SHE Tribe: An Intervention to Improve Health Behavior Among Women in Underserved Communities

The leading causes of death for women in the United States are heart disease, cancer, and
stroke. Chronic diseases disproportionately affect underserved communities where race,
poverty, education-level, healthcare access, and other social and environmental determinants
intersect. African-American (AA) and Hispanic women are at particularly high risk for
diabetes-related mortality 1 and are more likely than white women to be functionally impacted
by chronic disease . Factors associated with increased disease risk include physical
inactivity, poor nutrition, obesity, underutilization of health screenings, and high
stress/allostatic load . While healthy lifestyle behaviors have been identified as
instrumental to preventing chronic disease, programs to successfully promote healthy behavior
adoption in underserved communities have had limited sustainable success, due in part to
perceived relevance of program outcomes, lack of cultural tailoring, access to care, and lack
of social support for health behavior change.

The Texas Center for Health Disparities received National Institute of Minority Health and
Health Disparities funding to address women's chronic health conditions through community
outreach and research strategies from 2012-2017. A workgroup of community members, former
research and program participants, and University of North Texas Health Science Center
faculty and staff utilized a Community-Based Participatory Research (CBPR) process to design
SHE Tribe (She's Healthy and Empowered), a social-network based initiative to support healthy
behavior adoption among women in underserved communities. This effort was based on earlier
findings that women in underserved neighborhoods were often resistant to participating in a
"disease-labeled" intervention (e.g., obesity prevention) and expressed a desire to practice
wellness-oriented behaviors that have been adapted for their social and cultural groups.
These findings were consistent with the growing body of literature indicating that being
"healthy and strong" is perceived as more desirable than engaging in a program where the
explicit expectation is to lose weight. As part of the development process, the workgroup
sought to develop a sustainable, evidence-based approach that would appeal to underserved
communities that are disproportionately impacted by chronic disease.

Components of SHE Tribe include evidence-based characteristics associated with the adoption
and maintenance of health behaviors: a) incorporating social network to promote healthy
activities, b) setting goals that are specific to the needs and interests of the individual ,
c) self-monitoring of desired behaviors, d) motivational interviewing-based dialogue that
promotes intrinsic motivation to change, e) choosing small units of change for the purpose of
habit formation, and f) combining practice and reflection to promote integration with
existing life patterns and beliefs. The advantage of SHE Tribe over previous models is its
explicit use of social networks and reliance on a broader set of activities that are
consistent with a healthy lifestyle rather than disease. SHE Tribe was initially pilot-tested
with a small cohort of 5 peer facilitators. Based on their feedback, it was then enhanced to
include telephone or tablet-based assessment and tailored feedback at the beginning
(baseline) and end of each 5-session cycle. The current version is being pilot-tested as a
community-initiated project, and as such includes only a basic set of assessment tools that
are necessary to make the intervention work. The purpose of this 2-year exploratory
submission is to examine the effects of SHE Tribe on key health outcomes such as health
self-management, coping, diet, activity, and social network health norms.

AIM 1. Determine whether SHE Tribe can be feasibly implemented with groups of women from
communities at high risk for chronic health conditions. The research team will examine the
characteristics of women recruited to SHE Tribe to determine whether the network-based
recruitment is an effective method for reaching the underserved communities. This will
include a review of audio-recorded sessions, session summary reports, and semi-structured
interviews with participants and facilitators to understand the perceived value and adoption
of different intervention components.

AIM 2. Examine how health behaviors are adopted by individuals and diffused through social
networks. At the individual level: Using validated measures, the research team determine
which goals are selected and the relationship between goal selection, key health outcomes,
and activation of health behavior self-management. At the interpersonal level: Using a social
network analysis instrument which measures participants' perceptions of identified
individuals in their networks, the research team will examine the diffusion of healthy
lifestyle norms.

The impact of this study will be the refinement of an intervention that supports
sustainability and reach in underserved communities that are at high-risk for chronic
diseases. The emphasis on a constellation of healthy behaviors and the use of peer
facilitators will appeal to the cultural identities of women residing in underserved and/or
high poverty communities.

Inclusion Criteria:

- Female

- representative of underserved community (determined by race, ethnicity, socioeconomic
status, and/or neighborhood)

- 18 and older

Exclusion Criteria:

- Males

- Children