1. 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

2. 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 Intervention aims, hypotheses, structure and design Processes used to develop and implement the projects Processes used to develop and implement the projects Recruitment and retention strategies Recruitment and retention strategies Process evaluation methods and results Process evaluation methods and results Workshop Methods: brief presentations, review of materials and interactive discussion

3. 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

4. Percentages of Overweight or Obesity, African American and Latino Women of Childbearing Age 70.8 % 61.6% 49.0% Flegal et al, 2002

5. Percentages of Type 2 Diabetes, African American and Latino Women of Childbearing Age 27.60 % 22.40 % 10.10 % Harris et al, 1998

6. 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

7. Community-Based Participatory Research Partnership approach to researchPartnership approach to research Community, health and academic organizations and residents equal partners in all research activitiesCommunity, health and academic organizations and residents equal partners in all research activities Partners share expertise, responsibility and ownership; capacity building is keyPartners share expertise, responsibility and ownership; capacity building is key Knowledge gained leads to interventions to improve community health and well-beingKnowledge 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.

8. 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

9. BACKGROUND Changes in diet, exerciseChanges in diet, exercise Stress and depressionStress and depression Excessive pregnancy weight gainExcessive pregnancy weight gain Postpartum weight retentionPostpartum weight retention Pregnancy and months following childbirth may increase the risk of becoming overweight or obese

10. Percentages of Overweight or Obesity, African American and Latino Women before Pregnancy Detroit, pregnant women, 1998-2001 37% 47% 7 Kieffer et al, 2001

11. Excessive Pregnancy Weight Gain Among African American and Latino Women in Detroit 53.0% 37.0% Kieffer et al, 2001 Excessive Pregnancy Weight Gain

12. BACKGROUND Frequent contact with care providersFrequent contact with care providers Focus on health of mother and babyFocus on health of mother and baby Need for social support and informationNeed for social support and information Pregnancy and months following childbirth opportunities for prevention

13. Promoting Healthy Lifestyles Among Women *Steering Committee Project Design Staff Recruitment, Hiring, Training Individual Interviews Women’s Focus Groups Policy Program Focus Groups Intervention Plans Pilot Intervention 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 Model

14. Barriers to Healthy Eating Social 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 skills Food preferences/dislikes Poor access to healthy foods Distance and lack of transportation to storesDistance and lack of transportation to stores Cost and qualityCost and qualityB

15. Barriers to Regular Exercise Social 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 transportation Community environmental barriers Lack of programs for pregnant/postpartum womenLack of programs for pregnant/postpartum women Poor access to facilities; transportation and costsPoor access to facilities; transportation and costs Unsafe physical and social environmentUnsafe physical and social environment Lack of motivation, Lack of knowledge, skills/Uncertainty about safety

16. Women’s Recommendations Group programs Group programs Safe, trusted community environment Safe, trusted community environment Support from other women Support from other women Get together, share, learn from each other Learn how to exercise safely and make healthy recipes Learn how to exercise safely and make healthy recipes Pregnancy and parenting education Pregnancy and parenting education

17. Women’s Recommendations Essential program elements Low or no cost Low or no cost Child care Child care Transportation Transportation Recommended program elements Group facilitators “like them” in language, culture and experience Group facilitators “like them” in language, culture and experience Enjoyable activities (not like school) Enjoyable activities (not like school)

18. 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)

19. 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

20. 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. Hypotheses

21. 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

22. STUDY DESIGN Reduce physical and social environmental barriers to adopting healthy lifestyles and to participation in project activities Social support from advocates and peers Social support from advocates and peers Trusted community organization locations for Trusted community organization locations for meetings and data collection meetings and data collection Transportation and child care provided for all Transportation and child care provided for all activities activities Modify beliefs, attitudes, norms, perceived control Modify beliefs, attitudes, norms, perceived control Based on preliminary study of community women’s beliefs, practices, recommendations; behavioral theories

23. 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

24. Baseline, Pregnancy Follow-up and Postpartum Data Collection Visit 1Visit 1 √ Healthy MOMs Questionnaire (Social and Neighborhood Characteristics, Stress and Depression, Health, Social Support, Weight/Physical Activity/Dietary Beliefs and Attitudes); pedometer Visit 2Visit 2 √ Nutrition Assessment (24 hr Recall, FFQ) √ Physical Activity Assessment (7-PAR, LTPA, step counter); collect pedometer Visit 3Visit 3 √ Anthropometry, Blood Pressure, Metabolic Assays √ Randomize

25. IMPLEMENTATION

26. Healthy Lifestyle Group 2 home visits 2 home visits 9 group meetings 9 group meetings 10 activity days (optional) 10 activity days (optional) Healthy Pregnancy Group 3 group meetings 3 group meetings STRUCTURE OF HEALTHY MOMS Pregnancy 2 home visits 1 group meeting 1 group meeting “Pamper-Me Day” “Pamper-Me Day” 1 group meeting “Pamper-Me Day” Postpartum

27. 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 Depression  MEETING 13: Healthy for Life!  MEETING 14: Celebrate Success  10 weekly group meetings & 10 linked weekly optional activity days  4 one-on-one Home Visits

28. Optional Activity Days Jen Brewer, Nutritionist, giving a healthy eating demonstration Participants tasting a healthy dessert

29. Healthy Pregnancy Education Curriculum Content Pregnancy: Meeting 1: Healthy Mom, Healthy Baby!Meeting 1: Healthy Mom, Healthy Baby! Meeting 2: Getting Ready – Labor & Birth!Meeting 2: Getting Ready – Labor & Birth! Meeting 3: Infant Care!Meeting 3: Infant Care!Postpartum: Meeting 4: PP Self- Care; Stress & DepressionMeeting 4: PP Self- Care; Stress & Depression

30. Recruitment and Retention

31. 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) Congratulations on the Birth of Your Baby) Participant to staff contacts -Postcards (Address/Contact Change, Birth Announcement, Withdrawal) Efficient Scheduling of Appointments

32. Health Mothers on the Move Recruitment Flyers (Spanish and English):

33. Healthy Mothers On the Move Newsletter (English version, Pages 1 and 2):

34. Healthy Mothers On the Move Newsletter (English version, Pages 3 and 4):

35. Healthy Mothers on the Move Newsletter (Spanish version, Pages 1 and 2):

36. Healthy Mothers on the Move Newsletter (Spanish version, Pages 3 and 4):

37. Healthy Mothers on the Move Birth Announcements (Spanish and English):

38. Process Measures Instrument Examples of Questions Participant Feedback Form 1.What other information about ____ would be helpful to include in today’s meeting? 2. How do you think you can use the information that your heard today? Facilitator Feedback Form Observer Feedback Form 1.Were you able to cover all of the material planned for today’s meeting? 2.What areas needed more time? 1. Describe topics that seemed difficult for participants 2. Topic coverage checklist

39. Process Measures Instrument Examples of Questions Focus Group Guide for Women 1. How helpful was the information in motivating you to try out things at home? 2. What made it easy or hard for you to come to the meetings? Focus Group Guide for Facilitators Focus Group Guide for Host Sites 1. Was there any part of the curriculum that was hard for you to facilitate? 2. How could the training be improved to help you facilitate the weekly meetings? 1. What would you describe as the challenges of hosting the project at your site?

40. Lessons Learned … Group program can work!Group program can work! Social support aids retention despite/because of major social issues women facedSocial support aids retention despite/because of major social issues women faced Community host sites improve access and trust!Community host sites improve access and trust! Transportation and child care essential but difficulties can cause huge problemsTransportation and child care essential but difficulties can cause huge problems Pregnancy education rare in community and much appreciatedPregnancy education rare in community and much appreciated

41. Lessons learned from pilot… AreaImplication 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

42. ChallengesChallenges –Moving nature of pregnancy and postpartum –Recruitment and retention (African American women) –Changing community conditions (transportation) –Staffing (qualifications, professionalism, language skills) –Data collection (scheduling) –Transportation (can’t always count on it!) –Research needs vs. community priorities –Lack of linguistically and culturally-appropriate materials –Costs! AND Time! StrengthsStrengths –Staff (knowledge of community, bonding with participants) –Group support is appreciated and works! –Curriculum design and content; new materials and methods –Community partnerships (problem solving, knowledge of community, trusted locations) Where are we now?

43. 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 and where we can find those resources so we can make our own decisions.” “We want action and justice.”

46. Investigators Principal Investigator Edie Kieffer, MPH, PhD, School of Social WorkCoinvestigators 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

47. 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

48. 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)

49. Support and Acknowledgements Centers for Disease Control and PreventionCenters for Disease Control and Prevention Detroit Community Academic Urban Research CenterDetroit Community Academic Urban Research Center Michigan Diabetes Research and Training CenterMichigan Diabetes Research and Training 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 Scholars ProgramW.K. Kellogg Community Health Scholars Program

50. For Additional Information Paris A. Watson, Project Manager 734.647.2533 pwat@umich.edu