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

PURPOSE: To compare the effects of a physical activity (PA) intervention of group meetings versus group meetings supplemented by personal calls or automated calls on the adoption and maintenance of PA and on weight stability among African-American women. DESIGN: Randomized clinical trial with three conditions randomly assigned across six sites. SETTING: Health settings in predominately African-American communities. SUBJECTS: There were 288 women, aged 40 to 65, without major signs/symptoms of pulmonary/cardiovascular disease. INTERVENTION: Six group meetings delivered over 48 weeks with either 11 personal motivational calls, 11 automated motivational messages, or no calls between meetings. MEASURES: Measures included PA (questionnaires, accelerometer, aerobic fitness), weight, and body composition at baseline, 24 weeks, and 48 weeks. ANALYSIS: Analysis of variance and mixed models. RESULTS: Retention was 90% at 48 weeks. Adherence to PA increased significantly (p < .001) for questionnaire (d = .56, 128 min/wk), accelerometer (d = .37, 830 steps/d), and aerobic fitness (d = .41, 7 steps/2 min) at 24 weeks and was maintained at 48 weeks (p < .001), with no differences across conditions. Weight and body composition showed no significant changes over the course of the study. CONCLUSION: Group meetings are a powerful intervention for increasing PA and preventing weight gain and may not need to be supplemented with telephone calls, which add costs and complexity.

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.

Effectiveness, efficiency, duration, and costs of recruiting for an African American women's lifestyle physical activity program.

In a 48-week lifestyle physical activity controlled trial in African American women, we analyzed recruitment effectiveness, efficiency, duration, and costs. Social networking was the most effective approach for inviting women to the trial. Of the 609 who responded to invitations, 514 completed telephone screening; of these, 409 (80%) were found eligible. The health assessment screening was completed by 337 women; of these, 297 (88%) were found eligible. The mean number of days from completion of the telephone and health assessment screenings to beginning the intervention was 23.01, and the mean cost was $74.57 per person. Results suggest that provision of health assessment screening by study staff as part of recruitment is effective for minimizing attrition and also might be cost-effective.

Physical activity intervention studies and their relationship to body composition in healthy women.

Engaging in regular physical activity is a key component for maintaining a healthy weight and preventing overweight and obesity. Obesity continues to be a concern globally, especially for women, and women are less physically active than men. This systematic review examined current research on physical activity interventions designed for healthy community dwelling women and assessed the effects of those interventions on physical activity and body composition. Three author-developed data collection tools were used to extract and examine study variables. For studies with suitable data, effect sizes were obtained. The initial search identified 1,406 titles published between 2000 and 2012, of which 40 randomized clinical trials met inclusion criteria. Of these 40 studies, 16 had a physical activity intervention that did not have a diet component and 24 had a physical activity intervention along with a diet component. The overall weighted mean effect was d = .21, 95% CI [0.06, 0.36] for physical activity outcomes (n = 18 studies) and d = -.16, 95% CI [-0.22, -0.09] for body composition outcomes (n = 24 studies). Both physical activity interventions without and with a diet component were effective in promoting physical activity and improving body composition. Physical activity interventions without a diet component were more effective than physical activity interventions with a diet component at promoting physical activity. The most effective interventions need to be adapted for dissemination into practice.

The effect of an inpatient transition intervention on attendance at the first appointment postdischarge from a psychiatric hospitalization.

BACKGROUND: Only 42% of initial appointments following psychiatric hospitalization are kept nationally. Missed appointments increase the likelihood of rehospitalization and increase costs of outpatient care. OBJECTIVE: This study explored the feasibility, outcomes, and cost of a transition intervention on attendance at the first postdischarge appointment. DESIGN: A pilot study using a one-group prospective design interviewed 15 patients hospitalized with psychosis to address potential barriers to attendance at the first postdischarge appointment. Patients also identified an agenda for this appointment and received a reminder letter. RESULTS: Twelve (92%) of 13 patients attended the postdischarge appointment compared with the previous rate of 44%. Two additional patients were unable to attend because they had been rehospitalized before the scheduled time of the first appointment. DISCUSSION: Contact with a clinician who can bridge the gap between discharge and the first postdischarge appointment is feasible and may be helpful in increasing attendance rates.

Women's walking program for African American women: expectations and recommendations from participants as experts.

Effective interventions that increase adherence to physical activity are important for African American women because generally they are less active and more obese compared to white American women. The purpose of the authors in this study was to elicit from women who began a 12-month physical activity program between 2002 and 2005: (1) their recollections of outcome expectations and barriers, (2) feedback on program components, and (3) suggestions for program change. In 2007, the authors conducted qualitative post-intervention focus group interviews with women who had participated in the enhanced treatment group. Thirty-three African American women aged 44-69 years at the time of the study participated in one of four focus groups held at their community intervention site. Focus groups were formed on the basis of low (walked<50% of expected walks) versus high (walked≥50% of expected walks) adherence and low (0-2) versus high (3-4) attendance at the four workshops held during the 6-month adoption phase. Audio-taped sessions were transcribed, coded independently, and then uploaded into NVivo7 for final coding and data analysis. Suggestions for future program components include a lifestyle physical activity prescription, pedometers for self-monitoring, ongoing group support, and automated telephone support. Focus group participants can serve as experts to assist in content development for improving program effectiveness.

Integrated primary and mental health care services: an evolving partnership model.

TOPIC: Persons with serious psychiatric disabilities experience high rates of medical co-morbidities that, if properly treated, could improve overall well-being and the course of recovery. PURPOSE: This brief reports describes how two organizations-Thresholds Psychiatric Rehabilitation Centers and University of Illinois College of Nursing-partnered to offer integrated behavioral and physical health care responsive to the needs of the population and committed to consumer-centered, holistic and preventative care. Most recently, the partnership offers primary care in different community settings through different service models-tele-monitoring, home visits, group visits. SOURCES USED: A combination of published literature, staff report, and quality assurance data informs this report. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The authors conclude that primary care outreach is a promising strategy in mental health settings and that the Chronic Care Model (CCM) provides a set of guidelines for designing and monitoring quality integrated care for a partnership model of integrated care.

Effects of perceived and objective neighborhood crime on walking frequency among midlife African American women in a home-based walking intervention.

BACKGROUND: Crime may be a significant barrier to physical activity for urban African American women, yet few studies have examined this relationship in intervention studies. This study examines relationships among neighborhood crime incidents, perceptions of crime and safety, and adherence in a walking intervention among urban, midlife African-American women. METHODS: The sample includes 148 women living in the City of Chicago. Violent crimes, disorder crimes, gun violence, and crime-related safety were examined. Adherence to walking frequency was measured as the percentage of recommended walks completed. RESULTS: Controlling for demographic characteristics and treatment group, multivariate regression analyses showed walking adherence was not associated with any of the crime measures or crime-related safety (R(2) = 0.130 to 0.147). The effect of enhanced treatment did not differ by levels of objective or perceived neighborhood crime or safety. Weak to moderate bivariate correlations were observed between objective crime measures and perceived disorder crime and crime-related safety (r = 0.04 to 0.25). CONCLUSIONS: Weak correlations between perceived and objective crime measures suggest they are measuring different aspects of the crime environment. Future studies should examine perceived and objective measures in other populations and settings and other neighborhood social factors which may moderate crime and safety effects on outcomes of physical activity interventions.

Neighborhood characteristics, adherence to walking, and depressive symptoms in midlife African American women.

BACKGROUND: African American women have more symptoms of depressed mood than white women. Adverse neighborhood conditions may contribute to these symptoms. Although reductions in depressive symptoms with physical activity have been demonstrated in white adults, little research has examined the mental health benefits of physical activity in African American women. Further, it is unknown whether physical activity can offset the effects of living in disadvantaged neighborhoods on depressive symptoms. The purpose of this study was to examine the relationships among neighborhood characteristics, adherence to a physical activity intervention, and change over time in depressive symptoms in midlife African American women. METHODS: Two hundred seventy-eight women participated in a home-based, 24-week moderate-intensity walking intervention. Either a minimal treatment (MT) or enhanced treatment (ET) version of the intervention was randomly assigned to one of the two community health centers. Walking adherence was measured as the percentage of prescribed walks completed. Objective and perceived measures of neighborhood deterioration and crime were included. RESULTS: Adjusting for demographics, body mass index (BMI), and depressive symptoms at baseline, walking adherence and objective neighborhood deterioration were associated with significantly lower depressive symptoms, whereas perceived neighborhood deterioration was associated with significantly higher depressive symptoms at 24 weeks. CONCLUSIONS: Adherence to walking as well as aspects of the environment may influence depressive symptoms in African American women. In addition to supporting active lifestyles, improving neighborhood conditions may also promote mental health among African American women.

Neighborhood environment and adherence to a walking intervention in African American women.

This secondary analysis examined relationships between the environment and adherence to a walking intervention among 252 urban and suburban, midlife African American women. Participants received an enhanced or minimal behavioral intervention. Walking adherence was measured as the percentage of prescribed walks completed. Objective measures of the women's neighborhoods included walkability (land use mix, street intersection density, housing unit density, public transit stop density), aesthetics (physical deterioration, industrial land use), availability of outdoor (recreational open space) and indoor (recreation centers, shopping malls) walking facilities/spaces, and safety (violent crime incidents). Ordinary least squares regression estimated relationships. The presence of one and especially both types of indoor walking facilities were associated with greater adherence. No associations were found between adherence and other environmental variables. The effect of the enhanced intervention on adherence did not differ by environmental characteristics. Aspects of the environment may influence African American women who want to be more active.

Smoking cessation and serious mental illness.

A focus group methodology was employed to identify personal, social, and environmental factors that affect smoking cessation in persons with serious mental illness. Four focus groups were held: two for those who had attempted to quit smoking and two for those who had never attempted to quit. Smoking is central to daily survival in patients with serious mental illness. Social and environmental reinforcement can both assist and hinder efforts to stop smoking. Smoke-free environments influence decisions to quit smoking if positive social comparisons with nonsmokers occur. Peer modeling and interpersonal connections with nonsmokers can offer links to forming supportive nonsmoking relationships.

Outcomes of a home-based walking program for African-American women.

PURPOSE: As compared with minimal treatment (MT), to determine the effectiveness of a home-based walking intervention enhanced by behavioral strategies targeted and tailored to African-American women (enhanced treatment [ET]) on adherence, physical activity, fitness, and body composition at 24 and 48 weeks. DESIGN: Using a quasi-experimental design, treatments were randomly assigned to one of two community health centers. SETTING: The centers were in predominately African-American communities. PARTICIPANTS: Sedentary women (156 ET, 125 MT) 40 to 65 years were recruited within a 3-mile radius of each center. INTERVENTION: Both treatments had the same orientation. The ET group had four targeted workshops followed by weekly tailored telephone calls over 24 weeks. METHODS: Generalized linear mixed models were used to test effects of treatments on adherence, physical activity, aerobic fitness, and body composition. RESULTS: Adherence was significantly higher in the ET than the MT group and was related to the number of workshops attended (r = .58) and tailored calls (r = .25) received. On-treatment analysis showed significant postintervention improvement in waist circumference and fitness in the ET group; however, these improvements were not statistically different between the two groups. Intent to treat analysis showed a significant increase in fitness, decrease in waist circumference, and no change in body mass index in both treatments. CONCLUSION: Findings suggest the potential impact of workshop group support on adherence in African-American women.

Recruitment of African American women to a walking program: eligibility, ineligibility, and attrition during screening.

The purposes of this study were to identify strategies successful in the recruitment of African American (AA) women to a home-based walking program and to examine factors that contribute to attrition, eligibility, and ineligibility during the recruitment screening protocol. Of the 696 women who contacted the researchers, 281 (40.4%) women enrolled in the study, 227 (32.6%) were lost to attrition, and 188 (27%) were ineligible. Those not enrolled due to attrition during screening or ineligibility reported more family risk for cardiovascular disease (CVD) and lived in neighborhoods with higher poverty. Although our recruitment strategies may have been successful in attracting low-income AA women, we were not as successful in preventing their attrition during the screening protocol, particularly for those living in poorer neighborhoods.

Perceptions of barriers and benefits to physical activity among outpatients in psychiatric rehabilitation.

PURPOSE: To explore perceived barriers and benefits to physical activity in people with serious and persistent mental illness (SPMI) who were enrolled in community-based psychiatric rehabilitation. DESIGN AND METHODS: Four focus groups, two for men and two for women, were held with a total of 34 outpatients from two program sites. The investigators used a semistructured interview guide to facilitate the discussions. Audiotapes of the discussions were transcribed and analyzed for concepts and themes. FINDINGS: Significant barriers to physical activity were: mental illness symptoms, medications, weight gain from medications, fear of discrimination, and safety concerns. Being in a psychiatric rehabilitation program offered comfort and belonging, but it also had the effect of leaving activity initiation up to the program staff, which some participants perceived was part of required program compliance. However, participants viewed physical activity positively, and they linked being active to improved mental health. CONCLUSIONS: Outpatients in psychiatric rehabilitation valued physical activity, but mental illness symptoms, medication sedation, weight gain, fear of unsafe conditions, fear of discrimination, and interpretations of program compliance were barriers. Confronting how attitudes and barriers specific to this population can affect activity and reframing program compliance to include the independent initiation of activity as part of improving health might help clients of mental health services to become more active.

Integrated primary and mental health care: evaluating a nurse-managed center for clients with serious and persistent mental illness.

Nurse-managed centers have been at the forefront of providing ambulatory care alternatives for underserved populations lacking access to care. Following this model, the Center for Integrated Health Care of the College of Nursing at the University of Illinois in Chicago delivers primary and mental health care services to a population of people with serious and persistent mental illness. The authors' experience illustrates the many rewards and challenges that nurse-managed centers face. This article describes their center's model of integrated care, examines selected performance indicators, and discusses the implications, opportunities, and challenges ahead.

A walking program for outpatients in psychiatric rehabilitation: pilot study.

The purposes of this quasi-experimental pilot study were to determine adherence to a 12-week group-based moderate-intensity walking program for sedentary adult outpatients with serious and persistent mental illness and to examine change from baseline to after the walking program in health status (mental and physical health, mood, and psychosocial functioning) and exercise motivation (exercise outcomes expectancies, exercise decisional balance). The 15 volunteers in this study were aged 21 to 65 years and enrolled in psychosocial rehabilitation; they participated in a 12-week walking program meeting three times per week for 1 hr, supplemented with four health information workshops delivered at the beginning of the study. Participants received individual exercise prescriptions determined by preprogram fitness testing and used heart rate monitors during walking sessions. Thirteen participants (87%) completed the study and attended 76% of the walking sessions. Overall, they walked at lower intensity than prescribed, with pulses within target heart rate ranges 35% of the time during Weeks 1 through 4, 26% of the time during Weeks 5 through 8, and 22% of the time during Weeks 9 through 12. However, mood improved (Profile of Mood States, t = -2.51, two-tailed, df = 12, p = .02), as did psychosocial functioning (Multnomah Community Ability Scale, two-tailed, df = 12, t = 2.49, p = .02). The findings indicate a walking group may be feasible for rehabilitation programs. In addition to the known cardiovascular risk-reduction benefits of regular walking, walking may improve mood and psychosocial functioning in adults with serious and persistent mental illness.

Menopausal status, moderate-intensity walking, and symptoms in midlife women.

The purpose of this randomized clinical trial study was to determine the effectiveness of a 24-week, home-based, moderate-intensity, walking intervention in improving symptoms (vasomotor, uro-genital/sexual, sleep, psychological, cognitive, physical) experienced by midlife women. One hundred and seventy-three Caucasian and African American women aged 45 to 65 who were not on hormone therapy, had no major signs or symptoms of cardiovascular disease, and were sedentary in their leisure activity were randomly assigned to the moderate-intensity walking group or the nonexercise control group. The exercise prescription was walking at a frequency of 4 times a week for a duration of 20 to 30 minutes. The symptom impact inventory included the frequency, intensity, and bothersomeness of 33 symptoms collected at baseline and 24 weeks. Adherence was measured with a heart rate monitor and exercise log. Average adherence to frequency of walking was 71.6% of the expected walks. After 24 weeks, there were no differences between the walking and control group on change in symptoms. However, multiple regression revealed that frequency of adherence to walking along with change in physical symptoms and menopausal status were significant predictors of change in sleep symptoms. While walking did not improve most symptoms experienced by midlife women, frequency of walking may improve sleep.

Integrating physical activity into mental health services for persons with serious mental illness.

This article reviews evidence supporting the need for interventions to promote physical activity among persons with serious mental illness. Principles of designing effective physical activity interventions are discussed along with ways to adapt such interventions for this population. Individuals with serious mental illness are at high risk of chronic diseases associated with sedentary behavior, including diabetes and cardiovascular disease. The effects of lifestyle modification on chronic disease outcomes are large and consistent across multiple studies. Evidence for the psychological benefits for clinical populations comes from two meta-analyses of outcomes of depressed patients that showed that effects of exercise were similar to those of psychotherapeutic interventions. Exercise can also alleviate secondary symptoms such as low self-esteem and social withdrawal. Although structured group programs can be effective for persons with serious mental illness, especially walking programs, lifestyle changes that focus on accumulation of moderate-intensity activity throughout the day may be most appropriate. Research suggests that exercise is well accepted by people with serious mental illness and is often considered one of the most valued components of treatment. Adherence to physical activity interventions appears comparable to that in the general population. Mental health service providers can provide effective, evidence-based physical activity interventions for individuals with serious mental illness.