1. Intervention Planning, Program Development, and Implementation Health Works for Women/Health Works in the Community and HOPE Works Nutrition and Public Health Salli Benedict, MPH August 23, 2006

2. Health Works for Women/Health Works in the Community and HOPE Works UNC Center for Health Promotion and Disease Prevention Centers for Disease Control and Prevention Funded Marci K. Campbell, PhD, RD, MPH Salli Benedict, MPH Leigh Belton, MA Margaret Bentley, PhD Ronni Bowen, PhD Brenda DeVellis, PhD Chantelle Fisher-Borne, MPH Elizabeth Hooten, PhD Kristine Kelsey, PhD

3. Promoting the Health of Rural Blue Collar Women in the Workplace Health Works for Women-1 Health Works for Women-1(1993-1998) 9 manufacturing plants; healthy eating, physical activity, cancer screening, and smoking; 2 levels of socio-ecologic model

4. Promoting the Health of Rural Blue Collar Women in the Workplace and the Community Health Works for Women 2/Health Works in the Community Health Works for Women 2/Health Works in the Community(1998-2003) Builds on HWW-1; 12 manufacturing plants; stress, healthy eating, physical activity and smoking; new populations and worksites; 4 levels of socio-ecologic model

8. Overall Goal: to reduce morbidity and mortality among low income working women in Eastern N.C. Heart disease Heart disease Obesity Obesity Cancer Cancer Hypertension Hypertension Diabetes Diabetes

9. Improve health behaviors that contribute to leading causes of morbidity and mortality Decrease smoking Decrease smoking Increase fruit and vegetable intake Increase fruit and vegetable intake Decrease dietary fat Decrease dietary fat Reduce stress levels Reduce stress levels Increase physical activity Increase physical activity

11. Participant Characteristics (1166 women) 68% overweight or obese 68% overweight or obese 6% eat 5 a day; 33% eat low fat 6% eat 5 a day; 33% eat low fat 25% exercise 3x week (with ADL & work) 25% exercise 3x week (with ADL & work) 26% currently smoke; 38% live with smoker 26% currently smoke; 38% live with smoker 78% felt nervous/stressed most or some of the time in last month 78% felt nervous/stressed most or some of the time in last month

13. MATCH Phase I: Goal Selection Phase I: Goal Selection Phase II: Intervention Planning Phase II: Intervention Planning Phase III: Program Development Phase III: Program Development Phase IV: Implementation Phase IV: Implementation Phase V: Evaluation Phase V: Evaluation

14. Intervention Planning: select theory- based approaches Individual ~ tailored health messages Individual ~ tailored health messages Interpersonal ~ lay health advisor programs Interpersonal ~ lay health advisor programs Organizational ~ employee wellness committee projects Organizational ~ employee wellness committee projects Community-societal ~ Community Advisory Committee projects Community-societal ~ Community Advisory Committee projects

15. Intervention Planning: Choose Objectives and Target 1. Provide health information and practical strategies to help individual female employees change unhealthy behaviors (nutrition, smoking, physical activity, weight management, and stress).

16. Intervention Planning: Choose Objectives and Target Intervention Planning: Choose Objectives and Target 2. Provide information and practical strategies to groups of female employees for supporting co-workers in efforts to improve health behaviors.

17. Intervention Planning: Choose Objectives and Target 3. Provide consulting and practical assistance to employee wellness committees to increase organizational (workplace) support for practicing healthy behaviors.

18. Intervention Planning: Choose Objectives and Target 4. Provide assistance and support to a community advisory group for addressing community–wide health and wellness issues.

19. Intervention planning: identify mediators of behavior change for blue collar women 1. Information and knowledge about health behaviors 2. Practical strategies and skills practice 3. Barriers and motivators (all levels) 4. Stage of readiness to change 5. Culture (attitudes)

23. MATCH Phase I: Goal Selection Phase I: Goal Selection Phase II: Intervention Planning Phase II: Intervention Planning Phase III: Program Development Phase III: Program Development Phase IV: Implementation Phase IV: Implementation Phase V: Evaluation Phase V: Evaluation

24. Formative Research for Intervention Planning & Program Development Focus groups (13) with women from each shift were used to determine: Health priorities of women Health priorities of women How women support each other How women support each other Barriers to change Barriers to change Facilitators for change Facilitators for change Program implementation strategies (time, location) Program implementation strategies (time, location) Women’s words for training manuals and tailored messages Women’s words for training manuals and tailored messages

25. Baseline Health Surveys for Intervention Planning and Program Development Demographic information (age, weight, height, ethnicity/race, children, etc.) Demographic information (age, weight, height, ethnicity/race, children, etc.) Health behaviors: exercise, diet, stress, smoking Health behaviors: exercise, diet, stress, smoking Stage of readiness to change Stage of readiness to change Barriers Barriers Behavioral priority Behavioral priority

27. Program Development: Create program components Tailored women’s magazines Tailored women’s magazines --2 magazines, 6 months apart --multiple health behaviors: diet, physical activity, smoking, cancer screening --feedback based on behavioral priority --recipes, advice columns, personalized to individual and workplace

29. Program Development : Create program components Lay health advisor programs highly interactive training sessions for each health behavior as well as social support and program maintenance highly interactive training sessions for each health behavior as well as social support and program maintenance training sessions fun, interactive, provide information and skills practice training sessions fun, interactive, provide information and skills practice

32. Program Development : Create program components Employee Wellness Committees: Representative of all job categories and ethnic groups Representative of all job categories and ethnic groups Consultation and technical assistance from HWW/HWC Consultation and technical assistance from HWW/HWC Choose a wellness or health issue based on survey data Choose a wellness or health issue based on survey data Implement a project to address that issue with emphasis on organizational and environmental level changes Implement a project to address that issue with emphasis on organizational and environmental level changes

35. Program Development : Create program components Community Advisory Committee: Community Advisory Committee: Provides advice, consultation and direction to the Center and HWW: key to participatory research Provides advice, consultation and direction to the Center and HWW: key to participatory research Members are from workplaces, local health departments, Healthy Carolinians, migrant- community health center, domestic violence agencies, cooperative extension, mental health, dispute settlement center, and the state health dept. Members are from workplaces, local health departments, Healthy Carolinians, migrant- community health center, domestic violence agencies, cooperative extension, mental health, dispute settlement center, and the state health dept. Chooses, plans, organizes and implements community-wide health and wellness activities Chooses, plans, organizes and implements community-wide health and wellness activities

36. MATCH Phase I: Goal Selection Phase I: Goal Selection Phase II: Intervention Planning Phase II: Intervention Planning Phase III: Program Development Phase III: Program Development Phase IV: Implementation Phase IV: Implementation Phase V: Evaluation Phase V: Evaluation

37. Plans and timelines Production and distribution of tailored messages Production and distribution of tailored messages Recruit LHA’s, develop materials and training programs Recruit LHA’s, develop materials and training programs Employee wellness committees: recruit members, develop session outlines and strategies Employee wellness committees: recruit members, develop session outlines and strategies Community Advisory Committee: form committee, develop plans and strategies with the committee Community Advisory Committee: form committee, develop plans and strategies with the committee

38. Implementation Preparations STEP 1: Develop implementation plan Tailored messages: plans for distribution through workplace channels Tailored messages: plans for distribution through workplace channels Natural helpers: recruit natural helpers and provide trainings (at the workplace, usually not on work time) Natural helpers: recruit natural helpers and provide trainings (at the workplace, usually not on work time)

39. Implementation Preparations Employee Wellness Committees: work with management contacts to recruit committee members representative of all sections/employees; set first meeting and agenda Employee Wellness Committees: work with management contacts to recruit committee members representative of all sections/employees; set first meeting and agenda Community Advisory Committee: recruit members based on formative work and previous contacts; set first meeting and agenda Community Advisory Committee: recruit members based on formative work and previous contacts; set first meeting and agenda

40. Implementation Preparations STEP 2: STEP 2: Select and train staff Select and train staff Include process evaluation and feedback Include process evaluation and feedback

41. Employee Wellness Committee Accomplishments Vending machine changes Vending machine changes Canteen food options (fruit, yogurt, salads) Canteen food options (fruit, yogurt, salads) VCR in break room VCR in break room Wellness bulletin boards Wellness bulletin boards Fundraising to build a walking trail Fundraising to build a walking trail Walking groups Walking groups Work stretch breaks Work stretch breaks Health fairs and health screenings Health fairs and health screenings

42. Community Advisory Committee Projects Women’s Empowerment Days: Planned and implemented by the Community Advisory Committee Planned and implemented by the Community Advisory Committee Address health and economic needs of blue collar women Address health and economic needs of blue collar women Community-wide events Community-wide events New linkages among agencies New linkages among agencies

43. Lessons Learned about intervention planning, program development and implementation~ Plan WITH the participants: Formative research: ask, listen, and use the data (qualitative and quantitative). Formative research: ask, listen, and use the data (qualitative and quantitative). Relationships are key, and take time. Relationships are key, and take time. Build on previous work and contacts. Build on previous work and contacts. Address unique barriers and motivators. Address unique barriers and motivators.

44. Lessons Learned about intervention planning,program development and implementation~ Use the Socio-Ecologic model. Use the Socio-Ecologic model. Flexibility is important in planning. Be sure to allow for mid-course corrections. Flexibility is important in planning. Be sure to allow for mid-course corrections. Real-world problems WILL occur; e.g, manufacturing workplace constraints; economic and community changes. Real-world problems WILL occur; e.g, manufacturing workplace constraints; economic and community changes.

45. Lessons Learned about intervention planning, program development and implementation~ Health Works for Women/Health Works in the Community: A rewarding experience for the researchers and the participants A rewarding experience for the researchers and the participants Contributions to practice and research; development of next project Contributions to practice and research; development of next project

48. HOPE Works (2004-2009) Builds on HWW-1 and HWW-2/HWC Builds on HWW-1 and HWW-2/HWC Community-based participatory research project, active participation of Community Advisory Committee Community-based participatory research project, active participation of Community Advisory Committee Addresses high prevalence of obesity… Addresses high prevalence of obesity… …and addresses social determinants of health (education, employment, living situations) …and addresses social determinants of health (education, employment, living situations) Modeled on loan circles/microenterprise Modeled on loan circles/microenterprise

50. Planning for HOPE Works (2003-2004) CAC women trained to lead focus groups (8 focus groups conducted) CAC women trained to lead focus groups (8 focus groups conducted) CBPR Process/Committees formed: CBPR Process/Committees formed: Facilitator trainingFacilitator training MarketingMarketing KickoffKickoff Evaluation (baseline and community surveys)Evaluation (baseline and community surveys)

51. HOPE Works Intervention HOPE Circles: Low income, overweight women, African American, Latina, Coharie, Anglo Low income, overweight women, African American, Latina, Coharie, Anglo Community women trained as facilitators to lead Circles Community women trained as facilitators to lead Circles Provide social support, strategies for weight management, goal-setting for health and life improvement (school, jobs) Provide social support, strategies for weight management, goal-setting for health and life improvement (school, jobs)

52. HOPE Works Intervention Monthly tailored messages on health and life goals Monthly tailored messages on health and life goals Community-wide events (walk-a- thon, kickoff/health fairs, connection with community groups and events) Community-wide events (walk-a- thon, kickoff/health fairs, connection with community groups and events)

53. Community Partner: MBA (Multicultural Business Alliance)

54. HOPE Works Intervention Community Coordinators Community Coordinators Facilitator Recruitment Facilitator Recruitment Facilitator Training Facilitator Training HOPE Circles: surveys and baseline data; comparison groups HOPE Circles: surveys and baseline data; comparison groups

57. Seeds of HOPE Threads of HOPE Seeds: Using CBPR to address economic empowerment: strategic planning year Seeds: Using CBPR to address economic empowerment: strategic planning year Seeds Circles: voter registration, financial literacy Seeds Circles: voter registration, financial literacy Threads: formative work with Latina’s to pursue micro-enterprise Threads: formative work with Latina’s to pursue micro-enterprise

61. Bumps (challenges and opportunities!) CBPR CBPR Staff changes; timeline Staff changes; timeline PAR Q PAR Q First wave as pilot: flexibility to improve First wave as pilot: flexibility to improve Controls Controls

62. HOPE Works, August 2006 3 Circle Leader trainings 23 Circles complete or ongoing

64. Preliminary data: random community surveys (500) What do you believe is the single biggest issue facing your community today? Jobs and the economy Jobs and the economy Drugs/alcohol Drugs/alcohol Social change/social capital Social change/social capital Poverty Poverty Hispanic immigration Hispanic immigration Cost of health care, prescriptions Cost of health care, prescriptions Environment (hog, poultry farms, landfill) Environment (hog, poultry farms, landfill)

65. “No jobs. Most of the factories are closing—send the work overseas. If they keep this up no one will be able to buy their products when it comes back to America because no one will have jobs. The gas prices have increased faster than the cost of living increases in wages. Depression is hitting everyone because they cannot afford what they’ve been having. No jobs, no pay increase, but everything keeps going up. Yes everything was better years ago. So obesity and health problems are on the rise. This problem will continue to increase as long as there is no jobs and depression from losing everything grows.” “No jobs. Most of the factories are closing—send the work overseas. If they keep this up no one will be able to buy their products when it comes back to America because no one will have jobs. The gas prices have increased faster than the cost of living increases in wages. Depression is hitting everyone because they cannot afford what they’ve been having. No jobs, no pay increase, but everything keeps going up. Yes everything was better years ago. So obesity and health problems are on the rise. This problem will continue to increase as long as there is no jobs and depression from losing everything grows.”

66. “In my community we don’t have anywhere for the children to go like a recreation center and its hardly any stores or restaurants where I live it’s a very small town. Something about me I am 31 years old, single mother with asthma. I have 3 children ages 10, 7 and 5. I would really like to lose weight for my health and to do more things with my children. I weigh about 300 pounds right now. And its hard for me to try and exercise because of my asthma and then my breasts are real big.”