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From 2000 to 2005, staff at the Black Women's Health Imperative created and implemented an online version of a self-help fitness program for African-American women called Walking for Wellness.
Researchers at the University of Pennsylvania School of Medicine, working with project staff at the Black Women's Health Imperative, designed and implemented an independent evaluation to test the effectiveness of the Walking for Wellness program in increasing women's physical activity levels.
They assessed two different levels of the program: Participants in Washington (Site 1) used the online fitness program alone. Participants in Philadelphia (Site 2) used the online program and received telephone counseling to support their progress.
Evaluation data were collected approximately 12 months after the women started the program and compared with data collected when they entered the program.
A third version of the program, in which the online program was combined with regular in-person group meetings, was implemented in Los Angeles (Site 3), but insufficient data were collected from that site to support the evaluation component.
Key Findings from Evaluation
Key Conclusions of the Evaluation Team
The Robert Wood Johnson Foundation (RWJF) supported the Black Women's Health Imperative with two grants totaling $350,000 (ID# 039973, unsolicited, for planning; and ID# 044363, solicited, for implementation).
RWJF supported the evaluation with a solicited grant of $300,000 to the University of Pennsylvania School of Medicine.
African-American women have lower than average levels of physical activity and higher body weight compared to non-Hispanic white women. They also have disproportionately higher rates of health problems, such as high blood pressure and diabetes, which may improve with increased physical activity.
A number of barriers get in the way of African-American women increasing their physical activity, including the lack of effective programs to help them make permanent behavior changes to increase their physical activity levels and the lack of safe places to exercise.
In 1991, the Black Women's Health Imperative (the Imperative—then called the National Black Women's Health Project) sought to overcome some of these barriers by starting the Walking for Wellness program. (The Imperative is a self-help and advocacy organization working to improve the health of African-American women.)
As a demonstration project, the Imperative formed walking clubs, of six to 10 women each, in four cities. In 1996, RWJF funded the Imperative to create 15 new walking clubs in 10 cities. (See Grant Results on ID# 019874.)
"The Walking for Wellness program model was very appealing to women—allowing for both increased physical activity and an opportunity for social support from other walking club members, but the logistics of sustaining walking clubs proved to be complex in many locations," according to Shiriki Kumanyika, Ph.D., M.P.H., the University of Pennsylvania School of Medicine evaluator, who was formerly a member of the Black Women's Health Imperative's board of directors and research committee chair. Transient programs. She noted, do not usually help people to maintain behavior changes permanently.
"Minimal contact" interventions—such as those using the Internet, the telephone or direct counseling—are low cost and easy to use and show promise for facilitating long-term behavior changes. The project team and staff at RWJF wanted to test the effectiveness of different levels of minimal contact interventions in a physical activity program reaching black women.
The grants were made by a program team focused on increasing physical activity for specific populations (members of ethnic minority populations; older people) and on helping communities become more physically active.
Since 2003, RWJF's focus on physical activity has been on children as part of its effort to help halt the rise in childhood obesity by promoting healthy eating and physical activity in schools and communities throughout the nation.
Project staff at the Black Women's Health Imperative created and implemented an online version of Walking for Wellness as a self-help fitness program for African-American women.
Kumanyika, at the University of Pennsylvania School of Medicine, and familiar with Walking for Wellness based on her prior service on the Imperative's board of directors, worked with project staff at the Imperative to design and implement an evaluation of the self-help, fitness program at two sites, to test its effectiveness (a third site in the study, in Los Angeles, initially offered a version of the program but did not complete the evaluation study).
The project included a planning phase (grant ID# 039937) and an implementation phase (Grant ID# 044363). During the planning phase, the project team consulted with Kumanyika's team at the University of Pennsylvania School of Medicine, working under a subcontract, and with an RWJF consultant on issues related to the evaluation study design.
During the implementation phase, staff at the Imperative implemented the online self-help program (Grant ID# 044363). Staff at the University of Pennsylvania School of Medicine (Grant ID# 040357) implemented the online + telephone counseling component and conducted the evaluation.
The original plan, as developed through the planning grant, called for a six-month feasibility study using two minimal contact approaches to help participants increase their physical activity: (1) counseling based on social cognitive theory and (2) motivational interviewing. (See the Glossary for definitions.)
Project staff planned to test each approach at three sites with participants at each site getting different levels of individual and social support. The plan also called for participants to engage in group walking events. The team planned to use the approach that got the best results in an 18-month demonstration study.
After reviewing the plan, staff at RWJF asked the project team to revise it substantially to bring it more in line with the Imperative's capacity. In response, the project team revamped the Walking for Wellness program as a 12-session online self-help fitness program, with a focus on individual walking instead of walking clubs.
Based on social cognitive theory, the 12 sessions offer women information and advice on general health issues, nutrition, physical activity and weight control. The program teaches basic behavioral change principles such as goal setting, self-monitoring and building knowledge and self-confidence.
A key component of the online program is an interactive tracking tool called LEAP (Lifetime Exercise Adherence Program). Women use LEAP to track such things as weight, height and levels of physical activity. In addition, the tool provides feedback to the women—e.g., tracking important health measures over time, and scores on health status.
The Walking for Wellness program resides within the Imperative's Web site, which provides additional information regarding health education, research and advocacy for African-American women. The program encourages participants to use these other resources available at the site. (For more details on the Walking for Wellness program and LEAP, see Appendix 1.)
The RYKÄ Women's Fitness Foundation, based in East Meadow, N.Y., provided additional funding ($3,400) to the project.
The project team established three sites so that the online program's effectiveness alone and with two different levels of support could be evaluated:
The project team recruited participants through:
To be eligible participants had to:
Some 62 participants enrolled at Site 1, 68 at Site 2 and 30 at Site 3. After enrolling, participants attended orientation meetings in which they received:
Because of scheduling conflicts, the project team had to provide program orientation to a large number of participants in individual, face-to-face meetings.
Participants enrolled in the study using a secure Web site to collect participant contact information and self-reported current physical activity level, and to request medical clearance (for participants who reported having conditions that might preclude participation in regular physical activity). The project team used the orientation meetings to collect objective baseline data on weight and height, and to distribute and teach participants how to use pedometers.
The project team had planned to have participants provide follow-up data during the study—about health status, stage of behavior change, self-reported physical activity levels and perceived stress—through electronic questionnaires sent and returned via a secure Internet link. Baseline data were collected via electronic questionnaires. Because of computer and Web site technical problems, the evaluation team decided to collect additional follow-up data using paper questionnaires.
A research team at the University of Pennsylvania School of Medicine led by Dr. Kumanyika conducted the process and outcome evaluations.
The evaluation sought to determine whether the interventions were delivered as intended, what the effects were within sites, and how the effects compared across sites, with particular attention to the effects of the telephone counseling combined with the online program compared to the online program alone.
As the program progressed, the evaluators found substantial attrition: only 58 of the 130 participants who initially enrolled in the study provided survey data at the final visit. The project team terminated all work at Site 3 (Los Angeles), because of a change in leadership at the collaborating organization and attrition of participants.
This part of the evaluation looked at whether the interventions were delivered as intended:
This part of the evaluation examined what the effects were within sites, and how the effects compared across sites.
For other outcomes of interest, see Appendix 2.
According to the evaluation team, the data seem to provide credible support for the effectiveness of the online program plus telephone counseling (as provided in Site 2, Philadelphia) compared to the online program alone for increasing African-American women's physical activity if they engage in and stay with the program.
The role of the online program as such (i.e., minus the telephone counseling) is not yet clear. Women at both sites reported low regular use of the Web site. Future studies should explore whether the telephone counseling alone would achieve the same results.
The Walking for Wellness program continues to serve as the Black Women's Health Imperative's signature physical activity program.
The evaluation team plans to write a paper on the project and submit it for publication in a peer-reviewed journal.
Implementation and Evaluation of a Walking Program for African-American Women
National Black Women's Health Imperative Inc. (Washington, DC)
University of Pennsylvania School of Medicine (Philadelphia, PA)
Details of the Walking for Wellness Online Program
The Walking for Wellness online program consists of 12 monthly topics and themes designed to address basic behavioral change principles such as:
The program also addresses issues identified in the literature as of particular importance for African-American women, such as decreasing negative attitudes about exercising and increasing the cultural salience and social rewards of being more physically active.
A key component of the program is an interactive tracking tool, referred to as LEAP (Lifetime Exercise Adherence Program). Women can use LEAP to track such things as weight, height and levels of physical activity. In addition, the tool provides feedback to the women—e.g., tracking important health measures over time, and scores on health status.
Each of the monthly topics included the following features, linked from the Web site's first page:
The titles/themes of the 12 monthly topics are:
Other Outcomes of Interest
|Assistance needed||Site 1||Site 2|
|Regular telephone contacts||17.39%||6.06%|
|Regular group meetings||52.17%||21.21%|
|A place to walk safely||34.78%||33.33%|
|A group with which to walk||43.48%||42.42%|
BMI (Body Mass Index). A measure of body fat based on height and weight that applies to both adult men and women. Calculate BMI by dividing weight in pounds (lbs) by height in inches (in) squared and multiplying by a conversion factor of 703, or calculate your BMI online. The score indicates whether your weight falls within a healthy range.
Motivational interviewing. A directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with nondirective counseling, it is more focused and goal-directed. The examination and resolution of ambivalence are its central purpose, and the counselor is intentionally directive in pursuing this goal.
Social cognitive theory (SCT). A learning theory that defines human behavior as a dynamic interaction of personal factors, behavior and the environment. A key construct is that people acquire and maintain certain behavior patterns by (1) observing others whom they identify with (modeling), (2) participating in an action personally and (3) response consequences (such as rewards and punishments).
Report prepared by: Robert Crum
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: M. Katherine Kraft
Program Officer: Dwayne C. Proctor
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