Randomized Clinical Trial of the Women's Lifestyle Physical Activity Program for African-American Women: 24- and 48-Week Outcomes

A Systematic Narrative Review of Recent Obesity Interventions with Black Women in the United States

OBJECTIVES

This study is to comprehensively review recent obesity interventions for Black women in the United States.

METHODS

We searched PubMed and EBSCOhost for articles published between 2013 and 2022 using a comprehensive search strategy. Two reviewers screened titles, abstracts, and full texts. Data from the included articles were extracted. Qualitative themes related to the intervention designs were identified across studies.

RESULTS

Fifty-two studies were included in the review. Interventions typically aimed to reduce weight by targeting diet and/or physical activity. Intervention activities were delivered virtually and in-person via several formats including didactic content and interactive sessions. Outcomes were assessed through a variety of research designs. Across papers, we identified six key themes of intervention design: integration of technology, centering community and culture, personalization of content, use of social support, skill-building through intervention activities, and addressing comorbid health conditions.

CONCLUSIONS

To address the obesity epidemic, future research can build upon key lessons learned from recent interventions tailored to Black women.

Overcoming Pandemic-Related Challenges in Recruitment and Screening: Strategies and Representation of Older Women With Cardiovascular Disease for a Multidomain Lifestyle Trial to Prevent Cognitive Decline

BACKGROUND

Recruiting participants with cardiovascular disease into research during the COVID-19 pandemic was challenging, particularly those at risk of health disparities.

OBJECTIVE

During the pandemic, 12 cohorts of older women with cardiovascular disease were recruited from cardiology clinics into a lifestyle intervention trial to prevent cognitive decline. Objectives were to (a) describe the results of modified recruitment/screening strategies to overcome pandemic-related challenges and (b) evaluate differences in age, race, and ethnicity between patients recruited/randomized, recruited/not randomized (entered recruitment but not randomized because of being ineligible or not interested), and not recruited (clinic patients who met preliminary criteria but did not enter recruitment).

METHODS

This was a cross-sectional descriptive analysis. In-person study strategies proposed before the COVID-19 pandemic were modified before study onset (September 2020). Women 65 years or older with cardiovascular disease were recruited from cardiology clinics by clinicians, posted flyers, and letters mailed to patients randomly selected from electronic health record data extractions. Patients were classified as recruited/randomized, recruited/not randomized, and not recruited.

RESULTS

Of 5719 patients potentially eligible, 1689 patients entered recruitment via referral (49.1%), posted flyers (0.5%), or mailed letters (50.3%), and 253 patients were successfully recruited/randomized. Recruited/randomized participants were, on average, 72.4 years old (range, 65-90 years old), non-Hispanic White (54.2%), non-Hispanic Black (38.3%), Hispanic/Latinx (1.6%), and other/not reported (5.1%). The recruited/randomized group was significantly younger with fewer patients of Hispanic/Latinx ethnicity compared with those not recruited.

CONCLUSIONS

During the pandemic, all recruitment/screening goals were met using modified strategies. Differences in sociodemographic representation indicate a need for tailored strategies.

DNP-PhD Collaboration in NINR-Funded Physical Activity Trials: A Series of Case Studies

Collaboration between Doctor of Nursing Practice (DNP) scholars and Doctor of Philosophy (PhD) scholars is crucial to efficiently advance and disseminate nursing science. Also, DNP-PhD collaboration can help achieve priorities outlined in the recent National Institute of Nursing Research (NINR) Strategic Plan. The purpose of this series of case studies is to describe exemplars of ongoing DNP-PhD collaborations across three NINR-funded trials (1 completed, 2 ongoing) testing physical activity interventions for women at risk for cardiovascular disease. In our three physical activity intervention trials for women, we categorized examples of DNP-PhD collaboration by the four phases of the team-based research model (development, conceptualization, implementation, and translation). Across all three trials, DNP and PhD scholars contributed successfully to all phases of research in an iterative manner. Future work should focus on expanding DNP-PhD collaboration in behavioral trials, which can inform adapted, contemporary models of iterative DNP-PhD collaboration.

Blended Care Interventions to Promote Physical Activity: A Systematic Review of Randomized Controlled Trials

Background

Blended care interventions combine therapeutic guidance with digital care. Current research results show the promising role of the blended care approach in clinical care. This new way of delivering health care could have the potential to effectively promote physical activity in different public health settings.

Objective

The aim of the systematic review is to investigate the varieties of intervention characteristics of blended care interventions to promote physical activity in terms of structure, behavior change goals, behavior change techniques, and effectiveness of blended care interventions compared to a control group.

Methods

We searched for randomized controlled trials published from 2000 to March 2021 in MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, SPORTDiscus, PsycINFO, and Web of Science according to the PRISMA guidelines. Risk of bias was assessed using the Cochrane Collaboration tool. Study characteristics, intervention characteristics, and outcome data were extracted. Furthermore, the effect size on the outcome of physical activity was examined or calculated.

Results

In total, the number of reports identified from the database searches was 4828. Of these, 25 studies were included in the review, with a total of 5923 study participants. Results indicated that the characteristics of blended care interventions showed a high heterogeneity. The combinations of therapist-guided interventions and digital interventions allowed the identification of specific subgroups, but they varied in length (range 8–52 weeks, SD 16.6), intensity, and the combination of the components. The most used combination of blended care interventions to promote physical activity was the combination of one-on-one meetings via telephone and Web-based interventions. Motivational models of behavior change were used most frequently as underlying theoretical foundations. Certain behavior change techniques were used consistently across the individual components, e.g., “problem solving” in the therapist-guided component and “feedback on behavior” in the digital component. Considering the effect size of blended care interventions compared with control groups, most studies showed a small effect.

Conclusions

It can be concluded that blended care interventions have potential to promote physical activity. In the future, further high-quality studies should investigate which type of blended care intervention is effective for which target group. Additionally, insights are required on which intervention characteristics are most effective, taking into account new evidence on behavior change.

Registration This systematic literature review was registered in PROSPERO (CRD42020188556).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00489-w.

Living labs for a mobile app-based health program: effectiveness of a 24-week walking intervention for cardiovascular disease risk reduction among female Korean-Chinese migrant workers: a randomized controlled trial

Background

The risk of Cardiovascular disease (CVDs) among adult populations is influenced by environmental factors, and immigrant populations tend to be more vulnerable. This study examined the effectiveness of a 24-week walking program based on social-cognitive determinants through mobile app for CVD risk reduction among female Korean-Chinese middle-aged workers.

Methods

This study used a parallel randomized controlled trial. Participants were recruited by distributing posters and flyers and randomly assigned to either the standard treatment (ST, n = 22) or enhanced treatment group (ET, n = 28). Participants were provided with a mobile app linked to Fitbit Alta for 24 weeks and instructed to walk at least 30 minutes five times a week and moderate-intensity physical activity. The ET group had additional interventions that enhanced social-cognitive determinants such as self-efficacy, social support. All participants were guided to voluntary physical activity during the 12-week maintenance period. Data were analyzed by the Mann Whitney U-test and a generalized estimating equation.

Results

There were significant between-group differences regarding the number of steps (B = 1.295, P < .001) and moderate physical activity time (OR = 6.396, P = .030) at week 12. ET group had significant changes in high-density lipoprotein cholesterol (B = 10.522, P = .007), low-density lipoprotein cholesterol (B = -16.178, P = .024), total cholesterol (B = -20.325, P = .039), fasting blood sugar (B = − 8.138, P = -.046). In addition, there was a significant reduction of 10-year CVD risk for the ET group over 12 weeks compared to the ST group (B = -0.521, P<. 001).

Conclusions

Long-term studies are needed to reduce the risk of cardiovascular disease in large-scale migrant workers and to confirm the direct and insdirect effects of social-cognitive determinants on health outcomes.

Trial registration

The trial was retrospectively registered in WHO ICTRP (KCT0006467) August 19th, 2021. (https://trialsearch.who.int/Trial2.aspx?TrialID=KCT0006467,

Effects of a Walking Exercise-Focused Health Promotion Program for Middle-Aged Women in the Korean Community

We assessed the effectiveness of a walking exercise-focused health promotion program based on an information-motivation-behavioral skills model. This intervention study employed a non-equivalent control group pre-test/post-test design. We recruited 44 middle-aged women (22 per group) who visited two health check-up centers in G city of South Korea. The intervention included information (health education), personal motivation (pedometer monitoring, setting goals, and keeping an exercise log), social motivation (group discussion and support, telephone counseling), and behavioral skills (walking exercise) components. Ten sessions of this program involved three face-to-face and seven online interactions via mobile instant messaging. As primary outcomes (health behavior), physical activity level and health-promoting lifestyle were measured by standardized scales. As secondary outcomes (health status), physiological indicators by body measurements and perceived stress by a scale were produced. We used the chi-squared test, independent t-test, and Mann-Whitney U test for the analysis. After the intervention, in the experimental group, the level of physical activity (Z = -2.065, p = 0.039) and health-promoting lifestyle improved (t = 3.344, p = 0.002), and both waist circumference (t = -4.328, p < 0.001) and perceived stress (t =-3.578, p < 0.001) decreased. In conclusion, our theory-based intervention has advantages in terms of high standardization potential, high availability, and improvement of health behavior and health status. In future, this approach will be useful for devising interventions that meet the health needs of people who are concerned about quality of life in the second half of life.

Effects of the COVID‐19 pandemic on recruitment for the working women walking program

The global pandemic of coronavirus disease 2019 (COVID‐19) affected many aspects of randomized controlled trials, including recruiting and screening participants. The purpose of this paper is to (a) describe adjustments to recruitment and screening due to COVID‐19, (b) compare the proportional recruitment outcomes (not completed, ineligible, and eligible) at three screening stages (telephone, health assessment, and physical activity assessment) pre‐ and post‐COVID‐19 onset, and (c) compare baseline demographic characteristics pre‐ and post‐COVID‐19 onset in the Working Women Walking program. The design is a cross‐sectional descriptive analysis of recruitment and screening data from a 52‐week sequential multiple assignment randomized trial (SMART). Participants were women 18–70 years employed at a large urban medical center. Recruitment strategies shifted from in‐person and electronic to electronic only post‐COVID‐19 onset. In‐person eligibility screening for health and physical activity assessments continued post‐COVID‐19 onset with Centers for Disease Control and Prevention precautions. Of those who expressed interest in the study pre‐ and post‐COVID‐19 onset (n = 485 & n = 269 respectively), 40% (n = 194) met all eligibility criteria pre‐COVID‐19 onset, and 45.7% (n = 123) post‐COVID‐19 onset. Although there were differences in the proportions of participants who completed or were eligible for some of the screening stages, the final eligibility rates did not differ significantly pre‐COVID‐19 versus post‐COVID‐19 onset. Examination of differences in participant demographics between pre‐ and post‐COVID‐19 onset revealed a significant decrease in the percentage of Black women recruited into the study from pre‐ to post‐COVID‐19 onset. Studies recruiting participants into physical activity studies should explore the impact of historical factors on recruitment.

A scoping review of behavior change techniques used to promote physical activity among women in midlife

Women in midlife experience health risks that could be mitigated by regular physical activity and reduced sedentary time, but this population rarely achieves physical activity levels that would protect their health. As a result, many behavioral interventions are designed to promote physical activity in this population, which are purportedly guided by theoretical models of health behavior (change) and activate an associated set of behavior change techniques (BCTs). The efficacy and effectiveness of these interventions appear to be limited, however, raising questions about their design and adaptation for women in midlife. Several aspects of these interventions are currently unclear. Specifically, which women they target (i.e., how “midlife” and “sedentary” or “inactive” are defined), which theoretical models or behavior BCTs are used, and how BCTs are activated in such interventions. A synthesis of this information would be useful as an initial step toward improving physical activity interventions for this at-risk group, and thus, represented the goal of the present scoping review. Eligibility required publication in a peer-reviewed journal in English between 2000 and 2021, inclusion of only women in midlife who did not have any medical or other restrictions on their physical activity (e.g., cancer diagnosis), and free-living physical activity or sedentary behavior as the target outcome (with associated assessment). Of the 4,410 initial results, 51 articles met inclusion criteria, and these described 36 unique interventions. More than half of the articles (59%) named an underlying theoretical model and interventions included an average of 3.76 identifiable BCTs (range 1–11). However, descriptions of many interventions were limited and did not provide enough detail to determine whether or how specific BCTs were activated. Interventions also used a wide range of inclusion criteria for age range and starting activity level, which has implications for targeting/tailoring and effectiveness, and many interventions focused on marginalized populations (e.g., women from racial/ethnic minority backgrounds, those un- or under-insured). The present review identifies some strengths and highlights important limitations of existing literature, as well as key opportunities for advancing the design and potential utility of physical activity interventions for women in midlife.

Self-Efficacy, Outcome Expectations, Group Social Support, and Adherence to Physical Activity in African American Women

BACKGROUND

African American women have lower levels of leisure time physical activity compared to White American women. Interventions to improve physical activity have mixed benefits for African American women, even when guided by theory. Understanding how theoretical constructs used in physical activity interventions relate to changing behavior may provide direction for more successful interventions.

OBJECTIVE

The study aimed to examine the relationships among social cognitive constructs (self-efficacy, social support from group behavioral meetings, outcome expectations/realizations), and change in physical activity from baseline to 48 weeks in African American women participating in a lifestyle physical activity program.

METHODS

A secondary data analysis of longitudinal data using a correlational design was conducted using data from a 48-week physical activity randomized controlled trial (RCT). The RCT included a group behavioral meeting component with one of three telephone intervention conditions (no calls, personal motivation calls, or automated motivational calls) randomly assigned across six community healthcare sites. The participants were 260 sedentary, midlife African American women with no major signs or symptoms of cardiovascular disease who completed baseline and 48-week assessments of the RCT. Measures included self-efficacy for change in overcoming barriers to physical activity at 24 weeks, physical and psychological outcome realizations at 24 weeks, social support from group behavioral meetings at 24 weeks, and physical activity (self-report and device-measured) change from baseline to 48 weeks.

RESULTS

In a hierarchical regression model predicting change in self-reported time spent in weekly moderate-vigorous physical activity at 48 weeks, psychological outcome realizations at 24 weeks were significant positive predictors. In a hierarchical regression model for change in device-measured daily steps at 48 weeks, a self-efficacy change at 24 weeks was a significant positive predictor.

DISCUSSION

Attention should be given to increasing self-efficacy to overcome physical activity barriers and achieve self-identified physical and psychological outcomes in physical activity programs.

The Feasibility of a Lifestyle Physical Activity Intervention for Black Women with Asthma

BACKGROUND

Black women are disproportionately affected by both physical inactivity and asthma. Lifestyle physical activity (PA) interventions targeted for Black women with asthma are lacking.

OBJECTIVE

To assess the feasibility and acceptability as well as preliminary effects of a lifestyle PA intervention culturally tailored for Black women with asthma.

METHODS

Black women (age 18-70 years) with uncontrolled asthma (Asthma Control Test <20) were recruited. Outcome assessments at baseline and 24 weeks included measures of: feasibility and acceptability, asthma control, quality of life, health care use, and PA levels. Participants were randomized to the intervention (asthma education, Fitbit, monthly group sessions, text messages, individual step goals, and study manual) or enhanced usual care (EUC) (asthma education plus Fitbit) group.

RESULTS

Of the 53 women randomized (EUC = 28; intervention = 25), 92% remained in the intervention (23 of 25) and 76% completing the 24-week outcome assessment. Overall intervention satisfaction (mean score, 6.88 of 7) and individual components were high at 24 weeks. Mean change in asthma control questionnaire between groups was not significant at 24 weeks (intervention = -0.41 vs EUC = 0.03 [P = .08]; effect size = -0.38) but approached clinical significance (0.5). At 24 weeks, more women receiving the intervention had controlled asthma compared with EUC (36.84% vs 9.52%; P = .04). Clinically significant improvements (0.5) in quality of life were found in the intervention group (mean change: intervention = 0.58 vs EUC = 0.10; P = .10) at 24 weeks.

CONCLUSIONS

A culturally tailored lifestyle PA intervention is feasible and demonstrates improvements in asthma control and quality of life among Black women with asthma. These preliminary findings support the need for PA lifestyle interventions in urban Black women with asthma.

Development and Feasibility of an Obesity Prevention Intervention for Black Adolescent Daughters and Their Mothers

Black female adolescents and women have disproportionately higher rates of obesity than their racial/ethnic counterparts. There is an urgent need to address obesity prevention in Black adolescent females through interventions that enhance lifestyle physical activity and improve dietary behaviors. Middle adolescence presents an important opportunity to strengthen the daughter-mother bond and improve healthy behaviors such as physical activity and dietary intake. Because of the intersection of adolescent development, culture and structural racism, it is essential to include mothers; however, this approach is understudied in the literature. This pre-pilot proof of concept study, Black Girls Move, was conducted using a 12-week pre-post within-subjects design to assess feasibility of conducting and delivering the BGM intervention, program satisfaction, and ability to obtain outcome measures in Black ninth and tenth grade daughters and their mothers. Twenty-two dyads were recruited and 14 dyads completed baseline assessments; however, only eight daughters and their mothers attended the first session and remained for the entire study. All dyads had valid objective and self-reported physical activity data. However, two of eight daughters and one mother provided self-reported dietary data that were considered invalid. All individual sessions were rated highly. Excellent attendance, retention, and satisfaction among participants suggest that we succeeded in developing an accepted, culturally relevant intervention. This lifestyle intervention would be strengthened by modifications to recruitment and retention, as well as incorporation of a computerized dietary assessment tool, a tailored dietary app for self-monitoring, and increased photo-based and group homework activities.

Using Fitbit as an mHealth Intervention Tool to Promote Physical Activity: Potential Challenges and Solutions

Consumer-based physical activity (PA) trackers, also known as wearables, are increasingly being used in research studies as intervention or measurement tools. One of the most popular and widely used brands of PA trackers is Fitbit. Since the release of the first Fitbit in 2009, hundreds of experimental studies have used Fitbit devices to facilitate PA self-monitoring and behavior change via goal setting and feedback tools. Fitbit’s ability to capture large volumes of PA and physiological data in real time creates enormous opportunities for researchers. At the same time, however, it introduces a number of challenges (eg, technological, operational, logistical), most of which are not sufficiently described in study publications. Currently, there are no technical reports, guidelines, nor other types of publications discussing some of these challenges and offering guidance to researchers on how to best incorporate Fitbit devices in their study design and intervention to achieve their research goals. As a result, researchers are often left alone to discover and address some of these issues during the study through “trial and error.” This paper aims to address this gap. Drawing on our cumulative experience of conducting multiple studies with various Fitbit PA trackers over the years, we present and discuss various key challenges associated with the use of Fitbit PA trackers in research studies. Difficulties with the use of Fitbit PA trackers are encountered throughout the entire research process. Challenges and solutions are categorized in 4 main categories: study preparation, intervention delivery, data collection and analysis, and study closeout. Subsequently, we describe a number of empirically tested strategies used in 4 of our interventional studies involving participants from a broad range of demographic characteristics, racial/ethnic backgrounds, and literacy levels. Researchers should be prepared to address challenges and issues in a timely fashion to ensure that the Fitbit effectively assists participants and researchers in achieving research and outcome goals.

Group Dance and Motivational Coaching for Walking: A Physical Activity Program for South Asian Indian Immigrant Women Residing in the United States

BACKGROUND

South Asian Indian immigrants residing in the United States are at high risk of cardiovascular disease (prevalence ≥35%), diabetes (prevalence 45.4%), and stroke (prevalence 26.5%). This study examined the effect of culturally relevant physical activity interventions on the improvement of physiological measures and average daily steps in at-risk midlife South Asian Indian immigrant women.

METHODS

In this 2-arm interventional research design, the dance (n = 25) and the motivational phone calls group (n = 25), attended social cognitive theory-based motivational workshops every 2 weeks for the first 12 weeks. Data for weight, waist circumference, blood pressure, blood sugar, cholesterol level, and 12-lead electrocardiogram were collected at the baseline, 12 weeks, and 24 weeks.

RESULTS

Significant differences were seen in body weight (F2,94 = 4.826, P = .024; ηp2=.093), waist circumference (F2,92 = 7.496, P = .001; ηp2=.140), systolic blood pressure (F2,94 = 19.865, P = .000; ηp2=.2970), triglyceride (F2,94 = 11.111, P = .000; ηp2=.191), cholesterol (F2,94 = 8.925, P = .001; ηp2=.160), blood sugar level (F2,94 = 8.851, P = .000; ηp2=.158), and average daily steps across both intervention groups over time (F2,96 = 30.94, P = .000; ηp2=.392).

CONCLUSION

Culturally relevant motivational workshops with Indian dance and walking are an innovative approach to increasing lifestyle physical activity among South Asian Indian immigrant women.

A study protocol for MindMoves: A lifestyle physical activity and cognitive training intervention to prevent cognitive impairment in older women with cardiovascular disease

INTRODUCTION

Cognitive impairment (CI) and cardiovascular disease (CVD) disproportionately affect women compared to men, and CVD increases risk of CI. Physical activity and cognitive training can improve cognition in older adults and may have additive or synergistic effects. However, no combined intervention has targeted women with CVD or utilized a sustainable lifestyle approach. The purpose of the trial is to evaluate efficacy of MindMoves, a 24-week multimodal physical activity and cognitive training intervention, on cognition and serum biomarkers in older women with CVD. Three serum biomarkers (brain-derived neurotrophic factor [BDNF], vascular endothelial growth factor [VEGF], and insulin-like growth factor 1 [IGF-1]) were selected as a priori hypothesized indicators of the effects of physical activity and/or cognitive training on cognition.

METHODS

The study design is a randomized controlled trial with a 2 × 2 factorial design, to determine independent and combined efficacies of Mind (tablet-based cognitive training) and Move (lifestyle physical activity with goal-setting and group meetings) on change in cognition (primary outcome) and serum biomarkers (secondary outcomes). We will recruit 254 women aged ≥65 years with CVD and without CI from cardiology clinics. Women will be randomized to one of four conditions: (1) Mind, (2) Move, (3) MindMoves, or (4) usual care. Data will be obtained from participants at baseline, 24, 48, and 72 weeks.

DISCUSSION

This study will test efficacy of a lifestyle-focused intervention to prevent or delay cognitive impairment in older women with CVD and may identify relevant serum biomarkers that could be used as early indicators of intervention response.

The Feasibility of a Combined Lifestyle Physical Activity and Cognitive Training Intervention to Prevent Cognitive Impairment in Older Women With Cardiovascular Disease

BACKGROUND

Cognitive impairment disproportionately affects older women with cardiovascular disease (CVD). Physical activity (PA) and cognitive training (CT) may have synergistic effects in combined interventions. However, no combined intervention has targeted women with CVD or utilized a sustainable and preferable lifestyle approach. The purpose was to test feasibility and acceptability of the 24-week MindMoves program, a lifestyle intervention that combined PA and CT developed for older women with CVD.

METHODS

The PA component included goal setting with Fitbits and 5 behavioral group meetings. The CT component was evidence-based BrainHQ delivered on a tablet in three 30-minute weekly sessions. Participants included 10 women aged ≥65 years with CVD. Exclusion criteria were cognitive impairment, regular PA, and CT use. Measures were feasibility (recruitment, attendance, participation, retention, and acceptability), change in PA (Fitbit min/steps), and change in cognitive function (NIH Toolbox®).

RESULTS

Of the 10 participants, 70% attended ≥4/5 group meetings, and overall attendance was 76%. Participants completed 2.3/3 CT sessions weekly. Participant retention was 100%. Over 90% of participants rated MindMoves with the highest levels of satisfaction. Participants had significant improvements in steps, light PA, and moderate PA, and there was a trend for improved cognition.

CONCLUSIONS

Findings support testing MindMoves in an efficacy trial.

Mobile App-Based Small-Group Physical Activity Intervention for Young African American Women: a Pilot Randomized Controlled Trial

A lack of adequate physical activity among young African American women remains a serious public health challenge. Few evidence-based interventions are available to increase physical activity in this population, and none has leveraged mobile technologies, even though African Americans are among the most avid users of mobile applications (apps). We conducted a pilot randomized controlled trial to test the efficacy of a mobile app-based small-group intervention in increasing physical activity among African American women aged 18 to 35 years (N = 91) in Philadelphia, PA. Cohorts of eight participants were randomized in a 1:1 ratio to a 4-women small-group intervention or an individual control condition. Control participants used the app to track their own activities. Small-group participants could track their own activities and those of the other three women in their group and could message the other women using a chatting tool. The primary outcome was meeting the goal of engaging in at least 90 min/day of light physical activity during the 3-month study period objectively assessed by a Fitbit device. Data were collected in 2016 and analyzed in 2017. Group participants had higher odds of meeting the goal (OR = 1.48, p = .048) than did control participants, an effect that did not wane during the 3-month study period. Irrespective of condition, participants had lower body-mass index (p = .01) and performed more push-ups (p < .0001) at the 1-month and 3-month assessments compared with the baseline measures. Mobile apps facilitating small online groups can contribute to efforts to increase physical activity among young African American women.This study is registered at www.clinicaltrials.gov NCT02736903.

A Walking Intervention Supplemented With Mobile Health Technology in Low-Active Urban African American Women With Asthma: Proof-of-Concept Study

Background

Physical inactivity is associated with worse asthma outcomes. African American women experience disparities in both physical inactivity and asthma relative to their white counterparts. We conducted a modified evidence-based walking intervention supplemented with mobile health (mHealth) technologies to increase physical activity (PA).

Objective

This study aimed to assess the preliminary feasibility of a 7-week walking intervention modified for African American women with asthma.

Methods

African American women with suboptimally controlled asthma were identified from a health system serving low-income minorities. At a baseline data collection visit, participants performed spirometry and incremental shuttle walk test, completed questionnaires, and were given an accelerometer to wear for 1 week. The intervention comprised an informational study manual and 3 in-person group sessions over 7 weeks, led by a nurse interventionist, in a community setting. The supplemental mHealth tools included a wearable activity tracker device (Fitbit Charge HR) and one-way text messages related to PA and asthma 3 times per week. A secure Web-based research platform, iCardia, was used to obtain Fitbit data in real time (wear time, moderate-to-vigorous physical activity [MVPA] and sedentary time) and send text messages. The feasibility of the intervention was assessed in the domains of recruitment capability, acceptability (adherence, retention, engagement, text messaging, acceptability, complaints, and concerns), and preliminary outcome effects on PA behavior (change in steps, duration, and intensity).

Results

We approached 22 women, of whom 10 were eligible; 7 consented, enrolled and completed the study. Group session attendance was 71% (5/7), 86% (6/7), and 86% (6/7), respectively, across the 3 sessions. All participants completed evaluations at each group session. The women reported being satisfied or very satisfied with the program (eg, location, time, and materials). None of them had concerns about using, charging, or syncing the Fitbit device and app. Participants wore their Fitbit device for at least 10 hours per day in 44 out of the 49 intervention days. There was an increase in Fitbit-measured MVPA from week 1 (19 min/week, SD 14 min/week) to the last week of intervention (22 min/week, SD 12 min/week; Cohen d=0.24, 95% CI 0.1 to 6.4). A slight decrease in step count was observed from week 1 (8926 steps/day, SD 2156 steps/day) to the last week of intervention (8517 steps/day, SD 1612 steps/day; Cohen d=−0.21, 95% CI −876.9 to 58.9).

Conclusions

The initial feasibility results of a 7-week community-based walking intervention tailored for African American women with asthma and supplemented with mHealth tools are promising. Modifications to recruitment, retention, and the intervention itself are needed. These findings support the need to conduct a further modified pilot trial to collect additional data on feasibility and estimate the efficacy of the intervention on asthma and PA outcomes.

Study protocol for a sequential multiple assignment randomized trial (SMART) to improve physical activity in employed women

INTRODUCTION

Physical activity monitors, motivational text messages, personal calls, and group meetings, have proven to be efficacious physical activity interventions. However, individual participant response to these interventions varies drastically. A SMART design (sequential multiple assignment randomized trial) provides an effective way to test interventions that start with an initial treatment and then transition to an augmented treatment for non-responders. We describe a SMART to determine the most effective adaptive intervention to increase physical activity (steps, moderate-to-vigorous physical activity) and improve cardiovascular health among employed women who are not regularly physically active. The SMART uses combinations of four treatments: 1) enhanced physical activity monitor (Fitbit wearable activity monitor and mobile app with goal setting and physical activity prescription), 2) text messages, 3) personal calls, and 4) group meetings.

METHODS

Participants (N = 312) include women ages 18-70 employed at a large academic medical center. Women will be randomized to an initial intervention, either an enhanced physical activity monitor or enhanced physical activity monitor + text messaging. Non-responders to the initial intervention at 2 months will be randomized to either personal calls or groups meetings for the next 6 months. At 8 months, all participants will return to only an enhanced physical activity monitor until their final 12-month assessment.

DISCUSSION

Results of this study will add to the literature on improving physical activity in employed women. This study will identify effective interventions for women who respond to less intensive treatments, while maximizing benefits for those who need a more intensive approach.

The evaluation of a fourth-generation multi-theory model (MTM) based intervention to initiate and sustain physical activity

Background: The United States Department of Health and Human Services (USDHHS)recommends that adults achieve 150 minutes per week of moderate-intensity aerobic activity.Most African American women do not meet these guidelines. The purpose of this study was to determine the efficacy of an intervention based on the fourth generation, multi-theory model (MTM) of health behavior change for initiating and sustaining physical activity among African American women when compared to a first generation, knowledge-based intervention.

Methods: The randomized controlled trial (RCT) utilized a pre-test, post-test and 6-week followup evaluation with an experimental (n=25) group and a comparison group (n=23). Process evaluation for satisfaction and program fidelity was conducted along with impact evaluation for changes in MTM constructs, intent to initiate and sustain physical activity, minutes of physical activity, body mass index (BMI), waist circumference and blood pressure in hypertensives.

Results:The MTM-based intervention proved significantly efficacious in increasing the minutes of physical activity from pre-test mean of 37 minutes to 172 minutes at follow-up (mean difference135.08 minutes, 95% CI: 106.04 to 164.13, P<0.0001), reducing waist circumference from pretest mean of 39 inches to 38 inches at follow-up (mean difference -1.12 inches, 95% CI: -1.70 to-0.545, P<0.001) and modifying the MTM construct of changes in physical environment from a mean of 7 units at pre-test to 9 units at follow-up (mean difference 2.08 units, 95% CI: 0.73 to 3.43, P<0.004) when compared to the knowledge-based intervention over time.

Conclusion: There were directional improvements in the mean scores for most of the study variables over time for the MTM intervention group and statistically significant improvement in minutes of physical activity and waist circumference.

Telehealth Interventions Designed for Women: an Evidence Map

BACKGROUND

Telehealth employs technology to connect patients to the right healthcare resources at the right time. Women are high utilizers of healthcare with gender-specific health issues that may benefit from the convenience and personalization of telehealth. Thus, we produced an evidence map describing the quantity, distribution, and characteristics of evidence assessing the effectiveness of telehealth services designed for women.

METHODS

We searched MEDLINE^® (via PubMed^®) and Embase^® from inception through March 20, 2018. We screened systematic reviews (SRs), randomized trials, and quasi-experimental studies using predetermined eligibility criteria. Articles meeting inclusion criteria were identified for data abstraction. To assess emerging trends, we also conducted a targeted search of ClinicalTrials.gov .

RESULTS

Two hundred thirty-four primary studies and three SRs were eligible for abstraction. We grouped studies into focused areas of research: maternal health (n = 96), prevention (n = 46), disease management (n = 63), family planning (n = 9), high-risk breast cancer assessment (n = 10), intimate partner violence (n = 7), and mental health (n = 3). Most interventions focused on phone as the primary telehealth modality and featured healthcare team-to-patient communication and were limited in duration (e.g., < 12 weeks). Few interventions were conducted with older women (≥ 60 years) or in racially/ethnically diverse populations. There are few SRs in this area and limited evidence regarding newer telehealth modalities such as mobile-based applications or short message service/texting. Targeted search of clinical.trials.gov yielded 73 ongoing studies that show a shift in the use of non-telephone modalities.

DISCUSSION

Our systematic evidence map highlights gaps in the existing literature, such as a lack of studies in key women's health areas (intimate partner violence, mental health), and a dearth of relevant SRs. With few existing SRs in this literature, there is an opportunity for examining effects, efficiency, and acceptability across studies to inform efforts at implementing telehealth for women.

The effectiveness of eHealth interventions on physical activity and measures of obesity among working-age women: a systematic review and meta-analysis

Physical inactivity and obesity are modifiable risk factors for cardiovascular disease, particularly in women. eHealth interventions may increase physical activity and improve obesity-related outcomes among women. The objective of this study was to review the evidence of the effectiveness of eHealth interventions to increase moderate-to-vigorous physical activity among working-age women. The secondary objective was to examine their effectiveness on improving obesity-related outcomes. A comprehensive search strategy was developed for eight electronic databases; through July 2016. All studies consisting of >80% women of working-age (18-65 years) in high income countries were included. Multiple unblinded reviewers determined study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Risk of Bias Tool and data quality using the Grading of Recommendations Assessment, Development and Evaluation approach. Data were pooled using a random-effects model. Sixty studies were included in the review of which 20 were in the meta-analysis. The meta-analysis demonstrated eHealth interventions improved moderate-to-vigorous physical activity (standard mean difference = 1.13, 95% confidence interval: 0.58, 1.68, P < 0.0001); an increase of ~25 min week^-1 . No changes were observed in obesity-related outcomes; waist circumference (P = 0.06), body mass (P = 0.05) and body mass index (P = 0.35). eHealth interventions are effective at increasing min week^-1 of moderate-to-vigorous physical activity among working-age women from high income countries.

Randomized Controlled Trial of Lifestyle Walking for African American Women: Blood Pressure Outcomes

The aim of this study was to test the effects of a lifestyle physical activity intervention (group meetings alone vs supplemented by personal or automated calls) on changes in systolic/diastolic blood pressures from baseline to 24 and 48 weeks among African American women. This was a randomized controlled trial with intervention conditions randomly assigned across 6 community health care sites. Participants were 288 sedentary African American women without major signs/symptoms of cardiovascular disease. Each intervention had 6 group meetings over 48 weeks, with 1 of 3 options between meetings: (1) no calls, (2) personal motivational calls, or (3) automated motivational calls. Blood pressures were taken at baseline, 24 weeks, and 48 weeks. Separate analyses were conducted using blood pressure classifications from the 2003 and 2017 high blood pressure guidelines. Average blood pressures decreased approximately 3 mm Hg for systolic and 2 mm Hg for diastolic from baseline to 48 weeks, with no differences between conditions. For both 2003 and 2017 blood pressure classifications, the risk ratio (odds of moving to a lower classification) was 1.44 for each assessment (P < .001). This lifestyle walking intervention appears beneficial in lowering blood pressure across blood pressure classifications in midlife African American women.

Engaging African American Women in Community-Based Health Promotion Programs: Key-Informant Recommendations

This explorative qualitative study describes the lived experiences of urban-dwelling African American (AA) women who participated in a nurse-led community-based health-promotion program for up to 20 years. Data were collected using semistructured interviews and analyzed using a phenomenological approach. Two central themes arose, the program facilitated behavior change and supported retention and recruitment. The findings suggest that AA women will attend classes and invite other participants when facilitators embed relevant community-engaged principles in the program. The participants recommended essential elements that supported the longevity of the program. Future studies may determine if these suggestions resonate with other AA women.

Sistas Inspiring Sistas Through Activity and Support (SISTAS): Study Design and Demographics of Participants

Introduction

Recruiting racial, ethnic, and other underserved minorities into conventional clinic-based and other trials is known to be challenging. The Sistas Inspiring Sistas Through Activity and Support (SISTAS) Program was a one-year randomized controlled trial (RCT) to promote physical activity and healthy eating among AA women in SC to reduce inflammatory biomarkers, which are linked to increased breast cancer (BrCa) risk and mortality. This study describes the development, recruitment, and implementation of the SISTAS clinical trial and provides baseline characteristics of the study participants.

Methods

SISTAS was developed using community-based participatory research (CBPR) approaches. At baseline, study participants completed assessments and underwent clinical measurements and blood draws to measure C-reactive protein (CRP) and interleukin-6 (IL-6). Participants randomized to the intervention received 12 weekly classes followed by nine monthly booster sessions. Post-intervention measurements were assessed at 12-week and 12-month follow-ups.

Results

We recruited a total of 337 women who tended to: be middle-aged (mean age 48.2 years); have some college education; be employed full-time; have Medicare as their primary insurance; be non-smokers; and perceive their personal health as good. On average, the women were pre-hypertensive at baseline (mean systolic blood pressure = 133.9 mm Hg; mean diastolic blood pressure = 84.0 mm Hg) and morbidly obese (mean BMI >40.0 kg/m²); the mean fat mass and fat-free mass among participants were 106.4 lb and 121.0 lb, respectively.

Conclusion

The SISTAS RCT addresses some of the gaps in the literature with respect to CBPR interventions targeting AA women, such as implementing diet and physical activity in CBPR-based studies to decrease BrCa risk.

Effects of culturally adaptive walking intervention on cardiovascular disease risks for middle-aged Korean-Chinese female migrant workers

The purpose of this study was to examine the effects of a standard treatment (ST) walking program compared to an ST walking program enhanced (enhanced treatment, ET) on cardiovascular health outcomes among Korean-Chinese female migrant workers in Korea. A quasi-experimental sequential design was used. A total of 132 Korean-Chinese women without contraindications to physical activity participated in the study. Both ST and ET groups had monthly goal settings; the ET group received text messages to encourage walking adherence and acculturation. A significant decrease was found in 10-year risk for cardiovascular disease (CVD), blood pressure, fasting glucose, body mass index, and waist-hip ratio at weeks 12 and 24 in both groups, but there were no significant group differences. This indicates that culturally adaptive walking intervention is a promising way to reduce CVD risk factors for underserved Korean-Chinese migrant women.

Healthy Weight in Lesbian and Bisexual Women Aged 40 and Older: An Effective Intervention in 10 Cities Using Tailored Approaches

BACKGROUND

Lesbian and bisexual women are more likely to be overweight or obese than heterosexual women, leading to increased weight-related health risks.

METHODS

Overweight women aged 40 or older who self-identified as lesbian, bisexual, or "something else" participated in five pilot interventions of 12 or 16 weeks' duration. These tailored interventions took place at lesbian and bisexual community partner locations and incorporated weekly group meetings, nutrition education, and physical activity. Three sites had non-intervention comparison groups. Standardized questionnaires assessed consumption of fruits and vegetables, sugar-sweetened beverages, alcohol, physical activity, and quality of life. Weight and waist-to-height ratio were obtained through direct measurement or self-report.

ANALYTICAL PLAN

Within-person changes from pre-intervention to post-intervention were measured using paired comparisons. Participant characteristics that influenced the achievement of nine health objectives were analyzed. Achievement of health objectives across three program components (mindfulness approach, gym membership, and pedometer use) was compared with the comparison group using generalized linear models.

RESULTS

Of the 266 intervention participants, 95% achieved at least one of the health objectives, with 58% achieving three or more. Participants in the pedometer (n = 43) and mindfulness (n = 160) programs were more likely to increase total physical activity minutes (relative risk [RR], 1.67; 95% confidence interval [CI], 1.18-2.36; p = .004; RR, 1.38; 95% CI, 1.01-1.89; p = .042, respectively) and those in the gym program (n = 63) were more likely to decrease their waist-to-height ratio (RR, 1.89; 95% CI, 0.97-3.68, p = .06) compared with the comparison group (n = 67).

CONCLUSION

This effective multisite intervention improved several healthy behaviors in lesbian and bisexual women and showed that tailored approaches can work for this population.

Barriers to physical activity as moderators of intervention effects

The impact of interventions to increase physical activity (PA) may vary as a function of participants' barriers to PA. The aim of this paper is to determine whether individual barriers (demographic, physical health, psychological health, neighborhood factors, perceived barriers to PA, social support for PA) moderate treatment effects on increases in PA. Three treatment conditions tested the relative efficacy of a group-based PA intervention alone or supplemented by either personal or automated phone calls made between group meetings. From 2010 to 2012, 284 African American women (ages 40-65) living in the Chicago, IL, area were randomized to one of the three treatment conditions. Data collection occurred at baseline as well as 24 and 48 weeks after baseline. Moderation of intervention effects by barriers to PA were tested across four outcome measures (self-reported moderate-vigorous PA, self-reported walking, accelerometer steps, and aerobic fitness) using multilevel mixed-effects analyses. Significant condition by barrier interaction effects for the accelerometer steps outcome were found for material hardships, general health, depressive symptoms, neighborhood crime rate, and perceived barriers to PA. For aerobic fitness, intervention effects were moderated by material hardships and perceived pain. Increases in the outcome variables were greater for the conditions in which group sessions were supplemented with personal and/or automated calls. Among participants with greater barriers to PA, supplementing the intervention group meetings with between-session personal and/or automated phone calls may be an effective way to strengthen intervention effects. These results may inform the use of treatment supplements in the context of adaptive interventions.

Bilingual Text4Walking Food Service Employee Intervention Pilot Study

Background

Half of all adults in the United States do not meet the level of recommended aerobic physical activity. Physical activity interventions are now being conducted in the workplace. Accessible technology, in the form of widespread usage of cell phones and text messaging, is available for promoting physical activity.

Objective

The purposes of this study, which was conducted in the workplace, were to determine (1) the feasibility of implementing a bilingual 12-week Text4Walking intervention and (2) the effect of the Text4Walking intervention on change in physical activity and health status in a food service employee population.

Methods

Before conducting the study reported here, the Text4Walking research team developed a database of motivational physical activity text messages in English. Because Hispanic or Latino adults compose one-quarter of all adults employed in the food service industry, the Text4Walking team translated the physical activity text messages into Spanish. This pilot study was guided by the Physical Activity Health Promotion Framework and used a 1-group 12-week pre- and posttest design with food service employees who self-reported as being sedentary. The aim of the study was to increase the number of daily steps over the baseline by 3000 steps. Three physical activity text messages were delivered weekly. In addition, participants received 3 motivational calls during the study.

Results

SPSS version 19.0 and R 3.0 were used to perform the data analysis. There were 33 employees who participated in the study (57.6% female), with a mean age of 43.7 years (SD 8.4). The study included 11 Hispanic or Latino participants, 8 of whom requested that the study be delivered in Spanish. There was a 100% retention rate in the study. At baseline, the participants walked 102 (SD 138) minutes/day (per self-report). This rate increased significantly (P=.008) to 182 (SD 219) minutes/day over the course of the study. The participants had a baseline mean of 10,416 (SD 5097) steps, which also increased significantly (P=.017) to 12,540 (SD 5149). They significantly improved their performance on their aerobic fitness test (P<.001). The participants had a baseline mean systolic blood pressure of 120 mm Hg and diastolic blood pressure of 76 mm Hg, a mean body mass index of 29.29 kg/m2, and a mean waist circumference of 36.95 inches, without significant changes seen at 12 weeks.

Conclusions

We were able to conduct a motivational physical activity text messaging intervention within the workplace setting. Both physical activity and aerobic fitness improved. However, at baseline, participants were more active than they perceived themselves to be. Although there is insufficient evidence to draw strong conclusions about the study findings, it would be useful to test this physical activity text messaging intervention in a sedentary sample within a larger workplace intervention study trial conducted over a longer time frame.

Cardiovascular Risk in Midlife African American Women Participating in a Lifestyle Physical Activity Program

BACKGROUND

Cardiovascular disease (CVD) is the largest contributor to disparate morbidity and mortality in African American women.

OBJECTIVE

The aims of this article are to describe in a cohort of sedentary, urban community-based midlife African American women eligible for a physical activity program their (1) CVD risk factors and (2) awareness, treatment, and control of hypertension and hypercholesterolemia.

METHODS

Cross-sectional baseline findings on 297 women were examined at baseline of a controlled physical activity clinical trial. Cardiovascular disease risks included hypertension, hypercholesterolemia, smoking, diabetes, and obesity. Among women with hypertension and hypercholesterolemia, rates of awareness, treatment, and control were calculated.

RESULTS

Our sample had significantly more hypertension and obesity than reported in other national samples of African American women. The women mirrored national samples of African American women: fewer than 60% had adequate control of hypertension. Versus national samples of African Americans (men/women combined), our study groups both showed significantly lower low-density-lipoprotein cholesterol level: treatment, 33% versus 63.8%, and control, 24.8% versus 45.3%.

CONCLUSIONS

Because national samples are more heterogeneous, our sample provides important information about CVD risks in inactive, urban community-dwelling, midlife African American women. Given the opportunity, many such women at elevated risk for CVD are willing to participate in a physical activity intervention. They must be identified and offered pharmacological and lifestyle interventions.

Retention of African American Women in a Lifestyle Physical Activity Program

The purpose of the article is to examine how well individual characteristics, neighborhood characteristics, and intervention participation predict study retention and staff level of effort needed for retention, using a cohort of African American women enrolled in a physical activity program. Secondary data analysis was conducted from a randomized clinical trial. Participants were aged 40 to 65 years without major signs/symptoms of cardiovascular disease. Assessments were conducted at community sites in/bordering African American communities. Study retention was 90%. Of those retained, 24% required moderate/high level of staff effort for retention. Retention was predicted by being older, having lower perceived neighborhood walkability, living in neighborhoods with greater disadvantage and crime, and having greater program participation. More staff effort was predicted by participants being younger, having more economic hardships, poorer health, or lower intervention participation. We may be able to identify people at baseline likely to require more staff effort to retain.