Designing and Pilot-Testing a Church-Based Community Program to Reduce Obesity among African Americans

Article excerpt

Abstract: Obesity raises the risk for many chronic diseases and poor health outcomes. African Americans have the highest rates of excess weight in the nation, and standard weight management programs have not worked well with this population. The Genesis Health Project, a community-designed, culturally competent intervention to reduce obesity and promote healthy lifestyles, represents a successful partnership among Syracuse University, local Black churches, and several sponsors to empower families of color to adopt and sustain positive health practices across the lifespan. This article describes the Phase I design and pilot-testing of this demonstration project, and reports the results of the first-year nutrition education/exercise-fitness program. Participant feedback indicates notable shifts toward healthier food choices, cooking methods, and exercise habits, as well as increased motivation, improved health indicators, and revamped church menus. Lessons learned from this project can be helpful in developing other community/faith-based health promotion programs for African Americans.

Key Words: Obesity among African Americans, Minority Health Education and Promotion, Culturally Competent Healthy Lifestyles Intervention, Church-based Health Program, Community Development Approach

The obesity epidemic in the United States is a serious health concern. The health consequences of excess weight include increased risks for hypertension, stroke, heart disease, diabetes, certain cancers, sleep apnea, asthma, arthritis, complications during pregnancy or surgery, respiratory distress, cognitive decline, lower quality of Ufe, and premature death (USDHHS, 2001). Beyond the detrimental impacts for individuals, families, and communities, we all bear the financial burden of escalating healthcare costs for chronic illnesses.

African Americans have the highest rates of excess weight in the nation and are thus at greater risk for many serious diseases. According to the CDC (2003), while 65% of U.S. adults are overweight [BMI of 25.0-29.9] and 31% of this group are obese [BMI of 30.0 or above], 70% of African Americans are overweight, with 38% obese. By gender, 77% of Black women are overweight with nearly 49% obese; 63% of Black men are overweight with 28% obese (CDC, 2002). These figures illustrate a clear health disparity for this vulnerable population, and effective interventions and treatments for overweight people of color remain a challenge. The Genesis Health Project, launched in 2004 at Syracuse University, is a community-driven, culturally competent intervention to reduce obesity and promote healthy lifestyles among African Americans in Syracuse, New York. It targets Black families at churches in a low-income area, and is helping them improve their eating and exercise habits. The key goal is to empower participants to adopt and sustain positive health practices across the lifespan.

Phase I of this demonstration project involved building a partnership with the churches and community sponsors, assessing the health needs and program interests of church members, and designing a pilot nutrition education-exercise program with participants' input. This article describes the design and pilot testing stage, reports findings, discusses lessons learned, and offers specific recommendations for developing healthy lifestyle programs for African Americans.

LITERATURE REVIEWAND CONCEPTUAL FRAMEWORKS

Why is obesity so severe among African Americans? High obesity rates in this population are often associated with poor eating habits and sedentary lifestyles (Han, Tijhuis, Lean, & Seidell, 1998). African Americans have traditionally eaten more meat and other high-sodium, high-fat, and high-calorie foods; they consume fewer fruits, vegetables, fiber, and calcium (Han et al., 1998; Paschal, Lewis, Martin, Dennis-Shipp, & Sanders Simpson, 2004). Low physical activity also fosters weight gain. While ~23% of U.S. adults do not exercise, among African Americans, 55-75% of women and 30-66% of men rarely exercise (Paschal et al., 2004). In addition, a widespread cultural acceptance of excess weight reportedly contributes to obesity among Blacks (Kumanyika & Charleston, 1992). Standard weight loss programs have not been very successful with people of color. A pervasive distrust of the healthcare system and limited access to quality care remain obstacles to effective health education for many low-income minorities (King & Wheeler, 2004). In recent years, efforts have been made to develop more culturally sensitive programs, including faith-based and community-designed interventions. Such programs can provide the culturally relevant context, personal motivation, and social support needed for African Americans to change their health behaviors for the longer term.

Programs based in Black churches have had good results for reducing weight and health risks (Campbell et al., 2000; Kumanyika & Charleston, 1992; McNabb, Quinn, Kerver, Cook, & Karrison, 1997; Sbrocco et al., 2005). Because the Black church is so important in the African-American community, ministers have power "to significantly affect knowledge, attitudes, beliefs, and behaviors within their congregations. . . [C]lergy are often able to get their message across without encountering the resistance other prevention efforts might experience" (Swartz, 2002).

Studies have identified key components for effective faithbased interventions. McNabb et al. (1997) found that successful programs used "lay advocates" (trained health volunteers). The "Healthy Body/Healthy Spirit" guide recommends using culturally sensitive material, empowering participants to be responsible partners in the program, and using lay health workers with whom church members can identify (Resnicow, et al., 2002). Another study derived five culturally appropriate essentials from focus groups with African-American women: fostering identification between counselors and participants; building social support and decreasing isolation; providing information in a demonstration format; involving family and community; and increasing program ownership, including making changes based on participants' input (Karanja, Stevens, Hollis, & Kumanyika, 2002). Peterson, Atwood and Yates (2002) outlined seven elements of successful church-driven health interventions: partnerships, positive health values, availability of services, access to facilities, communityfocused intervention, health behavior change, and supportive relationships. Wolfe's (2004) review also emphasizes the importance of social support in weight management programs for African- American women.

Our team of African- American nurse educators had previously developed a successful local program educating Black men about prostate cancer (Cowart, Brown & Biro, 2004). Their experience promoting health awareness among African Americans led them to design an obesity/ healthy lifestyles project informed by best practices and based on their model of collaborating with the Black community to educate and motivate families of color to adopt positive health practices. The intervention would be community-driven (e.g., developed with input from church leaders and members), culturally competent, and sustainable to foster long-term behavior change. The Information-Motivation-Behavioral skills (1MB) model provided a conceptual framework to promote lasting changes in health behaviors (Prochaska, DiClemente & Norcross, 1992).

PURPOSES, PROCESS AND METHODS

The purpose of Phase I of the project was to develop a culturally competent health intervention in partnership with six Black churches in a low-income, inner-city neighborhood of Syracuse, and to test this pilot program for its effectiveness and perceived value to participants. The primary goal was to demonstrate the feasibility of such an approach; a secondary intent was to build on preliminary results to expand the project. A descriptive research design was used.

The process involved: recruiting pastors and church participants, assessing the health needs of members, designing a faith-based program to address health issues, running the pilot intervention, and obtaining and analyzing participant feedback. Several community organizations were contacted about funding and related resources for the project; funding was awarded for meetings, training activities, a needs assessment, and pilot program development.

Methods included building partnerships with the churches and others, designing survey instruments, developing and implementing the pilot program based on best practices and input from participants, and soliciting their feedback via surveys and personal testimonies. Special care was taken to ensure cultural competence and church engagement throughout. The team collected qualitative and quantitative data, using SAS version 9. 1 for quantitative analysis. Qualitative data are notably useful because of the project's exploratory nature and focus on participant attitudes, behaviors, and sense of empowerment. No clinical outcomes (e.g., weight, blood pressure) were measured after the pilot as the aim was to test for feasibility. A brief survey was administered to 21 participants four months post pilot to assess whether they were maintaining healthier habits.

Program Structure and Assessment

First, the Genesis team contacted African-American pastors to discuss working together to improve the health of their congregations. Ministers from six Black churches were recruited, and a Pastors' Health Council was formed to provide leadership for the project. Next, the pastors identified congregants to serve as "Lay Health Advocates" for the program. Fifteen people (2 to 3 per church) agreed to undergo the required training. These two faith-based groups provided the project's organizing infrastructure. In fall 2004, the Pastors' Health Council met monthly with the nurse educators for orientation: discussing project goals, pastoral roles and responsibilities, organizational matters, and health information specific to Black Americans. The pastors pledged to commit to the program, practice healthy behaviors, deliver health-focused messages from the pulpit, support church engagement and encourage participation. Pastor involvement and role modeling were deemed crucial to success, and these sessions gave pastors more knowledge about the serious risks of obesity for Black families and how to introduce health into their ministries.

To prepare Lay Health Advocates (LHAs) for their health ministry roles, a train-the-trainer model was used. LHAs were expected to adopt healthy habits, facilitate parishioner buyin, and help design, implement, and evaluate the intervention. They were asked to sign a pledge of commitment to the project- a crucial process because these volunteers were not paid. A fall retreat was held to introduce LHAs to basic principles of communication, group dynamics, team building, confidentiality, role modeling, community engagement and networking resources. They then met semi-monthly to learn about obesity, cardiovascular disease, nutrition, health disparities and other topics. Sessions opened with prayer and ended with a benediction. Integrating scripture and safeguarding biblical significance were critical to facilitating cultural competence.

An (IRB-approved) initial assessment was then conducted across the churches to determine the health concerns, lifestyle practices, and program interests of parishioners. The pastors and LHAs served as advocates for the project and helped administer the survey at each church during regular service nights. The survey was designed to be easy to read and fill out; LHAs and Genesis staff were available to answer questions and assist participants in completing it. All respondents provided informed consent. Exceeding expectations (target =100), 155 adults ages 18-70+ (a convenience sample) filled out the assessment. Most respondents were African American, with a few African, Caribbean, and white families. We surveyed more women (68%) than men because women are the primary shoppers, meal preparers, and health gatekeepers in families of color so they have great influence on the lifestyle risks of their children and spouse.

The instrument was a 15-page survey on: (1) demographics, health and quality of life issues; (2) exercise and eating habits; and (3) program interests for building healthier lifestyles. Heights and weights were taken in private screenedoff areas to calculate BMIs. Data confirmed the prevalence of obesity and related health issues. Over 87% were overweight: mean BMI was 32.5, with over half falling into the "obese" category; yet only 16% checked obesity as a medical condition. Over half admitted that a doctor had advised them to lose weight, but only 20% were on a diet. Hypertension (39%), arthritis (17%), and high cholesterol (17%) were cited most often.

The survey revealed some common lifestyle patterns for African Americans. Questions on weekly food choices showed that dairy intake was limited and generally high-fat, French fries were the most popular vegetable, and a majority ate barbecued meat (63%) and drank regular soda (68%) in an average week. Frying was the second most popular cooking method (after baking). Over 75% of respondents fried at least some foods (especially fish and chicken), a behavior targeted for reduction. Though 95% agreed that physical activity was positively related to their health, 27% admitted getting no exercise in the past month; 60% reported walking.

PILOTPROGRAM: A NUTRITION EDUCATIONEXECISE FITNESS INTERVENTION

In early 2005, the Genesis team began working with the pastors, LHAs, and health professionals to develop a pilot program focused on weight control and improved wellbeing. Research indicates that effective obesity management programs incorporate three main strategies: decreased calorie intake, physical exercise, and behavior modification (Willett, 2002). A recent study further suggests that culturally relevant community-based programs should include both nutrition education and physical fitness components to teach African Americans how to change practices that increase their obesity and health risks (Paschal et al., 2004). The program goal was to empower participants to adopt healthier behaviors.

A 12- week time frame was chosen because research indicates that it takes about three months to establish a new habit (Prochaska et al, 1992). Nutritionists from two community agencies and a college fitness expert helped plan, implement, and evaluate a nutrition education and exercise program for this population. At the first session, 55 people from the six churches registered. The free program, held at one of the churches, ran for 12 consecutive Saturdays from May to August. Each 3-hour session began with a "Share V Praise" where participants talked about successes and challenges regarding healthy eating and exercise during the week. A 1.5-hour fitness class followed, which included the instructor's presentation, discussion, questions and feedback from participants as well as aerobic exercise. The last hour alternated between nutrition education and health information/motivation.

The six nutrition clinics focused on major themes for healthy eating. Topics included:

1 . Think Your Drink- select healthy drinks to limit sugar and reduce calories

2. The Power of Produce - select, prepare and enjoy more fruits and vegetables

3. Portion Distortion- control portion sizes to maintain a healthy weight

4. Read Food Labels - note nutritional content and avoid high fat, sugar and salt

5. Go for the Grain- choose whole grains to gain the benefits of fiber and nutrients

6. Sample New Foods- introduce healthy new items into your family's diet

7. Adjust Ethnic Recipes- keep the taste but decrease calories, fat, and sodium

8. Review My Pyramid- learn about food variety and daily nutritional requirements

9. Putting it all together- review menus and make healthy choices when eating out.

These sessions provided hands-on learning in an informal setting. The interactive format included presentations, group dialogue, storytelling, questions, and cooking demonstrations. At the end, participants discussed ideas for choosing healthier foods, increasing their confidence in maintaining a healthy diet, setting goals, and sharing health knowledge with family and friends.

The exercise segment was designed to improve fitness and establish exercise as a habit. Motivation was critical. The first session provided a pep-talk to get participants focused on the same goal: behavior change. All were encouraged to find personal reasons to commit to exercise, and urged to follow weekly exercise prescriptions. To make the commitment more concrete, each was asked to complete an "exercise behavior contract." The orientation also established a community for effective reinforcement. Participants were invited to select a buddy to help them fulfill weekly assignments and make exercising more enjoyable. Later fitness sessions began with educational reinforcement, followed by group exercise. Classes acknowledged gains and assisted with barriers to completing prescribed exercise. Since most participants exercised rarely or not at all, frequency was the initial goal; exercise intensity increased gradually over 12 weeks. The first exercise session was only 10 minutes long, but by week 12, the exercise portion lasted 45 minutes. Weekly home exercise prescriptions mirrored this progression of increasing activity.

Participants were told to exercise at their own pace. Since the goal was to change long-term behavior, no target heart rate was assigned and exercise intensity was not monitored. But intensity increased with the difficulty and repetitions of the exercises. If someone perceived an exercise as too difficult, (s)he was encouraged to do something different (e.g., marching). A key goal was for participants to be able to complete 40 minutes of moderate activity five times/week by week 12. Each week, the previous assignment was collected and the next exercise prescription was distributed. The assignment was designed as a checklist: when a participant completed the day's exercise, s/he would initial and date the box adjacent to it. The fitness expert analyzed these sheets and wrote individualized comments on them to bolster regular exercise and further motivate participants. This personalized attention was meant to provide effective reinforcement.

After the final week, a Victory Celebration was held for participants and invited guests (e.g., sponsors). Honoring the faith-based, culturally appropriate setting, the program included prayers and scripture readings. A healthy breakfast was provided, and participants were asked to "Share 'n' Praise" regarding their 12- week experience. People who had attended at least three sessions were given certificates and Genesis Tshirts to recognize their hard work, fitness efforts, and new knowledge. Photos from the program were shown, and guests offered positive feedback.

INTERVENTION RESULTS AND DISCUSSION

Post-pilot data from participants revealed mostly positive outcomes. Twenty-two (22) people returned the post-pilot survey, and over a dozen described their personal experiences at the celebration event. Though only 1 1 of the 22 post-pilot surveys could be linked directly to the earlier assessment, a comparison of assessment data (representing the general church population) with feedback from those attending 3-12 pilot program sessions shows a pattern of beneficial changes in nutrition and exercise habits among the intervention group. The nutrition education program emphasized dietary changes that would confer health benefits but be relatively easy to maintain. Participants were encouraged to reduce frying, eat more fresh vegetables and whole grains, and curtail certain foods. Items targeted for reduction- fatty meats, full-fat diary, French fries, and high-sugar fruit juices and soda - were chosen on the basis that healthier choices could be substituted without drastically altering the customary eating habits of this population. Only a few items were targeted because an overly restrictive eating plan would have risked non-acceptance by participants and led to low compliance.

Findings indicate clear shifts to healthier food choices and cooking methods. Table 1 shows the average weekly consumption of certain targeted foods before and after the pilot. For dairy items, post-pilot respondents reported drinking less whole milk than the assessment (pre-) group. They ate less cheese, and much more yogurt (presented as a cheese and ice cream substitute). Pilot respondents consumed more green leafy vegetables and broccoli/cauliflower overall but still liked their French fries. They also checked fruits/vegetables as a snack more than twice as often as pretzels, chips, cookies or candy, and reported eating more high-fiber cereals and dark bread. Barbecue and high-fat meat intake showed little change except among the linked group, but dry-cooked fish consumption rose moderately. While high-sugar juices remained popular, regular soda consumption plummeted 71% overall and 75% for linked respondents. Anecdotal evidence indicates people were drinking more water. Several anomalies for the linked group (e.g., fewer green leafy vegetables, more fries) might be explained by the small sample size, seasonal variations, or varying attendance (from 3 to 6 nutrition sessions, so some people missed some classes).

Healthier cooking methods were clearly evident. Fewer post-pilot respondents reported frying beef/pork, chicken, or fish: e.g., 69% of assessment vs. 50% of all post-pilot respondents fried fish; for the linked group, the percentage plummeted from 91% to 55%. Pilot participants were much more likely to bake than fry chicken. The preparation of vegetables also showed a marked change: from boiling to steaming as the preferred method.

Nutrition education also transformed the menus for church events. Chicken is now baked rather than fried, green salads have replaced potato salad, and healthier beverages are offered instead of soda. These institutional changes in church menus reinforce the lessons regarding healthy diets- and expand them to the larger membership across the partner churches.

The exercise program results are more mixed. Most participants were expected to begin at below-average fitness, so exercises were chosen to help them achieve average fitness, which is associated with the therapeutic effects of exercise. Surprisingly, a higher percentage of post-pilot respondents reported virtually no exercise in the past month compared to the assessment group, but among the 1 1 linked respondents, "None" dropped from 45% pre- to 27% post-pilot, and 7 reported exercising 3 or more days a week. Several post-pilot respondents initiated aerobic or strength training activity, while a majority maintained or stepped up their activity level. Most participants showed they could complete 40 minutes of moderate activity five times a week. And they began to internalize their ability to exercise regularly, enhancing long-term adherence.

When asked what motivated them to exercise (n=20), post-pilot respondents cited good health (7), the Genesis program (5), a desire for fitness (4), sense of well-being (2), desire to lose weight (1) and support from others (1). Among the barriers to exercise, they reported time constraints (8), psychological factors (low motivation, procrastination, poor time management, 5), and pain, chronic health condition, or fatigue (3). Half of respondents (8 out of 16) said they dealt with stress during the pilot program by exercising; five listed prayer or spiritual exercises.

All respondents judged the program "very helpful." Themes that emerged regarding its benefits were: useful educational content promoting greater awareness of health issues, improved well-being, greater motivation and discipline, increased self-esteem and empowerment, social support, and family involvement. When asked what worked best for them (n=20), respondents cited exercise (14), nutrition/ food preparation (4), everything (4), health information (1), and motivation (1). Challenges included busy schedules (6) and cutting out sodas/sweets (3). Most (77%) felt nothing needed to be done to improve the program; a few advised extending the time period or including more churches. "Thanks for the inspiration to want to live better," one wrote.

The personal testimonies at the celebration event were informative and compelling (see Table 2). These stories reveal both improved clinical outcomes and positive changes in attitudes and behaviors. Participants reported weight loss, lower blood pressure, improved cholesterol, better diets, increased physical activity, more energy, higher self-esteem, and greater well-being. Some cited specific health benefits such as greater mobility. They said that Genesis made them more aware of good health habits and motivated them to take better care of themselves. A few affirmed the camaraderie of the Saturday sessions; several mentioned "spreading the word" to family and friends. Not everyone was successful in reaching his/her goals during the 12 weeks, but all who shared a story felt they had made progress toward better health and quality of life.

In the follow-up survey (n=19 to 21), respondents reported healthier lifestyle behaviors 4 months post intervention. Sixteen of 19 people (84%) said they practiced better dietary habits: consuming fewer fried and fatty foods (95% each), more fruits and vegetables (85%), less sugar (84%), less salt (79%) and more herbal seasonings than before the pilot; and drinking less soda (80%) and more water (90%). Though less than 25% of respondents said they exercised regularly before the pilot, 48% reported exercising at least once a week 4 months post-pilot, with 19% doing at least an hour of physical activity daily. The rest cited an exercise frequency of once or twice a week. More than half considered themselves "exercisers," and 94% said they were using the exercise plan they learned in the pilot program. A majority reported weight loss (57%), more loosely fitting clothing (81%), a better quality of life (75%) and greater ease in accomplishing daily tasks (71%). A third said their doctor had noticed improvements in their health.

SUMMARY: LESSONS LEARNED

The Genesis pilot suggests that working with Black churches to develop weight loss/ healthy lifestyles programming for African Americans can be effective. Minorities can pose a challenge for health education and promotion, but churches can provide an entrée. Winning support from pastors is key: they can inspire trust in a health program and serve as role models for healthier habits. Using participants' input also creates programs targeted to thenneeds and preferences - and gives them ownership and pride in their church-designed health intervention.

A culturally sensitive design is critical. We deliberately excluded survey questions about income, for example, because African Americans often view this topic as an invasion of privacy. Another sensitive issue involved measuring weights. Having private screened-off areas with electronic scales made it easier for people to record their weights. Even so, seven people did not provide both height and weight measurements so their BMIs could not be calculated. The missing numbers indicated the need to engage data checkers on site for future data collection. The discrepancies between participants' perceptions, behaviors, and weight-related health risks are interesting. While just 16% checked obesity as a medical condition, the clinical data found 87% overweight or obese, suggesting that they failed to recognize or acknowledge excess weight as a medical risk- presumably due to ignorance, personal denial or cultural conditioning. Most agreed that losing weight would improve their quality of life and that weight is linked to chronic disease risk, but this perception did not translate to personal health awareness or habits. Anecdotal evidence from pastors and congregants suggests that many African Americans do not take health risks seriously or change their behaviors until they receive a doctor's warning or diagnosis of illness, when it is often too late to prevent disease. General knowledge that excess weight raises health risks is not sufficient to alter their lifestyle habits; they need increased motivation, plus specific information on how to improve health practices and support to help them persist in their efforts. Culturally relevant education about how to make healthier food choices, use better cooking methods, and follow an exercise routine is essential. Such knowledge, coupled with pastoral advocacy, church fellowship and professional support, builds confidence that they can succeed- and empowerment leads to better longterm outcomes.

The pilot intervention demonstrated both dietary improvements and fitness gains. Of particular note are increased yogurt, vegetable, and water consumption, much lower soda intake, the switch from frying to baking chicken and fish, more regular exercise, and weight loss- all of which foster better health. Targeting high-fat, high-sugar items for reduction and substituting healthier food choices proved effective. The pilot also showed that African Americans can learn to cook traditional foods by alternative methods to decrease fat and oil. Though this population is not likely to give up barbecue, fries, or desserts, teaching them to control portions, read food labels, and substitute healthier choices and cooking methods can help improve their diets. This approach provides an eating plan that can be successfully implemented in the short term, and should prove sustainable over the longer term. Despite obstacles to regular exercise, the majority of participants also increased their physical activity and improved fitness. Personal attention and group support seem particularly helpful. Survey data and anecdotal evidence suggest that most participants were maintaining healthier practices four months later.

Motivation is critical and seems linked to the project's faith-based, community-driven, culturally sensitive design. Interactive tactics can engage participants: e.g., storytelling, positive feedback, exercise buddies, and Share 'n' Praise sessions all foster a sense of connectedness. Cooking demonstrations can provide hands-on experience and bolster confidence to prepare healthy meals at home. People said that fellowship, prayers and scripture helped them adhere to their new diet and exercise plans. Recognizing accomplishments also reinforces success, self-confidence, and community. Since most respondents said they spend time building relationships with church members, structured faith-based support groups specific to health concerns can be useful in improving behaviors and health outcomes in this population. Respondents also reported being very involved with their families, so we adopted a family approach to healthy lifestyles.

Finally, community-based interventions require substantial time and resources. Our partnerships with the churches and initial funding sponsors were vital to launching Genesis. We developed the most critical elements first, building the project's infrastructure over time. Phase I had clear limitations such as small sample size (notably for linked respondents), survey defects and missing clinical data, imposed largely by resource constraints. But the project's purpose was to develop a targeted health education program that African Americans would find acceptable and helpful. The good participation rates (for this population) and high participant satisfaction with the pilot were crucial outcomes that attracted additional funding and fostered the expansion of the nutrition-exercise program- and other healthy lifestyle components- in subsequent years.

Phase I of the Genesis Project showed that careful program design can have a powerful effect on the lifestyle choices of African Americans. Our findings included positive changes hi awareness, knowledge, attitudes, motivation, individual behaviors and health outcomes, family health habits and church practices. Minorities are often viewed as "difficult to reach" on health issues, but in reality we need new strategies to effectively engage them. And we need to prepare health practitioners to do this critical work - by strengthening cultural competence training, designing culturally sensitive interventions, and marshaling community resources. As it grows, the Genesis Project is affirming that personal connectedness and program ownership through Black churches can empower African Americans to adopt and maintain healthier lifestyles.

[Reference]

REFERENCES

Campbell, M.K., Motsinger, B.M., Ingram, A., Jewell, D., Makarushka, C, Beatty, B., et al. (2000). The North Carolina Black Churches United for Better Health project: intervention and process evaluation. Health Education Behavior, 27(2), 241-53.

Centers for Disease Control and Prevention (2002). National Health and Nutrition Examination Survey, Health.United States, 2002. Hyattsville, MD: Author.

Centers for Disease Control and Prevention & National Center for Health Statistics (2003). Health, United States, 2003. Hyattsville, MD: Author.

Cowart, L. W., Brown, B., & Biro, DJ. (2004). The Barbershop program: Educating African American men about prostate cancer. American Journal of Health Studies, 19(4), 205-213.

Han, TS., Tijhuis, M. A., Lean, M.E., & Seidell, J.C. (1998). Quality of life in relation to overweight and body fat distribution. American Journal of Public Health, 88(12), 1814-20.

Karanja, N., Stevens, V.J., Hollis, J.F., & Kumanyika, S.K. (2002). Steps to soulful living (STEPS): a weight loss program for AfricanAmerican women. Ethnicity & Disease, 12(3), 363-71.

King Jr., TM., & Wheeler, M.B. (2004). Inequality in health care: Unjust, inhumane, and unattended! Annals of Internal Medicine, 141(10), 815-17.

Kumanyika, S.K., & Charleston, J.B. (1992). Lose weight and win: A church-based weight loss program for blood pressure control among black women. Patient Education and Counseling, 19(1), 19-32.

McNabb, W., Quinn, M., Kerver, J., Cook, S., & Karrison, T. (1997). The Pathways Church-Based Weight Loss Program for urban AfricanAmerican women at risk for diabetes. Diabetes Care, 20(10), 1518-23.

Paschal, A.M., Lewis R.K., Martin, A., Dennis-Shipp, D., & Sanders Simpson, D. (2004). Baseline assessment of the health status and health behaviors of African Americans participating in the activities-for-life program: A community-based health intervention program. Journal of Community Health, 29(4), 305-18.

Peterson, J., Atwood, J., & Yates, B. (2002). Key elements for churchbased health promotion programs: Outcome-based literature review. Public Health Nursing, 19(6), 401-11.

Prochaska, J.O., DiClemente, CC, & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.

Resnicow, K, Jackson, A, Braithwaite, R, Dilorio, C, Blisset, D., Rahotep, S., et al. (2002). Healthy Body/Healthy Spirit: A church-based nutrition and physical activity intervention. Health Education Research, 17(5), 562-73.

Sbrocco, T, Carter, M.M., Lewis, E.L., Vaughn, N.A., Kalupa, K.L., King, S., et al. (2005). Church-based obesity treatment for AfricanAmerican women improves adherence. Ethnicity & Disease, 15(2), 246-55.

Swartz, Aimee (2002). "Breaking the silence: The Black church addresses HIV," HIV Impact, September/October 2002, p. 1-2.

U.S. Department of Health and Human Services (2001). Overweight and Obesity: Health Consequences. January 11, 2007 revision available at http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact consequences.htm.

Willett, WC. (2002). Harvesting the fruits of research: New guidelines on nutrition and physical activity. CA: A Cancer Journal for Clinicians, 52, 66-67.

Wolfe, WA. (2004). A review: Maximizing social support- A neglected strategy for improving weight management with African- American women. Ethnicity & Disease, 14(2), 212-18.

[Author Affiliation]

Luvenia W. Cowart, EdD, MS, MSN, RN, Diana J. Biro, PhD, Timothy Wasserman, MS, Ruth Federman Stein, PhD, Lindsey R. Reider, MPH and Betty Brown, RN

[Author Affiliation]

Luvenia Cowart, EdD, MS, MSN, RN, principal investigator and Director of the Genesis Health Project, is Associate Professor of Practice in the Department of Health and Wellness, College of Human Ecology at Syracuse University, 406 Ostrom Avenue in Syracuse, New York 13244. Dr. Cowart may be reached at: 31514439808 or e-mail: lwcowart@.syr.edu. Diana Biro, PhD, is a research and writing consultant, member of the Genesis team, and former research development specialist with the College of Human Ecology at Syracuse University. Timothy Wasserman, MS, a statistician and data analyst, is Assistant Director of the Office of Institutional Research and Assessment at Syracuse University. Ruth Federman Stein, PhD, was a teaching consultant at the Center for Support of Teaching and Learning at Syracuse University during the pilot study and preparation of the initial manuscript. Lindsey R. Reider, MPH, the Genesis fitness expert, is Associate Professor and Chair of the Health, Physical Education, and Recreation Department at Onondaga Community College in Syracuse. Betty Brown, RN, program coordinator for the Genesis project, is an oncology nurse retired from the Department of Radiology, SUNY Upstate Medical University in Syracuse.

Acknowledgment: The authors thank the pastors and lay health advocates of the partner churches for helping develop the pilot program. Phase I of this project was funded by Excellus BlueCross BlueShield of Central New York, Wegmans Food Markets, and Wal-Mart Corporation.