Group-Based Lifestyle Sessions for Gestational Weight Gain Management: A Mixed Method Approach Samantha M. Harden, PhD; Mark R. Beauchamp, PhD; Brian H. Pitts, BSc; Edith M. Nault, MS; Brenda M. Davy, PhD, RD; Wen You, PhD; Patrice Weiss, MD; Paul A. Estabrooks, PhD Objective: To integrate group-based lifestyle sessions (GBLS) within prenatal care for gestational weight gain (GWG) management. Methods: In Study 1, participants attended GBLS during prenatal care visits. Participants in Study 2 attended off-site GBLS whereby care providers were asked to discuss the program with patients. Process and outcome evaluation were conducted through a mixed-methods approach. Results: In both pre-experimental feasibility studies, data provide preliminary support for GBLS (eg, positive care

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he Institute of Medicine (IOM)1 proposed recommendations for gestational weight gain (GWG) that, if followed, decrease the risk of complications for both mother and child (eg, cesarean delivery, low birth weight or macrosomia2). Nevertheless, 60%-70% of women exceed GWG recommendations.3 Moreover, there are particular disparities associated with this excessive GWG for women with higher pre-pregnancy BMI status, lower income, as well as those who are first-time mothers, are younger, or frequently diet.4,5 Related

Samantha M. Harden, Postdoctoral Fellow, University of British Columbia, School of Kinesiology, Vancouver, BC. Mark R. Beauchamp, Associate Professor, University of British Columbia, School of Kinesiology, Vancouver, BC. Brian H. Pitts, Medical Student, Virginia Tech Carilion School of Medicine, Student, Roanoke, VA. Edith M. Nault, Graduate Student, Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA. Brenda M. Davy, Associate Professor, Department of Human Nutrition, Foods and Exercise, Virginia Tech, Blacksburg, VA. Wen You, Associate Professor, Department of Agriculture and Applied Economics, Virginia Tech, Blacksburg, VA. Patrice Weiss, Chair and Professor, Carilion Clinic, Virginia Tech Carilion School of Medicine and Research Institute, Paul A. Estabrooks, Professor and Chair, Fralin Translational Obesity Research Center, Department of Human Nutrition, Foods and Exercise, Virginia Tech, Department of Family and Community Medicine, Carilion Clinic, Roanoke, VA. Correspondence Dr Harden; [email protected]

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provider and patient feedback, weight gain patterns) as well as highlight areas for future research (eg, lack of GWG management discussions, preference for GBLS location). Conclusions: GBLS represents a promising approach to GWG management. Future research should assess the generalizability, sustainably, and compatibility of GBLS within prenatal care. Key words: group-based, physical activity, gestational weight gain Am J Health Behav. 2014;38(4):560-569 DOI: http://dx.doi.org/10.5993/AJHB.38.4.9

to these disparities, obese women who exceed GWG are at increased risk for maternal complications,6 fetal congenital abnormalities,7 and increased risk of obesity for the child later in life.8 Due to the risks associated with excessive GWG, numerous dietary and physical activity interventions have been conducted with pregnant women. However, no particular strategies involving exercise and/or individual counseling have been identified as robust in limiting excessive GWG.9 The mixed results of previous behavioral interventions to reduce excessive GWG can be attributed to the heterogeneous nature of the studies; varying greatly on gestational age commencement, duration of the intervention, and even specifics on randomization.8 Inconclusive results across trial types necessitate the need to determine which features of effective interventions are key in the reduction of excessive GWG.9,10 One mode of intervention delivery that has the potential to increase behavior change, and subsequently reduce excessive GWG among expectant mothers, corresponds to the use of group-based strategies. Participants that engage in group-based strategies (eg, establishing group norms, developing a sense of distinctiveness11) in the presence of others have demonstrated increased adherence and have been successful at initiating physical activity behavior change.12 Participants in group-based

Harden et al lifestyle sessions (GBLS) receive social support, have the opportunity to interact and communicate with others who are similar to them (eg, pregnant, low-income), and can set goals in relation to GWG. Group-based strategies have been found to be consistently effective in various populations including older adults,13 post-partum women,14,15 and worksite groups.16 Pregnant women, in particular, may benefit from these strategies due to their unique physical condition and the corresponding need for support and information exchange (eg, overcoming barriers). In addition, group-based strategies could be integrated into successful models of group medical visits.17 Group medical visits typically include shared leadership between a physician and nurse or health educator to provide information and support to a group of 5 to 15 patients with a similar health condition. Group visits present a pragmatic approach to reduce healthcare costs18 and deliver GWG information and support within the context of prenatal visits. In this paper we report on 2 feasibility studies that integrated GBLS to limit excessive GWG within prenatal care. Study 1 was delimited to women who had a pre-pregnancy BMI > 30 and who attended a clinic that served low-income families. We hypothesized that women would have greater success in limiting excessive GWG through participation in the GBLS (held during prenatal care visits), when compared to a standard care comparison condition. Based on qualitative feedback provided by participants, the data indicated the need to refine the program design by conducting the prenatal care visits separate from the GBLS. Therefore, the design of Study 2 included GBLS separate from prenatal care visits and providers (ie, physicians and nurse practitioners) were asked to discuss the program during prenatal care visits with patients. Participants in Study 2 attended off-site sessions for 6 months at a fitness facility. We hypothesized that women in the GBLS in Study 2 would be more likely to comply with the IOM GWG recommendations than women in a comparison condition without group-based strategies.

physical activity and/or were non-English speaking. Of the 137 women who attended a prenatal visit during recruitment, 28 had a BMI > 30 and were eligible for the program. Five women declined the invitation to participate due to lack of transportation (N = 2), their busy schedule (N = 2), or being uninterested in group prenatal care (N = 1). Six patients initially agreed to participate but did not complete the enrollment process. Finally, one patient was a medical removal due to miscarriage. As a result the final enrolled sample in the study included 16 patients. These women were randomly assigned to either the intervention condition (N = 8) or the standard of care (N = 8). Participants were women aged 21.9 years (+ 4.84 years), and with racial identities of Caucasian (61.5%), black (23%), multiracial (7.6%), and unreported (7.6%). The clinic assigned one registered nurse and one physician (both Caucasian women) to care for the patients during the monthly group visits. Study Design Study 1 was a pilot feasibility study that integrated GBLS within prenatal medical visits with the goal of using the findings in a subsequent larger-scale replication (ie, pre-experimental design). Quantitative data were used to compare GWG for those in the intervention condition and participants in the standard of care. Qualitative inquiry was used to evaluate the program from the perspectives of both the patients and care providers. Both of the care providers were asked to participate in one-on-one interviews with a trained qualitative researcher. Four of the 7 participants in the GBLS were asked to participate in a semi-structured focus group.

METHODS: Study 1 Participants The research team partnered with an OB/GYN clinic that primarily serves patients from low-income families to recruit women at high risk for exceeding GWG recommendations (ie, obese and low-income). These patients were identified as low-income based on their eligibility for Medicaid, which is government-sponsored health coverage for populations in need (often calculated based on a set percentage of the Federal Poverty Level).19 Patients were eligible to participate in the program if they had a pre-pregnancy BMI > 30 (as assessed by medical records), physician clearance for attendance, were 21-35 years of age, and were less than 21 weeks gestational age. Ineligible patients were those who had a medical contraindication to

Intervention Program This pilot study was developed through a research-practice partnership including members of the Department of Obstetrics and Gynecology, nurses within the clinic and behavioral scientists. The intervention was developed based on previous group medical visit research20 and a team-building model outlined by Carron and Spink11 as a method to increase participation in healthful eating and physical activity. With the goal of developing group cohesion21,22 around healthful eating and physical activity, group visits were planned for one hour and included safe group exercises, nutrition education and demonstrations, and group-based activities (eg, group goal setting21-23) detailed in Table 1. Patients also completed individual prenatal checkups during the group visit (ie, left intermittently for their routine check-up). To ensure adequate opportunities for interaction between group members, the intervention was delivered once a month over a 6-month period (from 12 to 36 weeks of gestation). The class focused on supporting patient adherence to the IOM GWG recommendations by promoting physical activity (eg, 150 minutes of moderate physical activity per week24) and healthful eating

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Table 1 Group-Dynamics Based Principles and Strategies Session by Session Guide for the Prenatal Group Visit Model Session 1

Introduction Session Introduction of staff and explanation of study, timeline of program discussed, details, Q & A Name circle: sit in circle, everyone says an alliteration of their name with a word they would use to describe themselves (eg, Creative Catherine) Journal distribution; introduction of food guide recommendations; set individual goals

Session 2

Active Team Building Exercise Reestablishment of Group: Name Circle and one challenge and success they faced over the last month Participants share their PA and dietary histories in the context of childhood, young and early adulthood, prior to joining the group Creation of team name, establishment of team goals Set weekly group goals

Session 3

Active Team Building Exercise Reveal team progress report on discussion board After review of progress, share portion booklets for future goal setting Set weekly group goals Kickball; say one positive, unexpected pregnancy feeling/experience, then kick the ball over to a fellow mother-to-be

Session 4

Active Team Building Exercise Follow the leader: participants share what their favorite home work-out exercise is and pick a song to coincide with the motion Discuss portion control, reduction of fast food intake Set weekly group goals

Session 5

Active Team Building Exercise Food (models, real, or pictures) will be on the table, and participants must place them in the appropriate food category (ie, yogurt in the milk category) Set weekly group goals

Session 6

Active Team Building Exercise Progress report for team Evaluation of team progress. Roadmap creation…who were you 38 weeks ago, how did you see yourself as part of the group? Create a collage.

based on United States Department of Agriculture recommendations for pregnant women.25 Feedback on GWG was provided by the group leader at the end of each session. The group leader was a graduate student with expertise in group dynamics and lifestyle interventions during pregnancy. Measures Qualitative data were collected through semistructured interviews and focus groups. The interview scripts were loosely based on the RE-AIM Framework.26 The interview gleaned information on recruitment procedures (Reach), program effectiveness (Effectiveness), suggested program adaptations to make the program fit within the prenatal care pathway (Adoption), issues related to program delivery (Implementation), and potential program sustainability (Maintenance). Specifically, one-onone interviews were conducted with the nurse and physician that participated in the group visits (ie, the care providers who saw the patients during the visit) and queried the feasibility of the program, the degree to which the program was delivered as

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intended, and the potential sustainability of the program in the current healthcare system. In addition, a semi-structured focus group interview was completed to elicit patient perceptions of feasibility and value of the intervention content and structure. Participants were queried on potential adaptations to the program content, structure, and costs. Weight measurements were collected throughout gestation via patients’ electronic medical records. Data Analysis Descriptive statistics were completed on the study outcome variables. Between group intention-to-treat ANOVAs were conducted to compare intervention and control participants on mean GWG after 4, 8, 12, 16, 20, and 24 weeks of intervention contact. Audio recordings of focus group discussions and semi-structured interviews were transcribed verbatim. An inductive interpretation of the transcriptions was used to create a narrative based on the semi-structured format of the focus group and per-

Harden et al sonal interviews (ie, major themes under a specific question).26 The narrative was developed by the lead author (SH) and confirmed by the last author (PE). Narrative qualitative data identify particular phenomena and common themes.28 The narratives were member-checked by participants to ascertain the veracity of their accounts.

sponded to it. Additionally, she felt that she was able to develop a stronger relationship with the patients in the group-visit model. Similarly, the provider indicated her perception that patients became particularly familiar with the staff involved with the program, which resulted in compliance with program sessions and recommendations.

RESULTS: Study 1 Gestational Weight Gain On average, the women (N = 16) were recruited by 11 weeks, 5 days (+2.7 days) of gestation. Participant weight at baseline was 96.77±13.97 kg with an average BMI of 37.64 kg/m2 (+ 6.56) with no difference across groups. After the 6-month intervention, the participants in the intervention condition had limited GWG at every time point, compared to those in the control condition: week 4 (.66±1.39kgs. versus 1.22±2.57kgs); week 8 (.71±1.72kgs. versus 3.12±2.85kgs); week 12 (2.12±3.53kgs. versus 5.96±3.81kgs.); week 16 (5.22±3.58kgs. versus 7.50±3.58kgs); week 20 (5.29±5.33kgs. versus 8.64±3.88kgs). However, only the differences in weight gain at 20 weeks were statistically significant (F(1,15)=11.87, p < .01).

“And, I think that helped them too, knowing their own nurse and knowing their one provider- it helped motivate them to do things”

Providers’ Qualitative Feedback Providers indicated that recruitment procedures were “pretty simple…pretty well organized… fit in the flow…worked out really good.” The providers also commented that the recruitment procedures were able to attract a fairly representative sample of target population (ie, low-income, obese): “[the participants] were representative” and “I’d say they were fairly representative.” When asked about the perceived effectiveness of the program, both providers reported a degree of effectiveness suggesting that the participants in the GBLS “did really well” with preventing excessive GWG and enjoyed themselves during the program. There were divergent opinions on the optimal frequency of class meetings. The nurse said: “I think if they were able to do something like that every day, then ya, I think it woulda really helped.” But, the physician stated: “I think once a month is probably appropriate.” From a sustainability perspective, the providers note that the GBLS cannot be “the responsibility of physician or nurse” because there “would be a significant additional use of resources.” Instead, the program would need to continue to be delivered by someone with the expertise required to deliver GBLS. The nurse was in full support of adopting the content of the GBLS. The physician expressed that “there are space constraints... but, you know, that’s going to be true for most practices.” The physician felt that it was a positive experience, and she felt she could say the same for the participants. The nurse enjoyed both assisting with the program and seeing how the patients re-

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Finally, when prompted, neither provider made suggestions for program content improvements. Participant Qualitative Results Table 2 highlights the emergent themes with illustrative quotes from the participant focus group. There was general consensus that the program was enjoyable, easy, and useful. Most participants felt encouraged by others within the group as they aimed to limit GWG. All of the women reported that they increased their portion control and physical activity behaviors. Notably, if the program was associated with a cost at baseline, all participants reported that they would have declined participation. However, after being part of the group, most reported that they would be willing to contribute to pay a nominal participation fee or bring healthy snacks to the group sessions. The women also suggested that they would join a program like the one involved in this study if one were made available after they give birth. However, all of the participants reported that they “didn’t like having the doctor visits with it [GBLS] because people are constantly getting up and leaving and you miss stuff.” Suggested adaptations were to conduct medical appointments before or after the GBLS. Similar to providers, patients had varying opinions on the appropriate frequency of the GBLS. Most participants suggested an increase in the frequency of the GBLS stating: “4 times a month, I think that would be a benefit for everybody” and “Just maybe meeting more often, would encourage me to do it more often.” However, one patient indicated an increased frequency would be difficult to attend due to scheduling and the distance from her home to the clinic. DISCUSSION: Study 1 The purpose of Study 1 was to test the preliminary efficacy and utility of GBLS to assist low-income and obese prenatal women in limiting their GWG. The IOM weight gain recommendations for obese women are between 4.98kg and 9.07kg; women in this pilot study gained, on average 5.29kgs (+5.33kgs). In fact, by week 20 of the intervention, women had a substantive (p < .01) reduction of excessive GWG when compared to the standard of care. Corroborating the quantitative data, participants and providers found the program to be feasible and helpful. Patients felt connected to

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Table 2 Summary of Qualitative Feedback from Participants on the Content of Group Visit Prenatal Care: Semi-structured Topics and Illustrative Quotes Discussion Topic

Lower-Order Themes

Illustrative Quote

Overall experience

Group interaction was most important

“I think class interaction was the best.”

Sessions initiated lifestyle changes

“It sounds kinda dramatic, but life changing because it makes you change the way you live.”

Motivation for postpartum behavior change

“I think I’ll continue to implement it as we go on, after pregnancy too”

Being in a group is encouraging

“That’s my biggest thing; meeting up with others for encouragement.”

Interactions about GWG

“Usually when I told people how much you’re suppose to gain and how much I’ve gained...they’re all like ‘Really? That’s all you’re supposed to gain? You’re doing a good job’”

GWG goal accomplishment

“That for me is a huge accomplishment because I didn’t wanna gain weight. I was wanting to lose weight before I got pregnant.”

Encouragement about limiting GWG

“People are like ‘how much weight have you gained cause you don’t look that far along?’ And I’m like yay!”

Critiqued the group visit model

“I didn’t like having the doctor visits with it because people are constantly getting up and leaving and you miss stuff.”

Suggestions to more frequently

“Maybe if we met more, we could have a slow day where we don’t do a lot, and then the other times we meet could be more about the nutrition and exercise.”

Separate class from prenatal care

“Maybe still having [class] separate from the clinic, but having the doctor’s appointment on the same day.”

Food preparation demonstrations

“The portion book is really good, but it’s only one dimensional. So, maybe if we could actually see it on a plate?”

Limiting gestational weight gain

Feedback on the program structure

PA portion of the Exercises were easy and not class meetings. painful

Healthy eating information presented in class

Goal setting

Program Features

Cost

“It was easy enough for you to do while you’re pregnant because a lot of times you think about exercise when you’re pregnant and it’s like ‘it’s going to be uncomfortable and it’s going to hurt’ but the exercises weren’t uncomfortable, and they didn’t hurt.”

Increased PA behaviors

“It helped out 100% because before I was doing 0 [PA]. And now, I do it [PA] several times a week.”

Positive perception of portion booklets that were brought into class

“I’m only supposed to have this much, but you have THIS much on your plate, so you just think about it.”

Awareness & confidence with portion control

“I eat smaller meals, and I eat more frequently versus I used to eat one gigantic lunch and then I’d be hungry again at 9 o’clock at night and things like that.”

Knowledge acquisition

“I can spout off information about things I’m supposed to eat but actually setting a goal that pertained to something I do, was helpful.”

Created a bit of competition

“I’m competitive too, so like it’s like Ok [stick to goal].”

Phone calls were convenient and helped participants keep on track

“You did real good with call(ing) late enough in the evening where I wasn’t still working, but not too late, where I was in the middle of dinner, or things like that so those worked out really well for me as well.”

Journals

“I did like the journal because things that I didn’t quite remember from class, I could look back- like the exercises and things like that.”

Discussion and hands-on experiences were most helpful

“I think class interaction was the best.”

Would not have initially joined if there was a cost

“Cause I woulda been like ‘Oh well, it’s gonna cost me extra money, I’ll be ok.’ That kinda thing. I think the fact that it was included was a huge- because I truly think I would have said no.”

Would contribute financially once enrolled and committed to the program

“But now, I mean definitely, I woulda paid for that.”

other group members and used the group sessions to motivate themselves to stay within GWG targets. Participants even reported the desire to continue

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with a program “like this” post-partum (ie, once the baby is born and women are capable of exercising once more). From a clinical perspective, provid-

Harden et al ers were pleased with the ease of delivery and the programs fit within prenatal care. A consistent theme, however, was to disentangle the group sessions from the prenatal physician visit to allow more time to address important physical activity and healthy eating issues without participants leaving the room intermittently for their prenatal care (ie, disrupting the groupness). In the same vein, the major divergence in feedback from the providers and patients corresponded to the frequency of sessions in that the physician thought the frequency utilized in this study (once per month) was appropriate and viable, whereas the nurse and a majority of the patients thought the sessions should be more frequent. Notwithstanding the positive results from both outcome and process evaluation data, there is a need for future research, especially based on the small sample size. The patients felt disrupted during the group visit, and most patients (75%) and one provider (50%) indicated the need to increase the frequency of the GBLS. Therefore, Study 2 was developed to incorporate these suggestions. Study 2 In Study 1, a small sample of low-income, obese prenatal women were able to reduce excessive GWG through GBLS delivered within prenatal care. However, through qualitative feedback, participants and care providers indicated the need to disentangle the GBLS from the prenatal care. Therefore, in Study 2 we wanted to test the efficacy and feasibility of GBLS that were delivered off-site while still incorporating a care provider component. Study 2 was not restricted to obese women only as all women could benefit from engaging in physical activity and healthy eating during pregnancy—and the IOM provides GWG recommendations specific to weight status categories.1 In the development of Study 2, the research team was cognizant of the role that physicians and other healthcare professionals play in addressing misconceptions related to physical activity during pregnancy and ensuring that pregnant patients participate in safe physical activity and healthful eating.29 That is, physicians provide expert advice about physical activity, eating, and weight gain recommendations that is perceived to be credible by their patients.30,31 However, a large proportion of women (>60%) do not receive GWG advice from providers.32 Physicians often feel overburdened33 or lack skills to deliver behavioral information.34 Therefore, Study 2 provided a means for providers to incorporate a behavioral intervention into their GWG care practices, without incurring time or resource burdens. Study 2 was developed through a research-practice partnership to incorporate provider credibility and referral GBLS aimed at limiting excessive GWG. The partnership included support from the OB/GYN Department Chairperson (author PW), integrating the research team in departmental

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meetings, and preparing the clinic staff for the implementation of the program. The development of this partnership was to ensure that: (1) providers were aware of study procedures; (2) providers were abreast of IOM GWG recommendations; and (3) an open relationship was fostered to assist in an iterative process during this feasibility trial. The purpose of this feasibility study was to determine if participants were able to limit excessive GWG when attending GBLS external to prenatal care and the degree to which care providers discussed the program with their patients. As stated previously, we hypothesized that the GBLS would provide participants with strategies and support to increase the likelihood of compliance with the IOM GWG recommendations. Furthermore, these strategies and support were expected to increase the proportion of women meeting the IOM GWG recommendations in the GBLS when compared to the matched contact comparison condition. METHODS: Study 2 Participants Fifty-one pregnant women were recruited from an obstetrics clinic that served low-income families for a 6-month study. Inclusion criteria were: (1) < 20 weeks of gestation; (2) age 18–45 years: (3) English-speaking; and 4) single parity pregnancy. Participants were excluded if they had a contraindication to physical activity and/or a BMI 37 weeks of gestation (full term). Provider component. Care providers were given information on a patients attendance at the program sessions via a “stop-light” indicator in the patient’s EMR (red= not attending; yellow= sometimes attending; green= always attending). Providers in the research-practice partnership informed the research staff, mid-study, that they were not utilizing the attendance rate updates (via EMR) to remind participants about the off-site program. As a result, the clinic nursing staff and research team also placed signs on participants’ exam room doors as a visual reminder to prompt the care provider to discuss the program and GWG with the patient. Providers were asked to inform patients that the clinic supported the program and that regardless of absences the patient was still welcome to attend the Baby Steps class. This brief discussion of attendance was meant to integrate physician credibility of the program sessions without placing an unmanageable time burden on physicians.35 To measure the degree to which care providers engaged in program related discussions with their patients, participants were asked 3 questions: “Did your provider discuss: the program with you today?…gestational weight gain progress?…gestational weight gain goals?” To elucidate patientprovider discussions better, patients were asked to share open-ended information related to each of the 3 questions. Data Analysis Based on pre-pregnancy BMI, participants were categorized dichotomously on whether they met the BMI- specific GWG recommendation or not. If a participant did not have gestational weight recorded > 37 weeks of gestation, we conservatively estimated that they did not meet GWG recommendations and included them in the intention to treat analysis (N = 19). Pearson’s chi-square test was conducted to see if there was a significant difference (p < .05) in exceeding GWG recommendations by condition. Trained research assistants captured data on whether or not patients reported discussion of the program or GWG with their provider. In addition, the research assistants were trained to record open-ended responses and immediately member check for accuracy. The proportions of participants that discussed the items of interest (eg, program, GWG) with their provider were recorded. The openended responses were used to describe the content of and degree to which participants had programrelated conversation with their providers.

Harden et al RESULTS: Study 2 Gestational Weight Gain Of the 51 participants in the study, 19 patients did not have GWG data > 37 weeks and were recorded as not meeting the recommended guidelines. Those who were lost to follow-up were more likely to be overweight (p < .05) but loss to follow-up was not different between conditions (ie, 36% from GBLS and 39% from control). Of the participants randomized to GBLS (N = 28), 10 (36%) gained within the appropriate GWG ranges based on their pre-pregnancy BMI. In the control arm (N = 23), only 3 participants (13%) gained within the recommended ranges. Based on chi-square analysis, using our intent to treat analytic approach, there was no significant difference (χ2=3.42; p = .06) in the proportion of participants meeting the recommended GWG guidelines by condition; however, the differences were in the hypothesized direction. Provider Component Thirty-four women in both conditions (18 in the GBLS intervention arm and 16 in the comparison condition) attended an average of 3 prenatal visits. Nineteen independent care providers saw these patients: 4 nurse practitioners, 15 physicians. There were no significant differences between conditions in the proportion of patients who reported discussions of the program, GWG, or GWG goals with the care provider (p > .05). Across both conditions, 70% of patients reported never discussing the program, with 79% in the intervention condition and 62.5% in the comparison condition. For all participants, almost half (49%) reported never discussing GWG with their care provider, with 42% and 56% by intervention and comparison condition, respectively. Ninety-four percent of participants (N = 32) reported never discussing appropriate GWG goals with their provider. Ten participants (29%) reported that they discussed the program on at ‘at least one’ of their visits: “…asked me how many times I attended” and “she said it was a good program to go to.” Three participants (8.82%) served as the initiators of a discussion of the program, whereas 3 others lamented not having a discussion with their provider (“they never talk about class with me”) during their visit. Two participants (5.8%) across both conditions reported receiving positive feedback from their providers about gaining a sufficient amount of weight (ie, “gaining what I’m supposed to be gaining” or being “on target”). Most participants (68%) who provided additional qualitative feedback gave the impression that they had received incomplete GWG information during their visit: “I was wondering if I had gained any, but no one said anything” and “She is supposed to tell me…[I’m] concerned because I’ve gained almost 30 pounds and it seems like a lot to me.” Some participants (N = 8; 23.5%) provided additional statements that implied a desire to have received more GWG information at the

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visit: “…they say everything is normal. That’s all they say about it.” Some statements reflected that participants brought up GWG during the visit: “I was asking her how much I gained as she was going out the door.” Although rare, patients did report that their care provider had voiced concerns regarding under gaining (N = 3 meaning units) or over gaining (N = 2 meaning units). DISCUSSION: Study 2 The purpose of Study 2 was to test the efficacy of 2 lifestyle interventions that were held at a fitness facility separate from their prenatal care; one that was delivered through a GBLS format and the other delivered in a standard exercise class with didactic nutrition education. One of the key components of Study 2 was to hold the sessions off-site while still integrating the credibility of care providers. Across both conditions, patients reported infrequent discussions about the program with their providers. In spite of care providers’ low fidelity to GWG management discussions, the difference between patients’ GWG in the GBLS and matched contact control was in the hypothesized direction (although not statistically significant). As all patients who did not have weight gain data > 37 weeks of gestation were categorized as not meeting IOM guidelines, our analytic approach (intent to treat) may underestimate the effect of the GBLS for increasing IOM compliance. Notably, however, a large proportion of women exceeded GWG, regardless of condition allocation. Future research, with a larger sample, is needed to explore the relationship more thoroughly among participation in GBLS, patient and setting characteristics, and limiting excessive GWG. We also found that there was low provider adherence to the incorporation of program discussion within their prenatal care practices. This finding was similar to work by Olson et al37 who attempted to integrate GWG management into prenatal care. They initiated color-coded BMI tracking grids, but found that providers rarely implemented the appropriate GWG grid with their patients. A subsequent limitation to this study is the lack of data for reasons care providers did not discuss the program with their patients. This information may be helpful in knowledge translation and the replication of GBLS for prenatal women. That is, future studies should include qualitative data that capture care providers’ feedback on the research-practice partnership, how the partnership could improve their GWG management skillset (eg, more training), and what barriers exist. GENERAL DISCUSSION The main purpose of the research presented in this manuscript was to test the feasibility of GBLS to limit excessive GWG within prenatal care. Our hypothesis that obese, low-income women in GBLS would limit excessive GWG was statistically supported in Study 1 (p < .01). Whereas partici-

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Group-Based Lifestyle Sessions for Gestational Weight Gain Management: A Mixed Method Approach pants randomized to GBLS in Study 2 were not significantly (p = .06) more likely to comply with IOM GWG recommendations than participants in the matched contact control, the differences were in the hypothesized direction. Future studies of GBLS are needed to determine generalizability to all women (ie, regardless of pre-pregnancy BMI) and determine the most sustainable method to incorporate care provider involvement in GWG management. The extant literature supports intervening during pregnancy to modify health behaviors32 and GBLS proved to be a promising approach for low-income pregnant women. Using the formative data from Study 1, the primary goal of Study 2 was to integrate the credibility and influence of care providers, while not requiring the clinic to utilize resources needed for program delivery (ie, space). Primary care providers often have little time (< one minute) to devote to behavior interventions.37 To align with this need for brevity, the protocol asked providers to initiate a brief discussion about program attendance. However, patients did not report frequent program or GWG-based discussions, indicating a need for future research to increase care provider fidelity to GWG management and to explore the relationship among these patient-provider discussions, attendance in GBLS, and resultant weight gain throughout gestation. Notably, these feasibility studies identified facilitators (eg, partnerships, group-based exercise) and barriers (eg, travel resources, lack of communication between patients and providers) to the efficacy of these interventions. Across both studies, transportation to the sessions was cited as a reason to decline participation or the need to drop out. Delivering group content through different mediums such as the Internet may be another potential avenue to modify the GBLS, without placing a burden on the patients or the prenatal care system. The Internet has been identified as salient means for managing health in the twenty-first century.38 Group-based interventions that do not require all interactions to be in person have been successful for community-wide walking programs39 and for women who participated in an Internet-based book club that aimed to promote physical activity.40 One overall limitation to both of these pilot studies is that they were conducted within one clinic, and therefore, lack the data necessary to provide generalizable results. However, the results presented here provide preliminary support for GBLS within the prenatal care setting. Secondly, the high rate of attrition (ie, participants lost to follow-up) in Study 2 highlights the difficulties of retaining high-needs prenatal patients and may have underestimated the intervention effects based on our approach in making a conservative estimate that missing data were equitable to not meeting GWG recommendations. Future research is needed to determine how to translate appropriate GWG strategies into standard clinical practice that will

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attract and retain low-income prenatal women. Study 2 also highlights the need to increase research focused on effective ways to retain participants as well as to train care providers to participate in GWG management endeavors within research-practice partnerships. One systematic review of behavior change curricula for medical trainees indicates the need for a combination of didactic learning that is enhanced through roleplaying and real-time feedback from experts in the field.41 Strategies such as these may increase care providers’ confidence in their GWG management. Human Subjects Statement All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study. The Carilion Clinic Institutional Review Board approved all research procedures. Conflict of Interest No authors have a conflict of interest to disclose. Acknowledgements We would like to acknowledge the VT-Carilion Research Institute seed grant for funding Study 1 and the American Heart Association Pre-Doctoral Fellowship, Mid-Atlantic Affiliation (443268) for funding Study 2. We would also like to thank the clinic staff and participants, without whom this research would not have been possible. The authors have no financial or personal conflict of interest to disclose. References

 1. Rasmussen KM, Yaktine AL. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, DC: Editors; 2009.  2. Siega-Riz AM, Viswanathan M., Moos MK, et al. A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: birthweight, fetal growth, and postpartum weight retention. Am J Obstet Gynecol. 2009;201(4):339.e1-.e14. doi: 10.1016/j.ajog.2009.07.002.  3. McDonald SD, Pullenayegum E, Taylor VH, et al. Despite 2009 guidelines, few women report being counseled correctly about weight gain during pregnancy. Am J Obstet General. 2011;205(4):333.e1-e6. doi: 10.1016/j. ajog.2011.05.039.  4. Davis EM, Strange KC, Horwitz RI. Childbearing, stress and obesity disparities in women: a public health perspective. Matern Child Health. 2012;16:109-118.  5. Kramer MS, Séguin L, Lydon J, Goulet L. Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly? Paediatr Perinat Epidemiol. 2000;194-210.  6. Vahratian A. Prevalence of overweight and obesity among women of childbearing age: results from the 2002 National Survey of Family Growth. Matern Child Health J. 2009;13(2),268-273.  7. Stotland NE, Haas JS, Brawarsky P, et al. Body mass index, provider advice, and target gestational weight gain. Obstet Gynecol. 2005;105(3):633-638.  8. Thornton PL, Kieffer EC, Salabarría-Peña Y, et al. Weight,

Harden et al diet, and PA-related beliefs and practices among pregnant and postpartum Latino women: the role of social support. Matern and Child Health J. 2006;10(1):95–104.  9. Streuling I, Beyerlein A, von Kries R. Can gestational weight gain be modified by increasing physical activity and diet counseling? A meta-analysis of interventional trials. Am J Clin Nutr. 2010;92:678-687. 10. Tanentsapf I, Heitmann BL, Adegboye AR. Systematic review of clinical trials on dietary interventions to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. BMC Pregnancy Childbirth. 2011;11:81. 11. Carron AV, Spink K. Team building in an exercise setting. The Sport Psychologist. 1993;7:8-18. 12. Estabrooks PA, Harden SM, Burke SM. Group dynamics in physical activity promotion: what works? Soc Personal Psychol Compass. 2012;6(1):18-40. 13. Estabrooks PA, Carron AV. Group cohesion in older adult exercisers: prediction and intervention effects. J Behav Med. 1999;22(6):575-588. 14. Cramp AG, Brawley LR. Moms in motion: a group-mediated cognitive-behavioral physical activity intervention. IJBNPA. 2006;3(1):23. 15. Cramp AG, Brawley LR. Sustaining self-regulatory efficacy and psychological outcome expectations for post-natal exercise: effects of group-mediated cognitive behavioral intervention. Brit J Health Psych. 2009;14(Pt 3):595-611. 16.  Green BB, Cheadle A, Pellegrini AS, Harris JR. Active for Life: a work-based physical activity program. Prev Chronic Dis. 2007;4(30):1-7. 17. Housden L, Wong ST, Dawes M. Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis. CMAJ. 2013;185(13):E635E644. 18. Glasgow RE. What does it mean to be pragmatic? Pragmatic methods, measures, and models to facilitate research translation. Health Educ Behav. 2013;40(3):257265. 19. Medicaid Eligibility (on-line). Available at: http://www. medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Eligibility/Eligibility.html. Accessed December 17, 2013. 20. Scott JC, Conner DA, Venohr I, et al. Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the Cooperative Health Care Clinic. J Am Geriatr Soc. 2004;52(9): 1463-1470. 21. Estabrooks PA. Group integration interventions in exercise: theory, practice, & future directions. In: Beauchamp MR, Eys, MA, (Eds). Group Dynamics in Sport and Exercise Psychology: Contemporary Themes. New York, NY: Routledge; 2008:141-156. 22. Martin LJ, Burke S, Shapiro S. The use of group dynamics strategies to enhance cohesion in a lifestyle intervention program for obese children. BMC Public Health. 2009;9:277. 23. Sénecal J, Laughed TM, Bloom GA. A season-long team-building intervention: examining the effect of team goal setting on cohesion. J Sport Exerc Psychol. 2008;30(2):186-199. 24. American College of Obstetricians and Gynecologists. Exercise during pregnancy and the postpartum period.

Obstet Gynecol. 2002;99(1):171-173. 25. United States Department of Agriculture. Dietary Guidelines for Americans 2005. Available at: http://www.dietaryguidelines/dga2005.gov/. Accessed December 30, 2013. 26. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the REAIM framework. Am J Public Health. 1999;89(9):13221327. 27. Patton MQ. Qualitative Research and Evaluation Methods, 3rd ed. London: Sage Publications; 2002. 28. Harris JE, Gleason PM, Sheean PM, et al. An introduction to qualitative research for food and nutrition professionals. J Am Diet Assoc. 2009;109(1):80-90. 29. Kuehn BM. Guideline for pregnancy weight gain offers targets for obese women. JAMA. 2009;302(3):241-242. 30. Ockene JK, Edgerton EA, Deutsch SM, et al. Integrating evidence-based clinical and community strategies to improve health. Am J Prev Med. 2007;32(3):244-252. 31. van Gerwen M, Rosman, FS, Le Vaillant M, PelletierFleury N. Primary care physicians’ knowledge, attitudes, beliefs and practices regarding childhood obesity: a systematic review. Obesity Reviews. 2009;10(2):227-236. 32. Phelan S. Pregnancy: a “teachable moment” for weight control and obesity prevention. Am J Obstet Gynecol. 2010;202(135):e1-e8. 33. Grandes G, Sanchez A, Cortada JM, et al. Is integration of healthy lifestyle promotion into primary care feasible? Discussion and consensus sessions between clinicians and researchers. BMC Health Serv Res. 2008;14(8):213. 34. Power ML, Cogswell ME, Schulkin J. US obstetriciangynaecologist’s prevention and management of obesity in pregnancy. J Obstet Gynecol. 2009;29(5):373-377. 35. Legare F, Ratte S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns. 2008;73(3):526-535. 36. Olson CM, Strawderman MS, Reed RG. Efficacy of an intervention to prevent excessive gestational weight gain. Am J Obstet Gynecol. 2004;191(2):530-536. 37. Stange KC, Woolf SH, Gjeltema K. One minute for prevention: the power of leveraging to fulfill the promise of health behavior counseling. Am J Prev Med. 2002;22(4):320-323. 38. Gutierrez N, Kindratt TB, Pagels P, et al. Health literacy, health information seeking behaviors and Internet use among patients attending a private and public clinic in the same geographic area. J Commun Health. 2013 [Epub ahead of print]. 39. Estabrooks PA, Bradshaw M, Dzewaltowski DA, SmithRay RL. Determining the impact of Walk Kansas: applying a team-building approach to community physical activity promotion. Ann Behav Med. 2008;36(1):1-12. 40. Huberty JL, Vener J, Sidman C, et al. Women Bound to Be Active: a pilot study to explore the feasibility of an intervention to increase physical activity and self-worth in women. Women Health. 2008;48(1):83-101. 41. Hauer KE, Carney PA, Chang A, Satterfield J. Behavior change counseling curricula for medical trainees: a systematic review. Acad Med. 2012;87(7):956-968.

Am J Health Behav.™ 2014;38(4):560-569

DOI:

http://dx.doi.org/10.5993/AJHB.38.4.9

569

Group-based lifestyle sessions for gestational weight gain management: a mixed method approach.

To integrate group-based lifestyle sessions (GBLS) within prenatal care for gestational weight gain (GWG) management...
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