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.
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
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
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.
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.
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.
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.
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
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.
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.
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.
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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