Responding to findings from CVH Perceptions, building from a theoretical framework, and returning to the targeted communities to gain community-specific perspectives, we developed a problem-solving intervention, Decide 2 Care for You, to promote heart-healthy behaviors by adults with stressful life circumstances. Project DECIDE (12,13), which was based on social problem-solving theory (8,14), was the basis for Decide 2 Care for You. Project DECIDE was a didactic program that provided education in problem solving, coaching, modeling, rehearsal and practice, performance feedback, shaping, and positive reinforcement for skill development (8,12). For lifestyle counseling, we used materials from the New Leaf program (15); these materials were designed for use in clinical settings serving low-income populations (15–17) and support individually tailored lifestyle counseling (18).

Each site (WVU, UNC-CH and UC-AMC) obtained institutional review board approval from its respective university for each aspect of the study (need's assessment and evaluation and implementation of the intervention).

At the 3 sites, investigators collected information and later implemented the program in different populations and settings. Focus groups (site 1: 2 groups, 18 participants; site 2: 4 groups, 17 participants; site 3: 2 groups, 16 participants) provided insights about how to create an acceptable program and market it to the local community in the summer of 2009. Specifically, site 1 (UNC-CH) included older African American women attending an African American church located in a semirural area of central North Carolina. Site 2 (WVU) included multigenerational adults from an Appalachian community center. Site 3 (UC-AMC) included Hispanic and non-Hispanic white adult women from worksites in the rural San Luis Valley of southern Colorado. Common themes included the following:

Building from the Project DECIDE curriculum (19) and incorporating focus group input, we designed Decide 2 Care for You (http://hpdp.unc.edu/research/projects/chirtn/) as an 8-session program. Each site’s IRB also approved the evaluation and implementation of the intervention study. Because of scheduling constraints, site 2 combined sessions 2 and 3 and sessions 4 and 5; site 3 combined Sessions 6 and 7, and site 1 scheduled the sessions for every 1 to 2 weeks. Sessions were offered twice during the week; however, site 1 and site 3 sessions lasted approximately 2 hours, while site 2 sessions lasted approximately 90 minutes. To train interventionists from each of the communities, an expert conducted a 1-day training session. Once the intervention began, weekly telephone conferences with the interventionists were held to promote sharing successful techniques, resolving problems, and maintaining fidelity.

Each site created a sampling frame suitable for its target population. The recruitment goal was 2 groups of 15 adults at each site (a total of 90 participants across the 3 study sites). Study staff contacted potential participants by telephone to provide information about the study. Participants at all sites received $20 for the data collection sessions (cash, gift cards, or checks depending on university policy) and $5 for each of the remaining program sessions. All participants gave signed, informed consent. The intervention took place at all sites during the fall of 2009.

Participants completed baseline measures, including a demographic form, during an enrollment session before the first intervention session. Responses to questions adapted from the Physical Activity Readiness Questionnaire (20) determined participants’ ability to engage safely in moderate-intensity physical activity; a “yes” response to any of the questions excluded the participant from the physical activity component of the intervention. Throughout the data collection procedures, the interventionists were available as necessary to read questionnaire items or answer any questions the participants had. Materials were reviewed for language and terminology appropriateness by the investigators and interventionists before intervention implementation. For more information about the materials and measures used, see http://hpdp.unc.edu/research/projects/chirtn/.

Study measures assessed at the baseline enrollment visit and final study visit included the following 5 variables:

In addition, a 25-question acceptability questionnaire developed for this study was administered at the final visit. Of the original 25 questions, 11 questions examined acceptability and feasibility of materials and activities, group leader and group format, participant interaction, usefulness of the problem-solving approach, and program structure, with a consistent 4-point Likert-type response (1 = not at all satisfied, 2 = not very satisfied, 3 = somewhat satisfied, and 4 = very satisfied).

Statistical analyses were conducted using SPSS, version 18.0 (IBM Corp, Chicago, Illinois) and SAS, version 9.2 (SAS Corp, Cary, North Carolina). Three responses to physical activity questions had extreme values and were excluded. Analyses included descriptive statistics and repeated measures of ANOVAs to assess main effects of time, group, and the interaction between time and group for continuous pre- and postvariables; significant omnibus tests were analyzed with Tukey pair-wise comparisons by group. Main effects for time were examined because weight were taken pre-, post- and at every session whereas the other outcomes were taken pre- and postintervention. Matched pair t tests were conducted for within-site differences of pre- and post-results. Results were considered significant at α = 0.05. Last known weight was brought forward for missing weight values; weight results were examined with regard to attendance. Acceptability and feasibility questions were examined by using frequencies; because of the low numbers of negative responses, the 2 negative-response categories were combined for some items.

Problem-solving skills (PSS) improved significantly, from mean 135.2 to mean 146.7 for the total study group (F [1, 64] = 18.04, P < .001). Each group increased from baseline except site 1. Pair-wise comparisons indicated that site 1 participants had significantly higher baseline PSS than did site 3 (P < .01). Site 2’s baseline PSS scores were not significantly different from those of either site 1 or site 3. These differences could be attributed to site 1’s initially high scores, which were maintained at follow-up. Within-site analysis indicated that both site 2 and site 3 showed significant increases from pre- to postintervention (P < .002), whereas site 1 maintained a high mean from baseline to follow-up.

Perceived stress (PS) decreased significantly across the whole study group from baseline (37.9) to follow-up (36.0) (F [1, 64] = 6.05, P < .05). Differences existed between groups at baseline and follow-up (P < .05); pair-wise comparisons indicated that site 1 had significantly lower scores than site 2 (mean difference = −4.73, P < .05); site 3 PS scores did not differ significantly from either those of site 1 or site 2 at baseline or follow-up.

There were no significant differences from baseline to follow-up (P = .057) or between the groups (P = .171) for number of servings of fruits and vegetables although number of servings increased, albeit not significantly, for site 2 (from 4.1 to 4.9 servings, P =.08) and site 3 (from 3.6 to 4.3, P = .06), whereas site 1 maintained an initially high baseline number of servings at follow-up (4.9). Individually, 43 (64%) participants reported any increase in daily fruit and vegetable intake, and 48 (72%) maintained or increased their daily fruit and vegetable intake.

There was no significant difference in number of minutes of physical activity from baseline to follow-up (P = 0.913) in the total study group. However, a significant difference was found between groups (F [2, 39] = 3.41, P < .05), although no differences were apparent in post-hoc pair-wise comparisons. Within sites, both site 2 and site 3 increased in minutes per day (site 1, from 37.1 to 46.2 minutes, P = .32; site 3 from 20.4 to 31.1, P = .15) (not significant increases), whereas the minutes for site 1 decreased from a mean of 54.6 minutes per day to 36.4. Individually, 20 participants (44%) reported some increase in daily minutes of physical activity, and 30 (67%) maintained or increased their physical activity.

Although weight change was not a primary outcome, it was measured at every session as part of the intervention program. The mean weight of the entire study group remained virtually the same across time (204.9 to 204.4 pounds) and within sites (Table 2). An examination of attendance by weight revealed that the 20 participants who attended fewer than 75% of the sessions were on average heavier than the 61 participants with better attendance (218.4 pounds vs 199.9, P = .15), although this difference was not significant.

Table 3 presents selected acceptability questionnaire results from program completers (84%, N=68). Nearly all (91.2%) participants reported that they used their newly acquired problem-solving skills to address a problem or problems. Most participants (70.6%) reported that they learned a lot about the problem-solving process. The majority of participants (57.4%) found problem-solving very useful, and 41.2% found it somewhat useful. Most participants (70.6%), however, reported that they were only somewhat successful in solving the problems.

In terms of the materials, participants found the following information very useful: healthful eating (88.1%), the New Leaf materials (82.1%), and physical activity (73.1%). The problem-solving workbook, the facts and information booklet, physical activity and relaxation stretches, and information about problem-solving were also found very useful by at least 70% of participants. Log sheets, the food provided, and information about stress reduction were found very useful by 49% to 63% of participants. Fewer than 10% of participants found these materials not at all or not very useful.

Participants were asked to name the top 3 aspects of the Decide 2 Care for You Program that were helpful in making lifestyle changes. Among participants 4 aspects were given as the top 3: 1) problem-solving workbook, 2) New Leaf materials, 3) weekly weight checks, and 4) group format. Other areas of the Decide 2 Care for You Program, including satisfaction with the group leader, the way in which participants interacted with each other, and ease of understanding presented information, were viewed overwhelmingly as positive.

In terms of program procedures, most participants (61.2%) thought the number of sessions was “just right,” and 31.3% thought there were “not enough” sessions. At site 3 (8 sessions long) most participants (45% of that group) said there were not enough sessions; site 2, however, had fewer sessions (7 sessions total), and only 24% of that group responded that there were not enough sessions. Across groups, 83.8% thought the length of each session was just right. Only at site 2 (with 90-minute-long sessions) did a few participants (16%) report that the sessions were too short. Across groups, 46.3% of participants thought that the program should last 6 or more months instead of 2 to 3 months, and 57.4% would be willing to attend the longer program. Perhaps because at least 2 different sessions were offered for each group, only 13.2% of participants had to regularly take time off from work to attend. By the time the program ended, 87.7% of participants had already shared the information they learned with others.