Assessing the health knowledge, attitudes and behaviors of Midwestern African American adolescents.
|Abstract:||African Americans continue to die prematurely from preventable health conditions. The current study examined the health knowledge, attitudes and behaviors of African American adolescents and applied the socio-ecological model to those health needs. Three hundred and three African American adolescents aged 12-19 were surveyed. The results showed that the health knowledge was low among African American adolescents. There was a statistically significant relationship between overall health attitude and the amount of exercise actually completed. In regards to health behaviors African Americans adolescents reported not eating the recommended servings of fruits and vegetables nor engaged in the recommended physically activity.|
Lewis-Moss, Rhonda K.
|Publication:||Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500|
|Issue:||Date: Wntr, 2009 Source Volume: 24 Source Issue: 1|
|Product:||Product Code: E121930 Youth; 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs|
Disparities in health continue to be a serious problem in U.S. African Americans in particular continue to bear the burden of having poor health and dying prematurely from preventable and treatable health conditions. For instance, the death rate for heart disease among African Americans is more than 40% higher than Caucasians (U.S. Depart of Health and Human Services, 2000). Cancer death rates are 30% higher for African Americans than Caucasians (USDHHS, 2000) and African Americans also have higher hypertension rates than Caucasians (National Center for health Statistics, 2000). Thus it is important to address the social determinants of health (i.e., poverty and environment) that may be contributing to this problem.
The Healthy People 2010 initiative clearly states that having a healthy diet and being physically active are two behaviors that should be established, especially in childhood before poor health behaviors become entrenched (Cohall, 2001). Given the poor health outcomes of African Americans it is important to implement effective programs during adolescence. Therefore researchers should intervene at this level and make environmental changes so that positive health decisions can be supported.
In comparison to other Racial/Ethnic groups, African American adolescents are less likely to engage in healthy behaviors. According to the CDC African American high school students, are less likely to report participating in physical activity than Caucasian adolescents (CDC 2000). In regards to eating fruits and vegetables only 26% of African American males and 20% of African American females reported eating fruits and vegetables on a regular basis (Morbidity and Mortality Weekly Report, 2006).
Although, there have been a number of studies that have targeted African American adults in health interventions however only a few studies have focused on the health behaviors of African American adolescents. For instance, Befort, Kaur, Nollen, Sullivan, Nazir, Choi, Hornberger, & Ahluwalia (2006) designed their study to determine how location impacts fruit and vegetable intake among African American adolescents. They found that when it came to eating fruits African American adolescents were more likely to eat fruits when they were eating a sit down meal, on the other hand when it came to eating vegetables African American adolescents reported that eating at a buffet was the place where they were more likely to eat vegetables. These results are promising particularly in determining the behavioral eating patterns of African American adolescents. However these results do not focus on physical activity which researchers have noted is an important part of being healthy (UDHHS, 2001). On the other hand Molaison, Connell, Stuff, Yadrick & Bogle (2005) conducted focus groups with African American adolescents to examine what personal and environmental factors had on eating fruits and vegetables. The authors made a number of recommendations to make environmental changes such as making fruits and vegetables more accessible to the youth. However the study did not note how the attitudes and behaviors of the youth needed to be changed in order to consume more fruits and vegetables. Lastly, Resnicow, Yaroch, Davis, Wang, Carter, Slaughter, Coleman, & Baranowski, (2000) implemented an intervention to reduce obesity among African American girls. The intervention showed that girls who consistently attended the intervention had higher nutrition knowledge scores, reported more low-fat eating, and were more likely to perceive the dietary changes as positive than those who did not attend the sessions consistently. This study shows the importance of conducting gender specific programs that address gender specific needs.
The literature outlined a number of studies to address dietary intake of African American adolescents. However a number of gaps remain: 1) a few studies lacked an emphasis on physical activity; 2) Resnicow was only responsive to the needs of adolescents girls; and 3) many of the studies focused on individuals and spent less time addressing environmental issues. Strategies that are implemented at multiple levels and are comprehensive are needed to reduce health disparities among African Americans.
We propose to use the socio-ecological model developed by Stokols (1996) as a guiding framework to address the personal, cultural and environmental factors that influence health behavior. We apply the socio-ecological model to the participant's responses in order to determine potential ways public health practitioners might intervene. Other authors have also suggested using the socio-ecological model, for example, Robinson (2008) applied the socio-ecological model to improve fruit and vegetable intake among low income African Americans. Likewise, Green, Lewis, and Bediako (2005) suggested using the theory to reduce health disparities. Two theories, specifically the Transtheoretical and Health Belief Model (Glanz, Rimer & Lewis, 2002) are both widely cited theories that have been used in the literature, however, they were not selected for this paper because our focus intends to go beyond the individual behavior change these theories were based upon. Given the complicated nature of reducing health disparities we believe that using the socio-ecological model is a way to frame health disparities among Racial/Ethnic groups and take steps toward making systematic changes at all levels.
The social ecological model was developed by Stokols (1996) and provides a useful approach to addressing the multiple levels of society that would be needed to see a reduction in health disparities. Table 1 outlines the levels of influence and provides a description of where researchers might intervene.
First, the model states that intrapersonal issues would need to be addressed in changing health behaviors. For example the target of an intervention might focus on the knowledge that participants had concerning an issue and determine what the knowledge was and intervene to increase knowledge. Second, the model offers making interpersonal change which includes the family and friends in order to encourage healthy eating, for example. Third, organizational change is needed that enforces rules and regulation such as having smoke- free restaurants in an effort to reduce smoking and the side effects of second hand smoking. This is an example of trying to reduce smoking. Fourth, the model suggests addressing social networks and norms that either promote or change in behavior. Lastly, public policy might include policy change that would provide incentives for people to quit smoking and reduce their health insurance. In all, the socio-ecological perspective is an approach that promotes comprehensive change that reduces health disparities by targeting the health knowledge, beliefs and behaviors of individuals and while also providing the environmental supports of the family, organizations and community to reinforce healthy eating and exercise. In addition, to providing public policy change this would create institutional changes that foster support at each level of government to demonstrate the investment in promoting the health of all of its citizens.
To demonstrate how the socio-ecological model might be applied, the health knowledge, attitudes, and behaviors relating to eating fruits and vegetables and physical activity among a sample of African American adolescents was assessed. A cross-sectional study was conducted. Although the study examined the intrapersonal aspects of the socio-ecological model, the intent of the manuscript is to make recommendations that would address healthy disparities and offer a strategy to implement effective interventions for African American adolescents at all of the levels of influence.
PARTICIPANTS AND SETTING
The participants in this study were 303 African American adolescents aged 12-19 (Mean age was 14.5). There were 153 males and 150 females. Youth were recruited from Wichita, Kansas and surrounding cities through radio and newspaper articles as well as word of mouth methods. Participants were recruited from churches, youth sports teams (i.e., wrestling) and from youth serving organizations (i.e. Boys & Girls Clubs of South Central Kansas). The population in Wichita Kansas Metropolitan area is 452,000 according to the census (U.S. Census, 2002).
The study received approval from the Institutional Review Board at the local university. Youth along with their parents arrived at the university to complete the survey information. Youth and parents completed the informed consent forms. The consent form described how the youth could withdraw from the study at any time. After completing the consent forms youth were given a behavioral contract that informed them that the information they shared on the survey would not be communicated to their parents or shared with anyone else other than as an aggregate group individual answers would not be divulged.
The surveys were conducted on Saturdays and were administered by project staff. Surveys were given in large classrooms or a large auditorium at a local university. Participants were seated every other seat to ensure privacy and confidentiality. After surveys were completed project staff collected the surveys. Participants received a small cash incentive for completing the survey ($20.00)
Participants were asked to complete a 270 item survey which was developed by John and Loretta Sweet-Jemmott (Jemmott, Jemmott, & Fong, 1992). The survey consisted of questions on health behaviors, HIV/AIDS knowledge, health knowledge inventory and demographic information. For purposes of this study the health knowledge inventory (chronbach's alpha= .62), health attitudes (chronbach's = alpha .44) and health behaviors (chronbach's alpha =.45) was used to investigate the health knowledge, attitudes, and behaviors of African American adolescents. All of the health attitudes or behaviors were not used in the analysis however when chronbach was performed on similar questions chronbach displayed a higher alpha score. Table 2 outlines the questions that were used.
Statistical analyses were performed using SPSS version 16. Frequencies, means and standard deviations and cross tabulations were used to summarize the data. Chi-squares were conducted for the health knowledge questions, Pearson-product moment correlations were ran for the health attitude questions and descriptive statistics were ran for the health behavior questions.
The results showed that the overall health knowledge of African Americans was relatively low and that participants did not know or did not answer the questions correctly concerning general health knowledge. In regards to health attitudes African American adolescents feel strongly about not smoking and intend to exercise in the future. Health behaviors such as eating more fruits and vegetables and being physically fit are behaviors that need improvement if health disparities are to be adequately addressed in this population.
Health knowledge was analyzed by creating a health knowledge score and determining which questions were answered correctly by participants. Five questions were reversed scored so that low scores indicated a correct answer. Overall health knowledge for African American adolescents was fairly low in terms of the number of questions participants answered correctly. A chi-square was conducted to assess differences in genders on health knowledge. There was no statistically significant difference between males and females on the health knowledge scores. African American males and females were similar in knowledge of various health issues.
Health attitudes were analyzed by creating a health attitudes score from four health attitude questions (feelings about cigarettes in the next three months, feelings about doing aerobic exercise in the next three months, likelihood of smoking in the next three months and likelihood of doing aerobic exercise in the next three months). The mean health attitude score was 8.07 with a minimum score of 4 and a maximum score of 20. Table 3 lists the male and female frequencies and percentages of the health attitude responses by question. Table 4 outlines the means and standard deviations of each health attitude question. Participants felt strongly that smoking was a bad idea and reported that the likelihood of them smoking in the next three months was low. A significant correlation was found for feelings about smoking in the next three months and the likelihood of smoking in the next three months (r = .50, p<.01). Thus if participants felt smoking was a bad idea they also reporting not intending to smoke in the next three months. Table 4 also highlights participants' feelings about exercise. The mean scores indicate that participants' who had positive feelings about exercising were more likely to have favorable attitudes about intending to exercise in the next three months.
Although there was no statistically significant correlation between health attitude and health knowledge, there was a statistically significant relationship between overall health knowledge and likelihood of smoking in the next three months (r.=12, p = 46). This suggests having more knowledge of healthy behaviors is related to deciding not to smoke cigarettes in the next 3 months.
Table 5 lists the means and standard deviations of health behavior. Overall the average number of days the participants exercised was 2.89. The average number of days vegetables were eaten in the past 7 days was 3.34 which was higher than the number of days participants ate fruit which was 2.88. Both genders were not likely to eat fruits or vegetables. A chi square analysis to test gender differences in health behaviors was conducted to compare the number of days, fruits and vegetables were consumed in the past 7 days. The results showed that there were no statistically significant differences between males and females in the sample.
In regards to exercising, a chi-square analysis was conducted to compare the differences between males and females and the results showed no statistically significant difference, although, the statistical test did approach statistical significance at .08.
There was a statistically significant relationship between overall health attitude and the amount of exercise actually completed. This implies that participants with more favorable health attitudes were likely to engage in more exercise per week. The data suggest that African American adolescents are not engaged in sufficient physical activity as they should be nor are they eating the recommended fruits and vegetables that lead to a healthy lifestyle and reduce chronic diseases.
This study like other studies found that African American adolescents are not eating the recommended servings of fruits and vegetables (Befort, Kaur, Nollen et al, 2006, Lewis-Moss, Paschal, Redmond, et al, 2008, Molision et al, 2005) nor are they engaged in physical activity as recommended. A number of factors both personal and environmental (i.e. poverty, access issues) are effecting their behavior. This study revealed that the more positive attitude the participants had toward a behavior they were the more likely they were to engage in that behavior or refrain from it such as exercise or smoking in the next three months, respectively. The study also showed the health knowledge of both genders needs to be addressed. Not only is this information important for the adolescent to know and understand but being aware of health issues can impact the health of their loved ones and future generations. It is important to note that education alone is not effective to change behavior but it is often the first step toward behavior change. Thus it is crucial for researchers to implement interventions that adequately addresses the health knowledge, attitudes and behaviors of African Americans. The socio-ecological model is a logical next step toward eliminating health disparities.
A number of intrapersonal factors need to be addressed in this African American adolescent sample. For example, a fairly large percentage of African American adolescents did not answer the health knowledge questions correctly and because of their lack of knowledge they responded "don't know" on the survey. The health knowledge they hold concerning cigarettes and their harm should be reinforced by developing interventions that are designed to support negative attitudes toward smoking as African American enter adulthood. As African Americans move into adulthood they start smoking and it is often very difficult for them to quit smoking (Flack, Mann, Ramappa, & Rangi, 2000).
In regards to the interpersonal levels of change toward reducing health disparities, participants reported not eating fruits and vegetables or exercising. Interventions targeting aspects of behavior are needed with family and friends that support a healthy lifestyle. Interventions might include family and friends and help families learn to cook nutritious healthy meals and support a smoke free lifestyle.
ORGANIZATIONAL LEVEL OF INFLUENCE
Organizational change might occur as organizations institute rules and informal structures to promote healthy eating and physsical activity. Organizations such as schools might re-introduce more physical activity in schools and create healthier school lunches.
Interventions on the community level might target neighborhood associations to work with youth and civic organizations such as Boys & Girls Clubs to support exercise and healthy eating and make neighborhoods safer to walk in. These community organizations could make being physically fit and eating healthy be part of what the neighborhood association's support particularly in terms of community gardens, developing newsletters, and bringing in grocery stores that have affordable and high quality fruits and vegetables. Interventions could also target neighborhoods to build more parks, set up security, install lights to make neighborhood safe to walk around the block. It is likely that the participants who completed the survey may have had negative attitudes about eating healthy or their families may not have had access to fruits and vegetables that are affordable.
Local, state and federal policies are needed that invest in people and promote a positive health message. Governmental agencies can leverage public and private dollars to target disease prevention and health promotion by allowing youth to use the school facilities after hours and on weekends, to develop relationships with local gyms to offer a reduced monthly charge, to implement policies that ban smoking in restaurants and encourage restaurants to offer a variety of healthier food choices such as vegetables for people to try.
The socio-ecological model offers a logical next step towards reducing health disparities. All interventions cannot be focused only on changing the knowledge, and attitudes of program participants. Although this is an important influence on behavior, after the program participants understand the importance of general health knowledge and having attitudes against smoking there needs to be support from the family, organizations, community and society (public policy) that reinforce what the person has been encouraged to do. For instance, it is contradictory to convince youth to eat healthy or exercise then allow vending machines full of unhealthy snacks in their schools. Interventions are needed that ensure that positive behavior change begins and is maintained. If these poor behaviors are not curbed in adolescents the adolescent will likely continue these behaviors into adulthood and model these behaviors with their children and family, friends, organizations, and other community members.
A number of limitations are noted. First, this study used a convenient sample which may not generalize to all African American adolescents living in this Midwest city. Second, the answers were based on self-report and self-report information may not be truthful or valid in that participants may have just filled in answers without thinking. Third, the survey was long and may have caused the participants to be fatigued resulting in inaccurate responses. Fourth, a Cronbach's alpha test was conducted to determine how the items for health knowledge, health attitudes and the health behavior questions held together. The Cronbach's alpha test was fairly low. However anecdotal information notes that if there is a low Cronbach's alpha score it may be due to the number of items that were calculated to generate the Cronbach and in this case the number of items was low with the exception of the health knowledge scale. The health knowledge questions may not have held together because of the variety of issues included on the scale. The health knowledge scale included information concerning smoking to breast cancer which may have contributed to the low Cronbach's alpha score.
Future research should be focused on implementing interventions that target all of these levels in order to reduce health disparities. The socio-ecological model requires an interdisciplinary approach to addressing health disparities and all social scientists are needed to implement these kinds of interventions. For example, potential funders would need to understand the multiple levels in which people can change and might be encouraged to change. Those change mechanisms need to be in place if behavior change is to be supported and maintained. Another important future research project would be to target healthy eating and promoting physical activity in one study and determine what might be the barriers for getting males and females involved. According to this sample, males (not statistically significant) reported being involved in sports more so than females. Researchers may need to examine ways to make exercise more attractive for females.
Chronic diseases are disproportionately present in the African American community and dramatic changes are needed to reduce health disparities. Designing effective interventions are needed to get youth, families, friends, organizations, community members and public policy makers to understand the impact that disparities in health can affect the entire society. Researchers need to change attitudes of young people towards fruit and vegetable consumption but at the same time build structures in their homes, neighborhoods and leisure time that supports these healthy behaviors.
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Rhonda K. Lewis-Moss, PhD, is an Associate Professor of Psychology, Wichita State University. Angelia Paschal, PhD, is an Assistant Professor in Preventive Medicine, University of Kansas School of Medicine. Jamilia Sly, MA, is a Doctoral Student, Wichita State University. Shani Roberts, MA, is a Doctoral Student, Wichita State University. Shoshana Wernick, MA, is a Doctoral Student, Wichita State University. Please address all correspondence to Rhonda K. Lewis-Moss, PhD, 1845 N. Fairmount, Box 34, Wichita, KS 67260. Phone: 316-978-3695, Fax: 316-978-3086, Email: email@example.com.
Table 1. A Socio-Ecological perspective: Levels of Influence Levels of Description Influence Intrapersonal Individual characteristics that influence behavior, such as knowledge, attitudes, beliefs and personality traits Interpersonal Interpersonal processes, and primary groups including family, friends, peers that provide social identity, support and role definition Organizational Rules, regulation, policies, and informal structures, which may constrain or promote recommended behaviors Community Social networks and norms, or standards, which exist as formal or informal among individuals, groups and organizations Public policy Local, state, federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control and management. (National Cancer Institute, 2008) Table 2. Health Knowledge, Attitude and Behavior Questions Health Knowledge questions Health Attitudes questions Smoking cigarettes does not How do you feel about smoking affect your lungs cigarettes in the next 3 months Being around someone who How do you feel about doing smokes is not a very dangerous aerobic exercises 3-4 times to one's health a week for a least 20 minutes in the next 3 months Nicotine in cigarettes makes How likely is it that you will smoking addictive smoke cigarettes in the next 3 months You can have high blood How likely is it that you will pressure and not know it do aerobic exercise 3-4 times a week for at lest 20 minutes in the next 3 months Cigarette smoking makes the heart beat slower When breast cancer is diagnosed early the rate of cure is high Most women who get breast cancer have no family history of it A woman should examine her breasts every month within one week after her menstrural period To have a healthy body, person should do aerobic exercise at least 20-30 minutes 3 to 4 times a week Aerobic exercises are the best exercises to strengthen your heart Weight lifting is a good way to strengthen your heart Exercise affects how much fat you have in your body A well balanced diet includes protein, vitamins, minerals, fat, carbohydrates and water Meat is a good source of carbohydrates Fruits are a good source of fiber Eating fiber is a good way of preventing colon cancer One drink of beer has the same amount of alcohol as one serving of wine or liquor Drinking a lot of alcohol increases the chance a person will get heart disease and cancer Two marijuana joints can hurt your lungs as much as 20 cigarettes Using cocaine raises your blood pressure, heart rate and body temperature Cancer of the testes is most common among men between the ages of 15 and 34 If testicular cancer is detected early, it is easy to treat The best time to do testicular self-exam is after a warm bath or shower, when scrotal skin is more relaxed Mismanaged anger can result in domestic violence and road rage One out of every 5 American has an anger management problem Relaxing clenched muscles is a strategy to use to keep calm Health Knowledge questions Health Behavior questions Smoking cigarettes does not In the past 7 days, on affect your lungs how many days did you eat fruit? Being around someone who In the pas 7 days, on smokes is not a very dangerous how many days did you to one's health eat vegetables? Nicotine in cigarettes makes In the past 7 days, on smoking addictive how many days did you exercise for 20 minutes or more? You can have high blood In the past 7 days what pressure and not know it exercises did you do? Cigarette smoking makes the heart beat slower When breast cancer is diagnosed early the rate of cure is high Most women who get breast cancer have no family history of it A woman should examine her breasts every month within one week after her menstrural period To have a healthy body, person should do aerobic exercise at least 20-30 minutes 3 to 4 times a week Aerobic exercises are the best exercises to strengthen your heart Weight lifting is a good way to strengthen your heart Exercise affects how much fat you have in your body A well balanced diet includes protein, vitamins, minerals, fat, carbohydrates and water Meat is a good source of carbohydrates Fruits are a good source of fiber Eating fiber is a good way of preventing colon cancer One drink of beer has the same amount of alcohol as one serving of wine or liquor Drinking a lot of alcohol increases the chance a person will get heart disease and cancer Two marijuana joints can hurt your lungs as much as 20 cigarettes Using cocaine raises your blood pressure, heart rate and body temperature Cancer of the testes is most common among men between the ages of 15 and 34 If testicular cancer is detected early, it is easy to treat The best time to do testicular self-exam is after a warm bath or shower, when scrotal skin is more relaxed Mismanaged anger can result in domestic violence and road rage One out of every 5 American has an anger management problem Relaxing clenched muscles is a strategy to use to keep calm Table 3. Frequencies and Percentages of Health Attitude Responses by Gender Health Attitude Males %(n) Females%(n) Responses Feelings about smoking Very bad idea 62.7% (96) 60% (91) Bad idea 21.6% (33) 20% (30) In the middle 13.1% (20) 15.3% (23) Good idea 2% (3) 1.3% (2) Very good idea 0.7% (1) 0.7% (4) Feelings about exercise Very bad idea 8.5% (13) 3.3% (5) Bad idea 6.5% (10) 3.3% (5) In the middle 20.3% (31) 16.7% (25) Good idea 26.1% (40) 34% (51) Very good idea 38.6% (59) 42.7% (64) Likelihood of smoking Extremely Unlikely 60.1% (92) 62.7% (94) Moderately unlikely 13.7% (21) 14.7% (22) In the middle 17.6% (27) 12.7% (19) Moderately Likely 4.6% (7) 5.3% (8) Extremely Likely 3.9% (6) 4.7% (7) Likelihood of exercising Extremely Unlikely 7.8% (12) 9.3% (14) Moderately unlikely 13.1% (20) 9.3% (14) In the middle 31.4% (49) 34% (51) Moderately Likely 26.1% (40) 22% (33) Extremely Likely 20.9% (32) 25.3% (38) Table 4. Means and Standard Deviations of Health Attitude Variables By Gender Responses Overall Standard Male Mean Deviation Mean Attitudes toward Smoking 1.66 1.18 1.62 Attitudes toward Exercise 2.06 1.15 2.20 Likelihood of Smoking 1.77 1.14 1.78 Likelihood of Exercising 2.58 1.20 2.61 Responses Male Female Female Standard Mean Standard Deviation Deviation Attitudes toward Smoking 1.15 1.70 1.20 Attitudes toward Exercise 1.26 1.91 1.02 Likelihood of Smoking 1.13 1.75 1.15 Likelihood of Exercising 1.18 2.55 1.23 Note: A low score indicates more positive health attitudes Table 5. Means and Standard Deviations of Health Attitude Variables By Gender Questions Overall Standard Male Mean Deviation Mean In the past 7 days the 1.66 1.18 1.62 number of days fruits were eaten In the past 7 days the 2.06 1.15 2.20 number of days vegetables were eaten In the past 7 days the 1.77 1.14 1.78 number of days of exercise Questions Male Female Female Standard Mean Standard Deviation Deviation In the past 7 days the 1.15 1.70 1.20 number of days fruits were eaten In the past 7 days the 1.26 1.91 1.02 number of days vegetables were eaten In the past 7 days the 1.13 1.75 1.15 number of days of exercise
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