Moderate Physical Activity and Healthy Eating Habits Among Older African American Women with Diabetes and Hypertension: A Qualitative Study of Barriers and Facilitators

Abstract

African American women have a high prevalence of atherosclerotic risk factors. Many of these atherosclerotic risk factors can be modified through increased physical activity and a healthy diet. We conducted a phenomenological qualitative study on perceptions of physical activity and healthy eating among 26 African American women, 55 years and older. Interviews were conducted and coded for emerging themes on barriers and facilitators of physical activity and dietary behaviors. Perceived barriers were pain and motivation to be active, limited definition of physical activity, time, preparation, cost of healthy meals, and daily decisions on food choice and preference. Facilitators were a routine of regular physical activity, awareness of healthy food choices, and influence of family. Overall, participants had a general perception about the importance of physical activity and healthy eating, however, their motivation to engage in these behaviors depends on their definition, personal motivation, and food preference.

Introduction

Physical activity and healthy nutrition are important for maintaining good health and for preventing chronic conditions such as diabetes and peripheral arterial disease (PAD) in older adult populations. Typically, PAD is diagnosed in adults 40 year and older. African Americans tend to have the highest prevalence of PAD compared to other racial/ethnic populations. For African Americans, they are twice as likely (22.8%) to have PAD compared to other populations non-Hispanic whites (13.2%), Hispanics 13.7%) (Collins et al. 2003). Risk factors for PAD are commonly linked to cardiovascular disease such as diabetes, hypertension, hyperlipidemia. These are prevalent disparities for African American adults thus leading to disparities in PAD prevalence amongst this population (Collins et al. 2003). The risk factors for PAD can be tied to physical activity and diet choice. Understanding how physical activity and diet choice may affect these chronic conditions in an older African American female population is relevant. Studies which examine older African American women, with cardiovascular disease risk factors such as diabetes, hypertension, and hyperlipidemia are understudied. A few studies have examined the perceptions African American women hold about physical activity, with only a few about healthy eating (Collins et al. 2003; Barnett and Praetorius 2015). Results from prior studies indicated common barriers to physical activity and healthy eating included social support, family responsibilities, and lack of motivation (Barnett and Praetorius 2015; James 2004; Joseph et al. 2015; Price, Greer and Tucker 2013). Our current study explores barriers and facilitators of physical activity and healthy eating among an older population of African American women with one or more atherosclerotic risk factors (i.e., diabetes, hypertension, and or hyperlipidemia) for PAD.

As of June 2022, The Centers for Disease Control and Prevention along with the American College of Sports Medicine recommends adults engage in 150 minutes of regular physical activity, most if not all days of the week (CDC 2016; Garber et al. 2011). Only 29% of African American women meet daily recommended physical activity recommendations, compared with 44% of non-Hispanic white women (CDC 2016). Webb and colleagues surveyed over 100 African American women and discovered more than half engaged in less than the recommended amount of moderate physical activity in a week (Webb et al. 2016). Mathieu and colleagues found African Americans and Hispanics were least likely to engage in physical activity regardless of education or income status, in comparison with non-Hispanic whites (Mathieu et al. 2012). This is important because a lack of physical activity is linked to cardiovascular disease risk and mortality, particularly among African American populations (Mathieu et al. 2012).

The importance of maintaining a healthy diet is apparent when examining the connection between nutrition, obesity, and atherosclerotic risk factors and future adverse cardiac outcomes (Palaniappan et al. 2002). Traditionally, African Americans have dietary patterns that contain higher fatty foods or fried foods. The dietary pattern is tied to tradition, familial customs, and heritage (Wilson, Musham and McLellan 2004). These traditional dietary patterns may have a stronger association with atherosclerotic risk factors that can commonly put one at risk PAD. Lane and colleagues found poor self-reported nutrition (i.e., diets high in fat) were prevalent among participants with PAD (Lane et al. 2008). African American women report diets higher in fat and cholesterol intake and lower in dietary fiber (Palaniappan et al. 2002). Diets with these characteristics are often risk factors for PAD. In the current study, we took the same approach as Nies, and colleagues which looked at barriers and facilitators of physical activity and maintain healthy eating habits among younger African American women to better understand what motivates and hinders older African American women from participating in these healthy behaviors. (Nies, Vollman, and Cook 1999).

Methods

Phenomenology, the practice of understanding a person’s perceptions, perspective, or lived experience of an event was the theoretical basis for this study (Giorgi and Giorgi 2003). Our study sought to understand barriers, facilitators, and experiences with physical activity and healthy eating from the perspective of African American women with risk factors for PAD. This method allowed for a deeper, richer understanding of the issues hindering African American women from engaging in physical activity and maintaining a healthy diet. Therefore, we utilized a phenomenological approach which guides the researcher in describing the experience from the perspective of the participant (Giorgi and Giorgi 2003).

Study Participants

For study eligibility we sought women who self-identified as African American, had risk factors for PAD (hypertension, diabetes mellitus, high cholesterol, smoking history) but no objective evidence of PAD (ankle-brachial index > 0.95), and were at least 55 years or older were eligible to participate (See Table 1). Women were originally recruited from a former participant list from past participation in a parent study which assessed the efficacy of counseling to promote walking and improve functional outcomes in African Americans with PAD (Love, Nwachokor, and Collins 2016). We identified women who had a diagnosis of hypertension, diabetes mellites, high cholesterol, or smoked, which put them at-risk for PAD, but had no current diagnosis of PAD from the former parent study database. We also conducted open community recruitment in Wichita, KS and Kansas City Metropolitan area through fliers and word of mouth.

Table 1. Baseline characteristics of the 26 interview participants.

	Total
	N=26	%
Race/Ethnicity
Non-Hispanic black	26	100
Hispanic/Latino	0
Employment
Not Employed/retired	17	65.4
Employed	9	34.6
Education
High School (≤12 years)	6	23.1
Some College	10	38.5
College Graduate or Higher	4	15.4
Post-Graduate (≥ 17 years)	6	23.1
Insurance
Yes	26	100.0
No	0
Income
Under $25,000	9	34.6
$25,000-$39,999	5	19.2
$40,000-$49,999	2	7.7
$50,000-$74,999	4	15.4
$75,000 and Over	2	7.7
Prefer not to answer	4	15.4
Marital Status
Single	5	19.2
Married	9	34.6
Divorced	8	30.8
Widowed	3	11.5
Separated	1	3.8

Procedures

This study was approved by the Human Subjects Committee (Institutional Review Board) at the primary author’s university. Once screened for eligibility, participants were consented before engaging in the semi-structured interviews. Twenty-six semi-structured interviews were conducted by the primary author (MLR) who is trained in qualitative interviewing methodology. Participants did not receive a monetary incentive. They received an insulated grocery bag and pen for their participation.

Data Collection

A standard demographic questionnaire was completed during the baseline interview. Participants were then invited to complete a one-on one in-person qualitative interview. Interviews lasted for one hour. The interviewer (MLR) utilized an interview guide that addressed the following content areas: barriers to physical activity, frequency of physical activity, type of physical activity normally engaged, places where one is physically activity, definition of physical activity, and healthy eating habits (See Table 2). All interviews were recorded and followed the planned qualitative interview guide. Study data was collected and managed through REDCap (Research Electronic Data Capture), which is a secure web-based application designed for data collection (Harris et a. 2009).

Table 2. Semi-structured Interview Topics and Questions.

Topic	Questions
Physical Activity	How often do you engage in physical activity?
	What types of activities do you like to do the most? Where do you normally go to engage in physical activity?
	Do you have any specific barriers that prevent you from engaging in physical activity? How do you define regular physical activity?
	Does your family, friends or other social support networks support you engaging in Physical activity?
	What type of activities or circumstance interferes with you engaging in physical activity, if any?
Nutrition	What is your biggest barrier to healthy eating?
	How do you define a healthy diet?
	What would you consider to be unhealthy? Are these items a part of your current diet?
	Does your family, friends or important others have what you would consider a healthy diet? How does this affect the choices you make?
	What is your biggest barrier if any, in getting enough fruits and vegetables?
	Do you have any problems getting fresh fruits and vegetables from your local grocery store?
Food Choices	What kinds of choices do you make when you eat out?
	Are you more likely to eat in during the week?
	How do you control portion size when you eat out?
	When you eat in (cook food at home) how do you usually prepare your meals?

Data Analysis

Transcribed data were individually analyzed by two researchers (MLR, TCC). The transcript of each interview was read and supplemented with written notes as needed. The analysis of the text was a process by which the researchers identified emerging themes across written summaries and identified salient themes based on excerpts from the transcribed interviews. We utilized thematic analysis to extract themes from transcribed interviews. Using open coding, broad descriptive categories were generated using topics addressed in the interview scripts. Emergent themes, including keywords and ideas, were identified, and ordered logically. Categories were combined, when appropriate, to reduce and organize data. Quotes that represented key themes were selected.

Trustworthiness.

Data saturation did occur, leading the authors to believe we had collected trustworthy and credible data from the participants. All transcripts were read repeatedly and confirmed with the actual records to assure accuracy of the data.

Results

This study captured data from 26 qualitative interviews conducted with older African American women living in two Mid-western States (Kansas and Missouri). Overall, participants were all female, majority had attended some college or held a college degree, and the average age was 67 years. Most participants were retired but still lead an active lifestyle (See Table 1). We identified themes that emerged from the two broad areas of barriers and facilitators for physical activity and healthy eating (See Table 3). Details on each theme are presented below.

Table 3. Semi-structured Interview Themes.

Theme		Definition
Barriers
Interpersonal issues Subtheme for physical activity barriers: Pain, time, motivation to be active Subtheme for healthy eating barriers:	Personal, environmental, or social challenges or obstacles that prevent participants from engaging in physical activity and maintaining healthy eating habits
Time, preparation and cost of healthy meals
Limited Definition of Physical Activity	Physical activity that is defined as everyday
		activities
Daily Decisions on Food Choice and Preference	Decisions that are made to eat foods that are
		more desirable or more palatable regardless
		of nutrition value
Facilitators
Routine of Regular Physical Activity	Engaging in a pattern of moderate physical activity
		for 30 minutes or more on a regular set number of
Awareness of Healthy Food Choices	Being aware of food items that can help or
		hinder current health conditions/health
		like sodium
Influence of Family	How family habits and traditions influence
		positive decisions around food

Barriers to physical activity

Pain, Time, and Motivation to be Active

Common barriers to physical activity were musculoskeletal or orthopedic pain. For example, when asked about specific barriers to physical activity one participant replied, “Well, right now I have shoulder pain and my knees give me problems,” which inhibited her from being more physically active. Many participants begin to limit their frequency and duration of physical activity over time as they were recovering from illness or surgery. This was confirmed by a participant who indicated, “I am probably about 20 to 30lbs heavier than I usually am because I couldn’t do anything. I was suffering with back problems, and it stopped me. I couldn’t stand. I couldn’t bear my own weight.” Other physical activity barriers were more personal such as time restraints, work schedules, no workout partner, or lack of motivation. One participant’s response to engaging in less physical activity was, “just lazy.” When asked to elaborate she indicated, “just lazy, no reason that I don’t, just feel like I don’t have to” [engage in physical activity]. When further asked why she felt this way she said, “If I had to do it … I could.” The notion of laziness came up often for some women, as one participant when asked why she is not physically active, stated, “no reason, just lazy.” She also indicated it was an issue of time by stating, “too busy, it’s hard to find the time”. Others elaborated on similar statements to include no gym membership or wanting a someone to walk with. One participant stated when she was working, she belonged to a gym, but since retirement stopped going. This same participant commented on the lack of gyms in her community, “Wyandotte county… don’t have a lot of gyms.” In general, those who answered “lazy” indicated it was a personal choice not to be active. There was also the perception of no barriers which was supported by a general lack of desire to engage in planned physical activity. One 68-year-old participant stated, “I know what to do [physical activity], I’m a nurse. I just don’t do it.”

Limited Definition of Physical Activity

Most participants seemed to be less knowledgeable about physical activity. While there were those who maintained a regular pattern of physical activity, several did not. Participant’s physical activity levels ranged from every day to less than two days a week. When asked to further explain their activities participants tended to describe everyday activities that were not planned physical activity or events that would normally be categorized as regular physical activity for a sustained period. For example, “I walk up and down the stairs, clean-up, cook, do laundry, catch [the] bus. I have a lot … of groups I go to.” When asked where she goes to be physically active, she stated, “I go to church, to bingo, to the casino, and out to eat.” Another stated, “The only time is when I am out and about going to various meetings or something like that. So, it’s not consistent, like I’m doing something for 30 minutes straight. It’s like I’m getting into my car, getting out, going to a meeting, sitting down.” Another participant’s definition of regular physical activity was even more limited, “We do arm exercises [stretches] at work.” Other participants indicated they walk around the store for physical activity. Others increased steps through everyday activities, “When I go shopping, I try to park far and do a bit more walking” or use the stairs in their home to increase their physical activity, “I walk up and down the stairs a lot” or perform yard work or general household chores, “ I have a flower garden…I mow my lawn. I watered my grass and sweep and vacuum almost daily.” While a few participants had a membership to a gym and were exercising for 30 minutes or more, it was more common to find the limited definition of physical activity that did not reach the level of moderate physical activity.

Barriers to health eating

Time, Preparation, and Cost of Healthy Meals

Time management was often mentioned as a barrier to the preparation of healthier food options. Some participants indicated they lacked enough time to effectively prepare healthy foods at home, so fast food or take-out options were more convenient for them and their family. One participant indicated, “time, it’s easier in certain neighborhoods to pick up the wrong foods, quicker…you know if you are on the go” While another participant indicated the time it takes to prepare healthy foods was an obstacle, “I don’t take the time to prepare healthy meals. I eat on the run. I grab whatever is available to eat and go” When asked further about the time it takes to prepare healthy foods this participant indicated it was also somewhat of a choice because they did not like to cook. Time of preparation was a similar barrier for yet another participant who indicated, “I could cook at home, and it would be a lot healthier. But if I’m out[and] hungry I’ll just pull in and get something from fast food or pick up stuff that’s already cooked…” In addition, the cost of healthy foods also emerged as a barrier. Several participants mentioned the cost of healthy foods, particularly fresh fruits and vegetables impacted their decisions of what to eat and buy. When asked about the most significant barriers to healthy eating, a 55-year-old participant simply remarked, “being poor.” When asked to elaborate she stated, “I only have food stamps that keep being cut. I go to churches…and they want to give you a lot of processed food which I don’t eat, and I cook everything from scratch but sometimes it’s hard.” Cost was also a factor from a different perspective. One participant stated that it was expensive to eat healthy and buy fresh fruits and vegetables when her grandchildren would not eat them, “I tried to cook all these healthy meals and they wouldn’t eat them, and I end up throwing food away… It’s expensive you know. Those healthy foods are expensive.” While cost was mentioned as an issue, it was not always a deterrent in consuming fruits and vegetables or selecting healthier food options. One participant mentioned price was a factor, but she continued to purchase fresh fruits and vegetables regardless of the expense “You have to know how to pick them…they [are] just too expensive now. Prices are not good.” Overall, cost prohibited some participants from purchasing healthier food items while others were just aware of the expense and adjusted. For example, only purchasing canned food goods, frozen items, or seasonal fruit and vegetables.

The influence of family was strongest with eating habits and preparation of food at home. One participant stated, her food choice is influenced by what she ate as a child, “growing up you eat what you’re use to eating.” She indicated this pattern had continued into adulthood. Some participants were responsible for grandchildren who influenced the choice of meals prepared and consumed. One participant felt she made fewer healthy choices because her grandchildren would not eat a healthy home cooked meal. While another participant when asked about support of family stated, “they really don’t support me too much…I support my daughter and she support me…husband has always been slim and trim”. Thus, stating a desire for more familial support. There was also the influence of having a lack of family or other household members around when preparing meals. One 60-year-old participant said her biggest barrier to eating fruits and vegetables was, “living alone.”

Daily decisions on food choice and preference

A theme around choice and preference for certain foods emerged throughout the interviews. Participants indicated preference for less healthy foods such as a more palatable food item, fried fish. Many participants had an enjoyment of food, not to a level of excess but as a treat or as a special occasion, particularly when eating out. One participant stated, “I eat what I want when I’m out. Most of the time I bring something home…I’m dieting and being a good girl at home.” While another stated, “I enjoy food. I think I eat pretty healthy for the most part, but just too much during meals and snacks.” There was one participant who admittedly, stated she was, “just addicted to food”. The idea of portion control was inconsistent among most participants. Some associated portion control to weight, or depravation, while others defined it as the total amount of food placed on your plate. When asked about portion control when eating out one participant stated, “after I pay all of that money, please I’m eating all of my food.” The desire for certain foods and general choice was a strong factor in healthy eating habits among participants.

Facilitators to Moderate Physical Activity

Routine of Regular Physical Activity

The most frequently cited facilitators of moderate physical activity amongst the participants were the desire to feel better and to improve their health. Those participants who were actively engaged in physical activity often cited walking as their exercise of choice. For some women, establishing a daily or weekly routine of physical activity that included a variety of activities was how they stayed active. One participant stated, “I try to switch it up, pool, walk, and lift weights…[I] workout minimum [of] one hour a day.” While another stated, “…variety. At the gym [I] circuit train, water aerobics, line dance, [take] fitness classes, and walk in the water for a mile.” Participants also stated having someone to exercise with would be helpful in maintaining their physical activity. A 60-year-old participant talked about enjoying exercise with her nephew, stating, “Even [my] nephews like to run and go to the gym…get involved”.

Facilitators to Healthy Eating

Awareness of Healthy Food Choices

Some participants were aware of the importance of physical activity and maintaining a healthy diet. For example, a participant stated, “I’m a salt o’holic. But I guess that’s how I got in trouble with high blood pressure. So, I …. use garlic and onion powder or other spices when cooking.” There were others who lacked awareness, as one participant stated, “I don’t mind eating healthy… I would like to eat healthy, but I just don’t really know how … If I knew I could do better.”

Influence of Family

There was also the influence of family traditions that seemed to shape decisions about current food choices. One participant commented on the influence of her father for her love of fruits and vegetables from the garden, “My daddy grew everything like apples, pears, the whole nine yards.” When asked about potential barriers to eating healthy she stated she had none and that, “I love vegetables.” A 60-year-old participant stated she is intentional about healthy meals at gatherings, even though family and friends don’t have the same diet and tend to eat what taste good. So, there is the effort among at least some to influence their family’s healthy food choices.

Discussion

This study was conducted to learn more about the barriers and facilitators of physical activity and healthy eating habits among older African American women with one or more atherosclerotic risk factors. Barriers to moderate physical activity were motivation to be physically active beyond everyday activities, definitions of moderate physical activity, and physical pain. Motivation, time, food choices and preference, as well as cost were barriers to healthy eating. Participants also confirmed certain facilitators which led to more physical activity and healthier dietary choices such as awareness, family tradition, and desire to be healthy.

Women in our study made a conscious choice not to engage in regular physical activity. Overwhelmingly, participants indicated they had no significant barriers to being physical active, other than their own personal choice. Previous studies have found similar results with African American women regarding motivation and desire to be physically active (Miller, Marolen and Beech 2010; Fallon, Wilcox, and Ainsworth 2005; Walcott-McQuigg and Prohaska 2001). This finding is not necessarily specific to African American women. In general, starting or maintaining a regular daily living routines can be difficult. Interventions which incorporate motivational interviewing or readiness to change measures may be beneficial when designing physical activity intervention programs for this population Miller, Marolen and Beech 2010; Fallon, Wilcox, and Ainsworth 2005). In addition, we found women often defined physical activity as their regular daily routines, rather than a separate planned activity. This finding is also confirmed from previous studies (Airhihenbuwa et al. 1995; Lavizzo-Mourey et al. 2001). Nies, Vollman, and Cook found that African American women appreciated practical and convenient activities such as walking to the bus stop, being physically active while doing dishes, or playing with the kids in the park (Nies, Vollman, and Cook 1999; Wilbur et al. 2003). Wilbur and colleagues found African American women classified themselves as physically active. However, this definition of physical activity does not coincide with the level of exercising needed to receive health benefits such as doing moderate or vigorous physical activity at least 150 minutes a week. (Wilbur et al. 2003) Incorporating motivational interviewing in intervention programs may help, however, increasing participant’s knowledge and scope of regular physical activity may be more beneficial.

In addition, women in our current study indicated the effects of a “work-out buddy” on levels of physical activity. Women who had a “work-out” buddy reported increased engagement in physical activity while not having a “work-out buddy” acted as a barrier to physical activity as it was the reason the participant chose too not be physically active. Richter and colleagues also found having social support or someone to workout with was beneficial (Richter et al. 2002). The women in our study were not averse to physical activity in a general sense, but they believed they were doing enough; their definition or perception of “regular” physical activity was limited and there was not a strong desire to expand this definition by most participants. Henderson and Ainsworth found similar findings, which they termed “Sedentary, but busy” (Henderson and Ainsworth 2003). We found women in our current study, while retired, did keep busy schedules, whether it was volunteering, church related activities, or family obligations. The women often perceived these daily “routine” or “busy” activities as their regular daily living routines, and therefore, did not include a set time for physical activity but a lot of moving around that was not necessarily at a level of intensity to result in a health benefit.

Perceptions of physical activity were in direct opposite to participants perceptions of healthy eating. Most participants were aware of the need to lower sodium intake, fat intake, or other items that might impact their chronic disease condition (hypertension, high cholesterol, or diabetes). In some instances, they actively worked to make better food choices such as avoiding fried foods or red meat. In other cases, their motivation was not there. Thus, indicating they deserved the sweet treat or wanted to enjoy whatever meal they wanted. This level of awareness was also found in a study by Drayton-Brooks and White who found African American women were aware of the connection between healthy eating and chronic disease prevention (Drayton-Brooks and White 2004). Awareness is vital as it provides a catalyst for change and knowledge of what types of healthy choices are needed to maintain a healthier diet. The same level of awareness that exist for healthy eating needs to be increased for physical activity.

There were certain barriers to physical activity and health eating that may be tied to social determinants of health. Cost of fresh fruits and vegetables did cause barriers for some of the women in this study. This could eventually be connected to food insecurity. One participant event mentioned the lack of available grocery stores in her neighborhood. This was not a finding amongst most participants but was mentioned enough to address. The connection between food insecurity and PAD among older adults has some validity (Redmond et al., 2016).

Our findings on influence of family were similar in some areas, but also different. We found past eating habits, having parents who ate a lot of vegetables, and tending one’s own garden had an influence on food choice, but it also caused some to stray away from more healthful foods as they aged. A similar study which touched on physical activity and African American women also found a familial history or pattern of past behavior was related to current activity (Young et al. 2002). We also found the family was an influence on what is prepared to eat. Having to feed multiple family members and issues of time management were a factor for a few participants. One participant was caring for her grandchildren, which adds an additional layer to food choice and family influence. This is a place for intervention, using familial history to further learn about barriers to healthy eating, introduce new facilitators of diet choice and more physical activity. In one of our interviews, a participant admitted they were just addicted to food. It is also worth exploring what if any family influences are connected to food addictions and they attachment to food many may have.

Limitations

Due to a small sample size, we cannot generalize these results to the larger population. We reached data saturation within this study and are confident of our results. However, the checking in with study participants to have them review the emerging themes and overall findings did not take place. A future study on this work will make sure to accomplish this important data check for validity. Another limitation to the study was the presentation of the term “regular physical activity.” Our intent was to understand how the women defined physical activity, without leading on this question. In retrospect, we should have provided a broad definition and ask them to further define the term. A broader definition would be beneficial. In addition, cultural influences on physical activity and diet were not examined in depth. Analyzing the cultural impacts or cultural barriers to physical activity and diet would provide more knowledge on the social determinants of health for this population. We also did not examine the influence of age on the responses. Meaning, not all captured quotes are categorized by age. This is also a missing piece which could have implications for creating tailored interventions for an older adult population and should be examined in the future.

Conclusion

Through this study we were able to learn more about the possible barriers and facilitators existing for older African American women with atherosclerotic risk factors. The findings from this study confirm previous work by existing literature and brings to light new knowledge on issues related to the limited definition of physical activity and food choice and diet in general. While more work is needed in this area, our findings provide a sound foundation for understanding older African American women’s views of physical activity barriers and perceptions of healthy eating.

Future studies should strive to move older African American women from a level of awareness to a level of initiation, then action, and finally maintenance of healthier lifestyle behaviors. In addition, future interventions need to be tailored to the target group, meaning, considering all the barriers preventing this population from engaging in moderate physical activity and healthy eating. A first step to intervention is helping participants expand their definition of moderate physical activity and help them overcome challenges to physical activity due to physical ailments (i.e., pain, joint pain, arthritis) (Miller, Marolen and Beech 2010). Addressing these barriers could possibly increase motivation and desire to be physically active. One way to do this may be through incorporating motivational interviewing into any planned intervention. For barriers related to healthy eating, identifying the major barriers such as cultural traditions, general awareness of healthy food choices, and food security is priority. Then, targeting these barriers through a tailored intervention program has the potential to combat restrictions to a healthy diet.

The facilitators that were identified by the participants are helpful reminders of key aspects that need to be incorporated into interventions or programs to maintain moderate physical activity and healthy eating habits. Such as awareness of healthy food choices, establishing a routine of moderate physical activity, and finally encouraging older women to find or establish a work or an exercise partner. These findings illustrate the facilitators aiding these African American women in a healthy lifestyle, therefore, incorporating these facilitators in future interventions is important for participants to maintain healthy eating and engagement in moderate physical activity.