Promoting Physical Activity and Healthy Eating in Latino Communities

Coordinator: Welcome and thank you for standing
by. At this time all participants are in a listen only mode until the question and answer
session of today’s call. At that time, if you would like to ask a question, you may
do so by pressing star 1. Today’s meeting is also being recorded. If you have any objections, you may disconnect
at this time. I now would like to turn the meeting over to Ms. Margaret Farrell. You
may begin. Margaret Farrell: Great. Thank you. Good afternoon
everyone. I’m Margaret Farrell. And on behalf of National Cancer Institute, I’d like to
welcome everyone to our May Research to Reality Cyber Seminar. NCI launched the Research to Reality community
practice more than five years ago with the idea of bringing together researchers and
practitioners in an ongoing discussion around the promise, as well as the perils, of moving
evidence based cancer control programs and policies into action. And certainly, there are few topics that lend
themselves so well to these discussions, as found around creating environments where healthy
behaviors can be socially supported and made more accessible. And, you know, in preventing
cancer and reducing health disparities. Today’s cyber seminar will highlight two innovative
and successful interventions designed to address these challenges in Latino communities. Dr. (Alvo) – I’m sorry. Dr. Elva Arredondo
will describe the faith in action, fe en acci’n, study designed to improve the health of Latina
women in San Diego. The study aims to increase moderate to vigorous
physical activity among churchgoing Latina women, while evaluating the impact of (field)
environment on physical activity in various communities in the San Diego area. In giving an idea around the study and its
interventions, she’ll also look at some of the challenges and the solutions in implementing
health promotion programs in faith based organizations in Latina communities. Dr. Guadalupe Ayala, will describe an innovative
store-based intervention to increase both the accessibility of fruits and vegetables
in tiendas and increase the purchasing of healthy vegetables and fruits by shoppers
in these – in these neighborhood stores. She’ll conclude by presenting new measurement
approaches for assessing the food environments and discussing opportunities to translate
this intervention into other settings. Following their presentation, we invite you
to join with us in a robust, interactive discussion about your experience in building the capacity
of others to move evidence based programs and policies into practice. And we invite you to ask questions of our
speakers and share your own experiences during that time. Full bios for today’s speakers are available
on where you’ll also be able to engage in a discussion
forum on today’s topic and view an archive of previous cyber seminars. We specifically and warmly welcome those of
you who are joining us for the first time. And we ask that you engage in the discussion
today, both on the call and online with the R to R community’s practice. If at any time during the presentation you
would like to pose a question, you can press star 1 and that’ll place you in queue to ask
your question live during the question and answer portion of the seminar. Or if you’d
prefer, you can also submit your question using the Q&A function at the top of your
screen. So I think that’s all of our housekeeping
items. With all of the housekeeping done, Elva I’d be happy to turn this over to you
and (Suchi). Thank you so much for joining us. Dr. Elva Arredondo: Oh, thank you. Well it’s
a privilege to have the opportunity to present the implementation of our randomized controlled
trial that promotes cancer screening and physical activity among churchgoing Latinas. Today
I’ll be focusing on the implementation of the physical activity intervention. And in this presentation, I’m going to be
using the terms Latinas and Hispanic women interchangeably. However, the majority of
my work has involved Mexican Americans. So just to give you a quick overview, I’m
going to give you the approach I use in a lot of my work, which is the social ecological
framework. And then ‘ill shift gears and focus more specifically on the randomized control
trial, which is Faith in Action or fe en acci’n. I’ll talk about the rationale, the study design,
intervention and evaluation as well as I will probably give the preliminary findings and
then talk more about the challenges and solutions. So most of my work involves addressing disparities
that affect Latinas. We know that there are disparities in obesity
and a likely contributor is the low rate of leisure time physical activity. In this slide,
we note disparities in leisure time physical activity between Mexican Americans and non-Hispanic
Whites and between men and women. And leisure time physical activity is defined
as activity that’s performed during free time – activities such as swimming, running and
so forth. So you can see here that overall, fewer Mexican Americans engage in leisure
time physical activity compared to non-Hispanic Whites. And a lower percentage of Hispanic women engage
in less leisure time activities than men. So why are people in the US more active? Well according to many ecological frameworks,
individual or intrapersonal factors such as biological, psychological as well as behavioral
skills, play an important role in influencing behavior. We also know that interpersonal factors such
as social support, is also an influential factor in influencing behavior, including
physical activity. And we also know that environmental factors likely play a role. Emerging research
shows a link between the environment and physical activity. So we know that that – we also need to consider
that particular level when we’re promoting physical activity. We also know that policy
likely plays a role. For instance, schools that have policies that
protect the recess of children’s time and also in those schools we tend to see higher
physical activity. And I would probably modify this model to include cultural factors. We
know that culture also plays an important role in influencing physical activity. So for this reason, multi-level interventions
are increasingly being proposed, as they tend to optimize behavior change. So the majority
of the interventions promoting physical activity to date, have focused on addressing intrapersonal
and interpersonal correlates of physical activity. And a few have included that – addressing
the field environment. Focusing on the individual and using theory based programs are useful.
But perhaps not sufficient. Why would that be? These programs reach a limited percent
of the population and also tend to have short term effects. So the next set of pictures that I’m going
to show you perhaps will highlight the importance of addressing the field environment. See, in this picture we can see that this
is a neighborhood that has not a well-marked class walk, compared to the next picture where
you see it’s a much better marked class walk. It has more trees. It’s a much more appealing
environment for people to walk. It has some lighting so people are likely
to feel safe to walk at night. And compared to the last picture where there are a lot
of reasons for people to walk. There are some shops and perhaps other stores. And so motivators
for people to really engage in walking in that particular community. And this is particularly important given that
Latinas are less likely to have access safe places to walk. So I am now going to delve
into the actual intervention that we’ve been implementing over the last five years, which
is Faith in Action or fe en acci’n. And so Faith in Action is a group randomized
controlled trial that intervenes at multiple levels, to increase physical activity and
cancer screening among churchgoing Latinas. So we identify and hire church members of
Promotoras, to deliver the intervention activities within the church context. We’re intervening
in religious communities such as churches, because churches have important social, political
and educational functions in Latino communities. This is where Latinos celebrate baptisms;
first communions; quincea’eras; and other festivities. According to the (Pew) report,
68% of Latinas identify as Catholic. And close to 42% of Latino Catholics indicate attending
church at least weekly. So faith based organizations are ideal ways
to promote health, due to the mind, body and soul connection that faith based communities
often promote. And the current intervention, Faith in Action, is a two year intervention. So this is the study design that we use. So
as I mentioned to you before, it’s a randomized controlled trial and a primary outcome is
minutes of moderate to mid – to vigorous physical activity as (effect) through an accelerometer.
So churches get randomized to either the physical activity or the attention control. So that’s the unit or – of randomization.
And as I mentioned to you, I will be focusing on the physical activity intervention. So
to participate in the study, women have to be fairly inactive. And we go through a two
stage screen in which the first stage is they self-report the activity. And then the second stage is we assess our
activity through the accelerometer. And once we know that they’re fairly inactive, then
they are eligible to enroll in the study. Women who participate have to be between the
ages of 18 and 65, self-report being Latina and commit to being in the area for at least
two years, given that’s the duration of the intervention. And they have to be attending the church at
least four times a month and live relatively close by, because we’re going to be – we are
intervening in their community. And then not attend other churches in the
study and be eligible to participate in our physical activity intervention through the
assessment of the Part Q. This is just the (contact) table just to give
you an appreciation of the number of women that we contacted and recruited all the way
to those who end up enrolling. So there is a significant number of people
who end up being not eligible for the study because they engage in more activity than
– than what we prescribed. So I’m going to be focusing now on aspects of the intervention
of this study. There are a number of (unintelligible) intervening
with Latinas and other members have entered sub groups. And one strategy that we have
found to be effective is working through Promotoras. Promotoras are members of the community that
tend to be leaders of the community and tend to have the relational aspects and other characteristics
that make it – make it easy for an intervention to be implemented. So participants – Promotoras who I recruited
also are likely to be committed to the – to the church community. So when the program
ends, they may be more motivated to sustain the program activities afterwards. So we recruit
these Promotoras from the churches. And we recruit two types of Promotoras. And
the reason that I have these two, to highlight the different characteristics that we have
– that we look for, for the two different conditions. So Promotoras – and this is the
activity intervention. We look for women who, you know, value activity
in their daily lives. And who engage in some leisure physical activity during the week.
whereas in the cancer control, Promotoras we look for leadership characteristics; people
who, you know, could really deliver a presentation and really engage women in the educational
components of the cancer screening condition. And just real quick, these are the different
levels of the Promotoras that are intervening. As you know, it – they are the levels of the
social ecological model that we’re using, to inform the study. And I’ll talk about each
of these in the next few slides. So when – once we identify the Promotoras,
they go through a series of six weeks of training. So they get trained on the benefits of physical
activity – warm up and proper cool down; injury prevention. They do get trained in CPR as
well, and strength training and so forth. They also get training in delivering motivational
interviewing. And I’ll talk a little bit about that in the next couple of slides. And then
following the training, about every six to 12 months we provide booster training just
in case things come up and they have questions. And we want to make sure that we address any
issues that come up during the implementation of the program. And we, you know, we want
to make sure that they’re up to date with current guidelines and so forth. So and then they work closely with a physical
activity specialist and intervention coordinator, throughout the intervention. So they meet
with the physical activity specialist and the intervention coordinator initially more
frequently. And then over the course of the two years
they meet less frequently. So once they’re trained, the Promotoras target the different
levels of the ecological model. So at the individual level they’re tasked with implementing
physical activity programs in the church and outside of the church, in nearby parks. So they offer two walking groups; two cardio
dance classes; two strength training classes. And then within those classes, they also – they
also talk about the importance of nutrition and monitoring and goal setting. And I’d like to note too that because this
is in a church setting, they – the Promotoras initially start their classes by – with a
prayer and sometimes the Father joins them in that prayer. And then they start their
activities following those prayers. So they – this picture notes the types of
activities that they engage in, in local parks or nearby streets. So they do – people who are more interested
in really starting a physical activity program and they haven’t engaged in physical activity,
they tend to begin with a walking group and then shift to the more – the other classes
that are a little bit more intense. So at the interpersonal level, the Promotoras
deliver three calls during the first year. And this is to help address barriers, increasing
confidence and motivation of physical activity. And in – provide overall social support to
our individual participants. Now anybody can participate in the program,
but these are delivered to our evaluation cohorts. So at the environmental level, the
Promotoras go out into local parks and areas in which they want to increase access to physical
activity opportunities. Here, you can see that the Promotoras are
cleaning a path that actually leads to one of the churches. So this is an – this is one
of the Promotoras – the person in red, leading some of these activities. And this is another example of how the Promotoras
is trying to beautify the field environment. This is one of their – they’re refinishing
one of the benches in a natural preserve, improving the aesthetic to increase physical
activity. And this is in the area of (Southwark). And they also – so they also identify problems
in local parks and advocate to improve those parks in local community meetings. So – so
those are aspects of the intervention. I’m going to shift gears to the evaluation component.
Just real quickly, these are the different levels that we are assessing. So at the individual level, we, as I mentioned
to you before, we are assessing physical activity through the accelerometer. We’re also assessing
diet, behavior (unintelligible) plus physical activity and some correlates of physical activity,
such as depression. At the interpersonal level we’re assessing
social support for physical activity. And then at the environmental level, we’re assessing
perceived neighborhood environment as well, and park use. We’re collecting extensive process evaluation
data. We’re collecting attendance sheets. You know, we want to know who’s coming to
these physical activity classes; who’s attending the advocacy component; and basically who’s
interfacing with any of – any aspect of the intervention. Another component of practice evaluation is
affecting the intensity of physical activity delivered in the classes. So trained assessors evaluated 28 group exercise
classes with (So Fit), which is a validated observational tool that audibly prompts the
recording of observations on class participants’ posture and intensity, along with class context
and instructor. We want to make sure that the Promotoras who
are delivering the intervention, are really delivering at the moderate to vigorous level,
which is what we’re powered to detect differences in. So real quick, in terms of some of the challenges
and solutions to implementing the Promotoras in church based intervention – so we’re finding
definitely compared to the cancel control condition, finding Promotoras in the community
who are physically active was a challenge and has been a challenge. There is not a lot of people that we were
able to identify within the church community, who could be really ideal role models. So
we had to involve women who were somewhat active, but really take them to the next level
so that they become role models in the community as physical activity leaders. So this involved intensive training. We have
– oh, an amazing physical activity specialist who really worked with them closely, to really
– to deliver the physical activity intervention. And it also involved a tremendous amount of
support from our staff, to make sure that that Promotoras feel that, you know, if they
have questions they can always, you know, come to us and we address them. Or they have
all the – all the tools that they have to (demo) these physical activity classes. So it was a lot easier for us to identify
women to deliver the cancer intervention than it was to deliver the physical activity intervention.
For many of these women this is the first time they have a job. So we’ve – in their training, we’ve had to
talk about time management; speaking in front of a group; completing the necessary documentation;
and process work documentation that is needed for the study. And we also – we also – because this is an
RCT and we rely heavily on what the Promotoras are saying or doing in the community, is – we
have to collect a lot of process evaluation data. And we opted to pay Promotoras because it
is a huge burden for the Promotoras to complete all of this paperwork in addition to leading
all of the activity – all of the activities in the church. So it’s something to keep in mind because
when a Promotoras is not always, you know, compliant with submitting her process evaluation
paperwork, you know, a staff member needs to make sure that they contact them and make
sure that they submit it within a timely fashion, so that we have that data in-house. In terms of participants, we – we were finding
that a lot of participants do actually not just attend one church but they attend multiple
churches. So we were – even though this was part of
our eligibility criteria that they had to attend the primary church on a weekly basis,
we were finding that well once in a while, they’d attend other churches. So we – we have to document this really well,
because if they attend one of the controlled churches we need to make sure we – we account
for that in our findings. We also have a number of people who go to Mexico for the weekend
or sometimes they work in Mexico. So we have to make sure that in our screening
criteria, that women are actually in the targeted region most of the time, so that they have
opportunities to go and attend the physical activity classes in the churches. But there is definitely a lot of class border
activity and that obviously women who spend half of their time in Mexico obviously are
less likely to participate in program activities. So we – we monitor that carefully and we also
screen for that very carefully. And given that we are involving inactive women,
getting women to be physically active is – has been a challenge. So we’ve had to build in
a lot of motivators in the program, to participate in program activities. So we’ve had to offer raffles, you know, people
are more likely to attend a fun and high quality class than one that obviously is not as motivating.
And we have to offer low impact classes, especially for women who have not really been active
in – throughout their lives. It’s very intimidating to – to come to one
of these group exercises and see all these women follow the choreography very easily. So we – we engage women at first through the
walking group and then once they’ve built their confidence, these women are more likely
to participate in the high intensity group activities. The MI – MI calls have really
made a difference in reaching out to women individually. So we know that clearly helped. And, you know,
did we have to – because we offer classes, physical activity classes throughout the year,
we have to be very flexible. So the Promotoras have to be very flexible as to when they offer
the classes. Because once it turns dark here, women are
absolutely not likely to participate in classes. So we have to shift the schedule throughout
the year to make sure that people feel safe and are interested in participating in group
activities. So with that in mind, I’d like to acknowledge
my team and my wonderful call investigators and (ascenders) as well. And I’d like to thank
everybody for giving me the opportunity to give this presentation. And I would like to
turn it over to Dr. Ayala. Dr. Guadalupe Ayala: Great. Thank you so much
Elva. You might Elva, want to click on, if your computer, the Q&A, because there’s a
really good question on resources and safety issues. So I was going to respond, but you
might want to take a look at that. So anyway, thank you folks for joining us
today or this evening, wherever you may be in the world. What I’m going to do is talk
about a second NCI funded study. This is about promoting fruit and vegetable consumption
through a store based intervention. So I’ll also acknowledge my wonderful co-investigators,
in particular, (Barbara Vaccaro), Assistant Professor at the University of Iowa, who did
the pilot study with me as well, in North Carolina. So some of you may be familiar with
that study. And this essentially builds on that one. And also, our wonderful staff, (Julie Pikvaldo),
the Project Manager for this project. So before I start, I say store but really what I’m referring
to is a tienda. A tienda is a small community in size, Latino or Hispanic grocery store. It usually has about 50% of its products dedicated
to food products, because we also know that these stores can carry a lot of other items,
depending on where it’s located in the United State. So for example, a new immigrant receiving
(unintelligible) may be more likely to carry clothing or other items that people may be
accustomed to having in their home country. They are very similar to what we would consider
a convenience store or a corner store, in that they have a lot of sugary beverages;
a lot of sweet and savory products – chips, candies and whatnot. But they are unlike a
convenience store in that they at least have some availability of fresh produce. They often have a butcher – a butcher department,
somebody who knows how to cut meats the way Latinos specifically in their communities,
may want them. And as they evolve over time, they tend to introduce then ready to eat foods
– so a small, prepared food department. So obviously much bigger than what we would
normally think about as a convenience or a corner store, but not as large as a grocery
store or a supermarket or a big box store. So why did we decide to work with the (tienda)? We are doing a couple of studies, both here
in California and in North Carolina, central North Carolina. We found that this is a location
that people purchase a lot of their products and in part, because it’s a location that
they visit frequently. In most recent data, we found that it is a
very common location to go to do quick – what are called quick trips, whether they are single
meal or to pick up, you know, fill in, grocers say a stock up trip which would be another
type of shopping behavior. So it’s a place where people go to frequently.
And they also buy a lot of their produce. So if you know a little bit about Latino or
Hispanic food shopping, they obviously want the freshest products. They want to prepare
a meal for the day. And so these tiendas serve a really important
role in their lives in terms of getting groceries in. So for me, as a health promotion interventionist,
it seemed like the perfect setting to be able to reach the target population with the behavior
of purchasing of fruits of vegetables, that was very relevant to their health. So what did we do? We received funding from
NCI for this R1 study, to conduct a random – a group randomized controlled trial which
you see depicted here. So the top half of this graph essentially
illustrates how we arrived to 16 stores that were randomly assigned, but essentially starting
with a very systematic enumeration process using about five or six sources of data, ranging
from Reference USA to the County Health Department records, to a database from another researcher,
(unintelligible), here in San Diego, who is doing some similar work. So using all those sources of information;
updating it; and screening the stores both first by phone and internet, and then in person,
to arrive at 16 stores that were eventually recruited to participate in this study. Baseline
data is collected in the store environment as well as risk managers and customers. And then the stores are randomized to one
of two conditions – the intervention condition which just involves a six month intervention,
or what we call a wait list control condition, in which those stores receive pat of the intervention,
not the full intervention, at the completion of all data collection activity. The – we do data collection throughout in
the stores. But then we do follow up data collection with the managers and customers
at six months and then at 12 months. And that – those are obviously to assess the efficacy
of the intervention. So that gives you a little bit of a sense
of our study design. A little bit more information on the stores or tiendas, themselves. I mentioned
that they are small to medium. You can see here the number of aisles – about four, and
cash registers, about three. Very challenging if you’re engaged in this
work in terms of how to classify small, medium and large stores. It’s very challenging because
stores are constructed so differently. So we can have stores that are say very wide
or – or some stores that are very narrow. And so that then determines the number of
aisles. Length can vary. But anyway, beyond those sort of nuances, this gives you a little
bit of a sense of the size of the store. You see that only half of the stores have prepared
foods. That allows us to evaluate the extent to which
we can deliver the intervention, as part of a prepared foods department. But in general, and you’ll see this more in
a moment when you see some of the customer characteristics, this is a relatively low
income population that are WIC eligible and (SNAP) eligible though not necessarily getting
benefits. And obviously these stores were sort of very
similar to that, so you can see here that 69% are WIC eligible. Here’s the first number
of unique products in the store. And you can see here, the – what was reported by the managers,
as well as a report on square footage. We don’t have as much confidence in these
data because managers often don’t have a complete handle on their inventory. They don’t have
point of (unintelligible) systems like you do see in the supermarkets. And their inventory
control is very much, you know, on – on paper. So their assessment of (sale)s is really a
ballpark figure, as well as square footage of the store. Okay. So let me jump into the
intervention, because that’s I think what most people are probably interested in. So
the intervention timeline was six months. The first two months were really dedicated
to gear up the store and the employees to help with intervention delivery. So it involved meeting with the manager, obviously
getting his or her buy-in from the get go; filing a memorandum of agreement; and then
putting all the rest of the intervention into place, which I’ll describe more in a moment.
But it mainly involved trainings and then some structural changes within the store. And then we moved to the customer directed
component which I’ll describe in more detail in a moment. But that went over a four month
period. So what was the store directed component? The first component was infrastructure changes
to support the sale of fruits and vegetables. The second component was modifications to
the butcher department and then the prepared foods section. I’m going to go into great
detail with infrastructure so let me just mention two quick things with the modifications
to butcher and prepared foods. Essentially what we did, is we gave the butcher
department or specifically the butcher, depending on who the manager wanted us to work with,
a series of options that they could select from, in order to try and promote purchasing
fresh fruits and vegetables from within the butcher department. So among the options that they were given
was promotional signage; obviously the opportunity to participate in the training, which I’ll
describe more in a moment. But then it was actually also offering options within the
butcher department that have some vegetables in them. So for example, a common food that might be
available here would be fajitas which is a combination of meat and produce. And so this
is something that they could prepare and offer as one of the – the many items that they offer
as part of the butcher department. Another option might be skewers with vegetables
and meat on them. So those are some examples of the modifications that we recommended to
the butcher. And then in the prepared foods department,
as part of our customer directed campaign, we were promoting a variety of recipes that
use the specific produce item. And on the demonstration days as well as during
the week, in between the demonstration days, we would encourage the store, the prepared
food department specifically, to prepare that item and then potentially even keep it as
part of the many options that they offer in the prepared food department. So as you can see here, what we were trying
to do is really create some change within the store, to make the choice of purchasing
fruits and vegetables easier in as many departments as possible. When we refer to the physical infrastructure
changes, we allocated $2000 per store in which we learned very quickly that it was not a
lot of money. But it’s nice to know that changes could be made with potential impact with that
amount of funding. But we offered it again, to offer them a couple
of different options. And you can see I think the pictures depict them the best. So the
picture on the left most side, you can see is a display, a produce display. So it allows
them to do some cross product marketing within the store, near the cereal aisle. If you look at the top right picture, you’ll
see that it’s actually a cold master display case that has these cold master pans in them
so they stay frozen throughout the day. And most of them are using them for prepared
fruits and vegetables, so actually preparing them and chopping them up to get at the issue
about convenience the customers are very interested in. This picture here actually just displays
ready to eat grapes that were raw, washed and ready to eat. So it was another form of getting something
that was easy to – for the customer to eat immediately but didn’t also require a lot
of preparation on the side of the staff. And then the bottom right picture displays produce
infrastructure items that some of the stores decided to purchase. So for example, maybe they had a produce section
but it was badly in need of repair. Or the spritzer system needed to be fixed or the
curtains or whatever, so they could use those – that funding for that purpose. So it was really whatever they wanted to use
it, with some guidance from us based on the evidence of what might work and what may be
sustainable in the store. We also, obviously not only wanted to change
the physical environment, but we wanted to change the social environment in terms of
promoting consumption – sales and consumption of fruits and vegetables. And so we know we
can’t obviously be in there all the time. Our goal is not to – although these approaches
we know are affected, they hire a nutritionist and put them in the store. We didn’t feel
that that was a sustainable model. So we said how much can we train the employees in an
effective way, for them to be the ones to be suggesting items? And so we created a four part DVD series.
It was informed by an advisory group, industry representatives, including from the Food Marketing
Institute, Partners for Health and others. And it’s a bilingual training that goes through
four different topics. It makes it very easy and entertaining for
the employees to watch. And then there is some role playing. So that’s all done during
the first two months of the intervention. And then during the customer directed campaign,
they also get booster letters. All the employees in the store get booster
letters so they sort of know what the campaign activities are, even though they might not
have a central role in the actual campaign itself. Our goal is to train at least 25% of the in
store employees and preferably over across as many departments as possible, because although
these stores are small, employee size can range anywhere from three to 16, I think might
be the highest. Don’t quote me on that. But that gives you a sense of sort of the
range. So we wanted to have a cutoff but also to try and reach as many different departments
as possible, so that the messages would be consistent across. Now here are the training
topics. So what we learned in the pilot study that
Dr. (Vaccaro) and I did in North Carolina, is that one of the ways to really engage the
managers, in particular the owners, is to offer something that they need. And one of
the things that we identified that they need, is customer service training for their employees. So in our pilot we used (unintelligible) from
the Food Marketing Institute, which were very good, but not really tailored to this specific
environment. And also they were dubbed in Spanish which is often not – not the best
approach. We don’t – we use it, but it’s obviously not
the best approach because it’s not as relevant for the target population. So with NCI funding,
we were able to create these training videos. And the topics included again, customer service,
product knowledge. So this really was honing in on what they
needed to know about why fruits and vegetables were important and what are some of the key
messages which I’ll describe in a moment. And then merchandising – so we obviously know
that they’re there to sell. They need to know how to market and display
fruits and vegetables. And so we went into things like cross product marketing, appropriate
use of the displays and whatnot. And then the last one was sort of putting
it all together so that they can (unintelligible) with the customer directed component, which
you see here. So we worked with a graphic designer and with researchers and marketing,
to develop a food marketing campaign. And it included a variety of very traditional
food marketing products, including the terrible name, aisle violators but that’s the thing
on the right most side, which is essentially you can see it in the little picture there,
this actually forces you to stop at that point in the aisle and focus on what products are
being displayed. Shelf anglers; produce FAQ sheets; the recipe
cards and recipe posters were part of all the food demo. And what we wanted to do was
try to show people how they could use either fresh fruits and vegetables that maybe they
were accustomed to eating in Mexico, maybe not eating as much anymore. Or maybe new fruits and vegetables that they
hadn’t yet tried and how might they integrate them into their diet or into their families’
diet. So the campaign itself, over the four month period, involved a rotating campaign
every two weeks that was around a specific recipe. And so you can see the card there. We had a food demo so it was organized by
ourselves and the employees in the store. And the stores were – the employees themselves,
they were compensated a little bit for their time, to assist with the food demo. During that food demo we distributed samples
of that recipe. And again, as I mentioned earlier, if they had a prepared food department
they were also asked to prepare the item there. We gave out some reusable grocery bags and
as you’ll see on the right hand side, some of the stores actually went an extra step
and actually advertised the food demo and some of the other activities, either in their
store circular or in banners and other products that they may – that they normally use to
promote whatever’s happening in their store. So there was definitely some buy-in from several
of the stores to try and promote this campaign beyond the materials that we gave them. So
here are the core messages. Because again, ultimately what we’re interested
in, is how is it we can change people’s eating behaviors by what they’re purchasing in the
store? So for us and a lot of our healthy eating
interventions, no matter where they’re occurring, whether they’re occurring at home, in a grocery
store or now most recently, in a restaurant, we’re really trying to hit home what are the
behavioral strategies that I need to do in order to change my eating habits? And so this was based on (Alan)’s crystal
– crystals work from, you know, the ’90s, where it’s very specific behavioral messages.
And these were then integrated into the shelf anglers and other marketing material. And so you can see they’re reading down favor,
which is essentially taste or tasty. It’s not a great translation. But they really stand
for the five key behavioral strategies, which is substituting say a lower fat item or a
less healthy item with a healthier item. Adding fruits and vegetables, making sure
you have a balanced plate. And that goes now to our ((Spanish Spoken)), which is very similar
to the My Plate. It’s nice that they sort of converged and came out at the same time,
for us. Opt for variety, so we know that although
the Latino diet is pretty good in terms of fruits and vegetables, we know that it’s not
very varied. And then also, reforming the way one prepares those too. Okay, so that gives you the intervention in
a nutshell. Very quickly, our evaluation is just as Dr. Arredondo mentioned, was the first
study. It is mostly level. So we are – we have recruited these 369 customers, 23 per
store. And we have collected their data from baseline to six months. And now we’re also looking at potential moderators
and mediators. So among those that I just listed here, promotional sensitivity so we
know that some individuals may be more sensitive to promotional materials in – in stores and
to what extent does that moderate the intervention effects. And they’re also looking at behavioral strategies.
So concurrent with the behavioral strategies messages, we also have behavioral strategies
assessment. And we’ll be able to see whether changes in
those behavioral strategies, potentially mediated changes in customers’ fruit and vegetable
intake, which is the primary outcome. At the store level, we’ll be looking at changes
in availability and promotion, but also looking at, from a customer perspective, whether the
intervention stores exhibit greater customer service and whether the environment feels
healthier, cleaner, more conducive to – to purchasing. We have a lot of process evaluation data that
Dr. (Vaccaro) is going to be leading on, in a paper looking at reach – those delivered
and those received; fidelity very similar to a paper, although much more extensive given
the amount of data we have. But very similar to a previous study she published. So I’m going to just go through these very
quickly because the main goal with this is just to show you the number of control we
need to approach. And really how far the research assistants and staff can make all this work
possible. So in order to reach our 369 – I messed up
on this one. Sorry. But we had to – the research assistant had to approach over 6000 people.
And you can see there that almost 2/3 of the people don’t give you the time of day when
you first approach them. But they persevere. And, you know, eventually screen and recruit
the participants that we need. Here are some baseline characteristics. I think what is
really unique for us and what I think is surprising to a lot of people but not very surprising
to the food industry, is that 30% of our cohort involves men. So we’ll be able to look at the extent to
which gender moderates in the intervention effects. You can see – actually I want to
– the slides – those things moved a little bit. The poverty status – let’s look at the
level of poverty in this sample. We have – because we are in Southern California,
we obviously have a very traditional Latino, a very Spanish speaking, but you can also
see that we have some people who are seen bicultural, so sort of living between these
two cultures. Okay, our retention rate is pretty amazing
given the fact that these individuals are people who are approached as they’re entering
a store. I know I often ask myself, would I stop and answer a survey and participate
in a research project? And that really makes me think twice about,
you know, what we agree to. But amazingly, we’ve retained almost – well 90% in this control
submission and 88% over a one year period. So again, hats off to the team. I want to
show just one innovation in terms of how we’re evaluating store changes. And so very similar to (planogram)s that the
store industry uses. What we’re trying to track as well is sort of the placement and
amount of space that’s dedicated to fresh produce in stores. And then we’ll be able
to look at that and see how much of this really makes a difference. But also, I think just looking at the dynamic
environment in which we work, and we find often that, you know, these stores do change
up from one week to the next. I mean in one way it’s one of the beauties about working
with them, because they are so innovative and willing to try things. On the other hand, when you’re doing a randomized
control trial and trying to control things, it makes it a little challenging. So speaking
of challenges and solutions, I think one of the first things we often get asked is the
store recruitment, like how do you get people. And really it’s just, you know, being straightforward,
being very clear about what you need and being really efficient with your time. We have a
lot of people that tell us, you know, this was a diffused – we get a lot of passive refusals
essentially, of people not wanting to tell us outright. So we often have to be a little bit more forceful
and say okay, you know, do you think you’re in or not, because I don’t want to – time
is always the issue. And should one continue trying to pursue a store that may really not
want to participate? Here are some reasons we’ve been given for
why they haven’t wanted to recruit. It’s often a lack of time. But also for us, is we don’t
want to recruit stores that are in transition, because then obviously that could ruin our
design. And we actually had some problems where we
had to remove one store because of some personnel issues. But then that forced us to remove
the (map) store, which became a problem in terms of our timeline. In terms of challenges and solutions with
intervention, we often do our interventions or recruitment in waves. And so that – the
beauty of that has allowed us to make slight modifications in what we do and subsequently,
not huge changes. And the first one was although we had fully
intended to work with the butcher, we didn’t make that entirely clear with the managers
from the beginning in the first place. So we decided to add a few additional material
to make that clear, that we wanted their involvement. Because for us, working with the butcher is
really important in the tiendas. They’re often the person that has the highest credibility
in the store. They’re the people that most people interact with, unlike the cashier,
sort of the person on the way out, the butcher is the person that you’re often more likely
to greet. We were more specific with the change under
the prepared foods section requirement, to make sure that they happened a little bit
more. We had the training that we were targeting
for 25%, but then we realized after the first wave, that we needed to provide a mini-training
for all employees, to make sure that everybody was aware that was going on. And then for pure cost reasons, we decreased
the amount of time and the amount of samples that were given out, during the food demos.
You can see here, again the dynamic environment, where on the left side, you know, a wonderful
environment to be able to do a food demo. And you’ve got the two pictures on the other
side where we had to figure out how to do it outside, in some cases even on a busy street.
So really challenging environments because these stores are not huge. All that said, our – some of the process evaluation
data that we collected at six and 12 months, has indicated that the stores are at least
seeing some of the improvements. So you can see some of their direct quotes. And including
also seeing some changes in the employees. You can see one comment regarding better customer
service. So that’s – that gives us some hope that at least maybe this will be receptive
and our potential is disseminated to other stores, maybe higher if managers see some
sort of ancillary benefit beyond being able to sell fruits and vegetables. If you’re interested in more information,
we have a protocol paper in Contemporary Clinical Trials. And then if you’re interested just
more generally about our research, there you can see our Web site. So now just for the last few minutes, I’ll
turn it over to Margaret to facilitate any questions that there may be pending on there. Margaret Farrell: Yes, great. Thank you both
so very much. Elva and (Suchi), these were really some robust and interesting, really
fascinating presentations. And thank you so very much. And I appreciate how – how well
they dovetailed on each other. So we would like to open the line for any
questions. We have a few minutes remaining. And so if you do have a question you’d like
to ask live, you can press star 1. Or continue to use the Q&A feature at the top of the screen. What I will say is that we’ve never had speakers
actually answer questions live during the presentations, during the Q&A, on their own
time. So we thank them for that. And I’m going to, in the interest of time,
I’m going to post all of your questions as well as all the thoughtful answers, up on So we’ll – we’ll capture all of that there. But just
a few questions – and an interesting question came in. (Suchi), this came about your – you mentioned
in passing that you had such a level of men participating in the research. And what role
do you think that the – that the male – the husband or the male significant other, play
within the context of – of the shopping behavior? Dr. Guadalupe Ayala: Yeah. It’s a really great
question and we have so much other data now based on some observational work we’ve completed
in some similar stores. They are actually at least in our communities and what we observed
in North Carolina, they are actually very involved in the food shopping part of it. They – obviously the women in general, I’m
speaking of stereotypes here, still has the primary role in terms of food preparation
and food serving in the home and sort of maintaining that aspect of the home. But when it comes to the shopping and deciding
what to purchase, the husband actually plays a very important role in this. And we’ve seen
it over and over again. And in particular, in the food shopping research,
even shopping with their kid which was a phenomenon that we did not anticipate seeing in another
study. So I think it – it’s an interesting – it’ll be interesting to be able to evaluate
this to see the effects on them. Margaret Farrell: No. I think so too. I mean
just speaking from my own family’s shopping experience as well. And another question along
those lines, about the study, to what do you attribute the high retention rate of the people
that accepted the invitation to be a part of the intervention? Dr. Guadalupe Ayala: Do you mean the customers
or do you mean the managers? The customers. Margaret Farrell: I think I mean the customers. Dr. Guadalupe Ayala: Yeah. Well the customers,
you know, that’s interesting. That’s a great question, because they are recruited to be
part of an evaluation cohort. So they are actually – because the stores are randomized
after baseline data collection. So all of the – the customers know is they’re
being recruited; asked dietary questions; told that they are going to be contacted again,
six weeks, 12 months later, to redo the assessment. Because there is no real direct intervention
involvement with them. The changes that are happening within the
store. And so it’s sort of like the term, you know, if you build it, will they change?
That’s essentially what we’re testing here. There is no direct customer – nothing that
we, as an intervention team are doing with the customer. Does that make sense? Margaret Farrell: It does. It does. Dr. Guadalupe Ayala: Yeah. Margaret Farrell: Thank you. Another question.
Elva, this one for you, with regard to I guess it’s the study design. What made you choose
vigorous exercise as the intervention, as opposed to walking or another – well what
made you choose vigorous exercise? Dr. Elva Arredondo: So it – the primary outcome
is actually moderate to vigorous physical activity. So we were promoting moderate to
vigorous activity mostly because it’s – its association with lower cardiovascular risk
and cancer risk as well. So we – there’s a lot of evidence showing
that this intensity level is preventive in a lot of chronic diseases. And there’s more
– there’s emerging evidence that walking and light activity also plays an important role. So – but that the time we were most interested
in – in promoting moderate to vigorous activity because of the evidence. Margaret Farrell: Excellent. No, thank you.
Certainly the harder way to go, right? But – and another question for you – where – where
can I find more studies about using Promotoras for Latino communities? Dr. Elva Arredondo: Yeah. No, that’s a great
question. So some of our work actually does feature the involvement of Promotoras in different
studies. We’ve published a study that basically the title is, Recognizing the Diverse Roles
of the Community Health Workers in the Elimination of Health Disparities. There are also systematic reviews looking
at the role of Promotoras in – in various communities. So and (Suchi) you – you’ve also
– you’ve delved into this literature as well. So you may want to add or comment on other
resources. Dr. Guadalupe Ayala: Sure. Yes. I mean those
are – those are perfect ones. I’ll also paste some references onto the – the Q&A because
that’ll be easy. There’s also an article by (Rhodes), by (Scott Rhodes), which – it’s
a little bit old now but at least gives you some historical data. And then if you go to the (NHLBI), the National
Institute of Heart Lung and Blood Web site, they also have some resources. So if you just… Margaret Farrell: Great. Dr. Guadalupe Ayala: …go to their Web site
and type in community health worker, you probably will also find a significant amount of resources
on the CDC Web site, the Centers for Disease Control and Prevention. You just type community
health worker. So the names are used interchangeably although
there may be some differences obviously in how they’re trained and their expectations.
But the names tend to be used interchangeably. Margaret Farrell: Great. Great. Well we’ve
gotten to the top of the hour and I know that I want to be respectful of everyone’s time.
And to invite you to – to continue the discussion online. Sarah Bernal and I will be posting
resources as well as our speakers will continue the discussion. And – and hope that you’ll be looking there
for the archive which we hope to have up next week. And, you know, please mark your calendars
for next month’s cyber seminar on tobacco cessation for cancer patients and survivors.
And that registration should be coming out next week. So with a final thank you to our outstanding
speakers, it was such an energetic and exciting presentation today. So thank you both so very,
very much. And thank you everyone for joining us. And finally, if you’d like to continue this
discussion, I hope to see you later over on Thank you
everyone for joining us. Coordinator: This now concludes today’s meeting.
All lines may disconnect at this time.

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