# Presentation: 046603

## The WOMAN Challenge 2006Women and girls On the Move Across the Nation

**Michelle Hoersch, Regional Women’s Health Coordinator**
**Amy Dolgin, Graduate Student Intern**
**Angeline Widmer, Public Health Advisor**
**The National Prevention Summit:**
**Prevention, Preparedness and Promotion**
**September 27, 2006**

**Notes:**
Intro self 
OWH 

Here to tell you about our experiences with the WOMAN Challenge –  a physical activity program developed for National Women’s Health Week 

Acknowledge Amy and Angeline

## The Problem:

- 127 million American adults are overweight or obese
- 75% of Americans participate in low levels of physical activity

**Notes:**
An estimated 127 million American adults - 64.5% of the adult population, are overweight or obese.  

More than 9 million children and teens, aged 6–19 years, are considered overweight. 

Only 25% of Americans participate in the recommended levels of physical activity, and 29% of Americans are not physically active at all.

Research has demonstrated that small improvements in nutrition and physical activity, and especially pedometer-based walking programs, can significantly improve health.

## Contributing to the Problem for Women: 

- Physical inactivity - Women vs. Men
- Aging in women
- Risks of sedentary lifestyle

**Notes:**

Physical inactivity is more prevalent among women than men

As women age, participation in physical activity decreases

Sedentary women have increased risks for cardiovascular disease, diabetes, hypertension, colon cancer, and depression;

## Gender-Specific Programming

- 	Addressing the gender-specific barriers and needs of women is critical in developing a physical activity intervention for women and girls.

**Notes:**
We considered:

The realities of women’s lives – time constraints and competing demands
Importance of social support
Overall design – women specific information

## What we created

- 	In 2004/2005:
- 	The **WOW Challenge**** **
**	**_**W**_**omen and girls **_**O**_**ut **_**W**_**alking**
**	**
- a regional pedometer-based physical activity challenge

**Notes:**
We conceived of WOW for NWHW 2004
Hoped for 500 participants
We were overwhelmed with response and had to cap registration at 2000!
12-week walking challenge – not automated or web-based at all 
One virtual route around the region 
Weekly e-mail messages with motivational messages, health information and reminders to track steps

For 2005:
Web-based and interactive
Expanded to three HHS regions – Region VI – Dallas and Philly – in addition to Chicago 
Added new route for Region VI participants
Again about 2000 participants – pedometers limiting factor
Added focus of intergenerational teams

## 2006 WOMAN Challenge Women and girls On the Move Across the Nation

**National Women’s Health Week**
**Six virtual routes across the country**
**17,699 participants nationwide**
**6500 free pedometers**
**138 free arm-band pedometers**
**Individual or Team participation**
**Participants received:**
- Tracking log
- Weekly motivational emails
- Age-appropriate health information on nutrition, physical activity, disease prevention, and health promotion.
**The Challenge was free and operated through an interactive website, enabling participants to track their progress on virtual routes.**

**Notes:**

2006 WOMAN Challenge differed from previous years’ WOW Challenges
National program
Six virtual routes to choose from 
All web-based
Attempt to make it inclusive to women and girls with mobility impairments – hence the arm-band pedometers

The first 6500 to register received a pedometer and hard copy of tracking log as well as some other women’s health information 
After we exhausted our pedometer supply, participants needed to get their own pedometer and could down-load the tracking log

EMAILS INCLUDED:
age-appropriate health information on nutrition, physical activity, disease prevention, and health promotion.

## 2006 WOMAN Challenge

- Who participated?
- 17,699 women and girls
- Every state and many U.S. territories represented

**Notes:**
We were particularly pleased with the response as we had delays that caused us to launch late.  Our broad reach was possible due to the participation of:
All of the RWHC from OWH
State Women’s Health Coordinators from most states
Article in Shape Magazine
Enthusiasm  of past participants
Word of mouth – what women do best!  They find something good and they share this info with others!

We even had a considerable number of participants from around the world including Iraq, China, Canada and Europe

## 2006 WOMAN Challenge 

- Participants chose one of
- two goals:
- _Goal 1_: more than 10,000
- steps/day
- _Goal 2_: less than 10,000
- steps/day

**Notes:**
We wanted to ensure that we didn’t scare off those for whom 10K steps a day was completely unrealistic.
For the under 10K/day folks, the objective was for them to log something everyday to increase their consciousness and ultimately the goal would be for them to increase their daily steps as well.

## 2006 WOMAN Challenge

- Participants chose one of six virtual routes
- Pacific Coast
- Gulf and Caribbean
- Cross Country
- Northeast
- Plains and Midwest
- Rocky Mountains

**Notes:**
Each route had a multiplier for step counts that advanced a participant to the next city over the course of a week if they met their daily step goals.

It was fun to pretend to be walking a route far from home.

## Why Pedometers?

- Capture full day’s activity
- Low-cost
- Ease of use
- Immediate feedback
- Standardized

**Notes:**
Pedometers have been used in Japan as a tool of measurement and motivation for more than 30 years.  Language barriers prevent us from accessing this body of research.  However, in the United States, pedometers are gaining popularity for their relative low-cost, easy personal use, and motivational effect.

There is something very compelling about looking at your pedometer on a particularly sedentary day and realizing how little activity you’ve actually had.  It then motivates you to take a longer walk at lunch or walk to the next el stop or whatever fits the context of your life.

## Why 10,000 steps?

- Japanese model
- Active lifestyle

**Notes:**
Japanese pedometer-based health promotion programs recommend a goal of 10,000 steps/day.  

Several American studies have identified that 10,000 steps/day may be an unrealistic goal, especially in our largely sedentary society.  However, it does provide an important target for achieving an active lifestyle.  

## Theoretical Framework:Stages of Change (SOC) Model

- In 1983, Prochaska and DiClemente developed the SOC Model, and it has since been applied to physical activity studies.  The stages include:
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance

**Notes:**
Participants were in the ACTION stage of the Stages of Change Model.  
However, they may have encouraged countless others to become physically active, or at least consider it, moving them along this continuum as well – perhaps moving these others into the “CONTEMPLATION” stage.

Precontemplation: Has no intention to take action within the next 6 months 

Contemplation: Intends to take action within the next 6 months. 

Preparation: Intends to take action within the next 30 days and has taken some behavioral steps in this direction. 

Action: Has changed overt behavior for less than 6 months 

Maintenance: Has changed overt behavior for more than 6 months.
*we hope WOMAN Challenge participants are continuing with these changed behaviors!

- 	“Although I did not achieve 10,000 steps everyday, I became **committed to walking** **everyday**. Your challenge motivated me to get moving. I looked forward to seeing my progress on the map and I am proud of my accomplishment. I hope you do it again. I would love to participate.
*	**Pam, California*

**Notes:**
This is a quote from a 2006 WOMAN Challenge participant, highlighting her increased commitment to behavior change.  Here it is clear that she has progressed on the Stages of Change Model.

## Interesting Findings

- _Value of team participation_
- Higher step counts
- More days logged
- commitment & accountability
- competition

**Notes:**
Team participants’ step counts were approximately 235% higher than individuals’, regardless of goal, 
and team members logged their steps on at least twice as many days per week than individual participants.

## Slide 16

**Notes:**
Regardless of goal, team members had higher step counts than individual participants.

Note the Yellow and Aqua colored bars which represent the team participants in both the over 10K and under 10K steps a day goal categories

## Interesting Findings

- _Free Pedometers_
- Participants who had to provide their own
- pedometers, on average, logged more daily
- steps
- 	Our theory:
- Participant investment in program increases participant commitment

**Notes:**
Buying their own pedometers means they’ve also invested in the program

Or

Perhaps they are already committed to physical activity because they already own a pedometer.

However, I don’t want to discount the role of providing a free pedometer to those who might otherwise have not been able to afford one
Or those who looked at this free pedometer as an opportunity to make a change in their activity level

## Slide 18

**Notes:**
None = no pedometer provided by us.

## Interesting Findings

- _Past participants_
- Higher step counts
- More days logged
- Our theory:
- Each year participants become more committed
- to behavioral change.

**Notes:**
Past participants’ step counts were up to 172% higher than first-time participants’, and past participants logged up to twice as many days per week than first-time participants.

## Slide 20

**Notes:**
Non-past participants = first-time participants

## Interesting Findings

- _Age_
- Higher step counts
- More days logged
- 	Our Thoughts on this:
- Should we be targeting this intervention towards older populations of women as well?

**Notes:**
The age group with the highest step count and highest average days logged was the 91+ category.

There were 7 participants in the 91+ category.

## Similar Findings of Other Research on Pedometer Walking Programs

- Subject attrition and fatigue
- Behavioral change
- Problems with reaching goals
- Benefits of personalized, incremental goals

**Notes:**
Subject attrition and fatigue remain critical challenges in physical activity interventions – behavioral change is a slow process;

Behavioral change: Stages of Change model (Prochaska) – It often takes several attempts for a new behavior to become integrated in an individual 

Difficulty in achieving goals:
Less than 35% of participants in similar programs achieved >10,000 steps/day;

Personally relevant, incremental goals may be a more effective approach;

*Participants overwhelmingly report positive feedback on the intervention, regardless of whether or not they met their goals.

## Slide 23

**Notes:**
There were 7 women in the 91+ category

The participants in the 71-80 and 81-90 age categories had steady improvements in their step counts and days logged throughout the 8 week challenge.  Their step counts didn’t show fatigue like the younger participants’ did.

The 41-50 age category shows upward spike during last week of Challenge – are they more committed to making behavioral changes? Most of our advisory group volunteers were also from this age category.

## Participant Feedback

- Make it year-round
- Provide a discussion board for participant interaction
- Being on a team made me more motivated to log my steps each day and increase my steps each week
- We loved the motivational emails – send more of them!

**Notes:**
During the Challenge we received ongoing feedback from participants regarding their experiences.

## Participant Feedback

- This program has really opened my eyes as to how much activity I was REALLY doing. Not nearly enough. Now my activity level has increased dramatically, and I can feel the difference. It has also been contagious. Our office is now full of people wearing pedometers. Thanks for the inspiration!
*	**Leasa, Illinois*
- This exercise of logging steps has been a wake up call to me. I now have a clearer perspective how sedentary my lifestyle has been sitting at my desk 10 hours/day! I now walk 40 minutes day instead of sitting for lunch! I don't think I can ever return to less than 10,000 steps per day! My energy level is higher than ever! Thank you!
*	**Estelle, Hawaii*
- This has been great! I've been able to participate in a team event with my family even though we live all over the country!*Kimberley, Virginia*

**Notes:**
quotes

## Lessons Learned:

- Greater availability and earlier publicity
- Increase the # of pedometers (budget)
- Encourage team membership
- Market to older women and past participants
- Be creative to keep women and girls motivated and moving!

**Notes:**
These are lessons learned from our own evaluation and from the conference call with the Participant Advisory Board. 

They will shape our planning of the 2007 WOMAN Challenge.

## References

- American Obesity Association. “AOA Fact Sheets: Obesity in the U.S.” 2002. Available: www.obesity.org/subs/fastfacts/obesity_US.shtml.  Accessed on June 19, 2006.
- Bassuk SS, Manson JE.  Preventing Cardiovascular Disease in Women: How much physical activity is “good enough”?  *President’s Council on Physical Fitness and Sports Research Digest* 2004, 5(4): 1-9.
- Centers for Disease Control and Prevention.  Overweight and Obesity: Home. Available: http://www.cdc.gov/nccdphp/dnpa/obesity.  Accessed on June 19, 2006.
- Croteau KA.  A Preliminary Study on the Impact of a Pedometer-based Intervention on Daily Steps.  *American Journal of Health Promotion* 2004; 18(3): 217 – 20.
- Hultquist CN, Albright C, Thompson DL.  Comparison of Walking Recommendations in Previously Inactive Women.  *Medicine and Science in Sports and Exercise* 2005; 37(4):676-683.
- Institute of Medicine.  Fact Sheet:  Childhood Obesity in the United States:  Facts and Figures.  *Institute of Medicine, National Academies of Science*.  Washington, DC: National Academies Press; September 2004.
- Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampfer MJ, Willett WC, Speizer FE, Hennekens CH.  A Prospective Study of Walking as Compared with Vigorous Exercise in the Prevention of Coronary Heart Disease in Women.  *The New England Journal of Medicine *1999, 341(9):650-658.
- Marcus BH, Lewis BA. Physical Activity and The Stages of Motivational Readiness for Change Model.  *President’s Council on Physical Fitness and Sports Research Digest* 2003: 4(1):1-8.
- Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, Kriska A, Leon AS, Marcus BH, Morris J, Paffenbarger RS, Patrick K, Pollock ML, Rippe JM, Sallis J, Wilmore JH.  Physical Activity and Public Health. *JAMA* 1995; 273(5): 402-407.
- Prochaska JO, Velicer WF.  Behavior Change: The Transtheoretical Model of Health Behavior Change.  A*merican Journal of Health Promotion* 1998, 12 (1): 38–48.
- Pronk N. One Step at a Time – The 10,000 Steps Program Increases Physical Activity.  *The Permanente Journal* 2003; 7(2): 35-36.

## References

- Rodearmel SJ, Grotz VL, Goldsmith LA, Smith SM, Ogden LG, Wyatt HR, Moran JR, and Hill JO.  America on the Move Family Study.  Presented at the *Pediatric Academic Societies Meeting in San Francisco*, CA, May 2006.
- Rooney BR, Smalley K, Larson J, Havens S.  Is Knowing Enough?  Increasing Physical Activity by Wearing a Pedometer.  *Wisconsin Medical Journal* 2003; 102(4): 31-36.
- Segar M, Jayaratne T, Hanlon J, Richardson CR.  Fitting Fitness into Women’s Lives: Effects of a Gender-tailored Physical Activity Intervention.  *Women’s Health Issues* 2002; 12 (6): 338-347.
- Speck BJ, Harrell JS.  Maintaining Regular Physical Activity in Women. *Journal of Cardiovascular Nursing* 2003; 18(4): 282-291.
- Speck BJ, Looney SW.  Self-Reported Physical Activity Validated by Pedometer: A Pilot Study.  *Public Health Nursing* 2006; 23(1):88-94.
- Speck BJ, Looney SW.  Effects of a Minimal Intervention to Increase Physical Activity in Women.  *Nursing Research* 2001; 50(6): 374-378.
- Tudor-Locke C, Marshall S, and Vehige T.  Pedometers and Public Health.  Teleconference presented by the *Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity*; December 2005.
- Tudor-Locke C.  Taking Steps Toward Increased Physical Activity: Using Pedometers to Measure and Motivate.  *President’s Council on Physical Fitness and Sports Research Digest* 2002; 3(17): 1-8.
- Tudor-Locke C, Myers AM, Bell RC, Harris SV, Rodger NW.  Preliminary Outcome Evaluation of the First Step Program.  *Patient Education and Counseling* 2002; 47: 23-28.
- Wilbur J, Chandler P, Miller AM.  Measuring Adherence to a Women’s Walking Program.  *Western Journal of Nursing Research* 2001; 23(1): 8-32.
- Wyatt HR, Peters JC, Reed GW, Barry M, Hill JO.  A Colorado Statewide Survey of Walking and Its Relation to Excessive Weight.  *Medicine and Science in Sports and Exercise* 2005; 37(5): 724-730.

## For more information:

**Michelle D. Hoersch, M.S.**
**Office on Women's Health - Region V**
**U.S. Department of Health and Human Services**
**233 N. Michigan Ave, Suite 1300**
**Chicago, IL  60601**
**312-353-8122**
**312-353-7800 fax**
- _[michelle.hoersch@hhs.gov](mailto:michelle.hoersch@hhs.gov)_

**Notes:**

Thanks!

## Thank you so much, I am really looking forward to this challenge!  What a wonderful country to live in that my government cares so much about my health!

Robin, Texas

*Robin, Texas*