Case 1159901402

DANCE AND PHYSICAL ACTIVITY IN AFRICAN AMERICAN WOMEN
by
CAROLYN J. MURROCK
Submitted in partial fulfillment of the requirements
For the degree of Doctor of Philosophy
Dissertation Advisor: Dr. Faye A. Gary
Department of Nursing
CASE WESTERN RESERVE UNIVERSITY
January, 2007
CASE WESTERN RESERVE UNIVERSITY
SCHOOL OF GRADUATE STUDIES
We hereby approve the dissertation of
Carolyn J. Murrock
______________________________________________________
candidate for the Ph.D. degree *.
Faye A. Gary
(signed)_______________________________________________
(chair of the committee)
Elizabeth Madigan
________________________________________________
Beverly Roberts
________________________________________________
Marco Cabrera
________________________________________________
________________________________________________
________________________________________________
September 11, 2006

(date) _______________________
*We also certify that written approval has been obtained for any
proprietary material contained therein.
Copyright© 2007 by Carolyn J. Murrock
All rights reserved
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TABLE OF CONTENTS
Page
LIST OF TABLES...............................................................................................................7
LIST OF FIGURES……………………………………………………………………….9
ACKNOWLEDGEMENTS...............................................................................................10
ABSTRACT……………………………………………………………………………...11
CHAPTER I
Statement of the Problem……………………………………………………………..13
Background and Significance…...……………………………………………………15
Dance………………………………………………………………………………….15
The Use of Culturally-Specific Dance to Improve Health……………………….16
Physical Activity………………………………………………………………………17
Physical Inactivity in African American Women………………………………..18
Morbidity related to Physical Inactivity In African American Women……….....19
Mortality related to Physical Inactivity In African American Women.……….…20
Economic Impact of Physical Inactivity…………………………………………20
Physical Activity and Functional Capacity………………………………………21
Lifestyle Physical Activity……………...…………………………………………….21
Assessment of Lifestyle Physical Activity………………………………………22
Functional Capacity ………………………………………………………………….23
Self-Efficacy for Physical Activity in African American Women………………...…25
Social Support for Physical Activity in African American Women……………...…..25
Social Support in Church-Based Programs………………………….…….……..26

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Predictors of Physical Activity Adoption and Maintenance in African American
Women…………………………………………………………………………………...27
Significance of the Proposed Study………………………………….………….……28
Conceptual Framework………………………………………………………….……28
Four Sources of Efficacy Information………………………………………….…….29
Bandura’s Set of Conditions for Self-Efficacy……………………………….………30
Personal Factors………………………………………………………….………31
Behavioral Factors……………………………………………………….………32
Psychosocial Factors…………………………………………………….……….33
Environmental Factors…………………………………………………….……..34
Summary of Conceptual Model………………………………………….………35
Significance to Nursing Science……………………………………………………...36
Significance to Nursing Practice…………………………………………….………..39
Purpose…………………………………………………………………….…………39
Research Hypotheses……………………...……………………………….………...40
Assumptions………………………………………………………………….…….…40
Definition of Terms………………………………………………………….………..41
CHAPTER II REVIEW OF THE LITERATURE
Independent Variable: Dance……………………………………………….………..44
Maximal Oxygen Uptake…………………………………………….………….45
Lifestyle Physical Activity…………………………………………….………...45
Body Composition…………………………………………..……….………….46
International Perspective on Culturally-Specific Dance…..….…………………46

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Dependent Variable: Lifestyle Physical Activity…………….……………….…….51
Dependent Variable: Functional Capacity………………….………………….……53
Functional Limitation…………………………….………………………….……54
Mediating Variables of the Proposed Study……………………………………..….55
Efficacy Expectations and Outcome Expectations………………………..……56
Social Support ……………………………………………………………..…...59
Social Support from Family and Friends for Physical Activity………….……..60
Relationship between Dance and Social Support....……………………..……..63
Relationship between Self-Efficacy and Social Support………………..……...64
Covariates……………………………………………………………………………65
Conclusion…………………………………………………………………………...66
CHAPTER III METHODS
Research Design………………………………………………………………..……67
Setting………………………………………………………………………….……68
Entering the African American Communities………………………………………69
Sample………………………………………………………………………………71
Power Analysis…………………………………………………………………..….71
Sampling Procedure.…………………………………………………………..…….72
Recruitment Procedure………………………………………………………..…….73
Experimental Protocol………………………………………………………..……..75
Comparison Group Protocol…………………………………………………..…….76
Procedures for Data Collection Among All Study Participants…………………….76
Recruitment Period………..……………………………………………….......77
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First Face-to-Face Interview…………………………………………………..77
Second Face-to-Face Interview…………………………………………….....78
Third Face-to-Face Interview………………………………………….……...78
Strategies to Prevent Attrition……..………………………………………………79
Study Variables and their Measurement…………..………………………….……79
Independent Variable-Culturally-Specific Dance………………………….………79
Safety Monitoring of Dance Sessions………………………………….….……80
Evaluating Dance Sessions…………………………………………….………..81
Dependent Variables…………………………………………………….…………82
Lifestyle Physical Activity………………...…………………………….…………82
Physical Activity Scale for the Elderly (PASE)………………………….…….…..82
Reliability and Validity of PASE…………………………………….…………83
PASE and Functional Capacity…………………………………….…………...84
Functional Capacity……………….…………………………..…….……………...85
6-Minute Work Test…………………………………………….……………....85
Origin of 6-Minute Work Test…………………………………….….………...86
Functional Capacity in Community Populations………………….…….….…..87
Mediating Variables…….……………………………….………………………...88
Efficacy Expectations for Exercise.…………………………………………..88
Outcome Expectations for Exercise…………………………………………..88
Social Support for Exercise…….……………………………………………..89
Covariates………………………………………………………………………….90
Data Management and Analysis…………………………………………………...91

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Protection of Human Subjects……………………………………………………..91
Conclusion………………………………………………………………………….93
CHAPTER 4 RESULTS
Results……………………………………………………………………………..94
Sample and Setting………………………………………………………………..94
Data Analysis of Study Questions………………………………………………...94
Question 1………………………………………………………….………….…..94
Question 2………………………………………………………………………..101
Question 3………………………………………………………………………..103
Retention for the Study Sample……………………………………………….…106
Attendance…………………………………………………………………….…109
Assessing the Culturally-Specific Dance Intervention……………………….….110
Conclusion………………………………………………………...………….….110
CHAPTER 5 DISCUSSION
Discussion of Major Findings………………………………….………………..112
Functional Capacity………………………………………………….………112
Lifestyle Physical Activity…………………………………………………...113
Mediating Variables……………………………………………………….…115
Hierarchical Regression………………………………………….…………..117
The Women’s Perspective………………………………………………...…118
Health Disparities……………………………………………………………119
Limitations of the Study………………………………………………………..120
Implications for Nursing………………………………………………………..120

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Implications for Nursing Practice...................................................................121
Nursing Practice in African American Communities……………………….122
Implications for Nursing Theory……………………………………………125
Recommendations for Further Research……………………………………….126
Summary…………………………………………………………………….….127
Appendices …………………………………………………………………...129
References.……………………………………………………………………..157
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List of Tables
Table 1-Comparison of Covariates at Baseline……………………………….……..95
Table 2-Comparison of Marital Status at Baseline…………………………………..96
Table 3-Comparison of Lifestyle Physical Activity and Functional Capacity
Scores by Group for Each Time Point…………………………………………...…..96
Table 4-Correlation Matrix of Dependent Variables at Baseline, 8 weeks, and
18 weeks………………………………………………………………………….......97
Table 5-Overall Repeated Measures MANOVA Sphericity Assumed………….….100
Table 6-Comparison of Distance Walked in Feet by Group for Each Time Point.....100
Table 7-Correlation Matrix of Mediating Variables and Dane at Time 2…………...102
Table 8-Regression Analyses: Outcome Expectations as a Mediating Variable
between Dance and Lifestyle Physical Activity.........................................................103
Table 9-Regression Analyses: Social Support from Friends as a Mediating
Variable between Dance and Lifestyle Physical Activity..........................................103
Table 10-Correlation Matrix of Lifestyle Physical Activity, Functional Capacity,
Mediating Variables, and Baseline Covariates..........................................................104
Table 11-Hierarchical Regression Analyses: Change in Lifestyle Physical Activity
at 18 weeks when controlling for Covariates and Mediating Variables....................105
Table 12- Hierarchical Regression Analyses: Change in Functional Capacity
Table 13- Hierarchical Regression Analyses: Change in Functional Capacity

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Table 14-Correlation Matrix of Attendance, Body Weight, Body Fat, Distance
Walked in Feet, and Lifestyle Physical Activity at 8 weeks....................................109

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List of Figures
Figure 1-Conceptual Model of the Proposed Study...................................................36
Figure 2-Box Plot of Means for Functional Capacity for Both Groups.....................98
Figure 3- Box Plot of Means for Lifestyle Physical Activity for Both Groups……..99
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Acknowledgements
I would like to thank Dr. Faye Gary, chairperson of my dissertation committee. Dr.
Gary assumed leadership of this research study shortly after arriving at Case. Her
kindness, expertise, positive attitude, and patience extended to me during this process
were commendable. Dr. Gary helped me gain access to African American church
communities and develop a better appreciation and understanding of the African
American culture. She was very instrumental in obtaining Predoctoral funding from the
National Institutes of Nursing Research. I would also like to thank Dr. Elizabeth
Madigan, Dr. Beverly Roberts, and Dr. Marco Cabrera for their respective expertise and
contributions in developing, implementing, analyzing, and critiquing my dissertation.
I would like to thank my husband, Kevin, our daughters’ Channing and Paige, and my
mother, Arla, for their support, understanding, and patience during my doctoral studies.
Without them, I would not have attempted or completed my dissertation in the manner
that I did.
Finally, I would like to thank Dr. Reverend Otis Moss, Jr. and the Olivet Institutional
Baptist Church and Reverend E. Theophilus Caviness and the Greater Abyssinia Baptist
Church. With their support, I was surrounded by the most wonderful, positive, happy
people that I have ever met. I enjoyed getting to know not only the women who
participated in the research study, but also their family members and the staff from each
church. The research study allowed me to grow not only as a doctoral student, but as a
human being as well.

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Dance and Physical Activity in African American Women
Abstract
by
CAROLYN J. MURROCK
Culturally-specific nursing interventions are underutilized to improve health outcomes in
minority populations. This 2-group longitudinal study examined the effects of a
culturally-specific dance intervention on functional capacity and lifestyle physical
activity in sedentary African American women, ages 40 years and older. The culturally-
specific dance intervention was choreographed by and for African American women.
Two African American churches were randomly assigned to treatment or comparison
group protocols and a sample of 126 participants, 66 in the treatment group and 60 in the
comparison group, were recruited. Variables measured were lifestyle physical activity,
functional capacity, efficacy expectations, outcome expectations, social support, body fat,
age, co-morbidity, and socioeconomic status. The participants were measured at
baseline, 8 weeks, and 18 weeks. The results of the study determined that a culturally-
specific dance intervention increased functional capacity in distance walked from
baseline to 8 weeks and remained at 18 weeks when controlling for baseline covariates in
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those who received the intervention compared to those who did not. Also, outcome
expectations and social support from friends mediated the effects between dance and
lifestyle physical activity in the experimental group compared to the comparison group.
This study yielded information about the meaning each African American woman
attributed to culturally-specific dance, self-efficacy, and social support within the context
of their lives.
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Chapter 1
Statement of the Problem
The national guidelines for physical activity recommend that adults engage in regular,
moderate-intensity physical activity for at least 30 minutes per day (USDHHS, 1996a).
Unfortunately, a large percentage of African American women are sedentary, which is
defined as not engaging in any structured physical activity in the past month (National
Institutes of Health, 1996). Several of the leading causes of morbidity and mortality in
African American women are related to a sedentary lifestyle, which increases their
chances of developing obesity (Kushner, Racette, Neil, & Schoeller, 1995),
cardiovascular disease (American Heart Association, 2005), type 2 diabetes (Cowie,
Harris, Silvarma, Johnson, & Rust, 1993) , and hypertension (Boutain, 1999). Being
sedentary decreases functional capacity (Felton, Boyd, & Tavakoli, 2002), which reduces
the ability to perform day-to-day activities. In African American women, physical
activity also tends to decrease with age (Grembowski, Patrick, & Diehr, 1993), co-
morbidity (Moore, Dorros, Kiel, O'Sullivan, & Silliman, 1995), and low socioeconomic
status (SES) (Walcott-McQuigg, Logan, & Smith, 1995). The environment also plays an
instrumental role in decreased physical activity for African American women. Lack of
exercise facilities nearby, unsafe neighborhoods, weather (Nies, Vollman, & Cook,
1999), and lack of a companion for physical activity (Conn, 1998) are environmental
barriers frequently expressed by African American women.
In many cultures, dance is a longstanding practice passed down through the
generations and is an activity in which most people have participated in at some point in
their lives. Dance requires the movement and coordination of large and small muscle
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groups and encompasses the elements of purpose, intentional rhythm, and culturally
shaped sequences of nonverbal body movement that have inherent aesthetic value
(Hanna, 1995). It also involves visual, tactile, and auditory stimulation enabling
emotional release and creative expression of feeling and mood greater than other forms of
physical activity (Conner, 2000). The significance of dance in the African American
culture reflects an intrinsic cultural orientation toward physical expression and creativity
(Farr, 1997). Dance has the potential to generate health benefits and the proclivity to
provide African American women with the recommended amounts of physical activity.
However, it is seldom used as an intervention to increase physical activity even among
studies advocating culturally-specific interventions (Farr, 1997). As a result, empirical
data about a culturally-specific dance intervention to generate health benefits and reduce
health disparities common in sedentary African American women is paramount.
Efficacy expectations and outcome expectations, the components of self-efficacy
(Marczynski-Music, 1994), and social support from family and friends (Chogahara,
O'Brien-Cousins, & Wankel, 1998; Courneya & McAuley, 1995) have been identified as
strong predictors of participation in physical activity programs in African American
women. The location of a physical activity program is vital as church settings are
favored by African American women (Banks-Wallace, 2000; Prohaska, Peters, &
Warren, 2000). Churches are unique settings due to existing social support systems in
familiar and safe locations (Prohaska, Peters et al., 2000). The church is symbolic of a
strong sense of community, belonging, and purpose in the lives of African American
women (McRae, Carey, & Anderson-Scott, 1998). Church-based interventions for
physical activity may be more effective in promoting physical activity. Thus, the purpose
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of the proposed study is to determine the effects of a culturally-specific church-based
dance intervention and to identify the relationship of self-efficacy and social support on
lifestyle physical activity and functional capacity in sedentary African American women,
ages 40 years and older.
Background and Significance
Dance
Moderate-intensity physical activities are appealing to women as they require less
energy than vigorous activities, not as much stress on muscles and joints, and have a
lower risk of injury (Conn, 1998). Moderate-intensity activities are easier to incorporate
into an individual’s daily routine and can be performed intermittently through out the
day. Incorporating moderate-intensity activities even for short time periods (5-10
minutes) is better than being sedentary (Andersen et al., 1999). Furthermore, African
American women are more likely to participate in moderate-intensity physical activities
and have less attrition from these types of programs than vigorous, high intensity-level
activities (Ainsworth, Irwin, Addy, Whitt, & Stolarczyk, 1999).
In the proposed study, the moderate-intensity physical activity will be dance, which is
defined as a patterned, rhythmic movement in space and time (Pepper, 1984). Dance, in
its many European/Western forms (ballet, ballroom, jazz, folk, modern, square, and
country line dance) has recently received attention as a type of moderate-intensity
physical activity that yields positive health outcomes. Dance has been shown to improve
physical health by strengthening the immune system, improving muscle tone, flexibility,
coordination, and balance. It also improves mental health by reducing tension, chronic
fatigue, and other stress-related conditions (Hanna, 1995). Moderate-intensity dance is

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characterized by choreographed routines performed to music where one foot remains in
contact with the floor at all times. It is appealing for many women since it is easy to
perform and has a low risk of injury (Kudlacek, Pietschmann, Bernecker, Resch, &
Willvonseder, 1997). Studies show that square dancing (M. Jette & Inglis, 1975) and
country line dancing (Gordon, Overend, & Vandervoort, 2001) meet the recommended
national guidelines for moderate-intensity physical activity. Moderate-intensity dance
programs decreased resting heart rate and body fat, and enhanced weight loss in
community dwelling adults (White et al., 1984). There are also social benefits of dance
such as group camaraderie (Gillett, White, & Casetra, 1996) enjoyment and fun (Wankel,
1993) and the option to dance with or without a partner (Conner, 2000). Thus, moderate-
intensity dance programs are attractive to women and yield positive health benefits.
The Use of Culturally-Specific Dance to Improve Health
Dance has played an important role for African Americans as a means of emotional
expression, is symbolic of traditional African heritage, and is a means of interaction,
support, and cohesion (Farr, 1997). The African American inclination toward a physical
and aesthetic expression of feeling provides an intrinsic cultural affinity with dance as a
therapeutic medium (Farr, 1997). Culturally-specific dance is a dance within a
community or group that serves one or more purposes related to traditional practices,
cultural transmission, social acceptance, or connectedness (Jain & Brown, 2001).
Cultural dance includes those activities having a cultural or regional influence or those
choreographed to cultural music. Culturally-specific dance may serve as a formal or
informal means of health promotion through positive lifestyle change. Effective
culturally-specific interventions must be consistent with the shared beliefs, values, and
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practices of the specific culture (USDHHS, 2000a), as it is the cultural and daily
experiences that deeply influence how people choose their health behaviors (Eyler,
Baker, Cromer, & King, 1998). Culturally-specific dance programs have reported
decreased trait anxiety in American Indian women (Skye, Christensen, & England, 1989)
and increased bone density in older Viennese women (Kudlacek et al., 1997).
Only one study was found that used culturally-specific gospel music to develop a
church music exercise videotape to increase exercise specifically for African American
women (Turner, Sutherland, Harris, & Barber, 1995). The African American women
exercised to gospel music once a month for one year. The results indicated that the
women increased physical activity, but it was not statistically significant. No other
studies about African American women and dance were identified. African American
women may prefer dance over walking as a type of physical activity (Banks-Wallace &
Conn, 2002), but it has been underutilized as a culturally-specific intervention with
documented positive health outcomes. Thus, the proposed study will examine culturally-
specific dance as a form of physical activity to increase lifestyle physical activity and
functional capacity in African American women.
Physical Activity
Physical activity is a leading health indicator and is defined as bodily movement
produced by skeletal muscles that require energy expenditure (National Institutes of
Health, 1996). It is often confused with exercise, a subcategory of physical activity
defined as planned, structured movement to improve or maintain one or more aspects of
physical fitness (Caspersen, Powell, & Christenson, 1985). In general, women encounter
many more obstacles to being physically active across the lifespan than men. Because of
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traditional socialization of sex roles, generations of women were deterred from being
physically active so as not to damage their reproductive organs or interfere with
motherhood (Lutter, 1994). Social and gender roles also reinforced the belief that
competition and sports were “unladylike” and women who did participate in sports were
perceived as “manly” (Yeager & Macera, 1994). Societal expectations were that women
should not sweat (Solmon, Lee, Belcher, Harrison, & Wells, 2003) and women were
discouraged from vigorous physical activity in elementary through high school. Prior to
1972, women had no opportunities for athletic scholarships at colleges or universities (A.
C. King et al., 1992). As a result, many middle-aged and elderly women did not
participate in competitive sports or physical activities and have no intention to start at this
point in their lives (Nies et al., 1999). The ever-changing role of women in society
(wife/partner, parent/caregiver, and employee/employer) has caused the largest impact on
women’s physical activity, such as lack of time, low energy, and varied financial
situations, that influence women’s health practices (Women's Health Initiatives, 2002).
The substantial number of women in the workforce and other role responsibilities has left
little time for physical activity. Thus, gender roles, societal expectations, and historical
perspectives of women and physical activity has limited the opportunity for many women
to engage in physical activities.
Physical Inactivity in African American Women
African American women have even more barriers to overcome resulting in higher
levels of physical inactivity than Caucasian women (Brady & Nies, 1999). African
American women perceive less support for physical activity from their husbands and
physician, and have fewer friends who are physically active (O'Brien-Cousins, 1995). It
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is also culturally inappropriate to take time from family and work obligations for physical
activity (Kriska & Rexroad, 1998; Marcus & Forsyth, 1998), moreover, many African
American women consider rest more important for one’s health than physical activity
(Airhihenbuwa, Kumanyika, Agurs, & Lowe, 1995). Cultural and daily experiences play
an instrumental role in shaping African American women’s values and beliefs of the
meaning attributed to physical activity. For African American women, physical activity
is perceived as movement and being busy. It is regular, intentional, and beyond the
typical movement of daily living for the purpose of improving oneself to the demands of
daily work and home life (Tudor-Locke et al., 2003). The African American women also
believed that physical activity should be easily incorporated into their daily routines.
Morbidity related to Physical Inactivity in African American Women
Several of the leading causes of morbidity and mortality in all women are related to a
lack of physical activity, or sedentary lifestyle. Unfortunately, nearly 68% of African
American women are sedentary, resulting in detrimental effects on their overall health.
Approximately 39.6% of African American women have cardiovascular disease (CVD),
77.3% are overweight, 49.7% are obese, 9.5% have diabetes mellitus, and 44.7% have
hypertension (Centers for Disease Control and Prevention, 2002). Additionally, the
prevalence of hypertension in African Americans is the highest in the world, and they are
more likely to be physically inactive, middle-aged or older, overweight or obese, and
have diabetes (Collins & Winkleby, 2002). Also, more African American women than
African American men have hypertension after 55 years of age (Centers for Disease
Control, 2002).
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Mortality related to Physical Inactivity in African American Women
The development of these chronic diseases, largely due to physical inactivity,
adversely impacts the mortality rate of African American women. Cardiovascular
disease is the leading cause of death, accounting for 49% of deaths in all women. For
African American women, CVD accounts for 40.6% deaths (American Heart
Association, 2005). The prevalence rate increases even more so when it comes to
diabetes and obesity. In 2000, the overall death rate from diabetes mellitus in Caucasian
women was 20.5% but 48.1% in African American women (Centers for Disease Control,
2002). Obesity also has an unfavorable effect on an African American woman’s length
of life. For example, a 20-year old Caucasian women with a body mass index of greater
than 45 is estimated to have 8 years of lost life while an African American woman is
estimated to have 25 years of lost life (Fountaine, Redden, Wang, Westfall, & Allison,
2003).
Economic Impact of Physical Inactivity
Importantly, the annual cost of chronic diseases and death associated with physical
inactivity is $76 billion (USDHHS, 1996b). Furthermore, in 2003, the estimated cost of
CVD (direct and indirect) was $189 billion and for 2004, the estimated cost of CVD is
$368.4 billion (American Heart Association, 2005). By comparison, the estimated cost of
HIV in 1999 was only $28.9 billion. The incremental lifetime medical cost of treating
just one woman (in 2002 dollars) with CVD was $423,000, which is 3.4 times higher than
the costs of treating a woman without CVD (Birnbaum, Leong, & Kabra, 2003). Finally,
the estimated annual cost attributable to obesity-related diseases is $100 billion
(Morbidity and Mortality Weekly Report, 2002). Overall, physical inactivity is

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associated with five of the ten leading causes of death in African American women; it has
a profound economic impact on the health care system in the United States.
Physical Activity and Functional Capacity
Physical inactivity also decreases functional capacity, which is another predictor of
morbidity and mortality. Decreased functional capacity reduces the ability to perform
lifestyle physical activities, and change in functional capacity is an important outcome to
show the benefit of a moderate-intensity intervention in healthy and unhealthy
populations (Bittner, Sanderson, Breland, Adams, & Schumann, 2000). Physical activity
tends to decrease with age (Grembowski et al., 1993), co-morbidity (Moore et al., 1995),
and low socioeconomic status (SES) (Walcott-McQuigg et al., 1995). It has been
postulated that the high rates of morbidity and mortality in African American women
may be reduced by increased physical activity (Adams-Campbell et al., 2000).
Therefore, it is important to develop a culturally-specific intervention to enable sedentary
African American women to increase physical activity, decrease their morbidity and
mortality, and reduce their health disparities.
Lifestyle Physical Activity
Lifestyle physical activity is the daily accumulation of physical activity, which
includes leisure, occupational, household, and moderate-intensity activities that are part
of everyday life (Dunn, Andersen, & Jakicic, 1998). Of particular importance is that
lifestyle physical activities can be performed intermittently in short time periods of 5-10
minutes throughout the day instead of being performed continuously for long time
periods, usually 20-30 minutes. These short time periods can accumulate to meet the
recommended 30 minutes of physical activity per day. Lifestyle physical activity

Murrock 22
depends on what a person generally does during the course of the day, activities a person
enjoys doing, and what options are available on a daily basis to increase physical activity
(Belza & Warms, 2004). It is based on practical issues of making activity participation
less complicated, more convenient, less intimidating, and less expensive (Kohl, Dunn,
Marcus, & Blair, 1998). The incorporation of lifestyle physical activity into sedentary
individuals’ daily lives typically results in more walking, increased use of the stairs, and
more yard work (Blair, Kohl, & Gordon, 1992). Benefits associated with increased
lifestyle physical activity include decreased systolic blood pressure and body fat,
improved cardiorespiratory fitness (Dunn, Garcia et al., 1997), decreased diastolic blood
pressure and significantly increased physical activity (Dunn et al., 1999). Thus
significant health benefits can be achieved by increased lifestyle physical activity, which
has particular relevance to African American women and the potential for improved
health benefits.
Assessment of Lifestyle Physical Activity
Although past surveys of physical activity documented low activity in women,
especially elderly women, the measures used did not include household or occupational
activities and hence, underestimated actual physical activity. Most physical activity
surveys focus mainly on individuals involved in organized sports, conditioning exercises,
and recreational activities that have been developed and validated in Caucasian men
(Masse et al., 1998). This often leads to the misclassification of physical activity in
African American women, as they do not often participate in these types of physical
activities, and even less than Caucasian women (Ainsworth et al., 1999). There is a need
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to incorporate moderate-intensity activities into physical activity surveys that involve
carrying, lifting, and pushing objects (Masse et al., 1998).
Estimates from physical activity time and motion studies suggest that women,
regardless of ethnicity, spend less time in organized sports, recreational, and conditioning
activities and significantly larger portions of their day in occupational, household, and
family care activities (Ainsworth et al., 1999). These types of moderate-intensity
activities are often not counted toward the recommended amount of physical activity and
need to be included in physical activity surveys to accurately assess their lifestyle
physical activity (Masse et al., 1998).
Marital status, household responsibilities, taking care of children or older adults, and
cultural expectations shape the roles of all women and influence their definition of
physical activity. Furthermore, most African American women have been socialized to
put family first, as the needs of others take priority over their own personal well-being
(Banks-Wallace, 2000), resulting in lower importance of physical activity and frequently
poor health status. Therefore, in order to provide an accurate assessment of lifestyle
physical activity, surveys need to include occupational and home-related activities that
are such an integral part of an African American woman’s life (Ainsworth et al., 1999).
Functional Capacity
Functional capacity is the ability to walk for a distance and is a key element of
independent living (Guralnik, Branck, & Cummings, 1989). Functional capacity reflects
the capability to carry out day-to-day activities, such as climbing stairs, carrying objects,
performing household tasks, and occupational skills (Masse et al., 1998). It is a
biological marker and improved functional capacity is a key outcome indicating the
Murrock 24
benefits of a physical activity intervention (Bittner et al., 2000). It is typically measured
with a maximal or submaximal stress test (treadmill/bike), walking a specific distance (50
feet), or walking for a specific time period (6 minutes). Interventions that documented
increased functional capacity include low-impact dance measured by a submaximal bike
stress test (Gillett et al., 1996) and half-mile walk test (Hopkins, Murrah, Hoeger, &
Rhodes, 1990), walking program measured by the 6 minute walk test, (Ettinger, Burns,
& Messier, 1997), and walking/aquatics programs measured by the 50 foot walk test
(Minor, Hewett, Webell, Anderson, & Kay, 1989). These studies included mostly
Caucasian women.
Cardiac rehabilitation is a 12-week physical activity program and is often used as an
intervention to improve functional capacity. Fortunately, cardiac rehabilitation programs
have included a small number of African Americans, both women and men, in studies of
functional capacity. In two studies, functional capacity was measured by a maximal
treadmill stress test at baseline and 12 weeks with an overall increase in both women and
men. Regrettably, neither study reported the results of functional capacity by gender or
gender by ethnicity. In both studies, results were reported only by ethnicity. Caucasian
participants had significantly greater baseline and 12-week scores compared to African
American participants (Bittner et al., 2000; Verrill, Barton, Beasley, Lippard, & King,
2003). Therefore, information specifically about functional capacity changes in African
American women who have completed a physical activity intervention program is yet to
be described.
Murrock 25
Self-Efficacy for Physical Activity in African American Women
A predictor known to improve lifestyle physical activity is self-efficacy, which is
defined as a judgment of one’s own capability to accomplish a certain level of
performance (Bandura, 1977). The major components of self-efficacy are efficacy
expectations and outcome expectations. Efficacy expectations influence short-term
behavior, and positively have an effect on exercise behavior in healthy individuals
(Resnick, 1998a) and those with cardiovascular disease (Jeng & Braun, 1994). Outcome
expectations indirectly influence long-term health maintenance, and is a good predictor of
exercise continuation (Resnick, Zimmerman, Orwig, Furstenber, & Magaziner, 2001).
Thus, choosing to be physically active is influenced by an individual’s belief in the
ability to perform the behavior (efficacy expectations) and the consequences of
performing the behavior (outcome expectations). The significance of this study is that it
will examine self-efficacy (efficacy expectations and outcome expectations) for physical
activity and its role as a mediator for changes in lifestyle physical activity in sedentary
African American women.
Social Support for Physical Activity in African American Women
Another predictor of physical activity is social support, which is the comfort,
assistance, and information received through formal and informal contacts with others
(Wallston, Alagna, DeVellis, & DeVellis, 1983). Social support from family and friends
has been shown to increase physical activity in African American women (Chogahara et
al., 1998; Courneya & McAuley, 1995; Dishman & Sallis, 1994; Eyler et al., 1999; Oka,
King, & Young, 1995). Social support provides a sense of belonging to a group that
shares similar values and interests (Wallston et al., 1983). A part of social support is the
Murrock 26
interpersonal interactions that occur during physical activity, which is a motivating factor
for beginning and continuing a physical activity program in African American women
(Clark, 1996; Eyler et al., 1998). Thus, social support and positive interpersonal
interactions are important for physical activity in African American women (Henderson
& Ainsworth, 2003).
Social Support in Church-Based Programs
In the African American church, social support is provided to the members and the
community through shared group norms, values, and a sense of identity (McRae et al.,
1998). Church-based programs can influence behavior change through existing social
support systems and have been found to positively influence health related lifestyle
changes in African Americans (Peterson, Atwood, & Yates, 2002). Church-based health
promotion programs in African American churches include dietary changes to reduce
cancer (Campbell et al., 1999; Campbell et al., 2000), smoking cessation (Voorhees et al.,
1996), weight loss (Kumanyika & Charleston, 1992; McNabb, Quinn, Kerver, Cook, &
Karrison, 1997), and reduction in hypertension and lipid levels (Doshi et al., 1994; Smith,
1997; Yanek, Becker, Moy, Gittelsohn, & Koffman, 2001). In African American
women, a church-based health promotion program increased health-seeking behaviors
related to breast health (Duan, Fox, Derose, & Carson, 2000).
Church-based programs are more appealing to African American women than
community-based programs. A focus group of African American women cited lack of an
exercise partner, family and job responsibilities, lack of family and friend support, cost,
and unsafe neighborhoods as reasons not to participate in community-based physical
activity programs (Nies et al., 1999). Another study noted that African American women
Murrock 27
wanted an exercise facility close to their homes (Young & Voorhees, 2003) and that they
favored women only exercise classes (Banks-Wallace & Conn, 2002). African American
women participate in and value church experiences and are more likely to attend physical
activity programs located in churches (Peterson et al., 2002). Thus, church-based
interventions for physical activity may be more effective in promoting physical activity
than community-based interventions (Prohaska, Peters et al., 2000).
Predictors of Physical Activity Adoption and Maintenance in African American Women
In order to reap the health benefits, an individual must adopt and maintain the
moderate-intensity physical activity program. Physical activity adoption is the
modification of behavior by performing the desired activity for at least 1-2 months. In
African American women, predictors of adoption or initiation of physical activity
programs include: previous experience (Felton et al., 2002), self-efficacy (Prohaska,
Walcot-McQuiqq, Peters, & Li, 2000), social support (Young, Gittelsohn, Charleston,
Felix-Aaron, & Appel, 2001), and moderate-intensity physical activity programs
(Prohaska, Peters et al., 2000). Physical activity maintenance is the continued
performance of the desired activity for at least 3-6 months (Walcott-McQuigg &
Prohaska, 2000). On the other hand, predictors of maintenance in African American
women include: outcome expectations (Banks-Wallace & Conn, 2002), social support
(Izquierdo-Porrera, Powell, Reiner, & Fountaine, 2002), moderate-intensity physical
activity programs (Sallis et al., 1986), women only groups (Banks-Wallace, 2000), and
church-based programs (Yanek et al., 2001). Thus, identifying the predictors of physical
activity adoption and maintenance is a vital element in the development of physical
activity interventions for African American women.

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Significance of the Proposed Study
In the proposed study, the effects of a culturally-specific church-based dance
intervention on lifestyle physical activity and functional capacity in sedentary African
American women will be examined. The foremost innovation of the proposed study is
that the culturally-specific dance will be choreographed and taught by an African
American woman who is well-known and respected for dance activity in Cleveland.
Other study innovations include dancing to gospel music selected by African American
women and studying the effects of social support from friends and family within the
context of the church community. Thus, the overall significance of this study is that it
will analyze efficacy expectations and outcome expectations for physical activity, social
support from family and friends for physical activity, and their influence on increased
lifestyle physical activity and functional capacity in African American women, ages 40
years and older, within the context of the church community.
Conceptual Framework
The theoretical underpinnings for this study are based on Social Cognitive Theory
(SCT), developed by Bandura (1977). SCT is practical for understanding physical
activity behavior as it combines the premise that perceived capabilities of performing a
specific behavior is pivotal to maintaining the specific behavior. A central construct of
SCT is self-efficacy, which is defined as a judgment of one’s own capability to
accomplish a certain level of performance (Bandura, 1977). Self-efficacy affects an
individual’s choice of behavior, the amount of effort a person will spend on a particular
task, and the length of time a person will persist in performing a particular task despite
Murrock 29
barriers. Self-efficacy is behavior specific as an individual may have high self-efficacy
for one behavior (dancing) but low self-efficacy for another behavior (swimming).
Four Sources of Efficacy Information
There are four major sources of efficacy information that influence self-efficacy: 1)
performance accomplishment, 2) vicarious experience, 3) verbal persuasion, and 4)
physiological arousal/physical feedback. The first is performance accomplishment as
performance is the most powerful source of efficacy information for enhancing self-
efficacy (Jeng & Braun, 1994). Performing the behavior enables the individual to
achieve mastery over a difficult task. Successful performance will enhance self-efficacy
only if it is ascribed to one’s own skill and ability and not chance or external factors
(Strecher, DeVellis, Becker, & Rosenstock, 1986). Successful mastery of a skill or task,
or performance accomplishment, will require the African American women to engage in
culturally-specific dance for at least 30 minutes two times per week. The second source
of information is vicarious experience, which is the opportunity to observe someone
similar to oneself performing the particular behavior. The individual who is observed
mastering a skill is viewed as a “model”. When individuals are exposed to others that
they can identify with and are successful in performing that specific behavior, their self-
efficacy will increase (Jeng & Braun, 1994). The culturally-specific dance could offer
vicarious experience by providing opportunities for the African American women to
experiment and practice the dance steps, and observe other African American women
performing the same dance steps at the same time. The sample of African American
women will be from the same church, neighborhood, may have similar health conditions,
and may have comparable dance skills or no dance skills. The third source of efficacy
Murrock 30
information is verbal persuasion, which is the influence of encouragement and
compliments from family, friends, peers and a respected authority, an African American
dance instructor. Verbal persuasion is the use of encouragement with respect to the
benefits of the behavior and the progress the individual makes in achieving mastery of the
behavior (Keller, Fleury, Gregor-Holt, & Thompson, 1999). Verbal persuasion provides
validation of an individual’s efforts and reinforces an individual’s capability to master a
given task or skill. Verbal persuasion is also the ability to give and receive social support
(Berarducci & Lengacher, 1998).
In the proposed study, the dance instructor and the participants will provide verbal
persuasion as they will give and receive praise, encouragement, support, and other forms
of persuasion during the culturally-specific dance classes. The fourth and final efficacy
information source is physiological arousal or physical feedback (i.e. energy, strength,
stamina), which allows the individual to judge her capability of performing a specific
behavior. Physical efficacy is based on the individual’s energy, strength, and endurance
to perform a behavior. Furthermore, physiological arousal can influence mental health.
Increased mental alertness, enhanced mood, and improved sense of well-being has been
noted by those who experience increased energy, stamina, and strength when
participating in physical activity programs (McAuley, Talbot, & Martinez, 1999).
Successful mastery of the dance steps and verbal persuasion can also influence the
physical feedback of energy, strength, stamina, and well-being.
Bandura’s Set of Conditions for Self-Efficacy
An individual’s self-efficacy yields important information about the psychosocial
factors of health-related behavior. The conceptual framework for this study is based on
Murrock 31
self-efficacy which posits that physical activity behaviors are acquired (efficacy
expectations) and maintained (outcome expectations) through a complex set of personal,
behavioral, psychosocial, and environmental conditions (Bandura, 1986). These
components will be explored in this study as success in the ability to initiate and maintain
a physical activity program is determined by the interactions among the individual’s
personal factors (gender, age, health status, body fat, co-morbidity, SES), behavioral
factors (previous and current physical activity patterns), psychosocial factors (self-
efficacy, social support), and the environment (church). Each factor will be examined
separately.
Personal Factors
Personal factors (gender, ethnicity, age, health status, body fat, co-morbidity, SES)
have been identified as influencing lifestyle physical activity and functional capacity. In
the proposed study, age, body fat, co-morbidity, and SES will be analyzed as covariates.
African American women, aged 40 years and older, endure a marked excess risk of
obesity, sedentary lifestyle, and cardiovascular risk factors (Yanek et al., 2001). For
example, physical activity tends to decrease with age largely due to family, childcare,
employment, and other responsibilities (Kriska & Rexroad, 1998). Also, there is an
approximate 10% decline in oxygen capacity due to physical inactivity (Hawkins &
Wiswell, 2003) beginning as early as the 4th to 5th decade of life which limits the ability
to maintain autonomy and independence within the home and community (Cousins &
Tan, 2002). Furthermore, almost 30% of African American women are overweight by
the end of their 30’s, increasing to 60% by 49 years of age (Kuczmarski, Flegal,
Campbell, & Johnson, 1994). Persons over 50 years of age represent the most sedentary
Murrock 32
segment of the entire adult population (USDHHS, 1996a), and women, regardless of
ethnicity, begin to exhibit decreased functional capacity (Huang et al., 1998), and develop
co-morbidity factors as early as their 40’s (Eyler, Brownson, King, & Brown, 1997).
Thus, efforts to increase physical activity in African American women should start as
early as 40 years of age (Adams-Campbell et al., 2000). African American women with
low SES tend to be less active and have increased incidence of obesity (Thomas, 1995),
type 2 diabetes (American Diabetes Association, 2002), and cardiovascular disease
(American Heart Association, 2005).
Behavioral Factors
Behavioral factors (previous and current physical activity patterns) are influential in
determining physical capabilities. If an African American woman has danced in the past
and has enjoyed it, the chance of her engaging in dance in the future is greatly increased.
If an African American woman believes she can participate in a culturally-specific dance
program, the chance of her climbing more stairs, having additional energy to do routine
household chores, and doing extra gardening are also increased. In this fashion, past and
present physical activities are important components of behavioral factors. Perceived
health benefits can also influence physical activity behavior. If an African American
woman believes that a physical activity program will increase energy and improve her
health status, the greater the chance of her participating in the physical activity program
(Jones & Nies, 1996). The proposed study will also examine the influence of behavioral
factors in sedentary African American women, ages 40 and older.

Murrock 33
Psychosocial Factors
A psychosocial factor known to improve physical activity is self-efficacy, which is a
component of the conceptual model. Self-efficacy is composed of efficacy expectations
and outcome expectations. Efficacy expectations is the person’s perceived ability to
perform a specific behavior and outcome expectations is the belief about whether a
specific behavior will cause a certain outcome (Bandura, 1977). A reciprocal relationship
exists between efficacy expectations and outcomes expectations: successful change in
health behavior will increase efficacy expectations and strengthen the belief that the
desired outcomes will occur. Thus, choosing to be physically active is influenced by an
individual’s belief in the ability to perform the behavior (efficacy expectations) and the
consequences of performing the behavior (outcome expectations). Efficacy expectations
and outcome expectations have been identified as strong predictors of participation in
physical activity programs in African American women (Marczynski-Music, 1994).
Another psychosocial factor of physical activity is social support, which is the
comfort, assistance, and information received and shared through formal and informal
contacts with others (Wallston et al., 1983). Social support provides a sense of belonging
to a group that shares similar values and interests (Wallston et al., 1983). This important
psychosocial factor of social support from family and friends is an important predictor of
physical activity (Chogahara et al., 1998; Courneya & McAuley, 1995) and has been
shown to increase physical activity in African American women (Chogahara et al., 1998;
Courneya & McAuley, 1995; Dishman & Sallis, 1994; Eyler et al., 1999; Oka et al.,
1995). An important part of social support is the interpersonal interactions that occur
during physical activity. Interpersonal interactions have been identified as motivating

Murrock 34
factors for beginning and continuing a physical activity program in African American
women (Clark, 1996; Eyler et al., 1998). Social support and interpersonal interactions
are important for physical activity in African American women (Henderson & Ainsworth,
2003).
Environmental Factors
An environmental factor that influences physical activity is location. Health
promotion programs located in church settings are favored by African American women
(Banks-Wallace, 2000; Prohaska, Peters et al., 2000). They are a preferred site to deliver
culturally-specific health promotion interventions and are well-accepted settings for
health screenings (Yanek et al., 2001), weight management (McNabb et al., 1997), health
education (Oexmann et al., 2000), and physical activity programs (Prohaska, Peters et al.,
2000) in African American communities. Few studies were found that developed church-
based physical activity programs for African American women. As part of a weight loss
program, Kumanyika et. al (1992) included one low-impact aerobic class per week for 8
weeks. The participants exercised to secular music that was approved by church
officials. There is no mention of how the low-impact aerobic class influenced weight
loss. Another church-based physical activity program described an intervention where
African American women walked on church grounds three times per week for at least one
hour over 6 months. The results indicated a decrease in depression and an increase in
exercise motivation (Izquierdo-Porrera et al., 2002). African American women
participate in and value church experiences and may attend physical activity programs to
increase lifestyle physical activity located in churches in their communities (Peterson et
al., 2002).
Murrock 35
Summary of Conceptual Model
In summary, the culturally-specific church-based dance intervention should increase an
African American woman’s lifestyle physical activity and functional capacity through
enhanced self-efficacy and social support (See Figure 1). The culturally-specific dance
will be choreographed with dance steps that are easy to master, thereby increasing self-
efficacy (efficacy expectations and outcome expectations) which is postulated to
influence the relationship between the intervention and increased physical activity and
functional capacity. The intimacy of the church environment capitalizes on an existing
social support system that will augment the relationship between the intervention and
increased lifestyle physical activity and functional capacity. Thus, the culturally-specific
dance intervention is a moderate-intensity activity in a supportive church environment
that has the potential to increase lifestyle physical activity and functional capacity in
sedentary African American women, ages 40 years and over. Body fat, age, co-
morbidity, and SES will be analyzed as covariates.

Murrock 36
Self-Efficacy
-Efficacy Expectations
-Outcome Expectations
Increased Lifestyle
Physical Activity
Culturally-
specific
church-based Increased Functional
Dance Capacity
(Decreased Functional
Limitation)
Social Support
For Exercise
Covariates
Body fat, age
comorbidity, SES
Figure 1. Conceptual Model of the Proposed Study
Significance to Nursing Science
Nursing science is the foundation of knowledge underlying human behavior, social
interactions, and response to normal and stressful conditions across the lifespan. It is the
process of ordering and organizing events and phenomena of interest to the discipline of
nursing. Human understanding is the premise of nursing science and such knowledge is
generally obtained through systematic inquiry, theory testing, and observation (Gortner,
1990). The philosophical orientation of nursing science is both empirical and interpretive
which involves the exploration, description, and classification of the phenomena of
interest through observation and interpretation of the findings.
For the proposed study, the philosophical approach to nursing science will be
contemporary empiricism. It is a paradigm that develops nursing knowledge based on
scientific fact learned from empirical methods within the context in which it happens.
Contemporary empiricism helps broaden the scope of nursing science by maintaining
objectivity in observations, but both theory and observations are value-laden, not theory
Murrock 37
neutral (Giuliano, 2003). For contemporary empiricists, scientific knowledge is
acceptable if the concepts of interest are clear and distinct, and are linked to
corresponding pieces of reality. The proposed study has clearly defined and distinct
concepts that link reality through personal, behavioral, psychosocial, and environmental
factors of the African American women. The behavior will be observed in the context in
which it happens. The culturally-specific dance intervention will be choreographed and
taught by an African American women and will be held in an African American church
located in an African American community.
Contemporary empiricism seeks to understand phenomena in all its complexities, not
just break it down into pieces. Parts of the conceptual framework (self-efficacy and
social support) will be tested, as well as the overall outcome of how these parts and the
culturally-specific dance intervention influence lifestyle physical activity and functional
capacity in sedentary African American women. Thus, contemporary empiricism will
provide a strong scientific nursing foundation (clearly defined concepts, observation,
measurement, theory testing) and apply this nursing knowledge in the context of the lives
of the sedentary African American women, ages 40 years and older.
The goal of nursing science is to discover truth about particular phenomena, thus,
nursing research is how nursing science is created. The credibility of nursing science is
based on the rigor and scientific quality of nursing research and the nursing implications
of the findings. There is limited scientific work reported in the literature about African
American women and lifestyle physical activity. There is a need to build a scientific
knowledge base about African American women, as most research on lifestyle physical
activity has been conducted on Caucasian men and to a lesser extent, Caucasian women.
Murrock 38
Most physical activity instruments have been developed, tested, and validated in
Caucasian men, with little attention to occupational, household, and family care activities
that are a significant part of African American women’s lives. They do not reflect the
daily experiences of African American women, their values, their beliefs, and lifestyles.
To accurately measure physical activity in African American women, an instrument
needs to integrate the issues of ethnicity, gender, and be culturally relevant by including
family and life experiences (Masse et al., 1998). This proposed study will contribute to
nursing science by utilizing a culturally appropriate instrument the Physical Activity
Scale for the Elderly (PASE) to measure lifestyle physical activity in African American
women. The PASE is culturally relevant to the lives of African American women as it
reflects the gender role of caregiving and represents activities African American women
do on a daily basis, such as household chores/tasks, occupational, and leisure time
activities. For intervention studies, it is essential to utilize an instrument that accurately
assesses physical activity, evaluates the effects of the intervention, and monitors physical
activity over time (Wilcox, 2002). The PASE is an appropriate instrument as it gauges
lifestyle physical activity, allows for comparison between individuals or groups, and
measures lifestyle physical activity behavior change over time in African American
women.
Other contributions to nursing science are based on the study’s innovations including:
the culturally-specific dance choreographed and taught by an African American woman,
dancing to gospel music selected by African American women, and studying the effects
of social support from friends and family in a church community. Thus, empirical data
will be produced about the effects of a culturally-specific dance intervention and the
Murrock 39
relationship of the mediators on lifestyle physical activity and functional capacity in
sedentary African American women, ages 40 years and over.
Significance to Nursing Practice
A large percentage of African American women are sedentary which increases their
chance of developing chronic health conditions. Therefore, a culturally-specific dance
intervention to increase physical activity in African American women can play a key role
in changing sedentary behaviors. Physical activity is embedded in their lifestyles, and
this assessment will provide information about the meaning each African American
woman attributes to physical activity, self-efficacy, and social support within the context
of their lives. Cultural dimensions are also important determinants of how African
American women view their roles within the family and how they spend their day
(Ainsworth, 2000). African American women are heavily involved in activities related to
care of the family and home, such as caring for children or grandchildren, caring for older
adults, loading and carrying groceries, and doing laundry. Assessments that include these
physical activities provide greater understanding about their lifestyle physical activity.
Nursing practice should be culturally-specific and manifest cultural competence by
incorporating cultural values and norms (Banks-Wallace, 2000). Culturally-specific
physical activity interventions are undeniably needed to guide nursing practice to help
reduce health disparities in sedentary African American women, ages 40 years and older.
Purpose
The purpose of the study is to determine the effects of a culturally-specific church-
based dance intervention and to identify the relationship of self-efficacy and social
Murrock 40
support on lifestyle physical activity and functional capacity in sedentary African
American women, ages 40 years and older.
Research Hypotheses
Q1: Does an 8-week culturally-specific church-based dance intervention increase
lifestyle physical activity and functional capacity in sedentary African American women
from baseline to 8 weeks, and is it maintained at 18 weeks compared to women who do
not receive the intervention?
Q2: Do efficacy expectations, outcome expectations, and social support mediate the
effects of a culturally-specific church-based dance intervention on lifestyle physical
activity and functional capacity at 8 weeks compared to women who do not receive the
intervention?
Q3: Does the increase in lifestyle physical activity and functional capacity at 18 weeks
remain when controlling for baseline body fat, age, co-morbidity, and socioeconomic
status when compared to those who do not receive the intervention?
Assumptions
The proposed study is based on the following assumptions.
An African American woman:
Values her health and wants to live independently for as long as possible.
Knows what behaviors are beneficial to her overall health.
Will decide what specific behavior to engage in based on previous knowledge and
experience of the specific behavior.
Should have the opportunity to observe the specific behavior by someone who has
mastered the specific behavior.

Murrock 41
Should have the opportunity to compare her performance of the specific behavior to
someone similar to herself who is viewed as having mastered the specific behavior and is
considered to “model” the specific behavior.
Should have the chance to perform the specific behavior in a supportive environment.
Should have the chance to give and receive social support for the specific behavior.
Should be able to perform the specific behavior in a safe environment.
Definition of Terms
Independent Variable (Intervention)
Dance is a patterned, rhythmic movement in space and time (Pepper, 1984) and will be at
a moderate-intensity characterized by choreographed routines performed to gospel music
where one foot will remain in contact with the floor at all times.
Culturally-specific dance is a dance within a community or group that serves one or more
purposes related to traditional practices, cultural transmission, social acceptance, or
connectedness (Jain & Brown, 2001).
Dependent Variables
Lifestyle physical activity is the daily accumulation of at least 30 minutes of physical
activity, which includes all leisure, occupational, or household activities that are at least
of moderate-intensity and are part of African American woman’s everyday life (Dunn et
al., 1998). Leisure activities will include walking, strenuous sport and recreation, and
muscle strengthening; occupational activities will be either paid or unpaid work; and
housework activities will include lawn work/yard care, home repair, outdoor gardening,
and caring for others. This will be measured using the Physical Activity Scale for the
Elderly (PASE).
Murrock 42
Functional capacity is the ability to walk for a distance and perform daily activities
(Guralnik et al., 1989) and is a key element of independent living. Functional capacity
will be measured by the 6-minute work test (6MworkT), which will be the distance
walked in meters multiplied by body weight in kilograms during a 6-minute time period.
Mediating Variables
Self-efficacy-The components of self-efficacy that will be studied are:
A) Efficacy expectations is the person’s perceived ability to perform a certain
behavior, which influences short-term behavior and is very behavior specific (Bandura,
1977). It will measure an African American woman’s perceived ability to dance for the
duration of the 8-week culturally-specific dance intervention. This will be measured by
the Self-Efficacy for Exercise (SEE) scale.
B) Outcome expectations is the belief about whether a specific behavior will cause a
certain outcome and indirectly influence long-term health maintenance and health
promotion (Bandura, 1977). Outcome expectations will measure the physical benefits
(energy, strength, stamina) and mental health benefits (mental alertness, mood, well-
being) of dancing and will be measured by the Outcome Expectations for Exercise (OEE)
scale.
Social support is the comfort, assistance, and information received through formal and
informal contacts with others (Wallston et al., 1983) and this study will focus on social
support from family and friends for exercise. This will be measured by the Social
Support for Exercise Scale (SSES).

Murrock 43
Covariates
Body fat is the amount of fat in the human body and will be measured using a segmental
bioelectrical impedance analyzer (BIA), a non-invasive method of estimating body
composition, which is the percentage of fat, muscle, blood, and bone in the human body.
Age is the time from birth to the present and will be measured in years by self-report.
Socioeconomic status is the annual, yearly household income of each participant and will
also be assessed by self-report.
Co-morbidity is the number of self-reported diseases or conditions a person has and will
be measured using the Charlson Scale, which is a weighted sum of co-morbid conditions
that mirror the functional burden of illness conditions.

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Chapter 2
Review of the Literature
Introduction
This chapter reflects an extensive integrated literature review of each concept in the
conceptual model of the proposed study. The review will include the independent
variable of dance and the dependent variables of lifestyle physical activity and functional
capacity. The literature review will continue with the mediating variables of efficacy
expectations, outcome expectations, and social support from family and friends in
community dwelling adult populations. It will conclude with a brief discussion of the
covariates, age, body fat, comorbidity, and socioeconomic status. Of particular
importance is the lack of African American women participants in all the reviewed
research studies related to the concepts of interest.
Independent Variable: Dance
Dance is defined as a patterned, rhythmic movement in space and time (Pepper, 1984)
and requires the movement and coordination of large and small muscle groups. It has the
potential to generate positive health outcomes, and has the propensity to provide African
American women with the recommended amounts of daily physical activity. For the
purpose of this review, moderate-intensity dance and low-impact aerobic dance will be
used as interchangeable concepts, which are reflected in the literature. Both forms of
dance are defined as having one-foot in contact with the floor at all times. An extensive
review of the literature showed that participation in a low-impact aerobic dance program
influenced maximal oxygen uptake, lifestyle physical activity, and body composition in
mostly Caucasian women and in small numbers of African American women.

Murrock 45
Maximal Oxygen Uptake
Maximal oxygen uptake (V02 max) is the largest amount of oxygen that an individual
can utilize under the most strenuous exercise conditions, and has been used as the
measure most representative of cardiorespiratory fitness (Pollack, Wilmore, & Fox,
1983). Improvements in oxygen uptake depend on gender, age, initial fitness level,
presence/absence of lung impairment, and the intensity, duration, and frequency of
exercise training. For example, individuals with a low initial V02 max will show greater
gains following training than individuals with higher V02 max values. Additionally,
VO2 max improvements are also related to the length of the training period.
Significant improvements in maximal oxygen uptake after completion of moderate-
intensity dance programs have been documented in sedentary, obese, middle-aged, and
older women. Following a 16-week program, one study reported a 31.9% improvement
in V02 max in 70 sedentary, obese women ages 60-70 years (Gillett et al., 1996) and
another reported a 41% increase in 20 overweight, middle-aged women, ages 35-57 years
(Gillett & Eisenman, 1987). Thirty women, ages 57-77 years, reported a 13% significant
improvement in VO2 max (Hopkins et al., 1990) and 37 Japanese women, age 50-56
years, reported an 18% significant improvement in V02 max after concluding 12-week
low-impact aerobic dance programs (Shimamoto, Adachi, Takahaski, & Tanaka, 1998).
Although not measured as an outcome variable, improvements in lifestyle physical
activity were reported anecdotally in two studies. Gillett et al. (1996) reported that the
women commented on their increased ability to perform daily living tasks, such as
dressing, carrying groceries, and laundry after completing an 8-week dance program.
Murrock 46
Also, dancing to appropriate music, the social support inherent in the dance classes, and
being with other women who were similar in age, weight, and fitness level increased their
enjoyment. This contributed to the high attendance rate of 86%. The authors concluded
that low-impact dance can improve physical health and future studies should include
measures of lifestyle physical activities that are relevant to women (Gillett et al., 1996).
Another study noted improved ability to perform household activities, such as grocery
shopping, doing laundry, and attending to household finances, in individuals with
rheumatoid arthritis who participated in a 12-week low-impact dance program (Noreau,
Martineau, Roy, & Belzile, 1995).
Body Composition
One study was noted that studied body composition and low-impact dance. Thirty
seven Japanese women, age 50-56 years, significantly reduced their body mass by -3.1%
and body fat by - 6.1% at the conclusion of a 12-week low-impact aerobic dance program
(Shimamoto et al., 1998). Following a 16-week low-impact dance program, 70
sedentary, obese, older women significantly decreased their percent body fat by -5.4%
(Gillett et al., 1996) but another study reported a small but insignificant change in body
weight in 20 overweight, middle-aged women (Gillett & Eisenman, 1987).
International Perspective on Culturally-Specific Dance
Culturally-specific dance is a dance within a community or group that serves one or
more purposes related to traditional practices, cultural transmission, social acceptance, or
connectedness (Jain & Brown, 2001). In many cultures, dance is a longstanding practice
passed down through generations and is an activity in which most people have
participated in some time during their lives. Culturally-specific dance involves visual,
Murrock 47
tactile, and auditory stimulation enabling emotional release and creative expression of
feeling and mood (Conner, 2000). Culturally-specific dance in groups is especially
important to women as it includes social contact and companionship; it does not always
require a partner. It can be altered to match the age and health status of individuals
without reducing the psychological and physiological benefits. Culturally-specific dance
can capture the imagination of individuals in ways that other forms of physical activity
cannot due to its symbolic qualities (Conner, 2000). It can cross language barriers and
can lead to an increase in understanding of other cultures and their customs, traditions,
and music.
An extensive review of the literature noted several studies that tested culturally-
specific dance in adult female populations. Thirty-nine American Indian college women,
mean age 28 years, evaluated whether a culturally-based dance education model could
reduce stress (Skye et al., 1989). This model was based on relaxation techniques,
stretching, movement and creative activities, Indian cultural symbols, music, and visual
effects. The classes were conducted twice a week for 4 weeks and stress was measured
using the Spielberger State-Trait Anxiety Inventory. State anxiety is current oriented and
transitory in character while trait anxiety is a condition of anxiety proneness over time.
The results indicated a significantly lowered trait anxiety in the intervention group than
control group but no significant difference in state anxiety between the groups. The
authors concluded that lower trait anxiety was associated with the chronic exercise-
relaxation training and state anxiety was not reduced since it is a transient response to an
acute stressor.
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Weight-bearing activities are considered essential for its beneficial effects on
regenerating and maintaining bone integrity. A 12-month prospective study on bone
density of 28 Viennese women, ages 46-78 years, were divided into 2 groups, an
osteoporotic group (n=15) and normal group (n=13). Though the sample size was small,
the results of the study are instructive. Groups were determined based on their lumbar
bone mineral density (BMD) measured by spinal x-rays and quantitative computed
tomography (qCT). The participants danced the Viennese waltz, other folk dances, and
aerobic movements for approximately 3.2 hours per week (Kudlacek et al., 1997).
Results indicated a significant increase in BMD for the osteoporotic group and no
significant change in the normal group. The results indicate that Viennese and other folk
dances have a weight bearing effect on bone and can increase and preserve BMD.
Falls are one of the most frequent causes of injury related morbidity and mortality in
older adults, especially women. A folk dance program was designed to improve indices
of falling risk in elderly Japanese women (Shigematsu et al., 2002). Thirty-eight
community-dwelling Japanese women, ages 72-87 years, were randomly assigned to
either the folk dance protocol (n=20) or control group (n=18). The folk dance classes
were held 3 times per week for 12 weeks. The folk dance steps included: side-stepping,
fast walking, forward and backward stepping, leg lifts, knee bends, forward and side
lunges, and heel rises. The outcome measures consisted of balance (single-leg balance
with eyes open/closed and functional reach); strength (hand-grip strength and keeping a
half-squat position); locomotion/agility (walking time around two cones and a 3-minute
walking distance); and motor processing (hand-reaction time and foot tapping). At
pretest, both groups were similar in all tests. After 12 weeks of folk dancing, the
Murrock 49
intervention group showed significantly greater measures of balance and one measure of
locomotion/agility (walking time around two cones). There were no significant
improvements in any of the outcomes measures for the control group. It can be
concluded that a folk dance program designed for elderly women can improve
components of balance and locomotion/agility thereby decreasing their risk of falling.
Other studies describe the role and importance of culturally-specific dance forms in
American Indian, African, African-American, Hispanic, Egyptian, Middle Eastern, and
Chinese communities. The underlying theme of these descriptive studies is that
culturally-specific dance integrates the physiological, psychological, and sociological
aspects of one’s lived experiences and worldviews into highly personal movement.
Numerous American Indian dance rituals are rooted in traditional healing principles
that promote mental and physical health. The Salish spirit dance, the sun dance, and the
gourd dance are professed to provide participants with spiritual and emotional well-being,
consciousness raising/mood altering experiences, and self-healing powers over various
evil forces (Jilek, 1989).
In many African communities, dancing is a part of all the stages of life (Malboum,
1993). It is a vehicle for rhythmic and cultural expression, especially during times of
celebrations and major life events, including birth, initiation, marriage, and death.
Physical expression and creativity are also apparent through dance in the African
American culture (Farr, 1997). A dance style known as hip-hop, which is the
culmination of rap music and dance, is a means to formulate African American identity in
adolescents. Farr argues that hip-hop and other cultural dance forms in African American
communities may serve as an effective mode to reach out to African American

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adolescents who are at risk for emotional or behavioral disorders and stress-related health
conditions (Farr, 1997).
Culturally-specific dance programs can increase physical activity by recruiting
members of underserved populations. A study conducted in a largely Hispanic
community was designed to determine if local culturally-specific dance programs could
increase physical activity (Whitehorse, Manzano, Baezconde-Garbanati, & Hahn, 1999).
The culturally-specific dances included salsa, cumbia, quebradita, merengue, Macarena,
and other Latin dances. The results showed that the culturally-specific dance programs
were successful in recruiting sedentary Latino women and that these programs have the
potential to improve health in this population.
In the Middle East, dance is an expressive form performed primarily by women. The
Zar is an ancient Egyptian dance for the primary purpose of healing, and is especially
used for treatment for emotional or mental disorders (El Guindy & Schmais, 1994).
Also, Middle Eastern dance may be an effective and enjoyable exercise program for the
elderly (El-Halawani, Sebesta, & Sandberg, 1982) and belly dancing may help improve
back problems, reduce stress, and tighten pelvic muscles (Trevelyan, 1996).
Tai chi is a traditional Chinese martial art and is not considered a true dance form.
However, it is worth mentioning as it has strong cultural and traditional origins. Briefly,
research shows that tai chi improves cardiovascular fitness (Hong, Li, & Robinson,
2000), lowers blood pressure (Young, Appel, Jee, & Miller, 1999), increases muscular
strength (Lan, Lai, Chen, & Wong, 1998), improves balance (Hain, Fuller, Weil, &
Kotsais, 1999), improves flexibility (Hong et al., 2000), enhances proprioception and
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overall well-being (Cheng, 1999). Thus, tai chi is a type of culturally-specific physical
activity that has the potential to improve physical and mental health.
In summary, dance generated positive health outcomes in American Indian, Japanese,
and Viennese women. Culturally-specific dance was a vehicle for cultural transmission
of beliefs, values, and traditional healing in African, Hispanic, Egyptian, Middle Eastern,
and Chinese cultures and it too produced physiological and psychological benefits. In the
African American community, dance has played an important role as a means of
emotional expression, symbolic of traditional African heritage, and as a form of
interaction, support, and cohesion (Farr, 1997). Therefore, empirical data about a
culturally-specific dance intervention to generate positive health benefits in African
American women, ages 40 years and older, is paramount.
Dependent Variable: Lifestyle Physical Activity
Lifestyle physical activity is the daily accumulation of at least 30 minutes of physical
activity and can be planned or unplanned activities that are a part of everyday life (Dunn
et al., 1998). Lifestyle physical activity interventions encourage individual’s to integrate
more walking and stair climbing and incorporate short bouts of moderate intensity
activities throughout the day. A review of the literature noted that interventions to
increase lifestyle physical activity were just as effective as structured, vigorous exercise
programs to improve maximal oxygen uptake, change body composition, and reduce
cardiovascular risk factors (CVRF).
Project Active was a longitudinal study that evaluated whether a structured exercise
group (S) versus a lifestyle group (L) would meet the recommended 30 minutes of
accumulated physical activity (Dunn, Garcia et al., 1997). A sample of 235 healthy,
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community dwelling women and men were randomized into either the structured or
lifestyle group. The structured group (n=114) exercised vigorously 3-5 times per week at
local health club. The lifestyle group (n=121) attended classes to learn how to
incorporate more daily physical activity one hour per week for 16 weeks, then one hour
every other week for the next 8 weeks. There is no mention of the ethnicity or gender
make up of either group. However, the study included 14% African Americans in the
overall sample. At 6 months, both groups demonstrated similar and significant changes
for decreased sitting time (L=9.3%; S=12.2%); increased stair climbing (L=64%;
S=30.2%); increased minutes walked (L=25%; S= 20.9%); and increased maximal
oxygen uptake (L=18%; S=31%). Both groups had significant reductions in serum
cholesterol and lipid levels, blood pressure, and body fat. By 24 months, both groups
significantly maintained their increased level of physical activity (L=25%; S=30%) and
significantly increased stair climbing (L: p=.003; A: p=.009) (Dunn, Blair et al., 1997).
The principle finding was that the lifestyle group had just as favorable changes as the
structured group, and accumulating 30 minutes of physical activity would be a means to
encourage sedentary individuals to adopt and maintain physical activity at both 6 and 24
months.
Another study examined the short and long-term changes in body composition and
maximal oxygen uptake by comparing a diet with structured aerobic group (A) to a diet
with lifestyle physical activity group (L) (Andersen et al., 1999). Forty sedentary, obese
women, including 10 African Americans, age range 21-60 years, were randomized to
either group. The lifestyle physical activity group (n=20) was taught to incorporate short
sessions of physical activity into their daily lives, such as taking stairs more frequently
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and walking short distances instead of driving. The diet and structured aerobic program
group (n=20) attended a one-hour step aerobic class, 3 times per week for 16 weeks. By
the end of the 16-week intervention, the lifestyle group increased their daily activity by
28%. At 16 weeks, both groups demonstrated significant changes in weight loss (L=7.9
kg; A=8.3 kg); reduced body fat (L=6.2%; A=4.3%); and increased maximal oxygen
uptake (L=16.2%; A=18.8%). At 68 weeks, there were still significant changes in
maximal oxygen uptake (L=24.2%; S=16.3%) and neither group significantly regained
any weight (l=.08kg; A=1.6kg) from baseline. The authors concluded that diet plus
lifestyle physical activity offered similar health benefits as diet and vigorous activity.
Increasing lifestyle physical activity may be a better alternative that vigorous activity for
sedentary, obese women.
Dependent Variable: Functional Capacity
A goal of many older adults is to preserve their ability to walk, as it is necessary for
independent living. The ability to walk is an essential component of functional capacity;
it reflects the capability to carry out day-to-day activities in the home, community, and
workplace (Guralnik et al., 1989). Functional capacity is also important to many
everyday activities like shopping, caretaking, domestic activities, and errands (Rikli &
Jones, 1998). It is a predictor of morbidity and mortality and change in functional
capacity is an important outcome to show the benefit of an intervention in healthy and
diseased populations (Bittner et al., 2000).
Functional capacity is assessed by improvement in timed walking tests, graded
exercise tests, or cycle ergometer tests. A review of the literature noted two United
States studies and one Canadian study documented significant changes in functional
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capacity among rheumatoid arthritis participants who completed low-impact dance
programs. One study of 19 individuals, mean age 49.3 years, reported a significantly
decreased time to walk 50 feet after a 12-week low-impact dance program (Noreau et al.,
1995). Unfortunately, no significance values or percent change was noted. In another
study, 43 participants significantly decreased their time to walk 50 feet (p< .0005) after
finishing a 16-week low-impact dance program (Perlman et al., 1990). There is no
mention of the ethnicity or gender of the participants in these two studies. Finally, 10
Canadian women significantly improved their 6-minute walking distance (p=.017)
following an 8-week low-impact dance program (Moffet, Noreau, Parent, & Drolet,
2000). Thus, a timed walking test was sensitive enough to detect significant changes in
functional capacity after completing a low-impact dance intervention.
In summary, the ability to walk for a distance is a quick and inexpensive way to assess
the capability to carry out day-to-day activities. The proposed study will assess the
functional capacity of African American women who have and have not participated in a
culturally-specific dance intervention. This will add to the current functional capacity
scientific knowledge base and help to determine how the culturally-specific dance
intervention impacts functional capacity in sedentary African American women.
Functional Limitation
Functional capacity is not the only important factor reflecting the ability to perform
everyday activities in the home, community, and workplace. Individual factors may have
some bearing on an African American woman’s ability to perform her daily routines
resulting in functional limitation and disability. These factors include pain, fatigue,
ailments, acute and chronic health conditions, and various types of disabilities.
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Functional limitation of physical functioning is a significant predictor of loss of
independence, increased use of medical facilities, and mortality. Functional limitation
can be measured by a variety of questionnaires. However, the few studies that assessed
functional limitation (Haley, Jette et al., 2002; Haley, Kooyoomjian, & Ludlow, 2002; A.
Jette et al., 2002) and disability (Dubuc, Haley, Ni, Kooyoomjian, & Jette, 2004; A. Jette
et al., 2002; Sayers et al., 2004) included mostly Caucasian women ages 60 years and
older.
In summary, functional limitation and disability are important to assess in African
American women to determine their capability to carry out daily routines and activities.
Of particular importance is that both functional limitation and disability can change
across a wide variety of life tasks and can be tracked across time (A. Jette et al., 2002).
The proposed study will assess the functional limitation and disability and provide
empirical data about African American women who have and have not participated in a
culturally-specific dance intervention.
Mediating Variables of the Proposed Study
A mediator provides useful information about the mechanism through which the
independent variable is able to influence the dependent variable. It is a third variable that
changes the association between the independent and dependent variable as it explains
how or why external physical events take on internal psychological significance (Baron
& Kenney, 1986). A mediator effect exists if the following conditions are met: a)
variations in the independent variable predict variations in the mediator variable, b)
variations in the mediator variable predict variations in the outcome variable, and c) when
the associations in (a) and (b) are controlled in the model, the direct relationship between
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the independent variable and the outcome variable becomes nonsignificant (Baron &
Kenney, 1986). In the proposed study, efficacy expectations, outcome expectations, and
social support from family and friends are hypothesized to mediate the relationship
between culturally-specific dance and lifestyle physical activity and functional capacity
in African American women, ages 40 years and older. A review of the literature noted
empirical support for efficacy and outcome expectations and social support from family
and friends as mediators between physical activity and positive health outcomes in
various samples of community dwelling adults, predominately Caucasian, elderly
women.
Efficacy Expectations and Outcome Expectations
Social Cognitive Theory implies that individuals with high efficacy expectations and
outcome expectations are more likely initiate and persist in a specific physical activity
behavior (Bandura, 1997). The theory states that previous physical activity experience
and physical and mental health will directly influence efficacy expectations while age,
gender, efficacy expectations, and current physical activity behavior will directly
influence outcome expectations. Both efficacy and outcome expectations claim to
directly and indirectly influence current physical activity behavior. There has been
considerable testing of efficacy and outcome expectations and physical activity behaviors
in older adults. These adults were living in their own homes or in retirement
communities and the majority of the individuals were women (76%-85%) and Caucasian
(97-100%), with age range between 35 to 86 years.
Efficacy expectations was measured using the Self-Efficacy for Exercise (SEE) scale
(Resnick & Jenkins, 2000) and outcome expectations was measured with the Outcome
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Expectations for Exercise (OEE) scale (Resnick et al., 2001). Several descriptive studies
using these instruments reported moderate to strong correlations of efficacy and outcome
expectations with physical activity. Model testing using path analysis was conducted and
many hypothesized paths were statistically significant and revealed a wide range of
explained variance. These studies will be briefly discussed.
The first descriptive study explored the factors that influence functional performance
and found statistically significant correlation between physical activity and efficacy
expectations (r=.61) and outcome expectations (r=.53) and together efficacy and outcome
expectations accounted for 57% of the variance in exercise behavior (Resnick, 2000).
Another descriptive study (Resnick, Palmer, Jenkins, & Spellbring, 2000) described the
factors that influence physical activity behaviors between exercisers and nonexercisers.
It noted statistically significant differences in means between the exercisers (E) and non-
exercisers (N) in efficacy expectations (E=7.7; N=4.2), outcome expectations (E=3.9; N=
2.5), mental health (E=54.3; N=51.7), and physical health scores (E=48.7; N=41.8). The
study also reported statistically significant correlation of efficacy expectations (r=.56;
p<.05) and outcome expectations(r=.45; p<.05) with physical activity and model testing
using path analysis showed the model accounted for 20% of the variance in efficacy
expectations, 37% of the variance in outcome expectations, and 32% of the variance in
physical activity behavior (Resnick, Palmer et al., 2000). Another study (Resnick,
2001a) hypothesized that efficacy and outcome expectations were directly or indirectly
associated with current physical activity behavior. Efficacy expectations (r=.57, p<.05)
and outcome expectations (r=.47, p<.05) were significantly correlated with physical
activity. Path analysis showed that physical health (.34, p<.05) and prior physical
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activity behavior (.29, p<.05) were significantly associated with efficacy expectations and
accounted for 22% of the variance in efficacy expectations. Physical health (.30, p<.05)
mental health (.23, p<.05), and efficacy expectations (.53, p<.05) were all significantly
associated with outcome expectations and accounted for 49% of the variance in outcome
expectations. Furthermore, prior physical activity behavior (.27, p<.05), efficacy
expectations (.30, p<.05), and outcome expectations (.17, p<.05) were all directly
associated with current physical activity behavior. Finally, prior physical activity
behavior and mental and physical health were indirectly associated with current physical
activity behavior through efficacy expectations and/or outcome expectations and all these
variables accounted for 40% of the variance in current physical activity behavior
(Resnick, 2001a).
Still, another descriptive study (Resnick, 2001b) tested a model that (a) mental and
physical health directly influence efficacy expectations, (b) mental and physical health,
age, and efficacy expectations influence outcome expectations, (c) all of these variables
directly or indirectly influence overall physical activity. Efficacy expectations (r=.41,
p<.05) and outcome expectations (r=.35, p<.05) were significantly correlated with overall
physical activity. Physical (.53, p<.05) and mental health (.18, p<.05) significantly
influenced efficacy expectations and accounted for 28% of the variance in overall
physical activity. Efficacy expectations (.21, p<.05) and age (-.14, p<.05) significantly
influenced outcome expectations and accounted for 8% of the variance in overall physical
activity. Efficacy expectations directly influenced activity (.23, p<.05) and indirectly
influenced activity through outcome expectations. Outcome expectations had a
significant direct effect on activity (.28, p<.05) and all these variables accounted for 29%
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of the variance in overall activity (Resnick, 2001b). Resnick, Orwig, Magaziner, and
Wynne (2002) tested the relationship of efficacy and outcome expectations and physical
activity behavior and noted that efficacy expectations directly influenced outcome
expectations (.70, p<.05), physical activity behavior (.40, p<.05) and indirectly
influenced physical activity behavior through outcome expectations. Outcome
expectations (.32, p<.05) directly influenced physical activity behavior. The model
explained 5% of the variance in efficacy expectations, 49% of the variance in outcome
expectations, and 53% of the variance in physical activity behavior. Finally, to test the
relationship of efficacy and outcome expectations and physical activity behavior, one
study revealed that efficacy expectations (r=.78, p<.05) and outcome expectations (r=.66,
p<.05) correlated significantly with physical activity (Resnick & Nigg, 2003).
In summary, the findings from these studies provide empirical support that efficacy
and outcome expectations directly and indirectly influence physical activity and account
for a large percentage of explained variance in predominately Caucasian, elderly women
living in retirement communities. The results also support the fact that interventions to
improve physical activity should incorporate both efficacy and outcome expectations
related to physical activity. However, it is paramount that future studies include more
African American women to provide culturally-specific empirical data about efficacy and
outcome expectations for physical activity.
Social Support
Social support has various dimensions including guidance (advice/information),
reliable alliance (material assistance), reassurance of worth (recognition of competence
and value), attachment (emotional closeness), social integration (a sense of belonging to a

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group sharing similar interests and concerns), and opportunity for nurturance (others
relying on you for personal well-being) (Duncan & McAuley, 1993). These dimensions
may enhance an individual’s ability to attain personal goals through behavior change.
Social Cognitive Theory purports that social support is a key determinant of an
individual’s behavior (Bandura, 1986).
Social Support from Family and Friends for Physical Activity
Social support, especially from family and friends, has been shown to have a positive
influence on physical activity in women (Oka et al., 1995) and African American women
(Eyler et al., 1999). In the studies reviewed, social support from family and friends was
measured with the Social Support for Exercise Scale (SSES), which assessed how often
family and friends offered support, gave reminders, discussed physical activity, or gave
encouragement for physical activity (Sallis, Grossman, Pinski, Patterson, & Nader, 1987).
Studies using this instrument were reviewed and found positive correlations between
social support and physical activity in women and African American women.
One study assessed the association of social support on four levels of physical activity
in a national survey of 2912 ethnic, minority women (26% Caucasian, 26% African
American, 25% Asian, and 23% Hispanic), ages 40-70 plus years (Eyler et al., 1999).
Physical activity was categorized as 1) sedentary-no participation in any form of physical
activity, leisure, or hobbies; 2) regular physical activity-physically active at least 5 times
a week for at least 30 minutes per session 3) cumulative physical activity-accumulating
150 minutes of physical activity, leisure, and or hobbies per week, and 4) lifestyle
activity-cumulative total of physical activity from leisure, housework, and occupational
activities. Overall, Hispanic women had the highest percentage of regular (17%),
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cumulative (34%), and lifestyle activity (82%), while African American women were the
most sedentary (41%) and had the lowest percentage of regular (7%), cumulative (18%),
and lifestyle activity (72%). The results also indicated that Hispanic women had the
highest total social support (56%), family support (58%), and friend support (49%) for
physical activity among all ethnic groups. By comparison, African American women
received 50% from total social support, 48% from family, and 48% from friends. The
results indicated that those with high social support, whether from family or friends, were
more physically active than those with low social support. The authors recommended
that interventions should promote social support from both family and friends to provide
a supportive atmosphere for physical activity for ethnic women.
A relationship between social support and physical activity was described in two
different community samples of Caucasian and African American women and men who
participated in a health behavior study (Treiber et al., 1991). The first sample consisted
of 230 (141 women, 89 men) elementary school teachers, 25% were African American
women, with a mean age 38 years. Among African American women, the results showed
a significant correlation between social support from family (r=.53, P<.001) and friends
(r=.47, P<.001) for leisure time activities and social support from family (r=.38, P<.05)
for physical activity. The second sample consisted of 238 couples (16% African
American women) with a mean age of 36 years. For the African American women, there
was a significant correlation between social support from family (r=.45, P<.01) and
physical activity and social support from family (r=.39, P<.05) for leisure time activity.
The authors concluded that social support from family was more significant than friend
support for physical activity in these two samples.

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An intervention study was designed to promote adoption and maintenance of physical
activity through physician recommendation and counseling. Social support from family
and friends, self efficacy, and cognitive and behavioral processes of behavior change
were hypothesized as mediators of increased physical activity (Calfas, Sallis, Oldenburg,
& Ffrench, 1997). The sample consisted of 212 participants (Intervention (I) n=98;
Control (C) n=114), predominately Caucasian (I=73%; C=70%), women (I=83%,
C=86%), and mean age 39 years (both groups). There was no mention of gender by race.
Multiple regression analysis showed that social support was not a significant mediator in
any model when entered alone. However, when entered with self-efficacy, it accounted
for 9% of the variance in physical activity. The authors concluded that social support
was not significant because it was not systematically included in the intervention. In
spite of this, it was recommended that social support be incorporated into future physical
activity recommendations and counseling.
Two descriptive studies examined social support as a correlate of physical activity.
The first study included 49 African American women, ages 18-55 years, looked at the
social factors of social support associated with physical activity (Felton et al., 2002). The
results indicated that social support for physical activity from family and friends
correlated significantly with a safe environment (r=.45, p<.01) and positive social
interaction (r=.84, p<.01). The second study consisted of 102 rural women (41% African
American), a mean age of 70 years, found that social support (collapsed into one
variable) was significantly correlated with physical activity (r=.28, p<.01) (Wilcox,
Bopp, Oberrecht, Kammermann, & McElmurray, 2003).

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Moreover, two additional studies tested both social support from family and friends
and efficacy and outcome expectations on physical activity in older adults, predominately
Caucasian (98%) and women (85%), and a mean age 85 years. Model testing using path
analysis was conducted in both studies. The first study included 74 adults and only friend
support correlated significantly with physical activity (r=.28, p<.05) and had a direct
statistically significant influence on efficacy expectations (r=.22, p<.05) but was not
significantly related to outcome expectations (Resnick, Orwig, Magaziner, & Wynne,
2002). A subsequent study (Resnick & Nigg) 2003consisted of 179 adults and found that
social support (collapsed into one variable) correlated significantly with efficacy
expectations (r=.30, p=.05), outcome expectations (r=.38, p=.05), and physical activity
(r=.37, p=.05). In the overall model, both health and social support explained 59% of the
variance in outcome expectations and 63% of efficacy expectations.
Relationship between Dance and Social Support
There appears to be a relationship between dance and social support, however, this
relationship has received little empirical attention. Participating in a dance program
include the social contact, camaraderie, and laughter that comes with enjoying the
company of others (Conner, 2000). The social support inherent in dance programs
appears to be an important factor for sedentary, obese women when the dance program is
compose of peers similar in weight, age, gender, and fitness level (Gillett et al., 1996).
The social support in dance classes have been postulated to contribute to high attendance
rates (Gillett & Eisenman, 1987; Gillett et al., 1996; Moffet et al., 2000). Therefore, the
relationship between dance social support may be an important aspect of the proposed
dance intervention.
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Relationship between Self-Efficacy and Social Support
There may be an association between self-efficacy and social support as social
influences are important characteristics for boosting efficacy cognitions (Bandura, 1986).
Self-efficacy and social support may be closely related to one another as opposed to
having orthogonal influences on physical activity behavior (Duncan & McAuley, 1993).
The social support that is available to an individual for physical activity may be more
important in understanding physical activity behavior than just relying on an individual’s
judgment of her capability of performing physical activity. However, there is limited
empirical data to substantiate this relationship. Social support affects physical activity
behavior through its association with self-efficacy (Duncan & McAuley, 1993). It may
indirectly influence physical activity behavior by strengthening self-efficacy through
appraisal and sharing information about physical activity. Social support in the form of
encouragement to be physically activity may play a role in enhancing self-efficacy
(Sallis, Hovell, Hofstetter, & Barrington, 1992). For example, commenting on a friend’s
increased energy and stamina, and improved ability to carry groceries after beginning a
physical activity program could influence that individual’s self-efficacy (Resnick et al.,
2002). Although not measured directly, researchers noted that the social support inherent
in dance classes may have contributed to increased self-efficacy in sedentary obese
women (Gillett et al., 1996). It is important to note that none of the studies included
African American women.
In summary, social support from family and friends positively correlated with physical
activity in women and in African American women. Social support from family and
friends incorporated into physical activity interventions may be advantageous for

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sedentary African American women (Eyler et al., 1999). Interventions should focus on
creating a supportive environment for physical activity, which may help African
American women initiate and maintain physical activity. The promotion of social
support in a culturally-specific manner merits further investigation. Thus, it is imperative
that future studies include more African American women to provide culturally-specific
empirical data about the relationship between social support from family and friends and
physical activity.
Covariates
A review of the literature noted that there are many influencing factors associated with
low physical activity levels in African American women. These factors are known as
covariates, and typically have an extraneous, potentially confounding influence on the
dependent variable. Covariates should be measured at the outset of the study and be
statically controlled during data analysis. For the proposed study, ethnicity and gender
are implied while age, body fat, comorbidity, and socioeconomic status (SES) will be
analyzed as covariates. Being African American (Brownson et al., 2000) and a woman
(Pate, Pratt, & Blair, 1995) implies lower rates of physical activity. As for age,
individuals over 50 years of age represent the most sedentary segment of the adult
population (USDHHS, 1996a) and age has been negatively related to physical activity in
African American women (A. King et al., 2000). Body fat is a potential confounder as
almost 30% of African American women are overweight beginning in their 30’s,
increasing to 60% by 49 years of age (Kuczmarski et al., 1994). The more body fat, the
less likely an African American woman engages in moderate to vigorous activities
(American Heart Association, 2005).

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Comorbidity factors begin to develop and interfere with physical activity during the
latter third and beginning the fourth decade of life (Carter-Nolan, Adams-Campbell, &
Williams, 1996). Furthermore, low SES tends to result in less physical activity (Crespo,
Ainsworth, Keteyaian, Heath, & Smit, 1999) for African American women. The
significance of the proposed study is that it will provide empirical data on the impact of
age, body fat, co-morbidity, and SES as intervening variables for lifestyle physical
activity in African American women, ages 40 and older.
Conclusion
This chapter reviewed the independent variable of dance, with respect to culturally-
specific dance, and the dependent variables of lifestyle physical activity and functional
capacity. It included a discussion of the mediation and reviewed the proposed mediating
variables of efficacy expectations, outcome expectations, and social support from family
and friends for physical activity in primarily Caucasian, elderly women. It concluded
with a short discussion of the covariates in the proposed conceptual model. An
overwhelming finding was the deficient number of African American women in the
research studies related to the concepts of interest. Further investigation is warranted to
provide scientific data about the effects of a culturally-specific church-based dance
intervention and to identify the relationship of self-efficacy and social support on lifestyle
physical activity and functional capacity in sedentary African American women, ages 40
years and older.

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Chapter 3
Methods
Introduction
This chapter includes a description of the research design, setting, sample, and power
analysis of this intervention study. The sampling procedure and both the experimental
and comparison group protocols are described. The procedures for data collection,
strategies to prevent attrition, and the study variables and their measurements are
explained in detail. Finally, this chapter concludes with the analysis of the study
questions and the documents that are related to the protection of human subjects for the
study.
Research Design
A quasi-experimental design was used to accommodate the 8-week and 18-week
observations. This design controlled for the main and interaction effects of testing the
intervention and increased generalizability by testing the intervention in a natural setting
(Tabachnick & Fidell, 2001). The two churches in the local African American
community were randomly assigned to either the dance intervention or the comparison
group protocols based on a blind draw of a sealed envelope that contains either the word
“intervention church” or “comparison church.” The randomization of the churches
helped to control for diffusion of treatment. The first dependent variable, lifestyle
physical activity, measured by two questionnaires, was assessed at baseline, 8 weeks, and
18 weeks. The second dependent variable, functional capacity, was a biological marker
that served as an objective measure of physical activity and was measured at baseline, 8
weeks, and 18 weeks. To provide evidence of the mediators with which the dance
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intervention produced an increase in lifestyle physical activity and functional capacity,
efficacy expectations, outcome expectations, and social support from family and friends
were measured before and after the intervention was applied (baseline, 8 weeks, and 18
weeks). Baseline body fat, age, co-morbidity, and SES were also assessed and treated as
potential covariates in data analyses that examine the effect of the culturally-specific
dance intervention at 8 weeks and 18 weeks. The dance intervention was implemented
twice a week for 8 weeks at the church. Studies of dance interventions two-three times
per week for 4 to 16 weeks yielded evidence of physical activity adoption by
improvements in lifestyle physical activity (Noreau et al., 1995) and functional capacity
(Hopkins et al., 1990). In this study, the physical activity maintenance of the dance
intervention was measured at 18 weeks. This time frame was selected since the
maintaining effects of a dance intervention to increase lifestyle physical activity
(Andersen et al., 1999) and increase functional capacity (Gillett et al., 1996) were
documented as long as 16 to 24 weeks. Unfortunately, none of these studies included
African American women. Thus, this study provided empirical data of the effects of a
culturally-specific dance intervention on the dependent variables at 8 weeks and 18
weeks in African American women, age 40 years and older.
Setting
The settings consisted of two African American churches located in Cleveland, Ohio
neighborhoods (Appendix A). The churches matched on important characteristics such
as: membership (500+ members), ethnicity (100% African American), SES, number of
women age 40 years and older, values, health beliefs, community interests, and having
served the community for approximately 40 to 50 years.

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Entering the African American Communities
Churches can provide low cost, convenient, and community-oriented heath promotion
programs to improve health, well-being, spirituality, physical function, and independence
among its members (Ransdell, 1995). Entry into the African American churches required
careful planning that focused on being culturally relevant, respectful of their beliefs and
values, and forming a community partnership between the churches and the school of
nursing. An important component of the community partnership was a shared
understanding of the importance of the research in addressing health issues that the
African American women experienced in their daily lives. This community partnership
was also an effective way to promote a culturally-specific dance intervention to reach the
African American women in the comfort of their own familiar and safe environment.
Moreover, the culturally-specific dance intervention focused on a holistic approach to
health promotion by including the relationship between physical, psychological, and
spiritual health.
Entry began with making telephone calls and sending letters of intent to local African
American churches that explained the research study. Several telephone conversations
with the church secretary led to an appointment with the minister and important members
of each church. The principal investigator and faculty member worked together to assure
that the approach was respectful of the members and the community, and would involve
the leaders of the church in a meaningful manner. The two of them briefly described the
purpose and the anticipated outcomes of the research study in lay terms and in familiar
language. Time was designated for questions and concerns and all questions were
answered openly and honestly. It was of paramount importance that the ministers, the
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secretaries, and others in the church administration clearly understood the intent of the
study and exactly what the potential participants would be asked to do, once they agreed
to participate. Also, an overview packet, consisting of two pages of a brief description
and a copy of all the research instruments, was given to the ministers and others who
attended the meetings. The experimental church owns and operates a medical health
center located across the street from the church that is affiliated with University Hospitals
of Cleveland. The primary care physician of the medical health center was included in
the discussion of the research study and was also given a copy of the overview packet.
The principal investigator and the faculty advisor met with the primary physician, met the
nurses, and other staff at the center. The physician understood the importance of the
research study; she offered to serve as the primary healthcare provider for any woman
from both churches who did not have a primary physician but wished to participate in the
study. After several meetings, it became clear to the ministers and other important
church leaders that the primary purpose of the research study was to encourage the
women to be more physically active thereby increasing their strength and endurance to
perform their daily routines in their homes and community, not on disease prevention.
The ministers, church leaders, and the primary physician are aware that hypertension,
heart disease, and diabetes are rampant in the African American community. Too often
these health conditions are explained in morbidity and mortality statistics, from credible
healthcare members and research institutions, with little attention paid to quality of life or
daily life experiences of the members of the congregation. By highlighting the culturally-
specific dance intervention as a way of integrating physical, mental, and spiritual health
of the women, each minister and other church officials understood the cultural relevance
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of the study and fully supported it in both verbal and written forms. Both of the ministers
identified a respected woman from their congregation as a liaison between the research
team and the women of the church. Many meetings, telephone conversations, and emails
between the liaison women and the principal investigator helped to enhance the level of
understanding among all parties involved, and helped to create a facilitating environment
within which the research could occur.
Sample
A convenience sample of 126 African American women who met the study criteria
were selected based on: (1) 40 years of age and older, due to the documented negative
effects of sedentary behavior and increased body fat in African American women
beginning in their early 40’s (Banks-Wallace & Conn, 2002), (2) ability to speak and read
English, (3) membership in the church, (4) having written medical clearance from their
physician/healthcare provider to participate in the study, and (5) having signed the
written informed consent form. Exclusion criteria included those women who were
confined to a wheelchair. This was an important exclusion because the dance
intervention required predominately the large muscle groups of the legs for the
movements and the dependent variables measured the large muscle groups of the legs.
Power Analysis
A meta-analysis of longitudinal intervention studies, ranging from 4 weeks to 6
months, to increase lifestyle physical activity among adults of various ages, various
intensities, and various types of programs indicated an overall effect size (ES) range of
.26 to .58 (Conn, Valentine, & Cooper, 2002). Higher ES were found in moderate
intensity interventions (.58), community based (.47), supervised (.44), and group
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interventions (.37) studies. However, the dance intervention was hypothesized to
improve lifestyle physical activity and functional capacity when controlling for baseline
covariates of body fat, age, co-morbidity, and SES. The dance intervention was expected
to have little effect on the covariates that could not be changed but may be important
predictors of lifestyle physical activity and functional capacity in sedentary African
American women, ages 40 years and older. Therefore, power analysis using hierarchical
regression was conducted. Based on the innovation of the proposed study, a power of .90
was chosen to protect against a Type II error. Type II error was more important since
the use of dance as an intervention is relatively unexplored in the African American
population and the intervention is not lethal or harmful. Using a power of .90, alpha of
.05, and a medium effect size of .15, and 8 predictors, yielded a sample of 136
participants, or 68 per group (Faul & Erdfelder, 1992). Based on other physical activity
studies that involve African American women (Prohaska, Peters et al., 2000; Psaty et al.,
1994; Wierenga & Wuethrich, 1995), a 15% attrition rate was calculated into the needed
study sample size, thus, a sample of 156 participants, or 78 women per group was needed
to maintain power. However, only 126 participants (66 in the experimental group and 60
in the comparison group) volunteered for the study resulting in an observed power of .97
and a medium effect size of .14.
Sampling Procedure
To reduce contamination across study groups, diffusion of treatment was prevented as
the churches were randomized to either the experimental church or the comparison
church. The research team consisted of five members: the investigator, three African
American undergraduate nursing students from Case Western Reserve University, one
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African American Exercise Physiologist, and one African American registered nurse.
Research team members attended the Sunday morning worship services during the
recruitment period and the principal investigator continued to attend Sunday morning
worship services during the 8 week intervention period to enhance communication
between and among them and the African American women.
Recruitment Procedure
The investigator met with the ministers of both churches, discussed the purpose of the
research and the specific activities that were involved, and received permission to
conduct the study. The ministers were informed that a blind draw would determine
which church would be the experimental church and receive the intervention or be the
comparison church and receive the intervention after the 18-week study was finished.
Each minister received an outline of the research activities that would occur at his
respective church. A respected woman from each congregation, chosen by her minister
to serve as a liaison, delivered a public announcement during Sunday church service that
provided a verbal description of the study and its benefits and risks. The announcement
of the research study and the culturally-specific dance intervention was explained in lay
language and clearly stated that participation was voluntary, and that there was no cost to
the participants, regardless of study group assignment. It was stressed that their church
would either be assigned to the experimental group and receive the culturally-specific
dance intervention or the comparison group and dance after 18 weeks. It was pointed out
that the culturally-specific dance intervention would be held twice a week for 8 weeks at
their church around other church related activities. The respected female liaison from the
church congregation carefully explained that assignment to the comparison group meant
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that they would continue doing their normal daily routines. The public announcement
occurred every Sunday morning at each church one month prior to the beginning of the
study. In addition, the research study was advertised weekly in the church bulletin for the
experimental church (Appendix B) and the comparison church (Appendix C). The
research team was introduced to both congregations. However, the introduction for each
church was different. At one church, the minister asked the research team to come to the
pulpit and he introduced the team members and the research to the congregation. This
was a great honor for the research team as it is a privilege to be invited to the pulpit in the
African American church. At the other church, the minister repeated the announcement
of the study from the pulpit and encouraged the women to seriously consider signing up
for the study. During the recruitment period, research team members attended the
church services and were available for approximately one hour after each Sunday
morning church service at the information display table in the vestibule of the church.
This enabled the researchers to discuss the study, answer questions about the study, and
recruit the women. Questions and concerns about the research study or the health related
information were welcomed from the women and their family members. Women who
verbalized interest in the study and met the inclusion criteria were recruited from each
church. Furthermore, attending the church services enabled the principal investigator, the
ministers, the church leaders, and the women to become familiar with one another and
develop a relationship over the course of this study. This relationship helped the
principal investigator to form a mutual trust that led to discussions about health related
issues and physical activity among the women, and a better understanding of the African
American community.
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Experimental Protocol
An experienced African American female dance instructor (Appendix D) led each
dance session, twice a week for 8 weeks, for a total of 16 sessions. Each dance session
lasted for 45 minutes and included a 5-minute warm-up period, 30-minute dance
segment, and 10-minute cool-down period. The dance protocol consisted of simple
culturally-specific dance steps that were easy to learn and master (Appendix E). The
dance routines were choreographed to gospel music, as it was considered positive,
uplifting, and acceptable in a church setting. The gospel songs included: “Presence of the
Lord”, “Glorious”, “Free”, “Let’s Dance”, “You Don’t Know”, “Hosanna”, “Brighter
Day”, and “I Worship You.” The same gospel music and dance routines were used in
each dance session. Achieving mastery of the simple dance steps was viewed as a source
of enhancing efficacy and outcome expectations for increasing physical activity. This
study utilized self-limiting progressive intensity, meaning each participant increased her
intensity based on her own desires and limitations. Many dance steps were modified to
increase intensity for those who elected to “pick up the pace”, or at a lower intensity for
those with physical limitations, such as pain, arthritis, or hip/knee discomfort. The
progression of intensity is based on the overload principle, which is the adaptation in
metabolic and physiologic systems in the body by progressively working at intensities
above normal levels based on each individual’s physical condition (McArdle, Katch, &
Katch, 2000). The self-limiting progressive intensity is especially important in unfit,
overweight individuals, especially women (Gillett & Eisenman, 1987). In general, the
self-limiting progressive intensity of the dance sessions occurred in 2-week increments.
For the first two weeks, the intensity was low as the participants were initiated to the
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basic movements and began to learn the choreography of each dance routine. As the
participants became more familiar with each dance routine, they increased the intensity
from low to moderate by week 3 and 4. Finally, most participants increased their
intensity from low to moderate by week 5 and 6 and many participants remained
moderate for week 7 and 8 as they did not stop and rest during the dance routines or
between songs. Those who did stop between songs stopped for a few moments to
rehydrate themselves and then they resumed dancing. Dance sessions were held in the
fellowship hall of the church to comfortably accommodate the dance participants. At the
end of the 8-week culturally-specific dance intervention, the participants received a free
video of the dance routines to enable them to continue to receive the benefits of dancing.
Comparison Group Protocol
The comparison group continued their normal daily activities and routines and
received health information mailings about African American women: (1) heart disease at
2 weeks, (2) obesity at 6 weeks; (3) type 2 diabetes at 10 weeks; (4) and hypertension at
14 weeks during the study. The research team members attended Sunday morning church
services during the 8-week and 18-week data collection periods. After the 18-week data
collection period, they received a free dance video and they were invited to participate in
the 8-week culturally-specific dance intervention at their church.
Procedures for Data Collection for all Study Participants
The research team members and the participants completed three face-to-face
interviews held in a private area of their own church. All three interviews were
scheduled at the convenience of each participant. During each of the three face-to-face
interviews, participants had the option of having the measures read aloud to them
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question by question or they completed the measures without assistance from the research
team members. Regardless, one research team member remained with the woman in a
private area of the church until the measure was completed. For all three interviews,
participants wore appropriate clothing and shoes that helped to assure measures of
functional capacity and body fat.
Recruitment Period
Recruitment began during the month prior to implementation of the study at the
participant’s own church. The study began when the research team members provided
the participants with a verbal description of the study and its benefits and risks. After the
women verbalized their interest to participate in the study, a research team member read
the informed consent to the women and asked them to follow along. Signing the
informed consent constituted participation in the study and all participants obtained
written medical clearance from their physician/healthcare provider prior to beginning the
study. If a woman did not receive clearance from her physician/healthcare provider, she
was not included in the study. Only three were excluded (1 from the experimental church
and 2 from the comparison church) because they did not have a physician/healthcare
provider. Once the informed consent form was signed, a research team member
scheduled the first face-to-face interview at the participant’s convenience.
First Face-to-Face Interview
During the first face-to-face interview, a member of the research team collected
baseline data about demographics, body fat, and co-morbidity (Appendix F), lifestyle
physical activity (Appendix G), efficacy expectations and outcome expectations for
exercise (Appendix H & I), social support for exercise (Appendix J), and functional
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capacity (Appendix K) on all participants. The principal investigator trained the research
team members about the procedures, instruments, and interrater reliability according to
protocol (Appendix L). This interview took approximately 45 minutes. Within two
weeks following the baseline data collection, participants in the intervention group began
the 8-week culturally-specific dance intervention. Participants in the comparison group
continued their normal daily activities and routines during the course of the 18-week
study.
Second Face-to-Face Interview
For the women in the experimental group, the second face-to-face interview began
approximately one week after completing the 8-week dance intervention. For the women
in the comparison group, a member of the research team contacted them by telephone to
schedule an appointment 8 weeks after the baseline data collection. During this face-to-
face interview, data were collected on measures of lifestyle physical activity, efficacy
expectations and outcome expectations for exercise, social support for exercise, and
functional capacity for both groups. Only the experimental group completed the
culturally-specific dance intervention section of the evaluation form (Appendix M). The
interview was about 40 minutes in length and completed by research team members
trained in the study protocol (Appendix L).
Third Face-to-Face Interview
The third and final face-to-face interview began at 18 weeks for both groups. Again,
research team members collected data on measures of lifestyle physical activity, efficacy
expectations and outcome expectations for exercise, social support for exercise, and
functional capacity. Only the comparison group completed the health information section
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of the culturally-specific dance intervention evaluation form (Appendix N). The
interview lasted 40 minutes and research team members followed the same protocol
during data collection at baseline and at 8 weeks.
Strategies to Prevent Attrition
To reduce attrition over the course of the study, participants were given $10 at each of
the three measurement points: baseline, 8 weeks, and 18 weeks for a total of $30 per
participant. All participants were given the phone number to the investigator’s research
office and were encouraged to telephone the office at any time if there were any concerns
or questions regarding this study. Very few calls were made by the participants to the
research office and usually pertained to refreshing their memories of the time of the
dance classes. The participants mainly chose to talk with the research team members after
church or before/after dance class, and most of the concerns were about missing classes
due to certain life situations.
Study Variables and their Measurement
Independent Variable
Culturally-specific Dance Intervention
The culturally-specific dance intervention was held twice a week to encourage
participation among a sedentary population that tends to have a high rate of comorbidity
and functional limitations. Furthermore, dance interventions held twice a week
demonstrated high attendance (Moffet et al., 2000), improved functional capacity
(Perlman et al., 1990), reduced body fat (Shimamoto et al., 1998), and no significant
increase in joint pain (Noreau et al., 1995; Perlman et al., 1990). The intervention is not
proposed to improve maximal aerobic capacity or other measures of aerobic fitness that
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are typically seen from physical activity interventions held three to five times per week.
The culturally-specific dance intervention was of moderate intensity, choreographed to
have one foot in contact with the floor at all times, and involved repetitive movement of
the legs and trunk and intermittent movement of the arms. Movement of the legs
included: extension, flexion, abduction, adduction, and rotation of the leg and foot to
perform forward, backward, and side stepping movements. Other leg movements
included placing one foot to the front, side, and behind the other foot, heel rises, and
forward and side lunges.
Safety Monitoring of Dance Sessions
Before the research began, the principal investigator conducted a training session with
all members of the research team. The training included the early identification of
symptoms of physical activity intolerance (shortness of breath, fatigue, lightheadedness,
and general muscle weakness that may happen during the dance session) and basic first
aid care. Research team members were on site during all dance sessions and a first aid kit
was available for each dance session. As a component of the training, all members of the
research team become familiar with the local community and knew the locations of the
nearest urgent care facilities and emergency rooms. Research team members had cell
phones for immediate access to 911 or other medical support services that might have
been needed at the church.
Participants assigned to the culturally-specific dance intervention group were
informed of the potential risk of injury such as muscle strains, sprains, and other
musculoskeletal injuries. Prior to beginning the study, each participant had received
written medical clearance from her physician/healthcare provider to participate in the

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study that ensured her capabilities of dancing safely. A 5-minute warm-up period before
each dance session and a 10-minute cool-down period after each dance session was led
by the dance instructor to reduce the chance of muscle strains, joint pain, or other
musculoskeletal injuries. The participants were informed of the importance of not
pushing themselves beyond their own limitations and not competing with others. Some
dance steps and routines required more coordination and balance than others, therefore, it
was very important for each participant to recognize her own limitation and adjust
accordingly. For example, they were told that if they could not sing along to the music
without stopping to catch their breath, they were dancing “too hard.” The dance
instructor was skilled at making subtle modifications and adjustments of dance steps and
routines for participants with reduced mobility or limitations to ensure safety. She
encouraged the participants to adjust the dance steps and routines according to their own
limitations to reduce the incidence of injuries and joint pain. They were shown how to
modify the dance step and were allowed to stop and rest if needed. Allowing the
participants to warm up, cool down, and adjust to their own limitations resulted in no
reported injuries or reported increase in joint pain.
Evaluating Dance Sessions
Attendance was recorded at each dance session by the principal investigator. It was
stressed to the participants that attending at least 12 of 16 dance sessions was needed to
evaluate the desired outcomes. Participants who attended 78-85% of dance sessions
showed improved oxygen uptake (Garber, McKinney, & Carleton, 1992; Gillett et al.,
1996), improved balance and locomotion/agility (Shigematsu et al., 2002) and decrease in
body fat (Gillett et al., 1996). The sum of the number of dance sessions performed
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during the study period was used to assess the observed dose effect of the culturally-
specific dance intervention.
Dependent Variables
The instrument that assessed lifestyle physical activity considered the gender and
cultural factors of the target population. The Physical Activity Scale for the Elderly
(PASE) was selected for its culturally appropriate assessment of lifestyle physical activity
in African American women. The PASE’s conceptualization of physical activity
included the leisure, household, occupational, and volunteer activities common in African
American women ages 40 and over. This instrument measured lifestyle physical activity
of African American women in their natural settings as they participated in the
responsibilities of caring for themselves, family, and home.
Physical Activity Scale for the Elderly (PASE)
The PASE was developed to measure physical activity over a 7-day time period in
adult populations to assess the effectiveness of physical activity interventions (Washburn,
Smith, Jette, & Janney, 1993). This instrument was a 10-item questionnaire that was
brief, easily scored, and administered in person (Washburn et al., 1993). Frequency of
leisure activity participation was assessed by how often the participant engaged in the
activity over the past week. Responses were recorded using a 4-point scale of 0= never,
1=seldom (1-2 days/week), 2=sometimes (3-4 days/week), and 5= often (5-7 days/week).
Duration was assessed by the recorded amount of time spent on the activity in the past
week. Responses were categorized on a 4-point scale of 1= less than 1 hour, 2= 1-2
hours, 3= 2-4 hours, and 4= more than 4 hours. Household activities (indoor, outdoor,
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and caring for others) were recorded as 1=no and 2= yes responses. However, this
instrument did not assess the frequency and duration of household activities.
Occupational activities indicated work for pay or volunteer (1=no, 2=yes). Occupation
included sitting, standing, and walking. Average daily frequency was computed by
dividing the number of hours worked in the past week by 7. The total PASE score was
computed by multiplying the amount of time spent in each activity (hours/week) by the
item weights and summed to provide an estimate of each woman’s physical activity level.
Higher scores indicate greater physical activity.
Reliability and Validity of PASE
Construct validity was established as PASE scores were positively associated with
grip strength (r=.37), static balance (r=.33), leg strength (r=.25), and negatively
associated with resting heart rate (r= -.13), age (r= -.34), perceived health status
(r= -.34), and overall Sickness Impact Profile score (r= -.42). Test-retest reliability
assessed over a 3-7 week period was .75 (95% CI=.69 to .80). Internal consistency
measured by Cronbach’s alpha was .69 (Washburn et al., 1993). Also, PASE scores were
positively significantly associated with peak oxygen uptake (r=.20) and balance scores
(r=.20) and negatively associated with systolic blood pressure (r= -.18) in a sample of
190 sedentary older adults (134 women and 56 men), mean age 66 years (Washburn,
McAuley, Katula, Mihalko, & Boileau, 1999). Thus, PASE scores were a reliable
measure of physical activity and were sensitive to changes in physical activity behavior.
For this study, Cronbach’s alpha was .79.
By definition, physical activity requires energy expenditure so PASE scores needed to
be compared to measures that assess energy expenditure. One measure is the doubly
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labeled water (DLW) method, which the subject ingests DLW and urine samples are
analyzed with an isotope ration mass spectrometry to assess energy expenditure
(Westerterp, Wouters, & Marken Lichtenbelt, 1995). A comparison of PASE scores with
energy expenditure was measured with doubly labeled water over a 2-week period in a
sample of 21 older adults, mean age 70 years (Schuit, Schouten, Westerterp, & Saris,
1997). The correlation coefficient was significant between PASE scores and total energy
expenditure as the dependent variable and resting metabolic rate as the independent
variable (r=.58, 95% CI = .51 to .81). Another measure of physical activity is an
accelerometer, which is an objective method used to measure activity in the lateral,
horizontal, and vertical planes. It is able to distinguish differences in activity levels
between individuals and to assess the effect of interventions on physical activity within
individuals (Tryon & Williams, 1996). One study compared PASE scores with physical
activity measured over a 3-day period using an accelerometer in 18 healthy adults (18
women and 3 men), mean age 73 years (Washburn & Ficker, 1999). The PASE scores
were significantly correlated with the average 3-day accelerometer readings (r=.49:
p<.05). Both studies indicated that PASE scores correctly measure the concept of
physical activity in community dwelling adults.
PASE and Functional Capacity
Only two studies were found that significantly correlated PASE scores with functional
capacity and physical functioning in community dwelling adults. The 6-minute walk test
measured functional capacity and physical functioning included walking, bending, and
climbing stairs. In one study, PASE scores demonstrated a significant relationship
between the 6-minute walk test (r=.68; p<.001) and physical functioning (r=.30; p<.001)
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in 87 community dwelling adults, mean age 75 years (Harada, Chiu, King, & Stewart,
2001). This sample consisted of 5% African Americans but no gender breakdown by
ethnicity was reported. In another study, PASE scores correlated significantly with the 6-
minute walk test (r=.35; p<.001) and physical functioning (r=.35; p<.001) in a sample of
471 participants (240 women and 231 men, mean age 71 years (Martin et al., 1999).
In summary, the instrument that measured physical activity was sensitive to gender and
cultural aspects of the target population. The PASE included measurements of leisure,
household, and occupational activities common in African American women ages 40 and
over. Even though it has not been empirically tested in a large number of African
American women, it did appear to be an accurate measure of physical activity in
community dwelling African American adults. The study assessed the lifestyle physical
activity in African American women who did and did not participate in a culturally-
specific dance intervention. The PASE scores provided scientific data and served as a
culturally-specific measure of physical activity in African American women.
Functional Capacity
6-Minute Work Test
Functional capacity was a biological marker of physical activity and was assessed
with the 6-minute work test (6MworkT). This was a convenient, inexpensive, and non-
invasive test that incorporated body weight into the more traditional 6-minute walk test to
assess functional capacity. It was easily administered and provided reliable and practical
measures of functional capacity (Carter, Holiday, Stocks, Grothues, & Tiep, 2003). The
test consisted of asking the participants to walk as far as possible around a pre-measured
area of their church at their own pace for 6 minutes. They were informed that they could
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rest if necessary. The distance walked was measured for each participant and multiplied
by her body weight in kilograms. Thus, the 6MworkT is a product of distance x body
weight and has been found to be highly correlated with laboratory measures of oxygen
uptake during exercise and is considered a recent improvement of the 6 minute walk test
(Carter, Holiday, Nwasuruba et al., 2003). The 6MWorkT was conducted at each
participant’s respective church for all three data collection periods.
Origin of the 6-Minute Work Test
The first walking test was developed to assess functional capacity and disability in
chronic obstructive pulmonary disease (COPD) patients who were unable to complete
conventional, maximal treadmill or cycle ergometer tests (McGavin, Gupta, & McHardy,
1976). It was originally designed to measure only the distance walked in 12 minutes and
did not take into account body weight. It was eventually decreased to 6 minutes based on
the correlation of 6-minute to 12-minute walking distances (r= 0.96) in COPD patients
(Butland, Pang, & Gross, 1982). The 6MWT was more efficient and corresponded more
closely to daily activities in mildly congestive heart failure patients (Faggiano, D'Alonia,
Gualeni, Lavatelli, & Giordano, 1997) and advanced congestive heart failure patients
(Cahalin, Mathier, Semigran, Dec, & DiSalvo, 1996) than cycle ergometry tests. As a
result, the 6MWT was a reliable measure of functional capacity in individuals with
compromised health status who could not tolerate conventional exercise testing methods
(Solway, Brooks, Lacasse, & Thomas, 2001).
Although the 6MWT was practical and useful, it had limitations. The 6MWT was
intended to account for energy expenditure which is work (W) =force (F) x distance (D);
however, only distance was measured and body weight was not factored into the
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equation. The 6MworkT is an improvement of the 6-minute walk test (6MWT) as it
takes into account both the distance walked and body weight. The distance covered in a
given time period is influenced by stride length and efficiency of walking, while body
weight affects the work/energy required to walk. Because there are known differences
between all individuals with respect to height and body weight, both factors need to be
included in the equation (Carter, Holiday, Nwasuruba et al., 2003). Thus, the 6MworkT
mimics the work of walking better than the 6MWT and can be used for evaluating
functional capacity for those with severe physical impairments (Chuang, Lin, &
Wasserman, 2001) to those who are not physically fit (Enright & Sherill, 1998). The
6MworkT has recently been empirically tested only in individuals with chronic
obstructive pulmonary disease (COPD) (Carter, Holiday, Nwasuruba et al., 2003; Carter,
Holiday, Stocks et al., 2003).
Functional Capacity in Community Populations
Assessment of functional capacity has gained importance in community dwelling
populations since a score can be obtained for those who walk only a few feet or hundreds
of feet. No studies were found that validated the 6MworkT among community dwelling
populations. Only a few studies used the 6MWT to assess functional capacity in
individuals residing in their communities. Studies noted a moderate to high correlation of
the 6MWT to maximal oxygen uptake (r=0.76; p<.05) (Stillwell, Forman, McElwain,
Simpson, & Garber, 1996) and exercise intensity that corresponded to 79.6% of VO2
max, 85.8% of heart rate max, and 78% of heart rate reserve (Kervio, Carre, & Ville,
2003). There was also a significant correlation between VO2 max and both
anthropometric values (age, weight, height) and 6MWT parameters (r = .97, P<0.01).
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Thus, the 6MWT is a submaximal test with empirical support as a reliable measure of
functional capacity in community dwelling populations. However, when it was
implemented in community dwelling populations, these studies included few African
Americans.
Mediating Variables
The mediating variables were measured using the following instruments, which are all
grounded in Social Cognitive Theory. They measured the concept of physical activity,
even though “exercise” is in the title of each instrument (Resnick & Jenkins, 2000).
Efficacy Expectations for Exercise
Efficacy expectations was measured using the Self-Efficacy for Exercise (SEE) scale
(Resnick & Jenkins, 2000). This self-report measure consisted of 9 items to which
participants responded on a 10-point Likert scale from “Not confident” (1) to “Very
confident” (10). The scale was scored by summing the numerical ratings for each
response and dividing by the number of responses. Higher scores indicate stronger
efficacy expectations for exercise. Resnick and Jenkins’ (2000) psychometric testing of
the SEE indicated an internal reliability alpha coefficient of .92. Criterion-related
validity has been established using structural equation modeling to estimate the
correlation between self-efficacy for exercise and each item. The Lambda X estimates
between the variables ranged from .61 to .87 (Resnick & Jenkins, 2000). For this study,
Cronbach’s alpha was .91.
Outcome Expectations for Exercise
Outcome expectations was measured using the Outcome Expectations for Exercise
(OEE) scale (Resnick, Zimmerman, Orwig, Furstenber, & Magaziner, 2000). The OEE
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was a 9-item instrument that measured the perceived consequences of exercise. Five
items assessed the physical benefits of exercise and four items assessed the mental health
benefits. Participants indicated their level of agreement on a five-point Likert scale
ranging from “Strongly disagree” (1) to “Strongly agree” (5). The items were summed
and the total score was divided by the number of responses. Higher scores indicate
strong outcome expectations for exercise. Construct validity has been established with a
strong correlation between self-efficacy expectations and outcome expectations (r=.66)
(Resnick, et al., 2000). Criterion-related validity was significantly related to exercise
behavior (Beta= .31), physical health (Beta=.27), and self-efficacy expectations
(Beta=.17). Alpha coefficient of .89 showed good internal consistency (Resnick,
Zimmerman et al., 2000). For this study, Cronbach’s alpha was .95.
Social Support for Exercise
Social support for exercise was measured using the Social Support for Exercise Scale
(SSES) (Sallis et al., 1987). This 10-item instrument measured support from family and
friends separately on a five-point Likert scale from 1 (none) to 5 (very often). A score
was summed separately for family support and friends support with a range of scores
from 1 to 5. Higher scores indicate strong support for exercise and lower scores indicate
weak support for exercise. Validity was based on statistically significant relationships
between the social support scale and exercise behavior. Construct validity was
established by correlating efficacy factors with support for vigorous exercise and were
significantly correlated with friend support for exercising together (r= .46) and family
support of participation and involvement in exercise (r= .35). Alpha coefficients ranged
from .61 to .91 and test-retest reliabilities were .55 to .86. This instrument demonstrated
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good internal consistency among community dwelling predominately Caucasian women
with alpha coefficients of .89 (family support) and .95 (friend support) (Speck & Looney,
2001). For this study, Cronbach’s alpha was .93 for family support and .95 for friend
support.
Covariates
Body fat was measured using a segmental bioelectrical impedance analyzer (BIA), a
non-invasive method of estimating body composition. The arm-to-arm analyzer is
comparable to hydrostatic weighing and has high validity coefficients for women (r=.83)
(Gibson, Heyward, & Mermier, 2000). Criterion measures of free-fat mass (FFM) and
percentage of body fat was based on the Siri equation, predicting percentage of body fat
from body density (Houtkooper, Lohman, Going, & Howell, 2003). Studies evaluating
the short and long-term reliability of BIA indicate high reliability (Lohman, 1992). In
validation studies using BIA to predict FFM, the amount of change ranged from .73 to
.98 and has been shown to have an uncertainty of 2-4% for prediction of total body
weight and FFM (Kushner, Gudivaka, & Schoeller, 2003). Age and SES were assessed
by self-report during the interview (Appendix D). Co-morbidity was the presence of
concurrent or multiple health conditions within an individual. It was collected by self-
report (Appendix D) and measured by a weighted sum of co-morbid conditions to
calculate a score using the Charlson Scale (Charlson, Pompei, Alex, & MacKenzie,
1987). The sum of co-morbid conditions mirrored the functional burden of illness
conditions. The Charlson Scale has demonstrated a significant relationship between
comorbidity and survival in both Caucasian and African American women with breast
cancer (West, Satariano, Ragland, & Hiatt, 1996).

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Data Management and Analysis
All data obtained from the instruments and measures were examined for completeness
prior to entry into the SPSS database. Intent-to-treat analysis was used, as all
participants’ data were used regardless of attendance at dance classes. Missing data were
imputed using the mean value of the item from the appropriate instrument and missing
data from the PASE was analyzed as no activity. Before proceeding with any statistical
test, we assessed the extent to which the assumptions underlying that particular statistical
test were met. In particular, regarding the assumption of independence of errors, the
Durbin Watson statistic was run at pre-test for each statistical test. Because the proposed
study used a quasi-experimental design, the intervention and comparison groups were
compared on all baseline measures to evaluate equivalence for descriptive and
interpretive purposes.
Protection of Human Subjects
The proposed study involved the participation of 126 sedentary African American
women who were members of two different churches, located about 5 miles apart, but in
the same community. Human Subjects Approval was obtained from University Hospitals
of Cleveland Institutional Review Board (IRB). African American women were recruited
from their church after a one-month recruitment period that consisted of the members of
the research team: attending church, being available at the display table in the vestibule,
and placing announcements weekly in the church bulletin. During the recruitment phase
of the study, the research team was also available to answer any questions or concerns
that the women or their family had about the study.

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All participants were given a verbal explanation of the study that described the
purpose, the degree of their involvement, confidentiality of their information, the benefits
and risks, and the right to withdraw from the study at any time without penalty. They
were informed about how the data collected from this study was to be used. The women
who agreed to participate were asked to sign a written informed consent form that
described the purpose, the degree of their involvement, confidentiality of their
information, and the benefits and risks associated with the study. The consent form
clearly stated that the women had the right to withdraw from the study at any time
without penalty. All participants had on file in the investigator’s office a signed informed
consent before they began participating in this study.
Participants in both groups had three face-to-face structured interviews with the
research team members at baseline, 8 weeks, and 18 weeks. Participants assigned to the
culturally-specific church-based dance intervention group participated in twice a week
dance classes for 8 weeks, for a total of 16 sessions. Each session lasted approximately
45 minutes. Participants in the comparison group received mailings at 2, 6, 10, and 14
weeks for a total of 4 mailings. There was no cost for participating in this study
regardless of study group assignment. To facilitate retention, participants in both groups
were given $10 at the end of each face-to-face data collection period (baseline, 8 weeks,
and 18 weeks), for a total of $30 per participant. A videotape of the dance routines was
given to participants in the intervention group at the end of the 8-week intervention and
to participants of the comparison group after the 18-week data collection period. After
the 18-week data collection period, the comparison group was invited to participate in the
8-week culturally-specific dance intervention at their church. Of those who participated,

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they performed the same dance routines to the same gospel music as the experimental
group.
Conclusion
This chapter described the methodology for the longitudinal intervention study. The
experimental and comparison group protocols as well as the procedures for data
collection, strategies to prevent attrition, and the study variables and their measurement
are addressed. Finally, the conclusion of this chapter discussed data analysis and the
protection of human subjects for the research study.

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Chapter 4
Results
This chapter presents the analyses of data that examined a culturally-specific dance as
a form of physical activity to increase lifestyle physical activity and functional capacity
in African American women. In addition, data were analyzed to determine if efficacy
expectations and outcome expectations for physical activity and social support from
family and friends for physical activity influenced lifestyle physical activity and
functional capacity in African American women, ages 40 years and older. The study was
conducted within two African American church communities.
Sample and Setting
A convenience sample of 126 African American women who attended two African
American churches, met inclusion criteria, and signed a consent form were enrolled in the
study. The participants’ age ranged from 36 to 82 years with no significant difference in
age, Charlson score, body weight in kilograms and pounds, percent body fat, or BMI
between the experimental and the comparison groups (See Table 1). Furthermore, there
was no significant difference in marital status, SES, and education between the two
groups (See Table 2). Both churches had 100% African American worshippers,
membership of greater than 500, and had served their respective community on average
of greater than 60 years.
Data Analysis of Study Questions
Three research questions were tested during the data analysis:
Q1: Does an 8-week culturally-specific church-based dance intervention increase
lifestyle physical activity and functional capacity in sedentary African American women
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from baseline to 8 weeks, and is it maintained at 18 weeks compared to women who do
not receive the intervention?
Repeated measures multivariate analysis of covariance (MANCOVA) assessed the
significance of the change in the dependent variables of lifestyle physical activity and
functional capacity by group, by time, and the interaction of group by time. There were
no significant differences in covariates (See Table 1 and Table 2) but there was a
significant difference in lifestyle physical activity scores at baseline and functional
capacity approached significance at baseline (See Table 3).
Table 1. Comparison of Covariates at Baseline of Experimental Group (n=66) and

Comparison Group (n=60)
Experimental Comparison
Group Group
(n=66) (n=60)
Variables M SD M SD t P
(range)
Age (yrs) 58.05 10.18 59.43 11.9 .71 .48
(36-82 yrs)
Charlson .74 1.15 .95 1.58 .85 .40
(0-7)
Body Weight 83.13 21.86 87.73 17.21 1.30 .20
(kg)
(48.8-146.8)
Body Weight 183.34 47.89 192.95 37.92 1.25 .21
(pounds)
(107-323)
Body fat 41.60 6.67 41.98 5.38 .36 .72
(bia %)
(26.5-60.8)
Body mass 31.75 7.31 32.79 6.11 .86 .39
Index
(bmi kg/m2)
(21-51.7)
Note. **p<.001, * p<.05
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A total of 97 participants (46 intervention group and 51 comparison group) completed
all three data collection time points. Box plots were utilized to examine each dependent
variable over time by group (See Figure 2 and Figure 3). The mean scores for each
Table 2. Comparison of Marital Status at Baseline of Experimental Group (n=66) and

Comparison Group (n=60)
Group Group
(n=66) (n=60)
Variables N (%) N (%) X2 P
Marital
Status
Single 12 (18.2) 16 (26.7)
Married 34 (51.5) 19 (31.7) 10.09 .07
Divorced 16 (24.2) 14 (23.3)
Widowed 4 (6.1) 6 (10)
Separated 0 (0) 2 (3.3)
Other 0 (0) 3 (5)
Note. **p<.001, * p<.05
Table 3. Comparison of Lifestyle Physical Activity and Functional Capacity Scores by

Group for each Time Point.
Group Group
PASE1 179.92 81.48 150.50 84.23 1.99 .05

PASE2 201.53 79.26 160.48 78.94 2.60 .01
PASE3 179.62 69.84 165.65 76.21 .938 .35
Funcap1 40875.33 13016.25 36647.44 10806.71 1.97 .05
Funcap2 42974.63 12869.04 38980.88 12629.80 1.57 .12
Funcap3 47564.48 14906.81 42528.66 11424.11 1.88 .06
PASE1= Lifestyle Physical Activity at baseline; PASE2= Lifestyle Physical Activity at 8
weeks; PASE3=Lifestyle Physical Activity at 18 weeks; Funcap1=6MworkT baseline;
Funcap2=6MworkT at 8 weeks; Funcap3= 6MworkT at 18 weeks
dependent variable is displayed by group and outliers are indicated by circles and
numbers that represent the corresponding case numbers. The star indicated an extreme
outlier but was not an influential data point based on the results of diagnostic testing.
The dependent variables were highly correlated (See Table 4) making repeated measures
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MANCOVA a better statistical choice to reduce the risk of Type I error and maintain
power. Significance of the MANCOVA indicated a difference in at least one of the
dependent variables and Pillai-Bartlett trace was used for explained variance reported as
η2. Prior to statistical analysis of the study question, the assumptions of MANOVA were
met including the assumption of compound symmetry using Mauchly’s test of sphericity.
For a significant MANCOVA, univariate analysis of covariance (ANCOVA) assessed the
difference between groups for each dependent variable using the Bonferroni statistic to
control for Type I error. The overall MANCOVA, reported as Pillai-Bartlett trace,
indicated a significant group main effect (p <.001; F=15.08; η2=.14), a non-significant
time main effect (p=.276; F=1.20; η2=.013), and a non-significant group-by-time
interaction effect (p=.28; F=1.18; η2=.013). However, since the assumption compound
symmetry was met, univariate results were reported as they are more powerful (Green &
Salkind, 2005) and are located in Table 5. The mean scores for lifestyle physical activity
and functional capacity by group for all 3 time points are located in Table 3. Observed
power was .97.
Table 4. Correlation Matrix of Dependent Variables at baseline, 8 weeks, and 18 weeks

Funcap1 Funcap2 Funcap3 PASE1 PASE2
Funcap2 .73**
Funcap3 .48** .88**
PASE1 .26** .30** .30**
PASE2 .17 .18 .20* .36**
PASE3 .04 .06 .13 .52** .54**
Funcap1=6MworkTat baseline; Funcap2= 6MworkT= at 8 weeks; Funcap3= 6MworkT at
18 weeks; PASE1= Lifestyle Physical Activity at baseline; PASE2=Lifestyle Physical
Activity at 8 weeks; PASE3= Lifestyle Physical Activity at 18 weeks
Note. **p<.001, * p<.05
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With a significant group effect, univariate ANCOVA tests were then conducted
separately on each dependent variable controlling for baseline measures of the
corresponding dependent variable. All assumptions for ANCOVA were met and the Box
Test of Equality of Covariance Matrices and the Levene’s Test of Equality of Error
Variances were not statistically significant. The dependent variable of functional
capacity was significant for time at both 8 weeks (p<.001; F=99.86; η2=.52) and 18
Figure 2. Box plot of Means for Functional Capacity for both groups
weeks (p<.001; F=113.59; η2=.55) but not by group at 8 weeks (p=.819; F=.053) or at 18
weeks (p=.395; F=.732).

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The dependent variable of lifestyle physical activity was significant for time at both 8
weeks (p<.001; F=44.26; η2=.32) and at 18 weeks (p<.001; F=32.77; η2=.26) but not by
group at either 8 weeks (p=.114; F=2.54) or at 18 weeks (p=.82; F=.052). The results
indicated that functional capacity and lifestyle physical activity increased significantly at
each time point for both groups but there was no statistical significance between groups.
Figure 3. Box plot for Means of Lifestyle Physical Activity for both groups
Thus, the hypothesis is rejected as an 8-week culturally-specific church-based dance
intervention increased lifestyle physical activity and functional capacity in sedentary
African American women from baseline to 8 weeks and was maintained at 18 weeks by
both groups regardless of study group assignment.

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Table 5. Overall Repeated Measures MANOVA Sphericity Assumed

Source SS df MS F P Eta
squared
Group 1022787470 1 1022787470 15.08 .001 .14
Time 12480367.3 1 12480367.26 1.202 .276 .013
Group x 12232685.1 1 122677727.0 1.183 .280 .013
Time
Error 954898993 92 10379336.89
(time)
However, functional capacity was defined as a component of kg x m. Many of the
participants in the experimental group lost weight as a result of being more active which
negatively impacted their functional capacity scores. When the dependent variable of
functional capacity was changed to distance walked in feet, univariate ANCOVA
revealed significant differences in distance walked in feet over time at 8 weeks (p<.001;
F=74.44; η2=.45) and at 18 weeks (p<.001; F=63.67; η2=.41) and by group at 18 weeks
(p=.043; F=4.20; η2=.04). This indicated that the culturally-specific dance intervention
increased the distance walked in feet in sedentary African American women from
baseline to 8 weeks and was maintained at 18 weeks compared to the women who did not
receive the intervention (See Table 6).
Table 6. Comparison of Distance Walked in Feet by Group for each Time Point.
Group Group
Distanceft1 1647.42 271.68 1373.84 307.18 5.31 **

Distanceft2 1699.05 256.42 1495.31 310.82 3.55 **
Distanceft3 1879.71 308.69 1569.75 290.14 5.10 **
Distanceft1= distance walked in feet at baseline; Distanceft2= Distance walked in feet at
8 weeks; Distance walked in feet at 18 weeks
Note. **p<.001, * p<.05
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Q2: Do efficacy expectations, outcome expectations, and social support mediate the
effects of a culturally-specific church-based dance intervention on lifestyle physical
activity and functional capacity at 8 weeks compared to women who do not receive the
intervention?
Following Baron and Kenny’s (1986) recommendation for testing mediation,
hierarchical linear regression analyses were performed to determine whether the
independent variable (dance) had a significant effect on the dependent variables (lifestyle
physical activity and functional capacity) through the mediating variables (efficacy
expectations, outcome expectations, social support from family and friends). An overall
analysis of the assumptions for multiple regression was performed prior to testing for
mediation. All four assumptions of regression were met: 1) zero mean (mean =0 and
standard deviation of the standardized residuals was .98; 2) residual normality;
3) Independence (Durbin-Watson 1.98); and 4) homoscedasticity. Furthermore, there
were no problems of multicollinearity or influential data points since the one case that
was an outlier had a Cook’s Distance of less than one. Hence, this case was included in
all data analyses.
One hundred one participants (46 intervention group and 55 comparison group)
completed all instruments at 8 weeks. A correlation matrix of the mediating variables by
group is displayed in Table 7. In the first step for mediation, efficacy expectations
(p=.76; F=.09) and social support from family (p=.08; F=3.02) were not significant when
regressed on the independent variable (dance). Therefore, no other tests of mediation
were conducted on these two variables. Outcome expectations (β=.33; p<.001; F=12.40)
and social support from friends (β=.22; p=.02; F=4.08) were significant for the first test
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of mediation when regressed on dance. For the second test of mediation, the dependent
variable of functional capacity (6MworkT at 8 weeks) was regressed on dance and was
not significant for either outcome expectations (β=.16; p=.12; F=2.46) or social support
from friends (β=.16; p=.12; F=2.46). Thus, the third test of mediation was not conducted.
Table 7. Correlation Matrix of Mediating Variables and Dance at Time 2 (N=101).

Group SEE OEE SSfm
SEE -.03
OEE .33** .32**
SSfm .17 -.03 .17
SSfr .22* .06 .26** .28**
SEE=Self-Efficacy; OEE=Outcome Expectations; SSfm=Social Support from Family;
SSfr=Social Support from Friends
Note. **p<.001,* p<.05
For the second test of mediation on lifestyle physical activity at 8 weeks, both
outcome expectations (β=.25; p=.01; F=6.75) and social support from friends (β=.25;
p=.01; F=6.75) were significant. For the third and final test of mediation, lifestyle
physical activity at 8 weeks was regressed on both dance and the mediating variable.
Both outcome expectations (β=.12; p=.02; F=4.08) and social support from friends
(β=.17; p=.01; F=4.99) were significant as noted in Table 8 and Table 9 by a reduction in
beta values in each step and a corresponding significant decrease in the p values in each
step. Observed power of outcome expectations was .88 (1-.12) and .83 (1-.17) for social
support from friends. Therefore, both outcome expectations and social support from
friends mediated the effects of a culturally-specific dance intervention on lifestyle
physical activity in sedentary African American women at 8 weeks compared to women
who did not receive the intervention.

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Table 8. Regression Analyses: Outcome Expectations as a Mediating Variable between

Dance and Lifestyle Physical Activity
Predictors R R2 Adjusted R2 Change F Change β
R2
Regression 1
Dance .33 .11 .10 .11 12.40* .33*
Regression 2
PASE
Dance .25 .06 .05 .06 6.75* .25*
Regression 3
Dance
OEE .28 .08 .06 .01 1.39** .12**
PASE=Lifestyle Physical Activity; OEE=Outcome Expectations

Note. **p<.001, *p<.05
Table 9. Regression Analyses: Social Support from Friends as a Mediating Variable

between Dance and Lifestyle Physical Activity
Predictors R R2 Adjusted R2 Change F Change β
R2
Regression 1
Dance .22 .05 .04 .05 5.24* .22*
Regression 2
PASE .25 .06 .05 .06 6.75** .25**
Dance
Regression 3
Dance
SSfr .30 .09 .07 .03 3.10** .17**
PASE=Lifestyle Physical Activity; SSfr=Social Support from Friends
Note. **p<.001, *p<.05
Q3: Does the increase in lifestyle physical activity and functional capacity at 18 weeks
remain when controlling for baseline body fat, age, co-morbidity, and socioeconomic
status when compared to those who do not receive the intervention?
Hierarchical multiple regression was conducted to determine the differences between
the study groups on each dependent variable at 18 weeks. Prior to conducting the
analysis, an overall analysis of the assumptions for multiple regression was performed.
All four assumptions of regression were met: 1) zero mean (mean =0 and standard
deviation of the standardized residuals was .96; 2) residual normality; 3) Independence

Murrock 104
(Durbin-Watson 1.77); and 4) homoscedasticity. The covariates of baseline body fat,
age, SES, and co-morbidity were added in the first step, the significant mediators of
outcome expectations and social support from friends added in the second step, and group
was added last. Correlation matrix of the dependent variables, mediating variables, and
baseline covariates are in Table 10.
Table 10. Correlation Matrix of Lifestyle Physical Activity, Functional Capacity,

Mediating Variables, and Baseline Covariates
Group Body Age SES Charlson OEE2 SSfr2 Funcap3
fat
Body fat -.02
Age -.06 .15
SES .16 .06 .09
Charlson -.08 -.07 .15 -.17
OEE2 .33** .01 -.09 .11 -.18
SSfr2 .22** .04 -.14 .09 .08 .26**
Funcap3 .19 .45** -.55** .08 -.16 .13 .11
PASE3 .10 -.14 -.34** .05 -.10 .24* .13 .13
SES=Socioeconomic Status; Charlson=Co-morbidity; OEE2=Outcome Expectations at 8
weeks; SSfr2=Social Support from Friends at 8 weeks; Funcap3=6MworkT at 18 weeks;
PASE3=Lifestyle Physical Activity at 18 weeks
Note. **p<.001, *p<.05
The overall equation was significant (p=.02; F=2.60) and the variables explained 11%
of the lifestyle physical activity score at 18 weeks when controlling for covariates and
mediators between groups (see Table 11). Of these variables, only age (β=-.30) was
significant (p=.003). For functional capacity, the overall equation was significant
(p<.001; F=18.23) and the variables explained 56% of the functional capacity score at 18
weeks when controlling for covariates and mediators between groups. Of these variables,
age (β=.-61) and body fat (β=.52) were significant (p<.001, p<.001, respectively) (See
Table 12). Thus, the hypothesis was only partially supported as increased lifestyle
physical activity and functional capacity at 18 weeks remained when controlling for
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baseline body fat, age, SES, and co-morbidity in both groups but there was no significant
difference between groups.
Table 11. Hierarchical Regression Analyses: Change in Lifestyle Physical Activity at 18

weeks when controlling for Covariates and Mediating Variables (n=97).
Variables β Beta
Step 1
Body fat -1.32 -.11
Age -2.12 -.32
SES 1.49 .07
Charlson -3.71 -.07
Step 2
Body fat -1.28 -.10
Age -1.98 -.30**
SES .95 .04
Charlson -2.12 -.04
OEE2 26.16 .18
SSfr2 .25 .04
Step 3
Body fat -1.28 -.10
Age -1.98 -.30**
SES .99 .05
Charlson -2.16 -.04
OEE2 26.49 .19
SSfr2 .26 .04
Dance -1.47 -.01
SES=Socioeconomic Status; OEE2=Outcome Expectations at 8 weeks; SSfr2=Social
Support from Friends at 8 weeks
F=2.60; p=.017, Adjusted R2 =.11 Note. **p<.001, *p<.05
However, when functional capacity was changed to distance walked in feet, the
overall hierarchical regression equation was significant (p<.001; F=11.89) and the
variables explained 45% of the increase in distance walked at 18 weeks when controlling
for covariates and mediators between groups. Of these variables, body fat (β=-.19), age
(β=-.42), and group (β=.35) were significant (p=.02, p<.001, and p<.001, respectively).
Therefore, the distance walked in feet remained when controlling for the covariates and
there was a significant difference in those who received the intervention compared to
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those who did not receive the intervention such that those who completed the intervention
had further distances walked (See Table 13).
Table 12. Hierarchical Regression Analyses: Change in Functional Capacity at 18 weeks

when controlling for Covariates and Mediating Variables (n=97).
Variables β Beta
Step 1
Body fat 1135.86 -.52**
Age -731.32 -.62**
SES 224.18 .06
Charlson -132.40 -.01
Step 2
Body fat 1142.40 -.52**
Age -727.52 -.62**
SES 202.49 .05
Charlson 16.81 .02
OEE2 1882.42 .07
SSfr2 -19.16 -.01
Step 3
Body fat 1139.49 -.52**
Age -718.20 -.61**
SES 109.87 .03
Charlson 104.47 .01
OEE2 1106.14 .04
SSfr2 -38.06 -.03
Dance 3420.25 .13
F=18.23, p<.001, Adjusted R2 =.56 Note. **p<.001, *p<.05
Retention for the Study Sample
The overall retention rate for the entire sample was 77% (97/126). By group, the
experimental group’s retention rate was 70% (46/66) and the comparison group’s
retention rate was 85% (51/60). Twenty participants dropped out of the experimental
group and most were contacted by the principal investigator in person after the church
service or contacted by telephone to identify the reason for dropping out. The majority of
these women had health concerns or pressing family issues, some had changes in their
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Table 13. Hierarchical Regression Analyses: Change in Functional Capacity in Feet

Walked at 18 weeks when controlling for Covariates and Mediating Variables (n=97).
Variables β Beta
Step 1
Body fat -10.49 -.19*
Age -14.07 -.47**
SES 24.15 .25*
Charlson -26.79 -.11
Step 2
Body fat -10.54 -.19*
Age -23.26 -.44**
SES 21.00 .21*
OEE2 103.25 .16
SSfr2 3.06 .11
Step 3
Body fat -10.74 -.19**
Age -12.51 -.42**
SES 14.56 .15
OEE2 49.28 .08
SSfr2 1.75 .06
Dance 237.76 .35**
F=11.89, p<.001, Adjusted R2 =.45 Note. **p<.001, *p<.05
work schedule, and three were lost to follow up. Nine participants dropped out of the
comparison group and almost all of them were contacted by the principal investigator in
person after the church service or contacted by telephone. Five of the participants were
lost to follow up, two had deaths in their families, and two had job changes. The
retention rate for this study was substantially better that other intervention studies
conducted in African American churches with retention rates of 40% (Kumanyika &
Charleston, 1992), 57% (Prohaska, Peters et al., 2000), and 60% (Oexmann et al., 2000).
There are several postulated reasons for a high retention rate. First, the ministers
fully supported the study. Without each minister’s support, the study would have never
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gone forward in either church. Second, the research team members were highly visible
by attending church during the recruitment period and the 8 week dance intervention.
Furthermore, the research team members attended other church related programs that
convened at the church over the course of the study. High visibility made the research
team members approachable and encouraged social interaction between not only the
women in the study, but their family members. This was essential in developing mutual
trust and understanding of the study by the participants and of the participants by the
research team. Third, great effort was taken to schedule the 3 face-to-face interviews for
both groups and the dance intervention around their respective church events, meetings,
Bible study, and choir rehearsals to enhance convenience and attendance. Many of the
participants were highly involved in various groups and committees and spent
approximately 2 to 3 nights per week at their church. Fourth, the dance classes were
conducted by an individual from their own community, an African American woman,
who was well respected and experienced in teaching dance. Finally, the dance instructor
choreographed easy, simple dance steps to popular gospel songs that many of the women
sang along with while they danced. The dance instructor was very positive, energetic,
and engaged the participants during each dance class. Each step was practiced many
times before dancing and this approach helped the participants gain confidence in each
step of each song. The dance instructor also came in early and stayed after each dance
class to help any participant who wanted extra practice. In addition, the dance instructor
had an assistant who provided individual support for those women who need extra
instructions, encouragement, and practice. She was present at every session.

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Attendance
Attendance was recorded at each dance class by the principal investigator. Participants
fell into several attendance categories: never attended (8%), attended 1-6 dance classes
(22.5%), attended 7-11 dance classes (22.5%), or attended 12-16 dance classes (47%).
The sum of the number of dance classes attended by each participant was used to assess
the dose effect of the culturally-specific dance intervention. Prior to beginning the study,
it was postulated that the participants needed to attend 12-16 dances classes in order to
show a dose effect (Garber et al., 1992; Gillett et al., 1996). Forty-six participants
attended 7-16 classes and positive changes were noted in body weight (pounds), body fat,
distance walked in feet, and lifestyle physical activity scores from baseline to 8 weeks
even in those who attended only seven sessions (See Appendix O). For this study,
attending a minimum of 7 classes over the 8-week dance intervention was enough to
show an observed dose effect. A correlation of attendance and body weight, body fat,
distance walked in feet, and lifestyle physical activity scores at 8 weeks are located in
Table 14.
Table 14. Correlation Matrix of Attendance, Body Weight, Body Fat, Distance Walked
in Feet, and Lifestyle Physical Activity Scores at 8 Weeks
Attendance Bodywtt2 Biat2 Distftt2
Bodywtt2 -.21
Biat2 -.32* .75**
Distftt2 .29* -.06 -.23
PASE2 .02 .04 -.11 .21
Bodywtt2=body weight in pounds at 8 weeks; Biat2=body fat at 8 weeks;
Distftt2=Distance in feet at 8 weeks; PASE2=Lifestyle Physical Activity at 8 weeks
Note. **p<.001, *p<.05
This can be explained by the fact that sedentary individuals will show improvements in
physiological outcomes following a physical activity intervention that is relative to the

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length of the training period (Gillett et al., 1996). None of the women reported
participating in any type of dancing on the PASE questionnaire at baseline.
Assessing the Culturally-Specific Dance Intervention
Effective health interventions must be consistent with the shared beliefs, values, and
practices of the target population (USDHHS, 2000b). To assess the culturally-specific
intervention, participants in the experimental group completed a questionnaire (See
Appendix N) during the final face-to-face interview. Overall, the participants agreed that
the dance intervention was culturally-specific by answering yes to: understanding the
importance of church in their life (100%), the importance of spirituality (97.8%), their
values and beliefs (93.5%), dancing with other African American women (97.8%), and
their role as an African American woman (97.8%). Furthermore, the participants felt that
the culturally-specific dance intervention was a positive arena for talking about their
health concerns (100%), helped them feel good about themselves (100%), was taught by
a qualified teacher (100%), and was carried out by research team members who respected
and cared about them (100%).
Conclusion
The results of this study indicated that a culturally-specific dance intervention
increased the distance walked in feet in sedentary African American women from
baseline to 8 weeks and was maintained at 18 weeks compared to the women who do not
receive the intervention. Also, the distance walked in feet remained when controlling for
covariates and there was a significant difference in distance walked in feet in those who
received the intervention compared to those who did not receive the intervention. Both
outcome expectations and social support from friends were mediators of the effects of a
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culturally-specific dance intervention on lifestyle physical activity in sedentary African
American women at 8 weeks compared to women who do not receive the intervention.
Finally, the participants found the dance to be culturally-specific.

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Chapter 5
Discussion
This chapter presents the major findings of the culturally-specific dance as a form of
physical activity to increase lifestyle physical activity and functional capacity in African
American women. In addition, the limitations of the study and implications for nursing
are identified. Finally, this chapter ends with a discussion of recommendations for future
research.
Discussion of Major Findings
Functional Capacity
The first hypothesis was not supported as there was not significant difference in
functional capacity and lifestyle physical activity scores from baseline to 8 weeks and at
18 weeks between those who received the culturally-specific dance intervention and
those who did not. For functional capacity, this could be explained by the fact that body
weight was an influential factor between groups as two people can walk the exact same
distance but have different functional capacity values based on their difference in body
weight. Many of the participants in the experimental group lost weight and the
participants in the comparison group maintained or gained weight which impacted their
functional capacity scores. When functional capacity was analyzed as distance walked in
feet, the experimental group walked significantly farther than the comparison group.
This was supported by previous studies that noted significant changes in functional
capacity after completing a dance program when measuring the distance walked and not
including body weight (Noreau et al., 1995; Perlman et al., 1990). Thus, a timed walking
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test was sensitive enough to detect significant changes in functional capacity in distance
walked after completing a culturally-specific dance intervention.
There are similar advantages in using the distance walked in feet (6MWT) or factoring
in body weight (6MworkT) as a measure of functional capacity. The advantages of both
measures are convenience, low cost, non-invasive, and easy administration. Both
measures are reliable and practical measures of functional capacity in healthy populations
(Carter, Holiday, Stocks et al., 2003) and those with heart and lung disease (Faggiano et
al., 1997) unable to tolerate conventional exercise testing methods. Both have been used
as an outcome measure to determine the effectiveness of an exercise intervention (Harada
et al., 2001). However, there are also disadvantages for each measure. The 6MWT is a
measure of lower body strength and endurance mimicking daily activities, while the
6MworkT includes weight to measure energy expenditure. For this study, weight was a
confounding factor as the outcome of interest was improvement in leg strength after
completing the culturally-specific dance intervention, not energy expenditure. Therefore,
the distance walked in feet would have been the correct measure for assessing functional
capacity.
As for lifestyle physical activity, many participants in the experimental group
commented on increased abilities to perform lifestyle physical activities and other daily
tasks which required strength and endurance. For example, many noted decreased
shortness of breath when they engaged in household tasks such as carrying laundry or
groceries up a flight of stairs. This was supported by two studies that reported improved
ability to perform household tasks in individuals who completed dance programs (Gillett
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et al., 1996; Noreau et al., 1995). Several other participants commented on their
increased ability to play longer with their grandchildren without getting tired.
Furthermore, many participants said they did not get as tired as they remembered in the
past after cooking, serving, and cleaning up after Thanksgiving dinner.
The PASE was selected for its culturally appropriate assessment of lifestyle physical
activity in African American women as it measured leisure, household, occupational, and
volunteer activities of caring for their self, family, and home. Leisure activities increased
in the experimental group from baseline to 8 weeks, but decreased from 8 weeks to 18
weeks. Many of the women continued to dance only one time per week after the
intervention causing a decrease in their computed score for leisure time activities at 18
weeks. The dance intervention was completed around Christmas time and many women
were preparing for the holiday with their families and were not able to continue dancing.
In addition, several women commented that they did not like to drive during the winter
months and would start an exercise program in the spring when the weather was more
cooperative to driving and walking outdoors. This also contributed to lower leisure
scores for the experimental group at 18 weeks. Conversely, the comparison group had
the highest PASE score at 18 weeks, as the data were collected in the spring. Many of
the women were preparing their flower and vegetable gardens or had begun their spring
walking routine. These activities increased their leisure scores. As a result, weather was
an extraneous factor in leisure activities for the women in both groups. In the future,
seasonal changes should be taken into consideration when using the PASE instrument.
Household activities were only recorded as yes/no responses. These activities were
constantly engaged in by both groups of women and did not change over the course of the
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study. This section of the PASE instrument is good for assessing daily activities of
women, but did not take into account how often these activities were performed or the
amount of time engaged in these activities. Many of the women remarked at how much
easier it was to carry laundry up and down steps and do other household chores after
completing several dance classes. Thus, the limitation of this section of the instrument is
that there is no computation of a score on a continuous scale to be able to assess change
over time.
As for the occupational/volunteer subscale, many of the women volunteered
extensively in their church by ushering, teaching Sunday school, teaching after school
programs, and partaking in various committees and organizations. Yet, most of these
women did not count it as time they volunteered. One lady said that ushering was not
volunteering because it was done on the “Lord’s time”, not her time. According to her,
engaging in activities of the church was a way to “thank the Lord for all His blessings”
and any activity outside of the church was considered volunteering. Several women
heard this explanation and agreed with her view. Therefore, the PASE measured
activities the women of the study engaged in but may need to be refined to be more
culturally-specific for these women.
Mediating Variables
The second hypothesis was supported in that outcome expectations and social support
from friends mediated the effect between dance and lifestyle physical activity at 8 weeks
in sedentary African American women. Previous studies reported that outcome
expectations indirectly effected physical activity behaviors (Resnick, 2001a; Resnick,
Palmer et al., 2000) and is an important component of adoption (Prohaska, Walcot-

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McQuiqq et al., 2000) and maintenance (Banks-Wallace & Conn, 2002) of physical
activity in African American women. Outcome expectations are concerned with the long
term consequences of exercise maintenance and are a good predictor of exercise
continuation (Resnick et al., 2001). The women of the study understood the long term
consequences of dancing as they hired the same dance instructor to continue the dance
classes at the church once per week for another 16 weeks. Conversely, efficacy
expectations, the person’s belief in the ability to initiate the behavior, was not a mediator
between dance and lifestyle physical activity at 8 weeks. Many of the women stated that
they would not be able to dance on their own even after receiving the dance DVD/video.
Their gender roles, work obligations, and social demands were not conducive to dancing
in their own home at a convenient time for them. Attending the dance at their church
allowed the dance instructor to initiate the dance classes and enabled them to get away
from their home responsibilities and focus on themselves and their own needs.
Social support from friends also mediated the effect between dance and lifestyle
physical activity in sedentary African American women at 8 weeks. Previous studies
showed that social support from friends was important for physical activity (Felton et al.,
2002; Wilcox et al., 2003) in African American women. Anecdotally, many of the
women had already developed friendships with each other through various functions,
groups, and activities at their church. Others became friends as they got to know one
another during the dance intervention, enjoyed the time spent socializing with each other,
and the focus of the intervention being on them. Some women developed carpools and
made child care arrangements with each other.

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Unfortunately, social support from family was not a mediator. This is in contrast to a
study that found social support from family as more important than social support from
friends in women who participated in a physical activity program (Wilcox et al., 2003).
The social support instrument may not have tapped into the family support received by
some of the women. For instance, many older women did not drive or did not like to
drive in inclement weather. These women relied on family members (sister, daughter,
granddaughter, son, husband, in-laws) for transportation which was not assessed by the
social support instrument. For example, one lady had surgery on her wrist and shoulder
and was unable to drive or dance for 2 weeks. Her husband brought her to the dance
classes just so she could sing, listen to the music, and interact with the other women.
Moreover, another elderly lady relied on her granddaughter for transportation. Her
granddaughter rearranged her work schedule so her grandmother could participate in the
classes. The family component of the Social Support for Exercise instrument measured
participation of a spouse/family member in the dance intervention and this study was not
designed to include a spouse/family member. Therefore, it is reasonable to understand
why the family component was not significant. The Social Support for Exercise
instrument may need to be altered to provide a better picture of the different types of
support the women received and to provide a more culturally specific understanding of
support systems among African American women.
Hierarchical Regression
For the third hypothesis, once again there was no significant difference between
groups on lifestyle physical activity and functional capacity at 18 weeks when controlling
for covariates and significant mediators. Nevertheless, when functional capacity was
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changed to distance walked in feet there was a significant difference between groups. As
stated earlier, body weight was an influencing factor in the calculation of functional
capacity. Even though there was no significant difference in the covariates between
groups at baseline, only age and body fat had relative influence on the dependent
variables at 18 weeks. Age changed by one year but body fat fluctuated with changes in
body weight. As explained earlier, many of the women in the experimental group lost
weight and reduced the body fat at both 8 weeks and 18 weeks. Additionally, the
significant mediators of outcome expectations and social support from friends at 8 weeks
were not influential on the dependent variables at 18 weeks. This may be due to the fact
that some of the women in the experimental group were unable to continue dancing after
the intervention was finished. They also appreciated the camaraderie during the 8 week
intervention that dissipated by the 18 week data collection period. As a result, the
culturally-specific dance intervention resulted in a significant difference in distance
walked and age and body fat had the most relative influence at 18 weeks when compared
to those who did not receive the intervention.
The Women’s Perspective
From the women’s perspective, the results of the study were more personal. Many of
them stated physical and psychological benefits after attending several of the dance
classes. For example, the physical benefits reported were: “I’ve already noticed a
difference in my legs. I went shopping yesterday and I didn’t have to stop and rest like I
usually do”; “I can tell my breath is easier already”; and “I’ve already lost 6 pounds”.
Some of the psychologic benefits noted were: “My friend noticed that I’ve been much
happier at work”, My husband says I’m less irritable since I’ve been coming to these
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classes”; “No matter how bad my day at work is, I know I will feel better after coming
here”; and “These dance classes make my Mondays and Saturdays more pleasant”.
Although not formally measured, spiritual benefits were observed as the women used the
dance routines to the gospel music as a form of worship and praise. One of the women
asked the dance instructor if they could make up a routine to a gospel song the
congregation sang every Sunday. The dance instructor worked with the woman and
together they choreographed a dance routine and called it “The Moss”. Thus, the
physical, psychological, and spiritual benefits of the dance intervention were different for
each woman but important to them as a group.
Health Disparities
The ministers and members of each church were highly interested in being involved in
this study and voiced concerns about other relevant health issues faced by many African
American women and men. With all the health disparities in the African American
community, church-based programs may be an avenue to approach health disparities,
develop culturally-specific interventions, and reach the people in the community who
need it the most. They are aware of the health problems, know they need to address these
health concerns, but may not necessarily know how to do it. This study provides an
example of how to engage the African American community and address certain health
issues that are important to them. As mentioned in Chapter 1, the annual cost of chronic
diseases associated with physical inactivity and obesity related diseases combined is over
$150 billion. The cost of this study was significantly less. Channeling more research
dollars into community-based health promotion and disease prevention interventions

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might be a good start to developing a health policy that addresses health disparities and
the spiraling cost of healthcare.
Limitations of the Study
First, the randomization of the churches, not the participants, limited the
generalization of the results even though the churches were matched on similar
characteristics. Although there were no significant differences between groups in
covariates and demographics, baseline differences of the dependent variables could be
due to lack of participant randomization. Because of the convenience sample, those who
volunteered may have been different from those who did not or could not participate.
Since the participants lived in one city, generalization to other African American women
who attend church may be limited, but still possible with the culturally-specific dance
intervention as the results were because of the intervention and not due to the church
attended. Furthermore, some of the changes associated with lifestyle physical activity
scores could be attributed to changes in the season and weather conditions and not
necessarily due to the culturally-specific dance intervention. For the experimental group,
baseline testing began in the fall and ended in the winter. For the comparison group,
baseline testing began in winter and ended in the spring. Thus, time schedule may have
been a confounding factor. Finally, the issues with body weight and functional capacity
have already been addressed.
Implications for Nursing
For many people, especially women, exercising 3-5 times a week is difficult to
schedule because of social, gender, and family expectations. Getting target populations
to exercise two times per week may be a good starting point as it might be easier to work
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into their schedules and child care arrangements. Furthermore, attending at least 50-65%
of the dance classes may be enough to show an observed dose effect in unfit, overweight,
and obese populations. Nursing interventions should include physical activity of low to
moderate intensity performed on alternate days to decrease the risk of bone and joint
injuries. This approach has been found to be the most effective way to promote
adherence and improved physical outcomes in middle aged, overweight, individuals
(Gillett et al., 1996). The individual should have more input into the progression of
intensity, known as self-limiting progressive intensity, of the physical activity instead of
the entire group being treated as a whole. This self-limiting progressive intensity allows
the participants to choose their intensity and respects their ability to make choices about
their own bodies and health conditions. Also, modifying dance steps incorporates the
needs of those who want greater intensity and those who have physical limitations.
Modification of the nursing intervention must take into consideration gender, age, health
status, body weight and body fat, and ethnicity of the target population. Because there
were no reported injuries during the 8-week intervention, it was concluded that the
culturally-specific dance intervention, including warm-up and cool-down and utilizing
self limiting progressive intensity, was deemed safe and effective for sedentary African
American women ages 40 years and older.
Implications for Nursing Practice
This study provided information about the meaning each African American woman
attributed to physical activity, self-efficacy, social support, and dance within the context
of their lives. Dancing within their own community fostered group cohesion, cultural
transmission through movement to gospel music, and social connectedness. The

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culturally-specific dance encouraged auditory stimulation, emotional, and spiritual
release through creative expression of feeling and mood. The dance steps were altered to
match the age and health status of individuals without reducing the health benefits.
Especially important is that the women from the experimental group took ownership of
the culturally-specific dance intervention by hiring the dance instructor for two more 8-
week sessions after the study was finished. The women paid for the dance classes and
the minister also wholeheartedly supported their efforts. Importantly, several men from
the experimental church wanted to participate. One man said, “I will put on a wig and
dress if you will just let me dance” implying that African American men are interested in
a culturally-specific dance intervention as well. The men had conversations with the
minister about a similar dance activity for the men.
The comparison group also took ownership of the culturally-specific dance
intervention. A couple of the women from the comparison church were working with the
dance instructor to write a grant to obtain funds from two separate community
foundations that support local health programs. Thus, the implication is that a culturally-
specific dance intervention was appealing to African American women and was a
beginning step to guide nursing practice to improve health outcomes in sedentary African
American women, ages 40 years and older.
Nursing Practice in African American Communities
This research study was conducted among women who were of a different race,
religion, education, and socioeconomic status than the principal investigator. In order to
gain their trust and confidence, the principal investigator felt that it was very important to
learn each woman’s name and the names of their family members. Calling them by their
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names made them feel like a human being and not a “research subject”. Many of the
women from both churches were amazed at how fast the principal investigator learned
their names instead of knowing them by their research number. Once the women from
both churches and principal investigator became familiar with each other, many of
women brought in pictures of life events (70th birthday party, 50th wedding anniversary,
first great-grandchild, vacation, etc.) to share. Furthermore, several women from both
churches would stop by the research table during the scheduling of their second and third
face-to-face interview just to “chat and catch up on things”. Some of the women from
both churches introduced other members of their family to the principal investigator and
research team members after the church service. For example, one woman made a
special point to make sure that the principal investigator met her son and her newborn
grandson who flew in from California. The women from the comparison church invited
the principal investigator to the annual Women’s Day luncheon at the church. The
principal investigator attended the luncheon and was amazed at how many of the women
offered a chair to sit next to them and volunteered to go get more coffee and ice cream.
At the luncheon, the principal investigator and her faculty advisory took the time to greet
the women who had participated in the study, speak to the minister and thank him and his
staff for their support, and stayed until the event ended. The women and their families
verbalized their satisfaction with our support of their activities. During the 8-week
dance intervention, many of the women invited the principal investigator to dance with
them during each dance session. When the 8-week dance intervention was finished, it
was an emotional outpouring of friendship with hugs exchanged between the women and
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the principal investigator. Tears of joy were shed as many of the women did not want the
special bond and camaraderie to end.
The overall retention rate of 77% was higher than any other study conducted in
African American churches. This can be attributed to the principal investigator’s high
visibility, respect for their values and beliefs, and dancing to gospel music especially
selected for them and by them. The study occurred in their own church, on days of the
week chosen by them, and at a time most convenient to fit into their schedules. This
dance intervention was designed for them to focus on them and their health. Thus, the
principal investigator was able to get to know and become involved in working with a
different population by treating the women and their families with mutual respect and
dignity. Acknowledging their time commitments, their family responsibilities, and their
desire to improve their health was also appreciated by the women.
To maintain the partnership between the principal investigator and the African
American churches, the results of the findings must be presented to the participants, their
families, and other members of the congregation. Both parties have a vested interest in
improving the health in the African American community and it must be perceived as a
partnership. Furthermore, this culturally-specific dance intervention can continue to be
built upon in several ways. The use of positive, upbeat secular music (hip hop, jazz, etc.),
different physiologic measures, and assessing the interaction between dance and
psychological well-being would be a good beginning. Additionally, including African
American men and children would further increase the credibility of the culturally-
specific intervention and improve the health of the population.

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Another concern of healthcare professionals is access to healthcare in African
American communities. To participate in the study, the women needed medical
clearance from their primary care physician. Of the 126 women in the study, only five
women (3 from the experimental group and 2 from the comparison group) did not have a
primary care physician. All of them were referred to the primary physician of the Otis
Moss, Jr. Medical Health Center affiliated with University Hospitals of Cleveland. From
the experimental group, two of the women received medical clearance and the other
chose to continue using the emergency room as her primary source of healthcare. The
two women from the comparison group did not seek any further healthcare access as both
stated they did not have insurance and did not have the financial means to pay for a
physical examination. The institutions from which the women received healthcare fell
into four categories: University Hospitals of Cleveland, The Cleveland Clinic
Foundation, Kaiser Permanente, and local community physicians. None of these women
had any difficulty in obtaining medical clearance. Many of the women had already had
their yearly physicals or were scheduled to get one in the near future. An overwhelming
majority of the women stated that their physicians were “thrilled”, “overjoyed”,
“ecstatic”, or “happy” that they were engaging in a dance program. Thus, the women of
this study did not experience barriers to access to healthcare facilities and professionals,
and they managed to successfully address transportation issues.
Implications for Nursing Theory
The study’s results partially supported applying Social Cognitive Theory to culturally-
specific dance and African American women as it implies that individuals with high
efficacy and outcome expectations are more likely to initiate and persist in a specific
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physical activity behavior. The findings were not consistent with the theory as efficacy
expectations was not a mediator between dance and the outcome variables. However, the
findings supported outcome expectations as a mediator between the dance intervention
and functional capacity. For this study, the participants realized they were not able to
initiate a dance program (efficacy expectations), but understood the long term benefits of
dancing (outcome expectations) and continued the dance program after the intervention
was completed. Social Cognitive Theory posits an association between self-efficacy and
social support as social influences are important characteristics for boosting efficacy
cognitions (Bandura, 1986). The results of this study found social support from friends
as a mediator and not support from family. This is in contrast to studies that found social
support from family as more important (Felton et al., 2002; Treiber et al., 1991). Thus,
the theory was only partially supported as the culturally-specific dance intervention
increased functional capacity in distance walked and was mediated through outcome
expectations and social support from friends.
Recommendations for Further Research
There is very little research about culturally-specific dance and positive health
outcomes in African American women. Future culturally-specific dance intervention
studies within this population might increase the length of the intervention to 3-4 months.
This will allow a more pronounced observed dose effect. Moreover, lengthening the time
frame to include a maintenance phase as part of the study might increase adherence to the
dance program and help the participants to see long term positive effects of dancing. To
have a more holistic approach, future studies ought to include physiological (range of
motion, strength, balance, sit and stand test, and flexibility), psychological (mood,
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anxiety, stress, depression, and loneliness), and spiritual measures to assess the health
benefits associated with culturally-specific dance. Moreover, culturally-specific dance
intervention studies should use other measures to assess physical activity, such as
pedometers or accelerometers. For example, a culturally-specific dance intervention
study could determine if a 45 minute dance class is enough to help the participants walk
10,000 steps per day. Using the accelerometers, energy expenditure for dancing could be
assessed for each participant. Given the prevalence of obesity, type 2 diabetes, and
hypertension in the African American community, culturally-specific dance intervention
studies should consider body fat, body weight, blood glucose, and high blood pressure
management as dependent variables. For instance, a study could ascertain the effects of a
culturally-specific dance intervention on blood glucose, or how weight loss impacts blood
pressure management.
Finally, future studies could use culturally-specific dance in other underserved or “at-
risk” populations as an intervention to increase physical activity. These dance
interventions should be taught by a respected member within the community to dance
steps basic enough to acquire with minimal skill. Also, researchers should consider
developing culturally-specific dance interventions to positive secular music located in
community or outpatient settings to reach those who are not affiliated with a church.
Summary
Findings of this study contribute to nursing knowledge about culturally-specific dance
and lifestyle physical activity, functional capacity, self-efficacy, and social support in
African American women, ages 40 years and older, in a church setting. The culturally-
specific dance intervention was of moderate intensity, low impact, and resulted in no
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reported injuries. The dance intervention, taught by a respected woman within the
community, was simple, easy to learn, and able to include those with and without
physical limitations. The results of this study support a culturally-specific dance
intervention as a beginning step to encourage African American women to become more
physically active to improve health outcomes.

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Appendix A
Ministers of the Experimental and Comparison Churches
Reverend Dr. Otis Moss, Jr., Olivet Institutional Baptist Church
Reverend E. Theophilus Caviness, The Greater Abyssinia Baptist Church, Inc.

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Appendix B
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Appendix C
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Appendix D
Belinda Haywood is a Professional Urban Line Dancercise Instructor and the creator of
an intervention
S. T. O. M. P. (Spiritual Treasures of Movement & Praise) Ministries, a Christian Line-
Dance activity. In 2000, Ms. Haywood began focusing on African American Christian
line dancing because she noticed that many parishioners in African American
communities were not exercising, and were developing functional disabilities because of
their sedentary habits.
Under the direction of Ms. Haywood, the Christian Line-Dance group has choreographed
creative line dances to popular gospel music and has developed a gospel line dance CD
with a DVD that is scheduled for production in the winter of 2004. S.T.O.M.P Ministries
has performed at various venues and it promotes spiritual growth, physical wellness and
educational enrichment throughout Cleveland, Ohio and other global communities. Most
importantly, S.T.O.M.P Ministries focuses on spiritually uplifting the women, enhancing
their self-efficacy as related to improved physical capacity, their emotional well-being,
and overall health status. It utilizes social support, the women’s spiritual strengths, and
their social relationships to reinforce the dance activity that occurs in church settings in
the African American community.
Ms. Haywood brings years of experience to her dance exercise classes. She began
studying dance and piano in the African American community, in Cleveland, Ohio, when
she was a young child. During her formal education, she studied at the renowned
Cleveland Music School Settlement and the Rainey Institute, also located in Cleveland.
After she completed her formal education, she continued her studies through continuing
education courses, workshops, and national seminars located throughout the United
States. Ms. Haywood began teaching and conducting dance exercise classes in the early
1970’s, and has continued her efforts for more than 3 decades. Some of her most
rewarding sessions have involved teaching visually impaired members of the Cleveland
Sight Center to line dance.
Over the past 3 decades she has engaged hundreds of people ranging in ages from 5 to
100, in the use of dance as a mechanism to enhance their overall physical capacity. She
invites individuals to meet her at local community centers, cookouts, fairs, clubs, major
centers, and churches. As is typical in many African American church communities, she
begins with “ Let everything that has breath praise the Lord. Psalm 150:6; then, the music
begins.
Murrock 133
Appendix E
Christian Line Dance Steps- (Belinda Haywood, choreographer)
BRIGHTER DAY
Moving right scoot four times with right leg leading (4 counts)
Left knee bends in and out for 4 counts
Walk to the left with left leg leading (4 counts)
Right leg steps out, pause; in pause, out, in out (4 counts)
Right leg swing behind; clap hands, followed by left, clap hands (4 counts)
Right, left, right; clap hands (4 counts)
Right leg leading: step up, pause; step back, pause; step up, step back, step out, step in,
right leg leading (8 count)
(Start over)
THE SPIRIT OF DAVID
Step out right, back in and turn (full turn)

Step out, back in and turn back (full turn)
Moving forward, right cha cha, left cha cha
Walk back right, left, right, left
Tap right, tap left, twist right, left, right, left
Tap right, tap left twist right, left, hop back right leg and quarter turn left
(Start over)
HOSANNA-WE WORSHIP YOU
Swiftly moving-step out, step in, step out, step in (both legs)
Right Heel-Left Heel
Step up using right foot-Back on Left-Half turn cha-cha-cha staring with right foot
turning to the right
Step up using left-foot-Back on Right-Half turn cha-cha-cha starting with left foot turning
to the left
¼ turn to left starting with right foot walk right, left, right, tap right (4 steps)
Walk left-right-left-tap right (4 steps)
Kick right step right, tap left, Kick left step left, tap right (repeat twice)
Tap left, tap right, tap left, tap right; step back on the right
Kick left, step back right kick left
(Start over)
Murrock 134
Appendix F
ID #_________
Date _________
DEMOGRAPHIC DATA
A member of the research team will read and mark the DEMOGRAPHIC DATA for all
participants. For those who choose to read it by themselves, please complete each
questions as honestly as possible. If you have any questions, a research team member
will be happy to help you to answer any question and will remain with you until you
complete this instrument.
AGE: ________years Weight (in kg) _________
Bioelectrical Impedance Analysis (BIA) _______________
6MworkT= kg __________ x distance traveled (in meters)_______ =_________
MARITAL STATUS: Single_____ Married_____ Divorced_____ Widowed_____
Separated_____ Other_____
LEVEL OF EDUCATION:
Did not finish high school_____ High school _____ Some College_____
Associate/Technical degree_____ Bachelor’s degree_____ Master’s degree_____ Ph.
D._____
FINANCIAL STATUS:
Less than 10,000 _____ 10,001-20,000_____
20,001-30,000_____ 30,001-40,000_____
40,001-50,000 _____ 50,001-60,000_____
60,001- 70,000 _____ 70,001-80,000_____
80,001-90,000_____ 90,001-100,000_____
Over 100,000_____
Have you ever danced before? Yes _____ No _____
Do you like to dance? Yes_______ No _______

Murrock 135
ID# _________
HEALTH ASSESSMENT * Date _________
Do you currently smoke? Yes_____ No_____
If yes, how many years have you smoked? _____years
How many packs per day?_____
If no, have you ever smoked? Yes_____ No_____
How many years has it been since you smoked? _______years
How many packs per day did you smoke?_______
Have you ever been told that you have high blood pressure? Yes_____ No_____
Do you take medications to control high blood pressure? Yes_____ No_____
How many years have you been treated for high blood pressure? ________years
Have you ever been told that you have high cholesterol? Yes_____ No_____
Do you remember your cholesterol number?__________
Are you currently taking medication for high cholesterol? Yes_____ No_____
Are you Diabetic? Yes_____ No_____
If yes, do you ONLY take insulin to control your blood sugar? Yes_____
No_____
If yes, do you ONLY take pills to control you blood sugar? Yes_____ No_____
If yes, do you take BOTH insulin and pills to control your blood sugar? Yes_____
No_____
How many years have you been Diabetic? _____years
* Adapted from the questionnaire used by Wynd, C.A., Murrock, C.J., & Zeller.
R.A. (2004). Health promotion and cardiovascular health in adult monozygotic
twins. Journal of Nursing Scholarship, 36 (2), 141-146.
Murrock 136
ID# _________
CHARLSON SCALE* Date_____
Have you ever been told that you have heart disease? Yes_____ No_____
Have you ever been told that you have had a heart attack? Yes_____ No_____
Have you ever been told that you have congestive heart failure? Yes_____
No_____
Do you have pain in your legs when you walk? Yes_____ No_____
Have you ever been told that you have had a stroke? Yes_____ No_____
Have you ever been treated for being short of breath? Yes_____ No_____
Have you ever been told that you have an ulcer? Yes_____ No_____
Have you received medical treatment for your ulcer? Yes_____ No_____
What kind of treatment did you receive? Dietary changes______
Medication______
Have you ever been told that you have kidney disease? Yes_____ No_____
Have you ever needed dialysis?
Yes_____ No_____
Have you ever been told that you have cancer? Yes_____ No_____
If yes, what kind of cancer? _________________________________________
Have you ever been told that you have leukemia? Yes_____ No_____
Have you ever been told that you have liver disease? Yes_____ No_____
*Adapted from Charlson, M.E., et al., A new method of classifying prognostic

comorbidity in longitudinal studies: Development and validation. Journal of
Chronic Diseases, 1987. 40: p. 373-383.
Murrock 137
Appendix G
ID# _________
Date _________
PHYSICAL ACTIVITY SCALE FOR THE ELDERLY (PASE)*
A member of the research team will read and mark the PASE for all participants.
For those who choose to read it by themselves, please read each of the questions and
circle a number that tells how often you do this activity. Circle 0 for never; 1 for
seldom (1-2 days), 2 for sometimes (3-4 days), and 3 for often (5-7 days). If you have
any questions, a research team member will be happy to help you and will remain
with you until you complete this instrument.
*
*Permission granted from the New England Research Institute (NERI). Washburn, R.A., et al., The
physical activity scale for the elderly (PASE): Development and evaluation. Journal of Clinical
Epidemiology, 1993. 46(2): p. 153-162.
Murrock 138
Murrock 139
Murrock 140
Murrock 141
Murrock 142
Appendix H
ID# _______
Date _______
SELF-EFFICACY FOR EXERCISE (SEE)*
A member of the research team will read and mark the SEE for all participants.
For those who choose to read it by themselves, the following instructions will be
given: Please read each of the questions and circle a number that tells if you are
confident or not confident about each question. If you are not confident about a
question, circle a number from 0 to 4. If you are confident about a question, circle a
number from 5 to 7. If you are very confident, then you would circle a number
from 8-10. If you have any questions, a research team member will be happy to help
you and will remain with you until you complete this instrument.
How confident are you right now that you could dance 2 times per week for 30
minutes if:
Not Very
Confident Confident
1. the weather was bothering your joints 0 1 2 3 4 5 6 7 8 9 10
2. you were bored by the program or activity 0 1 2 3 4 5 6 7 8 9 10
3. you felt pain when exercising 0 1 2 3 4 5 6 7 8 9 10
4. you had to exercise alone 0 1 2 3 4 5 6 7 8 9 10
5. you did not enjoy it 0 1 2 3 4 5 6 7 8 9 10
6. you were too busy with other activities 0 1 2 3 4 5 6 7 8 9 10
7. you felt tired 0 1 2 3 4 5 6 7 8 9 10
8. you felt stressed 0 1 2 3 4 5 6 7 8 9 10
9. you felt depressed 0 1 2 3 4 5 6 7 8 9 10
* Resnick, B. and L.S. Jenkins, Reliability and validity of the self-efficacy for exercise
scale. 2000, 49: p.16-22.
Murrock 143
Appendix I
ID# _______
Date _______
OUTCOME EXPECTANCY FOR EXERCISE (OEE) *
A member of the research team will read and mark the OEE for all participants.
given: Please read each of the questions and circle a number that tells if you
strongly disagree or strongly agree with each question. If you strongly disagree
about a question, circle 1, disagree with a question, circle 2, neither agree or
disagree with a question, circle 3, agree with a question, circle 4, and if you strongly
agree with a question, circle 5. If you have any questions, a research team member
will be happy to help you and will remain with you until you complete this
instrument.
The following are statements about the benefits of dancing. State the degree to
which you agree or disagree with these statements.
Dancing.....
Strongly Disagree Neither Agree Strongly
Disagree Agree or Agree
Disagree
1. Makes me feel better physically 1 2 3 4 5
2. Makes my mood better in general 1 2 3 4 5
3. Helps me feel less tired 1 2 3 4 5
4. Makes my muscles stronger 1 2 3 4 5
5. Is an activity I enjoy doing 1 2 3 4 5
6. Gives me a sense of personal 1 2 3 4 5

accomplishment
7. Makes me more alert mentally 1 2 3 4 5
8. Improves my endurance in 1 2 3 4 5
performing my daily
Activities (personal care, cooking,
shopping, cleaning)
9. Helps to strengthen my bones 1 2 3 4 5
* Resnick, B., et al., Outcome expectations for exercise scale. The Journals of
Gerontology Series B: Psychological Sciences and Social Sciences, 2000. 55: p. S352-
S356.
Murrock 144
Appendix J
ID# ________
Date _________
SOCIAL SUPPORT FOR EXERCISE SCALE (SSES) *
A member of the research team will read and mark the SSES for all participants.
given: Below is a list of things people might do or say to someone who is trying to
exercise regularly. If you are not trying to exercise, then some of the questions may
not apply to you, but please give an answer to every question and will remain with
you until you complete this instrument.
Please rate each question twice. Under family, rate how often anyone living in your
household has said or done what is described during the last three months. Under
friends, rate how often your friends, acquaintances, or coworkers have said or done
what is described during the last three months. If you have any questions, a
research team member will be happy to help you.
Please write one number from the following rating scale in each space:
a does
few very not
none rarely times often often apply
________________________________________________________________________
1 2 3 4 5 8
During the past three months, my family (or members of my household) or friends:
Family Friends
1. Exercised with me.

2. Offered to exercise with me.
3. Gave me helpful reminders to exercise (“Are
you going to dance class tonight?”)
4. Gave me encouragement to stick with my
dance program.
5. Changed their schedule so we could exercise
together.
6. Discussed exercise with me.
OVER
* Sallis, J., et al., The development of scales to measure social support for diet and
exercise behaviors. Preventive Medicine, 1987, 16: p. 825-836.
Murrock 145
ID# _________
Date _________
SOCIAL SUPPORT FOR EXERCISE SCALE (SSES)
Please write one number from the following rating scale in each space:
a does
few very not
none rarely times often often apply
________________________________________________________________________
1 2 3 4 5 8
During the past three months, my family (or members of my household) or friends:
Family Friends
7. Planned for exercise on recreational outings.
8. Helped plan activities around my exercise.
9. Asked me for ideas on how they can get more

exercise.
10. Talked about how much they like to exercise.

Murrock 146
Appendix K
Six Minute Work Test (6MworkT)*
The 6-minute work test (6MworkT) measures the distance walked over a 6-minute period
and is calculated as W=F x D, where W=work, F=force, and D=distance. Force is body
weight in kilograms (kg) and the distance walked is measured in meters (m). The
research team members will practice weighing, timing, and measuring the distance
walked on each other prior to assessing the study participants. The Work will be
calculated as kg x m =W and will be recorded on the appropriate data collection sheet.
Participants will be weighed in kilograms (wearing street clothes and shoes) using a
standard physician scale and calibrated according to manufactures guidelines.
Participants will be asked to walk along a pre-measured hallway for 6 minutes. The
participants will be instructed to walk as far as possible at their own pace and that they
can stop for a period of rest if necessary. The research team members will not be allowed
to verbally encourage the participants as this might influence the participants’ normal
pace. The research team members will be allowed to call out at each minute of the 6
minute time period (i.e. “one minute; two minutes, etc). All research team members will
be taught how to use a stopwatch and the same stopwatch will be used for each data
collection period. When 6 minutes has elapsed, the research team member will measure
the distance from the participant’s starting point to where she ended in meters. The
6MworkT can be done in groups of participants or one participant at a time without
affecting the results. Interrater reliability will be evaluated on every tenth participant by
comparing rater assessments (two raters assessing one participant) using a Cohen’s kappa
of .60 as an acceptable level of reliability and retraining will be done if the interrater
agreement falls below the required kappa.
* Peel, C., & Ballard, D. (2001). Reproducibility of the 6-minute walk test in older
women. Journal of Aging and Physical Activity, 9, 184-193.
Murrock 147
Appendix L
Protocol for Training Research Team Members
The objective is to hire African American nursing students, registered nurses, or other
health care providers from within the community to be members of the research team.
Through this hiring process, the desire is to start capacity building by which the research
team members will become health resources to the community. All research team
members will be oriented over a 3-day period (See Table 2). They will participate in a
tour of the community, and learn about the community resources, including information
about the health services in the local area (Urgent Care facilities, Emergency Rooms,
primary care practices, and so forth) and how to access them if necessary for the women
in the research study. Moreover, the research team members will become informed about
the health statistics of the community and become aware of other health related programs
that available to the African American women. They will also learn about the history of
the particular African American community in Cleveland and how the “minority
majority” concept is used in their area. [The concept refers to the fact that African
Americans, designated as a minority, are in the majority in Cleveland. Hence, the term,
“minority majority.”]
All team members will carry a cell phone in case there is a need for 911. All research
team members will be trained in first aid and a first aid kit will be readily available
during every dance session at the church. They will have the principal investigator’s
telephone number and she will be available at all times during this research to answer any
and all questions. Faculty members at Case Western Reserve University’s School of
Nursing (Dr. F. Gary) and College of Medicine (Dr. Esa Davis, pending) will also be on
call. The research team members will have their phone and cell numbers also.
The orientation period will inform the research team members of their assigned roles and
function in the study. This will include a detailed review of the purpose of the study,
study protocol, data collection methods, data entry, and the mechanisms that are in place
to protect the women’s confidentially. The type of data generated from the study will be
described and the team members will be told how these data will be used in the nursing
and health literature.
Purpose of the Study

The purpose of the study is to determine the effectiveness of a church-based dance
intervention to increase lifestyle physical activity in sedentary African American women.
This purpose and its rationale will be thoroughly discussed with the team members.
Study Protocol
The study protocol will be explained in detail and a copy of the study protocol will be
given to all research team members so they can refer to it when necessary.
Murrock 148
The Intervention
The intervention, S.T.O.M.P., will be introduced to the research team members and they
will be asked to listen to the entire video and then practice the dance steps. They will
also be informed about the selection of the dance intervention as how it relates to the
African American women’s culture, their history and how it has been determined that
dance might be a good form of physical activity.
It is at this point that the research team members will be presented scientific information
about (1) cultural diversity, (2) culturally-specific interventions for specific populations,
(3) the importance of physical activity and its utility for improved health status, and (4)
the research instruments.
Data Collection Methods

Instruments
Prior to collecting baseline data, the principal investigator will train research team
members in data collection methods. There will be mock face-to-face interviews
between the research team members to assure familiarity with each instrument and proper
administration (Demographic Data Sheet including the Charlson Scale, PASE, SEE,
OEE, and SSES). Data collected during the mock interviews will be reviewed for
interrater reliability and accuracy of data recording. At the same time, research team
members will be instructed to place their initials on each instrument they mark for the
participant, extrapolating to calculate a Charlson score, and when scoring the instruments.
A list of all research team members’ names and initials will be kept in the researcher’s
locked office.
It will be announced at the beginning of each data collection period (baseline, 8 weeks,
18 weeks) that the research team members will read every question of every instrument to
each participant and mark each participant’s responses appropriately on each instrument.
This will ensure that the questions are read and understood correctly by the participants to
reduce reading comprehension concerns and accommodate those who forgot their glasses
or who would prefer to have the questions read to them. However, to maintain the
participants’ autonomy and integrity, the participants will be given the option to read the
questions without assistance and mark their own responses. Team members will always
be available to answer any questions the participant might have about any item on any
instrument. Team members will always carry pencils and pencil sharpeners during data
collection periods. Research team members will be instructed to examine each
instrument (Demographic Data sheet, PASE, SEE, OEE, and SSES) for completeness and
legibility. The PASE, SEE, OEE, and SSES will be scored according to the scoring
guidelines of each instrument. This activity will take place in the principal investigator’s
office and always under her supervision.
In the proposed study, a co-morbidity score will be extrapolated from the demographic
data sheet and assigned a score using the Charlson Scale. Interrater reliability will be
evaluated on every tenth participant by comparing rater assessments (two raters assessing
one participant) using a Cohen’s kappa of .60 as an acceptable level of reliability. The
Murrock 149
research team member will successfully complete a specific retraining session if the
interrater agreement falls below the required kappa.
Biological Marker of Physical Activity

The 6-minute work test (6MworkT) measures the distance walked over a 6-minute period
and is calculated as W=F x D, where W=work, F=force, and D=distance. Force is body
weight in kilograms (kg) and the distance walked is measured in meters (m). The
research team members will practice weighing, timing, and measuring the distance
walked on each other prior to assessing the study participants. The Work will be
calculated as kg x m =W and will be recorded on the appropriate data collection sheet.
Participants will be weighed in kilograms (wearing street clothes and shoes) using a
standard physician scale and calibrated according to manufactures guidelines.
Participants will be asked to walk along a pre-measured hallway for 6 minutes. The
participants will be instructed to walk as far as possible at their own pace and that they
can stop for a period of rest if necessary. The research team members will not be allowed
to verbally encourage the participants as this might influence the participants’ normal
pace. The research team members will be allowed to call out at each minute of the 6
minute time period (i.e. “one minute; two minutes, etc). All research team members will
be taught how to use a stopwatch and the same stopwatch will be used for each data
collection period. When 6 minutes has elapsed, the research team member will measure
the distance from the participant’s starting point to where she ended in meters. The
6MworkT can be done in groups of participants or one participant at a time without
affecting the results (Enright & Sherill, 1998). Interrater reliability will be evaluated on
every tenth participant by comparing rater assessments (two raters assessing one
participant) using a Cohen’s kappa of .60 as an acceptable level of reliability and
retraining will be done if the interrater agreement falls below the required kappa. The
research team members will have mock practice sessions.
Covariate
Body fat will be measured using a segmental bioelectrical impedance (BIA) arm-to-arm
analyzer. Research team members will be taught how to enter gender, height, weight,
and age in years into the BIA. Team member will practice on each other before
measuring study participants, and they will gain a specified level of proficiency before
they will be able to collect this data. Team members will be trained to assure that
participants must stand erect with feet shoulder width apart, arms parallel to the ground,
and elbows extended. Team members will ensure the participant’s hands and fingers grip
the sensor electrodes on the handles of the device. Relative body fat will be calculated
and displayed and the team members will record it on the appropriate data collection
sheet. Once again, interrater reliability will be evaluated on every tenth participant by
comparing rater assessments (two raters assessing one participant) using a Cohen’s kappa
of .60 as an acceptable level of reliability and retraining will be done if the interrater
agreement falls below the required kappa.
Murrock 150
Data Analysis and Management

Statistical analysis will begin with preparatory activities such as the treatment of missing
data, identification of outliers and other such data cleaning tasks. The distributions of all
obtained measures will be plotted graphically for visual inspection regarding deviation
from normality and appropriate quantitative tests will be utilized to evaluate these
possible deviations. Visual examination of scatter plots, histograms, and other graphical
summaries will be employed to identify possible associations of interest and provide
quick but accurate information about the data. Before proceeding with any statistical test,
we will assess the extent to which the assumptions underlying that test have been met.
We will utilize descriptive statistics to determine frequency distributions, percentage
distributions, means and standard deviations, and inclusive ranges as evidenced by the
data. Upon completion of these preparatory activities, we will apply univariate and
multivariate analysis of variance (ANOVA) and covariance (ANCOVA) and correlation
and regression to address the study questions.
Data management will be the responsibility of the principal investigator and overseen by
appropriate faculty members. All data will be entered into SPSS by research team
members and stored on CD or papers that will be kept in the principal investigator’s
locked file cabinet located in her locked office. Each participant will have her own folder
containing all her research data, which will only be identified by the sequentially
assigned research number. The folder will be stored in a locked file cabinet and
accessible only to research team members. On the outside of the folder, a slip of paper
will be attached that will ensure correct data entry. A research team member will enter
each participant’s raw data and initial the appropriate box. Another research team
member will re-check the raw data for accuracy and will initial the appropriate box (See
Figure 1).
Data Entry Re-check of Data Entry
Initials of research team Initials of another
member research team member
Figure 1.
Confidentiality
All research team members will be informed that all data, conversations, and other
discussions during data collection periods are strictly confidential. They will also be
informed that the names of the participants are not be used in any report writing or for
any other purpose. Furthermore, the research team members will be instructed not to
contact the women for any reason unless it is in relationship to the study. All additional
contacts with the women must have prior approval from the principal investigator. It will
be emphasized that only research team members are allowed in the research office and
Murrock 151
have access to the data. All research activities will take place under the principal
investigator’s supervision.
Table 2. Protocol for Training Research Team Members

Day 1 Day 2 Day 3
8am–10am Orientation and 8am-10am Training in data 8am-10am
tour of the community to learn collection methods via mock Review of study purpose,
about the community resources face-to-face interviews and test retraining of any data
and location of health services for interrater reliability and collection methods, or data
Information about the health accuracy of data recording. Train entry into SPSS. Other
statistics of the community and in the scoring process according topics as deemed
other programs available to to the scoring guidelines of each necessary.
African American women. instrument. Teach how to
Inform them of the long held extrapolate data from the
beliefs and health practices demographic data sheet and
that center around the church. assign a score using the Charlson
Scale. Test for interrater
reliability and do retraining if
necessary.
10am-12pm Discuss 10am-12pm Practice weighing, 10am-12pm Discuss
culturally-specific and timing, and measuring the cultural competence and
culturally competent health distance walked on each other African American women
beliefs, spirituality, and values, and practice calculating kg x m in Cleveland, stressing the
of African American as it =W. Practice using a stopwatch. importance of social
pertains to their daily lives, Test for interrater reliability and support, self-efficacy, and
church, and community. do retraining if necessary. decreasing sedentary
Develop culturally competent behaviors, concluding with
health literature about heart recap of the research team
disease, obesity, type 2 members’ roles and
diabetes, and hypertension that responsibilities in the
reflects their health beliefs and study. Role play session
health literacy levels of for research team members
African American women to become familiar with the
beliefs and values of
African American women
12pm-1pm Lunch 12pm-1pm Lunch 12pm-1pm Lunch
1pm-2pm Inform the team 1pm-3pm Train team members 1pm-3pm Have Belinda
members of their assigned in proper use of BIA by teach 1-2 dance session to
roles and functions. A detailed practicing on each other. Test the research team members
review of the purpose of the for interrater reliability and do and community advisory
study, study protocol, data retraining if necessary. board to understand the
collection methods, data entry, theoretical, conceptual, and
and protection of the women’s practical significance of
confidentially dance, gospel music, and
health beliefs of African
American women
Murrock 152
2pm-3pm Discuss the purpose 3pm-5pm Training of data entry 3pm-5pm Evaluation and
and rationale of the study. and double check of data entry feedback of culturally-
Recognition of signs and into SPSS data bank, organizing specific dance intervention
symptoms of activity data folder for each participant, from Community Advisory
intolerance, first aid training, sequentially assigning research Board
and monitoring the rate of number, and confidentiality.
perceived exertion (RPE) for
all team members.
Distribution of the principal
investigator’s, Dr. Gary’s, Dr.
Esa Davis, and the team
members phone numbers.
Murrock 153
Appendix M
Evaluation of Culturally-Specific Dance Intervention Form
The following are statements about the cultural values, attitudes, and beliefs
that area a part of the culturally-specific dance intervention. Please state whether
or not you agree or disagree with these statements.
The dance intervention ……
Experimental Group Yes No I don’t

know
1. Recognized and respected my spirituality based on the
selection of gospel music
2. Understood the importance of the church in my life as an
African American woman
3. Understood the importance of dancing with other
African American women who belong to my church
4. Respected the values and beliefs of the African
American community
5. Was taught by a qualified African American woman
who respected my beliefs and values about dance
6. Was carried out by research team members who treated
me with respect and cared about me
7. Allowed me to talk to other African Americans about
my health concerns
8. The dance classes helped me feel good about myself
9. Valued me for my role as an African American woman
in my family, church, and community
Murrock 154
Appendix N
The health information….
Comparison Group Yes No I don’t

know
1. Increased my awareness of heart disease and how often
it happens in African American women
2. Increased my knowledge of obesity and how it can make
women have other health problems such as diabetes and
stroke
3. Helped me to understand the relationship between
physical activity and type 2 diabetes
4. Reminded me that physical activity can help me control
my blood pressure
5. Had pictures of African American women that I thought
were nice
6. Used words that I understood
Murrock 155
APPENDIX O
Number of dance classes attended with corresponding body weight (pounds), body fat,
distance walked in feet, and lifestyle physical activity scores at baseline and 8 weeks
including a separate table of means and standard deviation of each variable of the
experimental group only.
code # of classes Lbs1 Lbs2 Bia1 Bia2 Distft1 Distft2 PASE PASE
(%) 1 2
003 12 (75%) 183.5 184.5 42.4 44.3 1306.8 899.4 28.3 94.6
004 11 (68.8%) 301.5 296.5 58.0 49.6 1425.8 1844.3 207.2 244.5
006 10 (62.5%) 147.5 143.0 36.6 34.1 1564.2 1697.6 196.3 218.2
009 14 (87.5%) 213.5 208.5 44.9 43.7 1707.6 1833.8 290.7 178.2
010 16 (100%) 134 135 37.5 35.3 1764.6 1904.7 120.7 228.2
011 15 (93.8%) 276 268 57.4 49.1 1685.9 1798.5 208.1 298.8
014 14 (87.5%) 120 119 37.8 38.3 2099.5 2199.2 110.0 110.1
016 12 (75%) 234.5 225.5 47.5 48.3 1836.8 1737.1 265.2 338.7
017 9 (56.3%) 139.7 132.3 32.2 30.7 1845.3 1942.5 150.9 352.4
018 8 (50%) 323 319 60.8 53.2 1842.7 1816.7 521.2 199
021 12 (75%) 174 174 39.1 40.3 1898.1 1950.9 63.3 42
022 15 (93.8%) 176.5 166 43 42.1 1937.2 1979.5 207.1 228.3
023 10 (62.5%) 107.8 108 41.5 39.6 1517 1418.8 254.7 170.1
024 15 (93.8%) 151 152 37.7 35.3 1607.2 1568.2 209.9 218.7
026 16 (100%) 191 188 38.5 42.2 1765.3 1872.9 308.2 304.1
027 12 (75%) 184.3 178.5 40.5 36.8 1506.2 1918.8 227.3 224.1
028 11 (68.8%) 179.8 175 39.6 37.5 1987.7 1850.0 76.4 160.9
029 11 (68.8%) 170.5 172 33.3 33.4 1729.2 1753.8 191.1 210.1
033 16 (100%) 259.5 251 48.9 47.6 2160.2 1798.4 235.5 260.4
034 16 (100%) 159 159 31 30.6 1684.6 1849.9 186 167.9
035 14 (87.5%) 231.3 229 45.1 45.9 1538 1459.9 206.9 200.5
036 15 (93.8%) 169 170.5 44.9 44.4 1589.8 1789.6 163 62.86
037 13 (81.3%) 188 186.5 47.4 47.9 1135.2 1309.4 140 217.2
038 8 (50%) 278 271 55.1 53.3 1367.8 1368.4 108.2 119
039 15 (93.8%) 164.5 174 34.6 37.9 1595.1 1681.7 300.1 349.2
040 13 (81.3%) 142.5 141 38.9 39.9 1576 1678 82.7 144.4
041 16 (100%) 140.8 143 40.1 37.5 1778 1843.4 133.8 266.5
042 14 (87.5%) 116 113 36.2 38.6 1663.9 1849.9 219.9 263.1
044 15 (93.8%) 164 170 35.6 35.1 1426.8 1685.6 254.3 149.2
045 8 (50%) 272 272 48.5 47.6 1865 1941.4 55 66
046 12 (75%) 163 167 42.2 46.4 1867 2020.5 186.4 150
048 12 (87.5%) 215 219 41.2 41.9 1657.7 1668.8 159.2 202.6
049 11 (62.5%) 140 131 48 43.3 1286.7 1658.4 113.4 140.7
052 13 (81.3%) 148 149.5 43 43 1836.8 1995.3 164.5 148
053 12 (75%) 193.3 198.5 42.9 43.6 1436.3 1597.4 230.9 193.3
054 14 (87.5%) 175.5 177 42.3 44 1525.5 1761.4 97 99.1
Murrock 156
056 10 (62.5%) 202 202 45.4 46 1451.4 1663 183.5 232.5

057 10 62.5%) 174 172.5 38.6 40.2 1303 1522 247 277.3
058 13 (81.3%) 265 266 45.5 46.2 1653 1847.3 190 304
059 9 (56.3%) 149 138 35.9 35.9 1311 1539 187.5 193.4
060 10 (62.5%) 171 166.5 39.2 37.5 1864.4 1945 290.8 315.9
061 15 (93.8%) 185 176.5 38 36.9 1945.4 2051.3 170 207.3
062 7 (43.8%) 164 156 43.6 43.7 1445.5 1608.2 186.4 251.6
063 13 (813%) 150 145 36.4 33.7 1962.8 2020.5 217.5 253.1
064 9 (56.3%) 169 170.3 41.6 41.8 1407.4 1660.3 41 64.9
066 14 (87.5%) 164 156 36.8 34.1 2002.1 2038.2 85.5 163.6
Means SD
Lbs1 187.91 43.53
Lbs2 187.39 43.16
Bia1 41.79 6.10
Bia2 41.80 5.62
Distft1 1517.14 318.97
Distft2 1588.10 303.57
PASE1 165.91 83.78
PASE2 179.18 81.33
Murrock 157
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DANCE AND PHYSICAL ACTIVITY IN AFRICAN AMERICAN WOMEN

Submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Dissertation Advisor: Dr. Faye A. Gary

CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the dissertation of

candidate for the Ph.D. degree *.

September 11, 2006

Statement of the Problem……………………………………………………………..13

Background and Significance…...……………………………………………………15

The Use of Culturally-Specific Dance to Improve Health……………………….16

Physical Inactivity in African American Women………………………………..18

Morbidity related to Physical Inactivity In African American Women……….....19

Mortality related to Physical Inactivity In African American Women.……….…20

Economic Impact of Physical Inactivity…………………………………………20

Physical Activity and Functional Capacity………………………………………21

Lifestyle Physical Activity……………...…………………………………………….21

Assessment of Lifestyle Physical Activity………………………………………22

Functional Capacity ………………………………………………………………….23

Self-Efficacy for Physical Activity in African American Women………………...…25

Social Support for Physical Activity in African American Women……………...…..25

Social Support in Church-Based Programs………………………….…….……..26

Predictors of Physical Activity Adoption and Maintenance in African American

Significance of the Proposed Study………………………………….………….……28

Four Sources of Efficacy Information………………………………………….…….29

Bandura’s Set of Conditions for Self-Efficacy……………………………….………30

Summary of Conceptual Model………………………………………….………35

Significance to Nursing Science……………………………………………………...36

Significance to Nursing Practice…………………………………………….………..39

CHAPTER II REVIEW OF THE LITERATURE

Independent Variable: Dance……………………………………………….………..44

Maximal Oxygen Uptake…………………………………………….………….45

Lifestyle Physical Activity…………………………………………….………...45

International Perspective on Culturally-Specific Dance…..….…………………46

Dependent Variable: Lifestyle Physical Activity…………….……………….…….51

Dependent Variable: Functional Capacity………………….………………….……53

Mediating Variables of the Proposed Study……………………………………..….55

Efficacy Expectations and Outcome Expectations………………………..……56

Social Support ……………………………………………………………..…...59

Social Support from Family and Friends for Physical Activity………….……..60

Relationship between Dance and Social Support....……………………..……..63

Relationship between Self-Efficacy and Social Support………………..……...64

CHAPTER III METHODS

Entering the African American Communities………………………………………69

Comparison Group Protocol…………………………………………………..…….76

Procedures for Data Collection Among All Study Participants…………………….76

First Face-to-Face Interview…………………………………………………..77

Second Face-to-Face Interview…………………………………………….....78

Third Face-to-Face Interview………………………………………….……...78

Strategies to Prevent Attrition……..………………………………………………79

Study Variables and their Measurement…………..………………………….……79

Independent Variable-Culturally-Specific Dance………………………….………79

Safety Monitoring of Dance Sessions………………………………….….……80

Evaluating Dance Sessions…………………………………………….………..81

Lifestyle Physical Activity………………...…………………………….…………82

Physical Activity Scale for the Elderly (PASE)………………………….…….…..82

Reliability and Validity of PASE…………………………………….…………83

PASE and Functional Capacity…………………………………….…………...84

6-Minute Work Test…………………………………………….……………....85

Origin of 6-Minute Work Test…………………………………….….………...86

Functional Capacity in Community Populations………………….…….….…..87

Efficacy Expectations for Exercise.…………………………………………..88

Outcome Expectations for Exercise…………………………………………..88