PROJECT: Fitness and Wellness Voucher Survey, Round 2

UC Davis Student Health Services QUALITY IMPROVEMENT STUDY

DEPARTMENT: Health Education and Promotion DATE: December 19, 2014

PROJECT: Fitness and Wellness Voucher Survey, round 2

1.) Purpose of the Study A statement of the purpose of the QI activity including a description of the known or suspected problem, and explain why it is significant to the organization.

Background/History: The Fitness/Wellness Voucher program was started in winter 2006 as collaboration between Student Health Services (SHS) and Campus Recreation and Union’s (CRU) Fitness and Wellness Center. Providers were encouraged to give vouchers to students that they felt needed to increase their physical activity. From winter 2006 until summer 2008 there were four options, one personal training visit ($30), walking program membership ($10), a basic group exercise pass ($20) and an intensive group exercise pass ($50). The cost of each option was shared 50/50 between SHS and CR. In fall 2008 CRU eliminated the intensive group exercise pass and created the group exercise pass ($50). In fall 2010 CRU discontinued the walking program and added 3 personal training visits to the personal training option increasing the prices and thus leaving the program with two options: Personal training package ($70) or the three-month group exercise pass ($50). In fall 2011, CRU increased the cost of their personal training package ($84) to cover the additional certifications that their personal trainers have acquired.

During Summer 2013, discussions between HEP and CRU resulted in a revision of the deadlines for voucher redemption. The new guidelines were implemented beginning Fall 2014 are intended to increase voucher redemption rates.

Updated Guidelines for Voucher Redemption Step Deadline Pink referral sheet provided to student by n/a provider Student – Bring pink sheet to HEP to By the end of the quarter in which the receive voucher pink sheet was received Within one month of voucher receipt Student – Redeem voucher at ARC from HEP Within one month of voucher redemption Personal Training Package completion at ARC

Additionally, an MOU was created between HEP and CRU in March of 2014 outlining a new pricing structure to reflect changes to program costs. March 2014 MOU Pricing Structure Voucher Program Option Total Cost SHCS Cost Personal Training Package $110 $55 Group Exercise Pass $50 $25

Historical Redemption Rates Academic Year # Distributed # Redeemed Redemption Rate 2006 – 2007 (Winter/Spring) 35 21 40% 2007 – 2008 92 31 34% 2008 – 2009 92 30 33% 2010 – 2011 177 44 27% 2011 – 2012 368 164 44.6% 2012 – 2013 329 158 48% 2013 – 2014 285 213 74.7%

The purpose of the study is to discover if our Fitness and Wellness Voucher program is meeting the needs of our non-or-irregular exercising students and compare current data to survey results from 2012 regarding the satisfaction level of voucher recipients, any perceived barriers from redeemers/non-redeemers, and the effectiveness of the program to increase individual physical activity levels.

2.) Performance Goal(s) Identify the performance goal against current performance.

The current performance for the 2013-2014 academic year was 285 vouchers distributed with 213 redeemed, for a redemption rate of 74.7%. This reflects a 26.7% increase in redemption rate from the previous year, and is by far the highest redemption rate thus far for the program. This may be attributed to the changes implemented regarding deadlines for voucher redemption. We would like to continue to see high redemption rates, as well as see more vouchers distributed per quarter appropriately for a student’s stage of change, based on the Transtheoretical Model (TTM), thus hopefully ensuring that more vouchers are redeemed with higher satisfaction levels from providers and students. According to theory, students who are in the preparation and contemplation stages of the TTM would benefit the most from the voucher program. 3.) Data Collection Plan Describe the data that will be collected in order to determine current performance.

Consent forms were collected from voucher recipients at Health Education and Promotion (HEP). Confidentiality was maintained by having the forms locked up in a file cabinet. For those who agreed to receive a survey, we sent the survey with Survey Monkey via email approximately 6 months after they received a voucher. The survey was valid for two weeks and one reminder email was sent after one week.

4.) Describe the data collected Describe the data you actually collected (not the conclusions). What were you looking for? What information did you extract? How did you record the data?

Data was collected during October and November 2014 via Survey Monkey. The table below shows the timetable used. Voucher Received Data Collected April 2014 October 2014 May 2014 November 2014

We extracted data regarding student demographics, stage of change pre and post voucher program and how satisfied the students were with Campus Recreation’s services. The data was compiled in a report format via Survey Monkey. Our response rate was 20.8% with an n=15.

5.) Analysis Determine what the data tell you about the existence of a suspected problem. Does one exist? Describe your findings about the frequency, severity and source(s) of the problem(s). What are your conclusions?

Demographics: The average age of survey respondents was 24.2 years, with 80% identifying as female and 20% identifying as male.

Racial Identity White, non Hispanic (includes Middle Eastern) 40.0% Black, non Hispanic 6.7% Hispanic or Latino/a 33.3% Asian or Pacific Islander 26.7% American Indian, Alaskan Native, or Native Hawaiian - Biracial or Multiracial 6.7%

Year in School 1st year undergraduate - 2nd year undergraduate - 3rd year undergraduate 26.7% 4th year undergraduate 13.3% 5th year or more undergraduate 13.3% Graduate or professional 46.7%

This survey represents more of an older, primarily white, female student.

Voucher Redemption Rate:

Two-thirds of the survey respondents did redeem their vouchers (66.7%) and those that did not listed timing and issues with the multiple steps needed to redeem the voucher as reasons they did not redeem their voucher. Please see full Survey Monkey report for complete responses.

Use of Services Following Voucher Redemption

Group Exercise Classes Attended after Voucher Redemption Never - 1-5 37.5% 6-10 12.5% 11-20 50.0% More than 20 -

Personal Training Sessions Attended after Voucher Redemption Initial Consult Only - One Session - 2 sessions 66.7% 3 sessions 33.3%

Participant Stage of Change Pre- and Post-Voucher

Stage of Change - Aggregate Stage of Change Pre - Voucher 6 mos. Post - Voucher Maintenance 26.7% 46.7% Action 20.0% 26.7% Preparation 40.0% 6.7% Contemplation 13.3% 13.3% Precontemplation - 6.7%

Individual Movement Across Stages – Voucher Redeemed Pre-Voucher 6 mos. Post-Voucher Number Maintenance Maintenance 3 Action Maintenance 2 Preparation Maintenance 1 Preparation Action 3 Contemplation Contemplation 1

Individual Movement Across Stages – Voucher Not Redeemed Pre-Voucher 6 mos. Post-Voucher Number Maintenance Maintenance 1 Action Preparation 1 Preparation Action 1 Preparation Contemplation 1 Contemplation Precontemplation 1

All of the individuals who redeemed their voucher either improved (60%) or maintained (40%) their stage of change status. Of those who did not redeem their voucher, one individual (20%) improved their stage of change status and one (20%) maintained their status, while three individuals (60%) each dropped one level from their original stage.

In general, the Fitness and Wellness Vouchers are best suited for those in contemplation and preparation stages of the TTM, as those in the action and maintenance phases are already motivated to exercise and those in the pre-contemplation stage are not yet ready to be active. This appears to be supported in the reported positive stage of change shifts for those in preparation and action stage who redeemed their vouchers.

SHCS Satisfaction

86.7% of respondents said that they were very satisfied, 6.7% were somewhat satisfied, and 6.7% were very dissatisfied with the ease of receiving a voucher at the Student Health and Wellness Center. The individual who marked “very dissatisfied” provided feedback in their survey responses that the number of steps required and locations to visit in order to receive and redeem a voucher was a stressful barrier, but that once redeemed, the voucher experience was positive. Overall, these ratings indicate that SHCS procedures for distributing the vouchers were perceived as a barrier to receiving or redeeming a voucher for a small percentage of the students who responded to the survey, but most students reported being satisfied with the process. However, we do not know how many students were given a pink referral sheet by their provider and did not go to to HEP to receive a voucher. This may be an area for further study.

Motivation to Live a Healthier Lifestyle

Voucher Motivated Individual to Live a Healthier Lifestyle Voucher Strongly Strongly Total Agree Neutral Disagree Type Agree Disagree Responses Group 37.5% 50.0% - - 12.5% 8 Exercise Personal - 66.7% 33.3% - - 3 Training

Overall, both voucher options appear to have an effect on motivation to live a healthier lifestyle, with the group exercise pass potentially having a more prominent reported effect. Additionally, all three individuals who redeemed their personal training voucher agreed that the program increased their knowledge to continue exercising on their own. 75% of those who redeemed a group exercise pass indicated intention to participate in future group exercise classes.

6.) Compare current performance with previously stated goal. Compare current performance vs. goal.

Currently SHCS is on track to distribute more vouchers with higher redemption rates than previous years.

7.) Corrective Action(s) Determine what corrective action(s) needed to improve performance. Implement the corrective action and determine the appropriate length of time until re-measurement is to occur.

It is recommended that providers identify which stage of change their patient is in regarding physical activity via the intake questionnaire or by verbal exchange during an appointment. If a student is identified as being in the contemplation or preparation stage, a Fitness and Wellness Voucher should be given. If a student is in the action or maintenance stage, the distribution is at the discretion of the provider. Students in the pre-contemplation stage should be referred to our physical activity resources and given information about the benefits of physical activity in relation to health to facilitate potential future movement into the contemplation or preparation stage, with follow-up provided by a provider at future appointments to re- assess the patient’s stage of change related to physical activity. With this tailored approach to the Fitness and Wellness Voucher program, the voucher redemption rate and the number of students moving into action and maintenance stages should increase. A re-measurement should occur after providers have been introduced to the concept of distributing vouchers in accordance with the stage of change model and they have utilized this method for at least six months.

8.) Re-measurement At the appropriate time, repeat steps 4 and 5. Describe second round of data collected and how you collected it. Also state your comparison of the new current performance vs. goal(s). Objectively determine if corrective action(s) achieved and sustained demonstrable improvement.

Comparison of Results:

2012: The average age of survey respondents was 25 years, with 76.2% identifying as female and 23.8% identifying as male.

2014: The average age of survey respondents was 24.2 years, with 80% identifying as female and 20% identifying as male.

Racial Identity 2012 2014 White, non Hispanic (includes Middle Eastern) 47.6% 40.0% Black, non Hispanic 4.8% 6.7% Hispanic or Latino/a 19.0% 33.3% Asian or Pacific Islander 19.0% 26.7% American Indian, Alaskan Native, or Native Hawaiian 4.8% - Biracial or Multiracial 14.3% 6.7% Other 14.3% -

Year in School 2012 2014 1st year undergraduate - - 2nd year undergraduate 4.8% - 3rd year undergraduate 19.0% 26.7% 4th year undergraduate 23.8% 13.3% 5th year or more undergraduate - 13.3% Graduate or professional 52.4% 46.7%

Both surveys represent more of an older, primarily white, female student.

Voucher Redemption Rate Comparison

2012: The majority of survey respondents did redeem their vouchers (81%) and those that didn’t listed time and issues with the application for personal training on the Campus Recreation side. Please see full Survey Monkey report for complete responses. There were no comments on SHCS as any type of a barrier to redemption.

2014: Two-thirds of the survey respondents did redeem their vouchers (66.7%) and those that didn’t listed timing and issues with the multiple steps needed to redeem the voucher as reasons they did not redeem their voucher. Please see full Survey Monkey report for complete responses.

Use of Services Following Voucher Redemption

Group Exercise Classes Attended after Voucher Redemption 2012 2014 Never 16.7% - 1-5 16.7% 37.5% 6-10 33.3% 12.5% 11-20 16.7% 50.0% More than 20 16.7% -

Personal Training Sessions Attended after Voucher Redemption 2012 2014 Initial Consult Only - - One Session 9.1% - 2 sessions 9.1% 66.7% 3 sessions 81.8% 33.3%

Participant Stage of Change Pre- and Post-Voucher

Stage of Change - Aggregate 6 mos. Post – Pre – 6 mos. Post – Pre – Voucher Stage of Change Voucher Voucher Voucher 2012 2012 2014 2014 Maintenance 38.0% 42.8% 26.7% 46.7% Action 24.0% 14.5% 20.0% 26.7% Preparation 29.0% 38.5% 40.0% 6.7% Contemplation 5.0% 5.0% 13.3% 13.3% Precontemplation 5.0% - - 6.7%

Individual Movement Across Stages – Voucher Redeemed Pre-Voucher 6 mos. Post-Voucher Number - 2012 Number - 2014 Maintenance Maintenance 4 3 Maintenance Preparation 2 - Action Maintenance 2 2 Action Preparation 2 - Preparation Maintenance 1 1 Preparation Action 3 3 Preparation Preparation 2 - Contemplation Contemplation - 1 Precontemplation Preparation 1 -

Individual Movement Across Stages – Voucher Not Redeemed Pre-Voucher 6 mos. Post-Voucher Number - 2012 Number - 2014 Maintenance Maintenance 2 1 Action Preparation 1 1 Preparation Action - 1 Preparation Contemplation - 1 Contemplation Contemplation 1 - Contemplation Precontemplation - 1

2012: Of those who redeemed their vouchers, 7 individuals (41.2%) improved their stage of change, while 6 (35.3%) maintained their stage of change. 4 participants who redeemed their vouchers (23.5%) reported dropping at least one level from their original stage of change. Of those who did not redeem their voucher, 3 individuals (75%) maintained their stage of change and one (25%) dropped one level from their original stage.

2014: All of the individuals who redeemed their voucher either improved (60%) or maintained (40%) their stage of change status. Of those who did not redeem their voucher, one individual (20%) improved their stage of change status and one (20%) maintained their status, while three individuals (60%) each dropped one level from their original stage.

Motivation to Live a Healthier Lifestyle

Voucher Motivated Individual to Live a Healthier Lifestyle Strongly Strongly Voucher Type Agree Neutral Disagree Agree Disagree Group Exercise - 2012 42.9% 0 57.1% 0 0 Group Exercise - 2014 37.5% 50.0% 0 0 12.5% Personal Training - 2012 27.3% 18.2% 27.3% 27.3% 0 Personal Training - 2014 0 66.7% 33.3% 0 0

Increased Knowledge to Continue Exercise – Personal Training Strongly Strongly Year Agree Neutral Disagree Agree Disagree 2012 54.5% 9.1% 9.1% 0 27.3% 2014 0 100% 0 0 0

9.) Additional corrective action(s) If you have met and are sustaining your performance goal, this step does not apply. If applicable, describe additional corrective action(s) taken, including how implemented (repeating steps 7 & 8). Also describe your data and how it was collected; and state comparison of new current performance vs. goal.

10.) Reporting and Education Describe how the governing body will review the results, and how that review will be documented. Describe other education activities surrounding the study’s results, and how this notification will occur (“closing the QI loop”).

These study results will be shared with the Exercise is Medicine committee to inform future work related to physical activity promotion in the clinic, as the Fitness and Wellness Vouchers are a key component of the Exercise is Medicine project. Additionally, HEP staff will continue to provide training to providers related to the Fitness and Wellness Voucher program and incorporate training specific to the stages of change model as it relates to physical activity behavior change.