Physical Activity Engagement among Black Immigrants and African American Adults in the 2010 to 2018 NHIS Study

Abstract

Background

High rates of physical inactivity persist in the United States, with higher rates among non-Hispanic Black adults than among their White peers. However, a comparison of physical activity engagement across nativity among Black adults in the United States has yet to be fully documented. The purpose of this cross-sectional study was to examine physical activity engagement rates among African immigrant and Afro-Caribbean immigrant adults compared with native-born African American adults using data from the 2010 to 2018 National Health Interview Survey.

Methods

Using data from the 2010 to 2018 National Health Interview Survey, we used generalized linear models to compare levels of physical activity (meeting the moderate-to-vigorous physical activity [MVPA] recommendations) by ethnic subgroups of Black adults, sequentially adjusting for sociodemographic and health-related risk factors.

Results

Data from 38,037 adults (58.8% female, 21% college/graduate degree, and 41.4% with obesity) were included. Only 41.9% of all participants met the MVPA recommendations. In the fully adjusted models across the 9 years, higher levels of MVPA were seen among African Americans (42%) than among African immigrants (38%) and Afro-Caribbean immigrants (41%). Compared with African Americans, African immigrants were less likely to engage in physical activity that met the MVPA guidelines (prevalence ratio: 0.90; 95% confidence interval: 0.85, 0.96), whereas there were no differences in meeting the guidelines between Afro-Caribbean immigrants (prevalence ratio: 0.96; 95% confidence interval:0.90, 1.02) and African Americans.

Conclusion

Culturally tailored interventions addressing socioenvironmental barriers and facilitators of physical activity may have important impacts on physical activity promotion and long-term disease burden among Black adults across nativity.

Introduction

Physical activity participation is a vital health behavior known to reduce the risk for morbidity and mortality from several cardiovascular and metabolic diseases.1 Presently, the Physical Activity Guidelines for Americans recommend that adults ages 18 to 64 years engage in at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week for substantial health benefits.2 Despite the well-established importance of physical activity, evidence within the literature points to disparities in leisure-time health-enhancing physical activity, with higher rates of inactivity among racial and ethnic minoritized groups as well as immigrant groups.3–5 Among African American adults, for example, lower levels of reported leisure-time physical activity have been well characterized across nationally representative datasets.4 Similarly, among immigrants, individuals immigrating to high-income countries have been observed to have lower reported leisure-time physical activity levels than their native-born peers.5

These physical activity disparities are due, in part, to structural inequities, including, but not limited to, access to and diversity of recreational facilities and features, green spaces, and neighborhood safety, among several factors.6–8 When considering immigrant populations more specifically, researchers have pointed to the process of acculturation (adoption of customs and values of the dominant culture in their new host nation)9 as a hypothesized factor that may alter engagement in physical activity and increase sedentary behavior.10,11 Although researchers have accurately described many of the reasons underlying these physical activity disparities, much of this work has focused on cross-racial comparisons, with scant studies exploring levels of leisure-time physical activity across intraethnic groups of Black adults in the United States. Given the often-cited health inequities observed among Black adults, such as those with cardiovascular12,13 and metabolic diseases,14–17 coupled with the increasing foreign-born Black population,18 it is crucial to disaggregate and understand the current levels and trends of physical activity engagement across Black ethnic subgroups in the United States. This is particularly important, as evidence from the literature suggests that immigrants have better than expected health relative to their US-born peers.19,20 By examining current levels and trends of physical activity among US-born and foreign-born Black adults, future clinical and public health interventions to promote physical activity can be designed to address barriers and promote physical activity facilitators among these racially minoritized groups.

Thus, the purpose of this study was to compare rates of physical activity engagement among ethnic subgroups of Black adults (African American, African immigrant, and Afro-Caribbean immigrant) in the United States. Given evidence from prior studies examining physical activity among immigrants,10,11 we further hypothesized that foreign-born Black adults would have lower adherence to the physical activity recommendations than their US-born peers.

Methods

Design

Using a cross-sectional design, we examined data from African American, Afro-Caribbean immigrant, and African immigrant adults who participated in the National Health Interview Survey (NHIS) from 2010 to 2018. The NHIS is a nationally representative population-based survey of noninstitutionalized US adults administered by the National Center for Health Statistics (NCHS).21 The NHIS uses a 3-stage stratified cluster probability design that includes approximately 45,000 households and approximately 110,000 individuals yearly. In-person interviews were conducted by NHIS study staff members with a randomly selected adult from each household. The adult participant completed the self-reported Sample Adult Module that included information regarding health behaviors, health status, and health care services that they use.21 All data, questionnaires, related documentation, and guidance regarding analytical approaches for the NHIS study are publicly available and free of charge from the US Centers for Disease Control and Prevention’s National Center for Health Statistics website.22 Details regarding the study description and methodology have been previously reported and can be found elsewhere.23 Oral informed consent was obtained from all study participants. The Research Ethics Review Board of the National Center for Health Statistics and the US Office of Management and Budget approved the NHIS study. All procedures were done in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.

Study Participants

Participant characteristics, such as age, self-reported race/ethnicity, sex, education, income, employment status, health insurance status, and body mass index (BMI), were obtained and documented during in-person interviews by study staff. Persons reporting being born outside of the United States, the District of Columbia, Puerto Rico, Guam, and other outlying US territories were considered foreign born.24 Participants were excluded from the present analysis if there were missing data on physical activity (N=45,305), education (N=222), hypertension (N=33), and income (N=8) or if participants were not African American, an Afro-Caribbean immigrant, or an African immigrant (N=913,779). This resulted in a final unweighted analytic sample of 38,037 participants adults aged 18 or older.

Outcome Variable

Physical Activity Level

Participants were queried about their leisure-time aerobic physical activity engagement that included exercise, sports, and physically active hobbies using the leisure-time aerobic physical activity assessment in the NHIS.22 The assessment queried participants regarding frequency (times per day, week, month, and year) and duration (number of minutes or hours per occasion/activity) of vigorous- and moderate-intensity activity. Minutes per week of aerobic activity was calculated as the self-reported frequency × duration of activities.22 Total (weighted) moderate-to-vigorous leisure-time physical activity (MVPA) was obtained by summing the minutes of moderate activity + (vigorous activity minutes per week × 2) to account for intensity.25 Summary estimates of the total proportion of participants meeting or not meeting the recommended physical activity guidelines (≥150 minutes of MVPA per week) were then obtained.

Exposure

The exposure of interest was the Black ethnic subgroup. Self-identified Black participants born on the continent of Africa were considered African immigrants, whereas self-identified Black immigrants born in the Caribbean, Mexico, and Central America were considered Afro-Caribbean immigrants. Black participants born in the United States were considered African Americans. Black participants born in Europe were not included in this study, and specific information on participants’ countries of origin/birth was not publicly available and thus was not used in the current analysis.

Covariates

The following covariates were included in the analysis for the present study: self-reported age in years, sex (dichotomized as male or female), income, education, marital status, BMI, and history of hypertension; these variables have been previously used and are well established in the literature.24,26 More specifically, income was operationalized using the poverty income ratio (PIR), which is calculated by dividing the midpoint of an individual’s family income by the poverty threshold for the year in which the income was reported.27 PIR was further categorized into below the federal poverty level (PIR less than 1), between 100% and 200% of the poverty level (PIR of 1 to 2), and >200% above the poverty level (PIR greater than 2). Education was operationalized as less than or greater than or equal to a bachelor’s degree. Marital status was categorized as married or not married. BMI was calculated in NHIS using participants’ reported height and weight without shoes (kg/m²) and was then categorized as having obesity (≥30.0 kg/m²), overweight (25.0 to 29.9 kg/m²), normal weight (18.5 to 24.9 kg/m²), and underweight (<18.5 kg/m²) based on the Center for Disease Control and Prevention classifications.28 Last, hypertension was dichotomized as having or not having hypertension based on participants’ response to the question, “Have you ever been told by a doctor or healthcare professional that you had hypertension, also called high blood pressure?”

Statistical Analysis

All analyses were performed using Stata 17.0 (StataCorp LP, College Station, TX). Data from the NHIS surveys for the years 2010 to 2018 were pooled to increase and improve the reliability of estimates. Specifically, the Sample Adult and Person‐Level files for each of the years were merged, and sampling weights were adjusted to account for pooling the data. Sampling weights for the years 2010 to 2018 were included to account for the complex sampling design. Survey-weighted chi-square and t tests were used to examine differences in categorical and continuous sociodemographic variables across the intraethnic groups included in the analysis.

Prevalence ratios (PRs) by ethnic subgroup were estimated by fitting survey-weighted generalized linear models with a Poisson distribution and a log link to obtain the respective predicted probabilities for each ethnic subgroup. Sequential covariate adjustment was used, with Model 1 representing an unadjusted model, whereas Model 2 was minimally adjusted for age and sex. Model 3 was adjusted for sociodemographic variables (PIR, education, and marital status) and Model 2 covariates. Last, Model 4 was adjusted for health-related risk factors (BMI and hypertension) in addition to the Model 3 covariates. For prevalence estimates, nonoverlapping 95% confidence intervals (95% CIs) were used to indicate statistical significance. A P value of <.05 was set to determine statistical significance.

Results

Participant Characteristics

In total, 38,037 Black adults were included in the final sample. When weighted to the US population, these participants represented 12,695,233 individuals in the United States. Approximately 59% (58.8%) of participants self-identified as female, 21% of the participants had completed a bachelor’s degree or greater, 25.4% were married, and 41.4% were categorized as having obesity (Table 1). Additionally, 41.9% of participants met the MVPA recommendations, whereas 58.1% did not. The sample consisted of African American (89.65%), Afro-Caribbean immigrant (5.66%), and African immigrant (4.69%) adults. Adults who were African immigrants had a mean age of 39.8±0.4 years (mean±standard deviation) and were, on average, younger than those who were African American (46.5±0.2 years) and Afro-Caribbean immigrants (49.9±0.5 years). Afro-Caribbean immigrant adults had a higher income (ie, PIR>200%) than adults who were African immigrants or African American (P<.001). African immigrant adults, however, had the highest level of education compared with Afro-Caribbean immigrants and African Americans, respectively. The combined prevalence of overweight/obesity was highest among participants who were African American (74.1%) and Afro-Caribbean immigrants (69.3%) and lowest among those who were African immigrants (63.4%; P<.001).

Table 1.

Sociodemographic characteristics of Black ethnic subgroups (N=38,037)

	Total sample, %	African American	African immigrant	Afro-Caribbean	P value
Weighted, n	12,695,233	11,381,263	595,850	718,120
Unweighted, n	38,037	34,302	1,651	2,084
Age, mean(±SE)	46.0 (0.4)	46.5 (0.2)	39.8 (0.4)	49.9 (0.5)	<.01
Sex					<.001
Male	41.2	40.5	53.9	43.0
Female	58.8	59.6	46.1	57.0
Marital status					<.001
Married	25.4	23.5	45.0	40.2
Not Married	74.6	76.5	55.0	59.8
Education					<.001
<Bachelor’s degree	79.0	80.3	59.4	73.9
≥Bachelor’s degree	21.03	19.7	40.6	26.1
PIR					<.001
>200% above PIR	48.8	48.1	52.3	56.7
Between 100 and 200%	24.1	24.3	23.6	22.3
<100%	27.1	27.6	24.1	21.0
Employment					<.001
Employed	62.9	61.8	76.9	69.1
Unemployed	37.1	38.2	23.1	30.9
BMI categories					<.001
Normal weight	25.4	24.6	35.1	30.0
Overweight	31.9	31.0	39.6	39.4
Obese	41.4	43.1	23.8	29.9
Underweight	1.3	1.3	1.5	0.7
Hypertension history					<.001
No hypertension	58.7	57.2	80.8	64.6
Hypertension	41.3	42.8	19.2	35.4

Data are shown as percentages of the sample

BMI, body mass index; PIR, poverty income ratio; SE, standard error

MVPA Engagement Among the Intraethnic Groups

Unadjusted and adjusted PRs for meeting the MVPA recommendations can be seen in Table 2. In the unadjusted analysis, adults who were African immigrants (PR: 1.12; 95% CI: 1.05, 1.19) were more likely than African Americans to meet the MVPA recommendations, whereas no difference was observed between African Americans and Afro-Caribbean immigrants (PR: 0.97; 95% CI: 0.91, 1.03). In the age- and sex-adjusted pooled analysis, there were no differences across groups in meeting the MVPA recommendations, whereas when adjusted for income, education, marital status, age, and sex, a different pattern was seen as it relates to the likelihood of meeting the MVPA guidelines. More specifically, African immigrants (PR: 0.92; 95% CI: 0.86, 0.97) were less likely than African American adults to meet the MVPA recommendations, while there was no difference between Afro-Caribbean immigrants (PR: 0.97; 95% CI: 0.92, 1.04) and African Americans in meeting the MVPA guidelines. Last, in the fully adjusted model that included controlling for health-related risk factors (BMI and hypertension), the same pattern persisted, with African immigrants (PR: 0.90; 95% CI: 0.85, 0.96) significantly less likely than African American adults to meet the MVPA recommendations, but with no difference between Afro-Caribbean immigrant (PR: 0.96; 95% CI: 0.90, 1.02) and African American adults.

Table 2.

Moderate-to-vigorous physical activity engagement among Black adults from the National Health Interview Survey 2010 to 2018 (N=38,037)

	Model 1		Model 2		Model 3		Model 4
	Prevalence, % (SE)	PR (95% CI)	Prevalence, % (SE)	PR (95% CI)	Prevalence, % (SE)	PR (95% CI)	Prevalence, % (SE)	PR (95% CI)
African American	0.42 (0.004)	Ref	0.42 (0.004)	Ref	0.42 (0.004)	Ref	0.42 (0.004)	Ref
African Immigrant	0.47 (0.01)	1.12 (1.05, 1.19)	0.42 (0.01)	0.99 (0.94, 1.05)	0.39 (0.01)	0.92 (0.86, 0.97)	0.38 (0.01)	0.90 (0.85, 0.96)
Afro-Caribbean	0.41 (0.01)	0.97 (0.91, 1.03)	0.43 (0.01)	1.02 (0.96, 1.08)	0.41 (0.01)	0.97 (0.92, 1.04)	0.41 (0.01)	0.96 (0.90, 1.02)

Standardized prevalence and unadjusted and adjusted prevalence ratios are shown (95% confidence intervals)

Model 1: unadjusted generalized linear models pooled across years

Model 2: adjusted for age and sex at index year 2010

Model 3: adjusted for sociodemographic variables (poverty income ratio, education, and marital status) and Model 2 covariates at index year 2010

Model 4: adjusted for health-related risk factors (body mass index and hypertension) in addition to Model 3 covariates at index year 2010

P values of <.05 were considered statistically significant and are bolded. Results are weighted. A Poisson distribution was used with generalized linear models

95% CI, 95% confidence interval; PR, prevalence ratio; Ref, reference; SE, standard error

Given the potential role of acculturation29 and socioeconomic status30 on leisure-time activity, post hoc analyses examining meeting the MVPA recommendations by length of residence (<10 years versus ≥10 years; a proxy measure of acculturation) in the United States and by income were conducted. Among Black immigrants, those living in the United States for ≥10 years had a higher percentage of meeting the guidelines than those residing in the United States for <10 years (40.0% versus 36.0%, African immigrants; 42.0% versus 33.0%, Afro-Caribbean immigrants; Figure 1). African immigrants residing in the United States for <10 years (PR: 0.86; 95% CI: 0.78, 0.94; P<.01) and Afro-Caribbean immigrants residing in the United States for <10 years (PR: 0.78; 95% CI: 0.64, 0.96; P=.016) were less likely to meet the MVPA recommendations than African American adults. However, that was not the case among both African and Afro-Caribbean immigrant adults residing in the United States for ≥10 years (P values>.05). Across income, those with higher income (>200% above the poverty level versus less than 200%) had a higher percentage of adults meeting the MVPA recommendations than those with lower income (48.0% versus 36.0%). Those with higher income were also more likely to meet the MVPA recommendations than those with lower income (PR: 1.33; 95% CI: 1.29, 1.38; P<.01).

Figure 1.

Percentage of Black immigrants meeting the physical activity recommendations by length of residence in the United States (N=37,809)

Discussion

We sought to compare rates of physical activity engagement among ethnic subgroups of Black participants in a nationally representative sample of US adults. Our main findings were that African immigrant adults were significantly less likely to achieve the recommended levels of MVPA by approximately 4% and 2% lower rates than their African American and Afro-Caribbean peers, respectively. Within the total sample, however, approximately 40% of the total sample met the physical activity guidelines. It is plausible that this heightened level of inactivity among Black respondents may contribute to the higher prevalence of obesity, hypertension, and cardiovascular disease among Black adults in the United States and underscores the importance and need for renewed and novel efforts to alleviate barriers and elevate facilitators of physical activity participation among Black adults by addressing structural determinants of physical activity.

Previous investigators have described the disparities in physical activity engagement among Black adults compared with their non-Hispanic White peers.3,31 The current study adds to this established body of work by conducting an intraethnic examination of leisure-time physical activity among US and foreign-born Black adults, addressing a major gap within the physical activity literature. Differences in meeting the physical activity guidelines across the groups may be due to several factors that include, but are not limited to, cultural differences and perceptions of physical activity. For example, in a systematic review focused on African migrant women moving from lower income to higher income countries,32 investigators reported that competing priorities (ie, work, school, and family commitments), along with cultural and religious norms, were barriers among immigrant women in participating in physical activity. Moreover, physical activity-related perceptions, cold weather of the new host country, and built environmental challenges were cited as additional barriers limiting participation in health-enhancing physical activity.32 In another study, investigators observed that Black immigrants in Canada were more likely to report engaging in no physical activity, or when engaging in activity, it was in the form of active commuting or conventional exercise (eg, home-based exercise) than their White peers. The same investigators noted that Black immigrants along with other immigrants self-reported lower odds of engaging in endurance activities (eg, running), sports (eg, basketball and soccer), walking, and recreational (eg, golfing) exercise when adjusted for age, sex, BMI, income, and education.5 In summary, these prior findings along with those of the present study point to potential differences in physical activity engagement across Black ethnic subgroups and support previous calls to disaggregate data among Black persons in the United States.33

Previously, we have shown that among African immigrants, nearly 50% of respondents gained more than 13.6 kg after immigration to the United States, and that older age, longer time spent in the United States, and psychological stress were among the notable factors associated with unhealthy weight gain within the sample.34 Although this current work is descriptive in its design, our results describe differences in physical activity adherence among Black immigrants who are recent arrivals compared with those who have resided in the United States for longer periods. Among immigrants to the United States, the process of acculturation alters engagement in physical activity and has been shown by others to increase sedentary behaviors.10,11 Presently, we found that greater length of residence in the United States (proxy measure of acculturation) led to higher rates of meeting the MVPA guidelines among Black immigrants, comparable to that of African Americans. Cultural nuances and the aforementioned social factors together may work to decrease physical activity engagement among Black immigrants, especially when initially arriving in the United States. Moving forward, strategies that seek to understand and even take advantage of positive socioenvironmental features such as neighborhood social cohesion may help improve achievement of the physical activity guidelines across Black adult groups, as demonstrated in the study by Armstrong-Brown and colleagues where neighborhood social cohesion improved physical activity engagement among older African-Americans living in highly racially segregated neighborhoods.35

Prior investigators have observed a clear socioeconomic status gradient with leisure-time physical activity, with individuals of higher socioeconomic status having greater participation in leisure-time physical activity.30 Similarly, we observed that those with higher income were more likely to meet the MVPA recommendations than those with lower income. Factors such as residential segregation (the physical separation of groups into different neighborhoods) impact social and environmental risk exposure as well as access to spaces and places where individuals can safely engage in physical activity, in turn affecting levels of physical activity among Black adults of lower income.8,36,37 Although there is recent evidence pointing to positive improvements in trends regarding meeting the physical guidelines among Black adults,4,38,39 achievement of the physical activity recommendations is still low nationally. Thus, interventions addressing physical activity among Black adults must focus on the social and built environment along with the policies that affect such environments to design communities that facilitate an active lifestyle among all residents regardless of nativity and socioeconomic backgrounds. Moreover, the inclusion of culturally tailored interventions that incorporate dance or other aspects of culture are strategies that should be used as evidenced by prior studies in which Black immigrants have pointed to dancing as a common source of activity.40,41

We observed that among the total sample of respondents, 41.9% met the MVPA recommendations, whereas 58.1% of respondents did not achieve the recommended levels of MVPA. The fact that approximately 60% of the participants did not meet the guidelines is unsurprising. In a recent nationally representative sample of adults from the National Health and Nutrition Examination Survey study, exploring 10-year trends in physical activity participation between the years 2007 and 2008 and 2017-2018, the authors found that approximately 39% of adults were meeting the guidelines, whereas nearly 46% were inactive.38 In another nationally representative sample examining changes in physical activity between 1998 and 2018 in the NHIS study, researchers observed that 54.2% of adults were meeting the guidelines, whereas 26% of adults were inactive.42 Although both studies point to a general decrease in inactivity and an increase in meeting the physical activity recommendations, differences across race and ethnic groups in both outcomes remained. Together, findings from these population-level studies in addition to our present study reveal that much work remains to be done to increase the number of US adults meeting the physical activity recommendations, particularly among racial and ethnically minoritized groups.

Our study findings have several implications for both clinical practice as well as public health. First, for clinicians, general patient recommendations and reminders about regular engagement in physical activity across differing forms must continue. Further, physical activity prescriptions are necessary but must be done with consideration of the neighborhood and built environment where a patient resides, in addition to cultural perceptions of physical activity. Among public health researchers and stakeholders, wider implementation of policies and initiatives, such as “complete streets” and “safe routes to school,” can be done to improve local street environments and increase physical activity.43,44 These approaches should also be done through an equity lens, focusing on areas and communities that are economically disadvantaged, to avoid greater perpetuation of inequities.

The results of this study must be interpreted with a few limitations. First, frequency, duration, and overall levels of physical activity were each self-reported and thus subject to recall biases, social desirability bias, and overestimation of actual engagement in MVPA. Additionally, respondents were asked to report light or moderate physical activity simultaneously as well as bouts lasting at least 10 minutes. Current guidelines no longer recommend bouts lasting at least 10 minutes but rather any number of bouts at any duration of at least moderate intensity that meet the guidelines elicit health-enhancing benefits,45,46 and thus reported minutes of activity may be affected. Future studies examining physical activity across ethnic groups of Black adults should strive to incorporate objective measures of activity such as accelerometry to better quantify physical activity and overcome these limitations. Despite the limitations of this report, the strengths of this study should be noted. Of note, this study used data from a nationally representative database to capture participation in leisure-time activity among Black adults. Additionally, this study reported levels of engagement in leisure-time physical activity across Black ethnic subgroups, which has been a major gap within the literature and is an important step forward when assessing how to culturally tailor physical activity interventions to maximize success across ethnic groups.

Conclusion

Overall, we observed low levels of physical activity among Black adults, with the lowest levels of physical activity among African immigrants, followed by Afro-Caribbean immigrants and African Americans. The lower levels of physical activity likely contribute to the higher burden of cardiovascular disease risk factors among Black adults, highlighting the importance of tailored clinical and public health interventions within these groups. Moreover, there is a considerable need to understand the social, cultural, and environmental reasons for within-group differences in physical activity levels among Black adults. Together, such studies can inform and assist in tailoring physical activity prescriptions that address both socioenvironmental barriers and facilitators of health-enhancing physical activity engagement among Black adults to advance health equity.