Improving mental health in black men through a 24-week community-based lifestyle change intervention: the black impact program

The Black Impact community-based participatory research intervention has been described previously [27]. Briefly, in this single-arm pilot program, we enrolled Black men from the annual AAMWA walk/health fair with poor or average cardiovascular health (< 4 LS7 metrics in the ideal range). The inclusion criteria included: (1) Black men (self-report); (2) adults aged 18 years or older; (3) English speaking; (4) live in Metropolitan Columbus, Ohio area; (5) no healthcare provider-imposed limitations on physical activity; and (6) participant is appropriate for a group setting (e.g., does not have untreated psychosis or behavioral challenges). In July 2020, the study began with 74 participants and the programming phase was implemented over 24 weeks through December 2020. The flow of participants through the intervention is shown in Supplemental Fig. 1. The sample size was based on the number of participants needed to determine effect sizes for the primary outcome (50–100 participants). Baseline, 12 and 24-week biometric health screenings occurred at study sites, and survey data were collected electronically via research electronic data capture (REDCap). The study was reviewed and approved by The Ohio State University Biomedical Sciences Institutional Review Board (Study ID: 2019H0302). The study was retrospectively registered on ClinicalTrials.gov: NCT04787978 (09/03/2021). All participants provided written informed consent.

The 24-week community-based lifestyle intervention aimed to improve cardiovascular health among Black men. The intervention was adapted from the Diabetes Prevention Program [42] and American Heart Association Check, Change, Control programs applying evidence-based strategies and stakeholder feedback [43]. Thus, participants were not randomized, and all received the entire intervention. Each participant was assigned to a community health worker and grouped into 6 teams of 8–25 participants based on participant proximity to a central meeting location (e.g. Columbus Recreation and Parks recreation center). Each team had a personal trainer who delivered the physical activity curriculum. The personal trainers had pre-intervention meetings with American College of Sports Medicine Certified Personal Trainer (ACSM-CPT). They were trained in a standardized, 45-minute workout with increasing intensity over the study intervention consistent with Exercise is Medicine [27].

The 30-minute health coach led sessions focused on the Diabetes Prevention Program, AHA Check, Change, Control Curriculum, cooking, grocery store shopping, mental health, historical trauma, stress, financial wellness, and cancer screening [27]. Specifically in relation to mental health in Week 8, historical trauma, stress management and mental health strategies & resources were discussed by a mental health counselor from a local public health agency (18 min), followed by an introduction to a local resource for Black men to discuss mental health on a quarterly basis in a large group format 100–200 men (AAMWA Barbershop Talk and Real Men, Real Talk, 2 min) and DPP Session 15: Stress Management (10 min). In Week 13, DPP Session 11: Talk Back to Negative Thoughts (30 min) has mental health components [44]. Fourteen participants in the program attended one session of Barbershop Talk: Real Men, Real Talk where they discussed the importance of Black men being able to talk about mental health issues (2 h). Key health coach activities included delivering education and establishing and monitoring progress in achieving individual and team-based SMART (specific, measurable, achievable, relevant, and time-bound) wellness goals. The health coaches were healthcare providers (2 physicians and 1 nurse practitioner) experienced in lifestyle change, each assigned 2 teams. They were assisted by Ohio State University nursing students from Nursing Students Promoting Initiatives Reinforcing Equity (NSPIRE). All instructors were trained in the curriculum and protocol. Healthy food samples, cross-trainer shoes, GARMIN watches, and workout bands were provided to all participants. Individual incentives (e.g., gift cards) were provided to participants for follow-up survey completion. All participants received a one-year gym membership to a local recreation and park center at the study end for participating in the intervention.

Assessments were performed at baseline, 12 weeks, and 24 weeks. Data from participants included self-reported measures (sociodemographic and self-reported health history) and survey data collected via REDCap [27, 45]. The sociodemographic data included age, education, race, ethnicity, employment status, insurance status, and annual income. The self-reported health history included hypertension, diabetes, hyperlipidemia, and smoking status (I have never smoked, I currently smoke, I quit smoking > 1 year ago or I quit smoking ≤ 1 year ago), as well as medications for the aforementioned chronic conditions [27, 45].

The survey data included the following mental health questionnaires: Center for Epidemiological Studies Depression (CES-D) Scale,[46] Patient Health Questionnaire 2-question (PHQ-2) depression screener [47], Perceived Stress Scale (PSS) [48], and the Short Form Survey (SF-36) [49].

The CES-D survey is a 20-item scale measuring self-reported symptoms of depression experienced in the past week including depressed mood, feelings of guilt and worthlessness, feeling of helplessness and hopelessness, loss of energy, sleep disturbance, and change in appetite. Each item is scored 0 to 3 on a Likert scale (e.g. 0: “not at all”; 1: “a little”; 2: “some;” 3: “a lot”) for frequency of symptoms in the last week, for a total score range of 0 to 60 with higher scores suggesting a greater presence of depressive symptoms. The CES-D is validated across age, sex and race categories [50].

The PHQ-2 is a two-item questionnaire that assesses the frequency of depressed mood and anhedonia over the past two weeks [47]. Each question is scored on a ranges from 0 to 3 (0: “not at all;” 1: “several days;” 2: “more than one-half the days;” 3: “nearly every day”).

The PSS-10 is a 10 question stress assessment instrument to measure the perception of stress [48]. The questions in this scale ask about your feelings and thoughts during the last month and are scored on a 5-point Likert scale (0: “never;” 1: “almost;” 2: “sometimes;” 3: “fairly often;” 4: “very often”) [48]. The scale is valid and reliable [51].

The Short Form Survey (SF-36) is a 36-item questionnaire assessing self-reported health status. It is a general measure of health-related quality of life [52, 53]. Reliability estimates for summary measures are ≥0.90 [52, 53]. The SF-36 is composed of 8 multi-item scales (35 items) assessing physical function (10 items), role limitations due to physical health problems (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social functioning (2 items), role limitations due to emotional problems (3 items) and emotional well-being (5 items). These eight scales are aggregated into two summary measures: the Physical and Mental Component Summary (MCS) scores, as mental health symptoms increase, MCS scores decrease.

Biometric screenings including blood pressure (mmHg), fasting cholesterol (mmol/L), fasting glucose (mmol/L), weight (lbs), and BMI were performed by trained healthcare staff, including nurses and physicians. Blood pressure was checked via an automated oscillometric sphygmomanometer (Omron 5 series) with two measurements performed after the participants were seated for 5 min and averaged [27, 45]. Weight was measured using a zeroed and calibrated Omron Body Composition Monitor and Scale (Model: HBF-514 C). Height was measured via a tape measurer [27, 45]. BMI was calculated by multiplying weight (lbs) by 703 and then dividing by height squared (inch²). Blood total cholesterol and glucose were measured in the fasting state using the Cardio Check Silver® (Polymer Technology, Inc., Heath, OH, USA) device [27, 45].

A cardiovascular health (CVH) score was summed based on the individual LS7 metrics (glucose, cholesterol, blood pressure, BMI, physical activity, diet and smoking) categories of poor (0 points), intermediate (1) and ideal (2) CVH with a total score ranging from 0 to 14 at baseline, 12 and 24 weeks. Additionally, analyses used 6 components of the CVH score excluding diet (range 0–12; LS6) and 5 components excluding diet and physical activity (range 0–10; LS5), as has been done previously [27].

Descriptive statistics were performed for all variables, including mean (standard deviation [SD]) for continuous variables and frequencies and percentages for categorical variables. Correlations between baseline variables were assessed via linear models in a pairwise fashion to evaluate concordance between the mental health measures. The primary analysis was change in mental health measures during the intervention. The change in mental health scores from baseline to 12 and 24 weeks were evaluated using linear mixed-effects models adjusting for age, education, and income. Secondary analyses included: (1) Change in CVH scores by baseline mental health were evaluated using linear mixed-effects models with an interaction term (time*baseline mental health variable) and a random intercept for each participant; and (2) The correlation between change in mental health and change in cardiovascular health scores by: (A) Fitting a mixed effect model describing each outcome variable with a random slope for time for each participant. These random slopes were extracted and saved. Linear models were run comparing the generated slopes for one outcome variable to the generated slopes from another outcome variable; and (B) Calculating differences (ΔX = X₁-X₀), where X₀ is the baseline value and X₁ is the value at either 12 or 24 weeks. Differences in one variable were used to describe differences in another variable in linear models. Statistical significance for all analyses was defined as two-sided alpha < 0.05. All statistical analyses were performed using R statistical software version 4.05 (R Foundation for Statistical Computing, Vienna, Austria).

Divergent from the baseline mental health to LS7 associations in Black Impact, the majority of the extant literature in multi-racial and Black American observational cohort studies demonstrates that depressive symptoms and perceived stress are associated with poor levels of LS7 scores with an overall greater effect among the behavioral components of LS7 (smoking, physical activity, diet, and body mass index) including among Black Americans in the REGARDS study [19, 38, 41]. In Black Americans in the Jackson Heart Study, participants with higher scores for minor stressors and stressful major life events were less likely to achieve higher levels of CVH scores, with no difference between men and women [34]; and participants with hypertension with both high stress and depressive symptoms had lower composite LS7 than those with low stress and depressive symptoms [56]. While the findings are not consistent with the cross-sectional Black impact results, they are consistent with longitudinal findings in Black Impact that baseline depression was associated with a significant reduction in improvement for LS5 at Week 12 and trends towards reductions at Week 24 for depressive symptoms and Week 12 and 24 for perceived stress.

Additionally, the mental health-LS7 relationship is bi-directional with observational studies showing an association of LS7 with depressive symptoms and stress [35, 39, 57]. Baseline behavioral CVH score was inversely associated with perceived stress at four years, even after adjustment for perceived stress measured at baseline (p < 0.001) [41]. The differential findings in Black Impact may be due to a smaller sample size than prior studies, although it is important to note that the majority of the extant literature does not specifically examine these relationships among Black men. Among Black men, there may be domains of depressive or stress symptoms that are not captured by CES-D, PHQ-2, MCS or PSS. In a recent study by Adams et al. [58], investigators hypothesized that “Black men’s marginalized social status in the United States fundamentally shapes their depression symptoms, and ultimately, the ways in which they conceptualize the depression experience”. Concept mapping, a structured mixed methods approach, to characterize depressive symptoms in a community-based sample of Black men can be used to identify clusters of previously identified items including social pressures that are not captured in the validated measures of depression and stress used in Black Impact and other studies.

Thus, further work to contextualize the bi-directional association of mental health and Life’s Simple 7 is warranted in Black men. Additionally, delineating the underlying mechanistic pathways that mediate the mental health-cardiovascular risk-cardiovascular outcomes pathway is pivotal, including the role of allostatic load. Our group has previously shown that the neuroendocrine allostatic load subsystems (cortisol, aldosterone) and overall allostatic load (metabolic, cardiovascular, immune and neuroendocrine) are associated with coronary heart disease in Black men [12].

The Black Impact intervention was associated with a 25% reduction in CES-D scores over 24 weeks in a sample of individuals with low levels of depressive symptoms at baseline (mean 10.9 [SD 9.0]). By comparison in a culturally-adapted depression intervention for African American men and women experiencing depression, CES-D-measured depressive symptoms decreased by 43% over 6 months from a higher baseline (mean 26.9 [SD 9.6]) [59, 60]. In the intervention, participants met for 12 weeks for 2.5 h per week for cognitive behavioral therapy (CBT) and psychoeducation facilitated by African American Master’s level counselors. In a standard and patient-centered, culturally-tailored collaborative care (CC) intervention for African American patients with major depressive disorder (MDD), delivered by a primary care physician and consultation-liaison psychiatrist team that focused on education and evidenced-based practice [61], CES-D scores improved from 29.84 to 30.17 in standard and in patient-centered groups from 20.64 to 22.67, representing decreases of ~ 31% and 25%, respectively at 6 months. Thus, the effect size seen in Black Impact is lower than the CBT-focused intervention and consistent with improvements seen in the primary care led intervention [61].

Many factors of the Black Impact Program may have led to improvements in mental health: the program included two sessions that specifically addressed mental health, fourteen of the men participated in an additional two-hour session to discuss mental health in a community large group format (100–200 men), the program promoted physical activity with 45 min of physical activity in community parks per week, the men in the program built a camaraderie over the course of the intervention and were paired in teams influencing social networks and potentially decreasing isolation. These components are supported by the “Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder” [62]. We will discuss two of these components in further detail.

Among many racial/ethnic groups, a recent meta-analysis revealed the anti-depressive effect of exercise, even when adjusting for publication bias [28]. Forty-nine prospective studies (n = 266,939) across the world show a 22% and 21% lower odds of incident depression in adults and elderly persons, respectively, with high vs. low levels of physical activity [28]. In Black American adults, a systematic review of 13 randomized controlled trials, showed that while there was an effect of increasing physical activity in reducing depressive symptoms in Black adults, the majority of the studies analyzed were in Black women [29]. In a recent pilot RCT, resistance training improved depressive symptoms to a greater extent than health, wellness and education in a pilot of Black men over 12 weeks [63]. Consistent with these findings, in Black Impact at baseline, individuals with a PHQ-2 score of 0 vs. ≥1 had higher levels of physical activity.

Recently, there has been greater recognition of the additional benefits of “green exercise”, being physically active in the natural environment, on mental health with the greatest benefit among individuals with lower levels of mental health [62, 64]. Green exercise may lower negative affect, including anxiety, tension, anger, depression, and fatigue [65]. Nature-based interventions were effective for improving depressive mood, reducing anxiety, improving positive affect, and reducing negative affect. The most effective interventions were offered for between 8 and 12 weeks, and the optimal dose ranged from 20 to 90 min [66]. Linking back to allostatic load, spending time in nature also improves cortisol parameters [67], and cortisol dysregulation is a key underlying mechanism linking stress and depression with chronic disease [68]. The workouts for Black Impact were completed in urban parks with green spaces and large tree canopies. Thus, the Black Impact physical activity regimen, particularly in the natural environment, may have contributed to the improvements in mental health, and future studies should include objective measures of physical activity and include larger representative samples of Black men in a randomized intervention to further delineate the contribution of physical activity to improvements in mental health in Black Impact.

Social networks are the social ties that link people together through communication [30]. Two dimensions of social networks are social support and social connectedness. Social support is defined as the frequency or number of contacts a person has with friends, family members, and other supportive network members. Social connectedness refers to: (1) the structural, functional, and qualitative aspects of social relationships, including social isolation and loneliness [31, 32]; and (2) the strength or closeness of ties adults experience through friendships, both casual and intimate [33]. Social support and connectedness are often cited as a buffers in the relationship between stress and depression [33]. Previous research on social support has found that increased positive social support leads to a decrease in depressive symptoms and that social support acts as a buffer against stress [33]. Increasing social connectedness has been shown to reduce depression in underserved older adults living with depression in a multi-racial/ethnic majority female sample [32]. The organization of the men into teams was purposeful to induce a sense of camaraderie and to build social networks to enhance social support and social connectedness. In a survey of community-dwelling Black Americans, Black men were less open to acknowledging psychological problems and seeking help compared to women and were very concerned about stigma associated with mental health. Both men and women preferred religious coping and informal support networks over professional help and seeking mental health services [69]. Thus, the building and enhancement of social networks may be another potential factor that led to improvements in mental health in Black Impact and is an area of future quantitative and qualitative exploration in larger studies.

The strengths of our study include: (1) a focus on an understudied population with significant disparities in mental and cardiovascular health; (2) utilization of a community engagement framework for the community-based participatory research (CBPR) that addressed mental health needs in Black Impact; (3) the use of validated surveys to assess mental health; and (4) biometric data collection using evidenced-based approaches including collection by trained health professionals. Despite these strengths, the study should be considered in light of some limitations. As we have noted previously [27, 45], the study was not randomized due to: (1) no previous test of intervention feasibility and acceptability; and (2) concerns raised from community members in regards to not receiving a potentially beneficial intervention. A second limitation is the lack of a control group [27, 45]. Third, Black Impact participants may not be representative of other populations of Black men and did not have high levels of depressive symptoms at baseline. Fourth, data was not collected on previous diagnoses of depression or anti-depressant medications, which would be helpful in determining improvements in mental health among subpopulations. Lastly, our study was performed during the COVID-19 pandemic, which may have influenced improvements in mental health due to higher levels of social isolation in the general population during the COVID-19 pandemic. Thus, the increased social connectedness and physical activity may have had enhanced effects due to the general isolation experienced during the COVID-19 pandemic. Future larger randomized studies are planned to address these limitations.