SummaryWith the endorsement of the local Ministerial Alliance and the support of more than 60 churches, the Sisters in Action Program combined regular exercise, nutrition and wellness education, and case management over a 6-month period to combat overweight and obesity in African-American women. The program, a collaboration between Spectrum Health System and the YMCA of Greater Grand Rapids, encouraged participation by focusing on meeting the specific needs of the target population and by offering incentives and support. Sisters in Action improved exercise and eating habits, leading to better blood pressure control and lower body mass index. The program ended after 3 years of operation due to the loss of grant funding.Moderate: The evidence consists of pre- and post-implementation comparisons of blood pressure and BMI, along with post-implementation reports from participants on changes in behavior related to eating and physical activity.
Developing OrganizationsDavid D. Hunting YMCA; Spectrum Health Cardiology Department (HeartReach); Spectrum Health Healthier Communities
Date First Implemented2006
Age > Adult (19-44 years); Race and Ethnicity > Black or African American; Gender > Female; Age > Middle-aged adult (45-64 years); Vulnerable Populations > Racial minorities; Age > Senior adult (65-79 years); Vulnerable Populations > Women
Problem AddressedMost adults in the United States, including a disproportionate share of African-American women, are overweight or obese. Although regular physical activity and a healthy diet can help to prevent or reduce overweight and obesity, few African-American women adhere to these healthy lifestyle choices.
- A common problem, especially for African-American women: More than two-thirds of adults in the United States are considered to be overweight or obese.1 Nearly four in five (78 percent) African-American women are overweight, with more than half being considered obese.2
- Lack of physical activity: Although regular physical activity can help in losing weight (and/or preventing weight gain), relatively few African-American women engage in such activity. In 2008, 37.3 percent of African-American women in Michigan reported no leisure time physical activity, compared with 25.6 percent of white women in the state.3
- Poor nutrition: A diet high in fruits and vegetables helps with weight management and can also lower a person's risk of developing chronic disease.4 Yet in 2008, 72.1 percent of African-American women in Michigan reported eating less than the recommended five daily servings of fruits and vegetables.3
Description of the Innovative ActivityWith the endorsement of the local Ministerial Alliance and the support of more than 60 churches, the Sisters in Action Program combined regular exercise, nutrition and wellness education, and case management over a 6-month period to combat overweight and obesity in African-American women. The program, a collaboration between Spectrum Health System and the YMCA of Greater Grand Rapids, encouraged participation by focusing on meeting the specific needs of the target population and by offering incentives and support. Key aspects are described below:
- Outreach and marketing through African-American churches: Program developers leveraged existing relationships with more than 60 African-American churches and pastors in the community to generate word-of-mouth referrals to the program. The program proved to be quite popular during its 3 years of operation, with more than 250 women joining a waiting list for a 6-month session (with each session having the capacity to accommodate 50 participants). Key elements of this outreach and marketing effort are described below:
- Outreach to pastors: The program's community liaison traveled to local African-American churches to speak with pastors and other staff about the program and to distribute fliers. Some churches included the flyers in their church bulletins and distributed them at church events. Pastors were predisposed to support the program for two reasons—it had been approved by the local Ministerial Alliance (see Planning and Development section for more details), and program leaders designed the schedule so as not to conflict with church or bible study times. The pastors' support proved critical throughout the program; for example, many churches opened their doors early in the morning so that congregants could wait for the bus to the YMCA to participate in Sisters in Action, and many also provided space for special program-related events and celebrations.
- Community breakfast: The program hosted a church breakfast to further educate congregants about the Sisters in Action program, advertising the event through appearances on two local radio stations and through the churches, which invited their "First Ladies" (lay church leaders) to attend. The event proved quite successful, with more than 350 women attending.
- Outreach to "First Ladies": Many of the "First Ladies" invited to the breakfast joined Sisters in Action and acted as role models for other women in their churches (many of whom also joined the program). Throughout the program's 3 years, the community coordinator stayed in contact with these "First Ladies."
- Screening and enrolling participants: HeartReach/Healthier Communities clinical staff assessed each woman's health status to determine her ability to safely participate. This comprehensive assessment included two parts: a biometric screening and a comprehensive assessment using YMCA's Polar Tri Fit® online database. The assessment process included measuring of blood pressure, cholesterol, height, weight, waist circumference, body mass index (BMI), strength, blood glucose levels, and flexibility. Program developers invited women with a BMI between 25 and 55 who were not pregnant and did not have uncontrolled diabetes or hypertension to participate. Participants had to receive clearance from their primary care doctors and commit to attending program activities (as described below).
- Healthy lifestyle program: The program included three components—regular physical activity, wellness and nutrition education, and ongoing case management support. Spectrum Health HeartReach/Healthier Communities measured progress by completing biometric screenings Polar Tri Fit® testing after 12 weeks of program participation, measuring strength, flexibility, waist circumference, blood pressure, and other metrics to gauge client progress.
- Regular physical activity regimen: For the first 12 weeks (the active phase of the program), the 50 participants set exercise goals and participated together in 1-hour cardiovascular and resistance training classes two times a week. Participants also had to commit to exercise on their own one additional time per week, with many choosing to work out together (the YMCA monitored attendance through sign-in sheets). For the second 12 weeks (the maintenance phase), participants attended 1-hour exercise classes three times a week on their own or with other participants on an ad hoc basis at the YMCA. Participants completed health and fitness assessments at the beginning and after 12 weeks using the YMCA's Polar Tri Fit® system, which created personalized exercise programs and tracked progress for each participant.
- Wellness and nutrition education: During the first 12 weeks, an African-American dietitian led 1-hour classes twice a week on healthy weight loss, depression, stress management, diabetes prevention, tobacco avoidance, cancer and human immunodeficiency virus prevention, and empowerment. In addition, participants attended six 2-hour interactive nutrition classes during the first 6 weeks that focused on practical aspects of healthy eating, such as how to shop for healthy food, read food labels, and increase fruit and vegetable intake. The classes also allowed for socializing over traditional African-American dishes. Women also learned healthy cooking skills at a community-based demonstration kitchen on one Saturday during the 12-week session, and had the opportunity to share their knowledge of community resources and lessons learned around health and wellness during a designated resource night, also held once during the 12-week session. During the second 12 weeks (maintenance phase), a multidisciplinary team led 1-hour classes on a range of wellness and nutrition topics.
- Case management support: Throughout the 6-month program, case managers periodically met with and/or telephoned participants, with the goal of assisting them in adhering to the program and connecting them with needed resources, such as doctors, smoking cessation classes, counseling services, and depression screenings and workshops.
- Incentives and support to encourage participation: Participants received free 6-month family YMCA memberships, free child care at YMCA, and free transportation to and from the YMCA. Participants earned prizes (such as water bottles, bags, and pedometers) for exercising at the YMCA regularly. Women who attended 70 percent or more of their weekly exercise classes qualified for an additional 6-month free membership.
References/Related ArticlesCommunity Spectrum Health and YMCA of Greater Grand Rapids Receive Grant http://www.spectrumhealth.org/body.cfm?id=50&action=detail&ref=216
Centers for Disease Control and Prevention. Differences in prevalence of obesity among black, white, and Hispanic adults—United States, 2006-2008. MMWR Mortal Wkly Rep. 2009;58:740-4. [PubMed]
Contact the InnovatorCassandra Hankins, MA, LLPC
Community Program Supervisor
Spectrum Health Hospitals
665 Seward Ave NW Suite 110
Grand Rapids, MI 49504
Phone: (616) 391-3244
Innovator DisclosuresMs. Hankins has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe program improved exercise and eating habits, leading to better blood pressure control and lower BMI.
Moderate: The evidence consists of pre- and post-implementation comparisons of blood pressure and BMI, along with post-implementation reports from participants on changes in behavior related to eating and physical activity.
- More exercise: After 24 weeks, 90 percent of participants reported increases in their amount of weekly exercise.
- Healthier eating: After 24 weeks, the vast majority of participants reported increased daily intake of fruits and vegetables (96 percent) and consumption of fewer calories each day (91 percent).
- Better blood pressure control: After 12 to 16 weeks in the program, 59 percent of participants had blood pressure in the ideal range (less than 120/80 mm Hg), up from 39 percent when the program began.
- Lower BMI: Almost half of participants (41.6 percent) reduced their BMI by at least one point after 12 to 16 weeks in the program.
Context of the InnovationTwo local hospitals in Grand Rapids, MI—Blodgett and Butterworth—merged to form Spectrum Health in 1997. As part of the merger, the courts mandated that this newly formed health system invest $6 million annually to improve the health and wellness of residents in the Grand Rapids community. After the merger, Spectrum Health administrators created the Healthier Communities program to work with local Grand Rapids organizations to improve the health of area residents. In 2005, the Grand Rapids YMCA collaborated with Healthier Communities to complete a community-wide study of BMI, which found that many African-American women in the area were overweight or obese (with a BMI above 30). Spectrum Health already offered exercise classes in local churches. HeartReach (a part of Spectrum Health) took this a step further by developing the Sisters in Action program in 2006.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Identifying and building partnerships: Spectrum Health representatives approached YMCA leaders about forming a partnership to create a program to encourage healthier lifestyles in underserved African-American women.
- Applying for funding: HeartReach staff worked with Spectrum Health Foundation to prepare a grant proposal to the Health Resources and Services Administration (HRSA, an agency within the U.S. Department of Health and Human Services), which agreed to fund the program after reviewing the proposal.
- Hiring program coordinator/case manager: HeartReach hired a program coordinator/case manager to run the program. The YMCA also identified a coordinator to help this individual with day-to-day issues related to program implementation, including making participants feel comfortable and welcome at the YMCA.
- Hiring culturally competent staff: HeartReach hired a dietitian and exercise/wellness instructor to teach the classes. To foster trust and program adherence, these individuals came from similar backgrounds as did participants.
- Asking target population about health needs: Before starting the program, HeartReach held a focus group with 15 African-American women who had participated in a local church exercise program. During this session, facilitators asked the women what they valued most in an exercise program. Responses focused on the need for the following: one-on-one attention and support, a holistic approach that includes families and spirituality, eye contact with instructors, respect for privacy, and availability of classes on certain preferred days of the week.
- Creating program plan: Developers incorporated these focus group findings into program development to create a culturally sensitive program that met the needs of the target population. Part of this effort included finding physical space (at the YMCA) to hold program activities.
- Seeking endorsement of local Ministerial Alliance: To improve the ability to recruit participants from area churches, HeartReach vetted the program with leaders of the Ministerial Alliance, the key body that approves programs supported by area churches and information to be released from the churches. The alliance's endorsement cleared the way to advertise the program to local pastors and congregants.
- Informal cultural sensitivity training: Education and communication became necessary as a way to merge two different cultures—that of the African-American female participants and of the YMCA. To that end, the HeartReach coordinator educated YMCA staff on culturally sensitive issues, such as the definition of family in the target population. In response, the YMCA developed a comprehensive and culturally sensitive orientation for participants.
- Terminating program: The program operated for 3 years, but ended once HRSA funding ran out, as program developers could not secure additional funding to support operations.
Resources Used and Skills Needed
- Staffing: Program staff from HeartReach included a full-time master’s degree-level program coordinator and a part-time assistant coordinator with a nursing background. HeartReach contracted with the YMCA to hire an exercise/wellness instructor (who worked on the program 3 to 5 hours a week) and a master’s-level dietitian (12 hours weekly). A HeartReach multidisciplinary team (consisting of a full-time nurse, two cardiovascular nurses, and an exercise physiologist) donated their time to the program to conduct the health evaluations and assessments.
- Costs: The program served 300 participants (six classes of 50 individuals) at a cost of $435,000 over 3 years. Major cost categories included YMCA-related expenses (e.g., the costs of exercise and nutrition/wellness classes), child care ($12 per hour for 2 hours a week for each participant), transportation ($15,000 over 3 years), biometric screening ($50 per participant), laptop computers ($1,500), and database development/data analysis ($20,000).
Funding SourcesHealth Resources and Services Administration
A HRSA grant of $435,226 supported program implementation and operations; $140,000 of these funds went to the YMCA to cover its program-related costs. The YMCA provided an in-kind donation worth the equivalent of roughly $10,000 per year to cover the costs of the free family memberships.
Getting Started with This Innovation
- Obtain senior leadership buy-in: The support of senior leaders within all partner organizations is critical to program success. To obtain such support, emphasize the program's potential benefits with respect to improving health status and reducing health care costs in the target population.
- Build trust with local community: Before starting the program, develop ongoing relationships with the target population. Churches represent an ideal setting for identifying and recruiting individuals who could benefit from the program.
- Hire staff representative of target population: This step facilitates the building of trust between program staff and participants, thus increasing attendance at program-related activities.
- Designate coordinators for each partner: This step helps to ensure smooth communication and seamless delivery of services across partner organizations.
- Find suitable, convenient location: Plan ahead to identify an available, affordable, convenient, and comfortable space to run the program.
- Identify local funders: Work with local foundations to prepare and submit grant applications for program funding.
Sustaining This Innovation
- Involve entire family: Involving the entire family helps to ensure that participants attend classes throughout the 6-month program (and continue to engage in healthy lifestyle choices even after it formally concludes).
- Keep ongoing dialogue with program participants: Regularly ask participants how the program could be improved, and refine it in response to their feedback. For example, the Sisters in Action program held focus groups before the program began and again after 12 weeks.
- Maintain investment in case management: Case managers help to ensure that participants do not "fall through the cracks."
- Search for long-term funding: Seek funding from local and national organizations to support ongoing program operations, including in-kind contributions from partner organizations. To attract funding, share hard data on the program's benefits in terms of improving the health-related behaviors and health status of participants.
Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among U.S. adults, 1999-2008. JAMA. 2010;303(3):235-41. [PubMed]
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Service Delivery Innovation Profile
Original publication: September 15, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 14, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 29, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.