Scarinci IC, Moore A, Wynn-Wallace T, Cherrington A, Fouad M, Li Y. (2014). A community-based, culturally relevant intervention to promote healthy eating and physical activity among middle-aged African American women in rural Alabama: findings from a group randomized controlled trial. Preventive Medicine, 69 , 13-20.
Designed to improve nutrition and increase physical activity among rural African American women, this community-based intervention includes four scripted 2-hour group sessions and one individual session delivered by a lay health educator and handouts and homework assignments to establish goals and monitor food intake. The study showed an increase in fruit and vegetable consumption, decrease in fried food consumption, and increase in physical activity.
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Currently in the United States, 56% of African American women are obese. Obesity rates are higher among African Americans who live in rural communities in comparison with those who live in urban areas. Both exercise and a balanced diet can contribute to a healthy weight and reduce the risks of health-related conditions associated with obesity, including heart disease, stroke, type 2 diabetes, and certain types of cancer. However, African Americans are 20% less likely to engage in physical activity in comparison with non-Hispanic Whites. Further, poor diet, poverty, health care access, and environmental locations contribute to the health disparities faced by this population.
Physical activity guidelines suggest that adults should engage in a weekly minimum of 150 minutes of moderate-intensity aerobic activity (e.g., brisk walking, dancing) or 75 minutes of vigorous-intensity aerobic activity (e.g., jogging, swimming laps) along with muscle-strengthening activities at least 2 days each week, with adjustments made for older adults with chronic health conditions and a low level of fitness. Dietary guidelines suggest that a healthy weight can be maintained with a diet that stays within daily calorie needs and includes fruits, vegetables, whole grains, lean meats, fish, beans, eggs, and nuts. Interventions that are designed to combat obesity by targeting both nutrition and physical activity among rural African American women are needed.
Reach Up & Out: Toward a Healthy Lifestyle is a 5-week community-based intervention that promotes nutrition and physical activity among rural African American women aged 45 to 65. Developed in collaboration with a local coalition that identified the need for a healthy lifestyle program, Reach Up & Out was adapted from the New Leaf...Choices for Healthy Living With Diabetes program. New Leaf, a structured assessment and counseling program, employs practical strategies for change and uses a combination of behavior change theories (i.e., social cognitive theory, the transtheoretical model, basic behavior modification principles) to encourage better nutrition and greater physical activity among low-income and low-literacy adults living in the Southeast region of the United States. For Reach Up & Out, individual and group sessions were adapted to teach about and encourage healthy eating choices, physical activity, and stress management and to demonstrate ways to apply newly learned material to encourage behavior modification.
The intervention uses trained lay health educators (local community members) to deliver five in-person sessions: four scripted 2-hour group sessions and one 1- to 1.5-hour individual session. Group sessions occur at public locations convenient to participants, and individual sessions typically occur at the participant's home. The group sessions allow women to share their experiences and transformations with other group members.
The sessions are conducted as follows:
-- Group session one: Overview of the program, benefits of nutrition and physical activity, and ways to improve health (e.g., exercises that can be done at home)
-- Individual session: Individual assessment of current eating habits and activity level; discussion of height, weight, and body mass index (BMI); setting of SMART goals (goals that are specific, measurable, achievable, realistic, and time-bound); and education on additional exercises to promote physical activity
-- Group session two: Discussion of nutrition (e.g., mypyramid.gov guidelines, portion control), additional exercises, and skin care
-- Group session three: Discussion of grocery shopping (e.g., reading food labels, planning a healthy grocery list), eating out (e.g., choosing healthy foods), and additional exercises
-- Group session four: Discussion of stress management (e.g., signs and symptoms of stress and depression, coping techniques), review of healthy eating habits and physical activity, and education on additional exercises
Throughout the intervention, participants receive handouts and complete weekly homework assignments that include establishing goals and monitoring food intake.
-- 20-30 hours for lay health educator training and practice sufficient to master the material
-- 2 hours to deliver each of the four group sessions and 1 to 1.5 hours to deliver each individual session
The intervention is intended for African American women aged 45-65 who live in rural communities.
This intervention is intended to be implemented in home and community-based settings.
Required resources to implement the program include the following:
-- Training Manual
-- Participant Cards
-- Flip Chart Slides
-- Participants' Tracking Form
-- Food Assessment & Tips
-- Physical Activity & Tips
-- Educator Session Evaluation
-- Quality Assurance Assessment
-- Treatment Fidelity Assessment
For costs associated with this program, please contact the developer, Isabel Scarinci. (See products page on the RTIPs website for developer contact information.)
About the Study
A randomized controlled trial compared the intervention with an alternative condition among African American women living in rural Alabama. The study recruited six counties, and randomization occurred at the county level (three counties per group). Both conditions offered four group sessions and one individual session delivered by lay health educators, but the sessions for the comparison condition used educational and behavioral strategies to promote breast and cervical cancer screening. Comparison group participants also received post-intervention support (i.e., newsletters, phone calls, bimonthly reunions) related to breast and cervical cancer.
The study enrolled 565 African American women: 298 in the intervention group and 267 in the comparison group. At 24 months, the retention rate was 63.1% in the intervention group and 45.3% in the comparison group. The average age of participants was 53.9 years; about half were married or lived with a significant other, and 46% were employed full or part time. Nearly 90% had a high school education or higher, and about 70% earned less than $30,000 per year. Most participants (76.2%) had health insurance. Ninety percent of participants had a regular doctor, and the same percentage reported seeing a doctor within the past year for a regular check-up. At baseline, there were no significant differences between groups in the primary outcomes.
Each of the main outcome-- fruit and vegetable servings, consumption of fried foods, and physical activity-- were measured with one question at baseline and 12- and 24-month follow-up. At all three timepoints, participants were asked if they consumed five or more fruit and vegetable servings per day, if they ate fried food no more than once per week, and if they participated in physical activity five or more times per week. These questions, derived from the Behavioral Risk Factor Surveillance Survey, were administered at baseline as part of a 105-item questionnaire. At 12- and 24-month follow-up, these items were part of a short questionnaire administered via telephone.
- A greater percentage of participants in the intervention group than in the comparison group consumed five or more servings of fruits and vegetables per day at 12-month (p<.0001) and 24-month (p=.021) follow-up.
- A greater percentage of participants in the intervention group than in the comparison group consumed fried foods no more than once per week at 12-month (p<.0001) and 24-month (p<.0001) follow-up.
- A greater percentage of participants in the intervention group than in the comparison group engaged in physical activity five or more days per week at 12-month follow-up (p<.0001). However, at 24-month follow-up, a greater percentage of participants in the comparison group than in the intervention group engaged in physical activity five or more days per week (p=.024).
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