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Prime Time Sister Circles®II: Evaluating a
Culturally Relevant Intervention to Decrease
Psychological and Physical Risk Factors for
Chronic Disease in Mid-Life African American
Women
Veronica G. Thomas, Ph.D., Marilyn Hughes Gaston, M.D., Gayle K. Porter, Psy.D., Alicia Anderson, Ph.D.

INTRODUCTION
Financial disclosure: This study was supported by the Kellogg Foundation and
the Washington, DC and Tampa FL Departments of Health
Acknowledgements: This research was funded through grants from the
Kellogg Foundation and the Departments of Health in Washington, DC and
Tampa, FL. We wish to acknowledge also the medical/laboratory support of
Community Health Centers -Unity Health Care in Washington, DC and
Family Health Care and Park West Health Centers in Baltimore, M.D. for their
clinical assessments to all the participants and the medical care provided
to uninsured participants. Special thanks are extended to Denise Woods,
Prime Time Sister Circles’® Project Director. We also thank the American
Institutes of Research (AIR) (Washington, DC) for their support and allocation
of office space for the project.
Purpose: This article presents the results of two evaluation studies of the Prime
Time Sister Circles® (PTSC). The PTSC is a gender, cultural, and age specific,
curriculum-based, low-cost, short-term, replicable support group approach
aimed at reducing key modifiable health risk factors for chronic illnesses in
midlife African American women.
Methods: Study 1 includes an evaluation of 31 PTSCs (N¼656 women)
documenting changes in psychological and attitudinal outcomes (health
satisfaction, health locus of control), behavioral outcomes (healthy eating
patterns, physical activity, stress management), and clinical outcomes (weight,
BMI, blood pressure, non-fasting blood sugar). Study 2 includes evaluation of a
subset of the PTSC sites (N¼211 women) with comparison (N¼55 women) data
from those same locations.
Results: Study 1 showed significant changes (p&l; t;.0001) in the PTSC women’s
reports of (lower) stress, (higher) health locus of control, (increased) health
satisfaction, (increased) physical activity, and (healthier) eating patterns.
The PTSC women demonstrated a significant weight reduction at posttest (p
<.0001) and had slightly better clinical outcomes in BMI, hypertension, and
non-fasting blood sugar. Results document the sustainability of selected
changes over a six-month period. Findings from the Study 2 strengthen the
effectiveness claims of the PTSC intervention with significant changes for the
PTSC women on selected outcomes and little changes for the comparison
women.
Conclusions: Results reaffirm findings regarding the effectiveness of the PTSC, as
originally reported in Gaston, Porter, and Thomas (2007) and extends the
credibility of findings by examining participants’ clinical outcomes in addition to
self-reports.

Author affiliations: Veronica G. Thomas, Department of Human Development and
Psychoeducational Studies, Howard University; Marilyn Hughes Gaston, Gaston & Porter
Health Improvement Center; Gayle K. Porter, Gaston & Porter Health Improvement
Center; Alicia Anderson, Health Careers Opportunity Program (HCOP), College of
Medicine, Howard University
Correspondence: Veronica G. Thomas, Ph.D., tel: (202) 806e9093, fax: (202) 806-5305,
email: vthomas@howard.edu
Copyright ª 2016 by the National Medical Association

http://dx.doi.org/10.1016/j.jnma.2015.12.001

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A

frican American women in our Nation face major
disparities in both physical and emotional illness,
compared to Caucasian women, and are dying at
rates that are greater than all other women in this country.
They have higher rates of hypertension (twice as likely),
breast cancer at young ages, diabetes and its complications
(three times more likely), stroke, high cholesterol, lupus
and heart disease.1,2 African American women are more
than twice as likely to have cardiovascular disease (CVD),
hypertension, heart disease and stroke and 30% more
likely to die from it (ibid). Despite these facts, they are also
less likely to be aware that heart disease is their leading
cause of death3,4 and to make lifestyle changes that will
substantially reduce their risk.
African American women’s disparities in emotional
health are also compelling. They report higher rates of
emotional distress, depressive symptoms and panic attacks
than do Caucasian women.5-10 Health projections indicate
that African American women experience depressive
symptoms at some point during their lifetime and at a rate
that is significantly higher than Caucasian women, yet far
fewer of them receive treatment.11-13 Further, African
American women often cite stress as a greater threat to
their health than heart disease.14
One of the major reasons that African American women
are at increased risk for poor health and negative health is
because they have the highest prevalence of major risk
factors and multiple co-morbidities (i.e., overweight and
obesity with inactivity and stress, depressive symptoms
with high blood pressure, high blood cholesterol and diabetes) that contribute to both morbidity and mortality when
compared to Caucasian women.15,16 Chronic and acute
psychological stress has been documented to have a

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negative impact on morbidity and mortality rates especially in relationship to CVD.17,18 Various studies have
documented that an individual’s response to stress can be a
contributing factor to increased risk for CVD and cancer.19-22 Further, higher levels of psychological stress may
also lead to an increase in other negative behaviors such as
overeating and increased smoking.23
Poor lifestyle habits are major contributors to poor
health outcomes. Prevention and a healthy lifestyle are
increasingly recognized by health professionals as the
cornerstones to improving health outcomes and reducing
risk factors for chronic diseases. The Centers for Disease
Control & Prevention (CDC) has reported that a major
determinant of health is lifestyle, exceeding the impact of
genetics, the environment, and access to care.24 Numerous
studies have documented the negative impact of physical
inactivity, poor nutrition, and stress in overall health outcomes, especially on major morbidity and mortality from
cardiovascular disease (CVD).25-27 According to the
Healthy People (2010) report, poor nutrition, in conjunction with physical inactivity, leads to 300,000 deaths each
year.28 A review of mortality data reported to the CDC
showed a substantial increase in the proportion of estimated deaths attributable to poor diet and sedentary
behavior29-32 in many segments of the population based on
age, income, gender, race and ethnicity.
Various health statistics make a compelling case for the
need for successful interventions to help African American
women reduce and eliminate health risk factors. Further,
more research in culture-specific strategies to reach African American women, particularly those in midlife, is of
particular importance given the high level of risk factors
and mortality rates in this population and the different
constellations of their higher risks in comparison to other
female ethnic populations. This article describes the results
of an outcome evaluation of the Prime Time Sister Circles® (PTSC), a gender, cultural, and age specific,
curriculum-based, low-cost, short-term, replicable support
group approach aimed at reducing key modifiable risk
factors in a socioeconomically and geographically diverse
group of African American women.

PROGRAM NEED AND DESCRIPTION
The health outcomes of African American women not only
play a critical role in their own lives, but also in the lives of
their partners, children, grandchildren, and communities.
Women in mid-life, in particular, are often considered role
models and influence the health knowledge, attitudes and
behavior of their families and communities. Thus, education of midlife African American women and improvements in their health outcomes are critical. However, there

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remains a paucity of culturally and gender-relevant interventions and evaluations of such interventions targeting
improvements in the health outcomes of midlife African
American women by reducing their risk of chronic diseases. The PTSC represents one of the few interventions
targeting this specific population and one with existing
evaluation data indicating positive changes in the women
after PTSC participation.
The PTSC is a facilitated, curriculum-based, intensive,
support group intervention with an average of 25 African
American women per group. It consists of an initial 12week two-hour weekly program that includes data collections at baseline, 12-week and six-month posttest, a
training program for facilitators, and an Alumnae Association program for PTSC graduates. PTSC is a preventive
program that is outcome driven, comprehensive, and
replicable. It uses a cognitive behavioral modality to
address three key modifiable health risk factors which are
major contributors to morbidity and mortality from chronic
diseases: unmanaged stress, physical inactivity, and unhealthy nutritional choices. It also addresses two additional
risk factors which contribute to unhealthy lifestyles: lack
of knowledge or misinformation about major illnessesdcardiovascular disease, hypertension, diabetes,
cancer, and depressiondand the failure of African
American women to prioritize their health and take proactive steps to manage their health and health outcomes.
PTSC gives African American women the information,
motivation, tools, and consultative support they need to
improve and maintain their health. The Circles meet in
community settings (e.g., health centers, churches, public
housing community rooms). An added benefit of PTSC is
its low cost of $35 per woman per week (not including
administrative and evaluation costs). It should be noted,
however, that the women who participated in the PTSC, to
date, have not incurred any financial cost since their fees
were covered by external grant funds.
Conducted in a supportive group format, PTSC operates within a theoretical framework that characterizes
cultural, gender, and age-specific factors as the key to
understanding the unique values, beliefs, and preferences
of African American women, modifying lifestyles, and
improving health outcomes. It is also consistent with
empirical work documenting the importance of social
support and social circles in promoting positive health
changes among African American women.33
The conceptual framework for this intervention is an
integration of three theoretical approaches: (a) the socialcognitive theory that emphasizes the importance of
self-efficacy and empowerment through modeling,
communication, and role play,34 (b) the transtheoretical
model that illustrates stages of behavioral change and how

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and why individuals adapt their behavior over time
postulating a continuum of change that is influenced by an
individual’s knowledge and motivation to change;35 and
(c) the PEN (Person, Extended Family, Neighborhood)
model, that focuses on the integration of health education,
educational diagnosis of health behavior, and cultural
sensitivity.36 The PEN was initially used in African
countries as a health promotion disease prevention strategy
for the individual that was then spread to her/his family
and community. These three models have a strong body of
empirical evidence that document their effectiveness in
promoting positive health related behavior changes.
Further, all three approaches have been successfully utilized with women of color. In addition to the behavioral
modification framework underlying these three theoretical
approaches, the design and implementation of the PTSC
were based on information derived from numerous focus
groups conducted by the developers of the intervention
and material incorporated within their book, Prime Time:
The African American Woman’s Complete Guide To
Midlife Health and Wellness.37

OBJECTIVES OF PRESENT EVALUATION
The first published evaluation of the PTSC intervention
was in 2007 by the present authors (Gaston, Porter, and
Thomas) which documented statistically significant post
intervention changes based on subjective self-reports.38
This initial study included 106 African American women
from eleven PTSCs located in Washington, DC, Chicago,
Illinois, and Orlando, Florida. It also included a small (N ¼
34) comparison group. A major change in the implementation of the current set of PTSCs compared to those
reported in the 2007 manuscript is the addition of objective
pre/post clinical assessments of the women.
This article presents the results of two new evaluation
studies of the PTSC. Study 1 is an evaluation of 31 new
PTSC sites with 656 women. A one group time series
evaluation design was implemented to assess changes in
three major areas: psychological and attitudinal outcomes
(i.e., health satisfaction, health locus of control), behavioral outcomes (i.e., healthy eating patterns, physical activity, stress management, and prioritization of their
health), and clinical outcomes (i.e., weight, BMI, blood
pressure, non-fasting blood sugar). Study 2, utilized a
pretest/posttest quasi-experimental design and describes
results from a subset of the PTSCs (N ¼ 211 women) with
comparison (N ¼ 55) data from those same locations.
Collectively, the findings of these two evaluation studies
document the success of the PTSC intervention in
reducing some of the major health risk factors in a large
group of midlife African American women. The results

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also document the sustainability of selected changes
among the intervention women over a six-month period.

EVALUATION STUDY 1 e CHANGES
AMONG PTSC INTERVENTION WOMEN
Methodology
Data collection sites and participant description. The
PTSC interventions were conducted in various sites
located in Washington, DC, Tampa, Florida, and Baltimore, Maryland between 2008e2010. A total of 31 PTSC
groups (656 participants), with an average of 21 women
per group, were completed. These sites were community
based (i.e., churches; public housing; a historically Black
university; a state health education center; mental health
and community health centers; a book store; and a
hospital.
Each PTSC woman was given a copy of the Gaston and
Porter’s 2003 revised book, Prime Time: The African
American Woman’s Complete Guide To Midlife Health and
Wellness37 to use as the course text and curriculum/
workbook and $10 per session to defray transportation or
child care costs. Over the course of the 12-week intervention (two hours/week), the women received information from the PTSC facilitators and consultants related to
prevention, spirituality, self-esteem, prioritizing their
health first, stress, nutrition, exercise, chronic disease, and
utilizing the health care system. Expert consultants were
utilized to teach specific cognitive behavioral strategies
and provide tools to improve stress management, nutrition
and exercise habits, and to help the women develop and
implement individualized health plans in the targeted
areas.
The mean age of the women was 55.15 (SD ¼ 8.89). Of
the total, 25.7% of the women had a high school educational level or less; 28% had some college/technical level
education, 19.5% had graduated from college; 26.7% had
some post baccalaureate, graduate or professional degree.
Almost one-third (28.2%) of the women had personal
yearly incomes under $20,000 while 42.3% had personal
yearly incomes of over $40,000 or above. Only 45.2% of
the women were employed full-time and 17.2% were
completely retired. Less than one-third (31.3%) were
currently married; 24.0% were separated or divorced;
10.6% were widowed and 4.2% were unmarried, but had a
live-in partner, and 29.0% were unmarried without a livein partner. The overwhelming majority (82.1%) of the
women had children. Slightly more than one-half (53.3%)
of the women reported having grandchildren and 29.0%
indicated that they had minor children living in their home.
At baseline, many of the women reported that they had

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been diagnosed by a physician with certain chronic or
other diseases. Over one-half had been diagnosed with
hypertension (56.7%). Additionally, some of the women
reported being diagnosed with: hypercholesterolemia
(37.7%); Type II diabetes (21.9%); depression (19%); a
stress related illness (11.9%); heart disease (9.2%); cancer
(5.5%); and a cerebrovascular event (stroke) (3.2%). The
vast majority (89.9%) of the women reported having
visited a doctor or health care provider for a routine
checkup (or general physical examination) within the past
12 months.

INSTRUMENTS
The instruments used in the two studies reported in this
article were selected because of their previous use with
diverse populations and/or their ability to measure variables that were important for the present research. These
instruments were also pretested and previously utilized, in
whole or part, with other samples of PTSC women.38,40
In Study 1 the psychological/attitudinal and behavioral
instruments of focus were included as items within a larger
survey given to the PTSC women. The women’s clinical
assessments were taken by a set of subcontracted independently trained health care professionals.
Psychological/attitudinal outcomes. The psychological/
attitudinal factors of interest in this evaluation included
perceived stress, health locus of control, health satisfaction,
and importance of engaging in physical exercise. Perceived
stress was measured on a single item asking the women
to indicate their current stress level, taking all things
into consideration. This item was rated on a 7-point scale
from 1, “not at all stressed” to 7, “extremely stressed.”
Health satisfaction was a composite score, previously
used by the authors,38 that was calculated by summing the
women’s satisfaction rating across five items (i.e., satisfaction with weight, body shape, health knowledge, health
attitudes, health behaviors). The total scale score was an
average, which could range from 1e3, with higher scores
indicative of greater levels of health satisfaction. The
Cronbach internal consistency reliability coefficient for
this measure for the PTSC women was .75.
Health locus of control was measured using the 11item Health Locus of Control Scale.39 The items,
responded to on a 4-point Likert type scale, assessed the
degree to which the women believe they possess control
over their personal health. Sample items include (a)
People who never get sick are just plain lucky, (b) I can
only do what the doctor tell me to do, and (c) When I
feel ill, I know that it is because I have not been getting
the proper exercise or eating right. Total scores could
range from 11 e 44, with higher scores indicative of

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higher levels of locus of control. The Cronbach internal
consistency reliability coefficient for the Health Locus
of Control Scale for the PTSC women was .64.
Attitudes toward engaging in physical activity. The
women’s attitude regarding engaging in physical exercise
was assessed by a single 4-point item asking the women to
rate the importance of engaging in physical exercise at
least five times per week. They rated this item in terms of
1, “not at all important,” 2,“not too important,”
3,“somewhat important,” and 4,“very important.”
Behavioral outcomes. A number of self-reported
behavioral outcome items were included in the larger
PTSC survey. The specific behavioral outcomes examined
in this evaluation included engagement in physical activity
(i.e. exercise), healthy eating patterns, stress management,
and prioritization of their health.
The physical activity/engagement in exercise questions asked the frequency (days per week) of engagement in exercise that was at least 20 minutes in duration.
To assess healthy eating patterns, a Health Eating
Measure, adapted and shortened from an instrument
used by Gaston, Porter, and Thomas (38) to include 11
items, was utilized. Healthy eating items focused on
those relevant behaviors documented in the literature
such as consuming a balanced diet, watching one’s
caloric intake and food portions, and limiting the intake
of sugar, salt, and unhealthy fats. These items were rated
on a 3-point scale ranging from 1 “never” [engage in
this eating pattern] to 3 “always or almost always”
[engage in this eating pattern] The healthy eating pattern
items included both positive (healthy) behaviors and
negative (unhealthy) behaviors. For example, healthy
eating behaviors included: (a) ate breakfast, (b) watched
their caloric intake; and (c) watched serving size, etc.;
unhealthy eating behaviors included, for example, (a)
ate fast food and (b) ate high caloric sweets. The scores
were summed and averaged, with possible scores
ranging from 1e3, with higher scores indicative of more
healthy eating patterns. The Cronbach internal consistency reliability coefficient for this measure for the
PTSC women was .71.
A stress management survey was given that provided
participants with a list of 19 behaviors and asked them to
indicate if they engaged in these behaviors to help them
reduce their stress levels. The investigators drew this list of
behaviors from the literature and discussions with focus
groups of African American women. Sample behaviors on
the listing included more adaptive stress management behaviors such as: (a) praying, (b) deep breathing, (c)
meditation, (d) talking with a minister, (e) talking with a
professional mental health clinician and less adaptive
stress management behaviors such as (a) going shopping,

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(b) drinking alcohol, (c) avoiding [the stress], (d) forgetting[about it] or (e)“going off.”
Clinical outcomes. Several clinical assessments of the
PTSC women were taken. The clinical assessments
included the women’s (a) height, (b) weight, (c) body mass
index (BMI), (d) blood pressure, and (e) non-fasting blood
sugar level. The women’s body mass index (BMI), a
measure of body fat based upon height and weight, was
calculated. In this evaluation, and in accordance with
federal guidelines, a normal BMI is between 18.5-24.9; a
BMI between 25e29.9 is considered overweight; a BMI
between 30e40 is considered obese and a BMI greater
than 40 is classified as extremely obese.
Blood pressure was classified into three groups
including normal (120/70 or less), pre-hypertensive (>
120/70), and hypertensive (> 140/90). Non-fasting blood
sugar levels were classified into three groups including
normal (blood sugar less than 139), suspected pre-diabetic
(blood sugar 140e199), and suspected diabetic (blood
sugar greater than 200).

PROCEDURES
Research data (self-report and clinical assessments) were
collected from PTSC women participants at three pointsin-time: (a) pretest (baseline written surveys and clinical
assessments) and (b) posttest written surveys and clinical
assessments (12 weeks, 6-month follow up). The surveys
were administered onsite and collected by the PTSC
evaluator or the site-based facilitators. The clinical assessments, done by an independent group, were also
conducted on-site.
Confidentiality of the Data and Informed Consent
Procedures. All participants were provided an informed
consent form to review and sign prior to their participation
in the PTSC and completion of any data collection protocols. No identifying information was included on the
data collection measures. Participants created a code
number (using their mother’s maiden name and the last
four digits of their social security number). This information was also used to link the participants’ self-report
data to their clinical assessments.

Statistical Analyses
Three major outcome areas were analyzed in this study: (a)
PTSC participant changes on selected psychological factors related to their health (i.e., stress) or health perception
(i.e., health locus of control, health satisfaction), (b) PTSC
participant changes on selected behavioral dimensions
related to health (i.e., engagement in physical activity,
healthy eating patterns), and (c) changes in PTSC participants’ clinical outcomes (e.g., weight, blood pressure,

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BMI, blood sugar level). Descriptive statistics (e.g., frequencies, percentages) were done for each variable of interest. Internal consistency reliability statistics were
calculated for each scale. Additionally, pre/post t-test analyses were performed to detect statistically significant
changes.

EVALUATION STUDY I RESULTS
Participants, Follow-up Retention RatesEvaluation
Among the PTSC women, 656 completed the survey at
pretest, 447 completed at 12-week posttest, and 140
completed at 6-month follow up. Of these PTSC women,
521 clinical assessments were taken at baseline, 420 were
taken at posttest and 149 were taken at 6-month follow up.

Pre/Post Changes in the PTSC Women
The effectiveness of the PTSC was evaluated in terms of
the women’s changes in the selected psychological,
behavioral, and clinical outcomes of interest. The findings
related to these changes are reported in the sections below.
Changes in psychological/attitudinal outcomes. There
were significant improvements for the PTSC women for all
the psychological/attitudinal outcomes of interest in this
study. (See Table 1.) The women’s reported level of stress
changed significantly after the 12-week PTSC participation, t(366) ¼ 10.69, p < .0001. In particular, PTSC participants reported lower stress levels (M ¼ 2.99, SD ¼
1.44) after the intervention (12-week posttest) than at
pretest (M ¼ 3.96, SD ¼ 1.66). There was also a significantly lower pre/post difference at 6-month follow up
(pretest M ¼ 3.79, SD ¼ 1.59, 6-month post M ¼ 3.18,
SD ¼ 1.54, t(121) ¼ 3.96, p < .0000).
Results indicated a significant change in the PTSC
women’s health locus of control, t(401) ¼ 7.45. They reported a significantly higher sense of control over their
health outcomes at 12-week posttest (M ¼ 31.95, SD ¼
5.82) than they did at pretest (M ¼ 29.24, SD ¼ 7.04).
However, there was no significant pre/post difference in
health locus of control at 6-month follow up.
The findings demonstrated change in the PTSC
women’s health satisfaction after the PTSC intervention.
The women had a significantly higher level of health
satisfaction at 12-week posttest (M ¼ 2.12, SD ¼ .42) than
they did at pretest (M ¼ 1.75, SD ¼ .44), t(401) ¼ 15.95,
p < .001. They also had higher satisfaction scores at 6month (pretest M ¼ 1.83, SD ¼ .44, 6-month post M ¼
2.13, SD ¼ .44, t(124) ¼ 6.60, p < .0001).
The women reported a significant change in attitude
toward the importance of engaging in physical activity/
exercise (at least five times per week). At pretest, 65.5%

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Table 1. Study 1 PTSC Women’s Pre/Post Changes on Selected Psychological and Behavioral Outcomes

Psychological Outcomes

Pretest Mean

Posttest Mean

t-value

df

p-value

Pre/12-week post

3.96 (1.66)

2.99 (1.44)

10.69

366

<.000

Pre/6-month follow up

3.79 (1.59)

3.18 (1.54)

3.96

121

<.000

Pre/12-week post

29.24 (7.04)

31.95 (5.82)

7.45

401

< .000

Pre/6-month follow up

27.26 (6.42)

27.36 (5.88)

.16

129

>.05

Pre/12-week post

1.75 (.44)

2.21 (.42)

15.95

401

< .000

Pre/6-month follow up

1.83 (.44)

2.12 (.44)

6.60

124

<.0001

Posttest Mean

t-value

df

p-value

PTSC stress level

PTSC health locus of control

PTSC health satisfaction

Behavioral Outcomes

Pretest Mean

Engaging in exercise (physical activity)
Pre/12-week post

2.21 days (1.98)

3.26 days (1.75)

10.06

414

<.000

Pre/6-month follow up

2.37 days (1.82)

2.87 days (1.93)

2.60

118

<.01

PTSC healthy eating patterns
Pre/12-week post

2.14 (.39)

2.42 (.36)

15.51

416

< .000

Pre/6-month follow up

2.01 (.38)

2.18 (.29)

4.92

131

<.000

Note: Standard deviations are in parentheses. The mean score on the stress measure can range from 1e7, with higher scores indicating
higher stress levels. The mean scores for day per week engaged in physical activity can range from 0 e 7 days. The scores on the Health
Locus of Control scale could range from 11 e 44, with higher scores indicative of higher mean level of internal health locus of control.
The scores on health satisfaction could range from 1 e 3, with higher scores indicative of higher mean level of satisfaction. The mean
score on the exercise measure can range from 0e7 days. The scores of the healthy eating patterns can range 1 - 3, with higher scores
indicative of engaging in more healthy eating behaviors. It should be further noted that the correlated t-test analyses only retained
women in the pre/post analyses if they participated at both data collection points. For example, if a woman participated in the
baseline and 12 week follow up, but not did not participated in the 6 month follow up, her pretest results will not be included in the
pretest mean for the pre/6-month follow up data in the table. Therefore, pretest means can change across pre/ post data collection
time periods.

rated this item as “very important.” By 12-week and 6month posttest, 77.9% and 79.6%, respectively, rated this
item as “very important”.
Changes in behavioral outcomes. There were statistically significant pre-post differences in the PTSC women’s
behavioral outcomes of interest in this evaluation. In
particular, there were significant changes in the women’s
engagement in physical activity exercise. On average, at
pretest, the PTSC women reported participating in exercise
only 2.21 days per week (SD ¼ 1.98); however, at 12 week
posttest, the women reported participating in exercise, on
average, 3.26 days per week (SD ¼ 1.75), t(389) ¼ 10.06.
The range of engagement in physical exercise undertaken
by the women, at pretest, included: 31% of the PTSC
women reported engaging in physical exercise 0 days per
week and 11.7%, 14.2%, and 43.2%, respectively, reported
engaging in physical exercise 1, 2, or 3 or more days per
week. By 12-week posttest, only 7.4% of the women

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reported engaging in physical exercise 0 days per week
(a decrease of 23.6%); 8.1%, 16.2%, and 68.3%, respectively, reported engaging in physical exercise 1, 2, or 3 or
more days per week. At pretest, only 30.2% of the women
reported that they had exercised regularly over the past
three months, whereas by 12-week posttest, 49.3% of the
women reported that they had exercised regularly over the
past three months. The PTSC women continued to report
engaging in physical activity/exercise significantly more
days at 6-month (p <.01) than they did at pretest.
Additionally, the PTSC women reported significantly
higher levels of healthy eating patterns at 12-week posttest
(M ¼ 2.42, SD ¼ .36) than they did at pretest (M ¼ 2.14,
SD ¼ .38, t(416) ¼ 15.51, p < .000. The positive changes
remained at 6-month posttest. Upon closer examination of
specific eating patterns, the results illustrated improvements toward healthier patterns. For example, at PTSC
baseline, only 16.8% and 9.7% of the women reported,

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on average, that they “always or almost always” watch
their caloric intake and watch their serving size intake. By
12-week posttest, this percentage increased with 37.1%
and 46.1%, respectively, reported “always or almost always” watching their caloric intake and watching their
serving size. At baseline only 34.8% of PTSC women
reported “always or almost always” reading food labels,
whereas by 12-week and 6-month posttest, 53.9% and
54.2%, respectively, reported “always or almost always”
reading food labels. Additionally, at baseline 42.1% of the
PTSC women reported “always or almost always” baking,
grilling, or broiling their food, whereas by 12-week and 6month posttest, 59.9% and 60.8%, respectively, reported
“always or almost always” baking, grilling, or broiling
their food.
The most popular stress management technique utilized by the women included prayer (83.5% at pretest and
89.9% at 12-week posttest). Other stress management
techniques reportedly used by over two-thirds of the
women, at 12-week posttest, included watching television
or a movie (82.2%), exercising (84.3%), talking with
family or friends (79.8%), and listening to music (85.5%).
The results demonstrated that a higher proportion of the
PTSC women reported utilizing deep breathing and
meditation (both skills taught in the PTSC 3-month period)
at posttest (74.3%, 65.9% respectively) than they did at
pretest (48.9%, 41.8% respectively).
Clinical changes. There were significant weight differences for the PTSC women from pretest to posttest. As
expected, the PTSC women demonstrated a significant

reduction in weight from pretest (M ¼ 199.94 lbs., SD ¼
45.34) to 12-week posttest (M ¼ 194.95 lbs, SD ¼ 46.21),
t(305), ¼ 5.20, p < .0001 even though the PTSC is not
mainly a “weight loss program.” The PTSC women
assessed at 6-month follow up continued to demonstrate a
significant weight reduction (pretest M ¼ 200.15 lbs, SD ¼
50.3, 6-month post M ¼ 198.05 lbs, SD ¼ 48.5, t(131) ¼
2.06, p <.05) in comparison to their pretest weight.
As illustrated in Table 2, the BMI classification showed
at pretest, 46.7% (N ¼ 231) of the PTSC women were
classified as obese and 16.8% (N ¼ 83) were classified as
extremely obese. Only 7.5% (N ¼ 37) of the sample was
classified as normal and 29.1% (N ¼ 144) were classified
as overweight. There was a slight decrease of PTSC
women classified as extremely obese and obese at 12-week
posttest. Specifically, at 12-week posttest, 44.5% of the
women (N ¼ 145) were classified as obese and 16% (N ¼
52) were classified as extremely obese; 8.3% (N ¼ 27)
were classified as normal and 31.3% (N ¼ 102) were
classified as overweight. At 6-month follow up, very little
change was observed 42.7% (N ¼ 61) of the PTSC women
being classified as obese and 17.5% (N ¼ 25) were classified as extremely obese.
There were also pre/post changes in the women’s
blood pressure classification. At pretest, approximately
75% of the PTSC women had abnormal blood pressure
readings (Table 2). That is, 39.1% (N ¼ 196) were
classified as hypertensive and 35.7% (N ¼ 179) were
classified as pre-hypertensive with only 25.1% (N ¼
126) being classified as normal. By 12-week follow up,

Table 2. Study1: PTSC Women’s Pre/Post Clinical Results

Clinical Variables

% at Pretest

% at 12-Week Posttest

% at 6-Month Posttest

BMI Classification
7.5%

8.3%

8.4%

Overweight (25e30)

Normal (< 25)

29.1%

31.3%

31.5%

Obese (> 30)

46.7%

44.5%

42.7%

Extremely Obese (> 40)

16.8%

16.0%

17.5%

PTSC Normal (120/70)

25.1%

27.8%

37.2%

Prehypertensive (121/71 to 139/89)

35.7%

42.4%

34.0%

PTSC Hypertensive (> 140/90)

39.1%

29.8%

28.8%

PTSC Normal (less than 139)

84.1%

84.4%

86.7%

PTSC Suspected pre diabetic (140e199)

12.0%

12.2%

11.3%

3.9%

3.4%

2.0%

Blood Pressure Classification

Non-Fasting Blood Sugar Classification

PTSC Suspected diabetics (over 200)

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29.8% (N ¼ 116) of the women were classified as hypertensive; 27.8% (N ¼ 108) and 42.4% (N ¼ 165),
respectively, of the women were classified in the normal
and pre-hypertensive categories, demonstrating a
movement in the right direction of the hypertensive
women into the pre-hypertensive and normal categories.
At 6-month follow up, there was an even greater increase in normal values 37.2%, (N ¼ 58) from the prehypertensive levels, and 28.8% (N ¼ 45) of PTSC
women were hypertensive.
At pretest, 84.1% (N ¼ 407) of the women had
normal non-fasting blood sugar levels, 12.0% (N¼58)
were suspected to be pre-diabetic and 3.9% (N ¼ 19)
were suspected diabetic. By 12-week posttest, 84.4%
(N ¼ 318) of the women were classified in the normal
non-fasting blood sugar category; 12.2% (N ¼ 46) were
suspected to be pre-diabetic and 3.4% (N ¼ 13) were
suspected to be diabetic. Similarly, at 6-month follow up
there was no notable change in suspected abnormal
levels with 86.7% (n ¼ 130) of the women classified as
normal (Table 2).

EVALUATION STUDY 2 e PTSC VS.
COMPARISON WOMEN
METHODOLOGY
Data Collection Sites and Participant
Description
The second evaluation study reported in this article presents findings from a subset of the PTSC sites with comparison data from those locations. This study limited
intervention/comparison analyses to PTSC interventions
taking place in Tampa, Florida and Baltimore, Maryland
during 2009e2010. The Study 2 evaluation consisted of a
pre/post quasi-experimental design.
The participants for the Study 2 evaluation included
211 African American women who received the PTSC
intervention and 55 comparison women. Of the PTSC
women, 165 completed the 12-week self-report posttest
(78.2% survey retention rate), and 174 women completed
the 6-month self-report posttest (82.5% survey retention
rate). In addition, clinical assessments were taken at
baseline (N ¼ 167), 12-week posttest (N ¼ 137) (82%
clinical assessment retention rate), and 6-month posttest
(N ¼ 109) (65.2% clinical assessment retention rate) for
the PTSC women. The 55 comparison women who
completed the evaluation survey at baseline were recruited
from one Tampa comparison site and one Baltimore
comparison site. A total of 48 comparison women
completed the posttest survey at 12 weeks (87.3%
survey retention rate) and 42 (76.4% survey retention

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rate) comparison women completed the survey at the
6-month posttest. Of these comparison women, clinical
assessments were taken at baseline (N ¼ 55), 12-week
posttest (N ¼ 42) (76.4% clinical assessment retention
rate) and 6-month posttest (N ¼ 32) (58.2% clinical
assessment retention rate).
The comparison women were comparable to the intervention demographically-age, race/ethnicity, and socioeconomic status (e.g., education, income). The instruments
and procedures for Study 1 and Study 2 were identical,
with the exception of activities of the comparison group.
The comparison group received the copy of the Gaston and
Porter (48) text, but did not receive a curriculum, facilitator, or expert consultants. The women in the comparison
group received a stipend of $10 at pre/ post and 6 month
follow-up.

RESULTS
The PTSC and comparison women were compared on the
same dimensions as the participants in Study 1. Results
showed positive differences in selected outcomes in the
PTSC group relative to the comparison group (See
Tables 3 and 4). The PTSC women reported significantly
lower levels of stress at 12-week posttest and 6-month
posttest than they did at pretest (p < .05), while the
comparison group reported no significant pre/post
changes in stress level at 12-week or 6-month follow up.
The PTSC women reported a significantly higher level of
health satisfaction at 12-week and 6-month posttest than
they did at baseline (p < .05). There was also a significant pre/12-week post change in health satisfaction for
the comparison women (p ¼ .05). However, there were
no significant differences in the PTSC or comparison
women’s locus of health control from baseline to posttest
(12 week or 6 months).
The PTSC women reported engaging in more physical
activity/exercise at posttest than they did a pretest (p <
.05), whereas no significant change occurred for the
comparison group. At pretest, 28.9% of the PTSC women
(19.5% comparison women) reported engaging in physical
exercise 0 days per week. By 12-week posttest, only
3.74% of the PTSC women (19.5% comparison women)
reported engaging in physical exercise 0 days per week. In
terms of the women’s attitude toward the importance of
engaging in physical activity/exercise (at least five times
per week), at pretest, 68.8% PTSC women (64.8% comparison women) rated this item as “very important.” By
12-week and 6-month posttest, 79.0% PTSC women
(52.5% comparison women) and 76.4% PTSC women
(58.1% comparison women), respectively, rated this item
as “very important”.

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Table 3. Study 2: PTSC and Comparison Women’s Pretest/12-Week Post Changes in Selected Psychological and Behavioral Outcomes

Psychological Outcomes

Pretest Mean

12-Week Posttest Mean

t-value

df

PTSC women stress level

3.61 (1.70)

2.99 (1.50)

3.68

117

Comparison women stress level

3.97 (1.74)

3.92 (1.70)

.168

p-value
.001

37

> .05

PTSC women health locus of control

26.98 (5.10)

27.67 (5.93)

1.24

129

>.05

Comparison women locus of control

28.6 (4.47)

30.29 (6.13)

1.43

38

>.05

PTSC women health satisfaction

1.86 (.43)

2.21 (.43)

8.12

121

.001

Comparison women health satisfaction

1.87 (.50)

2.02 (.52)

1.99

38

.05

Pretest Mean

12-week Posttest
Mean

t-value

df

p-value

PTSC women engaging in exercise
(physical activity)

2.40 (1.82)

2.92 (1.91)

2.37

87

< .05

Comparison women engaging in
exercise (physical activity)

2.78 (2.06)

2.75 (1.83)

25

> .05

PTSC women healthy eating patterns

1.89 (.35)

2.25 (.35)

10.12

130

Comparison women healthy eating

1.89 (.41)

1.93 (.30)

1.23

37

Behavioral Outcomes

.093

< .0001
> .05

Note: Standard deviations are in parentheses. The mean score on the stress measure can range from 1e7, with higher scores indicating
higher stress levels. The mean scores for day per week engaged in physical activity can range from 0 e 7 days. The scores on the Health
Locus of Control scale could range from 11 e 44, with higher scores indicative of higher mean level of internal health locus of control.
The scores on health satisfaction could range from 1 e 3, with higher scores indicative of higher mean level of satisfaction. The mean
score on the exercise measure can range from 0e7 days. The scores of the healthy eating behaviors can range 1 - 3, with higher scores
indicative of engaging in more healthy eating behaviors. It should be further noted that the correlated t-test analyses only retained
women in the pre/post analyses if they participated at both data collection points. For example, if a woman participated in the
baseline and 12 week follow up, but not did not participated in the 6 month follow up, her pretest results will not be included in the
pretest mean for the pre/6-month follow up data in the table. Therefore, pretest means can change across pre/post data collection
time periods.

Additionally, the PTSC women reported significantly
higher levels of healthy eating patterns at 12 week and 6month posttest than they did at pretest (p < .001). For the
comparison group, there was no significant difference reported for healthy eating at 12-week posttest; however, the
comparison group also reported a significantly higher level
of healthy eating at 6-month follow up (p < .05).
A higher proportion of the PTSC women reported utilizing healthy stress management strategies such as exercise, deep breathing, and meditation at 12 weeks posttest
(90.7%, 77.9%, 77.9% respectively) than they did at
baseline (66.7%, 46.4%, and 41.1% respectively). This
pattern of change was also evident for the comparison
group. That is, among the comparison women, a much
larger proportion of them reported utilizing exercise, deep
breathing, and meditation stress management strategies 12
weeks posttest (73.8%, 53.7%, 64.3% respectively) than
was the case at baseline (19.5%, 18.8%, 23.8%
respectively)
Clinical changes. There were notable improvements for
the PTSC women on various clinical outcomes. For

14

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example, there was a statistically significant reduction in
the PTSC women’s weight from baseline to 12-week and
6-month posttest (p < .05). No significant pre-post weight
reduction emerged for the comparison women. Overall,
changes in the PTSC women’s BMIs showed positive
improvement.
Additionally, the PTSC women did show improvement on other clinical outcomes. For example, in terms
of blood pressure classification, a lower proportion of
PTSC women were classified in the hypertensive category at 12-week (40.7%) and 6-month (34.3%) posttest
than at baseline (45.7%). The results were mixed in
terms of posttest blood pressure classification for the
comparison women (i.e., higher proportion of comparison women in the normal category at 12-week posttest,
35.7%, than at baseline, 16.7%, or 6-month posttest,
6.5%). In terms of non-fasting blood sugar classification, a lower proportion of PTSC women had suspected
diabetes readings at 12-weeks (32.5%) and 6-months
(27.4%) than was the case at baseline (36.1%),
whereas the suspected diabetes readings for the

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Table 4. Study 2: PTSC and Comparison Women’s Pretest/6-Month Post Changes in Selected Psychological and Behavioral Outcomes

Psychological Outcomes

Pretest Mean

6-Month-Week
Posttest Mean

t-value

df

PTSC women stress level

3.55 (1.56)

3.09 (1.51)

2.58

93

<.05

p-value

3.97 (1.75)

3.92 (1.69)

.168

37

> .05

27.53 (5.13)

27.0 (6.29)

.827

95

>.05

Comparison women health locus of control

28.8 (4.49)

27.81 (5.84)

.96

30

>.05

PTSC women health satisfaction

1.95 (.43)

2.13 (.43)

3.41

.90

Comparison women health satisfaction

1.81 (.50)

1.99 (.52)

1.93

28

Comparison women stress level
PTSC women heath locus of control

Behavioral Outcomes

.0001
>.05

Pretest Mean

6-month Posttest Mean

t-value

2.40 days (1.82)

2.92 days (1.91)

32.37

87

< .05

Comparison women engaging in
exercise (physical activity)

2.78 (2.06)

2.75 (1.83)

.09

25

> .05

PTSC women healthy eating)

1.90 (.34)

2.22 (.29)

8.68

97

< .0001

Comparison women healthy eating

1.94 (.40)

2.20 (.36)

3.29

29

< .05

PTSC women engaging in exercise
(physical activity)

df

p-value

Note: Standard deviations are in parentheses. The mean score on the stress measure can range from 1e7, with higher scores indicating
higher stress levels. The mean scores for day per week engaged in physical activity can range from 0 e 7 days. The scores on the Health
Locus of Control scale could range from 11 e 44, with higher scores indicative of higher mean level of internal health locus of control.
The scores on health satisfaction could range from 1 e 3, with higher scores indicative of higher mean level of satisfaction. The mean
score on the exercise measure can range from 0e7 days. The scores of the healthy eating behaviors can range 1 - 3, with higher scores
indicative of engaging in more healthy eating behaviors. It should be further noted that the correlated t-test analyses only retained
women in the pre/post analyses if they participated at both data collection points. For example, if a woman participated in the
baseline and 12 week follow up, but not did not participated in the 6 month follow up, her pretest results will not be included in the
pretest mean for the pre/6-month follow up data in the table. Therefore, pretest means can change across pre/post data collection
time periods.

comparison women did not consistently improve. (See
Table 5 below)

LIMITATIONS
The results of these two evaluation studies must be
considered in view of several limitations. First, while the
response rate is quite respectable, there is attrition among
the participants across the various testing periods (from
baseline to 12-week posttest to 6-month posttest) that must
be recognized as potentially influencing the results. Second, the Study 2 comparison group is relatively small
which may limit its representativeness. Third, in
responding, the women’s self-reports may be influenced by
social desirability bias, that is, the participants’ tendency to
respond in ways to present themselves in the best possible
light. Fourth, we acknowledge that reports of statistical
significance and standard deviations, alone, from selfreport data do not provide sufficient information
regarding the clinical or practical importance of the findings of this study. Therefore, another limitation is the
inability to assess the clinical significance of all the

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findings, particularly those stemming from the self-report
measures. However, the inclusion of clinical assessments
provides some insight to the clinical value of findings from
this study.

SUMMARY AND CONCLUSIONS
Despite the limitations, the major strength of the results
reported from these present studies is its contribution
to the literature of health outcomes of midlife African
American women. Unfortunately, there continues to be a
paucity of empirical research on midlife African American
women’s health and their risk for chronic disease.
Particularly sparse are studies with large sample sizes,
reflecting the outcomes of African American women from
different regions of the country diverse socioeconomic
levels and including both self-report and clinical data. The
results reported in this article contribute to filling this void
by extending the knowledge base about midlife African
American women’s health outcomes and the effectiveness
of the PTSC on these outcomes over a 12-week and
6-month period.

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THE PRIME TIME SISTER CIRCLES® INTERVENTION

Table 5. Study 2: PTSC and Comparison Women’s Pre/Post Clinical Results

Clinical Variables

% at Pretest

% at 12-Week

% at 6-Month

Posttest

Posttest

BMI Classification
PTSC BMI Normal (< 25)

6.2%

11.5%

9.7%

Comparison BMI Normal (< 25)

20.0%

19.0%

15.6%

PTSC BMI Overweight (25e30)

32.9%

32.0%

31.1%

Comparison BMI Overweight (25e30)

27.3%

21.4%

28.1%

PTSC BMI Obese (> 30)

37.3%

36.1%

39.8%

Comparison BMI Obese (> 30)

41.8%

50.0%

40.6%

PTSC Extremely BMI Obese (> 40)

26.6%

20.5%

19.4%

Comparison Extremely BMI Obese (> 40)

10.9%

9.5%

15.6%

PTSC Normal (120/70)

20.1%

18.5%

29.5%

Comparison Normal (120/70)

16.7%

35.7%

6.5%

PTSC Hypertensive (> 140/90)

45.7%

40.7%

34.3%

Comparison Hypertensive (> 140/90)

63.0%

54.8%

67.7%

PTSC Normal (less than 139)

38.7%

34.2%

43.4%

Comparison Normal (less than 139)

14.5%

50.0%

6.5%

Blood Pressure Classification

Non-Fasting Blood Sugar Classification

PTSC Suspected pre diabetic (140e199)

36.1%

33.3%

29.2%

Comparison Suspected pre diabetic (140e199)

43.6%

18.8%

25.8%

PTSC Suspected diabetics (over 200)

36.1%

32.5%

27.4%

Comparison Suspected diabetic (over 200)

43.6%

31.3%

67.7%

Note: The women classified as pre-hypertensive were not included in this table.

Findings from the evaluation of 31 groups of PTSC
women (N ¼ 656 at baseline) from Washington, DC,
Tampa, Florida, and Baltimore, Maryland indicated significant changes in the women’s psychological, behavioral,
and clinical changes from baseline to 12-week and 6month posttest. Key Study 1 findings included significant
changes from baseline in the PTSC women’s: (a) reported
level of stress, (b) health locus of control, (c) health
satisfaction, (d) engagement in physical activity/exercise,
and reported healthy eating patterns. Additionally, based
upon clinical data, the PTSC women demonstrated a
weight reduction at posttest and slightly more women had
better clinical outcomes in terms of classification of BMI,
hypertension, and non-fasting blood sugar. The results
from the Study 2 evaluation strengthen the claims of the
effectiveness of the PTSC intervention with significant
pre/posttest changes evident for the PTSC women on
selected outcomes and little to no statistically significant

16

VOL. 108, NO 1, SPRING 2016

pre/post changes for the comparison women on the health
indicators under study.
The evaluation studies reported in this article reaffirm
the findings regarding the effectiveness of the PTSC, as
originally reported in Gaston, Porter, and Thomas.38 The
present evaluation extends the generalizability of the
original findings across different samples, settings, and
time frame. The current evaluation strengthens the credibility of findings by examining participants’ clinical outcomes in addition to their self-reported data.
The data obtained in this evaluation provide important
information about an underserved and neglected population, African American women in midlife, who are at the
highest risk for chronic illnesses. This selected age group
of women is critical to the spread of healthy lifestyle habits
among their families and communities. The importance
and utility of health promotion and disease prevention
interventions, which are culturally sensitive and age and

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THE PRIME TIME SISTER CIRCLES® INTERVENTION

gender-specific and have useful implications for clinicians
and researchers, are documented. This evaluation, consistent with the 2007 study, demonstrates the positive interactive impact of a program, PTSC, on selected
psychological, behavioral, and clinical dimensions of
health. These results support the PTSC as a useful addition
to ongoing quality primary care programs for this target
population to enhance psychological and clinical outcomes
and decrease African American women’s risk factors for
chronic diseases.

11. Mitchell, A. J., & Herring, K. (1998). What the Blues Is: Black
Women Overcoming Stress and Depression. New York, NY:
Perigee.
12. Miranda, J., & Cooper, L. A. (2004). Disparities in Care for
Depression Among Primary Care Patients. Journal of General
Internal Medicine, 19, 120e126.
13. Das, A. K., Olfson, M., McCurtis, H. L., & Weissman, M. M. (2006).
Depression in African Americans: Breaking barriers to detection
and treatment. J Fam Practice, 55(1), 30.
14. Prendergast, H. M., Bunney, E. B., Robertson, T., & Davis, T.
(2004). Knowledge of heart disease among women in an ur-

REFERENCES
1. Centers for Disease Control and Prevention. (2011). Health
Disparities and Inequalities Report. MMWR, 60(Suppl), 1e116.
2. National Center for Health Statistics. (2012). Health, United
States, 2011: With Special Feature on Socioeconomic Status
and Health. Hyattsville, M.D.
3. Mochari-Greenberger, H., Miller, K. L., & Mosca, L. (2012).
Racial/ Ethnic and Age Differences in Women’s Awareness of
Heart Disease. Journal of Women’s Health, 21(5), 476e480.
4. Mosca, L., Hammond, G., Mochari-Greenberger, H., Towfighi,
A., Albert, M. A., &, on behalf of the American Heart Association Cardiovascular Disease and Stroke in Women and Special

ban setting. JNMA, 1027e1031.
15. Mosca, L., Manson, J. E., Sutherland, S. E., Langer, R. D., Manolio, T., & Barrett-Connor, E. (1997). Cardiovascular disease in
women: A statement for healthcare professionals from the
American Heart Association. Circulation, 96, 2468e2482.
16. Warren, T. Y., Willcox, S., Dowda, M., & Baruth, M. (2012). Independent Association of Waist Circumference With Hypertension and Diabetes in African American Women in South
Carolina. 2007e2009. Prev Chronic Disease, 9, 110170.
17. Rozanski, A., Blumenthal, J. A., & Kaplan, J. (1999). Impact of
psychological factors on the pathogenesis of cardiovascular
disease and implications for therapy. Circulation, 99,
2192e2217.

Populations Committee of the Council on Clinical Cardiology,

18. Rafenmelli, C., Pancaldi, L. G., Ferranti, G., et al. (2005). Stressful

Council on Cardiovascular Nursing, Council on High Blood

life events and depressive disorders as risk factors for acute

Pressure Research, and Council on Nutrition, Physical Activity

coronary heart disease. Ital Heart J Suppl, 6(2), 105e110.

and Metabolism. (2013). Fifteen-year trends in awareness of
heart disease in women: results of a 2012 American Heart Association national survey. Circulation, 127, 1254e1263.
5. Bromberger, J. T., Harlow, S. D., Avis, N. E., Kravitz, H. M., &
Cordal, A. (2004). Racial/ethnic differences in the prevalence
of elevated depressive symptoms in midlife women: The Study
of Women’s Health Across the Nation (SWAN). Am J Pub
Health, 94, 1378e1385.
6. Spence, N. J., Adkins, D. E., & Dupre, M. E. (2011). Racial Differences in Depression Trajectories among Older Women: Socioeconomic, Family, and Health Influences. Journal of Health
and Social Behavior, 52(4), 444e459.

19. Steptoe, A., & Kivimäki, M. (2012). Stress and cardiovascular
disease. Nature Reviews Cardiology, 9, 360e370.
20. EschT, Stefano,GB, Fricchione,GL, & Benson, H. (2002). Stress in
cardiovascular diseases. Med Sci Monit, 8(5), RA 93e101.
21. Dimsdale, J. E. (2008). Psychological; Stress and Cardiovascular
Disease, M.D. J AM Coll Cardiol, 51(13), 1237e1246.
22. Thaker, P. H., Lutgendorf, S. K., & Sood, A. K. (2007). The
Neuroendocrine Impact of Chronic Stress on Cancer. Cell
Cycle, 6(4), 430e433.
23. Casper, M. L., Barnett, E., Halverson, J. A., Elmes, G. A., Braham,
V. E., Majeed, Z. A., et al. (2000). Women and Heart Disease: An

7. Commonwealth Fund, Selected Facts on U.S. Women’s Health:

Atlas of Racial and Ethnic Disparities in Mortality (2nd ed).

A Chart Book (New York: Commission on Women’s Health,

Morgantown WV: Office for Social Environment and Health

College of Physicians and Surgeons. (1997). Columbia University.

Research, West Virginia University.

8. Schultz, A., Israel, B., Williams, D., et al. (2000). Social Inequalities

24. National Center for Health Statistics. (2006). Health, United

Stressors and self-reported health stat. Soc Sci Med, 51,

States, 2006 with Chartbook on Trends in the Health of Ameri-

1639e1659.

cans. Hyattsville: Maryland.

9. Fiscella, K., & Franks, P. (1997). Does Psychological Distress

25. Govil, S. R., Weidner, G., Merritt-Worden, T., & Ornish, D. (2009).

contribute to racial & socieconom disparities in mortality? Soc
Science Med, 45, 1805e1809.

Socioeconomic status and improvements in lifestyle, coronary risk
factors, and quality of life: The multisite cardiac lifestyle interven-

10. Neal, A. M. J., & Turner, S. (1991). Anxiety Disorders Research
with African Americans. Current Status. Psychological Bulletin,
109(3).

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

tion program. American Journal of Public Health, 99, 1263e1270.
26. Mosca, L., Benjamin, E. J., & Berra, K. (2011). Effectivenessbased guidelines for the prevention of cardiovascular disease

VOL 108, NO 1, SPRING 2016 17

THE PRIME TIME SISTER CIRCLES® INTERVENTION
in women: 2011 update: a guideline from the American Heart

33. Drayton-Brooks, S., & White, N. (2004). Health promoting be-

Association [published correction appears in Circulation.

haviors among African-American women with faith-based

2011;123:e624] Circulation, 123, 1243e1262.

support. J Assoc Black Nurs, 15(5), 84e90.

27. Chomistek, A. K., Manson, J. E., Stefanick, M. L., et al. (2013).
Relationshipof sedentary behavior and physical activity to
incident cardiovascular disease: results from the Women’s
Health Initiative. Journal of the American College of Cardiology, 61, 2346e2354.
28. National Center for Health Statistics. (2012). Healthy People
2010 Final Review. Hyattsville, M.D.
29. Ford, E. S., Zhao, G., Tsai, J., & Li, C. (2011). Low-Risk Lifestyle
Behaviors and All-Cause Mortality: Findings From the National
Health and Nutrition Examination Survey III Mortality Study. Am J
Public Health, 101(10), 1922e1929.
30. Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L.
(2004). Actual Causes of Death in the United States 2000.
JAMA, 291, 1238e1245.
31. Dong-Chul, & Torabi Mohammad, R. (2006). Racial/ethnic
differences in body mass index, morbidity and attitudes toward obesity among U.S. adults. J Natl Med Assoc, 98(8),
1300e1308.
32. Foster-Schubert, K. E., Alfano, C. M., Duggan, C. R., Xiao, L.,
Campbell, K. L., Kong, A., et al. (2012). Effect of diet and

18

34. Bandura, A. (1986). Social foundation of thoughts and actions:
A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.
35. Prochaska JO, Velicer WF. (Sept. to Oct. 1997). The transtheoretica1 model of health behavior change. American
Journal of Health Promotion, 12(1).
36. Airhihenbuwa, C.O. (1992). Health Promotion and Disease
Preventive strategies for African Americans: A Conceptual
Model. In R. L. Braithworth, & S. E. Taylor (Eds.), Health issues in
the Black community. San Francisco: Jossey-Bass.
37. Gaston, M. H., & Porter, G. K. (2001, 2003). Prime time: The African
American woman’s complete guide to midlife health and
wellness. New York: Ballantine Publishing Group, Random House.
38. Gaston, M. H., Porter, G. K., & Thomas, V. G. (2007). Prime Time
Sister CirclesTM Evaluating a Gender Specific, Culturally Relevant Intervention to Decrease Major Risk Factors in Mid-Life
African American Women. Journal of the National Medical
Association, 99(4), 428e438.
39. Wallston, B. S., Wallston, K. A., Kaplan, G. D., & Maides, S. A.
(1976). The development and validation of the health related
locus of control (HLC) scale. J Consult Clin Psych, 44, 580e585.

exercise, alone or combined, on weight and body composition

40. Gaston, M. H., Porter, G. K., & Thomas, V. G. (2011). Paradoxes

in overweight-to-obese postmenopausal women. Obesity

in obesity with mid-life African American women. Journal of the

(Silver Spring), 20(8), 1628e1638.

National Medical Association, 103(1), 17e25.

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