This quasi-experimental field intervention study was conducted in a rural district of Manisa province in Turkey. The peer-led training intervention model used in this study was named the Leading Woman Model.
The study consisted of two main stages: population weight screening and field intervention. To start with, all women living in the district aged 18–64 (n = 655) underwent weight and height measurement. Of them, 396 women were found to be overweight or obese and subject to intervention. Forty women were excluded from the study due to medical conditions, and 219 women did not join the intervention program after being informed that it would include nutrition and exercise requirements. Eventually, 137 women were accepted for participation in the intervention program, which is the second stage of the study. The flow diagram of the study stages is presented in Figure 1.
The women were either national or international migrants, with the majority being Slavic Muslims known as Pomaks. Two distinct participant groups were identified:
Leading Women: Leading women (n = 11) were chosen to act as trustworthy mentors and guides for the women. They were recruited from the community based on the discussions of a panel of community health professionals including staff at a family health center and local pharmacists.
Target women: Overweight and obese women with a BMI range of 25.00 to 39.99 (n = 126) were the targets of the intervention. They were all willing to participate in the peer intervention program in the district.
Assigning the target group to the leading women
Each of the 11 leading women were asked to select the women with whom they had social contact, and preferably those who lived on neighboring streets or roads, to enable good communication and easy access. The range of the number of women assigned to a leading woman was 5 to 17.
Of the 137 women who agreed to participate in the intervention, 86.9% (n = 119) completed the first 3 months of the intervention and 78.1% (n = 107) completed its 6-month target.
The intervention infrastructure was divided into three main items.
1. Anthropometric and biometric device preparation
Each leading woman was given electronic scales sensitive to 100 grams to measure the weight of the women in her group. A stadiometer already present at the family health center was used to measure their height. Body analyses of the women, such as for body fat mass, body fat ratio, trunk fat mass, trunk fat ratio, body muscle mass, and body fat-free mass, were recorded using a bioelectrical impedance analyzer (InBody 230). A pedometer was distributed to all participants during the intervention period.
This battery consisted of the women’s demographic, anthropometric, and biometric characteristics and their medical conditions, exercise status, and self-assessment of compliance with the nutrition program. The battery also included three supplementary scales, namely the International Physical Activity Questionnaire (IPAQ), to assess the women’s physical activity; Attitudes Towards Obese People (ATOP), to measure their attitudes towards obesity; and the Hospital Anxiety and Depression Scale (HADS), to evaluate the depressive mood of the women. IPAQ classified respondents into three activity subcategories (high, moderate, and low) (9). ATOP scores were treated as a continuous variable in the analysis: the higher the score, the better the attitude towards obese people (10). HADS scores were recoded as dichotomous variables with a cut-off value of 7.0 (11). The HADS and IPAQ forms were filled in at baseline and at the 3rd and 6th month of intervention. ATOP was only tested at baseline.
3. Leading Woman Training
The leading women were initially given a 3-day training courses on obesity, nutrition, and physical activity and exercise. The courses were conducted by a community health dietitian and exercise experts working at Celal Bayar University.
The intervention lasted a total of 6 months (Figure 1). The inclusion criteria were having a BMI range of 25.00–39.99 kg/sqm and volunteering for the intervention. The exclusion criteria were pregnancy, breastfeeding, physical or intellectual disability (including cancer, post-myocardial infarct, multiple sclerosis, and chronic neurologic diseases), morbid obesity (BMİ ≥40.00 kg/sqm), and unexplained tachycardia.
Baseline height measurement, waist and hip circumference measurements, and bioelectrical impedance analysis were done for each woman. The forms were distributed to the target women and leading women following the baseline measurements. Each woman was given a standard diet list and asked to report her nutrition practices daily through the forms.
The three main tasks of the leading women were: 1) individual and group interviews (at least once a month) with the women under their guidance, 2) organizing regular neighborhood exercise sessions, and 3) keeping records.
At the 3rd month of intervention, we measured the waist and hip circumference and weight of the target women and applied the IPAQ and HADS depression subscales. The intervention ended at the 6th month of the intervention period.
Outcomes of the intervention
The outcomes of the intervention were classified into two groups:
1. Weight and mean weight differences
- Mean body weight difference (baseline–3rd month–6th month of the intervention)
- 5% weight loss (baseline–6th month of the intervention)
- BMI category reduction: from overweight/obese to BMI <25 or from obese to BMI = 25.00–29.99 (baseline–6th month of the intervention)
2. Mean difference in biometric indices (baseline–6th month of the intervention)
- Body fat mass (trunk plus extremities)
- Body fat ratio (trunk plus extremities)
- Trunk fat mass
- Trunk fat ratio
- Body muscle mass (trunk plus extremities)
The independent variables of this study were sociodemographic variables; physical activity (by metabolic equivalent of task (MET) score), attitude to obesity, and depressive mood; and health and body image perception, family history of obesity, previous weight loss attempts, previous physical activity practices, fertility history, and having any chronic illness.
Paired t-test and Wilcoxon test were conducted for comparisons of dependent groups; Student’s t test, Mann–Whitney U test, Kruskal–Wallis, Chi-square, and Fisher’s exact test were used for comparisons of independent groups, where appropriate. Cochrane’s Q analysis was employed for repeated measures of dichotomous variables. The analyses were performed by SPSS 23.0 statistical package and type 1 error was accepted as 0.05.
Ethical issues and funding
Written informed consent was obtained from the target women in this intervention. This study was approved by the Manisa Celal Bayar University Faculty of Medicine Clinical Research Ethics Committee, dated 21.06.2017, issue no 25160. It was granted by the Manisa Celal Bayar University Research Projects Coordination Office through Project Grant Number 2018-013.