Peer-Led Focus Groups Identify Barriers to Healthy Lifestyle in African American Adolescents from Baltimore City

Abstract

Objectives

Black youth are disproportionately affected by the US obesity epidemic. Early-age obesity often continues into adulthood and is associated with a higher risk of diabetes, cardiovascular disease, and premature death. Few studies have incorporated community-based participatory research (CBPR) facilitated by youth to provide frank discussions among teens living in inner cities about challenges and facilitators in maintaining a healthy weight and to design teen-identified interventions.

Design

Black youth (n=10) were recruited from a Baltimore City high school during the 2019 to 2020 academic year and were trained by seasoned investigators and mentored by graduate and undergraduate students on qualitative methods using CBPR. These youth then implemented focus groups with their peers aged 15 to 18 years (10 focus groups of 10 teens each). Topics included healthy lifestyle knowledge, behaviors, attitudes, and suggested interventions. Content analyses were conducted using dual-rater techniques.

Results

Focus group themes yielded strengths and challenges of weight maintenance for Black youth at various levels, including in their personal lives, families, school, and community. Themes also suggested several technology-based possibilities using social media to reach Black youth about healthy living practices.

Conclusions

Engagement of Black youth in CBPR projects can yield valuable data to design more culturally responsive and developmentally appropriate interventions. Youth are competent collectors of information to identify needed changes in their schools/communities and about the use of technology/social media to facilitate improved health practices among their peers and should be involved early in the process of developing targeted obesity prevention interventions and/or programs.

Introduction

The prevalence of obesity among children and adolescents in the United States is 19.7%,1 with prevalence rates of 25.1% in African American (AA) adolescents versus 13.5% in White adolescents.2 Research has consistently demonstrated that AA youth are disproportionately affected by the obesity epidemic, especially AA girls.3,4

Research has identified that type II diabetes, obstructive sleep apnea, hypertension, dyslipidemia, metabolic syndrome, and other noncommunicable diseases begin to develop in childhood, with childhood obesity serving as a primary vulnerability factor.5 The problem has reached the point where diseases such as type II diabetes, heretofore not seen in children, are increasingly diagnosed at a younger age.6 Obesity prevalence continuously increases through age 10, with levels commonly remaining unchanged thereafter.7 To address this disparity, it is imperative that we have a better understanding of adolescent perspectives regarding weight and the identification of adolescent-approved interventions. Few studies incorporate community-based participatory research (CBPR) cofacilitated by youth or provide frank discussions among teens living in inner cities about weight, challenges in maintaining a healthy weight, and possible teen-identified interventions, including the use of technology.

CBPR can be an effective research tool to tackle the adolescent obesity disparity. Despite promising community-based obesity prevention programs8,9 and some investigations showing reductions in childhood obesity,10 systematic reviews suggest little evidence that current primary care interventions sustainably reduce or control obesity.11,12 However, more research is required to build evidence to effectively tackle adolescent obesity in ways that engage youth at risk for overweight and obesity.13,14 CBPR commonly uses participatory and qualitative methods with community members, focused on the integration of culturally based evidence, practice-based evidence, and indigenous research methodologies.15 The use of CBPR methods within AA populations has been documented,16 including research focused on risk factors for obesity.17,18 These studies strongly support the effectiveness of using CBPR in developing innovative approaches to obesity prevention. Engaging minority youth in such CBPR efforts is poorly documented. The present study was designed to fill this important gap while identifying barriers to and facilitators of planning effective obesity-focused interventions for AA youth.

Two areas of inquiry were addressed: (1) how to actively involve AA youth in curtailing the growing epidemic of adolescent obesity and (2) how to identify barriers and facilitators to development and implementation of successful approaches within community and school settings to prevent and control obesity among AA teens. The objectives were to investigate the feasibility of training teens to conduct qualitative research and use that research to inform the development of interventions to tackle the adolescent obesity epidemic among AA adolescents. Mentorship and training on the use of qualitative methods was proposed as a strategy to equip adolescents with the ability to obtain and apply data collected from their peers. Moreover, this project was intended to address disparities in the public health workforce pipeline by incorporating underrepresented minority youth (in this case, AAs) into CBPR and exposing them to ways to conduct research to address obesity in their community.

This project’s geographic area for community engagement was Baltimore City, Maryland. With a population of just over 600,000 (64% are AA and 20% live below the poverty line), it is not surprising that this community’s minority populations continue to shoulder the cost of poor health at every age. The 2017 Youth Risk Behavior Surveillance Systems surveys in Baltimore revealed that overweight prevalence was 31% higher among Baltimore City high school (HS) students than among Maryland HS students statewide. Thus, the project was intended to inform the cultural adaptation of extant teen-endorsed obesity initiatives that might be effective with AA teens living in Baltimore City.

The conceptual framework for this project is based on a socioecological approach to health promotion interventions that posits that there are spheres of influence at various levels (eg, individual, familial, school, community, policy, and environmental levels) that are key determinants of health outcomes to consider in developing effective interventions.19 We examined the extent to which AA youth in a Baltimore City HS could elicit such factors through focus group research to identify barriers to and facilitators of efforts to promote healthy physical activity and nutritional practices. From a socioecological perspective, we were interested in adolescents’ individual knowledge, attitudes, feelings, and experiences related to obesity as well as interpersonal, familial, school, and community influences on their behaviors that could inform interventions.

Methods

We used qualitative research methods, by means of focus groups, with the simultaneous application of CBPR principles. CBPR was implemented by researchers and students at Morgan State University (MSU), a historically black college and university in Baltimore City, Maryland, in collaboration with a Baltimore City HS. The study protocol was approved by MSU’s institutional review board, and all procedures followed were in accordance with the ethical standards of the institutional review board and the Helsinki Declaration of 1975, as revised in 2000. Informed consent and parental assent were obtained from all participants included in the study. This study is reported according to procedures adapted from the consolidated criteria for reporting qualitative research.

Participants

HS staff nominated 10 (5 male and 5 female) willing teens to be trained as focus group facilitators. These facilitators assisted in recruiting an additional 45 male and 45 female (n=90) students from the same school. Among these students (ages 15 to 18 [mean=16] years), 96% self-identified as AA, 1% self-identified as White, 1% self-identified as Hispanic, 1% self-identified as Indian, and 1% provided no racial/ethnic identity. All participants provided written informed consent and, if applicable, assent before study enrollment.

Procedures

Training Procedures

Project staff (MSU principal investigator and research assistants [RAs]) received focus group training from an AA seasoned investigator (SI). A train-the-trainer model was used in which the 10 youth facilitators were trained at their HS by the principal investigator and SI and mentored by MSU RAs on qualitative methods using CBPR. Training for the principal investigator and RAs included coding, managing, analyzing, and displaying data from focus groups. The RAs assisted in developing the 10 focus group questions.

The training session for HS students included instruction on how to set up a focus group, using the materials (eg, the focus group guide and recording devices), managing interpersonal dynamics and time, and notetaking. Focus groups were conducted within 2 weeks of the training.

Focus Group Procedures

Students were bussed from their HS to MSU on 2 days (half on each day). Participants were given a brief MSU student-guided campus tour with lunch. Focus groups were conducted in MSU classrooms and meeting spaces. The HS student facilitators led the groups with their 90 peers (10 focus groups). Sessions focused on key aspects of adolescent health as it relates to weight/weight perception; nutrition/physical activity knowledge, behaviors, and attitudes; personal experiences; and perceived barriers to and facilitators of (suggested improvements to) interventions to address obesity in their population. The discussion guide included the following open-ended questions:

• What do you know about obesity?

• What are ways to prevent obesity?

• Do you know somebody who suffers from obesity?

  • Probe: How do you feel about it?

• Have you ever experienced obesity?

• What makes it hard to eat healthier?

• What would make it easier to eat healthier?

• What makes it hard to get in more physical activity?

• What would make it easier to get in more physical activity?

An RA was present at each session to ensure safety and that ethical standards were met, to take accurate notes, and to provide incentives for participation. Participants received $10 (facilitators received $25), an MSU t-shirt, and the campus lunch/tour. Focus groups were audio recorded and transcribed. The verbatim transcripts were the raw data.

Analytic Approach

A mixed methods approach that included a qualitative component (ie, content analysis of open-ended responses) was used to generate recurring themes related to obesity prevention and a quantitative component (ie, frequency analysis of open-ended responses) to summarize the prevalence of responses in each theme. For the thematic content analysis, base codes with operational definitions were generated to apply to the transcripts (text passages of at least 1 sentence) based on systematic literature reviews on adolescent obesity. Table 1 displays the base codes and their operational definitions. After completion of the focus groups, the SI conducted training for the RAs on analyzing the data from each session using a socioecological approach (tagging themes as related to the individual, familial, school, and community levels). Students were trained to identify specific themes, compile them to form final reflections, and determine linkages to community resources for intervention planning. Content analyses were conducted using dual-rater techniques, per Miles, Huberman, and Sadana,20 and a thematic coding process to identify common themes and outliers. After independent coding, the 2 raters met to conduct fidelity checks comparing notes to recorded focus groups and refined the themes based on consensus discussions with the SI.

Table 1.

Summary of coding for focus group responses: key terms, base codes, meaning, and subcodes

Base code	Coded as	Meaning
Knowledge of obesity definitiona	KO	Expressed definition about obesity/healthy living
Knowledge of prevention of obesitya	KP	Expressed information of how to prevent obesity (NOT suggested prevention)
Perceived barriersb	PB	Description of things/events/policies preventing healthy living
Personal prevention	PP	Description of ways of engaging in healthy lifestyle
Social influencec	SI	Influence from any factor outside of family (friends, casual acquaintances, people, peers, and classmates)
Perception of othersc	PO	Perception and observation of other peoples’ activities toward healthy/unhealthy living
Self-motivation	SM	Personal encouragement (+/−) toward any desire/goal
Provided resources	PR	Resources (equipment/food/items/technology/policy) supplied to help healthy living
Social economic status	SES	Status of individual socially and economically
Emotional influencec	EI	Feelings/attitudes displayed
Perceived threats	PT	Perception of tendency to be ill/unhealthy or diseases that may occur afterward
Personal experiencec	PE	Self-realized events
Nutritiona	N	Description of food and nutrients in general, including tastiness
Suggested improvement, physical activityd	SIP	Suggestions toward improving physical activity and active living
Suggested improvement, nutritiond	SIN	Suggestions toward improving nutrition and healthy eating
Familial influencec	FI	Influence from family members
Environment	E	Locations
Media	M	Any source of media information (social media and mass media)
Self-awareness of benefitsc	SAB	Personal awareness of benefits from healthy living
Physical activitya	PA	Any form of exercise
Price	P	Description of cost of anything

^aKnowledge of obesity and obesity prevention subcategory

^bBarriers to healthier living subcategory

^cInterpersonal awareness and familial influences subcategory

^dFacilitators of healthier living subcategory

Themes were tabulated by key terms, base codes, and subcodes, and frequencies of responses were calculated for each thematic category. For this paper, thematic categories based on selected subcodes (Table 2) were the focus: knowledge of obesity and obesity prevention, interpersonal awareness and familial influences, barriers to healthier living, and facilitators of healthier living (ie, suggested improvements to interventions).

Table 2.

Frequencies for base codes

Key term	N
Knowledge of obesitya	36
Knowledge of obesity: preventiona	30
Perceived barriers to obesity preventionb	17
Personal prevention	1
Personal experiencec	29
Self-awareness of benefitsc	28
Self-motivation	9
Perceived threats	4
Emotional influencec	22
Familial influencec	17
Media influence	14
Social influencec	7
Perception of othersc	32
Provided resources	15
Social economic status	6
Physical activitya	40
Nutritiona	59
Environment	12
Price	7

^aKnowledge of obesity and obesity prevention subcategory

^bBarriers to healthier living subcategory

^cInterpersonal awareness and familial influences subcategory

Results

The key themes for the selected questions are summarized below, first with respect to knowledge and interpersonal awareness/familial influences and second with respect to the barriers and facilitators using a socioecological approach. The parenthetical numbers are the frequencies for the number of text passages coded with a base code or subcode.

Knowledge of Obesity (n=36)

Youth were knowledgeable about and made specific mention of technical terms, such as “body mass” or “body mass index,” “BMI,” and “how BMI is measured.” Other technical terms were used such as “unhealthy weight” and references made to the disease burden of obesity (“A lot of people struggle with it,” “It’s a global issue,” and “Obesity is everywhere”). Some students were less technical in describing their knowledge, using descriptors such as “fat,” “big,” “chubby,” or “people with a lot of weight.”

Knowledge of Obesity Prevention (n=30)

Most of the prevention knowledge was on nutrition/healthy eating (eg, “5 fruits and veggies per day” and “reduced sweetened beverages”). However, there was also discussion about prevention related to physical activity (“walking, jogging, etc for 30 minutes of moderate activity”) or that involved personal responsibility (“Find people to work out with you” and “Take the stairs”), self-motivation (“Build up confidence to believe you can lose the weight”), and industry issues (“[Have] Surgery” and “Have a standing desk”).

Interpersonal Awareness and Feelings (n=29)/Familial Influences (n=17)

Several of the interpersonal awareness comments focused on the health status or influences of family members and students’ feelings about those situations. Participants knew family members who were living with obesity or were overweight (eg, “My brother is obese,” “My cousin,” “My father told me I was obese, but he was too,” “My grandfather suffers obesity,” “My aunt has it,” “My little sister is [obese],” “It hurt when my mom told me [I was obese] because me and her are the same size, she is just a little bit bigger than me,” “My mom, me, and my little sister,” and “It hurt coming from your own parent, and my friends try to tell me I am not obese, but I know I am”).

However, some participants see their weight as normative because of their family’s experiences (eg, “A lot of my family is supposed to be overweight…I don’t think of it as bad because we all are pretty healthy”). Some students are struggling with their feelings (eg, “My aunt—I don’t know how to feel about her condition”), and others are indifferent (eg, “I believe they should stop eating,” “It doesn’t affect me,” and “People view me as obese, but I am very active. I do not feel discriminated against”).

Perceived Barriers to Obesity Prevention (n=17)

The themes covered a wide range of barriers at various socioecological levels. Cultural norms and beliefs about body image were among these (eg, “To me, it’s just normal,” “Women lose fat faster than men,” “People are not worried about obesity,” and “Society feels that it’s your health; they don’t have to help”). There were several structural barriers related to physical activity (eg, “lack of recreational places—parks, playgrounds, walking paths,” “unsafe/unclean recreational spaces,” and “lack of physical activity offered in school, home, or community”). Some participants were concerned that mental health plays a role and may be a barrier to engaging in physical activity (eg, “can mess with your mental stability” [if students tease you in a sport], “If [students] aren’t already stable, they will get upset,” and “anger issues, some people will want to fight people [if teased]”).

Environmental barriers were mentioned, such as “too many fast-food places” and “The more reliable corner stores or markets don’t have as much healthy food.” There was also a familial barrier of “no healthy options offered at home” and “low income, they can only afford junk food and fast food.” There were also some participants who expressed emotional and mental health barriers to healthier eating (eg, “depression: people eat a lot or starve themselves” and “People eat their feelings away”).

Perceived Facilitators of Obesity Prevention: Suggested Improvements

The facilitators (factors that promote or assist individuals, schools, and communities with healthy nutrition and physical activity) included suggestions for changes at each of the socioecological levels. The facilitators at the individual level included improving self-motivation (“eating vegetables, but it has to be something that you want to do,” and “It has to be a mental thing; make yourself do it”) and increased information awareness and use (“start buying healthy food” and “knowing how to balance meals and include good seasoning so you enjoy your vegetables”). At the family level, suggestions included engaging parents (“Your parents can help to motivate you because as teenagers we eat whatever our parents bring into the house for us to eat”). At the systems level, technology was the focus. When asked whether an “app” would be beneficial for promoting healthier lifestyles, participants generally responded “yes,” and 1 student noted, “because a lot of people use their phone.” Suggestions for potential uses included “notifications,” “show you where healthy foods are,” “facts about unhealthy vs. healthy foods,” and “tell you when to eat.” Other systems-level improvements for healthier eating included “community gardens,” “farmers markets in low-income neighborhoods,” and policy changes to “limit the number of fast-food outlets in low-income areas.”

Regarding physical activity, several interpersonal-level facilitators were suggested to motivate individuals, such as finding others to engage in physical activity with you (“someone there to push you to work out and motivate you” and “If I had [a gym membership] with my friends we could do random days at the gym”). Another theme, self-motivation, was at the individual level (“putting your mind [determination] to activities” and “People should gain confidence to do it by themselves and to make a change in ourselves”). Unlike for nutrition/healthy eating, very little discussion was directed towards family-level facilitators for physical activity. One comment related back to a barrier, the need to address others’ negative reactions to a student’s limited physical activity or poor performance in sports (“If people were not judgmental about others’ performances during games”). At the school or community level, several comments related to policy or current practices arose (“Us as 10th graders we don’t have gym anymore, if we had it, it would be better. [Our school] only pays attention to football and basketball,” “There is no soccer team,” “No gymnastics team,” and “Schools are not interested in girls. Only interested in varsity boys”). Another comment related to the school environment (“There are big roaches in the gym”).

Specific to limited resources in the community, or in general, several comments were made about the cost (“If gyms would let people join for free”) and how to increase accessibility (“use what you have instead of using your money on gym membership”). There were also personal expressions related to expanding opportunities (“Having more opportunities to play basketball/sports despite your inability to be very good at basketball”).

Several suggestions were directed at systems-level changes. Students discussed the benefits of a specific fitness app (Fitbit) (“A friend used it every day to track steps. She didn’t have a goal it was a ‘Oh look what I did!’”) and suggested features of an ideal app (“an app to get paid to take steps” and “have prizes…”). Environmental changes are needed (“There’s nothing to do outside, you can get killed,” “It is too dangerous,” and “more places that are safe and clean”). When discussing ways to address cost, students simply referred back to the “barriers” and provided no other suggestions on reducing cost for food or recreation, except free gym memberships.

Discussion

CBPR methods have a longstanding history of effectively addressing health disparities. There is a paucity of evidence demonstrating the use of CBPR among minority adolescents to engage in research approaches that lead to developing successful obesity interventions. Recent systematic reviews demonstrate mixed evidence that standard interventions sustainably reduce or control obesity.21 Although obesity rates have slowed down in certain pediatric populations, the prevalence among teens has continued to rise, particularly among AAs.4 Base and subsequent coding using the socioecological model applied to the focus group transcripts yielded themes indicating strengths of and challenges to “weight maintenance” for AA youth at various ecological levels. Themes also suggested several “technology/social media-based possibilities” to reach AA youth about active-living practices. This investigation demonstrated the feasibility of training teens to administer focus groups as a strategy to collect data to address obesity disparities. Through a 3-tiered community-academic-private partnership, teens collected data to identify barriers to and facilitators of youth-specific interventions and health practices.

Engagement of AA youth in CBPR projects can yield valuable data to design more culturally responsive and developmentally appropriate interventions to address their needs from a first-hand perspective. This novel use of peer-led focus groups revealed that youth are competent collectors of information relevant to identify needed changes in their schools and communities. In addition to the traditional social determinants of health, youth were able to elicit information that indicates familial, emotional, and mental health components of this public health crisis. They documented that strategies aimed beyond the individual level may be needed to address the barriers to obesity prevention and promote or enhance facilitative factors at various socioecological levels. Thus, youth identified key themes that could be incorporated into planning for obesity interventions, which included the lack of access to affordable, nutritious foods, safe places to get physical activity, and motivation to make healthy lifestyle changes. Students suggested strategies at every level to address barriers to healthy eating/nutrition and at every level except and at all but the family level to address barriers to physical activity. These included the use of technology and social media to facilitate improved health practices among their peers as well as needed policy changes in the school and their community to address systemic barriers.

Although studies have explored youth advocacy for obesity prevention and other health interventions,22–28 few have incorporated youth in the development of obesity prevention interventions. Collaborations with youth engaged in data-driven decision-making about interventions and policies that affect their lives and their communities may be a viable strategy to combat the obesity epidemic.29 Applying the CBPR model to multiple stakeholder community groups (minority HS youth, the academic community at MSU, and private industry) helped build a relationship between 3 communities that was key to implementing this research. The collaboration combined with the scientific expertise of the academic research centers and their complementary missions (community capacity building and health disparity reduction) provided synergy with promising potential to significantly innovate and contribute to future scientific evidence.

Limitations

The coronavirus disease 2019 pandemic global shutdown began 2 weeks after the focus groups during the 2019 to 2020 school year. Because of the online classroom software and security protections, external entities were not able to connect with the online school courses or directly with the students. Thus, facilitators were unable to share the results with their peers as intended, and a 1-year follow-up assessment could not be done as intended. Despite this challenge, data from these focus groups could be used to design an intervention that would address the needs of these youth, and future studies should explore this option.

Conclusion

The feasibility of training HS students to lead focus groups and incorporating youth as implementers of research was demonstrated. Implications for research should reference the barriers and facilitators identified as starting points for intervention development. The students’ personal experiences (struggles with obesity), limited knowledge levels (especially for those who use less technical terms to describe obesity), adverse familial experiences (eg, concerns with their own health or family members’ health), and needed policy or systems-level changes should be considered in developing plans to culturally adapt, implement, and evaluate any proposed interventions. Practitioners are also encouraged to address the many social determinants of health and mental health identified as barriers to healthy living, which may require cross-disciplinary approaches to obesity prevention. Finally, several suggestions were made by these youth that will require policy, systems, or environmental changes (eg, affordable, accessible healthy foods and safe, clean recreational spaces). Policy makers and other decision-makers (including funders) are encouraged to identify opportunities to implement policy, systems, or environmental changes in their solutions to the persistent obesity epidemic in AA communities. Such system- level changes could interrupt the cycle of obesity, another area ripe for future research. This study found that youth can be at the center of collecting data to inform such data-driven decisions.