Research in Gerontological Nursing

Featured Intervention Study 

Physical Activity with Spiritual Strategies Intervention: A Cluster Randomized Trial with Older African American Women

Karen Joy Anderson, PhD, RN; Carol H. Pullen, EdD, RN

Abstract

A cluster randomized study was conducted using a convenience sample of four Christian faith communities from which 27 African American women 60 and older were recruited. The purpose was to determine whether African American women receiving a physical activity intervention with spiritual strategies compared to a control group would demonstrate differences over time in physical activity behaviors and biomarkers, in self-efficacy for physical activity, and in barriers to physical activity. Results with baseline and 12-week measurements included significant between-group findings at 12 weeks on muscle strength activity (minutes per week, z = −3.269, p = 0.001; days per week, z = −3.384, p = 0.001), favoring the intervention group. There were significant between-group findings in 6-minute walk change scores (z = −2.546, p = 0.009), favoring the intervention group. Barriers were significantly reduced within the intervention group (z = −2.184, p = 0.029). Evidence suggests a physical activity intervention with spiritual strategies increases physical activity behavior. The Health Promotion Model can be used to develop physical activity interventions with spiritual strategies for older African American women in faith communities, thus, supporting Healthy People 2020 goals.

Abstract

A cluster randomized study was conducted using a convenience sample of four Christian faith communities from which 27 African American women 60 and older were recruited. The purpose was to determine whether African American women receiving a physical activity intervention with spiritual strategies compared to a control group would demonstrate differences over time in physical activity behaviors and biomarkers, in self-efficacy for physical activity, and in barriers to physical activity. Results with baseline and 12-week measurements included significant between-group findings at 12 weeks on muscle strength activity (minutes per week, z = −3.269, p = 0.001; days per week, z = −3.384, p = 0.001), favoring the intervention group. There were significant between-group findings in 6-minute walk change scores (z = −2.546, p = 0.009), favoring the intervention group. Barriers were significantly reduced within the intervention group (z = −2.184, p = 0.029). Evidence suggests a physical activity intervention with spiritual strategies increases physical activity behavior. The Health Promotion Model can be used to develop physical activity interventions with spiritual strategies for older African American women in faith communities, thus, supporting Healthy People 2020 goals.

Hypokinetic diseases, or those caused by or associated with inactivity, such as heart disease, hypertension, and diabetes, occur at higher rates in ethnic minorities (U.S. Department of Health and Human Services, Office of Minority Health, 2012; Plowman & Smith, 2010). Specifically, the death rate from diseases of the heart was 26.5% higher among African American adults than among Caucasian adults. The rate of hypertension among African American women continues to exceed the rate among White women at 44.4% and 28.1%, respectively. Diabetes, a risk factor for cardiovascular disease, is 1.9 times more likely to be diagnosed in African American women than in White women (U.S. Department of Health and Human Services, Office of Minority Health, 2012).

An epidemiological study shows how physical activity plays an important role in reducing the burden of hypokinetic diseases (Kokkinos, 2008). Further, strengthening and resistance activity, an important way to increase physical activity behavior among older adults (Hunter, Wetzstein, Fields, Brown, & Bamman, 2000), improves older adults’ functional fitness (Topp, Boardley, Morgan, Fahlman, & McNevin, 2005), thus, slowing down the loss of functional capacity. Large decreases in functional capacity, often seen as a part of normal aging, are actually the result of an inactive lifestyle (McArdle, Katch, & Katch, 2009).

Low prevalence rates of regular physical activity among African American women (36.3%) compared with Caucasian women (49.8%) (Kruger, Yore, Solera, & Moeti, 2007) and decreasing prevalence rates of regular physical activity as women age (Centers for Disease Control and Prevention [CDC], n.d.a) warrant development of innovative interventions to promote more active lifestyles in older women, especially older African American women. Moreover, the Healthy People 2020 (U.S. Department of Health and Human Services, 2010) goal and objectives propose to eliminate health disparities, increase the proportion of adults who engage in moderate-intensity aerobic exercise for at least 150 minutes per week, and increase the proportion of adults who perform muscle-strengthening activities on 2 or more days of the week. Few randomized physical activity intervention studies were found based on theoretical determinants of physical activity and that were conducted with samples of African American women 60 and older (Agurs-Collins, Kumanyika, Ten Have, & Adams-Campbell, 1997; Duru, Sarkisian, Leng, & Mangione, 2010; Resnick, Luisi, & Vogel, 2008). Two of the three experimental studies noted significant change in physical activity outcomes (Agurs-Collins et al., 1997; Duru et al., 2010).

The Health Promotion Model (HPM) (Pender, Murdaugh, & Parsons, 2010), based on social cognitive theory (Bandura, 1985), was adapted by using selected concepts to serve as the intervention study framework (Figure 1). Four behavior-specific cognitions (i.e., perceived benefits, barriers, self-efficacy, interpersonal support) selected for use in designing the intervention have been widely supported in the literature as determinants of physical activity behavior change, but only a few studies were found with African American women. Only perceived interpersonal support was not measured. Perceived benefits were positively correlated (R = 0.568, p < 0.05) and barriers were negatively correlated (Spearman rho = 0.455, p < 0.05) with exercise behavior in a study with all African American women (Jones & Nies, 1996). Self-efficacy, a major determinant of physical activity (Keller, Fleury, Gregor-Holt, & Thompson, 1999; Williams, Bezner, Chesbro, & Leavitt, 2008), was investigated with samples containing older African American women where self-efficacy intervention groups had better physical activity outcomes compared with the control groups (p < 0.05) (Gary, 2006; Resnick et al., 2008). While the HPM concept commitment to a plan of action or goal setting is a best practice for physical activity interventions in older adults (Cress et al., 2005), experimental studies are inconclusive on the effectiveness of goal setting in older adults (Shilts, Horowitz, & Townsend, 2004), specifically African American older adults (Haber & Rhodes, 2004).

Physical Activity with Spiritual Strategies (PASS) intervention based on the Health Promotion Model (adapted).Note. min. = minutes; wk = week.

Figure 1. Physical Activity with Spiritual Strategies (PASS) intervention based on the Health Promotion Model (adapted).Note. min. = minutes; wk = week.

Of the HPM personal factors that can be modified (Pender, Murdaugh, & Parsons, 2010), spirituality, which is linked to health-promoting behavior (Bopp et al., 2007; Ruesch & Gilmore, 1999) holds promise for increasing physical activity behavior in older African American women. Since the faith community plays a significant role in the lives of many African American women (Musgrave, Allen, & Allen, 2002; Taylor, Chatters, & Levin, 2003) and spirituality/religion appears to become more important as people age (Crowther, Parker, Achenbaum, Larimore, & Koenig, 2002; Levin, Taylor, & Chatters, 1994), developing innovative interventions with spiritual strategies for faith communities may make physical activity interventions more relevant for African American women. Of three cluster randomized control trials with faith communities (Resnicow et al., 2005; Samuel-Hodge et al., 2009; Wilcox et al., 2007), one found significant changes in physical activity measured by self-report (p < 0.05) (Resnicow et al., 2005).

Therefore, the purpose of this cluster randomized study conducted in faith communities was to determine whether the cognitive-behavioral Physical Activity with Spiritual Strategies (PASS) intervention would increase physical activity behavior in African American women 60 and older. The specific aims of the study were to:

  • Determine the percentage of women reaching Healthy People 2020 goals for moderate-intensity physical activity and muscle strength activity.
  • Determine whether women who received the intervention compared with a wait-list control group (WLCG) would demonstrate the following differences from baseline to 12 weeks: (a) total daily energy expenditure (kcal per day); (b) amount of moderate-intensity physical activity per week; (c) walking minutes per week; and (d) muscle strength activity minutes and days per week, as measured by a behavioral marker 7-Day Activity Interview (7-DAI) and a biomarker (yards walked in 6 minutes).
  • Assess participant response to the PASS intervention.

Secondary outcomes were to determine group differences in perceived self-efficacy and in perceived barriers.

Method

Design and Sample

The study featured a cluster randomized design, using a WLCG, with faith community as the unit of randomization. A WLCG was used because of a commonly expressed expectation among African American faith community leaders that everyone receive the same treatment (Ammerman et al., 2003). A convenience sample of four faith communities in the southern United States were randomized by the statistician in blocks of size two, using a random sampling procedure in the statistical computing package S-Plus version 8.0.4 (TIBCO Software Inc., Palo Alto, CA). Faith community criteria included being a Christian faith community that formally acknowledged the practice of prayer and the Bible as a source of beliefs. Other inclusion criteria were a faith community with the majority being African American composition and a lay leader available to serve as liaison to assist with recruitment. Faith communities were similar in potential confounding characteristics (i.e., size of faith community, frequency and types of programs offered).

Participants recruited in faith communities met the following inclusion criteria: (a) African American woman 60 and older; (b) blood pressure ⩽140/90, or if above 140/90, physician permission obtained; (c) walk 50 feet with or without walking aids and self-reported ability to walk continuously for 10 or more minutes; (d) normal cognitive status based on objective assessment (Kane & Kane, 2004); (e) in the contemplation or preparation stage of change for physical activity behavior and/or muscle strength activity, as determined by the Stage of Change tool (Prochaska, DiClemente, & Norcross, 1992). Exclusion criteria were: (a) answered “yes” to any question on the Physical Activity Readiness Questionnaire (Cardinal & Cardinal, 2000) for ages 65 to 69 and older than 69 if denied by physician.

Procedures

Institutional Review Board approval was obtained. The 12-week research protocol included baseline data collection at Week 1, PASS intervention implemented from Weeks 2–10, and follow-up data collection at Weeks 11 and 12. Participants who met the inclusion criteria were individually consented to the study. To minimize bias in group assignment, faith communities were randomized to an intervention group (IVG) or WLCG after all baseline measures were collected. There was no blinding of participants or researchers to any study elements.

Intervention

The PASS intervention reflected selected concepts from the HPM (Pender et al., 2010) (Table 1). Intervention components delivered in one weekly session for 90 minutes over 10 weeks were administered by the principal investigator (PI, K.J.A.), an African American RN with certification in faith community nursing. The WLCGs continued their usual activities and received the PASS intervention in their respective churches after follow-up measures were taken.

Description of the Physical Activity with Spiritual Strategies (PASS) Intervention

Table 1: Description of the Physical Activity with Spiritual Strategies (PASS) Intervention

Goal setting, an important part of the intervention, consisted of seven steps that reflected the selected variables from the HPM and included spiritual growth strategies (Table 1). In the investigator-developed workbook, “PASS to Better Health,” Steps 1 and 2 guided participants in selecting a weekly walking and muscle strength activity goal. To ensure safety of participants with varying levels of function, participants were reminded to start low and go slow and use the “Talk Test” (CDC, n.d.b) as they built up to a moderate-intensity level of physical activity, as appropriate. Steps 3 through 5 related to reducing barriers. Step 6 helped formalize commitment to their goals by writing them on a “contract calendar”—a one-page calendar document used for tracking time spent on physical activity and spaces to write down information from each step. Since Step 7 was designed to acknowledge participants’ value of prayer and practice of claiming Bible promises as a way to facilitate spiritual growth, participants were asked to pray and self-select Bible passages for encouragement as they pursued their goals. Further, sharing favorite Bible passages in faith communities is a common activity that is believed to develop positive affirmations that can support health behavior change efforts.

Intervention Fidelity

An intervention fidelity plan was used based on Resnick’s model (Resnick et al., 2005). The PI delivered the intervention and followed a protocol to facilitate consistent implementation of theoretically-based strategies to both groups. The PI directly observed how muscle strength exercises and talk tests were performed and how content was received. To determine enactment, physical activity recorded on contract calendars was monitored by the PI.

Outcome Measures

Demographic data and information on individual characteristics were collected using an investigator-designed tool. Information collected included perceived health status, medical history, presence of selected chronic diseases, and number of medications prescribed. Physical activity behavior was measured both by self-report and objective measures.

The modified 7-DAI (Hellman, Williams, & Thalken, 1996) was used to calculate total daily energy expenditure, measure self-reported moderate-intensity physical activity behavior, and calculate walking minutes per week. With permission from the tool developers, an item was added to the tool to measure self-reported muscle strengthening activity (days per week and minutes per week). Concurrent and construct validity of the 7-DAI have been found to be valid for use in this population (Hellman et al., 1996). Results from a preliminary study indicated convergent validity of the 7-DAI is satisfactory in this population between the 7-DAI and RT-3 accelerometer (r = 0.781, p < 0.01). The 6-minute walk test, a biomarker for moderate-intensity physical activity, totaled the number of yards walked in 6 minutes and was simultaneously collected by two researchers. It is also valid for this population (Rikli & Jones, 2001).

Secondary outcome measures used at baseline and follow up were the Exercise Benefits and Barriers Scale (EBBS) (Sechrist, Walker, & Pender, 1987) and the Self-Efficacy for Exercise scale (SEE) (Resnick & Jenkins, 2000). The EBBS is a 43-item instrument consisting of two subscales: a 29-item benefits scale and a 14-item barriers scale. In addition to prior test-retest reliability and construct validity (Sechrist et al., 1987), internal consistency reliability for the EBBS were Cronbach’s alpha coefficients of 0.927 and 0.891, respectively, in the PASS study. The SEE assesses how confident participants are to exercise regularly in the face of various barriers, or strength of efficacy expectations (Resnick & Jenkins, 2000). The internal consistency and predictive validity have been demonstrated in other studies (Resnick & Jenkins, 2000). A researcher-developed tool designed to collect quantitative and qualitative data to assess participant responses to the PASS program was administered by other team members.

Sample Size and Data Analysis

Because of the pilot nature of this small study, a power analysis was not conducted. A convenience sample of four faith communities that matched on potential confounding characteristics was used. A total of 46 participants from faith communities were assessed for eligibility. SPSS version 17.0 for Windows® was used for data analysis. Outliers were retained because they reflected participants’ responses but were confirmed to rule out transcription and data entry errors. Means, standard deviations, and change values for actual observed data were calculated for all variables. Due to the skewed nature of the data, median values and interquartile ranges are presented.

The Wilcoxon signed-rank test for related samples with a non-directional two-tailed hypothesis determined significant within-group differences between baseline and follow up (Altman, 1991). The nonparametric Wilcoxon rank sum test was used to determine between-group differences at baseline and comparisons of the change in outcome measures over time (Altman, 1991). Fisher’s exact tests compared proportions between groups (Altman, 1991). An intent-to-treat paradigm was followed where data from all randomized participants were analyzed according to their randomized intervention assignment. If there were missing values, the last observation was carried forward. Effect sizes were calculated by dividing the difference in means between the IVG and WLCG by the pooled standard deviation, which were estimated using the SPSS independent samples t test.

Results

The flow of clusters and participants through each stage are shown in Figure 2. Of those 46 participants assessed for eligibility, 28 met the inclusion criteria. One participant was lost to follow up from WLCG, leaving 27 participants for data analysis. No significant between-group differences on demographic characteristics were found at baseline (p > 0.05). The percentage of chronic diseases and history of cancer were higher in the IVG compared with the WLCG (Table 2). For outcome variables, there were no between-group differences (p > 0.05) at baseline, except on perceived barriers where IVG participants had higher perceived barriers (p = 0.03).

Flow chart of study enrollment in the Physical Activity with Spiritual Strategies (PASS) intervention.

Figure 2. Flow chart of study enrollment in the Physical Activity with Spiritual Strategies (PASS) intervention.

Baseline Characteristics of PASS Intervention and Wait-List Control Groups

Table 2: Baseline Characteristics of PASS Intervention and Wait-List Control Groups

Table 3 presents descriptive data for PASS intervention outcome variables at baseline and 12-week follow up. The effect sizes were small (⩽0.20), except for muscle strength activity (⩾80) (Lipsey, 1989). Negative effect sizes mean that changes in the WLCG were higher than changes in the IVG. Thus, total kcal increased more in the WLCG, moderate-intensity physical activity increased more in the IVG, and barriers decreased more in the IVG (Table 3).

Descriptive Data for Study Variables at Baseline and 12-Week Follow Up (N = 27)

Table 3: Descriptive Data for Study Variables at Baseline and 12-Week Follow Up (N = 27)

Healthy People 2020 target for moderate-intensity physical activity behavior was reached by 73% (n = 8 of 11) and 69% (n = 11 of 16) for the IVG and WLCG, respectively. Healthy People 2020 target for muscle strength activity was reached by 73% (n = 8) of the IVG, compared with 12.5% (n = 2) of the WLCG. Table 4 presents results of pre/post measures within- and between-groups on outcome measures. There were no significant between-group differences in outcomes on total kcal expenditure or amount of moderate-intensity physical activity. Between-group differences approached significance on walking minutes per week. Muscle strength activity days and minutes per week and the 6-minute walk were significantly higher in the IVG compared with the WLCG (p < 0.05). While secondary outcomes self-efficacy and barriers were not significantly different between groups, barriers decreased significantly within the IVG (p = 0.029) with near significance between groups (Table 4).

Study Outcomes for HPM Variables Within and Between Groups (N = 27)

Table 4: Study Outcomes for HPM Variables Within and Between Groups (N = 27)

Participants in the IVG and WLCG attended 81.8% and 60% of the sessions, respectively. Post-program evaluation of IVG responses (n = 11) revealed that the most helpful parts of program were the exercise group and presentations on exercise safety, benefits of and barriers to physical activity, and the encouragement received from the PI. Qualitative evaluation of spiritual strategies incorporated in the program was all positive. Written comments from the participants included that they were “a wonderful encouragement” and “knowing that our bodies are the temple of God and that we should be good stewards over our bodies helps us to be mindful that we belong to God, and He wants us to be in good health, even as our souls prosper.”

Discussion

The findings of this study suggest that older women with varying functional levels in the faith community setting who participated in a cognitive-behavioral physical activity program with spiritual strategies exhibited more improvements in physical activity compared with the WLCG. There were significant between-group differences on muscle strength activity and yards walked in 6 minutes, favoring the IVG. There was also a significant decrease in perceived barriers within the IVG. These improvements may be due to 81.8% IVG attendance and 96% follow-up testing.

The lack of significant between-group findings on total daily energy expenditure and moderate-intensity physical activity as measured by the 7-DAI is similar to the study findings by Fitzgibbon et al. (2005) and Young and Stewart (2006). Neither found significant between-group differences in physical activity energy expenditure using the Stanford 7-Day Physical Activity Recall after interventions delivered over a 12- and 24-week period (Fitzgibbon et al., 2005; Young & Stewart, 2006). Intervention programs with cognitive-behavioral components conducted over a 12-week period have had varying results in increasing physical activity measured by self-report (King, Rejeski, & Buchner, 1998).

Like the PASS intervention study, but conducted with the majority population, Hughes et al. (2004) found significant gains in yards walked per minute (p > 0.05). Further, the 6-minute walk PASS results in the current study were noteworthy because the IVG tended to be older and had more chronic disease, cancer, and use of walking aids, compared with the WLCG. The significant statistical muscle strength activity results point to the need to include this activity as it is feasible for African American women to engage in it.

The decreased barriers in the IVG (p < 0.05) was notable because the goal-setting steps and self-efficacy enhancement, which included encouraging participants to pray about their barriers to goals and self-select scripture for encouragement, possibly played a role in decreasing perceived barriers. Spirituality and self-efficacy as potential mediators of physical activity outcomes need to be explored in this population (Rogers & Keller, 2009).

Study limitations included that the faith communities were a small convenience sample; therefore, the findings cannot be generalized to all Christian faith communities. The faith communities were randomized, but no adjustments were made for the effects of clustering because of the small number of faith communities. The small sample may have constrained the results. A major contributing factor to the small sample size was the essential safety criterion that required health care provider permission.

Conclusion

The combination of intervention components based on HPM variables—personal factors (health status, culture, and spirituality), self-efficacy, benefits of and barriers to physical activity, and goal setting—were helpful to the participants, as evidenced by a positive post-program evaluation. Considering the limitations of a small sample, preliminary evidence suggests that the PASS intervention had a positive impact on physical activity behavior in older African American women. The HPM can be used by nurses, particularly faith community nurses, to guide development of interventions with spiritual strategies to promote physical activity behavior in older African American women.

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Description of the Physical Activity with Spiritual Strategies (PASS) Intervention

Component HPM Concept Intervention Strategies
Education Component (45 minutes)
Weeks 1–10 Personal factors: Culture and spirituality

Deep structure cultural characteristic was the religious belief that one should care for the body because it is “God’s temple.”

Theme of PASS program was “Stewardship of the Body” based on I Corinthians 6:19,20.

Week 1

Exercise safety: Start low and go slow principle and normal sensations when increasing exercise.

How to gauge exercise intensity: “Talk Test” demonstrated and practiced.

Week 2 Perceived benefits and barriers

Presentation on benefits and barriers to physical activity.

Week 3 Perceived benefits

Goal-setting Step 1: Select long-term goal based on desired benefit.

Step 2:Select short-term goals based on Healthy People 2020 (30 minutes of physical activity per day, 5 or more days per week; one to two sets of 8 to 10 repetitions, conditioning major muscle groups on 2 nonconsecutive days per week).

Perceived barriers

Goal-setting Step 3: Identify barriers. Handout on common barriers with suggested plans to overcome.

Step 4: Develop a plan to overcome barriers, given as “homework.”

Week 4 Interpersonal support

Goal-setting Step 5: Select a buddy.

Faith community has naturally occurring social ties as well.

Commitment to a plan of action

Goal-setting Step 6: Complete a contract calendar.

Personal factor: Spirituality

Goal-setting Step 7: Participate in spiritual growth activities (i.e., self-select Bible passages for encouragement to overcome barriers and to reach goals, encouraged to pray about goals).

Week 5 Personal factor: Culture

Review goal-setting steps and how to complete contract calendar used for monitoring progress on short-term goals.

Group picture serves as a surface structure cultural piece. (Participants are given a copy of the group picture after follow-up measures completed.)

Weeks 6–10 Self-efficacy

Activities designed to enhance the sources of self-efficacy: (a) share short-term goal attainments; (b) present role model stories of older adults being physically active from the National Institute on Aging’s (2011) guide to exercise and physical activity; (c) principal investigator models muscle strength exercises; (d) counteract negative states that undermine self-efficacy by participating in spiritual growth activities (i.e., prayer and sharing self-selected Bible passages for encouragement).

Muscle Strength Exercise Component (45 minutes)
Weeks 1–10 Health-promoting behavior: Physical activity

Upper/lower body strength exercises from the National Institute on Aging’s (2011) guide to exercise and physical activity (one set of 8 repetitions each exercise): Arm raise, chair stand, triceps extension, biceps curl, knee flexion, hip flexion, shoulder flexion, knee extension, hip extension, and side leg raise. (Participants were encouraged to pursue their exercise goals on the other days of the week and to use the talk test to gauge appropriate intensity.)

Weeks 1–10 Personal factor: Spirituality

Warm-up/cool-down song: “Walking Up the King’s Highway” (Way, 2001). African American spirituals used for background music for muscle strength exercises.

Exercise safety requires 1-minute rest periods between exercise sets. Participants took turns sharing “encouraging self-selected scripture or blessings received” during rest periods.

Baseline Characteristics of PASS Intervention and Wait-List Control Groups

Intervention Group (n = 11) Wait-List Control Group (n = 16)
Characteristic Mean (SD) Mean (SD) p Value
Age, years 70 (5.5) 66 (5.47) 0.073
n (%) n (%)
Married 6 (55) 7 (44) 0.704
Educational level 0.452
  High school or less 6 (55) 6 (38)
  Some college/graduate, postgraduate 5 (45) 10 (63)
Health status 0.084
  Very good/good 6 (55) 14 (88)
  Fair 5 (45) 2 (13)
Medical history of heart disease 0.272
  Yes 3 (27) 1 (6)
  No 8 (73) 15 (94)
Medical history of hypertension 0.527
  Yes 9 (82) 12 (75)
  No 2 (18) 4 (25)
Medical history of diabetes 1.00
  Yes 4 (36) 5 (31)
  No 7 (64) 11 (69)
Medical history of cancer 0.056
  Yes 3 (27) 0 (0)
  No 8 (73) 16 (100)
Number of chronic diseases 0.056
  Three or less 8 (73) 16 (100)
  Four or more 3 (27) 0 (0)
Number of prescription medications 1.00
  Three or less 5 (45) 7 (44)
  Four or more 6 (55) 9 (56)

Descriptive Data for Study Variables at Baseline and 12-Week Follow Up (N = 27)

Intervention Group (n = 11) Wait-List Control Group (n = 16)
Baseline Follow Up Change Baseline Follow Up Change
Variable Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR) Effect Size
Total kcal/daya 1885.22 (329.31) 1767.15 (518.55) 1940.03 (394.46) 1838.08 (793.85) 54.81 (120.43) 108.87 (199.35) 2192.54 (649.64) 2166.43 (1014.43) 2316.52 (518.68) 2244.67 (671.56) 123.98 (300.11) 114.21 (355.68) −0.283
Moderate-intensity physical activity, min./weeka 327.33 (217.34) 270.00 (414.60) 391.64 (252.17) 318.00 (384.60) 64.31 (329.61) 208.20 (584.40) 357.75 (287.31) 347.40 (446.25) 319.28 (371.39) 162.30 (330) −38.48 (380.71) −77.40 (339.15) 0.285
Walking, min./weeka 30.00 (41.77) 00 (65) 110.98 (105.47) 90.00 (120) 80.98 (107.03) 30.00 (135.00) 81.56 (89.68) 60 (133.75) 54.38 (66.25) 22.50 (123.75) −27.19 (120.22) 00 (146.25) 0.94
Muscle strength, min./week 5.45 (18.09) 00 (00) 63.00 (43.86) 55.00 (60.00) 57.55 (34.75) 55.00 (60.00) 14.14 (27.48) 00 (18.75) 12.81 (32.35) 00 (00) −1.33 (44.14) 00 (11.56) 1.449
Muscle strength, days/weeka 0.09 (0.30) 0.00 (0.00) 2.45 (1.81) 2.00 (2.00) 2.36 (1.80) 2.00 (2.00) 1.00 (1.86) 0.00 (1.75) 0.56 (1.41) 0.00 (0.00) −0.44 (2.50) 0.00 (1.75) 1.25
6-minute walk, yardsb 351.41 (160.71) 373.00 (296.00) 397.73 (158.64) 416.66 (294.00) 46.32 (42.39) 51.00 (21.34) 392.31 (150.97) 435.83 (194.77) 419.36 (125.37) 429.67 (222.00) 27.05 (128.76) 8.50 (68.57) 0.191
SEE score 7.28 (1.94) 7.19 (2.65) 7.03 (2.00) 7.58 (2.77) −0.254 (−1.84) −0.192 (2.46) 6.07 (2.41) 6.23 (3.44) 6.53 (1.65) 6.54 (2.42) 0.466 (1.65) −0.077 (1.60) −0.418
Barriers EBBS score 31.40 (8.10) 28.50 (12.50) 26.80 (5.35) 30.00 (10.50) −4.60 (5.99) −5.00 (9.25) 24.40 (5.46) 24.00 (10.00) 24.33 (5.95) 23.00 (10.00) −0.067 (4.30) −1.00 (4.00) −0.89

Study Outcomes for HPM Variables Within and Between Groups (N = 27)

Within Group Between Group
Variable z Score p Value z Score p Value
Total kcal/day −1.334 0.182
  Intervention group −1.334 0.182
  Wait-list control group −1.706 0.088
Moderate-intensity physical activity −0.592 0.577
  Intervention group −0.622 0.534
  Wait-list control group −0.511 0.609
Walking, min./week −1.854 0.064a
  Intervention group −2.705 0.007*
  Wait-list control group −0.566 0.572
Muscle strength, min./week −3.269 0.001*
  Intervention group −2.807 0.005*
  Wait-list control group −0.281 0.779
Muscle strength, days/week −3.384 0.001*
  Intervention group −2.831 0.005*
  Wait-list control group −0.775 0.438
6-minute walk −2.546 0.009*
  Intervention group −2.223 0.026*
  Wait-list control group −0.596 0.551
SEE score −0.475 0.660
  Intervention group 0.000 1.00
  Wait-list control group −0.725 0.469
Barriers EBBS score −1.883 0.060
  Intervention group −2.184 0.029*
  Wait-list control group −0.029 0.977
Authors

Dr. Anderson is Associate Professor, Department of Nursing, Oakwood University, Huntsville, Alabama, and Dr. Pullen is Professor, Community-Based Health Department, College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This study was partially funded by a grant awarded to Dr. Anderson by the Office of Research on Women’s Health with funding support administered by the National Institute of Nursing Research grant 1 F31 NR008969-01. Dr. Anderson also acknowledges the dissertation research grant from the C.N. Atwood Memorial Research Fund.

The authors acknowledge Dr. Julie Stoner, Professor and Chair, Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, for sharing generously her time and statistical expertise. Data collection assistance from Dr. Caryll Dormer and Dr. Havovi Patel, Oakwood University, Huntsville, Alabama, was greatly appreciated. The authors also thank the program participants in the Physical Activity with Spiritual Strategies (PASS) to Better Health Study from the following Faith Communities: Apostalic True Temple Church of God, New Life Seventh-day Adventist Church, Pentecostal Lighthouse Church, and Saint John’s African Methodist Episcopal Church.

Address correspondence to Karen Joy Anderson, PhD, RN, Associate Professor, Department of Nursing, Oakwood University, 7000 Adventist Boulevard, NW, Huntsville, AL 35896; e-mail: kanderson@oakwood.edu.

Received: August 11, 2011
Accepted: March 29, 2012
Posted Online: December 12, 2012

10.3928/19404921-20121203-01

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