Title: Process evaluation of the WarriorWOD program to reduce PTSD in military veterans through physical activity and nutrition education

Authors: Kathleen Trejo Tello, Ph.D., Presenting and Corresponding Author
Phillip Palmer
Gita Walkup

Abstract

Purpose: The purpose of this study is to assess the feasibility and acceptability of the WarriorWOD intervention protocol to reduce Post Traumatic Stress Disorder symptoms in military veterans through nutrition education, physical activity, and peer to peer counseling.
Methods: Promising new research indicates that behavioral interventions promoting physical activity may be an effective approach to reducing PTSD symptoms in veterans (Shivakumar, et al, 2017). Drawing on this research, WarriorWOD, a non-profit community-based organization, established their mission of helping military veterans manage and reduce PTSD symptoms through fitness. Based on their mission, WarriorWOD created a multifaceted free program for veteran participants that includes physical activity, nutrition education and peer-to-peer mentorship. Participation entails veterans being provided with a six-month membership to a sport program, gym or fitness class of their choosing. They commit to attending a minimum of twice weekly. Additionally, they attend biweekly education sessions with a nutritionist and on alternating weeks they meet with a “battle buddy,” a fellow veteran, for peer-to-peer mentoring. To formally evaluate this program, community partners approached an academic partner to build a collaborative research relationship to conduct process and efficacy evaluation. A cohort of 30 participants were enrolled in the fall of 2023 in the Phase I process evaluation study. Participants completed online pre-intervention evaluations assessing their PTSD symptoms, motivations for, barriers to and perceptions of physical activity and health related questions. PTSD symptoms and program attendance are assessed and monitored monthly. Participants will be assessed following program completion for acceptability and feasibility. WarriorWOD organizers, nutrition counselors and peer-to-peer mentors will be interviewed for their experience in implementation.
Results: A total of 30 veterans completed the pre-intervention assessment, the majority (73%) were male. Factors affecting intervention implementation ease or difficulty, participant experience and acceptability of intervention components will be reported following conclusion of the six-month program in March of 2024. Full results will be available April 2024.
Conclusions: Findings from this study will help to evaluate the acceptability and feasibility of intervention components and inform any necessary modifications prior to evaluating the program’s efficacy for reducing PTSD symptoms in veterans through physical activity and nutrition.

Purpose: Less than 25% of pregnant women in the United States do not meet guidelines for recommended physical activity (PA). Community-based approaches to overcome barriers to PA during pregnancy are needed. This study applied the Replicating Effective Programs (REP) framework to adapt a research clinic-based intervention for PA in pregnancy for community-based delivery. The pre-conditions phase of REP was completed in prior work. The objective of the pre-implementation phase was to assess feasibility and acceptability of the intervention in a pre-test while gathering input from partners for further refinement.

Methods: Building on findings from the pre-conditions phase, the pre-implementation phase tested a fully virtual (N = 3) and a hybrid (in person and virtual, N = 6) approach to community-based delivery of the intervention during COVID-19. Participants were engaged to attend 3 workouts per week between 15 weeks gestation and delivery and achieve a Rated Perceived Exertion (RPE) of 15 on the Borg scale. Engagement with the intervention was measured by assessing observational, survey, and qualitative input of participants and trainers. Results were shared with the established Evidence-Based Quality Improvement (EBQI) Panel including 11 community partners from diverse perspectives to inform further refinements to the intervention.

Findings: On average, for the fully virtual pre-test, participants attended 1.3 workouts per week and reported a RPE of 11.9. Most workouts in the virtual pre-test were completed live with the trainer (89%) versus via pre-recorded sessions (11%). On average, for the hybrid pre-test, participants attended 1.8 sessions per week and reported a RPE of 13.3. As with the virtual pretest, participants engaged in the hybrid pre-test elected to do most workouts live with a trainer (87%) versus via recording (13%). Qualitative and EBQI input favored refinement of data collection systems, a need to reconceptualize the social support component of the intervention, and a preference for accountability gained from live workouts.

Conclusions: Live, synchronous sessions were more preferred and successful for engaging participants across both pre-tests with the hybrid resulting in improved engagement and targeted exertion. REP provided a standardized, partner-engaged model for guiding the process of pre-testing a lifestyle intervention for community delivery.

Purpose: To address the disproportionally high risk for obesity and related chronic diseases among Native American families, we collaboratively developed and demonstrated the efficacy and effectiveness of Turtle Island Tales, a year-long family-level wellness program. The purpose of this presentation is to describe additional adaptations that occurred to increase the generalizability and scalability of the intervention across a wider range of Native American communities.

Methods: After establishing the evidence base, a Native Advisory Group was engaged to further increase traditional knowledge integrated within the program and to improve cultural appropriateness. Program materials were revised collaboratively with this advisory group, a graphic design team, and other stakeholders with a goal to ensure the program could achieve greater reach, be easily adopted and implemented, and be sustained at reasonable cost.

Results/Findings: Adaptation of Turtle Island Tales from an evidenced-based intervention resulted in a program rooted in Native culture yet able to be adapted further to specific community contexts. For example, the Native Advisory Group informed the creation of the characters “Grandma” and “Igmu” (Grandma’s bobcat puppet “grandson”), who are featured throughout program materials and in short films on the program website. This use of a grandmother to model wellness aligns with Native values of elders passing on knowledge for the next generations, and communities can further adapt program materials with stories from their own culture or quotes from a local grandmother. Lessons also were adapted to feature a medicine wheel highlighting the interconnectedness of physical, spiritual, emotional, and mental health. New lessons on emotional regulation and family traditions were developed based on feedback from the advisory group and former participants. Comparisons of pre-post intervention materials provide a clear picture of changes that enhanced generalizability to a broader range of communities.

Conclusions: Even after interventions are designed using community-based, participatory approaches in the efficacy/effectiveness testing phases, additional unique adaptations can be applied to obesity prevention programs in Native American communities that change intervention form but are consistent with initial functioning principles. Culturally, the importance of a local grandmother to increase family and community engagement was a generalizable Native American specific innovation.

Purpose: Children require unstructured, unrestricted active play as infants, to encourage positive health, socioemotional and developmental outcomes in life. Certain social and environmental factors in the home setting can limit participation in play, particularly in low resource settings. As caregivers (particularly mothers) are their infants’ first teachers, they have the important role of providing opportunities for children to learn through play. However, there are limited interventions encouraging active play and development in low resource settings. This mixed methods, cross-sectional study aimed to test the acceptability of an intervention developed to improve health literacy around play and development with mothers from the Soweto community in South Africa. Methods: Fifteen mothers with infants aged 0-3 months were included to form a Community Advisory Group (CAG). Two rounds of focus group discussions (FGDs) were conducted to explore the understanding of, and barriers to play and development, and to determine the acceptability of an intervention prototype presented to the participants in the group. The prototype included developmentally appropriate activities which would be delivered to participants as part of the intervention. A further questionnaire was administered to participants one week after the focus group to determine the acceptability of intervention activities which the participants engaged with at home, with their infants. Thematic analysis and descriptive statistics were used to analyse the qualitative and quantitative data, respectively. Findings: A major theme emerging from the FGDs was around the reported barriers to play, which included limited options for safe outdoor play, overcrowding, insufficient time, limited resources, and conflicting information. Participants suggested that the intervention content be delivered weekly, through a data-free app, in English with subtitles in the local language. Overall, the prototype activities tested at home were deemed acceptable using the seven constructs of acceptability. Conclusion: The reported barriers, together with a lack of motivation and self-efficacy observed in the participants, guided the researchers to develop intervention content focused on improving health literacy in active play and development, delivered in the form of an interactive mobile app. Future research will develop and test the efficacy of this intervention in a low resource setting in South Africa.

Purpose: Sub-optimal breastfeeding practices related to the early cessation of exclusive breastfeeding, early introduction of complementary foods and mixed feeding are common despite well-documented benefits of breastfeeding. This study aimed to 1) understand maternal perceptions and barriers around breastfeeding, breastfeeding self-efficacy and breastfeeding support and 2) use this information to develop intervention material aimed at improving breastfeeding self-efficacy and thus breastfeeding outcomes, and 3) to determine the acceptability of proposed material.

Methods: Twenty mothers with infants aged between 0 to 3 months, were included in two rounds of FGDs occurring two weeks apart. The first sought to explore mothers’ perceptions and barriers around breastfeeding, based on which intervention material was created and presented to mothers in the second round of FGDs to ascertain acceptability. Following the acceptability discussion, participants were asked to complete an acceptability questionnaire exploring the mode, type of content and frequency of delivery that participants would prefer. Qualitative data was analysed using iterative thematic analysis and basic descriptive statistics were used for quantitative data analysis.

Results/Findings: Main barriers to breastfeeding were concerns around transmission of HIV, returning to work or school, impacted social life, lack of support, lactation concerns, lack of access to information and receiving conflicting advice.

Intervention material was generally considered acceptable, participants indicating that they enjoyed engaging with the content (86.7%) and that it was easy to understand (80%). Participants preferred engaging with videos (53.3%) or a combination of video content, encouraging messages and infographics.

Conclusions: We were able to assess participant needs and develop acceptable intervention content to be implemented in a low resource setting in South Africa.

Purpose: Culturally relevant and meaningful health promoting tools are limited for healthcare providers. Further, real world implementation must be considered during tool development to enhance its effectiveness and potential for dissemination and sustainability. Guided by Practical, Robust Implementation and Sustainability Model (PRISM), this study’s purpose was to identify organizational and family perspectives relevant to a family-centered digital health tool’s usefulness and potential implementation within community-based clinics.

Methods: Staff from community clinics in New York City, along with children 9-12 years, who attend the clinics and their parent/guardian, participated in semi-structured interviews via video-conferencing. Sessions were recorded and audio files reviewed using inductive content analysis processes to identify and categorize data into common themes related to three PRISM domains.

Results/findings: Participants included healthcare administrators/providers (n=5) and parent/child dyads (n=12). Both healthcare staff and dyads thought the tool would be helpful and appealing to the intended population, particularly as the clinics do not have regular nutritionist access. Parents appreciated its tailored content and as the tool would be directly connected to the clinics they thought it may motivate children to attend their wellness visit. All healthcare staff thought clinic staff would be receptive to the tool as it requires minimal provider effort and addresses important health issues, however, one administrator noted it should be introduced carefully as staff may be “tired of having to learn another new project”. A potential external environment barrier noted by healthcare staff was the patients’ limited access to technology in the clinics, which may interfere with introducing the intervention. However, implementation and sustainability infrastructure facilitators were highlighted, which included the Electronic Medical Record, where the intervention could be programmed as a pop-up reminder in the system. Also, the coordination across departments could support tool implementation as other staff, such as front desk associates and medical assistants, could also be engaged in the process.

Conclusions: While the tool appears to be useful for our intended population, findings highlight organizational barriers and facilitators that exist when considering implementation in a community clinic setting. Study insights will inform tool adaptation to enhance the potential for implementation in this real-world setting.