Translating evidence-based behavioral weight loss into a multi-level, community intervention within a community-based participatory research framework: the Wellness Engagement (WE) Project

Abstract

Black Americans and individuals from economically disadvantaged backgrounds are at disproportionate risk for obesity, yet are underrepresented in behavioral weight loss (BWL) trials and experience less benefit from traditional programs. The Wellness Engagement (WE) Project sought to translate evidence-based BWL within a CBPR framework to promote change across multiple domains of influence in an under-resourced, predominantly Black community. The purpose of this paper is to describe the efforts we undertook to translate data from our extensive formative phase into programming well suited to meet the needs of the Petersburg community. In addition, we present data from our pilot work on feasibility and acceptability. Formative data were collected using a variety of methods including a community-wide survey, asset mapping, house chats, focus groups, and key informant interviews. In collaboration with key stakeholders and community members, evidence-based approaches to weight loss were adapted to meet the needs of the community with respect to both content and delivery modality. Materials were adapted to focus on small, realistic changes appropriate for the specific context. Behavioral groups, experiential nutrition and exercise sessions, and walking groups leveraged existing assets and were open to all community members. Feasibility and acceptability ratings were promising. Furthermore, the WE Project appeared to contribute to a culture of wellness. CBPR might be a viable approach for engaging under-resourced Black communities in behavioral weight management; larger scale implementation and evaluation efforts are needed.

Implications.

Practice: Helping individuals identify existing assets in their interpersonal and physical environment and effectively engage members of their social network to support healthy changes to eating and physical activity has the potential to enhance behavioral weight loss treatment outcomes.

Policy: Policymakers have the opportunity to support the development of safe spaces at the neighborhood and/or street level to promote normative, communal, physical activity, thereby actively promoting a culture of health.

Research: Future research should explore innovative strategies to further enhance reach to communities and conduct rigorous evaluations regarding the impact and sustainability of leveraging community role models to deliver evidence-based weight loss programming.

INTRODUCTION

Developing sustainable, community-based behavioral interventions to address the national obesity crisis is critical in order to mitigate the alarmingly poor health outcomes faced by vulnerable populations. In the USA, more than 130 million adults meet criteria for obesity [1], and it is the third leading cause of preventable death [2]. Furthermore, data demonstrate stark disparities for racial/ethnic minority populations and those from economically disadvantaged backgrounds [3, 4]. Despite this, Black Americans and individuals from economically disadvantaged backgrounds have been historically underrepresented in behavioral weight loss (BWL) trials [5–7], and evidence suggests that extant gold-standard behavioral treatments are not as effective for Blacks, and women in particular, as they are for other demographic groups [8–10]. In fact, a systematic review of weight loss outcomes in multicenter trials indicates that Black participants lost up to 3.2 kg less than White participants enrolled in the same intervention [11].

Individual-level weight loss trials may not be sufficient to support long-term weight loss maintenance given the demonstrated role of cultural and structural determinants of weight and health among Black communities [12–14]. Indeed, traditional BWL trials are removed from the real-world setting in which participants live, especially for economically disadvantaged adults; and importantly, these traditional delivery models also largely disregard the potential social and cultural assets which exist within community settings. More recently, there have been translations of evidence-based lifestyle interventions into community settings—these trials have included adapted materials for literacy levels, as well as low-cost diet and physical activity options, and some have been delivered by community health workers and peers [15–22]. While outcomes from these trials are promising, there is still a need to truly integrate these programs within the community setting in a sustainable way—moreover, previously tested models have not fully harnessed the potential of community members as agents of change.

Programs implemented in a naturalistic community setting have the potential to leverage extant social networks and resources; however, these interventions are often difficult to sustain beyond the initial funding period. This is a particular concern in underserved majority-Black communities wherein poverty and financial strain play a critical role in the development and maintenance of obesity. Furthermore, programs yielding no benefit or the abrupt termination of beneficial programs once the research period ends may contribute to distrust of research and exacerbate challenges recruiting vulnerable populations [23]. Community-based participatory research (CBPR) represents a viable framework in which to address these challenges and reach the most vulnerable populations because this approach builds on existing community-level assets and strengths and emphasizes sustainability of intervention infrastructure and supports. CBPR involves collaboration between community members and researchers throughout every step of the research process—from formulating a research question to dissemination of findings [24, 25]. Thus, cultural and contextual factors are inherently addressed in a way that is relevant for the community.

Though few CBPR endeavors have targeted obesity in Black communities, extant trials demonstrate encouraging initial results. The Wholeness, Oneness, Righteousness, and Deliverance (WORD); [26]) trial implemented a CBPR approach to develop and test a faith-based weight loss intervention in a rural Black community. Lay health advisors were recruited from participating churches and received training to deliver the 8-week group-based intervention. At 8-week follow-up, participants in the WORD program lost significantly more weight compared to those in the control group; however, average weight losses were very modest (−1.4 kg ± 0.4). The Journey to Better Health trial [27] was designed by a long-standing partnership between community health advisors and academic researchers in rural Alabama and Mississippi. This study examined differences in weight loss and metabolic outcomes between a CBPR-informed 6-month intensive BWL program and that same program augmented with grant funding for community-level changes such as community gardens, establishment and maintenance of a walking trail, and exercise classes. At 6-month follow-up, both conditions produced weight loss averaging −2.4 kg ± 4.4 with no significant differences between groups; however, participants in the augmented group did attend more intervention class sessions.

These CBPR approaches to weight loss in Black communities acknowledge the importance of individuals’ naturalistic environment; however, they do not fully take advantage of multi-level social contexts such as family, local politics, and cultural beliefs. The Wellness Engagement (WE) Project aimed to translate extant evidence-based approaches to weight loss within a CBPR framework in a way that produces change across multiple domains of influence—that is, across individual, family, community, organizational, and environmental levels—within the Petersburg, VA community. Consistent with principles of participatory research wherein the population has volition and identifies the area of need, not the researcher [24, 25, 28, 29], Petersburg residents identified obesity as a high priority for intervention due to its role in the development and course of multiple chronic illnesses. As part of an R24 obesity planning grant, and grounded within a CBPR framework, the WE Project undertook extensive formative work and intervention planning efforts—this work was guided by several overarching principles and commitments. First, the work was to be community-driven, not researcher-driven. Second, we approached all elements of this work through a strength-based lens, and we sought to leverage existing assets within the community, including individuals, organizations, and the physical environment. Third, potential for sustainability was at the forefront—our goal was to build community capacity and design intervention implementation strategies that would facilitate long-term sustainability without the research team. In this paper, we report briefly on the formative phase we undertook, and focus on the process by which we translated this wealth of data into a multi-level health promotion initiative within a CBPR framework. In addition, we report data from our pilot work on the feasibility and acceptability of these approaches in the Petersburg community in preparation for future efforts.

METHODS

When the WE Project began, our first step was to partner with community residents who were engaged as Wellness Ambassadors (WAs) in all aspects of this project. WAs were recruited via community partners, community events, recruitment flyers, and word of mouth. Interested individuals completed an online or paper–pencil screening application. Eligibility criteria included: Petersburg resident, 18 years or older, high school diploma, computer literate, commitment to improving personal health, and ability to work at least 20 hr per month. A total of 18 WAs were engaged in all aspects of the R24 spanning recruitment, data collection, analysis and interpretation, report back events, and intervention development/adaptation and initial pilot testing. WAs completed human subjects and ethics training, met regularly with the research team, and were critical partners in the formative work which laid the foundation for our intervention.

Formative work conducted during the WE Project has been described previously along with initial key findings [30–33], but is briefly summarized here to provide context for the intervention targets and strategies. We conducted a comprehensive needs assessment and extensive formative data collection, including: asset mapping [30]; focus groups and house chats [31]; key informant interviews (M. Mosavel et al., unpublished data, 2020); and a community wide survey [32]. Across all data sources, the following four key themes emerged which informed intervention development. (a) Participants expressed a strong desire for obesity-related programming; 85% of respondents indicated they would like to make healthy lifestyle changes and would like programming which offers support and encouragement to assist them. (b) Participants emphasized that intervention targets and strategies need to be realistic and that experiential learning is important. (c) Community-level support for health and wellness and behavior change is needed. Participants highlighted the need for visible local role models and support for healthy behavior. (d) Participants emphasized that intervention components must be accessible and reduce structural and environmental barriers and that the intervention must be Petersburg specific and acknowledge the social determinants of health. Community residents also provided input at a working town hall meeting about efforts to improve their built environment and suggestions for beautification. Initially, the plans focused on erecting street signage to promote walking; however, this plan was deemed shortsighted since residents suggested that safety issues and having “a place to walk to” must be prioritized before signage. Popular suggestions for beautification included colorful murals that would promote images of residents engaging in healthy behaviors. Residents also participated in a photo voice and street audit process where they documented assets and barriers to healthy eating and exercise. Prior to the intervention development phase, data were reported back to the community in a series of data dissemination events in order to elicit feedback and ensure a shared sense of purpose. We held several report-back events in the community with adults and families (theatrical performance) and youth (World Café day); all events combined data dissemination activities with a formal opportunity for community members to provide reactions and feedback on our work to date, as well as suggestions for intervention development and next steps [33].

PHASE 1—intervention development: translating behavioral weight management

We closely examined evidence-based behavioral obesity treatment programs [34, 35] through the lens of the community feedback and our formative data to determine which aspects of existing evidence-based programs were consistently associated with behavior change and weight loss and must be represented in the adapted program, as well as what adaptations were needed in order to be feasible and acceptable within Petersburg, given that formative data reflected a clear desire for the programming to be Petersburg specific. Petersburg consists of seven wards with a population of ~32,000, of which 79% identify as Black [36]. High rates of poverty characterize the city and 43% of families report household incomes under $25,000 [36, 37]. Thus, we worked with our Wellness Ambassadors (WAs) to carefully consider community context during this process.

Consistent with the principles of CBPR [24], community members were actively engaged as partners in each step of this process. It was an iterative and collaborative process that involved data analyses, interpretation and meaning making, and a discussion of how each of the fundamental evidence-based BWL components (i.e., diet, physical activity, self-monitoring, goal setting and problem solving, social support) should be translated in a way that was consistent with the formative data, addressed specific barriers and facilitators noted by residents, and aligned with existing strengths in the Petersburg community (see Table 1 for an overview). Furthermore, we worked collaboratively to identify potentially viable implementation channels that would allow for broader community engagement than traditional BWL delivery models, with potential for sustainability and environmental supports at the forefront of these discussions.

Table 1.

How Key Findings from the Formative Phase Were Represented

Formative data theme	Translation
Realistic strategies	●  Small changes approach to lifestyle change ●  Personalized goal setting based on current behaviors and needs ●  Concrete behavior change targets, appropriate literacy level, and well-defined targets for change
Experiential learning	●  Free weekly nutrition and physical activity classes ●  Walking groups and accessible behavioral groups to promote behavior change via social modeling and support
Interpersonal support	●  Community and ward-wide awareness to foster a culture of change ●  Check-ins available with a lay support coach (Wellness Ambassador) ●  Engaging entire family in healthy changes and promoting family meal time ●  Weekly experiential activities offer a place for families and community members to interact and support one another around healthy behaviors
Motivation	●  Check-ins with Wellness Ambassadors conducted in the spirit of Motivational Interviewing, eliciting intrinsic reasons for change ●  Core lesson content (print materials and open behavioral groups) framed within the spirit of motivational interviewing ●  Raffle entry with attendance at community events
Accessibility	●  Lesson content delivered via sustainable channels (print and video) and used visuals and text on sixth grade reading level. Made widely available via email and community locations (library, experiential classes, Wellness Ambassador check-ins) ●  Experiential classes conveniently located in locations within their ward ●  Minimal exclusion criteria to maximize reach ●  Internet access is not necessary for access to intervention materials
Community engagement/Petersburg relevance	●  Collaborations with existing community organizations ●  Intervention structure and content grounded in formative data and needs assessment data from Petersburg residents; adapted to meet the needs of this community specifically ●  Community members engaged at every step of the process, including intervention development and delivery ●  Directory for community resources ●  Events available to entire community ●  Partnerships with community-based organizations, faith-based organizations, Virginia Cooperative Extension Services and YMCA
Family-based change	●  Family-based intervention activities ●  Emphasis on the importance of family meals ●  Focus on changes to the home environment to maximize potential for success and potential for ripple effect within the family

A set of print modules was developed and refined in an iterative process with extensive input from community partners and WAs—all focus on making small and realistic changes to eating and activity behaviors. Topics included: (a) decreasing sugared beverages; (b) increasing fruit and vegetable intake; (c) decreasing portion size; (d) family meals; (e) increasing physical activity, and (f) decreasing sedentary behavior. These modules retained evidence-based recommendations and strategies to assist individuals in making healthy changes, but included substantial adaptations to meet the needs of Petersburg families (e.g., cultural adaptations, emphasis on small and pragmatic strategies for low-resource families, adjusted for low literacy level to include more visuals and sixth grade reading level). The WAs suggested that we include “expert” videos to communicate key concepts, and indicated that using a graphic design format might resonate with residents. Thus, our research team and WAs collaborated with Zuri Creative Services on the development of brief, illustrated videos to accompany each of the print modules. The intent was that core education and behavioral skills content would be standardized and available to eventual study participants as well as community members more broadly. Please see Table 2 for an overview of how each construct was represented in the intervention and Fig. 1 for an overview of the intervention approaches.

Table 2.

Overview of How Evidence-Based Behavior Change Constructs Were Represented

Key theoretical/ behavioral/practical constructs	Intervention component
Knowledge provision/instruction (behavioral capability)	●  Print lessons; Videos; Monthly behavioral groups; Experiential nutrition and physical activity classes
Goal setting/intention formation (Self-regulation)	●  Print lessons; Videos; Monthly open behavioral groups
Vicarious experience/Social modeling (culture of health and wellness, self-efficacy)	●  Monthly behavioral groups (co-facilitated by WAs); Walking clubs; Experiential nutrition and PA classes
Self-monitoring of behavior (self-regulation)	●  Print materials; Tracking sheets that require little writing; Walking clubs/tracking miles; Pedometers given as prizes
Provide feedback on performance (self-efficacy)	●  Monthly behavioral groups; Experiential nutrition and PA classes
Reinforcement (self-regulation, self-efficacy, culture of health and wellness)	●  Print lessons; Monthly behavioral groups; Raffles/prizes given at experiential sessions; Support and encouragement from WAs
Barrier identification/problem solving (self-efficacy)	●  Monthly open behavioral groups; Print lessons
Social support and autonomy (culture of health & wellness, social support)	●  Monthly behavioral groups; Emphasis on family meals and family-based change; Walking clubs; WAs and staff attending community events; community microgrants
Increased access (culture of health and wellness)	●  Print lessons publicly available; Referrals for health services; Open and free behavioral groups and experiential sessions; Joint-use agreements, Beautification of physical environment; Walking clubs

Fig 1.

Overview of intervention programming in the WE Project.

PHASE 2—intervention pilot

Capacity building and training

We established collaborative relationships with the Petersburg YMCA and VA Cooperative Extension—existing community assets—to facilitate community-wide experiential offerings as part of the pilot phase. Harnessing these resources available in the community was a critical consideration to build local capacity and connection, and to enhance the potential for sustainability once the research funding ended. Additionally, Wellness Ambassadors (WAs) completed a series of trainings with the academic PI and Co-I to prepare them for their role as lay support coach during the intervention pilot phase. These sessions occurred over 4 months and included a mix of didactics and experiential learning (e.g., role plays); topics covered included the spirit of motivational interviewing, interpersonal communication, and principles of social modeling. Sessions also reiterated key topics covered prior to project onset (e.g., dual roles, processes for debriefing, and support). Community members serving in this role was meant to provide a potentially sustainable model for peer support and role modeling after the research grant ended.

Participants

WAs employed a multi-method, active recruitment approach (e.g., going door-to-door, community events, church programs) to recruit a small sample of participants to complete assessments in this study. To be eligible, individuals had to be adults 18 years of age or older and residents of Ward 1 or Ward 6 in Petersburg. We selected Wards 1 and 6 for this initial test of feasibility and acceptability as they were comparable in terms of race and proportion of residents <18, 18–64 years, and >64 years, but they are geographically distinct in their position within the city which we viewed as a strength in order to better generalize to the city as a whole. A total of 40 individuals consented and were offered a $20 honorarium to complete the study assessments 8 weeks after programming began. Please note that intervention programming was open and accessible to all residents within the two intervention Wards without restriction, and brief satisfaction/quality improvement surveys were conducted with attendees at all experiential sessions.

Overview of intervention programming

As depicted in Fig. 1, this pilot intervention spanned multiple levels, with the majority of the programming offered at the community and individual/family level. Importantly, all intervention components were accessible to all residents of intervention Wards without restriction. Activities were publicized through social media, flyers, partnerships with local churches and community organizations, and word of mouth through the WAs own social networks. A brief overview of the rationale and intervention targets at each level is provided below.

Environmental level

We partnered with a local arts group to design and coordinate the painting of a mural which included drawings of city landmarks, families, and individuals of varying abilities and sizes doing a variety of physical activity including biking, gardening, walking, cartwheels, and doing yoga. A homeless shelter located on one of the city’s busiest thoroughfares was the backdrop for this mural. The emphasis on creating an inclusive, culturally diverse mural, is a direct response to our formative phase wherein residents expressed a strong desire for physical beautification of the environment that invites health promoting behaviors especially walking.

Community level

Walking groups: Grounded in our formative data which emphasized a desire for social modeling and support, as well as potential safety concerns regarding walking, we established walking groups within each Ward. WAs served as walking group leaders to leverage their training as lay support coach and promote social modeling. Groups were open to all members of the Ward, without age restrictions; families were encouraged to walk together as part of the groups. Walking was promoted as a core strategy in an effort to promote accessible and sustainable physical activity. Experiential classes: In light of our formative data which underscored a desire for experiential learning, we offered community-based classes which mapped onto key theoretical, behavioral and practical intervention targets across both nutrition and physical activity.

Individual/family level

Lesson content: Print and video modules developed during Phase 1 were made publicly available to residents during Phase 2. Materials were made widely available via email and community locations (e.g., library), and were also available at behavioral groups and experiential classes. Behavioral groups: We offered group sessions, co-facilitated by a WA and a research team member. These sessions included a time for check-in and support, as well as discussion of the lesson content, and personalized goal setting. Lay support: WAs were present at behavioral groups, experiential nutrition and physical activity sessions, and led walking groups. Their role was to serve as a peer/lay support coach to residents across the intervention activities.

Evaluation of feasibility and acceptability

Assessments were primarily process oriented and drawn from WA and researcher field notes. There were two other data sources used to evaluate the potential of this intervention. First, attendees at experiential sessions were asked to complete a brief 4-item satisfaction survey. Second, enrolled study participants were asked to complete study surveys 8 weeks after intervention activities began; 70% of participants completed their 8-week assessment packet. Enrolled participations could have attended any of the offerings in the community, or could have elected not to attend any of them.

Engagement and culture of health

To operationalize engagement, we tracked the following metrics: attendance at open behavioral groups, participation in walking groups, and attendance at experiential activities. We also assessed perceived social support from family and friends.

Acceptability and satisfaction

To operationalize potential acceptability and satisfaction, we used a combination of attendance data and feedback data on brief surveys wherein participants were asked to respond to a series of questions (e.g., This event was fun and kept me interested; The skills I learned are realistic for me to continue in my daily life) on a Likert scale ranging from 1 to 4, where 1 is “strongly disagree” and 4 is “strongly agree.”

Potential to positively impact energy balance behaviors

We developed a brief survey that mapped on to key behavioral strategies targeted in the program materials (e.g., making small changes to portions; increasing family meals). At 8 weeks (i.e., 8 weeks after the programming began), participants were asked about changes to these areas to determine whether there was a signal in favor of this type of community driven health promotion initiative to have a positive impact on key individual level behaviors of interest in future work.

Statistical analyses

Given the nature of this phase, analyses are descriptive in nature. Means, standard deviations, and proportions or percentages are presented where appropriate.

RESULTS

Engagement and culture of health

More than 10 walking groups were established, each led by a WA. This count alone suggests that walking groups, led by a peer mentor, are feasible and acceptable to community residents. Moreover, logs completed throughout the pilot phase indicate that groups walk together once weekly on average, demonstrating initial efficacy of this approach to promote physical activity. Attendance at the behavioral group sessions was modest, with an average of 6 individuals attending these groups. Across two physical activity events, 36 adults attended (mean age = 33 years, 75% female, 78% Black, and high numbers of youth attended (n = 65, no other data available). Across two nutrition events, a total of 30 adults attended (mean age = 34 years, 73% female, 73% Black), and again, high numbers of youth were present (n = 50). Across all experiential community sessions offered, over half of attendees (52%) had heard of the WE Project prior to the event, which speaks to the penetration within the community, and to the potential to extend the reach and penetration of intervention activities with a fully scaled intervention. Moreover, satisfaction with the events was high, as was behavioral intention to attend future events and use the skills taught (see Table 3). Finally, 8 weeks after launching programming, 58% of participants reported that family or friends gave them encouragement to stick with their exercise program and 48% reported that family or friends reminded them to avoid high fat and high salt foods.

Table 3.

Acceptability and Satisfaction with Community Events

Physical activity sessions
This event was fun and kept me interested	4.0
I could see myself doing this activity with my family	3.5
Events like this benefit the Petersburg community	4.0
I want to attend future events like this one	4.0
The skills I learned are realistic for me to continue in my daily life	3.0
Nutrition sessions
This event was fun and kept me interested	4.0
I could see myself doing this activity with my family	3.0
Events like this benefit the Petersburg community	4.0
I want to attend future events like this one	3.0
The skills I learned are realistic for me to continue in my daily life	3.0

Assessed on a scale from 1 to 4, where 1 is “strongly disagree” and 4 is “strongly agree.”

Potential to positively impact energy balance behaviors

On the 8-week survey, 50% reported increasing their physical activity, and 55% reported efforts to reduce their amount of sitting time. In addition, 61% reported trying to make meaningful changes to the types of food they ate at least 2–3 times per week, and 50% reported making changes to the amount of food they ate with this same weekly frequency. Fifty-two percent indicated that they had reduced the amount of sugar-sweetened beverages consumed by their family at least 2–3 times per week. Lastly, 67% of participants reported increased frequency of family meals.

DISCUSSION

The findings presented here underscore that CBPR is a viable approach for translating behavioral weight management programs into community-wide initiatives to enhance reach and engagement among Black communities. Indeed, CBPR may be one of the few ways to truly promote community-driven health behavior change using evidence-based strategies. At the same time, this approach demands much of researchers if it is to be done well. CBPR is extremely time-intensive, requiring longer stretches between each phase of the research process in order to provide community updates and elicit feedback before proceeding to the next step [38, 39]. In addition, it requires a complete reconceptualization of our roles as researchers given that CBPR goes well beyond implementing an evidence-based protocol in a community setting; rather, CBPR projects are not only adapted for the community—they are led by the community. These investments have the potential to produce profound sustainable and long-term impact in under-resourced communities of greatest need which are not typically reached by evidence-based programs [40]. Our current findings suggest that a CBPR approach to weight management interventions is feasible and acceptable and holds potential for creating a culture of wellness within Black communities.

Data also signal the potential to impact energy balance behaviors on an individual level. Participants reported perceived improvements in their physical activity and fruit and vegetable intake, as well as perceived decreases in sugared beverage intake, fat intake and portion sizes over the course of a very brief 8-week period. Clearly, these findings should be interpreted with caution as they are not based on validated assessment tools and are subject to bias based on participants’ report at a single time point regarding the change in their behaviors. Additional work is needed which includes repeated assessment of key outcomes over time and employs validated methods; however, current findings suggest there is a potential signal present and that residents perceived they were making healthy lifestyle changes, which is encouraging. Furthermore, attempts to fully scale a program of this type to the entire community rather than just two wards would benefit from a comprehensive evaluation using a framework such as RE-AIM [41] to determine the overall impact and potential for sustainability and maintenance of change. Although we did not formally assess sustainability in this initial pilot, process data reflected that walking groups continued to walk together after the WE Project activities ended. In fact, as much as a year after the end of the award, two groups were still walking regularly and several walking club leaders went on to complete a program through the local YMCA to become fitness warriors. In addition, at the organizational level, the academic PI established a community coalition, which is now an independent entity with a board of directors consisting of more than 20 community partner organizations addressing health disparities in Petersburg [42].

Process data reflect better uptake at experiential sessions than at behavioral group sessions. On the one hand, this underscores the importance of experiential learning, which is consistent with our formative data and theory [43]. This also demonstrates the importance of community member involvement in these sessions, which may have played an important role in uptake and acceptability. In contrast, it also highlights the relatively poor attendance at the behavioral group sessions. This was somewhat disappointing given these were co-facilitated by a WA, open to all community members, and held at local churches that were easily accessible within each ward. Findings suggest the need to use targeted community outreach in order to enhance penetration. One potential avenue might be to harness existing social networks and offer these groups within community members’ homes. In our formative phase, we experienced great success using this approach—which we called house chats—to conduct focus groups in a grassroots way [31]. Future work might consider implementing this model as a novel approach to enhance reach and uptake of behavioral group sessions within a community-wide initiative such as this one.

There are a number of valuable lessons learned in this work. Discussions with residents led to our decision to open all aspects of the WE program to the entire community rather than carefully selected individual participants. In this way, we reinforced the message that this endeavor is truly meant to benefit the city as a whole. While study participants provided informed consent and completed assessments, there were no restrictions as to who was able to participate in program offerings. Events were advertised to the community at large, intervention materials were available at the public library, and participants were encouraged to bring their family and friends. Furthermore, just as we provided training for lay community members to serve as Wellness Ambassadors, we also provided training for our own research staff in order to assist with adjusting to serving as collaborators rather than experts. Though research staff was present at all study-related events, the majority of events were led and facilitated by WAs and/or other community members to enhance sense of community empowerment. A truly sustainable community-oriented approach to health behavior change requires that we recognize our role is to provide training and assist rather than lead endeavors. This is a critical consideration within a CBPR framework—the researchers should not and cannot be the drivers of the initiative or lead the implementation if the efforts are truly designed to be sustainable without the research team. This represents a departure from traditional clinical trials for BWL—even those delivered in a community setting—yet, this is a fundamental principle that must be upheld in future work.

Another important lesson learned is that this type of work requires environmental level supports and changes beyond what can typically be supported by a research grant. In order to accomplish this, it is likely that multiple funding streams will be needed and partnerships with local and state health departments may be an important avenue to pursue. Such efforts will of course bring design challenges with respect to internal validity—indeed, it will be more challenging to evaluate the effects of intervention efforts and to know what aspects of the programming are driving observed changes in health outcomes. However, this is the nature of real world implementation, particularly within a CBPR framework. We must lean in to the challenges and meet them head on in future work in order to have the type of long-term sustainable benefit so urgently needed. Furthermore, in order to truly “move the needle” on the health outcomes of interest in under-resourced Black communities such as Petersburg, a new lens is required—one that recognizes the effects of structural racism and disinvestment, and approaches multi-level health-related interventions and policy work through this lens.

Lastly, it is important to rethink how we evaluate outcomes—it is paramount that the community provides input regarding outcomes of importance to them. Furthermore, measurement must account for not only what is realistic and meaningful for the community but also methods that are valid and rigorous, and span multiple levels of influence. As we discovered in the WE Project, equally important to individual-level behaviors (e.g., diet and physical activity) was the measurement of impact on the culture of health and well-being for the Petersburg community. Operationalization of this type of macrosystem-level variable may look different across varying community context, but these represent potentially powerful constructs with respect to maintenance of intervention effects. In sum, initial process data reflect feasibility and acceptability of a number of implementation channels in the Petersburg community specifically. Findings suggest that CBPR is a viable approach to engaging Black communities in BWL—wider-scale implementation over longer-term follow up with rigorous outcome evaluation appears warranted.

Compliance with Ethical Standards

Conflicts of Interest: All authors declare that they have no conflicts of interest.

Human Rights: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All study procedures were approved by the Institutional Review Board at Virginia Commonwealth University.

Welfare of Animals: This article does not contain any studies with animals performed by any of the authors.