Volume 1: No. 1, January 2004
Interventions Engaging Communities of Color in Healthy Eating and
Active Living: A Review
Antronette K. Yancey, MD, MPH, Shiriki K. Kumanyika, PhD, RD, MPH, Ninez
A. Ponce, PhD, MPP, William J. McCarthy, PhD, Jonathan E. Fielding, MD, MPH,
Joanne P. Leslie, ScD, Jabar Akbar, MPH
Suggested citation for this article: Yancey AK,
Kumanyika SK, Ponce NA, McCarthy WJ, Fielding JE, Leslie JP, Akbar J.
Population-based interventions engaging communities of color in healthy
eating and active living: a review. Prev Chronic Dis [serial
online] 2004 Jan [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
The U.S. obesity epidemic is escalating, particularly among communities of
color. Obesity control efforts have shifted away from individual-level
approaches toward population-based approaches that address socio-cultural,
political, economic, and physical environmental factors. Few data exist for
ethnic minority groups. This article reviews studies of population-based
interventions targeting communities of color or including sufficient samples
to permit ethnic-specific analyses.
Inclusion criteria were established, an electronic database search
conducted, and non-electronically catalogued studies retrieved. Findings
were aggregated for earlier (early 1970s to early 1990s) and later
(mid-1990s to present) interventions.
The search yielded 23 ethnically inclusive intervention studies published
between January 1970 and May 2003. Several characteristics of inclusive
interventions were consistent with characteristics of community-level
interventions among predominantly white European-American samples: use of
non-interpersonal channels for information dissemination directed at broad
spheres of influence (e.g., mass media), promotion of physical activity, and
incorporation of social marketing principles. Ethnically inclusive studies,
however, also placed greater emphasis on involving communities and building
coalitions from study inception; targeting captive audiences; mobilizing
social networks; and tailoring culturally specific messages and messengers.
Inclusive studies also focused more on community than individual norms.
Later studies used "upstream" approaches more than earlier studies. Fewer
than half of the inclusive studies presented outcome evaluation data.
Statistically significant effects were few and modest, but several studies
demonstrated better outcomes among ethnic minority than white participants
The best data available speak more about how to engage and retain people of
color in these interventions than about how to create and sustain weight
loss, regular engagement in physical activity, or improved
diet. Advocacy should be directed at increasing the visibility and budget
priority of interventions, particularly at the state and local levels.
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The U.S. obesity epidemic is accelerating (1,2). Populations of color
have higher levels of overweight and obesity and have experienced greater
increases in overweight during the past decade compared with white
populations (3,4). Statistics on prevalence of overweight are implicated in
substantive ethnic disparities in chronic disease morbidity and mortality
(3,4) and are rooted in less healthful physical activity and eating patterns
Cross-sectional and prospective cohort epidemiologic studies provide
estimates of the population impact of small changes in body mass index,
dietary intake, and energy expenditure. For example, population decreases in
dietary fat of 1% to 3% could lower first-time heart attack rates by 25%
(7). In a study of working-class African Americans, Type 2 diabetes risk was
50% lower among individuals physically active at any level, and two thirds
lower among those who were at least moderately active (8). Recently, results
from a 6-year observation of the Nurses' Health Study cohort revealed that
30% of new cases of obesity and 43% of new cases of diabetes could be
averted by adopting a relatively active lifestyle (9). The potential
diabetes prevention value associated with eating a lower-fat diet and
increasing physical activity was realized in the Diabetes Prevention Program
randomized controlled trial. In this study, intervention participants
enjoyed a 58% reduced risk of diabetes after 3 years of follow-up (10).
Few intervention studies, however, have demonstrated sustained
effectiveness in preventing or controlling overweight and obesity (11-13).
Studies have mainly involved either 1) highly selected, relatively affluent
whites engaged in costly, individually targeted educational or behavioral
interventions; or 2) somewhat more heterogeneous, predominantly white
populations exposed to low-intensity mass media efforts. These studies
severely limit the ability to generalize to population-based public health
approaches targeting lower socioeconomic status groups or communities of
color. Despite the relatively optimal clinical circumstances of the
individually targeted studies, they have generally lacked sustainable
success (14). This lack of long-term success in improving most risk factors
has also characterized most large population-based cardiovascular disease
prevention projects (with large defined as annual budgets of $1 to $1.5
million for 10 or more years) (15). These failures have been increasingly
attributed to a modern obesogenic environment that promotes physical
inactivity and excessive food consumption (16,17). Environmental
obesogenicity is especially concentrated in communities of color (18). The
disappointing collective experience of these studies led Winkleby to suggest
that smaller, more focused studies within high-risk sub-groups such as
minority and low-literacy populations are needed (19). In fact, a number of
public health agencies and their academic, managed care, community health
center, and other community partners have begun to implement smaller-scale
cardiovascular disease prevention projects. A good example is the 15
WISEWOMAN projects, funded by the Centers for Disease Control and Prevention
(CDC), which target the low-income, predominately ethnic minority women
screened by the Breast and Cervical Cancer Early Detection Program.
Thus, the purpose of this paper is three-fold: 1) to review available
studies of community-level interventions targeting substantial proportions
of people of color in geographically defined populations; 2) to
qualitatively aggregate their findings; and 3) to explain the implications
of these findings for applied research and public health practice in
weight-control-related lifestyle change to prevent chronic disease. In
theory, there are many ways of defining populations (20). Operationally,
populations are generally comprised of individuals who self-report
ethnic/cultural status and who can be communicated with through defined
channels (e.g., churches, magazine subscription lists, television
Investigators attempting to achieve ethnically diverse samples have faced
major obstacles not only at the point of intervention and retention of
subjects, but even earlier in the research process — at the point of
outreach and recruitment (21-23). This paper will characterize the process
by which inclusive studies have engaged communities and identify ways to
facilitate effective outreach and recruitment. Additionally, the paper
examines the extent to which ethnically inclusive interventions have focused
on structural change beyond the individual level.
There is a paucity of high-quality data on sustained chronic disease or
obesity risk reduction from interventions targeting or including meaningful
numbers of people of color or people from low-income backgrounds. This gap
in the literature represents a major obstacle in developing effective
policies and programs. A quantitative review of the literature on nutrition
and physical activity interventions to reduce cardiovascular disease risk in
health care settings (24) found 32 studies that included a substantial
proportion of people of color — all but one were WISEWOMAN studies (25). Two
additional reviews of the literature on inclusive, individually targeted
interventions add to this picture (21, 26). The first of these 2 examined
physical activity interventions targeting people of color and other
"special populations" and identified only 8 ethnically inclusive
studies (26). The second identified 12 additional ethnically inclusive
lifestyle-change studies focusing on weight loss and nutrition (21).
Prior to 1996, most studies had small sample sizes and targeted low-income
segments of the ethnic groups studied. Study attrition was generally high,
with little reliable long-term data. Of those that did provide fairly long-term
(> 6 months) follow-up data, none was able to retain more than 60% of the
participants (27). Recent contributions to the literature have more than
doubled the number of studies, most with larger samples and more rigorous
designs (21,28). However, the small effect sizes and lack of sustainable
behavioral changes characterizing risk-reduction studies in affluent
populations of white European Americans are also characteristic of
individual-level studies (29). Data from community-level or population-based
approaches to obesity and chronic disease risk reduction are needed to
address broader, underlying determinants of excess risk and disease burden
in communities of color.
The focus of obesity control efforts has, in fact, shifted toward
interventions that address the socio-cultural, political, economic, and
physical environments (14). Population-based approaches are better suited
for intervening at these levels. Environmental intervention is particularly
indicated in lower-income communities and communities of color in which
excess environmental risk is concentrated (Table
Population approaches understandably lag far behind biological and
behavioral strategies (17). Alcalay and Bell undertook an exhaustive
international review of community-level social marketing campaigns promoting
healthy nutrition, physical activity, and weight control (34), and King
conducted a review of major U.S. community-level physical activity
interventions (35). Compared with individually targeted interventions,
population approaches are characterized by a greater emphasis on the
following: 1) formative research; 2) principles of social marketing; 3)
promotion of a broad spectrum of physical activity that includes transport,
household maintenance, and other routine activity; and 4) supplementing the use of health
and/or fitness professionals with other less personal channels for
information dissemination, including community agencies and organizations,
policy makers, and mass media. Both reviews revealed that only 12 of the 50
campaigns identified segmented their target audiences by ethnicity. Neither
review provided specific information about ethnically inclusive
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This review included the following study criteria:
- The study took place in the United States.
- The target population included an entire population or a
representative sample of a geographically defined community such as a
tribal reservation, housing project, or rural or metropolitan area.
- The target population was healthy, albeit high-risk. The
"healthy" distinction is important because identification as a
patient — particularly one with a life-threatening condition following cancer or heart attack — erases many cultural barriers to study
recruitment and retention and intervention adherence (23).
- The target population included an underserved ethnic group with a
sample predominantly comprised of that group, or included a sufficient
sample of such a group (African Americans, Asian Americans, Latinos,
Native Americans/Alaska Natives, Native Hawaiians, Pacific Islanders) to
report ethnic-specific analyses.
- The study targeted obesity-related lifestyle changes (eating, physical
activity, and/or weight control behaviors), not just knowledge,
attitudes, self-efficacy, and/or behavioral intentions.
- The study employed multiple health promotion approaches and
We conducted a search for studies that met the criteria above on the
following electronic databases: PubMed, AgriCOLA, Current Contents, and
PsychInfo. We limited searches to English-language articles and to articles
published between January 1970 and May 2003. The search strategy consisted
of 2 steps. First, we identified population-based or community-level
intervention research on diet, nutrition, physical activity, physical
exercise, and/or exercise. Second, we examined each result to determine the
extent of participation by communities of color. Two specific keyword
phrases were used in PubMed to produce broad-based results:
"population-based intervention adults United States AND (exercise OR
diet)," which yielded 12 articles; and "community intervention
adults United States AND (exercise OR diet)," which resulted in 111
publications. Five of the studies overlapped in these two PubMed searches,
yielding 118 studies in total. We modified search phrases to exclude the
limit of "United States" for the other electronic databases
because that specification was too restrictive. In the AgriCOLA database,
similar keyword phrases identified 17 additional studies. Using those keyword phrases, the PsychInfo and Current Contents searches did not yield
additional studies. The combined, non-overlapping electronic database
searches resulted in 135 studies, 3 of which met the selection criteria. For
each of these 3 studies, the PubMed option of retrieving "related
articles" was also explored, resulting in 614 additional articles, only
5 of which met the inclusion criteria. Thus, a total of 8 articles was
identified through the electronic database search.
In addition, we retrieved non-electronically catalogued peer-reviewed,
non-peer-reviewed, and unpublished studies from reference lists and
materials received from expert colleagues. The decision to include such
"grey literature" studies with limited distribution reflects our desire to
fully represent the available evidence. The recruitment, retention,
and resource generation challenges of inclusive intervention studies
militate against publication in mainstream scientific journals (36,37). We
contacted CDC and National Institutes of Health (NIH) staff, local and state
public health professionals, and authors of published articles by telephone
and electronic mail to identify "in process" and other unpublished
or uncatalogued intervention efforts. We evaluated these studies using the
The process of abstracting study data was performed in 3 phases
independently by 3 study co-authors: first, to produce a descriptive
project narrative (Results section); second, to generate a spreadsheet of
individual study data which was then aggregated in constructing
Table 2; and
third, to verify the information in Table 2 using a systematic abstraction
process. All 12 of the characteristics that were systematically assessed in
the second step across all studies are listed in Table 2. The third step was
performed by the co-author who was most familiar with the articles and
another co-author who had not previously seen the articles or been a
part of the review process, after agreeing on the appropriate elements
for the abstraction form. Discrepancies were then highlighted for discussion
among study collaborators to arrive at a consensus.
The lead author developed the criteria for assessing the studies. The
criteria reflect salient elements not previously presented in past reviews
focusing on communities of color — specifically, the prevalence of
information on the following: 1) nutrition and obesity-related lifestyle
change to prevent chronic disease; 2) facilitators of effective outreach and
recruitment; and 3) outcome measures that included efforts to affect both
individual, organizational and legislative/policy change. The 12
characteristics assessed systematically in each study are described below.
Ethnicity of Study Population: Each study targeted at least one
racial/ethnic minority community. Categories were restricted to the Office
of Management and Budget's (OMB) directive on racial and ethnicity
reporting, which lists 5 races (American Indian or Alaska Native, Asian,
Black or African American, Native Hawaiian or Other Pacific Islander, and
white) and 2 ethnicities (Hispanic or Latino, or Not Hispanic or Latino).
Although some studies targeted specific ethnic subgroups such as Cambodians
and Mexicans, the paucity of data on communities of color in general
warranted adherence to OMB standards. For studies reviewed here, ethnicity
was usually determined through individual self-report (ethnic
Setting: The type of geographical setting was evaluated by census
and defined as urban, suburban, semirural, or rural. A category for
interventions implemented in American Indian reservations was designated as
Theory: With one exception, all studies were characterized as
invoking well-defined behavioral theory that fit one of the following
categories: Social Learning (38); Organizational Development (39); Social
Ecological (40); Stages of Change (41); Diffusion of Innovation (42); or
Social Marketing (43).
Design: We evaluated studies by design type. Studies employed one
of the following 5 variants of evaluation research design: 1) randomized
controlled trial; 2) uncontrolled trial with pre- and post-test; 3)
uncontrolled trial with pre-test only; 4) uncontrolled trial with post-test
only; and 5) demonstration project. Randomized controlled trial and
uncontrolled trial with pre- and post-test facilitated evaluation of
intervention effect sizes. Uncontrolled trials were distinguished from
demonstration projects by study instigation: if the investigators who
implemented the intervention also conceptualized and evaluated the project,
the project was considered an intervention trial.
Recruitment Strategy: Effective recruitment strategies engaging
communities of color may differ from strategies that aim to impact a
mainstream population. We characterized recruitment strategies as one of the
following: 1) in-person (provider, community-based organizations, or CBOs,
and social networks); 2) mass media
(television, radio, mainstream newspaper or magazine, billboard); or 3)
targeted media (direct mail, flyer/brochure, local/ethnically targeted
newspaper or magazine, distribution posters, video showings).
Sample Type: This additional study dimension was included to
collect information that represented a geographically defined population, even if the study design
did not fit the "gold standard" of a randomized control trial.
Attrition Rate: High attrition rates have the potential to
seriously hamper study results. Studies reviewed in this paper were grouped
into 3 thresholds of attrition: less than 10%, 10% to 30%, or more
than 30%. A fourth category includes studies for which no attrition data was
Behavior Target: Interventions generally fell into one of the
following categories: diet, physical activity, and diet and physical
activity combined. Where possible, a behavior target was defined as one of
the following: fat; fruits and vegetables, fiber, sugar; physical activity,
nutrition and physical activity, or weight monitoring. Frequent weight
monitoring appeared to be a salient characteristic of long-term weight
control success in the National Weight Control Registry study (44).
Outcome Measures: Central to this review is the consideration of
community-level transformations, as well as individually targeted behavioral
and clinical changes. We identified the following outcome measures: 1)
self-reported behavior; 2) observed behavior; 3) clinical measures; 4)
morbidity/mortality rates; 5) organizational practice; and 6) legislative
Study Duration: We defined the duration of a study as encompassing
the following 3 phases: 1) the planning period preceding the intervention;
2) the intervention itself; and 3) post-intervention assessment. Long-term
follow-up is defined here as follow-up lasting at least 12 months (45). Studies
were grouped into 6 categories: less than one year, one to 2 years, 3 to 5
years, greater than 5 years, or undetermined.
Significant Findings (P < .05): Intervention studies
that reported significant effects (P < .05) of diet, physical
activity, or weight control were categorized by target outcome. The
"Other" category included findings that were related to indirect
target behavior, such as organizational policy changes supporting physical
activity or healthier food choices.
Primary Sources of Funding: Primary sources of funding may govern
the adequacy and representativeness of the sample and the scope and duration
of the intervention. Three distinct categories depict the studies analyzed:
federal, state and/or local, and private.
We aggregated results qualitatively for several reasons. One, we
anticipated and observed the absence of outcome data for many interventions.
Two, less-developed evaluation design, measures, and analytic approaches
were available for capturing the range of more upstream intervention effects (46). Three, we recognized that intervention effects at the individual
level may be small (not statistically significant, but meaningful in terms
of population benefit) and temporally distant from intervention
implementation (46), decreasing the likelihood of publication or
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The search yielded 23 interventions that met the selection criteria: the
interventions were implemented between 1972 and 2000. The following
narrative summarizes, in chronological order, the intervention methods and
results for projects implemented during 2 periods: the early 1970s to early
1990s (n=7), and the mid-1990s to the present (n=16). Nine of the latter 16
were projects of a CDC-funded California Department of Health Services
physical activity promotion initiative in underserved and understudied
ethnic communities. Table 2 presents project data by study characteristic
for early and later interventions.
Early Efforts (Early 1970s to Early 1990s)
Several early efforts to engage communities of color in healthy eating
and/or active living demonstrated modest improvements in outcomes. Within
the Stanford Three Community Study, Fortmann and colleagues (47) promoted
cholesterol and saturated fat restriction via mass and targeted print and
electronic media in 3 semi-rural northern California towns with substantial
proportions of Latinos (9% to 26% of the total population). Cross-sectional
surveys captured sociodemographic and cardiovascular disease risk data at
baseline and annually for 3 years. The reductions in dietary saturated fat
consumption at follow-up (versus baseline) observed in the intervention
areas compared with control areas were significantly greater among Latinos,
but no significant differences were observed among whites.
The Kaiser Family Foundation Community Health Promotion Grants Program
was designed to improve multiple health outcomes, including cardiovascular
disease and cancer, by changing community norms, environmental conditions,
and individual behaviors in 11 western communities (7 randomly assigned
intervention communities with 7 randomly assigned control communities, and 4 intervention communities selected on
special merit with 4 matched control communities) (48). Local coalitions, with
technical support from Stanford University, controlled program development.
The program was stratified by community type: suburban/rural, urban, and
state. In suburban and rural communities, nutrition and physical activity
promotion included media campaigns and nutrition education campaigns in
grocery stores. Urban community activity centered on school- and
community-based nutrition education. The state component targeted worksite
exercise. Only one intervention community — predominantly Latino — showed a
significant positive outcome: restaurants increasingly identified low-fat
choices. However, the only significant difference in self-reported dietary
behaviors in that community was a decline in fruit and vegetable
Lewis et al (49) used coalition building in public housing communities
(99% African American) in
Birmingham, Ala, to reach and involve residents in
group exercise instruction. Physiological measures were monitored to provide
individual feedback. Cross-sectional surveys documented aggregate
demographic and physical activity data at baseline, and outcomes for the
first and second years were assessed outcome ecologically, with no
differences demonstrated between intervention and control communities. In
"organized" intervention communities with enthusiastic exercise
leaders and higher class attendance, however, physical activity levels did
increase significantly compared with controls.
A similar intervention (Bootheel Heart Project) worked through regional
coalitions of community-based organizations to develop fitness promotion
activities such as walking clubs, cooking demonstrations and classes,
aerobic exercise classes, walking trails, and health fairs (50). The study
documented significant decreases in sedentary behavior within targeted
A similar study (Heart To Heart Project) (15, 51) used walk-a-thons, a
speaker's bureau, media messages, restaurant food labeling, and cooking
seminars. A telephone survey of a random sample of Florence, SC (35% African
American) residents, followed over 4 years as a cohort, demonstrated
prevention of increases in weight and hypercholesterolemia (though
hypertension prevalence increased), compared with a matched control town.
Other studies during this period did not report behavioral outcome data.
Project Salsa (52) used community organization techniques to promote
nutrition behavior changes and institutionalize intervention components in
San Ysidro, Calif. This study included the following components: cooking
classes, point-of-purchase education, newspaper columns, coronary heart
disease risk factor screenings, and school health and cafeteria programs. Of
these intervention components, only the latter 2 survived 4 years after
funding ended. Two communications strategies were aimed at diabetes
prevention and control by the A Su Salud en Accion project (53): 1)
role modeling — individuals who had initiated recommended behaviors were
promoted in broadcast and print media; and 2) mobilizing natural social
networks — trained volunteers distributed materials and prompted and
reinforced imitation of the media role models. Cross-sectional surveys were
conducted in the west San Antonio, Tex target community (90% Latino), but
only process data were reported during the 2-year project: 73 mass media
stories appeared, 34 newsletters and one booklet were produced, and 610
community networkers were recruited and trained.
Mid-1990s to Current Efforts
In 1994, the California Department of Health Services partnered with 9
ethnically underserved communities to implement physical activity promotion
projects as a part of its CDC-funded ON THE MOVE! Initiative. The 9 projects
were the following: African American Hypertension Risk Reduction (54);
Cultural Health & Mobilization Project/CHAMP (55); Families in Good
Health Program (56); Fitness Funatics (57); La Vida Buena Project (58);
Vida Caminando (59); Pittsburg Active Living Project/ALP (60); Walk for
Health (61); and Work Out to Lower Fat/WOLF (62,63). A special journal
supplement documented these efforts (54-63), so they will not be chronicled
here. The projects are, however, included in Tables 2 and 3.
Other inclusive community-level interventions initiated in the mid- to
late-90s built on earlier efforts. In a replication and expansion of the ON
THE MOVE! Fitness Funatics project (57), ROCK! Richmond, a fitness promotion
initiative in Richmond,Va, reflected the city manager's recognition that the
local health department needed to address contemporary as well as
traditional sources of morbidity and mortality. The primary direct service
component was a free fitness instruction at community sites in underserved
areas of the city, complemented by a social marketing campaign using
ethnically relevant role models to attack norms supporting sedentary
behavior and high-fat/low-fiber eating and to support individuals already
living actively and making healthy food choices. ROCK! Richmond recruited
disproportionately overweight, sedentary, older, African American women, and
individuals with family histories of chronic disease (64). However, less
formally educated and unemployed city residents were relatively
underrepresented among program participants, and outcome data were not
Many similarities may be seen between ROCK! Richmond's media component and
Alcalay and colleagues' Salud Para Su Corazon cardiovascular disease
prevention community intervention in Washington, DC (65). Its multimedia
bilingual communication campaign included TV telenovela-format public
service announcements, radio programs, brochures, recipe booklets, charlas, a
promotores training manual, and motivational videos. Pre-post intervention
intercept surveys (344 and 328, respectively) conducted in churches and
grocery stores in 3 Washington, DC, geographic areas with high
concentrations of Latinos of varying nationality demonstrated increases in
awareness but no behavioral changes.
Another similar obesity prevention intervention, Sisters Together: Move
More, Eat Better, targeted young African American women in 3 inner-city communities of
Boston, Mass (66). Strategies included social marketing and community
building efforts and extensive formative research, which was aimed at
forging partnerships and developing coalitions to institutionalize the
campaign. Demonstrations provided role models who offered illustrations on
how to implement campaign messages and activities to practice or prompt
action. Activities included developing a local cable television show
featuring local chefs who prepared healthy menu items available in their
restaurants. This study provided no outcome data.
Project DIRECT (Diabetes Intervention Reaching and Educating Communities
Together), a CDC-funded joint project of the local (Wake County, NC) and
state health departments, was designed to decrease the burden of diabetes in
an African American community (7 census tracts, 17,000 adults) located in
southeast Raleigh, NC (67). The study identified a comparison community with
similar sociodemographic and health-care resource profiles. A community
coalition, with oversight from an executive committee comprised of community
and agency representatives, directed project activities. The health
promotion component included primary prevention strategies aimed at
increasing participation in regular physical activity and decreasing dietary
fat intake. The study described plans for a multi-faceted process and
outcome evaluation; it did not present outcome data.
The Uniontown Community Health Project, also federally funded, was a Women's
Health Initiative project that developed, implemented and evaluated a
Community Health Advisor (CHA)-based intervention to reduce cardiovascular
disease in peri-menopausal African American women (68, 69). Uniontown, Ala,
a rural, underserved intervention community (67% African American), was
matched sociodemographically with a nearby control community. A coalition of
community leaders guided CHA-led social marketing activities and structured
programs for healthy nutrition and physical activity promotion. The planned
process and outcome evaluation described individual- and community-level
Recent inclusive interventions reflect a new emphasis on environmental
change strategies in obesity prevention and healthy nutrition and physical
promotion. In a replication of an earlier effort by the Center for Science
in the Public Interest in West Virginia (70), Spanish-language "1% or
less" milk campaigns were implemented in predominantly Latino
communities, Santa Paula (in 1999) and East Los Angeles (in 2000), by the
California Adolescent Nutrition and Fitness Program (Arnell Hinkle, personal
communications, December 22, 2000, and May 13, 2003). Campaign elements
included paid radio and print ads, point-of-purchase advertising, milk taste
tests, community presentations, public relations, and a school-based
program. After the 6-week campaign, sales of 1% and fat-free milk rose 60%
in Santa Paula. A follow-up survey of retailers at 6 months found that 25%
of this growth in sales was sustained.
Fuel Up/Lift Off! LA/Sabor y Energia! (18,71,72) is a Los Angeles County
Department of Health Services social marketing campaign targeted at obesity
control in predominantly African American and Latino areas. Primary
interventions include demonstrations of and staff training in strategies to
integrate physical activity and healthy food choices in routine business
activities. Examples of such activities include incorporating activity
breaks with music into lengthy meetings, offering healthy food choices when
refreshments are served, and hosting walking meetings. The campaign targets
both internal (county) and external cultures. External audiences include CBO
subcontractors, incorporated cities, or CBOs participating in a local
CDC-funded REACH project, which utilizes the county training curriculum and
audiovisual materials. A randomized, controlled trial testing the effects of
physical activity breaks incorporated into lengthy meetings demonstrated the
feasibility of engaging more than 90% of a sample of predominantly
middle-aged and older women of color in 10 minutes of moderate physical
activity (one third of the federally recommended daily allowance of physical
activity) during the workday, regardless of their physical activity levels
or overweight status.
Table 3 presents multiple examples of intervention approaches from each of
the 23 studies. Examples are grouped into levels of prevention as defined by
the ecological model Spectrum of Prevention (62,73). This model is similar
to other hierarchical social ecological models that provide a structure for
intervening at multiple and progressively more upstream levels of influence:
individual, interpersonal, institutional, community, and policy (40). Many
of the same examples were represented in more than one study, but each
example is cited only once. The table also indicates the proportion of early
versus later studies intervening at each level.
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Consistent with review findings (34,35) for community-level interventions
targeting general audiences, most of the inclusive community-level studies
reviewed here used non-interpersonal channels for information dissemination
directed at broad spheres of influence (e.g., mass media), promoted a wide spectrum of physical
activities, and incorporated social marketing principles. Distributions of
theories referenced or implied and behaviors targeted are similar to
earlier review findings, with social learning theory, community
organization, and ecological models predominating. However, a greater
emphasis on the processes of intervening is evident in this review,
paralleling processes observed in individual-level interventions targeting
underserved and understudied groups. These processes include the following:
involving communities and coalition building from inception; targeting
captive audiences; mobilizing social networks, particularly using lay health
advisors, community health workers or promotores; cultural tailoring
of messages and messengers (ethnically relevant role models in positions of
power) (53,64,66) or charismatic leadership of key staff (49); and
implementing strategies consistent with social marketing principles and
social learning theory (21-23,63,74,75). In fact, the reluctance of people
of color to participate in research, stemming from their history of
exploitation, blurs the boundary between individual-level and
community-level intervention more than in mainstream culture because of the
considerable community engagement and support necessary to successfully mount even
individual-level interventions (23, 76-78).
Given the presentation of outcome data in fewer than half of the studies,
and the few significant effects and modest effect sizes, the best data
available speak only to what it takes to engage and retain people of color,
not what it takes to create and sustain weight loss, engagement in regular
physical activity, or improved dietary quality. However, in 2 studies,
outcomes for populations of color were the only significant positive
outcomes demonstrated (47,48). The contribution of cultural adaptations to outcomes
is unclear, although an effect of these adaptations on recruitment and retention may be inferred
from the availability of these data on ethnic groups largely absent from
One salient observation is that population-based approaches must not
automatically be construed as upstream. Compared with the findings of
Alcalay and Bell (34), the studies reviewed here focus less on the individual level (65%
[studies reviewed here] versus 92% [Alcalay and Bell]) and
more on community norms and activities (100% [studies reviewed here] versus 56%
[Alcalay and Bell]). Also compared to Alcalay and Bell, the studies reviewed
here focus less on influencing policy and legislation (13% [studies reviewed
here] versus 92% [Alcalay and Bell]). The 13%, however, represents an increase
from 0% of the earlier studies to 19% of the later ones. Overall, a clear
progression toward using upstream approaches is apparent in later studies
compared with earlier studies; the increasing use of ecological models also
reflects the greater use of upstream approaches. The uniform program
requirements (community coalition formation and governance, for example) of
the 9 ON THE MOVE! projects created some skewing of results.
Only 2 out of 23 projects were funded by state and/or local health
departments. This demonstrates the importance of leadership within local
government and within communities of color to set priorities and direct
local resources toward chronic disease risk reduction. It also has
implications for project sustainability: federal and foundation funding are
generally limited to specific grant or contract periods of up to 5 years,
while local funds may continue substantially longer, subject to political
support and regional economic stability (i.e., tax base preservation).
Fourteen projects were funded primarily through federal sources (CDC, NIH,
Indian Health Services and the Food and Drug Administration). Most federal
support was — not surprisingly — from the CDC, given its applied and community
It is sobering to note that, as of 2001, fewer than 5000 participants in
individual-level interventions had been studied (and reviewed elsewhere)
(21) and fewer than 14,000
participants in population-based interventions had been studied (and
reviewed here) to control obesity and reduce chronic disease risk among 100
million persons of color — more than one third of Americans. This is
especially sobering when one considers that ethnic minority groups are
heterogeneous culturally, both within and between racial/ethnic categories,
and that many of these groups are known to have significantly elevated
obesity and chronic disease risk and burden. As an added challenge, data
derived from ethnically inclusive studies are not widely disseminated, with
only about one third of the studies reviewed here identified through
electronic database searches.
Insufficient evidence exists for drawing conclusions about the effectiveness
of individual-level versus community-level approaches targeting underserved
racial/ethnic groups. We view these approaches as complementary and possibly
synergistic. Further investigation is needed on many fronts. The
environmental context must be addressed for obesity epidemic control at the
population level, but the environmental context may be too limiting for the
more intensive, behavioral (downstream) approaches necessary for weight
management in individuals at highest risk — those already obese,
hypertensive, and/or hyperlipidemic, and living or working in socioeconomically
challenged circumstances. None of the studies reviewed here offered a
significant beneficial solution to weight management. The best approaches in
each category deserve rigorous trials (including study design and level of
resources) in multi-ethnic and ethnic-specific settings. The studies
reviewed here also point to the critical need for government investment in
greater surveillance at local (neighborhood and census tract) levels.
Federal support would allow under-resourced and overextended community
providers and organizations to focus on the service delivery that best
reflects their competencies and missions, relieving them of some of the
burden of evaluation. Also, the relative lack of outcome data and
significant findings underscores the need for evaluation methods that are
more effective at capturing upstream effects and small or delayed individual
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The authors are grateful to Johanna Asarian-Anderson, Dr. Tim Byers, Dr.
Graham Colditz, Dr. Karen Emmons, Dr. Eloisa Gonzalez, Angela Merlo Raines,
Danielle Osby, Sharon Pruhs, and Paul Simon for their contributions to the
conduct of this research or writing of this manuscript. This research was
supported in part by a National Institute for Child Health and Human
Development Research Award (R01-HD39103) to UCLA and a Nutrition Network
grant from the California Department of Health Services/USDA to the Los
Angeles County Department of Health Services (Contract #00-90906).
Corresponding Author: Antronette K. Yancey, MD, MPH, Department of Health
Services and Division of Cancer Prevention and Control Research, UCLA School of Public
Health, 71-279 CHS, 650 Charles Young Dr. South, Los Angeles, CA 90095.
Phone: 310-794-9284. E-mail: email@example.com
Author Affiliations: Shiriki K. Kumanyika, PhD, RD, MPH, Center for Clinical
Epidemiology & Biostatistics, University of Pennsylvania School of
Medicine; Ninez A. Ponce, PhD, MPP, Department of Health Services, UCLA
School of Public Health; William J. McCarthy, PhD, Department of Health
Services, UCLA School of Public Health, Division of Cancer Prevention &
Control Research, UCLA Jonsson Comprehensive Cancer, Department of
Psychology, UCLA College of Arts and Letters; Jonathan E. Fielding, MD, MPH,
Director of Public Health & Health Officer, Los Angeles County
Department of Health Services; Joanne P. Leslie, ScD, Department of
Community Health Sciences, UCLA School of Public Health; Jabar Akbar, MPH,
Department of Epidemiology, UCLA School of Public Health.
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Excess Environmental Risk in Communities of Color*
Excess fast food outlets
Limited shelf choices in groceries
Availability of high-fat food (home, church)
Less private transportation
Poorer public transportation
Distance to private fitness facilities
Few worksite fitness opportunities
Few or deteriorating neighborhood recreation facilities
High neighborhood crime rates
Less private transportation
Poorer public transportation
Low neighborhood demand for low cal/low fat foods
Low family incomes and cash flow
Other household expenses
Little home-grown food
Financial incentives offered to under-resourced schools by commercial cafeteria
Limited investment in parks/recreation facilities
Fees at fitness facilities
Cost of exercise equipment
Less stable employment patterns
Fewer trained school physical education (PE) instructors/large PE classes
Poorly equipped school facilities/fewer PE options
Lesser availability of parent/adult volunteers to assist school staff in
after-school sports/recreation programs
Extant food insecurity
Cultural attitudes about physical activity and importance of rest
Fears about safety
Cultural reverence for cars, particularly among males
Over-reliance on TV for engaging children after school hours
*Adapted with permission from Kumanyika SK (21).
Characteristics of Community-level Healthy Eating or Activity Interventions
Implemented Among Ethnic/Minority Communities, Aggregated to Early 1970s to
Mid-1990s and Mid-1990s to Mid-2003
Early 1970s to mid-1990s
N = 7
Mid-1990s to Mid-2003
N = 16
|Ethnicity of Study Population
|Latino or Hispanic
|American Indian or Alaskan Native
|Stages of Change
|Diffusion of Innovation
|Randomized control trial
|Uncontrolled trial, pre- and post-test
|Uncontrolled trial, pre-test only
|Uncontrolled trial, post-test only
|Fruits and Vegetables
|Nutrition and Physical Activity
|> 2 but < 3
|> 3 but < 5
(P < .05)
|Individual-level dietary change
|Individual-level physical activity change
|Individual-level weight change
|Organizational practice or policy change
|Legislative policy change
|Primary Funding Source
|State or local health departments
|Private foundation or disease-specific nonprofit organization
*A single study can include more than one
characteristic within a category.
Examples of Obesity Prevention Efforts Used by Studies Reviewed, Categorized
by Level of Prevention Within the Spectrum of Prevention Model*
Level of Prevention: Strengthening individual knowledge and
Definition of Level: Enhancing an individual's capability of
preventing illness/injury and promoting health
% Studies Intervening at this Level: Early 71; Later 62
Walking club orientation59
Culturally congruent exercise classes58
Risk factor screening52
Home-based education (e.g., cookbooks, videos)57
Peri-natal breastfeeding classes52
Level of Prevention: Promoting community education
Definition of Level: Reaching groups of people with information
and resources to promote health
% Studies Intervening at this Level: Early 100; Later 100
Mass media campaign47
Targeted media campaign65
Interdenominational or intertribal sports leagues63
Community fitness events and campaigns15
Community policy advocate training56
Community networker training53
Promotore/community health advisor training68
Neighborhood canvas for healthy meal options72
Culturally tailored community bulletins61
Government access channel broadcast of locally produced
exercise/nutrition video twice daily64
Development of cable TV show featuring local chefs preparing healthy
Sponsoring book signing for healthy ethnic cookbook66
Level of Prevention: Educating service providers
Definition of Level: Informing providers who will transmit
skills and knowledge to others
% Studies Intervening at this Level: Early 0; Later 52
Education for MD screening and referrals58
Engaging and educating journalists64
Walking leadership education for community-based organization staff66
Physical activity training of public health nurses, certified health educators71
Level of Prevention: Fostering coalitions and networks
Definition of Level: Bringing together groups and individuals
for broader goals and greater impact
% Studies Intervening at this Level: Early 86; Later 100
Local project coalitions and advisory committees60
Healthy Cities coalitions60
Regional (e.g., intertribal elders, councils)55
Governor's Councils on Physical Fitness & Sports64
Advocacy work to establish supermarket in underserved area66
Level of Prevention: Changing organizational practice
Definition of Level: Adopting regulations and shaping norms to
% Studies Intervening at this Level: Early 43; Later 62
Protocols for MD assessment, sliding fees, counseling, and referral67
Physical activity promotion within crime prevention street
Worksite and CBO practices (e.g., movement breaks, walking meetings,
prompting stair usage, including healthy refreshments, modeling
attire and hairstyles conducive to lifestyle integration of physical
Walking/fitness trail construction/signage50
Urban walking route maps/signage54
Public housing fitness programs49
Bilingual/bicultural staff at Y's56
Park/recreation department safety-related maintenance improvements58
Church kitchen committee recipe modification67
Healthier foods served at meetings/functions of elected/appointed
Restaurant menus with low-fat items48
Supermarket stocking and promotion of low-fat foods80
Discounted fitness facility memberships66
Level of Prevention: Influencing policy and legislation
Definition of Level: Developing strategies to change laws and
policies to improve health outcomes and enhance community well-being
% Studies Intervening at this Level: Early 0; Later 19
Land use policy established for community gardens56
Tribal government policy changes institutionalizing community events55
Stable funding for Indian Health Service clinics for physical
activity/nutrition promotion services55
City eligibility requirement policy changes to allow low-income
residents access to recreation classes60
"Healthy/fit workplace" memoranda of understanding, City Council agenda bills,
contract language modeled on federal smoke-free workplace mandates
of grantee organizations71
* Adapted from Cassady D et al (62) and Swift M (73).
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