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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Nursing Assistants’ Response to Participation in the Pilot Worksite Heart Health Improvement Project (WHHIP): A Qualitative Study a
Kelly Flannery & Barbara Resnick
a
a
University of Maryland Baltimore, School of Nursing Published online: 14 Feb 2014.
Click for updates To cite this article: Kelly Flannery & Barbara Resnick (2014) Nursing Assistants’ Response to Participation in the Pilot Worksite Heart Health Improvement Project (WHHIP): A Qualitative Study, Journal of Community Health Nursing, 31:1, 49-60, DOI: 10.1080/07370016.2014.868737 To link to this article: http://dx.doi.org/10.1080/07370016.2014.868737
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Journal of Community Health Nursing, 31: 49–60, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.868737
Nursing Assistants’ Response to Participation in the Pilot Worksite Heart Health Improvement Project (WHHIP): A Qualitative Study Downloaded by [Massachusetts PRIM Board] at 09:13 05 April 2015
Kelly Flannery and Barbara Resnick University of Maryland Baltimore, School of Nursing
Despite nursing assistants’ high risk for cardiovascular disease, few studies have aimed to reduce their cardiovascular disease risk. The purpose of this article is to explore factors that facilitated and hindered nursing assistants’ participation in a pilot physical-activity- and diet-focused worksite health promotion program that aimed to reduce cardiovascular disease risk. Three focus groups were conducted with 12 (67%) participants of the program. Four themes emerged: motivation to participate in a worksite health promotion program, program participation facilitators, barriers to program participation, and suggestions for future programs. This data can aid future program development.
Approximately 1.5 million nursing assistants (NAs) currently work in the United States (Bureau of Labor Statistics, 2009). Many NAs are minority women (Squillace, Remsburg, Bercovitz, Rosenoff, & Branden, 2007), making less than $12 an hour (Bureau of Labor Statistics, 2012) and living below the federal poverty line (Paraprofessional Healthcare Institute, 2009). NAs are at high risk for cardiovascular disease (CVD) due to gender, income, and race disparities (Agency for Healthcare Research and Quality, 2010; Chou et al., 2007; Office of Minority Health, 2010; Roger et al., 2011; Thom et al., 2006), as well as multiple CVD risk factors (Flannery Resnick, Galik et al., 2012) such as excess body weight (Flannery, Resnick, Galik et al. 2012; Nelson, 1997), low levels of physical activity (Flannery, Resnick, Galik et al., 2012; Nelson, 1997; Skargren & Oberg, 1996), hypertension (Flannery, Resnick, Galik et al., 2012), and hyperlipidemia (Flannery, Resnick, Galik et al., 2012).
WORKSITE HEALTH PROMOTION The US Department of Health and Human Services’ national agenda is to reduce health disparities by offering evidence based health promotion programs to low-income minority women (e.g., NAs; United States Department of Health and Human Services., 2011). Worksite health promotion (WHP) programs are an ideal way to provide minority low-income women with health promotion programs as these individuals are otherwise a challenging population to access (Huang Address correspondence to Kelly Flannery, PhD, RN, University of Maryland Baltimore, School of Nursing, 655 W. Lombard Street, Room 390, Baltimore, MD 21201. E-mail: [email protected]
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& Coker, 2010; Yancey, Ory, & Davis, 2006; Yancu, Lee, Witherspoon, & McRae, 2011). Also, employees, such as NAs, spend a large percentage of their time at work, and thus can integrate physical activity and heart healthy diets into their workday and practice newly learned behaviors in a supportive environment that promotes a culture of health (Centers for Disease Control & Prevention., 2005). Prior research has shown that participants in WHP programs experience improvements in body mass index (Aldana et al., 2005; Anderson et al., 2009; Chung, Melnyk, Blue, Renaud, & Breton, 2009; Conn, Hafdahl, Cooper, Brown, & Lusk, 2009), blood pressure (Calderon, Smallwood, & Tipton, 2008; Chung et al., 2009; Gemson et al., 2008; Milani & Lavie, 2009; Pedersen et al., 2009; Racette et al., 2009), lipid levels (Aldana et al., 2005; Calderon et al., 2008; Conn et al., 2009; Milani & Lavie, 2009; Racette et al., 2009), and depressive symptoms (Barr-Anderson, AuYoung, Whitt-Glover, Glenn, & Yancey, 2011). Employers that offer WHP programs receive a significant return on investment (Chapman, 2005) in the form of reduced employee healthcare costs (Baicker, Cutler, & Song, 2010; Chapman, 2005), absenteeism (Baicker et al., 2010; Chapman, 2005; Conn et al., 2009), and work productivity (Mills, Kessler, Cooper, & Sullivan, 2007). Despite the significant need to decrease the risk and incidence of CVD among NAs, few WHP programs have been done with these individuals. Three published WHP studies including NAs focused on improving musculoskeletal disorders. Specifically, these studies reported that WHP programs resulted in decreased musculoskeletal symptoms (Dehlin, Berg, Hedenrud, Andersson, & Grimby, 1978; Härmä, Ilmarinen, Knauth, & Rutenfranz, 1988; Skargren & Oberg, 1996), improved muscle strength (Dehlin et al., 1978; Härmä et al., 1988; Skargren & Oberg, 1996), increased cardio-respiratory fitness (Härmä et al., 1988), decreased job strain (Dehlin et al., 1978), and reduced fatigue while at work (Härmä et al., 1988) . A recently published study testing WHP with NAs focused on reducing CVD and resulted in decreasing blood pressure and depressive symptoms while also improving lipid panels and work productivity (Flannery, Resnick, Galik, et al., 2012; Flannery, Resnick, & McMullen, 2012). Challenges associated with participation in these programs due to work-related responsibilities have been noted in prior research (Hess, Borg, & Rissel, 2011; Lemon et al., 2010; Skargren & Oberg, 1996). Therefore, the purpose of this study was to use a qualitative approach to gain a better understanding of challenges associated with participation in WHP programs among NAs. NAs that consented to participate in a WHP program, the worksite heart health improvement project (WHHIP), were invited to participate in focus groups to consider the factors that facilitated, and hindered their participation in the WHHIP. We also aimed to explore how working as a NA affected their ability to eat healthy foods, and to engage in physical activity.
METHODS Design This study used a focus group approach to understand factors that facilitated and hindered participation in the WHHIP. Focus groups were deemed the most appropriate method of data collection because participants were similar and shared a similar experience (i.e., participation in the WHHIP) that helped form group cohesion (Creswell, 2006).
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Sample Nursing assistants were eligible to participate in the focus groups if they participated in the WHHIP (described briefly in the following) and worked in the site randomized to the intervention. The treatment site exposed to the WHHIP included 24 NAs that worked in a long-term care facility in Baltimore, MD. At the time the focus groups were conducted, 20 NAs remained in the facility and two of these individuals dropped out of the study (Flannery, Resnick, Galik, et al., 2012; Flannery, Resnick, & McMullen, 2012b). Thus, 18 NAs were invited to participate in the focus groups and 12 of these individuals (67%) participated. Table 1 describes the baseline demographics and CVD health status of the 12 participants that took part in the focus groups. The focus group participants were all African American/Black women that were middle aged (42.95 years; SD = 14.70), and worked at the facility for approximately 7 years. The majority (n = 10, 83.3%) had at least three risk factors for CVD (i.e. overweight/obese, hyperlipidemia, low-levels of physical activity, and/or high blood pressure). The WHHIP Briefly, the WHHIP was a 6-month study with a 3-month intervention. As shown in Table 2 the intervention consisted of three components that were based on the social ecological model (Linnan, Sorensen, Colditz, Klar, & Emmons, 2001) and the theory of self-efficacy (Bandura, 1977). The intervention included: (1) an environmental assessment and recommendations to make the worksite more heart health friendly; (2) education about heart healthy diets and physical activity; and (3) on-going motivation, as well as opportunities to actively engage in healthy eating and physical activity (Table 2; Flannery, Resnick, Galik, et al., 2012). Component 1 was designed to create a culture of health at the worksite. Examples of component one activities include: creating a policy that allowed employees to use the facility’s gym at no cost and creating a policy that provided employees three paid 10-min physical activity breaks per 8-hr worked. Component 2 used a one-time education lecture to provide the NAs a foundation of knowledge about physical
TABLE 1 Baseline Demographics of Sample That Participated in Focus Group (N = 12) Variable Age (in years) Tenure (in months) Body mass index Average daily steps African American/Black Latino Married Post high school education Day shift 3–4 Cardiovascular disease risk factors presenta
M 42.96 84.36 32.70 6,660.29
SD
N
%
11 0 2 7 5 10
100%
14.70 96.29 7.59 4, 517.41
18.2% 63.1% 45.5% 83.3%
Note. a Cardiovascular disease risk determined from the following factors: overweight/obese, hyperlipidemia, high blood pressure (i.e., prehypertension or hypertension), and engaged in less than 150 min of physical activity/week.
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TABLE 2 The Worksite Heart Health Improvement Project Intervention Summary
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Purpose Component 1: Environmental assessment
Assess work factors that affect nursing assistants’ health
Component 2: Initial education
Provide cardiovascular disease prevention education with particular focus on making physical activity, and diet changes at work Motivate nursing assistants to engage in physical activity, and reduce dietary fat and salt intake
Component 3: On-going motivation
Summary of What Was Done Performed an environmental assessment and provided management with recommendations based on assessment Performed an education lecture
Provided on-going motivation, additional education, and opportunities for nursing assistants to actively engage in physical activity (e.g., 10 minute physical activity breaks), and healthy eating (e.g., weekly healthy food taste tests)
activity and heart healthy eating. Component 3 expanded on the education foundation provided in component 2 and actively engaged NAs in physical activity and healthy eating interventions. During component 3, the interventionist and/or trained peer champions were instructed to foster self-efficacy for heart healthy behaviors as well as provide physical activity opportunities and/or healthy eating instruction. Measures An interview guide was used to facilitate questioning during the focus group. The questions included: (a) What were the barriers to participating in the WHHIP?; (b) What suggestions can you offer to facilitate participation in WHHIP activities?; (c) What did you like most about the WHHIP?; (d) What did you like least about the WHHIP?; (e) Why did you choose to participate in the WHHIP?; (f) Tell me about your experiences participating in the WHHIP?; (g) Is there anything else you would like to say about the WHHIP that we did not cover? Last, we considered two additional questions, from the study survey, that focused specifically on health behavior change for NAs. These included: (a) How does working as a NA influence your ability to exercise outside of work?; and (b) How does working as a NA affect your ability to eat a heart healthy diet (at work and outside of work)? Focus Group Three focus groups were conducted at the end of the WHHIP. Participants were invited to participate in a focus group via study flyers, personal invitations from research staff, and/or word of
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mouth from other participants. All focus groups were held during day and evening hours during typical work downtime. The focus groups were all conducted by a nurse researcher with experience in WHP. Focus groups were audio-taped and transcribed verbatim and hand-written notes were used to contextualize the tapes. This study was approved by the University of Maryland’s Institutional Review Board. Consent to participate in a focus group was obtained when obtaining consent for participation the WHHIP.
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Analysis Strategy Data analysis was done using content analysis and in vivo coding (Creswell, 2006). The following is an example of a quote and an in vivo code: “It’s much more fun to do with the group . . . ”, which we coded as group. Codes and themes were initiated by a nurse researcher with experience in WHP and revised by a second nurse researcher with experience working with the sample population and health promotion interventions. Code development and reduction of codes into themes were discussed among the two until unanimous agreement was obtained. For example, the following six codes—improve health, pedometer feedback, group interaction, experienced health benefits, program served as a kick start, and longevity—were reduced to the theme motivation to participate in a WHP program. Credibility of the Data The focus groups were done in one day, but at different times so that the findings from later focus groups could be used to confirm or refute prior codes and discover emerging themes. During the focus groups, the facilitator continually checked with participants to ensure that she heard the essence of the participants’ experience. In addition, confirmability of the data was established by having another member of the research team review the findings and provide feedback as to whether these findings logically fit in other settings and experiences (Creswell, 2006).
RESULTS From the focus groups, a total of 40 different codes were identified and reduced to four themes. These themes were motivation to participate in a WHP program, program participation facilitators, program barriers to participation, and suggestions for future programs. Motivation To Participate In A Worksite Health Promotion Program We identified six codes that corresponded with the theme motivation to participate in a WHP program. Participants identified motivators that initiated participation, motivators that helped them continue to engage in the program, and motivational factors that did both. The most common reasons participants gave for joining the program, and/or continuing to engage in the program were a desire to improve their health, positive reinforcement from pedometers about their daily physical activity counts (e.g., steps, aerobic steps), group interaction, and health benefits experienced (e.g., stress reduction, increased energy or reduced blood pressure). For example, one
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participant reported her motivation for participating in the WHHIP was group interaction. She said, “I’m good with a group as far as exercising. . . . When I do it by myself, I don’t do as much and slack off.” Another participant said her motivation for program engagement was noted health improvement. This participant stated, “Once I got started . . . and then I check my blood pressure . . . and I see this is really helping me, . . . if something is doing good why stop?” Less commonly, participants reported that they engaged in the WHP program to improve their health with a goal of living a longer healthier life or the program served as a kick-start and provided them the initial external motivation to start engaging in health behaviors.
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Program Participation Facilitators We identified 13 codes that fell under the theme program participation facilitators. The two most commonly reported codes under this theme were simple health changes and healthy behavior awareness. We found participants felt that making simple, small, gradual changes was effective in helping them change their health behaviors. These two quotes illustrate examples of some simple changes participants were initially able to make to improve their health: “I can take 10 minutes out and do my walk and do a little exercise” and “Before the program, I was not eating healthy. . . . Now, . . . I think, . . . ‘This is 300 calories.’ . . . I never did that before; . . . before this program I just ate away.” Consistently, participants noted that health tidbits led to changes in their health behavior. For example, one participant reported, “I loved when you showed the food items and all the things that is in them. . . . I learned about pickles . . . . Makes me look at labels more, . . . how much sodium is in one of those pickles. . . . I was eating a bowl everyday!” In addition, the participants reported that there were several aspects of the program that helped to make it successful. Specifically, participants reported they liked receiving healthy food for program prizes (e.g., prizes for meeting set program goals and/or winning competitions), as well as weekly taste tests of healthy food. Participants also reported they liked receiving healthy recipes as well as posting weekly health tips (in the staff room and handouts). Participants also liked exercise DVDs and dance games because they were fun and they could be used in the interventionist’s absence. The participants reinforced policy initiatives that occurred at the onset of the study (Flannery, Resnick, Galik, et al., 2012), such as allowing three 10-min breaks for physical activity and allowing employees to use the facility’s exercise room (typically used by the residents) at no cost, also boosted program success. Participants also felt the use of a sign-out board helped with communication and allowed the nurse and other staff members to know when an NA was taking a physical activity break. Participants also reported that the interventionist kept their spirit up and did not apply pressure, which allowed the participants to see, in a nonthreatening way, when they were not participating. They reported that this helped them reengage into the program and maintain motivation. Last, participants found that sharing what they learned in the program with family and friends was helpful because NAs also needed their family members’ and friends’ support when they were outside of work. Program Barriers to Participation Ten codes were reduced to the theme program barriers to participation. We consistently heard from participants that their biggest barrier to participation was their patient care workloads. For example, one participant noted,
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Getting to the end of the shift I become busy. . . . I become nervous . . . If I’m working and I leave the floor and come over there [to exercise], my mind is not really steady. . . . It’s more stressful to leave . . . if I have certain assignments. . . . You can’t leave that patient. . . . No one is gonna answer those lights.
Other participants stated that time (work time and outside-of-work time) and outside-of-work responsibilities (e.g., child care) were program participation barriers. The following quotes show how lack of time at work can serve as a program barrier: “It might sound easy . . . . It’s only ten minutes . . . . Ten minutes we don’t have;” and “You give somebody medicine in 10 minutes.” Several participants stated that their work was stressful and they wanted to use their break times to relax and they did not perceive physical activity as a way to reduce their stress and/or relax. In addition, participants reported that unpredictable work schedules and push back from staff members that were not participating in the program made it hard to participate in group activities. Another barrier reported was reduced staff numbers from high rates of turnover. With regard to adhering to a healthy diet in the worksite, participants reported that other staff ordering fast food from local restaurants for breakfast, lunch, and/or dinner was a temptation to healthy eating. Table 3 provides some data on the particular impact that working as an NA has on heart healthy behaviors. Most commonly NAs, reported being too tired, as a result of their job, to focus on healthy behaviors after they left work. Suggestions for Future Programs We identified 11 codes that focused on suggestions for future programs. The most common codes were inclusion of health promotion activities that were not on work time and on-going motivational inoculations from the interventionist and peer champions. For example, several participants stated that they would be willing to come into work early and/or stay after work to participate in group activities related to heart-healthy behaviors outside of work time. They suggested this because they were unable to leave their unit as much as they would have liked to engage in the WHHIP activities with the group, and/or they just wanted additional group support. Of note,
TABLE 3 Select Quotes On How Working As A Nursing Assistant Affects Participation in Health Behaviors Work’s Impact on Ability to Eat Healthy
Work’s Impact on Ability to Exercise Outside of Work
“Sometimes too tired to fix.”
“I work nights shift and when I get home I become tired and sleepy to do active exercises.” “Am exhausted.” “Too busy and too tired.”
“Don’t feel like cooking after leaving here.” “I rush for break and have to buy my lunch, which at times is not healthy.” “Depending on the activity going on, like party or dinner.” “Too tired to cook.”
“The fact that I work the night shift makes me unproductive during the day.” “Standing all day (7 hrs or more) make too tired to do anything.” “I go to school during the day and I get off really late.”
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however, the participants indicated that they would not have signed up to participate in the WHIIP if it occurred outside of work time. It was only after they began to experience the health benefits and the supportive group interaction that they reported they would engage in the WHHIP outside of work time. Although the intervention was designed to have peer motivators facilitate adherence to the WHHIP activities as the interventionist decreased the time she was spending with the participants, participants reported that peer motivators often stopped motivating participants. Peer motivators reported that they stopped motivating their peers because they were frustrated and discouraged by their peers’ lack of adherence to healthy behaviors (e.g., physical activity). Participants suggested an inoculation period to help with transition (e.g., when the interventionist leaves and peer champions sustain the project) and provide additional training for peer champions (e.g., review health information, provide innovative interventions to motivate non-compliant co-workers) would help maintain sustainability. Additional suggestions for future programs were around education. Participants suggested more education topics, holding refresher classes for complex topics (e.g., learning to read food labels), only covering one topic at a time (e.g., only covering one section of the food label at a time, such as fat content), and condensing all educational handouts to one page. One particularly unanticipated finding from the focus groups was the recommendation to increase the group work/support to help them deal with depression and stressful situations (i.e., work and personal stress). We also heard that times for group activities may need to be flexible, based on unit needs and staff levels on any given day. For example, evening shift NAs reported interventions that are delivered toward the end of the shift (9 pm and after) could allow for more participation because their workload is lighter at this time. Participants suggested that the use of a buddy system would help them feel more comfortable about leaving the units to exercise without worrying about their resident assignments. We found that participants were sincerely concerned that if they left the unit for their 10-min physical activity break, their residents would need something and they were not confident that someone else would address the care needs of the resident. They suggested that assigning a buddy to cover their assignment while they were off the unit engaging in a physical activity break would be helpful. Further, they suggested that rotating buddies would help with complacency and staff members working different schedules. One participant suggested that walking outside could help increase participation in physical activity interventions.
DISCUSSION Participants confirmed that their motivation to participate in the WHHIP was driven by personal relevant motivators, as well as external motivators such as food, social support, and encouragement from others. Prior research has also noted social support is an important motivator for minority women (Zunker et al., 2008). As seen in prior research with African American women (Harley, Odoms-Young, Beard, Katz, & Heaney, 2009), we also noted that African American NAs were motivated when health outcomes (e.g., reduction of blood pressure) were linked to health behavior changes (e.g., salt consumed). Future research with this population should continue to use personally relevant motivators (e.g., health outcomes) and external motivators such as healthy food incentives and social support to provide initial and on-going motivation for behavior change.
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Consistent with other studies with NAs (Nelson, 1997), our participants reported that they were unable to initiate physical activity or healthy eating outside of work because they had additional responsibilities, such as childcare. In addition, the study participants reported being too tired to engage in healthy behaviors, such as physical activity and heart healthy meal preparation, outside of work. This may be due to the demanding nature of their work, and/or because many NAs report working consecutively long shifts, mandatory overtime, and/or have second jobs (Flannery, Resnick, & McMullen, 2012). This reinforces the critically important need to incorporate health promotion activities into NAs’ workday. Although there is evidence that there is a significant benefit to engaging NAs in healthy behaviors during the workday, there are challenges as well. Specifically, some WHHIP participants reported feeling stressed and anxious when they focused on themselves instead of their residents during the workday. Although most NAs were interested and willing to engage in short bursts of physical activity during the workday, they wanted staff coverage to care for their residents and assurance their residents would received the care they needed. Prior WHP research with healthcare workers (Lemon et al., 2010; Skargren & Oberg, 1996) also found patient care tasks and lack of flexibility (real or perceived) in completing patient care tasks a barrier to WHP participation. Incorporating the participants’ suggestions of the use of a sign out board and buddy system could ameliorate these barriers and allow NAs uninterrupted time for engagement in health promotion interventions during work time as well as alleviate some of their work stress. The NAs who engaged in short bursts of physical activity during the workday generally adhered to the allotted time for physical activity breaks (i.e., three 10-min physical activity breaks). We did learn, however, that a few NAs took advantage of this benefit by taking more than 10-min at a time for physical activity breaks. Excessive time off the unit resulted in the charge nurses expressing concern about the program. As with any program, it is important to maintain on-going oversight and communication between the program champion(s) and the facility’s administration to assure activities are being performed as intended. Despite established research findings indicating that stress is decreased by regular physical activity (Wolff, Lindenberger, Brigitt-Leila, JensHeinz, & Ströhle, 2011), many of the NAs in this study did not generally believe that physical activity could be a coping mechanism for dealing with work and/or personal stress. It is possible that stress actually limited the NAs engagement (Clark et al., 2011; Lemon et al., 2010), and limited their ability to learn new information provided in the intervention (e.g., how to read food labels; Sandi & Pinelo-Nava, 2007). Given the high rate of stress noted among NAs (Ejaz, Noelker, Menne, & Bagaka, 2008; Lapane & Hughes, 2007) future WHP research might benefit from including a stronger focus on the benefits of physical activity with regard to stress and including additional stress reduction techniques (e.g., deep breathing) to increase participation in the program and facilitate adherence to heart healthy behaviors. Even though the participants reported that the program helped them engage in health behaviors and the intervention reduced systolic blood pressure, cholesterol, triglycerides, and depressive symptoms (Flannery, Resnick, Galik, et al., 2012), participants admitted that they needed an inoculation (i.e., external motivation and program reminders from program champions) to sustain engagement in health behaviors. We believe that an inoculation twice a week will help NAs maintain engagement in healthy behaviors over time. Moreover, it may be possible to train staff members to serve as peer champions that can provide these weekly inoculations. In a recent meta-analysis, lay champions were noted to facilitate adherence to heart-healthy behaviors as
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effectively as trained interventionists (Anderson et al., 2009). Future research should consider using a model that combines both an interventionist and peer champions. Future WHP programs could be initiated by a trained interventionist and then maintained by NAs (i.e., peer champions) trained by the interventionist.
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LIMITATIONS This study was limited in that it included a small number of NAs from a single nursing home in Maryland. Although saturation was achieved during the focus groups held, it is possible that NAs working in other regions and settings might have experienced participation in the WHHIP differently. Despite these limitations, the findings from this study provide valuable lessons associated with implementing a WHP program with NAs during paid work time and can be used to guide future interventions.
CONCLUSION This study provides the insight of 12 low-income African American women that participated in a WHP program aimed at reducing CVD risk factors. The data provided from this study indicate that participants are eager to improve their health, although they depend on social support to motivate them to engage in health behaviors. The data also suggest that inoculations are needed to help NAs sustain behavior change after the intervention is complete. Participants noted that educating them on how to make simple health changes and fostering healthy behavior awareness were the two largest program participation facilitators. One of the largest program participation barriers was their workload and participants suggested innovative suggestions, such as a buddy system and the use of a sign-out board, to ameliorate these barriers. Given the many known benefits of WHP programs and NAs’ risk for CVD, it is critical that WHP programs be offered to NAs. This study provides essential formative data that can aid in the design of future behavior change WHP programs in a high-risk population that is often underrecruited for health-promotion programs and, once recruited, they often experience additional barriers to retention (Huang & Coker, 2010; Yancey et al., 2006; Yancu et al., 2011). Successful behavior change interventions among these individuals have the potential to prevent the development and/or progression of CVD and serve as a model for changing other types of NAs’ health behaviors (e.g., smoking/tobacco use).
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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20
Nursing Assistants’ Response to Participation in the Pilot Worksite Heart Health Improvement Project (WHHIP): A Qualitative Study a
Kelly Flannery & Barbara Resnick
a
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University of Maryland Baltimore, School of Nursing Published online: 14 Feb 2014.
Click for updates To cite this article: Kelly Flannery & Barbara Resnick (2014) Nursing Assistants’ Response to Participation in the Pilot Worksite Heart Health Improvement Project (WHHIP): A Qualitative Study, Journal of Community Health Nursing, 31:1, 49-60, DOI: 10.1080/07370016.2014.868737 To link to this article: http://dx.doi.org/10.1080/07370016.2014.868737
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Journal of Community Health Nursing, 31: 49–60, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.868737
Nursing Assistants’ Response to Participation in the Pilot Worksite Heart Health Improvement Project (WHHIP): A Qualitative Study Downloaded by [Massachusetts PRIM Board] at 09:13 05 April 2015
Kelly Flannery and Barbara Resnick University of Maryland Baltimore, School of Nursing
Despite nursing assistants’ high risk for cardiovascular disease, few studies have aimed to reduce their cardiovascular disease risk. The purpose of this article is to explore factors that facilitated and hindered nursing assistants’ participation in a pilot physical-activity- and diet-focused worksite health promotion program that aimed to reduce cardiovascular disease risk. Three focus groups were conducted with 12 (67%) participants of the program. Four themes emerged: motivation to participate in a worksite health promotion program, program participation facilitators, barriers to program participation, and suggestions for future programs. This data can aid future program development.
Approximately 1.5 million nursing assistants (NAs) currently work in the United States (Bureau of Labor Statistics, 2009). Many NAs are minority women (Squillace, Remsburg, Bercovitz, Rosenoff, & Branden, 2007), making less than $12 an hour (Bureau of Labor Statistics, 2012) and living below the federal poverty line (Paraprofessional Healthcare Institute, 2009). NAs are at high risk for cardiovascular disease (CVD) due to gender, income, and race disparities (Agency for Healthcare Research and Quality, 2010; Chou et al., 2007; Office of Minority Health, 2010; Roger et al., 2011; Thom et al., 2006), as well as multiple CVD risk factors (Flannery Resnick, Galik et al., 2012) such as excess body weight (Flannery, Resnick, Galik et al. 2012; Nelson, 1997), low levels of physical activity (Flannery, Resnick, Galik et al., 2012; Nelson, 1997; Skargren & Oberg, 1996), hypertension (Flannery, Resnick, Galik et al., 2012), and hyperlipidemia (Flannery, Resnick, Galik et al., 2012).
WORKSITE HEALTH PROMOTION The US Department of Health and Human Services’ national agenda is to reduce health disparities by offering evidence based health promotion programs to low-income minority women (e.g., NAs; United States Department of Health and Human Services., 2011). Worksite health promotion (WHP) programs are an ideal way to provide minority low-income women with health promotion programs as these individuals are otherwise a challenging population to access (Huang Address correspondence to Kelly Flannery, PhD, RN, University of Maryland Baltimore, School of Nursing, 655 W. Lombard Street, Room 390, Baltimore, MD 21201. E-mail: [email protected]
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& Coker, 2010; Yancey, Ory, & Davis, 2006; Yancu, Lee, Witherspoon, & McRae, 2011). Also, employees, such as NAs, spend a large percentage of their time at work, and thus can integrate physical activity and heart healthy diets into their workday and practice newly learned behaviors in a supportive environment that promotes a culture of health (Centers for Disease Control & Prevention., 2005). Prior research has shown that participants in WHP programs experience improvements in body mass index (Aldana et al., 2005; Anderson et al., 2009; Chung, Melnyk, Blue, Renaud, & Breton, 2009; Conn, Hafdahl, Cooper, Brown, & Lusk, 2009), blood pressure (Calderon, Smallwood, & Tipton, 2008; Chung et al., 2009; Gemson et al., 2008; Milani & Lavie, 2009; Pedersen et al., 2009; Racette et al., 2009), lipid levels (Aldana et al., 2005; Calderon et al., 2008; Conn et al., 2009; Milani & Lavie, 2009; Racette et al., 2009), and depressive symptoms (Barr-Anderson, AuYoung, Whitt-Glover, Glenn, & Yancey, 2011). Employers that offer WHP programs receive a significant return on investment (Chapman, 2005) in the form of reduced employee healthcare costs (Baicker, Cutler, & Song, 2010; Chapman, 2005), absenteeism (Baicker et al., 2010; Chapman, 2005; Conn et al., 2009), and work productivity (Mills, Kessler, Cooper, & Sullivan, 2007). Despite the significant need to decrease the risk and incidence of CVD among NAs, few WHP programs have been done with these individuals. Three published WHP studies including NAs focused on improving musculoskeletal disorders. Specifically, these studies reported that WHP programs resulted in decreased musculoskeletal symptoms (Dehlin, Berg, Hedenrud, Andersson, & Grimby, 1978; Härmä, Ilmarinen, Knauth, & Rutenfranz, 1988; Skargren & Oberg, 1996), improved muscle strength (Dehlin et al., 1978; Härmä et al., 1988; Skargren & Oberg, 1996), increased cardio-respiratory fitness (Härmä et al., 1988), decreased job strain (Dehlin et al., 1978), and reduced fatigue while at work (Härmä et al., 1988) . A recently published study testing WHP with NAs focused on reducing CVD and resulted in decreasing blood pressure and depressive symptoms while also improving lipid panels and work productivity (Flannery, Resnick, Galik, et al., 2012; Flannery, Resnick, & McMullen, 2012). Challenges associated with participation in these programs due to work-related responsibilities have been noted in prior research (Hess, Borg, & Rissel, 2011; Lemon et al., 2010; Skargren & Oberg, 1996). Therefore, the purpose of this study was to use a qualitative approach to gain a better understanding of challenges associated with participation in WHP programs among NAs. NAs that consented to participate in a WHP program, the worksite heart health improvement project (WHHIP), were invited to participate in focus groups to consider the factors that facilitated, and hindered their participation in the WHHIP. We also aimed to explore how working as a NA affected their ability to eat healthy foods, and to engage in physical activity.
METHODS Design This study used a focus group approach to understand factors that facilitated and hindered participation in the WHHIP. Focus groups were deemed the most appropriate method of data collection because participants were similar and shared a similar experience (i.e., participation in the WHHIP) that helped form group cohesion (Creswell, 2006).
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Sample Nursing assistants were eligible to participate in the focus groups if they participated in the WHHIP (described briefly in the following) and worked in the site randomized to the intervention. The treatment site exposed to the WHHIP included 24 NAs that worked in a long-term care facility in Baltimore, MD. At the time the focus groups were conducted, 20 NAs remained in the facility and two of these individuals dropped out of the study (Flannery, Resnick, Galik, et al., 2012; Flannery, Resnick, & McMullen, 2012b). Thus, 18 NAs were invited to participate in the focus groups and 12 of these individuals (67%) participated. Table 1 describes the baseline demographics and CVD health status of the 12 participants that took part in the focus groups. The focus group participants were all African American/Black women that were middle aged (42.95 years; SD = 14.70), and worked at the facility for approximately 7 years. The majority (n = 10, 83.3%) had at least three risk factors for CVD (i.e. overweight/obese, hyperlipidemia, low-levels of physical activity, and/or high blood pressure). The WHHIP Briefly, the WHHIP was a 6-month study with a 3-month intervention. As shown in Table 2 the intervention consisted of three components that were based on the social ecological model (Linnan, Sorensen, Colditz, Klar, & Emmons, 2001) and the theory of self-efficacy (Bandura, 1977). The intervention included: (1) an environmental assessment and recommendations to make the worksite more heart health friendly; (2) education about heart healthy diets and physical activity; and (3) on-going motivation, as well as opportunities to actively engage in healthy eating and physical activity (Table 2; Flannery, Resnick, Galik, et al., 2012). Component 1 was designed to create a culture of health at the worksite. Examples of component one activities include: creating a policy that allowed employees to use the facility’s gym at no cost and creating a policy that provided employees three paid 10-min physical activity breaks per 8-hr worked. Component 2 used a one-time education lecture to provide the NAs a foundation of knowledge about physical
TABLE 1 Baseline Demographics of Sample That Participated in Focus Group (N = 12) Variable Age (in years) Tenure (in months) Body mass index Average daily steps African American/Black Latino Married Post high school education Day shift 3–4 Cardiovascular disease risk factors presenta
M 42.96 84.36 32.70 6,660.29
SD
N
%
11 0 2 7 5 10
100%
14.70 96.29 7.59 4, 517.41
18.2% 63.1% 45.5% 83.3%
Note. a Cardiovascular disease risk determined from the following factors: overweight/obese, hyperlipidemia, high blood pressure (i.e., prehypertension or hypertension), and engaged in less than 150 min of physical activity/week.
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TABLE 2 The Worksite Heart Health Improvement Project Intervention Summary
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Purpose Component 1: Environmental assessment
Assess work factors that affect nursing assistants’ health
Component 2: Initial education
Provide cardiovascular disease prevention education with particular focus on making physical activity, and diet changes at work Motivate nursing assistants to engage in physical activity, and reduce dietary fat and salt intake
Component 3: On-going motivation
Summary of What Was Done Performed an environmental assessment and provided management with recommendations based on assessment Performed an education lecture
Provided on-going motivation, additional education, and opportunities for nursing assistants to actively engage in physical activity (e.g., 10 minute physical activity breaks), and healthy eating (e.g., weekly healthy food taste tests)
activity and heart healthy eating. Component 3 expanded on the education foundation provided in component 2 and actively engaged NAs in physical activity and healthy eating interventions. During component 3, the interventionist and/or trained peer champions were instructed to foster self-efficacy for heart healthy behaviors as well as provide physical activity opportunities and/or healthy eating instruction. Measures An interview guide was used to facilitate questioning during the focus group. The questions included: (a) What were the barriers to participating in the WHHIP?; (b) What suggestions can you offer to facilitate participation in WHHIP activities?; (c) What did you like most about the WHHIP?; (d) What did you like least about the WHHIP?; (e) Why did you choose to participate in the WHHIP?; (f) Tell me about your experiences participating in the WHHIP?; (g) Is there anything else you would like to say about the WHHIP that we did not cover? Last, we considered two additional questions, from the study survey, that focused specifically on health behavior change for NAs. These included: (a) How does working as a NA influence your ability to exercise outside of work?; and (b) How does working as a NA affect your ability to eat a heart healthy diet (at work and outside of work)? Focus Group Three focus groups were conducted at the end of the WHHIP. Participants were invited to participate in a focus group via study flyers, personal invitations from research staff, and/or word of
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mouth from other participants. All focus groups were held during day and evening hours during typical work downtime. The focus groups were all conducted by a nurse researcher with experience in WHP. Focus groups were audio-taped and transcribed verbatim and hand-written notes were used to contextualize the tapes. This study was approved by the University of Maryland’s Institutional Review Board. Consent to participate in a focus group was obtained when obtaining consent for participation the WHHIP.
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Analysis Strategy Data analysis was done using content analysis and in vivo coding (Creswell, 2006). The following is an example of a quote and an in vivo code: “It’s much more fun to do with the group . . . ”, which we coded as group. Codes and themes were initiated by a nurse researcher with experience in WHP and revised by a second nurse researcher with experience working with the sample population and health promotion interventions. Code development and reduction of codes into themes were discussed among the two until unanimous agreement was obtained. For example, the following six codes—improve health, pedometer feedback, group interaction, experienced health benefits, program served as a kick start, and longevity—were reduced to the theme motivation to participate in a WHP program. Credibility of the Data The focus groups were done in one day, but at different times so that the findings from later focus groups could be used to confirm or refute prior codes and discover emerging themes. During the focus groups, the facilitator continually checked with participants to ensure that she heard the essence of the participants’ experience. In addition, confirmability of the data was established by having another member of the research team review the findings and provide feedback as to whether these findings logically fit in other settings and experiences (Creswell, 2006).
RESULTS From the focus groups, a total of 40 different codes were identified and reduced to four themes. These themes were motivation to participate in a WHP program, program participation facilitators, program barriers to participation, and suggestions for future programs. Motivation To Participate In A Worksite Health Promotion Program We identified six codes that corresponded with the theme motivation to participate in a WHP program. Participants identified motivators that initiated participation, motivators that helped them continue to engage in the program, and motivational factors that did both. The most common reasons participants gave for joining the program, and/or continuing to engage in the program were a desire to improve their health, positive reinforcement from pedometers about their daily physical activity counts (e.g., steps, aerobic steps), group interaction, and health benefits experienced (e.g., stress reduction, increased energy or reduced blood pressure). For example, one
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participant reported her motivation for participating in the WHHIP was group interaction. She said, “I’m good with a group as far as exercising. . . . When I do it by myself, I don’t do as much and slack off.” Another participant said her motivation for program engagement was noted health improvement. This participant stated, “Once I got started . . . and then I check my blood pressure . . . and I see this is really helping me, . . . if something is doing good why stop?” Less commonly, participants reported that they engaged in the WHP program to improve their health with a goal of living a longer healthier life or the program served as a kick-start and provided them the initial external motivation to start engaging in health behaviors.
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Program Participation Facilitators We identified 13 codes that fell under the theme program participation facilitators. The two most commonly reported codes under this theme were simple health changes and healthy behavior awareness. We found participants felt that making simple, small, gradual changes was effective in helping them change their health behaviors. These two quotes illustrate examples of some simple changes participants were initially able to make to improve their health: “I can take 10 minutes out and do my walk and do a little exercise” and “Before the program, I was not eating healthy. . . . Now, . . . I think, . . . ‘This is 300 calories.’ . . . I never did that before; . . . before this program I just ate away.” Consistently, participants noted that health tidbits led to changes in their health behavior. For example, one participant reported, “I loved when you showed the food items and all the things that is in them. . . . I learned about pickles . . . . Makes me look at labels more, . . . how much sodium is in one of those pickles. . . . I was eating a bowl everyday!” In addition, the participants reported that there were several aspects of the program that helped to make it successful. Specifically, participants reported they liked receiving healthy food for program prizes (e.g., prizes for meeting set program goals and/or winning competitions), as well as weekly taste tests of healthy food. Participants also reported they liked receiving healthy recipes as well as posting weekly health tips (in the staff room and handouts). Participants also liked exercise DVDs and dance games because they were fun and they could be used in the interventionist’s absence. The participants reinforced policy initiatives that occurred at the onset of the study (Flannery, Resnick, Galik, et al., 2012), such as allowing three 10-min breaks for physical activity and allowing employees to use the facility’s exercise room (typically used by the residents) at no cost, also boosted program success. Participants also felt the use of a sign-out board helped with communication and allowed the nurse and other staff members to know when an NA was taking a physical activity break. Participants also reported that the interventionist kept their spirit up and did not apply pressure, which allowed the participants to see, in a nonthreatening way, when they were not participating. They reported that this helped them reengage into the program and maintain motivation. Last, participants found that sharing what they learned in the program with family and friends was helpful because NAs also needed their family members’ and friends’ support when they were outside of work. Program Barriers to Participation Ten codes were reduced to the theme program barriers to participation. We consistently heard from participants that their biggest barrier to participation was their patient care workloads. For example, one participant noted,
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Getting to the end of the shift I become busy. . . . I become nervous . . . If I’m working and I leave the floor and come over there [to exercise], my mind is not really steady. . . . It’s more stressful to leave . . . if I have certain assignments. . . . You can’t leave that patient. . . . No one is gonna answer those lights.
Other participants stated that time (work time and outside-of-work time) and outside-of-work responsibilities (e.g., child care) were program participation barriers. The following quotes show how lack of time at work can serve as a program barrier: “It might sound easy . . . . It’s only ten minutes . . . . Ten minutes we don’t have;” and “You give somebody medicine in 10 minutes.” Several participants stated that their work was stressful and they wanted to use their break times to relax and they did not perceive physical activity as a way to reduce their stress and/or relax. In addition, participants reported that unpredictable work schedules and push back from staff members that were not participating in the program made it hard to participate in group activities. Another barrier reported was reduced staff numbers from high rates of turnover. With regard to adhering to a healthy diet in the worksite, participants reported that other staff ordering fast food from local restaurants for breakfast, lunch, and/or dinner was a temptation to healthy eating. Table 3 provides some data on the particular impact that working as an NA has on heart healthy behaviors. Most commonly NAs, reported being too tired, as a result of their job, to focus on healthy behaviors after they left work. Suggestions for Future Programs We identified 11 codes that focused on suggestions for future programs. The most common codes were inclusion of health promotion activities that were not on work time and on-going motivational inoculations from the interventionist and peer champions. For example, several participants stated that they would be willing to come into work early and/or stay after work to participate in group activities related to heart-healthy behaviors outside of work time. They suggested this because they were unable to leave their unit as much as they would have liked to engage in the WHHIP activities with the group, and/or they just wanted additional group support. Of note,
TABLE 3 Select Quotes On How Working As A Nursing Assistant Affects Participation in Health Behaviors Work’s Impact on Ability to Eat Healthy
Work’s Impact on Ability to Exercise Outside of Work
“Sometimes too tired to fix.”
“I work nights shift and when I get home I become tired and sleepy to do active exercises.” “Am exhausted.” “Too busy and too tired.”
“Don’t feel like cooking after leaving here.” “I rush for break and have to buy my lunch, which at times is not healthy.” “Depending on the activity going on, like party or dinner.” “Too tired to cook.”
“The fact that I work the night shift makes me unproductive during the day.” “Standing all day (7 hrs or more) make too tired to do anything.” “I go to school during the day and I get off really late.”
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however, the participants indicated that they would not have signed up to participate in the WHIIP if it occurred outside of work time. It was only after they began to experience the health benefits and the supportive group interaction that they reported they would engage in the WHHIP outside of work time. Although the intervention was designed to have peer motivators facilitate adherence to the WHHIP activities as the interventionist decreased the time she was spending with the participants, participants reported that peer motivators often stopped motivating participants. Peer motivators reported that they stopped motivating their peers because they were frustrated and discouraged by their peers’ lack of adherence to healthy behaviors (e.g., physical activity). Participants suggested an inoculation period to help with transition (e.g., when the interventionist leaves and peer champions sustain the project) and provide additional training for peer champions (e.g., review health information, provide innovative interventions to motivate non-compliant co-workers) would help maintain sustainability. Additional suggestions for future programs were around education. Participants suggested more education topics, holding refresher classes for complex topics (e.g., learning to read food labels), only covering one topic at a time (e.g., only covering one section of the food label at a time, such as fat content), and condensing all educational handouts to one page. One particularly unanticipated finding from the focus groups was the recommendation to increase the group work/support to help them deal with depression and stressful situations (i.e., work and personal stress). We also heard that times for group activities may need to be flexible, based on unit needs and staff levels on any given day. For example, evening shift NAs reported interventions that are delivered toward the end of the shift (9 pm and after) could allow for more participation because their workload is lighter at this time. Participants suggested that the use of a buddy system would help them feel more comfortable about leaving the units to exercise without worrying about their resident assignments. We found that participants were sincerely concerned that if they left the unit for their 10-min physical activity break, their residents would need something and they were not confident that someone else would address the care needs of the resident. They suggested that assigning a buddy to cover their assignment while they were off the unit engaging in a physical activity break would be helpful. Further, they suggested that rotating buddies would help with complacency and staff members working different schedules. One participant suggested that walking outside could help increase participation in physical activity interventions.
DISCUSSION Participants confirmed that their motivation to participate in the WHHIP was driven by personal relevant motivators, as well as external motivators such as food, social support, and encouragement from others. Prior research has also noted social support is an important motivator for minority women (Zunker et al., 2008). As seen in prior research with African American women (Harley, Odoms-Young, Beard, Katz, & Heaney, 2009), we also noted that African American NAs were motivated when health outcomes (e.g., reduction of blood pressure) were linked to health behavior changes (e.g., salt consumed). Future research with this population should continue to use personally relevant motivators (e.g., health outcomes) and external motivators such as healthy food incentives and social support to provide initial and on-going motivation for behavior change.
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Consistent with other studies with NAs (Nelson, 1997), our participants reported that they were unable to initiate physical activity or healthy eating outside of work because they had additional responsibilities, such as childcare. In addition, the study participants reported being too tired to engage in healthy behaviors, such as physical activity and heart healthy meal preparation, outside of work. This may be due to the demanding nature of their work, and/or because many NAs report working consecutively long shifts, mandatory overtime, and/or have second jobs (Flannery, Resnick, & McMullen, 2012). This reinforces the critically important need to incorporate health promotion activities into NAs’ workday. Although there is evidence that there is a significant benefit to engaging NAs in healthy behaviors during the workday, there are challenges as well. Specifically, some WHHIP participants reported feeling stressed and anxious when they focused on themselves instead of their residents during the workday. Although most NAs were interested and willing to engage in short bursts of physical activity during the workday, they wanted staff coverage to care for their residents and assurance their residents would received the care they needed. Prior WHP research with healthcare workers (Lemon et al., 2010; Skargren & Oberg, 1996) also found patient care tasks and lack of flexibility (real or perceived) in completing patient care tasks a barrier to WHP participation. Incorporating the participants’ suggestions of the use of a sign out board and buddy system could ameliorate these barriers and allow NAs uninterrupted time for engagement in health promotion interventions during work time as well as alleviate some of their work stress. The NAs who engaged in short bursts of physical activity during the workday generally adhered to the allotted time for physical activity breaks (i.e., three 10-min physical activity breaks). We did learn, however, that a few NAs took advantage of this benefit by taking more than 10-min at a time for physical activity breaks. Excessive time off the unit resulted in the charge nurses expressing concern about the program. As with any program, it is important to maintain on-going oversight and communication between the program champion(s) and the facility’s administration to assure activities are being performed as intended. Despite established research findings indicating that stress is decreased by regular physical activity (Wolff, Lindenberger, Brigitt-Leila, JensHeinz, & Ströhle, 2011), many of the NAs in this study did not generally believe that physical activity could be a coping mechanism for dealing with work and/or personal stress. It is possible that stress actually limited the NAs engagement (Clark et al., 2011; Lemon et al., 2010), and limited their ability to learn new information provided in the intervention (e.g., how to read food labels; Sandi & Pinelo-Nava, 2007). Given the high rate of stress noted among NAs (Ejaz, Noelker, Menne, & Bagaka, 2008; Lapane & Hughes, 2007) future WHP research might benefit from including a stronger focus on the benefits of physical activity with regard to stress and including additional stress reduction techniques (e.g., deep breathing) to increase participation in the program and facilitate adherence to heart healthy behaviors. Even though the participants reported that the program helped them engage in health behaviors and the intervention reduced systolic blood pressure, cholesterol, triglycerides, and depressive symptoms (Flannery, Resnick, Galik, et al., 2012), participants admitted that they needed an inoculation (i.e., external motivation and program reminders from program champions) to sustain engagement in health behaviors. We believe that an inoculation twice a week will help NAs maintain engagement in healthy behaviors over time. Moreover, it may be possible to train staff members to serve as peer champions that can provide these weekly inoculations. In a recent meta-analysis, lay champions were noted to facilitate adherence to heart-healthy behaviors as
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effectively as trained interventionists (Anderson et al., 2009). Future research should consider using a model that combines both an interventionist and peer champions. Future WHP programs could be initiated by a trained interventionist and then maintained by NAs (i.e., peer champions) trained by the interventionist.
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LIMITATIONS This study was limited in that it included a small number of NAs from a single nursing home in Maryland. Although saturation was achieved during the focus groups held, it is possible that NAs working in other regions and settings might have experienced participation in the WHHIP differently. Despite these limitations, the findings from this study provide valuable lessons associated with implementing a WHP program with NAs during paid work time and can be used to guide future interventions.
CONCLUSION This study provides the insight of 12 low-income African American women that participated in a WHP program aimed at reducing CVD risk factors. The data provided from this study indicate that participants are eager to improve their health, although they depend on social support to motivate them to engage in health behaviors. The data also suggest that inoculations are needed to help NAs sustain behavior change after the intervention is complete. Participants noted that educating them on how to make simple health changes and fostering healthy behavior awareness were the two largest program participation facilitators. One of the largest program participation barriers was their workload and participants suggested innovative suggestions, such as a buddy system and the use of a sign-out board, to ameliorate these barriers. Given the many known benefits of WHP programs and NAs’ risk for CVD, it is critical that WHP programs be offered to NAs. This study provides essential formative data that can aid in the design of future behavior change WHP programs in a high-risk population that is often underrecruited for health-promotion programs and, once recruited, they often experience additional barriers to retention (Huang & Coker, 2010; Yancey et al., 2006; Yancu et al., 2011). Successful behavior change interventions among these individuals have the potential to prevent the development and/or progression of CVD and serve as a model for changing other types of NAs’ health behaviors (e.g., smoking/tobacco use).
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