Results of a Community Translation of the “Women Take PRIDE” Heart Disease Self-Management Program

Abstract

This article reports the results of a community demonstration of an evidence-based heart disease self-management program for older women. Women Take PRIDE (WTP) is a group-based education and behavior modification program, based on social cognitive theory, designed to enhance heart disease self-management among older women. We implemented the program in community settings with 129 participants. Evaluation data was collected at baseline and at 4- and 12-month follow-ups. Outcomes included general health status, functional health status, and knowledge. Results showed significant improvements in self-rated health, energy, social functioning, knowledge of community resources, and number, frequency, and bother of cardiac symptoms. These results demonstrate that an evidence-based heart disease self-management program can be effective at improving health and quality of life among older women with heart disease when implemented in community settings.

Keywords

heart disease self-management evidence-based older women community intervention translation

Cardiovascular disease is a significant health problem for older women, affecting more than 70% of women over the age of 60 (Roger et al., 2012). Although there is still a common misperception that heart disease is not an important concern for women, in fact, one in three women will die from cardiovascular disease, and heart disease is the leading cause of death among women aged 65 and older (Centers for Disease Control and Prevention [CDC], 2008; Roger et al., 2012). Women have a lifetime risk of 32% of developing heart disease after age 50 (Roger et al., 2012). In addition, heart disease is the leading cause of hospital discharges among women (Roger et al., 2011), and is also a significant contributor to disability and decreased quality of life. In fact, women are more likely to develop disability and depression following a cardiovascular event as compared to men (Krantz, Leeman-Castillo, Watson, & Mehler, 2004). Since women tend to develop heart disease 10 to 15 years later than men, this health problem is particularly relevant to older women.

Evidence shows that proper chronic disease self-management by patients is related to better overall physical and psychological health outcomes (Clark, 2003). One evidence-based intervention in particular, the Women Take PRIDE (WTP) program, has demonstrated effectiveness in improving health and quality of life outcomes among older women with heart disease (Clark et al., 2000). In a randomized controlled trial among 570 women aged 60 or older with heart disease, participants in the WTP intervention group had significantly better physical functioning and improved ambulation, were less symptomatic, and had lost more body weight than control group participants at a 4-month follow-up (Clark et al., 2000). Additional analyses that examined hospital billing data over a 36-month period showed that participants in the intervention group had 46% fewer inpatient days and 49% lower inpatient costs than participants in the control group (Wheeler et al., 2003).

Heart disease in New York State is an especially significant problem. Death rates from coronary heart disease are the highest in the country, and since 1984, more women than men in the state have died from heart disease every year (American Heart Association, 2009; New York State Department of Health (NYSDOH), 2010). Age-adjusted heart disease death rates in the capital region of New York State are among the highest in the United States (Healthy Capital District Initiative (HCDI), 2002). In response to this, Senior Services of Albany, a senior service organization in New York’s capital district, in partnership with four other organizations, undertook a 3-year community-based implementation of the WTP program for older women in Albany and Rensselaer counties of New York, where an estimated 10,795 women or one fifth of the 47,297 women over 60 living in these two counties, had a diagnosis of heart disease. This article reports on the 4- and 12-month follow-up evaluation results of this community demonstration of the WTP program.

Methods

Intervention

WTP program

The original “WTP” program is a 4-week education and behavior modification program designed to improve heart disease management by enhancing women’s self-regulation (Clark et al., 2000). Based on social cognitive theory (Bandura, 1986), participants learn a self-monitoring, problem-solving approach to work on aspects of their heart disease self-management regimen, such as exercise, diet, or stress management. During the 4-week educational intervention, groups of up to 8 women, 60 years of age or older with diagnosed heart disease, attend weekly meetings lasting 2 to 2 hr and 30 min, facilitated by a trained health educator and peer leader using standardized educational materials. During the program, participants learn how to work through the steps of the “PRIDE” process to enhance their self-management behaviors. These steps are defined as: P roblem identification, R esearching one’s routine, I dentifying a management goal, D eveloping a plan to reach one’s goal, and E xpressing one’s reactions/establishing rewards for making progress.

In the randomized controlled trial of the WTP intervention, 570 women were recruited from six different hospitals in the Midwest and assigned to intervention or control groups. Participants were at least 60 years old, had a diagnosis of cardiac disease, were on at least one heart medication daily, and were seen by a physician approximately every 6 months. Data on physical and psychosocial function, as well as cardiac symptom experience were collected by telephone survey at baseline, 4-months, and 12-months. (Clark et al., 2000)

Local implementation of WTP

The community demonstration of the WTP program reported here was implemented by a partnership of five organizations in New York’s capital region. The lead agency was a private not-for-profit community aging service provider. Other partners included a comprehensive, not-for-profit network of healthcare, supportive housing and community services, an academic institution, a health insurance provider with a Medicare managed care product, and the local Area Agency on Aging.

A total of 24 WTP program sessions were implemented over a 3-year period at 18 community host sites throughout three counties, including senior service agencies, senior centers, senior housing, YMCAs, libraries, and churches. A nurse educator, who had previous experience with cardiac patients and with facilitating small groups, facilitated all of the programs. She received on-site training specific to the WTP program from a trainer from the original WTP program at the University of Michigan. Original WTP program materials were used in the classes, including facilitator manuals, participant manuals, handouts, and program videos, but some of these were updated and revised to make them more applicable to the local context.

The WTP model calls for a peer leader, ideally a past program participant, to co-lead classes with the health educator. Over the course of the 3-year program implementation, we recruited and trained 10 peer leaders, eight of which were past program participants. Participants identified during the course of a 4-week class as potential peer leaders were recruited at the conclusion of the class, to avoid influencing their current experience in the program. Peer leader trainees were selected based on their personal response to the program and demonstrated comprehension of the core components. Peer leader trainings were conducted as needed by the nurse educator either one-on-one or in small groups. Peer leaders needed approximately two hours of training to review the content of the leader manual, which differs from the participant manual. Training included a review of role expectations, job description and peer leader manual. Cultural sensitivity was highlighted in training sessions to accommodate the learning needs of different generations. The transition from program participant to peer leader was discussed to avoid role confusion.

It was necessary to adapt the WTP program slightly in order to recruit women directly from the community, and to offer classes in familiar, community-based settings. Instead of recruiting through medical chart review, we recruited women directly from the community and allowed women to self-identify that they had heart disease and/or that this program was suitable/relevant for them. Initially we restricted participation (as in the original intervention) to women diagnosed with a heart condition. Later we allowed women “concerned about heart health” to participate in order to enhance recruitment after finding that potential participants did not always self-identify as having a heart condition. We made small adaptations to the content of group sessions in order to accommodate those women without diagnosed heart disease, although in order to maintain program fidelity, the primary components of the program remained the same. For example, nutrition topics were slightly expanded to address prevention of heart disease among women with identified risk factors.

We also changed the program from 4 weeks to 5 weeks to incorporate an orientation/baseline data collection into the first class session. In addition, we scheduled social gatherings at 4 months and 12 months in order to collect follow-up data, and also to provide a social setting in which participants could reunite and discuss their progress and challenges with the PRIDE process.

Participants

The target population for the WTP program was women aged 60 or over with preexisting heart disease, for which they were under a physician’s care. To be eligible, participants needed to be able to actively participate in the educational program (i.e., read, speak, complete assignments) but did not need to be able to exercise or ambulate without the assistance of a cane, walker, or wheelchair.

Participants were recruited through extensive community-based efforts. The program was marketed with flyers, brochures, media advertisements, and presentations throughout the community. Brochures and flyers were posted at various community organizations, inserted in organizational bulletins and newsletters, and used in mailings. Recruitment also took place at information tables at health fairs and other community events. We also provided a press release framework to agencies that had agreed to host the program and encouraged them to individualize it and submit it to local media. The most effective recruitment strategy was newspaper ads, which generated 43% of total calls about the program and just over 30% of our pool of eligible participants. The use of medical language in recruitment efforts proved to be problematic. Language like “heart disease” was ineffective because we found the target population did not readily identify with the terminology. We had more success attracting the attention of our target population with language such as “worried about your heart” or “want to improve heart health.”

In all, 351 women expressed initial interest in the program. Of those, 120 (34%) were not eligible, or opted out after learning more about the program, 102 (29%) were eligible but never participated in the program, usually due to scheduling difficulties, and 129 (37%) completed the WTP program. Of these, 112 attended all five program sessions, 15 women missed one session, and two women missed 2 class sessions. In all cases of absence, a “makeup” session was provided, usually by phone, during which the session contents were reviewed with the participant.

Evaluation Procedures

Evaluation data was collected at baseline, 4 months, and 12 months; these time points were chosen because they corresponded to the evaluation intervals of the original randomized controlled trial of WTP. Data was collected with self-administered questionnaires. The baseline questionnaires were completed during the first WTP session. The 4-month and 12-month follow-up questionnaires were completed at the 4- and 12-month get-togethers. For those individuals who didn’t attend in person, a questionnaire was mailed. 4-month follow-up data was collected from 113 participants, representing an 88% response rate; 12-month follow-up data was collected from 90 participants, a 70% response rate.

As with similar translational research projects, which are designed to evaluate the effectiveness of evidence-based interventions when implemented in community settings, a pre-post evaluation design was used (see for example, Gitlin et al., 2008; Quijano et al., 2007; Wilcox et al., 2006). This allows us to compare the size and extent of our effects with what was achieved during the original rigorous randomized controlled efficacy trial of the WTP program.

Measures

The primary outcomes examined for the WTP intervention fell into three general categories: health status, functional health, and knowledge. Several indicators were used to evaluate each intervention outcome. We evaluated the same outcomes as the original WTP evaluation, using the same measures when possible.

Health status was indicated by general health status, cardiac symptom experience, and body weight.

General health status was measured with a one-item self-rated physical health measure, with responses ranging from excellent (1) to poor (5). This item is a widely used measure of general health status, with well-accepted validity and reliability (Idler & Benyamini, 1997). General health status was also measured by the RAND 36-Item Health Survey 1.0 (Hays, 1994), which is a widely used self-administered measure of general health status, developed as part of the RAND Medical Outcomes Study, with demonstrated excellent reliability and validity. It includes 36 items that measure several dimensions of health status, including general health status, physical functioning, role limitations, and social functioning. We used the general health, energy, emotional well-being, and pain subscales as indicators of general health status. Possible scores for each of these subscales range from 0 to 100 with higher scores indicating more favorable health status. The general health subscale contains five items related to general health perceptions; Cronbach’s α = 0.71 for our sample. The energy subscale contains four items assessing vitality, energy, and fatigue; Cronbach’s α = 0.79 for our sample. The emotional well-being subscale contains five items related to general mental health perceptions; Cronbach’s α = 0.79 for our sample. The pain subscale contains two items assessing perceptions of bodily pain; Cronbach’s α = 0.86 for our sample.

Cardiac symptom experience was measured with the Symptom and Health Problem Chart developed to evaluate the original “Take PRIDE” heart disease self-management program (Clark et al., 1997). This instrument measures presence, frequency, and level of bother caused by 14 cardiac-related symptoms during the previous 7 days. Number of symptoms, which can range from 0 to 14, indicate the total number of symptoms present. Symptom frequency was assessed on a 5-point Likert-type scale ranging from 1 (less than once/week) to 5 (several times per day); a summary score, which can range from 0 to 70, was calculated by summing the responses for each symptom. Level of bother of symptoms was assessed on a 5-point Likert-type scale ranging from 1 (not at all) to 5 (a lot); a summary score, which can range from 0 to 70, was calculated by summing the responses for each symptom.

Body weight, in pounds, was assessed by a portable scale; the class instructor weighed participants during the baseline and follow-up data collection sessions.

Functional health was indicated by physical functioning, role functioning, and social functioning.

Physical functioning was measured with the physical functioning subscale of the RAND 36-Item Health Survey (Hays, 1994). This subscale contains 10 items assessing limitations in performing a variety of typical daily activities; possible scores range from 0 to 100 with higher scores indicating more favorable health status. Cronbach’s α = 0.90 for our sample. The 6-min walk test (Guyatt et al., 1985) was also used as an objective indicator of physical functioning. During the 6-min walk, which was originally developed for use with heart failure patients, participants walked at a normal pace for up to 6 min on a measured course. The total distance walked, in feet, is recorded. This assessment was supervised by the class instructor and took place at the site where the classes, or the follow-up get-togethers, were being held.

Role functioning was measured with the role limitation subscale of the RAND 36-Item Health Survey (Hays, 1994). This subscale contains four items assessing role limitations due to physical health problems; possible scores range from 0 to 100 with higher scores indicating more favorable health status. Cronbach’s α = 0.85 for our sample.

Social functioning was measured with the social functioning subscale of the RAND 36-Item Health Survey (Hays, 1994). This subscale contains two items assessing the extent to which health problems interfere with social activities; possible scores range from 0 to 100 with higher scores indicating more favorable health status. Cronbach’s α = 0.75 for our sample.

Knowledge of community resources specific to heart disease self- management was measured with 10 items developed specifically for this purpose. These questions assessed participants’ perceptions of their familiarity with various community resources, such as fitness facilities or nutrition-related services. The 5-item response scale ranged from 1 (not at all) to 5 (a lot). The mean of these 10 items was used to indicate an overall summary measure of knowledge.

Data Analysis

To detect differences among participants with and without follow-up data, two-tailed t-tests and chi-square tests were conducted. Differences among these groups were examined in terms of baseline demographics, health status, heart health status, previous cardiac procedures, body weight, 6-min walk distance, cardiac symptom experience, and functional health. Differences in outcome measures between baseline and follow-up were examined with the Wilcoxon signed rank test. All analyses were conducted with SPSS, Version 19.0.

Results

Baseline Characteristics of Sample

Table 1 illustrates the baseline demographic and health characteristics of the sample of participants. Mean age of participants was 73 years, with a range of 60 to 91. The vast majority of participants were White. Almost half were widowed, about a third were currently married, and 58% lived alone. The majority had at least some post-high school education, was retired, and had incomes greater than US$25,000 per year. In terms of their health status, about half rated their health as good, 28% responded very good or excellent, and 19% responded fair or poor. When asked specifically to rate their heart health, the distribution of responses was similar. On average, participants had approximately 2.4 other chronic conditions, with arthritis, osteoporosis, and bladder trouble being the most common. About half indicated that their heart condition was their primary health problem. About 80% of participants had hypertension, and the vast majority took at least one heart medication daily. Other heart conditions represented among participants included arrhythmia (44%), angina (28%), valve disease (26%), coronary artery disease (22%), heart attack (15%), and congestive heart failure (7%). A small proportion of participants had previous cardiac surgery, with angioplasty being the most common procedure (13%).

Table 1.

Baseline Demographic and Health Background Characteristics of Participants (N = 129).

Characteristic	M (SD)	%
Age	73.2 (7.9)
Race
White		91.5
Non-White		8.5
Marital status
Married		34.1
Widowed		43.4
Divorced/separated		16.3
Never married		6.2
Education
Less than high school		3.1
High school graduate		25.6
Greater than high school		71.3
Employment status
Retired		58.1
Working for pay		14.0
Other		27.9
Income
< US$10,000		5.6
US$10,000-$24,999		38.0
US$25,000-$49,999		44.4
> US$50,000		12.0
Self-rated health
Very good or excellent		28.7
Good		52.7
Fair or poor		18.6
Self-rated heart health
Very good or excellent		26.3
Good		52.7
Fair or poor		20.9
Number of other chronic conditions^a	2.43 (1.49)
Number of heart conditions^b	2.20 (1.48)
Health conditions
Arthritis		58.1
Osteoporosis		40.3
Bladder trouble		33.3
Diabetes		18.8
Cancer		16.3
Asthma		15.6
Heart conditions
Hypertension		79.1
Irregular heart rhythm		44.2
Angina		28.1
Heart valve condition		25.6
Coronary artery disease		21.8
Heart attack		14.7
Congestive heart failure		7.0
Heart surgeries
Angioplasty		12.5
Coronary bypass surgery		7.8
Pacemaker/defibrillator		5.4
Other surgical procedure		7.9
Take 1+ heart med per day		86.4

Note. ^aMean of 11 chronic conditions, including arthritis, osteoporosis, asthma, lung disease, cancer, diabetes, back problems, bladder trouble, stroke, Parkinson’s disease and Alzheimer’s disease. ^bMean of 7 possible heart conditions including coronary artery disease, angina, heart attack, arrhythmia, hypertension, congestive heart failure, and valve disease.

Comparing the present sample with the sample of women who participated in the original WTP randomized controlled trial (Clark et al., 2000) reveals that the age and race distribution is similar. Fewer of the current participants were married (34% vs. 51%), while education levels and employment status were similar. In terms of their heart conditions, the present sample had lower rates of all types of heart conditions, with the exception of valve disease, as compared to the sample in the randomized controlled trial: arrhythmia (44% vs. 59%), angina (28% vs. 45%), valve disease (26% vs. 25%), heart attack (15% vs. 39%), and congestive heart failure (7%). In terms of surgical procedures, the present sample had much lower rates of past surgical procedures as compared to the original evaluation sample, in which over one quarter had undergone either coronary artery bypass surgery or angioplasty, perhaps reflecting an overall healthier sample due to our recruitment strategies, and/or changes over time in the way that heart disease is managed.

Attrition

Comparisons between those who had both baseline and 4-month follow-up data and those with only baseline data revealed a few significant differences. Compared to those with baseline data only, those who completed the 4-month follow-up were more likely to have a college degree, more likely to report spending some time volunteering, and less likely to report having diabetes. In addition, their baseline 6-min walk distances were greater. Similar comparisons between the original sample and those who completed the 12-month follow-up revealed that women who completed the 12-month follow-up were less likely to have asthma.

Participant Outcomes

Table 2 presents mean values for all outcome measures at baseline and 4-month follow-up among the sample of 113 who completed the 4-month follow-up. As illustrated, there were significant improvements in self-rated health, energy, social functioning, and knowledge of community resources. In addition, participants demonstrated significant improvements in their cardiac symptom experience: results indicated significant decreases in the number, frequency, and level of bother of cardiac symptoms. Although more than half of the sample experienced some weight loss between baseline and 4-month follow-up, and 16.5% lost at least five pounds, change in body weight was not statistically significant.

Table 2.

Four-Month Outcome Data for Women Take PRIDE Participants (N = 113).

Outcome measure	n	Baseline mean (SD)	4-month mean (SD)	Z^a	p-value
Health status
Self-rated health^b	113	2.8 (0.8)	2.7 (0.8)	−2.50	.012
General health^c	113	62.9 (17.1)	64.9 (19.7)	−1.53	.126
Emotional well-being^c	112	75.4 (15.3)	75.5 (18.0)	−.407	.684
Energy^c	112	54.4 (18.2)	58.0 (18.2)	−2.59	.010
Pain^c	112	61.8 (24.7)	65.7 (25.5)	−1.51	.130
Cardiac symptoms:
Number^d	107	5.8 (3.1)	5.2 (3.2)	−2.51	.012
Frequency^e	113	17.9 (10.9)	14.8 (10.2)	−3.79	.000
Level of bother^f	113	17.9 (11.9)	15.9 (12.2)	−2.25	.024
Weight (lbs)	85	171.4 (42.5)	170.8 (43.0)	−1.32	.186
Functioning
Role limitations^c	113	50.4 (41.5)	52.9 (41.0)	−0.66	.507
Social functioning^c	112	76.1 (22.2)	79.9 (21.5)	−1.99	.046
Physical functioning^c	113	61.2 (25.0)	63.1 (25.1)	−1.50	.111
6-min walk test (feet)	80	1094.4 (319.7)	1103.3 (351.8)	−1.05	.295
Knowledge
Community resources^g	113	1.74 (0.41)	1.95 (0.39)	−5.12	.000

Note. ^aWilcoxon signed rank test. ^bPossible scores range from 1-5, with 1 = poor and 5 = excellent. ^cFrom RAND 36-Item Health Survey 1.0. Possible scores range from 0-100. Higher scores indicate more favorable health status. ^dMean number of 14 possible symptoms respondent may have had during past 7 days. ^ePossible total scores range from 0-70 based on a 5-point Likert-type scale where 1 = less than once/week and 5 = several times per day. ^fPossible total scores range from 0-70 based on a 5-point Likert-type scale where 1 = not at all and 5 = a lot. ^gPossible scores range from 1-5; higher scores indicate more knowledge. The values in bold font indicate statistical significance.

4-month outcomes were also examined among only those participants (n = 55) who considered their heart problem to be their primary health problem. Results indicated significant increases in self-rated health, energy, and knowledge of community resource, and a significant decrease in frequency of cardiac symptoms.

Table 3 presents mean values for all outcome measures among the 90 twelve-month follow-up participants. Twelve-month outcomes were significantly different for emotional well-being, social functioning, number and frequency of symptoms, and knowledge of community resources. In addition, at 12 months there was a significant improvement in the 6-min walk distance.

Table 3.

Twelve-Month Outcome Data for Women Take PRIDE Participants (N = 90).

Outcome measure	n	Baseline mean (SD)	12-month mean (SD)	Z^a	p-value
Health status
Self-rated health^b	90	2.8 (0.8)	2.6 (0.8)	−1.69	.091
General health^c	90	64.0 (17.2)	64.7 (18.8)	−0.55	.585
Emotional well-being^c	89	75.9 (16.0)	78.8 (15.0)	−2.60	.009
Energy^c	89	54.9 (19.0)	59.0 (18.5)	−1.94	.053
Pain^c	89	63.0 (23.7)	67.1 (23.7)	−1.75	.079
Cardiac symptoms:
Number^d	88	5.8 (3.1)	5.2 (3.1)	−2.14	.032
Frequency^e	83	18.4 (11.1)	16.0 (10.7)	−2.37	.018
Level of bother^f	81	17.9 (11.6)	16.1 (12.2)	−1.74	.082
Weight (lbs)	62	171.4 (38.6)	171.2 (41.0)	−0.56	.577
Functioning
Role limitations^c	89	52.0 (41.8)	57.3 (42.3)	−1.26	.208
Social functioning^c	89	77.7 (22.2)	84.1 (19.4)	−2.87	.004
Physical functioning^c	89	61.8 (24.5)	62.5 (25.1)	−0.06	.956
6-min walk test (feet)	60	1052.0 (302.3)	1125.5 (345.9)	−3.64	.000
Knowledge
Community Resources^g	89	1.75 (0.38)	1.98 (0.42)	−5.07	.000

Because 30% of the final sample did not have diagnosed heart disease, 4- and 12-month outcomes were also examined among only those participants who indicated a previous heart disease diagnosis (i.e., coronary artery disease, angina, myocardial infarction, heart rhythm problem, congestive heart failure, and/or valve disease). Results were nearly identical to the results among the entire sample. At 4-months (n = 73), there were significant improvements in self-rated health, knowledge of community resources, and in the number, frequency, and bother of cardiac symptoms. At 12 months (n = 60), there were significant improvements in emotional well-being, symptom frequency, distance walked, and knowledge of community resources.

Discussion

It has been said that “If we want more evidence-based practice, we need more practice-based evidence” (Green & Glasgow, 2006, p. 126). In other words, evidence-based health promotion programs will not be effectively or widely disseminated into practice settings until we have more evidence concerning the extent to which these programs can be successfully implemented in real-world settings, and the outcomes to which they relate. This article adds to the growing body of practice-based health promotion evidence by demonstrating that implementing the WTP program in real-world settings can lead to significant, positive improvements in health outcomes among older women with cardiac conditions.

As compared to the original randomized controlled trial of WTP, which provided evidence of the program’s efficacy in improving physical functioning, body weight, and cardiac symptom experience, the current study of the program’s effectiveness demonstrated similar, though not identical outcomes. Most notable are the results related to symptom experience; participants in this WTP demonstration reported significant improvements in measures of symptom experience at both 4- and 12-month follow-up, reporting fewer overall symptoms, and lower frequency of symptoms at both follow-up time points, and less bother of the symptoms they did experience at 4-months. These results compare favorably to the WTP program’s evidence base. Our results also show improvements in some aspects of functional health and self-rated health, although we did not see many significant improvements in physical functioning, ambulation, or body weight. The improvement in symptom experience, despite the fact that there was little change in other outcomes that likely contribute to symptoms, like physical functioning and body weight, may be the result of enhanced ability among participants in using successful strategies to manage their symptoms.

These results may reflect the fact that our sample, recruited from the community, was generally healthier than the clinic-based sample that participated in the original evaluation of WTP. In addition, higher risk participants (i.e., those with diabetes and with lower 6-min walk times) were slightly more likely to be lost to follow-up, also contributing to a healthier sample. We also purposely broadened eligibility criteria to enhance recruitment, and this likely resulted in an overall healthier group of participants. However, the present sample is probably representative of the type of participants that would likely join such programs in community settings. Demonstrating positive results among the kinds of participants who would likely be reached by programs such as WTP when implemented in community settings enhances the external validity of translational research projects like this one, and enables one to better generalize the results to real-world populations of older women with heart disease (Wilcox et al., 2006).

It must be noted that the evaluation design employed in this project limits the ability to draw firm, causal conclusions about the impact of the WTP program. However, this design emphasizes external validity, and appropriately allows us to compare the effectiveness seen in this community trial with the efficacy results demonstrated in the randomized controlled trial of the WTP program. As such, it compares favorably. In addition, because the eligibility criteria were broadened during the project, the characteristics of the sample in terms of heart condition status changed over time, and some women who were initially excluded would have been allowed to join had they inquired later. We attempted to address this limitation by also examining our outcomes among only those women with heart disease diagnoses. It must also be acknowledged that given the lower response rate, the 12-month results should be interpreted with care. For example, the significant increase in the 6-min walk results at 12 months could possibly be attributed to the fact that those participants who experienced enhanced physical functioning in the year following the program were more likely than other participants to attend the 12-month assessment.

Another limitation of this study is the lack of racial diversity in the sample. African American women have high rates of heart disease (Roger et al., 2011) and yet they were not well represented in this sample; our results may not be generalizable to this population. Greater diversity in participation in this program, or other programs like this, may be achieved with increased emphasis on targeted recruitment strategies that employ specific outreach to African American community leaders and community organizations that serve this population (Warren-Findlow, Prohaska, & Freedman, 2003). In addition, the marketing materials and recruitment messages we used may not have resonated well with African American women and perhaps could be revised to be more culturally appropriate (Gitlin et al., 2008). Other researchers have also suggested that holding programs in familiar community settings, providing transportation, and making participation as easy as possible facilitate the recruitment and retention of minority participants (Burns, Soward, Skelly, Leeman, & Carlson, 2008; Ejiogu et al., 2011; Warren-Findlow et al., 2003).

This project demonstrated that this intervention was well-received by older women and successfully implemented in a variety of community settings. Further replication of programs such as WTP in various settings, including urban, rural and suburban environments, and among diverse populations, would add to our understanding of the suitability of programs such as these in different environments and their generalizability to different populations.

This project is also a good example of how different organizations can collaborate and successfully partner to sponsor community-based health promotion programs. In this case, a senior service agency, health care network, insurance company, and Area Agency on Aging, along with various community organization hosts, worked together toward the common goal of reducing negative outcomes related to heart disease. In this age of increasing fiscal pressures, such collaborations and partnerships may be more important than ever in order to ensure access to health promotion programs to those who most need them while minimizing overall costs.

In sum, the results reported here provide evidence that the WTP program is effective at promoting enhanced health outcomes among older women with heart disease. Given the prevalence of heart disease in this population, and the effects it has on health and quality of life, the WTP program appears to be an important addition to the repertoire of health promotion programs designed to enhance the management of chronic conditions among older adults. This may be especially relevant as we move towards a more managed care environment with increased emphasis on prevention and proper self-management of chronic conditions.

Footnotes

Acknowledgements

We wish to acknowledge and thank Ann DiSarro and Christine Ball for their roles in this project; the partner organizations that contributed to this project: Senior Services of Albany, Northeast Health, BlueShield of Northeastern New York, and Albany County Office for the Aging; the many community-based service providers who were engaged in hosting the Women Take PRIDE program; and the WTP program participants and peer leaders. We also wish to acknowledge Julia Dodge and Nancy Janz of the University of Michigan for their helpful advice and guidance regarding the translation of the WTP program, and the Center for Healthy Aging, National Council on Aging, for their invaluable technical assistance throughout this project.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was one of 13 projects funded by the U.S. Administration on Aging’s Evidence-Based Disease Prevention Program. This work was supported by a grant from the U.S. Administration on Aging to Senior Service Centers of the Albany Area [Grant # 90 AM 2781].

Author Biographies

Mary P. Gallant, PhD, MPH is an associate professor in the Department of Health Policy, Management & Behavior at the School of Public Health of the University at Albany, State University of New York. Her research interests include health promotion and self-care among older adults, the translation of evidence based health promotion interventions into community settings, psychosocial influences on chronic illness self-management, and falls prevention.

Tianna M. Pettinger, LCSW, is an Aging Services Representative with the New York State Office for the Aging providing technical assistance and monitoring to Area Agencies on Aging as they deliver community-based services to older adults. At the time of this project, she was a social worker at Senior Services of Albany (a private nonprofit agency delivering community-based services to older adults) and the project coordinator for Women Take PRIDE. Her areas of expertise include evidence-based programs and caregiver services.

Cassandra L. Coyle, MS, RN, CDE, is a Board Certified Diabetes Educator with the Diabetes Center at Albany Memorial Hospital in Albany, NY. She completed her master of science in Nursing at SUNY Institute of Technology and is currently completing postgraduate studies as an Adult Nurse Practitioner at Sage Graduate School in Troy, NY. At the time of this project, she was a Cardiovascular Nurse Educator for Northeast Health Cardiac & Stroke Services and the program educator for Women Take PRIDE.

Linda S. Spokane, MS, is director of Research & Analytics at LeadingAge New York. She develops and conducts research on nursing homes, home health organizations, assisted living, and senior housing focusing primarily on improving quality and access to care for low income older adults. At the time of this project, she was a graduate student at the University at Albany School of Public Health providing support with data input and analysis for Women Take PRIDE.

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