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St. John Fisher College St. John Fisher College
Fisher Digital Publications Fisher Digital Publications
Education Doctoral Ralph C. Wilson, Jr. School of Education
8-2016
An Examination of the Health Promoting Behavior of African An Examination of the Health Promoting Behavior of African
American Women American Women
Donna J. Thomas St. John Fisher College, djt08127@students.sjfc.edu
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An Examination of the Health Promoting Behavior of African American Women An Examination of the Health Promoting Behavior of African American Women
Abstract Abstract There is a sparse amount of data to substantiate the relationship between the African American women’s ability to practice preventative healthcare, reduce their risk to chronic disease, and improve their quality of life. A phenomenological approach was employed in this qualitative study to examine the factors that influence African American women’s health promoting behaviors and lifestyle choices such as regular physical activity, good nutrition, routine health screenings, and other health-promoting behaviors. These factors included the women’s perceived benefits and barriers to health promoting behaviors, self-efficacy, interpersonal and situational influences. In order to gain insight into the factors associated with health promotion, two focus groups were used to examine the lived experiences of the women. Using body mass index (BMI) as a guide, the researcher was able to compare and contrast the health promoting behaviors of one group that had a BMI within the normal range verses the other group of women with a BMI in the obese range. A purposeful sample of eight African American women between the ages of 30 – 45 years were used. The women in this study experienced continuous challenges implementing and sustaining health promotion activities to benefit their overall health over a long period of time. The factors that interfered were cultural traditions, competing demands on their time, and their own desire and ability to adhere to health promoting activities. With this information, the researcher made recommendations to implement future culturally appropriate interventions and health promotion programming to promote good health and lower the risk of chronic diseases in this population.
Document Type Document Type Dissertation
Degree Name Degree Name Doctor of Education (EdD)
Department Department Executive Leadership
First Supervisor First Supervisor Janice Girardi
Subject Categories Subject Categories Education
This dissertation is available at Fisher Digital Publications: https://fisherpub.sjfc.edu/education_etd/269
An Examination of the Health Promoting Behavior of African American Women
By
Donna J. Thomas
Submitted in partial fulfillment
of the requirements for the degree
Ed.D. in Executive Leadership
Supervised by
Dr. Janice Girardi
Committee Member
Dr. Jennifer Schulman
Ralph C. Wilson, Jr. School of Education St. John Fisher College
August 2016
Copyright by
Donna J. Thomas
2016
iii
Dedication
I dedicate this dissertation in loving memory of my parents, Basil and Imogene
Thomas. I thank them for setting a firm foundation for me to flourish. A heartfelt thank
you to my sister Paula for her support, understanding, and assistance when I needed it. I
appreciate Brian for his encouragement, patience, and helping me stay calm and focused
during this process.
iv
Biographical Sketch
Donna Thomas is the president and CEO of her company SmartFit, Inc. which
offers health promotion and fitness services that focus on the prevention of disease and
disability. She has over 30 years’ experience as an administrator and health educator. Ms.
Thomas attended Springfield College, graduating in 1984 with a Bachelor’s of Science in
Rehabilitative Services. Donna completed her Masters of Science in Community Health
in 1991 from Long Island University.
Donna Thomas began her doctoral studies in May 2014 with St. John Fisher
College in the Ed.D. Program in Executive Leadership. Ms. Thomas pursued her research
examining the health promoting behavior of African American women under the
direction of Dr. Janice Girardi and Dr. Jennifer Schulman and received the Ed.D. degree
in 2016.
v
Abstract There is a sparse amount of data to substantiate the relationship between the
African American women’s ability to practice preventative healthcare, reduce their risk to
chronic disease, and improve their quality of life. A phenomenological approach was
employed in this qualitative study to examine the factors that influence African American
women’s health promoting behaviors and lifestyle choices such as regular physical
activity, good nutrition, routine health screenings, and other health-promoting behaviors.
These factors included the women’s perceived benefits and barriers to health promoting
behaviors, self-efficacy, interpersonal and situational influences.
In order to gain insight into the factors associated with health promotion, two
focus groups were used to examine the lived experiences of the women. Using body mass
index (BMI) as a guide, the researcher was able to compare and contrast the health
promoting behaviors of one group that had a BMI within the normal range verses the
other group of women with a BMI in the obese range. A purposeful sample of eight
African American women between the ages of 30 – 45 years were used.
The women in this study experienced continuous challenges implementing and
sustaining health promotion activities to benefit their overall health over a long period of
time. The factors that interfered were cultural traditions, competing demands on their
time, and their own desire and ability to adhere to health promoting activities. With this
information, the researcher made recommendations to implement future culturally
appropriate interventions and health promotion programming to promote good health and
lower the risk of chronic diseases in this population.
vi
Table of Contents Dedication ………………………………………………………………………………………………………….. iii
Biographical Sketch …………………………………………………………………………………………….. iv
Abstract ………………………………………………………………………………………………………………. v
Table of Contents ………………………………………………………………………………………………… vi
List of Tables ……………………………………………………………………………………………………. viii
Chapter 1: Introduction …………………………………………………………………………………………. 1
Problem Statement ……………………………………………………………………………………………. 5
Theoretical Rationale ………………………………………………………………………………………… 7
Statement of Purpose ………………………………………………………………………………………. 11
Research Questions …………………………………………………………………………………………. 12
Potential Significance of the Study ……………………………………………………………………. 13
Definitions of Terms ……………………………………………………………………………………….. 15
Chapter Summary …………………………………………………………………………………………… 16
Chapter 2: Review of Literature …………………………………………………………………………… 17
Introduction and Purpose …………………………………………………………………………………. 17
African American Slave Narrative…………………………………………………………………….. 17
Effects of Health Disparities and Culture on African American Women’s Health …… 22
Definition and History of Health Belief Model and Health Promotion Theories ……… 38
Physical Activity Levels of African American Women ……………………………………….. 42
Chapter Summary ………………………………………………………………………………………………. 50
Chapter 3: Research Design and Methodology ………………………………………………………. 54
vii
General Perspective/Introduction………………………………………………………………………. 54
Research Questions …………………………………………………………………………………………. 55
Research Context ……………………………………………………………………………………………. 56
Research Participants ………………………………………………………………………………………. 60
Instruments Used in Data Collection …………………………………………………………………. 63
Procedures Used for Data Collection and Analysis ……………………………………………. 644
Chapter Summary …………………………………………………………………………………………… 67
Chapter 4: Results ………………………………………………………………………………………………. 68
Introduction ……………………………………………………………………………………………………. 68
Research Questions …………………………………………………………………………………………. 73
Data Analysis and Findings ……………………………………………………………………………… 74
Summary of Results ………………………………………………………………………………………. 103
Chapter 5: Discussion ……………………………………………………………………………………….. 106
Introduction ………………………………………………………………………………………………….. 106
Implications of Findings ………………………………………………………………………………… 109
Limitations …………………………………………………………………………………………………… 111
Recommendations …………………………………………………………………………………………. 112
Conclusion …………………………………………………………………………………………………… 114
References ……………………………………………………………………………………………………….. 116
Appendix A ……………………………………………………………………………………………………… 125
Appendix B ……………………………………………………………………………………………………. 1277
Appendix C ……………………………………………………………………………………………………. 1288
viii
List of Tables
Item Title Page
4.1 Categories and Related Themes 72
4.2 Categories and Themes (Frequency) 78
4.3 Characteristics of Participants 81
1
Chapter 1: Introduction
Our nation faces a crisis due to the burden of chronic disease, Centers for Disease
Control and Prevention (CDC, 2014). Today, seven of the 10 leading causes of death in
the United States are chronic diseases, and nearly 50% of Americans will live with at
least one chronic disease. As of 2012, approximately 26% of adults in the US had
multiple chronic conditions (MCC) (Ward, Schiller, & Goodman, 2014). The CDC states
that chronic diseases and conditions, such as heart disease, stroke, cancer, diabetes,
obesity, and arthritis, are among the most common, costly, and preventable of all health
problems (2015). Treatment for people with chronic conditions accounts for more than
75% of the $2 trillion spent annually on medical care in the United States (CDC, 2011).
The Center for Disease Control and Prevention (CDC, 2014) declares that we are
experiencing a national chronic disease crisis, and that the time to act is now.
According to the CDC (2014) African Americans experience a higher level of
chronic diseases than any other ethnic group. Cardiovascular disease is the most common
chronic disease in the African American community. The American Heart Association,
(AHA) states that morbidity rates for African Americans are higher than Caucasians for
stroke (AHA, 2013a), colon, breast, and prostate cancer. African American adults are
twice as likely to have and die from a stroke as their White adult counterparts (National
Stroke Association, 2016). Death rates for heart disease are 23% higher among African
Americans than among Whites, and death rates for stroke are 31% higher (CDC, 2011).
This is especially true for African American women who are 1.6 times more likely than
their White female counterparts to have high blood pressure (U.S. Dept. of Health and
2
Human Services [USDHHS], 2015). In addition to cardiovascular disease according to
USDHHS (2015), obesity plays a large role in the development of chronic diseases in
African American women.
Obesity is a primary risk factor for chronic disease. Obesity increases the risk that
persons may develop one or more serious medical conditions (CDC, 2009; The Obesity
Society, 2010). The CDC (2016) stated that obesity is a term that means your weight is at
least 20% more than what is considered a normal weight for your height (body mass
index [BMI] >30 kg kg/m2). The Obesity Society (2010) says that, obesity is usually
accompanied by excessive adipose tissue (fat cells), which create plaque that can build up
in the arteries and cause a blockage within the walls of the arteries. Over time, the
blockage in the arteries can lead to heart attacks, heart failure, and stroke. Obesity is
linked to chronic diseases because it is the common denominator and is a major risk
factor in combination with high blood pressure, high cholesterol, cigarette smoking, poor
diet, and physical inactivity that cause changes in the heart and blood vessels (The
Obesity Society, 2010). According to the CDC (2012), obesity contributes to chronic
diseases, such as heart disease, diabetes, and cholesterol. The CDC (2013) indicated that
during 2009-2010, more than one-third of adults in the United States, or about 78 million
people, were obese.
Data show that rates of obesity and related diseases are significantly higher
among Blacks, Hispanics, Pacific Islanders, and Native Americans than among Whites
and Asians (CDC, 2016). Compared with non-Hispanic Whites in the United States,
obesity is 1.4 times more prevalent in the African American community (CDC, 2016).
Thus, obesity is now recognized as a complex disorder caused by the interplay of
3
multiple contributing factors. Further, ethnic, racial, and cultural factors have
been found to influence obesity in the following ways: through genetic
predisposition, by affecting socioeconomic level and geographic location, through
traditional cultural attitudes and beliefs, and by influencing activity level and
dietary behaviors. (Stanziano & Butler-Ajibade, 2011, p.1)
Statistics have shown that African American women are more likely to be more
overweight, obese, and have a higher prevalence of physical inactivity than White and
Hispanic women (Harley et al., 2014). In fact, African American women are 60% more
likely to be obese than White women (CDC, 2016). This researcher goes on to say that,
when African Americans do not maintain normal body weight and waist circumference,
do not eat a healthy diet, and do not engage in regular physical activity, they are more
susceptible to an increased risk of cardiovascular disease.
Cardiovascular disease is responsible for more deaths each year than cancer,
chronic respiratory illnesses, accidents, and diabetes (CDC, 2016). Cardiovascular
disease (CVD) is the leading cause of death in the United States of America (AHA,
2013a). Hypertension, coronary heart disease, heart failure, stroke, and congenital
defects are the conditions included in the CVD group (Rosamond et al., 2007). Although
African American adults are 40% more likely to have high blood pressure, they are less
as likely than their non-Hispanic, White counterparts to have their blood pressure under
control. According to the American Heart Association (2013a), diabetes, smoking, high
blood pressure, high blood cholesterol, physical inactivity, obesity and a family history of
heart disease are all greatly prevalent among African Americans and are major risk
factors for heart disease and stroke.
4
The Center for Disease Control and Prevention (2015) states that, in the United
States, it is estimated that over 40% of African American adults have hypertension. The
CDC (2014), goes on to say that hypertension and its effects have an earlier onset, are
more severe, and occur more frequently in African Americans than in Caucasians. The
incidence rate of hypertension in African Americans in the United States is the highest in
the world (CDC, 2014). African American women are affected by hypertension more
than African American men, and the prevalence of hypertension in African American
women is 3 times that of Caucasian women (CDC, 2014).
African Americans are disproportionately affected by several health related
concerns (CDC, 2014; Mensah, Mokdad, Ford, Greenlund, & Croft, 2005). African
Americans also have a mortality rate from cardiovascular disease that is more than 40%
higher than Caucasians in the United States (CDC, 2012). The morbidity rate for African
Americans is higher than Caucasians for stroke as well as colon, breast, and prostate
cancer (CDC 2007). These, along with other health issues, are preventable diseases
(AHA, 2013a; National Cancer Institute, 2004).
According to the American Heart Association (2009), obesity and cardiovascular
disease plague the US. They say that what makes the phenomenon more concerning is
that it is not equitable among the various communities throughout the country and the
nation. In recent years, the nation has focused attention on disparities in health that exist
between White Americans and racial and ethnic minorities (Smedley, Stith, & Nelson,
2003). Health disparities are described as inequitable mortality and morbidity rates for
racial and ethnic minorities whom have higher rates and greater severity of disease than
Whites for most, if not all, of the leading causes of morbidity and mortality in the US
5
(USDHHS, 2015). Culturally relevant health promotion and education activities and
programs are one way of addressing health disparities and lowering chronic disease in
this population (Smedley et al., 2003). Webb and Gonzalez (2006) imply that health
promotion activities that are community-based and target the African American
population should include public health education sessions in familiar community sites
such as churches, community centers, hospitals, schools, and parks, where numerous
individuals can be provided with preventative health and chronic disease risk education.
In addition, health care providers and health educators should have access to the
latest research and data in order to empower them to have a positive impact on the health
promotion and intervention strategies for African American women (Pender, Murdaugh,
& Parsons, 2011). By gaining understanding about how a patient’s sociocultural
background can affect risk for obesity and obesity-related behaviors, clinicians can be
better prepared to offer effective, culturally sensitive care (Barroso et al., 2010;
Harrington, 2008; Stanziano & Butler-Ajibade, 2011).
This study identified factors that influence the health promotion behaviors in
African American women. With this information, culturally appropriate interventions to
promote good health and lower the risk of chronic diseases in this population can be
enhanced. This qualitative study focused on an examination of culturally sensitive health
promoting behaviors for African American women.
Problem Statement
Effectively addressing the national chronic disease crisis is central to the future of
health care in our nation, and a priority for policy makers and those who pay for public
and private health insurance plans (CDC, 2011). Myers, Olson, Kerker, Thorpe, and
6
Farley (2010) stated that, because African American women have a disproportionate
percentage of chronic illnesses compared to other ethnic groups, there is a need to
improve their health status. The American Heart Association’s (2009) study maintains
that chronic diseases are preventable and this can be achieved through lifestyle
modifications, such as, weight control, limitation of alcohol consumption, increased
physical activity, increased fruit and vegetable consumption, reduced total fat and
saturated fat intake, and smoking cessation. The adoption of healthy activities are critical
and should be encouraged to prevent the risks and complications of chronic diseases
(AHA, 2009).
One way to reverse the trend of African American women disproportionately
affected by chronic diseases, would be to address and decrease health risk behaviors.
Health risk behaviors are unhealthy behaviors you can change. Four of these health risk
behaviors, which are lack of exercise or physical activity, poor nutrition, tobacco use, and
drinking too much alcohol, cause much of the illness, suffering, and early death related to
chronic diseases and conditions (CDC, 2012). Further research is needed to examine the
factors that affect African American women and their motivators and barriers to health
promoting behaviors. Pender et al. (2011) define health promotion as behavior motivated
by a desire to increase well-being and promote change and growth in the human health
potential. Health promotion behaviors are those activities motivated by the desire to
protect or promote health (Pender et al., 2011). The agenda for health promotion is
directed toward maximizing behaviors that move individuals and groups to a high-level
of health and well-being. Primary prevention and health promotion have substantial
benefits in decreasing morbidity and mortality. To accomplish the goal of improving
7
health in any given population requires an understanding of the motivational dynamics
that influence health promotional behaviors with the populations of interest (Pender et al.,
2011).
There has been some research on African American women (Bowen, Eaves,
Vance, & Moneyham, 2015; Gross, Anderson, Busby, Frith, & Panco, 2013; Vidrine et
al., 2013) and their knowledge level, attitudes, and perception about chronic diseases.
However, more information is needed as it relates to their being motivated to practice
health promoting behaviors and their willingness to address unhealthy behaviors. There is
limited existing research on African American women’s ability to practice preventative
healthcare and their health promoting behavior for long-term health benefit.
This study examined the factors that affect African American women’s health
promoting behaviors and lifestyle choices, such as regular physical activity, good
nutrition, routine health screenings, and other health-promoting behaviors. It is this
researcher’s goal to inform the future development of health promotion and prevention
programs that are culturally sensitive and assist in the reduction in the chronic diseases
and the high rate of morbidity and mortality in African American women.
Theoretical Rationale
Health belief model. The theoretical rationale for this study has its roots in the
health belief model (HBM). The HBM is a psychological health behavior change model
developed to explain and predict health-related behaviors, particularly as it relates to
participating in health services. The health belief model was developed in the 1950s by
social psychologist Irwin M. Rosenstock (1974) at the U.S. Public Health Service to
better understand the widespread failure of a screening program for tuberculosis.
8
Rosenstock (1974) stated that more recently, the model has been applied to understand
patients’ responses to symptoms of disease, compliance with medical regimens, lifestyles
behaviors, and behaviors related to chronic diseases. There has been emerging evidence
about the role of self-efficacy in decision making and behavior.
The HBM became one of the most widely recognized conceptual frameworks for
creating healthy behaviors by focusing on positive behavior change at the individual
level. The HBM is designed to assist in explaining and predicting preventative health
behavior (Romano & Scott, 2014). The HBM provides a framework to examine an
individual’s health promoting behaviors. Romano and Scott (2014) stated that the focus is
on the individuals’ motivation and self-identifying perceived susceptibility, perceived
seriousness, perceived benefits of taking action, barriers to taking action, and cues to
action. The HBM can provide guidelines for program development, allowing planners to
understand and address reasons for non-compliance. The HBM addresses four major
components for compliance with recommended health actions:
1. Perceived barriers of recommended health
2. Perceived benefits of recommended health action
3. Perceived susceptibility of the disease
4. Perceived severity of the disease
Modifying factors that can affect behavior compliance include, media, health
professionals, personal relationships, incentives, and self-efficacy of recommended health
action. (Bandura, 2004).
One drawback of the health belief model is that it does not take into account other
factors that influence health behaviors. For instance, habitual health-related behaviors
9
(e.g., smoking) may become relatively independent of conscious health-related processes.
The HBM provided a basis for the development of future health promotion models and
the examination of the factors that influence health behaviors.
Pender’s health promotion model. The health promotion model (HPM) is
relevant to this researcher’s study of African American women because it provided a
foundation to examine the background influences of this population as it relates to health
promotion activities that can lead to a healthy lifestyle (Pender et al., 2011). In order to
assist individuals in lowering their risk for chronic diseases and improving their health
status, it is important to examine perceptions to evoke a positive health behavior change.
Nola Pender attended Michigan State University to earn her bachelor’s and
master’s nursing degrees in 1964 and 1965, respectively. She earned her Ph.D. from
Northwestern University in 1969. Pender began studying health-promoting behavior in
the mid-1970s. Pender developed her health promotion model, (HPM) after seeing
professionals intervening only after patients developed acute or chronic health problems.
She believed that a patients’ quality of life could be improved by the prevention of
problems before they occurred, and health care dollars could be saved by the promotion
of healthy lifestyles (Nursing Theory.org, 2016).
Pender’s health promotion model – theoretical roots. Pender used the expectancy
value theory and the social cognitive theory as a basis to develop her health promotion
model. Expectancy value theory promotes the idea that individuals engage in actions to
achieve goals that are perceived as possible and that result in valued outcomes. The social
cognitive theory examines the thoughts, behavior, and environmental interactions of
10
individuals. It also assesses how people alter their behavior and their thinking (Pender et
al., 2011).
HPM is based on 8 categories:
1. Perceived benefits of action
2. Perceived barriers to action
3. Perceived self-efficacy
4. Activity-related affect
5. Interpersonal influences (family, peers, providers)
6. Situational influences (options, demand characteristics, aesthetics)
7. Commitment to plan of action
8. Immediate competing demands and preferences
The purpose of Pender’s health promotion model. Nola Pender’s health
promotion model was developed after the health belief model, to assist nurses in
understanding the major determinants of health behaviors as a basis for behavioral
counseling to promote healthy lifestyles (Pender et al., 2011). Pender describes her theory
as, “the model that identifies background factors that influence health behavior. However,
Pender et al. (2011) states that the central focus of the model are on eight beliefs that can
be assessed by the nurse. Using the model and working collaboratively with the
patient/client, it can assist them in changing behaviors to achieve a healthy lifestyle.
Using the HPM provided some insight as to why some African American women
are not practicing preventative health care. Smedley et al. (2003), stated future analyses
should consider the roots of attitudes in historic and contemporary, social and cultural
forces, in and outside medical practice, that play a role in minority patients perceptions of
11
health institutions. Webb and Gonzalez (2006), indicated that personal perception is
influenced by the whole range of intrapersonal factors affecting health behavior.
Behaviors models that fail to contain beliefs and perceptions of the target population pose
a barrier to scientific advances.
Statement of Purpose
Based on the urgency to address health care needs and disparities of African
Americans, the purpose of this qualitative narrative research was to capture the lived
experiences of African American women as it relates to the factors that are motivators
and barriers to engage in and sustain preventative health care practices to reduce their risk
of chronic diseases. There is a sparse amount of data to substantiate the relationship
between the African American women’s ability to practice preventative healthcare for
long-term benefit in order to reduce their risk to chronic disease and improve their quality
of life. Tucker (2014) agrees and stated that there is also limited data on what factors are
motivators and barriers to practicing self-promoting health behaviors.
According to a statement made in the Westchester County Health Improvement
Plan (Westchester County Department of Health, 2014b), in an effort to make New York
the healthiest state, New York Department of Health adopted the Prevention Agenda
2013-2017, a 4-year plan, to identify New York’s most urgent health concerns. The plan
identified preventing chronic disease as one of its public health priorities. The Prevention
Agenda calls for improving health status in the priority areas and reducing health
disparities for racial, ethnic, disability, socioeconomic and other groups who experience
them.
12
There has been some research on African American women and their knowledge
level, attitudes, and perception about chronic diseases; however more information is
needed as it relates to their being motivated to practice health promoting behaviors
(Tucker, 2014). This study contributes to the knowledge and practice of health promotion
in African American women. The researcher examined African-American women’s
lifestyles, their perceptions and beliefs regarding health, the amount of health education
and knowledge they had, their access to good health care providers, access to physical
activity opportunities, and the access to quality food sources or appropriate health care
services and how these play a role in the execution of engaging in health-promoting
behaviors. Identifying motivators that will encourage the motivational process among
African American women is important, since a lack of motivation is a major cause for
less than optimal engagement in health-promoting behaviors (Tucker, 2014).
Health care interventions can include, but are not limited to, health education,
health screenings, physician’s office visits, access to physical activities, and healthy
nutrition sessions. Health interventions can be considered effective when an individual
has lowered their risk for chronic diseases by attaining a healthy weight, healthy body fat
levels, healthy blood pressure, and cholesterol levels.
Research Questions
This study examined the factors that affect the health-promoting behaviors in
African American women and answered the following questions:
1. Does culture impact African American women’s willingness to adopt a
healthy lifestyle?
13
2. What factors influence African American women’s participation in
preventative health practices (health promoting behaviors)?
3. What are the factors that influence African American women’s motivation
towards a healthy lifestyle?
4. What factors influence African American women’s participation in
preventative health programs?
Potential Significance of the Study
There is a plethora of health policies and initiatives that have been developed or
are in the development stages of addressing chronic disease reduction. The question is,
what are the strategies for effectively implementing these policies in order to address the
health care disparities in African American women? Healthy People 2010, the U.S.
Department of Health and Human Services (USDHHS) 10-year agenda for health
promotion and disease prevention in the 21st century, has two main goals: (a) to increase
quality and years of healthy life and, (b) to eliminate health disparities (USDHHS, 2010).
In order to reach the goals indicated by the USDHHS, research is needed to inform gaps
in knowledge on MCC (Parekh, Goodman, Gordon, & Koh, 2011; USDDDS, 2010),
including an effort to more frequently monitor MCC across the U.S. population by using
data from national health survey such as the NHIS and other surveillance systems
(Goodman, Posner, Huang, Parekh, & Koh, 2013). Such research can inform individuals
leading prevention efforts and could improve the targeting of appropriate interventions.
In addition, the 2010 Affordable Care Act responds to the need for Americans to
have access to recommended preventative healthcare services. The 10 titles of the law,
especially Title IV, Prevention of Chronic Diseases and Improving Public Health, address
14
the national need for improved health promotion (Kohl, Dunn, Marcus, & Blair, 2010).
The act strengthens the vital role of communities in providing health promotion
opportunities and elevates disease prevention as a national priority.
This study is significant because it adds research and data to address health
promotion initiatives and strategies by examining the factors that affect African
American women’s health promoting behaviors. These health promoting behaviors
include physical activity, good nutrition, health screenings, and other positive lifestyles
habits. The factors assist in identifying culturally sensitive, evidence-based training
guidelines for health professionals that interact with African American women. Cultural
sensitivity training is imperative to provide quality care to African American women
(Barnes & Kimbo, 2012). Understanding their cultural beliefs and what motivates them to
engage in health promoting activities would guide health professionals to provide
culturally-based interventions.
To accomplish the goal of improving health in any given population requires an
understanding of the motivational dynamics that influence health promotion behaviors
with the population of interest (Pender et al., 2011). Knowing the cultural beliefs,
attitudes, behaviors, and other factors that motivate African American women to engage
in and sustain long-term health promotion behaviors as one means of chronic disease risk
reduction can assist physicians, health care providers, and other stakeholders in
developing specific and effective health promotion strategies among African American
women.
15
Definitions of Terms
To ensure clarity the following terms will appear in this study.
African American or Black — The term “black” or “African American” are used
interchangeably to describe people who have origins in any Black racial groups of Africa.
Body Mass Index (BMI) — A measurement of weight in relation to height. (Schub, 2014)
Body Fat Percentage — The body composition that refers to the body weight that
measures fat mass and lean body mass (included but not limited to muscles, bones,
organs and internal fluids) (Yoke & Gladwin, 2007)
Chronic Diseases — Recurring health problems that are the leading causes of death and
disability in the United States (Heart disease, stroke, high cholesterol, diabetes, arthritis
and cancer) (CDC, 2014)
Culture — The beliefs, customs, arts of a particular society, group, place, or time. A
particular society that has its own beliefs and ways of life.
Health Promotion Program — Health education program designed to encourage good
health habits. (CDC, 2014)
Physical Activity — Any activity that gets your body moving for cardiovascular
conditioning and muscular strengthening benefits. (Yoke & Gladwin, 2007)
Obese — Obesity in adulthood is defined as a body mass index. > 30 (Schub, 2014)
Overweight — Overweight in adulthood is defined as a body mass index between 25 and
30. (Yoke & Gladwin, 2007)
White — “White” refers to a person having origins in any of the original people of
Europe, the Middle East, or North Africa. It will be used interchangeably with Caucasian
(U.S. Census Bureau, 2010).
16
Chapter Summary
This chapter reviewed how African Americans have higher morbidity due to
chronic diseases than any other ethnic group. It highlights the need for conducting
further research on health-promoting behaviors as it relates to lowering the risk of
chronic diseases such as obesity and cardiovascular disease in African American women.
There is an emphasis on the fact that more research should be conducted on the role
culture and health disparities play in African American women’s health-promoting
behaviors. Research plays an important role in finding effective solutions to address
chronic diseases in African American women and lowering their risk toward chronic
diseases. Chapter 2 provides a review of the relevant literature in the field of health
promotion for African American women. The review starts with the history of African
American culture as it relates to slavery, diet, and lifestyle. Thereafter a review on the
literature related to health care disparities, health care interventions, prevention strategies,
health promotion theories, and physical activity levels in African American women is
discussed. Chapter 3 provides a review of the research methodology used for this study.
This section includes: general perspective, research questions, research context, research
participants, instruments used in data collection, and procedures for data collection and
analysis. The findings of the study are presented in Chapter 4. This chapter includes:
major findings, qualitative research methods, research questions, data analysis and a
summary of the findings. Chapter 5 provides implications of the findings, the limitations
of the study, and the researcher’s recommendations for practice and future studies.
17
Chapter 2: Review of Literature
Introduction and Purpose
A literature review was undertaken to explore the existing research related to the
history and factors affecting African American women’s health promoting behavior. The
review of literature examined six areas influencing the barriers and motivators of health-
promoting behavior among African American women. The review commences with
literature related to the history of African American’s diet and lifestyle, beginning with
slavery within the United States, and the link between their history and the cultural
patterns demonstrated now. A definition and history of health promotion theories is
outlined. This includes the research conducted by Nola Pender and similar health
promotion and health behavior theories over the past three decades. Research related to
health care disparities affecting African American women was evaluated. Literature
related to the physical activity levels of African American women was also examined.
Lastly, there is a section that discusses health care intervention, prevention strategies, and
health promotion for African American women.
African American Slave Narrative
In order to obtain a better understanding of the factors that affect African
American women’s health behavior, it is important to explore the evolution of African
American’s experience with regard to their health care. According to Bronson and
Nuriddin (2014), the first enslaved Africans were brought to Virginia in 1617 and this
continued until 1865. During this time, the first recognizable signs of the modern formal
18
health care system became apparent. History and research tell us that slaves suffered from
poor health more than Whites and received unequal and inadequate healthcare (Covey,
2007). Both free and enslaved African Americans were discriminated against. They were
not afforded the same access to quality healthcare. In addition, the decline in the
enslaved Africans health can be attributed to many factors including eating a healthy diet
in their homeland, based on fresh fruits, vegetables, and beans, as compared to eating the
scraps, leftovers, and grain provided by their slave master. Insufficient diets meant the
proper nutrients were not received, leaving them susceptible to diseases of nutritional
deficiencies (Covey, 2007).
The brutal and deplorable conditions of slavery led to poor health, injuries
(inflicted and accidental), and untimely death for millions of Africans. Slaves were often
expected to work regardless of a health condition or illness (Bronson & Nuriddin, 2014).
Former slaves described their living conditions as poor, including improper sanitation,
poor ventilation, damp floors, and cramped quarters. These situations caused increased
stress in their life, which affected their health and well-being. These conditions, along
with stressful working environments, resulted in epidemics of typhoid, typhus, measles,
mumps, and chicken pox among slaves (Savtt, 1978).
The social control of human labor during slavery made it difficult if not nearly
impossible for enslaved Africans in America to lead both healthy and fulfilling lives.
Those who were enslaved were forced to work oftentimes, under conditions that did not
allow them to take care of their total health and well-being (Bronson & Nuriddin, 2014).
For the vast majority of the period of slavery in America, medicine was quite primitive
19
and knowledge of specific diseases and illnesses was severely underdeveloped
(Washington, 2006).
“After emancipation and the Civil War, poor African American health continued
into the next century due to poverty, poor living conditions, inadequate sanitation and
housing, and persistent racism and racial discrimination” (Bronson & Nuriddin, 2014, p.
713). There was little or no recourse due to institutional discrimination and prevailing
racial stereotypes which still considered African Americans as inferior to their White
counterparts (Bronson & Nuriddin, 2014). The enslavement of African Americans lasted
for 246 years and ended with the emancipation proclamation. This set the foundation for
many African Americans to mistrust the medical community due to the perceived
unequal and inadequate medical treatment they encountered during slavery (Bronson &
Nuriddin, 2014).
Based on the narratives of many African Americans who were interviewed,
Bronson and Nuriddin (2014) shared that the former slaves participated in an array of
health practices including the elaborate use of herbs, roots, and potent elixirs to prevent
and treat illnesses. Sometimes, these practices were with or without the consent of their
owners. Some slaves who did not have access to doctors were often allowed to get
treatment from “granny doctors.” A granny doctor was common name used among the
slaves when they referred to an older woman that medically treated the slaves. The folk
remedies used by the slaves to prevent and treat illnesses were preferred to doctor
administered medicines and there was an inherent mistrust of doctors’ treatments and
medications that were prescribed (Bronson & Nuriddin, 2014; Hammond, 2010.). The
inherent lack of value placed on the lives of enslaved African Americans and their
20
vulnerability meant that their bodies would be utilized most often for medical
experimentation, training, and education which became a widespread practice in the
United States (Fett, 2002; Kennedy, Mathis, & Woods, 2007; Washington, 2006).
Kennedy et al. (2007) reported that in surveys of African Americans, they have reported
that they feared they would be used as guinea pigs for medical research. This same
survey also found that African Americans were more likely than Whites not to trust that
their doctors would fully explain the significance of their participation in clinical research
or other studies. For example, this was evidenced in the now infamous Tuskegee syphilis
study. As indicated by Kennedy (2007), the United States Public Health Service
conducted a study on African American men from 1932 to 1972. The study involved
tracking the progression of the disease syphilis by not administering treatment to
approximately about 400 African American men. Although penicillin became the
standard cure, these men did not receive the treatment. Many people have considered this
study to be a classic case of governmental racism against African Americans and is one
major reason why so many African Americans distrust the health care system (Kennedy,
2007).
Historical cultural patterns that influence African American women’s health.
In addition to the historical, structural influences on health and medical care, public
health researchers in the US overwhelmingly argue that an agenda to eliminate health
disparities must also account for the way that culture affects health behaviors and
attitudes (Odoms-Young, Zenk, & Mason, 2009). Kreuter and McClure (2004) who
studied the health disparities in the African American community, defined culture as,
“Culture is learned, shared, transmitted inter-generationally, and reflected in a group’s,
21
beliefs, norms of communication, familial roles, and other social regularities” (p. 237).
The cultural practices of many African Americans began in Africa, but were impacted
upon once their ancestors arrived in the United States. One cultural practice that saw a
significant impact was food and eating practices. Researchers have found that some
African Americans feel their food practices have been shaped by the impact of slavery on
the ancestor’s diet (James, 2004). James (2004) described the impact in the following
manner:
Slaves who were brought to the USA combined their West African cooking
method with British, Spanish, and Native American techniques with whatever
foods were available to produce a distinctive African America cuisine called ‘soul
food’… Soul food emphasizes fried, roasted, and boiled food dishes using
primarily chicken, pork, pork fat, organ meats, sweet potatoes, corn, and green
leafy vegetables. (p. 351)
Examples of soul food dishes include fried chicken, barbecued meats such as
pork, beef, and chicken, collard greens, macaroni and cheese, chitterlings, corn bread,
biscuits, cakes, and pies (James, 2004). Many African Americans refer to these dishes as
soul food because, as James (2004) indicated, “the foods of the ancestors nourish the
body, nurture the spirit, and comfort the soul” (p. 352). To many African Americans,
these dishes are traditional and an important part of their culture and heritage. Veering
away from them would mean turning their back on their culture. Unfortunately, the way
these foods are traditionally prepared and consumed is not healthy because of the high fat
and salt content (James, 2004).
22
Effects of Health Disparities and Culture on African American Women’s Health
Health disparities are differences in health outcomes between groups that reflect
social inequalities (Myers et al., 2010). For African American women, this is a national
issue. Racial and ethnic disparities in health care are known to reflect access to care and
other issues that arise from differing socioeconomic conditions. There is, however,
increasing evidence that even after each difference is accounted for, race and ethnicity
remain significant predictors of the quality of the health care received (Smedley et al.,
2003). Experts agree that health disparities result in avoidable illnesses and deaths in one
group of people versus another, and arise from a variety of causes, not all of which are
fully understood (Myers et al., 2010). The United States is known for its ability to
provide the most advanced health care that medical science can offer. Although there has
been notable progress in medical advancement, persistent disparities remain in the burden
of illness and mortality experienced by African Americans (AHA, 2014; CDC, 2013).
The U.S. Department of Health and Human Services (2015) asserts that, African
Americans are disproportionately overrepresented in women’s reproductive health
disparities. African American women are less likely to have access to reproductive health
care, including medically appropriate contraceptives, annual gynecological exams, and
prenatal care. In addition, women of racial and ethnic minorities are less likely than
White women to receive a Pap test, which can prevent invasive cervical cancer by
detecting precancerous changes in the cervix.
In contrast, Myers et al. (2011), stated that in New York City, cervical cancer
screening rates for Black women was 81% compared to 77% of White women between
the years 2009 to 2011. In 2009, White women ages 40 and older were less likely to be
23
screened for breast cancer (75%) than Black women (81%). In Westchester County, New
York the Westchester County Department of Health, (2014) reported that compared to
White women (10.8%), Black women (23.8%) were more likely to receive family
planning services in a 12 month period from 2009-2010.
According to the Westchester County Health Improvement plan (Westchester
County Department of Health, 2014b), it was stated that in order to prevent chronic
disease there must be a reduction in racial disparities by decreasing the percentage of
Blacks and Hispanics dying prematurely from heart related diseases. Between the years
2008 and 2010, the percentage of premature deaths due to heart disease was 8.6% for
non-Hispanic White residents and 22.4% for non-Hispanic Black residents. The average
age at death was 79.9 for non-Hispanic Whites and 69.1 for non-Hispanic Blacks during
the years 2008 to 2010.
Similarly, researchers (Myers et al., 2010; Tucker, Smith, Arthur, & Wall, 2014;
White, 2011) agree with the need to reduce racial disparities to help prevent chronic
disease. Disparities in health care have been on the national agenda since the 1990s.
Given the history in America of racial prejudice, it wasn’t a surprise that Blacks were
especially subject to inferior treatment (White, 2011). Compared to Whites, African
Americans have lower rates of effective health interventions. For example, Myers et al.
(2011) reported that hypertension rates have decreased for both Whites and Blacks, as has
the Black/White gap. Despite these gains, hypertension death rates among Black New
Yorkers remain almost 4 times higher than among White New Yorkers (35 vs. 9 per
100,000 adults).
24
Smedley et al. (2003) cited ineffective health care intervention strategies exist due
to failures in the health care system to properly address the healthcare needs of African
American women. Few intervention studies have demonstrated sustained effectiveness in
preventing or controlling overweight and obesity. Studies have mainly involved either
highly selected, relatively affluent Whites engaged in costly, individually targeted
educational or behavioral interventions. Studies have shown that interventions have failed
because of an environment that promotes physical inactivity and excessive food
consumption. Although many studies support that health disparities exist, there has been
some criticism in the research literature (Smedley et al., 2003). Clarification regarding
the overall value of addressing health disparities first with African American women in
an effort to have better health care outcomes is needed.
Health disparities and women’s failure to practice preventative health care.
Health disparities do not only exist because of some failures of the health care system;
women also have the responsibility to practice preventative healthcare. Smedley et al.
(2003) affirmed that women report various reasons for delaying care, including cost, lack
of insurance, and competing family work responsibilities. Early detection is critical for
effective treatment and management of several illnesses that affect women. Women of all
races fall short of maximizing use of available screening tests and racial and ethnic
differences are apparent in this area as well.
Although African American women are given the tools and resources to practice
good preventative health care, they may not continue to do so. Some women participate
in health promotion programs, however, when the health promotion programs conclude,
the participants may not continue to implement what they learned, therefore the
25
intervention did not realize sustained effectiveness in preventing or controlling obesity
(Smedley et al., 2003).
Shortage of primary care physicians with the same cultural background.
According to White (2011), there is a shortage of primary care physicians who have the
same cultural background of African Americans and this could be a contributing factor to
ineffective health care interventions. The experts (Nelson & Shavitt, 2002; Westchester
County Department of Health, 2014a; White, 2011) agree that, because of this difference,
the physicians may not be culturally sensitive to the health care needs of the individuals
they serve. Myers et al. (2011) reported that, in New York State, 70% of active patient
care physicians in New York were non-Hispanic Whites. Underrepresented minorities
(URMs) (Blacks/African American, Hispanic/Latinos, and American Indians) made up
10% of the physician workforce in 2006. At the same time, URMs made up
approximately 35% of New York’s population. In studies conducted by Smedley et al.
(2003) the participants indicated that it is easier to develop a rapport or discuss treatment
options with healthcare providers of their own race who already understand their
language and cultural idiosyncrasies.
Health care interventions and culturally sensitive health promotion
programs. In spite of the research and the education of some, African American women
are not practicing preventative care (CDC, 2008). Medical and health professionals are
using health promotion programming as a tool to address the effects health disparities and
culture have on African American women’s health care (Smedley et al., 2003). The high
prevalence of chronic diseases in African American women, and their lack of
participation in traditional risk reduction programs, underscores the need for accessible
26
health promotion and disease prevention programs that take into consideration the
cultural perspective of the African American woman (Barnes & Kimbo, 2012).
There are numerous factors that affect health care intervention strategies that lead
to good health care outcomes for African American women as it relates to chronic
diseases such as heart disease, stroke and diabetes. (Joseph et al., 2013; Parra-Medina, et
al., 2011; Ray, 2013). One such intervention would be culturally sensitive health
promotion programs geared toward the elimination of chronic diseases. Health promotion
has been described by the World Health Organization (WHO) (2016) as a process of
enabling people to increase control over, and to improve their health. It moves beyond
individual behavior towards a variety of social and environmental inventions. Pender et
al. (2011) declared that health promotion has become integral to our efforts to improve
public health.
Goals of health promotion include the primary and secondary prevention of
disease and health-compromising conditions. Health promotion programs offer
opportunities for African American women to engage in healthy activities that will assist
them in lowering their risk for chronic diseases. These health promotion programs
emphasize prevention. Prevention reduces the chronic disease risk (CDC, 2014).
Although chronic diseases are among the most common and costly of all health problems,
they are also among the most preventable. Prevention encompasses health promotion
activities that encourage healthy living and limit the initial onset of chronic diseases.
Early detection is important; therefore, health screening of at-risk populations is critical.
According to the CDC (2008), an adult with healthy blood pressure and healthy blood
cholesterol levels has a greatly reduced risk of cardiovascular disease. Lifestyle changes
27
in diet and exercise, including a 5%-7% maintained weight loss and at least 150 minutes
per week in physical activity, can prevent or delay the onset of type 2 diabetes for
Americans at high risk for the disease.
A relatively new idea is engaging African American women in health
promoting programs via an Internet-delivered physical activity program. Internet-based
physical activity interventions represent a potential high-reach, low-cost method to
promote physical activity (Marcus et al., 2006). A pilot study conducted by Joseph et al.
(2013) tested a 6-month theory-based (social cognitive theory – SCT) culturally-relevant
website intervention to promote physical activity (PA) among African American female
college students. A single group pre-posttest design was used. PA and associated SCT
constructs (outcome expectations, enjoyment, self-regulation, and social support) were
assessed at baseline, 3 months, and 6 months. The results indicated that the sample was
comprised of mostly obese young adults. Fifty percent of the sample completed all
assessments. Significant increases from baseline to 6 months were found in self-
regulation for PA and social support for PA from friends. Changes in the SCT variables
were not significantly associated with changes in PA; however, this may have been due
to the small sample size. Future studies with larger samples and more aggressive
retention strategies are needed to further explore the applicability of web-based
approaches to promote PA in this at-risk population.
Banks-Wallace and Conn (2002) reviewed the intervention research literature
testing strategies to increase activity among African American women. Eighteen studies
with 1,623 subjects were reviewed. Diverse interventions, settings, and measures were
reported. Common methodological weaknesses included lack of randomization of
28
subjects, single-group design, instruments without documented validity and reliability,
significant attrition, and questionable timeliness of the outcome variable measurement.
Strategies to design and deliver culturally appropriate interventions were reviewed.
Suggestions for future research, such as examining intergroup differences and communal
resources, were provided. The number of studies designed to promote activity among
African American women is growing, but study design and measurement limitation
combined with inadequate replication of intervention components prevent the existing
evidence from forming a solid base for practice.
In Davis-Carroll’s (2011) study, she analyzed the health messages that focus on
high mortality and morbidity rates, yet have not reduced health disparities, but have
instead reduced Black women’s bodies to carriers of disease. Davis-Carroll (2011) found
that media messages directed toward African American women had content that
emphasized negative outcomes or sexual stereotypes. The researcher recommended
improving health outcomes of African American women by improving the health
messages that are delivered in the media.
Culturally sensitive health promotion and the church setting. The church
setting is one environment where health promotion programs have been implemented due
to the nature of the captive group audience and the possibility of success resulting from
the social support systems. Many of these health promotion programs were implemented
with church members because it is a familiar environment where there is a certain level
of trust of the church leaders and members. The church setting is an environment where
there may be preexisting communication exchanges and support systems (Lumpkins et
al., 2013).
29
The African American Church today has evolved into a multi-faceted
organization, serving the needs for members but also the surrounding
communities through various types of partnerships that involve educational, social
welfare, social justice and also health programs. The church’s role in the
community makes it a natural partner in addressing health disparities among
African Americans. (Lumpkins et al., 2011, p.1095)
Church-based health promotion interventions (CBHP) and church-based health
promotion programs (CBHPP) have shown to significantly impact several health
behaviors among African Americans (Campbell, Resnicow, Carr, Wang, & Williams,
2007; Peterson, Atwood, & Yates, 2002).
The effectiveness of a pastor’s communication can be instrumental in the
delivery of important health promotion messages. This was exemplified in the American
Heart Association’s (AHA) Search Your Heart Program, (2004) a faith-based program
for heart health and stroke prevention. This program was geared toward educating people
and reducing cardiovascular disease and stroke risk factors in minority communities
using the American Heart Association-Search Your Heart Kit. This program’s primary
focus was on health education and did not emphasize the motivators and barriers to
engaging in and sustaining physical activity as one health promoting behavior. Since the
early 2000s when the Search Your Heart program was implemented, the AHA has
partnered with numerous churches to encourage members to participate in the “Power to
End Stroke” campaign (American Stroke Association, 2009). This program emphasized
the education of recognizing stroke signs and symptoms.
30
Another program was the National Cancer Institute (2004) Body & Soul
program. The Body & Soul: A Celebration of Healthy Living program emphasized the
increased consumption of fruits and vegetables among African American church
members to help reduce their risk of cancer and other diseases. The objectives of the
program were to (a) increase church members understanding of National Cancer Institute
nutrition guidelines, (b) increase participants’ awareness, knowledge, and self-efficacy
related to increased fruit and vegetable consumption, (c) to change social norms related to
the importance and benefits of eating fruits and vegetables, and, (d) increase the
availability of fruits and vegetables in the environment of church members (National
Cancer Institute, 2004). This program was developed out of efficacy intervention studies
(between 2004 and 2006) with the African American community in mind. At the 6 month
follow-up, the intervention participants showed a significant increase in fruit and
vegetable intake, a decrease in fat intake, and a greater motivation to eat fruits and
vegetables.
Participants learned about the health program in multiple ways. The majority
(89%) of the participants self-reported that they heard messages from the pulpit in
support of the project (Campbell & Quintiliani, 2006); 75% of the participants also
learned of the program by attending the church kick off and 90% indicated they learned
about the program from educational materials such as a video and church cookbook.
This study showed that the participants’ successes were linked to interventions on
multiple levels such as health education materials, volunteer assistants, and support from
the pastor. The pastor’s health messages and spiritual messages created influential
communication that impacted health promoting behaviors among church members.
31
Project TEACH was a church-based program to impact obesity in African
American women participants between the ages of 20 and 65. The individuals self-
reported being in reasonably good health, overweight, having a BMI body mass index
great than 27.5, and having no debilitating injuries or illnesses. Cooper, King, and
Sarpong (2015) researched this program that was implemented over 12 weeks within the
church, in hopes of establishing new health habits. Overall, at the completion of the
intervention, the mean changes in weight, BMI calculation, and circumference
measurement were all statistically significant.
The decrease in all measurements suggested that Project TEACH was successful.
Although the project results showed success, there were limitations to the program. The
12 weeks required a level of commitment that was not possible for all participants.
Because the program was free, it may have encouraged participants who were less
invested and not strongly committed to making changes, decreasing the likelihood of
consistency and involvement. The program was also held during the holiday season,
October through January. This may have also affected consistent attendance. Although it
seemed that this did not negatively impact the group, perhaps the positive results could
have been greater during another time of the year. The age range of invited participants of
20 to 65 years also frustrated the excluded individuals who wished to participate. Project
TEACH has shown that even with a small sample, educating and promoting health
among African American community will provide a knowledge base which will
potentially help to reduce monumentally significant health disparities.
In a study, Sessoms and Payne (2013) examined a group of African Americans in
September 2006 who attended Mississippi Boulevard Christian Church in Memphis,
32
Tenn. The goal was to increase the women’s physical activity and endurance by starting a
running program that would lead to running races. A group of six church members grew
to over 150 church members known as “Sisters in Motion Memphis.” The majority of the
members attended approximately four to five races per year. This study showed that this
group of women went from depending on their individual efforts to improve their
physical activity to community health improvement collectively. As a group, “Sisters in
Motion Memphis” were able to increase their physical activity and endurance.
Seale et al. (2013) studied 20 African American church members who previously
participated in a church-based group weight loss program. The members were recruited
to participate in focus groups. A qualitative inquiry focused on the role of faith in
maintaining healthy lifestyle behaviors, such as healthy eating and regular physical
activity. This study resulted in the identification of seven conceptual domains that the
participants thought were important aspects of a faith-based weight-maintenance
program. They included (a) accountability for change targets, (b) programmatic tools, (c)
group benefits and support, (d) keys to successful behavior change, (e) keys to church
and programmatic level success, (f) addressing barriers, and (g) faith. Eleven
recommended components for a faith-based weight maintenance program were
developed. The top four included scriptures and prayers which were; “walk of faith,”
healthy diet, exercise, and focusing on God. The results suggest that integrating faith
themes into a weight loss maintenance program may increase its long-term impact on
participants’ health behavior change.
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