Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension.

Behavioral risk factors are among the preventable causes of health disparities, yet long-term change remains elusive. Many interventions are designed to increase self-efficacy, but little is known about the effect on long-term behavior change in older, low-income African Americans, especially when facing more problematic barriers. A cohort of 185 low-income African-Americans with hypertension reported barriers they encountered while undergoing a multiple behavior change trial from 2002 to 2006. The purpose of the present study was to explore the relationships between self-efficacy, barriers, and multiple behavior change over time. Higher self-efficacy seemed to be partially helpful for smoking reduction and increasing physical activity, but not for following a low-sodium diet. Addiction was indirectly associated with less reduction in smoking through lower self-efficacy. Otherwise, different barriers were associated with behavior change than were associated with self-efficacy: being "too busy" directly interfered with physical activity and "traditions" with low-sodium diet; however, they were neither the most frequently reported barriers, nor associated with lower self-efficacy. This suggests that an emphasis on self-efficacy alone may be insufficient for overcoming the most salient barriers encountered by older African Americans. Additionally, the most common perceived barriers may not necessarily be relevant to long-term behavioral outcomes.

Simultaneous vs sequential counseling for multiple behavior change.

BACKGROUND: Many patients in primary care settings present with multiple behavioral risk factors for cardiovascular disease. Research has provided little information on the most effective ways to approach multiple behavior change counseling in clinical settings. METHODS: We implemented a randomized trial in a publicly funded primary care setting to test whether a sequential presentation of stage of change-based counseling to stop smoking, reduce dietary sodium level to less than 100 mEq/L per day, and increase physical activity by at least 10,000 pedometer steps per week would be more effective than simultaneous counseling. African Americans with hypertension, aged 45 to 64 years, initially nonadherent to the 3 behavioral goals, were randomized to the following conditions: (1) 1 in-clinic counseling session on all 3 behaviors every 6 months, supplemented by motivational interviewing by telephone for 18 months; (2) a similar protocol that addressed a new behavior every 6 months; or (3) 1-time referral to existing group classes ("usual care"). The primary end point was the proportion in each arm that met at least 2 behavioral criteria after 18 months. RESULTS: A total of 289 individuals (67.3% female) were randomized, and 230 (79.6%) completed the study. At 18 months, only 6.5% in the simultaneous arm, 5.2% in the sequential arm, and 6.5% in the usual-care arm met the primary end point. However, results for single behavioral goals consistently favored the simultaneous group. At 6 months, 29.6% in the simultaneous, 16.5% in the sequential, and 13.4% in the usual-care arms had reached the urine sodium goal (P = .01). At 18 months, 20.3% in the simultaneous, 16.9% in the sequential, and 10.1% in the usual-care arms were urine cotinine negative (P = .08). CONCLUSIONS: Long-term multiple behavior change is difficult in primary care. This study provides strong evidence that addressing multiple behaviors sequentially is not superior to, and may be inferior to, a simultaneous approach.

Weight loss maintenance in African-American women: focus group results and questionnaire development.

BACKGROUND: African-American women are disproportionately affected by obesity. Weight loss can occur, but maintenance is rare. Little is known about weight loss maintenance in African-American women. OBJECTIVES: (1) To increase understanding of weight loss maintenance in African-American women; (2) to use the elicitation procedure from the theory of planned behavior (TPB) to define the constructs of attitude, subjective norms, and perceived behavioral control regarding weight loss and maintenance; and (3) to help develop a relevant questionnaire that can be used to explore weight loss and maintenance in a large sample of African Americans. DESIGN: Seven focus groups were conducted with African-American women: four with women successful at weight loss maintenance, three with women who lost weight but regained it. Discussions centered on weight loss and maintenance experiences. PARTICIPANTS: Thirty-seven African-American women. APPROACH: Content analysis of focus group transcripts. RESULTS: Weight loss maintainers lost 22% of body weight. They view positive support from others and active opposition to cultural norms as critical for maintenance. They struggle with weight regain, but have strategies in place to lose weight again. Some maintainers struggle with being perceived as sick or too thin at their new weight. Regainers and maintainers struggle with hairstyle management during exercise. The theoretical constructs from TPB were defined and supported by focus group content. CONCLUSIONS: A weight loss questionnaire for African Americans should include questions regarding social support in weight maintenance, the importance of hair management during exercise, the influence of cultural norms on weight and food consumption, and concerns about being perceived as too thin or sick when weight is lost.

Accelerometer feedback to promote physical activity in adults with type 2 diabetes: a pilot study.

This study examined whether giving activity feedback to obese, sedentary adults with Type 2 diabetes would improve their adherence to a home-based walking program. 49 subjects were recruited. Ten failed a treadmill cardiovascular test. Another 9 dropped out before the intervention, and 4 dropped out during the intervention. The remaining 26 adults (14 women, 12 men; age M = 48.1 yr., SD = 7.1) received behavioral counseling monthly for 3 mo. regarding exercise. All subjects wore a triaxial accelerometer during these 3 months. Randomly, half of the subjects were blind to the data from the accelerometers, i.e., no feedback, and had counseling based on their self-report diaries. The other half had access to the accelerometer data, got a computerized graph of their physical activity for the period between counseling sessions, and had counseling based on these objective data, i.e., feedback. The feedback group showed an increase in exercise over the 3 mo. The nonfeedback group showed an increase in activity at 1.5 mo. but reverted to their baseline exercise levels at 3 mo. However, analysis of variance showed there was at least an 8% probability that this effect was due to chance, so the hypothesis that feedback would improve exercise adherence could not be supported. Further studies with larger sample sizes and greater control of experimental conditions are needed to determine the utility of objective activity feedback.