Individuals from socioeconomically marginalized racial and ethnic groups are at greater risk for most chronic diseases. The increasing ethnic diversity and aging of the populations of the United States and many European countries have increased the necessity and political priority for engaging underserved communities in health-related research and service efforts to address these problems.

Healthy lifestyle change is indicated for the prevention and treatment of many chronic diseases, particularly cardiovascular diseases and cancer. There is a paucity of high-quality data, however, on chronic disease risk reduction by interventions targeting or including meaningful numbers of people from low-income backgrounds or people of color. This gap in the literature represents a major obstacle in the development of effective policies and programs.

Getting members of these underserved groups to participate in research and service provision has been viewed as difficult by medical researchers. Ethnic minority populations have been labeled as "hard to reach," despite the easy access to these groups by commercial concerns selling health-destructive substances (eg, tobacco, alcohol) and food products (eg, sodas, fast foods). This problem may have a number of roots including differential access to and use of healthcare services, underrepresentation of physicians and scientists of color conducting the investigations, historical exploitation of underserved communities for commercial profit and scientific gain by medical and public health institutions, and underappreciation of the influence that culture has on behavior in the delivery of health services and the construction of health messages. 1

Jolly et al 2 began to address this gap in the literature, providing needed insight into the barriers to and facilitators of participation in cardiac rehabilitation programs among ethnic minority patients in the United Kingdom. Their findings underscore and extend the minimal prior research in this arena, with implications of promising directions for future study:

[white square] Nearly 50% of nonattendees preferred home-based programs, as compared with the preference of attendees for hospital-based programs.

[white square] Tobacco, diet, and exercise were mentioned by only 2 of 12 nonattendees as causing their illness, as compared with 10 of 29 attendees, whereas stress and worry were more likely to be mentioned by nonattendees (4/12) than attendees (5/29)

[white square] Nonattendees were disproportionately female with a non-English language preference

[white square] A disproportionate number of nonattendees reported dissatisfaction with their care.

The limitations of the Jolly et al 2 study include, as the authors pointed out, the questionable generalizability of the results given its small, heterogeneous sample (dominated by English-speaking, South Asian Indian males) and low response rate (17%). There also was a skewing of the sample toward attendees (only 12 of 41, or 29% of sample, were nonattendees), which is typical in these studies, but nonetheless problematic for comparisons of nonrepresentative groups unequal in size. Finally, although ethnic minority status and socioeconomic status tend to be highly confounded, it is possible that nonattendees were of a lower socioeconomic status than attendees, which would explain some of the group differences.

It is interesting to note that the difficulties inherent in the recruitment and retention of people of color in cardiac rehabilitation programs are common to programs for other disease processes. Exercise training programs, borrowing concepts from cardiac rehabilitation, are now emerging as an accepted adjuvant to traditional breast cancer therapy in the rehabilitation of survivors. However, rates for participation by ethnic minority women are disproportionately lower than for white women. 3 Home-based strategies for increasing physical activity among breast cancer patients are currently being tested, 4 as they are in cardiac rehabilitation. 5 Further efforts at cultural tailoring of program design and content, as well as recruitment and retention, are indicated, and should be modeled on health promotion successes. 6-8

The "obesogenic" (obesity-producing) postmodern environment in the United States, however, is not conducive to a physically active lifestyle or healthful eating patterns. 9,10 The United States has only recently begun to make progress toward a tobacco-free existence.

Obesogenic environments are characterized by a pervasively advertised and marketed smorgasbord of relatively inexpensive, readily available, highly palatable, and energy-dense but nutrient-poor foods, and by television remote control devices, garage door openers, automobiles, elevators, and escalators. All this is accompanied by underinvestment in mass transit, engineering most obligatory physical activity out of our lives.

The physical, economic, and sociocultural environments are particularly hostile to healthy lifestyle change in low-income communities and communities of color. 11 Scarcity of neighborhood private fitness facilities, a deteriorating public parks and recreation infrastructure, high neighborhood crime rates, poorly maintained and aesthetically unappealing streets, poorly equipped school physical education facilities and fewer trained instructors, overreliance on TV to engage children after school, and less availability of parent and adult volunteers to assist in after-school sports and recreation programs are barriers to physical activity participation. Nutritious food selection is constrained by pervasive fast food outlets, financial incentives offered to underresourced schools by commercial vendors, fasting and feasting patterns associated with food insecurity, high levels of culturally tailored and targeted marketing and advertising, and prevalent obesity influencing cultural norms. 12

In the United Kingdom, for instance, policy debates on health disparities focus increasingly on the concept of "food deserts," poor neighborhoods in British cities in which few supermarkets featuring cheap and nutritious foods are found, and low-income residents without reliable transportation who shop in corner stores with poor or nonexistent selections of fresh produce and much shelf space occupied by high-priced highly processed foods. 13

As noted in the study by Jolly et al, 2 "many of the nonattendees gave several reasons for nonattendance that together may make the personal "costs" of attending too great" (p. 5). The accelerating obesity rates in most developed and developing nations indicate that the "cost" of a healthy and fit lifestyle is too great for most of people. 14

To address the problem at its core, however, greater resources and attention must be directed to health promotion efforts that address the primary, secondary, and tertiary prevention of cardiovascular disease. Societal structures must share with individuals and families the high cost of adopting and maintaining a lifestyle characterized by high levels of physical activity and consumption of nutritious foods. Organizations, particularly those concerned with community well-being or bearing of the costs associated with unhealthy lifestyles (government agencies, community-based health and social services organizations, schools, places of worship), must use their physical and social infrastructure to "walk the talk," making engagement in healthy eating and active living the easier choices, and sedentariness and poor nutrition the harder choices. Capitalizing on opportunities to teach and model skills involved in healthy food selection, in simple but healthy food preparation, and in physical activity integration can greatly expand the pool of these skills in the community. Similar to the successful evolution of tobacco control efforts in the United States, efforts to control obesity and its chronic disease comorbidities should be implemented to change organizational practices so that physical activity and healthy foods are incorporated into the normal conduct of business. These efforts also should be evaluated rigorously.

If the evolution of tobacco control policies is modeled, adoption of these practices should generate the political will and popular support necessary for aggressive legislative policy change and compliance. The results would include, for example, urban design for walkable and bikeable communities, neighborhood safety, investment in public park and recreation infrastructure, restructuring of food subsidies to promote competitive pricing of healthy options, and regulation of commercial food advertising to vulnerable populations.

There are many examples of environmentally oriented organizational practices and policies that can be used to promote healthy and fit lifestyles, in contrast to measures that rely primarily on individual motivation or voluntary program participation. 15 The strategies in the following list promulgated by the UCLA Physical Activity Promotion and Obesity Prevention and Control Collaborative have been incorporated largely into the recommendations for promoting physical activity and healthy eating in the workplace recently released by the California Department of Health Services. 16

[white square] Including healthy food choices at meetings, events, or other gatherings at which refreshments are served

[white square] Implementing 10-minute exercise or movement breaks in meetings or gatherings lasting 1 hour or longer (eg, school board and parent-teacher association meetings, gospel choir rehearsals, continuing education sessions, adult basic education or English-as-second-language classes, neighborhood association meetings, city council hearings) and at a certain time of the workday

[white square] Placing bowls of fresh fruit in reception or central congregating areas

[white square] Offering healthy and competitively priced food choices in vending machines, cafeterias, and on-site food vendor selections

[white square] Substituting small "snack packs" of raisins, nuts, or other healthy alternatives for organizational leaders' candy or cookie jar contents

[white square] Posting stair prompts (eg, signs, riser banners) and using other means of encouraging stair usage (eg, slowed elevators, improved lighting, wall artwork, modeling of the behavior by organization leaders)

[white square] Hosting walking meetings

[white square] Encouraging casual attire at organizational functions compatible with physical activity (eg, discouraging neckties and high-heeled shoes)

[white square] Including language in grants, contracts, and subcontracts that mandates or provides incentives for contracting organizations to adopt these healthy and fit organizational practices and policies.

The diagnosis of a life-threatening condition has been thought to create a "patient" identity (accompanied by behavior with a single-minded purpose in hope of a cure) that supercedes other cultural identities. This view is supported by cancer treatment trial accrual rates for ethnic minority patients, which generally are higher and closer to population representation than the accrual rates for prevention and screening trials. 1 However, the findings of Jolly et al 2 and others in cardiac and breast cancer rehabilitation suggest that this "patient" identity is time-limited, and that the physical, economic, and sociocultural environmental barriers associated with minority status reemerge with longer-term survival. Cardiologists, cardiac rehabilitation nurses, physical therapists, and other healthcare providers in this field must appreciate and accommodate gender and cultural differences in their individual-level clinical endeavors with patients, as do Jolly et al. 5 A higher level of commitment is needed, however, to afford ethnic minority patients the more sustainable lifestyle changes in response to cardiac events enjoyed by whites. Clinicians must begin to recognize and embrace their broader leadership roles by making and proselytizing personal lifestyle changes that their patients and others may emulate; by making fit and healthy practice and policy changes in the organizations wherein they work, play, worship, and live; and by advocating for organizational practice and legislative policy changes with the school boards, city councils, hospital boards, county boards of supervisors, neighborhood associations, and state legislatures that govern their communities. 17

Acknowledgments

The author thanks William McCarthy, Joanne Leslie, Todd Berrien, Cynthia Harding, Jonathan Fielding, Lester Breslow, Eloisa Gonzalez, Gary Fraser, and other members of the Collaborative who have participated in the evolution of these ideas.

References