Overall, the Eban Health Promotion Intervention taught the participants that many health problems can be prevented by changing personal behaviors, including physical activity, eating habits, cigarette smoking, alcohol and drug use, and medication adherence. Each group session began with an activity called “Group Welcome” and ended with a “Session Closing.” Participants and facilitators formed a tight circle with their chairs. The facilitators spoke and then participants around the circle spoke in turn. In Session 1, this approach was used to introduce the group members to each other. In later sessions, it was used to allow participants to share their feelings and observations about the group and the program. In a “Group Guidelines” activity, participants established guidelines for establishing a safe, comfortable, and cohesive environment.
Session 1: Welcome and Black/African American Health Issues and Assessment
Session 1 includes Module 1 “Getting to Know You,” which was implemented to all participants in a group, and Module 2 “Assessing One’s Health,” in which the participants were separated into single-gender groups. The goals of Module 1 were to introduce participants to the purpose of the program and to each other, instill a sense of personal investment in the program, and build group cohesion, comfort, and feelings of respect, safety, and trust. Other goals of Module 1 were to introduce concepts of the prevention, early detection, and control of disease and the health problems affecting black/African Americans.
In the activity “Introduction of Prevention, Detection, and Control,” brainstorming focused on the concepts of prevention, early detection, and control, including what they were, why they were important, and examples of strategies. In the activity “Diseases that Affect the black/African American Community,” brainstorming focused on what it means to be healthy; diseases that affect the black/African American community; risk factors for such diseases; identifying which of them can be prevented, detected, or controlled; and specific strategies for achieving these goals.
Participants were then divided into two single-gender groups each led by the same-gender facilitator to address gender-related health issues. The structure was the same in both groups. Participants focused on diseases that affect black/African American women or men depending on the group. The women focused on breast cancer, cervical cancer, ovarian cancer, and uterine cancer; the men focused on prostate cancer and testicular cancer. Prevention, early detection, and control were covered. Then the “Health Risk Assessment” activity highlighted their personal behaviors that placed them at risk for various diseases, and motivated them to begin to modify those behaviors.
In the “Personal Health Goals Setting” activity participants set personal health behavior goals that would be useful in their day-to-day lives. Creating such intentions should increase the likelihood that participants will change their health behaviors. In the “Barriers and Solutions to Goal Setting” activity, participants identified barriers they may face when pursuing personal health goals and with the help of the group fashioned strategies to avoid, surmount, or diminish those barriers. Sessions 1–7 included a take-home assignment, which was reviewed at the subsequent session. At the end of Session 1, participants were given the take-home assignment, which was to set a short-term health goal and accomplish it. They then formed a tight circle with their chairs for the “Session Closing” activity in which they shared “the most important thing I learned in today’s session,” and “as a goodbye, I would like to say___________to the rest of the women/men in the group.”
Session 2: Prevention: Exercise and Nutrition
Session 2 was an individual couple session that included Module 3 “Exercise—You Are What You Do” and Module 4 “Nutrition—You Are What You Eat.” Module 3 sought to increase knowledge about the impact of exercise on health, particularly heart disease, high blood pressure, and diabetes, and to provide strategies for making exercise a part of a daily routine. Participants reviewed their take-home assignment from the previous session and discussed barriers to accomplishing their short-term goals and how they might overcome them. They (a) assessed their current physical activity; (b) learned to distinguish among three types of exercises—aerobic, strength-building, and flexibility-increasing exercises; and (c) learned guidelines for amount of physical activity each week. They were given pedometers, exercise bands, and a home video illustrating their use and identifying three levels of exercise to choose from depending on their desire and fitness level. The lowest level involved exercises that could be done seated. Participants developed their own daily exercise routines.
In Module 4, participants learned that diet plays an important role in the etiology and pathogenesis of specific chronic diseases, including heart disease, stroke, hypertension, cancers (of the esophagus, stomach, colon, breast, lung, and prostate), diabetes, and chronic liver disease. The roles of fat intake in increasing the risk of cancers of the colon, prostate, and breast and the roles of diets high in plant foods, including fruits, vegetables, legumes, and whole-grain cereals, in reducing risk of heart disease, colon cancers, and diabetes were discussed. Participants learned about the “Food Pyramid” guidelines for healthful eating and about the 5-A-Day Diet, which suggests consuming daily 5 to 9 servings of a combination of fruit and vegetables, especially green and yellow vegetables and citrus fruits. Sources of excess fat among African Americans, including fats added in cooking, frequent use of frying to cook food, use of mayonnaise (e.g., potato salad), and use of sauces and gravies on meats, were covered (Kumanyika & Odoms, 2001
). The health benefits of specific fruits and vegetables, barriers to following the 5-A-Day diet, strategies for overcoming the barriers, and using fruits and vegetables as snack foods were discussed. In addition, proper preparation of vegetables was discussed—namely, that vegetables should not be overcooked to the point where they are mushy and lose their nutritional value.
Participants learned about Body Mass Index (BMI) and the role of caloric intake and expenditure. Thus, participants learned that obesity develops because of insufficient physical activity, overeating, or both. The association of obesity with increased risk of heart disease, stroke, hypertension, diabetes, and endometrial cancer was discussed. Participants were taught to identify their personal Body Mass Index (BMI) and whether they were underweight, normal weight, overweight or obese. The facilitators emphasized the importance of balancing food intake and physical activity to maintain a healthful body weight. The take-home assignment was to use the Food Pyramid Guide and the 5-A-Day Diet to create a menu for healthful meals over the next week and follow it.
Session 3. Prevention, Early Detection, and Screening
Session 3, an individual couple session, included Module 5 “Prevention: Smoking, Drinking, and Your Health” and Module 6 “Early Detection and Screening.” In Module 5, participants learned about the harmful health effects of cigarette smoking and of alcohol abuse, particularly for those infected with hepatitis C. Participants reviewed their take-home assignment from the previous session and discussed barriers to implementing their healthful menu during the past week and how they might overcome those barriers. They learned that consumption of alcoholic beverages is related to health risks. Facilitators made a distinction between the effects of moderate intake and excessive intake, or alcohol abuse. Participants learned that moderate alcohol drinking is associated with a lower risk of heart disease, whereas excessive alcohol consumption increases the risk of heart disease, hypertension, stroke, chronic liver disease, and cancers of the oral cavity, pharynx, esophagus, and larynx.
Participants were advised that alcohol consumption is not recommended for those who do not normally drink alcoholic beverages. For those who drink, the message was that consumption should be limited to two or fewer drinks per day. Participants were advised that pregnant women and persons with liver disease (e.g., hepatitis C infection) should abstain from alcohol consumption. In addition, they viewed and discussed the video “How to Begin a New Healthier Life by Stopping Smoking,” which covered effects of smoking on health, healthful alternatives to smoking, and strategies to quit. Afterward, participants discussed personal barriers to quitting smoking and to limiting alcohol consumption and how they could overcome those barriers.
In Module 6, participants learned about early detection strategies regarding hepatitis C, cervical cancer, breast cancer, prostate cancer, and colon cancer. In a single-gender activity, women learned about breast cancer and breast self-examination (BSE), clinical breast examination, and mammograms. The female facilitator demonstrated breast self-examination using a breast vest and then the female participant practiced it. The female participant’s take-home assignment was to talk to another woman about what she learned about breast cancer and BSE in the session. In a concurrent single-gender activity, men learned about the prostate, prostate cancer, and the prostate-specific antigen blood test (PSA) and digital rectal examination to detect prostate cancer. The take-home assignment was to talk to another man about what he learned in the session regarding prostate cancer and screening.
Session 4: Communicating with Your Provider
Session 4, an individual couple session, included Module 7 “Communicating with Your Health Care Provider” and Module 8 “Medication Adherence: Following Your Health Care Provider’s Advice.” In Module 7, participants discussed potential problems in contacting their health care providers, including physicians, nurses, pharmacists, and medical social workers, as well as ways to surmount those problems. Participants considered guidelines to communicate effectively with their providers on the telephone and face-to-face during a visit. Co-facilitators modeled an effective call. Role-play scenarios in which participants took turns role-playing patients and one of the facilitators role-played the health care provider were critiqued according to guidelines for effective communication and discussed. Participants were taught techniques for effective communication in the doctor’s office, such as making a list of questions in advance, rephrasing important information the doctor provides to confirm that they understand, and asking the doctor to explain in lay terms. The types of questions that might be asked were brainstormed. Role-play scenarios with each participant playing the patient role were used to allow participants to practice the communication techniques.
In Module 8, the focus was on both medications in general and those for HIV treatment. The rationale and importance of medical adherence, drug resistance, barriers to adherence, and strategies to surmount the barriers were discussed. The latter included writing down the prescription schedule and their daily activities to identify areas of potential conflict and to develop strategies to resolve the conflict. The take-home assignment was to develop independently a strategy to help people follow their medication schedule that the participants would share with the group in the next session.
Session 5: Exercise and Nutrition
Session 5, a group session, included Module 9 “Exercise and Your Health” and Module 10 “Nutrition and Your Health.” In Module 9, participants reintroduced themselves, reviewed the group guidelines, and then reviewed the take-home assignment. The “Benefits of Exercise” activity highlighted participants’ positive outcome expectancies regarding exercising and reviewed ways to make exercise a part of their daily lives. A forced-choice activity was used to identify positive and negative attitudes about exercise, to strengthen positive attitudes, and to weaken negative attitudes. In another activity, the participants viewed an exercise video, engaged in an aerobic exercise routine with feedback from the facilitators on how to exercise properly and effectively, and learned to monitor the effects of exercise on the heart by taking their pulse before and after exercising.
In Module 10, participants reviewed their nutritional habits, how nutrition relates to health, and the importance of safe food storage and preparation. They prepared and ate a smoothie as an example of how to incorporate easily a healthful snack into their daily diet. Participants played the entertaining game “Nutrition BINGO,” which reinforced the diet information covered. The take-home assignment was to review their exercise plan and to perform the exercises listed.
Session 6: Prevention and Screening
Session 6, a group session, included Module 11 “Smoking and Alcohol and Your Health” and Module 12 “Early Detection and Screening.” In Module 11, participants reviewed the effects of smoking on health. Emphasis was on positive outcome expectancies regarding quitting smoking and on self-efficacy to overcome pressures to smoke. Participants reviewed the health effects of alcohol abuse and ways of overcoming pressures to abuse alcohol. The participants formed two teams and competed in a lively game, “Wheel of Misfortune,” which reviewed information regarding alcohol, smoking, cancer, and hepatitis C.
In Module 12, participants reviewed information about early detection and screening, considered barriers that prevented people from being screened, and suggested solutions to overcome each of the barriers. The participants then separated into single-gender groups led by the same-gender facilitator. The women reviewed breast cancer information and practiced BSE on an anatomical model, attempting to find the lumps in the model while receiving guidance and corrective feedback. They reviewed barriers to performing monthly BSE and ways of overcoming those barriers. The men reviewed prostate cancer and prostate cancer screening. They watched the video “Prostate Cancer” and then discussed risk factors, symptoms, benefits of and barriers to screening, and ways to overcome such barriers. A take-home assignment was designed to give participants an opportunity to practice some of the behaviors that were recommended in the intervention. For women, it concerned behaviors related to breast cancer screening and for men, prostate cancer screening.
Session 7: Medical Adherence
Session 7, the last group session, included Module 13 “Adhering to Your Medication Schedule” and Module 14 “Communicating with Your Health Care Provider.” In Module 13, the group participated in the “HIV Medications Questions and Answers” activity, which provided a review of information about medications that people living with HIV often presented. By turn, participants were asked questions. If the participant did not know the answer, someone else in the group was asked to answer. Afterward, participants received a handout with all the questions and answers. In the “HIV Medication Adherence Pros and Cons“ activity, the group brainstormed positive and negative consequences of HIV medication adherence. The activity did not require participants to reveal their HIV status, and by design, there were more “pros” than “cons.” After all the pros and cons had been listed, the facilitators asked the participants for ways to overcome the cons. The group viewed and processed the video “Taking Control: Adherence and HIV/AIDS Medication.”
In Module 14, the group reviewed ways to improve communication with health care providers, particularly physicians and pharmacists, and the importance of advising these specialists if they have been unable to follow their advice. Men and women formed teams and competed in “Health Basketball,” in which teams earned points for correctly answering questions about the information covered in the program. The take-home assignment was to write a three-sentence plan for adhering to their medication and treatment regimens or healthful behaviors like exercise and the 5-A-Day diet and to describe their importance. The “Session Closing Ceremony” activity brought closure to the group portion of the program. It included a series of brief activities designed to encourage participants to reflect and share how the information they learned may change their lives in a healthful manner and to empower them to put that knowledge into practice.
Session 8: Review and Wrap-Up
Session 8, an individual couple session, included Module 15 “Review of Topics” and Module 16 “Wrap-Up and Review.” In Module 15, participants reviewed the importance of prevention and control of various health problems, benefits of a healthful diet and regular exercise, and discussed barriers and strategies for overcoming the barriers to each. “Fast Food Facts,” a handout, provided nutritional information on specific fast foods.
In Module 16, the participants reviewed and discussed early detection, benefits, barriers, and strategies for overcoming them, and how it personally related to them. They reviewed and discussed the risks of smoking and alcohol abuse, barriers and strategies for overcoming barriers to cessation of smoking and alcohol abuse. They reviewed and discussed medical adherence, benefits, barriers, and solutions to barriers. Participants competed in a lively review game, “Health Jeopardy,” in which they earned points for correctly answering questions. In the “Letter to Self” activity, each participant wrote a letter to himself or herself promising to make more healthful choices like exercising and eating right, not smoking, limiting alcohol consumption, and adhering to his or her health care provider’s advice and medication regimen. They put their letter in an envelope, addressed it to themselves, and sealed it. The letter was mailed to them one month later as a reminder of their promise and a prompt to work toward making more healthful choices. Participants received a Certificate of Completion as part of the “Final Session Closing.”