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LoginFlorida Department of Health in Orange County
Step into Your Best Life - Cardiovascular Disease Prevention in Priority Populations
Dr. Tralonda Triplett
Director, Community Health
tralonda.triplett@flhealth.gov
4077235113
Orlando
Florida
32835
Your summary must address all the questions below:
The Florida Department of Health in Orange County (FDOH-Orange) is one of 67 Public Health Departments under the governance of the integrated Florida Department of Health (DOH). DOH-Orange is responsible for protecting, promoting and improving the health of the county’s 1.2 million residents and over 75 million annual visitors. Included in the Department’s geographical purview is Orlando, the county’s seat, residence to some of our nation’s most sought-after theme parks and tourist attractions, and a over 175 incorporated municipalities and towns along. As Florida’s fifth most-populated county, Orange County boasts a tapestry of racial and ethnic communities, generous distributions of varying age ranges, and economic strata that call Orange County home. FDOH-Orange welcomes opportunities to reach and impact all of these diverse communities to improve health status and health outcomes.
In May 2019, the FDOH-Orange County Office of Community Health (FL DOH-Orange) joined comprehensive efforts statewide to address chronic conditions that critically impact community health and well-being. While billions of dollars are spent annually in Florida to address heart disease risks, heart disease remains the leading cause of death. In 2018, Florida Charts confirmed hypertensive heart disease deaths in Orange County as exceeding state rates. While only marginally increased from 2017 counts, 2018 hypertensive heart disease deaths showed the highest levels since 2015 and nearly 37% increase since then. Particularly, current data indicates rates of cardiovascular disease and stroke among Black and African American populations in Orange County exceeded rates in White populations.
Goals
In collaboration with the Centers for Disease Control and Prevention and the Million Hearts® in County Health Departments program, FDOH-Orange piloted the Step Into Your Best Life program (SIYBL). Illustrating Million Hearts® 2022 strategies, SIYBL was purposed to use an 8-week period to prevent cardiovascular disease incidence by:
Objectives
SIYBL’s 8-week curriculum focused on educating participants on individual and community-level CVD risks, improving health literacy, and providing instruction on Chicago-style Steppin’ as a method for increasing regular physical activity in target populations. Objectives, therefore were programmatic and participant-based. By the culmination of Step into Your Best Life, the following objectives were to be accomplished:
Implementation
Step into Your Best Life collaborated with Hebni Nutrition and launched during a World Record-breaking attempt for the world’s largest line dance. This opportunity offered unparalleled access to participants and seamless integration into the event purpose. Three locations throughout Orange County served as venues for dance lessons. Three, two-hour, dance lessons weekly offered SIYBL opportunities to accomplish its primary objectives. Two screenings of the High Blood Pressure documentary featuring post-screening panels from well-known Orange County residents (including form CBS Morning anchor Mark McEwen) recovering from strokes provided opportunities to discuss preventive measures. Finally, a culminating event entitled Summer Breeze provided a shared experience for participants to initiate sustained lifestyle changes learned, and display dance skills acquired during SIYBL.
Outcomes
Gratefully, all objectives of SIYBL were accomplished. Outcomes showed that as many as 60% of participants attended lessons at all three locations weekly. Such retention and participation has been unmatched previously. Further, more than 55% of participants reported increased frequency and duration of weekly physical activity due to participation in SIYBL. More than 70% of participants indicated intentions to continue physical activity in consecutive weeks, and 90% recognized dance as a viable physical activity after participating in the 8-week program. Two community screenings of the High Blood Pressure were implemented during Minority Health Month and National Hypertension Month, and garnered noteworthy support from various communities. The culminating event, Summer Breeze 2019, brought more than 200 participants from all venues to celebrate completion of the program and to pledge sustained commitment to health promoting activities and expanded self-management of chronic conditions.
Factors for Success
Step into Your Best Life was designed to meet unique needs of targeted populations. Imaging, training contexts, no cost, and direct interactions with professionals reflected the inclusiveness needed for Black and African American populations to recognize the program’s targets and respond accordingly. Engagement from notable community stakeholders recovering from strokes offered direct connections with target populations and allowed educational material dispersion. Participation in existing community events and marketing on social media increased awareness and resulted in high levels of retention and participant increase over the duration of the program.
Public Health Impact
Among various cultures, dance has historically been considered creative art and identity support. FDOH-Orange’s reframe of dance as a health-promoting physical activity through SIYBL removed barriers priority populations currently face in sustaining prescribed levels of weekly physical activity, increased social interaction, and reduced loneliness. SIYBL’s use of dance offered various levels and complexities to heighten endorphins, increase heart rates, increase lung capacity, and improve motor skills for participants were tangible to target populations and enjoyable. Additional activities focused on target population needs and increased awareness of preventive and self-management methods to reduce CVD incidence and mortality in Black and African American populations.
Website: http://orange.floridahealth.gov/
A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
The American Heart Association cites African American populations as disproportionately affected by numerous cardiovascular diseases. AHA specifically cites high blood pressure prevalence in African Americans as among the highest in the world. The American Heart Association and various other standard bearers for health promotion and disease prevention encourage regular exercise as a key component to manage blood pressure and reduce risks for subsequent cardiovascular diseases. However, innovative measures like the Million Hearts ™ Initiative, co-lead by the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services, focuses efforts on rising rates of death from heart attack or stroke particularly among adults ages 35 to 64. Million Hearts Initiatives ™ identifies Black and African American adults ages 35 to 64 among its national priority populations. In Florida, even with billions of dollars allotted annually to address heart disease risks, heart disease remains the leading cause of death. In 2018, Florida Charts confirmed hypertensive heart disease deaths in Orange County as exceeding state rates.
Of US Census estimated 1.38 million residents in Orange County, Black and African American (not Hispanic or Latino) populations comprise 19.5 percent. Further, Florida Charts suggests that Black and African American (non-Hispanic or Latino) adults ages 18-64 comprise 22.1 percent (199,884). Based on current population levels, estimates of Orange County Black and African American populations with hypertension (diagnosed or undiagnosed) can be as high as in 43,887 in men, and 48,836 in women. While SIYBL reached only a minute percentage of target populations in Orange County, it held poignant indicators to engage even more participants in need. Various community-based organizations in Orange County are knowledgeable of cardiovascular disease incidence and prevalence in African American populations. While current community activities including community health fairs and Florida Healthiest Weight programs have shown great promise in heightening awareness of disease risks for brief periods, establishing sustained physical activity in priority populations has remained elusive.
Healthy People 2020 (HP 2020) HDS-9.4 and HDS 10.4 requested increases in proportions of adults with pre-hypertension or hypertension who meet the recommended guidelines for physical activity. HP 2020 continues by identifying recommended durations and frequencies of physical activity for adult populations to accomplish these directives. The goals explain requested increases in adults who report moderate physical activity for at least 150 minutes per week or vigorous physical activity for at least 75 minutes per week or an equivalent combination. The Step into Your Best Life program offered an innovate definition for physical activity in which participants could enjoy, interact socially, and accomplish recommended frequencies and durations for physical activity in priority populations. In doing so, SIYBL addressed primary objectives to not only initiate physical activities, but to sustain healthier qualities of life. Steppin’—as the dance style is called—is a couple-based intricate dance initiated in Chicago, with national and international fans. The dance style offered an exceptional opportunity to introduce dance as sustainable and legitimate physical activity.
While dance is not in itself a new practice, its introduction to public health efforts is innovative in the targeted age groups. Further, the use of a couples-based dance style offered shared utility among men and women. Because dance lessons included regular interaction with peers, lessons offered fertile opportunities to initiate and build social interactions and reduce loneliness among participants. This attractiveness, coupled with direct interactions with medical professionals (Black Nurses Rock! provided blood pressure screenings) and community stakeholders (community screenings of documentary and panel discussions) discussing impacts and preventive measures for cardiovascular diseases added to participants’ willingness to continue participation. As such, participation and retention grew ever more rapid in proportion.
Continued use and study of dance as a viable method to improve physical activity frequency and duration are essential. Over time, evidence bases are sure to amass.
The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broadbased involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
Step into Your Best Life offered an innovative approach to addressing cardiovascular disease risk for Black and African American adults ages 34-65 in Orange County, Florida. By leveraging dance to reduce inactivity, decrease social isolation and loneliness, increase community knowledge on individual and group-level risks for cardiovascular diseases, and enhance access to places for physical activity, Step Into Your Best Life reframed a familiar cultural activity and translated information to palatable portions for populations often overlooked or underserved in such efforts.
Objectives
SIYBL’s 8-week curriculum focused on educating participants on individual and community-level CVD risks, improving health literacy, and providing instruction on Chicago-style Steppin’ as a method for increasing regular physical activity in target populations. Objectives, therefore were programmatic and participant-based. By the culmination of Step into Your Best Life, the following objectives were to be accomplished:
Implementation of the pilot included initiating essential partnerships between FDOH-Orange with local dance instructors skilled in Chicago Steppin’ principles and methods, and community stakeholders with vested interests in CVD risk reduction and community education. In addition, FDOH-Orange secured venues in Eastern, Western, and Central locales throughout the County to support dance lessons for eight consecutive weeks. Partnerships with professional organizations such as Black Nurses Rock provided access to blood pressure screenings and direct interactions for participants to build individual knowledge and peer support. Engagement with other professionals at FDOH-Orange allowed for documentary screenings and panelist discussions in collaborations with additional Hypertension Month and Minority Health Month observances. Once these primary partnerships were established FDOH-Orange implemented the practice by engaging multi-level marketing via direct interaction and social media outlets. Handbills describing dance lesson venues, along with digital flyers provided awareness for communities-at-large. Implementation included community discussions at all program activities identifying program goals, establishing relationships between participants, and sharing information about culminating event. On-going reporting on social media outlets detailed growth in dance lesson participation, documentary screenings and panel discussion participants, and maintained community visibility. Coverage of culminating event on closed-circuit cable television, and attendance by State health leaders heightened importance of program goal and finalized completion of objectives. Combined, successful implementation required fostering new and focused internal and external partnerships, intentional placement of venues, inclusive direct and social media marketing efforts, and provision of positive reinforcement to sustain lessons for participants.
No eligibility criteria were established for participation in the practice.
The program was launched April 27, 2019, with dance lessons and activities beginning May 1 and culminated with Summer Breeze 2019 on June 22. Documentary screenings and panel discussions were completed during the May and June months. Dance lessons were held on Tuesdays and Wednesdays from 7 PM – 9 PM, and Saturdays from 3:30 PM – 5:30 PM for eight consecutive weeks.
Time limitations did not allow in-depth inclusion of stakeholders in planning phases. Participating stakeholders’ roles were clearly identified, and discussed at-length prior to program implementation. Additional stakeholders shared information about SIYBL classes and other events with their congregants and memberships. Community awareness became so prevalent, that local radio stations included program information on their community calendars and mentioned the program during morning peak times.
To foster collaboration, FDOH-Orange Director of Community Health served as Program Coordinator. In doing so, existing partnerships with community-based organizations, academic, and civic groups were all informed of the program through the Community Health Improvement Board and encouraged to participate. The creativity of the goal allowed FDOH-Orange to initiate new partnerships in diverse sectors. Business and faith-based sectors were invited to participate in the activities and introduced to creative ways to meet broad organizational and congregational needs. Further, groups were kept abreast of the progress of the program and the culminating outcomes. By devising regular channels to initiate and sustain communication with diverse partners throughout the practice, FDOH-Orange elevated its role to serve the needs of the entire county. Further, diverse partners were able to connect and build new partnerships under a common goal. Resulting partnerships, both new and emerging, are integral to improving population-level knowledge and awareness about health priorities and avenues to address them.
No staff salaries or consulting fees were assessed for this pilot program. All budget costs were assessed to implement and evaluate the program. The total budget was $15,000; however an estimate of all appropriated costs is approximately $50,000 for all expenditures.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improve practice. Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
Upon completion of the SIYBL practice, outcomes greatly exceeded initial expectations, and all objectives were accomplished. Program participation and retention exceeded initial estimates by nearly 40%. While three venues were established to improve access to dance lessons, more than 50% of participants attended all three venues over the eight week period. Participants were very vocal and expressive of how they embraced imaging on marketing tools that were racially diverse. To restate, objectives included:
Objectives
SIYBL’s 8-week curriculum focused on educating participants on individual and community-level CVD risks, improving health literacy, and providing instruction on Chicago-style Steppin’ as a method for increasing regular physical activity in target populations. Objectives, therefore were programmatic and participant-based. By the culmination of Step into Your Best Life, the following objectives were to be accomplished:
Process evaluations concluded completion of the full program as designed. Outcome evaluations illustrated improvements in regular physical activity duration, frequency, and intended sustainability among targeted populations. In addition, evaluations showed successful reframing of dance as a viable physical activity by participants, and 20% of all dance participants participating in at least five of eight weeks of lessons reduced systolic blood pressure readings by 5%.
Primary data was devised and analyzed by the Program Coordinator, and collected by collaborating nurses. No secondary data sources were accessed. Results were analyzed using simple linear regression analyses and content analyses of qualitative participant feedback. No modifications of the practice were necessary as a result of the data findings.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that the stakeholders are invested in its maintenance and to ensure it is sustained after initial development (NACCHO acknowledges that fiscal challenges may limit the feasibility of a practice's continuation.)
Step into Your Best Life offered clear acknowledgment by participants that imaging and marketing that reflected target populations were appreciated. Further, offering an innovative approach to addressing health priorities fostered internal, external, existing and emerging partnerships. These partnerships were essential to community awareness and response, and greatly impacted participant levels and resilience throughout program implementation. Further, this practice emphasized the necessity to maintain regular communication with partners to retain support, share progress, and foster program growth to completion.
While a formal cost-benefit analysis was not completed because of the relatively small sample size, what is clear is that no previous practice blended art to improve health in the manner that SIYBL did. There remains substantial stakeholder interest and commitment to sustain the practice, and plans are already underway to expand the curriculum to 12 weeks to include dance instruction, panel discussions and additional information self-management of CVD including reduction of sodium intake through nutritional education, medical adherence, and comprehensive wellness practices. Budgets are already aligned and submitted to implement SIYBL 2.0 in early 2020.
