Healthy Habits for Life:

1. Healthy Habits for Life: Using evidence-based healthy weight messages to develop a consumer booklet for 18-24 year-old African American women in North Carolina Presented by: Megan Fazekas, BA 3rd National Preconception Health Summit June 14, 2011 Tampa, FL

2. About us • The North Carolina Preconception Health Campaign is a new statewide initiative aimed at improving birth outcomes by reaching out to women with important health messages before they become pregnant. • The Campaign formerly functioned as the North Carolina Folic Acid Campaign, a nationally recognized, award-winning campaign created to improve infant and maternal health by promoting the benefits and consumption of folic acid. • The Campaign uses health care provider outreach, lay-health education and social marketing to share our messages. • The Campaign is an External Program Grant of the March of Dimes

3. Our goals • Reduce infant mortality, birth defects, premature birth, and chronic health conditions in women, while also aiming to increase intended pregnancies in North Carolina. • Because the goals are so broad, a strategic decision was made to initially focus on only one additional preconception health area, in addition to folic acid • In 2010 the Campaign added Healthy Weight as our newest preconception health initiative.

4. Why healthy weight? • Natural link between nutrition, folic acid & weight • Health care providers consistently express desire for training on this topic; health care provider education is our specialty. • Growing obesity epidemic demands more action

5. Objectives • To determine if existing public health messages about weight appeal to our target audience • To determine what messages may be more effective than traditional messages • To create materials appropriate for the target audience

6. Women in North Carolina • More than half (58%) of women ages 18-44 are overweight or obese • 73% of African American women ages 18-44 are overweight or obese, compared to 53% of Caucasian women. BRFSS, 2009

7. Obesity Among N.C. Mothers

8. Narrowing our audience • African American women are more likely to be overweight or obese than women of other races/ethnicities. • African American women also have higher rates infant mortality, low-birth weight and prematurity rates than women of other races/ethnicities. • Chose 18-24 year old African American women to narrow our target audience further. • Final target audience includes mothers and non-mothers.

9. Process • In June 2010 a group of public health experts met to discuss the development of a brochure for this audience. • Members were from the Division of Public Health Women’s Health Branch, the Nutrition Services Branch, WIC and the North Carolina Preconception Health Campaign.

10. Process • Group found a lack of high quality educational materials about healthy weight aimed at our target population. • The materials reviewed were dated, and many appeared to be either too vague or too dense. • As it stood it did not appear that any existing materials would be effective in raising awareness or changing behavior around weight.

11. Wish list • The brochure needed to be fresh and appealing. • Had to include some sort of empowerment or advocacy piece so that women could feel confident about addressing their weight. • Should contain easy strategies and tips. • Should educate consumers about Body Mass Index (BMI).

12. Eat Smart, Move More North Carolina • Evidence-based healthy weight campaign featuring easy tips and strategies seemed like a good starting point. • Features seven key behaviors that have been well-tested. • BUT ESMM materials didn’t quite fit our needs; their materials are too general and focus too much on family. Plus, no comprehensive brochure/booklet.

13. Preliminary testing • The Campaign needed to get a good idea of what this audience wanted before any materials were developed. • Five different types of healthy weight materials were tested during the preliminary focus group. • Focus group was small: 9 women, not prescreened. • Their ages ranged from 17-25, with an average age being 22 (median age 23). • All women self-identified as black. • Two thirds had children, with the average number of children being 1.33 (median number 1).

14. Preliminary testing results • Women had weight goals and admitted that it was challenging to lose weight. • All participants reacted positively to the BMI chart and said it was the most important thing to include in a new brochure. • All participants reacted positively to the 7 health behaviors from ESMM. • Preferred the small booklet size because they thought a brochure was too small and a magazine was too large.

15. Preliminary testing results • The participants’ ideal booklet would include: • A BMI chart • A checklist • Tips on where to start • Lots of pictures of people doing things, like exercising and eating healthfully • Colorful pictures (of real people, not illustrations) • Something that will catch one’s attention

16. Booklet development • A 16-page draft booklet was developed. • Booklet was colorful – pink, green and purple. • Contained pictures and “sticky notes” with tips. • The seven ESMM key behaviors were included. • Two more behaviors, taking a multivitamin every day and tracking your progress, were included. • Additional content was adapted from the CDC and the Weight-control Information Network.

17. Secondary testing • Consumer group: 7 women ages 18-22 • All African American and all had children, although two indicated that their child was deceased. • The average age of the participants was 20.3 (median age 20) • No one had more than one child. • Key informant group: 10 health professionals: 1 male and 9 females • Their ages ranged 30 to 61. • 8 African Americans, 2 Caucasians. • Their collective titles were Child Service Coordinator, Maternity Care Coordinator, Enhanced Care Coordinator, Health Check Coordinator, Health Educator, Nutritionist, Community Health Assistant and Outreach Supervisor. All but one had children.

18. Secondary testing results • Consumer group: • Reacted positively to the BMI chart, the use of colors and pictures, and the overall organization of the booklet. • 6 of 7 used the chart in the booklet to find their BMI. • Disliked booklet’s length, especially the amount of information on the first few pages. • Felt like some people wouldn’t want to read the brochure or wouldn’t consider becoming healthy. • Agreed with the use of the words “overweight” and “obese.” • Favorite tips: Right-size your portions, enjoy more fruits and veggies, prepare more meals at home, breastfeed your baby and take a multivitamin every day.

19. Secondary testing results • Key informant group • Reacted positively to use of colors and pictures, and the overall organization of the booklet. Liked the diversity shown in photos. • Main concern with the brochure was its length, especially the amount of information on the first few pages. • None of the participants noted that the BMI chart stood out to them. • Most said that they would hand it out to their clients, but that it needed to be pared down first.

20. Results: Booklet • The booklet was edited to reduce the amount of text. • Other items were rearranged, but most of the pictures, colors and tips remained the same.

21. Healthy Habits for Life!

30. Results: Booklet • Overwhelmingly positive response from public health community and health care providers • 130,000 printed and are being distributed through DPH. • Campaign staff are also distributing at Healthy Weight trainings for health care providers. • A Spanish version is in the works for this fall.

31. Take home messages • Decide the purpose of your product, what messages you want to have and general ideas before production begins. • Thoroughly review and research existing materials that may already be serving your target audiences. Discuss why they may fall short or if they serve a need that your proposed product may not. • Take these existing materials and test them with at least one formative focus group. Ask them what they want to see in a product aimed at them. • Make sure your focus group represents your target audience.

32. Take home messages • Draft your new item based on the formative focus group’s feedback. • Test the new items with at least one focus group that represents your target audience • Use key informants and secondary audiences to test the materials. Since these people work with the target audience on a regular basis, they’ll have good ideas on how to improve or change the product. • Revisit the comments and feedback from your focus groups often as you revise and finalize your product.

33. Conclusions • The evidence-based Eat Smart, Move More messages and a BMI chart resonate with young African American women in North Carolina. • Women requested specific tips to assist them with implementation and liked the informal and motivational tone of the resulting booklet.

34. Implications • Well-tested educational materials developed for a specific target audience are likely to be well-received by that population. • Evidence-based messages should be used whenever possible to promote healthy weight.

35. Questions? Thoughts?

36. Contact us • Megan Fazekas, BACommunications Coordinatormfazekas@marchofdimes.com Amy Mullenix, MSW, MSPHStatewide Coordinatoramullenix@marchofdimes.com 919-781-2481 EveryWomanNC.com