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U-M CCC - Progress Newsletter Winter 2004 Online
An Unlikely Laboratory
A landmark study on behavioral change -- holding promise for cancer prevention -- takes place in America's black churches Kenneth Resnicow, Ph.D., relied on both scientific precision and "divine intervention" to create a novel program to modify eating habits.
The U-M Comprehensive Cancer Center has more than 65,000 square feet of dedicated research laboratory space. Ken Resnicow, Ph.D., didn't use an inch of it to complete the scientific study that recently earned him the accolades and significant ongoing financial support of the National Institutes of Health (NIH). Instead, he found alternative lab space, in African-American churches in Atlanta. Resnicow, a Cancer Center member and professor of health behavior and health education at the U-M School of Public Health, studies behavioral change. Not just in individuals, but in social groups. His work with black churches dates back to 1991, and has encompassed behaviors from smoking to diet and physical activity. The current study attempted to demonstrate that a group of behavioral modification tools -- called an "intervention" -- could be employed with a population to increase their intake of fruits and vegetables.
From Oppression to Mission
Why attempt to undertake research in a church, and a black church specifically? An unintended positive consequence of slavery, racism and segregation in our country's past was the establishment of the black church as a comprehensive social and political institution. Since the days of slavery, these churches have served their communities as one of the only places where social and political discourse was allowed, albeit often in secrecy. Many black leaders came from a background in ministry, and black churches produced many great orators, in part because they were shut out of other institutions. Black churches continue to serve multi-purpose roles today. Many have a social agenda operating alongside their spiritual mission, often including formal health ministries or committees.
Other factors, like stability and loyal church attendance, and the fact that in major metropolitan areas parishes exist at every socioeconomic level, make black churches ideal "laboratories" for health researchers like Resnicow. That does not mean that every risky health behavior is highlighted in this population. Some are less problematic among black church attendees than the overall black population -- smoking rates are 30 to 50% lower, for instance. "But for some indicators, like poor diet, obesity, and perhaps cancer risk," says Resnicow, "the church represents a 'fruitful' environment to conduct health programs."
Collaborating in Good Faith
From the outset, the study's goals were defined in terms the NIH deemed both "public health-meaningful" and achievable. But Resnicow was to be held to not only scientific standards, but the "higher" standards of the participating communities. The spiritual leaders of each group needed to be reassured of how the science was being conducted, and what role they were playing.
"They were sensitive to the 'guinea pig scenario'," recalls Resnicow, "based on historical experiences like Tuskegee. All along we were careful to point out the individual risks and benefits of the study as well as the societal benefit of advancing science. The fact that they were involved in creating the intervention also made a big difference."
The research methodology used for the intervention had to be absolutely sound. They would perform a randomized trial, exposing one group to a series of interventions and putting the results side-by-side with a comparison receiving no interventions. The interventions consisted of specially-created materials, including brochures, videos, cookbooks, a health fair and behavioral counseling, administered by professionals.
How the interventions were created and the research conducted is a testament not only to Resnicow's scientific rigor, but his remarkable sensitivity. Not just anyone could work in this lab. The project was a collaborative effort, involving a team of spiritual leaders from each community to create a unique set of materials for that population. It required adapting to cultural differences. When it came to the incorporation of a spiritual connection to the health message, some groups wanted more biblical references, some less. "Some preferred a more overt 'fire and brimstone' approach than others," recounts Resnicow.
Resnicow is proud of the breadth and depth of materials his team compiled during this formative research, and in recounting the process, one potential reason for his success becomes clear. "I remember one discussion with a group of ministers about scripture and food. At one time, I studied to become a rabbi, so I'm quite familiar with the Old Testament. My tradition holds that, up until the generation of Noah, everyone was a vegetarian. The consumption of meat came after the fall of man. Fruits and vegetables are in that sense more pure. One minister felt uncomfortable with that interpretation of scripture, so we chose not to include it. In another case, Resnicow recalls a different group allowing the use of a reference to God "delighting in every small step you take," as a theme for a walking regimen. "Clearly," says Resnicow, "that was not a biblical exhortation for strapping on a pedometer, but we were allowed some latitude in that instance. The whole process was a wonderful learning experience."
In total, three rigorous trials were undertaken. In the first two studies, which combined the intervention elements with professional counseling, fruit and vegetable intake increased by about one serving per day from an average of three to four to near the government”s goal of five. In the third study, using lay counselors recruited from local churches, the results were nearly as positive. That number might look small, but it represents the most significant shift recorded to date. Many previous studies had only managed to shift intake by one-half of one serving.
How does Resnicow feel about the result? "I'd have to say both gratified and at the same time relieved, since the undertaking involved so much time, energy and cost. This behavioral shift is a wonderful start."
Enough of a start for the NIH to ask Resnicow to roll the program out nationally. They've funded the creation of a training kit for organizations like the NAACP, the Urban League or others, with the hope of disseminating the program to thousands of churches over the next few years.
In the fight against cancer, the highest premium is placed on translational research -- moving advances out of the lab and right to the patient”s bedside. When it comes to preventing cancer by changing behavior, this represents a good example of translational research. "There have been only one or two cases before this of a study progressing from a 'pure lab setting' to real world effectiveness phase and then dissemination in a very large population," says Resnicow. "It's great to see the rigor pay off."
To learn more about making nutritional changes to prevent cancer, and to see a few of the recipes developed in conjunction with Dr. Resnicow”s research, see Diet, Weight and Exercise.