Intervention Effects on Latinas' Physical Activity and Other Health ...

BRIEF REPORT

Intervention Effects on Latinas’ Physical Activity and Other Health Indicators Guadalupe X. Ayala, PhD, MPH,1,2 Marisa Molina, MPH,2 Hala Madanat, PhD,2,3 Jeanne F. Nichols, PhD,2,4 Thomas L. McKenzie, PhD,2,4 Ming Ji, PhD,2,5 Margarita Holguin, MPA,6 Lisa Cuestas, BA,7 Caryn Sumek, MPH,8 Carolina Labarca, MPH, RN,2 Sandra Elvira, MPH,2 Elva M. Arredondo, PhD,2,3 John P. Elder, PhD, MPH2,3 Introduction: U.S. Latinas do not engage in sufficient leisure-time physical activity. This study examined whether adding promotor-facilitated healthy lifestyle classes to an exercise intervention would promote exercise session attendance and improve health indicators.

Methods: The Familias Sanas y Activas II (Healthy and Active Families II) study used a withinsubjects, longitudinal design, with measures at baseline and at 6 and 12 months post-baseline. The intervention was developed by the San Diego Prevention Research Center and implemented between May 2011 and June 2014 in South San Diego County. Three organizations each hired a part-time coordinator and trained volunteer promotores (six to ten per organization) to deliver the intervention in various community locations. A convenience sample of 442 Latinas were in the evaluation cohort. Measured variables included a step test, blood pressure, waist circumference, height, and weight; physical activity was self-reported.

Results: Attendance at healthy lifestyle classes was positively associated with exercise session attendance (pr0.001). Mixed effects models showed improvements in systolic and diastolic blood pressure (pr0.001); waist circumference (pr0.001); weight (pr0.05); and BMI (pr0.05) between baseline and 12 months. At 12 months, fewer participants met clinical guidelines for being hypertensive and having an at-risk waist circumference. Exercise session attendance was associated with improved fitness (pr0.05) and increased self-reported MET minutes of leisure-time physical activity (pr0.01). Conclusions: The intervention represents an effective strategy for improving the health status of Latinas, a population with significant health disparities, including high obesity rates. Research efforts are needed to assess methods for scaling up such interventions. Am J Prev Med 2017;52(3S3):S279–S283. & 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION espite the benefits,1 a national study showed that 69% of Latinas failed to achieve Z150 minutes/ week of moderate to vigorous physical activity (MVPA).2 PA interventions for women, though effective at increasing expended energy,3–5 have identified lack of program attendance as a concern.6 In a previous study, few women attended recommended twice-weekly exercise sessions for 12 months despite classes being held in their neighborhoods.7 Community Engagement Committee members suggested that adding healthy lifestyle

D

From the 1College of Health and Human Services, San Diego State University, San Diego, California; 2Institute for Behavioral and Community Health, San Diego, California; 3Graduate School of Public Health, San Diego State University, San Diego, California; 4School of Exercise and Nutritional Sciences, San Diego State University, San Diego, California; 5 College of Nursing, University of South Florida, Tampa, Florida; 6Chula Vista Community Collaborative, Chula Vista, California; 7Casa Familiar, San Ysidro, California; and 8San Ysidro Health Center, San Ysidro, California Address correspondence to: Guadalupe X. Ayala, PhD, MPH, 9245 Sky Park Court, Suite 220, San Diego CA 92123. E-mail: [email protected]. This article is part of a supplement issue titled Prevention Research Centers Program – 30th Anniversary: Translating Applied Public Health Research into Policy and Practice. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2016.10.001

& 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. This is Am J Prev Med 2017;52(3S3):S279–S283 S279 an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

S280

Ayala et al / Am J Prev Med 2017;52(3S3):S279–S283

classes to the exercise sessions may better prepare women to engage in leisure-time PA (e.g., build their self-efficacy for participating in group exercise).8 In this study, it was hypothesized that the addition of healthy lifestyle classes would improve attendance in the exercise sessions, and that attendance would improve fitness; blood pressure (BP); waist circumference; BMI; and self-reported leisure-time MVPA.

completing other professional activities that were then redeemable for exercise equipment, clothing, and music. Gas cards (originally $25/month, raised to $35/month) offset travel costs. Promotores and coordinators identified a time and location to conduct the healthy lifestyle classes and exercise sessions. Promotores were provided a manual, a healthy lifestyle class toolkit, and an MP3 player and speakers for the exercise sessions. Additional equipment such as mats and circuit training equipment were provided when requested. Upon completion of the healthy lifestyle classes, group participants received a certificate and a T-shirt. They also received a water bottle at 6 months, and a workout towel at 12 months.

METHODS Familias Sanas y Activas II (Healthy and Active Families II) used a within-subjects, longitudinal design (baseline, 6 months, 12 months). The decision to not include a control group was made jointly with the Community Engagement Committee given significant health disparities in this community and lack of resources.8 The San Diego State University and University of California, San Diego, IRBs approved the study protocols. The study occurred in the South Bay Region of San Diego County, California, between May 2011 and June 2014. This region has approximately 475,000 residents (60% Latino) with a median household income of $35,000–$50,000 annually.9

Intervention Familias Sanas y Activas II was the core research project of the San Diego Prevention Research Center, an academic–community partnership among San Diego State University, University of California, San Diego, and partner agencies San Ysidro Health Center, Casa Familiar, and Chula Vista Community Collaborative. Agencies hired a part-time coordinator, identified volunteer promotores, and provided facilities for study activities. The Center employed a three quarter–time Intervention Coordinator and a full-time Project Manager to assist agencies with trainings, procurement of locations, and other duties. Selected promotores were aged 18–55 years, bilingual Spanish/English or monolingual Spanish, had a sixth-grade reading level, physically able to exercise as determined by the Physical Activity Readiness Questionnaire,10 interested in promoting PA, and intended to remain in the area for the study duration. Consented promotores received 48 hours of training to deliver 11 healthy lifestyle classes twice with ten to 20 participants each and provide exercise sessions twice weekly for 12 months (see training outlines in Appendix Table 1, available online). Trainers modeled the delivery of the healthy lifestyle classes and exercise sessions for the promotores. Informed by theory,11,12 the hour-long healthy lifestyle classes elicited behavior change through the development of skills such as goal setting, problem solving, and seeking social support. Promotores provided circuit training and conducted dance, aerobics, and multi-rhythmic exercise sessions. These hour-long exercise sessions included 5 minutes each for warm-up and cool-down. Given low participation in leisure-time PA in these communities,13 some exercise sessions were of low to moderate intensity; a few (e.g., Zumba) were moderate to vigorous intensity. Prior to implementation, promotores completed several evaluations, including observations of their teaching methods. During implementation, promotores received 3hour booster trainings monthly. Finally, the volunteer promotores received professional development incentives such Red Cross First Aid and cardiopulmonary resuscitation training and points for

Evaluation Cohort Recruitment and Procedures Evaluation activities occurred in several locations, including community centers and schools. Participants were screened for evaluation cohort eligibility: identifying as Latino, bilingual English/Spanish or Spanish-language dominant, aged 18–69 years, and intending to remain in the area for the study duration. Individuals were excluded if they were participants in another health study. Health status was assessed using the Physical Activity Readiness Questionnaire,10 and if any response was yes, doctor approval to participate was required. Research assistants completed the consenting process and administered baseline assessments; assessments were administered again at 6 months and 12 months. Participants received $15 at baseline, $20 at 6 months, and $25 at 12 months. Although invited, only six men enrolled; their data were excluded from analyses.

Measures Cardiorespiratory fitness was assessed using a standardized 3-minute step test (10″ bench at 26 steps/minute, guided by a metronome).14 Step rate was modified for women who reported exercising o15 minutes/week and those aged Z60 years to 17 steps/minute. Polar heart rate monitors were used, and cardiorespiratory fitness was evaluated as HRR60 (heart rate recovery60) calculated as the difference between peak heart rate while stepping and recovery rate at 60 seconds post-test. Sitting resting BP was assessed on participants’ left arm using an Omron automated BP monitor and appropriately sized comfit cuff.15 Waist circumference was measured in centimeters just above the iliac crests using a non-stretch measuring tape.16 At least two measurements were taken and repeated until two consecutive measurements were within 0.2 cm and then averaged. BMI was calculated from weight using electronic SECA scales and height using Shorrs boards. Measures were taken at least twice and repeated until two consecutive measurements were within 0.5 kg for weight, and 1.0 cm for height.12 Self-reported MET minutes of leisure-time MVPA were obtained using the 16-item Global Physical Activity Questionnaire.17 This was calculated by multiplying a participant’s predicted resting metabolic rate to the MET for leisure-time MVPA and its corresponding duration in minutes, yielding a continuous outcome variable. Demographic questions from Behavioral Risk Factor Surveillance Surveys18 assessed age, birthplace, marital status, household size, education, employment status, and income. Presence of cardiovascular disease or diabetes was self-reported. Promotores maintained participant attendance records. Using established criteria,19 attendances between baseline and 12 months were dichotomized as 1¼attended at least two thirds of the healthy lifestyle classes (or exercise sessions) and 0¼less than two thirds. www.ajpmonline.org


Statistical Analysis Pearson correlation tested the first hypothesis, and a mixed effects model tested the second hypothesis with time and dichotomized attendance as predictor variables. Mixed effects models have a built-in tolerance for data missing at random; thus, all available data points were analyzed. Analyses were conducted using PROC MIXED in SAS, version 9.2.

S281

with cardiorespiratory fitness at 12 months. Increases were reported in MET minutes of leisure-time MVPA from baseline to 6 months and exercise session attendance was associated with these self-reported changes. Healthy lifestyle class attendance was not associated with any changes.

DISCUSSION AND CONCLUSIONS RESULTS Figure 1 depicts the CONSORT figure. The mean age of the 442 predominantly foreign-born (82%) women was 39 years (see participant characteristics in Appendix Table 2, available online). Participant retention was 82% at 6 months and 83% at 12 months. No baseline health differences were observed; however, those retained versus not at 12 months were older (pr0.001) and more likely to be foreign born (85% vs 71%, pr0.01). Forty-two adults (98% female) served as promotores; 29 completed training and 20 delivered the intervention. Schools, community/recreation centers, a public housing complex, and a health center provided free space. Exercise sessions (mean, 47/week) were scheduled at different times (between 8AM and 9PM) on weekdays. Participants attended an average of three of the 11 planned healthy lifestyle classes (SD¼4) and 27 of the planned 48 exercise sessions (SD¼4). Healthy lifestyle class attendance was associated with exercise session attendance (r¼0.77, pr0.001). Improvements were observed for BP, waist circumference, and BMI between baseline and 12 months (Table 1). Lower percentages of women met clinically relevant cutpoints for BMI at 6 months, and BP and waist circumference at 12 months. Exercise session attendance was associated

Figure 1. CONSORT figure of a within-subjects time series study through the 12-month follow-up. March 2017

Promoting PA is an urgent public health need, especially for populations who do not engage in leisure-time PA.2 This study provides evidence that adding even a few healthy lifestyle classes to a PA intervention is associated with increased exercise session attendance, which in turn is associated with health improvements among Latinas. Nevertheless, given no control condition, use of selfreported PA, and only a small percentage of Latinas meeting the attendance goals, additional intervention research on how to promote PA is needed. Further, research is needed on methods for sustaining interventions within and across organizations to ensure access to health-promoting resources.20

ACKNOWLEDGMENTS This publication is a product of the Prevention Research Centers Program at the Centers for Disease Control and Prevention. The findings and conclusions in this publication are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This study was part of an academic–community partnership known as the San Diego Prevention Research Center (SDPRC); all authors provided consent for their names to be included. Community Engagement Committee members, excluding coauthors, included: Mari Jo Ricanor and Erek A. Estrada, City of San Diego Park and Recreation Department; Ana Gonzalez, American Diabetes Association; Kendra Brandstein, Scripps Mercy Hospital Chula Vista; Silvia Cornejo Darcy, Southwestern College; Karemi Alvarez, Network for a Healthy California; Willow Elementary School; Susana Villegas, Casa Familiar; Veronica Medina, San Ysidro School District; Jazmin Nuno, San Ysidro Health Center and Familias Sanas y Activas; Elena Quintanar, San Diego County Health and Human Services Agency, South Region; and Matthew Henry, YMCA. Core SDPRC staff, excluding co-authors, included Karmin Rodriguez-Pulido, Valentina Tena, Mariela Contreras, Diana Carolina Becerra, Jeannette Ruiz, Mariela Vergara, Xinia Sanchez, and Sara De La Rosa. The team thanks the coordinators, promotores, community residents, and students who made the study possible. The study was funded by CDC (U48-DP001917) to Dr. John P. Elder, SDPRC Director and Principal Investigator; Dr. Guadalupe X. Ayala, Research Core Principal Investigator and SDPRC CoDirector; and Dr. Lisa Madlensky, SDPRC Co-Director. CDC/PRC had no role in the study design, data collection, data analyses, data interpretation, writing this report, or the decision to submit for publication. GXA, MM, JFN, TLM, MJ, MH, LC, CS, EMA, and JPE wrote the grant proposal and secured funding for this study. In addition to

S282


Table 1. Intervention Effects and Dose-Response Relationships Among Familias Sanas y Activas II Participants (N¼442) Significance levels

Outcome variables Measured Cardiorespiratory fitness (HRR60)a Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) % (n) hypertensive (4140/90) Waist circumference (cm) % (n) at-risk waist circumference (488 cm) Weight (kg) BMI % (n) overweight or obese (BMI Z25) Self-reported Leisure-time MVPA (MET mins) % (n) not meeting MVPA guidelines of Z150 minutes per week

Baseline6 months

Baseline12 months

Exercise

Healthy lifestyle

n.s.

n.s.

r0.05

n.s.

r0.01

r0.001

n.s.

n.s.

r0.001

r0.001

n.s.

n.s.

n.s.

r0.01

n.s.

n.s.

Baseline

6 months

12 months

38.2 (10.4) 383 118.5 (13.9) 441 73.5 (9.0) 441 9% (38)

38.5 (10.3) 308 117.1 (13.6) 359 72.0 (9.4) 359 7% (25)

37.7 (10.3) 284 116.4 (13.8) 352 71.8 (8.9) 352 7% (24)

100.9 (14.1) 440 83% (365)

98.9 (14.0) 357 77% (273)

98.8 (13.7) 349 78% (271)

r0.001

r0.001

n.s.

n.s.

r0.001

r0.001

n.s.

n.s.

76.6 (16.8) 440 30.5 (6.3) 440 83% (365)

75.5 (16.8) 357 30.0 (6.2) 357 80% (286)

75.8 (16.9) 350 30.2 (6.2) 350 83% (289)

r0.001

r0.05

n.s.

n.s.

r0.001

r0.05

n.s.

n.s.

r0.05

n.s.

n.s.

n.s.

1,024 (1,204) 441 46% (202)

1,227 (1,414) 362 41% (146)

1,093 (1,296) 365 43% (156)

r0.01

n.s.

r0.01

n.s.

n.s.

n.s.

r0.0001

r0.05

Note: Boldface indicates statistical significance (po0.05). a 59 women did not complete cardiorespiratory fitness testing at baseline because of elevated blood pressure (4140/90; n¼8), being severely deconditioned (n¼36), or could not complete the fitness test (n¼12); one participant had missing data. Additional missing baseline data for measured variables were mainly due to pregnancies. HRR60, heart rate recovery; MVPA, moderate-to-vigorous physical activity; n.s., not significant.

these authors, MM, CL, and SE were responsible for carrying out the study. MJ and MM were responsible for data management and analyses. GXA drafted the first version of the manuscript and all authors approved the final version. Trials that do not include drugs, biologics, or devices (such as behavioral interventions) are excluded from registration and results submission requirements of FDAAA801. No financial disclosures were reported by authors of this paper.

SUPPLEMENTAL MATERIAL Supplemental materials associated with this article can be found in the online version at http://dx.doi.org/10.1016/j. amepre.2016.10.001.

REFERENCES 1. Wilson MG, Ellison GM, Cable NT. Basic science behind the cardiovascular benefits of exercise. Heart. 2015;101(10):758–765. http://dx.doi.org/10.1136/heartjnl-2014-306596.

2. Arredondo EM, Sotres-Alvarez D, Stoutenberg M, et al. Physical activity levels in U.S. Latino/Hispanic adults: results from the Hispanic Community Health Study/Study of Latinos. Am J Prev Med. 2016;50(4):500–508. http://dx.doi.org/10.1016/j.amepre. 2015.08.029. 3. Perez A, Fleury J, Keller C. Review of intervention studies promoting physical activity in Hispanic women. West J Nurs Res. 2010;32(3): 341–362. http://dx.doi.org/10.1177/0193945909351300. 4. Cleland CL, Tully MA, Kee F, Cupples ME. The effectiveness of physical activity interventions in socio-economically disadvantaged communities: a systematic review. Prev Med. 2012;54(6):371–380 http://dx.doi.org/10.1016/j.ypmed.2012.04.004. 5. Sharma M. Physical activity interventions in Hispanic American girls and women. Obes Rev. 2008;9(6):560–571. http://dx.doi.org/10.1111/ j.1467-789X.2008.00501.x. 6. Smith-Ray RL, Mama S, Reese-Smith JY, Estabrooks PA, Lee RE. Improving participation rates for women of color in health research: the role of group cohesion. Prev Sci. 2012;13(1):27–35. http://dx.doi. org/10.1007/s11121-011-0241-6. 7. Ayala GX, San Diego Prevention Research Center Team. Effects of a promotor-based intervention to promote physical activity: Familias Sanas y Activas. Am J Public Health. 2011;101(12):2261–2268 http://dx.doi.org/10.2105/AJPH.2011.300273.

www.ajpmonline.org

Ayala et al / Am J Prev Med 2017;52(3S3):S279–S283 8. Elder JP, Ayala GX, Arredondo E, et al. Community health partnerships for chronic disease prevention among Latinos: the San Diego Prevention Research Center. J Prim Prev. 2013;34(1-2):17–29 http://dx.doi.org/10.1007/s10935-013-0292-5. 9. U.S. Census Bureau. http://quickfacts.census.gov/. Published 2011. Accessed November 10, 2010. 10. Public Health Agency of Canada and the Canadian Society for Exercise Physiology. Physical Activity Readiness Questionnaire (PAR-Q). 2007. 11. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–377. http://dx.doi.org/10.1177/109019818801500401. 12. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall, 1986. 13. Martinez SM, Ayala GX, Patrick K, Arredondo EM, Roesch S, Elder J. Associated pathways between neighborhood environment, community resource factors, and leisure-time physical activity among MexicanAmerican adults in San Diego, California. Am J Health Promot. 2012;26 (5):281–288. http://dx.doi.org/10.4278/ajhp.100722-QUAN-249.

March 2017

S283

14. Siconolfi SF, Garber CE, Lasater TM, Carleton RA. A simple, valid step test for estimating maximal oxygen uptake in epidemiologic studies. Am J Epidemiol. 1985;121(3):382–390. 15. NHANES Cardiovascular Fitness Procedures Manual 2005. www.cdc.gov/ nchs/data/nhanes/nhanes_05_06/CV.pdf. Accessed September 1, 2014. 16. NHANES Anthropometry Procedures Manual 2005. http://www.cdc. gov/nchs/data/nhanes/nhanes_09_10/BodyMeasures_09.pdf. Accessed September 1, 2014. 17. Armstrong T, Bull F. Development of the World Health Organization Global Physical Activity Questionnaire (GPAQ). J Public Health. 2006;14(2):66–70. http://dx.doi.org/10.1007/s10389-006-0024-x. 18. CDC. Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, GA: DHHS, CDC; 2005 and 2009. 19. Coatsworth JD, Duncan LG, Pantin H, Szapocznik J. Patterns of retention in a preventive intervention with ethnic minority families. J Prim Prev. 2006;27 (2):171–193. http://dx.doi.org/10.1007/s10935-005-0028-2. 20. Wilcox S, Dowda M, Leviton LC, et al. Active for life: final results from the translation of two physical activity programs. Am J Prev Med. 2008;35(4):340–351. http://dx.doi.org/10.1016/j.amepre.2008.07.001.