Increasing Physical Activity in Rural Counties: Get Fit Challenge

State: NC Type: Neither Year: 2016

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Brief Description of the LHD The mission of the Jackson County Department of Public Health (JCDPH) is to enhance, promote, and protect the health of all Jackson County residents with an overall effort to enhance their health status through prevention and education.  Located in the heart of Western North Carolina, JCDPH is surrounded by the Great Smoky Mountains and the Blue Ridge Parkway.  Jackson County is a Tier 1, rural county of approximately 40,000 residents.  JCDPH serves four main townships, additional residential areas, and the Qualla Boundary-- a tribal reservation for the Eastern Band of Cherokee Indians.  Residents are predominately Caucasian (84.5%) or American Indian (9.5%).  As a result of geographic isolation and lack of resources and employment opportunities for the area, 21.8% of the population lives below the poverty level. Describe the Public Health Issue In 2011, the County Health Rankings indicated that 30% of Jackson County adults were obese, an increase from 28% the previous year. The surrounding counties of Western North Carolina were experiencing a similar uptrend in obesity as well. Additionally, data collected during the 2011 Community Health Assessment determined that many adult residents were not engaging in the recommended 150 minutes of moderate to vigorous physical activity per week. In fact, only 25% of adults surveyed in Jackson County indicated that they met the recommended weekly physical activity goal. Goals To improve the health of Jackson County residents through increased physical activity. Objectives To implement an eight-week community-wide fitness Challenge annually. To increase participation in the Challenge annually. To increase the percentage of adults in Jackson County getting at least 30 minutes of physical activity five or more days a week to 30%. Practice Implementation The Active for Life (A4L) Action Team (an action team made up of representative from the Health Department, local hospital, Western Carolina University, Recreation Department, Senior Center, and community members) meets monthly to discuss the planning and implementation of a variety of community-wide physical activity initiatives.  To plan for the Get Fit Challenge, A4L first built a website that explained the rules of the Challenge, offered information on physical activity, and a way for teams to register and submit points.  Get Fit Challenge participants were encouraged to form or join a team.  Teams could be comprised of three to ten individuals-- family members, friends, church groups, co-workers, etc.  Teams then picked a name, team captain, and registered through the newly developed website.  Each week for eight weeks, the team captain was responsible for averaging the minutes of physical activity their team members accumulated and submitting this score through the website.  All scores were visible on the website to promote healthy competition. Additionally, A4L offered coordinated physical activity opportunities (walks, hikes, free yoga classes, etc.) throughout the Challenge that participants could participate in.  Weekly "Wellness Wednesday" emails were sent out to all participants with information on these physical activity opportunities plus tips for a healthy lifestyle.  Throughout the Challenge, small prizes (pedometers, water bottles, etc.) were given away to maintain motivation and momentum. The Challenge ends with an End of Challenge Celebration in which the team with the highest score is given a rotating trophy.  Other superlatives such as "Most Creative Team Name," "Most Prompt Score Reporting," "Most Consistent," etc. are also awarded. Results/Outcomes The Challenge has been implemented for five iterations since 2011.  Participation in the Challenge has peaked at approximately 700 participants, waned at approximately 150 participants, and averaged at approximately 450 participant.  Challenge participants report an improvement in body image, increased muscle tone, and increased knowledge and awareness regarding physical opportunities available community-wide.  Community survey results indicate that the percentage of adults in Jackson County getting at least 30 minutes of physical activity five or more days a week has increased from 25% to 52.2%. Many factors led to the success of this program including the fact that it was team-based, self-report in nature, and made available primarily electronically. Public Health Impact There are well-established physical and emotional benefits with physical activity.  However, many Jackson County residents are not meeting the recommendations for weekly physical activity.  As a result, residents are at risk for various illnesses, chronic disease, and more.  By promoting physical activity in a fun, competitive way, the A4L Action Team works to improve the health of Jackson County residents by addressing a modifiable risk factor. Additionally, community-wide fitness challenges address two of the 10 Essential Public Health Services.  These include: Inform, educate, and empower people about health issues Mobilize community partnerships and action to identify and solve health problems Website JCDPH's website: http://health.jacksonnc.org/ Get Fit Challenge website: http://wncgetfit.weebly.com/
Statement of the Problem/Public Health Issue The emergence of obesity as a public health issue has prompted many efforts to both determine and understand the underlying causes of this issue.  Much research has indicated that physical inactivity, directly linked to obesity, can have serious implications on one's health.  Further, a sedentary lifestyle increases many causes of both of mortality and morbidity-- cardiovascular disease, diabetes, colon cancer, high blood pressure, depression, and more.  To address this public health issue, it is recommended that all adults exercise for 30 minutes, five days a week combined with an active lifestyle.  Leading a preventative lifestyle, that includes physical activity, can drastically reduce one's risk of chronic disease. In 2011, the County Health Rankings indicated that 30% of Jackson County adults were obese, an increase from 28% the previous year. The surrounding counties of Western North Carolina were experiencing a similar uptrend in obesity as well. Additionally, data collected during the 2011 Community Health Assessment determined that many adult residents were not engaging in the recommended 150 minutes of moderate to vigorous physical activity per week. In fact, only 25% of adults surveyed in Jackson County indicated that they met the recommended weekly physical activity goal. Target Population Affected by the Problem The Get Fit Challenge targets all residents in Jackson County, aged 18 years and older.  Approximately 40,000 residents live in Jackson County.  Of these 40,000 residents, 82.9% (33,160 residents) are 18 years and older.  When the Challenge began, approximately 30% (9,948 residents) of residents were obese and 75% (24,870 residents) did not meet the weekly physical activity recommendations. The following indicates reach for each iteration of the Challenge: Iteration 1 Participants: 700 participants Reach: 700 participants/33,160 adult residents= 2.1% of adult residents in the county Iteration 2 Participants: 336 participants Reach: 336 participants/33,160 adult residents= 1.0% of adult residents in the county Iteration 3 Participants: 141 participants Reach: 141 participants/33,160 adult residents= 0.4% of adult residents in the county Iteration 4 Participants: 441 participants Reach: 441 participants/33,160 adult residents= 1.3% of adult residents in the county Iteration 5 Participants: 539 participants Reach: 539 participants/33,160 adult residents= 1.6% of adult residents in the county Past Efforts to Address the Problem As the rising public health issues of obesity and physical inactivity have been issues not only in Jackson County but nationwide for years, much has been done to previously address this problem.  Listed below include a variety of efforts to increase physical activity among Jackson County residents, age 18 years and older: Implementation of Physical Activity Classes for Older Adults:  In partnership with the Jackson County Senior Center and the Southwestern Commission Area Agency on Aging, the Jackson County Department of Public Health has worked to implement a variety of physical activity classes focused on older adults.  These classes include the Arthritis Foundation Exercise Program, Walk with Ease, Get Some Balance in Your Life, and Matter of Balance.  Not only do these classes increase physical activity among older adults but they also work to improve the balance of older adults and, by default, reduce fall risk. Implementation of Educational Classes for Adults: In partnership with the Jackson County Cooperative Extension, the Jackson County Department of Public Health has worked to implement a variety of educational classes that include a physical activity component to any adult in Jackson County.  These classes include Eat Smart, Move More Weigh Less and Strong Women Stay Young. CATALYST Trail Project:  In partnership with the Jackson County Parks and Recreation Department, the Jackson County Department of Public Health worked to oversee the construction, finances, trail maintenance, and policy agreements of the CATALYST trail built around the Aging Complex in Webster, NC.  Shared Use Agreements:  In partnership with MountainWise, the Jackson County Department of Public Health worked to develop shared use agreements with the Jackson County Public Schools.  These agreements would open the school outdoor facilities to the public after hours, effectively turning them in to community parks. Well@Work Program:  The Jackson County Department of Public Health, working with representatives from all other county agencies, developed a work site wellness program for all county employees.  A large component of this program includes physical activity.  Participants are encouraged to keep a quarterly physical activity log, participate in monthly challenges, and submit wellness opportunity vouchers for participating in a 5k or other wellness activities. Reasons the Current/Proposed Practice is Better Adequately addressing sedentary behavior and physical inactivity will require interventions on the individual, community, environmental, and policy change levels.  In years past, much emphasis has been placed on individual level interventions, interventions that assist individuals in making behavioral changes in themselves.  These interventions (such as implementing educational classes) provide education, training, and services to individuals with the goal of achieving knowledge and behavioral changes. The Get Fit Challenge addresses sedentary behavior and physical inactivity on individual, group, and community levels.  Participants are encouraged to modify their knowledge, attitudes, behavior, and emotional well-being through physical activity.  As a team, group-level change occurs as new physical activity skills emerge if participants choose to exercise together.  Further, the Get Fit Challenge promotes norms that support physical activity through team captains as popular opinion leaders, community mobilization through Challenge promotion, and sharing information through social networks.  By working through multiple channels and levels, the Get Fit Challenge requires complex coordination and increases the probability of success. Innovation of the Current Practice Competitive, team-based physical activity is not a new concept.  What makes the Get Fit Challenge new and innovative is the county-wide (and in later years, region-wide) coordination between partners and agencies.  Further, the Get Fit Challenge is implemented in a rural, mountainous region of Western North Carolina where travel is difficult due to geographic isolation.  Through technology and the electronic presence of this Challenge, participants are able to participate without in-person attendance.  Is the Current Practice Evidence-Based? The practice is not evidence-based.
Nutrition, Physical Activity, and Obesity
Goals of the Practice To improve the the health of Jackson County residents through increased physical activity Objectives of the Practice To implement an eight-week community-wide fitness Challenge annually. To increase participation in the Challenge annually. To increase the percentage of adults in Jackson County getting at least 30 minutes of physical activity five or more days a week to 30%. Steps Taken to Achieve Goals and Objectives To implement this program, many steps were taken to ensure that the goals and objectives were achieved.  First, the local Health Department completed a Community Health Assessment in 2011.  During the CHA process, data was collected to determine a physical activity baseline for Jackson County residents.  From there, the Health Department formed an action team charged with increasing physical activity, the Active for Life (A4L) Action Team.  Community members that represented all aspects of health were invited to join the team.  A4L has representation from the Senior Center, Department of Social Services, Recreation Center, Western Carolina University, local hospital, county government, and more.  A4L met monthly to brainstorm ideas on how to increase physical activity among Jackson County residents and determined that a competition-based community wide physical activity event could be an ideal strategy. Using ideas and research from similar programs, A4L developed the Get Fit Challenge.  Participants would form or join a team of three to ten individuals.  These individuals could be family members, friends, church groups, co-workers, etc.  The team would then pick a name, a captain and register through a website.   Each week, each team captain would average the minutes of exercise their team members accumulated.  Minutes were submitted by captains through the website.  At the end of the eight-week Challenge, A4L sponsored an End of Challenge Celebration where the winning team was recognized.  Additionally, superlatives were distributed to teams who had the Most Creative Name, Most Prompt in Score Reporting, Most Consistent, etc. A key component in implementing this Challenge was the development of the website.  A4L worked with an IT professional at the local hospital who developed a website using Weebly, a free website platform.  Registration and score submission were built into the website using Google Forms.  After it's creation, the Health Department maintained the website with Challenge updates, score updates, and more. A4L promoted physical activity throughout the eight-weeks of the Challenge.  Members of A4L wrote press releases on physical activity and submitted them to the local newspaper.  Flyers and handouts were given throughout the community to publicize the event.  Participants who were also part of work-site wellness programs were given points for participating in the Challenge.  To keep momentum and interest peaked, the Health Department sent out Wellness Wednesday emails to participants who provided their email addresses.  Wellness Wednesday emails contained health tips, physical activity opportunities throughout the region, and more.  Additionally, teams were awarded small prizes (like pedometers, water bottles, etc) through the emails.  If selected as a winner, captains were asked to notify the Health Department and come pick up their prize.  A4L also offered free coordinated physical activity events (walks, hikes, yoga, etc) throughout the Challenge. After each Challenge's conclusion, A4L would send out an evaluation to participants to determine successes, areas for improvement, and more.  A4L met to discuss the results of the Challenge, number of participants, number of teams, and any other pertinent information.  The Health Department added data from the State of the County Health (SOTCH) Report on resident physical activity levels to determine if the Challenge, paired with other initiatives, helped to increase physical activity levels of residents. Criteria for Those Selected to Participate Any resident of Jackson County is welcome to participate in the Get Fit Challenge.  During it's fifth iteration, A4L decided to open the Challenge to any resident of Western North Carolina. Timeframe The Challenge lasts for eight-weeks, usually from mid-September to mid-November.  Planning for and conclusion of the Challenge takes an additional month.  In it's entirety, planning, implementation, and evaluation of the Challenge takes approximately three months. Stakeholders Involved, Including Their Role in Planning and Implementation All stakeholders involved are a part of the Active for Life (A4L) Action Team, an action team that arose from the health priorities selected during the 2011 Community Health Assessment.  A4L selects a chairperson to lead the action team every other year but is supported by the LHD as the convening agency.  A4L is one of the three action team that feeds into the Healthy Carolinians of Jackson County partnership led by the LHD.  With this established structure in place, A4L is able to rely on an agency for operational support and guidance while working on strategies set forth by the community. The following stakeholders participate in A4L and support the Get Fit Challenge: Jackson County Department of Public Health Convening agency Challenge promotion Website upkeep and support Door prize collection and donation Physical activity coordination Develop Wellness Wednesday emails Jackson County Department on Aging Door prize collection and donation Challenge promotion Physical activity coordination Potential host of End of Challenge Celebration Jackson County Parks and Recreation Department Door prize collection and donation Challenge promotion Potential host of End of Challenge Celebration Jackson County Government Challenge promotion Physical activity coordination Harris Regional Hospital Door prize collection and donation IT support Physical activity coordination Challenge promotion Department of Social Services Challenge promotion Western Carolina University Challenge promotion Door prize collection and support Physical activity coordination Potential host and sponsor of End of Challenge Celebration Start-Up or In-Kind Costs to Include Funding Services Much of the support given throughout the Challenge was in-kind, offered through volunteer hours from stakeholders.  Below is a breakdown of in-kind support and financial costs of the Challenge: In-Kind Costs Volunteering of Time:  Members of A4L have donated their time to planning the Challenge, implementing physical activity opportunities, maintaining the website, and implementing the End of Challenge Celebration. Website development: The Get Fit Challenge website was developed through a free website platform by an IT professional at Harris Regional Hospital.  After development, the website was maintained by a representative from the Health Department. Recreation Center Memberships:  The Department of Parks and Recreation donated two 1-month memberships to participants to be given away as door prizes throughout the competition. Senior Center Memberships:  The Department on Aging donated two six-month memberships to participants to be given away as door prizes at the End of Challenge Celebration. Western Carolina University (WCU) Basketball Tickets:  WCU donated two tickets to a basketball game to be given away as door prizes at the End of Challenge Celebration. FitBit:  The local hospital donated a FitBit to be given away as a door prize at the End of Challenge Celebration. Media: The local newspaper printed six press releases to promote the Get Fit Challenge at no cost and the local radio station promoted the Challenge on air at no cost. End of Challenge Celebration:  Agencies donated employee time, use of facilities, and use of supplies so that A4L could host an End of Challenge Celebration.  The End of Challenge Celebration has been held at the Department on Aging, WCU, and the Department of Parks and Recreation throughout the years. Financial Costs Printing of Flyers: $0.10 x 100 = $10 Printing of Superlative Certificates: $0.15 x 60 = $9 Rotating Trophy: $30 Pedometers: $1.25 x 25 = $31.25 Water bottles: $2.15 x 20 = $43 T-shirts: $6 x 10 = $60 Drawstring bags: $1.89 x 15 = $28.35 FitBit: $99 Subway Gift Cards: $10 x 5 = $50
What Did We Find Out? Evaluation is an essential component to program implementation.  Including evaluation in any program ensures that you can attribute successes to your implementation efforts.  A variety of evaluation components were included in the Get Fit Challenge to ensure that successes, areas to improve, and additional feedback from participants and action team members were addressed. To What Extent Were the Objectives Achieved? Each objective was thoroughly addressed in the implementation of the Get Fit Challenge. Objectives To implement an eight-week community-wide fitness Challenge annually. To increase participation in the Challenge annually. To increase the percentage of adults in Jackson County getting at least 30 minutes of physical activity five or more days a week to 30%. The Get Fit Challenge has been implemented for eight weeks for five iterations, meeting the objective set forth in Objective One.  A4L did not meet the objective set forth in Objective Two-- the Challenge began with 700 participants, waned at 141 participants, and has ended the fifth iteration with 539 participants.  Though not increasing every year, the Challenge has seen more participant annually since it waned in the third iteration.   Finally, the Challenge surpassed the final objective, increasing the percentage of adults in Jackson County getting at least 30 minutes of physical activity five or more days a week to 52.2% (surpassing the 30% objective). Evaluation Many types of evaluation were used to build a comprehensive picture of the Get Fit Challenge.  Data was gathered from both participant and A4L action team members alike. Primary Data Sources A major source of primary data came from a survey distributed to Get Fit Challenge participants at the end of the Challenge.  Participants were asked questions about the amount of exercise they participated in before versus after the Challenge, ways the Challenge improved different areas of their life, the length of the Challenge, and more. Additionally, A4L met to debrief post-Challenge.  At this time, survey results were shared along with any first-hand feedback from a stakeholders' perspective.  Any suggestions for improvement were documented and referred to at the next year's planning meeting. Finally, the Health Department conducts primary data gathering for the Community Health Assessment (CHA) every three years and the State of the County Health (SOTCH) Report annually.  A community-wide survey is distributed for these reports to determine, among many things, the percentage of residents who get the recommended amount of physical activity. Secondary Data Sources During evaluation, a few secondary data sources were accessed to supplement the primary data sources.  The NC State Center for Health Statistics reports on obesity and overweight provided a larger picture on the need for a program such as this in our community.  Data pulled from the Centers for Disease Control and Prevention on physical activity rates, chronic disease rates, and more also helped supplement the need for continuing this program.   Performance Measures, including Process and Outcome Measures Process Process measures were collected from the feedback of the A4L Action Team during monthly meetings throughout the Challenge.  Measures included: Are the Wellness Wednesday emails on topic? Is the website working appropriately? How many participants attended the coordinated physical activity events? What avenues can we take to better promote physical activity events to participants? Any feedback from participants that needs to be addressed immediately? Outcome Outcome measures were collected through the survey given to participants at the end of the Challenge.  Measures included: Please select the following types of exercise that are moderate to vigorous. (Choices include: Walking at a brisk pace, lifting weights at the gym, anything that passes the "Talk Test," walking around the grocery store, playing basketball, bowling) How many minutes did you exercise before the Challenge?  And after the Challenge? T/F The Challenge has helped me become more physically active. How do you get most of your moderate to vigorous physical activity? T/F I plan to continue to be physically active even though the Challenge is over. I feel as though I have improved in the following areas since the beginning of the Challenge (Choices include: Increased energy, improved balance, increased self-esteem, improved muscle tone, improved body image, increased motivation to exercise, lost weight, gained knowledge on physical activity opportunities in the area) Did you participate in any of the coordinated physical activity events? T/F Eight weeks for the Challenge was appropriate. T/F I found the Wellness Wednesday emails helpful. T/F I would participate in the Challenge again next year. Analysis of Results All results were analyzed during a debriefing meeting by A4L.  Comments on areas for improvement were recorded and referred to in the planning for the following year's Challenge. Modifications Made as a Result of Data Findings Based on the results of the data findings, A4L decided to expand the Challenge to anyone who lived in Western North Carolina.  Many comments indicated that participants had friends who worked in Jackson County, but didn't live in Jackson County, and still wanted to participate.  An additional modification made including limiting the number of coordinated physical activity opportunities-- most opportunities were not well attended as participants opted to work out on their own time.
Lessons Learned in Relation to Practice Many lessons were learned in relation to practice.  To begin, one of the main objectives set forth by A4L was to increase participation in the Get Fit Challenge annually.  This proved to be difficult as years passed-- community members seemed less engaged and/or interested, promotion waned, etc.  To boost interest, A4L learned that promoting in all communities and work-sites-- the school system, county government, among university/community college systems, with older adults helped increase interest again.  Further, A4L learned to rely on the collaboration and support of local media sources.  In Western North Carolina a weekly local newspaper and daily AM radio station offered in-kind promotion of the Challenge, reaching 50,000+ readers and listeners.  This promotion far surpasses flyer distribution.  Finally, A4L learned that participants preferred exercising on their own schedule versus during a coordinated event.  Instead of offering weekly coordinated events, A4L promoted existing physical activity resources on their website and through Wellness Wednesday emails that participants could take advantage of at their leisure. Lessons Learned in Relation to Partner Collaboration Each partner and stakeholder in the Get Fit Challenge volunteered their time and expertise to the Challenge.  In order to be respectful of this donation of time, A4L learned to hold succinct but productive meetings.  Additionally, much business was conducted through email to ensure all could participate, based on busy schedules.  It became obvious, through five iterations of the Challenge, that certain team members had certain specialties and preferences in duties.  The A4L chairperson worked diligently to not ask too much of team members and highlight the skills of each. Cost/Benefit Analysis No formal cost/benefit analysis was completed. Stakeholder Commitment All stakeholders are committed to sustaining this program.  A4L arose from a health priority identified in the 2011 Community Health Assessment.  A new Community Health Assessment is almost completed for 2015 and, consequently, health priorities will change.  Regardless of this potential shift in focus, each stakeholder has committed-- through the commitment of time, door prize donation, and more-- to continuing the Get Fit Challenge for years to come.
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