THE goal set forth in Healthy People 2010 is to completely eliminate health disparities.1 This is a tall order given that researchers have only recently begun to focus on underserved populations.2 The National Institutes of Health has prioritized research that develops knowledge about underserved populations and training minority researchers as strategies toward achieving the goal of eliminating health disparities.3 Another way to work toward eliminating health disparities is to develop health-promotion interventions tailored to underserved populations. However, as the author found in a recently completed pilot study on emotional eating in a sample of rural, underserved Mexican American women, the women experienced so many barriers to lifestyle change that the prospect of developing an effective intervention to promote healthy eating for them seems overwhelming. Before embarking on intervention development, it seems that a clearer understanding about barriers to health promotion in underserved women is needed.
This article examines how different types of barriers influence healthy eating in underserved women, how individual characteristics, experiences, and culture influences these barriers, and what approaches could be used to address these barriers. Barriers are defined as factors that impede health-promoting behavior and include perceptions about the potentially negative aspects of changing behavior (eg, inconvenience, unpleasantness).4,5
Barriers are an important component of several conceptual frameworks that are used to facilitate lifestyle change. In Pender's Revised Health Promotion Model, barriers are modifying factors that directly interfere with performing the health-promoting behavior (eg, healthy eating) or indirectly interfere by reducing commitment to the plan of action for changing behavior.4 For example, if the barriers to increasing fruit and vegetable intake are lack of time and lack of access to affordable produce, then difficulty in obtaining affordable produce directly reduces the likelihood of eating more fruits and vegetables. Lack of time would interfere with commitment to a plan of action since extra time would need to be expended to obtain fresh, affordable produce. Kaufman found that more than 70% of rural, low-income households in Mississippi would have to travel more than 30 miles to reach a large retail supermarket.6
Barriers have been established in the health-promotion and disease prevention literature as important predictors of behavior change. More than three quarters of the studies testing Pender's Health Promotion Model supported the idea that barriers are an influential determinant of engaging in health-promoting behaviors.4 In the Health Belief Model, barriers are the most powerful predictor of behavior change across studies.5 Barriers do seem to be an important determinant of healthy eating behavior in underserved women. In a large study of low-income women (n = 3,122), a 1 standard deviation increase in barriers resulted in a 0.50 decrease in the number of daily fruit and vegetable servings consumed.7 Despite the research support for barriers as a predictor for behavior change, less attention has been paid to the types of barriers faced by underserved women.
TYPES OF BARRIERS TO HEALTH PROMOTION
Examining different types of barriers and how they are interrelated provides a comprehensive understanding of what barriers to lifestyle change need to be addressed. Health-promotion recommendations (eg, lose weight, eat 5 servings of fruit and vegetables per day) are frequently delivered without considering the individual's resources, skills, or barriers to implementing the advice. In one study, nutrition was discussed by physicians in only 24% of office visits, and the information provided was limited (ie, on average <1 minute).8 By failing to assist people to identify and overcome their specific barriers, healthcare providers may be setting individuals up for failure and blaming them for noncompliance.
Although some researchers have dichotomized barriers into internal and external barriers, this article will discuss 3 types of barriers: internal, interpersonal, and environmental.4 Each category contributes to an understanding of the complexities of the barriers faced when changing behavior. As illustrated in Figure 1, the 3 types of barriers are not distinct but rather overlap and influence each other.
|Figure 1. Relationships among types of barriers.|
Internal barriers encompass a variety of internal thoughts and emotions that individuals identify as reasons why making behavioral changes are difficult.4 Internal barriers include lack of time and motivation, lack of knowledge, enjoyment of the "bad" behavior, inconvenience, fatigue, boredom, and disbelief that the behavior can successfully be changed.4,5,9 Miller10 argues that resolving the conflict between one's intellectual self, which attempts to adopt a healthier behavior (eg, consume less fat), and one's emotional self, which struggles to maintain the current behavior because of distorted thoughts and feelings about the healthier behavior (ie, I'll feel deprived of foods I enjoy), is the key to overcoming internal barriers to behavior change.
In a large study of adults (n = 11,090) comparing internal and external barriers to changing one's diet, 61% identified only internal barriers, 9% identified only external barriers, and 30% identified both.9 Another study also found that internal barriers (eg, lack of time) were more problematic than external barriers (eg, cost) in adopting healthy eating practices.11 Unfortunately, less is known about the internal barriers experienced by underserved women. Chatterjee et al12 found that the internal barrier, lack of time, emerged from interviews as the primary barrier to healthy eating identified by community workers serving families from a low-income, predominantly Hispanic neighborhood. Thus, many of the barriers encountered are internal and should not be ignored in planning effective health-promotion interventions.
Interpersonal relationships are barriers when they encourage unhealthy behaviors or discourage behavior change.4 Women's caretaking roles in families may indirectly pose a barrier to behavior change. Researchers have found that some wives, especially those whose family roles are influenced by gender, defer to their husband's food preferences, making diet changes difficult.13 Interpersonal barriers were also identified as impeding healthy eating in a sample of rural Mexican American women, who prioritized taking care of the family by cooking favorite foods rather than taking care of self.14 Other interpersonal barriers identified by these participants were expectations of others to have food at family celebrations, and, as a gesture of hospitality, along with perceived lack of social support for their efforts to eat healthy.14
Environmental barriers include those factors in the environment that make it difficult to change behavior.4 For healthy eating, the environment needs to include access to sufficient quantities of high-quality fruits and vegetables at affordable prices. Individuals from low-income households living in urban and rural areas are less likely to have access to supermarkets that have the same variety of affordable fruits and vegetables available to people living in suburban areas.6,15 These same individuals are also more likely to have difficulty with access to transportation needed to purchase food, thus spending more time and money traveling to obtain food.6,15,16
As noted earlier, the 3 types of barriers cannot be viewed independently (see Figure 1). Instead, internal, interpersonal, and environmental barriers are entwined, illustrating the complexity of human behavior and the interaction between individuals and their environments. For example, in a qualitative study of older women's lifestyle changes after a myocardial infarction, some participants viewed the time (internal barrier) and the cost (environmental barrier) associated with caregiving for family members (interpersonal barrier) as a barrier to lifestyle change.17 Another example is the way that a family's food preferences have priority (interpersonal barrier), making healthy eating a process of preparing separate foods, thus requiring additional effort that may be constrained by lack of time (internal barrier).14 For underserved women, environmental barriers may be more problematic than for other populations, because they may influence internal and interpersonal barriers. It is likely that underserved women experience a number of barriers they may perceive as overwhelming. Because the barriers influence each other, multiple levels of intervention will be needed.
Individual characteristics, experiences, and cultural influences on barriers
Barriers to health-promoting behaviors are different for each individual. Individual characteristics, personal experiences, and cultural background influence what is perceived as a barrier along with its magnitude. Individual characteristics such as hardiness (ie, stress-resistant personality style),18 optimism, and persistence can also influence individuals' abilities and motivation to overcome barriers.
For underserved women, personal experiences such as poverty, racism, immigration, inadequate housing, family turmoil, violence, and lack of access to healthcare may contribute to stress, low self-esteem, and depression.19-21 Thus, underserved women are likely to have numerous internal and interpersonal barriers to lifestyle change that have been influenced by their life experiences. Underserved women who are chronically stressed and who may suffer from low self-esteem or depression may feel powerless to change their behavior.22
The relationship between culture and barriers to lifestyle change has not been clearly described in the literature. It is commonly accepted that health-promotion interventions should be culturally relevant17,22,23 and that healthcare professionals should be culturally competent.3,24,25 However, it is useful to avoid classifying culture as a type of barrier. This would avoid the pitfall of overgeneralizing and assuming that similar barriers apply to all members of a cultural group, thus minimizing the diversity within cultural groups.25
Barriers need to be identified from the individual's perspective rather than from the healthcare professional's perspective, thereby avoiding the incorrect assumption that culture is automatically central to the problem.26 On the other hand, it is important not to ignore the role of culture when it is central to the problem.26 Since barriers are perceived by each individual within the context of culture, daily life, and personal experiences, it would be more accurate to assess barriers from each person's point of view.
Culture influences all 3 types of barriers considered here. For example, African American women in the qualitative study by James23 perceived that eating healthy meant giving up their cultural heritage. Eating traditional cultural foods may represent comfort and a way to stay connected with one's cultural group.23 Cultural food preferences that are unhealthy (eg, fried foods) could be viewed as internal barriers. This raises the issue that some barriers may have a cultural component that needs to be acknowledged and respected. The mandate to eliminate health disparities does not include the mandate to change culture.27
To respect cultural preferences for foods that are high in energy and promote health at the same time, the healthcare provider first needs to acknowledge the importance of the cultural preference and then negotiate potential compromises that incorporate the preferred food into healthy eating. For example, recipes can be modified so that heart-healthy canola oil is substituted for lard.3 Other suggestions might be to limit portion size or the frequency with which foods high in energy are eaten.
An example of culture influencing interpersonal barriers is based on the Hispanic values of familismo in which women are socialized to sacrifice in the service of family.26 Sacrificing for the family may play out in cooking favorite traditional family foods and not wanting to inconvenience other family members by cooking less desirable, healthier foods for oneself.14 This scenario is supported by some research findings that male partners and children are not receptive to dietary changes.23
African Americans, Hispanic Americans, and American Indians are likely to live in communities where most other residents are ethnic minorities, and many of these communities face environmental barriers of access to nutritional food.28 Thus, culture may influence environmental barriers indirectly.
APPROACHES TO ADDRESS BARRIERS TO HEALTH-PROMOTION INTERVENTIONS
To provide health-promotion interventions that have a chance of eliminating health disparities, barriers must be addressed.4,10 Yet this goal assumes that healthcare professionals can control that which is uncontrollable (eg, poverty, others' thoughts and emotions). The notion that barriers to behavior change can be completely removed seems unrealistic. However, with enough resources and attention to addressing barriers, some progress might be made toward making interventions more effective.
Healthcare professionals may also fail to appreciate that factors they would classify as barriers can be desirable from the individual's perspective because they serve an important purpose. For example, in the author's pilot study on emotional eating in Mexican American women, participants talked about how food enhances mood and provides comfort. (This unpublished pilot study, titled "Emotional eating and basic need satisfaction in Mexican American women," was funded by the Center for Health Promotion and Disease Research in Underserved Populations, P30NR005051.) Recommending that women stop using food to cope with stress without helping them develop other coping strategies demonstrates a lack of empathy. Coping strategies (eg, eating, smoking, and drinking) are frequently used to escape the suffering that is common in disadvantaged environments.21 Failure to acknowledge the important purpose that the coping strategy may serve is not productive for promoting lifestyle change.
Researchers, healthcare professionals, healthcare consumers, and health policy experts need to focus attention on a variety of ways to deal with barriers so that multiple, innovative solutions can be developed. The Behavior Change Consortium, a collective of the National Institutes of Health behavior change projects, affirms that a multilevel approach to behavior change is warranted.29 This is consistent with addressing the 3 types of barriers (ie, internal, interpersonal, and environment). On the basis of literature review and qualitative research experiences with underserved women, the author identified 4 possible approaches to addressing barriers to health promotion: individualized interventions, collaborative partnerships with the community, use of positive deviance inquiry to build on community assets, and policy changes (Figure 2).
|Figure 2. Approaches to dealing with barriers to health promotion.|
Barriers to behavior change are unique to each individual and to the health behavior. The challenge is to design a health-promotion intervention that meets individual needs and addresses barriers unique to the behavior, yet is applicable to a broader population. One approach to this challenge is to incorporate strategies into the intervention that address barriers to lifestyle change and can be individualized to each participant. The "one size fits all" approach to health-promotion programs is no longer a viable concept.4 In a study examining the effectiveness of different self-care strategies for lifestyle change, participants rated being able to individualize interventions as being most important to goal achievement.30
There are 3 ways to individualize interventions: (1) interactive programming; (2) goal setting; and (3) self-care skill development.
In 6 focus groups, low-income families enrolled in the Supplemental Nutrition Program for Women, Infants, and Children recommended an interactive approach to nutrition education that might include facilitated discussion, cooking classes, and Internet resources (eg, chat rooms and Web sites).24 Interactive approaches provide an opportunity for individualizing by adapting the program to fit the individual's specific needs and address the individual's barriers. For example, if the barrier is a lack of knowledge about reading food labels, the facilitator and the participants can identify this barrier and address it through small group discussion.
Soliciting solutions from role models who have successfully overcome barriers may also be useful.24 Health-promotion information delivered through the Internet could be individualized by providing a selection of topics that could be chosen by the individual and by providing self-assessments or checklists that assess individual needs and provide the appropriate answers. One drawback to interactive health-promotion programs is that intervention fidelity becomes hard to maintain and measure, potentially reducing evidence for the intervention's effectiveness.
Goal setting within the context of health promotion can be used to increase or maintain the motivation for behavior change.31 Goal setting has consistently demonstrated the most significant intervention effect as a strategy that promotes dietary change.32 Goals set by participants can directly address barriers to behavior change. For example, if the barrier is that low-fat food does not taste good, then the goal might be: Mrs. M will identify 2 low-fat meals that taste good this week. Goals can also focus on the behavior change (eg, Mrs. M will eat 5 servings of fruits and vegetables at least 3 days this week). These goals require a plan with strategies to facilitate goal achievement that includes dealing with barriers.
Goal setting is a flexible approach that can be adapted to a variety of health-promotion program formats (eg, one-on-one counseling, small group sessions, e-mail support). Because the women are actively involved in choosing their goals and developing a plan of action to meet those goals, perceived barriers are more likely to be addressed. Goal setting has the added advantage of increasing self-efficacy as participants successfully attain goals.33
Self-care skill development
Another approach is to help individuals develop the self-care skills needed for behavior change. Individuals can learn skills such as how to set realistic, measurable goals and how to develop strategies to achieve the goals (eg, planning for barriers and addressing social support). By developing lifestyle change skills, participants would then be able to address whatever behavior change(s) they desire and tailor their health-promotion plan to their specific needs and barriers.
This self-care approach has been successfully used with college students.30 The health-promotion intervention of Stuifbergen et al30 for women with multiple sclerosis had participants set individualized goals and identify barriers to and resources for facilitating goal achievement. Most participants met or exceeded their goals at 5 months. This empowering approach provides a setting for individuals to assume responsibility for their health and facilitates their commitment to a plan of action.
One self-care skill that can be developed to address encountered barriers is problem solving. Steps in the problem-solving process include identifying the problem, generating possible solutions through brainstorming, evaluating the proposed solutions using a cost-benefit analysis approach, and trying out the solution.34 Problem-solving skills can be applied to a wide variety of barriers.
Guidelines for planning health-promotion programs, especially for underserved populations, typically include involving members of the focus population in the planning and evaluation of the program.25 Because of a lack of minority healthcare professionals, many of the healthcare professionals delivering health-promotion interventions to underserved women may have different ethnic or racial backgrounds.3 Thus, community involvement is needed to ensure that common barriers experienced by a target group of underserved women are addressed and that healthcare professionals do not inadvertently create additional barriers through cultural insensitivity. Focus groups are one method for gaining a better understanding of the targeted community.3 Employing community health workers who liaise between community members and healthcare providers is another strategy that can improve the use of health services.35
Creating a partnership between the community and healthcare professionals in which a shared vision and common purpose exist optimizes the effective use of resources.4 These collaborative partnerships are sustained through continued personal connection, respect, reciprocity, and frequent feedback.36 For example, African American participants from diverse backgrounds recommended neighborhood churches as central to health-promotion efforts.23 Incorporating churches helps programs to be perceived as trustworthy by the community and also locates programs in close proximity to their intended participants (thereby avoiding the barrier of inconvenience).
For nutrition interventions, partnering with local grocery stores, restaurants, and schools may be needed to tackle environmental barriers of access to affordable, nutritious food.23 Other local community resources (eg, farmer's markets, produce stands, food pantries) can be promoted along with information about sources of public transportation to increase access to nutritious food.37
Positive deviance inquiry
One promising approach to dealing with barriers to behavior change in underserved women is positive deviance inquiry. It identifies individuals within a community who have better health outcomes than the majority of its members and analyzes their behaviors to determine what strategies they use that promote successful outcomes. These strategies are then shared within the community.38,39 Researchers have found that those who adopted positive deviant behaviors reported facing fewer barriers to the behavior change than those who did not,40 indicating that barriers continue to play a central role in behavior change.
Positive deviance inquiry has successfully addressed preventing teen obesity and HIV transmission, and treating childhood malnutrition in developing countries.28,40 It shifts the focus of community health programs from a traditional needs-based approach to an asset-based approach. The major advantage of this paradigm shift is that it employs a community's existing resources to promote changes in behavior that are sustainable given that community's resources.39 This approach may be particularly useful for addressing those environmental barriers that center on a lack of resources. Positive deviance inquiry is addressed further in this issue by Fowles.41
Individual efforts to make healthy lifestyle change may fail if environmental barriers such as health policies do not support healthy living.4 Addressing environmental barriers (eg, poverty, transportation) requires changes in health and social policies.4 Intervention via public policy may offer a very immediate way to impact health problems such as obesity.42 Examples of public policy solutions are regulating the size of packaging in high-energy foods, improving nutrition labeling, and taxing higher energy foods.43 The advantage of policy change is that it can have a population-level effect. The disadvantage to policy change is the economic cost.
Since policy change involves governmental regulation and programs, it may not address environmental barriers that may best be handled by the private sector. Public policy cannot mandate that large supermarket chains build stores in areas with low-income households or that smaller neighborhood groceries stock fresh, affordable produce. Yet, no underlying structure exists to facilitate these types of negotiations with the private sector to overcome these barriers. This may be an area of opportunity requiring further exploration.
The problem is that barriers faced by underserved women represent a complex mix of factors about the real world that are difficult to address in any one health-promotion intervention. Without rethinking how barriers function in the lives of individual women, lifestyle changes that promote health are unlikely to be successful. Comprehensive plans for overcoming different types of barriers need to be an integral component of health-promotion interventions. As researchers and healthcare professionals sally forth in their attempts to eliminate health disparities, creative solutions are needed to address perceived barriers to lifestyle change.
The approaches to addressing barriers to health promotion proposed in this article are (1) individualizing interventions; (2) developing collaborative partnerships with the community; (3) utilizing a positive deviance approach; and (4) facilitating change in public policy. These approaches have the potential to address the multiple types of barriers encountered during lifestyle change. Yet, the lack of widely available, effective approaches to tackle the internal barriers that center on conflict between the intellectual recognition of the need for change and the emotional fight to maintain current behaviors44 will likely remain problematic for a long time. Although this article presents several approaches that are useful to reducing barriers to lifestyle change, the real intent is to stimulate a dialogue to further explore new ways to address the multitude of barriers faced by underserved women to changing eating behavior.