The Epidemic of Obesity in African American Communities and the Need for a Culturally Sensitive after school Childhood Obesity Prevention Program

An after-school obesity prevention program for African American children is proposed in this paper. The prevention program is a behavioral education program designed to facilitate healthy behavior changes in obesity self-care and provide culturally sensitive interventions specifically for obese African American children. The self-care concepts addressed involve: knowledge of obesity, exercise, and nutrition. The culturally sensitive interventions address the problems of low self-esteem, communication, and ineffective family coping. The implementation of the after-school obesity program included four phases: needs assessment, planning and goal setting, implementation, and monitoring for progress. This afterschool education program is designed to promote self-care, family support, and improve the quality of life for obese African American children. © 2006 Californian Journal of Health Promotion. All rights reserved.


Introduction
Obesity is not just a matter of personal healthit's a costly and deadly public health concern that affects economic productivity and personal and family well being (Centers for Disease Control and Prevention, 2001).Minority children with less education and from families with lower incomes are more likely to be overweight or obese ( National Institute of Health, 2001).One in five African American children is obese, and there has been a ten-fold increase in the number of African American children with adult onset diabetes in the last five years.The result of this ongoing problem for African American children has resulted in an increase in suffering from stress (Danner, 2002).Recent studies have demonstrated that obesity was related to an increase in depression and social isolation (Sjoberg, Nilsson, & Leppert, 2005), and anxiety (Willard, 1991).In fact, Schwimmer, Burkwinkle, and Varni (2003) found that severely obese children missed more school days than the general student population.After school behavioral education programs are urgently needed in African American communities.
Studies reviewed consistently demonstrated a positive relationship between obesity and psychosocial and cultural variables (Neumark-Sztainer, Story, Resnick, & Blum, 1997).Neighbors, Braithwaite and Thompson (1995) and Braithwaite (1992) explain that the majority of high risk health conditions experienced by African American children have a strong behavioral component; therefore health promotion should be encouraged.Studies have shown that there are some cultural differences between African Americans and Whites with respect to obesity.Renzaho (2004) found that due to poverty and the amount of hours parents work that many African American children are trained to be responsible and take care of themselves from an early age which enables African American children to make poor nutritional choices.Renzaho (2004) found that "thinness" is enviable among Whites and considered highly socially undesirable from an African perspective.If fact, excessive weight among African Americans is characterized as being a breadwinner and having the capacity to afford luxury foods such as meats and fried foods.For health promotion to be effective in the African American community, the intervention must integrate culturally sensitive factors.

Purpose
An after-school obesity prevention program for African American children is proposed in this paper.This is a behavioral education program designed to facilitate healthy behavior changes in obesity self-care and provide culturally sensitive interventions specifically for obese African American children.The self-care concepts addressed involve: knowledge of obesity, exercise, and nutrition.The culturally sensitive interventions address the problems of low self-esteem, communication, and ineffective family coping.

Interventions and Solutions
The after-school obesity prevention program for African American children is a behavioral educational program that provides culturally sensitive interventions and is designed to facilitate healthy behavior changes in obesity self-care.The implementation of this program consists of four phases (see Figure 1 for timeline): (1) needs assessment, (2) planning and goal setting, (3) implementation, and (4) monitoring for progress.

Task
Monthly Time Line for Accomplishment Jan Feb Mar Apr May June Needs Assessment X Planning and Goal Setting X Implementation X Orientation/Intake X Assessment X Goal Setting X Prescription for Change X Program Plan X X Monitoring for Progress X

Figure 1 A task development time line for an after school obesity prevention program
for African American children

Phase 1: Needs Assessment
The needs assessment phase will consist of evaluating support from the local African American community and performing a needs assessment and cultural assessment through focus groups, meetings with after school directors and staff, and meetings with obese African American children.Program staff of the after-school program will perform a cultural assessment of obese children using The Cultural Assessment Guide for African Americans (Irwin, 1995).The guide includes the following two sections: (a) health beliefs, perceptions of overweight and obesity, and cultural background, (b) self-esteem, communication, and ineffective family coping.

Phase 2: Planning and Goal Setting
The planning phase will involve developing a health planning committee, developing goals, training staff, recruiting participants, and determining the format.The health planning committee will consist of people in the local African American community who can provide emotional support and influence others to modify their health behavior.
The program will be implemented by a multidisciplinary team including a health educator, dietician, and exercise instructor.The health educator will be the program coordinator.
The health educator will train the staff regarding behavior change strategies and culturally sensitive health promotion for African American obese children.The Cultural Assessment Guide for African Americans (Irwin, 1995) provides intervention guidelines for clients' problems and will be utilized in staff training sessions.These guidelines address the problems of low self esteem, communication, and ineffective family coping.
Strategies will focus on recruiting obese African American children between the ages of six to eleven.Family members of the participants may attend the program.Childcare services for other siblings will be offered as an incentive for participation.Community Health majors from a local college will handle the recruitment.The program will be publicized through after school meetings, flyers, informal communication among parents whose children attend after school programs, after school newsletters, local newspapers, and the local college radio station.
The planning committee will select which African American children will participate based on the assessment data.The criteria for selection will be children whose body mass index for age is greater or equal to the 95th percentile.Hammer, Kraemer, Wilson, Ritter, and Dornbusch (1991) used BMI-for-age in children because it can be used to track body size throughout life.The format will include groups with 10 to 15 participants.For a six-month period, weekly meetings will be held at the after school center and will last approximately two hours.Program activities will consist of counseling with the health educator regarding individual plans for behavior change, emphasis on providing support, and aerobic exercise.
A registration fee will demonstrate the parents' commitment to encourage their child to participate.In addition, the fee will provide funds for gifts and monetary prizes awarded during and upon completion of the program.Participant's inability to pay the fee will not result in the exclusion from the program.
Weekly prizes, with gifts will be offered as incentives.

Phase 3: Implementation
The behavior change strategies will ensure compatibility with the child's needs, empower the child, and enhance the success of the child through behavior changes.The implementation phase includes the following stages: (1) orientation and intake, (2) assessment, (3) goal setting, (4) prescription for change, and (5) program change.
Stage 1: Orientation and intake.An orientation and intake interview will be performed by the health educator who will discuss program expectations and protocol to the child and his/her parent.The child and his/her parent will then choose to either continue the program thereby entering the assessment stage or to discontinue participation.
Stage 2: Assessment.The initial assessment phase will include screening of obese African American children for conditions suitable for the program.For this program a BMI over 25 kg/m 2 is defined as obese.If inappropriate conditions are present, the child and his/her parent can discontinue participation.If the conditions are favorable, the child continues in the assessment stage.The child's assessment will incorporate the following behavioral factors: the stages of behavior change (Prochaska, Norcross, & DiClemente, 1994), modifying factors for behavior change, and individual perceptions regarding health promotion.During the assessment stage, program staff will administer the Cultural Assessment Guide for African Americans (Irwin, 1995).
Stage 3: Goal setting.Following the assessment stage, the child and his/her parent will begin targeting behavior, developing goals, and taking small steps toward behavior change.The child and his/her parent will develop a contract for achieving short-term and long-term goals.The goals of the participant will be related to the following obesity self-care concepts: knowledge of obesity, exercise, nutrition, stress management, and low self-esteem.
Stage 4: Prescription for change.During stage four, a step by step program will be developed with the child and his/her parent present for promoting behavior change.This prescription will be based on the child's assessment factors.If the child fails to follow the contract for behavior change, the child and his/her parent will be discontinued from participation in the program.
Stage 5: Program plan.The program plan outlines action strategies for providing the prescription for behavior change and involves two components: education and behavioral intervention.Reinforcement strategies will be applied through community support.The support network within the after-school community is essential to program success.Support groups will include mothers, fathers, sisters, brothers, and other extended family members and friends.
Phase 4: Monitoring for Progress.The participants who demonstrate progress with behavior change will continue in phase four: monitoring for progress.The participants who fail to demonstrate progress may either discontinue participation or return for reassessment by the program staff.During the reassessment stage the child's behavior change will be evaluated and the child's program plan will be revised.
An impact evaluation of skills and outcomes will be performed with children who exhibit progress with behavior change.Objective indications of progress and outcomes will include behavioral, psychological, and physiological measures.The behavioral measures will consist of attendance, learned skills, and behavior change.An evaluation by the health educator will measure psychological outcome, while the physiological measures will include self reports of self-esteem.
Children who demonstrate a negative impact evaluation will have two alternatives: (a) to discontinue participation, and (b) return to the re-assessment phase.Children who display positive evaluations will be provided maintenance support and follow-ups.A series of support sessions will be offered at the afterschool center to extend the intervention program.If children become overwhelmed during the monitoring phase the option to discontinue the after-school obesity program is available.

Summary
After school prevention programs are particularly effective in facilitating behavior changes in the African American community (Cella, Tulsky, Sarafian, Thomas, & Thomas, 1992).An after-school program can be a valuable resource for building self-esteem, communication, and family support.This paper proposes an after-school obesity prevention program for African American children.The program is a behavioral education program designed to facilitate healthy behavior changes in obesity self-care.In addition, the program provides culturally sensitive interventions specifically for obese African American children.
The self-care concepts addressed are: knowledge of obesity, exercise, and nutrition.The culturally sensitive interventions direct attention to the problems of low self-esteem, communication, and ineffective family coping.The implementation of the after-school obese program included four phases: needs assessment, planning and goal setting, implementation, and monitoring for progress.The after-school childhood obesity program provides a potential solution for health problems experienced by African American obese children and is designed to promote self-care, enhance family support, and improve children's quality of life.