As a result of the COVID-19 pandemic, certain vulnerable populations were disproportionally affected by social isolation, access to services, and severity of illness. Seniors and the aging population are at a greater risk for serious illness and death if infected with COVID-19, and this population was the first to be isolated from family, friends, and resources. Individuals with pre-existing chronic disease such as diabetes mellitus, and those who are overweight or obese are at a greater risk to become severely ill if infected with COVID-19. Minority populations such as black non-Hispanics and Hispanics experience disproportionate rates of COVID-19 illness. Prior to the COVID-19 pandemic, the team targeted and tailored diabetes education, diabetes prevention, and obesity programming in-person in the communities where diabetes and obesity rates are highest. The team focused on ways to remove the barriers of transportation, access, and time by offering in-person programming in these locations and during times that were convenient to participants. Additionally, best practices and CDC National DPP evidence indicate that group support and the group dynamic is the biggest factor in program retention and adherence. Therefore, a lot of emphasis was placed on building in-person group cohesion for the best overall impact and positive program outcomes.

Prior to COVID-19, the DSME, DPP, and GIFT programs all had significant measured success in these populations. The team’s DPP is recognized by the CDC with 7.1% total body weight loss (the CDC standard is 5%) and DSME had a an overall A1c improvement of .91% (.5% is considered clinically significant). The team’s NACCHO Model Practice Award winning GIFT program demonstrates that 79% of people in the program lose weight, 84% increase fruit and vegetable intake, and 88% increase physical activity within 12 weeks. All these programs focus on instructor led group facilitation rather than a lecture-style environment, which is a tenant in program outcomes and success. Hence, when the impact of the COVID-19 pandemic to programming was realized, it required a complete mindset shift to adapt the environment from in-person to virtual and it needed to be done rapidly.

By mid-March of 2020 all community sites were closed, senior living communities were closed to all outside visitors, and people were encouraged to shelter in place. This made reaching these vulnerable populations impossible for the team. All team members were well versed in the programs, facilitation techniques, and were somewhat comfortable with virtual meeting platforms. The Go to Meetings platform was identified to reach participants who could interact with each other in a comparable way to the in-person environment. Although, the challenge of internet access and adaptability to technology in several populations had to be addressed. One newly formed group that started just prior to the pandemic was a DPP group of black non-Hispanics in a low-income neighborhood. The group showed great cohesion prior to the pandemic and all were at a high risk to develop type II diabetes, and as a result of their weight, was at an increased risk for COVID-19 severity if they contracted the illness. This group was formed originally through a local community center but that location had to shut down for months. The only option was to take the program virtually. Almost half of the group did not have a computer or wireless internet connectivity, they only had cellular data internet access. Through Go to Meetings group members could call in if they did not have access to the internet. The instructor sent out all materials via email or traditional mail depending on the participant’s needs. As a result of this innovative program offering, 100% of those participants were retained. Additional DPP and DSME classes were offered through Go to Meetings for new groups. The team maintained a best practice of keeping a waitlist (prior to COVID-19) for participants who wanted programming but could not attend sessions due to location, transportation, date, time or other barriers. The team called individuals on this waitlist to inform them of virtual offerings in addition to advertising programming through web-based advertising and conducting electronic outreach to healthcare providers and churches in the zip codes where diabetes and obesity rates are high. In other DPP’s offered by the team, participants were offered the opportunity to call in or attend virtually with a camera. Instructors encouraged cameras when possible, but it was not a deterrent from participation. As a result of the virtual environment, several positive unintended outcomes occurred for the group such as individuals being able to show other group members food labels from their pantry, share their cooking techniques, and demonstrate physical activity options from home. One of the biggest challenges during the shift from in-person to virtual occurred at a senior living community. The community would not allow the team to register participants directly during the pandemic, hence the team offered virtual programming through the community’s closed-circuit television channel. The GIFT program materials were transferred to a PowerPoint platform and an instructor recorded their sessions over the slides. The GIFT materials were adapted for seniors so that physical activity elements were applicable in their home environment. The program ran non-stop for seniors in the community so that time of day would not be a barrier. Offering the GIFT program in this way was vital to the seniors having an option for accurate health information that was tailored to their needs during the COVID-19 pandemic. Given the tight restrictions to the community, those seniors would not have received the programming otherwise.

The virtual group environment has proven to be more effective in participant retention and group support than traditional in-person environments. All groups maintained over 90% retention of participants and the same standards of weight loss and biometric outcomes. To the best of the team’s knowledge, this specific practice is not evidence-based. However, it would not be surprising if it becomes evidence-based if not a best practice post-pandemic. The team continues to improve virtual practices to best serve the community and we are certain that these virtual options will continue post pandemic.

Virtual Programming at the Florida Department of Health in Hillsborough County

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