Report Operation Heart to Heart

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1 Report Operation Heart to Heart Elkhorn Logan Valley Public Health Department (Burt, Cuming, Madison, and Stanton Counties) Gina Uhing, Health Director Ionia Research Newcastle, Nebraska Joseph Nitzke December 20, 2015 Ionia Research

2 Contents CONTENTS Summary... 1 Introduction and Comments... 8 Demographics, Service Dates, and Goals: Case Managed Participants (CMP)... 9 Findings Case Management Participants (CMP) Measurements Risk Assessments Measurements BMI Measurements Weight and Waist Measurements Blood Pressure/Case Management Measurements Glucose Measurements Lipids Education Modules for CMPs: Pre- and Post CMPs: Behaviors and Attitudes Participation Case Management Results Personal Goals Achieved by CMPs Community Presentations, Screenings, and Education Index of Goal Statements... 30

3 SUMMARY Over three years, Elkhorn Logan Valley Public Health Department s (ELVPHD) Operation Heart to Heart (OHH) program identified goals and activities designed to improve cardiovascular health, implemented those goals, and collected data which tracked progress on the goals. The results are described here in terms of measurable changes in behaviors, knowledge, and attitudes among the participants at various levels of involvement for year 3; further, the results are also described in terms of changes across measures that are indicators of cardiovascular health. Overall, the grant activities target improvement across a number of topics. There are, for example, eight education modules for Case Management Participants (CMP) and progress on those is measured via paired pre- and posttests. Page 1 Of those goals the first is a program goal for participation, the number reached and the number tracked. In addition, OHH has identified 14 specific goal targets: Of those: 5 are biometric measurements of CMPs, including Body Mass Index (BMI), Blood Pressure (BP), Lipoproteins and triglycerides, Glucose, and Weight. 4 goals that target knowledge and behaviors, including topics related to nutrition, physical activity, and cardiovascular disease. 5 additional key measures with specific goals for non-cmps related to blood pressure (knowledge and measurements), goal setting by CMPs and their retention in the program. In terms of cardiovascular (CV) health, the data show: Reductions in blood pressure, cholesterol, weight, waist measures, Reduction in proportions of participants who were at risk Improvements in knowledge, attitudes, and behaviors of CMPs and Improvements in the knowledge and attitudes for a broad range of individuals at events and presentations throughout the four county area. Based on year end measures, measures indicate that OHH successfully achieved nearly all but two of the goals outlined in the year 3 project proposal. Demographics. The demographics of Operation Heart to Heart demonstrate a good fit between the case management participants and the parameters and focus of the project. Also, information about participant s attending public presentations and other project-related events reinforces this conclusion, that the demographics of those attending these events/presentations are consistent with the goals of those phases of the project. In reference to those participating in case management (CMP): Gender. Unlike 2014 when the proportions of male-female were balanced, females in 2015 made up two-thirds (62.5%) of the CMPs and males one third (37.5%). Average age was the 54.7 years, with males 56.3 on average and females 53.7 during The age range in 2015 (31-70) was narrower than in 2014 (26-72). Weight. The average initial BMI decreased from 33.6 in 2014 to 32.8 in 2015; a smaller portion of the 2015 CMPs were at normal weight at their initial screening (7.5%; 15%, 2014), and 92.5% were overweight (27.5%) or obese (65%).

4 CMP Visits During 2015 staff recorded 284 visits with Enrolled Case Managed Participants (CMPs) an increase from 2014 in both the number of CMPs (40 in 2015, 37 in 2014) and in the number of visits (229 in 2014). For the duration of the project staff have increased the number of visits per CMP, and this year the number of visits per CMP on average increased from six in 2014 to seven in Duration of Service. On average, participants were enrolled in case management for 6.75 months (median, 7 months), with a range from 4-8 months. Most (87%) were enrolled for more than six (6) months, and two of three (63%) were enrolled for more than seven (7) months. The first completion was July 21, 2015 and continued through November 24, Risk. A summary review of both scores shows improvement overall as well as improvement for those at or above the benchmarks. Page 2 Using the risk scores from the two scales (ELV and Omnibus), 65% of all CMPs showed improvement (or lowered risk) across the measures. Looking at just those who were above the benchmark on either scale, two-thirds (67%) showed reduced risk during their participation in the program to the point that they were below the benchmark. BMI was measured, on average, 3.5 times per participant. From those multiple measures: Overall results: 72.5% (2014; 65%) of all CMPs lowered their BMI. 42.5% lowered their BMI by at least one unit. 10% reduced their BMI by two (2) or more units. 7.5% of CMPs decreased their weight to the point that they would be classified at a lower BMI, such as moving from obese to overweight or from overweight to normal. Of those classified as overweight, 55% decreased their BMI. Of those classified as obese, 77% decreased their BMI. Goal for BMI. For those CMPs who were overweight or obese, the project goal was that 30% would reduce their BMI by at least one (1) point. Two of every five (41%) lowered their BMI by at least one point, exceeding the goal by a third. Weight. By years end a total of 139 pounds were lost by those who were classified as overweight initially. Those who increased weight (30% of CMPs who were overweight) gained a total of 30.6 pounds, an average of 2.78 pounds; on the other hand, those who decreased weight (70%) lost a total of pounds, an average loss of 6.62 pounds. Of those overweight, 42% lost five (5) pounds or more during the course of the program, and 14% lost 10 pounds or more. The average weight loss for all participants was 4.2 pounds (median, 2.3), with one participant losing 19.4 pounds. Of those who were overweight, 55% lost from 1 to 9 pounds; since nearly equal proportions gained/lost (55% lost, 45% gained), the average weight loss for that category was 0.7 pounds. Of those who were obese, 77% lost from 1% to 8% of their initial weight by years end, and for all the average loss was 5.15 pounds.

5 As noted above, one-third (27.5%) of CMPs were overweight and two-thirds (65%) were obese at enrollment. The weight loss goal for those with an elevated BMI was that 30% would lose 5% of their body weight. In addition, 25% lost at least 4% of their initial body weight. Goal for Weight. Although the CMPs had a consistent pattern of weight loss, the goal for weight loss (30% of those overweight would lose 5% of body weight) was not met. At the time of the final measurement, 14% lost 5% or more of their body weight by year s end. Page 3 Waist. Waist measurements were taken at each visit. By year s end, two of three (63%; 2014, 80%) of participants achieved a reduction in their waist measurement. On average, waist measures decreased about one-half of an inch (.553), with a maximum decrease of 4 inches. One in three (34%) saw a reduction of one inch or more; and one in eight (12.5%) recorded a reduction of two inches or more. Blood Pressure. Systolic blood pressure (BP) overall decreased 5.25 mm from the initial assessment to the year s end. The average for all decreased from mm to mm. Three in four CMPs (58%) showed a reduction in systolic BP; one in eight (12.5%) lowered systolic BP by 20 or more mm, and 33% of all reducing systolic BP by 10 mm or more. Diastolic BP. Two-thirds (68%) of CMPs reduced their diastolic BP an average of 4.68 mm, with a minimum decrease of 1 mm and a maximum of 26 mm. Of those above the normal range at the initial assessment, 37% decreased the DBP by at least 10 mm, and 62% were in the normal range at the final measure. Goal for Blood Pressure. The OHH goal was that 30% of CMPs with high blood pressure will see a 5 point improvement in either systolic or diastolic measures. Results from the data file show that OHH exceeded the goal in either measure. Three of four (78%) had either high systolic or diastolic blood pressure readings at the first screen. Of those (N = 31), 58% had a decrease of 5 mm on one or both of the measures. In systolic BP, 72% of CMPs with high blood systolic blood pressure on the initial measure saw a decrease of 5 or more mm at the year end. In diastolic measures, 78% (two times the goal) saw a decrease of 5 or more mm by the year end measure. Glucose All CMPs. In 2015, fewer CMPs reported a diagnosis of diabetes (7.5%; 2014, 22%). At year end, average glucose was , an increase over the initial measure of 96.5, and at that point 55% were considered in the normal range, 25% pre-diabetic, and 13% diabetic. For those who were at risk in the initial screening, 40% (of the 42% assessed at risk) were measured at <100 at the year-end final measure. For those initially at risk, 80% decreased their glucose reading, by a range of 3 to 100 mg. Over half of those (53%) showed decreases of at least 19 mg. Goal for Glucose. During 2015, only 6% of CMPs reduced their glucose readings by 10 pts, falling short of the 30% targeted. The project goal was that 30% of CMPs would have a reduction in glucose by at least 10 mg. The project did not meet that goal. Lower overall glucose at the initial screen as compared to previous years resulted in fewer individuals needing to reduce their glucose; therefore, this could be a contributing factor in not meeting the 30% goal since fewer had room to improve as they were already in the normal category initially. Total Cholesterol. In terms of the proportion of CMPs at risk, initial measures showed 36% with cholesterol above 200. By years end that dropped to 32%.

6 For all participants, 57% showed a decrease from the first to the final measure, 37% by 15 or more, and 14% by 30 or more. Of those with initial readings >=200, 45% were below 200 at mid-year, 18% were below 200 at the final measure, 46% decreased by 25 or more and 53% decreased by 15 or more. HDL. The HDL average at baseline was below the At Risk level for males (38.14) increasing slightly at the final measure (39.22). Females were above the At Risk level at the first measure (51.8) and increased that slightly for the final measure (53.4). At the first measure: 50% of males were above 40 at the initial measure, and 52% of females were above 50. At the final measure: 36% of males increased their HDL, about the same proportion as females (37%). Page 4 LDL. At the year-end, the proportion at the Optimal level (<100) had increased from 32% to 52%, and 73% had decreased their LDL reading, 24% by more than 20 mg and 52% more than 10 mg. For those above 130, 71 percent decreased their LDL, including 48% by more than 10 mg, and 24% by more than 25 mg. Also, at the final measure 61% had moved from above Borderline High (>=130), with 22% at Optimal (<100) and 39% at Near Optimal ( ). Triglycerides. The project goal was that 30% of CMPs would reduce their triglycerides by at least 10 mg. At the final reading: 58% were at the optimum level; 23% were borderline high; 16% were high; and 4% were very high. In terms of change/improvement, 57% of participants decreased their triglycerides: 6% by 100 mg or more; 14% by 50 mg or more; and 37% by 10 mg or more. Change of Classification: Of those who were not at the optimal level at the first reading; 36% moved up to that level at the second reading. Goal for Triglycerides. 57% reduced their triglycerides, and 37% did so by at least 10 mg, exceeding the goal of 30%. Education Modules. After completing education modules, CMPs demonstrated significantly improved knowledge as measured on pre- and posttests for all of the education modules. Two of those were singled out in goals: Nutrition from the Healthy Eating module, and Knowledge of Cardiovascular disease in the Heart Attack and Stroke module. Nutrition Goals. For Nutrition, the target was to achieve gains pre- to post of at least 10%. The baseline was an average score of 72.45% on the Healthy Eating pretest for 37 CMPs (N = 37). On the posttest the average score increased to 89.57% (only matched scores are used). So the average scores pre- to post for the Healthy Eating (Nutrition) module was increased by 17%, exceeding the project of goal of a 10% increase. Knowledge of Cardiovascular Disease Goals. The target for the CVD module was to increase the average scores for the Heart Attack and Stroke module by 10% pre- to post. The baseline score for 37 CMPs was 68.9% and the average of posttest scores increased to 85%, an increase of 16% which exceeded the goal of 10% set for Physical Activity, Fruits, Vegetables. Exercise. Overall, CMPs increased their levels of activity while enrolled in OHH. At the initial assessment, three-of four (59%, N = 39) exercised at least two times each week. At the mid-year measure, 78% (N =

7 23) exercised at least two times each week. At the final measure, CMP exercise at least two times per week increased to 88% (N = 32). At least four times per week: the initial measure showed 15% at this level, increasing to 34% at the final measure. Six to seven (6-7) times per week: the initial measure showed 3% at this level, increasing to 16% at the final measure. On the other hand, the proportion that reported exercising no more than once per week (1 time and never) decreased from 41% initially to 13% at the final measure. Page 5 Goal for Physical Activity. For the year, 41% of CMPs (N = 32) increased their activity level, exceeding the goal of 30%. In addition, 16% of CMPs increased physical activity by 2 levels, and 9% by 3 levels. Fruits and Vegetables Fruits. In 2015, the goal combined fruits and vegetables. While enrolled in OHH, the proportion who reported having at least one serving of fruit per day decreased from 75% in the initial assessment to 69% in the final assessment. That change was accompanied by an increase in the proportion having at least 3 servings per day, which increased from 22.5% initially to 28% at the final measure. Vegetables. In 2015, CMPs increased their daily servings of vegetables while enrolled. At the initial assessment, 28% reported having at least three servings of vegetables each day, and at the final assessment that increased to 44%. Goal for Fruit/Vegetable Intake. The Goal was that 30% of CMPs would Eat Better by increasing their average daily intake of fruits/vegetables. Overall, 34% of CMPs increased their average daily intake of fruits and vegetables, exceeding the goal of 30%. Retention. The stated goal was that 60% of case management participants will remain in the program for 6 months following enrollment. On average, CMPs who completed the program were enrolled for 6.75 months. The minimum enrollment was 4 months; the maximum 8. In addition; 30% were enrolled for 8 months, 63% were enrolled for at least 7 months and 88% of CMPs who completed the program were enrolled for at least 6 months. Goal. With the goal set at 60% of CMP remaining in the program for at least 6 months, 69% Of all CMPs (N = 51, including those who dropped from the program) were enrolled in for at least 6 months, exceeding the 60% target. In addition, 75% of all were enrolled 5 for at least months. Personal Goals Achieved by CMPs. The goal content in 2015 was similar to the previous year. As articulated by CMPs, goals for individualized, such as increasing exercise to three times each week for 30 minutes, or walking to the park three times a week for three months. Nutrition related goals included drinking more water, increasing fruit/vegetable intake or reducing carbs. Weight loss goals ranged from weight (10 pounds by Christmas) or target weights (165, 190, 220, or even 300 pounds). Three in four CMPs (78%) achieved at least personally set goal, exceeding the target for the project; further, 47% of those who set a second goal were able to achieve that as well. Of the 69 individual CMP goals set (1 and 2 combined), 65% were achieved.

8 Goal for Participation. The goal was that 75% of CMPs will achieve at least one of the three goals CMPs set by the end of their enrollment, data files show that 78% of CMPs met at least one goal by year s end, exceeding the 70% target. Goals for community presentations Presentations (some accompanied screenings) were delivered throughout the four county area, allowing interaction with a wide range of demographics, both in terms of age and education. Data files, separately constructed (with evaluator input) and maintained by staff, allowed staff to track screenings, the recording of repeated measures and the administration of pre- and posttests (where administration was feasible). Venues included schools, events and agriculture shows, large group presentations and worksite programming. Educational Presentations. The Presentation Tracking file contained 1,059 records from different sites, including schools, community centers, businesses and health fairs. For educational presentations, OHH set a goal that 70% of educational presentation participants will reflect an increase in knowledge from pre- to post test. To evaluate this goal, participants were selected who had scores of less than 100% on the pretest, otherwise no improvement would be possible. Selecting those who scored less than 100% (N = 1,035), the pretest average score is 53.9% correct and the posttest 87.2%. Of those, 90% increased their score pre- to post; 10% either scored the same pre- to post or had a post test score that was lower. Goals for Educational Presentations. For educational presentations, OHH set a goal that 70% of educational presentation participants will reflect an increase in knowledge from pre- to post test (of those who did not have 100% on the pre-test). Of those educated who did not have 100% on the pretest (N = 1,035) 90% demonstrated an increase in knowledge pre- to post, exceeding the goal. Blood Pressure Screening and Education. In sessions focusing on blood pressure 445 participants were pretested about their knowledge of BP readings and asked to classify their own blood pressure. Data elements reflect previous vs. post knowledge of normal BP as well as the accuracy of estimates of their own BP. Outcomes. In the pretest, 40% of participants could correctly identify the elements of a normal BP, 60% could not. Comparing their estimates of their own BP status with the reality of their BP status. Of those who thought their BP Normal (this is 67% of this group, N =177): 43% were correct, one third (35%) were prehypertensive, and one in four (22%) were either Stage 1 or 2 Hypertensive. Looking at those who could not name a Normal BP (N =177) on the pretest, the change of knowledge measured in the posttest (after the presentation) was that 94% of those 177 were able to correctly identify a normal BP after the presentation/instruction as measured on the post test. Overall, 92% correctly identified normal BP on the post, an improvement from 40% correct on the pretest, a gain of 52% pre- to post. Screening and Tracking at special events. In some instances Operation Heart to Heart was able to collect multiple measures of biometric data through subsequent interactions with participants and these are maintained in a screened and tracked data file (N =230). This group was comprised of 37% males, 63% females, with an average age of 49 (median, 50); the first quartile <= 39, the second 39-50, the third is years, and the fourth 58 and above. Page 6

9 The goal focuses on those above normal. Of these who were screened and tracked, 77% (N = 177) recorded initial SBP or DBP above normal. Blood Pressure Goal, non-cmps. For non-cmps who were screened and tracked, the OHH goal for 2015 was that 20% with high blood pressure would have a 5 point improvement in either systolic or diastolic blood pressure from their first to their final measure. Of those screened and tracked with elevated BP readings (N = 177), 61% improved either their SBP or DBP by 5 or more points, three times the parameter identified in the goal. Page 7 Also, 53% decreased BMI during the screenings, from 0.1 to 4.6 units, and 13% decreased BMI by at least 1 full point. Though average weight stayed about the same (first measure = ; second measure = ), 56% of screened participants lost weight. The average weight loss by second measure, 0.72 pounds, with a maximum loss of 26.3 pounds. Some of the screened and tracked individuals were employees at work sections taking part in the Take 10 program. Employees were encouraged to improve their heart health, with screenings for blood pressure, weight, and a review of physical activity and diet. Some of the data collected through screening was very similar in format, then, to the screenings for CMPs. Of the 230 screened and tracked individuals in OHH during year 3, 201 were enrolled in the Take 10 program. Part of the Take 10 program included the practice of establishing goals. Two thirds (63%) set goals related to health. Of those 29% (N = 127), reported their goal was achieved. The project also recorded modest increases in physical activity, as well as increases in consumption of fruits and vegetables. Finally, participants decreased the number of times per week they had fast food and restaurant food.

10 INTRODUCTION AND COMMENTS This evaluation report summarizes activities during 2015 of Operation Heart to Heart, a project of developed and administered by the Elkhorn Logan Valley Public Health Department and funded by the AstraZeneca HealthCare Foundation Connections for Cardiovascular Health SM. The overarching goal of Operation Heart to Heart is to reduce the incidence of cardiovascular disease (CVD) through educations and health screening opportunities among agricultural laborers in and rural citizens in Burt, Cuming, Stanton and Madison counties by increasing knowledge of cardiovascular health screenings, reducing blood pressure and weight and improving cardiovascular biometrics measures. Page 8 In this project case management is on an individual basis, with observations and outcomes recorded at that level. Similarly, presentations and screenings also include data for individuals: two measures for knowledge and awareness (pre- and post); knowledge of blood pressure measures; measures for biometrics, (including repeated measures for BMI, blood pressure, lipoproteins, glucose, and weight). This evaluation component focuses on elements of the program design that include comprehensive health screening pertaining to several CVD risk indicators, case management, general education components, education components developed for case management participants (i.e., curricula that are evidence based). Special attention is given in this project to: Clinical measures. BMI, BP, lipoproteins (HDL and LDL) and triglycerides, glucose and weight. Based on data and interactions with the staff, this evaluator observed that biometric measures were obtained during regular visits with Case Management Participants (CMP). Data on visits. During 2015 staff recorded 284 visits with Enrolled Case Managed Participants (CMPs) an increase from 2014 in both the number of CMPs (40 in 2015, 37 in 2014) and in the number of visits (229 in 2014). And, as it has for the duration of the project, the number of visits per CMP increased from six on average in 2014 to seven on average in Knowledge/Attitudes/Behaviors. The education component addresses issues for the CMPs and extends to participants at presentations and in educational settings. Considerable effort and results were measured by testing and observing behaviors in these venues. Data for CMPs and their progress were tracked by staff at each visit, describing progress in terms of biometrics, behaviors, and attitudes. For other measures, data were recorded three times (initial, midyear, year-end); examples are BMI, glucose, cholesterol, and triglycerides. Examples include: Weight. For CMPs, these data were normally recorded at each visit, with variables that calculate total weight gain/loss. BMI. Repeated measures, summed up in initial and final measures. Blood Pressure. Multiple measures of both systolic and diastolic are part of the record. Records also include pretest from education module for CMPs. In addition, other data files contain data collected at presentation and screening events with repeated measures as well as results from pre- posttests where appropriate. Cholesterol. Three measures (benchmark, midyear, year-end) of total cholesterol, HDL and LDL.

11 Waist. An average of 4 waist circumference measures were recorded for each of the CMPs (163 individual measurements overall.) Triglycerides. Three measures were recorded in the data files. Behavioral and knowledge measures track the extent to which CMPs increase their knowledge of cardiovascular disease (CVD), their knowledge of healthy eating, the extent to which they increase consumption of fruits and vegetables and increase their physical activity. Page 9 DEMOGRAPHICS, SERVICE DATES, AND GOALS: CASE MANAGED PARTICIPANTS (CMP) For CMP, Operation Heart to Heart targets participants who present higher risk for cardiovascular disease. Data for that assessment include information about current health conditions and health related behaviors (e.g., tobacco use, high blood pressure, diabetes, exercise, nutrition) which are recorded on the intake form and in appropriate data collection instruments. Once selected, CMPs are asked what they were looking to improve. In 2015, two goals were recorded per participant and staff tracked which of the goals were achieved. For their first goal, the majority of CMPs list weight loss (54%), and one third (30%) list exercise. For most, then, the second goal is exercise (if they chose weight), followed by nutrition (33% as a second goal choice, just 7% as a first choice) and weight (18% as the second goal choice, with exercise the first goal recorded). Content of Goals. The goal content in 2015 was CMP GOAL CATEGORIES 2015 similar to the previous Other, 9% year. As articulated by Nutrition, 18% CMPs, many were specific, such as increasing exercise to three times each week for 30 minutes, or walking to the park three times a week for three months. Nutrition related goals included drinking more Weight, 38% Exercise, 34% water, increasing fruit/vegetable intake, or reducing carbs. Weight loss goals ranged from weight (10 pounds by Christmas) or target weights (165, 190, 220, or even 300 pounds). Three in four CMPs (78%) achieved at least personally set goal, exceeding the target for the project; further, and 47% of those who set a second goal were able to achieve that as well. Of the 69 goals set (1 and 2 combined), 65% were achieved.

12 Dates of Service. The first contact with a participant was the initial screening, and for those in case management that was followed by an enrollment date. The first screening for participants began February of 2015 and continued through October. For most of the CMPs (88%) the first visit and enrollment were on the same day. As a result, the average of enrollment to first visit is 1.4 days, much less than the previous year s six (6) weeks. 8% Duration of Service. On average, participants were enrolled in case 1st Goal 2nd Goal management for 6.75 months (median, 7 months), with a range from 4-8 months. Most (87%) were enrolled for more than six (6) months, and two of three (63%) were enrolled for more than seven (7) months. The first CMP completion was July 21, 2015 and continued through November 24, % CMP Goal Categories % 38% 54% 19% 11% Nutrition Exercise Weight Other 9% Page 10 Demographics. Demographics for the CMPs in 2015 varied to some degree from those in 2014, and some of these differences are noted here though the selection process is based on health/risk related metrics. Gender. Two of three CMPs were female (62.5%; 2014, 53%) and one-third male (37.5%; 2014, 47%). Average age was 54.6 (2014, 57.3), with the average for females 53.7 (2014, 57.7) and for males 56.3 (58.5 in 2014), and the age range from 31 to 70 years. Overall, CMPs were younger in 2015 than the previous year. The average BMI was 32.8 (33.6, 2014), higher for male CMPs (35.35) than female CMPs (31.27). Of the 92.5% who were overweight/obese, 30% were Class 1 obese (BMI: 30-35), 15% were Class 2 (35-40), and 20% Class 3 (40 and above). Table 1. CMP Demographics, Nutrition, and Behaviors Gender Male = 37.5% Female = 62.5% All Male Female Average Age Age Range Age Quartiles <=48.5: 25% <=57 = 50% >=64.5 yrs. = 25% BMI (Initial) Initial Mean Median Final Mean BMI Categories Normal Overweight Obese 7.5% 27.5% 65% Average Weight Std. Dev Counties Risk Factors

13 Antelope 4% Tobacco use 8% Burt 28% Hypertension 47.5% Cuming 10% Diabetes 7.5% Madison 37% Cholesterol Meds 22.5% Stanton 16% Blood Pressure Meds 45% Thurston 2% Wayne 2% Page 11 Nutrition: Servings per day Frequency of Exercise (Initial) Fruits Vegetables Never 12.8% Never 2.5% 0.0% Once per week 28.2% 1-2 Servings 75.0% 72.5% 2-3 times per week 43.6% 3-4 Servings 20.0% 22.5% 4-5 times per week 12.8% Over 5 2.5% 5.0% 6-7 times per week 2.6% Summary Observations, Other Measures As noted above, staff monitor a number of biometrics, starting with initial measures at screening and enrollment; they also monitor behaviors and attitudes. For nutrition, those include intake of fruits and vegetables on the positive side, along with processed meat, fried foods, fats, desserts, soda and fast food on the negative side. For many of these, data entries were made at the initial screening, mid-year, and at the end of the program. As noted, biometrics were monitored as part of the visits (blood pressure, weight, waist measures for example), providing regular feedback to participants on their progress. Some of the data from initial screenings are noted below (using responses from CMPs who completed the program). Initial measures and Behaviors: Health General Health. About half (59%) said their general health was good (2014, 65%), 23% very good (2014, 19%), and 15% fair (2014, 16%). Nearly all reported having a primary care provider (95%; 2014, 84%). 45% are being treated for hypertension or prescribed BP meds, slightly more than 2014 participants (40%). 7.5% are diabetic. Nutrition Most (95%) have a goal of losing weight. At the initial health screening, three of four (82%) believe they have good support system for making healthy lifestyle choices; nearly one in five (18%) said they did not. On a daily basis: One in ten (10%) do not have a serving of fruit, 69% have 1-2 servings, and 21% have at least three servings per day. Nearly two-thirds (69%) have fried food at least once per day.

14 Four of five (72%), have at least one serving of sweets/desserts, and 13% have at least three servings per day. Half (44%) have at least one soda. One in eight (13%) have three or more servings of fats (butter, cream sauces) each day. Two thirds (69%) have at least one serving per day. On a weekly basis: Page 12 Half (50%) eat Fast Food 1-2 times per week, and one in six (18%) so 3-4 times per week. Three of four (72%) eat at a restaurant at least one time per week, with 13% eating three or more times per week at a restaurant. One in four (28%) rarely or never read food labels, some because they do not know how. Nearly half (44%) read labels sometimes. FINDINGS CASE MANAGEMENT PARTICIPANTS (CMP) Measurements Risk Assessments Risk measurements are the primary basis for enrolling participants in case management, and for the purposes of this project, staff used at least one of two tools, sometimes both, for the purposes of risk assessment. Data for these assessments are recorded along with other screening results in the participant file and in the appropriate data worksheet. The Omnibus Risk Estimator results are applicable only for individuals between the ages of 40-79, while the ELVPHD Risk Score was used only for individuals under 40. The former is a spreadsheet (American Heart Association, available also as an App) that estimates an individual s 10-year and lifetime risks for atherosclerotic cardiovascular disease (ASCVD). The data elements in the calculation includes age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure lowering medication use, diabetes status, and smoking status. With the Omnibus Estimator, an individual with a score above 7.5 is eligible for case management. The ELV Risk Score uses measurements from seven (7) risk areas: BMI, systolic blood pressure, total cholesterol, HDL, smoking, diabetes, and treatment for hypertension. If an individual s measures exceed defined benchmarks in three (3) or more of these areas, that person is eligible for case management. Changes. As noted above, the two scales were generally used to assess qualification for case management status. As a result, many of the CMPs had measures in those two scales. Both are considered here. Subsequent measures were normally taken for three points in time: initial screening, mid-year, and final measurement. Omnibus Risk Estimator Of the 36 participants measured, 18 (38%) were above the 7.5 benchmark. Of the 31 with an Omnibus score, 18 (58%) lowered their level of risk. Of those above the 7.5 benchmark, the average reduction was 3.7. The range of reduction for those above the benchmark was 2 to 14.5.

15 ELV Risk Score Of those above the 7.5 benchmark at the initial measure, two-thirds (62%) were lower than the benchmark at the final measure. Of the 34 cases where the ELV Risk Score was recorded, 67% were below the benchmark and 33% were at or above (qualified for case management). Page 13 Overall improvement. With ELV scores recorded for 34 CMPs, one-third (35%) showed lower scores during the course of their enrollment. Of those who were at or above the benchmark for case management, 54% showed an improvement in the risk score. Overall, 38% improved their risk scores to a point below the ELV benchmark, while another 15% showed improvement but not enough to put them below the case management benchmark. Summary Risk Results Using Both Measures A review of both scores shows improvement overall as well as improvement for those at or above the benchmarks. Using the risk scores from the two scales (ELV and Omnibus), 65% of all CMPs showed improvement (or lowered risk) across the three measures. However, not all of those who were enrolled in case management were above the benchmarks (usually spousal status); therefore, the review of the risk status looks at overall improvement and improvement for those who above the benchmarks. Looking at just those who were above the benchmark on either scale, two-thirds (67%) showed reduced risk during their participation in the program to the point that they were below the benchmark. Measurements BMI Initially, 7.5% CMPs were classified as Normal BMI, one in four (27%; 2014, 24.3%) as Overweight, and two in three (65%; 2014, 62%) as Obese. At the initial screening, the average CMP was obese (Average = 32.73; Median =31.6), the minimum was 21.3 and the maximum Proportions for the initial and final screening are displayed in the adjacent chart, which shows a decrease in those Overweight and Obese and a corresponding increase in CMPs at Normal weight. Overall results: 72.5% (2014; 65%) of all CMPs lowered their BMI. 42.5% lowered their BMI by at least one unit. 7.5% 12.5% Normal weight: 18.5 to 24.9 BMI % 62.5% 27.5% 25.0% Overweight: Obese 30+ Initial Final

16 10% reduced their BMI by two (2) or more units. 7.5% of CMPs decreased their weight to the point that they would be classified at a lower BMI category, such as moving from obese to overweight or from overweight to normal. Of those classified as overweight, 55% decreased their BMI. Of those classified as obese, 77% decreased their BMI. Goal for BMI. For those CMPs who were overweight or obese, the project goal was that 30% would reduce their BMI by at least one (1) point. As noted above, 41% lowered their BMI by at least one point, exceeding the goal by a 37% margin. Page 14 Measurements Weight and Waist Weight and Waist biometrics were recorded in the biometrics data file, with a potential of eight individual measures. Weight. By years end, a total of 139 pounds were lost by those who were overweight. Those who increased weight (30% of CMPs who were overweight) gained a total of 30.6 pounds, an average of 2.78 pounds; on the other hand, those who decreased weight (70%) lost a total of pounds, an average loss of 6.62 pounds. Of those overweight, 42% lost five (5) pounds or more during the course of the program, and 14% lost 10 pounds or more. The average weight loss for all participants was 4.2 pounds (median, 2.3), with one participant losing 19.4 pounds. Of the participants at normal weight, 100% lost weight by the final measurement. With respect to their original weight, those at normal lost on average 8.9 pounds. Of those who were overweight, 55% lost from 1 to 9 pounds; since nearly equal proportions gained/lost (55% lost, 45% gained), the average weight loss for that category was 0.7 pounds. Of those who were obese, 77% lost from 1% to 8% of their initial weight by years end, and for all the average loss was 5.15 pounds. As noted above, one-third (27.5%) of CMPs were overweight and two-thirds (65%) were obese. The weight loss goal for those with an elevated BMI was that 30% would lose 5% of their body weight. In addition, 25% lost at least 4% of their initial body weight. Goal for Weight. With reference to weight and the BMI index, Operation Heart to Heart set a goal that 30% of CMPs with elevated BMI will lose 5% of their body weight by the end of the calendar year. At the time of the final measurement, 14% lost 5% or more of their body weight by year s end, so the 5% goal was not met for this year. Waist. Waist measurements were taken at each visit. By year s end, two of three (63%) of participants achieved a reduction in their waist measurement. Average waist size at the initial visit was (Median =42). On average, the waist decreased just over one-half of an inch (.553), with a maximum decrease of 4 inches. One in three (34%) saw a reduction of one inch or more; and one in eight (12.5%) recorded a reduction of two inches or more. Measurements Blood Pressure/Case Management Blood pressure readings are recorded both for CMPs and for individuals attending screening events and presentations. The data files for the CMPs show readings recorded in the biometrics file as well as in the screening result file.

17 From the initial assessment (presented in the demographics section), 47.5% reported they were being treated for hypertension. From the screening data, three-fourths (74%) had readings above the normal range for Systolic Blood Pressure (SBP), as did 69% with readings above the normal range for Diastolic Blood Pressure (DBP). Systolic Blood Pressure (SBP) In the initial screening data of blood pressure for case managed participants (N =40): the average initial systolic measure for all was mm (median, 124 mm), For those who said they had not been diagnosed with hypertension the average was 124 mm, and For those who did have a Hypertension diagnosis (and/or on BP meds), the average was mm. For all CMPs, the minimum recorded systolic mm was 102, the maximum 158. In terms of improvement: Screening for SBP % 54% 29% 26% 21% 3% Normal Pre-HTN HTN1 Initial Final Page 15 Systolic blood pressure (BP) overall decreased 5.3 mm from the initial assessment to the year s end. The average for all decreased from mm to mm. o About three in four CMPs (72%) showed a reduction in systolic BP (another 12.5% showed no change), o 7.5% lowered systolic BP by a range of 25 to 44 mm, o 12.5% lowered systolic BP by 20 or more mm, and o 33% of all reduced systolic BP by 10 mm or more. For CMPs (78%) who were measured above normal SBP at their initial screening o The average SBP decreased 9.2 mm, from mm at the initial reading to at the final reading. o 27% of those initially above Normal were in the Normal range at the final measure. o In addition 45% showed decreases of at least 10 mm, 69% showed decreases of at least 4 mm. Diastolic Blood Pressure (DBP) In the initial assessment, the diastolic average for all CM participants was 79.9, with a minimum of 60 and a maximum of 98. For those who did not report a diagnosis/medication for hypertension, the average was 82.33, and for those with a diagnosis the average was Diastolic BP. Two-thirds (68%) of CMPs reduced their diastolic BP an average of 4.68 mm, with a minimum decrease of 1 mm and a maximum of 26 mm.

18 Of those above the normal range at the initial assessment, Screening for DBP % were in the normal range by mid-year, 37% decreased the DBP by at least 10 mm, and 62% were in the normal range at the final measure. Page 16 By the year s end, the average DBP for all decreased from mm to mm, with an average decrease of 4.68 mm overall. The average for those with a DPB above the normal range decreased from 83.7 mm to 76.5 mm, an average decrease of 7.85 mm. Normal Pre-HTN HTN1 Initial Final Goal for Blood Pressure. The OHH goal was that 30% of CMPs with high blood pressure will see a 5 point improvement in either systolic or diastolic measures. Results from the data file show that OHH exceeded the goal in either measure. Three of four (78%) had either high systolic or diastolic blood pressure readings at the first screen. Of those (N = 31), 58% had a decrease of 5 mm on one or both of the measures. In systolic BP, 72% of CMPs with high blood systolic blood pressure on the initial measure saw a decrease of 5 or more mm at the year end. In diastolic measures, 78% (two times the goal) saw a decrease of 5 or more mm by the year end measure. Measurements Glucose All CMPs. In 2015 just one in twelve (7.5%) CMPs reported a diagnosis of diabetes; this is onethird of 2014 (22%). The first glucose screening reflects that 8% are diabetic, almost equal to the level self-reported, and it shows 18% at the level of pre-diabetic (see chart). The average level at the initial measure was (N= 26). At mid-year, the overall average glucose measure was and the proportion of Glucose Categories: First Screening 2015 <100 - Normal, 74% Prediabetes, 18% Over Diabetic, 8% those classed as Normal dropped from 74% from the first screening to 54%. At year end, average glucose was , and 55% were considered in the normal range, 25% pre-diabetic, and 13% diabetic. For those who were at risk in the screening, 40% (of the 42% assessed at risk) were measured at <100 at the year-end final measure. For those initially at risk, 80% decreased their glucose reading, by a range of 3 to 100 mg. Over half of those (53%) showed decreases of at least 19 mg.

19 Diabetics. Initially, for those CMPs with a diagnosis of diabetes (N = 3), the average glucose reading was ; the average did drop to 133 at the year end. During 2015, only 6% of all CMPs reduced their glucose readings by 10 pts, falling short of the 30% targeted. Goal for Glucose. The project goal was that 30% of CMPs will have a reduction in glucose by at least 10 mg. The project did not meet that goal (6% for all). Measurements Lipids This section will describe measures and outcomes that are recorded for CMPs, including total cholesterol, HDL, LDL, and triglycerides. Within individual records, OHH data include three measures (initial, midyear, and year end) and these were recorded as part of the data file by staff. Page 17 Measurements Cholesterol Of the three measures, cholesterol is perhaps best known. At baseline, the initial measure, the average cholesterol was (N = 39); the average at second measure decreased to ; and the final reading (N = 31) was , a decrease of 6.52 on average. Median total cholesterol was at 183 at the baseline, 172 mid-year and 171 at year-end, a decrease of 12 on average. In terms of the proportion of CMPs at risk, initial measures showed 36% with cholesterol above 200. By years end that dropped to 32%. For all participants, 57% showed a decrease from the first to the final measure, 37% by 15 or more, and 14% by 30 or more. Of those with initial readings >=200, 45% were below 200 at mid-year, 18% were below 200 at the final measure, 46% decreased by 25 or more, and 53% decreased by 15 or more. Measurements HDL and LDL HDL. In the standards adopted by OHH, an HDL of 60 is considered ideal; for males, a measure of 40 is acceptable and for females the comparable is 50. The HDL average at baseline was at the At Risk level for males (38.14) increasing slightly at the final measure (39.22). Females were above the At Risk level at the first measure (51.8) and increased that slightly for the final measure (53.4). First Measure: 50% of males were above 40 at the initial measure, and 52% of females were above 50. Final Measure: 36% of males increased their HDL, about the same proportion as females (37%). LDL. The program standard for LDL was <100 for the Optimum level (52% for CMPs), for Near Optimal (24%), Borderline High (16%), High (14%). For CMPs, the average was at the initial measure, decreasing to at the final measure, with an average change at -9.9.

20 At the year-end the proportion at the optimal level had increased from 32% to 52%, and 73% had decreased their LDL reading, 24% by more than 20 mg, and 52% more than 10 mg. For those above 130, 71% decreased their LDL, including 48% more than 10 mg, and 24% by more than 25 mg. Also, at the final measure 61% had moved from above Borderline High (>=130), with 22% at Optimal (<100) and 39% at Near Optimal ( ). Measurements Triglycerides In 2015, 23% of CMPs had triglyceride readings in the high range ( ; 2014, 33%). This year, no CMPs were in the very high range (>=500). For the initial reading, the average reading was 149.7, just below the optimal level; the average dropped slightly at the second reading to 146.4, but Triglyceride Measurements 2015 increased just above the optimal level for the final reading (151.7). 64% The median decreased by from 135 at the initial reading to 124 at the third/final reading. In % Page 18 64% of CMPs had readings at the optimum level (<150) at the initial reading, 13% were borderline high ( ), and 23% were high ( ). At the final reading, 13% 23% Optimal <150 Borderline High Initial 23% 16% 3% 0% High Very High 500+ Final 58% were at the optimum level, 23% were borderline high, 16% were high, and 4% were very high. In terms of change/improvement, 57% of participants decreased their triglycerides: 6% by 100 mg or more; 14% by 50 mg or more; and 37% by 10 mg or more, and Change of Classification: Of those who were above the optimal level at the first reading: 36% moved to that optimal level at the second reading. Goal for Triglycerides. 57% reduced their triglycerides, and 37% did so by at least 10 mg, exceeding the goal of 30%.

21 Education Modules for CMPs: Pre- and Post Eight education modules are available for use in the case management portion of OHH; results for eight of those are reviewed here. Educational materials are administered to CMPs as appropriate; for example, the module for Smoking was not used as none of the CMPs were noted as tobacco users at enrollment. For the education modules, the pre-post tests were designed in a prior year, and each year staff review content, relevance, test administration, and scoring. The scores used here are for CMP who completed the program only (N = 40), and the number who actually receive the education module depends on relevance to their health profile and goals. Healthy Weight Blood Pressure Heart Attack & Stroke Physical Activity Cholesterol Diabetes Healthy Eating Nutrition Label Education Modules 2015 Percent Correct 47% 55% 77% 89% 72% 69% 85% 75% 92% 71% 91% 86% 90% 72% 90% 97% Page 19 The charts presented here show 1) the differences in percent correct for the pretest Pretest Posttest and the posttest, and 2) a chart with the differences (post - pre). The table (page 20) presents the results from the t-test for the individual modules. For all education modules the differences pre- post were significant. Pre-post scores. After completing education modules, CMPs demonstrated significantly improved knowledge. Average gains and average scores include: Healthy Weight: a gain of 12% from 77% correct to 89% correct. Blood Pressure: a gain of 19% from 72% correct on the pretest to 91% on the post. Heart Attack and Stroke: a gain of 16% from 69% on the pretest to 85% on the post. Physical Activity: a gain of 17% from 75% to 92%. Cholesterol: A gain of 31% from 55% to 86%. Diabetes: gain of 19% from 71% on the pretest to 90% on the post. Healthy Eating: an average gain of 17% from an average of 72% on the pretest to 90% on the post. Overall or Average Score As part of the data file for education modules staff calculated an average of all pretest scores and compared those to the posttest. Taking those same scores, using only those that were matched, and evaluating those with a t-test, shows a pretest mean of 69.9% and posttest mean of 88.9%. The difference was significant (The mean gain in the all modules (M = , SD = , N =37) was significantly greater than zero, t(36) = , p = 0.000, providing evidence that taken as a group the education modules increased the participant's knowledge.)

22 Skill Demonstrations In two education modules the CMPs are asked to demonstrate their skills in 1) reading nutrition labels and 2) identifying portion/serving sizes. In both the skills/topics and scoring are defined through criteria established in a rubric, and scoring is on a Pass/Fail basis. In this year, Reading Nutrition and Food Labels: a gain of 50% from 47% on the pretest to 97% on the post. Identifying Portion and Serving Sizes: the skill demonstration was evaluated for 34 CMPs, and of those, 31 satisfactorily demonstrated this skill. The percent correct, then, is 91% (post only). Limitations. Several limitations are acknowledged when looking at the pre-post differences. The research design here offered limited control: participants were not selected at Nutrition Label 50% random and once selected they were not assigned to treatment/non-treatment groups. On the other hand, the design was common for projects of this type. The advantage here is that the testing provides a comparison of performance by the same group of participants before and after exposure to the project intervention(s), the education modules. As in last year, a high proportion of CMPs completed the education modules and the pre- and posttests, but again, one of the factors in delivering the module was how appropriate the content was to individual CMPs. The table (page 21) includes the number of participants completing both the pre- and posttests for an education module, a listing of topics, and a standardized statement detailing the results of the pair t- test. Goals for Education Modules: Nutrition and Cardiovascular Disease Percent Improvement Pre- Post 2015 Healthy Weight Blood Pressure Heart Attack & Stroke Physical Activity Cholesterol Diabetes Healthy Eating For 2015, targets for the Nutrition module along with the Cardiovascular Disease module were the focus of goal statements. Nutrition Goals. For Nutrition, the target was to achieve gains pre- to post of at least 10%. The baseline was the average score of 72.45% on the Healthy Eating pretest for 37 CMPs (N = 37). On the posttest the average score increased to 89.57% (only matched scores are used). So the average scores pre- to post for the Healthy Eating (Nutrition) module was increased by 17%, exceeding the project of goal of a 10% increase. Knowledge of Cardiovascular Disease Goals. The target for the CVD module was to increase the average scores for the Heart Attack and Stroke module by 10% pre- to post. The baseline score for 37 CMPs was 68.9% and the average of posttest scores increased to 85%, an increase of 16% which exceeded the goal of 10% set for % 19% 16% 17% 19% 17% 31% Page 20

23 Education Module Healthy Weight (N =37) Blood Pressure (N =33) Heart Attack (N =37) Physical Activity (N =36) Cholesterol (N =35) Diabetes (N =32) Examples of topics Role in mortality, high risk diets, weight loss, BMI, fiber in foods, portion control. The mean gain in the HW module (M = , SD = , N =37) was significantly greater than zero, t(36) = 4.381, p = 0.000, providing evidence that HW education module was effective in increasing the participant's knowledge. Understanding systolic & diastolic BP, risk factors, optimum BP, how to take, BP and diets. The mean gain in the BP module (M = , SD = , N =33) was significantly greater than zero, t(32) = 4.963, p = 0.000, providing evidence that BP education module was effective in increasing the participant's knowledge. HA defined, what to do, symptoms, stroke, HA risk factors, symptoms by gender, CPR. The mean gain in the HA module (M = , SD = , N =37) was significantly greater than zero, t(36) = 4.938, p = 0.000, providing evidence that Heart Attack education module was effective in increasing the participant's knowledge. Benefits, blood flow, calories, improved blood pressure. The mean gain in the PA module (M = , SD = , N =36) was significantly greater than zero, t(35) = 5.683, p = 0.000, providing evidence that Physical Activity education module was effective in increasing the participant's knowledge. Risks with high cholesterol, Risk with LDL, sources of HDL and LDL, high fiber foods, triglycerides, reading food labels. The mean gain in the Cholesterol module (M = , SD = , N =35) was significantly greater than zero, t(34) = 6.912, p = 0.000, providing evidence that this education module was effective in increasing the participant's knowledge. What is diabetes, insulin, treatment, risk with heart disease, symptoms, and types. Page 21 Healthy Eating (N =37) Reading a Nutrition Label (N =30) The mean gain in the diabetes module (M = , SD = , N =32) was significantly greater than zero, t(31) = 5.602, p = 0.000, providing evidence that the diabetes education module was effective in increasing the participant's knowledge. Topics include goals for a nutrition plan, lowering cholesterol, weight loss/gain, and reading nutrition labels. The mean gain in the Healthy Eating module (M = , SD = , N =37) was significantly greater than zero, t(36) = 4.877, p = 0.000, providing evidence that the Healthy Eating education module was effective in increasing the participant's knowledge. This was a skills demonstration exam where CMPs were asked to interpret food labels for nutritional values. The mean gain in this skills demonstration module (M = 0.500, SD = 0.509, N =30) was significantly greater than zero, t(29) = 5.385, p = 0.000, providing evidence that the Label Reading education module was effective in increasing the participant's knowledge. CMPs: Behaviors and Attitudes CMPs were monitored for their attitudes and behaviors, and data representing their responses were entered in Behavior Change files and in a Physical Activity and Nutrition data file.

24 Behavior Changes of the CMPs were monitored (using the Behavior Change Questionnaire) three times during their enrollment. The questions covered general health issues (primary care provider, healthy goals), food consumption (fruits, vegetables, dairy, protein, processed foods), and the frequency of eating foods prepared in restaurants/fast food chains. The Physical Activity/Nutrition file mirrors the intake form Health Survey, including responses about physical exercise, eating fruits and vegetables, and the frequency of reading food labels. Page 22 Responses for Behavior Change The questions when looking at the file is whether behaviors changed and whether changes were positive or negative. The benefit (not so measurable) is that administering the form several times during enrollment in case management is that it encourages CMPs to look repeatedly at their eating and exercise behaviors, and at the same time it reinforces the content of the education modules. Physical Activity, Fruits, Vegetables, Labels Exercise. CMPs overall increased their levels of activity while enrolled in OHH. Table 2. Initial Measures of Physical Activity Frequency Percent Valid Percent Cumulative Percent Valid never per week per week per week per week Total Missing System Total At the initial assessment, three-of four (59%, N = 39) exercised at least two times each week. At The midyear measure, 78% (N = 23) exercised at least two times each week. At the final measure, exercise at least two times per week increased to 88% (N = 32). At least four times per week: the initial measure showed 15% at this level, increasing to 34% at the final measure. Six to seven (6-7) times per week: the initial measure showed 3% at this level, increasing to 16% at the final measure. On the other hand, the proportion that reported exercising no more than once per week (1 time and Never) decreased from 41% initially to 13% at the final measure. To calculate a change in the level of exercise, each value of the exercise variables represented one unit, beginning with never (=1) and ending with 6-7 per week (= 5). Given the timeframe of when the measures were recorded, two variables were calculated, one from mid-year to the final measurement, and one showing the change in levels of exercise for the total time enrolled. A CMP who never exercised (a value of one) who increased to 2-3 times per week (a value of three) would have increased his level of exercise by two units. Using this to show changes in exercise for the year: 16% increased by one unit. 16% increased by two units (like moving from 1 per week to 4-5 per week). 9% increased by three units (so the total increase = 41%).

25 19% of CMPs decreased the amount of exercise per week. 41% showed no change. Putting CMPs (39 CMPs across five levels at initial measure and 32 at the final) into a group based on their initial response to the question: Exercise-Never: one-third (33%) did not change, but two-thirds (67%) increased two levels, from never to 2-3 times per week. Exercise -1 time/week: 78% increased from one three levels. Exercise times/week: 28% increased by one or two levels. Exercise times: 60% dropped one level; 40% stayed the same. Exercise 6+: The one CMP dropped by one level. Page 23 Goal for Physical Activity. For the year, 41% of CMPs (N = 32) increased their activity level, exceeding the goal of 30%. In addition, 16% of CMPs increased physical activity by 2 levels, and 9% by 3 levels. Fruit and Vegetable Servings per Day Fruit. Daily Intake of fruits and vegetables was measured three times for the year with a four item scale (none = 1, 1-2 servings = 2, 3-4 servings = 3, and 5 or more servings = 4). As with Exercise, similar variables were calculated to show increases of servings and vegetables. In the initial measure, 1-2 servings was the median category (75%). While enrolled in OHH, The proportion who reported having at least one serving of fruit per day decreased from 75% in the initial assessment to 69% in the final assessment. That change was accompanied by an increase in the proportion having at least 3 servings per day, which increased from 22.5% initially to 28% at the final measure. In all, 12.5% of CMPs decreased their intake of fruit, 69% stayed the same, and 19% increased by one or more levels. Vegetables. CMPs increased their daily servings of vegetables while enrolled. At the initial assessment, 28% reported having at least three servings of vegetables each day, and at the final assessment that increased to 44%. Goal for Fruit/Vegetable Intake. The Goal was the 30% of CMPs would Eat Better by increasing their average daily intake of fruits/vegetables. Overall, 34% of CMPs increased their average daily intake of fruits and vegetables, exceeding the goal of 30%. Nutrition Labels. OHH emphasizes the knowledge of nutrition as well as the ability to use that knowledge in practical settings, both in the content of education modules and in the related skills demonstrations of CMPs. Responses to the questions here tells how often those skills are utilized by CMPs. Rarely used. The proportion that rarely (or didn t know how) read food labels decreased from 28% at the initial assessment to 9% at the final assessment. The proportion that sometimes read labels decreased from 44% in the initial assessment to 38% at the final assessment. The proportion that read labels very often increased from 28% in the initial assessment to 53% at the final assessment.

26 Behavior Changes These questions focused on general health issues (primary care provider, healthy goals), food consumption (fruits, vegetables, dairy, protein, processed foods), and the frequency of eating foods prepared in restaurants/fast food chains. Trends across the three measures are not always consistent, perhaps because of the level of response. Generally the initial survey at 39 respondents, the second or mid-year 30, and the final 22. Contradictory trends are noted in the examples below. Page 24 The proportion of CMPs that described their health as at least Very Good/Excellent increased from 26% initially to 46% in the final assessment. The proportion who reported having a primary care provider increased from 95% to 100%. The proportion who reported having support for making healthy lifestyle choices increased from 82% to 97% mid-year (N = 31) and to 86% at the final measure (N = 22). (Comparing responses shows that CMPs who responded Yes to having support did not change their response in subsequent administrations, and that 55% who responded No to support initially changed to Yes in subsequent administrations.) Most of the CMPs said they have losing weight as a goal (95% at the initial assessment). Daily Eating Habits CMPs reported a modest increase in their consumption of dairy products (None decreased from 18% initially to 9% at the final measure; 1-2 servings increased from 62% to 73%; more than 3 servings decreased from 21% to 18%). They reported an increase in protein (meat, nuts, and beans) at least three times per day from 48% to 54%. The servings of processed meats decreased, with 49% having no processed meat daily to 57% having no processed meat daily. Those having at least one serving per day decreased from 49% to 38% at the final measure. The proportion having fried foods per day did not change from initial to final measure (None, 31% initially; 32% at final); however, the second mid-year measure with a greater response suggests decreased consumption, with None increasing from 31% to 60%, and 1-2 servings decreasing from 62% to 37%. (Initial N = 39; mid-year = 30; final = 22). The proportion having No daily servings of sweets/desserts increased from 15% initially to 23% at the second assessment, and then 14% at the final assessment. The proportion not having a daily serving of soda increased slightly from 56% at the initial assessment to 64% in the subsequent assessment. (Of those who said none initially, 38% increased to 1-2 servings at the final. Of those who said 1-2 servings, 55% decreased to none at the final assessment.) Weekly Habits The proportion who did not eat fast food on a weekly basis stayed the same through the three periods. Overall, about one-third do not eat fast food on a weekly basis.

27 Participation Case Management Results One measure of the program is retention; for the CMPs participation was voluntary and their persistence depended on their ability to see benefits. Looking at retention: The stated goal was that 60% of case management participants will remain in the program for 6 months following enrollment. On average, CMPs who completed the program (40) were enrolled for 6.75 months. 8, 30% Months Enrolled , 5% 5, 8% Page 25 The minimum enrollment was 4 months; the maximum 8. 30% were enrolled for 8 months. 63% were enrolled for at least 7 months, 7, 33% and 88% of CMPs who completed the program were enrolled for at least 6 months. 6, 25% For the purpose of evaluating the following goal, the number used accounts for all persons enrolled in the program, looking then at retention of all individuals, including those who are labeled non-cmps along with those who are CMPs who completed the program and the period of time they were in the program (at least six months). Goal. With the goal set at 60% of CMP remaining in the program for at least 6 months, 69% of all CMPs (N = 51) were enrolled in for at least 6 months, exceeding the 60% target. In addition, 75% of all were enrolled 5 months. Of those who completed the program, 88% were enrolled at least 6 months. Personal Goals Achieved by CMPs Goals set by CMPs were discussed earlier. The data file on goals contains up to two goals per CMP, along with staff evaluation as to whether those goals were met, along with comments. In all, CMPs identified 69 goals (about 1.7 per person) and of these, 65% were achieved. Goal for Participation. For the goal was that 75% of case management participants will achieve at least one of the three goals CMPs set by the end of their enrollment, data files show that 78% of CMPs met at least one goal by year s end, exceeding the 70% target. COMMUNITY PRESENTATIONS, SCREENINGS, AND EDUCATION Presentations (some with accompanied screening) were delivered throughout the four county area, allowing interacting with a wide range of demographics, both in terms of age and education. Data files, separately constructed (with evaluator input) and maintained by staff, allowed staff to track screenings, the recording of repeated measures, the administration of pre- and posttests (where administration was

28 feasible). Venues included schools, events and agriculture shows, large group presentations, and worksite programming. Pre-Post. Data maintained for the project includes two files for pre- and posttests given for presentations. The first Presentation Tracked file contained records from 17 different sites, many of which were school related, others in community centers, as well as businesses and health fairs. Elem. Schools, 19% Health Fairs, 2% Business, 3% Community Senior Centers, 9% Presentations w/ Pre- Post Page 26 The audiences for these presentation range from early High Schools, 6% childhood school-type settings, schools (elementary, middle and high school, and post high school), and community groups. Middle Schools, 61% Outcome. In this file, the average pretest score was 55% correct, and the average post score was 87%, a gain of 32%. These short term gains (before and after the presentation) were also reviewed in a matched pair t-test. The mean gain in the for these presentations (M = , SD = , N = 1,059) was significantly greater than zero, t(1,057) = , p = 0.000, providing evidence that over the short term these presentations were effective in increasing the participant's knowledge. For educational presentations, OHH set a goal that 70% of educational presentation participants will reflect an increase in knowledge from pre- to post test. To evaluate this goal, participants were selected who had scores of less than 100% on the pretest, otherwise no improvement would be possible. Selecting on those who scored less than 100% (N = 1,035), the pretest average score is 53.9% correct and the posttest 87.2%. Of those, 90% increased their score pre- to post; 10% either scored the same pre- to post or had a post test score that was lower. Goals for Educational Presentations. For educational presentations, OHH set a goal that 70% of educational presentation participants will reflect an increase in knowledge from pre- to post test (of those who did not have 100% on the pre-test). Of those educated who did not have 100% on the pretest (N = 1,035) 90% demonstrated an increase in knowledge pre- to post, exceeding the goal. Blood Pressure Education In sessions focusing on blood pressure 445 participants were pretested about their knowledge of BP values and asked to classify their own blood pressure. Data elements reflect previous vs. post knowledge of normal BP as well as the accuracy of estimates of their own BP. Age. The average age for these participants was 57.2 (median =58), with a range of 18 through 102. One in four (21%) were 47 and under, the second quartile was 47-58, the third 58-75, and the fourth 70 and above.

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