Cardiovascular Disease Risk in Rural Adults: A Pilot Intervention Study Using Registered Nurse/Community Health Worker Teams.

BACKGROUND: Cardiovascular disease (CVD) risk reduction programs led by a nurse/community health worker team are effective in urban settings. This strategy has not been adequately tested in rural settings. OBJECTIVE: A pilot study was conducted to examine the feasibility of implementing an evidence-based CVD risk reduction intervention adapted to a rural setting and evaluate the potential impact on CVD risk factors and health behaviors. METHODS: A 2-group, experimental, repeated-measures design was used; participants were randomized to a standard primary care group (n = 30) or an intervention group (n = 30) where a registered nurse/community health worker team delivered self-management strategies in person, by phone, or by videoconferencing. Outcomes were measured at baseline and at 3 and 6 months. A sample of 60 participants was recruited and retained in the study. RESULTS: In-person (46.3%) and telephone (42.3%) meetings were used more than the videoconferencing application (9%). Mean change at 3 months differed significantly between the intervention and control groups for CVD risk (-1.0 [95% confidence interval (CI), -3.1 to 1.1] vs +1.4 [95% CI, -0.4 to 3.3], respectively), total cholesterol (-13.2 [95% CI, -32.1 to 5.7.] vs +21.0 [95% CI, 4.1-38.1], respectively), and low-density lipoprotein (-11.5 [95% CI, -30.8 to 7.7] vs +19.6 [95% CI, 1.9-37.2], respectively). No between-group differences were seen in high-density lipoprotein, blood pressure, or triglycerides. CONCLUSIONS: Participants receiving the nurse/community health worker-delivered intervention improved their risk CVD profiles, total cholesterol, and low-density lipoprotein levels at 3 months. A larger study to explore the intervention impact on CVD risk factor disparities experienced by rural populations is warranted.

Weight management telehealth intervention for overweight and obese rural cardiac rehabilitation participants: A randomised trial.

AIMS AND OBJECTIVES: To determine whether a weight management intervention (WMI) plus cardiac rehabilitation (CR) compared to CR alone improves outcomes for overweight and obese cardiac revascularisation patients. BACKGROUND: Despite participating in cardiac rehabilitation (CR), few cardiac patients lose enough weight to achieve clinically significant cardiovascular disease risk reduction. DESIGN: A randomised controlled design was used with measurements at baseline, 4 and 6 months, guided by the CONSORT checklist, see Supporting Information File S1. Adults who had undergone either coronary artery bypass surgery (CABS) or percutaneous coronary intervention (PCI) and participated in a rural CR programmes were recruited. Subjects were randomised to a 12-week telehealth WMI or control group. The primary outcome was weight loss. Secondary outcomes included physical activity, patient activation, perceived self-efficacy and use of weight management behaviours. RESULTS: A total of 43 subjects participated, with a mean age of 63 (±9.3) years. The WMI group had significantly more weight loss averaged across the 4 and 6 months of 13.8 (±2.8) pounds compared to the control group [mean = 7.8 (±2.2) pounds]. There were no significant differences in physical activity (activity counts or daily minutes in moderate or more intense activity). The WMI group had significantly higher levels of patient activation. They also had significantly higher total scores on the Diet and Exercise Self-Management survey, and subscales that included self-efficacy for specific eating habits and managing diet behaviour. CONCLUSIONS: Findings demonstrated the usefulness and feasibility of using telehealth delivery of the WMI for cardiac rehabilitation participants in rural communities to improve weight management outcomes. RELEVANCE TO PRACTICE: Study findings underscore the opportunity to further improve weight loss of overweight and obese cardiac participants using a weight management intervention to augment CR participation.

Methodological strategies in using home sleep apnea testing in research and practice.

PURPOSE: Home sleep apnea testing (HSAT) has increased due to improvements in technology, accessibility, and changes in third party reimbursement requirements. Research studies using HSAT have not consistently reported procedures and methodological challenges. This paper had two objectives: (1) summarize the literature on use of HSAT in research of adults and (2) identify methodological strategies to use in research and practice to standardize HSAT procedures and information. METHODS: Search strategy included studies of participants undergoing sleep testing for OSA using HSAT. MEDLINE via PubMed, CINAHL, and Embase with the following search terms: "polysomnography," "home," "level III," "obstructive sleep apnea," and "out of center testing." RESULTS: Research articles that met inclusion criteria (n = 34) inconsistently reported methods and methodological challenges in terms of: (a) participant sampling; (b) instrumentation issues; (c) clinical variables; (d) data processing; and (e) patient acceptability. Ten methodological strategies were identified for adoption when using HSAT in research and practice. CONCLUSIONS: Future studies need to address the methodological challenges summarized in this paper as well as identify and report consistent HSAT procedures and information.

Seasonal Work and Cardiovascular Risk Factors in Farmers.

BACKGROUND: Cardiovascular disease is the leading cause of death and hospitalization in the rural United States. Midwestern farmers are integral to rural communities, but little is known about the effect of occupational variability of seasonal work and technology use on their cardiovascular disease risk. AIMS: This study describes the relationships of health behaviors and cardiovascular disease risk in 40 Midwestern farmers during peak and off-peak farming seasons. METHODS: Objectively measured physical activity and self-report of demographics, diet, and health-related quality of life were collected during each farming season. RESULTS AND CONCLUSIONS: Farmers in this study were physically active, ate consistent diets, and reported high health status ratings throughout the year. Cardiovascular disease risk was positively correlated with age and body mass index (P < .01), and half of young and middle-age farmers reported anxiety and depression problems. Cardiovascular disease risk reduction interventions for farmers should address both physical and emotional aspects of farming.

Patient recovery and transitions after hospitalization for acute cardiac events: an integrative review.

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Symptom management strategies used by elderly patients after coronary artery bypass surgery.

The purpose of this secondary analysis was to describe symptom management strategies used by elderly patients (n = 236) 3 and 6 weeks after coronary artery bypass surgery (CABS). Three weeks after surgery, the most frequently used strategies were rest to manage shortness of breath (53%) and fatigue (53%), medications for incision pain (24%), and repositioning for swelling (35%) and sleep disturbance (18%). Overall, fewer patients experiencing sleep disturbances (39%), incision pain (39%), swelling (46%), and appetite problems (17%) reported using a strategy to manage their symptom. Nurses must assist patients in symptom identification and problem solving to accomplish effective symptom management.

Symptom profiles of coronary artery bypass surgery patients at risk for poor functioning outcomes.

The purpose of this secondary analysis was to profile or cluster 226 patients, who had participated in a randomized controlled trial, on symptoms after coronary artery bypass surgery and to examine how these profiles could potentially be used by clinicians to identify groups at risk for impaired functioning during the first 6 months after surgery. Variables measured were symptom presence and burden and functioning. The model-based clustering method was used for cluster analysis of the symptom burden measure, and analyses of covariance were used to determine if there were differences on functioning (physical functioning and physical activity) by symptom burden group at 6 weeks and at 3 and 6 months after dismissal. The majority of the 226 subjects were married (86%), male (83%), and had a mean age of 71 (SD, 4.96) years. Eight symptoms were used in the model-based clustering method-shortness of breath, fatigue, depression, sleep disturbances, pain, swelling, anxiety, and appetite problems-and demonstrated that there were 3 patient clusters of symptom burden. Cluster 1 had low symptom burden on all 8 symptoms, cluster 3 had moderate symptom burden on all 8 symptoms, and cluster 2 had a combination of low (shortness of breath, fatigue, depression, pain, and anxiety) and moderate symptom burden (sleep problems, swelling, and appetite problems). Analyses of covariance revealed no significant cluster x time interactions for any of the variables. However, there were significant main effects (P < .01) for symptom burden groups for physical functioning (physical and vitality functioning) and physical activity (estimated energy expenditure and mean daily total activity counts). Significant main effects for time indicated physical functioning and physical activity measures, except bodily pain, improved over time (P < .05). Study results indicate that the use of profiling coronary artery bypass surgery patients on their symptoms prior to hospital discharge may assist health care providers to identify patients who could be at risk for having more difficulty with physical functioning and physical activity during the first 6 months after surgery.

Vicarious Experience to Affect Physical Activity in Women: A Randomized Control Trial.

People compare themselves to others for self-evaluation, practical information, and motivation for healthy behaviors. The effect of active peer models on comparative thinking is unknown. The purpose of this 12-week, randomized, two-group pilot study was to evaluate the effect of a workplace peer modeling intervention on self-efficacy, motivation, and comparative thinking. The attention control group (ACG; n = 24) received general health information. The intervention group (n = 26) met with active peer models, received an exercise prescription and information. No significant group by time interaction effects were found. Comparisons on ability (how well am I doing), opinions (what should I think or believe), future self (think about my future), and modeling (be like someone else) all increased in the intervention group (n = 21) but decreased in the ACG (n = 22). Active peer models may support physical activity behavior change through specific lines of comparative thinking.

Impact of Yoga on Inflammatory Biomarkers: A Systematic Review.

BACKGROUND: Many chronic conditions, including heart disease, cancer, and rheumatoid arthritis, are associated with underlying chronic inflammatory processes. Literature reviews have analyzed a variety of integrative therapies and their relationships with chronic inflammation. This systematic review is unique in reporting solely on yoga's relationship with inflammation. Its purpose was to synthesize current literature examining the impact of yoga interventions on inflammatory biomarkers in adults with chronic inflammatory-related disorders. METHOD: Searches of several electronic databases were conducted. Inclusion criteria were (a) English language, (b) sample age >18 years old, (c) yoga interventions involving postures with or without yoga breathing and/or meditation, and (d) measured inflammatory biomarkers. RESULTS: The final review included 15 primary studies. Of these, seven were rated as excellent and eight as average or fair. There was considerable variability in yoga types, components, frequency, session length, intervention duration, and intensity. The most common biomarkers measured were interleukin-6 ( n = 11), C-reactive protein ( n = 10), and tumor necrosis factor ( n = 8). Most studies reported positive effects on inflammatory biomarkers ( n = 11) from baseline to post yoga intervention. Analysis of the dose showed higher total dose (>1,000 min) resulted in greater improvements in inflammation. CONCLUSION: This review suggests that yoga can be a viable intervention to reduce inflammation across a multitude of chronic conditions. Future studies with detailed descriptions of yoga interventions, measurement of new and well-established inflammatory biomarkers, and larger sample sizes are warranted to advance the science and corroborate results.

Adapting an Evidence-based Cardiovascular Disease Risk Reduction Intervention to Rural Communities.

PURPOSE: Using the RE-AIM framework, the primary purpose of this qualitative study was to assess focus group data to generate information on the applicability of an evidence-based cardiovascular disease (CVD) risk intervention developed for an urban setting for rural areas in Nebraska. We also sought to determine potential adaptations that may be necessary to implement the study in a rural setting. The CVD risk reduction intervention is based on the Community Outreach and Cardiovascular Health (COACH) program, which included nurse practitioner/community health worker teams. METHODS: This qualitative study involved conducting 3 focus groups with patients with CVD risk factors to assess community readiness for participating in the intervention, the mode of the delivery of the intervention, the setting of the intervention, program content, and raising awareness of the intervention. FINDINGS: Findings from the focus groups indicate acceptability toward a CVD risk reduction program modeled after the COACH. Participants favored initial in-person face-to-face interactions with a nurse practitioner that could transition to phone-based meetings and Skype. In addition, participants underscored that confidentiality can be a concern in small communities and therefore community health workers need to be trusted individuals. Calls for additions to COACH materials were very specific and participants underscored the need for social support. CONCLUSIONS: With minor adaptations, the COACH program can be pilot tested in rural settings to address key health concerns and behaviors that affect risk for cardiovascular health.

Adapting an Evidence-Based Cardiovascular Disease Risk Reduction Intervention to Urban American Indians.

PURPOSE: Using the RE-AIM framework, the primary purpose of this qualitative study was to conduct focus groups to identify areas for future adaptation of an evidence-based cardiovascular disease (CVD) risk intervention (COACH) developed for an urban primary care setting to urban American Indian (AI)-serving settings. METHODS: This qualitative study involved conducting three focus groups with 31 urban AI patients with two or more CVD risk factors to maximize reach and efficacy of COACH. The patients had not yet participated in an adapted COACH program. RESULTS: Findings from the focus groups indicate that a culturally adapted CVD risk reduction program modeled after COACH would be acceptable among urban AI populations. Recommendations for cultural adaptation include a need for images of AI people, traditional AI exercise activities and AI foods, information on the portion sizes of traditional foods, and expanded information on tobacco use and resources. CONCLUSION: With cultural adaptations, the COACH program can be pilot-tested in urban AI-serving primary care settings to address health concerns and behaviors that affect cardiovascular health outcomes.

Acute Coronary Syndrome Symptom Clusters: Illustration of Results Using Multiple Statistical Methods.

Researchers have employed various methods to identify symptom clusters in cardiovascular conditions, without identifying rationale. Here, we test clustering techniques and outcomes using a data set from patients with acute coronary syndrome. A total of 474 patients who presented to emergency departments in five United States regions were enrolled. Symptoms were assessed within 15 min of presentation using the validated 13-item ACS Symptom Checklist. Three variable-centered approaches resulted in four-factor solutions. Two of three person-centered approaches resulted in three-cluster solutions. K-means cluster analysis revealed a six-cluster solution but was reduced to three clusters following cluster plot analysis. The number of symptoms and patient characteristics varied within clusters. Based on our findings, we recommend using (a) a variable-centered approach if the research is exploratory, (b) a confirmatory factor analysis if there is a hypothesis about symptom clusters, and (c) a person-centered approach if the aim is to cluster symptoms by individual groups.

Psychometric testing of the Family-Carer Diabetes Management Self-Efficacy Scale.

The aim of this study was to develop and test the construct and content validity, internal consistency of the Family-Carer Diabetes Management Self-Efficacy Scale (F-DMSES). A sample of 70 Thai individuals who cared for those living with type 2 diabetes mellitus (T2DM) in a rural community in Thailand was included in the study. Data were collected by a questionnaire survey in January 2014. The F-DMSES was initially derived from the DMSES, with subsequent forward and backward translations from and to English and Thai languages. The psychometric properties (content, construct and internal consistency) of the Thai version were explored using the Content Validity Index approach, exploratory factor analysis and Cronbach's alpha test. The F-DMSES initially designed with 20 items was reduced to 14 items within four factors (general diet and blood glucose monitoring, medications and complications, diet in differing situations, and weight control and physical activities), and explained 72.2% of the total variance in overarching construct. Internal consistency was supported (α = 0.89). The F-DMSES was also able to measure change over time following an intervention, with an effect size of 0.9. The F-DMSES is a valid and reliable self-administered instrument that measures the diabetes management self-efficacy of family-carers of individuals with T2DM. This instrument can be used in practice and clinical trials to assess the impact of family-carers on the health outcomes of individuals with T2DM.

Perceptions of a Peer Modeling Workplace Physical Activity Intervention for Women.

A workplace physical activity (PA) study tested a novel use of peers to deliver the intervention. Peer models provided vicarious experience for living physically active lifestyles to a group of inactive women. The purpose of this study was to describe participants' perceptions of the peer modeling intervention. Nine women from the intervention group ( n = 26) participated in a 90-minute focus group. Qualitative description using thematic analysis was used to identify themes from the focus group transcript. Two themes about the intervention were "I am left wanting more" and "focus on food." Two themes about the peer models were "real people" and "it is doable." Focus group participants perceived the peer modeling PA intervention favorably; however, they desired more attention to healthy eating and more time with peer models. Replication of the study accounting for themes identified by focus group participants is needed to strengthen the peer modeling intervention.

Comparisons of measures used to screen for obstructive sleep apnea in patients referred to a sleep clinic.

STUDY OBJECTIVES: Obstructive Sleep Apnea (OSA) contributes to all-cause mortality. An American Academy of Sleep Medicine task force is focusing on improving detection and categorization of OSA symptoms and severity to promote screening, assessment, and diagnosis. The purpose of this study was to psychometrically compare measures used in OSA screening (Berlin, Epworth Sleepiness Scale (ESS), STOP Bang) and a portable sleep monitor (PSM) to apnea-hypopnea index (AHI) and levels from polysomnogram (PSG). METHODS: An observational, cross-sectional design was used. Patients referred to a sleep specialist were enrolled at initial sleep evaluation. Participants completed measures used in OSA screening, then sent home for one night using PSM. PSGs were ordered by the physician and AHI results were obtained from the medical record. RESULTS: Participants (N = 170) were enrolled in the study. Almost all participants completed the OSA measures, approximately half-completed PSM measurement, and the majority completed laboratory PSG. The STOP Bang had the highest levels of sensitivity; the ESS had the lowest. The ESS had the highest specificity and reliability levels; the STOP Bang had the lowest. The PSM measure had the highest positive predictive value (PPV) and the strongest psychometric properties of the screening measures. CONCLUSIONS: The STOP Bang was the preferred self-report OSA screening measure because of high levels of sensitivity. The ESS was the least desirable measure. PSM measurement consistently predicted the presence of OSA but at the expense of low sensitivity at AHI levels ≥30. This expands the knowledge of validity testing of screening measures used for OSA.

A Qualitative Study of Experiences of Participants in Cardiac Rehabilitation.

PURPOSE: Maintenance of lifestyle changes after cardiac rehabilitation (CR) is suboptimal. In addition, partners of cardiac patients are invited to participate in CR educational sessions and implicitly expected to assist patients with their lifestyle changes. The purpose of this study was to qualitatively examine patient and partner perceptions of phase 2 CR 3 mo after completion of the program. METHODS: A purposive sample of 11 couples (patients post-heart surgery and their spouses) was interviewed following completion of CR. Semistructured, in-person interviews were conducted with patients and spouses separately. Data were analyzed using line-by-line coding to identify themes. RESULTS: Themes were identified in relation to program elements of CR. Exercise themes were as follows: (1) benefitted from exercise and (2) felt held back. Education themes were as follows: (1) received basic education and (2) needed more personalized information. CR environment themes were as follows: (1) developed confidence; (2) made social comparisons; and (3) helped to have partner there. CONCLUSION: Overall, participant perceptions of exercise, education, and the CR environment were very positive. Nevertheless, there is a need to improve educational efforts within CR to rely less on "canned" presentations and more on participants developing their own self-management methods to maintain a healthy lifestyle after CR.

Couples' Experiences With Healthy Lifestyle Behaviors After Cardiac Rehabilitation.

PURPOSE: Many cardiac patients discontinue heart-healthy eating and physical activity (PA) behaviors in the months following cardiac rehabilitation (CR). Involving the spouse in CR with the patient may be 1 strategy to increase the maintenance of these behaviors after CR. Assisting patients and spouses with the maintenance of healthy eating and PA behavior following CR begins with a better understanding of the couple-focused factors, impacting their experiences with these behaviors. The purpose of this study was to qualitatively examine couple-focused facilitators and barriers to maintaining changes in healthy eating and PA behavior from the perspectives of both cardiac patients and their spouses following phase 2 CR. METHODS: A purposive sample of 11 couples (patients undergoing postcoronary artery bypass graft surgery and their spouses) were selected from a larger randomized control trial. Semistructured, in-person interviews were conducted with patients and their spouses separately following CR. Data were analyzed using line-by-line coding to identify facilitator and barrier themes. RESULTS: Two couple-focused barrier themes emerged: unnegotiated situations and unshared behaviors. Two couple-focused facilitator themes emerged: supportive exchanges and partnerships. CONCLUSION: These findings will help guide interventions targeting changes in diet and PA behavior in both patients and their spouses through minimizing unnegotiated situations, fostering supportive exchanges, and creating a partnership for the couple to work together on shared diet and PA goals. Targeting both patients and their spouses may be an innovative and effective way to intervene to increase adherence to healthy eating and PA behaviors post-CR.

Evaluation of strategies designed to enhance student engagement and success of indigenous midwifery students in an Away-From-Base Bachelor of Midwifery Program in Australia: A qualitative research study.

BACKGROUND: A strategy to close the gap in relation to Indigenous health is the employment of more Indigenous health professionals. However, despite government reviews, research studies and educational initiatives, Indigenous students' retention and completion rates of tertiary education remains below those of non-Indigenous Australians. OBJECTIVE: To evaluate two enhancements to an Away-from-Base Bachelor of Midwifery program for Indigenous students, namely the appointment of an Indigenous Academic Liaison Midwife to provide academic and cultural support and an additional clinical placement in a high-volume tertiary hospital. METHOD: In this qualitative study, 10 Indigenous students enrolled in the Away-from-Base Bachelor of Midwifery program participated in one of two focus groups. Focus group transcriptions were subjected to a manual thematic analysis, and key themes were identified and explored. FINDINGS: The role of the Indigenous Academic Liaison Midwife was highly valued as students had access to a resource who provided cultural and academic support, and who encouraged and advocated for them. Regular contact with the Indigenous Academic Liaison Midwife enabled students to stay connected with and focussed on their study. Students were overwhelmingly positive about the opportunity to undertake the additional clinical placement, as it exposed them to complex clinical cases they may not have seen in their home communities. CONCLUSIONS: The introduction of an Indigenous Academic Liaison Midwife and an additional clinical placement in a high-volume tertiary hospital were perceived as valuable additions to the range of support mechanisms already in place for Indigenous Away-from-Base Bachelor of Midwifery students. These interventions have had a direct impact on retention, course progression and completion rates for Indigenous students. Students expressed enhanced clinical learning and knowledge retention as a result of the additional clinical placement, and the Indigenous Academic Liaison Midwife provided culturally sensitive support for students undertaking remote learning, and during on-campus intensive sessions.

Feasibility and Effect of a Peer Modeling Workplace Physical Activity Intervention for Women.

Most working women do not meet current guidelines for physical activity (PA). A 12-week pilot study tested a workplace, peer modeling PA intervention. Inactive female employees from a health system were randomized to an attention control group (ACG; n = 26) or an intervention group (IG; n = 26). The ACG received health information. The IG participated in six group sessions with an active peer model and received an exercise prescription and PA information. Pre and post measures were PA (ActiGraph), Estimated VO2max (cycle ergometer), resting heart rate (HR), glucose and lipids, and cardiovascular risk. Using hierarchical linear modeling, no significant group by time effects were found. Although PA increased in both groups, F( df = 1) = 11.4, p = .002, the IG had greater improvements in fitness (VO2max, HR) and cardiovascular risk (total cholesterol, triglyceride, low density lipoprotein [LDL], calculated risk score) compared with ACG. Results support repeating this intervention in a fully powered study.

The effects of a symptom management intervention on symptom evaluation, physical functioning, and physical activity for women after coronary artery bypass surgery.

The purpose of this subset analysis was to examine the effect of a symptom management (SM) intervention on postoperative symptom evaluation, physical functioning, and physical activity among the female participants (N = 40) of the larger parent study of coronary artery bypass graft patients aged 65 years and older. The intervention group (n = 23) had significantly lower fatigue scores at 6 weeks (Z = 1.96, P < .05) and higher levels of physical activity (Z = -1.71, P < .05) reflected in the expended kcal(-1) x kg x d(-1), as measured by the activity diary at 3 months after coronary artery bypass graft surgery. At 6 weeks and 3 months after surgery, there were significant correlations between cardiac surgery-related recovery symptoms (shortness of breath, fatigue, depression, incision pain, and sleep problems) and physical functioning (physical, vitality, and bodily pain functioning subscale scores), with correlations ranging from 0.31 to 0.46. Given that this was a subset analysis of a larger study, significant differences were not expected for all variables. Study findings support the need for a targeted (women-focused) and tailored (self-management recovery) intervention to assist females in recovering from coronary artery bypass graft surgery to improve symptom management, thereby enhancing physical functioning and physical activity outcomes.