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Interventions Promoting Physical Activity in African American Women: An Integrative Review

Jenkins, Felicia MSN, RN; Jenkins, Carolyn DrPH, APRN, RD, LD, FAAN; Gregoski, Mathew J. PhD, MS; Magwood, Gayenell S. PhD, RN

The Journal of Cardiovascular Nursing: January/February 2017 - Volume 32 - Issue 1 - p 22–29
doi: 10.1097/JCN.0000000000000298
ARTICLES: Cardiac Rehabilitation
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Background: Physical inactivity significantly impacts mortality worldwide. Physical inactivity is a modifiable risk factor for obesity, diabetes, cardiovascular disease, and other chronic conditions. African American women in the United States have the highest rates of physical inactivity when compared with other gender/ethnic groups.1 A paucity of research promoting physical activity (PA) in African American women has been previously identified. The purpose of this review was to identify intervention strategies and outcomes in studies designed to promote PA in African American women.

Methods: Interventions that promoted PA in African American women published between 2000 and May 2015 were included. A comprehensive search of the literature was performed in Health Source: Nursing/Academic Edition, PsycINFO, CINAHL Complete, and MEDLINE Complete databases. Data were abstracted and synthesized to examine interventions, study designs, theoretical frameworks, and measures of PA.

Results: Mixed findings (both significant and nonsignificant) were identified. Interventions included faith-based, group-based, and individually focused programs. All studies (n = 32) included measures of PA; among the studies, self-report was the predominant method for obtaining information. Half of the 32 studies focused on PA, and the remaining studies focused on PA and nutrition. Most studies reported an increase in PA or adherence to PA. This review reveals promising strategies for promoting PA.

Conclusions: Future studies should include long-term follow-up, larger sample sizes, and objective measures of PA. Additional research promoting PA in African American women is warranted, particularly in studies that focus on increasing PA in older African American women.

Felicia Jenkins, MSN, RN Doctoral Student, College of Nursing, Medical University of South Carolina, Charleston; Senior Instructor, University of South Carolina Upstate, Spartanburg.

Carolyn Jenkins, DrPH, APRN, RD, LD, FAAN Professor, College of Nursing, Medical University of South Carolina, Charleston.

Mathew J. Gregoski, PhD, MS Assistant Professor, College of Nursing, Medical University of South Carolina, Charleston.

Gayenell S. Magwood, PhD, RN Associate Professor, College of Nursing and Chair, Department of Nursing, Medical University of South Carolina, Charleston.

C.J. is supported by National Institutes of Health/National Institute of Nursing Research (Grant # R15 NR009486) and Centers for Disease Control and Prevention (Grant # U58 DP001015 and # U50 DP422184). G.S.M. is supported by National Institutes of Health/National Institute of Nursing Research (Grant # K01 NR013195) and National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (Grant # R34 DK097724). The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention, National Institutes of Health, National Institute of Nursing Research, or National Institute of Diabetes and Digestive and Kidney Diseases.

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcnjournal.com).

Correspondence Felicia Jenkins, MSN, RN, College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St, Charleston, SC 29425 (jenkinf@musc.edu).

Physical inactivity is a leading risk factor for mortality worldwide.2 Physical inactivity is associated with heart disease and other chronic health conditions.1 According to the World Health Organization,2 1 in 3 adults worldwide are physically inactive. Physical activity is defined as “any bodily movement produced by skeletal muscles that requires energy expenditure.”2Healthy People 2020 estimated that more than 80% of adults in the United States do not meet the minimal recommended Centers for Disease Control PA guidelines3 (ie, recommendation of 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity each week, plus strength conditioning at least twice per week).4,5 For example, in an analysis of stroke and heart disease statistics reported in 2011, an estimated 24.5% of US adults met the muscle-strengthening criteria, and 21.0% met both the muscle-strengthening and aerobic criteria.1 Increasing the proportion of adults who meet federal PA guidelines is 1 of the Healthy People 2020’s established objectives. Physical activity is essential to health promotion and decreases risk for various conditions, including but not limited to heart disease, stroke, and diabetes.4,5 In addition to reducing the risk of heart disease, meeting PA guidelines has been associated with lowering the risk of hypertension and hyperlipidemia.1,4

Heart disease is the leading cause of death for African American women.6,7 African American women have a higher rate of risk factors associated with heart disease, including hypertension, physical inactivity, and obesity. African American women have the lowest rate of exercise and leisure time PA.8 Among African American women, 35.5% meet PA guidelines, compared with 50.9% for non-Hispanic white women, 47.5% for African American men, and 56.4% for non-Hispanic white men.1 According to data collected in 2011 by the US Department of Health and Human Services, African American women were 80% more likely to be obese than non-Hispanic white women.9 African American women had an obesity rate of 54.0%, compared with 38.3% for non-Hispanic black men and 32.5% for non-Hispanic white women.9 The American Heart Association/American College of Cardiology Guideline on Lifestyle Management to Reduce Cardiovascular Risk5 suggests additional research is needed to determine strategies for effectively implementing evidence-based recommendations to improve cardiovascular health. Additional research is warranted to increase understanding of racial/ethnic/socioeconomic factors that may act as barriers and prevent adoption of PA recommendations.5 Healthcare providers, including cardiovascular nurses, can be actively involved in determining strategies to implement recommendations and promote adoption of PA recommendations. Promoting PA in African American women is an essential factor in reducing the risk of heart disease and other chronic health conditions. Therefore, it is important to understand which intervention strategies are most effective when promoting PA among African American women.

This integrative review examines intervention studies published between 2000 and May 2015 that promote PA among African American women. It is important to note this review includes studies completed after the review by Banks-Wallace and Conn,10 which examined 18 studies from1984 to 2000; 7 specifically focused on African American women.10 Because of the paucity of research at the time, Banks-Wallace and Conn10 included studies that consisted of a sample of at least 35% African American women. The current review includes studies specifically focusing on African American women or studies reporting results separately for African American women. Race, ethnicity, and gender should be a central focus when developing and implementing effective PA interventions among specific populations; the inclusion of additional population subgroups other than African American women may unknowingly reduce the generalizability of results.8,11

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Methods

The purpose of this review is to identify intervention strategies and outcomes in studies designed to promote PA specific to African American women. As a result, interventions that solely focused on African American women or that reported findings separately for African American women were included. In addition, only intervention studies with direct measures of PA were included. Direct measures of PA included questionnaires, self-reporting, and objective measures such as pedometers and accelerometers. As recommended by Whittemore and Knafl,12 5 stages of review were completed: problem identification, literature search, data evaluation, data analysis, and presentation.

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Problem Identification

Studies that met the following criteria were included in the search: (1) English language, (2) reported measures of PA in African American women, (3) published between January 2000 and May 2015, and (4) sample consisted of African American women only, or results were reported separately for African American women. Excluded were studies that did not report PA results by race and gender, as well as abstracts, and dissertations.

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Literature Search

A literature search12 occurred in PsycINFO, Health Source: Nursing/Academic Edition, CINAHL Complete, and MEDLINE Complete electronic databases for studies published from January 2000 to May 2015. The following search terms were included: “physical activity” or “motor activity” or “exercise” and “African American” or “black” and “women” and “intervention.”

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Data Evaluation

After abstracts were screened for duplicate studies and relevance, 32 articles were included in the review. The Figure provides a description of the search outcome. Studies included in this review were appraised using the Centre for Evidence-Based Medicine criteria, and the appraisal is shown in the Table, Supplemental Digital Content 1, http://links.lww.com/JCN/A18. The Centre for Evidence-Based Medicine provides a framework for assessing the level of evidence.13 The majority of the selected studies were randomized controlled trials.14–27 After reviewing CONSORT (Consolidated Standards of Reporting Trials),28 the investigator determined that most of those randomized controlled trials adhered to the CONSORT reporting guidelines (60%). The most common omission was identification of the study as a randomized trial in the title.17,18,22,23,25–27

FIGURE

FIGURE

TABLE 1

TABLE 1

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Data Analysis and Presentation

Studies included in this review are presented in the Table, Supplemental Digital Content 1, http://links.lww.com/JCN/A18, with the following column headings: purpose, design, intervention, theoretical framework, sample/location, physical activity (PA) measure, PA outcomes, and strengths/limitations.

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Results

Results identified in this review include significant and nonsignificant changes in PA. Thirty-one studies focused solely on African American women. One study included non-Hispanic white and African American women, with results reported separately for each racial group.29

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Sample Description

The patient populations across the studies were heterogeneous and included low-income women,30 postpartum,31 pregnant,32 breast cancer survivors,33–35 type 2 diabetes,19 mobility disabilities,36 and women with high-normal or untreated stage 1 hypertension.22 Common inclusion criteria included overweight or obesity15,18,23,32,34,37 and sedentary.16,22,29,31,33,36,38–40 Few studies focused on women who were 40 years or older19,25 and 60 years or older.14,16

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Theoretical Framework

Twenty-two of the 32 studies included in this review relied on a theoretical framework,11,14–17,20,21,23–27,29,34,35,37,39–42 with all reporting significant or mixed results, with the exception of 2 studies reporting nonsignificant changes in PA.25,26 The most commonly used theory identified was the Social Cognitive Theory, either used alone16,17,23,26,27,30,32,37,43 or in combination with another theory.11,20,21,34,42 Several studies did not report using a theory-based intervention; however, significant changes in results were reported including an increase in total minutes of PA,33,36,45 increase in steps per day,31,38 and self-reported energy expenditure.22 Several concepts identified in the intervention strategies included goal setting,11,14–16,20,22,26,32,33,36,39,40,42 reinforcement,16,32 and problem solving.15,22,32,35,36,44,47 Self-monitoring of PA15,22,32,37,42 and PA barriers15,36 were identified as intervention strategies. Notably, both theoretical and atheoretical studies reported significant and mixed results.

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Intervention Strategies

Intervention strategies included culturally tailored interventions, faith-based interventions, group-based programs, and individually tailored programs. Furthermore, strategies included face-to-face sessions, telephone sessions, a combination of face-to-face and telephone sessions, and peer support.

As in the previous review by Banks-Wallace and Conn,10 several studies described culturally tailored interventions. Culturally tailored interventions will refer to studies that tailored the intervention to African American women. Many studies11,15,17,19–21,23,24,37,40,41,43,44 reported culturally tailored interventions cited in prior research or focus group findings that were incorporated into the design of the intervention strategies. Several studies were led by ethnically matched individuals.25,26,32,39,43,44 Additional culturally tailored strategies identified include adapting educational materials and sessions for African American women, choice of location,43,44 and social support.15,26,39,43,44 Across studies using a culturally tailored intervention, significant results,11,19–21,43 mixed results,17,24,40–42 and nonsignificant results15,37 were reported.

Faith-based settings are commonly used as research intervention delivery sites.10 However, similar to the previous review by Banks-Wallace and Conn;10 few faith-based studies were found. Three studies26,43,45 were conducted in faith settings; however, these studies did not include a faith intervention. Studies conducted in a faith setting reported significant,43 nonsignificant,26 and mixed45 results. Five studies14,16,25,27,39 were faith-based interventions. Faith-based intervention strategies included health information messages that were relayed by the pastor,25 faith community nurse,14 prayers,14,16,25 Bible messages on holistic wellness,39 and Bible scriptures.14,16,25,27 Faith-based intervention studies reported results that were mixed14,16,39 and nonsignificant.25,27

The majority of the studies included an educational or instructional component. Several studies16–18,21,25–27,34,38,39,43–45included group exercise sessions. This review revealed that several studies included a group meeting or educational session.11,16–19,21,25–27,32,34,38–40,43,45 Across home-based18,29,33,40,42 and telephone-based36 studies, significant and nonsignificant results were reported. Another strategy identified were phone calls from a peer counselor or research staff member.18,19,31–33,36,40,45 Motivational interviewing was used as a strategy in several studies.15,20,33,36 Peer support was a component of several intervention strategies by including a walking or exercise partner.21,26,31,38 The Table, Supplemental Digital Content 1, http://links.lww.com/JCN/A18, provides additional information regarding PA interventions. The Table includes strategies from selected studies that reported significant changes in PA.

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Physical Activity Measures

Physical activity measures included self-report, pedometers, accelerometers, heart rate monitors, and an armband with accelerometer and galvanic skin response (ie, SenseWear). The most common objective measures were pedometers16,31,35,38 and accelerometers.19,33,37,39,43 Nine studies included both objective and self-report measurements.16,24,26,33,37,39,40–42 This review revealed that self-report measures of PA are more commonly used, with only 14 of the 32 studies using an objective measure. The majority of studies using an objective measure reported significant results. Although self-report measures provided significant and nonsignificant results, future studies using self-report measures should include an objective measure as well. For example, a faith-based, pilot study39 reported significant, self-reported results, although an objective measure provided nonsignificant results. The Table, Supplemental Digital Content 1, http://links.lww.com/JCN/A18, provides information regarding the various self-report measurements.

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Physical Activity Outcomes

The majority of the studies did not include a follow-up period or measure outcomes beyond the intervention. Of the 32 studies, 28 reported significant results in at least 1 outcome. Although several studies reported significant results for 1 measure, nonsignificant results for another measure were reported. This finding is similar to the previous review,10 with mixed results of interventions promoting PA in African American women. Significant results were reported for muscle-strengthening activities,14 6-minute walk test,14 steps,16,30,31,34 total minutes of PA,32,35,39 changes in PA,16,19,21 time spent in PA,32,36,39 and time spent in leisure time PA20 and vigorous activity.34 Other studies reported nonsignificant results for overall PA hours per week,16 moderate to vigorous activity,18 PA intensity,39 and walking intensity.40 Total daily expenditure of energy was significant for 2 studies22,32 and nonsignificant for 2 studies.14,25 Although weight loss was not the focus of this review, studies reported significant weight loss (based on body mass index [BMI] and/or weight)23–25,31,34,35,43 and nonsignificant difference in weight.16,18,33 This review reveals mixed findings for changes in PA, with several studies indicating significant changes and other studies reporting nonsignificant findings. The Table provides additional information for measures and outcomes in this integrative review.

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Discussion

Increasing PA is important for all populations; however, intervention strategies that promote PA in African American women are essential because African American women have the highest rate for physical inactivity and obesity in the United States. Increasing PA in African American women is a crucial component to reducing the prevalence of chronic health conditions. This review provides insight into the current state of the science focusing on intervention strategies that promote PA in African American women.

Older adults are more likely to not meet PA guidelines when compared with younger adults.4,46 In a 2011 report,46 only 15.9% of older adults (≥65 years) met aerobic and muscle-strengthening guidelines. Older African American women tend to have a lower level of PA.14,16 Most studies promoting PA in African American women have primarily focused on young and middle-aged women.10 This review revealed a dearth of PA interventions focusing on older African American women. Several studies included age ranges that included women through age 65 or 70 years; however, only 2 studies14,16 specifically focused on women 60 years or older. Both studies reported significant findings including change in steps16 and changes in muscle-strengthening activity14 and nonsignificant findings for change in overall PA or total daily energy expenditure, based on objective and self-report data. One study14 reported a significant difference in muscle-strengthening activity and a nonsignificant difference for moderate PA or total daily expenditure. The other study16 focused on strategies to increase walking and reported a significant increase in steps, yet nonsignificant for overall PA in hours per week. Increasing both aerobic activity and muscle strengthening is important for older African American women and older adults in general.

The use and benefit of interventions utilizing a theoretical framework are mixed. The review by Banks-Wallace and Conn10 revealed an infrequent use of theoretical frameworks, which are essential to intervention studies.47 Theoretical frameworks have been emphasized as integral to behavioral and health science research to guide intervention design and evaluation.47 This review revealed various theoretical frameworks that were utilized in PA interventions for African American women. In addition to theoretical frameworks, culturally tailored interventions should be considered.11 Interventions that are culturally tailored increase acceptability by participants.11 The majority of culturally tailored interventions reported significant or mixed changes in PA.

This review revealed promising PA intervention strategies for increasing PA in African American women. As with the previous review,10 intervention components included problem solving, social support, goal setting, and group exercise. These intervention components have been identified as effective ways to increase PA.10,29 Despite faith-based settings being a commonly used site for interventions,10 few studies in this review were identified as a faith-based setting or faith-based intervention. Notably, mixed results were reported for faith-based interventions and studies held in faith-based settings. Faith communities have the potential to influence the health of African American women,39 particularly for those who consider their faith to be an important part of their life.14,16 Future faith-based intervention and faith-based setting studies are warranted. In addition to faith-based intervention studies, group-based and individually tailored interventions were identified. Various barriers to PA for African American women have been reported including costs, child care/caregiving, lack of safe places to exercise, hair maintenance, and lack of time.11,42,48 Home-based programs are a promising approach to increase PA while also eliminating several potential PA barriers. Home-based programs included in this review yield mixed results18,40,42 and significant changes in PA33 and PA adherence.29

Physical activity outcomes were most commonly measured by self-report. Moreover, various measurements of PA were included in the review. Physical activity measures included self-report questionnaires and objective measures such as pedometers, accelerometers, 6-minute walk test, and 1 study that utilized SenseWear armbands. Objective measures may decrease the rate of errors, specifically the potential to report inaccurate PA levels with self-report questionnaires. Objective measures may also influence behavior change. For example, research indicates that pedometers help to increase PA.49

Participants reported that increasing PA was the most difficult behavior change.11 However, despite difficulty of behavior change, several studies reported high participant satisfaction.19,34,35,42 This review identified a diversity of study designs, interventions, and outcomes. Several findings should be cautiously considered because of their lack of a randomized controlled design or a comparison group.11,20,27,33–36,38,39,42–44 Several studies utilized a single-arm pre-post design29,33,34,37,38,42–44 or quasi-experimental design.11,30,40 In addition, several studies included a small sample size.14,16,18,22,32–35,38,39,42 Future studies should include a randomized controlled design and objective PA measures. Examining participation rates beyond the study would be an important consideration for future studies. Although several studies report significant results, additional studies focusing on long-term PA maintenance are warranted. Most studies in this review did not include a follow-up period beyond the postintervention measurements. Of the 9 studies that included a follow-up period for measurements, low return for follow-up was identified as a limitation in 2 studies.25,26 One study23 reported significant differences in vigorous and moderate PA at 6 months for the intervention and control groups; however, at 18 months, PA results were nonsignificant.50

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Limitations

This review does not include abstracts, dissertations, or studies referenced in other databases. A second limitation is the limited number of studies that focused on older African American women. As with the previous review, small sample size was a common limitation. Additional limitations include the use of self-report measures by most studies and the exclusion of indirect measures of PA including BMI and weight. However, this review focused on direct measures of PA. Indirect measures of PA such as BMI and weight may be influenced by dietary behaviors as well as PA10; therefore, indirect measures were not a search criterion for this review.

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Future Implications/Conclusion

Sixteen of the 32 studies included in this review focused on PA only, whereas the other studies focused on PA and nutrition. Many studies did not include follow-up measures. Future studies that include measures beyond the immediate postintervention measurement are warranted. Many studies included self-report data that may be affected by measurement errors, for example, PA overreporting. Thus, also warranted are future studies using objective measures entirely or studies that combine self-reports with objective measurements. Moreover, future studies including larger sample sizes, randomization, and control groups are needed. Since the Banks and Wallace10 review, intervention studies promoting PA focusing solely on African American women have increased. This integrative review provides important findings regarding the current state of science for interventions promoting PA within this specific population. Although more PA promotion research is occurring with this population, additional research is warranted. Intervention strategies have the potential to increase PA in African American women and reduce their risk of cardiovascular disease and other chronic health conditions. Nurses, in particular cardiovascular nurses, may use these findings to improve the quality of existing practices and to generate future research. Cardiovascular nurses, as well as other healthcare providers, may use this review to identify intervention strategies that will promote PA in African American women.

Physical inactivity is an important modifiable risk factor for obesity, diabetes, cardiovascular disease, and other chronic health conditions. Intervention strategies that promote PA in African American women are essential to reduce the risk of these preventable health conditions and to reduce health disparities. Many studies in this review revealed promising results. Further studies are needed to evaluate long-term outcomes and sustainable methods for PA behavior change.

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What’s New and Important
  • Physical activity interventions that are theory driven and culturally tailored and include social support have the potential to increase PA in African American women.
  • Nurses, including cardiovascular nurses, should be aware of research findings including strengths and limitations. Nurses may utilize findings to design interventions and integrate research into practice.
  • Further research promoting PA in older African American women is warranted.
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Acknowledgment

The authors thank John Dinolfo, PhD, Center for Academic Excellence & Writing Center, Medical University of South Carolina, for his support and editing of this article.

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Keywords:

African American; intervention studies; physical activity; women

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