Qualitative Study among African American Parents to Inform an Intervention to Promote Adoption of the Dietary Guidelines for Americans Food and Physical Activity Recommendations

This qualitative study was conducted to enable the research team to culturally tailor an intervention to increase adherence to Dietary Guidelines for Americans (DGA) in African American parents and their children living in Lower Mississippi Delta (LMD) communities. Focus group results guided the planning of an obesity prevention intervention utilizing the We Can! (Ways to Enhance Children’s Activity and Nutrition) obesity prevention program. Main outcome measure was perceptions of approaches to use in culturally tailoring a nutrition and physical activity intervention. Six focus group sessions were conducted with 86 African American adults to identify cultural concerns, intervention strategies in two Louisiana parishes in the LMD. Focus groups discussions were audio recorded, transcribed, and analyzed to identify recurring trends and patterns among focus groups. Major themes that emerged included cultural influences on food habits and physical activity, challenges of meeting the DGA and the CDC physical activity guidelines, facilitators and barriers to adhering to healthy food and physical activity guidelines and program development. Wider acceptance and use of the DGA recommendations are needed by LMD populations, leading to reduced prevalence of overweight and obesity and parallel reductions in the prevalence of chronic diseases. Interventions are needed that will enhance adherence to the DGA particularly for diverse subpopulations in the U.S. This study provides important insights for culturally tailoring an intervention to promote adoption of the DGA in two low-income African American Delta communities.


Introduction
African Americans comprise a large segment of the Lower Mississippi Delta population and have the highest prevalence of obesity and its associated risks for chronic diseases [1].The disparities pose a major challenge for policymakers and practitioners planning strategies for obesity prevention.Although there is science-based nutrition and health information available, it is not reflected in the African American community in dietary changes as reported by surveys [2] [3].There is a need to identify effective strategies that will enhance adherence to the healthful food and physical activity recommendations set forth in the Dietary Guidelines for Americans (DGA) and the Physical Activity guidelines, particularly for diverse subpopulations in the United States.
An intricate relationship exists between food intake patterns and culture.Therefore, it is important to target specific demographic subgroups with tailored interventions to move all Americans toward achievement of the DGA [4].Tailoring health education is a strategy used to bring individualization and personalization of health messages to members of a target group [5] [6].Thus, targeted programs that deal with population-specific needs within a cultural group should also be tailored to the individuals within that group [7] [8].
The Social Cognitive Theory (SCT) is a sound theoretical framework for the development of an intervention addressing complex behaviors that act as barriers to adoption of healthful food and physical activity patterns [9].SCT is based on the concept of reciprocal determinism, in which there is a dynamic interaction between environmental influences, personal influences, and behavior.SCT considers factors at both the individual and environmental levels to support behavioral change related to dietary intake and physical activity.
Focus group methodology has been used extensively to capture African Americans' perceptions of specific health conditions and various aspects of health behavior to implement culturally tailored or culturally sensitive interventions [6] [10]- [14].Cultural sensitivity is defined by two dimensions: surface and deep structures.Surface structure involves matching intervention materials and messages to characteristics of a target population.This may involve using personal and environmental factors familiar to, and preferred by, the target audience.Surface structure refers to how well interventions fit within a specific culture.Deep structure involves incorporating the cultural, social, historical, environmental and psychological forces that influence the target health behavior in the proposed target population.Whereas, surface structure generally increases the "receptivity" or "acceptance" of messages, deep structure conveys salience [15].
Focus groups were used to guide the planning of an intervention to make it most acceptable to the participants and thus effective in increasing adherence to the DGA and the 2008 CDC Physical Activity Guidelines [16]- [18].Focus group discussions with parents provided insight into cultural influences on dietary and physical activity patterns and overweight/obesity in an African-American population.Data derived from the formative evaluation will be used by the research team to determine intervention implementation strategies for designing an effective, culturally tailored nutrition/physical activity intervention for parents and their children.

Study Design
Six focus group sessions were conducted in two Louisiana parishes for parents 18 years of age or older and six focus group sessions for children 8 to 13 years of age in the same parishes.Focus group sessions were conducted between January 2010 and January 2011 on different days of the week at local churches and parish Cooperative Extension offices.Only the findings from the focus groups sessions held with parents will be presented in this paper.
Recruitment of focus group participants was through outreach and direct appeal.Screening of participants was through a screening form which included demographic data.Participants were 18 years of age or older, a resident of the selected parish, responsible for preparing meals and purchasing food for the household, and parent of a child 8 -13 years of age.Participants were served light refreshments and parent and child participants received a $20.00 and $10.00 gift card, respectively to encourage participation and compensate for time and travel expenses.Participants signed an informed consent form before each session.This study was approved by the Southern University Institutional Review Board.
Focus groups were conducted according to standard procedures [19].Focus groups ranged in size from 8 -10 individuals.The same focus group team conducted all six sessions.The duration of each focus group session was 75 -90 minutes.

Interview Questionnaire
Questions were designed by the research team to determine perceptions of approaches to use in culturally tailoring an intervention designed to increase adherence to the DGA healthful food and physical activity recommendations.Content validity of the focus group question guide was established by a literature review of cultural tailoring indices and by consensus of the research team.Questions were informed by the constructs of and reciprocal interactions posited in the Social Cognitive Theory and the two dimensions of cultural sensitivity posited by Resincow [15].Ten to 20 open-ended questions were developed.Questions were arranged from general to specific [19].University faculty and staff reviewed questions for content and clarity and modifications were made based on their suggestions.Pilot focus group sessions were held to pretest the focus group questions and methodology with a similar group of parents and children.
Set I: Parent focus group questions Questions were designed for parents to explore cultural experiences, history, beliefs, values and traditions that influence eating and physical activity behaviors and perceptions of health and obesity prevention (deep structure).Other influences explored included spirituality, social support and family pride and dedication.Participants responded to questions about weight status and challenges to meeting DGA and CDC physical activity recommendations and program development strategies for a healthy food choices and physical activity program (Table 1) [16]- [18].
Set II: We Can! Families Finding the Balance: A Parent Handbook focus group questions We Can! is a national education program developed by the National Institutes of Health [20] and is designed for parents and caregivers to help youth ages 8 -13 maintain a healthy weight.The program focuses on three important behaviors: improved food choices, increased physical activity, and reduced screen time.
Parents reviewed the We Can! Families Finding the Balance: A Parent Handbook [20] for understanding and appeal.Questions captured participants' ideas and opinions for culturally tailoring the proposed intervention curriculum.Inquiry was made to determine whether materials were reflective of participants' language and cultural characteristics and delivery preferences of the intervention (surface structure).For example, participants were asked to respond to questions relative to organization/arrangement, print size, and font style of the information printed in the We Can! Handbook.Questions also addressed appeal and appropriateness of graphics, in particular, foods familiar to the intended audience, physical features and social network structures (family, friends, etc.) and settings (common time and place among the intended audience) of individuals portrayed.Questions also assessed participants' understanding of words, phrases and expressions used in the information (Table 2).Research has recommended assessment of these elements of educational materials for cultural sensitivity [21].

Data Analysis
Focus group data were analyzed following procedures recommended by Krueger [19].At the conclusion of each session, a moderator/recorder report was completed which summarized key points, notable quotes, and overall findings.Audiotapes of all sessions were transcribed by a professional transcriber.Project staff listened to the focus group tapes and compared them against the written transcript.This enabled errors in understanding to be corrected.Using the transcripts, field notes, and moderator/recorder reports, the focus group team reviewed the data for the purpose of identifying recurring trends and patterns among the focus group sessions.This data were coded and sorted using the organizing framework of the discussion guide and the recurring trends and patterns.Topologies were constructed to determine if any data were omitted and agreement was reached relative to the organization of the data.The research team identified emerging themes from a list of most frequent responses by two or more focus groups and categorized according to SCT constructs.Each team member reviewed the summary of emerging themes to arrive at consensus for the final summarization.The most relevant quotes were included along with the emerging themes.A descriptive summary was compiled highlighting the most frequent and dominant responses.Prior to development of the final report to evaluate consistency, data, transcripts, field notes, and summary reports were reviewed and summarized by an independent reviewer.

Demographic Characteristics and Theme Identification
A profile of the participants is presented in Table 3.The study population included 86 parent participants.Of the 86 participants, 70 (81%) were age 18 -44 years of age; 16 (19%) were over 45 years of age.The majority of participants were female, 78 (91%) and 8 (9%) were male.

Table 2. Focus group questions for
We Can! Families finding the balance: A parent handbook.
1) What were your feelings when you first picked the booklet up to read? 2) What are your thoughts about the front page and title of the booklet?3) What are your thoughts on the pictures used in the booklet?Did they encourage you to read further?Are any changes needed?4) What are your thoughts on the size and style of the letters used?Suggest changes if needed.5) How would you describe the reading level of the booklet, for example, "difficult-to-read?" "not easy-to-read?""hard-to-read?" "easy-to-read?" Was there a section that you found too technical or difficult or hard to understand?If so, which section?What changes are needed?6) What topics were most interesting and useful to you? 7) What activities can be added to the lists related to physical activity (pp.[23][24][25] that are popular in your community?8) Are there other foods which are frequently consumed in your community that are not listed or would make good examples: What other "go, slow" and "whoa" foods should be added to the lists?p. 16. 9) What are your thoughts on the section "What can my family and I do to encourage a healthy weight?"(pp.[4][5][6].Are the strategies suggested realistic for your family to follow?Explain your answer.10) Are there other topics, information or thoughts that should be added to the booklet that would cause/encourage you to make needed changes in your eating and physical activity habits?11) This fall, we plan to carry out a nutrition and physical activity campaign in the parish, focused on preventing overweight and obesity in children.What aspects of your culture should be included in the program that would make it special for you, and parents like you and therefore increase the likelihood of acceptance of the program?This study is subject to some limitations.The results of the study may only be relevant for an African American population.The sample was not randomly selected; however, recruitment information was widely distributed through different venues in the two parishes.Participants were majority female, likely a result of the selection criterion that specified that the participant be the primary food purchaser and preparer.The intervention strategies proposed may not be applicable to men.

SCT Constructs and Cultural Sensitivity Themes
Major themes were categorized by the SCT constructs and by the cultural sensitivity dimensions, deep structure and surface structure based on the most frequent responses by three or more focus groups.Table 4 summarizes the SCT themes identified, personal and environmental determinants.

Personal Determinants
Personal determinants derived from the data included knowledge and skills and body size perceptions.Environmental determinants included challenges of meeting the DGA and the CDC physical activity guidelines, and facilitators and barriers to adhering to healthy food choices and physical activity guidelines.The deep structure themes that emerged were cultural influences on food habits and physical activity and the surface structure theme identified was program development.
Table 4 summarizes responses to inquiry about the Dietary Guidelines for Americans.The groups were not very familiar with the DGA.Approximately 50% of the participants indicated that they meet the fruit but not the vegetable recommendation.Few groups indicated that children meet the recommendation.The school lunch program was cited as helping children to meet the fruit and vegetable recommendation.Participants were not familiar with the 2008 Physical Activity Guidelines for Americans and did not participate in the recommended levels of physical activity.However, all groups indicated that they meet the guideline through the kind of work they were performing and from taking care of children.
All focus groups felt that there were concerns about weight in adults in the community.The related health concerns mentioned were high blood pressure, diabetes, asthma and heart disease.There was less concern about weight in children in the community.
Participants described an attractive body size for women relative to dress size ranging from size 18, 14, and 12, respectively.Most of the participants described an attractive body size for men relative to physique.An attractive body size for children was based on the individual child.

Environmental Determinants
Participants indicated that quality, availability and cost of fruits and vegetables were obstacles in meeting DGA for fruits and vegetables.All focus groups indicated that they as well as their children do not meet the DGA fat Challenges to meeting the physical activity guidelines included lack of time, safety, tired from work, weather, and no facility in the community for working out.Walking was the preferred activity indicated by a majority of the participants followed by riding bikes.
Based on a scale of 1 -5, focus group participants indicated a moderate degree of confidence that they could follow the DGA (Table 4).

Deep Structure
Cultural influences on food habits and physical activity.Table 4 summarizes the responses to five questions intended to gain participants' perspective on the concept of culture and mediating factors that could impact lifestyle change toward improved food habits and increased physical activity.Participants perceived God, family, health, education, and character as important to them.Family traditions such as holiday celebrations, family meals, and cooking methods influence eating habits.Physical activity habits were influenced by patterns of parents, while approximately a third of the groups indicated that neighborhood safety and busy schedules (Table 5).
The traditional foods or recipes most frequently mentioned by 37% of groups were greens and fried chicken; gumbo; potato salad; barbeque; boiled crawfish; sweet potato pie; boudin; jambalaya; turkey necks; and homemade cake.When asked which traditional foods are considered healthy, participants responded that it depends on how it is prepared.

Surface Structure
Program development.Table 5 presents the program development perceptions of participants.Varied responses were provided relative to previous participation in healthy eating educational activities, but the most common responses were weight watchers, church weight loss challenge, cooperative extension service nutrition programs and through place of employment.Programs most preferred by participants were menu modification, recipes, and food demonstrations.
To increase the amount of physical activity in the community, two-thirds of the groups indicated having access to facilities in the community such as a park, recreation center; group physical activity; and support groups.Participants also suggested organized sports for children and recess in school and provision of playground equipment.
When asked what topics should be included in a program to promote healthy food choices and regular physical activity for parents and children in your community, participants indicated food demonstrations, interactive family oriented nutrition and exercise activities and provide incentives (food, prizes, money).Of approaches mentioned by participants to include in a program to promote regular physical activity for parents and children, access to safe facilities was most frequently cited followed by group activities; after-school health programs; and safe places for activities.
Table 6 summarizes participants' perspective following a review of We Can! Families Finding the Balance: A Parent Handbook for understanding of the text and appeal.All four groups indicated that the handbook was colorful and eye catching and depicted family togetherness and families eating and exercising together.Participants indicated that the printing on the cover should be in black rather than white.Participants indicated that there should be more Black families on the cover.In the body of the handbook, a majority of the groups indicated that there should be more pictures of Blacks and pictures of local scenes.No changes were suggested for size and style of the font used.All four groups indicated that the Handbook was "easy-to-read".
Participants indicated that the section on Calorie Count and BMI information was technical and should include more examples.The most interesting topics indicated by participants were statistics; Energy In; Energy Out; Go (eat almost anytime), Slow (eat sometimes, or less often), and WHOA (eat only once in a while or on special occasions) foods; energy requirements; and portion size information.Participants suggested that other activities should be added to the physical activity list including interactive video games (Wii), Zydeco dancing; rollerblading, skateboarding, skating, baseball, and tennis.
Participants suggested the addition of foods consumed in the local area to the list of "GO, SLOW and WHOA foods".Suggested foods included: "GO" foods: wild game (rabbit, deer), goat, soymilk, yams, salad, healthy snacks; powerades; "SLOW" foods: fried chicken; and "WHOA" foods: boudin, cracklings, chitterlings, neck bones, wild game (deer, rabbit), gumbo, alcoholic beverages, and pickles."Appropriate;" "very good" "No changes to font; you can read with or without glasses; good, anyone can read it;" "I like where the title was done in color and the information was done in another color" 5) How would you describe the reading level of the booklet, for example, "difficult-toread?" "not easy-to-read?""hard-to-read?" "easy-toread?"Was there a section that you found too technical or difficult or hard to understand?If so, which section?What changes are needed?
I think a 6 th grader can read it; it was very understanding; and easy to read and to the point; not to technical; simple and basic, as far as the pyramid and everything broken down; I like the way they left the website so you could go to the website and get other information When asked to respond to the chapter in the handbook, "What can my family and I do to encourage a healthy weight", participants felt that the strategies should include a sample family plan.A related quote was "family plan with kids, give an incentive for keeping up with plan".The groups were divided regarding whether the strategies were realistic.Half of the group indicated that it would be a challenge to follow the recommendations.
In response to the inquiry about local cultural aspects to include in a program focused on preventing overweight and obesity in children, participants indicated participant accountability, family and community activities; marketing by local professional athletes and doctors; music; dancing/Zydeco; form walking groups; provide aerobics; offer incentives; involve school board for early childhood intervention and provide more details about the consequences of obesity.Participants indicated that it was important to get more men involved in the program.levels of insufficient physical activity underscore a need for better dissemination and adoption of strategies to increase physical activity levels within these high-risk communities [34] [35].A review to examine consumer response to healthy eating, physical activity and weight-related guidelines on behavior found that many respondents reported that the guidelines were confusing, and that simple, clear, specific, realistic, and in some cases, tailored guidelines are required.Recognition of guidelines did not signify understanding nor did perceived credibility of a source guarantee utilization of guidelines [36].
There was concurrence on the opportunities suggested by participants for meeting the guidelines and those recommended by the CDC.According to the Centers for Disease Control and Prevention's (CDC's) Guide to Community Preventive Services [37], the evidence-based strategies to increase physical activity levels include the following: community-wide campaigns, individual behavioral change, social support in community settings, the creation or enhancement of access to places for physical activity, and point-of-decision prompts.
Culture, defined as the unique shared values, beliefs, and practices of a group, can influence the behaviors of individuals by affecting their thoughts, feelings, acceptance, and adoption of health education messages [38] [39].For example, to reduce the prevalence of excess weight, current health strategies promote lower fat intake.However, among African American populations, especially in the southeastern United States, consumption of foods high in fat is a documented dietary and cultural practice [40].This study found that cultural factors affect food choices, physical activity levels and body size satisfaction.Findings from our study are largely consistent with existing studies.Adults in the LMD consume 20% fewer servings of fruits and vegetables compared to national intakes and have higher intakes of fat and lower intakes of several micronutrients [41].In African-American culture, food has been the center of social interaction.Research found that African-Americans in north central Florida felt that eating healthier food meant giving up part of their culture.Sunday dinner composed of family favorite foods is an integral part of African American culture [42].
The diets of most Americans fall short of the Dietary Guidelines for Americans [43].The participants in study were not overwhelmingly confident that they could adhere to the DGA or the physical activity guidelines.Participants indicated that the support of family and friends was important for changing behavior.This highlights the need for healthy lifestyle interventions to be tailored to the specific population with consideration given to inclusion of support groups and family-centered activities.Healthy eating and physical activity strategies should focus on reducing intakes of high-calorie, low nutrient foods such as sugar-sweetened beverages, high-fat dairy, and desserts while promoting as alternatives water, fat-free or low-fat milk, and fruits or low-fat/low calorie dessert choices [44].In community settings, the creation or enhancement of access to places for physical activity is important [37].
Health promotion interventions will be more effective when they are culturally appropriate for the population served [8].Understanding personal and external determinants of food choices and physical activity and application of deep and surface structure elements for modifying food and physical activity behavior are necessary to plan effective, culturally sensitive, and relevant interventions aimed at increasing adoption of healthy food and physical activity recommendations.The surface structure dimensions identified by this LMD population included a variety of interactive program strategies and barriers to promoting healthy food choices and regular physical activity.Surface structure elements identified include language, facilities, location, music, food and nutrition messages.Research has shown that there is limited or no access to physical fitness programs and facilities in low-income communities [43].Similarly, previous research has found that participants want a variety of active learning intervention strategies [44]- [47].New culturally relevant, credible, and trusted approaches for health promotion must be identified for health status indicators to improve for African American populations.These data therefore suggest a potential role for cultural tailoring to enhance the cultural appropriateness and, ultimately, program outcomes, of healthy eating and physical activity interventions.
Overall, focus group participants approved of the We Can! Families Finding the Balance Handbook.The Parent Handbook received the 2005 NIH Plain Language Award for an Outstanding Plain Language Product [23].Some modifications to the Handbook were recommended including ethnic pictures, local foods, familiar physical activities and other topics for maintaining healthy weight, nutrition, and physical activity including healthy cooking and budgeting.Local cultural aspects were cited as important to energize participants and better equip them to maintain a healthy lifestyle.Deep structure dimensions identified suggest that culture, history, religion, friends and family and environment play a role and influence food choices and physical activity behavior.
Local cultural aspects were cited as important to energize participants and better equip them to maintain a healthy lifestyle.Deep structure dimensions identified suggest that culture, history, religion, friends and family and environment play a role and influence food choices and physical activity behavior.

Conclusion
More effective health promotion programs to reach African American parents and their children living in LMD communities are needed to increase adherence to the healthful food and physical activity patterns set forth in the DGA.Qualitative research methods to develop health promotion programs that are culturally targeted to the issues common to the population being served and tailored to the needs and interests of the population may be an effective approach to increase adoption of the healthful food and physical activity guidelines.Focus groups gave important insights into likelihood of this LMD population adopting the DGA.Focus groups data is important for designing interventions strategies that can appropriately target needs within the LMD.The results of this study instructed us to emphasize a holistic concept of health that includes high self-esteem and achievement orientation, value systems and norms, spirituality and cultural awareness as well as physical health, role of food, a community atmosphere and social support, and involving extended family members.It is anticipated that appropriately adapting Dietary Guidelines to culture, economic and social differences will result in reduced weight gain and improved health risks in African American parents and their children living in Delta communities.

Table 1 .
Parent focus group discussion questions.

Table 3 .
Profile of focus group participants.

Table 4 .
Social cognitive theory constructs.Failure to meet the fat recommendation was attributed to the consumption of high calorie foods and snack foods.
Challenges to meeting the fruit and vegetable DGA recommendationsToo expensive; quality and quantity of fruits and vegetables Lack of time to cook vegetables recommendation.

Table 6 .
Summary of review of We Can! Families finding the balance: A parent handbook.We Can, so the title tells us if we all try hard enough, we really can; What is the President's slogan, Yes, we can-if the President is saying we can do it, we can do it.Decrease the amount of blue background; Enlarge the picture, the blue covers more than the picture; Graphics in the middle should be larger, the blue will throw you off; title needs to be at the top of the book; be bolder; Write in black instead of white.Appropriate, no changes needed (all agreed); to me they did a good job, a very good job.Show families it's a good idea to spend time together, get away from T.V. and video games; Parents preparing healthy meals; …so they encouraged their kids to be involved in eating healthy foods.Colorful; food is colorful and looks like it's just waiting for you to just eat it off the plate; Good choices because we as Black Americans, we need to promote good eating habits and physical activity and diet and parents eating together with their children and spending time; Shows different activities they could do.If someone picked up the book and couldn't read, they could look and see them riding a bicycle or playing ball or whatever without reading; Changes: Comparison of good and bad… show unhealthy and come back with healthy; Pictures of children in local activities (riding horses); More pictures of black families eating together and doing physical activity with kids; More pictures of minorities; more pictures of families from the parish;