Health behavior patterns of African Americans: are we making progress toward the Healthy People 2010 goals?

Abstract: Despite efforts to decrease health disparities they continue to exist and have increased in some health areas. Interventions are needed that educate the public about health disparities and to determine ways to implement culturally appropriate and gender specific programs that include evaluation and monitoring tools. After the intervention has been completed it is important to track what progress the intervention made towards attaining the target goals outlined by Healthy People 2010. This paper documents health behaviors related to diet, nutrition and physical activity of African Americans living in the Midwest, compares their health outcomes to the targeted Healthy People 2010 goals, and determines whether the designed intervention improved their health behaviors.

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Although life expectancy has increased in the U.S. population and among African American men and women, life expectancy for African Americans continues to lag behind Caucasians by as much as seven years (Braithwaite & Taylor, 2001). Steps should be taken to identify the lifestyle patterns of African Americans and to lead them to feel empowered to takecontrol over their health. Healthy People 2010 (HP 2010) established goals to determine whether health in the U.S. population is improving for all Americans. Before that time Healthy People 2000 established goals and had health goals for different segments of the population. In the year 2000, Healthy People 2010, the American Public Health Association (APHA) and the other governmental entities decided to focus on reducing health disparities through the common goal of improving health for all. In light of efforts to reduce health disparities, there is still much work that needs to be done. Health disparities have persisted and in many cases have worsened despite advances in medicine, advances in public health, and an increase in the overall standard of living (Braithwaite & Taylor, 2001).

There is no mystery that African Americans are disproportionately affected by chronic disease and excessive deaths from chronic diseases. For instance, hypertension rates among African Americans are four times higher than that of whites (National Center for Health Statistics, 2000). African Americans still have a higher ratio of strokes and cardiovascular disease compared to non-Hispanic whites (Braithwaite & Taylor, 2001). In addition, African Americans have a higher incidence of cancer and higher cancer mortality rates than any other racial or ethnic group. A number of intervention programs have been designed to address these health disparities By improving health and nutrition, increasing physical fitness and reducing obesity, especially among African Americans (Baranowski et al., 1990; McNabb, Quinn, & Kerver,1997; Resnicow et al., 2002; Young, Miller, Wider, Yanek, & Becker, 1998). These include church-based programs (Campbell et al., 2000; Resnicow et al., 2002) and community-based programs (Baranowski et al., 1990; Haire-Joshu et al., 2003; Paschal, Lewis, Martin, Shipp, & Simpson, 2004) designed to improve the health of African Americans. Overall, they accomplished the goals of increasing physical activity and reducing weight; however, they did not compare their outcomes to the HP 2010 guidelines to insure that progress was being made toward attaining goals set by the public health agenda.

In order for health disparities to be reduced or eliminated throughout the U.S., more interventions that target nutrition and physical activity will need to be implemented within the African American community. In addition to implementing interventions in the African American community we need studies to document health status and compare the results with goals established by HP 2010 to determine whether we are making progress toward the goals. If intervention studies are falling short of the goals, this information could be used to persuade funding entities that more work needs to be done to reduce health disparities. If interventions are being shown to be effective, policy makers and public health organizations such as the APHA might serve as a leader in disseminating effective programs to local public health association chapters and to state governmental health agencies.

African Americans report low rates of physical activity and have diets high in sodium and saturated fat that often lead to poor health outcomes. Comprehensive health interventions are needed if health disparities are to be reduced by the year 2010. With only six more years to go, more comprehensive programs are needed in the community; however, programs that actually document progress are needed to determine whether the programs are effective in reaching goals set by the public health agenda. The purpose of this paper is to 1) assess the overall health behavior patterns of African American adults living in the Midwest, 2) determine whether a health education program reduced health risks and 3) examine whether progress towards attaining HP 2010 goals to eliminate health disparities were attained.

METHOD

PARTICIPANTS AND BACKGROUND

African American adults were recruited to participate in a year-long health education program designed for them and their children in Wichita, Kansas and surrounding areas (population was 452,000 as of the year 2000). The program was a partnership between a midwestern university (psychology department), the Knox Center (a substance abuse treatment facility) and the Center for Health and Wellness (a primary health care facility). The year-long health education program (1 year for youth and six months for parents) was designed for African American youth aged 12-17 and their parents. Parents were assigned to two different intervention conditions based upon the group to which their children were assigned. One group received information primarily on HIV/AIDS and substance abuse. The other group received general health information which included health status, information on diet and nutrition and the impact of physical activity. Over a three-year period (20012004), more than two hundred African American adults participated in the program. For the purposes of this study, only African American parents were included in the analysis (N=239). Thirteen percent of the participants were men (n=33) and 87% of the participants were women (n=227). Participants' mean age was 39 years, and participants ranged in age from 20 to 67 years. Thirty-two percent of participants reported having a high school education, 42% having some college, 11% less than high school, and 15% having graduate level education. Data concerning participants' income level were not collected.

PROCEDURES

The study received approval from the university's Institutional Review Board. Once participants arrived on the university's campus, they completed a consent form and were informed that they could withdraw from the study at anytime. Participants were then instructed to complete a 74item survey. Parent participants were required to present a social security card in order to receive a cash incentive (e.g., $50.00 at baseline and $25.00 at both the 3-month and 6-month follow-up).

INTERVENTION

The Knox Center and the Center for Health and Wellness provided facilitators to teach parent participants. The initial parent education session lasted three hours with one hour booster sessions at three and 6-month follow-up. Training sessions took place on Saturdays on the university campus. Parents who were assigned to the HIV/AIDS and substance abuse prevention group were given information about HIV/AIDS and substance abuse, statistics and facts concerning substance use and abuse among adolescents, the interplay between substance use and HIV infection, and how to communicate with their child about drugs and HIV/ AIDS. In the health education group, parents received overall health information including an overview of the health status of African Americans and the importance of building healthy lifestyles. This group of parents also received encouragement to increase physical activity and to improve eating habits. The health education group was taught by the CEO and Co-President of the Center for Health and Wellness who is an advanced registered nurse practitioner.

INSTRUMENT

A survey was used that included two different survey tools. The first survey tool was the Government Performance and Results Act (GPRA). The second tool was a health survey developed by Green (1996). Table 1 lists the questions used in the analysis. A few questions were added concerning anger and feelings of sadness to document mental health. A total of 18 questions were used in this analysis.

RESULTS

Table 2 shows a comparison of the overall health behaviors of African Americans enrolled in the health education program compared to the HP 2010 goals. At baseline, approximately 26% of those who participated in the study reported smoking compared to the HP 2010 goal of 12%. Participants in this study are still smoking in greater numbers than deemed acceptable.. Approximately 57% of the participants reporting eating vegetables five or more days compared to 50% for HP 2010. Fourteen percent of the participants reported exercising five or more days compared to the 23% goal established by HP 2010. Fifty-eight percent reported having their blood pressure checked in the past year compared to the 95% goal set by HP 2010. Fifty-five percent of the participants had their cholesterol checked in the past five years compared to the HP 2010 goal of 80%. Less than two-thirds (65%) of participants reported having health insurance in comparison to the HP 2010 goal of 100% of Americans. Participants in this sample exceeded the vegetable eating goal established by HP 2010, but fell short in a number of areas including having their blood pressure and cholesterol checked, and exercising regularly.

Table 3 shows a comparison between the male and female participants. The results show that African American men had a number of health indicators that were in their favor. Although only about one third of the men reported exercising five or more times a week, this number was much higher than that of female participants (10%). Sixty-five percent of men rated their health from excellent to good compared to 57% for female participants. Conversely, only 43% of the male participants had health insurance compared to 68% of the female participants, an indicator that females may have better access to health providers.

Health behaviors such as eating fruit and vegetables and drinking water were similar for African American males and females. For instance, 25% of both males and females reported eating fruit five or more days per week. Approximately 50% of male respondents reporting eating vegetables compared to 58% for female participants. Eighteen percent of males and 15% of female participants reported drinking seven or more glasses of water per day.

Preventive health activities such as blood pressure checks and physical exams showed surprising results. Men reported having their blood pressured checked more often than female participants (71% vs. 57%). Cholesterol checks were similar for both male participants and female participants at 53% and 56%, respectively. More men reported having a physical exam than female participants. Nearly 75% of male participants compared to only 70% of female participants reported having had a physical exam within the past year.

Other behavior patterns showed surprising results as well. Male participants (63%) in this sample self-reported feeling sad or depressed more than the female participants (55%). Also, more male than female participants reported smoking (39% versus 24%) and drinking alcohol (57% versus 29%) during the last 30 days.

Table 4 shows the results for those participants who completed a questionnaire at the initial training session and returned for the 6-month follow-up. The results show that a number of self-reported health behaviors improved. At the 6-month follow-up, participants reported eating breakfast more often. This number increased from 37% at baseline to 40% at the 6-month follow-up. Participants also reported drinking at least eight glasses of water at the 6-month follow-up than at baseline (15% vs. 9%). More participants reported eating more fruit (35% vs. 26%) and vegetables (62% vs. 58%) at 6month follow-up than baseline. The number of participants who had their blood pressured checked went from 54% at baseline to 87% at the 6-month follow-up. In addition, cholesterol checks increased from 55% at baseline to 64% at the 6-month follow-up. The percentage of people believing that a healthy lifestyle can improve health increased from 46% to 96%. The percentage of people reporting feeling sad or depressed decreased from 58% to 48%.

DISCUSSION

The results of this study demonstrate that the health behavior patterns of Midwestern African Americans need to be improved and that, despite advances in medicine and public health, stronger and more effective interventions are needed to reduce health disparities. African American health behavior patterns in this sample are similar to health patterns across the nation. Although the study does not suggest that the intervention itself contributed to these results it is suggestive that health information can help African Americans begin to think about their health and to consider making changes. Thus, African Americans need more information about health and existing health disparities. Cigarette smoking did not decrease between baseline and 6-month follow-up. Perhaps this is a much more difficult health behavior to change. The intervention was not successful in addressing this issue; however, participants did self-report that they were trying to eat more fruits and vegetables, exercise more, and have their blood pressure and cholesterol checked. The literature is extremely clear that modifications in diet and exercise can reduce the risks for cancer, stroke and heart disease. More health interventions are needed that target African Americans and teach them about their health, follow-up with them, and build skills to empower them to change their habits.

MAJOR CONTRIBUTIONS OF THE STUDY

This study showed that the health of African Americans living in the Midwest needs to be improved. African Americans in this sample were not exercising, eating fruits, or having their blood pressures or cholesterol levels checked at the recommended levels developed by HP 2010. However, African American men in the sample were reporting exercise at a higher rate than the recommended levels. With this information we can tailor our interventions and target health promotion programs to specific segments of the population rather than treating each population the same. For example, African American men in this sample were exercising more than female participants. Even so, the men also reported smoking and drinking alcohol at a higher rate than female participants. This information suggests that physical activity interventions should target both men and women but the intervention might be more gender-specific and to address barriers that are unique to each gender. In addition, health promotion programs might approach the topics of alcohol and smoking cigarettes differently for both men and women since they were smoking and drinking alcohol at different rates. Another finding from this study showed that a higher percentage of men reported feeling sad or depressed compared to women. Anecdotally, women usually report feeling sad or depressed more than men. The percentage of men reporting feeling sad or depressed might be associated with the percentage of men who reported drinking alcohol. This finding may indicate that men are using alcohol as a method of dealing with these feelings. In addition, this finding suggests the importance of having a mental health component in our health promotion programs. We must develop programs that are holistic and address mental and physical health issues of the target population. Without this information, health professionals will continue to develop monolithic interventions for African American men and women when in fact different interventions are needed.

Lastly, this study was able to compare the results we found to a standard benchmark. It is important that researchers who are conducting this type of research use the same questionnaires and standard surveys so that results may be compared to a national standard. Instruments could be made available through organizational websites such as APHA, the National Institutes of Health and the Centers for Disease Control and Prevention to help researchers document progress that they are making towards attaining the HP 2010 goals to eliminate health disparities.

LIMITATIONS

A number of limitations are noted in this study. First, the African Americans represented in this study may not be reflective of all African Americans living in the Midwest or in this community. Second, the number of African American men in the study was extremely small; the number of African American women was more than double that of men in the study. This fact might account for the different percentages between the genders. Third, using self-reported measures can be dangerous in that participants may not be truthful about their behaviors in order to please the researcher. This may have influenced the results. Additional measures such as weighing participants at baseline and at six months would validate whether behaviors among the parents had truly changed.

HP 2010 provides a benchmark for health professionals to follow. It is important that researchers begin to document results of their studies and to compare their results with a national standard. Without this information, researchers will not know if they are making progress toward the goal of eliminating health disparities. Health disparities will continue unless health professionals make a systematic effort to 1) educate African Americans and other racial and ethnic minorities about the disparities that exists; 2) implement culturally appropriate and gender-specific programs in different sectors of the community such as faith-based organizations, clinics and community-based settings; 3) document the results; 4) compare the results to national standards; and 5) change and adapt ineffective interventions. Given the trajectory of current health trends, if we do not make changes, we are unlikely to attain the goals by 2010. We will merely continue to report how we have not attained our goals and that disparities continue to exist. It is important for the health of the entire nation to make sure that this does not happen. The poor health status of racial and ethnic minorities is driving up health care costs for us all. By implementing culturally appropriate and gender specific interventions that include evaluation, we can make progress toward our goal.

REFERENCES

Baranowski, T., Simons-Morton, B., Hooks, P., Henske, J., Tierman, K., Dunn, J., et al. (1990). A center-based program for exercise change among black American families. Health Education Quarterly, 17, 179-196.

Braithwaite, R., & Taylor, S. (2001). Health issues in the black community. San Francisco: Josey-Bass.

Campbell, M., Motsinger, B., Ingram, A., Jewell, D., Makarushka, C., Beatty, B., et al. (2000). The North Carolina Black Churches United for Better Health project: Intervention and process evaluation. Health Education & Behavior, 27, 241-253.

Green, B. (1997). Health promotion program needs assessment survey. College of Education/Professional studies. The University of Alabama, Tuscaloosa.

Haire-Joshu, D., Brownson, R., Nanney, M., Houston, C., Steger-May, K., Schechtman, K., et al. (2003). Improving dietary behavior in African Americans: The parents as teachers high 5, low fat program. Preventive Medicine, 36, 684-691.

McNabb, W., Quinn, M., Kerver, J. (1997). The PATHWAYS church-based weight-loss program for urban African American women at risk for diabetes. Diabetes Care, 20 1518-1523.

Paschal, A., Lewis, R., Martin, A., Shipp, D., & Simpson, D. (2004). A baseline assessment of the health status and health behaviors of African Americans participating in the Activities for Life Program A community based health intervention program. Journal of Community Health, 29, 305-318.

Resnicow, K., Jackson, A., Braithwaite, R., Dilorio, C., Blisset, D., Rahotep, S., et al. (2002). Healthy body/healthy ppirit: A churched-based nutrition and physical activity intervention. Health Education Research, 17, 562-573.

U. S. Department of Health and Human Services. (2000). National Center for Health Statistics (NCHS). Health, U. S. 2000: Chartbook on Trends in the Health of Americans. Washington, D.C: United States: Government Printing Office.

U.S. Department of Health and Human Services. (2000). Healthy People 2010. U.S. Department of Health and Human Services: Government Printing Office.

Young, D., Miller, K., Wilder, L., Yanek, L., & Becker, D. (1998). Physical activity patterns of urban African Americans. Journal of Community Health. 23, 99-112.

CHES AREAS

Responsibility II--Planning Effective Health Education Program

Competency B--Develop a logical Scope and Sequence plan for a health education program

Responsibility IV--Evaluating Health Education Programs

Rhonda K. Lewis, PhD, MPH is an Associate Professor of Psychology at Wichita State University. Michelle Redmond, PhD is an NIMH Research Fellow for the Institute for Social Research at the University of Michigan. Angelina Paschal PhD is an Assistant Professor of Preventive Medicine and Public Health at University of Kansas School of Medicine- Wichita. B. Lee Green, PhD is Executive Director of the Office of Institutional Diversity and Professor for Health Outcomes and Behavior at H. Lee Moffitt Cancer & Research Institute. Address all correspondence to Rhonda K. Lewis, PhD, MPH, Wichita State University, Wichita, KS 67260; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].

Table 1. Health Questions Used in the Survey

During the past 30 days have you smoked part or all of a cigarette?
During the past 30 days how many days have you used any alcohol?
Have you sought healthy ways to vent your anger?
Do you eat breakfast?
How many glasses of water did you drink yesterday?
In the past seven days, how many days did you eat fruit?
In the past seven days, how many days did you eat vegetables?
In the past seven days, how many days did you exercise for 20 minutes
  or more?
Have you had your blood pressure checked in the past year?
Have you had your cholesterol checked in the last five years?
Do you believe good health is dependent on fate or destiny?
Do you think a healthy lifestyle can help you live longer?
How would you rate your overall physical health at this time?
How many times per week do you eat foods high in fiber
  (whole grain bread, fresh fruit, vegetables)?
Do you ever diet?
When was the last time you had a physical exam performed by a
  physician?
Do you have health insurance?
Have you felt sad or depressed in the last thirty days?

Table 2. Overall Health Behaviors of African American Adults
Enrolled in the Youth Empowerment Project

Health Behaviors                 Percent    Health People 2010 Goal

Percent smoking                    26%                12%
Percent who eat vegetables         57%                50%
Percent who exercise 5 or more     14%                23%
Percent blood pressure checked     58%                95%
Percent cholesterol checked        55%                80%
Percent have health insurance      65%               100%

Table 3. Male and Female Percentages Compared Within Each Group.

Health Behaviors                         Male (n=28)   Female (n=204)

Percent Smoking                              39%            24%
Percent who eat breakfast                    36%            34%
Percent drink water (7 or more)              18%            15%
Percent who eat fruit (5 or more)            25%            25%
Percent who eat vegetables                   50%            58%
Percent who exercise 5 or more days/wk       36%            10%
Percent blood pressure checked               71%            57%
Percent cholesterol checked                  53%            56%
Percent believe in fate and destiny          29%            37%
Percent believe healthy lifestyle            53%            53%
Percent rated health good to excellent       65%            57%
Percent eat foods high in fiber              38%            48%
Percent who diet                             38%            58%
Percent had a physical exam                  75%            70%
Percent have health insurance                43%            68%
Percent felt sad or depressed                63%            55%
Percent who drink alcohol                    57%            29%

Table 4. Comparison of Health Behaviors from Baseline to
6-Month Follow-up for those Participants who came to the
Initial Session and 6 Month Follow-up Session (N=166)

Health Behaviors                         Baseline   6- Month Follow-Up

Percent Smoking                            27%             26%
Percent who eat breakfast                  37%             40%
Percent drink water (8 glasses)             9%             15%
Percent who eat fruit (5 or more)          26%             35%
Percent who eat vegetables                 58%             62%
Percent who exercise 5 or more days/wk     15%             22%
Percent blood pressure checked             54%             87%
Percent cholesterol checked                55%             64%
Percent believe in fate and destiny        37%             45%
Percent believe healthy lifestyle          46%             96%
Percent rated health good to excellent     54%             48%
Percent eat foods high in fiber            51%             48%
Percent who diet                           54%             50%
Percent had a physical exam                75%             67%
Percent have health insurance              62%             68%
Percent felt sad or depressed              58%             48%
Percent who drink alcohol                  26%             24%