African Americans are disproportionately affected by fetal alcohol exposure. African Americans have the second highest incidence of FAS in the United States. Only Native Americans have higher incidence (Abel, 1995; Checky, n.d.). In addition, FAS incidence among African Americans is estimated to be seven to ten times higher than in Caucasian counterparts (Abel, 1995; Checky, n.d.; Graves, 2002; May & Gossage, 2001; National Institute on Alcohol Abuse & Alcoholism, 1994).

    Caetano, Clark and Tam (1998) found that a complicated mesh of individual attributes, environmental factors, and cultural characteristics affect a person’s decision to quit drinking. Approximately two-thirds of women who report drinking alcohol prior to pregnancy spontaneously quit upon recognition of their pregnancy status (Curry, Grothaus, Lando, McBride, & Pirie, 2000; Day, Goldschmidt & Lucas, 2003; Ockene, Ma, Pbert, Goins, & Stoddard Zapka, 2002). Many factors contribute to abstinence. One factor that may influence sobriety during pregnancy is a woman’s ethnic cultural background. Compared to Caucasian women, African American/Black women are more likely to continue drinking throughout pregnancy (Lucas et al., 2003).

    A limited number of research studies have addressed alcohol consumption patterns among women of different ethnicities. Ethnic differences influence social norms and beliefs; cultural differences, religious practices and beliefs, and social roles all influence drinking patterns (Collins & McNair, n.d.; Herd & Grube, 1996). Peindl (1992) in an unpublished doctoral dissertation cited in Lucas et al. (2003) found that African American women were more likely to continue drinking during pregnancy. Ockene et al. (2002) was the only study identified that indicated the rate of spontaneous cessation among pregnant African American/Black women. In this study 80% (57 of 71 respondents) of the Black women in the study spontaneously quit drinking. Okene et al. suggested that “the women who gave up alcohol may have been light or moderate alcohol users, rather than addicted” (p. 157). No other study was found that discussed possible reasons for cessation.

    There is a need to gain more understanding about factors that influence abstinence from alcohol use during pregnancy among women who self identify as African American or Black. For simplicity in describing participants the term Black will be used which includes those who self identified as African American, Black, or mixed race. There were two primary focuses for our study. One was to identify factors that influence the intention to quit drinking alcohol during pregnancy. The second was to investigate the differences between Black women who quit drinking during pregnancy and those who continue to drink. Ajzen’s (1991) theory of planned behavior provided a framework to address these two issues.

    Ajzen postulates that intention to engage in a behavior is dependent upon (a) one’s attitude toward the behavior, (b) the impact of subjective norms, and (c) perceived control — that is, the perceived ability to execute the behavior.

    Factors influencing the intention to quit drinking alcohol among pregnant African American/Black women in San Bernardino and Riverside counties, California were investigated using the theory of planned behavior. Qualitative data were collected via focus groups from 22 pregnant women to ascertain behavioral outcomes, normative, and control beliefs associated with drinking during pregnancy. These data were used to develop a quantitative questionnaire. One hundred forty eight questionnaires were analyzed. Most of the women (86%) reported current alcohol use and 14% were former users. When adjusted for attenuation the correlation of intention with perceived control was .89, attitude .80, and subjective norm .77 all of which were statistically significant. The prediction of these three from their underlying beliefs provides insight into factors which may need to be changed to reduce alcohol use by pregnant African American/ Black women.
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    Alcohol abuse is a major public health issue that has no socioeconomic, ethnic, educational, or geographic boundaries. It is a leading cause of morbidity, premature mortality, and loss of productivity (National Center on Addiction and Substance Abuse [CASA], 2000). Alcohol consumption among women of childbearing age is of particular concern because of the potential consequences to the offspring. Alcohol use during pregnancy is associated with serious health consequences that can last well beyond the perinatal period. It has been linked to pregnancy complications, preterm delivery, stillbirth, neonatal death, neonatal withdrawal, sudden infant death syndrome, Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE), growth retardation, developmental delays, behavioral problems, anxiety disorders, and physical abnormalities (Cosden & Peerson, 1997; Gittler & McPherson, 1990; Hutchins, 1997; Ondersma, Simpson, Brestan, & Ward, 2000; Ostrea, Brady, Gause, Raymundo, & Stevens, 1992).

    According to estimates by the Substance Abuse and Mental Health Services Agency, SAMHSA (2002), approximately 45% of all childbearing age women and nearly 40% of African American women reported alcohol consumption in the month preceding the national SAMHSA survey on drug use and health. Data from the 2001 California health interview survey indicates that approximately 44% of African American women 18-45 in the Inland Empire (comprising the South Western areas of Riverside and San Bernardino counties) report drinking in the month prior to the survey, compared to 54% for the State. Vega, Noble, Kolody, Porter, Hwang, & Bole (1992) conducted a study designed to obtain an accurate estimate of the number of California infants prenatally exposed to alcohol and/or other drugs. The study utilized urine analysis of women in active labor to determine prenatal exposure. The overall State prevalence rate for alcohol use was 6.7%. The rate for African American/Black women was almost double the State prevalence rate at 11.6%. Since 1992 there has not been an equivalent study conducted in California. According to McMillan and Conner (2003) ten studies were conducted in the 1990’s that applied the theory of planned behavior to alcohol use. McMillan and Conner conducted a study to gain understanding about alcohol and tobacco use in college students. They reported that intentions were significantly correlated with attitude and perceived behavioral control. The authors reported that “attitude, subjective norm, and perceived behavioral control account for an average of 41% of the variance in intention to drink alcohol” (McMillan & Conner, 2003, p. 318). A study conducted by Johnston and White, 2003, used the theory of planned behavior to assess binge drinking in undergraduates. According to the authors, attitude, subjective norm, and perceived behavioral control were predictive of binge drinking intentions. Both studies provide further support for the efficacy of the theory of planned behavior in predicting behaviors associated with drinking.

    Although participants reduced their intake of animal products, no one permanently adopted a vegetarian diet as a result of the course. Acceptance of diet concepts was similar among Latino and African American participants. Themes related to acceptance of vegetarianism are listed in Table 3. Decreasing fat through limits on daily fat gram intake, was cited most frequently as the most important thing learned and was one of the behaviors maintained after the program ended.

    The core foods, legumes, vegetables, and grains, were familiar to the majority of participants, though they had been previously considered by some participants to be “poor foods” that were eaten when one could not afford meat. Several women expressed relief on learning to prepare tasty, nutritious meals without having to focus on meat. Participants also reported that the course provided new ways to cook old foods.

    A Comparison of the Spanish and English Language Courses
    The most notable difference between the Spanish and English language courses was the striking industriousness and curiosity of the participants in the Spanish sessions. Their keen interest to expose themselves to new information raised the level of interaction in the class. On the first day of each Take Charge class, participants observed a cooking demonstration and tasted the new, healthier foods. Thereafter, the Spanish courses took on a life of their own with participants exchanging new recipes and bringing food to share with the class on a regular basis although financially, the Spanish language class members were no better off than their English language counterparts. In sharp contrast to the common perception of poorly educated, recent immigrants as clinging to their traditional lifestyles, Latino participants in the Spanish language course enthusiastically adopted the new, healthier methods of cooking to prepare traditional recipes and also incorporated American recipes taught in the class into their daily diet. The women came eager to learn and ready to adopt new behaviors. They reported a strong appreciation for the self-esteem content of the class and a desire to protect their children from the problems they had experienced as a result of being overweight. Since these women were responsible for cooking for their families, the changes they made impacted larger numbers of people.

    In comparison, the English language courses seemed more complacent. Many expressed a desire to do something with their lives but felt that their health would not permit it, or they worried that doing so would jeopardize their eligibility for disability income. There seemed to be a subgroup with a lower sense of self-efficacy and a greater dependence on the class instructors to help them set targets and meet their goals. Although they were willing to follow instructions and complete home assignments, the participation of this subgroup was more passive.

    Impact of the Take Charge Course
    Gains in health status were achieved both during the 8 week course and into the second year following class completion (Table 2). The average weight lost during the 8 week course was 4 pounds (n=16; p<0.05; range= +5 to –18 pounds). Longer-term weight loss is available for follow-up periods ranging from 3 months post graduation to 2 years later (mean follow-up period =11 months). Using the last known weight as compared to baseline, there was an average 14 pound weight loss (n=16; p<0.01; range= +13 to –52). The ratio of weight reducers to weight gainers during the class period was 2.25:1 and in the follow-up period was 4.3:1. Group support and food-related content were rated most important by participants in the class. English and Spanish speaking participants ranked support, cooking information, and health information similarly high in importance. Although exercise and relaxation were seen as much less important components of the course, according to long-term follow-up interviews, exercise practices increased following the course. One third of the respondents wanted instruction on exercises appropriate to their disabilities (joint problems, hip pain, pacemaker, use of a cane). Most participants continued using class recipes and techniques for reducing fat.

    Drop-outs (attended 2-5 sessions) were surveyed to see whether objections to the class caused their limited attendance. Explanations for low attendance were personal and unrelated to the course. In spite of lower attendance, these participants were able to list concepts they learned from the course and behaviors they changed as a result of their participation.

    Take Charge instructors realized early in the course that eating habits of patients did not result from a lack of information but instead reflected larger psychosocial issues. The course was not designed to cure eating disorders, but by combining motivational activities with health education was able to successfully circumvent emotional factors that led to the unhealthy diet choices of many of the patients.

    The evaluation interviewers summarized participant response to the intervention as “effusively happy.” This satisfaction is credited in large part to empowerment derived from the social support and self-esteem enhancing activities. The instructors credit the wholistic approach of the Take Charge course for impacting the lives of participants beyond its primary aim of encouraging patients to adopt healthy diets. For many participants, the class provided the impetus to pursue new careers and fulfill old aspirations, from enrolling in piano classes to starting a home business. Some Alumni members returned to teach subsequent classes, taking over teaching responsibilities from the instructors. The alumni instructors were recruited for their natural leadership and commitment to the class; all had completed high school, some had additional training or education. These alumni instructors served as role models for participants, enhanced the cultural content of the class, and validated the impact of the course, making their involvement invaluable.

    Patient Profile
    Participants in the English language class were primarily African American and ranged from young adults to great grandmothers. A majority of the participants were middle-aged or older and lived alone, while some were raising their grandchildren. Many participants were on disability as a result of their weight related comorbidities and spent much of their time alone at home.
    Participants in the Spanish language class were more likely to be living in families. Most of them were women with husbands and younger children. A majority were recent immigrants from Mexico or Central America. Although this group was also overweight and had related diseases such as hypertension and diabetes, they were less likely to be as obese as participants in the English language group.

    The Class Curriculum
    The curriculum of the Take Charge class was created to reflect the wholistic approach taken by Family Medicine towards patient needs and it emphasized the role of biopsychosocial factors in health. The course curriculum consisted of diet education, fitness exercise, and empowerment and motivational activities. Medical issues related to obesity, such as the relationship between fat and heart disease, were taught by the physician instructor during class discussions. The physician instructor also addressed individual health questions of patients and referred them to their primary care physicians for follow-up as needed.

    Participants were instructed to follow a very low-fat, high fiber vegetarian diet, restricting daily fat intake to about 20 grams. The content of the diet education included cooking demonstrations and samples, healthy food displays, and information on shopping, reading labels, and calculating fat and fiber gram intake.

    The class devoted time to low impact aerobic exercise, stretching, deep breathing, and meditation relaxation. Empowerment activities designed to enhance self-esteem, raise consciousness, motivate behavior change, and provide support were also regular curriculum features. Active peer support was delivered through group “go-rounds” and a “listening exercise.” The focus of the go-rounds was to provide each person time to share with the group and learn about others. The one-on-one listening exercise allowed participants to explore thoughts and feelings with a partner who practiced listening without offering advice. To expand this peer support beyond the classroom, participants were encouraged early in the program to exchange contact information and set up walking dates. As the class progressed, exercises like identifying “10 things I want to do in this lifetime” were incorporated into the Take Charge curriculum to address the deeper motivational needs of participants, especially those on disability who had been out of work for several years. The instructors felt that participants found lifestyle change easier when they were occupied with other lifetime goals and were busy with activities that satisfied them and kept their minds off food.

    The lack of onsite educational options, and absence of referral resources, prompted faculty from the USC/California Hospital Family Medicine Residency Program to develop the Take Charge class. The course was designed to promote lifestyle change through a group intervention in an overweight, inner-city minority patient population experiencing a variety of lifestyle-influenced chronic diseases. This paper uses a case study to illustrate the health education program.

    Methods
    The case study was developed by the course instructors with the assistance of an external researcher using quantitative and qualitative assessments. Information was triangulated to increase the validity of findings.

    The course was delivered to 13 cohorts of patients. Weights were collected from cohorts 1 and 2 (n= 31) to measure change before and after the eight week course, as well as at three month follow-up intervals, using one-tailed paired t-tests for significance. Evaluation questionnaires measuring individual perceptions of class content were given to cohorts 4, 5, and 6 on the last day of the course (n= 34: 25 Spanish, 9 English). Long-term follow-up phone interviews were also conducted. External interviewers were used to promote honest responses. The follow-up interviews were designed to control for the temporal dimensions of course acceptance and life-style change. Phone interviews were conducted with cohorts 1, 2, 3 and 5 (n= 49). Average time since graduation was 21 months (range = 12-26). Since the course instructors thought there might be an upward bias in graduation-day evaluation responses, the long-term evaluation sample included both graduates and “drop-outs” and analyses compared the responses of each group.

    The Lifestyle Change Intervention
    The Take Charge course was developed and facilitated by a Family Physician and a doctor of Public Health. The course consisted of 2-hour sessions held on a weekly basis for eight weeks. Courses were conducted separately in English and Spanish.

    California Hospital is home to a Family Medicine residency which operates a primary care Family Practice Center (FPC) across the street from the hospital near the garment district of Los Angeles. For the Take Charge class, faculty members outfitted a large conference room at the FPC, normally used for physician education, with large chairs, some cooking equipment, and educational materials.

    FPC patients were referred to the class by their primary care providers. As word of the class spread, patients from neighboring community clinics were also referred. To make the classes more accessible for these outside patients, some sessions were conducted offsite. 124 participants were enrolled in 13 cohorts over four years. The average weight of participants was 237 pounds (95% confidence interval=217-258, range=122-503). This population had multiple related co-morbidities, including: hypertension, coronary artery disease, congestive heart failure, hyperlipidemia, diabetes, arthritis, chronic back pain, depression, and hypothyroidism. Other co-morbidities included: anemia, addiction, blindness, chronic obstructive pulmonary disease, glaucoma, lupus, multiple sclerosis, and seizure disorder.

    Participants attending six or more of the eight sessions received graduation certificates. Seventy-four participants graduated and were invited to join alumni activities.

    In low-income minority communities, there is high prevalence and clustering of obesity, coronary heart disease, dyslipidemia, hypertension and diabetes mellitus. Evidence suggests one way to treat and prevent these conditions is through a very low-fat, high fiber, vegetarian diet. A feasibility study was conducted to determine whether inner-city African American and Latino patients will accept a low-fat vegetarian diet and to assess attitudes about the life-style intervention. Reductions in fat and animal products were acceptable, though complete conversion to vegetarianism was not. Meanwhile, group support was the most highly rated component of the class. Contrary to common perceptions of immigrants needing to maintain traditional habits, the Latino participants enthusiastically adopted new concepts and incorporated new recipes into their diet. Weight loss was achieved during the 8 week course and continued through 18 month follow-up. It appears that individual empowerment through the group intervention, coupled with simple diet messages, supported life-style change in a high-risk group.
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    Several studies suggest that the optimal diet for prevention as well as treatment of obesity, dyslipidemia, coronary artery disease, hypertension and diabetes is a very low-fat, high-fiber, vegetarian or near-vegetarian diet (Anderson, Gustafson, Bryant, & Tietyeb-Clark, 1987; Barnard, 1991; Barnard, Jung, & Inkeles, 1994; McDougall, Litzau, Haver, Saunders, & Spillers, 1995; Ornish et al., 1998; Singh, Rastogi, Verma, & et al, 1992). However, most physicians stop short of prescribing such diets for their patients because they believe that patients will not accept a vegetarian diet or one that is very low in fat. Contrary to this view held by many physicians, several studies indicate that patients can and will accept such diets, both in the short term (Barnard et al., 1994; McDougall et al., 1995) and in the long-term (Anderson et al., 1987; Ornish et al., 1998) subsequently experiencing several positive results, such as improved cholesterol, diabetes control, weight loss, and regression of coronary artery disease. A program for Native Hawaiians promoting low fat traditional foods without calorie restriction demonstrated similar long-term success (Shintani, Beckham, Tang, O’Connor, & Hughes, 1999). There is nothing in the literature regarding acceptance of such diets in low-income Latino and African American communities in the United States. This paper describes a health intervention program designed for low-income minority patients and its impact on members of these communities.

    Los Angeles is home to a diverse population. In the inner-city, residents are predominantly low-income Latino or African American. Income, race and ethnicity are associated with a higher prevalence of common lifestyle related chronic diseases, and a greater burden of complications and mortality from them.(U.S. Department of Health and Human Services, 2003). The prevalence of diabetes, coronary heart disease, and hypertension, for example, are higher in Hispanics and Blacks than in Non-Hispanic whites (Centers for Disease Control, 2003). These problems are believed to be more aggravated by limited resources in the inner-city for lifestyle change: food choices in restaurants and supermarkets are more limited, opportunities for exercise and healthy recreation are scarce, and education classes are difficult to access. Lifestyle and disease management classes offered by some health plans and community agencies remain underutilized by inner-city patients in Los Angeles because patients are often faced with difficulties in accessing classes offered across town or feel compelled to restrict their movement due to safety concerns in certain neighborhoods.

    This study filled a gap in the gerontological literature and showed that exposure to a 6-month Tai Chi exercise program can effect long-term changes in HRQL identified by the General Health Survey, a well-established HRQL measure which includes distinct dimensions of quality of life indicators.
    On all measures, Tai Chi exercise resulted in significant changes in the HRQL indicators except social functioning, compared to the no-Tai Chi waiting-list control. Overall, Tai Chi participants reported significant improvements over the 6-month period in physical-, role-functioning, bodily pain, mental health, and health status.
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    Over the 6-month intervention, we observed an 18% drop-out rate in the Tai Chi group. This is relatively low given the fact that many who decide to become more physically active return to a sedentary lifestyle within three to six months (Dishman, 1988; Martin & Sinden, 2001). Failure to complete the study was attributed to traveling or family-related commitments rather than dissatisfaction with the program itself. In fact, people who completed the study looked forward to enrolling in further courses offered in the community. Such a finding corroborates findings of Wolf et al. who noted that almost half of their Tai Chi participants chose to continue meeting informally after the study was completed.

    Results from present study have a number of implications. First, important domains of HRQL such as physical and psychological health can be enhanced through Tai Chi because it improves balance and coordination in a framework of meditation and concentration thus, theoretically, integrating one’s physical and mental states. This is important because global wellness is predicated not merely on the functioning of each domain but the interaction between the two.

    Second, physical functioning is an important HRQL indicator which affects continued independence of older adults. As with other studies that have shown difficult-to-observe change in physical functioning (Kutner et al., 1997; Stewart et al., 1997), this study demonstrated that physical functioning could be improved through a relatively short 6-month Tai Chi program. Overall, the Tai Chi group had 83% improvement across the six individual functional status items, suggesting the Tai Chi intervention enabled participants to improve aspects of their physical functioning. Thus, Tai Chi should be considered favorably as a health promoting program for older adults with or without physical limitations. Finally, results from this study appear to support health promotion and disease prevention benefits of Tai Chi in older adults, which may be achieved without the strenuous physical impact of more common activities such as jogging or aerobics.

    There are several limitations of the current study. First, the study used exclusively self-report (self-rated) health measures, which rely on respondents’ memories. Future studies need to consider use of objective physical health measures (e.g., functional tests) that would not only allow us to confirm the current findings but also more rigorously examine the effects of Tai Chi on quality of life. Another limitation is that the study sample was comprised of volunteers who might have been more highly motivated to participate in activity than the typical sedentary older adult population. Additionally, the mode of advertising the study (local newspapers, senior center flyers, retirement community notices) could also have created a selection bias toward people who receive and read newspapers and those who live in or visit certain locales in the community. Therefore, the sample might not be representative of the older adult population as a whole. Finally, although the randomized nature of the study is a strength, we must be mindful of the absence of an attention control group. This experimental protocol does not control for the influence of attention on the outcome measures. It is possible that the participants in the Tai Chi group were benefiting from the social support and attention provided by the instructors and members of the classes, with respect to both the outcome variables and compliance. Further studies should control for this effect by having the control participants attend non-exercise health education classes in a group format (Wolf et al., 1996).

    In summary, we conclude that Tai Chi classes taught by experienced Tai Chi teachers improved self-reported quality of life among older persons in a 6-month randomized controlled study. The results confirm that Tai Chi can also be considered a suitable and acceptable health promoting activity for older adults over a long term period, as evidenced by the low rate of attrition in the classes. The extent to which the Tai Chi – HRQL relationship is moderated by psychosocial variables could be explored in future studies. Similarly, it would be useful to replicate our findings using individuals with functional deficits and psychological impairment.

    Baseline Characteristics of Participants and Dropouts
    Preliminary analyses (t-tests or chi-square tests) comparing participants in the Tai Chi group (n = 49) and the control group (n = 45) indicated that the two conditions did not differ significantly (p.09) at baseline on any of the demographic measures involving age, gender, income, and education. Additionally, there were no significant differences (p.13) by group on any of the HRQL measures at baseline. These results indicated no need for adjusting any demographic and/or baseline measures in the subsequent main analyses.
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    Furthermore, two (completion status: drop vs. remain) by 2 (condition) analysis of variance (ANOVAs) on age, gender, income, and education revealed that there were no significant differences between those who dropped (n = 22) and those who remained (n = 72), nor were there any interactions between completion status and conditions (p=.25).

    Change Over Time in HRQL Measures
    The outcomes of the study were tested by comparing participants receiving Tai Chi with those on the waiting-list condition on change in HRQL measures from pretest to posttest. Scores from the various dimensions of SF-20 were entered into univariate repeated measures ANOVAs to test for differences in follow-up HRQL scores between individuals in the Tai Chi and control groups. Because preliminary analyses indicated that the participants who dropped out were similar to those who adhered to intervention on the demographic and outcome variables, we analyzed the change in HRQL measures with participants who completed the study (n = 72).

    The results of ANOVAs indicated that, over the course of the study, individuals receiving Tai Chi had better outcomes had those on the waiting list on all the SF-20 subscales (significant Group by Time interaction): F(2,69) = 4.234, P < .02, for physical functioning; F(2,69) = 2.953, P < .05 for social functioning; F(2,69) = 5.369, P < .007, for role functioning; F(2,69) = 4.630, P < .05 for bodily pain; F(2,69) = 2.763, P < .01, for mental health; and F(2,69) = 6.653, P < .002, for health perceptions. Higher scores indicate an increase/improvement in HRQL measures over time. Examination of means for each condition showed that, in general, participants in the Tai Chi group reported a significant improvement (i.e., higher HRQL mean scores) over time in all domains of SF-20 measures. Identical results were obtained when these dropout individuals were also included in the analyses.

    Using the five-point difference as the criterion (Ware et al., 1993), only changes (i.e., from baseline to posttest) in Physical Functioning and Health Perceptions reached clinical significance.
    The effect sizes were: .69 (physical functioning), .92 for social functioning, .78 for role functioning, .5 for bodily pain, .56 for mental health, and .54 for change in health perceptions. Based on our criteria on effect size, these values were judged as meaningful treatment effects.

    All subscales were transformed to a 0 to 100 scale, with higher scores indicting better functioning, and five points “defines differences that are clinically and socially relevant” (Ware et al., 1993). In general, physical-, role-, and social-functioning subscales capture behavioral dysfunctioning caused by health problems. The dimensions of overall health, bodily pain, and particularly mental health reflect more subjective components of health and general-welling (Stewart et al., 1989). The consistency estimates of the four multi-item SF-20 measures varied from .77 (physical functioning) to .89(mental health) for Week 1, .78 to .88 for Week 12, and .79 to .86 for Week 24.

    Procedures
    All participants completed the measures described previously during an initial group orientation meeting (Week 1). Before beginning, participants signed consent forms, indicating the voluntary and anonymous nature of the study. Instructions were read aloud by the researcher, and sample questions were provided prior to the administration of the questionnaire. Additionally, participants were encouraged to clarify any questions/confusions they might have with regard to the questionnaire. No problems were encountered with participants understanding the questions or completing the questionnaire.
    Participants from the experimental group completed these measures a second (Week 12) and third (Week 24) time either at the end of class or at home within a week interval. Participants in the control group completed their second and third assessments by mail. Trained research assistants in compliance with institutional review board procedures for studies involving human subjects, administered the survey measures.

    Program Compliance
    From the initial sample of 94 participants, seventy-two completed all assessments. Nine participants in the Tai Chi group (18% attrition rate) dropped out of the study for reasons such as traveling and family-related commitments. Thirteen participants dropped out of the control group (29% attrition rate) because of unwillingness to wait for the Tai Chi class offered at the end of the study. Thus, the total attrition rate at the end of the study was 23%. Class attendance was recorded for each subject in the experimental group. The average attendance rate (2 times/per week, a total of 48 possible sessions) in the Tai Chi group was approximately 90% with a median compliance of 41 sessions, and ranging from 29 to 47 sessions. Reasons for missing sessions included inclement weather, holidays, and family commitments.

    Statistical Analyses
    Before conducting the primary analyses of the study, we examined whether attrition influenced the representativeness of the remaining subject sample and whether the experimental participants were different on demographic variables that were not controlled in the random assignment procedure. All tests were completed using the analysis of variance (ANOVA) procedure. Following these preliminary tests, repeated measures ANOVA procedures (with Group as a between-subjects factor and Time as a within-subject factor) were used to examine changes over time and differences between Tai Chi and control groups. An interaction between Group and Time indicated a difference in group responses on HRQL measures, suggesting a treatment effect. The primary outcomes (dependent variables) analyzed were the six dimensions of SF-20. Statistical significance was defined as a P value of less than .05; all P values are two-tailed.