Abstract
African American (AA) women have the highest rate of obesity in the United States. To date, there are mixed findings on AA women’s perception on obesity and their perceived changes in health behaviors over time that may have contributed to obesity. Therefore, the aims of this current qualitative descriptive study were to explore: 1) AA women’s perception on obesity and perceived changes in health behaviors related to obesity through their reflection on life; 2) AA women’s perceived facilitators and barriers to maintaining healthy behaviors; and 3) AA women’s suggestions for future health promotion programs to manage obesity. Semi-structured interviews with open-ended questions were conducted with 21 AA women. Luborsky’s method for thematic analysis was used to analyze data. Three main themes with subthemes were identified. First main theme was the AA culture that served as a facilitator and barrier to maintaining healthy lifestyle from childhood to young adulthood. Second main theme was gradual changes in their healthy lifestyle due to social and physical environment from young adulthood to middle adulthood. Third main theme was AA women’s various suggestions for future health promotion programs. This study found obesity to be a multifactorial phenomenon that is a result of complex interaction of culture, environment, and social networks. Therefore, clinicians need to address the issue of obesity from a holistic perspective for AA women to actively engage with their primary health care. Future health promotion programs should incorporate culturally tailored lifestyle components and increase knowledge on healthy lifestyle against obesity through community-based programs.
Keywords: African-American, Culture, Health Promotion, Obesity, Women’s Health
Introduction
The prevalence of obesity continues to increase annually and has become an epidemic in the United States (US) (Hruby & Hu, 2015). An estimated 40% of adults in the US are currently considered to be obese (Hruby & Hu, 2015). Obesity has critical health implications as it is a major risk factor for hypertension, diabetes, and hypercholesterolemia, all of which are associated with a higher risk of developing coronary heart disease, stroke, and cancer (Hammond & Levine, 2010). Among men, racial and ethnic groups do not differ significantly in the prevalence of obesity (Abraham et al., 2013). However, among women, African American (AA) women have the highest rate of obesity in the US compared with women in other racial ethnic groups (Abraham et al., 2013). For example, African American women are 70% more likely to be obese than Non-Hispanic White women (Agyemang & Powell-Wiley, 2013). As a result, AA women disproportionately suffer from obesity-related health problems which may lead to poor health outcomes such as increased risk of disability and mortality (Williams et al., 2015).
Perception of obesity refers to a way of understanding and interpreting obesity that determines an individual’s behavior related to health promotion (Visscher et al., 2017). Despite significant efforts in obesity prevention and management, many women do not perceive obesity as a significant health issue which often results in poor health behaviors (Mawardi et al., 2019). Such obesity perception is more evident in the AA women community (Awad et al., 2015; Davidson & Knafl, 2006; Fujioka et al., 2009). While some AA women expressed concerned towards their body shape (Awad et al., 2015), a number of AA women viewed being “thick and curvy” as a cultural symbol of beauty, good health, and high socioeconomic status (Fujioka et al., 2009). In other words, these AA women did not perceive the severity of obesity and its related health consequences (Davidson & Knafl, 2006). Such obesity perception remains as a significant barrier among AA women in obesity prevention and management that requires further investigation.
A substantial amount of evidence supports the association between lifestyle behaviors (i.e. consumption of high-caloric food, sedentary lifestyle) and development of obesity in AA women (Affenito et al., 2012). In addition, chronic disease comorbidities such as hypothyroidism or osteoarthritis may further contribute to obesity because the associated pain and fatigue can limit an individual’s physical activity (King et al., 2013; O’Connor, 2019; Sanyal & Raychaudhuri, 2016). Social determinants of health such as financial strain and limited access to healthy food or facilities for exercise can also contribute to obesity (Casagrande et al., 2009; López-Hernández et al., 2020). To date, many studies have used cross-sectional design where data on obesity and the obesity-related risk factors are captured and analyzed only at a single point in time (Pawlak & Colby, 2009; Shuttlesworth & Zotter, 2011). For example, cross-sectional studies have found that AA women are at high risk for obesity due to their lack of physical activity and disordered eating behavior such as binge eating (Joseph et al., 2015; Pawlak & Colby, 2009; Shuttlesworth & Zotter, 2011). Yet, there is a lack of understanding in how AA women’s health behaviors may have changed over time that contributed to obesity. This knowledge will help identify vulnerable time points that place AA women at high risk for obesity and assist in future development and implementation of timely intervention to manage obesity among AA women.
Reflection is a deliberate process of thinking back into past situation, experience, or behavior (Asselin et al., 2013). It has been widely used especially in professional practice that leads to critical insights into past behaviors and future behavioral changes (Asselin et al., 2013). Similarly, it is critical that we explore AA women’s perceived changes in their health behaviors that led to obesity through reflection of their lives from childhood to adulthood. This will allow AA women to gain better insights into understanding their perceived facilitators and barriers to a healthy lifestyle over time. Identification of perceived facilitators and barriers to a healthy lifestyle can provide unique opportunities for future research to guide the development of future obesity interventions that are culturally relevant to AA women, thereby improving their overall health and well-being.
Thus, the purposes of the current study were to explore: 1) AA women’s perception on obesity and perceived changes in health behaviors leading to obesity through reflection on life; 2) AA women’s perceived facilitators and barriers to a healthy lifestyle over time; and 3) AA women’s suggestions for health promotion programs.
Methods
Research Design.
This is a qualitative descriptive study. We invited 21 AA women who participated in our parent quantitative study to understand the relationship among obesity-related behaviors, functions and structures of social networks, and neighborhood environment to the current study (Jung et al., 2021).
Participants and Recruitment Strategies.
We recruited participants from urban areas in the Northeast in the US, using flyers posted in AA churches, weekly church newsletters, and meetings with an academic community partnership group (Yale University’s Clinical Translational Science Awards Program [CTSA]). Participant recruitment and the community engagement process for the study were described in detail elsewhere (Jung et al., 2021). Eligibility criteria for the current study included: (1) women over 21 years of age; (2) self-reported Black or African American; and (3) able to speak and read in English. In the parent study, we excluded individuals who reported disabilities or acute/terminal conditions that affect daily physical activity (e.g., terminal cancer, dialysis) and active psychiatric illnesses in the past 6 months (Jung et al., 2021). We invited AA women who participated in the parent study and met the eligibility criteria to this qualitative study based on the range of age and their perceived health status. Participants received a $40 gift card for their participation in the study.
Ethical Considerations.
All study protocols were reviewed and approved by the Yale University’s Institutional Review Board prior to the study implementation. We obtained written informed consent from participants for the current qualitative study.
Data Collection.
Interviews were conducted in each participant’s home or church depending on their preference. The interviewer used an open-ended, semi-structured interview guide (Table 1). The interviewer took field notes on the interview context and observations not reflected in the recording. Interviews were digitally recorded and transcribed verbatim. We obtained participants’ data on socio-demographics, perceived health status, and body mass index (BMI) from the parent study.
Data Analysis.
Data collection and data analysis were conducted simultaneously with modification of the interview schedule and probes as new patterns or directions emerge from the data. The interviews were de-identified and double-transcribed by two researchers (SN, SM) independently. The transcribed documents were audited by each researcher to correct any errors or inconsistencies and to ensure that all data were transcribed verbatim. The transcribed interviews were then entered into Atlas.ti (Scientific Software Development GmbH, Berlin, Germany), a qualitative software program. Luborsky’s method for thematic analysis of qualitative data was selected to analyze the transcribed data obtained from the semi-structured interviews (Luborski, 1994).
First, each researcher (SN, SM) read the transcribed documents to become acquainted with the content and provide insights before the coding process. These preliminary topics were recorded in phrases that could later be used as code words or descriptive labels. Margin notes were taken during the reading to summarize main ideas, and each note was compared for similarity and differences among the researchers. Initially, each transcript was coded via line-by-line coding by the researchers (SN, SM). Then, the researchers (SN, SM, HK, RW) gathered during research team meetings for discussion of codes and revised codes accordingly until consensus was met. A visual map of related codes was developed where subthemes and main themes were generated using the network function in Atlas.ti. We identified main themes by seeking statements that occurred repeatedly and frequently across participant interviews. Subthemes were identified that explain and support the main themes. The main themes and subthemes were reviewed several times during research team meetings to reach consensus in order to make sure they adequately capture the data. Data collection and analysis continued until data saturation was reached which is when the researchers (SN, SM) cannot identify new emerging themes in the collected data (Bowers, 1990; Luborski, 1994). Throughout data collection and analysis, reflexive journaling and research memos were recorded which informed the interpretation of findings and contributed to the audit trail. Trustworthiness was enhanced by a multi-member qualitative research team (SN, SM, HK, RW) who conducted data analysis, review of findings through “member checking,” and a detailed audit trail throughout the study (Bowers, 1990; Luborski, 1994; Sandelowski, 1993).
Results
The mean age of our participants was 51.7 years (standard deviation [SD] 12.74). The majority of participants completed some college (N=8, 40%) or graduate school (N=6, 35%). The mean BMI was 33.1 kg/m2 (SD 5.69) with 38.1% being overweight (BMI 25–30 kg/m2), and 61.9% being obese (BMI ≥30 kg/m2). For perceived health status, 38.1% reported very good, 14.3% reported good, 43% reported fair, and 4.8% reported poor health status. Table 2 presents the characteristics of the participants.
We identified three main themes with relevant subthemes from the individual interviews. Table 3 presents the main themes and the relevant subthemes identified in our study.
Theme 1. Cultural facilitators and barriers to a healthy lifestyle from childhood to young adulthood
AA women described their childhood experiences around eating and physical activity growing up in an AA family and how their ethnic culture played the roles of both facilitators and barriers to their health behaviors and overall well-being.
Subtheme 1A. Healthy eating during childhood from family who practiced healthy eating
When asked to describe their childhood experiences around eating, many mentioned healthy eating because their families practiced healthy eating through raising their own vegetables or owning a house garden.
Participant A (age 55) “I really miss growing my own vegetables. […] There were times when we would butcher a pig and make our own sausages and everything. […] We had nothing but fresh food.”
Similarly, some participants shared that their mothers had a garden where they planted various types of vegetables and raised chickens. This has led them to have access to fresh food all the time throughout childhood.
Participant B (age 83) “Well my mother had a garden. We had chickens. […] She’d plant different vegetables, beans and peas and collards and cabbage and tomatoes.”
Participant D (age 63) “We had our own gardens. […] We raised our own like chickens, um turkeys. […] So growing up there were a lot of vegetables available.”
One participant who did not raise her own vegetables described going to farmer’s market to buy fresh food or to a farm to pick fresh food.
Participant E (age 63) “The farmer’s market, and so we did a lot of fresh food. Cause I remember we always used to go to the farms and pick stuff.”
These participants referred to their childhood practices of healthy eating through raising their own vegetables and/or owning a garden and explained how AA family traditions contributed to their health behaviors and well-being throughout their childhood.
Subtheme 1B. Togetherness: weekend and holiday overeating patterns with family members
While practicing healthy eating most of the time in early life, many participants shared the AA’s cultural value of family togetherness. “Family togetherness” refers to family members gathering and spending time together during weekends and holidays. This is when they would eat home-cooked meals to their fullest. “Eating to the fullest” was another term shared by the participants which refers to overeating of food as a cultural way of appreciating what had been prepared by their family members. For example, some participants shared how they used to have a family tradition of holding big family meals on weekend and holidays.
Participant I (age 42) “We had big family meals every Sunday at my grandparents’ house.”
Participant J (age 40) “My grandmother’s place was always the central hub of where everybody went to eat on like every Sunday. […] I’d have a plate umm holidays, everybody has at least two plates cause you gotta taste everything.”
In addition, other participants shared how their mothers and grandmothers would make them eat whatever was served on their plate and not letting them leave the table if they did not finish the served food, thereby often resulting in poor portion control.
Participant L (age 56) “At the dinner table, we wouldn’t be able to get up from the table until we ate everything that was on our plates.”
Participant M (age 60) “You eat to the fullest. You eat what you want, get full and you can leave the table. So, and I thought that’s the way everybody ate.”
Participants referred to their AA culturally-embedded practice of “family togetherness” and “eating to the fullest” especially for weekend and holiday meals. This further explains how AA family culture played a role in their eating patterns throughout childhood.
Subtheme 1C. An active and skinny child
When asked about their physical activity patterns, majority of participants recalled being a physically active and skinny child throughout their childhood and young adulthood. For example, they stayed physically active by getting involved in various activities at school or in daily life through activities such as riding bicycles and walking.
Participant C (age 33) “We had to have, we practiced every single day after school. […] It was just like nonstop activities.”
Participant G (age 51) “We walked every evening you know as a family so that was just normal for us.”
Subtheme 1D. Living with working parents and living independently in young adulthood
When the participants transitioned into young adulthood, their eating patterns began to change as their parents became busy working or as they began to live independently. For participants whose parents were busy working, they reflected their meals consisting of quick, processed food.
Participant N (age 48) “A lot of junkie food cuz at that time that’s when my parents was working.”
For participants who began to work and live independently outside home, their eating patterns began to change.
Participant F (age 62) “I was 16 […] I would get something at Wendy’s or McDonald’s”
In contrast to healthy eating during childhood, their eating patterns began to change based on convenient food choice options.
Theme 2. Change in lifestyle from young adulthood to middle adulthood: the influence of social-physical environment
Within this theme, AA women described changes in their eating patterns and physical activity as they entered middle adulthood and how their social-physical environment affected their health behaviors.
Subtheme 2A. Quick and grab-and-go food for convenience
As participants entered middle adulthood, their lives became busier trying to manage family and work life, and their food choices were made based on convenience.
Participant F (age 62) “For lunch, maybe when I got off of work I didn’t feel like cooking”
Participant M (age 60) “I would come home from lunch and I will go on the corner, and they knew what I wanted, hamburger and fries.”
The participants shared that they were either exhausted from long working hours or that when they got off late from night shift that they tended to grab whatever is available around the corner.
Subtheme 2B. Food craving and constant eating from stress
Some AA women reported feeling stressed and overwhelmed by countless responsibilities and difficult social situations. As a result, they sought to relieve stress by eating high caloric food. In addition, they were craving food even though they were not necessarily hungry, which eventually led to significant weight gain and health problems.
Participant D (age 63) “Um, it could have been comfort food. Just eating to be eating. Because I went through a lot of stressful situations. I’ve been through two marriages and they both were stressful.”
Another participant reported that she used to refrain from eating past six in the afternoon. However, she became so stressed from work that she began to eat whenever she wanted to eat regardless of the time.
Participant G (age 51) “I don’t care, 6 o clock was my cutoff. But now I eat whenever. 8 o clock, 9 o clock, 10 o clock. Whenever I feel like eating.”
Subtheme 2C. Influences of social networks
Both positive and negative influences of social networks on health behaviors have been identified among the participants. Majority of the participants stated that they did not pay much attention in managing obesity until they witnessed obesity-related health problems from friends and family. This experience has led them to understand the importance of adopting healthy behaviors. In contrast, other participants had a different experience in which they began to engage in poor eating habits from being with a friend who constantly eats food and snacks.
Similarly, participants discussed their experience of gaining significant weight due to the interaction with their close friend who is also obese.
Participant G (age 51) “I started eating, I have a friend that’s really heavy. And I work with her, and it’s not her fault but she eats constantly. So I sit there and I eat constantly because she’s eating.”
For most of the participants, they witnessed the obesity-related health problems of their friends and family such as diabetes and heart failure as they entered middle adulthood and directly experienced the severity of obesity. Such jarring experiences awakened participants and led them to realize the importance of engaging in healthy behaviors to manage obesity.
Participant F (age 62) “But as I’ve gotten older […] I see people with all kinds of problems. Diabetes and this and that, cholesterol problems.”
Participant H (age 49) “Cause I think for some people, they get fit because they had a stroke or they had some type of health related jarring experience whether it be theirs or their own.”
Other participants shared how their health behaviors, specifically eating patterns, have changed as a result of their current efforts to stay healthy and to avoid obesity-related health problems.
Participant Q (age 62) “Um, as I started getting older, a lot of change behind trying to, you know, pretty much the diet was the same, except now you bake, boil, broil everything.”
Participant E (age 63) “I had to calm down my eating[…] I did cut out all those things, like I stopped eating a lot of bread. Um, a lot of sugars, a lot of sweets […].”
As a result, the social network seems to play a critical role in shaping health behaviors in AA women either positively or negatively.
Subtheme 2D. Sedentary work situation
AA women expressed that they were aware of the need to adopt a healthy lifestyle but reported great challenges due to their current work environments. Their work has been mostly sedentary with low demands of physical job, which may have contributed to obesity.
Participant G (age 51) “And now I sit at a desk and we sit at a computer all day and we eat. […] And I think it’s like I said lack of exercise now. I used to run faithfully, and now I do nothing as far as exercise.”
Participant M (age 60) “But then as you get older, there’s not too much you can be active about, […] you’re working.”
Both participants expressed concerns about lack of exercise and significant weight gain by sharing that this issue has been getting worse as they become older.
Subtheme 2E. Busy lifestyle
Some participants shared that they have little time for themselves due to their busy lifestyle from working, doing household chores, taking care of children, and being involved in church activities. They would often put physical activity to be their least priority.
Participant M (age 60) “You’re working. And you’re tired. So you come home, and you’re not thinking about a whole lot of other things to do.”
Participant I (age 42) “I didn’t make the workout the priority so I cause I would have tried to maybe rearrange my some things in my schedule take some things off.”
The subthemes indicate changes in the participants’ lifestyle as they enter middle adulthood along with the influence of their current social environments, including social network, stress, and busy lifestyle, and their physical environment, including easy access to quick, grab-and-go food and sedentary work situation contribute to their unhealthy food choices.
Theme 3. Suggestions for health promotion programs
At the end of the interview, all participants made suggestions on health programs that may be appropriate for AA cultural beliefs, values, and current living situation.
Subtheme 3A. Knowledge and education classes on healthy eating and cooking
Many participants did not have sufficient knowledge about how to cook healthy food or what healthy food options are available. For example, a participant did not know about kale until she saw a co-worker eat kale for lunch and tried it for the first time. Then, she began to be more open to other food options.
Participant R (age 53) “This was the first time I tried kale. And I was like, oh this is pretty good. So just smaller portions like she said, and and trying to, you know, be more active”
Many participants stated that AA women were not adventurous with their food choices because they did not have enough knowledge about healthy food options and were not exposed to other food choices other than those of their families and AA community. Participants recognized that the main issue was their lack of knowledge. As a result, they suggested an education class on portion control, benefits of healthy eating, exercise, and healthy cooking recipes.
Participant G (age 51) “Teaching them how to exercise, teaching them portion control.”
Participant Q (age 62) “The biggest thing is, knowledge, what I’ve noticed is there’s knowledge of the benefits of a certain vegetable […] the interactions of the foods that they’re eating.”
Participant M (age 60) “It would help to show them how to cook it. “
Subtheme 3B. Fun physical activity program
Many participants reported a lack of motivation to lose weight. A particular participant shared that the lack of motivation may come from her cultural beliefs where being thick and curvy has been viewed as optimal for women in the AA culture. Even though she feels the need to manage weight, she lacks motivation because she wants to maintain her thick and curvy body shape.
Participant H (age 49) “I think it’s lack of commitment.”
Participant J (age 40) “So I don’t want to change my diet per se, I don’t want to umm get crazy with exercise because I don’t want to lose it everywhere else.”
Therefore, participants suggested a fun physical activity program that would make them more engaged. Many considered themselves to be social and preferred physical activity programs to be done in a group setting. This would allow them to connect and share their personal concerns with others who may further motivate them to engage in physical activity.
Participant H (age 49) “I am a group person. I like group activities. I like doing stuff with people. That’s an additional motivator.”
A participant raised an AA culture-specific concern of getting her hair messed up after a rigorous physical activity. She suggested a partnership with a hair salon, which would allow other AA women with similar concerns to be more open to physical activity.
Participant J (age 40) “Maybe you have a partnership with a hair salon so that they get a discount so that they know, okay if I sweat it out it’s okay because I can go on Saturday and they’re gonna take care of it.”
Discussion
This study examined AA women’s perception on obesity and perceived changes in health behaviors leading to obesity through their reflection from childhood to adulthood. Our findings also offer insights for understanding AA women’s perceived facilitators and barriers to maintaining healthy behaviors against obesity and their suggestions for future health promotion programs.
One of the main study findings was that AA culture served as both facilitator and barrier to maintaining healthy lifestyle, from childhood to young adulthood, and to later life experiences. The present study identified commonly used terms such as “eating to the fullest” and “family togetherness”. During childhood, the participants’ food choices were mostly healthy because their parents grew own vegetables in family gardens and raised live stock, or their family used to go to farmer’s market to get fresh ingredients. Such findings extend previous research where AA’s eating patterns were mostly dependent on the passing of family traditions of cooking and food preparation (Bramble et al., 2009). On holidays and weekends, the participants would gather at their grandmother’s house and have a big family meal which is an important family tradition in the AA culture. This is when the participant’s parents would often encourage them to enjoy food by eating more and finishing what was served on their plates, resulting in poor portion control. While AA women practiced healthy eating during normal days, they engaged in overeating on holidays and weekends which emphasized AA’s cultural value on family eating and food preparation. Such finding supports previous research where family eating is perceived as a key to family cohesiveness in the AA community (Jarrett et al., 2016).
As they entered into adulthood, they started to gain weight and gradually encountered the issue of obesity. These participants shared common challenges to engaging in healthy behaviors related to busy lifestyles that include busy work schedule, taking care of family, and doing household chores. This may be due to AA women’s high priority in managing multiple jobs and household to take care of family, also known as the Black feminist theory of the Strong Black Woman or Superwoman schema. For example, in the AA community, “The Strong Black Woman or Superwoman” refers to the idea of being a strong, independent, perfect, emotionless, and sacrificing woman who is expected to fulfill countless domestic and social demands (Woods-Giscombé, 2010). This “Superwoman” role has been highlighted as a phenomenon that creates stress (Woods-Giscombé, 2010). As a result of stress, they often engaged in unhealthy stress coping strategies such as food craving and constant eating which may have further contributed to their weight gain (Woods-Giscombé, 2010).
Some participants pointed out challenges associated with lack of knowledge and motivation. This adds to previous study findings where AAs reported lack of time, motivation, and knowledge as personal barriers to healthy eating and physical activity (Bopp et al., 2007; Joseph et al., 2015). Despite such challenges, participants indicated that they are currently trying or hope to stay healthy after encountering many jarring health experiences of friends, family members, and colleagues related to unmanaged obesity. Culturally-tailored physical activity intervention has shown effectiveness for specific ethnic/racial group, leading to significant improvements in their cognitive, behavioral processes, impact of environmental factors on physical activity, and self-efficacy (Pekmezi et al., 2009). Therefore, we asked them to suggest ideas for future health promotion programs that could be culturally-tailored to the AA community at large.
The suggestions from our participants have some implications for future health promotion program development and research. First, they suggested an education class on healthy eating and cooking because many AA women may not be adventurous or knowledgeable with healthy food choices. An effective education class may include modifying current recipes for their favorite food to be healthy. AA women shared the reluctance of trying new food, and this modification approach will reduce the burden on the participants. For example, the class may discuss options of steaming and boiling rather than frying, scrubbing vegetables rather than peeling them, using healthy cooking oils, using no-salt butter, and trimming the fat from meat. Second, the participants suggested a fun group physical activity program that incorporates music and dance because AA women tend to be socially outgoing and would like to get support from their peers. Previous research shows that fun, culturally relevant, and age appropriate physical activities for AA women significantly increased the time spent in physical activity as well as their self-esteem (Peterson & Cheng, 2011). Through a fun group physical activity program, AA women can feel more motivated to actively engage in physical activity. Within the group setting, they can obtain social support, which has been identified by AA women as an important factor in promoting an active lifestyle (Peterson & Cheng, 2011). While they want to engage in fun group physical activity, AA women shared their view of being thick and curvy as a cultural value of beauty (Fujioka et al., 2009) and did not want to lose weight in every part of their body. In addition, they were concerned about getting their hair messy after engaging in physical activity. This highlights the need for future health promotion programs to be culturally tailored to meet the specific needs of AA women. Overall, our study found obesity to be a multifactorial phenomenon that is a result of complex interactions of culture, environment, and social networks. Therefore, it is critical that clinicians address the issue of obesity from a holistic perspective to allow for AA women to actively engage with their primary health care. In addition, clinicians need to understand the individualized needs of promoting healthy lifestyle and managing obesity in AA women. Such approach can further assist in the development of future health promotion programs that are tailored and individualized to achieve optimal health outcomes (Hensley, 2018).
There are several limitations to this study. First, the participants were recruited from one geographical area, a northeast urban community. Thus, study findings would have been different from findings in rural areas. Future research that includes both rural and urban areas and compare and contrast their health behaviors would increase our understanding of obesity-related health behaviors and the environments that impact those behaviors. Second, majority of the participants received college education or higher which may have influenced their perception on obesity and health behaviors (Margolis, 2013). Future research needs to include AA women with various education levels to get a comprehensive understanding of their perception on obesity. Third, we focused on eating patterns and physical activity as main health behaviors. Future research that includes other lifestyle choices that may be associated with obesity risk, such as smoking, alcohol consumption, sleep and seeking social support, would be beneficial because they are important lifestyle contributors to obesity and may serve as targets for future health promotion programs (Shigeta et al., 2001; Van Cauter et al., 2008). Lastly, the BMI of our participants were overweight or obese categories. As a result, findings from AA women with normal or underweight BMIs may be different. Future research should examine health behaviors in AA women who have underweight or normal BMIs and how they might be different from the current study’s findings.
Implications for future practice.
Our study findings presented perceived facilitators and barriers to healthy lifestyle among AA women and their suggestions for health promotion programs. The significant role that culture plays in AA community may be an effective strategy to promote health behaviors. AA women suggested future health promotion programs to incorporate music and dance to stay more actively engaged that aligns with their culture. For example, in a study of health promotion using culturally specific dance to reduce obesity in AA women, a community partnership was formed with two AA churches and culturally specific dance intervention was delivered two times per week for 8 weeks. As a result, body fat and BMI significantly decreased from baseline to 8 weeks and maintained at 18 weeks (Murrock & Gary, 2010). Therefore, when developing future health promotion programs, there is a need for understanding AA culture and incorporating culturally relevant components that will increase their level of engagement and motivation. In addition, the participants were mostly middle-aged and older adults. Women in early adulthood, middle adulthood, or late adulthood, experience different challenges associated with their life stages which can greatly affect their health behaviors. As a result, future health promotion programs should provide age- or role-specific programs to AA women. On the other hand, future health promotion programs with a wider range of age groups and family members are also needed that may have potential to address “togetherness” which is an important AA culture value in adopting and maintaining healthy behaviors. Both programs need to be considered to better achieve healthy lifestyle among AA women.
Another finding was AA women’s lack of knowledge on healthy eating and cooking as well as the importance of being physically active. A recent study showed the effectiveness of a community-based and gender-specific nutrition, obesity, and diabetes educational prevention program designed for African American women (Blanks et al., 2016). These participants reported increased engagement in exercise, decreased blood pressure, weight and BMI, and greater knowledge about nutrition and health following the intervention (Blanks et al., 2016). Future efforts for health promotion program should include knowledge-based classes, for example, healthy cooking class with fresh ingredients, that can inform AA women the importance of healthy lifestyle and how to engage and maintain such lifestyle. This may be more effective to take place in community settings (i.e. church) as AA faith-based organizations have played a critical role in addressing health disparities through various health-related activities and programs (Holt et al., 2017).
Conclusion
This study highlighted African American women’s perception on obesity and health behavior changes that relate to obesity, including eating and physical activity patterns, throughout their lives. Even though many engaged in healthy behaviors during childhood, their health behaviors began to gradually change from young adulthood due to lack of time, busy schedule, sedentary work situation, influence of social network, and stress. They indicated current desire to stay healthy after encountering jarring health experiences of people from unmanaged obesity but shared some challenges associated with their lack of knowledge and motivation. Future health promotion programs should target current barriers to healthy behaviors by incorporating culturally tailored lifestyle components and increasing knowledge on healthy lifestyle through community-based programs to effectively reduce obesity and promote healthy lifestyles for African American women.
Relevance for Clinical Practice.
Our findings build a strong foundation on African American women’s perception on obesity and offer suggestions that would address the issue of obesity in this population. First, clinicians should understand the clinical significance of obesity in the African American community and how African American women are at higher risk for developing obesity. Then, they should offer culturally relevant community-based programs that can help increase their level of knowledge on obesity, change their current eating habits, and be physically active.
Funding.
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support was received from the National Institute of Nursing Research [K23NR014661].
Appendix
Table 1.
Semi-structured interview guide
| First of all, thank you again for taking part in the study. As we start to interview, I just want to remind you what I am trying to learn. My job as a nurse and researcher is to understand African American women’s belief about their health, and lifestyle related to their culture, social relationship, or community so that we can serve culturally relevant health promotion program for this population. | |
| 1 | Tell me about yourself including your age, occupation, marital status etc. |
| 2 | Could you describe your eating from your childhood until now? In particular, who and what influenced your eating? |
| 3 | How do you think your friend/family influenced your eating? Tell me stories about that. |
| 4 | What does “healthy eating” mean to you? |
| 5 | How would you describe your body and body weight? |
| 6 | Have you ever felt you needed or tried to lose weight? Tell me stories about that. |
| 7 | Could you tell me about your physical activity from your childhood until now? |
| 8 | How would you describe your health? |
| 9 | If we develop a group program to promote physical activity and healthy eating, do you have any suggestions for us? What component do you think is helpful to incorporate to the program? |
Table 2.
Participant Characteristics (n=21)
| Demographic Characteristics | Mean (SD) or N(%) | Median (Q1, Q3) |
|---|---|---|
| Female | 21 (100 %) | |
|
| ||
| Age (years) | 51.7 (SD 12.74) | 53 (43.5, 61) |
|
| ||
| Education | ||
| High school graduate | 2 (10%) | |
| Vocational/technical school | 1 (5%) | |
| College graduate | 10 (47%) | |
| Graduate school | 8 (38%) | |
|
| ||
| Annual Household Income | ||
| $0-$39,999 | 7 (33.3%) | |
| $40,000-$79,999 | 9 (42.8%) | |
| $80,000 or higher | 4 (19%) | |
| Refused to answer | 1 (4.9%) | |
|
| ||
| Perceived Health Status | ||
| Poor | 1 (4.9%) | |
| Fair | 9 (42.8%) | |
| Good | 3 (14.2%) | |
| Very Good | 8 (38.1%) | |
| Excellent | 0 (0%) | |
|
| ||
| Body mass index (BMI) | 33.1kg/m2 (SD 5.69) | 33.53 (28.02, 38.41) kg/m2 |
| Overweight (BMI 25–29.9kg/m2) | 8 (38.1%) | |
| Obesity (BMI ≥ 30kg/m2) | 13 (61.9%) | |
Note: Q1 and Q3 indicate the 25th and 75th percentile respectively.
Table 3.
Main Themes with Subthemes
| Main Theme 1. Cultural facilitators and barriers to a healthy lifestyle from childhood to young adulthood | |
| Subtheme 1A | Healthy eating during childhood from family who practiced healthy eating |
| Subtheme 1B | Togetherness: weekend and holiday overeating patterns with family members |
| Subtheme 1C | Living with working parents and living independently in young adulthood |
| Subtheme 1D | An active and skinny child |
| Main Theme 2. Changes in lifestyle from young adulthood to middle adulthood: the influence of social-physical environment | |
| Subtheme 2A | Quick and grab-and-go food for convenience |
| Subtheme 2B | Food craving and constant eating from stress |
| Subtheme 2C | Influences of social networks |
| Subtheme 2D | Sedentary work situation |
| Subtheme 2E | Busy lifestyle |
| Main Theme 3. Suggestions for health promotion programs | |
| Subtheme 3A | Knowledge and education classes on healthy eating and cooking |
| Subtheme 3B | Fun physical activity program |
Footnotes
Conflict of Interest
The authors declare that they have no conflict of interest.
Contributor Information
Se Hee Min, Duke University, School of Nursing, 307 Trent Dr. Durham, NC 27710.
Robin Whittemore, Yale University, School of Nursing, 400 West Campus Dr. Orange, CT 06477.
Holly Powell Kennedy, Yale University, School of Nursing, 400 West Campus Dr. Orange, CT 06477.
Soohyun Nam, Yale University, School of Nursing, 400 West Campus Dr. Orange, CT 06477.
References
- Abraham PA, Kazman JB, Zeno SA, & Deuster PA (2013). Obesity and African Americans: Physiologic and Behavioral Pathways. ISRN Obesity, 2013, 314295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Affenito SG, Franko DL, Striegel-Moore RH, & Thompson D (2012). Behavioral determinants of obesity: Research findings and policy implications. Journal of Obesity, 2012, 150732. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Agyemang P, & Powell-Wiley TM (2013). Obesity and Black Women: Special Considerations Related to Genesis and Therapeutic Approaches. Current Cardiovascular Risk Reports, 7(5), 378–386. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Asselin ME, Schwartz-Barcott D, & Osterman PA (2013). Exploring reflection as a process embedded in experienced nurses’ practice: A qualitative study. Journal of Advanced Nursing, 69(4), 905–914. [DOI] [PubMed] [Google Scholar]
- Awad GH, Norwood C, Taylor DS, Martinez M, McClain S, Jones B, Holman A, & Chapman-Hilliard C (2015). Beauty and Body Image Concerns Among African American College Women. The Journal of Black Psychology, 41(6), 540–564. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Blanks SH, Treadwell H, Bazzell A, Graves W, Osaji O, Dean J, McLawhorn JT, & Stroud JL (2016). Community Engaged Lifestyle Modification Research: Engaging Diabetic and Prediabetic African American Women in Community-Based Interventions. Journal of Obesity, 2016, e3609289. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bopp M, Lattimore D, Wilcox S, Laken M, McClorin L, Swinton R, Gethers O, & Bryant D (2007). Understanding physical activity participation in members of an African American church: A qualitative study. Health Education Research, 22(6), 815–826. [DOI] [PubMed] [Google Scholar]
- Bramble J, Cornelius LJ, & Simpson GM (2009). Eating as a cultural expression of caring among Afro-Caribbean and African American Women: Understanding the cultural dimensions of obesity. Journal of Health Care for the Poor and Underserved, 20(2 0), 53–68. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Casagrande SS, Whitt-Glover MC, Lancaster KJ, Odoms-Young AM, & Gary TL (2009). Built Environment and Health Behaviors Among African Americans. American Journal of Preventive Medicine, 36(2), 174–181. [DOI] [PubMed] [Google Scholar]
- Davidson M, & Knafl KA (2006). Dimensional analysis of the concept of obesity. Journal of Advanced Nursing, 54(3), 342–350. [DOI] [PubMed] [Google Scholar]
- Fujioka Y, Ryan E, Agle M, Legaspi M, & Toohey R (2009). The Role of Racial Identity in Responses to Thin Media Ideals: Differences Between White and Black College Women. Communication Research, 36(4), 451–474. [Google Scholar]
- Hammond RA, & Levine R (2010). The economic impact of obesity in the United States. Diabetes, Metabolic Syndrome and Obesity : Targets and Therapy, 3, 285–295. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hensley RD (2018). Primary care management of obesity: Individualized treatment strategies. The Nurse Practitioner, 43(7), 41–48. [DOI] [PubMed] [Google Scholar]
- Holt CL, Graham-Phillips AL, Mullins CD, Slade JL, Savoy A, & Carter R (2017). Health ministry and activities in African American faith-based organizations: A qualitative examination of facilitators, barriers, and use of technology. Journal of Health Care for the Poor and Underserved, 28(1), 378–388. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hruby A, & Hu FB (2015). The Epidemiology of Obesity: A Big Picture. PharmacoEconomics, 33(7), 673–689. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jarrett RL, Bahar OS, & Kersh RT (2016). “When We Do Sit Down Together”: Family Meal Times in Low-Income African American Families With Preschoolers. Journal of Family Issues, 37(11), 1483–1513. [Google Scholar]
- Joseph RP, Ainsworth BE, Keller C, & Dodgson JE (2015). Barriers to Physical Activity Among African American Women: An Integrative Review of the Literature. Women & Health, 55(6), 679–699. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Jung S, Whittemore R, Jeon S, & Nam S (2021). Mediating roles of psychological factors and physical and social environments between socioeconomic status and dietary behaviors among African Americans with overweight or obesity. Research in Nursing & Health, 44(3), 513–524. [DOI] [PMC free article] [PubMed] [Google Scholar]
- King LK, March L, & Anandacoomarasamy A (2013). Obesity & osteoarthritis. The Indian Journal of Medical Research, 138(2), 185–193. [PMC free article] [PubMed] [Google Scholar]
- López-Hernández L, Martínez-Arnau FM, Pérez-Ros P, Drehmer E, & Pablos A (2020). Improved Nutritional Knowledge in the Obese Adult Population Modifies Eating Habits and Serum and Anthropometric Markers. Nutrients, 12(11), 3355. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Margolis R (2013). Educational Differences in Healthy Behavior Changes and Adherence Among Middle-aged Americans. Journal of Health and Social Behavior, 54(3), 353–368. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Mawardi G, Kirkland EB, Zhang J, Blankinship D, Heincelman ME, Schreiner AD, Moran WP, & Schumann SO (2019). Patient perception of obesity versus physician documentation of obesity: A quality improvement study. Clinical Obesity, 9(3), e12303. [DOI] [PubMed] [Google Scholar]
- Murrock CJ, & Gary FA (2010). Culturally Specific Dance to Reduce Obesity in African American Women. Health Promotion Practice, 11(4), 465–473. [DOI] [PMC free article] [PubMed] [Google Scholar]
- O’Connor MI (2019). Equity360: Gender, Race, and Ethnicity—Trapped in the Joint Pain Vicious Cycle (Part I). Clinical Orthopaedics and Related Research, 477(11), 2421–2423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pawlak R, & Colby S (2009). Benefits, barriers, self-efficacy and knowledge regarding healthy foods; perception of African Americans living in eastern North Carolina. Nutrition Research and Practice, 3(1), 56–63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pekmezi DW, Neighbors CJ, Lee CS, Gans KM, Bock BC, Morrow KM, Marquez B, Dunsiger S, & Marcus BH (2009). A culturally adapted physical activity intervention for Latinas: A randomized controlled trial. American Journal of Preventive Medicine, 37(6), 495–500. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Peterson JA, & Cheng A-L (2011). Heart and soul physical activity program for African American women. Western Journal of Nursing Research, 33(5), 652–670. [DOI] [PubMed] [Google Scholar]
- Sanyal D, & Raychaudhuri M (2016). Hypothyroidism and obesity: An intriguing link. Indian Journal of Endocrinology and Metabolism, 20(4), 554–557. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Shigeta H, Shigeta M, Nakazawa A, Nakamura N, & Yoshikawa T (2001). Lifestyle, obesity, and insulin resistance. Diabetes Care, 24(3), 608. [DOI] [PubMed] [Google Scholar]
- Shuttlesworth ME, & Zotter D (2011). Disordered eating in African American and Caucasian women: The role of ethnic identity. Journal of Black Studies, 42(6), 906–922. [DOI] [PubMed] [Google Scholar]
- Van Cauter E, Spiegel K, Tasali E, & Leproult R (2008). Metabolic consequences of sleep and sleep loss. Sleep Medicine, 9 Suppl 1, S23–28. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Visscher TLS, Lakerveld J, Olsen N, Küpers L, Ramalho S, Keaver L, Brei C, Bjune J-I, Ezquerro S, & Yumuk V (2017). Perceived Health Status: Is Obesity Perceived as a Risk Factor and Disease? Obesity Facts, 10(1), 52–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Williams EP, Mesidor M, Winters K, Dubbert PM, & Wyatt SB (2015). Overweight and Obesity: Prevalence, Consequences, and Causes of a Growing Public Health Problem. Current Obesity Reports, 4(3), 363–370. [DOI] [PubMed] [Google Scholar]
- Woods-Giscombé CL (2010). Superwoman Schema: African American Women’s Views on Stress, Strength, and Health. Qualitative Health Research, 20(5), 668–683. [DOI] [PMC free article] [PubMed] [Google Scholar]