So we gathered all the questions together and we essentially train our staff on the answers to those questions, but we also put them in newsletters that everyone gets once a month. And that has taken care of some of the time and staffing issues as well as we’re gathering information that overtime is really helping women answer their questions. So I guess that’s it and we can take a—
KAREN PETERSON: We should let them go to break, yeah?
EDITH KIEFFER: Go take a brief break and then we’ll talk all together.
KAREN PETERSON: Tell them to come back at 10:15 , so that will be almost 20 minutes, a coffee break. And so we’ll come back and really dive in on this and then do the, the last two pieces actually sort of go together. The (inaudible) and