Julie Fleury

Barriers to outpatient cardiac rehabilitation participation and adherence.

BACKGROUND A significant proportion of eligible patients do not participate in outpatient cardiac rehabilitation. The purpose of this study was to identify barriers to participation and adherence to outpatient cardiac rehabilitation by querying program staff. METHODS In January 1999, a survey was mailed to all North Carolina program directors of outpatient cardiac rehabilitation programs. The response rate was 85% (61/72). RESULTS Across programs, the most common barrier to participation in outpatient cardiac rehabilitation was financial. Other barriers identified by program directors included lack of patient motivation, patient work or time conflicts, and lack of physician support or referral. When program directors were asked to cite reasons that referred patients provided for not participating in rehabilitation, the most common answer was financial or lack of motivation or commitment. The most common reason cited for dropping out of the rehabilitation program was work, followed by financial reasons and lack of motivation or commitment. CONCLUSIONS The results of this statewide survey of program directors indicated a common set of barriers that many patients currently face to begin and continue participating in outpatient cardiac rehabilitation.

Risk factors for mobility limitation in community-dwelling older adults: a social ecological perspective.

Although a variety of risk factors for mobility limitation in older adults have been examined, a collective review of relevant literature has not been reported. The purposes of this review are to report the intrapersonal, interpersonal, environmental, and organizational risk factors related to mobility limitation using a social ecological perspective and to discuss the direction of future clinical practice consistent with current literature on mobility limitation of community-dwelling older adults. Intrapersonal risk factors related to mobility limitation include advanced age, female gender, low socioeconomic status, comorbidity, lack of motivation (i.e., dependent personality, decreased self-efficacy), lifestyle factors (i.e., sedentary lifestyle, smoking, obesity), and physiological factors (i.e., vitamin D deficiency, inflammation, poor nutritional status). Interpersonal risk factors related to mobility limitation include weak social networks and limited social activities. Geriatric clients may also experience a decline in mobility when they encounter environmental challenges such as an inconvenient home environment and lack of availability of services in their community, as well as lack of organizational resources stemming from social policy. Potential intervention strategies focused on modifiable risk factors may include lifestyle modifications, social networking programs, and enhancing awareness of environmental and organizational resources in the community for older adults at risk for mobility limitation.

Interventions for promoting mobility in community-dwelling older adults

Purpose: The purposes of this review were to provide an updated report of intervention studies designed to enhance mobility in older adults and discuss the strengths and limitations of existing intervention studies and their implications for practice. Data sources: Medline, CINAHL, and PsychInfo were searched to identify original research articles reporting interventions for promoting mobility in community‐dwelling older adults. Conclusion: Effective interventions for enhancing mobility in older adults include walking, aerobic exercise, and resistance training focusing on strength, balance, and flexibility. Group‐based interventions show significant beneficial effects in increasing mobility. To obtain significant effects of physical activity interventions, the patient should participate in the exercise programs for at least 12 weeks. Strengths of existing clinical trials for promoting mobility in older adults include testing of various types of physical activity and training interventions and the use of an experimental design with a control group. The major challenges of creating mobility enhancement recommendations for older adults include detailing a mobility enhancement program will delay disability, creating a specific program dose for different populations by gender and ethnicity, and developing culturally appropriate mobility enhancement programs to improve adherence over time. Implications for practice: Prescribing regular physical activity including aerobic exercise and resistance training in a primary care setting can be a beneficial approach to minimize progression of impaired mobility in older adults. The typical dose of the physical activity prescription is 20‐60 min of aerobic activity three times weekly. Adherence to mobility enhancement recommendations by older patients can be followed up by in‐person interview or use of mobility monitoring tools such as exercise diary or log.

Using Visual Methods to Uncover Context

The accurate assessment of physical activity and dietary intake is essential for assessing the relationships between physical activity, dietary intake, and health outcomes. However, the measurement of physical activity and dietary intake among women, particularly minority women, poses unique challenges related to gender, ethnicity, and social context. Measures that are not culturally relevant or sensitive to the experiences, traditions, or beliefs of ethnically diverse women might result in data that are unreliable, or which cannot be interpreted. Visual methods show promise for elucidating concepts that are important to refine established measures for assessing dietary intake and physical activity in diverse ethnic groups. Hispanic women, a largely understudied subgroup that experiences long-term health risks associated with dietary and physical activity behaviors, serves as the focal group for this discussion of the potential for visual methods to develop culturally and contextually relevant and valid approaches to outcome assessment.

Exploring Resources for Physical Activity in Hispanic Women, Using Photo Elicitation

Addressing cultural, social, and contextual resources to promote physical activity behavior among Hispanic women is necessary to establish effective intervention approaches. With this research we intended to (a) explore cultural, social, and contextual resources for physical activity among Hispanic women; and (b) evaluate the acceptability of visual methods as an innovative, formative method to enhance intervention relevance. A qualitative descriptive methodological design incorporating photo elicitation was used with 7 Hispanic women, aged 23 to 60 (X = 44.2). Results were varied, and themes captured cultural, social, and contextual resources. Culture provided an overarching perspective, guiding identification and choice of physical activity resources, support, and setting. Themes included being active as a way of life, acknowledging tradition, moving with me, creating place, and building resources. Photo elicitation was evaluated as an acceptable method. Data provide an initial step toward generating a more complete understanding of perceived resources for physical activity in Hispanic women, and support the acceptability of photo elicitation.

Social and Contextual Etiology of Coronary Heart Disease in Women

We explored the social and contextual etiology of coronary heart disease (CHD) prevention and management in women. Social and contextual influences on CHD risk include such factors as socioeconomic status, access to healthcare, cultural mores, working conditions including work overload, multiple role responsibilities, and social isolation. Women, particularly economically disadvantaged women, occupy lower levels on the social status hierarchy and, therefore, experience more stressful life experiences, less favorable living conditions, and less opportunity to affect positive health behavior and outcomes. Women are often discriminated against economically, politically, and socially, and this discrimination may adversely affect their efforts at CHD health promotion and treatment. Multiple role responsibilities within the family and psychosocial factors, including chronic life stress, are critical to an understanding of the health status of women, particularly poor and minority women. Although community-based interventions appear to be ideal for addressing the contextual risks related to CHD in women, a number of issues need to be considered, for example, the limited acknowledgment of secular trends in economic development that influence lifestyle decisions and health promotion efforts. Directions for research and interventions include recognition of the full spectrum of CHD risk in women, recognition of culturally competent interventions, and recognition of the need for empowerment of women.

The Role of Lay Health Advisors in Cardiovascular Risk Reduction: A Review

Interventions are needed to reduce the negative impact of cardiovascular disease. The combination of health risks for disease, disability, and mortality, particularly among underserved populations, might be best addressed with programs designed to enhance awareness and development of resources within a context of community support. The objectives of this review were to: (1) provide a comprehensive review and evaluation of the roles, evaluation, and effectiveness of LHA in community-based programs with an emphasis on cardiovascular risk reduction; and (2) provide recommendations for future research involving LHA in such programs. Computer and manual searches were conducted of articles in the English-language literature from 1980 to 2007. Twenty articles were evaluated, which emphasized the role of the LHA in cardiovascular risk reduction. A review of research literature provides a starting point for determining salient approaches for intervention and evaluation, issues related to program implementation and sustainability, and strengths and limitations of existing approaches.

Barriers to physical activity maintenance after cardiac rehabilitation.

PURPOSE Little is known about the contextual determinants for the maintenance of physical activity after cardiac rehabilitation. This study aimed to examine perceived social, psychological, and health-related barriers to the maintenance of physical activity among phase 2 cardiac rehabilitation graduates. METHODS Researchers using an open-ended format asked 160 participants (121 men and 39 women) 6 months after rehabilitation to identify perceived barriers to physical activity maintenance. The content of the participant responses was analyzed through categorization and coding of data, with independent review used to assess accuracy and reliability of decision rules. A social ecologic perspective was used for secondary coding and categorization. A chi analysis of categories was conducted to explore differences by gender, ethnicity, education, and employment. RESULTS Four categories were developed from the coded responses: intrapersonal, interpersonal, environmental, and organizational. In their responses, 93% of the participants reported intrapersonal barriers, with 24% reporting interpersonal barriers, 18% reporting environmental barriers, and 11% reporting organizational barriers. Years of education contributed significantly to acceptance of an inactive lifestyle among those less educated (chi = 32.489; P = .028). Employment status showed significant differences for work as a barrier among those employed full-time (chi = 13.570, P = .004). Barriers to physical activity by gender showed significant differences for interpersonal barriers as a whole (chi = 6.804; P = .009). CONCLUSIONS The open-ended format provided rich narrative data regarding barriers to the maintenance of physical activity. The acknowledgment of barriers, particularly from a social ecologic perspective, is needed to guide innovative, multilevel interventions for promoting physical activity maintenance among those with diagnosed coronary heart disease.

Factors related to physical activity in Hispanic women.

Hispanic women are more likely to be sedentary than the general population. Increasing physical activity in this at-risk group is an important challenge in the prevention and management of coronary heart disease. This article reviews research conducted with Hispanic women in whom physical activity was the primary focus of study or the primary outcome of interest. Computer and manual searches were performed to identify articles published from 1990 to 2005. Factors that influence physical activity in Hispanic women include self-efficacy, having a concern for own and family health, social support and norms for physical activity, serving as a role model to others, and perceived neighborhood resources. Despite significant efforts to understand and promote physical activity among Hispanic women, much work remains to be done in this area. Future research should include attention to cultural, social, and contextual resources in understanding and promoting physical activity.

Wellness Motivation Theory: An Exploration of Theoretical Relevance

Data were collected from 14 older, rural African American men and women to explore how individual motivation affects the initiation and maintenance of health-related behavior. The research consisted of an inductive exploration designed to examine the validity and cultural relevance of an existing theoretical framework for wellness motivation in health behavior change. Through the technique of constant comparative analysis, the basic social process of empowering potential was substantiated as a process of individual growth and goal-directed behavior that facilitated the initiation and maintenance of positive health patterns. The process of empowering potential consisted of three stages: appraising readiness, changing, and integrating change. Two categories provided a cultural context for the process: health value orientation and network affiliation. The data validated and expanded a developing theoretical framework for wellness motivation in health behavior change.