Abstract
Latinos report less leisure time physical activity (PA) than non–Latino Whites and suffer disproportionately from diseases related to sedentary lifestyle, yet remain underserved and understudied. Gaining a better understanding of PA behavior in Latinos is critical to intervene on this significant public health issue. This article discusses the growing literature on the facilitators and barriers of PA in Latino men and women and reviews recent interventions to promote activity. Apart from acculturation influences, facilitators of PA in Latinos are similar to those of non–Latino Whites, with most research focusing on self-efficacy and social support. Barriers for Latinas, however, are more culturally distinct, such as a focus on caregiving and cultural standards for body shape. Barriers unique to Latino men largely have not been studied. Researchers have adopted a variety of approaches to increase PA, including using promotores and incorporating culturally appropriate activities, and have had mixed success. However, the community and randomized controlled trials almost exclusively included only women. Studies reviewed here suggest that interventions should target culturally specific barriers beyond language to successfully increase PA in Latinos and highlight a need for formative research and design of interventions for Latino men.
‘Higher rates of morbidity and mortality have been observed in Latinos for conditions such as metabolic disorders, obesity, and certain types of cancer.’
Latinos living in the United States report a wide range of health disparities compared with non–Latino Whites. Higher rates of morbidity and mortality have been observed in Latinos for conditions such as metabolic disorders, obesity, and certain types of cancer.1-3 These disparities can be partially explained by differences in access to care. 4 Latinos are less likely than Whites to use preventive health services or have a primary care physician 5 and are least likely of all racial/ethnic groups to have health insurance. 6
It is also likely that health disparities in Latinos are partially due to behavioral factors, such as differences in leisure time physical activity (PA). Of all major racial/ethnic groups in the United States, Latinos have the highest rates of inactivity and the lowest rates of meeting guidelines of sufficient activity.6,7 Data from the 2010 wave of the National Health Interview Survey indicate that approximately 45% of Latinos report never engaging in any leisure time PA, compared with 28% of Whites, and while roughly half of Whites met national PA guidelines (51.4%), only 36% of Latinos were sufficiently active. 6 Furthermore, both male and female Latinos are less active than their non–Latino White counterparts. Estimates of inactivity are 40.5% for Latino men and 48.6% for Latinas (compared with 26.1% and 29.9% for non–Latino White men and women, respectively). Consequently, it is not surprising that Latinos suffer a higher disease burden than non–Latino Whites from conditions related to sedentary lifestyle, such as diabetes, stroke, obesity, and hypertension.2,8
It has been suggested that the lower rates of PA in Latinos primarily reflect differences in socioeconomic status (SES) rather than ethnicity.9-12 However, Crespo et al showed that this difference remains significant even when adjusting for education, family income, SES, marital status, occupation, employment level, and poverty. 13 Similarly, in the Dallas Heart Study, Latinos had less than half the odds of being physically active (compared with Whites) even in models accounting for SES and education. 14 These results suggest that, while SES factors may contribute to inactivity, there remains a robust effect of ethnicity on activity levels. Moreover, while there is a good deal of heterogeneity in health behaviors between Latino subgroups, trends of inactivity are pervasive. The highest levels of inactivity in the United States are seen in Cubans, South Americans, and Dominicans 15 ; however, all Latino subgroups report less leisure time activity than non–Latino Whites.7,16
Given the low rates of PA among Latinos—and the high rates of diseases related to sedentary lifestyle—understanding factors that predict activity in female and male Latinos and the unique psychosocial facilitators of and barriers to activity faced by this ethnic group is critical. The purpose of the current article is to review recent literature examining the psychosocial predictors of and barriers to leisure time PA in adult Latinos in the United States. Additionally, we explore potential differences in these factors between men and women, which may be important as the discrepancy in inactivity rates between Latinos and non–Latino Whites is greater between women than it is between men. 6 Perhaps in response to this, the growing literature examining PA in Latinos has primarily focused on Latinas.17-20 However, among studies that do include Latino males, very few have specifically examined gender differences. Finally, we will review recent PA interventions specifically targeting Latinos and provide recommendations for future directions.
To best illustrate the current research investigating PA interventions in Latino populations, multiple searches were performed on various research databases. Primary databases used included PubMed, PsychInfo, and Google Scholar to search for studies written in English and published between 1999 and the date of the search (August 2013). First, studies exploring facilitators of and barriers to PA in Latino populations were examined. Specifications such as “Latina women” and “Latino men” were also added in this search to further identify potential gender differences in these factors. Next, the following search terms were used to identify peer-reviewed articles implementing and assessing exercise interventions in Latinos: “physical activity intervention,” “exercise,” Hispanic,” “Latino,” and “adults.” To be included in the summary table of PA interventions for Latino adults, studies had to meet the following criteria: (a) reported a sample with a majority of adult Latino participants and/or provide separate analyses for Latino participants and (b) assessed objective and/or self-reported PA as a primary outcome. The initial search produced 210 results. We scanned the titles of the remaining search results and eliminated those whose target populations were adolescents or whose topics were clearly unrelated to our review, leaving 72 results. We read abstracts of the few remaining articles to determine whether or not they qualified for the review, which eliminated 55 additional articles. We also searched the bibliographies of articles included as well as related review articles to ensure completeness.17-20 Ultimately, 29 intervention articles were included for review.
Psychosocial Facilitators of Leisure Time Physical Activity
Self-efficacy has repeatedly been shown to be among the strongest predictors of PA in Latinos.21-25 A review by Marquez et al identified self-efficacy as the most commonly reported correlate of PA among Latinos and reported that it was predictive across age groups and occupations. 17 This has been found with self-efficacy measures specific to exercise and exercise barriers21,24 and measures of general efficacy.22,26 In this respect, Latinos closely mirror non–Latino Whites, for whom self-efficacy has also been shown to be among the strongest predictors of PA. 27
The majority of studies investigating self-efficacy only focused on Latinas, but Marquez and McAuley specifically compared self-efficacy between genders and found that self-efficacy for exercise and for overcoming exercise barriers did not differ between male and female Latinos. 28 This study also found that the perceived importance of exercise did not differ across gender and that male and female Latinos did not differ in their reported support for exercise from friends or from family. There were no analyses reported, however, of whether support or self-efficacy was more predictive of actually engaging in exercise for men or for women. Also, the men and women in this sample reported equal amounts of exercise, which is not consistent with previous data6,7,29; thus, the results may not be representative of all Latinos.
Social support has also been shown to predict greater activity.21,23,30 A multinational study found that across cultures those with social support were more likely to be physically active than those without, and Latinos are no exception. 31 In fact, some suggest social support may be particularly salient for Latinos given the emphasis on family and interpersonal relationships within Latino culture. 32 Qualitative studies with Latinos show that social support is often cited as an important motivator, and many participants said they would exercise if they had someone to do it with.27,33,34 An examination of social support specifically for exercise in ethnically diverse women found that high support predicted greater activity and that Latinas were the most likely to receive high levels of support. 35 Studies show that increased activity is predicted by both general support and activity-related support.28,36 In a national study of multi-ethnic women, Latinas were more likely to exercise if they knew people who also exercised, but also if they belonged to community or religious groups. 36 Social support is a strong correlate of PA across diverse populations 28 and has been found to predict PA in studies that primarily sampled females 30 and males, 23 suggesting that it is influential for both genders. However, more research is needed to determine whether it is more important to one gender than another in determining exercise behavior.
Health literacy and knowledge about the benefits of and how to safely engage in exercise are also factors demonstrated to increase PA in Latino individuals. 37 Health literacy has been linked to self-efficacy, a well-researched facilitator of PA. 37 In one study, the ability to understand basic health information and services needed to make appropriate health decisions was predictive of greater changes in PA self-efficacy regardless of condition assignment. 38 Becoming educated about the benefits of exercise also influences PA in Latinos.39,40 In one faith-based intervention, participants who received culturally and spiritually relevant education materials promoting health benefits of PA were more likely to identify reasons for exercising and accurately describe the PA recommendations. 39 Furthermore, the way in which information about exercise is delivered may affect PA in Latinos, with messages about the potential gains or benefits of PA predicting greater intention to exercise than messages presenting the consequences and costs of being inactive. 41
In addition to understanding the benefits of exercise, having access to the necessary resources to engage in PA is another key factor to becoming active.33,42 In one survey, older Latino adults described the importance of community support in encouraging exercise, such as the availability of resources. 33 This is supported by another finding, in which living in a community where places to exercise were provided was positively associated with PA. 42 Participants from one study suggested community dancing events featuring various kinds of Latin music as a desirable community resource for PA. 43 These events were viewed as a way to increase PA, as well as develop a sense of community and shared culture. Similar to social support, health literacy, knowledge of exercise, and access to resources are facilitators that have been cited in studies with both females39,42 and males.33,41 However, differences in the extent to which men and women identify with these motivators have been relatively unexplored.
Acculturation is another factor that has been suggested to influence Latinos’ awareness of exercise as well as their level of PA.44,45 Acculturation refers to the degree to which individuals and communities retain their culture of origin alongside the extent to which they learn and/or adopt certain aspects of the dominant culture in their new country of residence. 46 While smoking, drinking, and obesity increase with acculturation, 47 several studies have shown that acculturation, in particular high English language acculturation, is accompanied by increases in PA.29,48,49 However, some studies have demonstrated contradictory findings. 50 When assessing the relation between acculturation and barriers to exercise, one recent study demonstrated that Latinos who were more acculturated toward US culture and values also expressed fewer safety and partner-related constraints to engaging in exercise. 51
This highlights a need to tailor interventions across the acculturation continuum. In one evaluation of a diet and exercise intervention for Latinos, researchers found that while intervention effects were consistent across level of acculturation, some of the hypothesized treatment mechanisms (eg, problem solving and supportive resources) varied across those with high Latina versus Anglo orientations. 52 Therefore, research and interventions for Latinos should identify their target audience and ensure the interventions address the unique PA facilitators and barriers across the acculturation continuum. However, more research is needed to understand these nuances as well as to examine differences in acculturation and PA across Latino subgroups.
In one study, examination of acculturation across genders found acculturation had greater effects on PA for Latinas than Latino men and that for more acculturated Latinos activity rates were equal among men and women. 47 The data set used in this study, however, is outdated (1991) and included only one dichotomous question to measure activity. Again, a more thorough investigation of gender differences in acculturation and its influence on PA is needed.
Psychosocial Barriers of Leisure Time Physical Activity
Examinations of barriers to PA have perhaps revealed the greatest differences between Latinos and non–Latino Whites. While Latinos do cite exercise barriers typical to non-Latino populations, such as a lack of time,53-55 many of the barriers described by Latinos are culturally specific. 17 Latinas, for example, have often cited a cultural norm to spend much of their time caring for others, particularly their children, and reported that the idea of “leisure time,” when they could do something of their choosing, was foreign or frowned upon.17,55,56 An examination of barriers to exercise among ethnically diverse women showed that, while White women most often cited lack of time and energy, the top rated perceived barrier for Latinas was caregiving duties. 57 Many Latinas also consider caregiving duties as being physically active 54 ; thus, caregiving reduces both their amount of leisure time and their perceived need to be active during their leisure time.
Latinas may also face unique barriers to PA because of cultural attitudes toward weight and body shape. 17 In Latino culture, larger, curvier figures are more culturally acceptable 58 and signify desirable attributes such as wealth or motherhood.54,59 Some Latinas have reported a disinclination to exercise because they do not want to lose those physical attributes. 54 In fact, a recent study on body image in ethnically diverse women found that less than half (48%) of Latinas wanted to be classified as “normal weight”; the others preferred to be overweight. 60 In several ways, then, exercise is in conflict with cultural norms and goals for Latinas.
Given the lack of prior experience with PA, exercising may feel inappropriate or unnatural to some Latinas. A qualitative study with older, mainly female Latinos revealed that the sample felt that exercise was an inappropriate activity for them to engage in, 33 which may be linked to the dearth of female role models and lack of social norms supporting women’s leisure time PA. 31 Additionally, an examination of barriers among Latinas showed that, after caregiving, the second most common reason given by Latinas for not exercising was feeling self-conscious about their appearance. 57 Among Latinas in the action stage of adopting an exercise program, self-consciousness was rated as the number one barrier to exercise. 61
These cultural standards may influence lower value being placed on the potential benefits of exercise (eg, leaner physiques). Studies have generally found that Latinos have a more negative view of exercise than Whites.40,62,63 One study with an older ethnic population showed that Latinos were actually more aware of the benefits of exercising than older Whites in the sample, but they still were less interested in participating. 62 A key factor in motivating Latinos to exercise, then, may be in linking PA with outcomes they value, such as caring for one’s family and giving/receiving social support.
Gender differences in barriers to exercise have not been examined in Latinos, and very few studies have examined barriers unique to male Latinos. The vast majority of studies examining activity barriers in Latinos have exclusively surveyed Latinas.17,54,57,63 The few studies that have used Latino men have not analyzed gender differences. One assessment of PA barriers in underserved populations did examine gender-specific barriers; however, all of the barriers they reviewed applied exclusively to women. 56 Because the barriers that apply to Latinas, such as caregiving and body consciousness, are not only culturally specific but also gender specific, it is likely that the barriers that apply to male Latinos would be different. Researchers in one study conducted qualitative research to understand the barriers specifically facing Latino men. 64 This study found that immigrant Mexican men were generally open and receptive to preventive health interventions, yet cited mostly external barriers such as demanding work schedules and lack of facilities. However, to date this is the only study to specifically examine barriers in Latino men; thus, more research is needed to more thoroughly explore other environmental, personal, and psychosocial barriers.
This research focus on Latinas is likely due to their especially high rates of inactivity, even compared with Latino men. However, Latino men still report high rates of inactivity and health conditions related to sedentary lifestyle, such as diabetes and obesity. 65 Therefore, a thorough investigation of the cultural- and gender-specific barriers that prevent them from exercising is important, and deserving of prompt attention. This gap in the literature may be partially due to negligence or ineffective recruitment strategies in enrolling Latino men in research studies. To address this issue, researchers should explore and implement new methods for effectively engaging this population. Suggestions for such methods are described in the discussion section.
Physical Activity Interventions
To date, the majority of PA interventions have been conducted primarily with non–Latino Whites, despite the higher prevalence of inactivity among Latinos. Several studies have targeted underserved minorities 6 but do not make comparisons between different ethnic/racial groups. Thus, the number of interventions specifically targeting Latinos is relatively small, but growing. We organize our review of Latino-focused interventions using the Social Ecological Model 66 and classify interventions as (a) community/ecological, (b) interpersonal (promotore-led programs, group-based, or family interventions), or (c) individual interventions. In several instances, interventions may be considered to influence multiple levels of the Social Ecological Model. In these instances of overlap or ambiguity, we have tried to capture the primary focus of the intervention and relied on the authors’ descriptions.
Our search yielded 3 community/ecological studies, 16 interpersonal programs, and 10 individual interventions, totaling 29 studies. The majority of studies focused on women, with 16 including only women, 8 having mostly women (>50%), and 1 study having an equal sample of men and women. Four studies did not report percentages of men and women in their samples, and no studies were found assessing primarily or only Latino adult men that fit with our search criteria. With regard to ethnicity of the target population, the majority of studies included participants primarily of Mexican American or Mexican descent (19 studies), followed by Cuban (3 studies), Caribbean (1 study), and Puerto Rican descent (1 study). In addition, 4 studies did not specify participants’ countries of origin, reporting Latino or Hispanic, and 1 study reported a sample from mixed Latin American countries of origin but did not specify which countries of origin. Studies are summarized in Table 1.
Study Characteristics and Findings From Physical Activity Interventions With Latinos. Studies reviewed in the table are marked with an asterisk (*) in the references section.
Abbreviations: PA, physical activity; CVD, cerebrovascular disease; NHLBI, National Heart, Lung, and Blood Institute; RCT, randomized controlled trial; BMI, body mass index.
Community/Ecological Interventions
Several studies employed a community approach, attempting to increase health and fitness in predominantly Latino neighborhoods.67-69,71,98 One intervention used a community-based mass media approach (Salud Para Su Corazon) to increase awareness of risk factors and preventive behaviors for heart disease. 67 Pre- and postintervention focus groups were held with equal numbers of men and women and showed that knowledge increased significantly in both genders. However, there were no changes seen in behavior. Another community intervention targeted Latinos in Washington Heights in New York, and more directly attempted to increase PA by making free exercise classes available in Spanish. 69 While the classes were well attended, no data reported on whether this actually increased PA in the community.
One community-based study in El Paso, Texas, attempted to increase stair use in various community locations by posting both English and Spanish signs promoting the benefits of taking the stairs. 68 The messages focused either on the benefit to the individual or to the family. Overall, stair use increased in response to both types of signs, and despite Latino emphasis on familismo the family-centered sign was no more effective than the individual one. This study was one of the few to assess gender differences, and it found that women consistently increased stair use across sites, while men were less consistent but still generally increased their use of stairs. This type of intervention is both low cost and has the potential for very broad reach. It is uncertain, however, if changing small bouts of activity, such as occasional stair use, would lead to substantive changes in health.
Interpersonal Interventions
A major focus of programs for Latinos has been in targeting social support and interpersonal processes to increase PA. Recognized as a powerful factor in promoting PA with diverse groups, interpersonal relationships and social support have been emphasized in the development and adaptation of interventions for Latinos. In this review, we classify interpersonal interventions into 3 categories: promotore, group-based, and family-based interventions. In acknowledging that individual-focused interventions may be delivered in a group setting for cost-effectiveness, we classified interventions as group-based if the authors discussed the role of the group processes in promoting PA.
Promotore-Led Programs
An important movement in implementing health interventions with Latinos has been the use of promotores de salud (promotores), lay health workers in the Latino community who act as community health promoters, educators, and liaisons with health care providers. A number of PA interventions have relied on promotores to educate and lead community members in being physically active, and have generally been successful.68,70-74,76,77 In the Balcázar et al study, 71 promotores were trained across 7 sites and delivered lessons from NHLBI’s Su Corazón, Su Vida curriculum on heart healthy behaviors to 232 Latino families over the course of 6 months. At the end of the intervention, scores on heart healthy behaviors, including PA, significantly improved.
A similar approach was taken in Pasos Adelante, a 12-week program in which promotores in US–Mexico border communities delivered the Su Corazón, Su Vida curriculum in addition to organizing and leading community walking groups. 77 At the end of the program, participants reported significant increases in minutes of PA per week. Participants in this program, however, were almost all female (>90%). Promotores in a feasibility study 72 designed walking routes and led walking groups for older obese Mexican American women assigned to walk either 3 or 5 days per week. Participants reported walking 63.7 and 129.2 minutes, respectively, and showed significant reductions in body weight. Retention for the study, however, was quite low (48% at 36 weeks).
Another community promotore-led intervention focusing on cancer prevention successfully increased PA levels in low-income Latinas in Arizona. 74 Sessions were held twice per month at local church and community centers, during which promotores shared information on cancer screenings, diet, and PA. Social support was emphasized, and participants were encouraged to form walking groups, meal plan together, and develop a group identity. After 3 months, exercise frequency and duration significantly increased among participants. Promotores in another study 73 each provided 3 education sessions in Spanish on PA, diet, and tobacco use to Latino community members and recorded behavior before and 1 month after the intervention. Participation in PA significantly improved from pretest to follow-up, as did overall health behaviors. Finally, Ayala et al 70 assessed a sustainable train-the-trainer model by training promotores to lead fitness classes, which were offered for free in Spanish at various community locations. After 12 months, participants showed significant improvements on a variety of physical and mental health measures, including blood pressure, fitness, flexibility, and depression.
One randomized trial assessed the effectiveness of using promotores in addition to provider counseling and health education to increase PA in female patients at community clinics, most of who were Latina. 76 Participants were assigned to 1 of 3 conditions: (a) provider counseling (including prescription for behavior change), (b) provider counseling plus health education on nutrition and PA, or (c) provider counseling, health education, and support from promotores. After 1 year, women in all 3 groups showed significant increases in PA participation from baseline, and there were no significant differences between groups.
Group-Based Interventions
Several studies used group-based approaches but did not specify using a promotore, or peer-educator model, for facilitating the groups.75,78-84 One example of this approach is a pilot study to teach diabetes self-management in Latinas with type 2 diabetes. The study randomized participants to an intervention group that received 10 cognitive behavioral focused group sessions teaching self-management techniques, including exercise (though it was not the main focus of the intervention). 82 Compared with controls, intervention participants showed a trend toward increased PA. Because this was only a pilot study, however, only 15 participants received the intervention; thus, the study was not fully powered to show statistically significant changes between groups.
Nearly all exercise interventions with Latinos have focused on walking for exercise. One study, however, culturally tailored the intervention by using dance classes taught specifically for Latinas in Spanish. 80 Participants were randomly assigned to either a culturally tailored Spanish language dance class intervention or home safety lectures (control). Those in the intervention arm attended thrice-weekly salsa and merengue dance classes at a nearby community center that were followed by exercise education. At the end of the 6-month intervention, those in the treatment arm reported greater vigorous activity and showed greater VO2max. These results remained significant after 12 months.
In one study, 78 Latina participants were assigned either to a waitlist control group or an intervention, which included 1 instruction session per week by a bicultural Spanish-speaking physician on diet and exercise modification. Instruction focused on social support, monitoring, and problem solving in addition to diet and exercise information, and also included a 20-minute walking session. After 8 weeks, those in the intervention arm showed improvement in a range of measures, including fitness, diet and exercise knowledge, and exercise frequency compared with controls.
Family-Based Interventions
Despite the importance of the family unit within Latino culture, only 2 interventions were identified that targeted the family as the focus of intervention.85,86,89 Nader et al used a family-based model to promote PA in White and Latino families by randomizing families to a 24-month education intervention focused on improving diet and PA. 85 While there were significant improvements in dietary intake by the end of the intervention, there were no changes in reported PA or fitness. Another study focused on mother–daughter dyads, recruiting 42 dyads primarily of Mexican descent. 86 This program was delivered in community and school settings through a 12-week program that included dance, sport sessions, and behavioral counseling components. The program was tested through a 2-arm experimental design and found significant differences in walking MET, as well as in levels of depressive symptoms and stress.
Individual Interventions
There were 10 studies that identify individuals as the primary target of the intervention using a variety of approaches.87-89,91-97 There were also numerous Latino subgroups targeted by the interventions, including individuals with type 2 diabetes, pregnant prenatal care patients, premenopausal overweight women, health center patients, and low-income community-dwelling residents. One study of older men and women primarily of Caribbean descent with type 2 diabetes found significant increases in leisure and household PA, improved glycemic control, and decreased diabetes medications among individuals participating in a high-intensity progressive resistance training program. 89 Another program 95 provided individualized reports to male and female Latinos through a community-based health center kiosk computer program. In a 2-group repeated-measures design, there was a significant increase in the number of computer-literate adults who met PA recommendations in community and clinic settings. Another primary care-based study for primarily Spanish-speaking individuals with multiple chronic conditions assigned participants to either usual care or to receive additional support in the form of self-management training, community resource linkage, and follow-up phone calls and newsletters. 91 While participants reported significant improvements in diet, there were no changes in PA.
Other programs utilized the Transtheoretical Model to tailor interventions based on participants’ readiness to change PA. One large trial evaluated the California WISEWOMAN program for low-income Latinas with 1093 women from primarily Mexican descent (65%) participating in the trial.92,93 Women receiving the enhanced intervention, which included 12 weeks of one-on-one counseling sessions, reported significant increases in moderate and vigorous activities from baseline to follow-up and 67% were in the action/maintenance stage at follow-up as compared with 47% at baseline. In a print-based tailored intervention with 93 low-income, predominantly overweight/obese Latinas of mixed descent, there were significant increases in moderate to vigorous PA from baseline to follow-up. 97
Gender Differences in Interventions
The current data do not allow for a discussion of gender differences in PA interventions in Latinos, as the vast majority of participants in these studies were women. Of the community interventions open to both genders,69,68,71,90,99,100 nearly all the participants were still female and in many cases males represented less than 10% of the sample.68,71,90,98 Alcalay et al 67 was the only study to actively recruit equal numbers of men and women; however, these participants participated in focus groups to assess the effectiveness of the intervention rather than committing to actual behavior change. The stair use intervention 68 observed and compared behavior change in men and women, yet again these were observations of one-time behaviors rather than participants committing to an intervention. Nevertheless, as this study was the only intervention to assess gender differences, its results are especially informative. While it shows that men are not as consistently responsive to a simple informational intervention as women, it also shows that they will change behavior when given reminders, encouragement, and information.
Gender recruitment was even more skewed in the randomized trials: every single randomized trial reported here included only female Latinas as participants. In most cases this is likely because the intervention was designed for women, focusing on activities that might be less appealing to men. Designing interventions that include men or that are exclusively for men may be difficult simply because little is known about the facilitators, barriers, and preferences of Latino men in the realm of PA; as mentioned previously, all examinations of gender-specific barriers in Latinos have focused on women.
Conclusions
Low levels of PA in Latinos are concerning, particularly as they make up a steadily growing percentage of the US population, and interventions to address this disparity will need to be designed and implemented with specific ethnic and cultural considerations in mind. The interventions reviewed here showed mixed success. Many emphasized constructs shown to predict PA in Latinos, particularly social support, and the majority offered interventions in Spanish. The cultural adaptation of interventions may be especially important, as acculturation emerged as one of the most robust predictors of PA, with less acculturated individuals being less likely to exercise. In addition, the use of Latino physicians or promotores to deliver interventions may also increase success for less acculturated members of the community.
While these approaches are no doubt instrumental in overcoming barriers, studies reviewed here suggest that Latinos face unique barriers to being physically active beyond language barriers. Consequently, the actual content of interventions may need to be tailored for Latinos in order to be effective. In addition to barriers often reported by non–Latino Whites, such as constraints on time and money, 57 Latinos often cite culturally specific barriers, such as cultural views on weight and body shape, and more negative views about PA in general.40,62,63 Additionally, typical Latino gender roles do not include expectations about PA.17,55,56 The caregiver role assumed by many Latinas emphasizes placing the needs of others first and leaves little spare time for women to do something of their own choosing that does not involve children or other family members. And while Latinas did report a good amount of general social support for PA,17,40,42,101 they were also more likely to report their husbands discouraging them from exercising. 63 Addressing these cultural perspectives and expectations may therefore be a critical aspect of successful interventions.
Additionally, studies suggested that Latinos are more likely to feel awkward or uncomfortable engaging in PA.57,61 This may be the consequence of lack of experience and exposure to leisure time PA as well as the need to promote more culturally accepted and practiced activities. Activities such as dance may help overcome this type of barrier; an approach that proved successful in the Hovell et al intervention. 80 The use of Latino promotores, community members, and researchers for designing and delivering interventions may also be instrumental in addressing cultural norms and reversing the assumption that being physically active is not consistent with Latino culture.35,102
Ethnic and culturally specific barriers likely exist for Latino men; however, no studies have specifically examined barriers in this group, despite their low levels of PA. This highlights an urgent need for formative research and for interventions designed specifically for Latino men. The theoretical frameworks of such interventions may be similar to those used in studies reviewed here with Latinas, as the predictors of PA in Latinas, such as social support and self-efficacy, seem to also apply to Latino men.27,33,34 Such an effort was recently tested in a small pilot study that modified an intervention shown to effectively increase PA in Latinas.103,104 After conducting several qualitative interviews with Latino men, this intervention was modified to address their specific barriers and preferences, which included a preference for team sports and navigating conflicts with work and family time. The modified intervention was then tested in a small 12-week demonstration trial (N = 10). Participants significantly increased weekly PA from 1.3 minutes/week at baseline to 125.5 minutes/week at 12 weeks, and expressed enthusiasm for the program. These preliminary results are encouraging and suggest that programs shown to effectively increase PA with Latinas could be adapted to effectively address this behavior in Latino men.
The limited research with Latino men is parallel to the limited number of interventions and research studies with men more generally.105,106 However, the lack of Latino men in PA interventions also highlights the need for improved strategies in effectively recruiting and engaging this population. While promotores and other community members may be valuable resources in implementing PA interventions, investigators are nonetheless responsible for maintaining a commitment to participant involvement and interest, including establishing rapport with participants, and reducing barriers to participation. Exploring recruitment and retention of Latino adolescents to their research study, Villarruel et al 107 found that research staff who share salient characteristics with the population, such as being Latino/a or a native Spanish-speaker, may be more successful in building trust with participants. Trust between the researcher and participant was one factor that that was found to be particularly important to Latino men when participating in a research study. 108 Therefore, programs developed and implemented by bilingual and bicultural researchers and personnel may be important for developing rapport with this population.
Another reason for the limited research in PA interventions for Latino men may be due to the fact that these interventions were not designed specifically for men, and thus may not have been as appealing to them as a male-focused intervention might be. The dearth of programs for men may also be due to the unique challenges related to gender roles, such as limited time and interest in leisure time PA and other health programs. As few studies have tried recruiting male Latinos, more research is clearly needed on successful recruitment strategies, in addition to the types of interventions that would appeal to them and be successful in increasing their PA.
Interventions with Latino men may necessitate involvement of female family members. 4 Involvement of female spouses has been successful in increasing preventive health behaviors in men 107 and this may be especially effective for Latinos. The Latino emphasis on family involvement, known as familismo, extends to health care decisions, 109 and Latina women in particular have been shown to exert significant influence on husbands’ health care use and health related decisions.109,110 Family- or couple-centered interventions, therefore, may have greater potential to increase activity in Latino men.
The current literature has laid substantial groundwork for addressing health disparities related to low levels of PA in Latinos. There are robust findings identifying predictors of activity for Latinos, namely, social support, self-efficacy, and acculturation, and many barriers for female Latinas have been identified. Additionally, many interventions have been successful in increasing activity in Latinos and show maintained behavior changes over time. Further studies are needed to better understand ethnic and culturally specific facilitators and barriers, and to build strategic theory-based solutions to these barriers into interventions. These interventions would likely need to evolve with participants, as studies suggest that factors that predict adoption of PA may differ from those that predict maintenance. 111
There is a need for greater attention to within and between subgroup comparisons to determine the extent to which there are differences in PA and its correlates. The current review identified that the majority of interventions tested to date have focused on Latinos of Mexican descent, with little information currently available about other Latino subgroups. Similarly, there is a need to advance understanding of the influence of acculturation and its relation to PA and other health behaviors. Greater specificity in research and interventions would permit more targeted tailoring and the identification of specific subgroups at greatest risk.
Another important area for future research will be investigating effective channels of dissemination for these interventions. This could expand on existing culturally relevant channels, such as including promotores and bicultural physicians and staff in primary care settings, and expanding cultural competence training among health care providers.4,68,70-74,76,77 Expanded use of social networking and technology could also be instrumental in more broad dissemination of interventions among Latinos. Internet usage has risen significantly among racial and ethnic minorities in recent years 112 and may be an effective tool in recruitment. Delivery of such interventions could be instrumental in shaping public health, as studies reviewed here suggest that widespread dissemination of culturally tailored interventions could have a significant impact on PA in Latinos and related health and quality of life.