Background
Cardiovascular diseases (CVD) are the leading cause of death for women in the United States [
1]. Approximately 58.8% of non-Hispanic Black females and 42.7% of Hispanic females aged 20 years or older have CVD [
1]. One reason Black/African American and Hispanic/Latinx women are disproportionately affected by CVD is a higher prevalence of lifestyle-related risk factors, such as poor diet quality and physical inactivity [
2,
3]. Addressing these lifestyle risk factors through community-level interventions can reduce CVD risk, particularly for underserved and minority populations [
4].
One way to address CVD-related risk factors is to deliver evidence-based interventions (EBIs) that improve behavioral and health outcomes. Whether targeting whole populations or specific groups, health interventions are complex because they operate through active contextual interactions with significant variations across different populations and settings [
5]. Strong Hearts Healthy Communities (SHHC) is a 24-week multilevel EBI that has been demonstrated to be effective in reducing CVD-related health behaviors and outcomes among rural women living in medically underserved communities [
6]. SHHC focused on providing strength training, aerobic exercise, skill-based nutrition education and civic engagement components related to healthy food and physical activity environments. In intervention versus control participants, significant improvements were observed in body weight, body mass index (BMI), C-reactive protein and Life’s Simple 7 CVD risk score [
6].
Adapting EBIs that have proven effective in improving health behaviors and outcomes can help in the prevention or management of chronic diseases and save resources associated with developing new interventions for each context [
7]. Furthermore, research evidence has demonstrated the benefits of tailored EBIs compared to EBIs that were developed in a different setting or context [
8]. For instance, interventions tailored to a specific population’s culture, goals, needs, values, and beliefs are more likely to be accepted and utilized than those created without considering a population’s needs [
9,
10]. Additionally, understanding the needs of the population of interest, can help to better inform the design and implementation of health interventions [
10]. However, while the tailoring and adapting EBIs may involve assessing the population of interests’ socio-environmental context, goals, needs, values, beliefs, history, traditions, or language and using this information to tailor the intervention based on that knowledge, the decisions of what, when and how to adapt an EBI are not straightforward [
11,
12].
Previous research has not fully explored the perceptions, values and experiences that shape the health goals and needs of Black/African American and Hispanic/Latinx urban women. Therefore, to access the necessary information to tailor and adapt the SHHC program to an urban setting and a more diverse population, we conducted qualitative focus groups (FGs) to gain a current and in-depth understanding of the general health, diet, physical activity, and stress-related needs and goals of Black/African American and Hispanic/Latinx urban women.
Discussion
This qualitative study aimed to understand the health goals and needs of African American/Black and Hispanic/Latinx women in urban communities and to identify how the SHHC intervention could be adapted to address their health goals related to CVD prevention. Our findings revealed awareness and a positive attitude toward the importance of a healthy lifestyle. However, there were many barriers to trying to practice healthier behaviors. There was a strong link between culture, food, and community. Our participants reported that some of their cultural-related communal food practices promote unhealthy eating behaviors. Additionally, discussions on stress were viewed as culturally inappropriate, with generational differences in stress relief activities. For future health programs, there was a desire for individualized nutrition while building various nutrition-related skills and accessible, enjoyable physical activities since family social support was only possible where there were shared health goals. There was a preference for programs offering small-group or one-on-one support opportunities to achieve health goals.
Prior health studies have shown that Americans have relatively good knowledge and positive attitudes toward the importance of healthy eating and exercise in promoting good health [
14]. However, knowledge and positive attitudes alone do not translate to behavior [
15]. According to previous research, while health knowledge is important, broader social, economic and environmental factors influence the capacity to adopt and sustain healthy behaviors [
16]. Similarly, our results indicate that participants had good knowledge and positive attitudes regarding healthy lifestyle behaviors. Nevertheless, many participants faced obstacles to adopting or sustaining these behaviors, such as cost, time, and major life events, potentially exacerbated by social, economic and environmental constraints. Therefore, in addition to increasing awareness, health programs may address barriers to support the desired outcomes of healthier lifestyle behaviors. Furthermore, recognizing the influence of broader systemic influences, including social, economic, and environmental aspects, future studies should investigate these upstream factors in more depth to further understand their influence in impacting individual capacity to engage in a healthy lifestyle.
Participants in our study expressed a desire for individualized nutrition advice. Based on previous studies, this approach is likely to be more effective than generalized nutrition advice. Many dietary programs and guidelines often include a “one size fits all” nutrition approach but research evidence suggests that programs tailored to meet individual needs may be more acceptable and effective. For instance, the Food4Me trial, showed that adults who received individualized nutrition intervention had more significant changes in eating behavior after six months compared to the control who received conventional nutritional advice [
17]. These findings suggest that programs that offer opportunities to tailor nutrition education to individual needs are more effective. Therefore, future programs, including the adaptation of SHHC, may be more effective by delivering tailored nutrition interventions highly personalized to individual health needs, motivations, and assessments.
Additionally, our findings indicate a desire for programs that offer accessible, enjoyable, and familiar forms of physical activity over novel ones. Although novelty can initially attract individulas to physical activity [
18,
19], sustained engagement often relies on familiarity and enjoyment. For the women in this study, being familiar with the exercises in a health program, as well as enjoying and having access to the exercises, was preferred for engaging in and maintaining physical activity behavior. Undoubtedly, people often engage in novel physical activity where they are curious about the activities and their ability to perform them. However, this is usually short-lasting as the novelty period wears off, and many individuals discontinue [
18,
20]. Therefore, what may cause positive, sustainable changes in physical activity behavior may be rooted in how strongly the activity is supported by the individual’s social and environmental context [
20]. Thus, when designing interventions for African American/Black and Hispanic/Latinx urban women, activities such as walking and strength training (with or without weights) that are either physically and economically accessible would be more appealing and more likely to have continuity post-intervention—further understanding the barriers faced and how agency may be fostered through environmental and social mechanisms to encourage these women to engage in physical activity. These mechanisms may be as simple as having accessible transportation that is free or affordable to attend a healthy lifestyle program and creating an environment with support from fitness professionals, coaches, and peers, all of which can empower women to make positive physical activity choices.
While common barriers to engaging in healthy behaviors, such as weather, cost and time constraints, were identified in this study, it is interesting to note that major life events and transition times, such as going back to school, starting a family, and having a physical injury, were often the reasons why they stopped engaging in healthy behaviors. Life events and transitions often affect how people engage in healthy eating, physical activity and sleep, negatively impacting heart health [
21,
22]. The American Heart Association recommends practical strategies to support people in maintaining healthier lifestyles during major life events and transitions by building resiliency [
21]. Health programs such as the SHHC may be designed to increase awareness of the importance of maintaining a healthy lifestyle during major life events and transitions and offer relevant strategies applicable to such times.
In many cultures, including African American/Black and Hispanic/Latinx cultures, food has a social and communal role that is deeply entrenched as a channel of traditions, love, identity and acceptance [
10,
23]. Consequently, culture influences the selection and preparation of food and even the frequency of consumption of certain foods [
24]. For our study, while the culture around food positively fostered love and community, culture also contributed to unhealthy eating, including the consumption of large portions and increased consumption of energy-dense foods with high fat and added sugar. Culture also contributed to the social undermining of those who attempted to practice healthier behaviors. Our findings align with several qualitative studies that show a strong cultural tie to food in similar populations and the associated intake of foods high in calories, fats and sugars that can increase the risk of chronic diseases [
23,
25]. Others have also found that social expectations to conform to cultural norms often hinder healthy behaviors [
26]. Since food and culture are highly interconnected, future interventions could aim to preserve positive food culture while encouraging strategies for individuals to manage social norms and conflicts related to food and eating [
27].
Additional findings related to culture included the challenge of discussing stress, as it was often viewed as a sign of weakness and a personal matter to be kept private. There were also generational differences in approaches to stress management. These findings are not unlike those of other studies that have shown similar cultural and generational views of stress and stress management [
28,
29]. Individuals from the “baby boomer” generation often read or pray to manage stress [
29], while younger generations (e.g., Gen Z) are more open to discussing stress and mental health [
29]. Furthermore, the American Psychological Association found that millennials were more likely than older generations to engage in sedentary activities and other unhealthy behaviors such as alcohol abuse and smoking to relieve stress [
28]. Considering the cultural and generational views of stress and stress management, health programs could consider fostering an environment of open and non-judgmental dialogue and communication to help break down the cultural barriers associated with discussing such issues. Additionally, they could consider promoting different healthy coping strategies relevant to the age of individuals in the intervention.
Social support has repeatedly been linked to better long-term health outcomes [
30]. Individuals with strong social support are more likely to care for their physical and mental health than those with weaker social support [
31]. In our study, when family members had shared health interests, they directly or indirectly encouraged healthier lifestyle behaviors for the participants. In situations where families did not share similar health interests, there was either social undermining or no support. These findings concur with those of a study exploring how social relationships influence the health behaviors of adults at risk of chronic diseases, where the attitudes and actions of family members are either facilitators for supporting or sabotaging health behaviors [
26]. Their study also found that making healthier dietary changes was easier if spouses and family members were supportive, and that positive role modeling and encouragement from family members facilitated the adoption and maintenance of physical activity behaviors. In contrast, the lack of familial support affected motivation toward positive health behaviors [
26].
Furthermore, in our present study, there was hesitancy to involve unsupportive family members in making health behavior changes. Many previous health programs have focused on leveraging family and friends’ social support to improve behavioral health [
31]. However, with evidence that social undermining can be detrimental to practicing healthy behaviors [
26], future health interventions should consider providing avenues to build social support from like-minded participants or family members with shared health goals, as well as building on self-determination to motivate and sustain behavior change in the absence of adequate social support [
32].
A small sample size may be a limitation of our study, yet, it is important to note that thematic saturation was achieved, ascertained during the analysis process and supported by previous studies that indicate that more than 80–90% of all themes are discoverable using three to six FGs [
33]. Most of the participants were African American/Black, so the findings may not entirely represent the experiences of Hispanic/Latinx women. We did identify commonalities across cultures, for instance, the role of food in culture and the cross-cultural views on stress. Our analysis, however, did not identify differences between African American/Black and Hispanic/Latinx participants. This is not to suggest that important differences may not exist. As such, future studies with larger samples of diverse women are needed to confirm or expand upon the study findings presented herein.
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