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.

Care coordination to target patient complexity and reduce disparities in primary care.

OBJECTIVE: The purpose of this study was to describe our Activation and Coordination Team (ACT) model for interprofessional care coordination in primary care and examine feasibility of using ACT medical and social complexity criteria to categorize patients into Quadrants that determine resource utilization. Research questions were: (a) Are there significant differences in demographic, medical, and social characteristics by Quadrant; (b) Do patients with combined high medical and social complexity differ from those with either high medical or social complexity; and (c) Is there an association between initial screening risk level and ACT Complexity Quadrant placement? DESIGN: Cross-sectional, descriptive. SAMPLE: Patients (N = 167) aged 18-65 enrolled in an urban Medicaid managed care network. MEASUREMENTS: Screening and comprehensive health risk assessment questionnaires and clinical data collection from electronic health records. RESULTS: Patient characteristics differed significantly by Quadrant. Combined medical and social complexity produced greater impact than additive effects. Patients who initially screened low risk nevertheless met ACT criteria for medical and/or social complexity. CONCLUSIONS: Greater effects for individuals with medical and social issues are due to interactions among factors. Traditional screening may miss patients with complex needs who need care coordination. Care coordination skills should be incorporated into population health curricula.

Subjective Versus Objective Estimated Cardiovascular Disease Risk and Adherence to Physical Activity in African American Women.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death for African American (AA) women in the United States. Despite high prevalence of CVD risk factors, AA women perceive their CVD risk as low. OBJECTIVE: Our objectives were to (1) identify relationships between subjective (self-reported perceived) CVD risk and objective CVD risk estimated by the American College of Cardiology/American Heart Association atherosclerotic CVD (ASCVD) risk estimator, (2) identify demographic and psychosocial factors associated with subjective perceived risk and discrepancy with objective estimated CVD risk, and (3) determine whether subjective perceived CVD risk was associated with physical activity (PA) adherence. METHODS: This was a secondary data analysis of data collected from a 12-month lifestyle PA intervention conducted with 281 AA women. Subjective perceived CVD risk was measured by 1 question; objective estimated CVD risk was calculated using the ASCVD score. Women were categorized by congruence or discrepancy between subjective perceived and objective estimated CVD risk. RESULTS: Subjective perceived CVD risk and objective ASCVD risk scores were both low. Approximately 20% subjectively perceived their risk as lower than objective ASCVD scores. Atherosclerotic CVD risk discrepancy groups differed by depressed mood symptoms. Participants reported many perceived barriers to PA. Perceived CVD risk was not related to PA adherence. CONCLUSIONS: The significance of associated CVD risk factors may be underestimated by AA women, leading to discrepancy between subjective and objective risk estimates. Research is needed to clarify relationships among perceived risk, estimated risk using risk calculators such as ASCVD, and health behavior.

African-American Women's Perceived Risk for Cardiovascular Disease versus Framingham Risk.

Cardiovascular disease (CVD) is the leading cause of death among African-American women in the United States. Accurate CVD risk perception may motivate these women to participate in health-promoting behaviors; however, perceived risk may not align with objective CVD risk. Our objective was to examine CVD risk perception, risk factors, and objective estimated risk (based on Framingham scores). This was a secondary data analysis of data collected from a 12-month lifestyle PA intervention conducted with 281 African-American women. Subjective perceived CVD risk was measured with two questions; CVD risks were examined via health assessment and self-questionnaire; and objective estimated CVD risk was calculated using the Framingham Risk score. Despite having several objective risk factors for CVD development, most participants perceived their CVD risk as low, and their Framingham scores were low. The Framingham Risk score may not be the best predictor of CVD risk for African-American women.

Impact of Individual and Neighborhood Factors on Cardiovascular Risk in White Hispanic and Non-Hispanic Women and Men.

Cardiovascular disease (CVD) is the leading cause of mortality for adults in the US, regardless of ethnicity. A cross-sectional correlational design was used to describe and compare CVD risk and cardiac mortality in White Hispanic and non-Hispanic women and men. Data from 3,317 individuals (1,523 women and 1,794 men) hospitalized for non-cardiac causes during 2012-2013, and data from the 2010 United States Census were included. The sex-specific 10-year Framingham General Cardiovascular Risk Score (FRS-10) was used to estimate long-term risk for major cardiac events. Approximately three-quarters of the sample was White Hispanic. FRS-10 scores were generally low, but a high prevalence of risk factors not included in the standard FRS-10 scoring formula was seen. White Hispanic women had significantly lower estimated CVD risk scores compared to White Hispanic and non-Hispanic men despite higher non-FRS-10 risks. Neighborhood median household income had a significant negative relationship and Hispanic neighborhood concentration had a significant positive relationship with cardiac mortality. Hispanic concentration was the only predictor of estimated CVD risk in a multilevel model. CVD risk assessment tools that are calibrated for ethnic groups and socioeconomic status may be more appropriate for Hispanic individuals than the FRS-10. Neighborhood-level factors should be included in clinical cardiac assessment in addition to individual characteristics and behavioral risks. Researchers should continue to seek additional risk factors that may contribute to or protect against CVD in order to close the gap between estimated CVD risk and actual cardiac mortality for Hispanics in the US. © 2016 Wiley Periodicals, Inc.

Experiences of Military Spouses of Veterans With Combat-Related Posttraumatic Stress Disorder.

PURPOSE: To explore the experiences of military spouses living with veterans with combat-related posttraumatic stress disorder (PTSD). DESIGN: Husserlian phenomenology was chosen as the theoretical framework because it allowed a deeper understanding of the unfolding of the spouses' daily experience. METHODS: A purposive sample of 14 spouses living with veterans with symptoms of PTSD participated in unstructured interviews. Data were analyzed using a modification of the Colaizzi phenomenological method. FINDINGS: Spouses recognized that the veteran was no longer the same person, with life becoming one of living with the unpredictability of PTSD. The spouses bore the burden to maintain normalcy in the family and eventually created a new life. CONCLUSIONS: Military spouses endure psychological stress and strain, while living with a veteran with PTSD. There is a need for more programs to support the resilience of military spouses. CLINICAL RELEVANCE: Life for military spouses of veterans with PTSD is ever-changing and unpredictable. Practitioners need to be aware of the stress that spouses experience and develop programs and interventions that bolster the resilience of military families.

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.

Building a conceptual framework to culturally adapt health promotion and prevention programs at the deep structural level.

The debate on the effectiveness and merit for the amount of time, effort, and resources to culturally adapt health promotion and prevention programs continues. This may be due, in large part, to the lack of theory in commonly used methods to match programmatic content and delivery to the culture of a population, particularly at the deep structural level. This paper asserts that prior to the cultural adaptation of prevention programs, it is necessary to first develop a conceptual framework. We propose a multiphase approach to address key challenges in the science of cultural adaptation by first identifying and exploring relevant cultural factors that may affect the targeted health-related behavior prior to proceeding through steps of a stage model. The first phase involves developing an underlying conceptual framework that integrates cultural factors to ground this process. The second phase employs the different steps of a stage model. For Phase I of our approach, we offer four key steps and use our research study as an example of how these steps were applied to build a framework for the cultural adaptation of a family-based intervention to prevent adolescent alcohol use, Guiding Good Choices (GGC), to Chinese American families. We then provide a summary of the preliminary evidence from a few key relationships that were tested among our sample with the greater purpose of discussing how these findings might be used to culturally adapt GGC.

Individual, family, social, and cultural predictors of depressed mood in former Soviet immigrant couples.

Gender differences in predictors of depression for married couples from the former Soviet Union were examined in a cross-sectional, descriptive analysis. Data were collected during a longitudinal study of post-migration health and adaptation. The sample included 308 men and women (154 couples), ages 40-79, who had lived in the US for an average of 6 years. Generativity, marital satisfaction and communication, social support, immigration challenges, and alienation were independent predictors of depressed mood. A gender interaction was found for generativity, indicating that diminished opportunities to guide the next generation and be productive members of society may have been more depressing for women. Interventions should attend to gender differences in developmental needs, reduce immigration-related challenges, and strengthen family and social support.

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.

Correlates of lifestyle: physical activity among South Asian Indian immigrants.

South Asian immigrants are at increased risk for cardiovascular disease and diabetes, but little is known about their physical activity patterns. In this cross-sectional study, 110 participants were recruited to describe lifestyle physical activity behavior of this at-risk population. Education (p = .042), global health (p = .045), and self-efficacy (p = .000) had significant positive independent effects on leisure-time physical activity. Depression (p = .035) and waist circumference (p = .012) had significant negative independent effects, and frequency of experiencing discrimination a significant positive independent effect (p = .007) on daily step counts. Culture-sensitive physical activity interventions need to target South Asian Indian immigrants who are less educated, in poor health, concerned about racial discrimination, and have low self-efficacy.

A study protocol for e-PainSupport: The use of a digital application for reporting pain and pain management in home hospice.

High pain intensity is commonly experienced by patients with serious advanced illness. Impediments to improving pain intensity in home hospice include poor adherence to a pain management regimen due to caregivers' lack of knowledge and self-efficacy (confidence) in administering analgesics. e-PainSupport is a self-administered, digital application directly linked to patients' medical records. It has three elements: Education Module, Patient Pain Record, and the Pain Summary for Nurses. This study will test the effects of e-PainSupport on pain intensity when used by patients, caregivers, and nurses. The study's specific aims are as follows: Aim 1, compare the effects of e-PainSupport to a standard care condition, controlling for covariates (role [patient or caregiver], age, sex, ethnicity, education, and patient's diagnosis), on clinical improvement in pain intensity (primary outcome) and significant improvement on a pain intensity scale (secondary outcome); Aim 2, examine the mediating effects of patient and caregiver knowledge, self-efficacy, and adherence on change in pain intensity during 2 weeks, controlling for covariates and treatment condition; and Aim 3, identify nurses' perceptions of the use of e-PainSupport, including facilitators for and barriers to integration into agency workflow and benefits for patients. Participants (132 triads of patients, caregivers, and hospice nurses) will be recruited from Midwest hospice agencies. Patient and caregiver outcomes will be assessed at baseline and 2 weeks later. Data will be analyzed with multilevel modeling. Post-intervention, semi-structured interviews with nurses in the e-PainSupport condition will be analyzed using qualitative content analysis to identify perceived practice changes. e-PainSupport has the potential to facilitate nurse-patient communication and improve hospice patient pain management.

e-PainSupport: A Digital Pain Management Application for Home Hospice Care.

e-PainSupport is a digital pain management application (app) designed to facilitate better pain management in hospice. Early testing revealed caregivers found it was easy to use and successful in communicating patient pain and caregiver administration of analgesics to hospice nurses. However, caregiver knowledge of analgesic management remained low. The purpose of this study was to enhance e-PainSupport by (a) adapting and integrating an evidence-based pain educational intervention; (b) increasing ease of accessing and navigating the app; and (c) facilitating app communication with agency electronic health records (EHRs). An advisory board method, including two key stakeholder groups (an expert panel and a caregiver advisory board), guided the adaptation of an evidence-based pain educational intervention. Further, stakeholders recommended format changes to increase app usability. Study staff worked with four hospice agencies to facilitate app communication with EHRs. While modification to the e-PainSupport app to integrate a pain educational intervention and facilitate usability was successful, EHR integration was challenging. Future evaluation is needed to evaluate the effects of e-PainSupport on pain intensity among home hospice patients.

Risk of breastfeeding cessation among low-income women, infants, and children: a discrete time survival analysis.

BACKGROUND: Women who receive services from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) often stop breastfeeding earlier than recommended. Little is known about maternal background and intrapersonal variables that predict the timing of breastfeeding cessation over the 12-month postpartum period. OBJECTIVES: The aim of this study was to identify the maternal background and intrapersonal predictors associated with the timing of breastfeeding cessation in WIC participants over the course of the 12-month postpartum period. METHOD: Existing longitudinal survey and administrative data from low-income breastfeeding WIC recipients (n = 309) were analyzed using discrete time survival analysis. Risk of breastfeeding cessation was the outcome, and self-reported items were used to derive predictor variables that corresponded to the background and intrapersonal variables of the Interaction Model of Client Health Behavior. RESULTS: Rates of breastfeeding were low (31% at 6 months and 6% at 12 months). In the best fitting discrete time survival analysis model, women who were older and of Mexican ethnicity, who had previous breastfeeding experience, and who had breastfeeding support from family or friends were at lowest risk for breastfeeding cessation at each monthly interval. DISCUSSION: Breastfeeding duration rates were lower than Healthy People 2020 benchmarks of 61% at 6 months and 34% at 12 months. Clinicians and researchers can use the findings from this study to develop interventions that are targeted to periods of greatest risk of premature breastfeeding cessation to prolong breastfeeding duration in this vulnerable population.

Effects of Home-Based Exercise on Frailty in Patients With End-Stage Renal Disease: Systematic Review.

BACKGROUND: New or worsening frailty is a common problem in patients with end-stage renal disease (ESRD) during the prolonged time awaiting kidney transplantation. Structured physical activity in the dialysis setting has been shown to mitigate frailty, but little is known about the benefits of home-based exercise. The purpose of this systematic review was to summarize the effects of home-based exercise interventions on indicators of frailty (weakness, slowness, low physical activity, perceived exhaustion, and shrinking) among patients diagnosed with ESRD. METHODS: We searched PubMed, MEDLINE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar using Medical Subject Heading terms and free text keywords including kidney failure, exercise, and frailty. We identified 13 relevant articles (eight randomized controlled trials, five quasi-experimental studies). RESULTS: Our review found potential effectiveness of home-based exercise interventions on mitigating or preventing selected indicators of frailty (e.g., weakness, slowness, low physical activity, perceived exhaustion), particularly when the interventions combined aerobic walking, resistance exercise, and behavioral components and were delivered for at least 6 months. However, no published studies measured the effect of home-based exercise interventions on frailty as a whole. CONCLUSIONS: While existing studies suggest likely benefits of home-based exercise interventions among patients with ESRD, future research is warranted to develop and test home-based physical activity interventions that address all indicators of frailty.

Multiple instrument translation for use with South Asian Indian immigrants.

The purpose of this study was to describe translation of five measures (physical activity, acculturation, discrimination, self-efficacy, and depression) from English into Hindi using the committee translation method, focus group, and think-aloud interviews. Two South Asian Indian (SAI) immigrant bilingual translators and a moderator reached consensus on 93 of 102 items, using the committee method. Discrepancy in nine items was resolved with a focus group conducted with five bilingual SAI immigrants. Ten other bilingual SAI immigrants participated in think-aloud interviews to assess understanding and interpretation of the questions. More than 10 additional changes were made following the think-aloud interviews. Sequential use of multiple translation techniques improved translation with culturally acceptable language, thereby maintaining equivalence with original versions.

Lifestyle physical activity behavior of Korean American dry cleaner couples.

OBJECTIVE: The purposes of this study were to: (1) describe and compare lifestyle physical activity (leisure-time physical activity [LTPA], household physical activity [HPA], and occupational physical activity [OPA]), using both self-report and an objective measure of step counts, in self-employed Korean American married couples working together at dry cleaners, and (2) examine the relationship between self-report and objective measures of physical activity. DESIGN AND SAMPLE: 70 couples participated in this cross-sectional, descriptive, face-to-face interview survey. MEASURES: 2 self-reports (28-item Community Healthy Activities Model Program for Seniors Physical Activity Questionnaire and Tecumseh Occupational Physical Activity Questionnaire) and 1 objective measure (New Lifestyles-800 pedometer) were used. RESULTS: The husbands spent significantly more time than their wives in moderate- to vigorous-intensity LTPA (207 vs. 122 min/week) and OPA (2,585 vs. 1,065 min/week). Most couples (91%) met recommended levels of physical activity based on their OPA. Pedometer steps correlated significantly only with LTPA. CONCLUSIONS: Study findings suggest that to increase physical activity in Korean American couples who work in a small business, moderate-intensity lifestyle physical activity interventions across LTPA, HPA, and OPA will be more successful than traditional leisure-time interventions. In addition, results suggest that there is a need for interventions that target both members of the married couple.

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.

Feasibility of a Lifestyle Physical Activity Intervention to Prevent Memory Loss in Older Women With Cardiovascular Disease: A Mixed-Methods Approach.

BACKGROUND: Memory loss in older age affects women more than men and cardiovascular disease is a leading risk factor. Physical activity can improve memory in healthy older adults; however, few physical activity interventions have targeted women with cardiovascular disease, and none utilized lifestyle approaches. PURPOSE: The purpose of this study was to examine feasibility, acceptability, and preliminary effects of a 24-week lifestyle physical activity intervention (physical activity prescription, five group meetings, and nine motivational interviewing calls). METHODS: A sequential mixed-methods approach was used. Participants were 18 sedentary women ≥65 years with cardiovascular disease and without cognitive impairment recruited in August 2017. Feasibility, acceptability, self-reported health, accelerometer-assessed physical activity, and neurocognitive memory tests were measured using a pre-post test design. Two post-intervention focus groups (n = 8) were conducted in June 2018. Concept analysis was used to identify barriers/motivators of intervention participation. RESULTS: Meeting attendance was >72% and retention was 94%. Participants rated the program with high satisfaction. There were significant improvements at 24 weeks in self-rated physical health, objective daily steps, and estimated cardiorespiratory fitness (d = .30-.64). Focus group themes generated recommendations for modifying the intervention. CONCLUSION: Findings support adapting the intervention further for women with cardiovascular disease and testing it in an efficacy trial.

Longitudinal Changes in Acculturation for Immigrant Women from the Former Soviet Union.

Most research on immigrant acculturation has been conducted with cross-sectional samples, using statistical designs that may not capture different trajectories for the components that contribute to this complex concept. The purpose of this study was to examine change over time in acculturation for 226 women from the former Soviet Union who had lived in the US fewer than eight years when recruited. Using self-report data from four annual waves, growth trajectories were examined in four components of acculturation (American behavior, Russian behavior, English language proficiency, and cultural generativity). Results indicate that these components changed at varying rates. Acculturation is a process with multiple distinct components which should be measured separately to obtain a full profile of change over time.