Walking Program With Online and (Especially) Telephone Support Motivates African-American Women to Exercise
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
- Women at both sites reported an increase in brisk walking, but the change at Site 1 might have been a chance finding. The change at Site 2 was much larger.
- Women at Site 1 reported little change in total activity (the sum of brisk walking, moderate and vigorous physical activity). At Site 2, change in total activity was substantive and statistically significant.
- The percentage of women meeting the recommendation for more than 150 minutes of moderate physical activity per week (as established by the Centers for Disease Control and Prevention [CDC]) increased from 4 percent to 22 percent at Site 1 and from 11 percent to 29 percent at Site 2. Accordingly, most women did not meet the recommendation by the end of the study.
Key Conclusions of the Evaluation Team
- The data seem to provide credible support for the effectiveness of the online program plus telephone counseling for increasing women's physical activity—if they engage in and stay with the program.
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.
The Plan as Implemented: An Online Fitness Program
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:
- Washington (Site 1): Participants used only the online program. The online program and project staff for Site 1 were housed at the Imperative's main office.
- Philadelphia (Site 2): Participants used the online program in conjunction with telephone counseling—30-minute telephone counseling sessions, scheduled weekly for one month, biweekly for seven months and monthly for four months.
The project team for Site 2 was housed at the evaluation team's office at the University of Pennsylvania School of Medicine. The Imperative hired and trained two African-American women, independent of the evaluation team, to provide the telephone counseling.
Counseling protocols, based on both social cognitive theory and motivational interviewing, were tailored to each participant's level of readiness to change. The telephone counselors did not deliver a separate intervention, but rather supported the online intervention.
- Los Angeles (Site 3): Participants were to use the online program and participate in semi-monthly, in-person group counseling sessions throughout the duration of the program. The project team for Site 3 was housed at a collaborating organization affiliated with the Imperative. Staff at the Imperative's Washington office and the evaluator's Philadelphia office provided oversight from a distance for this arm of the study.
The counseling sessions, led by a facilitator hired for the project, focused on step-by-step behavioral change, with additional information on dietary change and physical activity. The group counseling facilitator did not deliver a separate intervention, but rather would support the Web intervention.
Recruitment and Orientation
The project team recruited participants through:
- Newspaper advertisements.
- Existing mailing lists within local affiliates at each site.
- Directly through the Imperative's Web site.
- Word of mouth.
To be eligible participants had to:
- Be at least 18 years old.
- Have a working telephone (Philadelphia only).
- Have reliable Internet access.
- Have no physical limitations or disabilities that would preclude participation in a walking program.
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:
- An introduction to the study and procedures.
- A manual of study procedures and a guide to the study Web site.
- Hands-on instruction for navigating the Web site.
- A schedule for telephone calls (Philadelphia) and group meetings (Los Angeles).
- Free pedometers.
- A video-audio package describing the program and the health benefits of walking.
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.
Process Evaluation Findings
This part of the evaluation looked at whether the interventions were delivered as intended:
- The project team implemented all 12 sessions of the Walking for Wellness online program as planned.
- At Site 2 (Philadelphia), staff provided telephone counseling according to the planned counseling protocols; however, less than a third of the participants had at least half of the intended 22 telephone contacts.
- A larger percentage (30 and 47 percent at Sites 1 and 2, respectively) reported using the Walking for Wellness online educational content.
- Less than 20 percent of the women at either site reported regular use of the Walking for Wellness, LEAP or Black Women's Health Imperative Web pages (defined as at least once per month).
- Web site use and contacts intended for administrative purposes (which did not vary in content) did not differ across sites, with the exception that more women at Site 1 reported regular telephone contact with the coordinator (for administrative purposes) than at Site 2.
Outcome Evaluation Findings
This part of the evaluation examined what the effects were within sites, and how the effects compared across sites.
- Baseline characteristics of participants at both sites were similar:
- Forty years of age on average (ranging from 19 to 67 years).
- Average BMI (body mass index) levels were in the obese range (i.e., a BMI score of 30 or more).
- On average, total physical activity was about 47 minutes per week in Site 1 and 51 minutes per week in Site 2—about a third of the total 150 minutes per week recommended by the CDC.
- Women at both sites reported an increase in brisk walking. The larger change was at Site 2 (Philadelphia), (an increase of 96 minutes per week, from a baseline of 22 minutes per week to 118 minutes per week), which was statistically significant. At Site 1 (Washington), minutes per week of brisk walking increased 29 minutes, from 37 at baseline to 66 minutes per week, but the change was not statistically significant.
- Moderate and vigorous activity other than walking decreased at both sites. However, the evaluators noted that the evaluation questionnaires separated the project's target activity, brisk walking, from other forms of moderate activity. Had walking been included in that category, moderate activity would have increased substantially.
- Women at Site 1 reported little change in total activity (the sum of brisk walking and moderate and vigorous physical activity); at Site 2, change was substantive and statistically significant (an increase of 77 additional minutes per week, from 54 minutes at baseline to 131 minutes).
- The percentage of women meeting the recommendation for more than 150 minutes of moderate physical activity per week (as established by the CDC) increased by about 17 percent at both sites (from 4 to 22 percent at Site 1, and from 11 to 29 percent at Site 2). However, less than a third of the women at either site met the CDC recommendation at the end of the study.
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.
- Be aware of difficulties that may be encountered when using an online data collection format. The study sites encountered numerous technical problems collecting data from participants online (e.g., participants were not able to access the online website to complete data collection forms because of unfamiliarity with using a computer to complete forms as well as security settings on individual computers that did not allow access to the online data collection site). To avoid total loss of evaluative data, the evaluators e-mailed questionnaires or had participants fill out paper questionnaires during in-person visits. (Evaluator)
- Consider site-specific infrastructure and inter-site communications for multisite projects. The Black Women's Health Imperative, with guidance from the University of Pennsylvania School of Medicine team, had the responsibility for developing and housing the online program (and providing support by telephone and email), and the expertise to do so. However, the Washington and Los Angeles sites each had only part of the experience and resources to manage certain other aspects of the program delivery or data collection. Long distance communications between sites proved inadequate to fully support all of the planned aspects of the walking programs. More in person interactions among staff across the three sites would have been useful. (Evaluator)
- Combining online programs with in-person programs and activities may present logistical challenges. Many participants lived far from the site offices or had very busy schedules and could not attend group meetings when scheduled for counseling (in Los Angeles) or data collection. Project staff had to orient and assess participants individually rather than in a group setting, as originally intended, which required more time. In addition, the lack of group contact was a disappointment to participants who wanted to meet each other. (Evaluator)
AFTER THE GRANT
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.
GRANT DETAILS & CONTACT INFORMATION
Implementation and Evaluation of a Walking Program for African-American Women
National Black Women's Health Imperative Inc. (Washington, DC)
- Increasing Sustained Participation in Walking Clubs
Amount: $ 50,000
Dates: December 2000 to July 2001
Dates: January 2003 to July 2005
University of Pennsylvania School of Medicine (Philadelphia, PA)
- Evaluating a Walking Program for African-American Women
Amount: $ 300,000
Dates: February 2003 to May 2006
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:
- Goal setting.
- Role modeling.
- Building knowledge and self-confidence.
- Positive health outcome expectancies.
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:
- Introduction to the monthly theme: a brief paragraph to stimulate interest in that month's content.
- Feature story: major information offered for the month, with embedded links to more detailed content within the Black Women's Health Imperative Web site.
- Walking in the Spirit: brief inspirational affirmations, linked to readings from An Altar of Words by Byllye Avery, founder of the national Black Women's Health Project.
- Myth Buster: statement of common myths related to activity, eating or exercise, countered by factual information.
- LEAP Check-In: links to the LEAP interactive program tools, activity plan and tracking tools.
- Walking for Wellness Archive: links to Walking for Wellness pages for other months.
The titles/themes of the 12 monthly topics are:
- Session 1: Get on the Path to Wellness
- Session 2: Getting Back to Basics
- Session 3: Reaching the Goal
- Session 4: Nutrition 101: Fuel for Walking
- Session 5: Burning for Better Health
- Session 6: Weigh-in on Weight Loss
- Session 7: Stressing Total Body Wellness, Part I
- Session 8: Stressing Total Body Wellness, Part II
- Session 9: Walking with a New Attitude
- Session 10: Support Your Fitness Plan, Part I
- Session 11: Support Your Fitness Plan, Part II
- Session 12: A New Path, a New You
Other Outcomes of Interest
- There was no significant difference between Sites 1 (Washington) or 2 (Philadelphia), respectively, in the percentage of women who:
- Had joined a gym or health facility (35 percent versus 39 percent).
- Deliberately changed their routines to improve their health (78 percent versus 82 percent).
- Planned to continue accessing the Web site (65 percent versus 48 percent).
- Planned to continue walking (100 percent versus 94 percent).
- A possible difference was observed in the percentage of women in Sites 1 and 2 who planned to continue tracking pedometer steps (65 percent and 42 percent, respectively), according to the evaluators.
- The most helpful continued assistance requested in order to encourage continuation of healthy behaviors after the program ended was for e-mail contact, a safe place to walk or a walking group.
Assistance needed Site 1 Site 2 Regular e-mails 43.48% 51.51% 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%
- Neither group was strongly predisposed to continue telephone contact, but about half the group at Site 1 thought group meetings would be helpful following the study, compared to only 21 percent at Site 2. However, when researchers rephrased the question to ask about adding group meetings to the Web site only group (Site 1), 78 percent of the women said it would have been helpful during the program. When they asked the rephrased question of the Web site + telephone contact group (Site 2), 58 percent of women thought that group meetings would have been helpful.
- Women at Site 1 felt that telephone calls would have been helpful; this question was not asked of the women at Site 2, who had been offered telephone counseling throughout.
- The majority of participants at both sites answered "yes" to questions about the salience of having African-American investigators and whether the program seemed tailored to African-American women.
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.
- Underweight = <18.5
- Normal weight = 18.524.9
- Overweight = 2529.9
- Obesity = BMI of 30 or greater
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