Community engagement to address socio-ecological barriers to physical activity among African American breast cancer survivors

Background With high rates of obesity, low levels of physical activity (PA), and lack of adherence to physical activity guidelines (PAGs) among African American (AA) breast cancer survivors (BCSs), culturally appropriate interventions that address barriers to participation in PA are needed. Methods To develop intervention content, members of an AA breast cancer support group participated in four 1-hour focus group discussions (related to the barriers to PA, strategies for overcoming them, and intervention content), which were audiotaped, transcribed, and analyzed. Results The support group collaborated with researchers to construct the Physical Activity Intervention Developed (PAID) to Prevent Breast Cancer, a multi-component (educational sessions; support group discussions; and structured, moderately intensive walking, strength training, and yoga), facilitated, 24-week program focused on reducing multi-level barriers to PA that promote benefits (‘pay off’) of meeting PAGs. Conclusions Community engagement fostered trust, promoted mutuality, built collaboration, and expanded capacity of AA BCSs to participate in developing an intervention addressing individual, interpersonal, organizational, and community barriers to PA.


INTRODUCTION
Compared to Whites, AA BCSs are less physically active and more sedentary (Behavioral Risk Factor Surveillance System, 2017), less likely to adhere to PAGs (American Cancer Society/ACS, 2017), and have larger reductions in breast cancer risk from PA (Ballard- Barbash et al., 2013). To reduce these disparities, community partnership approaches are needed to develop effective interventions.
Community engagement involves working collaboratively with groups of people affiliated by similar situations to address issues affecting their well-being (Centers for Disease Control and Prevention, 1997). In this brief report, we outline the process and results of engaging AA BCSs in developing a PA intervention.

METHODS
Participation in support groups may foster hope and offer emotional assistance, confidence, and strength, and thereby lead to improved coping, less distress, and an enhanced quality of life (Sears et al., 2003). They may be an untapped, indigenous resource for promoting PA.
Founded in 1995, SISTAAH (Survivors Involving Supporters to Take Action in Advancing Health) Talk has a mission of providing a forum for AA women to communicate about and make sense of their breast cancer experience in order to achieve improved physical and mental health outcomes. This support group has partnered with researchers to complete studies and publish findings, including the present report.
To undergird the process of engaging SISTAAH Talk members to develop a support groupbased, multi-component, community intervention addressing barriers that prevent AA BCSs from participating in PA to meet PAGs, the conceptual framework included: 1) community coalition action theory (Butterfoss, et al., 2002), which posits pooling abilities, expertise, and stakeholder resources to positively affect community health; 2) social ecological perspectives, which influence PA barriers and behaviors across various levels (McElroy et al., 1988); and 3) science-based PAGs to prevent cancer, which may also prevent recurrence (ACS, 2017; World Cancer Research Foundation/American Institute for Cancer Research, 2007).
The Institutional Review Board of Augusta University approved this study, and participant consent was obtained prior to enrollment. SISTAAH Talk members participated in four 1hour focus group discussions (FGDs) led by a BCS trained in qualitative assessments. Each FGD concentrated on barriers to PA and the cultural appropriateness, comprehension of health messages, length, and planned delivery format of the education and exercise sessions.

RESULTS
For participants (n=60; mean age 45.73 years; SD 7.91; range 35-75 years old), there were 4 FGDs, with findings organized into categories: 1) identification of barriers, 2) recommendation of strategies, and 3) selection of exercises. Identified barriers (Table 1) were classified based on a social ecological framework (Joseph et al., 2015): individual (post-treatment symptoms, fatigue, post-treatment body image, competing priorities, comorbidity, PA perceptions); interpersonal (lack of family and social support, intimate partner concerns); organizational (PA preferences, monetary costs, cultural appropriateness); and community (facilities, weather, safety).
To address PA barriers, the Physical Activity Intervention Developed (PAID) to Prevent Breast Cancer included three components:

1.
Didactic Instructions with strategies to enhance PA presented by PowerPoint, printed fact sheets, and SISTAAH Talk workout videos. The education sessions ( Table 2) include components of the social cognitive theory (SCT) (Murrock et al., 2009): self-efficacy (the belief that one is capable of meeting PAGs); outcome expectations (e.g., physical, social, and self-evaluative), linked to greater adherence to PAGs, including desired physical changes (e.g., improved body weight); opportunities for socialization (e.g., social support); and self-worth (e.g., goal setting and self-monitoring).

2.
Support Group Discussions to provide social support, monitor progress, and provide/receive feedback. Exchanges that occur during support group discussions will address barriers to PA. Each will consist of interactive presentations, demonstrations, and guest speakers, and will provide an open forum for sharing experiences, obtaining advice, accessing resources, and gaining support for PA.

3.
Exercise Sessions with an experiential engaged approach. To achieve a program of structured, moderate-intensity PA aimed at meeting the PAGs, BCSs selected three exercises: • Walking at various levels based on capability (power, speed interval, strength interval, walking-to-jogging, and stretching) • Yoga to address fatigue and poor physical functioning (physical postures, conscious breathing, and meditation) • Strength training using lightweight dumbbells with guidance on maintaining safety

DISCUSSION/CONCLUSIONS
This report describes a process of developing a PA intervention for AA BCSs using a community-engaged approach. Members of a breast cancer support group, mean age 45.7 years, 1) participated in four 1-hour FGDs, with findings organized as individual, interpersonal, organizational, and community barriers; 2) developed culturally tailored Smith et al. Page 3 strategies (in 24 educational sessions); and 3) selected three exercises (walking, strength training, and yoga) to meet PAGs.
Since benefits of PA include lower rates of all-cause mortality, and morbidity from conditions such as breast cancer, current guidelines recommend participating in moderate PA for 150 min/week (ACS, 2017). This study reveals that barriers, including post-treatment symptoms, social support, and neighborhood safety, prevent AA BCSs from participating in PA and meeting PAGs and that many of the currently available PA interventions are ineffective and unsustainable. PA-related health disparities among AA BCSs warrant the need for innovative and culturally relevant approaches to promote PA in this population. The involvement of a breast cancer support group in the development of PAID has the potential to enhance PA among AA BCSs.
SCT states that portions of an individual's knowledge acquisition may be directly related to observing others within the context of social interactions and experiences. SISTAAH Talk exemplifies a support system for affecting the health of AA BCSs. Similar projects involving community organizations that have demonstrated appropriate design, implementation, and efficacy in promoting PA among underserved populations include the Southeast Senior Physical Activity Network (SESPAN) and the Active Aging Community Task Force (AACTF) project, (Cheadle et al. 2010). These programs incorporate means of motivating people who are inactive; creating effective, culturally relevant programs for the target population; and sustaining research-tested programs in community settings. Community engagement in developing a PA intervention will likely address physical inactivity and inequity among AA BCSs.