Reducing Cardiovascular Disease one woman at a time!

Natasha DangEsha Fletcher

Andrea DePetris

Open Minds & Healthy Hearts

RFP #3

Proposals are being solicited for developing, delivering, and evaluating programs to reduce CVD mortality and morbidity among high-risk women through medical screening and risk behavior modifications. The CVD prevention programs must be targeted towards high-risk racial and ethnic minority women, aged 40 years and older; however, all high-risk women shall be eligible to participate in the programs regardless of race, religion or age. Each grantee shall propose to implement one program in 10 faith-based or community-based sites across Connecticut, including urban and rural areas. The main goal will be for program participants to increase their level of physical activity and establish or maintain a healthy weight over the course of the program. A comprehensive evaluation plan must accompany the proposal.

Healthy People 2020Overarching Goal: “Improve cardiovascular health

and quality of life through prevention, detection, and treatment of risk factors for heart attack and stroke; early identification and treatment of heart

attacks and strokes; and prevention of repeat cardiovascular events.”

Mission Statement

The Open Minds and Healthy Heart Programs in Connecticut are committed to providing quality, cardiovascular-related preventative services to

minority women and their families. Our dedicated team of professionals strive to

provide the community with knowledge and resources, along with instilling confidence and motivation to pursue a holistically healthy life.

Program Goals1. Lower the prevalence of risk factors for Cardiovascular disease (CVD)

among high-risk minority women

2. Reduce the incidence of heart disease in Connecticut

3. Reduce hospitalization rates for minority women as a result of heart-disease related conditions

4. Reduce health disparities among races or ethnicities

5. Increase overall awareness of Cardiovascular disease, as well as levels of both physical activity and self-efficacy among high-risk ethnic women throughout the duration of the interventions

6. Increase knowledge and awareness of high-risk ethnic women on the benefits of proper diet throughout the duration of the interventions

Mind Body & SoulEducating the Mind, Exercising the Body &

Nourishing the Soul

Esha Fletcher

Background• Few unsettling stats:

• CVD kills nearly 50,000 African-American women annually

• Of African-American women ages 20 and older, 49% have heart diseases

• Only 1 in 5 African-American women believes she is personally at risk

• Only 52% percent of African-American women are aware of the signs and symptoms of a heart attack

• Only 36% of African-American women know that heart disease is their greatest health risk

Program Objectives

• 1. Short-term- Within the first month, get participants to make small changes such as changing one bad eating habit

• 2. Short-term- Increase physical activity to at least one hour a week outside of the program

• 3. Intermediate- Look for 90% participation every week during the meetings

• 4. Intermediate- 70% improvement in the percent of participants performing average or better for the cardiovascular step test

• 5. Long-term- Reduce 5% body fat in all participants

• 6. Long-term- Reduce the risk factors of CVD in 95% of the participants that were active in participation over the 16 weeks

Goal-Setting Theory

Five Principles:• Clarity, Challenge, Commitment, Feedback,

Task Complexity• The goal setting theory will be pushed

because it challenges the participants to set meaningful and challenging goals. Dr. Edwin Locke, the creator of the goal setting theory found that setting clear goals and giving feedback, motivates people.

Concept Definition Application

Clarity Make clear goals so its known what you are trying to achieve and what behaviors to reward. Does the challenge motivate you?

Have participants write SMART goals on physical activity, diet and nutrition throughout program

Challenge Make goals challenging and motivating but achievable. Develop self-discipline and have persistence. Is it challenging enough to spark interest?

Coach participants to make strong goals with milestones to challenge themselves. Create friendly competition b/w groups or prayer partners. Competition can encourage participants to work harder

Commitment Being dedicated to a cause or activity. Commitment can be gained if person believes the goal is achievable and it follows their ambition

Participant more likely to stay committed if they understand and agree to goal. Creates commitment and sense of empowerment

Feedback Listening to feedback at each milestone and having opportunity to clarify expectations and adjust goals if necessary.Feedback can also be done by measuring your own progress.

Scheduling time each week to give participants feedback by analyzing their progress and accomplishments, while making adjustments along the way

Task Complexity Checking to ensure work doesn’t become too overwhelming when goals are highly complex. Give self plenty of time to accomplish goals and deadlines

Giving everyone training needs assessment, to identify any knowledge or skills gaps

Health Belief Model

Concept Definition Application

Perceived Susceptibility

One’s opinion of chances of getting a condition

Have participants take a poll on how many people they think have CVD, give them statistics and risk factors

Perceived Severity

One’s opinion of how serious a condition and its consequences are

Symptoms, effects, polling results. How many do you know people that died from disease? Does it affect one race more than another?

Perceived Benefits

One’s belief in the efficacy of the advised action to reduce risk or seriousness of impact

Discuss success stories, benefits of program, weight loss, how life would change after the lifestyle changes have been made

Perceived Barriers

One’s opinion of the tangible and psychological costs of the advised action

Tackle the “I can’t” do it thoughts, explain its not a sprint its a marathon, can be done but takes time and dedication

Cues to Action Strategies to activate “readiness”

Meetings, getting involved, using theory, making personal connections, working one-on-one and showing you’re invested

Self-Efficacy Confidence in one’s ability to take action

Discuss with them the importance of checkpoints, small wins, such as, only ate fried foods once this week

Explanation PlanProcess

• 3 year program• Held in churches (6 intervention, 4 control)• 16-week intervention (3 in a year)= 2 years of interventions• Intervention groups meet twice/week• 90 mins sessions- weekly educational topic, homework

assignments, 30 mins physical activity, devotional, weekly scripture and discussion

• Lottery, drawings and prize giveaways• Weekly checking of vitals• Weekly emails sent out to remind participants to exercise & work w/

prayer partners• Lessons on signs and symptoms of CVD

Design & Measurement

ToolsDesignYear 1: 6 months: Planning, funding approval, training health professionals, IRB consent forms, rolling recruitment, focus groups, randomly assign intervention and control groups, marketing 6 months: Start of intervention, data collection, participant consent formsYear 2: Continue intervention and rolling recruitmentYear 3: 6 months: Continue intervention 6 months: Data analysis, follow-up, program evaluation, phone surveys

Tools

• Baseline Assessment: height, weight, blood pressure, BMI, % body fat

• Resistance Bands• Pedometers• Cardiovascular fitness step test• Scales• Skin fold calipers• CPR equipment

Weekly Meetings Overview

Weekly Topics

• Food basics (carbs, fats, protein)• Reading food labels• Understanding Serving Sizes• DASH diet & guidelines• Meal Planning• Incorporating Fruits & Vegetables• Cultural Eating Habits• Holiday Survival Guide• Food Journaling• Readiness to Change:

Pedometers• Reducing & Lowering Risk Factors• Integrating Nutrition Knowledge

Weekly Handouts

• Spiritual scriptures w/ buddy• Heart-Healthy Recipes• Choosing Foods at Grocery

Stores• Snacks & Eating on the Go• CVD Signs & Symptoms• CPR Training• Heart-Healthy Exercise• Heart-Healthy Cooking Tips for

Family• Women CVD Facts• Nutrition Flashcards• Walking Challenge• Extreme Food Makeover• Healthy Dining Out

Program BudgetStaff

• Esha- $65,000/yr Data Analyst- $13/hr

• Andrea- $65,000/yr Snap Educators- $19/hr

• Natasha- $65,000/yr Fitness Specialist- $50/hr

• Nurse- $40/hrKickboxing- $40/hr

• Dietitian- $30/hrZumba/Aerobics- $40/hr

Recruitment/Marketing• Flyers, Newspaper, Radio- $100

Materials• Pedometers- $1.50 each

Nutrition Education Materials- $0.02/ sheet• Resistance Bands- $9 each

Surveys, Questionnaires- $0.02/ sheet• Food Journals- $5 each

Lottery, Drawings, Prizes- $20/week• Posters/Visuals- $16

Biometric Screenings• Health Screenings- $25 Skin Fold Calipers-

$25 (5)Other

• Cooking Classes (food, utensils)- $90/week Projected Program Cost: $850,000

Marketing• Social Media- Facebook, Twitter, Instagram,

Blog

• Church Bulletin- every Sunday

• YWCA (Young Women's Christian Association)

• Newspaper

• Doctors

• Church Website

• Radio

Sources of Funding

• American Heart Association- Go Red Campaign

• CDC: National Implementation and Dissemination for Chronic Disease Prevention (CDC-RFA-DP14-1418

• NIH: Self-management for Health in Chronic Conditions

• YWCA

• Private Donors

• Local Churches

One Love, One

HeartNatasha Dang

Program Rationale• CVD is the #1 killer on the top ten leading causes

of death for women in the U.S.• Attributed to lower awareness/education and

higher prevalence of risk factors/atypical symptoms

• Higher mortality/morbidity rates from CVD• 2003 Survey → Determined a knowledge deficit for

heart disease• 5 major risks• Ethnic minority women most at risk• CVD modifiable through lifestyle changes

The InterventionTo reduce the risk of CVD

of high-risk minority women by increasing physical activity and

prolonging the maintenance a healthy

weight through community-based sites

Trans-Theoretical Model

• Stages of change• All participant volunteers at contemplative stage

or higher• Material tailored to each participant• Studies show that it is time consuming, but

effective

MATCH ModelPhase 1Health Goal

Selection

Phase 4Implementa

tion

Phase 3Developm

entPhase 5

Evaluation

Phase 6Health Status

(Morbidity,

Mortality, &

Wellness)

Phase 2Interventi

on Planning

Phase 1: Health Goal Selection• Overarching goals:

• ↑ awareness and knowledge of PA and diet, ↓ prevalence of risk factors and CVD, and ↓ mortality & morbidity from CVD, maintenance of weight loss

• Priority population:• High-risk, postmenopausal, minority women of low-

socioeconomic status• Behaviors/Environmental Factors associated with

current health status:• High salt/fat/sugar intake in diet• Smoking• Obesity• Physical Inactivity• Poverty (food insecurity)

• Time restraints• Safety Concern• Lack of transportation

Phase 2: Intervention Planning• Target of intervention actions:

• Individual Level: Behavioral change influences actions or habits

• Organizational Level: Members of a community are influenced by their organizational leaders and residents

• Community Level: Individuals learn by practices and norms in the community

• Intervention Actions: • Morbidity, mortality, and wellness are changed by the

use of facilitation, activities, resources, practices, and education

Program ObjectivesAt the end of the program:

• At least 90% of the participants will have increased awareness for the risk factors of heart disease

• At least 50% of the program volunteers will participate in monthly health screenings.

• There will less than a 30% attrition rate• The number of participants who integrate an exercise

routine into their daily life will be statistically significant (p <0.05)

• Health screenings post-intervention will determine that at least 20% of the participants will be less at risk for CVD

Program ObjectivesAt the end of the program:

• 100% of all participants will have learned at least one cooking skill that can be used daily

• At least 20% of the participants will eat a diet with less fat content from the start at baseline

• At least 80% of the participants will complete the posttest

Phase 3: Program Development• Program Components:

STEP 1 STEP 2 STEP 3 STEP 4

January 1st 2015

July 1st 2015

July 2nd 2015October 1st

2015

October 2nd 2015

January 1st 2016

January 2nd 2016

July 1st 2017

6 Month Interval

3 Month Interval 3 Month Interval 18 Month Interval

Program Planning,

Development, and

Recruitment

Community Counseling Sessions

Maintenance Sessions

Program Evaluation

and Write-Up

Phase 3: Program Development• Proposed Intervention Setting:

• The program will be directed towards the New Haven County in CT• Highest poverty rates• High rate of obesity

• Proposed Intervention Approach:• Community Organizations

• Center for Black Women’s Wellness• Ct Chapter, Mocha Mom’s• Alpha Kappa Alpha Sorority, Inc. (AKA)• African American Cultural Society

Phase 4: Implementation• Supportive Evidence:

• Participants view positive support from others and active opposition to cultural norms as critical for maintenance

• Strategies are set in place to maintain lost weight if participants “struggle”

• Focus groups aided maintenance of healthy weight• Strategies:

• Multifaceted approach to intervention• Medically Trained Personnel • Social media and social support

Evaluation Plan• Process:

• ROI: $5.60 for every dollar spent over five years• Treatment costs much higher than implementing a

health promotion program• Satisfaction Ratings by participants

• Summative:• A questionnaire or survey is used to measure

knowledge/awareness of CVD related risk factors via posttest

• Post intervention health screening to identify the same risk factors from baseline

• Outcome Evaluation:• A questionnaire will be administered at a 5-year and

10-year interval post intervention

Program DesignSTEP 1 STEP 2 STEP 3 STEP 4

6 Month Interval 3 Month Interval 3 Month Interval 18 Month Interval

Program Planning, Development, and

Recruitment

Community Counseling Sessions

Maintenance Sessions Program Evaluationand Write-Up

IRB Consent form, Training

professionals, Marketing and

advertisements, Data Analysis,

Funding Approval, Seminar Designs

Lectures, cooking classes, low-

moderate physical activity, health

demonstrations, videos, field trips to

grocery stores, fitness centers,

restaurants, tracking food intake

Focus groups, social support, social media,

low-moderate physical activity

Data Analysis, follow-up, program

evaluation submitted

Measurement Tools• Anthropometric Data [Scales, BP cuff,

measurement tape]• Height, weight, waist circumference, BMI, BP

• Biochemical Data [Lab Reports]• Lipid panels (blood cholesterol), Metabolic

panels (sodium)• Surveys/Questionnaires before, during, and after

intervention (follow-up)• Reports from focus groups and social media• Cooking equipment• Other tools: lecture curriculum,

classroom/community center

Abridged Financial Budget

Marketing Strategies1. E-mail2. Formal Letters to Org.

leaders3. Social Media

a. Facebookb. Instagram

4. Program Website5. Advertisements to the public

(newspapers, online)

Funding Opportunities1. The Myocarditis Foundation

Supports an investigator proposing innovative basic, clinical or translational research projects relevant to the etiology, pathophysiology, diagnosis, treatment epidemiology and/or prevention of myocarditis [CHF].

2. The American Heart AssociationResearch broadly related to cardiovascular function and disease and stroke, or to related clinical, basic science, bioengineering or biotechnology, and public health problems, including multidisciplinary efforts.

Funding Opportunities3. Centers for Disease Control & Prevention

This FOA will support effective implementation of existing policy, systems and environmental improvements, and offers opportunities for communities to take comprehensive action to address risk factors contributing to the most common and debilitating chronic conditions. These risk factors include tobacco use and exposure, poor nutrition, physical inactivity, and lack of access to chronic disease prevention, risk reduction and management opportunities.

4. Prevention and Public Health FundsThis Funding Opportunity Announcement (FOA) supports implementation of population-wide and priority population approaches to prevent obesity, diabetes, and heart disease and stroke and reduce health disparities in these areas among adults.

ReferencesIntroduction to Evidence-Based Practice. (2014, September 5). Retrieved October 16, 2014, from http://guides.mclibrary.duke.edu/content.php?pid=431451&sid=353 0453.

RACIAL AND ETHNIC APPROACHES TO COMMUNITY HEALTH (REACH). (2014, July 14). Retrieved October 16, 2014, from http://www.cdc.gov/nccdphp/dch/programs/reach/about.htm

Villablanca, A., Arlene, S., Lewis, J., Raju, S., Sanders, S., & Carrow, S. (2009, June 30). Outcomes of national community organization cardiovascular prevention programs for high-risk women. J Cardiovasc Transl Res; 2(3): 306–320. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19654887.

Chronic Disease Prevention and Health Promotion. (2014, July 15). Retrieved November 15, 2014, from http://www.cdc.gov/chronicdisease/about/statelocalpubhealthactions-prevcd/index.htm

Heart Disease and Stroke. (2014, November 18). Retrieved November 18, 2014, from https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke

Barnes, A. Weight Loss Maintenance in African American Women: Focus group Results and Questionaire Development(2001, July).

Questions?

Heal and Soul

Andrea DePetris

Program Goals1. Increase awareness and knowledge of CVD among

parishioners throughout CT2. Lower CVD risk profiles of parishioners3. Increase overall levels of physical activity (PA) among

parishioners4. Increase levels of motivation and self-efficacy among

participants5. increase knowledge about nutrition and healthy eating

Program Objectives1. 90% of participants in the active intervention groups will attend at least one

of the two weekly sessions.2. 100% of participants in the active intervention groups will participate in the

angel motivation for walking program.3. There will be significant, positive improvements of at least 3 of the 13 CVD

physiological outcomes for at least 60% of participants in the active intervention group

(weight, BMI, waist circumference, body fat %, SBP, DBP, LDL-C, energy intake,

4. At least 60% of participants with a BMI ≥ 25 will lose 5% of their body weight by the end of the 16 week standard intervention.

5. Reported levels of self-efficacy for physical activity will improve for 100% of participants

6. 95% of participants in the active intervention sessions will fill out satisfaction surveys after each session

Bopp et. al 2009; Dodani and Fields 2010; Yanek et al. 2001)

Behavior TheorySocial Cognitive Theory- Interpersonal level theory- Reinforcement

- direct reinforcement (ex: verbal praise, weight loss, increased energy levels)

- vicarious reinforcement (ex: family spotlight, angels)- self-reinforcement (ex: returning walking logs and increasing

steps, healthy treat/ activity, lottery entry)- Self-efficacy

- performance attainment (ex: skill building & exercise mastery)- vicarious experiences (ex: observing peers, church leaders,

exemplars)- verbal persuasion (ex: peers, angels, PT, educators, church

leaders)- emotional arousal (ex: interpreting one’s emotional state with

PT)(McKenzie, Neiger, and Thackery 2009)

Planning Model 1Health Belief Model- Value expectancy theory- Health-related action depends on the simultaneous

occurrence of:- existence of sufficient motivation (or health concern) to

make health issues salient/ relevant- perceived threat (belief that one is vulnerable)- belief that following a particular health recommendation

would be beneficial to reducing perceived threat at an acceptable cost

- Recognizes self-efficacy as a perceived barrier

(McKenzie, Neiger, and Thackery 2009)

Planning Model: Health Belief Model

http://en.wikipedia.org/wiki/File:The_Health_Belief_Model.pdf

Planning Model 2PRECEDE-PROCEED Model- outlines the steps which precede an intervention and

provides guidance on how to proceed with implementation evaluation

- participatory process involving all stakeholders- health is a community issue

(McKenzie, Neiger, and Thackery 2009)

PRECEDE

PROCEED

Evaluation Plan: Process- Focus groups and pilot testing in both an urban and rural

area of Connecticut- Focus groups assembled prior to implementation, at the

end of month 2, at the end of month 4, and after 12 months- Paper surveys will be collected after the PA portion of each

bi-weekly meeting (before dinner and nutrition segment)- In-depth interviews with church leaders and lay participants- Informal interviews will be on-going- Protocol checklists (fidelity)

Evaluation Plan: Summative- Regression analyses will be used to assess for trends and

significance in changes in CVD risk profiles, self-efficacy for PA, social support for PA, weight loss (lbs and %), changes in both physical activity and nutrition, physical activity enjoyment, depression, and general health status

- Prevalence of CVD/ CVD risk post-intervention will be assessed, as well as knowledge about CVD

Program Design(Prior to year one, obtain IRB approval from UConn)Year 1:

- establish community expert panels, obtain informed consent, focus groups, pilot intervention in both a rural and urban setting

- cluster large, active churches in CT by region & select participating churches randomly - randomly assign churches to intervention (6) and comparison groups (4)

Year 2:Intervention and Comparison groups

- health fair (screening, baseline data collection)- one day church retreats (small groups going to stations): motivational sessions, intro. to nutritional

education, intro to PA, focus groups, light yoga, massage, review of results from baseline screenings with nutritionist, discussion of barriers to PA, intro. to angel program and angel pairings

- handout pedometers: collect one week’s worth of dataYear 3: (3 months)

- health fair and data collection, focus groups, interviews, fidelity checklists, analysis of results

- health fair and data collection, focus groups, interviews, fidelity checklist

Sample Presentation TopicsNutrition: spirituality and health, creating a healthy environment, strategies for overcoming barriers related to healthy eating, reading food labels, planning healthy meals, modifying recipes, stress reduction, portion size, grains and fiber, why we eat, meats & meat alternatives, dining out, breakfast, lunch, & snacks, holiday eating, vegetables: benefits/ preparationExercise:benefits of PA, sweating out your ‘do, proper exercise attire, building PA into your day at work/ home, goal setting, exercise angels, self-reward, stretching & flexibility benefits, other aerobic exercise, hot/ cold weather exercise, minor injuries, fitness walking, heart rate, cues and prompts, exercise interruptions, long-term maintenance of exercise

(Bopp et. al 2009; Yanek et al. 2001)

Measurement ToolsMedical Materials: calibrated digital scale, bioelectrical impedance tool, tape measure, sphygmomanometer, UConn laboratory, pedometersHealth History: demographic form, medical history packetQuestionnaires: the Physical Activity Readiness Questionnaire, the Block Food Questionnaire, the Self-Efficacy for Exercise Questionnaire, the Behavioral RIsk Factor Surveillance Survey Questionnaire (general health status and access questions), the Yale Physical Activity Survey, the Center for Epidemiological Studies-Depression, the Social Support for Diet and Exercise Questionnaires, the Physical Activity Enjoyment Scale

Bopp et. al 2009; Resnicow et al. 2002; Yanek et al. 2001)

Program Budget

Total Projected Costs for 2.25 years: $750,000

Marketing Strategies (Parishioners)Church Website

Church Bulletin (pastor plugs, weekly health newsletter)Weekly Angel phone callsFamily video camera footage shared on church projectorNourishing the Soul cookbookCD & Poster disseminationPartnerships with local bodegas, health food stores, supermarkets, and restaurantsSocial Media- Facebook, Twitter, Instagram

Resnicow et al. 2002; Yanek et al. 2001)

Marketing Strategies (Stakeholders)health is a community concern

goal: increase longevity of community, uplift the community, empower the communitychurch is a community stronghold, place of safety and sanctity, a holistic site of healingby reducing rates & risk of CVD, community members can live to rear the next generationwomen are generally at the center of a family, especially in racial/ ethnic minority communities, and can influence others in the householdprogram will be cost-effective and sustainable, decreasing hospital expenditures, and decreasing racial/ ethnic health disparities

Potential Funding SourcesNIH: Behavioral and Social Science Research on Understanding and Reducing Health Disparities ( R01/R21)NIH: Self-Management for Health in Chronic Conditions (R15)Catalog of Federal Domestic Assistance: Minority Health and Health Disparities Research Project Grants #93.307Rural Assistance Center for ORHP Cooperative AgreementLocal YMCAsThe National Academy of Sports Medicine

References Bopp, M., Wilcox, S., Laken, M., Hooker, S. P., Parra-Medina, D., Saunders, R., ... & McClorin, L. (2009). 8 Steps to Fitness: a faith-based, behavior change physical activity intervention for African Americans. Journal of physical activity & health, 6(5), 568.

•Dodani, S., & Fields, J. Z. (2010). Implementation of the Fit Body and Soul, a Church-Based Life Style Program for Diabetes Prevention in High-Risk African Americans A Feasibility Study. The Diabetes Educator, 36(3), 465-472.

•McKenzie, J. F., Neiger, B. L., & Thackera, R. (2009). Planning, Implementing, And Evaluating Health Promotion Programs: A Primer Author: James F. McKenzie, Brad L.

•Resnicow, K., Jackson, A., Braithwaite, R., DiIorio, C., Blisset, D., Rahotep, S., & Periasamy, S. (2002). Healthy Body/Healthy Spirit: a church-based nutrition and physical activity intervention. Health Education Research, 17(5), 562-573.

•http://en.wikipedia.org/wiki/File:The_Health_Belief_Model.pdf

•Yanek, L. R., Becker, D. M., Moy, T. F., Gittelsohn, J., & Koffman, D. M. (2001). Project Joy: faith based cardiovascular health promotion for African American women. Public health reports, 116(Suppl 1), 68.

https://www.goredforwomen.org/home/live-healthy/

http://www.mindtools.com/pages/article/newHTE_87.htm

http://www.utwente.nl/cw/theorieenoverzicht/theory%20clusters/health%20communication/health_belief_model/

Woods G, Levinson AH, Jones G, Kennedy RL, Johnson LC, Tran ZV, Gonzalez T, Marcus AC. The Living Well by Faith Health and wellness program for African Americans: an exemplar of community-based participatory research. Ethn Dis. 2013 Spring;23(2):223-9

Questions?