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1 MOTIVATORS OF AND BARRIERS TO HEALTHY EATI NG BEHAVIORS: PERSPECTIVES OF LOW-INCOME, CULTURALLY DIVERSE CHILDREN By LILLIAN BOYNTON KAYE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008
2 2008 Lillian Boynton Kaye
3 To my Mother
4 ACKNOWLEDGMENTS I thank all of the people who helped and suppor ted m e in completing such a daunting task. I am especially grateful to my advisor, Dr. Carolyn M. Tucker, who had confidence in my abilities and provided numerous opportunitie s since I began graduate school under her mentorship, including helping dire ct a fantastic research team. I am also grateful to my other supervisory committee members (Dr. Scott Mille r and Dr. Ken Rice) for kindly lending their time and their efforts. Additionally, I would like to thank the individuals who graciously edited various pieces of this work, including Marie Bragg, Angela Estampador, Sarah Nolan, and Delphia Flenar. Finally, I would like to thank Travis Mock, my loving family, and my supportive friends for providing continuous care and encouragement along the way.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES ................................................................................................................. ..........8 ABSTRACT .....................................................................................................................................9 CHAP TER 1 INTRODUCTION................................................................................................................. .11 2 LITERATURE REVIEW.......................................................................................................18 Rationale for the Nation al Advocacy for Healthy Eating among Children............................ 18 Current Trends in Eating Behaviors am ong Children..................................................... 19 Diet-Related Diseases/Health P roblems..........................................................................21 Psychological im pact of overweight/obesity............................................................ 23 Race/culture-related d isparities in di et-related diseases/health problems................ 24 Incom e-related disparities in diet-r elated diseases/health problems........................26 Benefits of Healthy Eating ..............................................................................................28 Contributors to Healthy/Unhealthy E ating among Children..................................................30 Environm ental Factors..................................................................................................... 30 Availability/access ibility of healthy/unhealthy foods.............................................. 31 Media influence ........................................................................................................ 31 School environm ent.................................................................................................. 32 Social Relationship Factors .............................................................................................33 Fa mily influence.......................................................................................................33 Peer influence ...........................................................................................................36 Cultural Factors ...............................................................................................................37 Econom ic Factors............................................................................................................39 Knowledge/Educational Factors ...................................................................................... 40 Psychosocial Factors .......................................................................................................41 Theories Used for Understanding Eating Behaviors ..............................................................43 Health Belief Model ........................................................................................................43 Transtheoretical Model of Behavior Change .................................................................. 44 Theory of Planned Behavior ............................................................................................44 Social Cogn itive Theory.................................................................................................. 45 Health Self-Em powerment Theory.................................................................................. 46 Theories Inform ing the Present Study............................................................................. 46 Interventions Prom oting Healthy Eating among Children..................................................... 48 Types of Interventions ..................................................................................................... 48 Efficacy and Lim itations of Interventions....................................................................... 49
6 Overview of Present Study.....................................................................................................54 Purpose of Present S tudy................................................................................................. 54 Need for a Culturally S ens itive Research Approach.......................................................56 Description of Present Study ........................................................................................... 56 3 METHODS ...................................................................................................................... .......58 Participants .............................................................................................................................58 Instrum ents.................................................................................................................... .........58 De mographic and Health Informa tion Data Questionnaire (DHIDQ)............................ 58 Focus Group Questioning Route (QR) ............................................................................59 Procedures..................................................................................................................... ..........60 Participant Recruitm ent................................................................................................... 60 Focus Group Leader Training ......................................................................................... 61 Focus Group Im plementation.......................................................................................... 62 Qualitative Data Analys is................................................................................................ 64 4 RESULTS ...................................................................................................................... .........70 Findings from the Health Info rm ation Questions on the DHIDQ.......................................... 70 Organization of the Analyzed Focus Group Data ................................................................... 70 Motivators of and Barriers to Eating Healthy Foods .............................................................. 73 Motivators of Eating Healthy Foods Reported among All Six Focus Groups ................ 73 Motivators of and Barriers to Eating H ealthy Foods Reported am ong Five of Six Groups..........................................................................................................................76 Motivators of and Barriers to Eating H ealthy Foods Reported am ong Four of Six Groups..........................................................................................................................78 Motivators of and Barriers to Eating H ealthy Foods Reported am ong Three of Six Groups..........................................................................................................................79 Motivators of Eating Healthy Foods Reported among Two of Six Groups .................... 80 Motivators and Barriers to Eating Hea lthy Foods Reported among One of Six Groups ..........................................................................................................................81 Indirectly Assessed Moti vators of and Barriers to Eating Healthy Foods ...................... 82 Motivators of and Barriers to Eating W hole-Grain Foods.....................................................83 Reported among All Four Groups ...................................................................................83 Reported among Three of Four Groups ...........................................................................84 Reported among Two of Four Groups .............................................................................85 Reported in One of Four Groups..................................................................................... 85 5 DISCUSSION ................................................................................................................... ......87 Summ ary of Findings............................................................................................................ .87 Most Commonly Reported Motivators of and Barriers to Healthy Eating ..................... 87 Other Reported Motivators of a nd Barriers to Healthy Eating ........................................ 88 Differences in Association with Gender or Race/Ethnicity ............................................ 89 Interpretations of Findings ......................................................................................................90 Lim itations.................................................................................................................... ..........94
7 Implications for Future Re search and Application.................................................................97 Conclusion ..............................................................................................................................98 APPENDIX A DEMOGRAPHIC AND HEALTH IN FORMATION DATA QUESTIONNAIRE............ 100 B PARENTAL CONSENT FORM.......................................................................................... 102 C FOCUS GROUP QUESTIONING ROUTE (EXCERPT)................................................... 104 REFERENCES ............................................................................................................................105 BIOGRAPHICAL SKETCH .......................................................................................................127
8 LIST OF TABLES Table page 3-1 Descriptive statistics of dem ographic variables................................................................. 69
9 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science MOTIVATORS OF AND BARRIERS TO HEALTHY EATI NG BEHAVIORS: PERSPECTIVES OF LOW-INCOME CULTURALLY DIVERSE CHILDREN By Lillian Boynton Kaye December 2008 Chair: Carolyn M. Tucker Major: Psychology This study used a focus group methodology to examine the perceived motivators of and barriers to healthy eatin g behaviors among African American, Hispanic, and non-Hispanic White American children from families with low household incomes. The present study also examined if there were differences in pe rceived motivators of and barriers to healthy eating behaviors in association with gender and race /ethnicity. Specifically, the hea lthy eating behaviors assessed in this study include: (a) eating foods and snacks that are lower in fat and calories and (b) eating fruits, vegetables, and whole grains. Participants were 37 children between the ag es of 9 and 12 years old who were from families with an annual household income of 40,000 dollars or less. These children participated in one of six genderand race/ethnicityconcorda nt focus groups that were conducted at various community sites and led by trained focus group lead ers of the same gender and race/ethnicity as the focus groups participants. Digi tal audio recordings of the fo cus groups were transcribed and then analyzed qualitatively by a team of cultu rally diverse researcher s using the constant comparative method. An inductive strategy was used to develop a coding scheme to describe and categorize the reported motivator s and barriers. Inter-coder re liability was found to be 0.89.
10 Overall, findings suggest a number of envir onmental, educational, sociocultural, and psychological factors that childr en reported as motivating or pr eventing them from engaging in healthy eating behaviors. The motivators of heal thy eating most commonly reported across focus groups included: (a) social influe nce, (b) taste, (c) availability of healthy foods, (d) weight concerns, and (e) the desire to be healthy. The barriers to healt hy eating most commonly reported across focus groups included: (a) taste and (b) issues of availability. A number of other motivators of and barriers to hea lthy eating were al so reported. Findings from the present study suggest that the perceived motivators of and barriers to healthy eating behaviors are generally similar ac ross gender and race/ethni city. The few potential gender and race/ethnicity differen ces that were found are reported. For example, in regard to gender differences, it was found that two of three female focus gr oups but none of the male focus groups reported that the immedi ate effects that accompany eating certain foods (e.g., feeling energetic) serve as a motivator for eating hea lthy foods. An example of a finding related to possible race/ethnicity differen ces is that the African American male focus group was the only group among which weight concerns was not discussed as a motiv ator for eating healthy foods. The limitations, implications, and conclusions of this study are presented. Future research may utilize the present study as a model for conducting similar studies that are culturally sensitive in nature and inclusive of children fr om low-income families as well as children of diverse cultural backgrounds. The present st udy can also inform the development of a quantitative assessment tool that can be used with diverse groups of children to determine their perceived motivators of and barr iers to healthy eating, with th e ultimate goal of using this assessment data to inform interventions aimed at reducing obesity and health disparities and promoting healthy eating behaviors among children.
11 CHAPTER 1 INTRODUCTION Over the past three decad es, the childhood obesity rate in the United States has more than tripled. One third of Amer ican children and youth are either obe se or at risk for becoming obese (Institute of Medicine, 2006). Although the United States Depa rtment of Health and Human Services identified overweight and obesity as one of the top 10 l eading health indicators years ago in the national initiative titled Healthy People 2010 progress reviews have indicated that trends for obesity and overweight have only worsened, especially among children and adolescents (Trust for America s Health, 2007; United States Depa rtment of Health and Human Services [USDHHS], 2007). The prevalence of over weight in female chil dren and adolescents increased from 13.8% in 1999-2000 to 16.0% in 20032004, and the prevalence of overweight in male children and adolescents increased fr om 14.0% to 18.2% (Ogden, Carroll, Curtin, McDowell, Tabak, & Flegal, 2006). Ov erweight has recently been considered to be a pandemic among children as well as adults (Baur & Denney-Wilson, 2003; Larson & Story, 2007). Because of the long list of potential physical, psychological, emotional, and social consequences of obesity in children and yout h, effective interventi ons to address childhood overweight and obesity are partic ularly needed. These potential c onsequences include: type 2 diabetes or glucose intolerance /insulin resistance, hypertension, dyslipidemia [disruption in the amount of lipids in the blood], he patic steatosis [fatty liver di sease], sleep apnea, menstrual abnormalities, impaired balance, orthopedic pr oblems, low self-esteem, negative body image, depression, social stigmatization, discrimination, and teasing/bullying (Institute of Medicine, 2004). Interventions to prevent/modify childhood obesi ty are especially needed also because youth who are overweight or obese in childhood tend to remain overweight or obese in
12 adulthood, and because early childhood overweight that persists into adult hood is associated with more severe obesity in adulthood (Freedma n, Scrinivasan, Valdez, Williamson, & Berenson, 1997; Dietz, 2004; USDHHS, 2007). In the long run, obesity in childhood may even reduce overall life expectancy, because it increases life time risk for type 2 diabetes and other serious disease conditions, such as cancer, cardiovascular disease, and metabolic syndrome (Institute of Medicine, 2004). It is also noteworthy that in recent ye ars, overweight and obesity among children and adults have been added to the li st of health disparities that pl ague our nation, with racial/ethnic minorities and low-income populations being disp roportionately affected (Strauss & Pollack, 2001; Dietz, 2004; Wang & Brownell, 2004; Delva, OMalley, & Johnston, 2006). Specifically, in regard to youth, it has been found that Hi spanic and non-Hispanic Black children and adolescents typically experience higher rates of overweight and obesity than non-Hispanic White children and adolescents (Hedley, Ogden, Johnson, Carroll, Curtin, & Flegal, 2004; Delva et al., 2006; Ogden et al., 2006). Additionally, overwei ght prevalence is disproportionately higher among children who are from families with low incomes and among children whose parents have attained fewer years of education (Haas, L ee, Kaplan, Sonneborn, Ph illips, & Liang, 2003). It is likely that such health disparities are partially due to lower engagement in health promoting behaviors among youth and adults in r acial/ethnic minority and low-income families. Support for this view comes from research findi ngs such as the finding that fruit and vegetable consumption is lower among low-income and r acial/ethnic minority populations (Beech, Rice, Myers, Johnson, & Nicklas, 1999; Feldman et al., 2000) and from the finding that Mexican Americans eat more meat and saturated fats a nd fewer low-fat dietary products than White Americans (Warrix, 2005). Furthermore, in a 17 -year longitudinal study by Delva and colleagues
13 (2006), the following findings were reported: (a) Black and Hispanic students reported eating breakfast less frequently than did White students, (b) low soci oeconomic status (SES) students reported eating breakfast less fre quently than did high SES student s, (c) a lower percentage of Black female students and Hispanic female students reported engaging in frequent vigorous exercise as compared to White female students, (d) a lower percentage of low SES students and mid SES students reported engaging in frequent vigorous exercise as compared to high SES students, (e) Black students a nd Hispanic students reported hi gher weekday television viewing hours than did White students, and (f) low SE S students reported higher weekday television viewing hours than did high SES st udents. Such findings suggest that there is a critical need for effective interventions to increase health promoting behaviors among low-income and racial/ethnic minority families. Thus, it is not su rprising that national agencies are calling for interventions to promote healthy behaviors among all Americans, but especially among lowincome and racial/ethnic minority ch ildren and adolescents (USDHHS, 2000). It is particularly noteworthy that dietary beha viors have been found to be linked to four of the top ten leading causes of death coronary heart disease, some types of cancer, stroke, and type 2 diabetes (Kochanek, Murphy, Anderson, & Scott, 2004; USDHHS & U.S. Department of Agriculture [USDA], 2005). The underlying pathology that leads to some of these diseases begins during childhood and adoles cence (Newman et al., 1986). However, many risk factors for these types of diseases, such as the risk factor of not eating recommended amounts of fruits and vegetables, are dietary behaviors th at are modifiable. It is thus important to focus on these risk factors, especially in younger populations whose nutrition behavior patterns whether healthy or unhealthy tend to continue from childhood to adolescence and into ad ulthood (Kelder, Perry, Klepp, & Lytle, 1994).
14 In a recent study of 232 6th graders and 607 9th graders, Omar and Rager (2005) found that the diets of 37% of the 9th graders and 59% of the 6th graders were inadequately nutritious. Additionally, 47% of the 9th graders and 33% of the 6th graders had Body Mass Indexes over the 85th percentile for their age. Such data are a cause for pessimism with regard to alleviating the obesity epidemic. Clear evidence has emerged indicating that a healthy diet and regular physical activity during childhood and adolescence promote normal growth and development among children and adolescents (USDHHS, 2000). Accordingly, Bara nowski and colleagues (2000) suggested that the goals of health promotion interventions s hould include increasing engagement in physical activity and healthy eating (Bar anowski, T., Mendlein, Resnicow, Frank, Cullen, & Baranowski, J., 2000). Unfortunately, it appears that many child ren and adolescents in the U.S. do not eat a healthy diet or engage in appropriate levels of physical exercise (Pate, Long, & Heath, 1994; Sallis, Patrick, Frank, Pratt, Wechsler, & Galuska, 2000). In response to the inadequate engagement in healthy eating and physical exercise among youth in the U.S., public health authorities have focused nine national health objectives from Healthy People 2010 on dietary behaviors among youth and eight national health objectives on physical activity behaviors among youth (USDHHS, 2000). Some of the objectives related to dietary behaviors, nutrition, and/or overweight in youth include: (a) reducing the proportion of children and adolescents who are overweight or obese (Objective 19-03), and (b) increasing the proportion of persons aged 2 years and older who engage in severa l health promoting behaviors. Regarding the latter, the Healthy People 2010 objectives include increasing the proportion of persons aged 2 years and older who do the following: (a) consume at least two daily servings of fruit and three daily servings of vegetables (Objectives 19-05 and 19-06, respectively), (b)
15 consume at least six daily servings of grain products, with at least three being whole grain (Objective 19-07), (c) consume less than 10% of calories from saturate d fat (Objective 19-08), (d) consume no more than 30% of daily calori es from fat (Objective 19-09), (e) consume 2,400 mg or less of sodium daily (Objective 19-10), (f) meet dietary recommendations for calcium (Objective 19-11), and (g) eat meals and snacks at school that contribut e to good overall dietary quality (Objective 1915) (USDHHS, 2000). Interventions targeting these healthy eating be haviors in children are especially needed, given the evidence that normal weight children report significantly higher health-related quality of life than do obese children (Schwimmer, Burw inkle, & Varni, 2003). Interventions aimed at increasing healthy eating behavior s among children have sought to increase fruit and vegetable intake (Baranowski et al., 2000; Cassady, Vogt Oto-Kent, Mosley, & Li ncoln, 2006), decrease fat and caloric intake (Raizman, Montgomery, Osganian, & Ebzery, 1994; Osganian, Hoelscher, Zive, Mitchell, Snyder, & Webber, 2003; Va n Horn, Obarzanek, Friedman, Gernhofer, & Barton, 2005), decrease sugar inta ke (Fragala-Pinkham, Bradfor d, & Haley, 2006), and increase the frequency of eating a healthy breakfast (Dwy er, Hewes, Mitchell, & Nicklas, 1996). Despite the growing recognition that hea lth promotion interventions shoul d seek to increase healthy eating and physical activity and decrease sedentary behavior, few interventions attempting to target these behaviors in child ren have demonstrated a sustai ned impact on healthy eating and physical activity (Mendlein, Baranowski, & Pratt, 2000). As a result, there have been numerous calls for research to identify the reasons childre n do or do not engage in health promoting levels of healthy eating and physical activity, as the findings from such research will help inform health promotion interventions for these youth (Cus atis & Shannon, 1996; Neumark-Sztainer, Story, Perry, & Casey, 1999).
16 One of the conclusions of the investigat ors at the Centers for Disease Control and Preventions Physical Activity and Nutrition in Children Program is that successful interventions must include innovative approaches based on sound behavioral prin cipals and an understanding of why children engage in these behaviors (Mendlein et al., 2000, p. S 151). Few studies have examined the motivators of and barriers to en gagement in health promoting behaviors among children. Identification of childrens motivators and barriers to increase healthy eating and physical activity and decrease sedentary behavior is especially important given the strong links between these behaviors and health indices (Sal lis & Patrick, 1994) and given that knowledge of these motivators and barriers can inform the development of effective health promotion interventions and assessment tools. It is important that research conducted to id entify the motivators of and barriers to health promoting behaviors (e.g., healthy eating) among children include s racial/ethnic minority groups and takes cultural factors into ac count. Support for this view comes from the conclusion of Dietz (2004) that the increased rate of weight gain among African American and Mexican American children and adolescents can be accounted for by pe rson-environment interactions that are likely to vary according to racial/e thnic background. Specifically, some studies with Hispanic persons have suggested that cultural influences, such as believing illness is caused by wrongdoing, bad luck or sin (Da Silva, 1984), eating as a family activity, eating large po rtions, and perceiving a large body as an indicator of success (Chattterjee, Blakely, & Barton, 2005), are among the factors that contribute to obesity-related behaviors. There are also cultural norms or influences re lated to obesity and h ealth behaviors that appear to be unique to African Americans. Th ese culture-specific norms/influences include (a) having a different conceptualizat ion of what is overweight or being too fat than the
17 perceptions held by healthcare pr ofessionals, the majority of non-Hispanic White Americans, and other ethnic groups; and (b) hon oring and adhering to cultural traditions (e.g., eating ethnic soul foods that are high in fat and/or sodium, and associating beauty with large body sizes) that are antagonistic to weight-loss recommendations made by providers (Kumanyika, Morssink, & Agurs, 1992). Similarly, in Project EAT, which ex amined the weight-related concerns of an ethnically diverse sample of 4,796 adolescent males and females, findings included the following: (a) African American girls reported fe wer weight concerns th an non-Hispanic White girls; (b) Hispanic, Asian Ameri can, and Native American girls re ported similar or more weightrelated concerns/behaviors when compared to non-Hispanic White American girls; and (c) body satisfaction was highest among African American girls, even though they had the highest prevalence of obesity (Neumark-Sztainer et al., 2 002). Thus, it is crucial to consider culture when examining factors that influence the hea lth promoting behaviors of culturally diverse groups. Dietz (2004) further posited that effec tive prevention of unhealthy weight gain and associated health problems among racially/eth nically diverse youth may require intervention strategies that are specific to each racial/ethnic group. The purpose of the present study is to use fo cus groups to identify perceived motivators of and barriers to engagement in healthy eat ing behaviors among African American, Hispanic, and non-Hispanic White American low-income ch ildren (ages 9 to 12). The specific healthy eating behaviors that are the focu s of this research include (a) eating healthy food and snacks that are lower in fat and calories and (b) eati ng fruits, vegetables and whole grains.
18 CHAPTER 2 LITERATURE REVIEW Rationale for the National Advocacy for Healthy Eating among Children Clear ev idence has emerged indicating that a healthy diet and regular physical activity during childhood promotes normal growth and de velopment (United States Department of Health and Human Services [USDHHS], 2000). Furt hermore, levels of engagement in physical activity and nutrition-related behaviors impact several physiological factors that can place children at risk for developing chronic diseas es. These factors include body composition (e.g., adiposity), blood lipid concentrations, blood pressure, and bone mineral density (Sallis & Patrick, 1994). To take steps toward increasing the overall he alth of children, adolescents, and adults, the U.S. Department of Health and Human Services created the Healthy People 2010 national health promotion and disease prevention initiative. Central to this initiative was advocacy for examining the health status of all Americans and increasing health promoting behaviors and decreasing health risk behaviors. In response to the need to improve nutrition and prevent obesity among children, the public health authorities who crafted Healthy People 2010 focused nine of its health objectives for th e nation specifically on dietar y behaviors among youth (USDHHS, 2000). Promoting healthy eating is important am ong children, particularly low-income and racial/ethnic minority children, because (a) resear ch has shown that many children, especially low-income and minority children, do not have a healthy diet or cons ume recommended amounts of healthy foods, (b) healthy eating helps prevent diet-related diseases/hea lth problems and thus can reduce health disparities, and (c) healthy eating promotes healthy physical and psychological development of children.
19 Current Trends in Eating Behaviors among Children Unfortunately, it appears that m any children in the U.S. do not enga ge in healthy eating behaviors (Pate, Long, & Heath, 1994; Sallis et al., 2000). For instance, a study of 232 sixth graders (mostly 12 year-olds) found that the diets of 59% of the students from this study were inadequately nutritious and th at 33% of the students from this study had Body Mass Indexes (BMIs) over the 85th percentile for th eir age (Omar & Rager, 2005). In fact, the U.S. Department of Agriculture (1998) has reported that 67% of U.S. youth ages 6 to 19 exceed dietary guidelines recommendations for fat intake, and 72% exceed r ecommendations for saturated fat intake. This is likely due in part to an increased frequency of children dining at fast food establishments. Fast food consumption has increased fivefold am ong children since 1970 (Guthrie, Lin, & Frazao, 2002). In fact, nearly one third of U.S. children and adolescents eat fast food every day, resulting in an impact of approximately six extra pounds per year, per youth (Bowman, Gortmaker, Ebbeling, Periera, & Ludwig, 2004). Additionally, childrens frequency of eating at fast food restaurants is associated with increased consump tion of cheeseburgers, pizza, French fries, soft drinks, and total fat and calories, as well as decreased consumption of vegetables, fruit, and milk (French, Story, Neumark-Sztain er, Fulkerson, & Hannan, 2001). Decreasing consumption of fruits, vegetables, and milk is an important factor in the inability of American youth to meet recommended dietary standards. The Dietary Guidelines for Americans includes choosing a variety of fruits and vegeta bles daily as well as a variety of grains daily, especially whole grains (USDA & US DHHS, 2000). Specifically, two to four daily servings of fruit are recommended (USDHHS, 2 004). However, progress reviews have shown that the age-adjusted average number of daily servings of fruit consumed by individuals two years of age and older is only 1.5 servings. Vegetable consumption is also below the recommended amount, with American youth aver aging 3.4 servings of vegetables daily.
20 Although this falls within the daily recommended ra nge of three to five servings, only 8% of vegetable servings consumed by children and adoles cents ages 2 to 19 were dark green or orange vegetables, whereas 46% of consumed vegetable serv ings were fried potatoes. This is a far reach from the recommendation that dark green or orange vegetables, which are high in vitamin content, constitute at least one third of total vegetable consumption (USDHHS, 2004). Similarly to the USDHHS evidence regard ing low vegetable consumption, a recent study by Zapata and colleagues (2008) th at included students from 73 public middle schools across the state of Florida found that only 26% of sixth-grade students repor ted consuming five or more fruits and vegetables a day (including fruit jui ce), and this percentage of recommended fruit and vegetable consumption decreased with increasi ng grade level. Additionally, when asked to identify the number of daily servings of fruits and vegetables recommended by experts, less than 20% of the students correctly identified the c onsumption of five or more servings per day. Another 20% of students answered that they we re not sure about the number of recommended servings, and 61% of students underestimated the recommended number of servings of fruits and vegetables per day (Zapata, Bryant McDermott, & Hefelfinger, 2008). Additionally, the Dietary Guidelines for Americans includes the recommendation that Americans consume at least three servings of whole-grain foods per day (USDHHS & USDA, 2005); however, national dietary intake data sh ows that children and adolescents typically consume less than one serving of whole grains pe r day (Harnack, Walters, & Jacobs, 2003). It is important to note that whole grains, as well as legumes, fruits, and vegetables, are critical sources of dietary fiber. Unfo rtunately, only 39% of children ages 2 to 17 meet the USDAs dietary recommendation for fiber consum ption (Lin, Guthrie, & Frazao, 2001).
21 Despite low engagement in healthy eati ng among the general p opulation of children, research has shown that engagement in healt hy eating behaviors, such as eating recommended amounts of fruits and vegetables is even lower among low-inco me and racial/ethnic minority populations (Beech, Rice, Myers, Johnson, & Nickla s, 1999; Feldman et al., 2000). For instance, findings from a large study conducted by Delva a nd colleagues (2006) showed that a greater percentage of non-minority youth reported eati ng breakfast frequentl y, as compared with minority youth. This study also found differences across socioeconomic status (SES), with a greater percentage of high SES youth reporting eating breakfast frequently as compared to low SES youth. Specifically, 64% of high SES males ve rsus 41% of low SES males reported eating breakfast frequently, and 51% of high SES fema les versus 25% of low SES females reported eating breakfast frequently (Del va et al., 2006). Clearly, there is a crucial need to better understand as well as promote healthy eating among children in order to prevent both obesity and other diet-related health problems and the ne gative consequences that come along with these conditions. Diet-Related Diseases/Health Problems Dietary factors are linked with several of th e top 10 leading causes of death, including coronary heart disease, stroke type 2 diabetes, and som e types of cancer (USDHHS, 2000; National Institutes of Diabetes and Digestive and Kidney Diseases, 2004; Centers for Disease Control and Prevention [CDC], 2005; USDHHS, 2005; Trust for Americas Health, 2007). Overweight/obesity, one of the most prominent current health concerns in the United States, generally occurs in children as a result of unhealthy eati ng patterns, lack of physical activity, or a combination of both factors (USDHHS, n.d.). Ob esity rates among children ages 6 to 11 have doubled during the past two decades, changing from 6.5% in 1980 to 17.0% in 2006 (Ogden, Carroll, & Flegal, 2008). The well-established trend of increased longevity of life now has the
22 potential to reverse by the end of the century, with children no longer outliving their parents (Ehrmann, 2007). National concerns over obesity are related to its association with the occurrence of chronic diseases such as diabetes, arthritis, hypertension, and cardiovas cular diseases (Kahng, Dunkle, & Jackson, 2004; Wray, Blaum, Ofst edal, & Herzog, 2004). Many of the chronic diseases associated with obesity (e.g., high c holesterol, hypertension, t ype 2 diabetes) were previously considered adult diseases; yet, they are now being di agnosed in child ren (Salinsky & Scott, 2003). In fact, annual childhood obesity-re lated hospital costs have increased threefold over the past 20 years, and in 2003 these costs totaled $127 million (Wang & Dietz, 2002). Poor eating patterns (that often result in obesity), along with genetics, contribute to high blood cholesterol levels, increase d risk of coronary heart dise ase, and fatty buildups in the arteries that can begin as ear ly as childhood (American Heart A ssociation [AHA], 2008). A study by Koplan and colleagues (2004) f ound that 60% of obese children ages 5 to 10 years who were part of a population-based sample had at least one risk factor for cardiovascular disease, such as elevations in total cholesterol, trig lycerides, insulin, or blood pressure. It is also noteworthy that overweight children have a 70% chance of becoming overweight or obese adults (C enter for Rural Pennsylvania, 2005). Furthermore, poor diets among youth are associated with a number of serious health problems, including: glucose intolerance and insulin resistance, hypertension, dyslipidemia, hepatic steat osis, cholelithiasis, sleep apnea, menstrual abnormalities, impaired balance, orthopedic problems, and type 2 diabetes (Koplan et al., 2004; Cullen & Thom pson, 2005; Neumark-Sztainer, French, Hannan, Story, & Fulkerson, 2005). The well-known cluste r of obesity, hyperglycemia, hyperinsulinemia, dyslipidemia, and hypertension is known as Syndr ome X, or Insulin Resistance Syndrome and
23 is now occurring in children (Bao, Srinivas an, Wattigney, & Berenson, 1994; Srinivasan, Meyers, & Berenson, 2002). The epidemic of type 2 diabetes in the U.S. is largely related to the rapid rise of individuals with obesity (B ray, 1998; Koplan, Liverman, & Kraak, 2004). Obese individuals with type 2 diabetes, a disease once called adult-ons et diabetes, are at a particularly high risk for death from cardiovascular disease in addi tion to other diabetes-related complications (Haffner, Lehto, Ronnemaa, Pyorala, & Laakso, 1998). The incidence of type 2 diabetes in children has increased alarmingly (Fagot-Campagna et al., 2000) and appears to parallel the increase in the prevalence of obesity among ch ildren (Troiano, Flegal, Kuczmarski, Campbell, & Johnson, 1995). Recently, it has been proposed that children born in the United States in the year 2000 have an estimated 30-40% chance of developi ng type 2 diabetes during their lifetime, and that the risk of type 2 diabet es is even higher among racial/eth nic minority groups as compared to majority groups (Koplan et al., 2004). Psychological impact of overweight/obesity In addition to potentially hazardous physical comorbidities, obesity also has negative psychological and social effects. Unfortunately, previous research has shown that obese persons are viewed less positively than other stigmatized groups (e.g., less friendly, less likely to succeed) (Staffieri, 1967; Wiener, Perry, & Magnusson, 1988; Wing & Jeffery, 1999). Additionally, obese children are more likely to experience loneliness, sadness, and nervousness (Strauss, 2000), low self-esteem, negative body image, depression, social stigmatization, discrimination, and teasing/bullying (Institute of Medicine, 2004). Strauss (2000) additionally found that obese children are more likely to en gage in risk-taking be haviors such as using tobacco and alcohol.
24 Furthermore, a number of youth have re sponded to unwanted weight-gain by using unhealthy methods of losing weight. A nationwide survey of adolescents found that during the 30 days preceding the survey, 12.3% of students went without eating for 24 hours or more; 4.5% had vomited or taken laxatives in order to lose we ight; and 6.3% had taken diet pills, powders, or liquids without a doctor's advice (Ogden et al., 2006). Such findings have lead to psychologists assuming leading roles in the study of eating disorders among youth (e.g., Klaczynski, Goold, & Mudry, 2004; Ackard, Fulkers on, & Neumark-Sztainer, 2007). Race/culture-related disparities in di et-rela ted diseases/health problems It is important to note that low-inco me and racial/ethnic minority groups are disproportionately affected by ove rweight/obesity and related health problems. For example, racial/ethnic minority groups as compared to the majority group experience higher rates of cancer, diabetes, heart diseases, and stroke (National Institutes of Health, 2006), as well as higher rates of type 2 diabetes (Diabetes Re search Working Group, 2002) and obesity (Clark & Gibson, 1997; Ogden et al., 2006). These health disparities are no longer only apparent among adults; indeed, they are now also apparent among children as well. Childhood obesity is particularly intransi gent among U.S. racial/ethnic minority populations (Dwyer et al., 2000; Goran, 2001). Specifically, Strau ss and Pollack (2001) report that the prevalence of overwe ight and obesity increased by 120% from 1986 to 1998 among African American and Hispanic children a nd adolescents versus by 50% among non-Hispanic White Americans children and adolescents. Research suggests that among boys, the highest prevalence of childhood obesity o ccurs in the Hispanic populati on and that among girls, the highest prevalence of childhood obesity occurs in the African American p opulation (Institute of Medicine, 2004). Furthermore, a large st udy of over 62,000 school-age d children, conducted through the CDCs National Center for Health Statistics, found that while one third (32.2%) of
25 non-Hispanic White American chil dren were overweight or obese, one half (49.2%) of African American children and nearly one half (44.0%) of Hispanic children were overweight or obese (Lutfiyya, Garcia, Dankwa, Young, & Lipsky, 2 008). Thus, it is clear that although the prevalence of overweight/obesity is high among non-Hispanic White Am erican children, the prevalence of overweight/obesity is even higher among racial/ethnic minority children. Another recent study determined that 41% of Mexican American adolescents were overweight and 23% were obese (Forrest & Leeds, 2007). Due to the high prevalence of overweight/obesity in this popul ation, there are calls for cult urally-appropria te programs including nutrition education to be developed that target this specific group (Forrest & Leeds, 2007). Such programs certainly must begin in ch ildhood in order to prevent adolescent obesity. Overweight/obesity is not th e only diet-related disease/ health problem that has a disproportionately high prevalence among racial/e thnic minority children. Type 2 diabetes, for instance, is also more likely to occur among U.S. racial/e thnic minority children (FagotCampagna et al., 2000). Specifically, type 2 di abetes has the highest prevalence rates among American Indian, African American, and Hisp anic children (CDC, 2004). Interestingly, it has also been found that Hispanic children and Afri can American children are more insulin-resistant than non-Hispanic White Ameri can children, and this finding was independent of adiposity (Goran, Bergman, Cruz, & Watanbe, 2002). It also noteworthy that seve ral large population studies have found higher rates of total cholesterol, LDL cholesterol, and HDL choles terol (but lower trig lycerides) among African American children as compared to non-Hispanic White and Hispanic children (Webber et al., 1995; Morrison, Sprecher, Barton, Waclawiw, & Dani els, 1999). These differences in lipids remained even after controlling for BMI, thus suggesting an intrinsic difference among these
26 racial/ethnic groups (Goran, Ba ll, & Cruz, 2003). Even if such differences are found to be intrinsic, preventing risks for high cholesterol and obesity by way of reducing unhealthy eating behaviors should still be a priority among racial/ethnic minority children. Several studies have also found higher rate s of elevated blood pressure among African American school-aged children as compared with non-Hispanic White children and Hispanic children (Winkleby, Robinson, Sundquist, & Krae mer, 1999; Cruz, Huang, Johnson, Grower, & Goran, 2002). However, other studies have not found this difference (e.g., Rosner, Prineas, Daniels, & Loggie, 2000). Such co nfusion may be the result of a l ack of consistent investigation into confounding factors such as age and BMI (Goran et al., 2003). Income-related disparities in die t-related diseases/health problems In addition to disparities rela ted to ra ce/ethnicity, interacti ons between race/ethnicity and socioeconomic status (SES) are important to no te. For example, in the previously-referenced study conducted by the CDC (2004), it was found that the association between living in a poorer household with being overwei ght or obese was strongest among Hispanic children, as comparison to non-Hispanic White children and Af rican American children (Lutfiyya et al., 2008). In some instances, there appear to be diffe rential interactions betw een race/ethnicity and SES. For example, a study by Gordon-Larsen and colleagues (2003) reported that among nonHispanic White adolescent girls, the prevalen ce of overweight decreased with increasing SES; however, among African American a dolescent girls, the prevalence of overweight remained the same or increased with increasing SES (Gordon-Larsen, Adair, & Popkin, 2003). Similar results, with the additional inclusion of Hispanic children, were reported by a recent U.S. National Health and Nutrition Examination Survey (Freed man et al., 2007) as well as by a large schoolbased study conducted in North Florida (Johnson et al., 2007). In both studies, family income was significantly and inversely associated with childhood overweight among non-Hispanic
27 White American children and among Hispanic American children, but not among African American children. Health disparities also occur exclusively in relation to SES, with low-income populations being disproportionately affected by diet-related diseases and health problems. For instance, previous research has found that children from low-income families are more likely to be overweight (Jain, Sherman, & Chamberalain, 2001; McArthur, Angui ano, & Gross, 2004; Freedman et al., 2007; Lutfiyya et al., 2008). Ob esity rates are also ge ographically-related to poverty rates in some areas of the United States. Fo r example, 8 of the 10 st ates with the highest poverty rates are in the South, and obesity rates are also highest in the South. Furthermore, the states with the lowest poverty rates also have the lowest rates of obesity (Trust for Americas Health, 2007). Interestingly, a recent study conducted in Baltimore with homeless children and their caregiversa population once likely to be underweightreported th at nearly half of the homeless children were either overweight or at risk for becoming overwei ght (Schwarz, Garrett, Hampsey, & Thompson, 2007). Furthermore, youth who have no insurance or who have public insurance such as Medicaid are more likely to be overweight than youth w ho have other types of insurance (Haas et al., 2003). Similarly, Lutf iyya and colleagues (2008) repor ted that overweight or obese children across three different racial/ethnic gr oups were more likely to have not received preventive care in the past 12 months, an issu e likely related to socioeconomic status. Clearly, research on healthy eating behavi ors and diet-related health pr oblems among children must take into account the health dispar ities that exist among low-inco me populations as well as among racial/ethnic minority groups.
28 Benefits of Healthy Eating Clear evidence has em erged indicating that pr oper nutrition along with regular exercise during childhood promotes normal growth and development among children (USDHHS, 2000). Furthermore, it is generally thought that nutrition and physical activity-rela ted behavior patterns and associated physiological outcomes-whether at healthy or unhealthy levels-continue from childhood to adolescence and into adulthood (Kelder, Perry, Klepp, & Lytle, 1994; Malina, 1996). Thus, the establishment of healthy ea ting patterns during childhood is especially important, because those patterns are likely to follow a child throughout his/her life. Proper nutrition is important for maintaining a healt hy weight. For example, Howarth and colleagues (2001) found that increased consumption of fiber was associated with decreased energy intake and loss of weight over a period of several months (Howarth, Saltzman, & Roberts, 2001). Healthy eating behaviors can also prevent many diet-related diseases/health problems. The American Heart Association (AHA, 2008) and other public health agencies have emphasized the importance of individuals ages 2 years and older having low intakes of saturated and trans fat, cholesterol, and added sugar and salt. The AHA (2008) states that eating at least five servings of fruits and vegetables daily, as well as a wide variety of other foods that are low in saturated fat and cholesterol, will help children to mainta in normal blood cholesterol levels and promote cardiovascular health. Multiple sources have also reported that dietary patterns with higher intakes of vegetables (including legumes), fruits, and grai ns are associated with a variet y of health benefits, including decreased risk for some types of cancer (USDHHS, 1988; National Research Council, 1989; USDHHS, Food and Drug Administ ration, 1993; Chief Medical O fficers Committee on Medical Aspects of Food, 1993; World Cancer Rese arch Fund, 1997). Additional support for the preventative effects of healthy eating behaviors can be garnis hed from a review of over 200
29 human epidemiological studies and 22 animal studies. This major review, conducted by Steinmetz and Potter (1996), supports the common a ssertions that consumption of fruits and vegetables plays an integral role in the preven tion of cancer, cardiovascular disease, cataracts, obesity, and diverticulosis, and th at low levels of consumption of fruits and vegetables may increase the risk for cancer. In addition to preventing diet-related diseases /health problems, eating healthy also has the power to reverse or combat certain health pr oblems, such as obesity and high blood pressure, once they have already occurred (Ogden, Ya novski, Carroll, & Flegal, 2007). The AHA has stated that reducing caloric intake is the simplest change that can be ma de to prevent or treat overweight in children (AHA, 2008), and pediatric intervention studies ha ve confirmed that a diet low in saturated fat and cholesterol can actually lower elevated cholesterol levels (Obarzanek et al., 2001; Talvia et al., 2004). Although the exact mechanism of the transition from risk factors (e.g., unhealthy eating) in childhood to diabetes and cardiovascular disease is not clear, compelling evidence points to the association of these childhood risk fact ors with overt disease in adults. It is reasonable to suggest that lifestyle modification and weight control in childhood ca n reduce the risk of developing insulin resistance syndrome, type 2 diabetes mellitus, and cardiovascular disease (Steinberger & Daniels, 2003). In fact, atherosc lerosis (i.e., hardening of the ar teries), a complex disease that may begin in its earliest stages in childhood (Beren son et al., 1998), appears to be reversible with behavioral modification. This is because chil dhood obesity is independe ntly associated with arterial endothelial dysfuncti on and carotid wall thickening (T ounian et al., 2001; Woo et al., 2004), which are early markers of arterial dama ge. Research by Woo an d colleagues (2004) has shown that vascular dysfunction a ssociated with obesity in childre n is partially reversible after
30 even a short program (i.e., six w eeks) of dietary modification, wh ich also resulted in decreased waist-hip ratio and cholesterol. Furthermore, a longer-term (i.e., one year) program that included an individualized exercise tr aining program along with dietar y modification resulted in significantly less thickening of th e carotid wall, as well as persistent improvements in body fat and lipid profiles (Woo et al., 2004). Despite the benefits of health promoting beha viors, including increased protection against disease, many American youth simply do not incor porate these behaviors into their daily life (Pate et al., 1994; Sallis et al., 2000), which further supports the magnitude of the public health problem regarding nutrition and di et-related diseases. Clearly, further research regarding the prevention of obesity and other diet-related di seases should focus on increasing engagement in health promoting behaviors, partic ularly healthy eating behaviors. Contributors to Healthy/Unhealthy Eating among Children As to be expected, there are num erous envir onmental, sociocultural, and personal factors that either motivate or prevent children from e ngaging in healthy eating behaviors. Perceptions of parents and children regarding healthy eating suggest that the number of barriers to healthy eating likely outweighs the number of motivator s (Hart, Herrio, & Truby, 2003). A review of current literature suggests that the most salient factors in the eating behavi ors of children include: (a) environmental factors, (b) social relations hip factors, (c) cultura l factors, (d) economic factors, (e) knowledge/educational factors, and (f) psychosocial fact ors. Each of these factors is described below. Environmental Factors A variety of environm ental factors influe nce the eating behaviors of children. These environmental factors include the following: (a) availability/accessibility of healthy/unhealthy foods, (b) media influence, and (c) school environment.
31 Availability/accessibility of healthy/unhealthy foods Availability/access ibility of healthy/unhealt hy foods is a prominent environment-related factor in the eating behaviors of children. Availability of healthy food and snack options has been cited by youth as a motivator to eating hea lthy, and availability of unhealthy food and snack options has been cited as a barr ier to eating healthy (Sheppard et al., 2006). Other studies have also found an association between availability of healthy foods and childrens consumption of these foods (Cullen, Baranowski, Rittenberry, et al., 2001; Cull en, Baranowski, Owens, et al., 2003). Convenience (e.g., healthy foods being not onl y available but also ea sily accessible) is a related factor that guides families food choices (G lanz et al., 1998). For inst ance, the availability of fruits and vegetables that have already been prepared, pre-cut, or placed in plain-view on the kitchen counter has been shown to increase child rens consumption of these foods (Baranowski T., Cullen, & Baranowski J., 1999). Availability/ accessibility-related barriers to healthy eating that have been reported among children include the absence of fruits and vegetables on fast food menus (Rees, 1992). Media influence The m edia appears to play a significant role in determining childrens perceptions of what constitutes healthy eating (Signorie lli & Lears, 1992; Signorie lli & Staples, 1997; Stevenson et al., 2007). Children themselves have id entified the media and advertising as barriers to healthy eating, suggesting the profound degree of influence that the media has on their food preferences. Research suggests that the media is sending contradictory messages to youth; on one hand, they report feeling influenced by the medi a to eat unhealthy fast food products, but on the other hand, they report feeling influenced by models and celebrities to be thin (Stevenson et al., 2007). Children also report that they are tempted by the packaging on junk foods and have even expressed the need for more advertisements that highlight healthy foods a nd their health benefits
32 (Hesketh, Waters, Green, Salmon & Williams, 2005). There is also non-self-report research to further support that the media does, in fact, have a significant influence on our attitudes and behaviors. For instance, increasing the number of television viewing hours has been shown to increase the demand for and consumption of advertised foods (Crockett & Sims, 1995). Food labeling also influences childrens eating behaviors. Though reading food labels may generally be thought of as an adult activity, it is important to note that children also come into contact with food labels on a daily basis and typically have some awareness about their purpose. In fact, better food labeling, so that nutritional information can be understood more easily, has been cited by youth as a potential mo tivator for their prac ticing healthier eating behaviors (Sheppard et al., 2006). School environment The school environm ent can influence childre ns eating behaviors through a variety of venues, including: price of foods at school, av ailability or lack of availability of healthy/unhealthy foods and snacks at school, and social influen ces at school related to food consumption and body image (e.g., Wills, Backet t-Milburn, Gregory, & Lawton, 2005; Sheppard et al., 2006). Of great im portance is the finding that children have reported believing that any food provided at school is healthy, especially if it contains natura l food items such as potatoes, vegetables, or milk, and regardless of the presence of additives such as sugar and fats (Hesketh et al., 2005). Thus, the abundance or even just the pr esence of unhealthy foods in schools is a major barrier to children eating healthy. Childrens appare nt difficulty with or bias in differentiating healthy school foods from unhealthy school foods s uggests that schools should be held especially accountable for influencing the food intake of children. Schools may also be negatively influencing eating behaviors by making unhealthy foods socially rewarding. In a study by Stevenson a nd colleagues (2007), students alluded to the
33 healthy eating barrier of schools and teachers rein forcing the perception of unhealthy foods as a treat, because the students received these foods on special oc casions. Since schools contribute directly to 35-40% of a student's total da ily energy intake (Burghardt, Gordon, Chapman, Gleason & Fraker, 1993), these institutions st rongly influence child rens overall eating behaviors. On a positive note, the National Schoo l Lunch Program, which aims to provide one third of the recommended dietary allowances for certain nutrients, report edly results in higher nutrient intake among students who participate. However, participation declines with age as students in middle and high school s have more freedom to make their own lunch choices (Burghardt et al., 1993). Social Relationship Factors There are several so cial relati onship factors that influence childrens eating behaviors. The two most prominent types of these social re lationship factors are family influence and peer influence, both of which are discussed in the following section. Family influence A high percentage of childrens daily eati ng occurs at hom e, though that percentage declines with age (Story, Neum ark-Szainer & French, 2002). In fact, Sheppard et al. (2006) reported results that further highlig ht the influence of family over ot her types of social influence. While influence from parents and family me mbers was commonly mentioned among youth in focus group discussions, teachers an d peers were least commonly cited as sources of information related to nutrition behaviors. Specifically, family factors such as parental modeling, parental encouragement, and parents personal experien ces with specific foods, are known to influence the eating behaviors of youth (Fisher, Mitchell, Smiciklas-Wright, & Birch, 2002; Zeller, Saelens, Roehig, Kirk, & Daniels, 2004; Bruss et al., 2005; Sheppard et al., 2006; Zabinski et al., 2006; Savage, Fisher, & Birch, 2007).
34 Parents can influence the eating behaviors of their children through food exposure and accessibility, (Olvera-Ezzell, Power, & Cousins, 1990; Klesges, Stein, Eck, Isbell & Klesges, 1991; Cousins, Power & Olvera-Ezzell, 1993), as well as through modeling and reinforcement (Perry et al., 1998; Campbell & Crawford, 2001). Parental modeli ng and parental encouragement have been specifically found to be positively asso ciated with childrens consumption of fruits and vegetables (Zabinski et al., 2006; Fisher et al., 2007). In fact, studies have shown that repeated exposure to a parent or teacher eating a particular food can increase a child's preference for that food (Birch & Fisher, 2000; A ddessi, Galloway, Visalberghi & Birch, 2005). Of course, there are also many barriers that may prevent parents from promoting healthy eating behaviors among their children. Many parents will, in fact, admit to being poor examples for their children when it comes to eating (C ullen, Baranowski, Rittenberry & Olvera, 2000). Barriers reported by parents include issues such as the lack of knowledge about and accessibility to healthy foods (Acheson, 1998). Parental percep tions of childrens eating behaviors could be another barrier limiting their successes in passing on healthy eating habits to their children. For example, it has been found that parents tend to pe rceive their children's food preferences as rigid and inflexible (Hart et al., 2003), which may actua lly make parents less lik ely to encourage their children to try new healthy foods and more likel y to give up on encouraging healthy eating behaviors, possibly before even making a significant attempt. Past research has also suggested that parental permissivene ss related to the consumption of unhealthy foods during childhood results in chil dren eating more fats, sweet foods, and snacks during adolescence (de Bourdeaudhuij, 1997). Conve rsely, some evidence s hows that stringent parental control of dietary behaviors during young childhood can actually result in increased negative effects, such as pref erences for high-fat foods, limited acceptance of a variety of foods,
35 and poor regulation of energy intake by decreasing responsiveness to internal cues of hunger and satiety (Birch & Fisher, 1998). An interesti ng study conducted by Hart and colleagues (2003) showed that parents apply their authority different ially in association with their SES, with high SES parents being more likely to restrict food choice, such as limiting "junk foods," and low SES parents being more concerned with their childrens eating ade quate amounts of food. Additionally, high SES parents expressed being unsure about their ability to control their child's diet and underestimated their own n eed for further nutrition education. Additionally, focus groups have revealed parent al perceptions of gender stereotypes that influence the way parents interact with their ch ildren in relation to eati ng behaviors and weight. A focus group study based in the United Kingdom reported that parents rarely mentioned discussing weight issues with male children, du e to parental perception of weight-gain as a natural occurrence for boys. In c ontrast, these parents reported directing greater concern toward short-term physical outcomes and weight gain in fe male children and as a result, were stricter regarding food choices for girls (Hart et al., 2003). Similarly, research has shown an association between mothers own dieting and restrictive eating pract ices and the degree of restriction of female childrens intake of snack foods but not male childrens intake of snack foods (Fisher & Birch, 1998). Even when parental encouragement does exis t, it may not always result in intended positive outcomes. For example, youth may express defiance or independence through intentionally eating less h ealthy foods or not eating what they are told to eat (e.g., Hill, Oliver, & Rogers, 1992). Additionally, parent s often apply their influence by using rewards or treats to encourage their children to lik e a particular food (Hart et al., 2003; Hesketh et al., 2005). However, the common practice of parents using u nhealthy snacks or fast food as a form of
36 reward has been described by young people as ne gatively influencing their eating behaviors (Stevenson et al., 2007). Family relations also appear to play a significant role in influencing childrens engagement in healthy behaviors, including family communication (Baranowski, Nader, Dunn, & Vanderpool, 1982; Rimal & Flora, 1998) and family cohesion (Franko, Thompson, Bauserman, Affenito, Striegel -Moore, 2008; Tucker, Butler, Loyuk, Desmond, & Surrency, in press). More specifically, Franko and collea gues (2008) found that among overweight girls, stronger family cohesion was signifi cantly associated with less s oda intake and higher rates of breakfast consumption, and family cohesion was associated at the trend level with greater consumption of milk, fruits, and vegetables. Additionally, children perceive family involvement as a facilitator to healthy eati ng (Monge-Rojas et al., 2005). In one study, simply an increase in the frequency of family dinners was found to be associated with healthier diets and increased fruit and vegetable consumption among children and adolescents (Story et al., 2002). Thus, parents may or may not be aware of the degree to which they directly or indirectly influence the dietary behaviors of their children. Peer influence At school and other locations, youth spend m uch of their time interacti ng with their peers. Children are susceptible to the social influence of peers, including the influence of peers on each others eating habits. Support for th is view comes from an experimental research study involving dyads of overweight and non-overweight children. In this study, part icipants were provided with several unhealthy and healthy snacks to choos e from and also a selection of games for entertainment. Results showed that an overweight child's consumption of healthy snacks was predicted by whether or not the other child in the dyad was also eating the healthy snacks. Interestingly, the non-overweight children were not affected by the eating choices of the other
37 member of the dyad (Salvy, Kieffer & Epstein, 2008). A similar phenomenon can occur in the school environment. Among students, friends' cons umption of unhealthy foods has been found to greatly influence the students to also consume such foods (Woodward et al., 1996). Additionally, focus group studies have cont ributed to the literature regarding the association of peer influence with the eating behaviors of youth. In a focus group study by Cullen and colleagues (2000), children reported th at consuming healthy food items would incite negative comments from friends (Cullen, Baranowski, Rittenberry, & Olvera, 2000). In another focus group study, youth participants reported that making healthy eating a socially-accepted practice at school would encourage them to eat healthier foods (Monge -Rojas et al., 2005). Furthermore, a study conducted in Costa Rica revealed that gender stereo types related to eating may be present among youth; specif ically, students in this study explained that the consumption of healthy foods by males is considered "effemina te" and something that is not socially-accepted (Monge-Rojas et al., 2005). Although these findings were reported in the context of a different culture, such issues should likel y be further investigated in the United States to determine if similar issues exist in the U.S. as well. Cultural Factors The prevalence of obesity in racial/ethnic m inority children in the U.S. tends to be even higher than in non-minority children (Dwyer et al., 2000; Goran, 2001), with sociocultural factors playing a significant role (Bruss, Morris & Dannison, 2003; Powdermaker, 1997). For instance, influential sociocultural factors may include cultural percep tions regarding dietary practices (Meigs, 1997; Powdermaker, 1997). Ethni c differences have been observed in the dietary intake of children (Brady, Lindquist, & Herd, 2000) and sociocultural messages have been identified as influentia l in childrens dietary hab its (Bruss et al., 2005).
38 Furthermore, studies with adults have shown that specific ethnocultural interpretations of healthy eating are used not only among older and less acculturated adults, but also to an extent among younger adults with higher levels of accult uration. Such findings suggest that even highly acculturated individuals in some racial/ethnic gr oups may still hold on to traditional ways of cooking and eating (Axelson, 1986; Satia-Abouta, Patterson, Ne uhouser, & Elder, 2002), and thus influence the children for whom they prepare food. Additiona lly, while nutritional inadequacy or high fat content of some cultural/traditional foods may be a factor as to why certain ethnic groups experience a greater prevalence of diet-related diseases, the opposite has also been found. Acculturation to the Western diet has been associated with decreased health (SatiaAbouta et al., 2002). On the other hand, a stronger cultural identity has been associated with healthier dietary behaviors (Bedaiko, Kwate, & Rucker, 2004). An enlightening study by Allen and colleagues (2007) described in further deta il how such changes occur differentially among first-generation and third-gene ration Asian youth and Hispanic youth who live in the U.S. Measuring nutrition behaviors, in cluding consumption of fruit, ve getable, milk, and soda, it was found that first-generation Asian youth and Hispan ic youth had healthier di ets than non-Hispanic White American youth. However, with succeedi ng generations, although Asian youths healthy diets were maintained, Hispanic youths fruit and vegetable consumption decreased and their soda consumption increased, such that by the third-generation, the Hispanic youths nutrition behaviors were poorer than those of the nonHispanic White youth (A llen et al., 2007). Currently, there is a lack of literature on the effects of cultu ral environment on children's food consumption among various racial/ethnic groups a nd on the perspectives of children and their
39 parents on healthy eating. These are two areas that require further explora tion in order to design health promotion interventions that are tailore d to the needs of different cultural groups. Economic Factors Econom ic concerns (e.g., cost) have been repo rted by adults to negatively impact healthy eating behaviors in regard to h ealthy food selection and preparation (Glanz et al., 1998; Bruss et al., 2005). In a study by Bruss and colleagues (2005) although participants identified reading labels as a strategy for selecting lower-fat f ood items, those who reported the tendency to look for lower-cost items reported not commonly using this strategy. Some studies have shown an awareness of economic issues among young people as well. Specifically, st udies have shown the perception among youth that healthy foods are more expensive and that price is a barrier to buying those foods over less expensive, unhealthy f oods (Sheppard et al., 2006; Stevenson et al., 2007). Economics research shows th at this phenomenon is more th an merely perception. From a baseline of 100 during 1982-1984, the price index for fresh fruit a nd vegetables increased to 258 by 2002 (far exceeding general inflation), whereas th e price index for soft drinks increased only to 126 by 2002 (below general inflation) (Sturm, 2005). Previous research has demonstr ated that health disparities regarding diet-related health problems, such as obesity, exist among children of lower socioeconomic status (Jain et al., 2001; McArthur et. al, 2004; Lutfiyya et al., 2008). Income impacts the likelihood of childhood overweight/obesity in at least two specific ways: (a) it result s in having to live in unsafe neighborhoods and (b) it impedes access to and the ability to purchase healthy foods. Indeed, children whose families have low household incomes are more likely to be limited in their ability to be physically active on a daily basis because of safety concerns that make outside play less likely. Additionally, ch ildren who live in lower-income neighborhoods are likely to have poorer access to stores that carry a variety of fresh produce and a variety of
40 other healthy food choices, such as whole-grai n foods and low-fat dairy products (Krebs & Jacobson, 2003). Low-income level may also aff ect prevalence of child hood obesity by way of decreased access to health care, a potential mechanism for exposur e to health education related to diet modification or for early intervention to promote a healthy diet and/or overcome obesity. In one study, not having received preventive car e in the past 12 months was significantly associated with being overwei ght or obese among children ac ross three racia l/ethnic groups (Lutfiyya et al., 2008). Knowledge/Educational Factors Previously conducted focus group studies that have assessed factor s influencing healthy eating among children have report ed that children have a genera l awareness of health, although many of these studies have occurred outside of the United States. For instance, a study conducted in Australia by Hesketh and colleagues (2005) re ported that children were well informed about the health value of different foods, could id entify healthy versus unhealthy foods, and were aware of the nutrients contributi ng to their perc eption of foods being more or less healthy. The study also found that many children mentioned food labels as a source of information and that some children discussed the consequences of eating healthy and unh ealthy foods (Hesketh, Waters, Green, Salmon, & Williams, 2005). Simila rly, a large focus group study conducted in England with 300 participants reported that ch ildren understood the concep t of a balanced diet and were aware of the relationship between th eir diet and their health, as well as the consequences of eating too much fat (Dixe y, Sahota, Atwal, & Turner, 2001). A mixed qualitative-quantitative study by Edwards and Ha rtwell (2002) reported th at 75% of children were familiar with the term healthy eating and that school was cited as the most common source of information.
41 Health knowledge appears to increase with grade leve l among elementary school students, although this is not neces sarily true for health behaviors (Cartland & Ruch-Ross, 2006). Research findings regarding the influence of knowledge on healthy eating (e.g., fruit and vegetable intakes) among child ren varies across studies (e.g., Resnicow et al., 1997; Gibson, Wardle, & Watts, 1998; Reynolds, Yaroch, & Fr anklin, 2002; Reynolds, Bishop, Chou, Xie, Nebeling, & Perry, 2004; Blanchette & Brug, 2005; Fahlman, Dake, McCaughtry, & Martin, 2008). This variation in findings ma y be partially due to variation in the type of and the way in which knowledge is assessed across studies. Based on their systematic review of the effec tiveness of interventions targeting fruit and vegetable consumption among children, Blanchette and Brug (2005) concl uded that specific knowledge of daily fruit and vegetable intake reco mmendations is a relevant determinant of fruit and vegetable intake. Other res earchers have reported that kn owledge of healthy eating is modifiable through interventions to facilita te such knowledge (e.g., Cullen, Bartholomew, & Parcel, 1997; Baranowski et al., 2000; Davis et al ., 2000; Reynolds et al ., 2002; Fahlman et al., 2008). However, because interventions to modify knowledge of healthy ea ting typically include other intervention components (i.e., are multifaceted), it is difficult to determine the independent effects of the knowledge of healthy eating component. Psychosocial Factors Personal preference, attitudes toward healthy eating, m otivation, awareness and knowledge of healthy eating, health self-efficacy, and concern about becoming overweight or getting other health problems are all examples of psychosocial factors that can impact childrens healthy or unhealthy eating behaviors. Preference/taste (e.g., preferri ng the taste of fast food) or other food aesthetics (e.g., texture, appearance, and smell) are possibly the most commonly cited factors influencing youths eating behaviors (e.g., Bruss et al., 2005; Sheppard et al., 2006;
42 Stevenson et al., 2007). Primary school children have described healthy food as boring and something for adults (Watt & Sheiham, 1997). Some young people tend to group foods into good foods and bad foods, with the perception of the bad foods being less healthy bu t more tasty than the good foods, and with the view that taste is a more infl uential factor than healthiness (Stevenson et al., 2007). Taste and food preferences often guide food choice (Birch & Fisher, 1998; Glanz, Basil, Maibach, Goldberg & Snyder, 1998), and childrens pref erence for junk foods is stronger than their preference for fruits and vegetables (Cullen et al., 2000). However, Af rican American, Mexican American, and European American children in focus groups reported th at modification during food preparation, such as adding strawberries to a salad or a favor ite vegetable to an unappealing dish, and being offered low-fat instead of fatfree alternatives, can make healthy foods more appealing (Casey & Rozin, 1989). Children exhibit generally positive attitude s toward healthy eating (Sheppard et al., 2006), yet it appears that children do not fully perceive the long-term health risks that accompany a poor diet (Watt & Sheiham, 1997). Per ceptions of value have also been found to influence the eating behaviors of youth (Sabis ton & Crocker, 2008.) For instance, lack of enjoyment in eating fruits, vegetables and foods low in fat has been found to be negatively associated with consumption of these f oods (Backman, Haddad, Lee, Johnston, & Hodgkin, 2002; Sabiston & Crocker, 2008). Other psychological factors (e.g., motivators or barriers) influencing the eating behaviors of young people include: having the w ill-power to eat healthy foods, valuing the ability to choose their own healthy foods (Sheppard et al., 2006) and experiencing a particular emotion or mood state (e.g., desiring certain foods such as chocol ate when feeling upset, depressed, or bored)
43 (Stevenson et al., 2007). Physical appearance has also been identified among youth as an influential factor, such as reporti ng a desire to eat healthy in or der to improve ones appearance, as well as the concern th at eating fast food can have negative consequences on ones weight and facial appearance (She ppard et al., 2006). Theories Used for Understanding Eating Behaviors A lim ited number of published studies with in terventions targeti ng healthy eating among children have included a discussion of the theory on which the intervention is based. Intervention studies that have included a discussion of theoretical framework have primarily utilized one of or a combination of the following theories: (a) the health beli ef model (e.g., Becker, Maiman, Kirscht, Haefner, & Drachman, 1977; Sin & Lee, 2006; Jones et al., 2007), (b) the transtheoretical model of behavior cha nge (e.g., Fitzgibbon, Stolley, Dyer, VanHorn, & KauferChristoffel, 2002; Di Noia, Contento, & Prochaska, 2008), (c) th e theory of planned behavior (e.g., Contento, Koch, Lee, Sauberl i, & Calabrese-Barton, 2007; Gratton, Povey, & Clark-Carter, 2007), and (d) social cognitive theory (e.g., Corwin, Sargent, Rheaume, & Saunders, 1999; Resnicow et al., 1997; Fitzgibb on et al., 2002; Horowitz, Shiltz, & Townsent, 2004; Rinderknecht & Smith, 2004; Thompson, Bara nowski, J., Cullen, & Baranowski, T., 2007; Richards & Smith, 2007). Each of these theories is presented br iefly below along with the more recently developed health selfempowerment theory (Tucker et al., in press). Health Belief Model The health belief model (HBM) is a psychological expectancy-value model (Janz et al., 2002) which suggests that an indivi duals engagement in a partic ular behavior is based on the value the individual places on a pa rticular goal (e.g., the desire to prevent illness or to get well) and on the individuals estimate of the likelihood that a given action will achieve that goal (Bartholomew, Parcel, Kok & Gottlieb, 2006). The HBM is comprised of the following four
44 constructs (Janz & Becker, 1984): (a) perceived susceptibility (p erceived personal risk), (b) perceived severity (perceived seriousness of contr acting an illness), (c) perceived benefits (of a particular action to reduce the threat of illness), and (d) perceived barriers (to engaging in that particular action to reduce the threat of illness). Some researchers have adapted the HBM to also include the constructs of self-efficacy and pe rceptions of social influence (e.g., Stecher, DeVellis, Becker, & Rosenstock, 1986). The HB M may be most helpful in understanding relatively simple health behaviors, such as pursuing mammography scre ening or immunization (Janz et al., 2002), but it has also been shown to have some predictive validity for more complicated health behaviors, such as di abetes self-care (Bar tholomew et al., 2006). Transtheoretical Model of Behavior Change The transtheoretical m odel of behavior ch ange (TTM) is informed by the stages of change model (Prochaska & DiClemente, 1984) Specifically, TTM involves examining an individuals psychological stage of change (i.e., how much inte ntion the individual has to actually change a behavior) and then choosing an appropriate me thod for processing that change. TTM was originally used in relation to cessati on for addictive behaviors but has more recently been used to predict engagement in health-p romoting behaviors (Prochaska et al., 2002). Theory of Planned Behavior The theory of planned behavior (TPB, Ajzen, 1988) is based on the premise that intention, as the most proximal determinant of behavior, results from three conceptually independent constructs: (a) attit ude, (b) subjective norms, and (c) perceived behavioral control. According to this theory, an i ndividuals attitude a bout a behavior is based on the individuals belief that a certain outcome will result from th at behavior. The second major determinant of behavior, according to TPB, is the construct of subjective norms. This construct is likened to perceived social expectations (i.e., the idea that important social refere nts either approve or
45 disapprove of performing the behavi or). Finally, the cons truct of perceived be havioral control is conceptually similar to Banduras (1986) self-e fficacy construct. Current developments in TPB have suggested additional determinants, such as personal moral norms, anticipated regret, and the relationship between inte ntion and behavior, known as implementation intention (Bartholomew, 2006). Social Cognitive Theory Social cognitive theory (SCT, Bandura, 1986) is an interpers onal theory that takes into account both the determinants of behaviors and the processes of behavior change (Bandura, 1997; Baranowski et al., 2002). The m ajor determinan ts of behavior as de scribed by SCT include the following: (a) outcome expectations, (b) self-e fficacy, (c) behavioral capability, (d) perceived behavior of others, and (e) envi ronment. Specifically, an outcome expectation is an individuals judgment about what consequences are likely to be produced by a certain behavior. Self-efficacy is a judgment about an individuals own abili ty to accomplish a certain goal. Behavioral capability is combined knowledge about a be havior and knowledge of how to perform the behavior (i.e., skill). Perceived behavior of others, a construct largely affected by modeling, is distinguishable from perceived soci al expectations in that it refe rs to an individuals perception of others engagement in a particular behavior, as opposed to an individuals perception about others opinions about engagement in a particular behavior. Finally, environment refers to all of the factors that are physically external to an individual and mi ght affect that individuals behavior (Bartholom ew et al., 2006). Finally, Bandura (1986) stated that in orde r for learning to take place, it must be accompanied by facilitation. Facilitation involves providing the means for the learner to take action or, alternatively, providing the means to re duce barriers to action (Bandura, 1986; Mullen, Mains, & Velez, 1992). More recently, Bandura ( 2004) has written about SCT specifically as it
46 relates to health promotion. Bandura (2004) posits that an effective prevention program for children would include four major components: (a ) an information component to inform children of the health risks and benefits of various behaviors, (b) a so cial and self-management skills component for translating concerns into eff ective prevention practi ces, (c) a self-efficacy inducing component to support the exercise of c ontrol in the face of difficulties and setbacks that inevitably arise (p. 158), a nd (d) a social support component. Health Self-Empowerment Theory The health self-em powerment theory (HSET, Tu cker et al., in press) is inclusive of the self-efficacy construct of SCT and acknowledges th e influence of social/e nvironmental variables (e.g., poverty, limited health care access). Howeve r, given the intractable nature of these variables in ethnic minority and low-income co mmunities, HSET gives central importance to the modifiable, self-empowerment-oriented, cognitive -behavioral self-variabl es, as they empower children and adolescents, as well as parents, to ex ert control over aspects of their lives that they can change, even though there may be a multitude of aspects that they cannot change. In this manner, individuals may become empowered to engage in goal behaviors (e.g., health promoting behaviors) under whatever social and environmental conditions exist in their lives. According to HSET, the self-empowerment variables are (a) health motivation, (b) health self-efficacy, (c) self-praise of health behaviors, (d) coping skills for managing emotions such as stress and anxiety, and (e) health responsib ility (i.e., being informed and doing the work needed to make healthy choices). Theories Informing the Present Study The current study explores the m otivators of and barriers to healthy eating behaviors among children. There is evidence that nutrition education progra ms are more likely to be effective if they attend to motivators and reinforc ers of change, as well as to knowledge/lack of
47 knowledge about relevant nutrition information (Contento et al., 1995; Baranowski et al., 2003). Evidence also suggests that examination of factor s that influence health behaviors is of great importance for developing interventions (Lowe, Dowek, & Horne, 1998). Furthermore, Heckhausen (1991) and Gollwitzer (1993) have suggested that the adoption of health behaviors involves two phases: motivationa l and volitional. The lesser-di scussed volitional phase goes beyond motivation to describe when a person engage s in planning, such as the development of an implementation intention, in order to actually act out the behavior (G ollwitzer, 1999). Gratton and colleagues (2007) point out that although mo tivational and volitiona l-based interventions have successfully brought about dietary behavior change among adults, only a small number of studies have examined these interventions e fficacy for changing the dietary behaviors of children. Examining the motivators of and barriers to childrens healthy eating behaviors fits well with many of the previously-described approaches. For instance, in the motivational and volitional phase approach of Gollwitzer (1993) and Heckhausen (1991), researchers developing interventions for healthy eating behaviors w ould clearly benefit fr om knowing childrens motivators of healthy eating, as well as their ba rriers to healthy eating, in order to create an implementation intention that incorporates ho w to increase motivators and overcome barriers. Additionally, the feeling of being able to overcome ones barrier s should lead to increased selfefficacy and/or perceived behavioral control, which are central constructs to theories such as SCT, TPB, and HSET. The idea of examining barriers is also incorporated in various ways into SCT (i.e., impediments), HBM (i.e., perceived barriers), and some of the processes of TTM (e.g., coping with barriers, and dealing with barriers). Similarly, id entifying motivators is incorporated in various ways into SCT (i.e ., facilitators), TTM (e .g., through perception of
48 benefits), HBM (i.e., in relati on to perceived benefits), an d HSET (e.g., health motivation) (Janz & Becker, 1984; Bandura, 2004; Bartholomew et al., 2006; Tucker et al., in press). Thus, the concept of identifying motivat ors and barriers to healthy ea ting appears to be supported by multiple health behavior focused theories. Interventions Promoting Healthy Eating among Children Types of Interventions To date, the m ajority of the interventi on research on promoting healthy eating among children has been based in school settings. These school-based interventions, both within and outside of the U.S., have taken a variety of a pproaches and targeted many variables including: changing school meals (Luepker et al., 1996; Reynolds et al., 2000; Sahota et al., 2001); teaching nutrition education (Fahlman, Dake, McCaughtry & Martin, 2008); increasing self-efficacy to engage in health behaviors (Reynolds et al., 2000; Fahlman et al., 2008); increasing the availability of healthy foods (French, Stor y, Fulkerson, & Hannan, 2004); working in schoolyard gardens (McAleese & Rankin, 2007); utilizing video-based peer modeling (Horne, Lowe, Bowdery, & Egerton, 1998); increasing family i nvolvement (Luepker et al., 1996; Reynolds et al., 2000); offering verbal encouragement from food-service staff (Pe rry, Bishop, & Taylor, 2004); and overcoming barriers to healthy beha viors (Gratton et al., 2007). Some of the intervention programs targeting healthy eating be haviors have been in the context of an overweight prevention/intervention program that also targets physical act ivity (e.g., Sanigorski, Bell, Kremer, Cuttler, & Swimburn, 2008), while othe rs have focused strictly on healthy eating behaviors, either in general (e .g., French et al., 2004; Fahlman et al., 2008) or in regard to a particular healthy eating behavior, such as consuming fruits and vegetables (e.g., French & Stables, 2003; Perry et al., 2004; McAleese & Rankin., 2007).
49 While past intervention studies have tended to utilize nutriti on education to influence attitudes, knowledge, skills, and eating practices, more recent interv entions have tended to focus on behavioral modification strategies (Shaya et al., 2008). In addition to knowledge, public health efforts have focused on individual awar eness to promote dietary changes (French & Stables, 2003). Some interventions have attempted to promote awareness and dietary changes by implementing more interactive pr ograms that are designed to res pond to the specific needs of a particular community and to f it with the population's current lif estyle. For example, one study used schoolyard gardening programs as a handson method for delivering nutrition education to children a method that resulted in a signifi cant increase in fruit and vegetable consumption among the children who participated in th ese programs (McAleese & Rankin, 2007). Other studies have focused on the home as the primary means of implementing interventions to promote healthy eating. For inst ance, the High 5 for Kids program underlined the importance of intervention in a "real wo rld" context by using a home-based education approach to improve the fruit and vegetabl e intake among children and their parents. Components included making home visits and pr oviding families with nutrition-focused storybooks (Haire-Jos hu et al., 2008). Efficacy and Limitations of Interventions The efficacy of various interven tion program s to promote healthy eating among children has been assessed using a range of variables. Ex amples of these variable s include physiological factors (e.g., BMI), dietary intake of certain foods (e.g., number of serv ings of fruits and vegetables or the number of servings of lowfat foods), and psychological factors (e.g., selfefficacy, awareness, knowledge and motivation). Systematic review s of interventions to promote healthy eating among young people have shown mixed results (White, Carlin, Rankin, &
50 Adamson, 1998; Campbell, Waters, OMeara, Kelly, & Summerbell, 2002; Sheppard et al., 2006). A review by French and Stables (2003) of school-based environmental interventions to promote healthy eating among children is one of th e reviews that showed mixed results. It was reported in this review that several multi-compone nt school-based programs aiming at increasing fruit and vegetable intake (e.g., including cla ssroom education, food service changes, and a parent activity component) have shown significa nt increases in fruit intake but few or no increases in vegetable intake, with change in vegetable intake ranging from 0 to 0.3 servings. The authors of this review questi oned the degree of prac tical significance of the increases in fruit intake found in some of the reviewed studies (i.e., increases ranging from 0.2 to 0.6 servings per day). In addition to fruit and vegetable intake, th e review also examined interventions targeting the consumption of low-fat foods. The results of school-based envir onmental interventions targeting the consumption of low-fat foods s uggest that increasing availability and reducing prices of these foods, as well as providing point of purchase promotions regarding these foods, are effective strategies for increas ing consumption of these foods. A large review by Shaya and colleagues (2008) examined school-based obesity interventions that occurred from 1986-2003. Most of the interventions targeted both nutrition behaviors and physical activity behaviors. The review reported th at some of the short-term interventions (i.e., less than six months in dura tion) demonstrated statistically significant positive changes in outcomes such as reduced diastolic blood pressure, increased physical activity, and reduced tricep skin folds. However, the persis tence of these results was not observed (Shaya, Flores, Gbarayor, & Wang, 2008). Similarly, findi ngs from the three-year school-based CATCH program, which involved over 5,000 ethnically-diverse children, dem onstrated reductions in self-
51 reported fat intake but no main tenance of these reductions at follow-up. Furthermore, findings from the CATCH program reveal ed no significant changes in participants blood pressure, body size, or cholesterol (Luepker et al., 1996). Sheppard and colleagues (2006) conducted a syst ematic review of studies that focused on barriers to and facilita tors of healthy eating among youth. This review included 22 outcome evaluation studies of intervention programs bot h within and outside of the U.S. Of the 22 examined programs, only 7 were judged by the authors to be methodologically sound. A summary of those seven program s and their results follows. A five-year school-based intervention in Ne w York (Walter, 1989) showed increases in knowledge but no significant changes in cholesterol levels or diet ary fat. The large three-year Gimme 5 program (Nicklas, Johnson, Myers, Farris, & Cunningham, 1998) aimed at increasing fruit and vegetable consumption utilized a multidimensional approach, including a school media campaign, classroom activities, parent involvement, and changes in the school meals, also showed significant changes in know ledge between control a nd intervention groups. Additionally, this program showed significant increases in fru it and vegetable consumption. It is noteworthy, however, that although the changes in knowledge were maintained at follow-up, the behavioral changes in fruit and vegetable cons umption were not sustai ned (Sheppard et al., 2006). Additionally, a United Kingdom-based inte rvention (Moon et al., 1989) that sought to make school-wide changes in curriculum and organizational functioning show ed little change in knowledge about healthy foods, but some increas e in choosing healthy foods, with variation according to age and gender. Another U.S. study, the Slice of Life in tervention program (Perry, Klepp, & Halper, 1987), which involved peer leaders, included a curriculum designed to promote healthy eating
52 and physical activity by targeting knowledge about benefits of fitness and characteristics of a healthy diet, social influences and environmental influences. The program showed significant increases among females in healthy eating, knowle dge, reading labels, and awareness of healthy eating and a decrease in salt co nsumption. However, males showed significant changes only for decreased salt consumption and increased knowledge scores. A school-based program that took place in Norw ay similarly utilized peer leaders as a main component of the interven tion. Additionally, this program pr ovided students with computer software that could be used to analyze the nutritional conten t of the foods they consumed. Results from this program showed significant in creases in healthy eati ng behavior (maintained among females but not among males) and in knowl edge about healthy foods (among males but not among females) (Klepp & Wilhelmsen, 1993). The North Karelia Youth Programme base d in Finland used a multi-dimensional approach involving classroom activities, a community media campaign, health-screening activities, changes to school meals, and health education initiatives in parents workplaces to increase health behaviors and improve coping skills among secondary school youth. The program was effective in increasing healthy eating behaviors and reducing systolic blood pressure among the participating youth. However, the program was not as effective in reducing cholesterol levels or diastolic blood pressure (V artiainen, Tossavainen, Viri, Niskanen, & Puska, 1991). In sum, the systematic review of th e above-mentioned studies by Sheppard and colleagues (2006) suggests that in terventions to promote healthy eating among children appear to be typically more effective among females than males and that while there is some evidence to suggest effectiveness [of these in terventions], the evidence base is limited (Sheppard et al.,
53 2006, p. 254). Furthermore, because many studies of interventions to promote healthy eating among children either do not test or test but do not demonstrate the sustainability of positive effects (e.g., Sahota et al., 2001; Perry et al., 2004; Gratton et al., 2007; McAl eese & Rankin, 2007; Fahlman et al., 2008; Haire-Jo shu et al., 2008), it is difficult to determine whether or not these interventions are effici ent and effective in making la sting improvements in eating behaviors among children. Consequently, it is di fficult to justify implementation of such interventions in schools. Other limitations of past intervention programs include the tendency to focus more attention on adolescents than on children and the failure to address low-income and/or racial/ethnic minorities (Horne et al., 1998; Sahota et al., 2001; Perry et al., 2004; McAleese & Rankin, 2007). Some programs have shown disp roportionate drop-out rates among African Americans as compared with other racial/eth nic groups (e.g., Luepker et al., 1996), while other studies have ignored the inclusion of minority groups altogether. In fact, Sheppard and colleagues (2006) noted in their review of inte rvention programs designed to promote healthy eating among youth that although the studies varied in thei r reporting of demographic characteristics, it appeared that most particip ants were non-Hispanic White American and lived in middle class urban areas. Specifically, only 6 of the 22 examined intervention studies included minority youth (Sheppard et al., 2006). Clearly, it is important that racial/ethnic minority youth and youth from low-income families be well-repr esented in future studies to investigate interventions designed to increa se healthy eating and/or other health promoting behaviors among youth. The fact that the obesity epidemic remains pe rsistent indicates that current interventions are still not fully addressing those variables th at are directly contri buting to the poor eating
54 patterns of children. Moreover, th e mixed results regard ing the long-term effectiveness of past intervention programs to promote healthy eati ng have impeded efforts to address childhood obesity (Shaya et al., 2008). It may also be th e case that the lack of success in eliminating childhood obesity is due to not having identified im portant factors in this health problem or in unhealthy eating behaviors. Past studies are supported by previous noti ons surrounding obesity and healthy eating, and these notions may not be reflective of the cu rrent eating environment of Americans or of the differential factors affecting various sub-gr oups of children. As noted in Sheppard and colleagues (2006) systematic revi ew, there appear to be differen tial impacts of interventions on male and female children, suggesting the possibility that some of the f actors influencing boys and girls healthy eating beha viors may be different. Furthe rmore, there may be factors influencing healthy eating behavior s that have yet to be uncove red and that are specifically associated with low-income children and/or with racial/ethnic minority children, as there is a paucity of research focusing on these populati ons. Further investigations surrounding healthy eating in children should incor porate investigation by gender and race/ethnici ty related factors and should allow children to voice their own experiences surrounding today's healthy eating practices, rather than relying on pre-existing theories or solely on the repo rts of adults (e.g., parents, teachers). Overview of Present Study Purpose of Present Study The purpose of the present study was to use focus groups to identify m otivators of and barriers to engagement in healthy eating behaviors among African American, Hispanic, and nonHispanic White American children (ages 9 to 12) from families with low household incomes. Focus groups may be defined as thoughtful, plan ned discussions among participants with similar
55 experiences that allow the moderator of these gr oups to obtain the individuals cognitive and emotional perceptions regarding a topic or topics and to do so in a non-threatening and relaxed environment (Heary & Hennessy, 2002). Unlike an interview or survey methodology, a unique aspect of the focus group methodology is that it creates a setting that encourages spontaneous discussion among its participants Specifically, listening to on e participant's response to a proposed question effectively encour ages other participants to sh are their own experiences, with minimal feedback from the moderator (Gilflores & Alonso, 1995). Focus groups have been successfully used to identify factors influe ncing engagement in health promoting behaviors among adults (e .g., Belza, Walwick, Shiu-Thornton, Schwartz, & Taylor, 2004; Birkett, Johnson, Thomps on, & Oberg, 2004; Croy & Marquart, 2005; Plowden, Wendell, Vasquez, & Kimani, 2006); however, few studies have used focus groups to identify factors that influence the healthy eating behaviors of children. Some studies that have used focus groups to examine the influences on childrens healthy eating behaviors have involved only the parents of children as focus group participants, as opposed to the children themselves (e.g., Hart, Herriot, Bishop, & Truby, 2003). However, recent re search has indicated that using focus groups is an excellent means of identifying young peopl es views on health and wellness (PetersonSweeny, 2005). Research that has used a fo cus group methodology to identify factors influencing healthy eating among youth has typica lly involved adolescents as partic ipants (e.g., Neumark-Sztainer et al., 1999; Monge-Rojas et al., 2005) rather than children. Furthermor e, the studies that have in fact used focus groups to identify useful, firs t-hand information about why children do or do not engage in healthy eating behavior s typically have occurred in countries other than the United States, such as Australia or England (e.g., Hesketh et al., 200 5; McKinley et al., 2005).
56 Need for a Culturally Sensitive Research Approach Focus group s in the present study were c onducted in accordance with the Difference Model research approach (Oyemode & Rosser, 1980). The Difference Model approach advocates separately studying groups who are culturally diffe rent, thus avoiding the Deficit Model research tradition of comparing one group to another and viewing lower performance by one group as an indicator of that groups deficits rather than as an indicator of group differences. As advocated by the culturally sensitive Difference Model rese arch approach, the present research examined the motivators of and barriers to healthy eating separately by racial/e thnic group. Such a method may be particularly indicated for health researc h, due to previous resear ch positing that factors influencing health outcomes and behavior s may vary according to ethnic background (Kumanyika, Morssink, & Agurs, 1992; Neum ark-Sztainer et al., 2002; Dietz, 2004). Additionally, people of culturally diverse ba ckgrounds have been traditionally underrepresented in research, specifica lly in research examining health promoting behaviors such as healthy eating and physical activ ity (Treloar, 1999). Many studie s focusing on youths views of factors that influence their healthy eating have either not reported race/ethnicity or have consisted of predominantly non-Hispanic Wh ite participants (Sheppard et al., 2006). Furthermore, Bruss and colleagues (2005) have a sserted that in order to develop clarity of definitions and culturally-sensitive language for use in childhood nutrition education, it may be necessary to conduct qualit ative studies that differentially examine children by age, gender, and/or culture. Description of Present Study The presen t study was part of a larger, multi-phase study (i.e., the UF-PepsiCo Community-Based Family Health Self-Empowerme nt Project to Modify and Prevent Obesity) funded by the PepsiCo Foundation that was designed to test the impact of a family health
57 promotion workshop series on the health promoti ng behaviors of low-income African American, Hispanic, and non-Hispanic White American ch ildren, adolescents, a nd adults. The present study, which was part of the first phase of the larger study, helped inform the workshop series intervention that was tested in the larger study. Specifically, the present study involved conducting focus groups with child participants (ages 9 to 12) for the purpose of identifying these childrens perceptions of the motivators of and barriers to their engagement in healthy eating behaviors. The specific healthy eating behaviors that were the focus of this research include (a) eating healthy food and snacks that are lower in fa t and calories and (b) eating fruits, vegetables, and whole grains. Because qualitative research su ch as focus group research typically involves moving from observation to hypothesi s (i.e., is inductive in nature), there were no predetermined study hypotheses/outcomes (Pope & Mays 1997). Research question #1 : What are the motivators of a nd barriers to healthy eating as reported by low-income children who self-ident ify as African American, Hispanic, or nonHispanic White American? Research question #2 : Are there differences among the perceived motivators of and barriers to healthy eating in associati on with gender and/or race/ethnicity?
58 CHAPTER 3 METHODS Participants Six focus groups were conducted with a tota l of 37 children (17 fe males and 20 males). Each participant was required to meet the follo wing inclusion criteria: (a ) be 9 to 12 years old, (b) have a family income of $40,000 or below, as reported by the particip ants parent/guardian, and (c) be African American, Hispanic, or nonHispanic White American, as identified by the participants parent/guardian. The participating children ranged in age from 9 to 12 years old, with a mean age of 10.7 years ( SD = 1.1). The racial/ethnic compos ition of the participants was 29.7% African American, 40.5% Hispanic, and 29.7% non-Hispanic White American. Descriptive information on the age, gender, and r acial/ethnic distributions of participants is shown in Table 3-1. The number of participants per focus group ra nged from four to seven, with five being the median number of participants per focus gr oup. The range of the numbe r of participants per focus group was largely due to the unpredictabili ty of how many confirme d participants would actually attend a focus group versus the number of participants who confirmed attendance to that focus group. Instruments Two instrum ents were used in conducting th is study. Below are brief descriptions of these instruments. Demographic and Health Information Data Questionnaire (DHIDQ) The Demographic and Health Inform ation Data Questionnaire (DHIDQ), which was given to each participant and their parent/ guardian to be comple ted together, assessed race/ethnicity, age, gender, whether or not the child was on a special diet because of a health
59 condition (such as diabetes or hypertension), and whether or not the child was trying to lose weight. Focus Group Questioning Route (QR) A research er-constructed Focus Group Questioning Route (QR) was developed to guide the focus group discussion (Krueger, 1988; Stewart & Shamdasani, 2000). The QR was orally administered by trained focus gr oup leaders for the purpose of expl oring participants motivators of and barriers to healthy eati ng and physical activity-related be haviors. However, the present study focused specifically on the following healthy eating behaviors: (a) ea ting healthy foods and snacks that are lower in fat and calories and (b ) eating fruits, vegetables and whole grains. The QR consisted of questions to elicit the motivators of and barriers to each healthy eating behavior. Example questions on the QR to elicit motiv ators of healthy eating behaviors are as follows: If you eat fruits and vegetables each day, why do you eat them? and If you do not eat fruits and vegetables each day, what would en courage you to eat them? Example questions on the QR to elicit barriers to healthy eating beha viors are as follows: If you dont eat fruits and vegetables each day, why not? and If you do eat fruits and vegetables each day, why is it not always easy to eat them? The QR also consisted of a few introductory qu estions that were not designed to elicit motivators or barr iers but rather to initiate c onversation about the topic at hand (e.g., What do you think about when you hear the words healthy eating? and What are some of your favorite fruits and vege tables?). Examples of healthy foods that are lower in fat and calories and whole-grain foods we re presented before the questions related to these topics, for the purpose of clarification (e.g., Examples of choosing healthy foods are baked chicken instead of fried chickena meal with vegetables in it instead of no vegetables in it).
60 Procedures Participant Recruitment Multip le strategies were used to recruit participants who met the inclusion criteria. One participant recruitment strategy involved the posting or dissemination of English and Spanish versions of participant recruitment flyers at local businesse s and institutions such as churches, grocery stores, restaurants, schools, and libraries. These flyers included a brief description of the study, the participation inclusion criteria, and information for contacting the researchers. Parents of potential particip ants who expressed interest in the project by calling the phone number on the flyers were asked to verify that thei r child met the participant criteria. Other participant recruitment strategies included (a) recruiting participants on-site at local community locations (e.g., churches, community recreation centers, grocery stores) and community events (e.g., a Martin Luther King, Jr. Day Celebration), (b) giving presentations about the project at community meetings, afte r-school programs, and neighborhood revitalization council meetings, and (c) using the snowball technique a stra tegy in which individuals who have agreed to participate in the project disseminate recruitmen t flyers to other persons they know and encourage these other pers ons to be research participan ts. Finally, given the research literature regarding the typical difficulty of recruiting minorit y research participants, two Hispanic community member participant recr uiters and two African American community member participant recru iters were paid a small honorarium to recruit participan ts for this study from within their local community. All recruiters and recruitment materials prov ided potential focus gr oup participants with information on the purpose and procedures of this study. The stated purpose of the research was to identify motivators of and barriers to health pr omoting behaviors. The stated procedures were as follows: (a) participants woul d take part in a two-hour audiot aped and videotaped discussion
61 group during which they would be asked a series of questions about what motivates them to engage in health behaviors and wh at prevents them from engaging in those behaviors, and (b) at the end of the focus group discussion, particip ants would be paid $15 in cash for their participation. It was also stated that (a) all information identifyi ng research participants would be kept confidential, (b) members in a discussion gr oup would be similar in terms of race/ethnicity, age group, and gender, (c) particip ants could choose to not res pond to any question asked by the discussion group leaders, (d) a parent or legal guardian must accompany e ach participant to the site of the focus group and sign a Parental/Guard ian Consent Form that provides permission for the child to participate in a focus group, and (e) before the discussion group began, each participant, along with a parent/guardian, would be asked to complete a written demographic questionnaire that would take approx imately five minutes to complete. Focus Group Leader Training Each of the six focus groups was conducted by a leader, co-leader, and notetaker whose gender and race/ethnicity matched the gender and race /ethnicity of the chil dren in that group. All Hispanic focus groups were conducted by leaders, co-leaders, and notetakers who were fluent in both English and Spanish. Focus group leaders we re typically university faculty or graduate students who were familiar with the resear ch project and focus group methodology. Focus group co-leaders were typically undergraduate student s whose primary role was to promote rapport between the leaders and the focus group partic ipants and to facilitate comfort among group participants. Notetakers were undergraduate research assistants who sat just outside the group circle and recorded observations of nonverbal behaviors, as well as key comments and interactions. Notetakers did not pa rticipate in focus group discussions. Before conducting the planned focus groups leaders, co-leaders, and notetakers participated in small group or individual training sessi ons led by project res earchers that included
62 training on (a) goals and procedur es of the focus groups, (b) st rategies and techniques for facilitating discussion among focus group partic ipants, and (c) methods of managing group dynamics (e.g., strategies for ensuri ng that everyone in the gro up has a chance to talk, including quiet or shy group members, and strategies fo r limiting the amount of talking by group members who try to monopolize the group disc ussion). All focus group leaders, co-leaders, and notetakers were provided with a training manual and the Focus Group Questioning Route days prior to leading the discussion. On the day of each focu s group, researchers met with the leader, coleader, and notetaker for the purpose of answering their questi ons and reviewing the focus group procedures. These researchers remained at the location of each focus group to answer questions from the focus group leaders, co-leaders, and notetakers, as well as focus group participants, and to help with focus group logistic s (e.g., setting up and testing the video cameras, reading Assent Forms to participants). Focus Group Implementation Each focus group was held at a convenient community site (e.g., a library or comm unity center) on a weeknight or a week end day. Upon arrival at the s ite, parents/guardians of the participating children were gi ven a Parental/Guardian Consen t Form to sign, and research assistants read an Assent Form to the particip ating children. Parents/guardians of participants were given the option of having forms read aloud to them if th ey preferred this to selfcompletion. Parents/guardians who preferred Span ish were provided with Spanish versions of Parental/Guardian Consent Form. The Parental/Guardian Consent Form and the Assent Form included information regarding the purpose of the study, length of time required for participation, payment amounts and methods, a nd various research pr ocedures, including procedures to protect the confidentiality of info rmation obtained from participants. Participants, along with their parent/gua rdian, then completed the Demographic and Health Information Data
63 Questionnaire. After completing these documents, focus group participants and their parents/guardians were served a meal for the purposes of promoting co mfort among participants and showing appreciation for their participation. Next, all non-participants (e .g., parents/guardians, researcher s) vacated the room where the focus group was to occur, leaving only the participants, the focus group leader and co-leader, and the notetaker in this room. Each focus group was then implemented, beginning with an icebreaker activity and introductions for the purpose of faci litating comfort among participants, and then continuing with di scussion of questions taken from the Focus Group Questioning Route. Focus groups were implemented in accordance with standard focus group procedures, such as those described in Krueger (1988), but modified to take a more culturally sensitive approach. Each of the six focus groups were gender and racial /ethnic group concordant; that is, one focus group was conducted for each combination of gender and racial/ethnic group (e.g., one focus group consisted of African American female children, one focus group consisted of Hispanic male children). In order to be cultu rally sensitive and promote comfort, each leader, co-leader, and notetaker matched the gender and r ace/ethnicity of that focus groups participants. Additionally, each Hispanic focus group was mode rated by a leader and a co-leader who were Spanish-English bilingual. Participants were engaged in discussion for approximately one to one and a half hours. Each focus group was audiotaped and videotaped, as explained in the Parental/Guardian Consent Form. Focus group participants were each paid $15 in cash immediately following the focus group and thanked for their partic ipation. Each participant was also asked to sign a payment receipt for the purpose of verifying that she/he ha d indeed been paid $15 for participating in the focus group discussion.
64 Qualitative Data Analysis Digital audio recordings of the focus groups were transcribed verbatim by a certified transcription company. Transcribers were asked to record all slang, slips of the tongue, and audible behaviors such as laughter and to distinguish the voices of the focus group leaders and co-leaders from those of the focus group part icipants. Focus group leaders were asked to recommend, but not require, that participants say either their first name or a fictitious name before speaking so that participants could be differentiated from each other during the transcription and data analysis processes. The decision to only recommen d, but not require, this name provision was made to facilitate spontaneo us responding and to increase the comfort level of the children who, for the most part, were unfam iliar with each other. This name provision was also not required because frequenc y of discussion of a particular factor within each focus group (i.e., the number of part icipants within a focus group who re ported a particular factor) was not used as a method of data analysis. Instead, anal ysis occurred across focus groups (e.g., factor X was mentioned in focus groups A, B, and C). Th is method of analysis was chosen based on the view that responses that are gi ven in more than one focus group are likely to be more reliable motivators and barriers than res ponses that are given by several persons within a single focus group. Additionally, analysis at the focus group le vel is useful for dete rmining if there are differences in reported motivators of and barriers to healthy eati ng behaviors in association with race/ethnicity and/or gender. Focus group transcripts were analyzed by a team of eight researchers (i.e., coders) from diverse cultural backgrounds. Each focus group transcript was coded by a two-member coding team that included at least one coder whose race /ethnicity matched the race/ethnicity of the particular focus groups participants. Additiona lly, each transcript from a focus group with Hispanic participants was coded by at least one coder who is Hispanic and Spanish-English
65 bilingual. The purpose of these procedures was to facilitate comprehension of the participants dialect and word usage during the transcription coding process. In order to increase the reliability and validity of transcript coding, coders were rotated so that co ding teams did not always consist of the same two coders. The author of this doc ument served as the coding analyst, the person responsible for closely supervisi ng the coding process to enhance internal consistency of coding between transcripts (Kidd & Parshall, 2000). All coders received training on the constant comparative method (Glaser & Strauss, 1967) Analysis (i.e., coding) of each of the si x focus group transcripts was informed by the constant comparative method (Glaser & Strauss, 1967) Specifically, conventional content analysis (Hsieh & Shannon, 2005) and inductive category development (Mayring, 2000) approaches were used for the purpose of deducing the codes directly from the data, as opposed to using a pre-existing theory to construct a coding scheme. Using an inductive approach to develop the codes based on the data, as opposed to using a pre-existing theory to preliminarily create a coding scheme and then make the data fit to th at pre-developed coding sc heme, is an approach that fit well with the cu lturally sensitive approach utilized in this study. Using an inductive versus deductive approach also avoids forcing the data to f it into pre-determined categories that were developed based on pr e-existing theory resulting from research that may not have included low-income or racial/ethnic minority research participants. To construct an initial coding scheme, c oders read through segments of a randomlyselected transcript and agreed upon an initial lis t of categories (i.e., c odes) and subcategories (i.e., sub-codes) to describe th e participants comments determ ined to be motivators of or barriers to healthy eatin g. Level of specificity of codes was determined on the basis of practicality. In other words, codes needed to be specific enough to capture information that could
66 be directly utilized in interven tions or health promotion programs and in the later development of a proposed inventory to assess perc eived levels of motivators of a nd barriers to health promoting behaviors. Coding procedures used in the present research were largely consistent with the coding guidelines of Schilling (2006, p.33), which he descri bes as follows: Starti ng with a theoretical discussion and explanation of the system, the researcher has to define main and (if necessary) subcategories as well as formulate anchor examples (prototypes) and coding rules. Thus, as needed, sub-codes (analogous to Schillings subca tegories) were also deduced from the data and added to the coding scheme and prototype ex amples. Coding guidelines were also specified. Each unit of speech in each transcription that described or referred to any kind of motivator or barrier was considered an instance. Thus, a coded instance could be as short as a single word or as long as a partic ipants entire uni nterrupted comment (i.e., given that it covered a single topic/idea). All instances referring to motivators of or ba rriers to healthy eating were coded; conversely, comments by part icipants in reference to anythi ng other than motivators of or barriers to healthy eatin g and comments by focus group leaders were not coded. Each instance was assigned a main code (e.g., social influence) or a main code as well as a more specific subcode (e.g., parental influence) according to Schillings (2006) recommendations. Every coded instance was labeled as either a motivator or a barrier. After the initial list of codes was develope d, coders constantly compared participants comments to the coding list, in order to determ ine if each instance could be described using a code from the coding scheme. Wh en instances did not fit within the scheme, an existing code was revised or a new code was developed to ac curately describe or categorize the instance.
67 Subsequently, new codes and sub-codes were de veloped and added to the coding scheme only when a participants comment did not fit under a code within the pre-existing coding scheme. Specifically, the transcript coding process involved four major steps. First, each transcript was independently and privately coded by two code rs. All coders used the same coding schema. Coders were encouraged to deve lop a new code if a participant s comment, determined to be a motivator or barrier related to he althy eating (i.e., an instance), did not f it any of the existing codes in the coding schema. Second, the two-me mber coding sub-team that coded a given transcript met with the coding analyst to review the transcript and compare codes. Each coded instance was discussed; if one coders choice of code did not match that of the other coder for any given instance, then the instance was determ ined to be a discrepancy. Discrepancies were recorded and later used to calcula te coding reliability. (Sub-codes we re considered an artifact of the code and were not used in determining di screpancies.) Third, each coding discrepancy was discussed among the coding analyst and the twomember sub-team who coded the transcript. After the discussion, the coding an alyst chose the most appropria te code based on the coders explanations and on her experien ce with the codes previous usage in other transcripts. If consensus was reached that there was no appropria te code already in the coding scheme, a new code was added to the coding sc heme. Although an effort was made to choose only one code per instance, on some occasions it was decided that two codes were necessary to capture the full meaning of the instance. In such cases, the instance was not recorded as a discrepancy. In the fourth and final step, the coding an alyst reviewed the c odes and combined or deleted any that appear to be redundant or overl y specific. Changes made based on alterations of the coding scheme as a whole (e.g., deleting, addi ng, or combining codes) were not considered discrepancies. Inter-coder reliability was calculated by dividing the to tal number of coder
68 agreements across all coded transcripts by the to tal number of coded instances (i.e., the sum of total coder agreements and total coder discrepanc ies across all coded transcripts). The result of this calculation was then multiplied by 100 to co nvert it to a percentage. Thus, the formula was (agreements/ [agreements + discrepancies]) x 10 0. Across the six focus group transcripts, a total of 857 coded instances were reco rded, 108 of which were record ed as discrepancies between coders. Using the described formula, the inter-coder reliability was 0.89.
69 Table 3-1. Descriptive statistic s of demographic variables Variable N % Age 9 8 21.6 10 6 16.2 11 12 32.4 12 11 29.7 Gender Female 17 45.9 Male 20 54.1 Race/Ethnicity African American 11 29.7 White American 11 29.7 Hispanic 15 40.5
70 CHAPTER 4 RESULTS This sec tion is divided into the following sections: (a) findings from the two health information questions on the Demographic and Health Information Data Questionnaire (DHIDQ), (b) a description of the organizati on of the analyzed focus group data, (c) a description of the motivators of and barriers to healthy eating as identified by the child focus groups, and (d) a description of the motivators of and barriers to eating whole-grain foods as identified by the child focus groups. Findings from the Health Information Questions on the DHIDQ The health infor mation section of the DHIDQ consisted of only the following two questions: (a) Are you on a special diet because of a health condition such as diabetes or hypertension? and (b) Are you tr ying to lose weight?. Responses to these questionsrevealed that none of the participants reported being on a special diet because of a health condition. However, thirty percent (30%) of the participants reported that they were trying to lose weight. Organization of the Analyzed Focus Group Data Findings from the focus group data analysis are presented by code/them e (e.g., social influence, taste, availability, and weight conc erns) and are ordered based on the frequency a given code. Sub-codes (e.g., parental influence is a sub-code of social influence and adding flavor is a sub-code of tast e), which were sometimes assign ed to reported motivators or barriers for the purpose of further description/spec ification, are placed in bold within the text. During the analysis process, each factor repo rted to influence healthy eating behaviors was labeled either motivator or barrier. Some of the factors that were reported to influence healthy eating were discussed across focus groups either exclusively as a motivator (e.g., weight concerns was discussed exclusively as a motivat or for eating healthy, never as a barrier) or
71 exclusively as a barrier (e.g., cost was referred to exclusively as a barrier for eating healthy, never as a motivator). However, other factors we re referred to as motivators in some instances and as barriers in other instan ces (e.g., taste was discussed acro ss groups both as a motivator for eating healthy and as a ba rrier to eating healthy). The findings related to the re ported motivators of and barrie rs to eating healthy foods and snacks that are lower in fat and calories are combined with the findings related to the reported motivators of and barriers to eating fru its and vegetables, except for where noted. Findings for these two topics were combined because of the great overlap between themoverlap likely due to the fact that the more ge neral topic (i.e., eating healthy foods and snacks that are lower in fat and calories) partially encomp asses the more specific topic (i.e., eating fruits and vegetables). However, there were some in stances in which motivators and barriers were identified only in relation to eating fruits and ve getables, and thus are noted to be the case. It is also noteworthy that findings from the focus groups are presented in order from most commonly reported to least commonly reporte d among the six focus groups. The degree of commonness of a motivator or barrier was determ ined by the number of groups in which it was reported (i.e., not by the number of times it was reported by individual part icipants). Thus the greatest degree of commonness of a motivator or ba rrier is indicate d by its mention in six out of six groups and the lowest degr ee of commonness of a motivat or or barrier is indicated by its mention in one out of six groups. Additionally, example quotes in which a partic ular motivator or barrier was reported are presented to further describe the findings. The ge nder and race/ethnicity of the child that stated each quote is also presented. Abbreviations are us ed to denote African American (AA), Hispanic American (HA), and non-Hispanic White American (WA). Quotes are included strictly for
72 illustrative and descriptive purposes and are not meant to be representative of a particular finding or a summary of the beliefs of a particular group. Findings are specific to a particular gender and/or race/ethnicity only where noted. Finally, it is important to note that reporte d motivators of and ba rriers to eating whole grains are presented separately after the findings for the motivators of a nd barriers to the other healthy eating behaviors (i.e., eati ng healthy foods and snacks that are lower in fat and calories, and eating fruits and vegetables). This is the case because only four of the six focus groups specifically discussed motivators of and barrie rs to eating whole-gr ain foods. Specifically, motivators of and barriers to eating whole grains were not discussed among the Hispanic male focus group or the non-Hispanic White American female focus group. Thus, there were fewer responses overall in relation to this topic. In the Hispanic male focus group, children discussed what kind of bread they typical ly ate but did not discuss why they ate that kind of bread. Additionally, it was clear that some of the participants did not know if foods (e.g., bread) that they were describing were whole-grain foods, thus preventing them from discussing the motivators of and barriers to eating whole-grain foods. Participants of the non-Hispanic White Amer ican female focus group were asked, in a single question, about their motivators of and barriers to eating fruits, vegetables, and whole grains. Inquiring about whole grai ns in the same question as fru its and vegetables appeared to be detrimental to elic iting responses about motivators of and barriers to eating whole grains because (a) participant responses focused mainly on fruits and vegetables, as opposed to whole grains, or (b) participants gave general responses that were ambi guous as to whether or not they were referring to whole grains. Additionally, it was clear that some participants did not know what whole grains were, in that they thought that oranges and bananas were whole-grain foods.
73 Although confusion in relation to whole-grain foods was apparent to some degree among nearly every focus group, participants in the other f our focus groups still reported some specific motivators of or barriers to eat ing whole-grain foods (e.g., the taste of these foods). Thus, participant responses about the motivators of an d barriers to eating whol e-grain foods from the other four focus groups were analyzed, while th e few responses about whole-grain foods from the Hispanic male focus group and the non-Hispan ic White American female focus group were deemed unable to be analyzed or inappropriate for analysis because the responses did not specifically describe motivators of or barriers to eating whole grains. Motivators of and Barriers to Eating Healthy Foods A num ber of motivators of and barriers to eating healthy foods we re discussed among the children. These motivators and barriers are descri bed below in descending order of prevalence across focus groups. In other words, the factors th at were reported among all six focus groups are presented first, and factors that were reported within only one of six focus groups are reported last. Motivators of Eating Healthy Foods Reported among All Six Focus Groups Social influ ence (motivator). Social influence was reported as a motivator of eating healthy foods across all six chil drens focus groups. Social infl uence was also reported as a motivator specifically in relation to eating fruits and vegetables among five of six focus groups. Parents were the most frequently reported so urce of social influence; some type of parental influence was reported across all six focus groups. Pa rental influence for eating fruits and vegetables was most often desc ribed in terms of an ultimatu m. An example of a parental ultimatum is conveyed in the following quote: My mom says, Eat your vegetabl es or else (HA male child)
74 Another type of social influence reported as a motivator for eating healthy foods was influence from non-parental family members (e.g., support from a brother). One male child even mentioned eating fruits and vegetables to impress the opposite sex. A few comments were made in relation to indirect social influences for eating healthy, such as people making fun of you if youre fat. A different type of familial influence, the effects of a family member having a health condition that requires that family member to eat healthy, was evidenced through this quote: Sometimes we might eat them (vegetables), li ke since my daddys on a diet cause he has to lose his stomach, and so hes eating hea lthy. Were eating bread but its not the same kind of bread that we [normally] eat. Its like a different kindA nd so he has to eat a lot of vegetables, because if he doesnt lose his stomach, the doctor said that he might end up dying, and so thats why Im getting on hi m about his diet. (AA female child) Taste (motivator). Not surprisingly, how a food tastes was one of the influential factors that was discussed with greatest frequency. Taste was discussed within the focus groups both as a motivator of and as a barrier to eating healt hy foods. Taste was discussed as a motivator of eating healthy foods within all si x focus groups. Taste was discusse d as a motivator specifically for eating fruits and vegetables among five of six focus groups. Example quotes illustrating taste as a motivator of eating healthy foods are presented below: I love bean burritos yeah, they are yummy. (HA female child) They [healthy foods] taste good. (WA male child) I like carrots, avocado, broccoli I like the ones that are li ke broccoli but they are white. (HA male child) Some children even reported preferring the taste of healthy foods to sugary foods: If I had a choice between the sugar and the healthy snacks, Id have the healthy snacks. (AA male child) Because it [healthy food] tastes better than some sweets (HA female child)
75 It [a banana] tastes better [t han a candy bar]. (WA male child) In reference to fruits and vege tables, children reported liking th e taste of fruits more commonly than they reported liking the taste of vegetables Some children clarified that their reason for liking the taste of fruits is due to the fruits sweetness: I like to eat fruits because, like, its rea lly better than eating candy. (AA female child) It [mango] is sweet, and I like it. (HA male child) Although a preference for sweet f oods was discussed with great frequency, there were only few comments made in reference to liking the sourness of foods. Interestingl y, each of the comments about liking the taste of sour foods was from Hispanic children, and each was in relation to fruits. In addition to simply liking or disliking the tast e of certain healthy f oods, other influential taste-related motivators and/or ba rriers to factors influencing eating healthy foods had to do with the following: (a) the addition of something (e.g., salt) to increase fl avor (a motivator) and (b) the way a food is cooked/prepared (a motivator or barrier). Interestingly, only Hispanic children mentioned eating fruit with something added as a motivator for eating fruits and vegetables: It [mango] tastes good with salt. (HA male child) I [would] rather eat a sour green apple with lemon and salt on it, because it make it even sourer. (HA female child) The way a food is cooked or prepared was reported as either a motivator or a barrier for eating healthy foods: I only like certain peoples baked chicken be cause sometimes it be dry. (AA female child) When my mom makes salads, it is like the entire world has become perfect because my mom makes the best sa lads (HA male child) Issues of availability (motivator). Availability of healthy foods was reported as a motivator for eating healthy foods across all si x focus groups. Among two groups, availability of
76 healthy foods as a motivator was discussed specif ically in reference to having them available as the only option Availability of fruits and vegetables wa s reported as a motivator in four of six groups. Children most often discussed availability of healthy foods in relation to having these foods accessible at home ; however, availability as a motivat or for consuming healthy foods was also identified in relation to school restaurants and social events : More of that [healthy] stuff around your hous e [would help me eat healthy foods]. (WA male child) [Having] enough of them [fru its and vegetables] on the table would encourage me. (AA male child) Motivators of and Barriers to Eating Healthy Foods Reported among Five of Six Groups Taste (barrier). Taste was discussed as a barrier to eating healthy foods am ong five of six focus groups. The only group that did not discu ss taste as a barrier to eating healthy foods was the Hispanic male focus group. Four of six focus groups reported taste as a barrier specifically in reference to eati ng fruits and vegetables. Among those four groups, disliking the taste of vegetables was discussed in three of th e focus groups. Disliking the taste of fruits was discussed in two of the focus groups. Taste was discussed as a barrier either in relation to not liking the taste of healthy foods or in relation to preferring the taste of unhealthy foods : Im not going to say I like a lot of that [unh ealthy stuff], but like fried foods are really, really good (AA female child) I dont really like salad that much. (WA male child) Responses by some participants spec ified that it is their desire or preference for sweetness (e.g., having a sweet tooth) that makes them choose unhealthy foods. One partic ipant described this as: The reason why I think I like it [ unhealthy foods] is c uz the ones that are not that healthy taste good are sweet. (AA male child)
77 In one case, the dislike of healthy foods was described as a broad generalization or negative association with healthy foods : Healthy foods are nasty excep t for corn. (AA male child) Weight concerns (motivator). Allusions to body weight, or concerns about ones weight, were mentioned as motivators of healthy eating among nearly all (f ive of six) childrens focus groups. The only focus group in which weight issues were not mentioned was the African American male focus group. When focus group lead ers asked specifically a bout eating fruits and vegetables, issues of weight were reported am ong three of six children s focus groups. Examples of weight-related issues mentioned as motivator s for eating healthy foods and snacks are as follows: Salt salt is fattening, so sometimes I dont put any on. (HA female child) You can eat a whole bunch of them [healthy f oods] and not get bigge r. (WA male child) Of particular interest is that a few children who mentioned weight issues as a motivator for eating fruits and vegetables connect ed the idea of gaining too much weight with the prospect of serious negative consequences, including dying. When you get bigger and bigger and bigger, you could have more chance of a heart attack. (WA female child) I heard on the news that someone died becau se they were too fat (HA male child) I think it [eating healthy foods] is important because when youre too big, like overweight you can faint. (AA female child) Some of the children discussed weight in relation to wanting to maintain their weight (i.e., not wanting to become fat), while others discussed wanting to lose weight : [I eat fruits and vegetables] so I wont be fa t, and so I will be skinny but not too skinny. (HA male child) [I eat fruits and vegetables] to get into a shirt that is a little smaller than I am (HA male child)
78 Motivators of and Barriers to Eating Healthy Foods Reported among Four of Six Groups Issues of av ailability (barrier). Just as the availability of healthy foods was cited as a motivator, the vast availability of unhea lthy foods was cited as a barrier. The prevalence of unhealthy foods was discussed as a barrier to choosi ng the healthier food s among four of six focus groups. This barrier was mentioned in reference to home school social events, and food provided by others (such as a friends family): Like tonight, if I go to a party, Im probabl y going to get 5,000 things of cotton candy and popcorn, which Im not supposed to have (WA female child) Additionally, three of si x groups reported the lack of availability of fruits and vegetables at home as a barrier for consuming them. Interestin gly, neither of the Hispanic American childrens focus groups was among the groups reporting a lack of availability of fruits and vegetables. Within each of the three focus groups that ment ioned the lack of availability of fruits and vegetables, at least one child repor ted the more specific barrier of fruits and/or vegetables being eaten quickly once those foods are bought and there not being any left: We got them, but by the time the next day, they be gone. (AA male child) Desire to be healthy (motivator). Children may be more interested in the idea of being healthy than one might think. The simple desire to be healthy was one of the most commonly reported motivators to eating healthy foods. Among four of the six childrens focus groups, there was mention of eating healthy foods and snacks in order to be healthy or to have a healthy body. The desire to be healthy was also reported in specific reference to fruits and vegetables among the same number of groups. Illustrative quotes are as follows: [I eat fruits and vegetables ] so I can be healthier a nd stronger. (HA male child) The reason I eat fruits and vegetables is because you can have a healthy body, and your bones will be very strong, and you wont have to worry about being all weak and lazy. (AA female child)
79 Motivators of and Barriers to Eating Healthy Foods Reported among Three of Six Groups Issues of fa miliarity (barrier). Being more familiar with unhealthy foods or less familiar with healthy foods was discussed as a barrier to eating healthy foods among three of six focus groups. Children described this familiarity as being used to or not used to or even attached to certain foods or certain types of foods: Like, our body isnt used to that healthy stuff, a nd so when we first eat it its like nasty, so weve got to like take some time and get used to it. And sometimes I dont get used to food (AA female child) Issues of variety (motivator/barrier). As opposed to desiring the foods that they are familiar with, some children described a lack of variety as a barrier to eating healthy foods. For instance, among three of six focu s groups, children reported that be ing bored of or tired of fruits and vegetables prevented them from eating more of these foods: You get tired of eating the same thing a ll the time every day. (HA female child) It appears that although ch ildren may be reluctant to try new healthy foods, they may also eat fewer healthy foods, such as fruits and vegetabl es, simply because they experience a lack of variety of these foods and thus find them unappea ling. Factors of familiarity and variety were not only discussed as barriers to eating healthy f oods; these factors were also cited among three groups as motivators for eating healthy foods. For ex ample, one child stated that she eats healthy foods because those are the type of foods she is us ed to, and others stated that they might try a new healthy food because of the desire to have something different (i.e., more variety). Thus, it appears that familiarity and the desire for variet y can work both wayseither as motivators for or as barriers to eating healthy foods. Physical activity (motivator). Of particular interest is the link made by some children between eating healthy foods and engaging in physical activity, such as the notion that eating healthy foods will help one to be active or that eating unhealthy foods will prevent one from
80 being active (e.g., becoming nauseous while ex ercising after eating something unhealthy). Physical activity was discussed as a motivator for eating healthy f oods or fruits and vegetables among three of six groups, with comments such as the following: You cant be not healthy, cause youre going to be doing a lot of running and jumping and stuff like that. And if you do that and youre not healthy you can just like faint. (AA female child) I eat it so I can get skinny, so I can run more, and so I can do exercise. (HA male child) Desire to eat / Cravings for junk food (barrier). Children among three of six focus groups described a strong desire or craving for junk food or sweets as a barrier to eating healthy foods. In other words, this factor was less about children not liking or not wanting healthy foods and more about them simply desiring junk foods: Especially at kids age, you just want j unk food for breakfast, lunch and dinner (WA female child) How can you give it up? I cant stand it. One day without candy? Ive got to sneak something in my life, and that s junk food. (WA female child) Motivators of Eating Healthy Foods Reported among Tw o of Six Groups Vegetarianism (motivator). Interestingly, two children-one in the Hispanic male focus group and one in the non-Hispanic White Amer ican female focus group-reported that their being vegetarian motivates them to eat healthy foods. Immediate effects (motivator). Among two of the three female focus groups, the immediate effects of eating healthy or unhealthy foods were mentioned as motivators to eating healthy foods. The comments either focused on the immediate positive e ffects of eating healthy foods (e.g., feeling strong, good, or energetic afte rward) or the negati ve effects of eating unhealthy foods (e.g., getting a sugar rush and being hyper after eating too much candy).
81 Awareness/thinking of the consequences (motivator). Among two of three female groups, thinking about the consequences of eatin g unhealthy foods was mentioned as a motivator for eating healthy foods, such as indicated in the following quote: I mean I like fat sometimes, but just some times I think, what am I doing to myself (HA female child) Motivators and Barriers to Eating Healthy Foods Reported among One of Six Groups Gastro intestinal effects (motivator). As a motivator for eating healthy foods, one African American female child described that he althy foods make her stomach feel better than do unhealthy foods: I mean, if I eat chicken, Im going to have to go to the bathroom, but when I eat healthy snacks, I feel real good and I dont have to go to the bathroom. My stomach dont start hurting. I dont feel overloaded. I dont feel like I have a lot of fat in my stomach. Desire to feel satisfied (motivator/barrier). As a motivator for eating healthy foods instead of sweets, at least one Hispanic female child mentioned that healthy foods make her feel more satisfied (i.e. not hungry): Sweets just make you want to have more sweets, it makes you more hungry, and healthy food fills you up, so you wont eat more. Alternatively, a child from the non-Hispanic Wh ite American male focus group expressed the opposite perspective as a barrier, by stating that a salad, for instance, is not really a meal. Personal health condition (motivator). A child in the African American female focus group shared that she has low iron and that this serves as a motivator for her to eat fruits and vegetables. Following is a commen t that reflects this finding: Because, I used to have to take pills for ir on but now I dont because like, it was something I was missing, I guess. It was some kind of ve getables or food that I wasnt eating like I was supposed to be eating Monetary incentives (motivator). At least one child in the non-Hispanic White American male focus group cited money as a hypothetical motivator for eating fruits and
82 vegetables. In other words, he stated that he would be more likely to eat fruits and vegetables if he was given a monetary reward to do so. Not seeing/feeling improvements (barrier ) A child from the non-Hispanic White American male focus group suggested that no t seeing or feeling improvements from eating healthy foods was a barrier to wanting to eat them. Everybody says that theyre really good for you, but you never really see an improvement. Like when you eat em, you never really see any changes or like feel any changes. So, it seems kinda worthless to just eat stuff that doesnt really taste as good and then you dont really see like any improvement s and dont feel any different. Cost (Barrier). At least one child from the African American female group showed an awareness of cost as a barrier to eating fruits and vegetables, as indicat ed in the following quote: But fruit is so high sometimes. Got to get a good price when you buy fruits. Appearance of foods (barrier). The desirable appearance of unhealthy foods, such as cake, was mentioned by a Hispanic female ch ild as a barrier for eating healthy foods. Indirectly Assessed Motivators of and Barriers to Eating Healthy Foods Though the following two influence variables were not ex plicitly reported as motivators or barriers by the child focus group participants, these factors were included in the discussions with frequency and thus appeared important to include as part of the findings of this research. Media influence. Among at least three of the si x childrens focus groups, media was mentioned within the discussion, th ough not necessarily as a motivator or as a barrier. However, these comments involving media su ggest that children make mental associations between healthy or unhealthy foods and the media, possibly as a source of either accurate or inaccurate information. Example comments follow: Cause I was watching this s how, and if you eat a lot of fr ied foods youll get bigger and bigger and it will make you feel lazy like you dont want to do nothing (AA female child)
83 On the news, it said that dark chocolate is better for you than broccoli. (HA female child) Knowledge. Although knowledge was rarely explicitly re ferred to as either a motivator or a barrier among the childrens focus groups, issu es of knowledge were fr equently indirectly discussed, sometimes in the form of informativ e statements such as the following statements: Like the popcorn that doesnt have the salt on it, thats better [for you]. (AA male child) Although the children seemed to evidence accura te general knowledge about healthy and unhealthy foods overall, they clearly also exhibited gaps of knowledge and unanswered questions. There was even debate in one group as to whether or not carrots are good for you. Some of the most striki ng questions included: Does bacon count as healthy? Does baking a chicken mean like sticking it in the oven? Is it true if you eat like too many bananas and potassium you could get like sick? Arent raisins good for you? Motivators of and Barriers to Eating Whole-Grain Foods Again, the findings related to whole-grain f oods are reported separately since m otivators of and barriers to eating whole grains were not explicitly discussed among two of the six focus groups (i.e., the Hispanic male focus group and the non-Hispanic White American female focus group). Reported motivators of and barriers to ea ting whole-grain foods are listed in order from most common (i.e., reported by four focus groups ) to least common (i.e., reported by one focus group). Reported among All Four Groups Taste (mo tivator). It is surprising that taste was reported as a motivator for eating whole-grain foods among all f our childrens focus groups that discussed whole grains. Following are example comments regarding this finding:
84 It tastes like regular bread. (AA male child) It [brown rice] doesnt taste any differe nt than regular rice. (WA male child) Some of them [whole-grain foods] actua lly do taste good (HA female child) The reason why I eat whole grains is because theyre tasty and ju st its not like the regular, but its still goo d. (AA female child) Reported among Three of Four Groups Taste (barrier). Am ong the four focus groups that discussed eating whole grains, three of the groups reported taste as a barrier to eating whole-grain foods. Particip ants reported taste as a barrier either in relation to not liking the taste of whole-grain produc ts or in relation to preferring the taste of products not comprised of whole grai ns. Some comments from these participants that substantiate this finding are as follows: I think of an example of like nasty stuff is like wheat croutons, because theyre all nasty, and they dont taste good at all. (WA male child) It [whole-grain food] doesnt really taste that good (HA female child) Issues of availability (motivator). Availability was mentioned as a motivator to eating whole-grain foods among three of the four focus groups that di scussed whole grains. It was reported that having whole-grain foods more av ailable would encourage children to eat these foods. Example comments from this disc ussion of whole grains are as follows: Id try it [brown rice] if it was around My dad always gets them [whole-grain foods ] ... theyre always around my house, so I eat them. (WA male child) Issues of knowledge (barrier). The lack of knowledge relate d to knowing whether or not a food is a whole-grain food was reported as a ba rrier to eating whole grai ns among three of four groups. Example comments from these focus groups are as follows: Sometimes I dont know what is in my food (HA female child) Ive heard of dirty rice, I havent heard of brown rice. (AA male child)
85 Reported among Two of Four Groups Issues of av ailability (barrier). The lack of availability of whole grains, or similarly, the availability of non-whole grain alternatives, was reported as a barrier to eating whole grains among two of the four focus groups that discus sed whole grains. Example comments from these focus groups are as follows: Because I dont have them (WA male child) Sometimes I dont [eat whole grains], because I have a kind of chocolate cereal, and I sometimes eat that (HA female child) Social influence (motivator). Influence from parents, both in relation to parents buying whole-grain foods and in rela tion to being influenced by parental preference was reported among two of the four focus groups in which eating whole-grain foods was discussed. An example comment is as follows: I dont have to ask my mom because she woul d put whole grain in my food, because she wants me to be healthy. (HA female child) Reported in One of Four Groups Issues of kn owledge (motivator). Among the Hispanic female group, obtaining knowledge related to being able to identify whole-grain foods wa s reported as a motivator for eating whole grains. The members of this group ev en discussed two methods of finding out what is in ones food: (a) reading la bels and (b) asking ones parents. Example related comments from this group are as follows: I usually always ask my parents, Is this w hole-grain? Is this? Th at? (HA female child) Sometimes I read the labels. (HA female child) Self-esteem/being proud (motivator). Additionally, among the Hispanic female group only, feeling proud of oneself for eating whole gr ains was reported as a motivator for eating these foods.
86 Weight concerns (motivator). Weight concerns as a motivator specifically in reference to eating whole grains was mentioned among only one of four groups-the Hispanic female group. An example comment is as follows: I dont want to be fat. (HA female child) Immediate effects (motivator). Among the non-Hispanic White American male group, positive immediate effects (e.g., feeling energetic af ter eating whole grains) were mentioned as a motivator to eating whole grains. Issues of variety (barrier). Among the non-Hispanic White American male group, a lack of variety was reported as a barrier to eating whole grains. An example comment is as follows: You get bored of eating whol e grains. (WA male child) Appearance of food (barrier). Among the non-Hispanic White American male group, the appearance of whole-grain foods was reported as a barrier to eating them, both in relation to the appearance of the actual food and in relation to the appearance of the packaging of wholegrain foods. Below are some related comments from this focus group discussion: Theyre really not that good-looking, so I dont really want to try it, because it doesnt look appetizing. (WA male child) Like Raisin Bran, it doesnt have like that cool-looking box or a nything like that (WA male child) Distraction/priorities (barrier). Among the White American male group, simply having other priorities was cited as a barrier to eating whole-grain foods. Specifica lly, reported priorities were sleeping and playing video games. In othe r words, thinking about eating whole grains was considered to be less important than ot her, likely more enjoyable, activities.
87 CHAPTER 5 DISCUSSION The purpose of this research was to use focus groups to identify pe rceived m otivators of and barriers to engaging in healthy eating be haviors among African American, Hispanic, and non-Hispanic White children from families with low household incomes. The specific healthy eating behaviors that were the focus of this re search included (a) eati ng healthy food and snacks that are lower in fat and calories and (b) eating fruits, vegetables, and whole grains. Additionally, this research examined if there were differen ces among the identified mo tivators of and barriers to healthy eating in association with gender an d/or race/ethnicity. This chapter includes the following: (a) a summary of the findings of this study, (b) interpretations of the findings of this study, (c) limitations of this study, (d) implications for future research and application, and (e) conclusions of this study. Summary of Findings The first research question asked about th e perceived m otivators of and barriers to healthy eating behaviors among African America n, Hispanic, and non-Hispanic White American children from families with low household incomes. A number of motivator s of and barriers to healthy eating behaviors (i.e., ea ting foods and snacks that are low in fat and calories, eating fruits, vegetables, and whole-grain foods) were identified by the six focus groups in this study, which varied in regard to their gender and r ace/ethnicity composition. The identified motivators and barriers were common across th ese six focus groups to differing degrees (i.e., were identified by all six focus groups to were id entified by only one focus group). Most Commonly Reported Motivators of and Barriers to Healthy Eating The most commonly reported motivators of h ealthy eating (i.e., reported among at least four of the six focus groups) included (a) social in fluence, (b) taste, (c) availability of healthy
88 foods, (d) weight concerns, and (e) the desire to be healthy. Specifically, parental influence was the most commonly reported type of social influence, and this in fluence was often described in terms of an ultimatum given by parents in reference to eating healthy foods such as vegetables. Surprisingly, influence from peers or from teach ers was rarely or not at all discussed among the participating children. Liking the taste of certain h ealthy foods was discussed ofte n, especially in relation to fruit. Specifically, some children reported that th ey liked healthy foods when a flavor enhancer such as salt was added or when the food was cooke d or prepared in a certain way. Issues related to the availability of healthy f oods were discussed as motivators, most commonly in reference to the availability of these foods in the home, but al so in reference to having healthy foods available at school, restaurants, and social events. Most surprising is the finding th at weight concerns (e.g., whether or not a food is fattening or the desire to prevent gaining too much weight) was one of the motivators of healthy eating most commonly mentioned among the childrens focus groups. Finally, the desire to be healt hy was also commonly reported as a motivator of eating healthy foods. The most commonly reported barriers to healt hy eating (i.e., reported among at least four of six focus groups) included (a) ta ste and (b) issues of availab ility. Taste was discussed as a barrier either in relation to not liking the taste of healthy f oods (e.g., vegetables) or in relation to preferring the taste of unhealthy foods (e.g., sweets). A dditionally, the prevalence of unhealthy foods as well as the lack of availability of healthy foods (e.g., at home, school, social events) were issues of availabil ity reported among children as barriers to healthy eating. Other Reported Motivators of and Barriers to Healthy Eating Motivators and barriers influencing healthy eating behaviors that were reported am ong three of six focus groups included (a) issues of familiarity (barrier), (b) issues of variety
89 (motivator/barrier), (c) physical activity (motivat or), and (d) desire to eat/cravings for junk food (barrier). Issues of familiarity and variety included instances in which children described being used to certain foods as either a motivator of or as a barrier to eating healthy foods, as well as instances in which children descri bed being bored with healthy foods (a barrier), or wanting to try new healthy foods for the sake of variety (a motivator). Interestingly, a connection was made between engaging in physical activ ity and eating healthy; children perceived eating healthy foods as an aid to engaging in physic al activity and eating unhealthy foods as potentially impeding their engagement in physical activity. Finally, chil dren reported that the sheer desire for or even the craving of certain unh ealthy foods prevents them from eating healthy foods. Motivators and barriers influencing healt hy eating behaviors that were reported among two of six focus groups included (a) vegetarian ism (motivator), (b) immediate effects of healthy/unhealthy eating (motiv ator), (c) awareness/thi nking of consequences of healthy/unhealthy eating (mo tivator), and (d) appearance of f oods or food packaging (barrier). Motivators/barriers influencing he althy eating behaviors that were reported among only one of the six focus groups included (a) gastrointestinal effects (e.g., of unhea lthy foods) (motivator), (b) the desire to feel satisfied (motivator/barrier), (c ) a health condition (motivator), (d) monetary incentives (motivator), (e) not seeing/feeling improvements (barri er), (f) cost (barrier), (g) feeling proud of oneself (motivat or), and (h) distractions/prioriti es (barrier). Notable topics discussed in the focus groups in relation to healthy eati ng but that were not specifically reported as motivators or barriers included (a) media influence on eating behavior and (b) issues of knowledge or lack of knowle dge regarding healthy eating. Differences in Association wi th Gender or Race/Ethnicity The second research question asked whether there were any differences in perceived motivators of and barriers to healthy eating behaviors in association with gender or
90 race/ethnicity. Few differences were found among the re ported motivators and barriers in association with gender or race/e thnicity. In a few instances, a difference was manifested when one group failed to report a cert ain influential factor that was mentioned by all other groups. Specifically, the only focus group out of six focus groups in which taste was not discussed as a barrier was the Hispanic male focus group, and the only focus group out of six focus groups in which weight concerns was not discussed as a motivator was the African American male focus group. Additionally, neither the Hispanic male fo cus group nor the Hispanic female focus group discussed a lack of availability of fruits and vegetables as a ba rrier. The only found differences in the identified motivators/barriers in association with gender were indicated by the fact that the two following motivators of healthy eating were id entified by two of three female focus groups but not by any of the male focus groups: (a) the immediate effects that a food brings (e.g., feeling energetic after eating it) and (b ) being aware of or thinking ab out the consequences of eating certain healthy/unhealthy foods. Interpretations of Findings A num ber of motivators of and barriers to hea lthy eating were revealed by data from the children in the six focus groups c onducted in the present study. So me of the revealed motivators and barriers are similar to those reported in previous qualitative and quantitative studies examining motivators of and barriers to healt hy eating among children, in cluding the following: (a) issues of availability/acces sibility (Corwin et al., 1999; Cu llen et al., 2001; McKinley et al., 2005; Sheppard et al., 2006; Brug, Ta k, Velde, Bere, & Bourdeaudhuij, 2008) (b) media influence (Signorielli & Staples, 1997 ; Hesketh et al., 2005; Stevenson et al., 2007) (c) social influence of family and of p eers (Corwin et al., 199 9; Cullen et al., 2000; Blanchette & Brug, 2005; Sheppard et al., 2006; Brug et al., 2008) (d) taste (Blanchette & Brug, 2005; Bruss et al ., 2005; McKinley et al ., 2005; Brug et al., 2008)
91 (e) weight concerns (McKinley et al., 2005; Sheppard et al., 2006). However, some of the specific motivators of and barriers to healthy eating that were found in the present study are novel. For instance, in the present study, influence from parents was discussed among focus groups more commonly than influence from peers. Previous research supports the importance of peer influence on child rens eating behaviors (e.g., Woodward et al., 1996), and children in some of the focus groups of the present study did in fact discuss peers as sources of influence on their eating behaviors. However, across focus groups of the present study, parents were reported as influencing childrens eating beha viors more often than were peers. This finding may be a manifestation of children being more aware of their parents influences on their eating behaviors, given the recently increased attent ion to healthy family eating in the media. Concern about weight or the potential fo r gaining weight due to unhealthy eating behaviors was another motivator that was men tioned across nearly every focus group in the present study, suggesting that children are either aware of the potential negative health consequences associated with gaining too much weight and/or are concerned because of issues related to physical appearance. Though some studies have found similar concerns among children about the effects of unhealthy eating on appearance or weight (McKinley et al., 2005; Sheppard et al., 2006), the preval ence (i.e., reported among five of six focus groups) of this motivator among the child focus groups in this study is particularly not able. Whether or not children understand what the poten tial health consequences of being overweight are, or how unhealthy eating can lead to being overweight, should be further examined. Children also discussed physical activity as a motivator for healthy eating. Specifically, children discussed the following: (a) not eating unhealthy foods before being physically active due to fear of becoming nauseous and (b) being mo tivated to eat healthy f oods so that they can
92 be healthy enough to engage in a nd excel in the physical activities that they enjoy. This finding suggests that motivating children to engage in enjoyable physical activities may al so indirectly motivate children to engage in healthy eating behaviors. The desire to eat a variety of foods and conve rsely, the desire to eat familiar foods, were also both reported among children as factors influencing their ea ting behaviors. These findings suggest that although children ar e typically more likely to choose foods with which they are familiar, children also get bored with eating the same foods (particularly the same healthy foods) repeatedly. Thus, it may be important to encourage families to provide children with a variety of fruits and vegetables by slowly in troducing new types of fruits and vegetables into a childs diet and also by involving children in th e selection of these new foods. The desire for junk food/sweets is a particularly noteworthy ba rrier to healthy eating that was reported with high frequency among the child focus groups. This barrier is noteworthy because words such as craving and addicted were actually used by some of the participating children to describe the intensity of their desire for junk food/sweets. Though such descriptions may be simply social constructions, they are of particular interest in the context of recent research to investigate the pot ential addictive qualit ies of certain types of foods (Hodgkins, Cahill, Seraphine, Frost-Pineda, & Gold, 2004; Uher et al., 2005). Findings in the present study related to the desire for junk f ood/sweets suggest that there is a need to teach children how to cope with sugar cravings as well as a need to teach parents and teacher s the importance of not reinforcing the idea that child ren are addicted to sweets. Other interesting findings, though less commonly reported among the focus groups, include the finding that a reporte d motivator for eating healthy foods is experiencing immediate positive feelings (e.g., feeling energetic/strong) af ter eating healthy foods whereas a barrier to
93 eating healthy foods is not seeing or feeli ng a difference (e.g., not noticing any positive effects) after eating healthy foods. Children may expect to feel or l ook better after eating healthylikely due to messages they have received related to this ideaand then either continue eating these foods or refrain from eating these foods as a result of whether or not such expectations are met. Knowledge, lack of knowledge, and unanswered questions may be highly influential on the eating behaviors of the pa rticipating children. These chil dren reported knowing or not knowing certain facts about heal thy eating and questioned whethe r or not certain foods are healthy. Overall, it seemed as if the children in the present study had a basic understanding of healthy versus unhealthy foods; however, they also appeared to have multiple unanswered questions and to exhibit some not ably incorrect knowledge or lack of knowledge regarding this subject. In sum, it appears that African American, Hispanic, and non-Hispanic White American children from families with low incomes report a wide variety of environmental, sociocultural, educational, and psychological factors that motiv ate or prevent their engagement in healthy eating behaviors. It is interesting to note that there were minimal differences in reported motivators and barriers in associ ation with gender or race/ethnicity. This finding could be interpreted in a number of ways One interpretation is that th ere are, in fact, only minimal differences in childrens motivators of and barrier s to healthy eating in association with gender or race/ethnicity. Alternatively, it may be th e case that race/ethni city and gender-based differences in some motivators of and barri ers to healthy eating may exist but are less pronounced/explicit among children of this age. Additionally, low socioeconomic status may serve as an equalizer across racial /ethnic groups; that is, the motiv ators of and barriers to healthy
94 eating among children that are associated with socioeconomic status may mask race/ethnicity and gender related differences in these motivators and barriers. Limitations Findings from this study m ust be interprete d with caution due to several limitations of this study. One limitation is a smaller sample size th an that which is typical in most quantitative studies. However, this limitation is common in focus group research and other types of qualitative research (LaPier & Scherer, 2001). Focu s group research tends to elicit a trade-off of greater richness of data for greater limits on generalizability. However, given the paucity of focus group studies related to hea lthy eating that have been conducted with children, the sample size of the present study is satisfactory at minimu m. Furthermore, the present study is important in spite of its small sample size given the pauc ity of focus group research conducted in the U.S. that examines motivators of a nd barriers to healthy eating am ong racial/ethnic minority children and children from families with low household incomes. Another limitation of the presen t study is that the participan t sample in the study may not be representative of African American, Hispanic and/or non-Hispanic White American children from families with low household incomes. Furthe rmore, these participants all lived in a smallto-medium-size city in the Southeastern United St ates, where the motivators of and barriers to healthy eating behaviors may be different from those in other parts of the country and thus limited in generalizability. Caution is also indicated with regard to the few differences found in association with gender and/or race/ethnicity due to the facts th at (a) there were only two focus groups conducted per racial/ethnic group and (b ) there was only one focus group conducted per gender within race/ethnicity (e.g., one African American fe male group). Despite these limitations, such findings may be useful for informing future research that quantitatively assesses motivators of
95 and barriers to healthy eating among a similar but larger sample of ch ildren like those in the present study. Another limitation of having cond ucted only one focus group per gender within race/ethnicity (e.g., one African American female group) is that differences in the number of participants per group, as well as differences in the level of enga gement of group participants and their focus group leaders, likely affected the numbe r and diversity of motivators and barriers that were reported in each focus group. Similarly, reported motivators and barriers were not analyzed based on the number of participants who stated each motivator/barrier ; instead, commonness of motivators/barriers across focus groups was determined. This commonness approach was utilized based on the con cept that factors reported in more th an one focus group are likely to be more reliable than factors reported by several persons within a single focus group. Furthermore, not requiring each participant to state his/her name every time before speaking (which would have been necessary to analyze findings at th e person-level of specificity) was based on the desire to promote a natural flow of conversation and to decrease th e degree of self-consciousness among the participating children who werefor the most partstrangers to one another. Some observed discomfort between the children in elementary school and those in middle school may have been a study limitation. This differ ence in grade level app eared to carry greater importance for the study participants than did diff erences in their age. Additionally, such gradelevel differences may have impeded group partic ipation by the elementary school children in focus groups that were comprised of both elementary and middle school children. One of the most observable limitations of the present study is the fact that the topic of whole-grain foods was not discusse d in two of the six focus groups This occurrence appears to be due to (a) the topic of whole grains being or iginally grouped with fruits and vegetables (i.e., fruits, vegetables, and whole grains) in the Focus Group Questioning Route and (b) an
96 avoidance of a discussion of whole grains becau se of a lack of familiarity or knowledge about whole grains by the participants. Once this lack of attention to whole grains was noticed, the Focus Group Questioning Route was revised to make whole grai ns a separate discussion topic (i.e., separate from fruits and vegetables); how ever, some groups had already been conducted by this point. An additional limitation of the present study is related to the training of focus group leaders. Although a structured two-hour training session was sche duled and conducted for focus group leaders and co-leaders, some of the leaders and co-leaders were una ble to attend this session and thus were trained in small-group or individualized make-up training sessions. Due to these differential situations, it is likely that not all of the focus group leaders and co-leaders were trained equallya situation th at may have resulted in more or less sharing of motivators and barriers within some focus groups. Additionally, an occasional situation occurred in which a focus group leader and his/her co-leader did no t meet until the day of the focus group, shortly before the event commenced. The degree of fa miliarity among focus group leaders and coleaders could also have potenti ally influenced the degree to which the focus group flowed smoothly and the degree to which participants comfortably shared motivators and barriers. Nevertheless, the diversity of participants and the richness of data generated in this qualitative focus group study render it a major c ontribution to the resear ch literature on the influences of healthy eating behaviors among ch ildren. Specifically, the present study describes the most common themes reported by the participating children as motivating or preventing them from engaging in healthy eating behaviors. This study is also important because of its use of a culturally sensitive research approach and its inclusion of children from families with low household incomes.
97 Implications for Future Research and Application Findings from the present study have several im plications for future research. First, the lim itations of the present study, namely th e limitations related to sample size and generalizability, should be addressed by conducting future simila r studies with larger samples of children in different areas of the United States. Comparing findings across such studies will further the understandin g of the motivators of and barrier s to healthy eating among culturally diverse children and will further clarify whether or not there are differences in the motivators of and barriers to healthy eating among children in association with gender, race/ethnicity, geographical location, and/ or cultural background. Additionally, the findings of the present qualitative study, as we ll as the findings of future similar studies, can be used to develop a pilot assessment instrume nt that quantitatively measures the levels of motivators of and barriers to hea lthy eating among children. The author currently is not aware of the existence of such a measure th at examines both motivators of and barriers to healthy eating and that covers th ose that are environmental, soci ocultural, educational, economic, and psychological in nature. Finally, the present study may also be used to inform similar culturally sensitive focus group research with groups that have been hist orically left out of research, including low socioeconomic status individuals racial/ethnic minority indivi duals, and children. The present study may also have implications for future research by serving as a model for conducting culturally sensitive qualitative data analyses. In the present study, the author ensured that the coding team that engaged in coding the focus group transcripts was not only culturally diverse but also that each transcript was analyzed by at least one coder who was of the same racial/ethnic background as the participants involv ed in that focus group. This step was taken to ensure that at
98 least one coder would likely understand any culture -specific language or culture-specific ideas that might have been conveyed in the focus group discussions. Conclusion This study used a focus group m ethodology to examine the perceived motivators of and barriers to healthy eatin g behaviors among African American, Hispanic, and non-Hispanic White American children (ages 9 to 12) from families with low household incomes. The present study also examined if there were differences in per ceived motivators of and barriers to healthy eating behaviors in association with gender and/or race/ethnicity. Ov erall, findings from this study suggest that a number of environmental, sociocu ltural, educational, economic, and psychological variables motivate or prevent the engagement in healthy eating behavior s by culturally diverse children from families with low household inco mes. The motivators of healthy eating most commonly reported across th e participating childrens focus groups included (a) social influence, (b) taste, (c) availability of h ealthy foods, (d) weight concerns, a nd (e) the desire to be healthy. The barriers to healthy eating most commonly re ported across the participating childrens focus groups included (a) taste and (b) issues of availability. A number of less commonly reported motivators and/or barriers were also reported by the participating children. In general, findings from the present study suggest that the percei ved motivators of and barriers to healthy eatin g behaviors are similar among male and female children, as well as among African American, Hispanic, and non-Hispanic White American children. The few possible gender and cultural differences in the motivators and barriers re ported by the children in the focus groups in this study are discussed. Future research should further examine these findings with larger numbers of focus group participants and in different geographical locations (e.g., in rural areas of the U.S.). Such research should be culturally sensitive and be inclusive of
99 children from families with low household income as well as children from diverse cultural backgrounds. Future research should also focus on developi ng an assessment tool that can be used with diverse groups of children to determine their perceived motivators of and barriers to engagement in healthy eating behaviors. Such an assessment tool would enable assessment-based intervention programs that are responsive to the factors that children identify as influencing their engagement in healthy eating behaviors. Interventions could additionally be customized to target motivators of and barriers to engaging in healthy eating among specific diverse gr oups of children in different areas of the country. Perhaps the most important conclusion from th e present study is that culturally diverse children can indeed identify motiv ators of and barriers to their engagement in healthy eating behaviors. Researchers and family members simply must empower them to provide this health promotion information. Indeed, it is children who are the true experts on what influences them to engage in healthy eating behaviors. Thus, in terventions with the ultimate goals of reducing obesity and health disparities and promoting healthy eating behavior s among children ideally should include children as major intervention part ners. Additionally, it is important that these intervention partners in clude children who are racial/ethnic minorities and/or are members of families with low household incomes.
100 APPENDIX A DEMOGRAPHIC AND HEALTH INFO RM ATION DATA QUESTIONNAIRE
102 APPENDIX B PARENTAL CONSENT FORM
104 APPENDIX C FOCUS GROUP QUESTIONING ROUTE (EXCERPT)
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127 BIOGRAPHICAL SKETCH Lily Boynton Kaye is a graduate student in the University of Floridas counseling psychology doctoral program under the mentorship of Dr. Carolyn M. Tucker. Lily serves as project co-director of the UF-P epsiCo-Community Family Health Self-Empowerment Project, a $1.2 million project designed to promote health and modify/prevent obesity among families, with a particular focus on low-income and racial/ethnic minority families. She received her undergraduate degree from the University of Fl orida in 2005, graduating summa cum laude with a Bachelor of Science degree in psychology and a Bachelor of Arts degree in linguistics. Currently, her research interests include de veloping prevention and intervention programs designed to reduce obesity, diet-relat ed diseases, and/or sexual risk behaviors, as well as increase health promoting behaviors such as healthy eating and physical activity.