Regular physical activity (PA) sufficient to maintain or increase cardiorespiratory fitness can reduce the incidence of and mortality from heart disease in women, their number one cause of death. Fewer than 15% of US women are active enough to achieve a reduction in coronary heart disease (CHD).1 Moreover, with increasing age, women's incidence of and death from CHD increases, whereas their level of PA declines.1 Eighty-five percent of US women who are not sufficiently active to achieve a reduction in CHD typically need only to increase their PA by a small amount to achieve improved fitness and a reduction in CHD.2 Brisk walking for 30 minutes, 5 days per week, reduces CHD in women.3
Rural women have a higher incidence of risk factors for and morbidity and mortality from CHD compared with urban and suburban women.4,5 Although the total dynamic of this health disparity is not fully understood, rural women are less active than urban and suburban women.4 Because rural women have both high rates of physical inactivity and mortality from CHD, it is critical to increase the number of rural women who are active enough to reduce their incidence of CHD. However, little research has been directed toward increasing PA in rural women. The purpose of this study was to address this critical gap by testing Heart-to-Heart (HTH), an intervention designed to encourage walking for health in rural women.
Women report different determinants of PA6 and have had different response patterns to PA interventions compared with men.7 Recent systematic reviews of PA interventions identified only a few PA interventions designed specifically for women and recommended tailoring interventions by gender.8-11 Interventions tailored specifically to women and delivered in a community setting have had mixed results. A 1-group study with 50 women involved 6 group meetings and showed a significant increase in PA that was sustained at 5 to 13 months postintervention.12 However, in another study, there was no significant change in PA in 199 women with young children randomized to receive written material and attend 1 group meeting at 5 months postintervention.13 Two randomized studies involving mailed written material had inconsistent results: in one study, women in all groups increased their level of PA, and in the other, women in both groups decreased their level of PA.14,15
Collectively, these studies indicate that more research is needed, but they do not provide a clear direction for future research. Interventions may be more successful with some women than others because of their motivation to change. Motivational interviewing (MI)16 is one way to address motivation individually. It is an approach to behavior change counseling that focuses on building self-efficacy and is tailored to an individual's readiness to make a change.16 Behavior-change programs with MI as the basis have been successful.17 Group-based activities may also help women make these behavior changes because of support, especially for rural women who may be more isolated. In fact, the Task Force on Community and Preventive Services recently reported that there was strong evidence to recommend social support interventions and individually adapted health behavior change programs delivered in community settings.11 Therefore, HTH combined individual strategies with group-based activities within a 12-week walking program.
An integration of social cognitive theory18 and the transtheoretical model19 guided the development of HTH. Both theories describe self-efficacy, situation-specific perception of capability, and social support as critical to behavior change. Because self-efficacy and social support have been shown to predict exercise adoption in women,20,21 HTH emphasized enhancing self-efficacy and social support. The chief component of the group-based activities designed to increase social support and self-efficacy consisted of women meeting weekly as a group to discuss barriers and motivators to walking and to walk together for 30 minutes. Motivational interviewing was the principal component of the individual-oriented component designed to increase self-efficacy. Women in a comparison group received brief advice on how to incorporate walking into their daily life.
Two hypotheses were tested in this randomized study using a 2-group, pretest-posttest design. First, women in HTH group compared with the comparison group will achieve a greater increase in cardiorespiratory fitness. Second, women in the HTH compared with the comparison group will experience a greater increase in exercise self-efficacy and social support for exercise. An additional aim was to determine the effect size of HTH on the outcomes. The university's Institutional Review Board approved this study.
The study was conducted in a rural county in the Pacific Northwest with a population density of 84 people per square mile. In 2000, 85% of the population was non-Hispanic white, and the per capita income was $19,282.22 Most jobs in the area are sedentary rather than in agriculture or forestry. Women lived in rural towns or unincorporated parts of the county. A town was considered rural if it was at least 10 miles from a town with a population of 30,000 or more.23
Recruitment and Randomization
Women were recruited from flyers placed at 2 community clinics and 2 private practices in the rural county. Women were eligible if they met the following inclusion criteria: (1) ability to speak and read English; (2) age 21 to 65 years; (3) physically inactive, defined by exercising less than 3 days a week at moderate intensity in the last month; (4) interested in increasing their exercise; (5) approval by the primary care provider to safely engage in exercise; (6) has access to a telephone; and (7) lived in a rural area. Exclusion criteria were as follows: (1)history of heart disease based on self-report, (2) a physical condition that precluded exercise, (eg, musculoskeletal or neurological disorder), or (3) pregnancy.
Because HTH involved group-based activities, it was necessary to recruit 14 to 16 women before conducting the intervention so that 7 to 8 women would be randomized to an HTH group. Therefore, women were grouped into cohorts to reduce the waiting time between when a woman enrolled and when a sufficient number of women enrolled to conduct the intervention. Pretest measures were collected for each cohort at the start of their 12-week intervention. After the pretest, women were paired based on their fitness level and were then randomized using a procedure akin to a coin toss to either HTH or the comparison group. This was done to reduce the chance of women in one group compared with the other being significantly less fit. A researcher who did not enroll participants or conduct study activities performed the randomization, thereby removing the possibility of selection bias. Posttest measures were collected for each cohort at the end of the 12-week program.
Table 1 outlines study activities for the HTH and comparison groups. An advanced practice nurse (APN) conducted the study activities in both the HTH and comparison groups. We deemed that it was ethically necessary to provide women in the comparison group with some advice and tools to promote PA; this decision may have lessened group differences on the outcome variables.
The key aspect of the individual-oriented component was MI. The main goal of the MI counseling was to assist the women in exploring their mixed feelings toward behavior change, articulating the pros to change, and developing an action plan to increase PA.16 An APN conducted a private, in-person, 30-minute MI session at the beginning of the 12 weeks, followed by weekly, 10-minute MI booster session telephone calls. Additional strategies aimed at enhancing self-efficacy included women establishing individualized and realistic goals and monitoring their progress with heart rate monitors and logbooks. Women received an individualized exercise prescription following the American College of Sports Medicine (ACSM) guidelines.24
The main aspect of the group-based component was a 1-hour, weekly group walk using strategies to promote social support and self-efficacy.18,19 During the group walk, women walked together around a track for 30 minutes and were encouraged to walk with women who had similar walking paces. The APN moved back and forth across the track to provide encouragement and positive reinforcement to each woman during the walk. In addition, the APN led a weekly 15- to 20-minute discussion guided by the philosophy of MI before the start of the group walk at the track. In concert with MI, the women in the group, rather than the APN, identified salient topics to discuss and provided ideas on how to overcome challenges. They validated their experiences with each other regarding exercising in the past week and progress toward reaching their goals. These strategies provided reinforcement, support, interaction, encouragement, mastery experiences, and role modeling.
Team-building strategies were implemented to encourage the formation of a cohesive group and enhance the connections among the women, thereby increasing social support.25 These included the development of a group T-shirt to create a distinctive group. The women put together a telephone contact list and were encouraged to telephone each other to discuss progress and provide support and reinforcement. Women also were encouraged to continue the weekly walks as the intervention came to an end.
Women randomized to the comparison group received a brief 10-minute individual and private advice session and a monthly 5-minute reinforcement telephone call. In addition, they received an individualized exercise prescription following the American College of Sports Medicine guidelines24 and a logbook to record their walking.
Cardiorespiratory fitness was measured by distance walked in the 12-minute walk test.26 This commonly used field test to measure fitness27 has been highly correlated with VO2max (r = .90).26 The 12-minute walk test is a measure of adherence to the walking program because the amount of walking performed during the 12 weeks would be reflected in the distance achieved in the 12-minute test and is correlated to fitness level. Distance walked in 12 minutes is physiologically expected to change in 3 months with regular, moderate-intensity PA.28
Self-efficacy for exercise was measured using the Self-efficacy for Exercise Habits Survey.29 On a 5-point Likert scale, respondents rated their confidence at being able to do behaviors related to persisting with exercise that are described in 8 statements. The total score is derived from the mean of the item scores with a range of 1 to 5. A higher score indicates greater self-efficacy. Significant correlation between level of self-efficacy and amount of self-reported exercise has been reported, supporting concurrent validity.29 In a previous study, the Cronbach alpha was reported to be .85.29 In this study, it was .63.
Social support for exercise was measured using the Social Support for Exercise Survey.30 Respondents rated the frequency of behaviors that friends may do in response to their exercise; these behaviors are described in 10 statements on a 5-point Likert scale. Item scores are summed with a range of 10 to 50. Significant correlations between self-report level of exercise and social support for exercise have been reported, supporting concurrent validity.30 A higher score indicates greater social support. In a previous study, Cronbach alpha was reported to be. 61.30 In this study, it was .84.
Exercise stage of change was determined using The Exercise Stage of Change Short Form.31 Respondents answer yes or no to 5 statements that relate to an individual's readiness to exercise. The pattern of responses to the 5 statements establishes the stage. In a previous study, the kappa index of reliability over a 2-week period was found to be .78.31 In another previous study, higher VO2max was associated with more active stages of change, supporting concurrent validity.32 Stage of change was measured to direct motivational interviewing to a woman's stage of change for women in the HTH group.
Physiologic measures. Body mass index was calculated from height reported by the participant and weight measured by an APN using a calibrated portable scale.
Demographic data. Sociodemographic characteristics and the presence of risk factors for CHD were documented by self-report.
Data were analyzed using the Statistical Package for the Social Sciences, SPSS (Chicago, Ill). Intention-to-treat analysis was used. A series of repeated-measures analysis of variance, with group and time as the independent variables and each outcome as the dependent variable, was used to evaluate group differences on cardiorespiratory fitness, social support, and self-efficacy. The analysis of interest was the interaction between group and time. Effect sizes, d, were calculated using the group means divided by pooled standard deviations for outcomes in which there was a significant group-by-time interaction. Alpha was set at .10. because this was a small study and we wanted to minimize type II error.
Figure 1 depicts the flow of women through recruitment, enrollment, the program, and analysis. Sixty-seven women contacted the investigator in response to the flyers, and 46 women who met the criteria enrolled in the study. Twenty-three were randomized to HTH and 23 to the comparison group. Forty-two completed the program (HTH, 20; comparison, 22). The 12-week program was conducted in 3 distinct cohorts during 2004 (June-August, September- November, and October-December). The overall attrition rate was 12%. There were no adverse events reported in either group.
Table 2 summarizes the sociodemographic characteristics, risk factors, stage of change, and physiological measures of the participants at baseline. There were significant differences between the HTH and comparison groups on 2 of the baseline characteristics. In the HTH group, more women reported diabetes. The HTH group had more women in the contemplation stage, whereas the comparison group had a greater number of women in the preparation stage, suggesting that, on average, women in the comparison group were more ready to adopt an exercise program.
The mean number of weekly group walks attended by the women in HTH was 8.50 with a range of 4 to 12 (possible total of 12). Sixty-five percent of the women attended at least 8 of the group walks (60% of total), and 80% attended at least 6 of the group walks (50% of total). There was no significant difference in attendance at the weekly group walk among the 3 cohorts. The weekly group walk and discussion were held in the evening at a centrally located outdoor walking track. The predominant weather experienced by each cohort varied from sunny and hot to rainy, dark, and cold. Despite this difference in weather, attendance at the outdoor weekly group walk did not differ. Thus, weather did not appear to be a factor in attendance. These data indicate that most women had the potential to receive the benefit from the group-based strategies in HTH.
All women in the HTH received an initial private, in-person MI counseling session that lasted from 20 to 35 minutes. Women received a mean of 4.85 (range of 3-8, with a possible total of 10) over-the-telephone MI booster sessions that lasted from 5 to 15 minutes. Sixty percent of the women received at least 5 telephone calls (50%). There was no significant difference in the mean number of telephone calls between each cohort. These data indicate that all the women in the HTH received the benefit of the initial MI session; however, they received inconsistent amounts of the beneficial potential of over-the-telephone booster MI sessions.
The APN was trained in MI, determined to be proficient in providing MI by independent evaluators, and conducted all the MI sessions. The APN also led all the group discussions and walks. Thus, there was consistency in the delivery of the intervention. The APN recorded written field notes after each telephone call and group walk. A researcher compared these field notes to the study protocol and determined that the APN had adhered to the protocol during all study activities.
Women in the HTH group compared with the comparison group will achieve a greater improvement in cardiorespiratory fitness.
Table 3 reports the results of the repeated-measures analysis of variance for cardiorespiratory fitness. One of the 20 women in the HTH group was not able to complete the posttest 12-minute walk test due to knee pain; therefore, in this analysis, n = 19 in the HTH and n = 22 in the comparison group. There was a statistically significant group-by-time interaction for cardiorespiratory fitness. The effect size, d, was .648. According to Cohen's criteria, this demonstrates a moderate effect.33
Women in the HTH group compared with the comparison group will experience a greater increase in self-efficacy and social support.
Table 3 reports the results of the repeated-measures analysis of variance for social support and self-efficacy. There was a statistically significant group-by-time interaction for social support; the effect size, d, was 1.3. This is a large effect according to Cohen's criteria.33 There was no statistically significant effect on exercise self-efficacy.
This innovative 12-week walking program targeted at rural women was feasible to conduct in a rural area and was well received by the rural women. The HTH intervention, guided by an integration of social cognitive theory and the transtheoretical model, emphasized building self-efficacy and social support by advantageously combining individual-oriented and group-based strategies.
Attendance at the weekly group walk in this study was similar or greater than that reported in other group-based programs for women. In HTH, 80% of the women attended 50% of the group walks, and 65% attended 60% them. Similarly, in another group-based program, 78% of participants attended 50% of the weekly classes during a 10- week program.34 In contrast, only 28% of women attended 60% of classes held 3 times a week during an 18-week program.35 Once-a-week group interaction may be more feasible than 3 times a week for women to fit into their complicated and busy lives. These attendance rates suggest that it is important to develop a program, such as HTH, that considers women's time constraints and complex schedules by condensing the beneficial aspects of a group into weekly group meetings. Scheduling the day and time of weekly meetings with input from potential participants may enhance attendance.
Heart-to-Heart improved cardiorespiratory fitness, as measured by change in distance walked in 12 minutes, in this sample of rural women. This increase in fitness is similar to the increase in fitness reported in a recent church-based program with rural women that involved group-based strategies and individual-oriented strategies.36 The findings from that study and this current study indicate that combining group-based and individual-oriented strategies is an effective approach to ultimately increasing fitness in rural women. To the authors' knowledge, there are not any reported studies that examine the effectiveness for rural women of either individual-oriented or group-based strategies alone. Thus, it is not known whether using a combination of individual-oriented and group-based strategies, such as the ones used in the HTH program, is more effective than using either independently. In future studies, determining the relative effectiveness of each strategy used will assist with learning the most influential aspects for an intervention and will inform where to concentrate future efforts to increase fitness in rural women.
Women in both groups experienced a minimal increase in exercise self-efficacy. Baseline levels on the self-efficacy scale were close to or greater than 4.0 (on a 1-5 scale) in women in both groups, indicating a high level of self-efficacy before starting the 12-week program. It is possible that increases in self-efficacy were not detected because of a ceiling effect. This sample of women may have started with high self-efficacy because only women who were interested in increasing PA were recruited. In addition, the modest Cronbach alpha of .63 on the self-efficacy scale in this study indicated low reliability in our sample. Another walking program conducted with urban women also reported that their participants had high levels of exercise self-efficacy at baseline; however, their self-efficacy declined postintervention, unlike the women in the HTH study.37 Self-efficacy is inherently dynamic; therefore, it may be necessary to measure it more frequently than pre and post to detect change.
Women in HTH compared with the comparison group experienced a greater increase in social support as hypothesized. The effect size, d, of 1.3 is large.33 The HTH intervention was designed to encourage support among women in the walking group. At the end of the intervention, women planned to continue the weekly group walks, in part, because of the support provided by the group. In the group discussions, women reported feeling validated and supported by members in the group and enjoyed the camaraderie of the group. Similarly, in an earlier 1-group study, social support from friends increased in response to an intervention designed to increase social support and exercise stage of change among mothers with young children attending a weekly group exercise class.34 The large effect size in HTH suggests that the group-based activities in HTH designed to increase social support were very effective and may have been an important factor in ultimately increasing fitness in our sample of rural women.
A potential limitation is that the same investigator conducted the intervention and activities with the comparison group and collected the data. Thus, there was a potential for similarity in the HTH and comparison groups counseling sessions and calls and for bias in measurement. To mitigate this potential, protocols for collecting data and conducting each activity in HTH and the comparison group were developed before the start of the study and strictly adhered to by the APN throughout the study.
Another potential concern was the possibility of crossover from the comparison group because this study was conducted in small rural towns. Three women did cross over. Because this could have narrowed the differences in outcomes between the groups, ultimately reducing the calculated effect sizes of the HTH program, a subsequent analysis was conducted without the 3 crossovers from the comparison group to examine this possibility. However, the same effect sizes, for change in fitness (d = 0.648) and social support (d = 1.3) were calculated in this subsequent analysis.
Nurses are instrumental in educating and counseling rural women about meeting the recommended 30 minutes of moderate-intensity PA at least 5 days a week. Nurses practicing in a variety of settings, including rural primary care practices, specialty practices, rural community hospitals, and tertiary urban hospitals, will encounter women who live in rural areas. The results from this study suggest that counseling rural women using motivational interviewing and encouraging rural women to combine individual strategies, such as self-monitoring, with participating in a walking group and gaining social support may increase the likelihood of successfully adopting a walking program. Increasing walking will subsequently increase fitness. In addition to counseling women, nurses could assist in coordinating local walking groups for rural women.
The HTH program was successful in increasing cardiorespiratory fitness in a sample of rural women. In addition, HTH was successful in increasing social support for exercise, and this increased social support may have contributed to the increase in fitness. Heart-to-Heart was feasible to conduct in a rural area. The combination of individual motivational interviewing sessions and group-based activities was well received by the women who participated in HTH. Increasing walking and therefore, fitness in rural women can reduce their risk of CHD. Few previous studies have examined increasing PA in rural women, and this study addressed this gap.
The authors acknowledge funding for this work from the National Institutes of Health, Office of Research on Women's Health & the National Institute of Nursing Research predoctoral fellowship (F31 NR08656), Oregon Health & Science University School of Nursing Dean's Dissertation Award, Northwest Health Foundation, and Sigma Theta Tau International, Beta Psi Chapter.
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