Given the changing demographic composition of the United States, which is projected to have increasing proportions of ethnic minorities (Centers for Disease Control and Prevention, 2008
), effective and sustainable interventions to increase physical activity and decrease cardiovascular risk is essential. Recommendations for research on physical activity include identifying relevant and practical interventions that can be built upon to extend the science and readied for application to practice (Conn et al., 2008
; Estabrooks, Lee, & Gyurcsik, 2003
While few studies documented positive changes in physical activity, significant changes were noted in health outcomes and related outcomes including knowledge, self-efficacy, and perceived support. However, the majority of physical activity measures were self-report, and lacked standardization, raising questions about the validity and maintenance of effects.
One area of concern within the studies reviewed is the lack of follow-up to evaluate the long-term impact of interventions. Hovell, Mulvihill, Buono, Liles, Schade et al, (2008) obtained 12 mo follow-up, indicating that physical activity was sustained over time, at a lower level. With some interventions implemented for only several weeks, and an overall limited time to follow-up, the lasting impact of interventions on physical activity maintenance and cardiovascular risk reduction is difficult to evaluate. With any health promotion intervention or program, one of the greatest challenges is the sustainability of resources and outcomes generated during the intervention. Many interventions within this review implemented comprehensive programs, but did not necessarily plan for, facilitate, or evaluate continuation of program activities or development of sustainable resources following program implementation. In developing physical activity interventions for Hispanic women, additional programs are needed which address both maintenance and sustainability issues relative to development and continuation of resources and lasting changes in physical activity behavior.
Few studies reviewed used a theoretical perspective to guide program implementation and evaluation. Of those that included theoretical frameworks, often insufficient detail was provided to permit understanding of the operationalization of the major concepts in the intervention, particularly from a culturally relevant perspective. Among studies that have achieved intervention effects, the mechanisms underlying treatment were not always clear, limiting the applicability of existing intervention findings to practice. While the majority of interventions included social support, motivational factors, goal setting, and education, it is not clear from the published literature what factors were critical for efficacious interventions among Hispanic women. General statements about intervention content and delivery methods limit evaluation of the relationship between physical activity and intervention delivery, including which component of multiple interventions may be responsible for an effect. Thus, greater attention is needed to intervention specification, and related quantification of intervention fidelity to the planned protocol.
In spite of the finding that the interventions reviewed in this report were limited in the use of theoretical approaches and consideration of contextual effects impacting intervention design and delivery, data to support such approaches are available. A significant number of research reports that used inductive methods and focused on Hispanic women and physical activity health promotion were noted in the research literature (Gonzales & Keller, 2004
; Juarbe, 1998
; Juarbe, Turok, & Perez-Stable, 2002
; Kieffer, Willis, Arellano, & Guzman, 2002
; Melillo et al., 2001
; Ramirez, Chalela, Gallion, & Velez, 2007
; Van Duyn et al., 2007
). Using primarily focus groups and content analysis procedures, the culturally relevant factors that motivate Hispanic women to engage in physical activity, and the accompanying barriers and facilitators for such activity are delineated, with remarkable consensus. Among Hispanic women, extending time to focus on their own needs, including physical activity is not possible; family needs come first. Safety in physical activity locales is exceptionally important to Hispanic women, as well as support that is gleaned from friends and families who value health promoting and physical activity behavior. Such contextual factors that have been apparent in reported research for several years needs to be incorporated into the design and implementation of future research on physical activity in Hispanic women. Failure of current research to adequately address social and contextual factors may contribute to the lack of success in developing theory-based interventions designed to promote physical activity among underserved and minority populations. Indeed, Glass and McAtee (2006)
have called for contextualized frameworks to guide theory generation and research efforts, which acknowledge the social context in which health behaviors occur, as well as how these behaviors can be changed.
The majority of studies focused on individual-level variables as primary outcomes. While important, these do not provide a full understanding of the potential for community mobilization and change. Evaluation of community-level indicators of intervention effects are needed, to demonstrate changes in community capacity, resource identification, and environmental change. Recommendations include use of qualitative methods to develop interventions during a formative phase before implementation (Krummel et al., 2001
). Such formative research may lead to the development of needed theory-based interventions that target specific populations, acknowledging social and contextual resources, and cultural values as a basis for practice (Belza et al., 2004
; Glasgow, Strycker, Toobert, & Eakin, 2000
Socioeconomic status has been demonstrated to exert significant influence on physical activity in Hispanic women. For example, among Puerto Rican women living in Connecticut, acculturation was positively associated with physical activity, but socioeconomic status was not (Fitzgerald et al., 2006). In 793 Spanish women, socioeconomic status was significantly related to lower levels of leisure-time physical activity (Schroder, Rohlfs, Schmelz, Marrugat, & REGICOR investigators, 2004). One survey showed that marital status (an indicator of socioeconomic status) was the most salient predictor of physical activity in Mexican-American women (Ransdell & Wells, 1998). The physical activity of women who are poor is strongly influenced by their neighborhood environments. Access to safe, affordable facilities is an important factor in physical activity participation, particularly among minority women. Yen & Kaplan (1998) noted for example in the Alameda County study, that poverty area residence was associated with a decline in physical activity. Further, the availability of recreational and exercise resources is shown to have a significant impact on participation in physical activity (Diez Roux et al., 2007; Powell, Slater, Chaloupka, & Harper, 2006). Women who live in neighborhoods and situations that preclude outdoor physical activity due to safety, disrepair, or neighborhoods without sidewalks and parks are likely to walk outdoors less. However, the differential effect of socioeconomic status was not examined in the research reports in this review. One intervention (Albright, Pruitt, Castro, Gonzales, Woo et al, (2005) targeted only low-income women (75% study group was Hispanic) showing intervention effectiveness.
Hovell, Mulvihill, Buono, Liles, Schade et al, (2008) described an intervention that included discussion of ‘cultural attitudes” with “myths debunked”; with a 91 % adherence and 60% participation, in depth description of cultural attitudes and debunking processes would add to the literature. Other investigator (Cousins, Rubovits, Dunn, Reeves, Ramirez et al (1992) employed a family intervention thought to be more culturally specific than individual level interventions for weight management in Latinas. Albright, Pruitt, Castro, Gonzales, Woo et al, 2005, with 72 Latinas, implemented “deep structure” in their intervention, and this included encouraging women to be physically active while respecting their core values related to family responsibilities. It was unclear how much impact this cultural tailoring had on the intervention efficacy, and retention.
To reduce disparity in health between Hispanic women and the general population and to provide a basis for the development of relevant interventions, research efforts must better reflect the needs of Hispanic communities (USDHHS, 2000
). Although interventions targeting Hispanic women have focused on counseling and health education, they may not adequately address the unique cultural needs of Hispanic women (Soto et al., 2000
; Staten et al., 2004
). Because ethnicity acts to moderate many health behaviors, and influences health, health beliefs and behavior (Gonzalez-Castro & Alarcon-Hernandez, 2002
), culturally tailored interventions are needed to increase their effectiveness in this changing environment (Chao & Moon, 2005