A qualitative study of ecological and motivational factors to inform weight management interventions for Black men in the rural South of the United States

Abstract

Rationale and objective:

Black men in the rural South of the United States (US) are underrepresented in weight management behavioral trials. Qualitative research is needed to inform interventions that can reduce obesity and health disparities in this population. We explored how intrapersonal, social, and environmental factors affect motivation and weight-related behaviors and how to culturally adapt behavioral interventions for Black men in the rural South.

Methods:

We conducted individual telephone interviews with 23 Black men (mean age 50 ± 14 years) with overweight or obesity living in rural South Carolina communities in 2020 and 2021. Interviews were audio recorded, professionally transcribed, and coded by two men’s health researchers who achieved an intercoder reliability of 70%. Content analysis using QSR NVivo 12 was used to generate themes using deductive and inductive approaches.

Results:

Physical health and health behaviors were perceived as key determinants of overall health. Family, friends, and other social contacts often provided positive social support that increased motivation but also hindered motivation by engaging in behaviors men were trying to avoid. Younger participants had stronger views of rural environments not supporting healthy lifestyles, which compounded personal challenges such as time constraints and lack of motivation. Comfort was discussed as a critical program consideration, and gender concordance among program participants and facilitators was perceived as promoting comfort. Participants noted preferences and benefits of in-person, group programs emphasizing physical activity, and younger participants more strongly endorsed programs that incorporated sports and competition.

Conclusions:

Findings from this study provide important evidence to inform the development of weight management interventions for Black men in the rural US South. Based on these findings, an innovative, competitive “football-themed” weight management program promoting peer support and integrating competitive physical activities is being evaluated for younger Black men in the rural South.

1. Introduction

Obesity, physical inactivity, and unhealthy dietary habits are three major risk factors for multiple chronic health conditions (Tsao et al., 2022; Wharton et al., 2020), and efforts to address these risk factors among Black men in the United States (US) are needed to reduce health disparities in this population. Approximately 41% of Black men in the US have obesity (Hales et al., 2020), roughly half meet national aerobic physical activity (PA) guidelines (Tsao et al., 2022), and on average diet quality is low among Black men (Thompson et al., 2020). These factors increase the risk for other health disparities in this population. Black men have a higher prevalence of diabetes and hypertension compared to White and Hispanic men (Teitler et al., 2021) and have among the shortest life expectancy in the US (Arias et al., 2021). Because lifestyle factors play a role in the higher mortality rates observed in Black compared to White adults (Luo et al., 2022), promoting healthy lifestyles in Black men has implications for reducing health disparities in this population.

While obesity and other weight-related chronic health conditions are more prevalent in Black compared to White populations, these Black/White health disparities are most pronounced in rural areas of the US (Cohen et al., 2022). Evidence shows Black men living in rural areas are at greater risk for poor health outcomes compared to those in urban areas (Ferdows et al., 2020; Shah et al., 2020), which may be particularly true in the rural US South where mortality rates are highest among Black populations (Miller and Vasan, 2021) and the obesity prevalence is highest in the US (Lundeen et al., 2018). Compared to rural residents in other regions, residents of the rural South also have a greater burden of risk factors and chronic diseases and are more likely to experience socioeconomic inequities while contending with healthcare access barriers (Miller and Vasan, 2021; Murray et al., 2006; Rhubart and Monnat, 2022). Finally, the prevalence of adults meeting PA recommendations is also lowest in rural areas and the South (Whitfield et al., 2019), and diet quality is low among Southern Black adults (Vadiveloo et al., 2019). These findings underscore the importance of understanding how the rural context impacts health disparities in Black populations, particularly for rural Black men whose life expectancy of 69 years was among the shortest in the US from 2005 to 2009 (Singh and Siahpush, 2014).

Irrespective of rurality, reviews of the obesity prevention and treatment literature regarding disadvantaged and minority populations reveals there is limited evidence on how to effectively address obesity among Black men (Harvey and Ogden, 2014; Kumanyika et al., 2014). One review of the literature suggests that only about 2% of participants in US-based weight loss trials are minority men (Pagoto et al., 2012), and one recent scoping review of the literature identified only 24 health promotion interventions targeting Black men, of which three targeted PA, one targeted dietary behavior, and one targeted obesity (Wippold et al., 2021). None of these studies appeared to target Black men living in rural areas. Efforts targeting Black populations in rural areas of the US have also experienced challenges reaching and engaging men. For example, men represented only 7% of the 426 rural Black churchgoers in the Wholeness, Oneness, Righteousness, Deliverance (WORD) weight loss and maintenance trial (Yeary et al., 2020).

Various scholars have argued that health promotion interventions should be adapted to Black men’s values, preferences, and unique social context to enhance cultural relevancy, increase intrinsic motivation, and increase intervention engagement (Griffith et al., 2021; Wippold et al., 2021). Our previous research suggested that exercise motivation is one of few variables associated with moderate-to-vigorous physical activity (MVPA) among Black men; however, we found that exercise attitudes, exercise self-concept, friend support, and having places to engage in PA are associated with exercise motivation (Abshire et al., 2019). Research involving a small sample of urban Black men suggests that culturally and gender tailored PA programs that promote socialization and friendly competition are highly appealing and can produce favorable changes in PA, PA self-efficacy, and social support (Hooker et al., 2011a). However, evidence is lacking on how to adapt behavioral interventions for Black men living in rural areas, which have unique built environmental and sociocultural contexts.

Guided by ecological models of health behaviors (Booth et al., 2001; Sallis et al., 2006) and Self-Determination Theory of motivation (Ryan and Deci, 2000), this qualitative study addresses gaps in the literature regarding factors affecting rural Black men’s PA, dietary behaviors, and weight management. Using these frameworks, we address three research questions: 1) How do rural Black men perceive health and how weight affects health? 2) How do rural Black men perceive that motivation and socioenvironmental factors affect their ability to engage in healthy weight-related behaviors and 3) What are rural Black men’s preferences for behavioral weight management programs? We also explored whether perceptions and preferences varied by age, as qualitative studies involving urban Black men suggests age may have important implications for weight management programs. For example, job-related stressors and time constraints may be more likely to hinder working-age Black men’s motivation and ability to engage in healthy dietary behaviors and PA compared to older Black men who are retired (Griffith et al., 2011, 2016). Age-related changes in functional abilities have additional implications for adapting PA components of behavioral interventions, as Black men have reported altering their PA due to aging and physical health conditions (Hooker et al., 2011b). Findings from this study can help guide the development of behavioral weight management interventions adapted for Black men living in the rural South.

2. Methods

2.1. Design, setting, and sample

This qualitative descriptive study took place with Black men living in rural areas of South Carolina. Individual telephone interviews were conducted to help overcome COVID safety concerns. The study was classified as exempt by the University of South Carolina Institutional Review Board. Participants were recruited through word-of-mouth advertising (ie., snowballing), distributing flyers to community organizations, newspaper advertising, and using an online recruitment company that places study advertisements on websites visited by target populations.

The PI screened potential participants for eligibility via telephone. Participants were eligible if they identified as being African American or Black American, male, were between 25 and 75 years of age, had a body mass index (BMI) ≥25 kg/m² based on self-reported height and weight, and lived in a rural area of South Carolina. Given there are multiple ways to define rural (Bennett et al., 2019), we determined rurality using county-based Rural-Urban Continuum Codes (RUCC) 4–9, (Economic Research Service, US Department of Agriculture, 2013) Zip code based Rural-Urban Commuting Area Codes (RUCA) 4–10, (Economic Research Service, US Department of Agriculture, 2020) or US Census Bureau maps of census tracts (Economic Research Service, US Department of Agriculture, 2017).

2.2. Interview guide

Interview guide questions (see electronic supplementary material) were similar to those used by others to examine perceptions, barriers, and facilitators of PA in rural communities (Lo et al., 2017). The interview guide was developed over multiple team meetings and under the guidance of a senior behavioral scientist (DKW) who has expertise using qualitative research to inform behavioral interventions for Black populations (Quattlebaum et al., 2021; Sweeney et al., 2019). The interview guide was pilot tested with 3 men in a mock focus group interview prior to the COVID-19 pandemic.

The first half of the interview guide included questions consistent with behavioral frameworks and models that consider how factors at the individual, interpersonal, community, and societal levels interact to influence people’s ability to engage in healthy lifestyle behaviors and weight management (Booth et al., 2001; Sallis et al., 2006). Given our prior research on the importance of motivation for engaging in MVPA among Black men (Abshire et al., 2019), we also explored how motivation played a role in weight management behaviors and factors affecting motivation. The second half of the interview guide included questions about developing healthy lifestyle programs addressing weight management for Black men living in rural areas. We used the term “weight management” rather than “weight loss” to emphasize achieving a healthy weight, to reduce stigma, and given evidence that men are less interested in losing weight compared to women (Santos et al., 2017).

2.3. Procedure

The lead author (DAA) conducted all interviews by telephone from June 2020 to January 2021. Prior to conducting interviews, participants were informed about the study purpose and given an overview of the interview process. Participants then provided verbal consent to participate in the study and to have the interview recorded. Audio-recorded interviews were professionally transcribed and were reviewed for accuracy. Participants were mailed $50 gift cards for completing interviews, which averaged 45 min in duration.

2.4. Data analysis

Deductive and inductive approaches were used to inform the development of the codebook that was used to code each transcript. Codes were first organized thematically according to multiple levels of influence from ecological models on diet and PA (Booth et al., 2001; Sallis et al., 2006) and informed by existing research of facilitators and barriers to healthy lifestyle behaviors among rural residents, men, and African Americans (Allen et al., 2013; Cornish et al., 2017; Gilbert et al., 2019; Griffith et al., 2011, 2013; Hooker et al., 2012; Sherman and Griffith, 2018). Four interviews were initially reviewed by DAA and a Black male graduate research assistant (GRA) who has experience working with Black men in rural areas. DAA and the GRA met weekly to review transcripts, to discuss codes that emerged from the data, and to discuss potential personal biases and cultural considerations. Codebook updates were made until the data were deemed to be thematically captured with a fixed set of codes. The lead author and GMW then independently coded the transcripts and met approximately once per week to reach consensus. An interrater reliability of 70% was achieved after coding three transcripts, and coding discrepancies were resolved through discussion. Thematic content analysis was performed using QSR NVivo 12. In general, codes applied to more than 50% of transcripts were grouped thematically to generate broader themes. We present differences in responses between younger and older participants using an age cut point of 50 years based on evidence that physical health conditions begin to affect Black men’s PA decisions at approximately this age (Hooker et al., 2011b). The data were deemed to be saturated with 23 interviews. Member checking was performed with two study participants who indicated the themes reflected their personal experiences and the experiences of other Black men in rural areas. As part of ongoing community engagement to prepare for a future weight management trial, study themes were also shared with other members of the target population who indicated the themes resonate with rural Black men’s experiences and perceptions.

3. Results

Study participants were drawn from online ads (n = 13), word of mouth (n = 7), and community organizations or local newspaper ads (n = 3). Respondents ranged in age from 28 to 71, with a mean age of 50. Based on reported height/weight, participant BMI status ranged from 25.62 to 54.82, with a mean of 33.73. Five overarching themes emerged from the interviews (Table 1). Each theme is discussed in detail below, documented with illustrative respondent comments.

Table 1.

Summary of Themes.

Themes	Supporting Codes	Total sample (n = 23)	Participants <50 years of age discussing theme (n = 12) n(%)	Participants >50 years of age discussing theme (n = 11) n(%)
Physical Health and Health Behaviors as Key	Physical Health	23 (100%)	12 (100%)	11 (100%)
Determinants of Overall Health	Physical Activity	20 (87%)	9 (75%)	11 (100%)
	Diet	22 (96%)	11 (92%)	11 (100%)
	Weight Management	23 (100%)	12 (100%)	11 (100%)
	Functional Abilities	13 (57%)	7 (58%)	6 (55%)
	Preventive Health/Disease Management	16 (70%)	8 (67%)	8 (73%)
Sociocultural Influences as Facilitators and Barriers of Health and Motivation	Promotes Health
	Family	20 (87%)	11 (92%)	9 (82%)
	Friends	13 (57%)	9 (75%)	4 (36%)
	Active Involvement	16 (70%)	9 (75%)	7 (64%)
	Encouragement/Monitoring	12 (52%)	7 (58%)	5 (45%)
	Role Modeling and Inspiration	18 (78%)	9 (75%)	9 (82%)
	Social Support/Relationships	12 (52%)	4 (33%)	8 (73%)
	Neighborhood Cohesion and Trust	13 (57%)	8 (67%)	5 (45%)
	Safety Hinders Health	19 (83%)	11 (92%)	8 (73%)
	Family	13 (57%)	8 (67%)	5 (45%)
	Negative Influences	17 (74%)	8 (67%)	9 (82%)
	Culture	12 (52%)	9 (75%)	3 (27%)
	Negative Social Norms	14 (61%)	10 (83%)	4 (36%)
Rural environments pose additional challenges to engaging in healthy behaviors	Environmental Barriers
	Access to unhealthy foods	14 (61%)	10 (83%)	4 (36%)
	Lack of healthy options	12 (52%)	9 (75%)	3 (27%)
	Physical activity resources not accessible	16 (70%)	7 (58%)	9 (82%)
	COVID-19	12 (52%)	5 (42%)	7 (64%)
	Absence/loss of programs	14 (61%)	7 (58%)	7 (64%)
	Work and school	13 (57%)	9 (75%)	4 (36%)
	Personal Challenges Lack of motivation	15 (65%)	10 (83%)	5 (45%)
	Lack of time	11 (48%)	9 (75%)	2 (18%)
	Personal preferences	19 (83%)	11 (92%)	8 (73%)
	Health status	18 (78%)	8 (67%)	10 (91%)
Comfort as a Critical Program Consideration	Gender Concordance	19 (83%)	10 (83%)	9 (82%)
	Community-based program	16 (70%)	7 (58%)	7 (64%)
	Relatable	11 (48%)	5 (42%)	6 (55%)
	Competent	18 (78%)	10 (83%)	8 (73%)
Preferences for Competitive, In-Person Group	Sports/Competition	17 (74%)	11 (92%)	6 (55%)
Programs Emphasizing Physical Activity	Group program	23 (100%)	12 (100%)	11 (100%)
	In-person program	19 (83%)	10 (83%)	9 (82%)
	Physical activity content	19 (83%)	10 (83%)	9 (82%)

3.1. Physical health and health behaviors as key determinants of overall health

All participants discussed physical health issues when asked to describe what health means to them. Some men spoke broadly about the importance of taking care of their bodies whereas others spoke specifically about certain health conditions such as having hypertension, diabetes, hyperlipidemia, and joint pain. Several men discussed physical health within the context of various functional abilities.

“Well, physical health is to move, your eyesight, your hearing sight, you know, your breathing, your sex ability, your strength-wise, you know, endurance, how much can you do.” P010 (age 71)

“Physically fit I guess, being able to carry out, like daily activities well with like getting, like short of breath so to say or, like feeling fatigued.” P016 (age 33)

Participants also discussed the importance of body weight and health behaviors on physical health. All participants discussed the importance of weight management to their health, and nearly all discussed the importance of PA and diet. Some participants spoke hypothetically about relationships among body weight, health behaviors, and physical health.

“Well a lotta people that are skinny, I would say, you know, mid-range, some of them may not work out, some of them may drink sodas instead of water, some of them may not exercise daily, so, but they’re able to keep, you know, their physique intact. Therefore, they are still skinny but they are unhealthy.” P006 (age 35)

Others gave specific personal examples regarding the effects of excess weight and behaviors on their health.

“Well, I would say this and particularly me, I remember one time, I’ve never weighed over 200 pounds before, never. And then I reached a point one time that I weighed exactly 200 pounds. And then when I know, when I was at that weight I was very sluggish. When I was at that weight I was, you know, I guess I wasn’t motivated, I just felt that, you know, I had let myself get to a point where I wasn’t paying attention to my health. And the results was a higher weight so, you know, it mattered to me not to be overweight because of some of the physical feelings that you feel from being overweight.” P015 (age 63)

Overall, participants were knowledgeable about health issues they experienced and the role that lifestyle behaviors and weight played in chronic disease risk and managing their health. Younger participants indicated that improving their physical health was an important motivator for engaging in healthy behaviors. Nearly all of the younger participants spoke about how experiencing a particular health event or desire to improve their health influenced their healthy behaviors.

3.2. Sociocultural influences as facilitators and barriers of health and motivation

Participants discussed several positive and negative sociocultural influences on their health. Many participants found it beneficial when their partners, family, and friends actively engaged in healthy behaviors with them. As one participant stated, “When you’re working out with someone that motivates you more, you’re gonna put more effort in if you’re working out with someone versus working out with yourself.” P023 (age 35)

Several participants also noted that their partners, family, and friends provided encouragement and helped monitor their health and health behaviors. The quotation below illustrates one participant’s positive perceptions regarding how his children played a role in his health.

“My children are super encouraging, super supportive so I’d say, you know what I hadn’t run in a while, y’all need to make sure I run when I get off work. They make sure it happens.” P013 (age 42)

Despite reporting several ways in which partners, family, and friends positively affected their health, participants described several ways in which these people negatively affected their ability to be healthy. For example, family and friends who provided positive encouragement often engaged in unhealthy behaviors that made it challenging for participants to engage in healthy behaviors. This was particularly true for younger participants and those with children, as reflected in the following quotation:

“… you got my kids so they see daddy working out, they come and they wanna work out … they wanna push me to make sure I do what I need to do to be healthy. With my, like with my wife she going to the store, she knows certain stuff I can’t have, I can’t eat or I wanna eat certain things in order for me to be healthy as I can so she makes sure that those are the things that she purchased. But at the same time they still have their eating habits and lifestyle habits that don’t fall in there exactly with what I’m doing for me and I hadn’t completely convinced them yet that they need to adjust over and follow the path I’m following. It get hard sometime.” P022 (age 41)

A similar sentiment was noted by another participant who reported that his children provided encouragement and helped monitor his PA but hindered his ability to eat healthy:

“Yeah, that’s a lot more difficult because while the children are definitely encouraging regarding – so while the children are very helpful with the exercise, they still bring junk food in the house. And so that’s hard.” P013 (age 42)

Negative influences from others led some participants to perceive that they could lead healthier lives by living alone. When asked to clarify whether living alone was perceived as a positive or negative health influence, one participant stated:

“Positive. Because if you had family, you would have to buy certain kinda foods and because, you know, they go out to eat a lot, you know. My kids, they ate out and you know, kids want certain types of foods, you know.” P018 (age 65)

Participants also perceived that broader social influences exerted a negative effect on their health. Several men specifically mentioned culture and how factors such as food preparation methods and healthcare avoidance hindered their ability to be healthy. Some men also spoke about cultural influences from a gender perspective and how men are less inclined to engage in certain healthy behaviors. Younger participants perceived these broader influences in a negative light.

“As a black man I don’t know that I ever really focused a whole lot on preventative treatment, right? It was like, if it’s not a problem you don’t fix it until it’s a problem. And I think that’s a part of how I was raised, it was a cultural thing. You know, we didn’t go to the doctors, at least with my experience growing up, we didn’t go to the doctor for a checkup unless it was absolutely required, like for a physical for sports or something. The only thing you saw the doctor is when something was wrong. And then, of course, by that time you got bad news from the doctor so the doctor became acquainted with the bringer of bad news so you just don’t go to the doctor. So we have the health department in my church and even now a nurse, you know, one of the nurses that goes to my church, she’s over the department. I still don’t talk to her about it anymore, she has meetings, I leave.” P013 (age 42)

“So I think growing up with the culture, neighbors who are in the same culture, will have an effect on your diet and how you see food as well, because you know, you don’t want the, if you decide to change your diet really rationally, they’re used to you eating the foods that they eat, you know, being in the black culture, so it looks frowned upon if you kinda refuse their plate cause you’re trying to change I guess.” P017 (age 28)

3.3. Rural environments pose additional challenges to engaging in healthy behaviors

All participants discussed having certain resources available to support healthy eating and PA. For example, many participants discussed having access to resources for healthy eating such as grocery stores and farmers markets. However, participants often discussed that a lack of motivation and personal choices served as barriers for making healthy decisions. Younger Black men tended to have stronger negative perceptions about how access to unhealthy foods and lack of healthy options affected their motivation.

“Hmm, I guess the fast food, the easy access to the quick and easy food that’s delicious but it’s detrimental to my health. It’s like I have a hard time fighting not having that in going home to cook a healthy meal, having all these fast food options and just not being able to get my fresh vegetables.” P012 (age 38)

Participants also reported having access to resources for PA including the natural environment, walking tracks, and gyms. However, several aspects of these resources were perceived to be suboptimal or undesirable and served as barriers for engaging in healthy behaviors.

“I think it’s [the local university] the only one that maintain a tennis court. The [a local park], they have just, they have turned the tennis court into a parking lot. And the [name blinded] tennis court is dilapidated for lack of a better word. I don’t think nobody goes over there.” P015 (age 63)

Overall, younger Black men tended to have more negative perceptions of their environment than older Black men. Various aspects of work and school were often perceived as barriers for engaging in healthy behaviors including time constraints and the physical nature of some occupations. As one participant said of working-age men where he lived,

“… most of the guys in this neighborhood … they work in the plants … You work to a plant 12 hours a day, I doubt if you have time to exercise cause I was talking to a friend, I was telling this guy, a friend of mine, I said, boy your stomach getting big, you need to exercise. But he say I walk enough at the plant. But that’s not, that’s not the kinda exercise, you know, he think he getting exercise in the plant, but no that’s not the right kind.” P018 (age 65)

3.4. Comfort as a critical program consideration

Participants in our study discussed several factors that underscored the importance of developing behavioral programs that addressed comfort considerations. Several men spoke about differences between men and women and how men would be more comfortable in an all-male program.

“So I never did the mixed group but with the men’s only group, like we might have, you know, it’s questions that are asked that probably if we were in a mixed group wouldn’t get asked. You know, concerns about different things and problems that they having that they think may be affected by, you know, just they general health that they might not ask in front of women. But they willing to discuss when it’s just amongst the guys.” P022 (age 41)

Some of the Black men in our study also had strong views that health programs should not be conducted in church settings because men would not be comfortable.

“Men are different from women, they don’t meet at no church. They wouldn’t be themselves, you know what I’m saying? And you want them to be relaxed and feel comfortable, you know what I’m saying?” P018 (age 65)

Several of the men spoke about the importance of having a program facilitator who was relatable, and participant-facilitator gender concordance was one factor that influenced relatability. Just over 80% of both younger and older respondents discussed how having a male program facilitator would be preferred among Black men participating in a behavioral program. There were mixed perspectives on whether a program facilitator should be race or age concordant.

“You want somebody that’s relatable. If you’re gonna talk about somebody about issues that affect them, you need to have somebody who they can relate to. And if you gotta talk to an African American male about African American health issues, then I think it should probably be an African American.” P008 (age 60)

3.5. Preferences for competitive, in-person group programs emphasizing physical activity

All participants discussed positive aspects of group-based programs for Black men whereas less than half noted positive aspects of individual programs. Positive aspects of group-based programs included the opportunity to socialize with other Black men and the enhanced motivation of being with others. Sports and competition were often mentioned when discussing group-based programs and what should be included in behavioral programs for Black men, particularly among younger participants. More than 80% of younger and older participants discussed the importance of having in-person programs and how behavioral programs for Black men should incorporate PA. Comparatively, 58% of younger participants and 36% of older participants discussed incorporating diet and nutrition.

“I would think it would have something to do with physical activity. Not as rigid as what I’m doing but I would imagine it would probably be something mild … to have football perhaps, maybe basketball, that sorta thing. Talking about touch football, not tackle. And basketball.” P008 (age 60)

“I think more outdoor activities, you know, such as sports that men are used to either watching on TV or have played in, you know, high school or college in their early years of life. As well as playing with, you know, other men who have that same motivation and interest. It takes a lotta motivation for me to do individual-based programs. Like I would really need to know what to expect at the end of the program so I could have something to work forward to, for individual-based. For a group program though I feel like you’re kinda working together with teammates, you know, to meet this end goal.” P017 (age 28)

4. Discussion

This qualitative study has generated important and novel insights relevant for developing weight management programs for Black men in rural areas. Findings suggest that Black men in rural areas place a strong emphasis on physical health and health behaviors when thinking of overall health, that various sociocultural influences promote or hinder weight management, and that making healthy choices is particularly difficult due to the compounding effects of personal and environmental barriers in rural areas. Novel findings included that sociocultural influences, personal challenges, and environmental factors tended to particularly affect younger participants, suggesting that younger Black men in rural areas need high levels of social support in behavioral weight management programs. Other novel findings include rural Black men’s perceptions that programs should be sensitive to issues of comfort and may be more appealing if competition and PA are integrated into an in-person, group format.

Findings from this study highlight the perceived importance of physical health and health behaviors to rural Black men’s overall health. This finding aligns with research conducted with urban Black men who note that health is a core value, perceive that behaviors are important to health, and link health with being independent, supportive, and life accomplishments (Cornish et al., 2017; Griffith et al., 2015). Similarly, more than half of the men linked health to various functional abilities. Given that men in general are motivated to lose weight if they believe they have a health problem that could be improved (Robertson et al., 2014), the potential to improve health should be emphasized when recruiting and engaging Black men in rural areas in weight management interventions.

Interestingly, multiple sociocultural factors were perceived as both facilitators and barriers to engaging in healthy dietary behaviors, PA, and weight management among Black men in this study. Family, friends, and other social contacts who provided positive support through verbal encouragement and health monitoring nevertheless decreased Black men’s motivation when they engaged in behaviors that participants were trying to avoid. This finding echoes research on the mixed effects of partner involvement on men’s weight loss and behavior change and how the social role of food with family and friends can be a barrier to weight loss (Allen et al., 2013; Robertson et al., 2014). Our findings also parallel evidence that active male peers increase Black men’s PA motivation but inactive male peers decrease PA motivation (Griffith et al., 2013), and that Black men may lack the social support needed to engage in healthy dietary behaviors and PA (Griffith et al., 2016; Hooker et al., 2011b). Thus, consistent with Self-Determination Theory and the postulation that supportive conditions are necessary to maintain intrinsic motivation (Ryan and Deci, 2000), weight management interventions for Black men in rural areas should incorporate strategies to optimize positive social support and minimize negative social support to enhance motivation.

Cultural influences around being Black and male were also perceived as barriers to engaging in healthy behaviors in this study, particularly for younger participants. Some participants described unhealthy cultural dietary practices and that Black men avoid seeking medical attention for health issues. These findings are consistent with research involving urban Black men in which cultural traditions surrounding food and poor dietary behaviors are perceived as negative influences on healthy behaviors (Amuneke-Nze et al., 2019; Sherman and Griffith, 2018) and that avoiding medical care is influenced by masculine ideals (Hooker et al., 2012). Collectively, these findings underscore the importance of developing interventions and programs that address various sociocultural influences that may affect weight management among Black men in rural areas.

Although the Black men in our study often reported having resources to support healthy eating habits and PA in their communities, they also noted substantial access to unhealthy foods, limited options for healthy foods, and that resources to support healthy lifestyles were of poor quality or inaccessible due to factors such as time constraints, financial costs, and the COVID-19 pandemic. In addition, participants noted personal preferences such as enjoying unhealthy foods that made it difficult to engage in healthy behaviors in their environments. Previous qualitative studies found preferences for unhealthy foods and limited availability of healthy food options among rural White men (Morgan et al., 2016) and that urban Black men report having access to healthy foods in their communities but perceived cost as a barrier (Griffith et al., 2016). Our findings are also consistent with other qualitative studies suggesting that poorly maintained outdoor public spaces and facilities are barriers to engaging in PA in rural communities (Lo et al., 2017; White et al., 2020).

Qualitative research among urban Black men has identified work, family, and other competing demands as barriers to prioritizing health (Hurt et al., 2015; Seawell et al., 2016). Competing demands were particularly salient for the younger Black men in our study, as they more frequently reported that lack of time, work, and school were barriers for engaging in healthy behaviors. Overcoming competing demands was particularly challenging in their rural environments due to the accessibility of unhealthy foods and barriers accessing PA resources. These new findings highlight the importance of considering age-related contextual factors when developing health promotion interventions for Black men living in rural areas.

A novel finding from this study was that comfort emerged as an important theme relevant for developing interventions for Black men living in rural areas. Having health programs solely for men and led by a male facilitator were often perceived as important for promoting comfort. Men participating in the Power Up for Health trial for low-income men from racially diverse background have noted that the all-male aspect of that program allowed them to more openly address sensitive topics without needing to filter comments (Realmuto et al., 2018). Midlife and older Black men have also reported preferences for programs comprised solely of other Black men to foster camaraderie and connectedness (Hooker et al., 2011b). Interestingly, a novel finding in this study was the mixed perspectives regarding the importance of racial concordance between participants and a program facilitator. This finding contrasts with other research in which Black men noted that racial concordance with their healthcare provider was important for enhancing trust and relatability (Amuneke-Nze et al., 2019) and that having Black male facilitators for health programs was important for understanding Black men’s lifestyles (Hurt et al., 2015). Future research is warranted to explore the importance of racial concordance for health programs that may include rural men from racially diverse backgrounds.

It is surprising and noteworthy that some participants in our study perceived that churches were not ideal settings for behavioral programs due to issues surrounding comfort. Although large behavioral and weight loss trials for rural Black adults have been conducted in faith-based settings, samples tend to be overwhelmingly female (Tussing--Humphreys et al., 2013; Yeary et al., 2020). Black women may be more likely than Black men to perceive churches as supportive settings for PA programs (Griffith et al., 2013), while Black men may have privacy concerns related to women’s involvement in church-based programs (Hooker et al., 2011b). Consistent with recommendations for more research about the role of churches for health programs for Black men (Hooker et al., 2011b), our findings regarding rural Black men’s perceptions of churches as intervention settings warrants further investigation and may have implications for developing future programs that are more effective at reaching and engaging Black men.

Many Black men in our study, particularly younger participants, reported that sports and competition should be included in programs for Black men. The importance of sports and competitive activities has been noted by Black men (Dean et al., 2018; Hooker et al., 2011b) and in rural communities in which football and basketball are considered an important part of the local culture (Abildso et al., 2021). Participants also reported a stronger preference for health programs involving other men who meet in person, as a group, and with a stronger emphasis on PA than diet for weight management. These findings are novel and are consistent with evidence that socializing and participating in group sporting activities are important aspects of PA for rural residents (Abildso et al., 2021), that Black men value the camaraderie and motivation associated with being in health programs with other men (Griffith et al., 2013; Hooker et al., 2011b; Hurt et al., 2015), and that single-gender programs are critical for health promotion efforts for Black men (Hooker et al., 2011b; Treadwell et al., 2010).

Based on our findings, a novel and innovative football-themed behavioral weight management intervention for Black men living in rural areas is being developed and tested. Notable adaptations for the intervention include the male-only aspect of the program and having an intervention facilitator and program participants who are race, gender, and age concordant to the extent possible (ie., similarly aged Black men). These adaptations are expected to enhance the relatedness of the intervention, which has important relevance for increasing intrinsic motivation (Ryan and Deci, 2000). Other adaptations include incorporating friendly individual- and team-based competition during intervention sessions and for meeting goals, devoting less time to educational content, and devoting more time for PA during meeting sessions. Less time will also be devoted to diet and nutrition given men’s preferences to emphasize PA for weight management. Many of these adaptations were also recommended and incorporated for the Power Up for Health trial, which was an adapted Diabetes Prevention Program (DPP) to engage urban minority men and promote weight loss (Gary-Webb et al., 2018; Realmuto et al., 2018). Although PA was not incorporated during intervention sessions despite being recommended by an advisory panel of minority men, trial investigators reported that having a PA component incorporated into the class structure was a “resounding theme among coaches” upon program completion (Gary-Webb et al., 2018). Similar to the Men on the Move-Nashville PA trial for middle- and older-aged Black men with overweight and obesity (Dean et al., 2018), PA during meeting sessions will be a core adaptation of this weight management program. Our finding that competition should be included in behavioral programs for Black men was also echoed by Black men in the Men on the Move-Nashville trial who preferred having more competition in that intervention (Dean et al., 2018). Incorporating sports and competition into a weight management program for Black men is expected to enhance this population’s motivation given that interest and enjoyment are important regulatory processes of intrinsic motivation (Ryan and Deci, 2000). Core intervention elements based on Social Cognitive Theory shared with other programs such as the DPP (Diabetes Prevention Program Research, 2002) include building self-efficacy for behavior change, setting weight and behavioral goals, self-monitoring of weight and weight-related behaviors, overcoming barriers, and strategies for generating social support (see electronic supplementary materials).

4.1. Limitations

Some limitations to this study should be noted. The Black men interviewed for this study resided in various rural areas across one Southern US state, so findings may not be transferrable outside of this geographic context. Facilitators and barriers to engaging in PA also vary according to different types of rural communities (Gilbert et al., 2019), and our broad approach for defining rural precluded generating insight about Black men’s weight management needs and preferences within particular types of rural settings.

Despite these limitations, this study addresses several important and recognized gaps in the literature relevant to developing more engaging, culturally appropriate, and effective weight management interventions for understudied Black men living in the rural South. Reviews of the literature have revealed that little is known about how rural environments affect Black men’s dietary behaviors, PA, and obesity (Casagrande et al., 2009) and that more research is needed to inform the development of obesity interventions that can better reach Black men (Kumanyika et al., 2014). Moreover, it has been more generally suggested that lifestyle interventions for obesity may need to be designed differently to be more appealing to men (Pagoto et al., 2012), yet evidence suggests that men have not been adequately involved in designing interventions that reflect their preferences (Robertson et al., 2016), especially for Black men in rural communities who are underrepresented in health promotion research (Wippold et al., 2021).

5. Conclusions

This qualitative study provides novel insights that can inform the development of weight management interventions for Black men living in the rural South. Findings highlight the need to adopt an ecological approach for understanding and addressing the multiple types of factors that affect Black men’s ability to manage their weight in rural settings. Developing and adapting weight management interventions to this population’s unique needs, preferences, and sociocultural context may have promise for increasing the relevance and acceptability of interventions and may be effective for better engaging this at-risk, underserved population.

Data availability

Data will be made available on request.