Promoters and Barriers to Fruit, Vegetable, and Fast-Food Consumption Among Urban, Low-Income African Americans—A Qualitative Approach

Abstract

To identify promoters of and barriers to fruit, vegetable, and fast-food consumption, we interviewed low-income African Americans in Philadelphia. Salient promoters and barriers were distinct from each other and differed by food type: taste was a promoter and cost a barrier to all foods; convenience, cravings, and preferences promoted consumption of fast foods; health concerns promoted consumption of fruits and vegetables and avoidance of fast foods. Promoters and barriers differed by gender and age. Strategies for dietary change should consider food type, gender, and age.

Diet-related chronic diseases—the leading causes of death in the United States^1,2—disproportionately affect African Americans^3–7 and those having low income.^8–10 Low-income African Americans tend to have diets that promote obesity, morbidity, and premature mortality^3,4,11,12; are low in fruits and vegetables^13–18; and are high in processed and fast foods.^19–23

Factors that may encourage disease-promoting diets include individual tastes and preferences, cultural values and heritage, social and economic contexts, and systemic influences like media and marketing.^24–30 Because previous research on dietary patterns among low-income African Americans has largely come from an etic (outsider) perspective, it has potentially overlooked community-relevant insights, missed local understanding, and failed to identify effective sustainable solutions.³¹ Experts have therefore called for greater understanding of an emic (insider) perspective through qualitative methods.³¹ However, past qualitative research on dietary patterns among low-income African Americans has been limited, focusing mostly or exclusively on ethnic considerations,^28,29 workplace issues,¹⁰ women,^32–38 young people,^38,39 or only those with chronic diseases^34,36,39,40 and neglecting potentially important differences by age and gender.^31,41–43

To build on prior research, we conducted interviews in a community-recruited sample using the standard anthropological technique of freelisting.^44–46 Our goals were (1) to identify the promoters of and barriers to fruit, vegetable, and fast-food consumption most salient to urban, low-income African Americans and (2) to look for variation by gender and age.

METHODS

We conducted interviews in Philadelphia, Pennsylvania, in a community that was more than 95% African American with 20% of residents below the poverty level.⁴⁷ Select community members participated in the conduct of the study by reviewing and helping revise study documents, providing space to conduct interviews, and advertising the study, which we conducted during the summer and fall of 2008.

Sample

Study participants self-identified as African American adults aged 18 to 81 years living in Philadelphia. Because past literature suggests that 15 to 20 participants are adequate for the methods we used,^48,49 we recruited 20 men and 20 women. Each gender group included 10 younger adults, aged 18 to 35 years, and 10 older adults, aged older than 35 years. (For the demographic characteristics of the participants, see Appendix Table 1A, which is available as a supplement to the online version of this article at http://www.ajph.org.)

Data Collection

The principal investigator (a White male physician) or a trained research assistant (an African American female undergraduate student) conducted interviews during both daytime and evening hours in a classroom at a local high school. Study participants' age and gender did not differ significantly by other sociodemographic characteristics or by interviewer (see Appendix Tables 1A and 2A). All participants gave informed consent and received a $15 gift card.

Participants verbalized “freelists” (stream-of-consciousness lists of single-word or short-phrase items) in response to visual cues (not available for publication because of copyrighted images, but available from authors upon request) and 6 different verbal prompts: “Tell me all the reasons you can think of that make it likely [unlikely], for you personally, to eat fruits [vegetables, fast foods].” Interviewers audio-recorded freelists and asked participants to clarify ambiguous items.

Data Analysis

Researchers edited participants' freelists with an established judgment rule⁵⁰ to divide compound items and collapse synonymous items. We strove to preserve intended meanings based on clarifying statements participants made after freelisting. Researchers imported edited freelists into Anthropac version 4983/X (Analytic Technologies, Natick, MA) to calculate Smith S,⁵¹ a measure of saliency, or importance, for each listed item.

RESULTS

For the whole sample (Table 1), taste or flavor promoted the consumption of all foods. Cravings promoted fast foods; preferences promoted fast foods and fruits but were barriers to vegetables. Cost and finances were barriers to all foods. Convenience and availability promoted fast foods but were barriers to fruits and vegetables. Health concerns promoted fruits and vegetables and were barriers to fast foods.

TABLE 1.

Top 20 Freelisted Promoters of and Barriers to Consumption of Fruits, Vegetables, and Fast Foods Among a Sample of Urban, Low-Income African Americans: Philadelphia, PA, 2008

Rating	Promoter	Smith S	Barrier	Smith S
	Fruits
1	Health and nutritionab	0.55	Cost and financesab	0.20
2	Taste or flavorcb	0.40	Availability and convenienceab	0.18
3	Vitamins and mineralsab	0.24	Have at home or on handab	0.14
4	Preferences and likesab	0.22	Craving or taste forb	0.14
5	Cost and financesa	0.09	Taste or flavorcb	0.11
6	Bowel functiona	0.09	Preferences and likesa	0.09
7	Energy-giving	0.07	Freshnessa	0.09
8	Refreshment	0.06	Away from home	0.08
9	Naturalness	0.05	Allergies or sensitivities	0.07
10	Availability and conveniencea	0.05	Variety or kindsa	0.06
11	Have at home or on handa	0.05	Appearancea	0.05
12	Time constraintsa	0.05	No reason	0.05
13	Balanced diet	0.03	Time constraintsa	0.04
14	Have resources to grow	0.03	Time of year	0.04
15	Weather, warmth	0.03	Health or nutritiona	0.03
16	Essentiality or necessitya	0.03	Bowel functiona	0.03
17	Family or friends' influencea	0.03	Weight concerna	0.03
18	Heaviness in the stomacha	0.03	Ease of preparing or servinga	0.03
19	Weight concerna	0.03	Value for moneya	0.03
20	Alternatives better	0.02	Being everywhere	0.03
	Vegetables
1	Health or nutritionb	0.47	Preferences and likesab	0.23
2	Taste or flavorcb	0.27	Cost or financesab	0.16
3	Vitamins and mineralsb	0.20	Availability and convenienceab	0.14
4	Preferences and likesa	0.13	Taste or flavorcb	0.12
5	Part of meala	0.12	Freshnessa	0.10
6	Bowel function	0.10	Preparation style or qualitya	0.10
7	Cost or financesa	0.09	Time constraints	0.09
8	Energy-giving	0.08	Having cooked alreadya	0.08
9	Essentiality or necessitya	0.08	Part of meala	0.07
10	Family or friends' influence	0.07	Cravings or taste fora	0.07
11	Example to kids	0.07	Away from home	0.07
12	Availability and conveniencea	0.05	Have at home or on handa	0.06
13	Blood flow	0.04	Appearance	0.05
14	Protein	0.04	Contamination or safety	0.05
15	Weight concern	0.04	Ease of preparing or servinga	0.04
16	Upbringing, how raiseda	0.04	Being everywherea	0.04
17	Balanced diet	0.03	Allergies or sensitivities	0.04
18	Living situation, who cooks	0.03	Forced to, only optiona	0.03
19	Longevity	0.03	Value for moneya	0.03
20	Cravings or taste fora	0.03	Time of yeara	0.03
	Fast Foods
1	Taste or flavorab	0.34	Health or nutritionb	0.45
2	Availability and convenienceab	0.25	Cost or financescb	0.28
3	Time constraintsab	0.25	Weight concernb	0.27
4	Cravings or taste forab	0.21	Fat or grease contenta	0.11
5	Preparation or serving easeb	0.17	Availability and conveniencea	0.09
6	No energy or desire to cookb	0.14	Cholesterol	0.08
7	Cost or financescb	0.14	Having cooked already	0.08
8	Preferences or likesab	0.09	Sugar contenta	0.08
9	Being everywhereb	0.08	Cravings or taste fora	0.07
10	Treat self, cheat on diet	0.06	Salt or sodium	0.06
11	Weekend or day of weeka	0.06	Discipline	0.04
12	Away from home	0.05	Skin health, acne	0.04
13	Time of day	0.05	Essentiality or necessity	0.03
14	Upbringing, how raised	0.05	Full already, other food eaten	0.03
15	Preparation knowledge	0.04	Have at home or on hand	0.03
16	Satisfying quality	0.04	Heartburn, upset stomach	0.03
17	Fat or grease contenta	0.04	High blood pressure	0.03
18	Hunger, appetitea	0.04	No reason	0.03
19	Filling or satiating	0.03	Same old stuff, tired of it	0.03
20	Value for money	0.03	Sickness	0.03

Note. Smith S is a measure of the item's saliency or importance. Total items per list are as follows: for fruits, 38 promoters and 39 barriers; for vegetables, 43 promoters and 36 barriers; for fast food, 39 promoters and 52 barriers. Mean items per list are as follows: for fruits, 4.2 promoters and 2.8 barriers; for vegetables, 4.1 promoters and 3.0 barriers; for fast food, 4.3 promoters and 3.9 barriers. Complete lists of freelisted promoters and barriers to consumption of fruits, vegetables, and fast foods are available in the appendix tables (available as a supplement to the online version of this article at http://www.ajph.org).

^aListed as both a promoter and a barrier (21 items [promoters or barriers] for fruits, 21 items for vegetables, 17 items for fast foods).

^bIndicates most salient promoters or barriers.

^cSalient as both a promoter and a barrier (1 item each for fruits, vegetables, and fast food).

For subgroups (Table 2), men identified family or friends' influence as promoters of vegetables. For women, the concept of being part of a meal was a promoter of vegetables whereas lack of freshness was a barrier; cravings and cheating on diet were promoters of fast foods whereas the fat and sugar content in fast foods were barriers. For younger adults, the energy-giving quality of fruits was a promoter, whereas having cooked something else already (convenience of alternatives) and schedule (time constraints) were barriers to vegetables. For older adults, ubiquity (being everywhere in the neighborhood) was a promoter of fast foods and bowel function (general digestive health) was a promoter of vegetables.

TABLE 2.

Salient Promoters of and Barriers to Consumption of Fruits, Vegetables, and Fast Foods Among a Sample of Urban, Low-Income African Americans, by Gender and Age Category: Philadelphia, PA, 2008

	Men Only	Men and Women	Women Only	Younger Only	Younger and Older	Older Only
	Promoters
Fruits		Health or nutrition		Energy-giving	Health or nutrition
		Taste or flavor		Cost or finances	Taste or flavor
		Preferences or likes			Preferences or likes (4)
		Vitamins and minerals			Vitamins and minerals (3)
Vegetables	Preferences or likes	Health or nutrition	Part of meal	Part of meal	Health or nutrition	Preferences or likes
	Family or friends' influence	Taste or flavor	Bowel function		Taste or flavor (3)	Bowel function
			Vitamins and minerals		Vitamins and minerals (2)
Fast Food		Taste or flavor	Cravings or taste for		Taste or flavor	Being everywhere
		Time constraints (3)			Time constraints (3)
		Availability and convenience (2)	Preparation or serving ease		Availability or convenience (2)
					Cravings or taste for
			No energy or desire to cook		Preparation or serving ease
					Cost or finances (7)
			Cost or finances		No energy or desire to cook (6)
			Treat self, cheat on diet
	Barriers
Fruits	Availability and convenience	Cost or finances	Freshness	Cravings or taste for	Cost or finances	Having at home
		Cravings or taste forTaste or flavor		Preferences or likes	Availability and convenience	Taste or flavor
	Having at home	Taste or flavor		Away from home
	Away from home
Vegetables	Availability and convenience	Cost or finances (2)	Freshness	Taste or flavor	Preferences or likes (2)	Part of meal
		Preferences or likes (1)	Taste or flavor	Having cooked already	Availability and convenience (3)
					Cost or finances (1)
				Time constraints
				Freshness
Fast Food		Health or nutrition	Sugar content		Health or nutrition
		Cost or finances (3)	Fat or grease content		Weight concern
		Weight concern (2)			Cost or finances

Note. Items are listed in decreasing order of saliency. Shared items are listed in order of saliency for men or younger adults (18–35 years). Numbers in parentheses for shared items indicate order of saliency for women or older adults (> 35 years).

DISCUSSION

In our community-based interview study among low-income African Americans, we used freelisting to identify and prioritize emic (insider) perceptions of promoters and barriers to eating fruits, vegetables, and fast foods, with particular attention to differences by age and gender. The importance of taste,^28,38,40,52 cost,^{28,29,36,38–40,52,53} convenience and availability,^{29,35,37–39,53} and health concerns^37,53 is consistent with prior research, as are weight concerns²⁸ and considerations regarding cooking and meals for women.^28,31 What is new is the influence of family and friends on men—who generally rely on women to shop, prepare meals, and make nutritional decisions²⁸—and the different importance of personal time during the life course (with time and convenience acting as an inhibitor of vegetable consumption only among young adults).

We used a novel method to identify salient influences on diet among urban, low-income African Americans. Taste, cost, health, and convenience and availability were generally salient among participants, but there were important differences in findings by food type, age, and gender. Future research should juxtapose and prioritize identified promoters and barriers to understand their relative and conditional importance. Resulting interventions, derived from such work that accesses emic perspective, may be more acceptable in African American communities and therefore more effective at producing sustainable changes toward improved health.