598 JULY-AUGUST 2019 • VOL. 51, NO. 7 FAMILY MEDICINE BRIEF REPORTS R acial and ethnic disparities in health persist in the Unit- ed States.1-3 These dispari- ties also exist in self-perception of health.4 African Americans (AA) were less likely to describe themselves as overweight versus whites,5 were par- ticularly less likely to adopt healthy weight-related attitudes and behav- iors, and have worse obesity out- comes.4 Health-specific self-efficacy is a strong predictor of health behav- iors.6,7 Recent research has shown efficacy for targeted, community- based interventions resulting in re- duced weight and cardiovascular risk factors for AA women in urban communities.8,9 Tailoring a weight- loss intervention to specific popula- tions may be a reasonable approach to reducing chronic disease in these groups.10 The Stephen Klein Wellness Cen- ter is a family medicine residency- affiliated federally qualified health center (FQHC) in North Philadel- phia serving a predominantly AA community. The FQHC’s target population was determined to have significantly poorer health than Phil- adelphia residents overall.11 Sociocultural factors play an im- portant, positive role in exercise ad- herence12; therefore, a community needs survey was performed and identified nutrition, exercise, and physical activity (PA) as very impor- tant aspects of health and wellness to community members. Respon- dents desired aerobic activities, spe- cifically indicating “urban” or “soul” (synchronized, choreographed, so- cial dance with cultural roots in Af- rica and the Caribbean) line dancing classes,13,14 confirmed by additional community meetings. This study evaluated how partici- pation in a community-tailored, soul line dancing class with nutrition ed- ucation correlates with changes in BACKGROUND AND OBJECTIVES: The population surrounding an urban federally qualified health center (FQHC) in Philadelphia has poorer health than Philadelphia overall. Community residents identified aerobics and dance classes as very important services or programs that an FQHC might provide. We sought to measure the impact of participation in a resident physician-led, patient-centered fitness and nutrition class on participants’ attitudes, knowl- edge, and self-efficacy regarding their health. METHODS: An urban line dancing class and brief healthy eating intervention for adults was held at a YMCA adjacent to a residency-affiliated FQHC weekly for 8 weeks. Pre/postsurveys were administered to assess attitudes and con- fidence toward physical activity and healthy lifestyles. RESULTS: Participants’ self-assessment of health and levels of physical activ- ity improved. Confidence in performing everyday activities, doing regular exer- cise and exercising without making symptoms worse increased. A significant decrease in participants’ physical activity gratification was observed. Partici- pants’ confidence improved in reading food labels for health, but confidence in eating a balanced diet did not improve. CONCLUSIONS: A resident-led fitness and nutrition class, tailored to per- ceived community needs, generated significant interest and sustained par- ticipation. This pilot study furthered development of community infrastructure addressing health, nutrition, and overall fitness, and the results reflect oppor- tunities and challenges of engaging communities in physical fitness. (Fam Med. 2019;51(7):598-602.) doi: 10.22454/FamMed.2019.641507 Attitudes Surrounding a Community-Based Fitness Intervention at an Urban FQHC Krys Foster, MD, MPH; John Stoeckle, MD; Alexis Silverio, MPH; Christine Castellan, MD; Angela Hogue, MD; Ayanna Gouch, MD, MA; Lara Weinstein, MD, DrPH, MPH From Thomas Jefferson University, Department o f Fa m i l y a n d C o m m u n i t y M e d i c i n e, Philadelphia, PA (Drs Foster, Stoeckle, Castellan, Hogue, and Weinstein, and Ms Silverio); Lewis Katz School of Medicine at Temple University, Philadelphia, PA (Dr Gouch); and Stephen Klein Wellness Center, Philadelphia, PA (Drs Stoeckle, Castellan, Hogue, and Weinstein). FAMILY MEDICINE VOL. 51, NO. 7 • JULY-AUGUST 2019 599 BRIEF REPORTS self-assessment of health, levels of PA, attitudes towards PA, and con- fidence to implement health promot- ing behavior. Additionally, we aimed to understand adherence to this type of activity. Methods Setting and Sampling Participants were recruited by FQHC staff. Flyers were posted throughout the FQHC and an adja- cent YMCA. Those under 18 years old and who self-identified as physi- cally unable to participate were ex- cluded. Individuals were consented by resident physicians to participate and signed a waiver of liability. Par- ticipants who attended two or more classes were included. Intervention A free, weekly, 50-minute line danc- ing class was offered for 8 weeks with a 10-minute nutrition lesson at the end of class. A hired instruc- tor from a North Philadelphia YMCA directed the class and physician res- idents observed their engagement in the class, administered surveys, and taught the nutritional compo- nent of the class. Residents were free to dance alongside participants, and often did, as a way to encourage re- lationship-building. The nutrition- al education was derived from the Academy of Nutrition and Dietetics (Table 1).15 Our budget was able to support the dance instructor and supplement the nutrition counseling sessions with food items/water. Our nutrition content was online, free, and resident delivered. The cost per participant was estimated at $10. Measures Participants completed a preinter- vention survey at the first class they attended. Postsurveys were adminis- tered at the final class; participants who did not attend the final class completed the final survey over the phone. The 31-item survey collected data about participant demographics, self- assessments of health, levels of PA, attitudes toward PA, confidence to implement health promoting behav- ior, and several program evaluation items (Table 2). The Institutional Review Board of Thomas Jefferson University ap- proved this study. Analysis A descriptive analysis was conduct- ed for participant demographics. For each survey section, paired samples t-tests were used to compare the means of continuous measurements pre- and postsurvey. Results Forty-seven individuals attended at least one class. Sixty percent of participants attended six or more classes. Twenty-eight completed both pre- and postsurveys. A com- plete descriptive analysis is shown in Table 3. The mean number of classes at- tended was 4.92 (SD=2.25). Only three participants had attended the adjacent FQHC’s nutrition class. All respondents “would recommend the class to a friend,” and all were “totally satisfied” with the class. Twenty-one wanted to learn more about nutrition. Participants’ favor- ite nutrition topics were healthy Table 1: Nutrition Topics Week Nutrition Topic 1 Benefits of water 2 Healthy grocery shopping tips 3 Reading nutrition labels 4 Healthy postworkout snacks 5 MyPlate overview 6 Portion control 7 Sodium awareness 8 Protein options Table 2: Sources for Health-Related Survey Questions Survey Question Domain Questions Drawn/Modified From* Self-Assessment of Health (Q1, Q2, Q3) The Validated General Health Question14 PROMIS Global Health Survey15 Physical Activity Behaviors (Q4, Q5, Q6) Behavioral Risk Factor Surveillance System (BRFSS)16 Physical Activity Attitudes (Q7, Q8, Q9, Q10, Q11) Physical Activity Enjoyment Scale17 Confidence Towards Exercise (Q12, Q13, Q14) Chronic Disease Self-Efficacy Scale14 Confidence Towards Diet (Q15, Q16, Q17, Q18, Q19) Self-Rated Abilities for Health Practices Scale6 * Survey questions for the health-related themes were drawn from several published health surveys. 600 JULY-AUGUST 2019 • VOL. 51, NO. 7 FAMILY MEDICINE BRIEF REPORTS postworkout snacks, the benefits of water, and healthy shopping tips. Only two participants had a pri- mary care doctor at the FQHC prior to the class; by the end of the inter- vention, three additional participants had established care. Sixty percent of participants had a YMCA member- ship preintervention, and two joined during the study. There were no significant chang- es in self-assessment of one’s over- all health, physical fitness, ability to carry out physical activities or PA levels. A significant decrease in PA gratification from pre- to post- survey was observed. There were no significant differences across the remaining domain questions for PA enjoyment, PA confidence levels, nor the ability to consume a healthy diet (Table 4). Discussion A resident physician-led pilot fit- ness and nutrition class generated significant interest and sustained participation. Our homogeneous pop- ulation consisted predominantly of AA women (96%). It has been shown in the literature that social support is a motivating factor for AA wom- en regarding participation in group physical interventions.13 The social cohesion of our population could have contributed to the high adher- ence observed. Gratification decreased signifi- cantly; this may reflect participants’ challenges with their experience of increased activity. Participation did not decrease throughout the study. Satisfaction was reported with mu- sic and the class instructor, which has been shown to correlate with Table 3: Demographics of Stephen Klein Wellness Center: Healthy Eating and Line Dancing Project Characteristics Participants n (%) Female 27 (96) Age range (years) 30-39 1 (3) 40-49 1 (3) 50-59 10 (35) 60-69 14 (50) 70-79 2 (7) Race* White 1 (3) African American 25 (89) Other 1 (3) Hispanic 1 (3) Marital Status Married 7 (24) Never married 11 (39) Divorced/separated 9 (31) Widowed 2 (7) Education Some high school 3 (11) High school or GED 9 (32) Some college or technical school 9 (32) College 7 (25) Household income $0–$25,999 9 (32) $26,000–$51,999 6 (21) $52,000–$74,000 3 (10) Declined 7 (25) Employment Full time 7 (25) Part time 1 (3) Retired 13 (46) Other 7 (25) Covered by health insurance 27 (96) Children under 16 years old living in household 4 (14) * n=28 unless otherwise indicated. FAMILY MEDICINE VOL. 51, NO. 7 • JULY-AUGUST 2019 601 BRIEF REPORTS exercise adherence.16 Sociocultur- al factors play an important role in exercise adherence,12,17 and could be why it remained strong. Our study suggests that using a culturally rel- evant, social model for PA may be effective at encouraging adherence. Participants’ overall self-assess- ment of health and level of physi- cal fitness trended positively. Global health self-assessments are strongly linked to mortality and other health outcomes,17 and longitudinal studies could demonstrate if a relationship exists between self-assessment of health and participation in exercise. Nonsignificant gains were also noted in confidence towards PA. Increased confidence improves an individual’s likelihood to main- tain PA, which is associated with improved quality of life and health outcomes.18,19 Inconsistent changes were noted in confidence to consume a healthy diet. Although our study addressed nutritional education, it did not ad- dress disparities that play a role in access to healthy foods and super- markets, racial and ethnic dispar- ities in food deserts, socioeconomic status and placement of chain gro- cery stores.20 These should be consid- ered in future attempts to improve confidence in healthy eating. The intervention’s short length and small sample size limited our findings. Our project was conduct- ed in a single neighborhood with largely older, female, AA participants limiting generalizability. A larger, more diverse sample over a great- er duration as well as determining motivational factors for participant sign up and attrition may be worth exploring. Additionally, combining questions from multiple instruments limited the validity and reliability of measurement and the ability to compare findings to other studies. Of note, the statistically significant find- ing of decreased gratification does not necessarily equate to meaning- ful clinical change in behaviors or motives for exercise participation. A qualitative approach would be an ap- propriate next step to determine if a decrease in gratification of physi- cal activity was clinically meaningful and why it occurred; this approach could also uncover barriers to partic- ipation in the class. Finally, relation- ship development with participants and the impact of the study on resi- dent attitudes and behaviors with Table 4: Health-Related Domains: Pre- and Postsurvey Mean Responses Health-Related Domain Survey Item Pre Post Significance (2-tailed) Grouped Significance Self-assessment of health Overall healtha 3.25 3.36 0.38 P=.37Physical fitnessa 2.89 3.04 0.33 Ability to perform ADLb 4.25 4.25 1 Physical activity enjoymentc Pleasurable 4.29 4.07 0.23 P=.36  Fun 4.48 4.36 0.52 Gratifying 4.04 3.54 0.03 Stimulating 4.58 4.5 0.73 Refreshing 3.89 4 0.74 Physical activity confidence levelsd Muscle strength and flexibility 4.29 4.57 0.27 P=.18 Aerobic exercise 4.18 4.46 0.25 Exercise without increased symptoms 4.14 4.5 0.18 Abilities to consume a healthy dietd Find healthy food 4 4 1 P=.74 Eat a balanced diet 3.78 3.63 0.33 Understand fiber content in food 3.74 3.89 0.55 Read food labels 3.89 4.11 0.21 Consume recommended water intake 3.78 3.7 0.7 Abbreviation: ADL, activities of daily living. a Self-assessment of health questions 1 (rate overall health) and 2 (rate physical fitness): excellent=5, very good=4, good=3, fair=2, poor=1. b Self-assessment of health question 3 (ability to carry out ADL): completely=5, mostly=4, moderately=3, a little=2, not at all=1. c Physical activity enjoyment: extremely “X”=5, very “X”=4, moderately “X”=3, slightly “X”=2, not at all “X”=1. d Physical activity confidence and abilities to consume health diet: completely confident=5, fairly confident=4, somewhat confident=3, slightly confident=2, not at all confident=1. 602 JULY-AUGUST 2019 • VOL. 51, NO. 7 FAMILY MEDICINE BRIEF REPORTS underserved populations are also two important factors that could be addressed in future studies. This project identified a commu- nity partnership with potential to improve the community’s ability to address health, nutrition, and overall fitness. The class increased YMCA memberships and the number of pa- tients receiving primary care at the FQHC. We encourage this FQHC and YMCA partnership to be mod- eled by others to foster active en- gagement in health and well-being. ACKNOWLEDGMENTS: The authors thank the Women’s Board of Thomas Jefferson Uni- versity for financial support of this pilot in- tervention, as well as the faculty and staff at the YMCA, TJUH and SKWC for support of the project, assistance with recruitment, and guidance with analysis. This study was presented as “Development of a Community-Tailored, Resident-Led, Fitness and Healthy Eating Intervention at an Urban Federally Qualified Health Center,” at the 2017 Society of Teachers of Family Medicine Annual Spring Conference, May 5-6, 2017, San Diego, CA. 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