Results of the Heart Healthy and Ethnically Relevant Lifestyle Trial: A Cardiovascular Risk Reduction Intervention for African American Women Attending Community Health Centers

摘要

Objectives. We evaluated a theory-based lifestyle intervention targeting physical activity and dietary fat intake among African American women at high risk for cardiovascular disease. Methods. The Heart Healthy and Ethnically Relevant Lifestyle trial (2005–2008) randomly assigned 266 low-income African American women aged 35 years and older who were patients of South Carolina community health care centers into comprehensive or standard care interventions. Comprehensive participants received standard care (stage-matched provider counseling and assisted goal setting) plus 12 months of telephone counseling and tailored newsletters. Primary outcomes were 6- and 12-month self-reported physical activity and dietary fat intake. Results. Comprehensive participants were more likely than were standard care participants to decrease total physical activity (odds ratio [OR] = 3.13; 95% confidence interval [CI] = 1.18, 8.25) and increase leisure-time physical activity (OR = 3.82; 95% CI = 1.41, 10.3) at 6 months (no 12-month differences). Mean reductions in Dietary Risk Assessment score occurred in both groups but were greater among comprehensive participants than among standard care participants (6 months, ?8.50 vs ?5.34; 12 months, ?7.16 vs ?3.37; P 1 because of their higher prevalence of CVD risk factors and lower socioeconomic status. 1 – 3 Interventions embedded in primary care settings, such as locally based, patient-driven community health care centers, have the unique potential to address these health disparities because they provide a large proportion of comprehensive health care services to medically underserved, vulnerable populations, regardless of ability to pay. About 66% of these centers’ patients are members of minority groups, 90% have incomes below 200% of the federal poverty line, and 39% lack health insurance. 4 , 5 The delivery of health behavior change interventions through these centers holds additional promise because providers are trusted sources of health information 6 and can reach underserved populations that are more likely than the general population to suffer from CVD risk factors. Despite this great potential, interventions have not been widely tested in this setting. Some evidence exists that lifestyle counseling based on the transtheoretical model 7 and social cognitive theory 8 delivered through primary care settings can yield small but significant improvements in CVD risk factors. 9 Such counseling is recommended by various health organizations, especially for overweight or obese individuals and those with chronic diseases. 10 – 15 Because of the many barriers (e.g., inadequate time, reimbursement, training, skills, and organizational support) 16 faced by primary care providers, however, lifestyle counseling is often suboptimal or abandoned. 17 – 20 In addition, few studies conducted in primary care settings have targeted underserved populations, 16 , 21 , 22 been integrated into routine office visits, 16 , 23 or used multidisciplinary models in which primary care providers delivered brief lifestyle counseling and made time-saving referrals to other professionals or community resources. 21 Telephone counseling has proven effective in changing physical activity and dietary behaviors in many populations and has been recommended for dissemination testing, 24 especially in clinical settings. 25 This approach is flexible for providers and underserved populations because it does not require transportation and can occur at convenient times for each party. In response to these literature gaps and to provide a novel, replicable method to help primary care providers implement lifestyle counseling for minority women at high risk of CVD, our Heart Healthy and Ethnically Relevant (HHER) Lifestyle trial compared the effectiveness of a standard care intervention (brief primary care provider counseling, nurse-assisted goal setting, community resource guide, and educational materials) with that of a comprehensive intervention (standard care intervention plus 12 months of tailored telephone counseling and tailored print materials) at increasing moderate-to-vigorous physical activity and reducing dietary fat intake (primary outcomes) among financially disadvantaged African American women patients at 2 community health centers in South Carolina. Because behavior change is a difficult process that requires new behavioral skills that must be practiced over time, we hypothesized that the comprehensive intervention would lead to significantly greater improvements in these modifiable CVD risk factors than the standard care intervention.