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Journal of Health Care for the Poor and Underserved, Volume 26, Number 2, May 2015 Supplement, pp. 96-103 (Article) 3XEOLVKHGE\-RKQV+RSNLQV8QLYHUVLW\3UHVV DOI: 10.1353/hpu.2015.0057

For additional information about this article http://muse.jhu.edu/journals/hpu/summary/v026/26.2A.nitta.html

Access provided by University of Hawaii @ Manoa (14 Jul 2015 01:31 GMT)

REPORT FROM THE FIELD

Policy, System, and Environment Strategies to Promote Physical Activity and Healthy Food Sources to Address Guam’s Disparate Non-Communicable Disease Burden Mavis Nitta, MPH, CHES Charles Tanner, MHA, MEd, FACHE Khrysthynn Narvarte Patrick Luces Alexis Silverio Roselie Zabala, MSW Dioreme Navasca, MPH Angela Sy, DrPH Neal A. Palafox, MD, MPH Summary: In 2013, the Guam Non-Communicable Disease (NCD) Consortium, Department of Public Health and Social Services, and University of Hawaii collaborated to address Guam’s NCD burden. This field report describes their efforts to implement policy, system, and environmental interventions through the worksite wellness and community garden programs. Key words: Guam, worksite wellness, community garden, physical activity, healthy food, health disparities, Pacific Islander, policy, system, and environment change.

Issue The United States Affiliated Pacific Islands (USAPI) comprises the territories and jurisdictions of American Samoa, Guam, Commonwealth of the Northern Mariana MAVIS NITTA, DIOREME NAVASCA, and NEAL PALAFOX are affiliated with the Department of Family Medicine and Community Health, John A. Burns School of Medicine at the University of Hawai‘i at Manoa. CHARLES TANNER and KHRYSTHYNN NARVARTE are members of the Guam NonCommunicable Disease Consortium, a partner with the Guam Department of Public Health & Social Services. PATRICK LUCES is affiliated with the Guam Diabetes Prevention and Control Program at the Guam Department of Public Health & Social Services, Bureau of Community Health Services. ALEXIS SILVERIO is affiliated with the Guam Office of Minority Health at the Guam Department of Public Health & Social Services. ROSELIE ZABALA is affiliated with the Guam Department of Public Health & Social Services, Bureau of Community Health Services. ANGELA SY is affiliated with the School of Nursing and Dental Hygiene at the University of Hawai‘i at Manoa. Mavis Nitta is the corresponding author and can be reached at the Department of Family Medicine and Community Health John A. Burns School of Medicine, University of Hawai‘i, 677 Ala Moana Blvd.—Suite 815, Honolulu, HI, 96813, and by email at [email protected]. © Meharry Medical College

Journal of Health Care for the Poor and Underserved 26 (2015): 96–103.

Nitta, Tanner, Narvarte, Luces, Silverio, Zabala, Navasca, Sy, and Palafox

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Islands, Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau. Five of the top 10 most obese countries were reported to be in the Pacific region. Two of the top 10 were in the USAPI: Republic of the Marshall Islands and Federated States of Micronesia.1 Guam, a U.S. Pacific territory since 1950 and the largest island in the USAPI, suffers from disparate levels of non-communicable disease (NCD) risk factors compared with the U.S. In Guam, 72% of Chamorro adults are overweight and obese2 compared with 69% of U.S. adults.3 The overall obesity rate in Guam increased an average of 2.9% each year, which amounted to a 26.4% increase in the prevalence of obesity from 2001 to 2009.4 In 2013, 20% of high school students were obese compared with 13.7% in the U.S. Guam has high death rates from heart disease and stroke (254.9 and 71.6 per 100,000 respectively).5 Notably, Guam’s total per capita expenditures on health amounted to $1,032 compared with the U.S. at $8,233 in 2014.6 Complex socio-demographic factors have contributed to Guam’s heavy burdens of NCD. In 2010, 23% of Guam’s population were in poverty while 15% were in poverty in the U.S.7,8 The gross domestic product (GDP) per capita of the U.S. ($51,749) is 2.3 times greater than Guam’s GDP ($22,293).9 In Guam, 21% of the 25 and older population, did not receive their diploma compared to 13% of the U.S.10,11 To address Guam’s NCD burden, the Guam NCD Consortium (Consortium) was established by the Guam Department of Public Health and Social Services (DPHSS) in 2011. The Consortium—which consists of representatives from the local community organizations, private business, government agencies, and the legislature—developed an NCD Strategic Plan. The plan guides efforts to address Guam’s major NCD health risks, including smoking, unhealthy nutrition, excess alcohol, lack of physical activity, and obesity.

Description The DPHSS and Consortium worked with the Department of Family Medicine and Community Health (DFMCH), John A. Burns School of Medicine at the University of Hawaii to implement strategies for the Worksite Wellness Program (WWP) and Community Garden Program (CGP). This project entitled Strategies to Research and Implement a Vision in Health Equity (STRIVE) was funded through the Asian and Pacific Islander American Health Forum and the New York University Center for the Study of Asian American Health. These institutions were supported by the Centers of Disease Control and Prevention’s Racial and Ethnic Approaches to Community Health program. The STRIVE goal was to implement high-impact, population-wide, and evidence-based strategies that reduce health disparities in Guam due to the lack of physical activity, poor nutrition, and weight. The WWP has demonstrated health benefits, such as positive effects on diet, exercise, physiologic markers, and health care costs.12 In 1998 and 2009, Executive Orders were established to promote physical activity and wellness programs to Government of Guam employees. Many of the government employees did not participate due to a lack of support for program implementation. In 2012, Guam’s Governor Edward B. Calvo signed Executive Order 2012-07 (EO 12-07) that re-established the Guam Gov-

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Addressing Guam’s NCD burden

ernment WWP. Under EO 12-07, the government employees were allowed three paid hours a week to exercise or attend health education sessions and required government agencies to designate health coaches to serve as liaisons for the WWP. Health coaches taught their colleagues about nutritious and healthy lifestyle choices pertaining to NCD prevention. A standardized health coach training program was established to train coaches about prevention of NCDs through lifestyle modification and nutrition, and to enhance coaching skills. The WWP was designed to develop health policies, promote healthy behaviors, improve employees’ health knowledge, and help employees obtain the necessary NCD health screenings and follow-up care. The CGP improves access to fresh fruits and vegetables, creates opportunities for physical activity and education, and empowers communities to create sustainable environmental changes.13 In 2012, community gardens were pilot-tested at four Mayor’s offices and with 13 families. Due to the popularity of the CGP environmental intervention, the Consortium expanded community gardens to provide fresh produce to 18 more communities under the STRIVE grant. The CGP promoted the health benefits of growing and consuming fresh fruits and vegetables and increasing physical activity through gardening.

The Programs The Consortium, DPHSS and DFMCH partnership initiated three policy and system based programs to ensure the availability of physical exercise and healthy foods in the workplace and community. The program content was adapted from existing WWPs and was tailored to employee needs through the use of an employee survey inquiring about interests in the areas of focus. To ensure that the WWP and CGP provided the maximum benefits to the community, the program staff, the Consortium, the health coaches, and community gardens participants met at regular intervals throughout the project period to monitor program and participation metrics. This collaboration of over 250 community representatives supported and developed successful health policy, system, and environment (PSE) changes. Health coach trainings. The unpaid health coaches’ duties included supporting colleagues, monitoring employee participation, and developing physical fitness and wellness activities. The Consortium’s Nutrition and Physical Activity Workgroups and the Community Wellness Partner designed and implemented standardized training curricula for the health coaches within the 52 Government Departments. The overarching training goal was to provide the health coaches an understanding of health, wellness, and healthy lifestyles, and provided hands-on training to facilitate individual health risk assessments. It provided methods to support, guide, and motivate colleagues in the WWP to exercise and eat healthy. Health coaches were encouraged to develop activities tailored to the respective department’s daily operations. Activities included organizing walking groups, Zumba classes, yoga classes, weight loss competitions, nutrition classes, and wellness classes. Website and pop-up videos. The “Live Healthy Guam” website was developed to ensure appropriate and timely communication and dissemination of WWP and CGP information. The website posted monthly email newsletters and program exercise


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schedules from the health coaches. The website reports and information were utilized as communication marketing strategies to implement and sustain the STRIVE programs. Pro bono exercise trainers from Guam’s Synergy and Paradise Fitness provided their expertise to create brief exercise workouts. The exercise video popped up on workers’ computer screens during the day to encourage Guam Government employees to exercise at their desks during breaks. The pop-up videos promoted active living and reinforced government support for the program through encouraging physical activities during the work day. Community gardens. The purpose of this activity was to increase the number of permanent gardens at Mayors’ offices (which are adjacent to senior health care facilities and parks) and family homes. This activity was designed to enhance nutritious dietary habits and increase the production of fruits and vegetables. To participate, an 11′x15′ plot of land with a water resource had to be designated at the target site. Program funds were spent to purchase supplies (such as soil and seedlings) to start the gardens. Agricultural experts and skillful gardeners provided their knowledge about growing fruits, vegetables, and medicinal plants, bokashi composting, earth buckets, and farmers’ co-ops to the new CGP members. Participants signed an agreement to become a member of the Consortium and to allow quarterly site visits by the program staff to assess progress of the garden.

Programs in Action The WWP and CGP have demonstrated promise as programs that may improve the overall health and well-being of the people in Guam. Health coach trainings. There were four Health Coach trainings: June 2013, August 2013, September 2013, and January 2014. By January 2014, all 104 health coaches were trained to record health assessments, coordinate WWP activities, practice approaches to healthier lifestyles, and erect health message signs (e.g., Take the Stairs). Ongoing trainings are provided as refresher information and to train new health coaches. The health assessments data provided awareness about individual and group health risks (Table 1). In 2013, at the start of the STRIVE project, only 193 Government of Guam employees completed health risk assessments; 73% were females, the average blood sugar was 113, and the average blood pressure was 129/80 mm HG. As awareness and interest in the WWP grew, so did participation: there was a 300% increase in participation in 2014. Of the 771 employees screened, 65% were female staff, the average blood sugar was 126.3 and the average blood pressure was 135/82 mm HG. These initial screenings provided baseline health metrics for the government employees. The health coaches coordinated healthy WWP opportunities, including scheduling healthy activities (e.g., exercise programs and cooking demonstrations). Health coaches also informed their colleagues of wellness opportunities and helped sustain and cultivate community interest on active lifestyle (e.g., Biggest Loser Challenge). A few health coaches even created designated wellness activity rooms for exercise and healthy lifestyle classes. Website and pop-up videos. The Consortium worked with consultants to create a

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Table1. 2013 AND 2014 WWP HEALTH RISK ASSESSMENTS

Total participation N= Females Males Average Age Average Weight Body Fat Percentage Body Mass Index (BMI) Systolic Blood Pressure Diastolic Blood Pressure Heart Rate Cholesterol Blood Sugar

2013

2014

193 140 53 45 172 33 30.1 129 80 57 n/a 113

771 501 270 48 170.1 36.0 29.7 134.9 82.4 76.3 192.7 126.3

system intervention to motivate employees. In October 2013, the “Live Healthy Guam” website was launched with motivational articles to exercise, fitness facts, healthy living and eating tips, and short exercise videos. Articles included studies on how sedentary work styles adversely affect health, how meditation helps with stress, and how to battle workout boredom. There was also a calendar of events, which allowed health coaches to publicize their activities. Health coaches could refer employees to the website for additional healthy living information. Three fitness instructors created short, easy-to-do exercise videos, including Zumba, stretching, and strength training. Six (3–5 minute) pop-up exercise videos were shown on weekdays at 10 a.m. and 3 p.m. on all government employees’ computers to remind them to take an exercise break. The videos are accessible on the Live Healthy Guam website: www.fitness.guam.gov. Community gardens. Six mayors and 12 local families established permanent gardens next to their offices or homes. They provided fruits, vegetables, and medicinal plants to approximately 360 people in their communities and families. When the program came to an end, there was a waitlist of 26 individuals and mayors who were interested in creating their own gardens.

Conclusions This STRIVE initiative established community-based programs and culturally-tailored interventions to decrease NCD related health disparities in Guam. The WWP and CGP worked towards increasing the community gardening capacity and sustainability through principles of participatory community engagement. Culturally relevant activities, such as farming methods and food, were used where possible. The program fostered multiple


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methods to enhance nutrition and healthy living. These included nutrition education, worksite healthy cooking, participation in physical activities, policies to allow program activities during government work time, and developing and supporting community gardens. STRIVE fostered a synergistic relationship between the community, the local and national government, and academic centers. The program was able to leverage the skills of the community leaders, cultural leaders, legislators, and content experts to strengthen the collaborative effort to understand, develop, and implement PSE changes that could decrease the NCD risk factors in Guam. The program extended beyond the target local government community and government worksites. The program reached the community health promotion professionals and private sectors. This project demonstrated a multi-sectoral, collaborative model. The STRIVE project enhanced community capacity through a participatory community engagement process. The programs appear to be sustainable as measured by ongoing gardens, public comment, continued government investment, and community participation. These nutrition and physical activity programs can be scaled up and exported to other USAPI health departments and communities.

Lessons Learned The WWP and CGP provided a strong foundation and served as a catalyst for further development towards a healthier Guam. Lessons learned included: a. When health risks or illnesses were identified in program participants, there was difficulty linking the participants to a primary health care provider. It would be ideal to invite physicians from local clinics to future WWP screening events to enable members to take action and address their identified health concerns. b. An evaluation plan would have been helpful to better track program participation and behavioral and health outcomes. We were unable to adequately capture and provide individual results from the initial health risk assessments and from the follow-up screenings for the WWP participants. Metrics such as a total duration of exercise participation, weight loss, and blood pressure levels were not readily available. A partnership evaluation using validated instruments and measures is also recommended. Other qualitative approaches to assess program relevance and sustainability, such as key informant interviews and focus group discussions, should be developed. c. For future CGP projects, it will be important to distinguish and clarify the difference between family-based community gardens versus public-based community gardens. Structured programs that support public-based community gardens (a plot of land is divided for community members to grow a garden for their personal use) would likely increase participation. Developing appropriate evaluation tools to measure process and outcome objectives of grassroots community PSE health promotion initiatives will be a future program focus. Both the WWP and CGP increased community awareness on the importance of incorporating healthy lifestyle choices in the work space, as well as in the community

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and family domains. These programs may serve as models to other Pacific Island health departments and communities on implementation of PSE change programs.

Acknowledgments This work was supported by the Cooperative Agreement 1U58DP004685-01 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

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