African American women have significantly higher mortality rates from heart disease and stroke than White women despite advances in treatment and the management of risk factors. Community health workers (CHWs) serve important roles in culturally relevant programs to prevent disease and promote health. This article describes the Pine Apple Heart and Stroke Project's activities to (1) revise the Women's Wellness Sourcebook Module III: Heart and Stroke to be consistent with national guidelines on heart disease and stroke and to meet the needs of African American women living in rural southern communities; (2) train CHWs using the revised curriculum; and (3) evaluate the training program. Revisions of the curriculum were based on recommendations by an expert advisory panel, the staff of a rural health clinic, and feedback from CHWs during training. Questionnaires after training revealed positive changes in CHWs' knowledge, attitudes, self-efficacy, and self-reported risk reduction behaviors related to heart disease, stroke, cancer, and patient–provider communication. This study provides a CHW training curriculum that may be useful to others in establishing heart disease and stroke programs in rural underserved communities.

This supplemental issue of Health Education & Behavior is devoted to the theme of prevention research in women’s health. Women’s health has improved markedly in the past century. A woman’s life expectancy increased from 48.3 years in 1900 to 79.8 years in 2001. The change in life expectancy for older women has been especially dramatic. In 1900, women rarely lived to age 90; in 1990, nearly one-quarter of 50-year-old women could expect to live to age 90. As documented in the recent Department of Health and Human Services (DHHS) publication, A Century of Women’s Health 1900-2000, life expectancy gains for women are largely attributable to prevention efforts such as washing hands, sanitizing medical equipment, and ensuring access to a safe water supply. That publication also describes how women’s health issues were integrated into health care training, public policy debates, health education programs, and clinical practice during the 20th century. Despite this progress, the scientific community paid little serious attention to genderspecific issues in research before the 1980s. When women were included in studies, gender differences were typically not reported and presumably not assessed. Findings from studies of men were generalized to women with little regard for the possibility that the results might lack validity across genders. In the decades since 1980, however, recognition of major differences between the sexes has increased substantially, as demonstrated by the establishment of an Institute of Medicine committee on understanding the biology of sex and gender differences. Increased attention has also been given to including women in research. This is reflected in such events as the 1986 National Institutes of Health (NIH) mandate that women be included in government-funded research (http://www4.od.nih.gov/orwh/ tracking97.pdf). At the same time, several federal-level offices were established that focused on women’s health, including the DHHS Office on Women’s Health (http:// www.4woman.gov/owh/), the NIH Office of Research on Women’s Health (http:// www4.od.nih.gov/orwh/), and the Centers for Disease Control and Prevention (CDC) Office of Women’s Health (http://www.cdc.gov/od/spotlight/nwhw/). In addition to

Purpose: We analyzed the impact of hormone replacement therapy (HRT) on psychological factors in white and black women. We hypothesized that both groups of women would have fewer symptoms of depression and lower hostility scores associated with HRT use. Methods: The cohort included 463 postmenopausal women from the National Heart, Lung and Blood Institute (NHLBI)-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. WISE is a four-center study of women with chest pain who underwent quantitative coronary angiography for suspected ischemia. The psychosocial indices included the Beck Depression Inventory (BDI) and the Cook Medley Hostility questionnaire measuring cynicism, hostility, and aggression. Results: There were no differences by race in use, duration, and type of HRT or presence of menopausal symptoms. There were differences by race in baseline psychological measurements, with black women exhibiting higher BDI scores and higher total Cook Medley scores (p = 0.03) than white women. Use of HRT was consistently associated with better psychological health in white women, with fewer symptoms of depression and lower aggression and cynicism scores (p < 0.04). Black women with menopausal symptoms who used HRT had significantly lower hostility (p < 0.01) and cynicism scores (p < 0.05) than black women who did not use HRT. The presence of menopausal symptoms and hysterectomy status were sig nificant independent predictors of HRT use for both white and black women (p < 0.05). Conclusions: We observed racial differences in associations between HRT use and psychological health. Within the white but not the black HRT users, there were fewer symptoms of depression and lower aggression and cynicism scores.

This study examined the relationship between socioeconomic status (SES), coronary artery disease (CAD) risk factors, and all-cause mortality in a cohort of women with chest pain. A total of 743 women (mean age = 59.6 years) with chest pain who were referred for coronary angiography completed a diagnostic protocol including CAD risk factor assessment, ischemic testing, psychosocial testing, and queries of SES. Patients were followed for about 2 years to track subsequent all-cause mortality. Results indicated that low SES was associated with CAD risk factors, including higher BMI and waist-hip ratios, cigarette smoking, lower reported activity levels, and a greater probability of hypertension. Low income also predicted all-cause mortality (RR = 2.7, 95% CI 1.4, 5.2), including after adjusting for proposed psychosocial and behavioral variables (RR = 5.9, 95% CI 1.2-29.7). Future research will require a thorough a priori focus on potential mechanisms to better understand SES effects on health.

Background. The purpose of this study was to examine the impact of the Pathways intervention on pychosocial variables related to physical activity and diet in American Indian children.Methods. Schools serving American Indian children were randomized to a multicomponent intervention or control condition. At baseline (fall of third grade) and in the spring semester of third, fourth, and fifth grades 755 boys and 692 girls completed a classroom-administered questionnaire. The questionnaire assessed self-efficacy, knowledge, and behavioral intentions related to diet and physical activity, as well as weight loss behaviors and body image.Results. Knowledge of nutrition and physical activity messages increased in both boys and girls in the intervention group compared to controls; however, knowledge of which foods contained more fat did not increase consistently. Compared to controls, self-efficacy to be physically active increased among girls in intervention schools, but not among boys, whereas self-efficacy to make more healthy food choices did not increase more than in controls in either gender. In the intervention group, compared to controls, healthy food intentions and participation in physically active behaviors increased in both boys and girls. Perception of healthy body size and weight loss attempts did not differ in the intervention and control groups.Conclusion. The Pathways intervention program had a positive impact on several aspects of obesity-related knowledge, attitudes, and behaviors. (C) 2003 American Health Foundation and Elsevier Inc. All rights reserved.

Aims Our goat was to evaluate health-related quality of life (QOL) in women undergoing angiography for suspected ischaemia.Methods and results QOL measurements were obtained in 406 women with chest pain symptoms in the Women's Ischemia Syndrome Evaluation (WISE). QOL measures included a general rating (GR), Duke Activity Status Index (DASI), and the Beck Depression Inventory (BDI). Higher scores on the GR and DASI are indicative of better QOL and functioning. Higher scores on the BDI indicate more symptoms of depression. Women were stratified by the presence and absence of obstructive angiographic coronary artery disease (CAD) and by the presence and absence of myocardial ischaemia. Women with angiographic obstructive CAD had lower DASI and higher BDI scores compared to women without obstructive CAD (both P<0.05). Stratification by the presence and absence of ischaemia demonstrated that women with ischaemia had better QOL, evidenced by higher GR QOL scores and lower BDI scores (both P<0.05) than women without ischaemia. Symptoms of angina were significant independent predictors of QOL scores (P<0.001).Conclusions Chest pain symptoms have a significant impact on health-related QOL in women undergoing coronary angiography for suspected myocardial ischaemia and are more important determinants of QOL than the underlying conditions of CAD or ischaemia. (C) 2003 The European Society of Cardiology. Published by Elsevier Ltd. All rights reserved.

Background African-American women are at risk of chronic diseases for which regular physical activity can provide benefits. This group, however, remains predominantly sedentary. Little research has been undertaken to elucidate the multiple factors that influence their physical activity levels. This study was designed to determine associations among personal, social environmental, and physical environmental factors with physical activity level in urban African-American women. Methods The Women and Physical Activity Survey, an interviewer-administered survey consisting of demographic, personal, and social and physical environmental factors, was given to 234 African-American women living in Baltimore, Maryland. Physical activity level was determined from the Behavioral Risk Factor Surveillance System survey. Women were divided into three groups: meeting current recommendations for moderate or vigorous physical activity, insufficiently active, and inactive. Comparisons were made between the group of women that met recommendations versus women who did not, and women who reported any activity versus women who were inactive. Results Twenty-one percent (48) of women met recommendations for physical activity, 61% (143) were insufficiently active, and 18% (43) were inactive. Women who had a partner or who had no children were less likely to engage in some physical activity. Inactive women were more likely than women who participated in some physical activity to know people who exercised. Women who belonged to community groups were more likely to be inactive than women who met current recommendations for physical activity. Women with fewer social roles were more likely to meet current recommendations. Physical environment factors were not associated with physical activity level. Conclusions Further exploration is needed to determine how personal and social environmental and physical environmental factors relate to physical activity in African-American women.

Objective: To compile lessons learned from the Uniontown Community Health Project. Methods: Lessons-learned information was gathered from project staff and community volunteers. Results: Analysis led to the identification of 6 lessons: (a) Establish personal working relationships in communities; (b) find a local community coordinator to lead efforts; (c) be patient in implementing a community health advisor (CHA) model; (d) be flexible and emphasize simplicity when implementing community activities; (e) recognize that meeting research goals requires compromise; and (f) plan transfer of project activities to the community from the beginning. Conclusion: These lessons may benefit others implementing CHA programs.

Objective: Depression and low social support are risk factors for medical morbidity and mortality after acute MI. The ENRICHD study is a multicenter, randomized, controlled clinical trial of a cognitive-behavioral treatment for depression and low social support in post-MI patients. A total of 2481 patients were recruited (26% with low social support, 39% with depression, and 34% with low social support and depression). Our objective is to describe the rationale, design, and delivery of the ENRICHD intervention, Methods: Key features of the intervention include the integration of cognitive-behavioral and social learning approaches to the treatment of depression and a diverse set of problems that can contribute to low social support; rapid initiation of treatment after MI; a combination of individual and group modalities; adjunctive pharmacotherapy for severe or intractable depression; training, certification, and supervision of therapists; and quality assurance procedures. Results: The trial's psychosocial and medical outcomes will be presented in future reports. Conclusions: The ENRICHD protocol targets two complex psychosocial risk factors with a multifaceted intervention, which is delivered in an individualized manner to accommodate a demographically, medically, and psychiatrically diverse patient population. Additional research will be needed to identify optimal matches between patient characteristics and specific components of the intervention.

Journal of Women's Health & Gender-Based MedicineVol. 10, No. 10 FeaturesObservations from the CDC. Community Prevention Study: Contributions to Women's Health and Prevention ResearchBarbara E. Ainsworth, Lynda A. Anderson, Diane M. Becker, Susan J. Blalock, David R. Brown, Ross C. Brownson, Nell Brownstein, Carol E. Cornell, Brenda M. Devellis, Loretta P. Finnegan, Suzanne Folger, Janet E. Fulton, Janet Y. Groff, Carla Herman, Deborah Jones, Thomas C. Keyserling, Dyann Matson Koffman, Cora Lewis, Louise C. Mâsse, Robert E. McKeown, Diane Orenstein, and Antonia J. SpadaroBarbara E. AinsworthSearch for more papers by this author, Lynda A. AndersonSearch for more papers by this author, Diane M. BeckerSearch for more papers by this author, Susan J. BlalockSearch for more papers by this author, David R. BrownSearch for more papers by this author, Ross C. BrownsonSearch for more papers by this author, Nell BrownsteinSearch for more papers by this author, Carol E. CornellSearch for more papers by this author, Brenda M. DevellisSearch for more papers by this author, Loretta P. FinneganSearch for more papers by this author, Suzanne FolgerSearch for more papers by this author, Janet E. FultonSearch for more papers by this author, Janet Y. GroffSearch for more papers by this author, Carla HermanSearch for more papers by this author, Deborah JonesSearch for more papers by this author, Thomas C. KeyserlingSearch for more papers by this author, Dyann Matson KoffmanSearch for more papers by this author, Cora LewisSearch for more papers by this author, Louise C. MâsseSearch for more papers by this author, Robert E. McKeownSearch for more papers by this author, Diane OrensteinSearch for more papers by this author, and Antonia J. SpadaroSearch for more papers by this authorPublished Online:7 Jul 2004https://doi.org/10.1089/152460901317193495AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byExercise and hot flashes: toward a research agendaMenopause, Vol. 13, No. 4Prevention Research in Women’s Health: Studies from the Field—Introduction4 December 2016 | Health Education & Behavior, Vol. 31, No. 4_supplRelationship of Satisfaction with Body Size and Trying to Lose Weight in a National Survey of Overweight and Obese Women Aged 40 and Older, United StatesPreventive Medicine, Vol. 35, No. 4 Volume 10Issue 10Dec 2001 To cite this article:Barbara E. Ainsworth, Lynda A. Anderson, Diane M. Becker, Susan J. Blalock, David R. Brown, Ross C. Brownson, Nell Brownstein, Carol E. Cornell, Brenda M. Devellis, Loretta P. Finnegan, Suzanne Folger, Janet E. Fulton, Janet Y. Groff, Carla Herman, Deborah Jones, Thomas C. Keyserling, Dyann Matson Koffman, Cora Lewis, Louise C. Mâsse, Robert E. McKeown, Diane Orenstein, and Antonia J. Spadaro.Observations from the CDC. Community Prevention Study: Contributions to Women's Health and Prevention Research.Journal of Women's Health & Gender-Based Medicine.Dec 2001.913-920.http://doi.org/10.1089/152460901317193495Published in Volume: 10 Issue 10: July 7, 2004PDF download

ENRICHD is a multicenter. randomized clinical trial designed to evaluate the effects of a psychosocial intervention on cardiovascular morbidity and mortality in post-AMI patients exhibiting clinical depression and/or social isolation. Recruitment procedures are described, along with demographic and clinical characteristics of patients with depression and social isolation.

OBJECTIVES:We sought to evaluate the ability of psychiatric anxiety-disorder history to discriminate between women with and without angiographic coronary artery disease (CAD) in a population with chest pain. BACKGROUND:A total of 435 women with chest pain underwent a diagnostic battery including coronary angiography in order to improve testing guidelines for women with suspected CAD. METHODS:Women referred for coronary angiography completed questionnaires assessing prior treatment history for anxiety disorder and current anxiety-related symptoms. Analyses controlled for standard CAD risk factors. RESULTS:Forty-four women (10%) reported receiving prior treatment for an anxiety disorder. This group acknowledged significantly higher levels of autonomic symptoms (e.g., headaches, muscle tension [F = 25.0, p < 0.0011 and higher behavioral avoidance scores (e.g., avoidance of open places or traveling alone by bus [F = 4.2, p < 0.05]) at baseline testing compared with women without prior anxiety problems. Women with an anxiety-disorder history did not differ from those without such a history with respect to the presence of inducible ischemia or use of nitroglycerin, although they were younger and more likely to describe both "tight" and "sharp" chest pain symptoms and to experience back pain and episodes of nocturnal chest pain. Logistic regression results indicated that the positive-anxiety-history group was more likely to be free of underlying significant angiographic CAD (odds ratio = 2.74, 95% confidence interval 1.15 to 6.5, p = 0.03). CONCLUSIONS:Among women with chest pain symptoms, a history of anxiety disorders is associated with a lower probability of significant angiographic CAD. Knowledge of anxiety disorder history may assist in the clinical evaluation of women with chest pain.

OBJECTIVE:We investigated associations between atherosclerosis risk factors (smoking behavior, serum cholesterol, hypertension, body mass index, and functional capacity) and psychological characteristics with suspected linkages to coronary disease (depression, hostility, and anger expression) in an exclusively female cohort. METHODS:Six hundred eighty-eight middle-aged women with chest pain warranting clinical investigation completed a comprehensive diagnostic protocol that included quantitative coronary angiography to assess coronary artery disease (CAD). Primary analyses controlled for menopausal status, age, and socioeconomic status variables (income and education). RESULTS:High depression scores were associated with a nearly three-fold risk of smoking (odds ratio (OR) = 2.8, 95% confidence interval (CI) = 1.4-5.7) after covariate adjustment, and women reporting higher depression symptoms were approximately four times more likely to describe themselves in the lowest category of functional capacity (OR = 3.7, 95% CI = 1.7-7.8). High anger-out scores were associated with a four-fold or greater risk of low high-density lipoprotein cholesterol concentration (<50 mg/dl; OR = 4.0, 95% CI = 1.4-11.1) and high low-density lipoprotein cholesterol concentration (>160 mg/dl; OR = 4.8, 95% CI = 1.5-15.7) and a larger body mass index (OR = 3.5, 95% CI = 1.1-10.8) after covariate adjustment. CONCLUSIONS:These results demonstrate consistent and clinically relevant relationships between psychosocial factors and atherosclerosis risk factors among women and may aid our understanding of the increased mortality risk among women reporting high levels of psychological distress.

Community-based programs have produced mixed results. Community capacity is thought to be a major determinant of program effectiveness. Thus, enhancing community capacity may increase the beneficial effects of existing programs and enhance future program effectiveness. This highlights the need to focus on understanding the components of capacity and the methods of enhancing capacity. Although we are just beginning to examine and understand key concepts, community capacity is probably influenced by both relatively nonmodifiable characteristics (such as demographic factors, institutional resources, and social structures) and relatively modifiable characteristics (such as knowledge, skills, and the ability and willingness of members and agencies to work collaboratively). In their relationships with community members and agencies, academicians and public health practitioners may help acquire categorical funding to enhance opportunities to build community capacity and their own capacity as well. The relationship between academicians/practitioners and community members/agencies probably is influenced by a host of characteristics which determine the degree to which capacity can be built. This paper discusses: the key components of capacity; the factors that influence building capacity through collaborations; a community health advisor (CHA) model which both builds on sociocultural aspects of African American culture and is consistent with methods for building community capacity; and how modifications to this model allow it to be compatible with categorically funded projects.

Objective: This study examined dieting, weight perceptions, and self-efficacy to eat healthy foods and engage in physical activity and their relationships to weight status and gender among American Indian elementary schoolchildren.Research Methods and Procedures: Data for this study were collected as part of the baseline examination for the Pathways study. Participants were 1441 second- through third-grade American Indian children in 41 schools representing seven tribes in Arizona, New Mexico, and South Dakota who filled out a questionnaire and had heights and weights taken.Results: Forty-two percent of the children were overweight or obese. No differences were found between overweight/obese and normal weight children for healthy food intentions or self-efficacy. Heavier children (especially those with body mass index > 95th percentile) were more likely to have tried to lose weight or were currently trying to lose weight. No gender differences were found. Normal weight children chose a slightly heavier body size as most healthy compared with overweight/obese children.Discussion: The results indicate that children are concerned about their weight and that weight modification efforts are common among overweight American Indian children. School, community, and family-based programs cue needed to help young people adopt lifelong healthful eating and physical activity practices.

CONTEXTDelayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality.OBJECTIVETo evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use.DESIGN AND SETTINGThe Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states.PARTICIPANTSA total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis.INTERVENTIONOne city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801).MAIN OUTCOME MEASURESTime from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs.RESULTSGeneral population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly.CONCLUSIONSIn this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

Psychosocial factors, particularly depression and tack of social support, are important predictors of morbidity and mortality in patients with coronary heart disease, This article describes the design and methods of the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) study, a multicenter, randomized clinical trial involving 3000 patients enrolled after acute myocardial infarction. ENRICHD aims to investigate the effects of a psychosocial intervention that targets depression and/or low social support on survival and reinfarction among adult men and women who are at high risk for recurrent cardiac events because of psychosocial factors (depressive or social isolation). Design features include the use of an individually tailored yet standardized intervention, rigorous clinical trial methods, and enrollment of a large number of women and minorities.