Active for life: final results from the translation of two physical activity programs

Description of an academic community partnership lifestyle program for lower income minority adults at risk for diabetes

PURPOSE

Translating strategies and approaches from the successful clinically based Diabetes Prevention Program's lifestyle intervention to community settings is a key next step. This article describes a lifestyle program developed in partnership by researchers at a major university and public health professionals at a local health department.

METHODS

The Live Well, Be Well (LWBW) program was designed to meet the needs of lower income, minority, and low-literacy adults at risk for diabetes. It was adapted from interventions with demonstrated efficacy and delivered in Spanish and English by health department staff. The program consisted of a 6-month active phase and a 6-month maintenance phase and was primarily telephone based, with one in-person planning session and several group workshops. In-person and group sessions were held in convenient community-based settings. Counselors provided education and skills training to modify diet and increase physical activity. Self-selected and attainable goal-setting and action plans were emphasized to enhance self-efficacy. LWBW is the intervention component of a randomized trial with primary outcomes of fasting glucose, weight, and other clinical measures.

CONCLUSIONS

The program provides a unique translational model for implementing diabetes risk reduction programs for underserved populations. Individually tailored and nonprescriptive, it utilized existing health department infrastructure, focused on telephone counseling, used culturally appropriate, low-literacy materials, and was delivered in local, community-based facilities.

Partners reducing effects of diabetes (PREDICT): a diabetes prevention physical activity and dietary intervention through African-American churches

Type 2 diabetes is epidemic in the United States with greater incidence rates in African-American communities. Lifestyle interventions during the phase of insulin resistance mitigate cardiovascular risk and prevent diabetes. The primary aim of this study is to test the impact of a Community Health Advisor (CHA)-based diabetes prevention controlled intervention in urban African-American communities. In this controlled trial, church congregants in New Haven, CT, receiving a 1-year CHA-led diabetes prevention intervention were compared with church congregants in Bridgeport, CT, who did not receive an intervention. Outcome measures included physical activity, dietary pattern, anthropometric measure, social support, diabetes knowledge, nutrition and exercise self-efficacy. The results indicate that at the end of the 1-year intervention period, there were no significant differences observed between intervention and control groups. Possible explanations for the lack of change include difficulty in engaging the CHAs, variability in the CHA-led interventions, baseline discrepancies between the two sites which could not be fully controlled and loss to follow-up. The results indicate important obstacles which impeded the successful implementation of this intervention and lessons learned for future interventions.

Results from the Active for Life process evaluation: program delivery fidelity and adaptations

Active for Life((R)) (AFL) was a large (n = 8159) translational initiative to increase physical activity (PA) in midlife and older adults. Translational research calls for a shift in emphasis from just understanding what works (efficacy) to also understanding how it works in more 'real world' settings. This article describes the process evaluation design and findings, discuss how these findings were used to better understand the translational process and provide a set of process evaluation recommendations with community-based translational research. AFL community organizations across the United States implemented one of two evidence-based PA programs (Active Living Every Day-The Cooper Institute; Human Kinetics Inc. or Active Choices-Stanford University). Both programs were based on the transtheoretical model and social cognitive theory. Overall, the process evaluation revealed high-dose delivery and implementation fidelity by quite varied community organizations serving diverse adult populations. Findings reveal most variation occurred for program elements requiring more participant engagement. Additionally, the results show how a collaborative process allowed the organizations to 'fit' the programs to their specific participant base while maintaining fidelity to essential program elements.

Public health interventions for arthritis: expanding the toolbox of evidence-based interventions

BACKGROUND

Since 1999, the Centers for Disease Control and Prevention's (CDC) Arthritis Program has worked to improve the quality of life for people with arthritis, in part by funding state health departments to disseminate physical activity (PA) and self-management education (SME) interventions. Initially, only one SME and two PA interventions were considered evidence-based and appropriate for people with arthritis. The purposes of this article are to describe the processes and criteria used to screen new or existing intervention programs and report the results of that screening, including an updated list of recommended intervention programs.

METHODS

A series of three sets of screening criteria was created in consultation with subject matter experts: arthritis appropriateness, adequacy of the evidence base, and implementability as a public health intervention. Screening interventions were categorized as Recommended, Promising Practices, Watch List, Future Possibility, or Unlikely to Meet criteria based on how well the intervention met the screening criteria.

RESULTS

A total of 15 packaged PA interventions and six SME interventions were screened. Three PA and three SME interventions met all three sets of criteria and were added to the list of recommended public health interventions for use by CDC-funded state arthritis programs. An additional two SME interventions are developing the infrastructure for public health dissemination and were categorized as Promising Practices, and six PA interventions have evaluations underway and are on the Watch List.

CONCLUSIONS

The CDC Arthritis Program identified arthritis-appropriate interventions that can be used effectively and efficiently in public health settings to improve the quality of life of people with arthritis. The screening criteria used offer a guide to intervention developers on necessary characteristics of interventions for use in public health settings. The expanded menu of interventions is beneficial to clinical care and public health professionals and, ultimately, to people with arthritis.

A lifestyle activity intervention in patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients have lower levels of physical activity compared to age-matched controls, and they limit physical activities requiring normal exertion. Our purpose was to compare the effectiveness of a traditional exercise therapy (TET) program with a behavioral lifestyle activity program (LAP) in promoting physical activity.

METHODS

Moderate physical activity (kcal/week) was assessed in 176 COPD patients using the Community Health Activities Model for Seniors questionnaire. Patients were randomized to either a three month TET program that meet thrice weekly or a LAP. The LAP was designed to teach behavioral skills that encouraged the daily accumulation of self-selected physical activities of at least moderate intensity. Interventionist contact was similar (36 h) between the two groups. Patients were assessed at baseline and 3, 6 and 12 months.

RESULTS

Compared to baseline values, self-reported moderate physical activity increased three months post-randomization with no significant difference (p = 0.99) found between the TET (2501 +/- 197 kcal/week) and the LAP (2498 +/- 211 kcal/week). At 6 and 12 months post-randomization, there were no significant differences (p = 0.37 and 0.69, respectively) in self-reported levels of moderate physical activity between the TET (2210 +/- 187 and 2213 +/- 218 kcal/week, respectively) and the LAP (2456 +/- 198 and 2342 +/- 232 kcal/week, respectively).

CONCLUSION

Although there was no difference between treatment groups, the TET and the LAP were both effective at in increasing moderate levels of physical activity at 3 months and maintaining moderate physical activity levels 12 months post-randomization. This clinical trial is registered with ClinicalTrials.gov. Its identifier is NCT00328484.

The working mechanisms of an environmentally tailored physical activity intervention for older adults: a randomized controlled trial

BACKGROUND

The aim of this study was to explore the working mechanisms of a computer tailored physical activity intervention for older adults with environmental information compared to a basic tailored intervention without environmental information.

METHOD

A clustered randomized controlled trial with two computer tailored interventions and a no-intervention control group was conducted among 1971 adults aged >/= 50. The two tailored interventions were developed using Intervention Mapping and consisted of three tailored letters delivered over a four-month period. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention additionally targeted environmental determinants, by providing tailored environmental information. Study outcomes were collected with questionnaires at baseline, three and six months and comprised total physical activity (days/week), walking (min/week), cycling (min/week), sports (min/week), environmental perceptions and use and appreciation of the interventions.

RESULTS

Mediation analyses showed that changes in cycling, sports and total physical activity behaviour induced by the environmentally tailored intervention were mediated by changes in environmental perceptions. Changes in environmental perceptions did not mediate the effect of the basic tailored intervention on behaviour. Compared with the basic tailored intervention, the environmentally tailored intervention significantly improved cycling behaviour (tau = 30.2). Additionally, the tailored letters of the environmentally tailored intervention were better appreciated and used, although these differences did not mediate the intervention effect.

DISCUSSION

This study gave some first indications of the relevance of environmental perceptions as a determinant of changing physical activity behaviours and the potential effectiveness of providing environmental information as an intervention strategy aimed at enhancing physical activity behaviour among older adults.

Maintenance of change in the Active-for-Life initiative

BACKGROUND

There is a notable gap in translating efficacious interventions to community-based organizations. Further, physical activity interventions have been less successful in promoting longer-term maintenance.

PURPOSE

This study examined 6-month maintenance of improvements seen in Active for Life (AFL), a translational research initiative.

METHODS

Participants from seven of 12 AFL sites enrolled in Years 3 and 4 were surveyed 6 months after completing the 6-month telephone-based Active Choices program (AC, one site) or the 20-week or 12-week group-based Active Living Every Day program (ALED, six sites). Repeated measures analyses controlled for site clustering and covariates. Programs were implemented from 2003 to 2007 and analysis was conducted in 2009.

RESULTS

For the AC (n=368) and ALED (n=2151) programs, respectively, participants were aged 72.0 and 70.8 years on average, were 70% and 78% non-Hispanic white, and were 72% and 83% women; 46% and 50% returned 6-month follow-up surveys. For AC, improvements from pre- to post-test were maintained at follow-up for physical activity; satisfaction with body function (SBF); and BMI. For ALED Year 3, there was a decrease at follow-up for physical activity and SBF. Body mass index decreased from pretest to follow-up. For ALED Year 4, increases in physical activity and reductions in BMI were maintained at follow-up. Satisfaction with body function increased from pretest to 12 weeks post-test, declined at 20 weeks, and was maintained at follow-up.

CONCLUSIONS

Improvements were generally maintained at the 6-month follow-up. When behavioral decay occurred, follow-up values remained more favorable than at pretest. Given the broad reach of this translational initiative, the results suggest the viability of evidence-based programming as an effective public health practice.

Efficacy of two tailored interventions promoting physical activity in older adults

BACKGROUND

Important health benefits can be obtained if effective low-cost interventions promoting physical activity, especially among older adults, are developed.

DESIGN

This RCT investigated the efficacy of two tailored physical activity interventions in promoting awareness, initiation, and maintenance of physical activity among older adults compared to a wait-list control group. Data were collected in 2007. Analyses were conducted in 2008.

SETTING/PARTICIPANTS

In total, 1971 Dutch older adults (mean age=64 years, 57% women) participated.

INTERVENTION

Two tailored physical activity interventions, consisting of three tailored letters delivered during 4 months, were systematically developed. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention (intervention-plus) additionally targeted environmental determinants.

MAIN OUTCOME MEASURES

Awareness of personal physical activity behavior, self-reported level of physical activity, and compliance with the physical activity guideline were assessed at baseline, 3 months, and 6 months.

RESULTS

Intervention participants became more aware of their personal physical activity level at 6 months (OR(Ibasic)=1.7, OR(Iplus)=1.6) and were significantly more physically active at 3 (EffectSize[ES](Ibasic)=0.20, ES(Iplus)=0.20) and 6 months (ES(Ibasic)=0.30, ES(Iplus)=0.35) when compared to control participants. Moderation analyses showed that the interventions enhanced physical activity initiation at 3 (ES(Ibasic)=0.26, ES(Iplus)=0.21) and 6 months (ES(Ibasic)=0.32, ES(Iplus)=0.27) among participants insufficiently active at baseline, and induced maintenance at 6 months among participants sufficiently active at baseline (ES(Ibasic)=0.33, ES(Iplus)=0.34) when compared to the control condition. No differences between the intervention arms were found.

CONCLUSIONS

The results indicate that tailoring can be an effective tool in attaining and enhancing awareness, initiation, and maintenance of physical activity among older adults. Targeting environmental determinants in addition to psychosocial determinants, however, did not result in an additional increase in physical activity behavior.

TRIAL REGISTRATION

This study was registered with the Dutch Trial Register NTR 920.

Heart Healthy and Ethnically Relevant (HHER) Lifestyle trial for improving diet and physical activity in underserved African American women

BACKGROUND

African American women are at increased risk for CVD morbidity and mortality relative to white women. Physical inactivity and poor dietary habits are modifiable health behaviors shown to reduce CVD risk. Community health centers have the potential to reach large numbers of African Americans to modify their risk for CVD, yet few lifestyle counseling interventions have been conducted in this setting.

METHODS

The HHER Lifestyle trial is a randomized controlled trial to compare the effects of a standard care intervention (provider counseling, nurse goal setting, and educational materials) to a comprehensive intervention (standard care intervention plus 12 months of telephone counseling and tailored print materials) on changes in physical activity and dietary fat consumption in financially disadvantaged African American women at 6 and 12 months. Secondary outcomes are body mass index, central adiposity, and total cholesterol. Potential mediators of outcome are self-efficacy for overcoming barriers, social support, and decisional balance.

RESULTS

African American women (N=266; 130 standard care, 136 comprehensive intervention) 35 years and older from nine clinics within two community health centers were enrolled. Most participants were overweight or obese with existing chronic health conditions.

CONCLUSION

The HHER Lifestyle trial is unique in that it targets financially disadvantaged African American women from community health centers, incorporates a standard care intervention into a routine clinical appointment, and includes a comprehensive process evaluation. The design will permit further research examining the added effect of regular telephone counseling and tailored print materials to a primary care provider and nurse intervention.