Using Black Feminist Theory and Methods to Uncover Best Practices in Health Promotion Programming

Abstract

This study was created to uncover the social determinants of Black American women’s success in health promotion programs. We used the Superwoman Schema to understand the complexities of Black womanhood and uncover best practices in the promotion of their health. The sample consisted of women ages 18–25 who attend a large southern HBCU. We collected data using qualitative focus groups. Participants reported the greatest health-related concerns Black American women facing are mental health, obesity, and relationships with Black men. When it comes to health promotion programs, respondents reported a desire for classes that are fun, interactive, informative, educational, and include group interaction, accessible, and incentivize participation. Uncovering the social determinants of Black American women’s health and program success is central in decreasing extant health disparities. Future health scholars are urged to incorporate Black feminist theory and methods into their work to create health promotion interventions tailored for Black women.

Introduction

It is well established that overweight (BMI ≥25 kg/m² and <30 kg/m²) and obesity (BMI ≥30 kg/m²) continue to be persistent public health problems in the United States impacting more than one-third of American adults (Fitzgibbon et al., 2011; Flegal et al., 2016). As weight increases, so does the social and economic cost of chronic diseases such as heart disease, diabetes, cholesterol, certain cancers, and a host of other physical and mental health-related comorbidities (Obesity and African americans.2020; Asiedu et al., 2017; Flegal et al., 2016). When we examine overweight and obesity rates by race and sex categories, Black American women have the highest rates compared to every other group in the United States. About 4 out of 5 (or 80%) of Black American women are overweight or obese (Obesity and African Americans, 2020; Fitzgibbon et al., 2011). Clinically, being overweight and obese is associated with chronic diseases such as heart disease, type 2 diabetes, hypertension, kidney disease, and some cancers. Morbidity and mortality rates for these chronic diseases are also highest among Black American women (Flegal et al., 2016). In terms of psychosocial outcomes, obesity has been linked to depression, stigma, and discrimination (Saguy & Gruys, 2010; Jaworowska et al., 2013). Finally, in terms of economics, the indirect and direct cost of medical care and lost productivity ranges from $ 5–42 billion every year in the U.S. (Dee & Colleagues, 2014).

Research has demonstrated the efficacy of behavioral-based weight-loss programs that focus on lifestyle changes. For Black American women, however, this is rarely the case. When they do participate and can be compared to White women, they tend to lose less weight and are less likely to sustain weight maintenance over an extended period (Rickel et al., 2011; Savoye et al., 2007; Tussing-Humphreys et al., 2013). Specially, Tussing-Humphreys et al. (2013) reported that Black American women are often less successful due to economic concerns, food access, a lack of safe places to exercise, poor mental health, experiences with discrimination, and weak social support systems. To combat this lack of engagement, researchers have identified culturally relevant intervention enhancements, such as social support or ethno-racially inspired meal plans and physical activities (Rickel et al., 2011; Tussing-Humphreys et al., 2013). Despite these programmatic adjustments Black American women continue to have higher rates of obesity and lower rates of weight loss maintenance. One key issue with adding cultural adaptations to interventions is that program designers tend to focus on one aspect of Black culture, like religion, when a multifaceted approach is needed to address the many barriers that Black American women face.

To date, there have been limited health promotion and behavioral-based programs that consider Black American women’s lived experiences or the social determinants of health that create barriers to adhering to diet and exercise recommendations. Perhaps less prevalent is research on health promotion programming that uses Black feminist theory and methodology to understand said barriers to and promoters of Black American women’s weight loss and weight maintenance. The following study uses Black feminist theory: the Superwoman Schema and Black feminist methods; qualitative focus groups operated by a team of Black female scientists to uncover what Black American women report as the greatest health problem they face and best practices in the development of health promotion programming.

Prior Studies of Health Promotion Programming

Health promotion programming for Black American women and girls, especially programming addressing overweight and obesity, remains an urgent, understudied area of research (Beech & Jernigan, 2014; Kumanyika et al., 2014; Whitt-Glover, 2014; Winkler et al., 2017). Recent studies in the field support a more integrated, holistic approach to such programming (Carson et al., 2014; Winkler et al., 2017). One emerging aspect of this approach is a questioning of weight and BMI score as predominant measures of success. BMI may not correlate with participants’ definitions of “health” (Cameron et al., 2018; Cassidy et al., 2018; Jernigan, 2019) and may contribute to their sense of medical language’s inscrutability (Jernigan, 2019). Narrowly focused obesity prevention may not be motivating in the absence of other health risks such as hypertension or diabetes, as found in a study of rural Black American girls (Cassidy et al., 2013). Existing literature also highlights the positive and protective effects of sedentary behavior during African American women’s leisure time, suggesting the need for subtle and strategic targeting of health interventions (Warren et al., 2018). The challenge of achieving significant weight- or BMI-related outcomes may prove demotivating to participants who fail to achieve early success (Joseph et al., 2015). Reinterpreting “health” may help to reframe and contextualize the often limited success, at least in terms of weight and BMI metrics, of health promotion studies among Black American women and girls (Winkler et al., 2017; White & Jago, 2012).

An integrated, holistic approach implies greater attention to the intersecting spheres of an individual’s life (Winkler et al., 2017) the specific and unique positioning at this intersection (Jernigan, 2019, 2020). Although cultural responsiveness and tailoring have long been a stated desideratum in health promotion research and programming, it has been the focus of limited studies (Burton et al., 2017) and remains a challenging category to theorize, operationalize, and evaluate (Barrera et al., 2013; Whitt-Glover et al., 2014). Such academic concerns need not cancel the value of cultural considerations in practice and in vernacular situations: Jernigan (2019; 2020), in a focus group of 15 adolescent Black girls, found her respondents discussing their health and health behaviors through an intersectional and socio-culturally aware lens. Burton et al. (2017) warns that individual-level change in health behaviors ought to be connected to changes at broader levels including the community. Social support, including family, may be a potential positive influence on health behaviors (Joseph et al., 2017), as well as a source of negative lessons and habits (Jernigan, 2020). Research that integrates the influence and context of the communities in which Black American women live is desirable. However, this approach may limit feasibility of randomized control trials (Burton et al., 2017).

Psychological factors are essential to an integrated, holistic view of health promotion. In the past, mental/emotional health has served as an exclusion criterion in research studies (Wang & Beydoun, 2007; Winkler et al., 2017) or has been minimized or overlooked by focusing only on a specific disorder (Jernigan et al., 2015), but the relationship between mental/emotional health and physical health is now well established (Harrington et al., 2010; Jernigan, 2020). There is also evidence that emotional health predicts changes in BMI z-scores among Black and Latino youth, and adolescent respondents support the importance of linking overeating to emotional challenges (Jernigan et al., 2015; Cassidy et al., 2018). Motivation is a particularly important psychological factor. In a study of 1110 educated Black American women who had lost weight through non-surgical means, Barnes and Kimbro (2012) found that weight-loss maintainers were more likely to initiate losing weight on their own than were respondents who regained weight; these maintainers were also more likely to incorporate durable behavioral changes, including changes to diet and physical activity, into their lifestyle. Fostering self-motivation and self-efficacy presents a key challenge to health promotion programming (Banerjee et al., 2018; Bruce et al., 2017), although a sample of 70 college students (83% women, 60% African American), and a sample of 338 overweight women (19% African American), report promising results for motivational interviewing (MI) approaches (Martens et al., 2012; West et al., 2011). Motivation must not be understood only as an individual quality, adjustable through interviewing, but as one that is socio-culturally conditioned by factors including beliefs, self-efficacy, and family dynamics (Williams & Yeo, 2016).

A Black feminist approach to health programming, resonant with that emerging in the mental health field (Jones & Harris, 2019; Jones & Pritchett-Johnson, 2018), may help to address some of the concerns raised in this literature: a need to (re)define success beyond weight, BMI, and the randomized controlled trial; a need to continue integrating mental health into our understanding of physical health; and a need to connect mental health, motivation, and physical health to broader socio-cultural contexts.

Why Black Feminist Theory and Methods

The idea that studies of Black American women should center their lived experiences is not new to gender or critical race studies. In fact, bell hooks (2000) argued that gender scholars who fail to center race miss the impact gendered racism, has on the lived experiences of Black women. Gendered racism consists of race-based prejudice, harassment, and violence experienced by Black American women (Szymanski & Stewart, 2010). These intersecting oppressive actions create chronic psychological stress which relates to negative mental health outcomes, such as depressive symptoms and anxiety (Jones et al., 2021; Lewis et al., 2017; Spates et al., 2020; Williams & Lewis, 2019). Davis (1983) added that while many women face gender oppression in the home, Black American women face household concerns alongside gender oppression in the workplace, a space they occupied long before the women’s liberation movement. As such, social issues that are specific to Black American women must be studied using Black feminist theory and Black feminist methodologies.

According to Black feminist theory, Black American womanhood involves navigating a racist, sexist society, which results in lived experiences that are distinct from the men of their race group and the White Americans of their sex category (Collins, 1990, 1999). A basic tenet of Collins’ theory is that a matrix of domination is in place that shapes the social realities of Black American women. The term matrix is used the connote the interconnected nature of social identifiers. It prompts social scientists to consider the fact that Black American women do not experience womanhood in some spaces and Black race in other spaces. They experience the oppressive factors that impact both groups, as well as unique factors that plague Black American women specifically, in all spaces. Collins’ framework also calls for the consideration of other social categories like class, body type, urbanicity, and religious affiliation when contextualizing phenomena like Black American women’s health and wellness. The use of this framework is a direct answer to the call from nutrition scientists who note health promotion programs have failed Black American women by solely focusing on one aspect of their culture (e.g., spirituality) when designing interventions.

To create health promotion programs that are successful in Black female populations, health scholars are tasked with examining questions like, “Why do existing curriculums have limited success in Black female samples?” and “How can programs be reworked to better serve Black American women?” A specific example comes from (Wade, 2018) who suggested that health promotion programs focus on how Black American women “do” (a dramaturgical performance of socially imposed norms by race, class, and gender) stress and food consumption. Our conceptual model for using BFT to inform health promotion programming is illustrated in Figures 1 below.

Figure1.

Conceptual model: using Black feminist theory and methods to inform health promotion programming

One way to contextualize the existing gradient in weight-loss and weight-management programs, using Black feminist theory, is through an analysis of the dramaturgical work Black American women “do” to convey strength (Beauboeuf-Lafontant, 2005) or to be superwomen (Woods-Giscombé, 2010). The strength mandate has followed Black American women from slavery to the present day. According to Hill (2009), Black American women’s health is compromised by the strength mandate because it leaves them feeling anxious about discussing mental and physical health troubles as that would involve some level of “weakness” and vulnerability. Beauboeuf-Lafontant (2005, p. 106) asserted that Black American women who subscribe to the Strong Black Woman script, “a social script that acknowledges them primarily when they tolerate the intolerable” are at greater risk for weight gain and obesity. The Strong Black Woman script has deleterious impacts on health because although Black American women appear to successfully wear many hats, they have been shown to use food to cope with stress. Diggins et al., (2015) provided empirical evidence of this theoretical stance as they found a significant relationship between perceived stress, contextual stress, and eating behaviors.

An understudied contributor to obesity in Black American women is the expectation of being a “Strong Black Woman” (SBW), which can negatively influence overall health. The Giscombé Superwoman Schema was developed to contextualize Black American women’s stress and coping using psychosocial aspects of race and gender to understand engagement in health risk behaviors. According to the Giscombé Superwoman Schema (2010), Black American women describe their gender role as an obligation to manifest strength, suppress emotions, resist being vulnerable or dependent, succeed despite limited resources, and help others. Guided by the Giscombé Superwoman Schema (2010), this project attempts to uncover the mechanisms through which Black American women struggle to mitigate diabetes risk. The major objective of this study is to analyze the strength mandate and its potential detriment to Black American women’s health. In this article, we use what is known about pressures to be superwomen to engage Black American women in conversations about health and health promotion programming.

The Current Study

The qualitative data used in this investigation comes from a larger study, “The Strong Black Woman Script and Obesity Risk - How to Navigate Your Reality.” The current study consisted of four focus groups conducted from February 2019 to February 2020. Inclusion criteria included being a Black female emerging adult ages 18–25 and a student of a large southern historically Black college/university (HBCU). Research assistants screened participants to ensure that they met the inclusion criteria. See table 1 for descriptive statistics on the sample.

Table 1.

Participant Demographics.

	N = 29
Father schooling
Less than high school	4
High school	10
Some college	8
Graduate school	4
Mother schooling
High school	2
Some college	14
Completed college	3
Graduate school	6
Attend religious services
Yes	18
No	11
Importance of religion
Extremely important	7
Very important	8
Pretty important	4
Little important	2
Moderately important	4
Not important	2
Urbanicity
Suburb	9
Urban	13
Rural	6
Body satisfaction
Extremely satisfied	2
Somewhat unsatisfied	1
Somewhat satisfied	14
Neither satisfied nor dissatisfied	6
Extremely dissatisfied	2

Key recruiting techniques and strategies such as flyer distribution calling for Black American women ages 18–25, email blasts, and snowball sampling, where interested participants or previous participants referred undergraduates to the Primary Investigators, were used to reach participants. Women received a $ 25.00 visa gift card and a meal during the focus group as an incentive for their participation. Respondents provided written consent prior to joining in the focus groups.

Focus groups are ideal for Black American women’s health research because they involve a group setting, promote social connection, and communication with historically understudied groups (see: Gerend & Pai, 2008; Weddington, 2014). Focus groups also create a space where women of similar life stages can be open and vulnerable. This research was approved by the Institutional Review Board of the sponsoring university.

To elicit responses, thirteen open-ended questions were developed by the principal investigators based on previous literature regarding the Superwomen Schema and diet and physical activity (see: Hargreaves et al., 2002; Woods-Giscombé, 2010). The goal of each focus group was to uncover connections between the Superwoman Schema, diet, and exercise patterns as well as aspects of being a Strong Black Woman that are unique to generation z, or individuals born after 1997 (Dimock, 2019). To enhance participation, the beginning portion of the focus group included reminding the participants of the purpose of the study, encouraging them to be respectful of each other, and to keep the discussion confidential. Participants also engaged in icebreakers to decrease study related anxieties.

According to Collins (1999) “Black women intellectuals are central to Black feminist thought for several reasons” one of which is our ability to empathize with and relate to psychosocial aspects of Black womanhood in ways that “those who live outside those structures cannot” (p. 35). Additionally, according to Lindsay-Dennis (2015) studies of Black American women and girls should use Black feminist–womanist approaches to ensure outcomes are culturally competent and do not add to the deficit centered narrative. This has been demonstrated empirically as studies of race and health behaviors have shown that researcher concordance is a key to engaging Black female participants (see Catania et al., 1996; Krysan & Couper, 2003; and Davis et al., 2009). To apply BFT and achieve race and gender concordance, we created a team of four Black female researchers and four Black female research assistants. Our team of geographically, academically, and generationally diverse Black American women worked together to ensure Black American women were centered and not used for comparison purposes. The research team also openly discussed the potential bias they might bring into the study and focused on using a script to ensure that participants responded to the same prompts.

Data Analysis

Qualitative data was audiotaped transcribed verbatim using Rev.com. Data were coded through semi-open coding by the two primary investigators and four graduate research assistants. Notes were taken during each focus group to aid in audiotaped transcriptions. Primary Investigators and research assistants debriefed after each focus group. Data were subsequently discussed for consensus and analyzed for emergent themes (Elliot, 2018).

Upon completion of data collection and analysis we engaged in member checking. This is a process by which findings are shared with participants to promote validity in qualitative research (Birt et al., 2016). Due to the disproportionate impact of 2020 stressors on Black American women (coronavirus pandemic and protests for racial equity) we reconvened the women to share our findings and discuss health and Black womanhood in a time of societal turmoil. This reconvening was not a part of our initial methodology which impacted our retention rates. We were only able to gather 14 of our initial participants to process our themes and codes as well as collect new data on the lived experiences of strong Black American women during 2020. We held three four-member checking sessions with three of the four lead investigators at each. Research assistants did not attend as stay at home orders required us to use zoom and did not want to overwhelm our participants.

Results

A total of 29 women participated in the four focus groups included in this study. Focus groups one and two had seven participants, focus group three had nine, and focus group four had five participants. Each focus group lasted for approximately 90 minutes. Details on the participants is available in table one below:

To contextualize our findings, it is important to understand existing health services on campus. The University health center offers a variety of services to address the health care needs of students. Health and wellness education programs promote healthy lifestyles among the college community. The University health center provides an opportunity for students to grow healthy foods in the community garden. Recreational and wellness and the campus walk challenge encourage students to develop healthy habits that will impact their short and long-term health. In addition, massage therapy and acupuncture offer alternative ways to address stress.

Themes regarding the greatest health-related challenges facing Black American women included (1) bringing Black American women’s mental health to the forefront, (2) obesity, and (3) relationships with Black men. When asked about how Black American women would want a health promotion program to be structured, themes revealed that it should be (1) fun and interactive, (2) informative and educational, (3) include group interaction, (4) be accessible, and (5) incentivize participation. Details on the women’s perspectives are presented in the analysis below. Themes and codes are summarized in Figure 2.

Figure 2.

Black women’s perspectives on health and health promotion programming codes and themes

Greatest Health-related Challenge Facing Black American women

Participants’ responses to, “What is the greatest health-related challenge facing Black American women today?” were summed up by two key themes, Bringing Black American Women’s Mental Health to the Forefront and Relationships with Black men. A third theme, Obesity was only mentioned by one focus group participant.

Bringing Black American Women’s Mental Health to the Forefront

Several participants cited mental health when asked about the greatest health-related concern facing Black women. In focus groups 3 and 4, participants spoke about the urgency to bring Black American women’s mental health concerns to the forefront. A major cost of social pressures to convey strength is that it comes with an obligation to always appear mentally solid. Our participants discussed how ending stigmas around mental health would promote other positive health-related changes:

The biggest concern, I think it would be like ending stigmas about mental health…I don’t know how to explain it, but maybe there should be more programs, more outreach to help Black American women end that stigma or just promote health overall, overall mental, and emotional and physical.

Participants also discussed how the pressure to be a strong Black woman, who masks her emotions, is unrealistic and an unfair standard for Black American women. This sentiment could reflect their ages (18–25) and status as emerging adults. According to Bethune (2019), when compared to all other generations, members of Generation Z are the least likely to report having good or excellent mental health. She argues that this is evidence of their greater comfort around discussing mental health-related concerns.

if we don’t live to …these in a way, then we’re not seen as a strong Black woman. Then we’re seen as less than or we’re not taken seriously because we’re not resilient, or we don’t love ourselves, or we’re supposed to say, ‘what mental health?’

Relationships with Black Men

In focus group four, there was somewhat of a consensus that relationships with Black men were at the center of Black American women ’s health-related concerns. Specifically, I feel like you can’t talk about Black American women unless you talk about Black men as well and how that plays into a lot of this. There are several potential causal mechanisms at play here. As Black American women, they have been trained to continue a legacy of unconditional support for Black American men (Richie, 2012). Part of their role as Strong Black women is to care for others more than self and to have a great sense of ethnic pride. This means both interpersonal relationships with specific Black American men, and experiences of vicarious racism (seeing Black American men experience discrimination in person or through technology), can take an emotional toll on Them. Some participants discussed relationship challenges with Black men that influenced their sense of self-worth.

I feel like men, men in general, Black men play a huge role in how we view ourselves and like wanting to be desired or desirable. Wanting to be, you know, like, I wanted to be valued, wanted to be wanted. You know?

Another participant described the perceived incongruence between standards some Black men have for Black American women and how Black American men show up in relationships.

I think I got older, and then she (her mother) was like, ‘your dad getting upset cause y ’all only ask me for stuff. You need to, you know, ask him as well for permission to do things. ’ And it’s interesting because I was like ‘oh, I didn’t think about him.’ That’s sad but like, I did not think about him. I just think it’s interesting. You know, Black women have been held to be all of this and more. If we did this (focus group) about the Black man, I can’t say that it would all be there.

In addition to expressing a perceived imbalance in gendered expectations, one participant described her desire to feel supported by Black men in general, I would say that Black men could help us out a little bit more. You know, I feel like a lot of times we play advocate for them when they don’t really do that for us. A final example comes from a participant who described a desire for more support from Black fathers.

I have mixed feelings, I have mixed feelings about that, but I think that fathers

should push more to (be involved in parenting).

Obesity.

Obesity came up as one of the greatest health-related concerns facing Black American women as well. Given black women’s obesity rates and growing concerns around wight, diabetes, food deserts, and access to places to exercise, it is not surprising that this theme emerged in our discussions. In focus group four, one participant recalled the implications of First Lady Obama’s nutrition initiative on her experience as a school-aged child.

It’s crazy cause when Michelle Obama, when she put all the healthy food in the schools and stuff, like trying to help, I was so mad. I was so mad. I remember I went to the school store, and they had fat free or low sugar pop tarts. Foolishness. I remember that. But it’s like, now I understand. I was so mad… but it’s like, as a child, I didn’t understand that. It didn’t make sense. I guess education then, right? Education. We didn’t really know why that was happening.

How Would Black American Women Want a Health Promotion Program to be Structured?

When asked how participants wanted a health program to be structured, the women reported the need for a holistic approach. They also desired a program that includes the following characteristics: accessible, incentivized participation, fun and interactive activities, informative and educational, and inclusive of group support. Finally, the women in our focus groups expressed a desire to have a program that focused on both physical and mental health.

Holistic Approach

Women in each focus group described a desire for a holistic approach to health promotion. They seemed to have a keen understanding of the interconnected nature of their weight and mental health. Women who desired a holistic program reported it should meet weekly and include a blend of cooking and physical activities such as yoga and dancing. Additionally, this program would have opportunities for participants to apply the knowledge they learned through hands-on applications such as cooking and gardening. As women with multifaceted barriers to weight loss and maintenance, this insight in particularly valuable to health promotion program designers.

… maybe like a class… like where you do like weekly classes, and then you go to the gym, and you have them write their goals or what they want to do. Like by the end of the four weeks or the six-week class, then they… like a competition…you check in and do you like how did you meet your goal within…blah blah. I think that would be cool. And I would do that as well.

Accessible.

The need for health promotion programs to be accessible came up in each focus group as well. The definition of accessible included geographically or via online tools. The idea that Black American women need accessible programs matches data on access to cars where 4.6% of White Americans lack access compared to a much larger 19% of Black Americans (Car Access, 2017) as well as time spent on social media where emerging adults and women are the greatest users (Pew Research Center, 2021).

Social Media: I think social media would be good because we ’re always on our phones, always on Instagram and stuff like that.

Geographic location: I live in a faraway dorm, and I know you struggle because I remember my freshman and sophomore year, you may not feel like what like the gym is a trip from my dorm… it’s like, when you go across campus, you’ve gotta factor in… mentally preparing yourself to make that walk, making the walk yourself. Then when you’re done, you time and got to make the walk always that way.

Accessible mental health support was discussed in focus group two, due to the overcrowding of the counseling center on campus. Our respondents reported a pressing need for mental health services based on seeing others express their suicidal thoughts and the need for mental health support on social media.

Incentivize Participation

The desire for incentives given during each program was expressed as a benefit to help women participating, so yeah, it’s like benefiting you and the person or like how you have given out gift cards. You know, something that can benefit us all. Using incentives has been shown to work as a tool to overcome medical distrust among Black American men (Graham et al., 2018) and to improve public health crises like smoking and obesity (Commonwealthfund.org, n.d.). Program designers should consider ways to use available resources to incentivize Black American women for their participation whenever possible.

Fun and Interactive

In focus group one, participants discussed how a program that was fun and interactive would increase their desire to participate. Specifically, they desired to have fun and be creative, but not steer away from the program goals or health-related objectives.

When we say fun and interactive, we don’t want to get distracted from the main goal which is awareness. Fun and interactive with people there, but if the fun and interaction bring awareness to get the job done, then it would be most effective.

Informative/Educational

In addition to fun and interactive activity, group members across each focus group expressed a desire to have professionals involved who were knowledgeable about healthy diets and exercise. They called for a nutritionist and physical trainer to provide them with support and educational information. The women in our focus groups expressed an aversion to formal education and more of a desire to be mentored. They sought a sense of empowerment which is compatible with the notion of the Strong Black Woman. They wanted tools that they could then take back to the community and use for themselves and their loved ones.

I think, like, I already want a mentorship program. I think mentorship really is helpful for any aspect of life. So, as they put pressure on you. But if there is like a nutritionist that was available to do some mentorship for Black women, even if it is in a setting like this or one on one, I’m not sure.

The women also talked about wanting to supplement education with interactive activities such as cooking classes that could teach them how to cook foods that were healthy and aided them in having a balanced diet. Other participants suggested having seminars and health fairs where women could express themselves in a judgment free community. These seminars and health fairs would provide them with the tools and knowledge on how to become better women and to make overall lifestyle changes.

Group Interaction

In each focus group, women expressed their desire to have a program that provided social support and group interaction. The use of groups settings is a well-established best practice in terms of haring health information with Black Americans. These groups would meet on a consistent basis and provide women with a safe and confidential space to discuss issues that affect Black American women such as weight, health, and discrimination.

I would probably do a program like this (referring to the focus group). Like, I like this. It made me comfortable. You know, and it just made me feel like I’m not alone under these circumstances…but it would just target a bunch of different issues and stuff that Black American women go through daily. You know, discrimination or like health, weight, stuff like that.

It was also suggested that these programs be open to men and provide a space where men and women could support each other. This is an idea health promotion program designers should take heed to considering our group of respondents made the connection between their relationships with Black American men and their personal health. So, stuff like this. I don’t feel like they should be excluded for just women. I think men should be a part of it…you know, have a look out. You know, you need somebody else looking out for you, too, right?

The women we met with described a space that was open to all Black American women but dispersed into small groups where women worked closely with strangers.

These small groups would provide a sense of anonymity and allow the women to express themselves free of judgment from people they know.

Oh, um, also like these (focus group settings) too because it’s better since we don’t know each other so we can kind of piggyback off each other instead of judging each other. Or be like, ‘no, it’s this way because…’ Like I’ve had friends who, I’ve tried to talk to and it’s like ‘Oh, I did this so you can too.’ But it’s like since I don ’t know y’all I can relate to what y’all are saying.

Participants discussed large networking events designed for Black women. This event would be organized for women to learn from each other’s experiences by sharing stories and motivating each other, which would ultimately lead to lifelong friendships. They also expressed the desire to have a mentor or partner that could support their mental and physical health.

Discussion

Summary of Findings

As we aim to contextualize Black American women’s health and center their lived experiences in the formation of effective health promotion programming, it is vital to hear from them directly. Findings from this qualitative study revealed that Black American women between the ages of 18–25 have a variety of concerns and challenges related to their overall health. Themes regarding their biggest concern for Black American women were bringing Black American women ‘s mental health to the forefront, obesity, and their relationship with Black men. To this end, they understand that effective interventions need to tackle stigma around mental health, include the men in their lives, and provide tools to fight obesity. Participants also expressed a strong desire for health promotion programs to include activities that were fun and engaging, educational, provided group support, had a holistic approach to health, and were accessible. The need to be incentivized for program participation was also mentioned in the focus groups. Findings further confirm the need to incorporate Black feminist theory in health promotion programs. Women in these focus groups discussed experiences that were unique to them and their desire to have programs that not only addressed their diet and physical activity but their mental health. In addition to other socio-cultural needs. These desired programmatic needs are in line with Collins’ theory matrix of domination. This theory encourages scholars to explore social categories that have a direct impact on health beyond diet and physical activity. Therefore, in working with this population, it is evident new approaches need to be taken to tackle the health-related cost of obesity and its related comorbidities.

Limitations

This study has two sample related limitations, namely, homogeneity and size. For one, the sample was limited to college students. Despite the important insights this population was able to provide, Black American women’s health concerns transcend social class and should be studied with community samples as well. The challenges Black American women face on college campuses (e.g., living with no kitchen, less access to cars, higher social stakes at the campus recreation center, and stress related to coursework) are unique and not always representative of the challenges nonstudent emerging adults face in the community (e.g., fear of crime and its impact on exercise, living in food deserts, parenting, stress related to working and/or seeking employment). For two, the strength of qualitative research (gaining context) is only possible with the use of small samples. There are undoubtedly health-related concerns and program preferences that were missed in this data collection process. The 28 women highlighted here provide a snapshot into Black American women ’s preferences and directions for future research but should not be viewed as a generalizable group who speak to Black American women’s experiences broadly.

Other limitations associated with focus group data collection include concerns around confidentiality, social desirability bias, and certain participants dominating the discussion this silencing other participants. First, as qualitative researchers, we cannot promise full confidentiality to participants who share their stories in group settings. Smith (1995) asserted that researchers can overcome this limitation by being transparent about confidentiality up front and encouraging respondents not to disclose truly private information. Our team followed that recommendation which aligns with our university IRB protocols as well. Second, Smithson (2000) suggested that focus groups can lead to biased data due to group members feeling obligated to provide socially acceptable answers. At the same time, she also asserted that focus groups can provide a space for members of minority groups to highlight and define their social reality. Our stance is that our participants provided valuable responses that add to the definition of Black women’s social reality. We believe that outweighs potential concerns around social desirability. Third, Queiros et al. (2017) asserted that a key limitation of focus group data collection is the possibility that some members will not engage in the discussion thus leading to nonrepresentative findings. We encouraged each participant to share their opinions throughout the process. The fact remains, however, that there were standout participants. This appears to be a true limitation of focus group data collection.

Future Directions and Practical Applications

Limitations aside, this study contributes to the health and inequalities literature in several ways. First, it centers race and gender, which Bowleg (2012) described as “both timely and overdue” (2012, p. 1268). Second, this study sheds light on health concerns that Black American women themselves consider pressing. Specifically, bringing Black American women’s mental health to the forefront, obesity, and relationships with Black men. This last element of our findings complements the work of Felder et al. (2019), who highlight the influence of Black college women on the health and health behaviors of Black college men. Third, and finally, this study showed that Black American women desire tailored health promotion programs that are holistic, accessible, fun, and interactive, provide group support, center mental health and are educational. As stated, the integration of a holistic approach to health interventions implies greater attention to the intersecting spheres of an individual’s life (Winkler et al., 2017) (Jernigan, 2019, 2020). Developing programs that are accessible, fun, and holistic incorporate the voices of Black American women in their programmatic needs. Which can further lead to more intervention development and sustained behavioral change.

Black American women play a unique role in the tapestry of our country. Hence, the incorporation of the Black feminist theory and methodology provided a new approach to addressing the need of Black American women as it relates to their health. Black American women adapt to gender and race-related obstacles by conveying strength. The act of conveying strength may be detrimental to their health in the context of suppressing their emotions, resisting displays of vulnerability, and prioritizing care for others over self-care (Woods-Giscombé et al., 2019). Consequently, when they expressed the need to bring Black American women’s mental health to the forefront, this desire was not surprising. When compared to their white counterparts, Black Americans are underserved by mental health professionals. Only 8.6% of Black adults seek professional mental health support, while a larger 16.6% of white adults do seek some form of formal support for their mental health (Substance Abuse and Mental Health Services Administration (SAMSHA), 2015). Black American women have shared that the traits associated with the Superwoman Schema influence the ways in which they utilize mental health services (Woods-Giscombé et al., 2016).

Black Americans are more likely to seek support from informal groups such as friends, church groups, and family. Therefore, the incorporation and desire for group support should not just be considered a “culturally salient approach,” but a critical approach to designing health promotion programs for Black women. For Black women, group support does not just provide motivation but is a form of mental health support. The group setting also feeds Black American women’s desire to care for others. Group style health promotion programs could also aid in improving the health of Black women, by providing them with a safe place to be vulnerable and unmask their strength.

In the series of focus groups, it was also suggested that programs involving Black American women provide formal support. The formal support identified was to come from experts such as personal trainers, nutritionists, dietitians, and mental health providers. Interestingly, the women wanted to be supported to empower themselves and described these professionals as providing more of a mentorship role in programmatic spaces. The women also preferred hands-on nutrition classes, such as cooking demonstrations and gardening activities. The women wanted to have fun, not feel like they were “working out” but like they were celebrating, Zumba and dancing came up frequently.

Additionally, our participants recommended that these classes be in a designated space such as their dorms or universal meeting space where only women in the program could come and participate. To them, it was important to establish a sisterhood and maintain privacy during exercise time. Such designated spaces would advance the suggestion of Rodney et al. (2020) that public health programming ought to be built into the institutional fabric of HBCUs.

As practitioners seek to address the needs of Black American women, they should consider providing tools that not only support dietary and physical activity changes but also mental health. Providing access to holistic programming can aid in effective and sustained behavioral change. Additionally, they should consider ways to connect patients who have seminary concerns about their health to facilitate group support in programs and interventions that focus on health. Future researchers should also consider investigating if these, health promotion needs are similar or different for Black American women who attend a predominantly white institution. Since these women have different challenges and opportunities, their needs for a holistic health intervention may be different. This is also applicable to community women. Understanding the unique needs of Black American women ages 18–25 from different walks of life can further aid in the development of health promotion programs and inform practitioners and researchers.

Understanding the health promotion needs for Black American women are essential to tackling the growing obesity, chronic disease, and mental health concerns in this population. Black American women face some of the greatest challenges nationally related to obesity and physical inactivity. Therefore, verbalizing Black American women’s needs related to health promotion can increase awareness within community base settings, and aid as an additional support system for Black women. The connection of the Black feminist theory to studies of Black American women’s health should continue to be explored to understand their unique needs and to create health promotion interventions tailored for them. Through the incorporation of holistic approaches that include lifestyle and cultural factors, researchers and healthcare workers can work to improve health behaviors, outcomes, and promote the sustainability of health promotion programs designed for Black women.

Biographies

Author Biographies

Dr. Jeannette Wade is an Assistant Professor of Sociology at NC A&T State University. She uses black feminist theory and methods to study health related social problems. Her main interest is uncovering and addressing psychosocial determinants of Black women’s health outcomes.

Dr. Ramine Alexander is an Assistant Professor of Food and Nutritional Sciences at NC A&T State University. Her research interests include engaging medically underserved areas in community-based participatory research (CBPR) to build community capacity and improve nutrition-related outcomes. She focuses on lifestyle risk factors (i.e., diet and physical activity) that have direct relevance to obesity and chronic disease prevention.

Dr. Cheryl L. Woods Giscombé is the Associate Dean of the PhD Division & Program and Levine Family Distinguished Scholar in Quality of Life, Health Promotion, and Wellness. Her program of research focuses on understanding and reducing stress-related health disparities among African Americans. Her research incorporates sociohistorical and biopsychosocial perspectives to investigate how stress and coping strategies contribute to stress-related psychological and physical health outcomes.

Dr. Daniel L. Keegan (A&T) is an MSW candidate with interests in mental health, substance use, psychotherapy, and the arts. Before social work, he was a Shakespeare professor.

Dr. Sharon Parker works as an Associate Professor in the Department of Social Work and Sociology at NC A&T State University. She is a health disparities researcher focused on the sexual health of African Americans. Her work examines the interconnectedness of HIV, concurrent sexual relationships, substance abuse, intimate partner violence, and gender inequality among criminal justice involved individuals and other high-risk populations.

Katia Jackson is a recent graduate of NC A&T State University with a bachelor’s degree in Psychology. She is currently a member of the inaugural cohort of Health Equity Scholars at Brown University. Her research interests include racial and ethnic health disparities, mental health barriers in under-represented communities, Black women’s health, nutrition, and obesity risk.

Jasmine Gibbs is a recent graduate of NC A&T State University with a bachelor’s degree in Sociology with a minor in English. Jasmine is now pursuing her master’s degree in Sociology at the University of North Carolina Greensboro. Her primary research interests include mental health, race, gender, and biracial identity.

Asha McElroy is a recent graduate of NC A&T State University with a bachelor’s degree in Food and Nutritional Sciences. Asha is now pursuing a master’s degree in Public Health with a concentration in Dietetics. Additionally, she works as a Program Coordinator for the University of Michigan Sustainable Food Systems Initiative.

JaVae Ferguson is a recent graduate of NC A&T State University with a bachelor’s degree in food and Nutritional Sciences. Her primary interests are community nutrition and health education.