Running head: OBESITY PROGRAM EVALUATION

Decreasing Obesity in African Americans in Baltimore: A Program Evaluation Hollis Misiewicz NURS 674

OBESITY PROGRAM EVALUATION Decreasing Obesity in African Americans in Baltimore: A Program Evaluation Health Problem Obesity has become a nationwide epidemic in the United States increasing from 56% in 1988-1994 to 66% in 2004-2005 (Griffin, Wilson, Wilcox, Buck, & Ainsworth, 2008). Significant increases in costs secondary to obesity-related chronic illnesses is of concern to public health care, healthcare systems and policy makers (McCarthy, Yancey, Harrison, Leslie, & Siegel, 2007). Obesity has been linked to an increased incidence of heart disease, diabetes, hypertension, and cancer and is associated with increased mortality (Clark et al., 2001; Jen, Brogan, Washington, Flack, & Artinian, 2007; Parra-Medina et al., 2010). Health disparities and living conditions among low-income minorities contribute to the increased risk for obesity.

African Americans in particular tend to be more obese than the general population (Griffin et al., 2008; McCarthy et al., 2007; Parra-Medina et al., 2010; Van Duyn et al., 2007). A relationship has been shown to exist between the environment and factors leading to obesity. Two major obstacles to decreasing the incidence of obesity among low income African Americans in urban areas such as Baltimore are; (1) lack of suitable environment in which to increase physical activity and; (2) lack of the availability of healthy food sources (Griffin et al., 2008; Haering & Franco, 2010: Van Duyn et al., 2007). The purpose of this paper is to evaluate a program designed to increase physical activity and improve nutrition within the urban African American population in Baltimore. Intervention Program Decreasing obesity within the African American population in Baltimore requires a multi-pronged approach addressing both measures to increase both physical activity and the availability of healthy food. Targeting the children at the school level is important so that they

OBESITY PROGRAM EVALUATION grow up with physical activity as a normal part of their lifestyle and good nutrition as second nature. Schools will be required to offer only healthy food and beverages and smaller portion sizes will be available and the hours required for physical education will be increased. Schools would allow use of their athletic facilities during non-school hours for community-based programs offering sports, dance and other structured activities. Area parks will also be used for these programs. Increasing safety and providing structured programs promoting physical activity have been shown to be most influential in increasing the level of physical activity of residents of low income neighborhoods (Cohen et al., 2009; Cohen et al., 2010; Gallagher et al., 2010; Griffin et al., 2008; McCarthy et al., 2007; Van Duyn et al., 2007). Local jurisdictions will be involved in order to increase police presence in areas with high crime rates. Athletic leagues coached by members of the police force will provide an outlet for physical activity and help to bind the police force to the community.

To increase the availability of healthy foods a community-run produce market based in a church will provide food at reasonable prices. Nutrition education will also be offered. This helps develop social cohesion within the community. Tax benefits, loans and loan guarantees will be offered to local stores that currently exist within low income neighborhoods to allow for them to build an infrastructure, such as refrigeration, so they will be able to stock perishable foods. The program is illustrated in Figure 1. The purpose of a process evaluation is to document the effectiveness of each individual step within an intervention program in order to determine whether the program was properly implemented and if the outcomes reflected the goals of the program (Saunders, Evans, & Joshi, 2005).

OBESITY PROGRAM EVALUATION Process Indicators For the purpose of this paper three process indicators will be chosen from the implementation model for process evaluation (Table 1). The first process indicator to be considered would be physical education in the schools. This could be categorized under dose delivered (completeness) in the process evaluation components. The method by which this would be evaluated would involve a survey of schools policy regarding physical education within the community schools, elementary through high school. The survey would determine if the policy requires physical education of all children and what the minimum number of minutes per week is. The second process indicator to be examined would be knowledge obtained by those community members who participated in classes offered by the church sponsoring the produce market or had children who attended schools in the local jurisdiction. This would be categorized under dose received (completeness) in the process evaluation components. Knowledge would include the value of increased physical activity and how to obtain and prepare healthy foods. This could be evaluated by two different surveys. Questionnaires would be distributed to

community residents who had attended the classes offered by the church and would address their knowledge of healthy foods. Another survey of residents who had children attending school would assess their knowledge of the benefits of physical activity. The third process indicator to be considered would be the percent of residents within a community who had obtained food from the church sponsored produce market. The process evaluation component that would include this indicator would be reach. To obtain the necessary information to evaluate the reach of this program a survey of the residents within the community

OBESITY PROGRAM EVALUATION of the church would be done to determine what percentage of these people had ever participated in or were aware of the produce market and the classes offered by the church. In order to evaluate the overall effectiveness of the program both proximal and final outcomes need to be assessed. The two most important outcomes of the program to decrease obesity in an African American population in Baltimore would be initially; (1) a change in the behaviors that are linked to obesity (proximal). It is hoped that the target population will increase their physical activity and buy and eat nutritious foods and, finally; (2) a decline in incidence of obesity among the African American population in Baltimore (final). Quantitative Study Design In order to evaluate the effectiveness of a program that is designed to decrease the incidence of obesity in African Americans in Baltimore a quasi-experimental study will be done that utilizes a nonequivalent control group and a pre-test, post-test format: O O X O O O = observation X = intervention

The study would be conducted in urban, low income, African American communities in Baltimore and another similar city. The experimental group would consist of residents who lived within a two mile radius of the church sponsored produce market in Baltimore. The comparison group would be in a neighborhood of similar demographics in a different city that did not require physical education in school and had no community-based produce markets. Independent variables would include mandatory physical education in school and the presence of a churchsponsored, community-run produce market with classes about nutritious foods offered at that church. Dependent variables would include amount of physical activity engaged in, amount of

OBESITY PROGRAM EVALUATION fruits, vegetables, and whole grains consumed and knowledge about the benefits of exercise and a healthy diet. Residents in these two areas would be surveyed twice, once prior to the initiation of the program and again six months later. These surveys would be administered door to door by a trained indigenous community worker. Height and weight would be obtained at both visits and BMI calculated. A questionnaire would be administered to assess the average amount of

physical activity engaged in and the amount of fruits, vegetables and whole grains consumed. In addition the survey would also assess knowledge about the value of physical activity and what constitutes a healthy diet. Information would also be obtained as to where food is purchased. A qualitative question that might be used to explain the outcomes would be: Are classes about nutrition and preparing nutritious foods helpful in changing current eating habits to more healthful habits? The information to this question could be obtained through group qualitative interviews where residents who attended classes at the church could voice their opinions on the usefulness of the classes as they currently exist. The information obtained here might shed light on either the effectiveness or ineffectiveness of the program on the proximal outcome of changes in behavior that will decrease the incidence of obesity. Strengths and Weaknesses The study design has both strengths and weaknesses. Strengths of the study involve a sample that includes an entire community within the impact area of the intervention. Both schools and churches are very influential in urban African American communities so a large population can be reached by the program. Access within the community to the program is widespread. The use of BMI to assess obesity is reliable and valid. The questionnaire used would also be tested for reliability and validity. This would accurately reflect changes in

OBESITY PROGRAM EVALUATION knowledge and assess changes in physical activity and eating habits that occurred after the

program was implemented. The use of indigenous community health workers would increase the trust of the study participants and increase the truthfulness of the responses. Weaknesses of the study are; (1) additional programs may be initiated in that community during the study period affecting both internal and external validity, (2) the first questionnaire could produce a change in both populations on answers on the second questionnaire affecting internal validity, (3) both groups are non-random which could cause selection bias and influence internal validity and, (4) the comparison group could have different characteristics than the intervention group, affecting the generalizability of the findings and external validity. Evaluation Time Line The time line for the program evaluation should extend over six months as stated previously. The entire program is complex and to implement it in its entirety could take years, particularly as some interventions would be dependent on legislation, government or private sector grants and school policy changes. Months 0 Program is initiated Survey # 1 completed (BMI, baseline knowledge, baseline activity and food type consumption) Nutrition classes weekly at church Police presence continues Local stores continue to provide nutritious foods Children continue PE in school All of the above occur during all months, experimental group Survey #2 completed (BMI, knowledge assessed, activity and food consumption noted) Data evaluated for significant changes in knowledge about benefit of physical activity and nutritious foods, BMI, activity levels and healthful food intake.

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OBESITY PROGRAM EVALUATION Conclusion

Obesity is linked to many chronic health problems such as diabetes, hypertension, heart disease and cancer (Clark et al., 2001; Jen et al., 2007; Parra-Medina et al., 2010). In the low income African American population of Baltimore obesity is increasing. Intervention to promote increased physical activity and healthy eating has been shown to lead to decreases in obesity (Ritchie et al., 2010). An intervention which starts at childhood and incorporates adults as well to provide knowledge about exercise and nutritious foods will help change attitudes about health. Involving community organizations such as the church lends strength to the intervention. Increasing available food sources by working with existing stores and developing markets at local churches encourages people to choose healthy foods. Structured programs at available facilities supported by a safe environment provide opportunities for increased physical activity. The evaluation of a program which combines these interventions will help to determine whether unhealthy behaviors can be changed and result in a decreased incidence of obesity and a healthier community.

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Figure I

OBESITY PROGRAM EVALUATION Table 1 Process Indicators for Obesity Program Evaluation Process Indicator Physical education in schools Category Dose delivered (completeness)

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Knowledge about healthy eating and benefits of increased physical activity

Dose received (exposure)

Percent of residents who utilize the church-based, community-sponsored produce market

Reach

Method Survey of local schools of policies for mandatory physical education and number of minutes per week required. Data on attendance of physical education classes Questionnaire given to community members who have purchased produce at the community-sponsored, churchbased market and attended classes provided at the church. The questionnaire would assess knowledge about healthy eating and benefits of exercise. Random survey of residents within the community to determine how many are aware of the existence of the produce market and how many have gone to the market and/or attended classes offered at the church.

OBESITY PROGRAM EVALUATION References Clark, J. M., Bone, L. R., Stallings, R., Gelber, A. C., Barker, A., Zeger, S., Levine, D. M. (2001). Obesity and approaches to weight in an urban African-American community. Ethnicity & Disease, 11(4), 676-686.

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Cohen, D. A., Golinelli, D., Williamson, S., Sehgal, A., Marsh, T., & McKenzie, T. L. (2009). Effects of park improvements on park use and physical activity: Policy and programming implications. American Journal of Preventive Medicine, 37(6), 475-480. doi:10.1016/j.amepre.2009.07.017

Cohen, D. A., Marsh, T., Williamson, S., Derose, K. P., Martinez, H., Setodji, C., & McKenzie, T. L. (2010). Parks and physical activity: Why are some parks used more than others? Preventive Medicine, 50 Suppl 1, S9-12. doi:10.1016/j.ypmed.2009.08.020

Gallagher, N. A., Gretebeck, K. A., Robinson, J. C., Torres, E. R., Murphy, S. L., & Martyn, K. K. (2010). Neighborhood factors relevant for walking in older, urban, African American adults. Journal of Aging and Physical Activity, 18(1), 99-115.

Griffin, S. F., Wilson, D. K., Wilcox, S., Buck, J., & Ainsworth, B. E. (2008). Physical activity influences in a disadvantaged African American community and the communities' proposed solutions. Health Promotion Practice, 9(2), 180-190. doi:10.1177/1524839906296011

Haering, S.A., & Franco, M. (Eds.). (2010). The Baltimore city food environment. Johns Hopkins Center for a Livable Future. Retrieved from: http://www.jhsph.edu/clf/PDF_Files/BaltimoreCityFoodEnvironment.pdf

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Jen, K. L., Brogan, K., Washington, O. G., Flack, J. M., & Artinian, N. T. (2007). Poor nutrient intake and high obese rate in an urban African American population with hypertension. Journal of the American College of Nutrition, 26(1), 57-65.

McCarthy, W. J., Yancey, A. K., Harrison, G. G., Leslie, J., & Siegel, J. M. (2007). Fighting cancer with fitness: Dietary outcomes of a randomized, controlled lifestyle change intervention in healthy African-American women. Preventive Medicine, 44(3), 246-253. doi:10.1016/j.ypmed.2006.08.019

Parra-Medina, D., Wilcox, S., Wilson, D. K., Addy, C. L., Felton, G., & Poston, M. B. (2010). Heart healthy and ethnically relevant (HHER) lifestyle trial for improving diet and physical activity in underserved African American women. Contemporary Clinical Trials, 31(1), 92104. doi:10.1016/j.cct.2009.09.006

Ritchie, L. D., Sharma, S., Ikeda, J. P., Mitchell, R. A., Raman, A., Green, B. S., Fleming, S. E. (2010). Taking action together: A YMCA-based protocol to prevent type-2 diabetes in highBMI inner-city African American children. Trials, 11, 60. doi:10.1186/1745-6215-11-60

Saunders, R. P., Evans, M. H., & Joshi, P. (2005). Developing a process-evaluation plan for assessing health promotion program implementation: A how-to guide. Health Promotion Practice, 6(2), 134-147. doi:10.1177/1524839904273387

Van Duyn, M. A., McCrae, T., Wingrove, B. K., Henderson, K. M., Boyd, J. K., Kagawa-Singer, M., Maibach, E. W. (2007). Adapting evidence-based strategies to increase physical activity

OBESITY PROGRAM EVALUATION among African Americans, Hispanics, Hmong, and native Hawaiians: A social marketing approach. Preventing Chronic Disease, 4(4), A102.

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