A GEOGRAPHIC COMPARISON OF AFRICAN AMERICANS HEALTH BEHAVIORS USING THE BRFSS.

Abstract: Health disparities continue to exist between African Americans and Caucasians. Health promotion efforts have been in place for many years in an attempt to better the health of African Americans. Despite these efforts disparities continue to exist and in some cases the gap has widened. The purpose of this paper was to use the Behavioral Risk Factor Surveillance Survey data, a national random-digit dialing telephone survey to examine various self reported health behaviors among African Americans in two geographic areas. Findings indicate that efforts have not been successful in changing overall health behaviors of African Americans. By utilizing the BRFSS and other data sources health professionals can monitor the success of programs in eliminating racial and ethnic disparities and determine areas that still need attention.

Despite the efforts to eliminate the health disparities among African Americans and the majority culture health disparities continue to exist. Numerous health promotion programs have been conducted in African American churches and in the community to reduce health problems that affect African Americans (Lewis & Green, 2000; Lowe, Barg, Norman, & McCorkle, 1997; Weinrich et al., 1998; Young, Miller, Wilder, Yanek, & Becker, 1998). Yet African Americans continue to report low exercise rates (Airhihembuwa, Kumanika, Agurs, & Lowe, 1995), smoke (Association, 1999), and eat an inadequate amount of fruits and vegetables (Lewis & Green, 2000). For example, several health promotion programs have been implemented in churches to lower the risks associated with adverse health outcomes, such as, eating more fruits and vegetables (McClelland, Denmark-Wahnefried, Mustian, Cowan, & Campbell, 1998). These programs have showed promise but the overall impact of reducing the disparities in health status has been minimal. To determine what factors might interfere with participation in various health promotion programs, Airhihembuwa, 1995 conducted a study to identify barriers. (Airhihembuwa et al., 1995). Other studies have focused on the attitudes and beliefs of African Americans to determine what impact attitudes and beliefs have on health behaviors and subsequent health outcomes (Lewis & Green, 2000; Thomas & Fick, 1993). In addition, these studies also show that African Americans are not participating in health programs or unaware of the existence of health programs in their communities (Lewis & Green, 2000).

It is understood that health promotion programs emphasize changes in psychosocial antecedents because most health outcomes are associated with these antecedents (i.e. diet, exercise, blood pressure checks), however, it is equally important to focus on issues such as public and provider education, prevention research, and policy and environmental changes that facilitate healthy living. To be effective, however, these strategies must be supported by ongoing surveillance of health risks. By the early 1980s, scientific research clearly showed that personal health behaviors played a major role in premature morbidity and mortality (Dixon, 1994). Although national estimates of health risk behaviors among U.S. adult populations had been periodically obtained through surveys conducted by the National Center for Health Statistics (NCHS), these data were not available on a state-specific basis. This deficiency was viewed as critical for state health agencies that have the primary role of targeting resources to reduce behavioral risks and their consequent illnesses. National data may not be appropriate for any given state; however, state and local agency participation was critical to achieve national health goals.

The purpose of this paper is to use the Behavior Risk Factor Surveillance Survey (BRFSS) using years 1995-1998 to examine the prevalence of selected self reported health behaviors, such as, exercise, alcohol use, tobacco use, weight loss, and hypertension among African Americans in Alabama and Kansas. It is important to focus on the health behaviors of African Americans as a group to isolate behaviors that are putting them at risk and behaviors that might be protective. Although, a comparison of African Americans to Caucasians is how one determines disparities in health status exist it doesn't look for commonalities within groups to develop programs that are culturally specific. The findings from this study might offer insights on how to target African Americans living in different regions and implement health promotion programs in various states to reduce the health disparities. The study will examine whether progress is being made toward reducing poor health behaviors thereby eliminating the health disparities among African Americans and Caucasians. It is important that the BRFSS is used and the findings communicated to alert communities and health professionals of improvements or continued problems in the areas that effect health outcomes. Other states might use this manuscript as a model to determine how their states compare to the nation and surrounding states.

This manuscript examines two states, Alabama and Kansas, using the BRFSS. First, we describe the two state samples used in the BRFSS. Second, we discuss the methods used to gather the data in each state. Third, we outline the results. Fourth, we discuss the implications for future health promotion programs and future research.

METHODS

The Behavioral Risk Factor Surveillance System (BRFSS) is a collaborative project of the Centers for Disease Control and Prevention (CDC), and U.S. states and territories. The BRFSS, administered and supported by the Behavioral Surveillance Branch (BSB) of the CDC, is an on-going data collection program designed to measure behavioral risk factors in the adult population 18 years of age or over living in households. The BRFSS was initiated in 1984, with 15 states collecting surveillance data on risk behaviors through monthly telephone interviews. The number of states participating in the survey increased, so that by 1997, 50 States, the District of Columbia, Puerto Rico, Guam, and the Virgin Islands were participating in the BRFSS (Prevention, 2000).

The objective of the BRFSS is to collect uniform, state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases in the adult population. Data are collected from a random sample of adults (one per household) through a telephone survey (Prevention, 2000).

PROCEDURE

Field operations for the BRFSS are managed by the health departments under guidelines provided by the BSB. These health departments participate in the development of the survey instrument and conduct the interviews either in-house or through use of contractors. The data are transmitted to the National Center for Chronic Disease Prevention and Health Promotion's Behavioral Surveillance Branch at CDC for editing, processing, weighting, and analysis. An edited and weighted data file is provided to each participating health department for each year of data collection, and summary reports of state-specific data are prepared by the staff of the BSB. Health departments use the data for a variety of purposes, including identification of demographic variations in health-related behaviors, targeting services, addressing emergent and critical health issues, proposing legislation for health initiatives and measuring progress toward state and national health objectives (Prevention, 2000).

The health characteristics estimated from the BRFSS pertain only to the adult population age 18 years and older living in households. As noted above, respondents are identified through telephone-based methods. Although 95 percent of U.S. households have telephones, coverage ranges from 87-98 percent across states and varies for subgroups as well. For example, persons living in the South, minorities, and those in lower socioeconomic groups typically have lower telephone coverage. No direct method of compensating for non-telephone coverage is employed by the BRFSS; however, post-stratification weights are used, and may partially correct for any bias caused by non-telephone coverage. These weights adjust for differences in probability of selection and nonresponse, as well as noncoverage, and must be used for deriving representative population-based estimates of risk behavior prevalence (Prevention, 2000).

INSTRUMENTATION THE BRFSS QUESTIONNAIRE

The questionnaire has three parts: 1) the core component, consisting of the fixed, rotating, and emerging core; 2) optional modules; and 3) state-added questions. Core component. The fixed core is a standard set of questions asked by all states. It includes queries about current health-related perceptions, conditions, and behaviors (e.g., health status, health insurance, diabetes, tobacco use, selected cancer screening procedures, and HIV/AIDS risks) and questions on demographic characteristics. The rotating core consists of two distinct sets of questions, each asked in alternating years by all states, addressing different topics. In 1997, the rotating core items covered cholesterol, hypertension, injury, immunization, colorectal screening and alcohol use. The emerging core is a set of up to five questions that are added to the fixed and rotating cores. Emerging core questions typically focus on issues of a "late breaking" nature and do not necessarily receive the same scrutiny that other questions receive prior to being added to the instrument. These questions are part of the core for one year and are evaluated during or soon after the year concludes to determine their potential value in future surveys.

Optional CDC modules. These are sets of questions on specific topics (e.g., smokeless tobacco, firearms) that states elect to use on their questionnaires. In 1997, 16 modules were supported by CDC, including 3 that were rotating core topics not used in the 1997 core component. Information on statistical clustering and sampling procedures are described elsewhere (Prevention, 2000).

DATA COLLECTION INTERVIEWING PROCEDURES

Interviews for 1997 were conducted through computer-assisted telephone interviewing (CATI) by 49 areas; paper questionnaires were used in the other three surveillance areas. CDC supports CATI programming using the Ci3 CATI software package. Following specifications provided by CDC, state health personnel or contractors conducted interviews. The core portion of the questionnaire lasts an average of 10 minutes. Interview time for modules and state-added questions is dependent upon the number of questions used, but generally extend the interview period by an additional 5 to 10 minutes. Telephone interviewing was conducted during a two-week period each month, and calls were made 7 days per week, during both day and evening hours. Standard procedures in the interviewing were followed for rotation of calls over days of the week and times of the day. The median response rate (Upper Bound) for 1997 was 76.5 %, but ranged from 45.6% to 92.7% (Prevention, 2000).

RESULTS

This study compares the health behaviors and demographic variables of African Americans living in the South (Alabama) and the North (Kansas) to determine the impact of health programs and how that might relate to health behaviors and health status. What follows are the results from the BRFSS focusing on overall demographics of the populations, hypertension diagnosis, smoking status, weight control, alcohol consumption, and physical activity. Note that many states do not conduct the BRFSS yearly therefore some variables were only available for two years and have been labeled to alert the reader.

DEMOGRAPHICS

Table 1 describes the overall demographics of both populations for years 1995 -1998. The table includes the age of respondents, marital status, household income, school completed, and employment status. The age of respondents was similar in both states. Kansas residents are more likely to be married than Alabama residents and more Alabama residents report higher levels of being single. Residents in Alabama are more likely to make less than $15,000 a year when compared to the Kansas population. More Kansas residents had higher household incomes than the Alabama residents. The rates of high school graduation was slightly higher for Alabama residents, but Kansas residents were more likely to have some post high school education and complete college. Residents in Kansas have a higher percentage of employed people than Alabama. For both Alabama and Kansas residents there were similar percentage of people who were self-employed, homemakers, worked greater than a year and less than a year. The percent (6%) of students was the same for both states and the percentage of retired persons was similar. Residents in Alabama had a higher percentage of people who were unable to work.

Table 1. Demographics of Respondents: Alabama and Kansas 1995-1998

Demographic Variables

                                   ALABAMA   KANSAS

Age of Respondents                 (N=413)   (N=115)
  18-34                            20%       20%
  35-54                            18%       19%
  55 and above                     13 %      11%
Marital Status                     (N=449)   (N=114)
  Married                          42%       48%
  Never Married                    30%       24%
  Divorced/Widowed and Separated   9%        8%
Income                             (N=394)   (N=95)
  <15,000                          31%       14%
  15-24,999                        32%       30%
  25-34,999                        16%       23%
  35-49,999                        12%       21%
  50,000+                          9%        12%
School Completed                   (N=454)   (N= 118)
  Less than H.S.                   25%       14%
  H.S. or GED                      38%       36%
  Some post H.S.                   25%       34%
  College+                         12%       16%
Employment Status                  (N=454)   (N=118)
  Employed                         57%       66%
  Self-Employed                    4%        4%
  Homemaker                        4%        4%
  No Work > yr                     4%        2%
  No Work < yr                     4%        1%
  Student                          6%        6%
  Retired                          14%       13%
  Unable to Work                   8%        4%

Note these percentages represent African American respondents the percentages will not add up to 100%.

Hypertension: Table 2 includes data from years 1995 and 1997 for Alabama and Kansas. The table shows that the majority of the respondents indicated that they have had their blood pressure checked in the past six months (73% and 81% for Alabama in years 1995 and 1997 respectively and 77% and 64% for Kansas in years 1995 and 1997 respectively). The number of respondents indicating getting their blood pressure checked increased for Alabama residents while the number decreased from 1995 to 1997 for Kansas residents.

Table 2. Selected Health Behavior Questions from the Behavioral Risk Factor Surveillance Survey African Americans living in Alabama and Kansas

Health Status Questions

                                      ALABAMA      KANSAS

Blood Pressure Checked                (N=337(*))   (N=74(*))
   1995                               73%          77%
   1997                               81%          64%
Current Smoker                        (N=83(*))    (N=52(*))
   1995                               19%          24%
   1996                               20%          15 %
   1997                               16%          20%
   1998                               20%          23%
Trying to Lose Weight                 (N=481(*))   (N=137(*))
   1996                               37%          25%
   1998                               34%          36%
Told by Health Professional           (N=100(*))   (N=15(*))
They Needed to Lose Weight
   1996                               18%          12%
   1998                               16%          7%
Consumed Alcohol in the Past Month    (N=132(*))   (N=41(*))
   1995                               32%          35%
   1997                               32%          43%
Participated in Physical Activities   (N=284(*))   (N=73(*))
   1996                               57%          45%
   1998                               67%          55%

(*) Represents the average number of respondents for the years data were available

Smoking Status: Data concerning smoking status were available for years 1995 - 1998. Table 2 shows that overall the percentage of current smokers is higher among Kansas residents than Alabama residents with 1996 being the only exception. The trend in smoking in Kansas seems to decrease from 1995 to 1996 and then in 1997 increased and then further increased in 1998. In Alabama the percentage of smoking increased slightly in 1996 and then showed a decrease in 1997 and in 1998 showed a slight increase in smoking.

Weight Control: The BRFSS asks questions about individuals trying to lose weight and if individuals were told by a health professional to lose weight. A number of respondents indicated that they were trying to lose weight. Table 2 shows that over 1/3 of Alabama residents were trying to lose weight in 1996 and 1998. On the other hand, only about 1/4 of Kansas residents reporting trying to lose weight in 1996. In 1998 more Kansas residents reported trying to lose weight. Table 2 also shows the number of respondents indicating that they were told by a health professional they needed to lose weight. Overall more Alabama residents were told by a health professional they needed to lose weight compared to Kansas residents.

Alcohol Consumption: Table 2 shows the percentage of Alabama and Kansas respondents who reported consuming alcohol in the past month for the years 1995 and 1997. Kansas's residents reported a higher percentage of consuming alcohol in the past month than Alabama residents (35% to 43% in Kansas and 32% in 1995 and 1997 for Alabama). The percentage of alcohol consumption increased in Kansas from 1995 to 1997 but remained the same for both years in Alabama.

Physical Activity: Table 2 shows the percentage of people indicating participation in physical activities for the years 1996 and 1998. Alabama residents report a higher percentage of participation in physical activities than Kansas's residents. There was an increase in physical activity from 1996 to 1998 for both Alabama and Kansas's residents, but the Alabama residents were involved in physical activities more than the Kansas residents were overall.

DISCUSSION

The use and examination of the BRFSS data can be helpful in identifying health behavior patterns in the African American population. The authors chose to use data from their respective states to uncover the overall health of African American residents in those geographical areas. The BRFSS is helpful because it gathers data that allow researchers to compare regional differences especially between northern and southern states with the same questions and methodology. If programs are to be disseminated it is important to know the health behaviors of residents living in different geographic locations so that programs and services are tailored to meet their needs.

The differences that emerged from the data set could be attributable to the demographic differences reported in Table 1, such as household income, and employment status, which in general are related to overall health status. However, in this sample the Alabama residents reported more protective health behaviors than Kansas's residents. For example, more Alabama residents were reporting getting their blood pressure checked, lower smoking status, lower alcohol consumption, a desire to lose weight and higher physical activity than Kansas's residents. Although Kansas's residents reported having higher incomes, being college educated, being employed more than Alabama residents, they displayed more at risk behaviors such as not exercising, and having higher rates of smoking. This difference could also be the result of data gathering and the higher percentage of African Americans who live in the south.

Overall this analysis of the BRFSS provides us with a snap shot of African Americans in the North and South. The data shows that in both states some health behaviors are showing improvement, however there are key behaviors that still need improvement if health disparities are to be eliminated. What follows is a discussion of specific health behaviors that were identified need improvement.

Hypertension: Heart disease is the number one killer of all Americans, however for African Americans it can be especially deadly. Black women are more likely to die from it than their Caucasian counter parts. The majority of heart disease cases in African American men and women have been linked to high blood pressure. Hypertension is a serious problem in the African American community with rates twice as high when compared to Caucasian (Medicine, 1998). The BRFSS indicated that most African Americans are getting their blood pressure checked with between 73% and 81% from 1995 to 1997 in Alabama. In Kansas the rates are slightly lower with 77% and 64% from 1995 to 1997. Having regular blood pressure checks is an important part of detecting a problem with hypertension. This behavior should continue to be promoted with health education and health promotion programs. Other health behaviors must also be stressed with African Americans including cutting fat and salt from the diet, not smoking, exercising regularly, controlling alcohol consumption, and controlling stress.

Smoking: The current prevalence of smoking among African Americans is approximately 26% compared to 25% among Caucasian (Association, 1999). When smoking status is examined by gender, African American males have the highest smoking rates (32%). The smoking rates found in the BRFSS for African Americans was found to be slightly lower that the national average of smoking. However, the numbers show that not much progress is being made to lower or reduce the current smoking trends in this population. The incidence of smoking was around 22% in 1995, it was lowered in both 1996 and 1997 but increased back to the original 23% in 1998 in Kansas and 20% in Alabama. If current smoking patterns continue, an estimated 1.6 million African Americans who are now under the age of 18 will become regular smokers and about 1/2 a million of those smokers will die of a smoking-related illness. It is hoped that programs will continue to be implemented that would help to reduce the smoking trend among this population. Smoking is the one behavior that can make a significant difference in one's overall health status.

Weight Control: Weight control has always been an issue related to the overall health of African Americans especially among African American women. The BRFSS indicates that a large number of respondents indicated that they are trying to lose weight. The numbers may in fact be higher than reported because many African American women may feel that they are not overweight because of the perception of being heavier as being more desirable. Educational programs should not attempt to change the perceived body image of African American women but attempt to educate them about the proportion of lean body mass to body fat. This is a much better indicator of health and fitness than the total weight on the scale. Activities should continue that would promote physical activity and eating healthy foods. Surprisingly, only between 7% and 18% in% in both states reported being told by a health professional that they are overweight. This counters the percentage of individuals who indicated that they needed to lose weight with between 25% and 37%. This could be an indication that African Americans are not accessing the health care system or health professional are not advising individuals to lose weight.

Alcohol consumption: Surprisingly Kansas residents reported a higher percentage of consuming alcohol while the percentage for Alabama residents remained relatively unchanged. Perhaps this is due to the South being identified as the Bible belt where people continue to attend church, particularly, African Americans. Alcohol consumption is associated with a number of disorders such as cirrhosis of the liver and some cancers. The fact that alcohol consumption increased in Kansas and the rate of drinking remained the same in Alabama is alarming. It is important that alternative ways to cope with stress and other environmental factors be developed to help lower alcohol consumption among African Americans.

Physical Activity: The BRFSS showed the participation in physical activity was higher for Alabama residents than for Kansas's residents. Perhaps this difference is attributable to the warmer climate of the South or a culture that values exercise. Physical activity must become a priority in the lives of African Americans. There is clear evidence that physical activity at least three times a week is associated with better health outcomes and lowers the risk of some cancers and cardiovascular disease (Lewis et al., 1993).

LIMITATIONS

The limitations of this kind of analysis are noted. First, the populations of Alabama and Kansas are different. A higher percentage of African Americans live in the South than who live in the North. Thus, the higher percentage of African Americans who live in Alabama may make the Alabama results more representative of African Americans across the state than the Kansas results. However, the same weights are applied in computing percentages for both states. The authors did no other statistical analysis, which might have interfered with the results. Second, other states could have been used in the analysis however the authors chose to identify the differences in regions (North vs. South) by using Alabama and Kansas. Third, in both samples it is difficult to draw conclusions about the entire African American population. Not everyone has a phone so the BRFSS is biased toward those individuals who have access to a phone. Many rural low income African American may not be adequately represented in the sample. Fourth, many of the health questions may have been answered more favorably by the respondents thus biasing the sample towards behaviors that make African American look good in the eyes of the telephone interviewer.

FUTURE RESEARCH

First, researchers could compare the state data to national date to determine how well the states are doing in comparison to the nation. Second, future research could look at how well the self-reported behaviors of African Americans and other groups are meeting the health objectives for the nation that are outlined in Healthy People 2000 and 2010 publications and meeting the goal of eliminating the health status disparities. Third, community-based groups (i.e., churches, non-profits) could incorporate the BRFSS into programming and assess the ultimate impact of their programs and projects on health behaviors of their target audience. They could also assess any long-term effects of their programs by using the BRFSS to gather information on health behaviors. Fourth, researchers could compare men and women's health across different ethnic groups and fill the dearth of research studies in the literature about ethnic groups and determine what are the healthy behaviors of these populations.

CONCLUSION

In this study we limited our analysis to behavioral factors, however, other factors must be considered that may impact health outcomes such as, ethnicity, discrimination, racism, and sociocultural factors. The BRFSS gives us a good marker of the progress being made towards eliminating the health status disparities as well as programs and services that are effective in bringing about positive health outcomes and detecting programs that need improvement.

REFERENCES

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Lewis, R., & Green, B. L. (2000). Assessing the health attitudes, beliefs, and behaviors of African Americans attending church: A comparison from two communities. Journal of Community Health, 25(3), 211-224.

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Medicine, S. o. B. (1998). Hypertension in African Americans can be prevented, [Internet]. P\S\L Consulting Group Inc. Available: http://www.pslgroup.com/dg/69DC6.htm.

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Thomas, S., & Fick, A. (1993). Cancer awareness and attitudes toward preventive health behavior. The Journal of the Louisiana State Medical Society, 145, 139-145.

Weinrich, S., Holdford, D., Boyd, M., Creanga, D., Cover, K., Johnson, A., Stromborg, M., & Weinrich, M. (1998). Prostate cancer education in African American churches. Public Health Nursing, 15, 195-199.

Young, D. R., Miller, K. W., Wilder, L. B., Yanek, L. R., & Becker, D. M. (1998). Physical activity patterns of urban African Americans. Journal of Community Health, 23(2), 99112.

Rhonda K. Lewis, Ph.D., M.P.H., Assistant Professor, Department of Psychology, Wichita State University, B. Lee Green, Ph.D., Assistant Professor, Department of Health Behavior, School of Public Health, The University of Alabama at Birmingham. Correspondence to: B. Lee Green, Ph.D., UAB School of Public Health, Department of Health Behavior, 1665 University Blvd, 227 Ryals Bldg., Birmingham, Alabama, 35294-0022, (PH) 205-975-5704, (FAX) 205-934-9325, e-mail:[e-mail]