Integrating a physical activity coaching intervention into diabetes care: a mixed-methods evaluation of a pilot pragmatic trial.

Physical activity (PA) counseling is under-utilized in primary care for patients with type 2 diabetes mellitus (T2D), despite improving important health outcomes, including physical function. We adapted evidence-based PA counseling programs to primary care patients, staff, and leader's needs, resulting in "Be ACTIVE" comprised of shared PA tracker data (FitBit©), six theory-informed PA coaching calls, and three in-person clinician visits. In a pilot randomized pragmatic trial, we evaluated the feasibility, acceptability, and effectiveness of Be ACTIVE. Sedentary patients with T2D were randomized to Be ACTIVE versus an enhanced control condition. Mixed methods assessments of feasibility and acceptability included costs. Objective pilot effectiveness outcomes included PA (primary outcome, accelerometer steps/week), the Short Physical Performance Battery (SPPB) physical function measure, and behavioral PA predictors. Fifty patients were randomized to Be ACTIVE or control condition. Acceptability was >90% for patients and clinic staff. Coaching and PA tracking costs of ~$90/patient met Medicare reimbursement criteria. Pre-post PA increased by ~11% (Be ACTIVE) and ~6% in controls (group difference: 1574 ± 4391 steps/week, p = .72). As compared to controls, Be ACTIVE participants significantly improved SPPB (0.9 ± 0.3 vs. -0.1 ± 0.3, p = .01, changes >0.5 points prevent falls clinically), and PA predictors of self-efficacy (p = .02) and social-environmental support (p < .01). In this pilot trial, Be ACTIVE was feasible and highly acceptable to stakeholders and yielded significant improvements in objective physical function consistent with lower fall risk, whereas PA changes were less than anticipated. Be ACTIVE may need additional adaptation or a longer duration to improve PA outcomes.

We report results from a pragmatic and behavioral theory-based physical activity (PA) coaching program, termed "Be ACTIVE," for patients with type 2 diabetes that was designed to improve PA and function for patients and to be reimbursable and feasible for primary care teams. As compared to those who did not receive coaching, patients who received Be ACTIVE had physical function improvements that lowered their risk of falls. Be ACTIVE was delivered with fidelity and was highly acceptable to the key primary care stakeholders of patients, clinic staff coaches, and clinicians. Patients particularly liked the focus on setting goals to do enjoyable activities, the accountability of wearing a PA monitor, and the support of their coach. Clinical care professionals felt that their role of encouraging behavior change (coach) and safety monitoring (clinician) aligned well with their clinical expertise, and was professionally rewarding. Coaches felt the program helped them guide many patients to overcome preexisting negative perceptions of PA and develop intrinsic motivations to be active. The costs of clinic coach time and PA tracker rental needed to deliver the 12-week program could be reimbursed by the Medicare Chronic Disease Management programs, albeit with a patient co-payment required.

"My hair or my health:" Overcoming barriers to physical activity in African American women with a focus on hairstyle-related factors.

Physical activity disparities among African American (AA) women may be related to sociocultural barriers, including difficulties with restyling hair after exercise. We sought to identify physical activity barriers and facilitators in AA women with a focus on sociocultural factors related to hairstyle maintenance. Participants (n = 51) were AA women aged 19-73 years who completed valid surveys and participated in structured focus groups, stratified by age and physical activity levels, from November 2012 to February 2013. The Constant Comparison method was used to develop qualitative themes for barriers and facilitators. The most frequently reported general physical activity barrier among exercisers was "lack of money" (27%) and among non-exercisers was "lack of self-discipline" (57%). A hairstyle-related barrier of "sweating out my hairstyle" was reported by 7% of exercisers and 29% of non-exercisers. This hairstyle-related barrier included the need for extra time and money to restyle hair due to perspiration. Hairstyle-related facilitators included: prioritizing health over hairstyle and high self-efficacy to restyle hair after perspiration. Participants were interested in resources to simplify hairstyle maintenance. AA women whose hairstyle is affected by perspiration may avoid physical activity due to time and financial burdens. Increasing self-efficacy to restyle hair after perspiration may help to overcome this barrier.

An international survey of assisted reproductive technologies (ARTs) policies and the effects of these policies on costs, utilization, and health outcomes.

OBJECTIVES: The purpose of this study was to compare existing policies regarding access to 7 assisted reproductive technologies (ARTs) and to examine the effects of these policies on costs, utilization, and health outcomes in 14 countries and 2 Canadian provinces based on publicly available information. METHODS: A systematic review of publicly available information from peer-reviewed literature (using biomedical and social science databases) and grey literature (e.g., health ministry websites, health technology assessment agency websites, etc.) was performed. RESULTS: ARTs services permitted or funded vary across jurisdictions. The goals and eligibility restrictions (e.g., on maternal age, number of embryos transferred, and number of cycles) defined in ARTs policies also vary across jurisdictions. Studies on the impact of such policies have primarily been retrospective and focused on short-term service utilization. Nevertheless, they suggest that the policies have achieved specific outcomes, such as reductions in multiple births and in costs to payers. CONCLUSIONS: Based on the evidence reviewed, policies aimed at reducing public coverage of ARTs or restricting the number of embryos transferred have achieved these goals. However, their effects on maternal and infant health outcomes have not been well explored.

Design and methods of a multi-site, multi-behavioral treatment trial for menopausal symptoms: the MsFLASH experience.

BACKGROUND: Behavioral strategies are recommended for menopausal symptoms, but little evidence exists regarding efficacy. PURPOSE: Describe design and methodology of a randomized controlled 3 by 2 factorial trial of yoga, exercise and omega-3 fatty acids. METHODS: Women from three geographic areas with a weekly average of ≥14 hot flashes/night sweats, who met exclusion/inclusion criteria, were randomized to 12weeks of: 1) yoga classes and daily home practice; 2) supervised, facility-based aerobic exercise training; or 3) usual activity. Women in each arm were further randomized to either omega-3 supplement or placebo. Standardized training, on-going monitoring, and site visits were adopted to ensure consistency across sites and fidelity to the intervention. Participant adherence to the intervention protocol was monitored continuously, and retention was actively encouraged by staff. Information on adverse events was systematically collected. RESULTS: Of 7377 women who responded to mass mailings, 355 (4.8%) were randomized; mean age was 54.7 (sd=3.7), 26.2% were African American, 81.7% were post-menopausal, and mean baseline frequency of daily hot flashes/night sweats was 7.6 (sd=3.8). Adherence of ≥80% was 59% for yoga, 77% for exercise training, and 80% for study pills. Final week 12 data were collected from 95.2% CONCLUSIONS: Conducting a multi-site, multi-behavioral randomized trial for menopausal symptoms is challenging but feasible. Benefits included cost-effective study design, centralized recruitment, and methodologic standardization.

Baseline results from Hawaii's Na Mikimiki Project: a physical activity intervention tailored to multiethnic postpartum women.

During the postpartum period, ethnic minority women have higher rates of inactivity/under-activity than white women. The Na Mikimiki ("the active ones") Project is designed to increase moderate-to-vigorous physical activity over 18 months among multiethnic women with infants 2-12 months old. The study was designed to test, via a randomized controlled trial, the effectiveness of a tailored telephone counseling of moderate-to-vigorous physical activity intervention compared to a print/website materials-only condition. Healthy, underactive women (mean age = 32 ± 5.6 years) with a baby (mean age = 5.7 ± 2.8 months) were enrolled from 2008-2009 (N = 278). Of the total sample, 84% were ethnic minority women, predominantly Asian-American and Native Hawaiian. Mean self-reported baseline level of moderate-to-vigorous physical activity was 40 minutes/week with no significant differences by study condition, ethnicity, infant's age, maternal body mass index, or maternal employment. Women had high scores on perceived benefits, self-efficacy, and environmental support for exercise but low scores on social support for exercise. This multiethnic sample's demographic and psychosocial characteristics and their perceived barriers to exercise were comparable to previous physical activity studies conducted largely with white postpartum women. The Na Mikimiki Project's innovative tailored technology-based intervention and unique population are significant contributions to the literature on moderate-to-vigorous physical activity in postpartum women.

My baby, my move: examination of perceived barriers and motivating factors related to antenatal physical activity.

INTRODUCTION: Based on a socioecological model, the present study examined multilevel barriers and facilitators related to physical activity engagement during pregnancy in women of low socioeconomic status. METHODS: Individual and paired interviews were conducted with 25 pregnant women (aged 18-46 years, 17-40 weeks' gestation) to ask about motivational factors and to compare differences in activity level and parity. Atlas/Ti software was used to code verbatim interview transcripts by organizing codes into categories that reflect symbolic domains of meaning, relational patterns, and overarching themes. RESULTS: Perceived barriers and motivating factors differed between exercisers and nonexercisers at intrapersonal, interpersonal, and environmental levels. DISCUSSION: Future interventions should take into account key motivating multilevel factors and barriers to tailor more meaningful advice for pregnant women.

Validity of social-cognitive measures for physical activity in middle-school girls.

OBJECTIVE: The factorial validity and measurement equivalence/invariance of scales used to measure social-cognitive correlates of physical activity among adolescent girls were examined. METHODS: Confirmatory factor analysis was applied to questionnaire responses obtained from a multi-ethnic sample (N = 4885) of middle-school girls from six regions of the United States. A cohort of 1893 girls completed the scales in both sixth and eighth grades, allowing longitudinal analysis. RESULTS: Theoretically and statistically sound models were developed for each scale, supporting the factorial validity of the scales in all groups. Multi-group and longitudinal invariance was confirmed across race/ethnicity groups, age within grade, BMI categories, and the 2-year period between grades. CONCLUSIONS: The scores from the scales provide valid assessments of social-cognitive variables that are putative mediators or moderators of change in physical activity. The revised scales can be used in observational studies of change or interventions designed to increase physical activity among girls during early adolescence.

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

BACKGROUND: Most evidence-based programs are never translated into community settings and thus never make a public health impact. DESIGN: Active for Life (AFL) was a 4-year translational initiative using a pre-post, quasi-experimental design. Data were collected from 2003 to 2007. Analyses were conducted in 2005 and 2008. SETTING/PARTICIPANTS: Nine lead organizations at 12 sites participated. Active Choices participants (n=2503) averaged 65.8 years (80% women, 41% non-Hispanic white). Active Living Every Day (ALED) participants (n=3388) averaged 70.6 years (83% women, 64% non-Hispanic white). INTERVENTION: In AFL, Active Choices was a 6-month telephone-based and ALED a 20-week group-based lifestyle behavior change program designed to increase physical activity, and both were grounded in social cognitive theory and the transtheoretical model. The interventions were evaluated in Years 1, 3, and 4. An adapted shortened ALED program was evaluated in Year 4. MAIN OUTCOME MEASURE: Moderate- to vigorous-intensity physical activity, assessed with the CHAMPS self-reported measure. RESULTS: Posttest survey response rates were 61% for Active Choices and 70% for ALED. Significant increases in moderate- to vigorous-intensity physical activity, total physical activity, and satisfaction with body appearance and function, and decreases in BMI were seen for both programs. Depressive symptoms and perceived stress, both low at pretest, also decreased over time in ALED. Results were generally consistent across years and sites. CONCLUSIONS: Active Choices and ALED were successfully translated across a range of real-world settings. Study samples were substantially larger, more ethnically and economically diverse, and more representative of older adult's health conditions than in efficacy studies, yet the magnitude of effect sizes were comparable.

Outcomes from the women's wellness project: a community-focused physical activity trial for women.

BACKGROUND: Given the low rates of physical activity participation, innovative intervention approaches are needed to make a public health impact. METHODS: The study was conducted at the Miriam Hospital/Brown Medical School in Providence, RI, and in communities of Southeastern Massachusetts from 2002 to 2005. Previously sedentary women (n = 280; mean age = 47.1; 94.6% Caucasian) were randomly assigned to one of three conditions: (1) Choose to Move, a self-help printed booklet (n = 93), (2) Jumpstart, a motivationally tailored, print based intervention (n = 95); or (3) Wellness, women's health materials (n = 92). Face-to-face contact at months 3 (M3) and 12 (M12) occurred within participants' communities in local libraries. RESULTS: At M3, participants in the Jumpstart condition reported significantly more minutes of physical activity per week (M = 140.4, SE = 14.82) than participants in the Wellness condition (M = 98.1, SE = 15.09), (t(275) = 2.00, p < 0.05). The Jumpstart arm showed a trend towards significance (t(275) = 1.93, p = 0.054) when compared with the CTM arm (M = 99.5, SE = 15.11); there was no significant difference between the CTM and Wellness arms (t(275) = 0.07, p = NS). At M12, there were no significant differences (F(2,275) = 0.147, p = NS) between any of the treatment arms. CONCLUSIONS: Results suggest that print-based programs for physical activity may be efficacious short-term, but more research is needed to find approaches that are effective long-term. It is possible to deliver print-based programs through existing community infrastructures, however these approaches need further evaluation to examine maintenance effects apart from the demand characteristics of a research study.

Exploring the effect of the environment on physical activity: a study examining walking to work.

BACKGROUND: Research on physical activity and the physical environment is at the correlates stage, so it is premature to attribute causal effects. This paper provides a conceptual approach to understanding how the physical design of neighborhoods may influence behavior by disentangling the potential effects of income, university education, poverty, and degree of urbanization on the relationship between walking to work and neighborhood design characteristics. METHODS: The study merges Canadian data from 27 neighborhood observations with information on walking to work from the 1996 census. Hierarchical linear modeling was used to create a latent environment score based on 18 neighborhood characteristics (e.g., variety of destinations, visual aesthetics, and traffic). The relationship between the environment score and walking to work was modeled at the second level, controlling for income, university education, poverty, and degree of urbanization. RESULTS: With the exceptions of visual interest and aesthetics, each neighborhood characteristic contributed significantly to the environment score. The environment score was positively associated with walking to work, both with and without adjustment for degree of urbanization. Controlling for university education, income, and poverty did not influence these relationships. CONCLUSIONS: The positive association between the environment score and walking to work, controlling for degree of urbanization supports the current movement toward the development of integrated communities for housing, shops, workplaces, schools, and public spaces. Given the need for research to guide environmental interventions, collaboration among public health practitioners, urban planners, and transportation researchers is essential to integrate knowledge across sectors.