H Tailoring BWL Programs 43

One of the main benefits of BWL programs is that they can be tailored. Tailoring is “developing…a single intervention approach for a defined population sub-group [taking] into account characteristics [that are] shared by the sub-group’s members”.172 Tailoring an

intervention is believed to improve treatment retention and adherence thereby increasing efficacy. Interventions can be tailored based one or more participant characteristics including: demographics, level of motivation, physical or cognitive limitations, etc..173,174 Developing BWL programs for African American women who are severely obese that are tailored effectively may be especially important given that higher attrition and lower treatment adherance have been associated with both race175,176 and BMI.177

Cultural tailoring is a frequently used strategy when designing BWL programs for non- White populations.32 As defined by Resnicow et al., there are two dimensions to cultural

tailoring: surface structures and deep structures.178 Surface-structure modifications are those that involve “matching intervention materials and messages to observable, "superficial"

characteristics of a target population” such as through language, images, locations, clothing, etc.178 _{Commonly used surface-structure cultural modifications for interventions with African}

American women include: conducting the intervention in an African American church or matching the race/ethnicity of the interventionist to that of the participants.179 Surface-structure adaptations theorize that when participants feel more comfortable in the intervention setting or can identify with the interventionist they may be more likely to attend sessions and adhere to the recommendations.

Deep-structure changes involve incorporating the “cultural, social, historical,

target population” into the intervention.178 _{One of the most frequently used deep-structure}

cultural modifications is adapting the curriculum content to reflect the values, beliefs and/or cultural norms of the race/ethnicity, gender and/or age of the participants.179

In developing BWL programs, caution should be taken when making assumptions about the efficacy of any adaptation when there are differences in age, race, gender or any other potentially relevant participant characteristic. For example, cultural adaptations that are relevant for African American women may not apply to African American men or vice versa. For African American women who are severely obese it is important to consider the potential roles of race, gender and body weight. To date, the studies that provide guidance on how to tailor based on these three characteristics are presented in separate literature bases by race/gender (research with African American females of varying BMI classifications) and by BMI classification (research with severely obese populations of varying races and genders). Very little is known about how the combination of these characteristics may modify needs for BWL program tailoring. III.I. Efficacy of BWL Programs for African American Women

As discussed previously, BWL programs can produce a weight loss of approximately 5- 10% (or 5 – 10 kg) in 4-6 months in the general population.180 _{However, these outcomes are not}

typical for African American women. A review by Fitzgibbon et al. (2012) of weight loss outcomes in African American women examined 25 articles published between 1990 and 2010. The authors report that the average weight change ranged from +0.5 kg to –3.2 kg in 4-6 months with only two exceptions.32 In the DPP African American women lost on average 4.7 kg (4.5%) and in the Weight Loss Maintenance (WLM) Trial,181 _{African American women lost 4.1 kg. One}

possible explanation for these findings is that both the DPP and WLM trial were large, well- funded research trials that utilized intense intervention strategies and had substantial resources at

their disposal to help facilitate weight loss in participants. However, although African American lost more weight in these studies than other smaller programs, they still lost significantly less (only slightly more than half) than their Caucasian counterparts (8.1%).3

The disparity in weight loss outcomes for African American women is the subject of many research papers. The general consensus of the findings from this literature base is that African American women face unique challenges with regards to engaging in healthy lifestyle behaviors and losing weight. For example, a 2015 paper by Joseph et al. summarizes the findings from 42 published studies reporting on barriers African American women face when trying to engage in physical activity. Three levels of the socialecological model were represented in the findings including individual (lack of time and/or motivation), interpersonal (lack of social support or a physical activity partner) and organizational (lack of facilities).

Cultural tailoring has been used in many BWL programs for African American women, but there is very little, if any, consensus on what types of modifications are most important. A review by Fitzgibbon et al. (2012) of weight loss interventions in African American women examined 25 articles and found that there were no differences in outcomes between trials that reported cultural adaptations and those that did not. A similar study by Whitt-Glover et al. (2009) examined 25 published interventions that were focused on improving physical activity levels in African American adults.182 In their results the authors note that the inclusion of cultural

adaptations did not seem to improve physical activity outcomes. They go on to explain that even in the three studies in their review that specifically compared/tested the efficacy of including a cultural adaptation vs. no adaptation, no between group differences were found. Despite the findings of these two review papers, cultural tailoring should not be ruled out as a way to improve treatment efficacy. As the authors of the first review (Whitt-Glover et al.) note,

assessing the efficacy of cultural adaptations was challenging due to the heterogeneity across study designs with regards to both the level (e.g. surface vs. deep) of cultural adapation as well as the degree to which they were integrated across all program components.32