South Asians (individuals from India, Pakistan, Bangladesh, Nepal, Sri Lanka, and Bhutan) are the fastest growing racial/ethnic minority group in the United States (31). Studies show that South Asians have a significantly higher prevalence of type 2 diabetes mellitus (DM) than that of non-Hispanic Whites, Blacks, and Hispanics (15,23,35). Although genetics may play a role, reducing the burden of DM in South Asians requires addressing lifestyle risk factors such as poor diet, physical inactivity, and overweight/obesity (15). Importantly, South Asians are some of the least physically active adults in the United States (35). Furthermore, they are prone to developing DM even with a small amount of weight gain (3). Clearly, targeted public health efforts are needed to prevent DM in the 3.8 million South Asians living in the United States.
Although physical inactivity is common in the United States, South Asians may require special considerations when designing and implementing physical activity programs. The vast majority of South Asians are immigrants, and studies show a mismatch between South Asian immigrants' sociocultural context and mainstream approaches to physical activity promotion (8,11). South Asian women, in particular, report little physical activity and have difficulty defining exercise (11). Our prior community-based participatory research (CBPR) found that social and cultural norms, rigid gender roles, and lack of social and family support strongly influenced South Asian women's proclivity for physical inactivity (11). Despite these barriers, South Asian women were willing to participate in exercise if it could be done in women-only classes and in a trusted community setting. Women also said that their children often encouraged them to do more exercise and that exercising with their children was a motivating factor. Exercise interventions that incorporate this larger sociocultural context are needed to maximize reach and effectiveness in the high-risk and rapidly growing South Asian population.
In partnership with the community partner (Metropolitan Asian Family Services (MAFS)), we adapted and applied evidence-based behavior change principles to develop a culturally tailored exercise intervention for South Asian mothers that would include their children. Although regular physical activity is an evidence-based DM prevention strategy (18,34), translating this evidence across diverse populations and settings is a major challenge. This study directly addresses the challenge by using CBPR methods and a social determinant framework (Fig. 1) to engage South Asian women in regular, structured physical activity.
Primary Research Goals
The primary research goal was to pilot test the 16-wk exercise intervention using a nonrandomized design to examine feasibility and initial efficacy among South Asian mothers with risk factors for DM. The primary efficacy outcomes were pre-/postintervention change in mothers' physical activity and weight. Secondary outcomes included pre-/postintervention change in clinical risk factors and exercise-related stages of change and self-efficacy. A qualitative evaluation was used postintervention to understand participants' experiences and perceptions of the intervention.
This study builds on CBPR principles, which contributed to the feasibility and sustainability of the intervention (7). MAFS and academic partner (Northwestern University (NWU)) collaboratively chose the focus of this research because it was relevant and responsive to the needs of this South Asian community. MAFS is a not-for-profit, community-based organization that provides comprehensive and integrated social services to immigrants. The organization serves about 1300 South Asian families, and all fall below 100% of the federal poverty level. MAFS and NWU had previously worked together on formative research to understand community needs and the sociocultural context of physical activity in this community (12,16,31). A third community partner, Ultimate Martial Arts (UMA), was also involved in this study. UMA is a fully equipped fitness facility with certified exercise instructors and was primarily involved to help deliver the exercise classes for mothers and children.
MAFS, UMA, and NWU developed a memorandum of understanding, and all partners engaged in formal capacity building activities (e.g., training on human subject research and study protocols and cultural competency training for exercise instructors). MAFS was also involved in the study design, review of study materials, and questionnaires to ensure cultural equivalence, implementation, recruitment and retention of participants, and evaluation. The study protocol and procedures were approved by the Institutional Review Board at NWU.
Participants and Setting
The majority of participants in this study were from India (77%) and Pakistan (20%). Indians and Pakistanis comprise 90% of South Asians in the United States in the Rogers Park neighborhood of Chicago, IL (25,30), where the study took place. Rogers Park is a major entry hub for South Asian immigrants (25), many of whom are medically underserved, meaning that they face economic, linguistic, and cultural barriers to health care (5). The study was conducted at MAFS, which has an office in the Rogers Park neighborhood, and UMA, which is an exercise facility located approximately 3 miles away from Rogers Park.
Eligibility and Recruitment Procedures
South Asian women with children between the ages of 6 and 14 yr and who had one or more risk factors for developing future DM (body mass index (BMI) ≥25 kg·m−2, and/or with a personal history of gestational DM, and/or with a first-degree relative with DM) were eligible to participate in the study (2). Only women who spoke Hindi or English were included in the study, because these are two of the most common languages spoken by South Asians in Chicago. In addition, the study team had the capacity and knowledge to translate documents for this pilot study into Hindi, but not multiple South Asian languages. Women who had a self-reported diagnosis of DM and/or were on DM medications, had a BMI ≥35 kg·m−2, blood pressure over 160/100 mm Hg, or were currently pregnant were excluded from participating. In addition, we used the Exercise Assessment and Screening for You Tool to screen women for conditions that might impact safe exercise, such as cardiac disease, uncontrolled blood pressure, or musculoskeletal conditions that could be exacerbated by exercise (26). Three women had comorbidities that prevented moderate-intensity physical activity and were excluded.
MAFS staff conducted outreach and recruitment at community sites and events. Participants who regularly use services at MAFS were also contacted for recruitment. Interested and eligible participants were invited to participate in the baseline assessments where written informed consent was obtained.
Intervention Design and Class Content
The study partners developed the exercise intervention by integrating evidence-based behavioral strategies (4) with unique culturally specific strategies based on formative CBPR (11) (Table 1). A conceptual model, relating individual, social, and environmental factors to physical activity, was also used to guide intervention planning and development (Fig. 1). The primary evidence-based goals of the intervention were for women to achieve 150 min of moderate-intensity physical activity per week and weight loss (18).
Every week, participants were required to attend a minimum of two exercise classes (classes were held three times per week to accommodate schedules). Certified exercise instructors conducted classes at MAFS and UMA. Instructors led participants in 45 min of moderate-intensity exercise drawing on Zumba® and aerobics. Classes began with a warm-up and ended with a cool down period. To accommodate previously sedentary women, the intervention used a discontinuous protocol (12), meaning that participants could rest as needed during class and rejoin the class once ready. Participants were instructed on how to gradually increase the amount and intensity of physical activity to achieve the 150 min of moderate-intensity physical activity per week. Study staff also participated in the exercise classes to help with translation into Hindi because one instructor did not speak Hindi.
To increase group cohesion and social support, we began weekly exercise classes with one participant sharing her reasons for participating and perceived benefits. In addition, the study team held biweekly contests where the top three participants were recognized during the exercise class with a certificate for achieving the contest goal. Examples include “most improved step count,” “best 2-min exercise routine,” and “best attendance.”
In this study, children were not a target of the intervention. The exercise classes for the children were used as a culturally tailored strategy to increase mothers' engagement and participation in the exercise intervention. All participants were given the option to enroll their children between ages 6 and 14 yr in a free exercise class at UMA, which was at the same time as the mother's exercise classes. The children's classes included 12 wk of martial arts and 4 wk of yoga. Mothers were required to attend the women's exercise class if their child was participating in the children's class.
Other Intervention Components
Participation in other intervention components was optional, but encouraged. Participants were given a Fitbit Zip™ wireless activity tracker and were taught how to use it to self-monitor daily step counts. Study staff provided participants with a biweekly report of their steps counts. Reports included a motivational message and recommended an individually tailored step goal, based on the prior weeks' step counts, to increase the number of daily steps.
As part of the study, women were given the option of attending two group classes about healthy eating where study staff provided culturally tailored information on portion control, reducing saturated fat and salt in diet, and a healthy South Asian dietary pattern. These classes were conducted in Hindi and English by the bilingual project staff. Forty percent of women attended these classes.
Transportation to and from the exercise classes was provided by MAFS, and class attendance was also incentivized. At the end of the 16 wk, women who attended at least 75% of the exercise classes (24/32) were given a $50 prize, and those who attended 90% (29/32) received a $75 prize. The amount of the incentive and potential for coercion was discussed by the study partners, MAFS and NWU; both agreed that it was important to incentivize a high level of attendance and agreed on an appropriate amount.
We assessed all outcomes of mothers at baseline (preintervention) and within 2 wk postintervention (i.e., at week 17 to 18). At baseline, we obtained demographic information and a brief medical history. Trained bilingual research assistants administered questionnaires and performed blood pressure and anthropometric (height and weight) measurements using standardized protocols (17,24) and calibrated equipment.
Physical activity was assessed using accelerometers and self-report (1). Accelerometers (ActiGraph, model 7164) were worn by study participants at baseline and postintervention for seven consecutive days. We examined change in bout-corrected moderate–vigorous physical activity. For comparison with national physical activity recommendations, 10-min activity bouts were defined as 10 or more consecutive minutes above the relevant threshold, with allowance for interruptions of 1 or 2 min below threshold. This is referred to as a modified 10-min bout. In order for a day of accelerometry to be used in our analyses, the participant had to wear the ActiGraph for at least 10 h. The Fitabase platform was used to collect, aggregate, and export data on daily step counts from the Fitbit Zip™ activity trackers. Forty percent of women had smartphones, and study staff assisted them with downloading the Fitbit™ application to their phones to self-monitor activity. Women who did not have smartphones were provided instructions on how to sync their Fitbit™ on their personal computers; however, none of them used their personal computers to sync their Fitbit™.
Participants underwent a venous blood draw to measure hemoglobin A1c at baseline and postintervention. We used established questionnaires to measure exercise-related confidence (28) and readiness to exercise (20). All study questionnaires were translated into Hindi by the study staff and reviewed and discussed by the study team to ensure cultural equivalency. Participants received a total of $45 after returning the accelerometers at the pre- and postassessments. Study staff tracked attendance. Children's attendance in exercise classes was tracked, but no other measurements were performed on the children.
Adherence was measured as class attendance, and data were analyzed using SAS version 9.4. For all the pre- and postintervention measures, descriptive statistics were used to summarize the variable. To test for differences in physical activity, we used mixed-effects models for pre- and postintervention accelerometer data. In these models, the outcome was daily minutes of bout-corrected moderate–vigorous physical activity. Time (pre-/postintervention) was treated as a binary variable to measure changes in physical activity. Models controlled for accelerometer wear time and weekend day. Changes in clinical and psychosocial outcomes and self-reported physical activity were also compared by pre- and postintervention using t-tests. Tests were considered significant if the two-sided P value was <0.05.
Qualitative Process Evaluation
Bilingual staff not involved in intervention delivery or outcome assessment conducted qualitative interviews with a random sample of participants (n = 6), stratified by attendance, to understand participants' perceptions of intervention components and the barriers and facilitators to exercise. A semistructured interview guide was used, and interviews were conducted in the participants' preferred language. All interviews were digitally recorded, translated, and transcribed, and the content was analyzed for emerging themes. Two team members independently read the transcripts and compiled themes using thematic analysis. Any areas of disagreement were discussed and resolved with the study principal investigator and other study staff.
Participants were enrolled into the study from November 2014 to February 2015. Participant outreach and recruitment are illustrated in Figure 2. Of the 200 women who were screened for eligibility, 55 met the inclusion criteria and 30 were enrolled into the study. The intervention was conducted between February to June 2015 with follow-up assessments in June 2015.
Overall, the participants' average age was 40 yr (SD, ±5), 57% had a high school education or less, and slightly more than one-third were limited English proficient (Table 2). The majority of women in this study were Muslim, were married, and had been living in the United States for an average of 11 yr (SD, ±8). All women had at least one child enrolled in the exercise classes. At baseline, the average BMI of women in the study was 30 kg·m−2 (SD, ±3). Based on our requirement of 10 h of accelerometer wear time, at baseline, only one participant wore the accelerometer for less than 4 d. All participants wore the device for four or more days at follow-up. Accelerometer data showed that participants did not meet the national physical activity recommendations at baseline (Table 3).
Overall, class attendance was 75%, and 57% of the women attended at least 80% of the classes. Thirty-eight children (17 girls and 21 boys) were enrolled in the exercise classes. Sixty-five percent of children attended at least 75% of the exercise classes. Study retention was 100%.
Participants' weight decreased significantly by 3.2 lb (95% confidence interval (CI), −5.5 to −1.0) postintervention (Table 3). We observed no significant changes in accelerometer-measured physical activity; however, self-reported exercise and exercise-related confidence increased significantly postintervention (95% CI, 23–42). There was a small statistically significant increase in hemoglobin A1c and no change in blood pressure (Table 3). At baseline, the majority of women were in the contemplation stage (57%) of the readiness-to-exercise scale, and 17% were in the action/maintenance stage; postintervention, the percentage of women in the action/maintenance stages increased to 45%, but the difference did not reach statistical significance (P = 0.11).
In a secondary analysis, we examined change in outcomes among women who attended at least 80% of the classes (n = 17), and observed significant weight loss postintervention (−4.8 lb; 95% CI, −7.7 to −1.9) (Table 3). Differences in weight change between women who attended at least 80% of classes and those who attended less than 80% of classes did not achieve significance. The Fitbit™ activity trackers showed that the average number of steps at the end of the first week of the intervention was 3161 per day, which doubled to 6700 per day by the last week of the intervention (data not shown).
The process evaluation revealed themes about participant-centered benefits and considerations for intervention development and implementation in South Asian communities (Table 4).
Physical and Psychosocial Benefits from Intervention
Women perceived multiple health benefits from the intervention, encompassing physical, psychological, and social benefits. Women reported that regular exercise increased energy levels and endurance at work and for household chores: “I am a quality inspector, so I have to walk 5 h. I used to complain to my boss that I am very tired, but now after exercise, my boss says I do not get tired.” They also talked about the benefits of weight loss and feeling more confident physically (Table 4, quote 1a). Another very common theme was that exercise helped with stress (Table 4, quotes 1b and 1c).
Effective Intervention Components
Participants liked group exercise for social support and encouragement (Table 4, quotes 1c and 1d). They specifically mentioned group sharing to be motivating: “I liked how every week, everyone used to share experiences and how they benefitted from the program.” Other helpful components that were mentioned included self-monitoring with the activity trackers, receiving feedback on step counts and goals, and learning about healthy eating in conjunction with exercise (Table 4, quotes 2a–2c).
Facilitators and Barriers
Women said that the exercise classes for their children facilitated their own participation (Table 4, quote 3a) and had benefits for their children: “Having your kid together is the most important thing. We cannot take time out and go for exercise when we want. We can go because of the children. Also children get their exercise.” Women were also very clear that they felt comfortable participating in the exercise classes because of sensitivity to cultural values and gender norms (Table 4, quotes 3b and 3c). Some women said they were unable to attend classes and continue exercising because of competing family priorities (Table 4, quote 4a). One participant, who attended over 90% of the exercise classes, mentioned that she could not enroll her 14-yr-old daughter in the children's class because the martial arts instructors were male (Table 4, quote 4b).
In partnership with community organizations, we used community input, formative data, and a CBPR framework to develop, implement, and pilot test a culturally tailored exercise intervention for South Asian mothers with DM risk factors that also included exercise classes for their children. We found that the intervention was feasible for community delivery and that program attendance was high. The participants had a significant increase in self-reported exercise and lost a small amount of weight over the course of the intervention. Although we did not observe a significant change in accelerometer- measured physical activity levels or clinical measures, the intervention effect on physical activity appeared to be in the hypothesized direction with improvements seen from baseline to postintervention. Importantly, the intervention improved exercise-related confidence significantly, which in prior qualitative research has been identified as a barrier to South Asian women's participation in exercise (9). Women also perceived multiple physical and psychosocial benefits to the intervention.
One possible explanation for the lack of increase in accelerometer-measured physical activity is that women may have exercised less once the exercise classes ended. Data from the Fitbit Zip™ activity trackers, which were worn during the intervention period, showed a significant increase in the number of daily steps from the first to the last week of the intervention. In contrast, accelerometers were worn after the exercise classes ended when women no longer had Fitbit Zip™ for self-monitoring or access to a structured physical activity opportunity. The requirement of sustained behavior change is a major challenge in physical activity promotion research (10). However, this study's process evaluation helped the study team to understand participants' perspectives about which intervention components may have been effective and will be used to inform the next phase of research. The process evaluation themes suggest that potential avenues to increase and sustain physical activity among South Asian women might include increasing the availability of community exercise programs that meet the cultural values of South Asian women (e.g., modesty, offering classes for children at the same time), investigating the longer-term efficacy of self-monitoring with activity trackers, and creating virtual social support groups through the use of activity trackers and smartphones to provide the support and motivation that women in this study said were helpful. Sustaining increased physical activity in all segments of the US population will require multimodal behavioral, social, environmental, and policy approaches that are scalable and sustainable.
It is unclear why hemoglobin A1c increased slightly in our study participants, despite weight loss. At baseline, the average hemoglobin A1c among women in this study was 5.7%, which is the lower limit for a diagnosis of prediabetes. This slight increase reached statistical significance but would not be considered clinically meaningful (19). Adding a more intensive dietary component to this intervention may enhance weight loss and promote greater reductions in hemoglobin A1c among South Asian women with risk factors for future development of DM. Another promising area for research is to examine the effect of different types of exercise (aerobic vs resistance vs a combination) on body composition and glycemic outcomes in South Asians. Pilot studies suggest that resistance exercise may confer a greater metabolic benefit in South Asians, who have less muscle mass and more adiposity at a lower BMI than other racial/ethnic groups (21).
A recent meta-analysis found a dearth of interventions addressing diet, physical activity, and overweight/obesity in migrant and native South Asian populations (6). Two recent studies evaluated the effects of Bollywood dance exercise interventions in South Asian women in the United States (22) and Canada (32). In both studies, the interventions were of shorter duration (12 and 6 wk, respectively) and included mostly Asian Indian women with higher education levels than that of the women in our study. Both studies demonstrated feasibility and acceptability of Bollywood dance exercise programs for South Asian women and, overall, had high participation rates. Interestingly, during the intervention planning for our study, the community partner and some community members were hesitant to incorporate Bollywood dance into an exercise intervention for South Asian women because of religious and cultural issues related to dance and modesty. The exercise intervention in our study was not advertised as a dance exercise class, but instructors did use South Asian music and Zumba® during the classes. Study staff reviewed the content of the music and activities with the instructors before the start of the intervention to ensure that activities were sensitive to the religious and cultural values that had been raised during the CBPR process (11). The different approaches used in these three studies highlight the cultural, religious, and socioeconomic heterogeneity of the South Asian community and the importance of CBPR when planning lifestyle interventions for South Asian populations.
Strengths and Limitations
There are several strengths of this study. First, the CBPR approach helped to engage and retain underserved South Asian immigrants in a 16-wk exercise intervention study; others have reported that recruitment and retention of South Asian immigrants into research studies have been a challenge (14,27,29,33). In addition, the study team included multilingual and culturally concordant staff who helped to engage and retain participants throughout the study. We implemented an exercise intervention in a real-world community setting, which increased external validity and provided information on strategies needed for future translation of lifestyle intervention research into community settings.
Limitations of this pilot study are inclusion of a single site in Chicago, lack of a control arm, and that we were only able to recruit and enroll 20% of the individuals we approached. Although some participants said they changed their eating habits after attending the optional healthy eating classes, diet was not measured in this study, and it is unclear how diet may have affected outcomes. It is also unlikely that we reached theme saturation in the process evaluation because we only interviewed a subset of participants. All of these factors limit interpretation and generalizability of results and should be addressed when conducting a larger confirmatory trial.
A culturally tailored multicomponent exercise intervention was an effective model for engaging South Asian mothers in structured physical activity. The results of this study will be used to refine the intervention and to plan a future trial to evaluate efficacy and to determine which intervention components are the most effective for increasing and sustaining physical activity among South Asian women.
This study was funded by the National Institutes of Health R56DK099680.
We thank Ruchi Gupta, M.D., and Ashley Dyer for input on the exercise classes for the children, and David Conroy, Ph.D., for input on measurement. We thank our exercise instructors, Adenia Linker, Manjari Patil, Carolina Escrich, Roberto Luna, Muhammed Javed, and Dante Peña. We would like to acknowledge Meraj Baig, Madhuri Pydisetty, Ankita Puri, and Vrati Parikh for assistance with data collection.
The authors have no conflicts of interest to disclose.
Results of the present study do not constitute endorsement by the American College of Sports Medicine.
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