Nice to your heart: A pilot community-based intervention to improve heart health behaviours in urban residents

Abstract

Objective:

Efforts to improve cardiovascular health among adult African American populations, particularly through organised physical activity, have met with limited success. This study pilot-tested a novel soul line dancing and nutrition education programme (Nice to Your Heart) that was designed and implemented as part of an academic community-based collaboration.

Design:

Eight, 2-hour sessions were delivered to 38 eligible and consenting participants. Each session included 60 minutes of soul line dancing and up to 30 minutes of nutrition education.

Methods:

The outcomes of programme attendance including days physically active and fruit and vegetable consumption in the last week, as well as blood pressure, were assessed.

Results:

In all, 58% of the sample (N = 13) attended five or more sessions, with women and those not currently employed more likely to achieve high attendance. Improvements in days active in the last week (t = −8.69, p < .01) and fruit consumption (t = −0.03, p = .04) were observed.

Conclusion:

These data show that this culturally sensitive programme of soul line dancing and nutrition education was well received and had positive indications for improved cardiovascular health in a high-risk group. A fully controlled trial is warranted to determine programme effectiveness.

Keywords

African American adults cardio-vascular health Community-based intervention physical activity line dancing

Introduction

Cardiovascular disease (CVD) remains a leading cause of death in the USA, with African Americans bearing a disproportionate burden of the associated morbidity and mortality (Goet al., 2013; Roger et al., 2012). African Americans report higher age-adjusted rates of heart disease and stroke than Whites (Roger et al., 2012), while the prevalence of behavioural risk factors for CVD, including sedentary behaviours (Marshall et al., 2007), hypertension (Delgado et al., 2012; Will et al., 2014) and higher body mass index (Jackson et al., 2013), is also higher in African Americans as compared to Caucasian groups. Demographic projections suggest that the national proportion of African Americans will increase by 59% between 2000 and 2050 (US Census Bureau, 2008); thus, reducing health disparities in CVD incidence and associated risk behaviours is critical to avoiding a considerable increase in the population burden associated with CVD (Mensah, 2005; Ski et al., 2014; US Department of Health and Human Services, 2012).

Intervention efforts to address CVD risk factors such as poor dietary intake and sedentary behaviours in African American groups have traditionally relied on community-based approaches, with faith-based initiatives being prominent (DeHaven et al., 2004; Wilcox et al., 2007). The Body and Soul programme is an example of a successful faith-based initiative to improve dietary intake (Resnicow et al., 2004). Programmatic components are ecologically based (McLeroy et al., 1988) and include peer-counselling in the context of a church environment and pastor. These programmatic elements have demonstrated improved fruit and vegetable consumption among churchgoers (Allicock et al., 2013; Campbell et al., 2000; Resnicow et al., 2004). Results from faith-based programmes to increase physical activity levels have shown mixed results; one programme that added a walking intervention to the Body and Soul programme showed modest increases in aerobic activity (Tussing-Humphreys et al., 2013), while other faith-based physical activity programmes showed no increases in activity levels at all (Baruth et al., 2010).

Community-based efforts to promote healthful eating and physical activity in the African American community have shown increased fruit and vegetable consumption (Rodriguez et al., 2012; Whitt-Glover et al., 2013) and to a lesser extent, physical activity levels (Johnson et al., 2010). Limiting the success of community-based physical activity programmes is low adherence rates (Waterman et al., 2014; Zoellner et al., 2013), as well as limited sustainability and portability (Backman et al., 2011). In contrast to the Body and Soul programme that has reported adherence rates of up to 97% (Woods et al., 2013), adherence rates of 20%–40% for community-based physical activity programmes are more typical (Banks-Wallace and Conn, 2002; Taylor et al., 1998; Young and Stewart, 2006). Physical activity interventions that prompt high adherence levels in African American communities are, therefore, needed.

For some populations, physical activity in the form of dance has yielded high adherence rates (Da Silva Borges et al., 2014; Robinson et al., 2003; Romero, 2012). For example, a 10-session, culturally relevant, hip-hop dancing intervention delivered to a group of young Mexican Americans yielded strong adherence rates (77%), while improving minutes spent engaged in moderate to vigorous activity (Romero, 2012). High adherence to dance interventions has been attributed to the high enjoyment factor, as well as the ability for everyone to participate irrespective of skill level (Duberg et al., 2013; Jago et al., 2011; Murrock and Gary, 2010). From a community programme perspective, dance is a highly portable and accessible form of activity.

Expanding on this literature of dance interventions promoting physical activity adherence, this study examined whether an eight-session culturally relevant soul line dancing and nutrition education programme could improve physical activity and dietary behaviours in a traditionally high-priority urban population.

Methods

Programme overview

Nice to Your Heart (NTYH) was a community-based wellness venture conducted as part of an academic–community partnership between public health faculty and a non-profit, community organisation, Earth’s Keepers. The NTYH programme used a community-based participatory approach to design and implement a 4-week, eight-session (two sessions per week for 4 weeks) soul line dancing and heart health education programme aimed at increasing physical activity levels and fruit and vegetable consumption among residents of a North Philadelphia community. The session frequency (two times per week) and programme duration (4 weeks) were chosen based on community member input. Community members felt that the more typical 8- to 12-week programme duration was too burdensome, while a 4-week commitment was more achievable. Three cohorts completed the programme between November 2012 and April 2013. Bi-weekly meetings between academic and community members were held throughout the programme period. This forum served as the ‘clearing house’ for all programmatic decisions and problem-solving.

Participant recruitment and eligibility screening

Several different approaches were used to recruit programme participants. Key community members including a leader of the community development organisation, neighbourhood block captains, church pastors and a recreation centre director were mobilised to distribute programme flyers inviting programme participation.

Community members interested in participating called the programme telephone number where they heard about the programme and completed an initial eligibility screening. Eligible participants were women and men between 18 and 66 years of age, who reported English as their first language, and could safely participate in physical activity (Thomas et al., 1992). Ability to safely participate in the low-moderate intensity physical activity was conservatively determined by the Physical Activity Readiness Questionnaire (PAR-Q) (Thomas et al., 1992). The PAR-Q is composed of seven yes/no questions that query participants about the presence of any contraindications for participating in physical activity (e.g. chest pain, dizziness and loss of balance). Participants who answered yes to any of the PAR-Q questions were required to receive physician approval to participate in the programme. Of the 38 programme participants, 20 (55%) had to receive physician approval to participate. Participants were also required to have a blood pressure reading below 170 mmHg (systolic) and 100 mmHg (diastolic) at the intake screening. Individuals with a history of diagnosed heart disease, uncontrolled diabetes or who were pregnant were excluded from participating. Also, individuals who reported meeting the American College of Sports Medicine recommendations for regular physical activity (Haskell et al., 2007) (150 minutes/week of moderate activity such as brisk walking or >75 minutes/week of strenuous activity such as jogging) were excluded. Written informed consent was obtained for all eligible and interested participants. All study procedures were approved by the Institutional Review Board (IRB).

Study procedures

All participants completed eight, 2-hour sessions over a 4-week period. A standardised protocol was used to direct all study procedures. The standardised protocol required that following a 30-minute check-in during which study measures were completed and blood pressure was measured, a 60-minute line dancing session was offered by a cardiopulmonary resuscitation (CPR) and first aid certified instructor. Each dance session began with a 5-minute warm-up period followed by 50 minutes of soul line dancing (4–6 choreographed line dances) and concluded with a 5-minute cool-down period. In the last 20 minutes of each 2-hour session, participants received a heart health education session that covered topics including understanding food portion sizes, cooking with lean meats and vegetables, reading menu labels, eating healthy on a low budget and eating healthy while dining out. A trained graduate student in public health led the heart health education sessions under the supervision of the study’s principal investigator.

Participant safety in completing the line dancing was facilitated through the ‘talk test’, where approximately every 10 minutes participants were invited to say something to their neighbour; this way participants could ensure that they were able to talk and his or her heart rate was not too elevated. Participants were also provided with a bottle of water at the start of the session to ensure proper hydration. A defibrillator was placed in the intervention room, and the university hospital was less than 1 mile away.

Study measures

The main dependent variable was programme attendance, which was categorised as high (5 or more sessions) or low attendance (0–4 sessions) (Laws et al., 2013; Resnicow et al., 2000). Other outcomes included days physically active in the last week and fruit and vegetable consumption; secondary outcomes were systolic and diastolic blood pressures. Self-reported days of any activity (low, moderate or vigorous intensity) in the past week were generated from the nine-item Short Form of the International Physical Activity Questionnaire (IPAQ-SF) (Craig et al., 2003). The IPAQ-SF has acceptable psychometric properties (reliability correlation = .8; criterion validity correlation = .3) (Craig et al., 2003).

Daily fruit and vegetable consumption over the last week was measured at the first and eighth sessions using the National Cancer Institute’s 5-A-Day for Better Health instrument (Subar et al., 1995). Participants were asked to report typical daily consumption over the last week of seven common foods (orange and grapefruit juice, other 100% fruit juices, green salad, fried potatoes, white potatoes other than fried, fruit and other vegetables) on a 10-point scale (1 = never eaten; 10 = eaten more than five times a day). The 5-A-Day instrument has moderate psychometric properties (validity correlation = .47–.56; retest correlation coefficient = .52) (Campbell et al., 1999; Thompson et al., 2000). Casual blood pressure was taken by a trained research assistant using an electronic sphygmomanometer at every programme session. Covariate measures included self-reports of perceived exertion on a scale of 6–20 following the line dancing (Borg, 1998), minutes line danced at each session and liking of physical activity (Lachapelle et al., 2011). The Borg Perceived Exertion Scale has moderate to strong psychometric properties (criterion validity correlation = .57–.72; inter-rater reliability = .81) (Chen et al., 2002). Additional measures included standard questionnaires to collect data on demographics (age, gender, race, education, marital status, income and employment).

Statistical analysis

Descriptive and bivariate analyses were conducted to examine patterns of programme attendance. Specifically, the mean and standard deviation (SD) for all study variables were calculated. Chi-square and t-tests were used to examine the association between all study variables and the primary outcome of programme attendance (low vs high). To examine the short-term impact of the programme, paired t-tests were used to assess changes in the programme variables across the 4 weeks. All analyses were conducted using SPSS version 22. Statistical significance was evaluated using two-sided tests with a significance level of .05.

Results

Demographic characteristics

Of the 38 programme participants, 31 (82%) were women and 97% were African American (N = 37). Only 13 (34%) participants were currently married, while 21 (55%) were employed. Exactly one-half of the sample reported attending some college (50%; N = 19). Over two-thirds reported an annual household income of US$45,000 or less (77%; N = 29), with almost one-quarter (24%; N = 9) having an annual income of less than US$15,000. At baseline, the mean systolic blood pressure was 148.9 mmHg (SD = 21.8 mmHg) and mean diastolic blood pressure was 95.2 mmHg (SD = 14.0 mmHg).

The age and gender composition of the cohorts was comparable. For the 18 participants in cohort 1, the mean age was 56.0 years (SD = 6.3 years) and 15 (83%) were women. For the 11 participants in Cohort 2, the mean age was 57.6 years (SD = 6.8 years) and 9 (82%) were women. For the nine participants in Cohort 3, the mean age was 53.0 years (SD = 9.1 years) and seven (78%) were women.

Session attendance

In all, 58% (N = 22) of programme participants were classified as ‘high attenders’. Participants who were not currently employed were more likely to be high attenders than those who were employed (75% vs 43% respectively, χ² = 3.82, p = .05). High attenders were statistically more likely to have a lower pre-treatment systolic blood pressure than low attenders (t = 142.4 vs 160.7; p = .03) (Table 1).

Table 1.

Baseline correlates of attendance.

Variables	Low attendance	High attendance	Test statistic	p
	N = 16 (42%)	N = 22 (58%)
	n (%)	n (%)
Gender
Male	5 (71)	2 (29)	χ² = 3.03	.08
Female	11 (36)	20 (64)
Marital status
Single/divorced/separated/widowed	9 (38)	15 (62)	χ² = 0.92	.34
Married	7 (54)	6 (46)
Education level
No college	10 (63)	9 (41)	χ² = 1.73	.19
Some college	6 (37)	13 (59)
Employment status
Not currently employed	4 (25)	12 (75)	χ² = 3.82	.05
Currently employed	12 (57)	9 (43)
	M (SD)	M (SD)
Age (years)	54.4 (8.5)	56.8 (6.0)	t = −1.02	.31
Physical activity
Days physically active in the last week	3.2 (2.0)	2.7 (2.5)	t = 0.68	.50
Enjoyment of physical activity (1- to 5-point scale)	4.1 (1.5)	4.0 (1.5)	t = 0.05	.96
Perceived exertion	8.7 (2.5)	9.1 (2.7)	t = −0.29	.78
Diet
Fruit consumption in the last week	5.3 (2.8)	5.2 (2.6)	t = 0.07	.94
Vegetable consumption in the last week	22.8 (10.2)	21.1 (9.6)	t = 0.44	.67
Blood pressure (mmHg)
Systolic blood pressure	160.7 (25.9)	142.4 (17.2)	t = 2.29	.03
Diastolic blood pressure	98.4 (13.5)	93.0 (13.7)	t = 1.06	.30

Impact of programme on outcome variables

Across the 4-week programme, daily fruit consumption in the last week, days physically active in the last week and minutes line danced in the last week all increased significantly (Table 2). Fruit consumption in the last week increased from a mean of 5.1 (SD = 2.8) in session 1 to 6.4 (SD = 2.4) in session 8 (t = −2.17, p = .04), while mean days physically active in the last week also increased from 1.8 (SD = 1.7) in session 1 to 4.3 (SD = 1.8) in session 8 (t = −8.69, p < .01). Minutes line danced increased across the programme period from 37.8 (SD = 15.6) to 60.00 (SD = 0; t = −4.26, p < .01). No significant changes in vegetable consumption, systolic or diastolic blood pressure, liking of physical activity or perceived exertion were observed.

Table 2.

Impact of programme on study variables.

Outcome variable	M (SD)		t	p
	Session 1	Session 8
Days physically active in the last week	1.8 (1.7)	4.3 (1.8)	−8.69	<.01
Fruit consumption in the last week	5.1 (2.8)	6.4 (2.4)	−2.17	.04
Vegetable consumption in the last week	21.6 (9.6)	21.6 (8.9)	−0.03	.98
Systolic blood pressure (mmHg)	148.9 (21.8)	142.1 (18.4)	1.66	.11
Diastolic blood pressure (mmHg)	95.2 (14.0)	91.6 (9.6)	1.31	.21
Minutes line danced	37.8 (15.6)	60.0 (0.0)	−4.26	<.01
Liking of physical activity	3.95 (1.50)	4.09 (1.48)	−.33	.74
Perceived exertion	9.8 (2.9)	10.8 (2.8)	−1.25	.25

Discussion

This study used a community-based participatory approach to test the feasibility and short-term impact of a low-cost, eight-session community-based physical activity and nutrition education programme in a sample of 38 adults, most of whom were African American (N = 37). The main finding from this evaluation was that 58% of the sample attended the majority (five or more) of the programme sessions and that even in the short programme period, there were indications that physical activity and dietary intake could be significantly improved.

From the outset, the community-based participatory approach (Horowitz et al., 2009) used in the development and implementation of the current programme helped ensure that the programme design and content were accommodating to the target population. Bi-monthly meetings between the programme developers from the community and the academic team ensured regular and meaningful interaction. Specific programme elements that were modified based on community feedback (Horowitz et al., 2009) include the session scheduling and the use of soul versus generic line dancing. Initially, the academic group members had suggested eight programme sessions delivered weekly; community members instead requested two sessions per week for 4 weeks. Community members felt this shorter duration, higher intensity format would be less burdensome and more appealing to participants. Community members also asked for a genre of line dancing called soul line dancing that used more culturally relevant music and movement. The use of a community member to deliver the soul line dancing sessions was another programme feature designed to resonate with participants. Anecdotally, participants were heard espousing how fun and enjoyable the soul line dancing was. Together, these elements contributed to a high attendance (>5 sessions) by 58% of the sample. Although the generalisability of this level of adherence is not known, it nevertheless suggests that soul line dancing may be a feasible and effective way to promote exercise in a community setting.

Adherence to organised physical activity programmes is well documented as a major barrier to achieving the health benefits procured from regular physical activity (Rodriguez et al., 2012), particularly among non-Caucasian and minority groups where retention rates as low as 21% have been recorded (Young and Stewart, 2006). Our data showed that unemployed African American adults (p = .03) and women (p = .08) had higher rates of attendance. This finding is consistent with previous work (Canuto et al., 2013). Limited time has been identified as a significant barrier to the uptake of regular physical activity (Parks et al., 2003; Sternfeld et al., 1999), and thus, it could be argued that for unemployed adults, lack of time may be less of a constraint to regular physical activity participation. Gender differences in predictors of programme adherence have also been noted. For example, social variables have been shown to affect the adoption of physical activity among women, while physical environmental variables are most predictive among men (Sallis et al., 1992). Our data suggest that more intensive efforts to support physical activity participation among men and employed individuals may be needed.

In terms of short-term programme impact, significant increases in days of physical activity and fruit consumption were observed. Related to the increases in physical activity levels, the data showed that the minutes line danced increased significantly from 38 minutes in session 1 to the full 60 minutes offered by the programme in session 8. While this increase is undoubtedly a training effect that has resulted from regular participation in the programme, minutes of exercise participation is a critical metric of health-related fitness (Lloyd-Jones et al., 2010). The fact that all participants reported participating for the full 60 minutes at the end of the programme holds immense public health relevance. Additionally, the after-session rating for ‘liking of physical activity’ reported by participants was quite high to begin with, but this too, along with perceived exertion, increased by session 8. Self-reported liking of physical activity is well documented as a predictor of adherence to regular physical activity (Salmon et al., 2003). The high levels of adherence, along with increases in minutes of participation across the programme period and high ‘liking’ of the soul dancing from the first session, point to soul line dancing being an effective intervention to achieve increased levels of physical activity.

Our finding that fruit consumption had increased significantly by session 8, but vegetable consumption did not, may be explained by earlier work documenting greater preference, access and exposure to fruit as compared to vegetables. Higher levels of availability and exposure to fruit as compared to vegetables have been found in urban neighbourhoods (Cullen et al., 2009). For example, while fruit and vegetables were found to be less available in predominantly Black urban neighbourhoods, fruits, such as bananas, apples, oranges, lemons and limes, are more widely available than vegetables (aside from potatoes) and other fruits (Morland and Filomena, 2007). Close proximity to multinational fast-food restaurants is also associated with decreased vegetable intake (Pearce et al., 2009). The increased fruit intake found in this programme is consistent with these data showing that fruit may be more appealing and available to urban residents, while vegetable consumption may be hindered by the close proximity of fast-food restaurants.

Together, these data move us forward in our understanding of how to help urban residents meet physical activity recommendations by showing that this community-based approach using line dancing is a potentially feasible approach to increasing the number of days of the week in which this high-risk group participates in physical activity. Although the small sample size, non-controlled design used in this study and self-report measures of physical activity limit the validity and generalisability of the findings, these pilot data suggest that a more fully controlled evaluation of this soul line dancing physical activity programme is warranted. Moreover, it must be recognised that increasing the days of activity is only one step in helping this high-risk group meet physical activity recommendations. Increasing the capacity for more intense physical activity and decreasing sedentary time (Bond et al., 2014), in addition to improving built environment features, such as increased green space (Hunter et al., 2014), are other approaches that warrant consideration in this urban population.

Footnotes

Funding

Funding for this study was provided by the Temple University Community Research Day initiative.

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