The Florida Department of Health in Hillsborough County (DOH-Hillsborough) has over 400 employees serving in seven divisions across Hillsborough County.  The Office of Health Promotion and Education within the division of Community Health in DOH-Hillsborough has a team dedicated to serving the residents of Hillsborough County through implementing programs for chronic disease prevention and education.  DOH-Hillsborough provides public health services to approximately 1,408,566 people in Hillsborough County Florida which is located along the central west coast of Florida.  Hillsborough County is the fourth most populous county in Florida including the metropolitan City of Tampa and several rural communities that include a large Hispanic migrant population.  Residents of Hillsborough County are 49.1% white non-Hispanic, 28.6% Hispanic, 17.8% black non-Hispanic and 4.3% Asian. 

The Office of Health Promotion and Education at DOH-Hillsborough has spent over a decade focusing on decreasing obesity and diabetes rates in Hillsborough County through group, in-person education including  Diabetes Self-Management Education (DSME), the CDC’s Diabetes Prevention Program (DPP) and the NACCHO Model Practice Award winning Get Into Fitness Today (GIFT) programs.  Prior to the COVID-19 pandemic, DOH-Hillsborough facilitated in-person programming at various community sites throughout Hillsborough County with the emphasis on bringing education to the public in order to limit transportation and time barriers.  The team also emphasized group support and instructor lead facilitation rather than didactic-style teaching methods to ensure effective programmatic outcomes.  However, in early 2020 when the realities of the COVID-19 pandemic were understood the team had to quickly adapt the methodology of program facilitation.  First, it was understood that programming could not be facilitated in person for the health and safety of the public and educators.  Second, programming could not cease because those who are overweight or have diabetes are more likely to become severely ill if infected with COVID-19.  Hence, the team promptly adapted programming to various virtual environments.

Programming was adapted to virtual environments based on the audience(s) served.  The DPP and DSME programs were offered to new and existing groups over the Go to Meetings platform and phone walking meetings.  The GIFT program was converted to a visual slide presentation with recorded voice-over education and played on a closed television channel in retirement communities.  In order to reduce health inequities due to lack of access to internet and technology, the team asked participants to call in to programming during active sessions with those who participated online (via Go to Meetings) and mailed packets with additional information.  As a result of these efforts, program enrollment and retention increased, in addition to reaching larger groups of people due to the flexibility of virtual programming (i.e. no transportation, childcare, and location barriers).  Most importantly, and perhaps most surprisingly, the group support has been immeasurable in fostering programmatic outcomes and combating social isolation.       

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.

The local health department, the Florida Department of Health in Hillsborough, is the organization that implemented this innovative virtual programming.  Collaboration through community partners and referring healthcare providers made this innovative virtual implementation possible.  The overall goal of the practice was to provide the same high-quality programming and group facilitation as would be demonstrated in-person through the virtual environment.  Community partners and stakeholders played a big role in the planning and execution of this innovation by communicating the needs of their community, assisted in the brainstorming process to find a way to offer programming in a virtual environment, and by informing the public about the new virtual offerings.  The team fostered collaboration through these community partners by asking and accepting feedback about the needs of the community.  Due to the COVID-19 pandemic, many groups (particularly seniors) quickly became isolated and the best way to understand their needs was to work with community partners in those neighborhoods such as senior community coordinators, resource centers, and providers in those areas.  The DOH-Hillsborough reached out to church leaders in the community to update them on the changes to the DOH-Hillsborough and to inform them of the virtual programming.  The team realized that one of the best ways to reach non-Hispanic black communities was to understand the needs of the community through the churches.  As a result, churches provided feedback on the needs of their participants and current challenges.  This feedback and exchange of information better informed the team at the DOH-Hillsborough and helped them realize the vital need for virtual programming and how to implement on a platform that was user friendly.    

One unexpected innovative partnership was the local children’s museum.  The DOH-Hillsborough does not have a local social media presence, but the children’s museum has a steady following on social media.  Hence, the team at the DOH-Hillsborough created cooking demonstrations and health videos that the museum posted to their social media and websites which also acted as advertising for the virtual programming.  An internal partner that became vital throughout the implementation to virtual programming was the management and information systems team (MIS team) at the DOH-Hillsborough.  Even though the MIS team was overwhelmed with bringing the entire DOH-Hillsborough online and working from home, they worked with the Office of Health Promotion and Education to develop electronic fillable forms so that the innovative programming could be truly 100% virtual.  Given that the team at the DOH-Hillsborough did not have experience implementing virtual programming, these partnerships were key to understanding the needs of the community and collaborating to come up with a strategy that would be beneficial for all groups.

The COVID-19 pandemic brought many programs and initiatives to a screeching halt.  However, adversity necessitates innovation.  The team at DOH-Hillsborough discussed offering virtual programming prior to the pandemic, however, the initiative had not gained traction due to the success of in person classes coupled with the challenges of virtual programming such as meeting the needs of all communities, troubleshooting lack of internet access, and reaching vulnerable populations.  The pandemic created an immediate mindset shift and that thought process allowed the team to fully plan and implement virtual programming with a focus on participant needs and access at the center of the initiative.  Throughout the pandemic the team had to adapt and overcome participant challenges regarding internet access, adept ability with technology, and ensuring processes were kept to the standards required for recognition and accreditations.  The team maintained the same level of high-quality program facilitation regardless of the class modality.  The documentation process and physical data forms for each program had to be modified into electronic versions since the team could not interact and capture this data in an in-person environment.  All these factors were addressed, and the new procedures are far more sophisticated than the previous processes.  The team within the Office of Health Promotion and Education in the DOH-Hillsborough learned a lot about ways to continually improve high quality programming that meets the needs of the community.  Looking to the future, the team will continue to work with community partners in order to ensure that vulnerable populations and communities at a high risk for developing chronic disease will be informed and have access to these programs virtually.  Through the innovative expansion to virtual programming, the DOH-Hillsborough has been able to reach more people and retain those individuals whereas in-person programming was not as successful.  Given that the DOH-Hillsborough works to improve the public’s health from a larger group perspective, rather than one by one, these advances will stand to only improve the health of the residents of Hillsborough County with a greater capacity than ever before.  More people will have access to these high-quality programs that empower them to improve their health for generations.