The Florida Department of Health in Hillsborough County (DOH-Hillsborough) has over 400 staff members serving in seven divisions across Hillsborough County. DOH-Hillsborough maintains an annual budget of $38,984,750 from federal, state and local grant funds. More information can be found at: http://hillsborough.floridahealth.gov/
DOH-Hillsborough provides public health services to Hillsborough County, the fourth most populous county (pop. 1,408,566)1 in Florida, located on the state's central west coast. Hillsborough County includes the large and rapidly-expanding1 metropolitan City of Tampa, as well as several rural communities, which include a large Hispanic migrant population. Residents of Hillsborough County are diverse in race and ethnicity, including 49.1% white non-Hispanic, 28.6% Hispanic, 17.8% black non-Hispanic and 4.3% Asian.1 The county's median household income is $51,681, and 16.4% of residents live below the federal poverty level.1
The public health issues addressed by this initiative, Get Into Fitness Today (GIFT), are overweight and obesity. Data from the 2016 BRFSS indicates that 63.9% of adults in Hillsborough County are overweight or obese.2 Furthermore, DOH-Hillsborough's 2016 Community Health Assessment (CHA) revealed that county residents consider obesity to be the most important health issue in the community.3 Overweight, obesity and associated diseases are preventable and largely reversible through changes in health behaviors.
The goal of GIFT is to reduce rates of overweight and obesity (and associated chronic diseases) among residents of Hillsborough County. The objectives of this intervention are to provide weekly community-based support groups that lead to increased health knowledge, increased consumption of fruits and vegetables, increased regular physical activity and healthy weight-loss in participants.
This initiative is implemented through 12-week sessions of weekly support groups held in a variety of community settings and delivered by either lay community members trained as community health workers (CHWs) or DOH-Hillsborough health educators (many of whom are certified as CDC Diabetes Prevention Program Lifestyle Coaches). GIFT is built on the positive impact of support groups, including relationship-building, accountability, validation and encouragement in making healthy behavior changes. GIFT meetings include facilitated group discussions, participant weigh-ins, food and fitness tracking and a structured presentation on twelve different health-behavior topics. All GIFT curriculum materials are accessible to community members on the GIFT website, at no cost, in both Spanish and English: http://www.getintofitnesstoday.net/. This website also provides a platform for visitors to read blogs about health topics, connect with peers and submit questions to a dietician.
Results since the inception of GIFT in 2007 include the establishment of over 350 DOH-Hillsborough-led GIFT groups, providing weekly support groups and health education to over 5,000 adult residents of Hillsborough County. Additional groups have been implemented by contracted partners in a variety of local organizations, from large hospital systems to independently-owned yoga studios. Among participants in groups established by DOH-Hillsborough, 79% of participants lost weight by the end of the 12-week session. Moreover, participants reported positive health changes at the end of the session: fruit and vegetable consumption increased in 84% of participants and physical activity levels increased in 88% of participants. Furthermore, participants' health knowledge and healthy lifestyle skills improved, and majority of participants indicated satisfaction with GIFT. The objectives of GIFT are being met, and GIFT has expanded in reach each year since its inception. Notably, in 2017, a Hillsborough County hospital network, which is the second largest employer in Hillsborough and three neighboring counties, implemented GIFT groups. This same hospital network received federal funding to implement GIFT throughout its locations in a neighboring county beginning in 2018.
The success of this program is supported by the trust, social support and group cohesion among group participants, which is facilitated by a trained instructor. Additionally, the partnerships between DOH-Hillsborough and community organizations supports the program's expansion into a variety of settings, including faith-based organizations, local businesses and local hospital networks. Meeting residents in the context of their daily lives and empowering them to implement lessons from GIFT curriculum in ways that are relevant and manageable in their lives are key to the initiative's success.
The public health impact of GIFT is an increase in healthy behaviors among Hillsborough County adults, which has the potential to lead to decreases in overweight, obesity, obesity-related chronic disease rates, and overall healthcare costs in Hillsborough County.
Sources: 1. U.S. Census 2016/2017 2. BRFSS 2016 3. DOH-Hillsborough's 2016 Community Health Assessment: http://hillsborough.floridahealth.gov/programs-and-services/community-health-planning-statistics/improvement-planning/_documents/doh-hillsborough-cha-report2016.pdf
This initiative addresses the public health issue of overweight and obesity, as well as related diseases such as type 2 diabetes and hypertension. Nationwide, rates of obesity and overweight have continued to rise over the last decade and incur a tremendous cost on the healthcare system.1 In Hillsborough County, 6 out of 10 adults are overweight or obese, and 13.2% of adults are diagnosed with diabetes, a rate which has doubled over the last decade.2 The most recent county-wide Community Health Assessment (CHA) found that 84% of adults in Hillsborough County eat less than the recommended five servings of fruits and/or vegetables a day, and 55.6% are inactive or insufficiently active.3 Furthermore, the CHA revealed that Hillsborough County residents believe obesity/overweight is the most important health issue in their community, and should be a top priority for the local health department.3
Overweight and obesity disproportionally impact racial/ethnic minorities. In 2013, 81.4% of black non-Hispanic adults were overweight or obese, compared to 66.1% of Hispanic adults and 64.6% of white non-Hispanic adults.4 Thus, while GIFT is designed for any adult, the original target populations for this intervention were communities where rates of overweight/obesity were highest, primary black non-Hispanic communities. Approximately 250,725 Hillsborough County residents are black non-Hispanic, accounting for 17.8% of the total population.5 Since the initial implementation of this program in 2007, GIFT groups have been held in zip codes across Hillsborough County that are primarily black non-Hispanic and have the highest rates of obesity and overweight. These groups in priority zip codes have reached community members directly as program participants, and impacted their families, peers and overall community indirectly with new information and healthy lifestyle changes.
Previous to the implementation of GIFT, the issues of overweight and obesity in Hillsborough County were addressed through periodic community presentations from DOH-Hillsborough health educators. These presentations from health educators provided information to attendees, but often lacked individual attention, relationship-building, accountability and cultural cohesion. Additional nutrition counseling was delivered by DOH-Hillsborough staff through client visits at Women, Infants and Children (WIC) Clinics. These interventions often assumed that audiences were ready to act to change behaviors in response to health promotion messages and presentations. Research suggests, however, that typically 20% of individuals needing to change an unhealthy behavior are ready to take the necessary action.
GIFT is an improved approach to the issue of overweight and obesity because it is strategic, organized, based on well-established practices and theories of behavior change, and supports development of ongoing relationships and social support within the groups. GIFT lessons provide sensible and realistic nutrition and physical activity advice and emphasize making gradual changes to one's lifestyle and habits, as research indicates that small, gradual lifestyle changes are the best strategies for incorporating permanent changes in food and activity habits and achieving and maintaining weight loss. The GIFT curriculum includes 12 sessions held weekly, each of which includes time for participants to share their experiences and feelings, measure their weight, practice a short exercise activity, and receive a presentation on a health behavior topic. These topics include: Tracking Food Intake & Activity; Planning for Success; Portion Control; Carbs, Fats, Fiber & Fads; Salt, Sodium, Herbs & Spices; Healthy Shopping & Meal Planning; Physical Activity, Water Intake & Stress; Flexibility, Strength & Exercise Intensity; Dining Out & Party Time; Maintenance; Health Disease & Diabetes Prevention; and Cancer, Oral Health & Childhood Obesity. Each lesson emphasizes the importance of small and realistic changes, and groups work together to brainstorm how to feasibly apply the information in the lessons to their individual circumstances. Furthermore, GIFT involves training lay community members to lead groups in community settings for peers, utilizing community health workers (CHWs) to assist in behavioral change. Additionally, GIFT was developed by DOH-Hillsborough dietitians and health educators and was based off of the Transtheoretical or Stages of Change Model, which accounts for individuals' differing levels of preparedness for behavioral change. DOH-Hillsborough's efforts with providers and marketing information are designed to help to move participants in the Pre-contemplation and Contemplation stages to the Preparation and later the Action Stage. Because being in the Action Stage is not enough to achieve Maintenance, GIFT includes the information, social support and resources necessary to help participants maintain their behavior changes after the duration of the session.7 GIFT is also founded in Social Support Theory in that it uses a support-group model in its meetings. This allows participants to receive the emotional, instrumental, informational and appraisal support through GIFT that strengthens capacity for behavioral changes that can lead to weight-loss.8 In addition to social support, GIFT allows program participants to set their own goals regarding diet, exercise and weight loss or maintenance. This is an important step away from the one size fits all” approach to health behavior change that has proven to be ineffective. Furthermore, the program is flexible, and GIFT groups can be tailored for the cultural and practical needs of the population or group participating.
The GIFT program is an innovative practice. While the use of community health workers (CHWs) is an increasingly popular approach in public health initiatives, the combination of CHWs, the support group setting, the flexibility of the program and its provision at no-cost for participants is unique to GIFT and makes GIFT an innovative program. Additionally, any member of the community can be trained to facilitate a GIFT group, and the groups can be held in locations convenient to the participants, such as community libraries, churches, recreation centers, etc. This creates an approach similar to other evidence-informed interventions with peer support, such as the CDC's Diabetes Prevention Program, but applied specifically to weight-loss (vs. diabetes-prevention), and in combination with a structured curriculum.
Building on to the success of the GIFT program and responding to the increases in childhood obesity in Hillsborough County, DOH-Hillsborough developed a GIFT program specifically for youth in 2018. This program, Get Into Fitness Together- a Learning Emotional Activity Program (GIFT-LEAP), adapts the original GIFT curriculum to educate youth and families on how to adopt healthy behaviors into their lifestyles and achieve and maintain a healthy weight. GIFT-LEAP has been presented by DOH-Hillsborough in local Federally Qualified Health Centers, the Department of Parks and Recreation and Hillsborough County Schools.
The Get Into Fitness Today (GIFT) program is not formally an Evidence-Based Intervention (EBI), but is built on evidence-based practices and theories, including the integration of CHWs into community-based efforts to address chronic disease, and the guidance of the Transtheoretical Model (TTM) and Social Support Theory in promoting healthy behavior change. GIFT is aligned with the Health and Medicine Division (formerly the Institute of Medicine)'s recommendations for implementing obesity-related interventions as the evidence for these practices continues to emerge. Furthermore, GIFT has existed for eleven years, has received recognition from the state of Florida as an Innovative Practice (2012), and continues to show evidence of success in helping program participants develop healthy habits and lose weight.
Sources: 1. https://www.cdc.gov/obesity/adult/causes.html 2. BRFSS 2016. 3. 2016 CHA 4. BRFSS 2016 5. US Census 6. CHWs 7. The Transtheoretical Model of Health Behavior Change: https://www.ncbi.nlm.nih.gov/pubmed/10170434 8. Social Networks and Health: https://www.annualreviews.org/doi/abs/10.1146/annurev.soc.34.040507.134601 9. Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making: https://www.nap.edu/read/12847/chapter/2
The goal of GIFT is to reduce rates of overweight and obesity (and associated chronic diseases) among residents of Hillsborough County. The objectives of this intervention are to provide weekly community-based support groups that lead to increased health knowledge, increased consumption of fruits and vegetables, increased regular physical activity and healthy weight loss in program participants.
To achieve these goals and objectives, DOH-Hillsborough dietitians, health educators and others designed a program that includes education and social support for weight-loss that can be delivered in diverse settings by trained community members or DOH-Hillsborough health educators. DOH-Hillsborough maintains rich relationships with community partners in health and other sectors, which helped inform the curriculum development in 2007, and continues to inform updates to the content, as well as program planning and marketing. The curriculum includes twelve weeks of educational topics on nutrition and exercise, and each session includes a discussion where participants can share their personal experiences with healthy decisions. Participants also receive a wellness diary to track their food choices, nutrition and physical activity. The program is designed to adjust to the needs of the specific community implementing a group, and can be successful in a variety of settings, from community groups that meet at public libraries to workplace teams that meet during their lunch hour. The role of DOH-Hillsborough is to support, train, and recruit lay health workers to facilitate GIFT groups, provide educational materials to ongoing groups, monitor facilitators and groups and collect data. DOH-Hillsborough also promotes GIFT to businesses as an employee wellness program model, to faith-based organizations as a health ministry tool, and to recreation centers and similar organizations as a programming tool. Additionally, the GIFT program was transferred to a CD format by DOH-Hillsborough and has been made available to other county health departments and organizations through Memorandums of Agreement (MOA) which facilitate data collection.
The steps taken to implement the program include internal process mapping, the development of a logic model for the program, identifying Hillsborough County zip codes where rates of obesity/overweight are highest, meeting with community partners to inform program planning, incorporating feedback from CHWs on curriculum materials, conducting outreach toward community partners who may be interested in hosting groups, networking with physicians to set up referrals to the groups, and marketing the groups via billboards, bus signage, radio advertisements, websites and more. As the program expands and is implemented in other organizations, a system of communication and data tracking between DOH-Hillsborough and community partners is established using a contract or MOA. This allows DOH-Hillsborough to track the progress and expansion of GIFT through quarterly and annual internal monitoring systems. Continual data tracking in the county of obesity and overweight, chronic diseases related to obesity, and health behaviors through data systems such as BRFSS and Community Health Assessments, informs program planning to ensure that communities with disproportionate burdens from overweight and obesity are prioritized for GIFT marketing and establishment of groups.
The steps taken to implement groups are flexible and can be adapted to the needs of the community and setting. There are two methods by which new GIFT groups are established. The first method begins by identifying a community location to hold a group. This is done by assessing the rates of overweight, obesity and diabetes in the zip codes and neighborhoods throughout the county and identifying the communities at greatest need for weight-loss interventions. Next, the group is advertised, using flyers, radio advertisements, billboards, bus stop posters and word of mouth. Networking with physicians also allows physicians to refer patients to DOH-Hillsborough staff, who can identify a GIFT group that is feasible for the patient to join. The second method for implementing the program begins when DOH-Hillsborough is contacted by an organization or community member interested in holding a group in their organization, neighborhood or workplace. In either of these scenarios, the group may be delivered by a DOH-Hillsborough health educator, or it may be delivered by a community member, who will work with a DOH-Hillsborough health educator to develop the skills needed to effectively facilitate a group. The groups meet weekly for 6 or 12 weeks.
The criteria for participant selection is broad and allows any adult (age 18 and up) in Hillsborough County who wants to learn healthy behaviors to enroll in the groups. Furthermore, the lesson materials are available for free online in both English and Spanish, making some level of program participation possible for anyone with access to the Internet, with or without an in-person group session.
The timeframe for the initiative includes sessions of 6 or 12 weeks, with weekly groups, delivered throughout the year. Participants are encouraged to find another participant or two to keep in touch with following the program, to extend the accountability and social support beyond the 12-week session. The final group meeting includes a discussion of how to maintain new healthy behavior changes and weight-loss, and the instructor facilitates the group to come up with plans for accountability; often, GIFT groups decide to continue to meet regularly for support even after the end of the 12-week session. The GIFT program was launched in 2007 and is currently ongoing.
DOH-Hillsborough worked with community partners to plan and implement this program. Partnerships are vital to the sustainability of programs that improve the health status of communities. Establishing relationships with decision-makers within community organizations like libraries, faith-based organizations, businesses, community groups, and neighborhood associations provides multiple ways for the community to access information and programming. Community partners engaged in implementing GIFT include county resource centers and libraries, which offer their facilities to host groups and promote the groups within their local communication systems. Collaboration with local hospitals has led to an agreement with a local hospital's Food is Medicine (FIM) program, where participants in GIFT groups are provided with food vouchers for each GIFT meeting they attend. These vouchers can be used to purchase fresh produce from the FIM food truck. These community partnerships further the goals of the intervention by extending the reach of the program into underserved communities, where obesity and related disease rates are often the highest. This leads to increased access to the GIFT program for community members with a diverse set of needs and whom face systemic barriers to participation. These community partnerships have led to the introduction of GIFT groups into a local hospital system in Hillsborough County, where groups are held within the hospitals, and available to patients and community members. Furthermore, a federal grant was awarded to support the expansion of GIFT groups into this same hospital system in a neighboring county.
DOH-Hillsborough fosters collaboration with community stakeholders by continuing to provide GIFT groups through a variety of networks and organizations, and by offering funding opportunities to partnering organizations. This has included offering grant opportunities to organizations to provide GIFT groups in the community. Organizations were encouraged to provide their groups in areas of the county that were otherwise not reached by DOH-Hillsborough networks, and contracted organizations received payment for the completion of milestones (e.g. number of participants completing 4 out of first 6 sessions). These community partnerships further the goals of the intervention by extending the reach of the program into diverse communities and populations, and increasing the cultural cohesion in each group.
Start-up costs for the intervention were an initial grant from the Office of Minority Health of $20,000 to cover the cost of CHWs. This covered hiring costs, supervision, salary, training, travel expenses in the community, materials for workers and program promotion. Beginning in 2008, however, majority of GIFT programming, including CHWs, program supervision, student materials, promotion, travel and training has been covered by state general revenue under health promotion and education. GIFT has, in part, become self-sustaining, as DOH-Hillsborough provides facilitator training to groups who implement their own program, utilizing a CD of information or the GIFT website lessons. DOH-Hillsborough staff remains accessible for data collection, consultation and assistance, as well as group instruction, depending on the needs of the host organization. In-kind cost has included meeting space and program promotion.
Evaluation of GIFT has indicated progress toward all program objectives. The objectives of this intervention are to provide weekly community-based support groups that lead to increased health knowledge, increased consumption of fruits and vegetables, increased regular physical activity, and healthy weight-loss in program participants.
GIFT has been implemented consistently over the last eleven years, providing over 350 courses of support groups to over 5,000 community members who are at-risk for or who are currently overweight, or obese. Because of the evolving nature of the program, the variety of community settings and the length of time over which the program has been delivered, the data collection has been inconsistent some years, leading to limitations in terms of evaluation. Currently, primary data is collected by the staff or instructor present at the time of the groups. This could include DOH-Hillsborough staff, trained CHWs, or staff from the local hospital who are contracted to deliver GIFT.
Primary data collected includes: participants' weight (measured at each weekly session); participants' self-reported fruit and vegetable consumption and physical activity (recorded by instructor); and participants' satisfaction with the program (collected by survey at the final session). Data is stored in excel spreadsheets and is analyzed using SPSS. Secondary data sources include: census tract data and data from the DOH-Hillsborough Community Health Assessment, which indicated both the importance of the health issue of obesity/overweight to residents, as well as the disparities in health behaviors and chronic disease outcomes between neighborhoods and racial/ethnic groups. This helps to target the intervention into the areas with the highest need.
Process evaluation measures include: number of groups held, number of participants attending some or all of session meetings, number of community partners engaged, number of participants referred by physicians and participant satisfaction. Outcome evaluation measures include: changes in participants' weight, changes in participants' weekly fruit and vegetable intake, and changes in participants' reported activity levels. Weight changes were calculated using weights collected at weekly sessions and behavior changes were assessed by participants' responses to survey questions. Data collection and evaluation methods varied throughout the course of the program. Outcome evaluations show that, consistently, the majority of program participants who completed the GIFT sessions lost weight. Across all eleven years, the proportion of participants who lost weight during the program is 79%. Furthermore, 84% of participants increased their fruit and vegetable consumption as a result of the program, and 88% of participants increased their physical activity as a result of the program. Process evaluations conducted at the end of each fiscal year showed the program goals and process measures have been met and exceeded each year, and have prompted continual increases in goals and benchmarks, expanding the reach of the program.
Additionally, two formal evaluations of GIFT were completed by graduate students of the University of South Florida's College of Public Health. In 2011 a mixed-methods approach was utilized including statistical analysis, participant observation during groups and semi-structured interviews with program participants. Results from this evaluation indicated that 64% of participants lost weight and those who were interviewed reported maintaining the weight lost beyond the 12-week program. Most met goals for the additional behavior changes. The program was reported to have a positive effect on friends and family. In 2012 the records of 276 past and present participants were evaluated, with a focus on participant satisfaction. Data collection included of follow-up phone calls with participants who completed the program as well as those who attended some sessions but did not complete the course. This helped gauge participant satisfaction with the course as well as barriers and facilitators to completing the sessions. The average satisfaction rating was 4.67 out of possible 5 (with 5 being the highest level of satisfaction). Feedback noted that the socialization/camaraderie that GIFT provides was instrumental in supporting healthy changes. One participant stated that GIFT gives people an opportunity to come together, for everyone to share their successes and failures, and discuss what has worked for them and what has not. Many participants expressed that they liked being with people who were dealing with similar issues. One respondent noted that GIFT just had so much good information. Stuff you didn't know and stuff you wouldn't have thought to know about.” Many participants liked the creative ideas from GIFT, saying it wasn't just book stuff”.
The GIFT website was also the focus of a formal quality improvement (QI) project to increase visitors to the site. Following root cause analysis which included feedback from partners and improvement actions, visitors to the website increased by more than 25%, which was the target of the Aim Statement. Improvements were especially evident in Hillsborough County's Spanish-speaking population.
Modifications have been made to the program in response to ongoing data collection and analysis. First, DOH-Hillsborough has responded to the need for Spanish-speaking groups by hiring bilingual staff and contracting with organizations that have bilingual facilitators. This ensures a Spanish-speaking GIFT group is nearly always available. DOH-Hillsborough dietitians work to ensure GIFT curriculum is modified to remain current with the most up-to-date dietary recommendations. GIFT curriculum has also been modified to create a program for youth, GIFT-LEAP, in response to increases in childhood obesity and program participants' concerns for the overall health of families. And, finally, modifications have been made in training facilitators within organizations to offer GIFT as a worksite wellness initiative. The GIFT curriculum is well-suited for a worksite wellness program, and DOH-Hillsborough health educators work with organizations to tailor the groups for their individual needs and environment.
The GIFT program has already proven to be sustainable. Eleven years ago, GIFT was implemented with support from a small grant. The program continues today as a health department program with no external and minimal internal funding. Additionally, community partners and agencies continue to utilize the program as either community or worksite wellness programs. Thirty-seven partners external to DOH-Hillsborough have been trained to facilitate GIFT groups, which adds to sustainability efforts through broad community networks. The ability of community members and health educators to access GIFT online in English or Spanish free of cost furthers efforts to promote wellness and obesity-prevention to anyone who is interested. The development and implementation of GIFT over the last decade has led to important lessons related to practice. First, when hiring lay health workers, even if part-time to implement the program, DOH-Hillsborough learned to ensure that systems are in place to provide the initial and ongoing training to CHWs on the program specifics such as the curriculum, as well as agency rules and policies. Many myths related to weight loss exist and it is important for facilitators to avoid incorporating any nutrition related information that is based on their personal opinions. Training, good communication and a well-designed curriculum minimizes this occurrence. Additional lessons related to practice include tailoring the program's nutrition sessions to be more culturally competent based on the audience and providing instructors with training and skills to properly facilitate and not lecture participants. Furthermore, facilitators should instill in participants that GIFT curriculum materials are intended to be general guidelines, and not a diet or specific nutrition recommendations for those with medical needs (i.e. individuals with diabetes, heart disease, kidney failure, etc.). In terms of partner collaboration, the lessons learned include the importance of including partners in outreach efforts. Marketing is a crucial and costly endeavor, and partners should be asked to assist in marketing and promoting the program.
In terms of implementation, the lesson learned relate to engagement with lay health workers. Community health workers should be paid or provided a stipend, as compensation honors their efforts and improves efficiency. Additionally, data collection methods should be clear, consistent and feasible for CHWs to follow, leading to the most robust picture of the program's effectiveness. A cost/benefit analysis was not completed; however, the cost of diabetes in Hillsborough County is significant, and often includes expensive and unnecessary Emergency Room and hospitalization care, which could be reduced or prevented with wellness programs such as GIFT. The benefit of the program in terms of lives changed, lives saved, improved health behaviors and the positive impact on participants and their families far exceeds the cost of the program (which is minimal).
The stakeholder commitment will continue to sustain and expand GIFT as DOH-Hillsborough continues to pursue the training of external facilitators. DOH-Hillsborough health educators continue to foster relationships with local organizations including physicians' offices and local businesses and are engaged in ongoing marketing for GIFT through community health fairs, word of mouth, bus and radio advertisements and more.
Sustainability plans for GIFT by DOH-Hillsborough include continuing to offer course materials online for free, continuing to train community members to become group facilitators and contracting external organizations to implement the program independently. Furthermore, DOH-Hillsborough is exploring the use of technology to further enhance the program, and will complete an in-depth evaluation of the program to determine and inform DOH-Hillsborough's next strategic steps.