The Challenges of Changing Dietary Behaviors of Underserved Populations

Abstract

The dietary behaviors of underserved populations contribute to diet-related health disparities. Behavior change is affected by many factors that may be grouped in four main categories; individual, interpersonal, institutional, and community and public factors.6However, underserved populations experience additional stressors that create greater barriers to achieving dietary behavior change. Researchers and health professionals are encouraged to work with and within underserved communities to provide appropriate and acceptable programming. This article highlights other stressors that make behavior change more challenging for underserved populations. Additionally, guidance to developing and implementing successful interventions to improve dietary behavior change in underserved populations is included.

‘. . . improving the dietary behaviors of underserved populations is an important aspect to decreasing diet-related health disparities.’

Underserved populations (low income, low education, rural and urban residence, racial/ethnic minorities) are disproportionately affected by diet-related chronic diseases such as diabetes, obesity, hypertension, cardiovascular disease, and cancer. For example, African Americans are more likely than whites to have a stroke (60%), to have high blood pressure (40%), and to have been diagnosed with diabetes (200%). ¹ Chronic diseases have been associated with negative dietary behaviors such as eating foods low in fiber, having a diet low in fruit and/vegetables, having a diet high in fat and sugar, and having low physical activity. Individuals with lower incomes and lower educational levels tend to consume fewer fruit and vegetables than individuals with higher incomes and more education.^2-4 Thus, improving the dietary behaviors of underserved populations is an important aspect to decreasing diet-related health disparities. Health disparities are a result of a lack of access to health care, environment, biology and genetics, and human behavior. ⁵

Like other health behaviors, dietary behaviors are multidimensional and challenging to alter. In the past, health behavior programs targeted individual factors; today, researchers understand the need to target multiple factors. Dietary behaviors of underserved populations influences, and is influenced by, individual, interpersonal, institutional, community, and public policy factors. ⁶ Individual factors are characteristics such as knowledge, attitudes, beliefs, and personality traits. Lack of nutrition knowledge and inadequate cooking skills are examples of individual factors that influence healthy eating.^7,8 Interpersonal factors are interpersonal processes that provide social identity, support, and role definition to family, friends, and peers. Food choices and physical activity level are predicated by the interactions with and the support of family and friends, as well as the amount of screen time.^9-11 Institutional factors include rules, regulations, policies, and informal structures that may constrain or promote recommended behaviors, whereas community factors are social networks and norms or standards that exist formally or informally among individuals, groups, and organizations. The built environment of schools and neighborhoods is an example of institutional and community factors that influence health behaviors. Public policy factors include local, state, and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control, and management. In the United States, federal, state, and local government develop policies and programs to influence positive health behaviors, for example, mandating minority inclusion in clinical trials ¹² and supporting behavioral counseling for eating and physical activity behaviors.^13-16 Unlike other populations, underserved populations experience additional stressors to the factors that influence dietary behavior change, making behavior change even more challenging. The focus of this article is to highlight four additional stressors that make behavior change challenging for underserved populations—trust, segregation, poverty, and access—and to describe culturally sensitive, successful intervention strategies.

Trust

Slavery, research abuse, immigration, and low literacy influence the distrust of majority populations by underserved populations. Underserved populations experience institutionalized racism which contributes to the reluctance in receiving dietary counseling, participating in dietary behavior research, and using recreational facilities. Low participation rates of underserved populations in disease prevention research have been attributed to sociocultural barriers that lack empirical evidence. ¹⁷ However, the paucity of data available regarding barriers to participation within underserved populations in behavioral research implies that behavioral researchers have either not published data to determine the barriers to participation of underserved populations in behavioral research or that behavioral researchers have assumed that the barriers to participation in medical research may be transferred to those of behavioral research. An extensive list of suggestions regarding participation barriers in medical research was detailed by Shavers et al ¹⁸ as follows:

the Tuskegee Study; distrust; lack of awareness about research studies; fear of being used as guinea pigs; economic barriers; communication issues; disproportionate study exclusion; beliefs regarding researchers willingness to conduct ethical studies; the failure to actively recruit African Americans for studies; fatalistic attitudes towards diseases such as cancer; negative attitudes towards study staff; racial composition of study staff; and racism.

Segregation

Separation by race/ethnicity, income status, educational status, and or rural/urban/suburban residence are factors that inhibit dietary behavior change. Communities with higher income and education have better schools, better grocery stores, better playgrounds, and better medical care than low income communities. As a result, residents of low income and education communities, who are able, commute to higher income and education communities to take advantage of the better resources. Spending in other communities is detrimental to the economic stability of the low-income, racial/ethnic, rural/urban/suburban community. The difference in communities is also apparent in the high availability of alcohol products and the marketing of tobacco and alcohol products, the absence of recreational facilities, and the burden of violence that strains outdoor physical activity in low-income, racial/ethnic communities.

Poverty

The rate of poverty for underserved populations is substantially higher than the poverty rate for the US population. For instance, in 2010, 15.1% of all persons lived in poverty. ¹⁹ However, 31.8% of African American families with children live in poverty, compared with 11.7% of White families with children. Impoverished individuals and families are stressed by the lack of money to provide the basic needs of food, health care, housing, and transportation. Healthy eating may be a low priority because of poor work and living conditions, ²⁰ not having enough food available as a result of relying on the disbursement cycle of supplemental food programs (ie, WIC, food banks, LINK), ²¹ and inadequate food storage conditions (ie, refrigeration, pest-free storage). ²² Income inequality in obesity appears to be a burden for the less affluent, especially for the female population. ²³ Furthermore, obesity rates were found to increase in females over time as neighborhood-level incomes decreased. ²⁴

Access

Neighborhoods with high populations of low-income, low-educated, rural/urban residence, and/ racial/ethnic minorities are saturated with fast food restaurants, but lack full-service grocery stores.^25,26 Thus, residents have limited access to and availability of quality fresh fruits, vegetables, whole grains, and low-fat dairy products. When available, healthier food options are usually more expensive than the inexpensive high-fat, high-sugar, high-calorie food items that are readily available by the saturation of fast food restaurants in underserved neighborhoods.^27,28 Indeed, fast food restaurants are known for their energy-dense, nutrient-poor menu items. The combination of expensive healthy food with easy access to unhealthy foods supports the negative dietary behaviors that increase the risk of diet-related chronic diseases. The lack of the availability of affordable and acceptable produce in underserved communities leave residents shopping at overpriced and poorly stocked convenient stores, or traveling to more affluent areas, thereby spending more money on food than is affordable.

Parks, green spaces, bike paths, and other recreational facilities are limited in underserved communities. ²⁹ When available, these facilities are not inviting because of debris, trash, crime, and/unsafe, and or worn equipment. Additionally, low-income adults are less likely to purchase membership to a fitness center, and low-income children are less likely to participate in organized sports. ³⁰ These factors predicate a sedentary lifestyle, hence increasing the risk of dietary chronic diseases.

Successful Strategies

The Office of Minority Health & Health Disparities, of the Centers for Disease Control and Prevention, and many researchers suggest that culturally sensitive education and intervention programs for underserved communities are needed to diminish health disparities.^31,32 Cultural sensitivity was defined by Resnicow et al ³³ as “the extent to which ethnic/cultural characteristics, experiences, norms, values, behavioral patterns and beliefs of a target population as well as relevant historical, environmental, and social forces are incorporated in the design, delivery, and evaluation of targeted health promotion interventions.” Cultural tailoring was defined by these same researchers as the “process of creating culturally sensitive interventions.” ³³ Hiring project staff of similar race and ethnicity to the participants and developing and using materials that are culturally relevant are effective strategies commonly used in health intervention projects. ³⁴ Culturally relevant approaches that focus on minority groups are useful in increasing knowledge of and improving attitudes toward nutrition. ³³ Researchers conducted individual interviews with African American and Latina women to gain insight into their recommendations to the best approaches to participatory health research in their communities. ³⁵ The women recommended that trust and commitment to the community be the foundation of the preventive research, a diverse and knowledgeable staff and researchers interested in the needs of the community are employed, and clear expectations about the project are provided to the participants.

Positive outcomes for underserved populations were improved in interventions where culturally relevant strategies were added. Research examining the impact of using a culturally tailored behavioral intervention in a randomized control study was conducted by Krueter et al ³⁴ relative to the use of mammography and fruit and vegetable consumption. African American female participants were randomized into 1 of 4 study groups: behavioral construct tailoring (BCT; more commonly called behavior models), culturally relevant tailoring (CRT), a combination of both (BCT + CRT), or delayed intervention/usual care (control). Results from this study demonstrated that women in the combined group were more than twice as likely to use self-reported mammography at the 18-month follow-up as women in the control group (95% confidence interval), whereas mammography adherence did not differ between the BCT or CRT and the control group. The combined group also reported greater increases in daily fruit and vegetable servings. The researchers found no evidence of effectiveness using the culturally tailored or behavioral constructs alone; however, the intervention was only effective when culturally relevant tailoring was combined with a behavioral construct.

Summary

Dietary behaviors are influenced by individual, interpersonal, institutional, community, and public policy factors. The factors that influence dietary behavior are exacerbated by distrust, segregation, poverty, limited access, and the lack of cultural sensitivity in programming and educational materials in underserved populations. Programming developed to change dietary behavior change should be multidimensional in nurturing all the factors that influence dietary behavior change in underserved populations. Researchers and health care personnel are encouraged to provide culturally tailored materials along with a behavioral construct when designing programs for underserved populations to increase participation, retention, and compliance.