Grown Woman: Understanding What Influences Health Behaviors in Black Female Students at a HBCU

Abstract

Objective:

The purpose of this study was to understand what influences health behaviors in Black female students at a Historically Black College and University (HBCU).

Participants and Methods:

Twenty-five Black female students enrolled at a HBCU in the southern United States participated in five focus groups and one interview. Qualitative analysis was used to analyze data for similar themes and codes.

Results:

The three areas that appear to influence health behaviors are interpersonal, community, and society.

Conclusions:

These findings highlight the need for HBCUs to develop health programs for Black women on their campus that include elements of interpersonal support. Additionally, HBCUs need to work on how they create an environment that provides their female students with the resources they need to be able to live a healthy life.

Black women have the highest rates of overweight and obesity than any other racial or ethnic group in the US.¹ Recent research has also reported higher percentages of obesity among Black females at a Historically Black College and University (HBCU).² College-aged Black women also have the highest rates for certain sexually transmitted diseases.³ Despite these adverse health outcomes among young Black women, there is a lack of research that focuses on the factors that influence health behaviors among Black women in college. Most research on Black women in college is focused on their body perception and sexual habits.^4,5 Yet, heart disease is the number five and number three killer among Black women 15–19 and 20–24, respectively.^1,6

Research reports that stereotypes about Black women, negative or positive, impact mental health, self-esteem, and sexual risk behaviors among Black women.^7,8 For this reason, research needs to look at the factors that influence behaviors in Black women across the life course. Because Black women are at a greater risk for certain chronic conditions and sexually transmitted diseases, it is important to understand what factors influence their health behavior to improve these behaviors and in turn improve their overall health outcomes.

Given that Black women have higher rates for most chronic health conditions across the life course, younger Black women, particularly those on college campuses, are an important population to focus on. College-aged Black women 20–24 have the highest rate of Chlamydia than any other gender, age group, and racial/ethnic group and one of the highest rates of Gonorrhea, second only to Black men 20–24.³ Additionally, research has reported that Black women in college are less likely to engage in physical activity.⁹

Some elements that have been reported to have impacts on health behaviors among young Black women are friendships with other women, stereotypes of how Black women should be, and cultural and societal norms.^4,10,11 These findings give support to conducting more research on Black women in college that is focused on the social elements that might impact and influence health behaviors among this group. Although studies have looked at what influences certain health behaviors in this group, there is a lack of research on what influences general health behaviors among Black women in college. By understanding what influences health behaviors among Black women in college, colleges can develop more targeted programs that utilize these findings to improve the health of Black females on campus. Additionally, because there is a lack of research on the health of students at HBCUs, this research adds to the literature by studying health behavior influence among Black female students at a HBCU. The following research question guided this study: What influences health behavior among Black women in college?

Methods

This study employed a qualitative design with the use of focus groups and in-depth interviews comprised of Black female students from a HBCU in the southern United States. Inclusion criteria for participation in the study were: currently enrolled in the university where the study was conducted during the Spring 2017 term, self-identify as African American or Black, and self-identify as female. After receiving IRB approval, participants were recruited by the second and third author’s contacting other faculty on campus and having them distribute the flyer via email, the second and third author emailing students in their classes, and sending the flyer through the communication service used by student organizations.

In all recruitment communications, participants followed a link that allowed them to select three possible focus group dates. Participants were then emailed letting them know which date they were selected for. Participants were also sent reminders for their focus group day. To obtain additional participants, three additional focus groups were held during the fall 2017 term with participants recruited via the same avenues.

Procedure

Focus groups were conducted by the second and third authors. The focus groups lasted no more than 1.5 hours. Because initial recruitment involved participants selecting potential focus group dates, one focus group didn’t have enough participants show up; thus, this focus group became an in-depth interview. The participant involved in the in-depth interview didn’t differ from participants in the focus groups. Having a mix of both methods allowed for assessment of group dynamics with the responses while comparing if responses were based on group dynamics with the in-depth interview. Focus group and interview questions were guided by the socioecological model. This model was used because it provides an overall look at the different elements that impact health behavior.¹² While the model can be found in many forms, this research was based on the model suggesting there are five areas or levels that impact the behavior an individual displays or engages in. These areas are the individual (individual factors that influence one’s health behavior); interpersonal (the influence of family, friends, peers on one’s health behavior); organizational (the influence of institutions on one’s health); community (the influence of one’s environment on their health); and policy (the influence of laws on one’s health).¹² For the purposes of this research, questions were developed for all areas of the socioecological model except organizational. Focus group and interview questions are listed in Table 1.

Table 1.

Focus Group and Interview Questions

How do you believe being a woman impacts your health? How do you believe being a Black woman impacts your health? Who or what influences your health? What do you see as barriers to your health on campus? What do you see as barriers to your health in the surrounding community? What could improve your health?

Before all focus groups and interviews, informed consent was explained and received. Additionally, all participants completed a questionnaire that included demographic and health questions. Fourteen questions from the American College Health Association, National College Health Assessment version 11c were also used to gain general health behavior information.¹³ All focus groups and interview were recorded. The first three focus groups were transcribed using a transcription service. The last two focus groups and one in-depth interview were transcribed by two research assistants. For the first three focus groups, each participant received a $100 Wal-Mart gift card after all groups were completed. The second groups did not receive gift cards because there was no more grant funding. The participants who received gift cards were unaware of the amount of the gift card or that they all would receive a gift card prior to their participation so it is not believed this impacted the results of the study.

Data Analysis

To analyze the focus group and interview data, qualitative analysis was conducted by hand. This analysis did not include any quantitative results, but relied on the thematic analysis that was conducted by hand by the second author and five research assistants. Qualitative analysis software was not available for the student research assistants. As a result, the second author picked an analysis method that was easy to explain and easy for the research assistants to analyze the data they were given. Thus, all analysis was conducted by hand using a process of chunking and coding text for themes and sub-themes based on methods used by Griffith and colleagues.^14–19 In the first step, each research assistant was given a transcript of a focus group or interview and asked to pull out chunks of data that related to a participant’s reference about who or what influences their behavior. The chunks of data had to stand on their own without the full transcript and had to explain either of the two areas mentioned above. Additionally, information such as focus group or interview number and transcript page number were also included. For the second step, data from step one was checked by having another research assistant look over the document to make sure no additional data chunks were missed. The third step involved having a research assistant combine all data chunks from steps 1 and 2 into one document for what influences behavior. For the final step, three research assistants were given the two documents with data chunks for what influences behavior and behavior influence and asked to list elements that were similar across all data. After this step, the second author reviewed the final analysis document from each research assistant to look for similar themes and concepts across the documents. Once similar themes were found, the second author grouped the themes based on which part of the socioecological model they reflected. Based on these groupings, final conclusions were made. The themes reported are not an absolute conclusion of the data that was analyzed, but a reporting of an overall consensus of the data based on the analysis that was conducted.

Results

There were a total of 25 participants, who included five focus groups and one interview. The number of focus group participants consisted of one group of three, two groups of five, one group of four, and one group of seven. Participants ranged in age from 18 to 23 years old. Participants represented all undergraduate levels at the university used in this study. Additional characteristics of participants are listed in Table 2.

Table 2.

Selected Characteristics of Participants

Characteristic	Total(n=25) n (%)
Age
18	4 (16)
19	5 (20)
20	6 (24)
21	8 (32)
22	1 (4)
23	1 (4)
Class Rank
Freshman	4 (16)
Sophomore	3 (12)
Junior	9 (36)
Senior	7 (28)
General Health
Excellent	3 (12)
Very Good	4 (16)
Good	12 (48)
Fair	5 (20)
Poor	1 (4)
BMI
Underweight (<18.5)	1 (4)
Normal (18.5–24.9)	10 (40)
Overweight (25–29.9)	7 (28)
Obese (≥30)	7 (28)

Influences on health

Participants’ responses on what or who influences their health were separated into three constructs from the Socioecological model: interpersonal, community, and society. Overall, participants’ responses appeared to reflect that the interpersonal and society levels were influential in their health; however, their responses also appeared to reflect that influences from the community level seemed to be the determining factor in their health.

Interpersonal

Participants mentioned two main groups that influence their health, friends and family. With both groups, they can influence health positively or negatively. Since these groups can influence health in a good or bad way, involving these groups in health promotion programming could be influential in making sure Black women in college have good health and good health outcomes.

Friends

Friends served as a support for either engaging in health behavior that is beneficial or health behavior that is not beneficial. As mentioned by one focus group participant in reference to the things friends will ask you to do. “There’s not too many, no one really say, ‘Hey you want to go for a walk?” Boyfriends also seemed to be an influence on health in a good way. As stated by one focus group participant.

…my ex-boyfriend, he was a workout fanatic, so…when we were together, I was like super-duper on top of myself. I was always working out, I was eating healthy, I wasn’t like eating bad…but then as soon as we broke up…he didn’t have that type of like influence on me to work out and be healthy. Umm…it was there in my mind but it wasn’t like there as much so like, I like fell way off.

Family

Family members also seemed to influence health in either a positive or negative way. Some saw their family as a marker for what they didn’t want to be because of their family’s bad health outcomes so they used their family as motivation to do better as stated by one focus group participant.

…I don’t want to look like my family. Cause, they all were my build, and then they got a little happy, got married, had some kids… And they said, okay. Like, it wasn’t even a thick thing, it was like an okay… you know what I mean?

However, others saw their family, specifically their mother, as someone to look to for health advice or advice in general.

I don’t rely on my mom to make my decision, I just need her opinion sometimes. That little bit of dependency on her when it comes to certain things because she’s been in the world longer, obviously, so she’s experienced a lot more than me. Just having that, okay, so I should definitely go with this decision versus this decision.

Community

Community, the college community and the community surrounding the college, was also seen as influencing to their behavior. Specifically, food; college campus; and transportation were seen as influencing why they are not able to have good health or good health outcomes.

Food

The participants talked about not having access to healthy food outside of the cafeteria because of the campus not being in walking distance of a grocery store. Some even noted that food in the cafeteria doesn’t always include healthy options so it is sometimes difficult for them to eat healthy.

College Campus

There were certain factors on campus that participants mentioned as influencing their health: gym hours, safety, and cafeteria hours. Participants stated that a lack of safety on campus prevented them from being able to exercise.

I would say safety, like I like to walk a lot. I don’t do much bigger activity, but walking has always been my thing and yoga…I can’t walk around the campus two, three times like I want at night.

…a lot of stuff goes on like safety wise and then nothing really happens about it, like even walking up the street, like you get those alerts about like people being robbed…

They also mentioned that the hours of the gym and the cafeteria prevent them from being able to work out consistently and to have access to healthy food, respectfully. As stated by one participant regarding the gym, “maybe sometimes the availability of the gym. Cause sometimes I want to work out on Sundays.” Another participant mentioned the cafeteria hours and healthy food options.

…I understand the cafe don’t be open ‘til 11:30 but why do I have the options of eating po’boys and wings at 11:30 at night, but I can’t get fresh fruit.

Transportation

For many of the participants not having access to transportation influenced their ability to have access to healthy food options. As stated by one participant.

…you’re in an area where you don’t have access to like fresh produce like within walking distance. Like you have to travel, like if you don’t have a car, you have to Uber or take the bus, yeah, you just can’t just go up the street

Society

Participants mentioned that the main element in society that influenced their health was expectations. Expectations consisted of what society expects of them as well as how the media and internet portrays them.

Expectations

The participants talked about how expectations of them as a woman and a Black woman could cause stress or pressure which may make it hard for them to maintain good health.

…I feel like people always just expect us to stay on top of our health or have the perfect health almost. So being a woman, it’s just, it’s hard on us to maintain health and then keep up with everything that goes along with being healthy.

…I feel like it’s a lot from the social prospect. Really because…like we need to have kids by a certain age, just to be married and then on top of that we’resupposed to learn how to struggle, um, having jobs and then taking care of the home. I think it adds pressure.

Internet/Media

Participants discussed the impact of the internet and the media on how they view themselves and their body which ultimately impacts their physical and mental health.

…you get on Instagram and you see everybody like an Instagram model, they have like the typical body that everybody gets. So it’s just like now you have all these trends to like lose weight and unhealthy ways. I just think the pressure to like always be like hip and keep up with society.

The media does play a major part…if one woman feels as though I need to look like the other woman in the video with the plastic surgery and the curves, mentally that’s going to tell them this is okay. This is what society is accepting right now. Let me do that to alter what I already have. Like she said, it does mentally play a role in women’s health.

Comment

This study examined what elements influence health behaviors among Black women in college. Although there is adequate research on factors which influence the general health of Black female students, there is limited data on factors which influence the health of Black women in college at HBCUs. Understanding factors which influence health behaviors can be beneficial to improving healthy behaviors among Black women in college through health programs and interventions. Participants reported that the interpersonal, community, and societal constructs of the socioecological model influenced their current health status. Overall, the interpersonal and society levels were influential, but the community level was the determining factor in their health because what they had access to through their community determined what health behaviors they were able to engage in.

Participants reported two main groups that influenced their health, friends and family. Friends served as a support for either engaging in health behavior that’s beneficial or health behavior that is not beneficial which is similar to other research reporting that friendship influence the safe-sex practices in Black college women.⁴ Research has also reported that one source of motivation to improve health, specifically eating habits in young to middle-aged Black women, was seeing the bad habits of friends and family, which is mirrored in the findings of this study that reported many participants using their family’s negative health outcomes as motivation to make better health decisions.²⁰ While support from friends was influential to participants’ health behaviors, it was not the determining factors in the behaviors they engaged in which is the same conclusion of other research which reported that no relationship existed between social support and physical activity in college-aged Black women.²¹

The college community and the community surrounding the college, was also seen as influencing participants’ behavior. Participants reported inadequate access to healthy food in the surrounding community. Various elements on the campus such as gym hours, safety, and cafeteria hours as well as available food options and a lack of access to transportation were reported as barriers to participants’ health which is similar to research findings that crime safety was a barrier to physical activity among college women.²² Additionally, participants mentioned that the main element in society that influenced their health was expectations. Expectations consisted of what society expects of them as well as how the media and internet portrays them. Similar to other research reporting that the stereotypes or images of Black women in society impact their mental health, this study reported that the internet and media influenced how Black women in college viewed themselves and their body which ultimately impacted their physical and mental health.¹⁰

Limitations

This study took place at a small HBCU which may have accounted for the low participant numbers. However, similar responses from the focus groups conducted in different semesters shows that a level of saturation with the data was reached. Because the participant numbers were low, findings may not be representative of all Black females at the university or generalizable to a larger group of Black female college students. Additionally, campus dynamics are different from campus to campus whether an HBCU or a predominately White institution; thus, the findings may have been different if female students from other campuses were used in the study. Also, recruiting participants through campus email and via other faculty members may have accounted for the low number of participants. Because students don’t typically check flyers on campus, email was the primary method used to recruit participants.

Conclusions

Black women continue to suffer high rates of many different health conditions. Because Black women have high rates of disease across the life course, understanding what influences health behaviors in Black women at all ages may be a way to decrease health disparities that exist within this group. Understanding what influences health behaviors in this group may be beneficial in developing programs that increase access and improve healthy behaviors among Black female college students. Additionally, this knowledge may also be beneficial in making sure college programming addresses access issues that exist on their campus that impact health behavior and not just develop programs to increase knowledge and awareness.

Findings from this study indicate the need for increased and improved implementation of public health programs on HBCU campuses. University administrators can use findings from this study to improve campus policies related to safety, extend cafeteria and recreational facility hours, improve access to fresh fruits and vegetables, and increase healthy food options in the dining hall. Additionally, universities should work to increase student awareness of mental, physical, and sexual health resources available on campus. Universities should also implement more programs aimed at enhancing body image perception among students.

Future research in this area should examine how campus policies impact the health and health behaviors of Black women in college. Additionally, research should examine if Black female students on campuses with more access to elements that encourage better health behavior actually engage in healthy behaviors. Because this study was conducted with Black women at a HBCU, future research should examine if these concepts are true for Black female students at majority institutions.