New YMCA Program Uses Coaching and Relationship Building to Promote Healthy Behaviors in Sedentary Adults
From 2002 to early 2004, the Young Men's Christian Association (YMCA) of Santa Clara Valley joined with YMCAs in four other western cities (Seattle; Portland, Ore.; San Francisco; and Los Angeles) in conducting an exploratory study of Total Health Plus+, a comprehensive nutrition and exercise program that helps sedentary adults adopt and sustain healthier lifestyles through a combination of individual coaching, relationship building and environmental change.
The YMCA of Santa Clara Valley and the project evaluator, the Stanford Center for Research in Disease Prevention, which operated under a subcontract, examined outcomes related to physical activity, nutrition and social connection in a group of 500 Total Health Plus+ participants and compared them to a group of 1,000 adults who participated only in a basic YMCA program. Comparing results for the two groups, the project team found that:
- At the start of the program, Total Health Plus+ participants were significantly more likely than their basic counterparts to be obese, lead a sedentary life and have less healthy eating habits; they also reported a greater readiness to change to a healthier lifestyle.
- After six months, Total Health Plus+ participants' perceptions of the barriers to lifestyle change, such as lack of willpower or time, were greatly reduced compared to their baseline levels. There was no significant change in the perceptions of barriers to change among participants in the basic Y program.
- At both six and 12 months, the percentages of Total Health Plus+ participants who engaged in vigorous exercise, strength training, abdominal exercises and stretching increased significantly, whereas the basic group increased significantly in only one physical activity area.
- In addition to improvements in physical activity and nutrition, at the one-year mark Total Health Plus+ participants were significantly more likely than their basic counterparts to report improvements in self-esteem, stress, mood management, quality of sleep and relationships to others.
The Robert Wood Johnson Foundation (RWJF) awarded a grant of $743,548 to support this project.
In the mid-1800s, the newly founded Young Men's Christian Association (YMCA) aimed to create healthy communities within the rapidly growing new cities of the Industrial Revolution by promoting individual fitness and nutrition and by building strong relationships to combat social isolation.
In the second half of the last century, the YMCA has shifted away from its broad public health mission, according to the project director, focusing instead, like many community organizations, on programs that help individual members and families make good, informed lifestyle behavior choices.
YMCAs in the 1990s found themselves competing for a small segment of the population, the already-active adults who make up between 15 and 20 percent of the total population, according to data from Healthy People 2010. While ensuring financial viability, this marketing strategy failed to reach what the YMCA calls the "start-stop" segment, the 40 to 50 percent of the adult population who lead sedentary lifestyles, have poor eating habits and make repeated attempts at behavior changes followed by relapses to inactivity.
To reach this growing, racially and economically diverse population, YMCAs in five western cities decided in 1999 to collaborate on a Total Health Initiative, a program that returned to the YMCA's historic mission by looking beyond exercise alone to emphasize long-term relationship building and community support as central to "wellness." The western region YMCAs were interested in sharing the Total Health approach with YMCAs throughout the country but realized that a rigorous evaluation was necessary to demonstrate its potential benefits for the start-stop population.
Promoting healthy communities and lifestyles is one of RWJF's goals areas. At the time of this grant, RWJF's Health and Behavior Team had as one of its strategic objectives the goal of increasing physical activity levels among sedentary mid-life and older adults. RWJF also supports an RWJF supports an Active Living Initiative to create activity friendly communities through four national programs:
- Active Living Research Program stimulates and supports research to identify environmental factors and policies that influence physical activity (for more information see Grant Results). Findings are expected to inform environmental and policy changes that will promote active living among Americans.
- Active Living by Design Program incorporates activity-promoting goals and processes into ongoing community planning efforts and to support the development and testing of local community active living projects, with special efforts to reach low-income Americans.
- Active Living Leadership is working to increase the number of state and local elected and appointed leaders who understand and champion community design to promote active living.
- Active for Life®: Increasing Physical Activity Levels in Adults Age 50 and Older seeks to increase the number of American adults age 50 and older who engage in regular physical activity. (For more information see Grant Results.)
The project, which examines how to build social capital in communities, also relates to an RWJF interest: the connection between social isolation and health.
In 2002, when this project began, RWJF was in the early stages of defining its interest in childhood obesity; since it was funded, the Health and Behavior Team has become the Childhood Obesity team, and RWJF's grantmaking in the physical activity area is focused on preventing and ameliorating childhood obesity.
The Total Health Plus+ evaluation project, led by staff from the YMCA of Santa Clara Valley, involved a collaboration of nine Metropolitan YMCA branches in five western cities: Seattle; Portland, Ore.; San Francisco; San Jose, Calif.; and Los Angeles.
The 12-month Total Health Plus+ program is a comprehensive nutrition and exercise program that helps sedentary adults adopt and sustain healthier lifestyles through a combination of individual coaching, relationship building and environmental change. It consists of activities emphasizing behavior change and support group development in the first six months, with a focus in the second six months on maintaining the changes and extending the program impact to natural networks and the broader community.
Program components include:
- Health and behavior assessments of each participant.
- Six months of feedback and coaching from group facilitators Total Health Specialists who help the members create an action plan for health improvement based on the assessments.
- Small group meetings, facilitated by Total Health Specialists and volunteers, to provide group support and reinforcement of lifestyle changes.
- Identification of mentors, opinion leaders and ambassadors from the small groups who can influence others in their natural networks (family, friends, co-workers and neighbors) as well as in the larger community.
Project goals at each participating YMCA branch were to:
- Engage the target market of "start-stoppers" in diverse communities.
- Create environments conducive to behavior change.
- Assess changes in the physical activity, nutrition and social-connection behaviors of the participants.
A fourth goal was to produce a model that other YMCAs and community-based organizations across the country could adapt. Evaluators from the Stanford Center for Research in Disease Prevention, working under a subcontract, provided consultation in program design, training, creation of evaluation instruments and data analysis.
For the program evaluation, the project team recruited over 1,500 new or returning YMCA members, all of whom were "start-stoppers," from the nine YMCA branches. Five hundred adults chose to participate in Total Health Plus+; 1,000 chose a basic YMCA membership program and selected their own exercise activities from the offerings available to all members.
Researchers assessed exercise behaviors, eating habits and supportive relationships of all participants at the beginning of the program, at six and 12 months, using online health and lifestyle survey instruments designed by the Stanford Center for Research in Disease Prevention.
The evaluation instruments included a 70-item health habits survey based on Healthy People 2010 physical activity and nutrition objectives (Health People 2010 is the national prevention agenda spearheaded by the federal Department of Health and Human Services and other federal agencies), an 11-item readiness for change survey, and a survey focusing on participants' perceptions of their relationships and personal behavior change. Evaluators also conducted hour-long interviews with 30 participants and reviewed group facilitators' reports.
The project team summarized their findings in a report to RWJF and a PowerPoint presentation:
- At the start of the program, Total Health Plus+ participants were significantly more likely than their basic counterparts to be obese, lead a sedentary life and have less healthy eating habits. More than 40 percent of Total Health Plus+ participants were obese versus less than 25 percent of basic YMCA participants. Total Health Plus+ participants also had lower scores when surveyed about eight physical behaviors from Healthy People 2010. They had significantly higher scores on the Stanford survey of readiness for change, and they had a higher perception of the importance and potential benefits of lifestyle change than their basic participant counterparts.
- After six months, Total Health Plus+ participants perceived that barriers to lifestyle change were significantly lower than at the start of the program. The percentage of Total Health Plus+ participants who felt that a lack of motivation was a barrier fell from 37 percent at the beginning of the project to 21.7 percent at six months. Those who felt that lack of time was a barrier fell from 33 percent to 24 percent. In contrast, basic group members felt that barriers were lower in only one area, lack of knowledge. In other areas, there was no difference or a slightly higher perception of a barrier.
- After six months, Total Health Plus+ participants reported significantly more progress than basic participants in many areas related to physical fitness, nutrition and social well-being. Eighty percent of Total Health Plus+ participants compared to less than 60 percent of basic participants reported that their commitment to health habits had improved. Other areas where Total Health Plus+ participants reported significant progress relative to their counterparts were overall health, energy, weight management, and coping with chronic disease. In addition to health-related improvements, the Total Health Plus+ participants also reported significant changes related to stress reduction and mental health behaviors. At the one-year mark, Total Health Plus+ participants were significantly more likely than their basic counterparts to report improvements in self-esteem, stress management, mood management, quality of sleep, effectiveness at work and relationships to others.
- At both six and 12 months, participants in the Total Health Plus+ program reported increases in all eight physical activity and all nine nutrition behaviors measured by the evaluation. The benefits of Total Health Plus+ appeared greater for physical activity than for nutrition behaviors. The percentages of Total Health Plus+ participants who engaged in vigorous exercise, strength training, abdominal exercises and stretching increased significantly over baseline. In contrast, the basic group increased significantly in only one area: the percentage of people who elected to walk, rather than drive, for trips of one mile or less. With regard to healthy eating practices, a higher percentage of Total Health Plus+ members met Healthy People 2010 recommendations for consumption of fruits, vegetables, fiber, grains and saturated fats after 12 months than at baseline. Basic members showed improvements in fiber, grain and vegetable consumption but not in reducing intake of saturated fats.
- Body Mass Index decreased over the one year period for both basic and Total Health Plus+ members. Although Total Health Plus+ participants had a greater reduction in Body Mass Index scores than their counterparts, they remained, as they had been at the program's start, significantly more obese.
Publishing and disseminating the evaluation findings were not objectives of this grant. The project team summarized the findings in a PowerPoint presentation, which they share at meetings of the YMCAs in the western region, the YMCA Urban Group and the YMCA of the USA. The project team rewrote the participant workbook and reissued it as "It's My Story A Journal of Well-Being," which staff of YMCAs throughout the country use as part of the Breakthrough Collaboratives, as described under After the Grant. (See Bibliography for details.)
SIGNIFICANCE TO THE FIELD
The traditional model of the YMCA is that of an organization that draws its membership from the small segment of the adult population who are already physically active. This exploratory study demonstrated that the YMCA has the potential to transform itself into an organization that can successfully engage the "start-stop" population, sedentary individuals and families who have a history of failed attempts at lifestyle change. It also showed the potential of the YMCA to engage a broad and diverse cross section of the community in significant sustainable behavior change and for new and returning members to influence their natural networks and the broader community.
- To help people achieve lifestyle changes, providers must listen long and hard to individuals, each of whom has a different definition of health and well-being. Rather than taking potential new members on the traditional tour of the YMCA building, staff should instead sit and listen to them, according to the project director. He recommends that all YMCA staff be trained in motivational interviewing techniques. (Project Director/Glashagel)
- The most effective group facilitators are those who share the life experiences of the group's participants. Participants valued most highly those facilitators who showed respect and were willing to listen to group members' stories. Empathy was more important than the facilitator's expertise in nutrition or physical fitness. (Project Director/Glashagel)
- To maintain positive lifestyle changes in exercise and eating habits, individuals need the support of a group. Few people can sustain behavior changes in isolation. The healthiest situation occurs when the individuals' natural network (family, friends and co-workers) becomes more supportive and the individual also has access to a specific support group. (Project Director/Glashagel)
- To become institutionalized, programs must be able to transform their organization's culture as well as produce successful outcomes for individual participants. Although all nine YMCA branches initially accepted the program because of the prestige of RWJF and the Stanford evaluators, they were not equally able to sustain the program after grant funding ended. A number of branches treated the Total Health Plus+ program as atypical and incompatible with the prevailing culture of the YMCA. (Project Director/Glashagel)
AFTER THE GRANT
Total Health Plus+ (now called Healthy Habits) groups continue in all of the nine branches that participated in the project; several branches have started new Healthy Habits groups with volunteer "graduates" of the original groups as co-facilitators. Each branch is adapting the model to suit lifestyle preferences of its members.
To help YMCAs nationwide adapt the Total Health Plus+ approach for their "start-stop" populations, RWJF recommended that the project director, Jerry Glashagel, receive training in the Breakthrough Collaborative Methodology, a model for cultural change in organizations pioneered by the Institute for Healthcare Improvement, a nonprofit Boston-based organization dedicated to advancing the quality and value of health care.
After receiving training from the institute, Glashagel presented this methodology to the Urban Group of YMCAs, which includes the 25 largest YMCAs in the country, and the YMCA of the USA. In January 2004, they agreed to launch two new Breakthrough Collaboratives. These two collaboratives are part of the YMCA's Gulick Project, a 10-year national initiative to combat the obesity epidemic and other health problems linked to a sedentary lifestyle and poor eating habits. In the Adult/Family Collaborative, 45 YMCA branches in 20 cities work together in locally defined efforts to change environments and influence family and community norms to be more supportive of healthy lifestyles. In the Youth Obesity Collaborative an initiative of 45 school sites with licensed YMCA child-care centers parents, teachers and children engage in a collective effort to promote healthy lifestyle choices for exercise and eating.
GRANT DETAILS & CONTACT INFORMATION
Studying the Influence of Social Networks on Sustainable Behavior Change
Young Men's Christian Association of Santa Clara Valley (San Jose, CA)
Dates: March 2002 to February 2004
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
It's My Story A Journal of Well-Being, San Jose, Calif.: YMCA of Santa Clara Valley, 2004.
Balfanz D. YMCA, Healthy Habits and Community: Project Summary and Results. San Jose, Calif.: YMCA of Santa Clara Valley, 2003.
Balfanz D. YMCA, Healthy Habits and Community: Stanford Readiness for Change Survey and Stanford Readiness for Maintenance Assessment Instruments. San Jose, Calif.: YMCA of Santa Clara Valley, 2003.
"The Stanford Healthy People Survey." Stanford Center for Research in Disease Prevention, fielded April 2002February 2004.
"The Stanford Readiness for Change Assessment." Stanford Center for Research in Disease Prevention, fielded April 2002February 2004.
World Wide Web Sites
www.gulickproject.org. The Web site of the Gulick Project contains information about the two Breakthrough Collaborative projects that the YMCA launched to continue the behavior change initiatives begun with RWJF funding. Information about the Breakthrough Collaborative methodology as well as lessons learned by YMCAs involved in the YMCA Breakthrough Collaborative projects are available on this Web site, which requires a password to access. YMCA of the USA, January 2004. Contact Lynne Vaughan for access at firstname.lastname@example.org.
Report prepared by: Jayme Hannay
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: Robin Mockenhaupt
Program Officer: Terrry Bazzarre