Problem Addressed

• High risk of cardiovascular disease: Cardiovascular disease is the leading cause of death for all African-American women 20 years of age and older.¹ In 2006, the prevalence rate (number of people having a disease at a specific point in time) among African-American women over the age of 20 for all cardiovascular diseases was 45.9 percent, as compared to 33.3 percent for White women.²
• Driven by health behavior–related risk factors, exacerbated by low socioeconomic status: African-American women are disproportionately affected by various health behavior–related risk factors that often lead to heart disease. Approximately 37 percent have hypertension, nearly half have a total cholesterol that's too high, nearly 80 percent are overweight or obese, and 55 percent are physically inactive. Lower socioeconomic status often contributes to these and other health disparities.³
• Failure to provide counseling, other support: Various organizations recommend that primary care providers offer lifestyle counseling to reduce cardiovascular and other risks, particularly for overweight or obese individuals and those with chronic diseases. However, primary care providers seldom offer such support (or do so in a suboptimal manner), due to a variety of factors, including lack of time, reimbursement, skills/training, and organizational support.⁴

Description of the Innovative Activity

• Program sign-up and initial assessment: Eligible individuals got a recruitment packet in the mail that included an informational letter, consent form, self-administered questionnaire, reminder card, and program magnet. Those interested received a home visit from a program researcher who conducted a baseline assessment to determine their readiness for change based on the Transtheoretical Model of Behavior Change, which lays out various stages of readiness (precontemplation, contemplation, preparation, action, maintenance). Nurses at each participating clinic received the assessment results. (For more information about the model, see http://www.ncbi.nlm.nih.gov/pubmed/10170434.)
• Culturally appropriate support, tied to readiness to change: Recognizing the unique barriers to lifestyle change experienced by low-income African-American women, the program's various components were framed in a culturally relevant context that considered the individual’s family responsibilities and social role and cultural beliefs regarding food, physical activity, and body weight. To that end, each participant received in-person counseling from health providers, assistance from nurses in setting goals, and monthly phone counseling, all designed to support them in increasing physical activity and reducing dietary fat intake. Support matched the individual's readiness for change. More details on each component are provided below:
  • Provider counseling during routine visits: During routine appointments, PCPs provided brief (2 to 4 minutes) motivational counseling on physical activity and fat intake tied to the individual's readiness stage (provided to the doctor by a nurse in the clinic). At each visit, PCPs focused on at least one topic of relevance, such as  overcoming barriers to exercising.
  • Nurse-assisted goal setting: During 5- to 10-minute sessions, nurses worked with patients to identify specific goals related to physical activity and dietary fat intake, again taking into account the individual's unique cultural context and readiness for change. Nurses recorded information on stage-appropriate dietary goal sheets and walking goal sheets.  
  • Introductory call with health educator: Lasting approximately 60 minutes, health educators reviewed major goals relative to physical activity and diet and sought to establish rapport with the study participant. The call addressed national recommendations for physical activity and diet, types of activities in which participants could engage, low-fat dietary goals, and use of a pedometer and calendar to track progress. At the end of the call, the participants agreed on a follow up call schedule (see bullet below for more details).
  • Monthly phone counseling by health educator: Throughout the year, participants had up to 14 phone counseling sessions with the health educator, each lasting roughly 20 minutes, during which they discussed progress and raised concerns. If patients raised a topic they could not sufficiently discuss in the available time, the counselor would send a follow up tip sheet with additional information. Topics covered on tip sheets included how to exercise in bad weather, eating healthy snacks, and maintaining healthy eating during the holidays.
• Educational tools and materials to support patients: Participants received educational materials (written at an eighth grade reading level) and providers used educational tools to support behavior change, as outlined below:
  • Tools and materials: Participants received a notebook with materials they could reference during phone calls, a pedometer and instructions on its use, a reference card on appropriate serving sizes for major food groups, and monthly calendars to track progress on physical activity and dietary goals. Patients kept logs of how many hours each week they engaged in physical activity, including leisure-time activities involving at least moderate physical activity (e.g., gardening) and purposeful exercise. To aid counseling sessions, providers used ethnically tailored educational materials on walking and low-fat diets, information about reading food labels and the DASH (Dietary Approaches to Stop Hypertension) diet, and a community resource guide on local physical activity and dietary programs.
  • Stage-matched, culturally tailored newsletter: Throughout the year-long program, participants received a culturally tailored, four-page color newsletter each month. Written at an eighth grade level, the newsletter incorporated photos, common foods, and testimonials to emphasize African-American cultural values and norms. It typically contained general program updates; information about various diseases that can occur due to physical inactivity and poor diet; testimonials highlighting the experiences of participants; and special sections on physical activity and nutrition, including "heart-smart" recipes. Content in most sections was the same for all women; however, content in the "Walking Corner," "Nutrition Notes," and "Interactive Learning" sections was tailored to meet the specific stage of readiness for change for each participant.

References/Related Articles

Contact the Innovator

Innovator Disclosures

Results

• Less dietary fat intake: Participants reduced their Dietary Risk Assessment score more so than a group of similar individuals receiving standard care. After 6 months, the average participants' score fell by 8.5 points (scores range from 0 to 104), well above the 5.34-point decline in those receiving standard care. After 12 months, the decline averaged 7.16 points for participants, versus 3.37 points for those receiving standard care. Changes of this magnitude suggest a substantially improved diet quality.
• More purposeful exercise, but less overall physical activity: Participants were almost four times (3.82) as likely as those receiving standard care to increase their levels of leisure-time physical activity (e.g., walking for exercise). However, their total moderate-to-vigorous physical activity declined (e.g., heavy housework, gardening). Program leaders believe this decline reflects a behavioral compensatory mechanism that causes individuals to increase sedentary behavior to compensate for a reduction in calorie intake and increased physical activity. 

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Conducting formative assessment and pilot testing: The principal investigators received a grant from the Centers for Disease Control and Prevention to perform a systematic literature review, conduct formative assessments, and develop and pilot test the intervention.
• Obtaining buy-in from health centers: The principal investigators had relationships with the medical directors of two federally funded community health care centers that oversee nine community clinics. The directors agreed to participate in the evaluation based on their past collaborations with the investigators.
• Submitting grant proposal: Researchers submitted a grant proposal to NHLBI, which agreed to fund the randomized controlled study.
• Developing training program and tools for providers: The project team developed a training program for PCPs and nurses that included a self-paced CD-ROM with five modules, a supplemental manual, and a pocket-sized, laminated counseling tool for nurses. Those completing the training qualified for continuing medical education credit hours (7.5 for physicians, 7.2 for nurses). The team also created the patient education materials used by the providers and health educator while working with patients.
• Introducing program to providers: The project team invited PCPs and nurses in the selected clinics to attend a kick-off dinner or luncheon to introduce the program and request their participation in it. Team member presentations focused on the minimal amount of time required to conduct stage-matched counseling and the potential to have a significant, positive impact on patients' health and well-being.

Resources Used and Skills Needed

• Staffing: The program required a full-time health educator to conduct the monthly calls; this individual should likely have a Bachelor's or Master's degree in health education, psychology, or another related field. The research study involved a team of individuals who participated as part of their regular duties, including principal investigators, a physician, and the aforementioned health educator. Participating clinics did not hire additional staff for the program. 
• Costs: The program was funded with a $2,145,433, 4-year grant. Actual program costs would consist primarily of printing and mailing materials, along with salary and benefits for the full-time counselor.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Obtain provider buy-in: Providers must commit not only to spending time at each visit discussing diet and physical activity, but also to undergoing upfront training on how to provide such counseling effectively. A physician champion can help win their support by speaking to the program's benefits for patients, the need to work as a team to promote patient health, and the obligation of providers to promote lifestyle changes in patients with chronic diseases.
• Consider merits of dedicated phone counselor: Researchers chose to use telephone counseling  instead of in-person sessions. Phone sessions have been shown to be effective, and compared to in-person sessions are less costly, more flexible, and not subject to transportation problems (which tend to occur frequently in low-income populations). Those choosing this option should consider hiring a dedicated counselor (either full- or part-time) to handle these duties.
• Invest in training, using existing materials: Training is critical to the program's success. The training materials developed for this program provide a good starting point. (See the Other Tools and Resources section below for information on these materials).

Sustaining This Innovation

• Track and report outcomes: To ensure program effectiveness, would-be adopters should track and report its impact on patient outcomes on an ongoing basis. Sharing this information can help to maintain support among institutional leaders and clinic-based providers. 
• Regularly update community resource guide: Various community-based resources, including exercise programs and cooking classes, can support patient efforts to improve eating and exercise habits. Would-be adopters should create and regularly update a guide offering information on free and low-cost programs available in the community.