Barriers to Fresh Fruit and Vegetable intake among African Americans in a Southeastern City : Preventive Implications for Cardiovascular Disease

C l i n M e d International Library Citation: Stephens T, Troutman A, Johnson L, Taylor T (2015) Barriers to Fresh Fruit and Vegetable intake among African Americans in a Southeastern City: Preventive Implications for Cardiovascular Disease. J Fam Med Dis Prev 1:003 Received: April 06, 2015: Accepted: May 08, 2015: Published: May 11, 2015 Copyright: © 2015 Stephens T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Stephens et al. J Fam Med Dis Prev 2015, 1:1 ISSN: 2469-5793


Introduction
Poor dietary practices are responsible for significant mortality and morbidity in the United States [1].Poor dietary practices correlate with increased risk to cardiovascular disease [1][2][3][4].Individuals who consume high levels of dietary fat and too little fiber, and limited fresh fruit and vegetables are those most at increased risk of heart disease, stroke, and cancer [5,6].Thus fruit and vegetable intake in the United States, as well as other developed countries, is well below a sample of youth and found differences in both fruit preferences and barriers during pre-contemplation and contemplation stages.Such measures may be used to identify stage of adoption of fruit and vegetable intake and can be used to guide in the development and implementation of dietary interventions [25].In another study, the authors used social cognitive theory to test parent's fruit, juice, and vegetable practices and concluded that self-efficacy was a strong predictor of children's low fat consumption [26].
Given the aforementioned, it is understandable that the US health goals, as presented both in Healthy People 2010 and REACH 2010, is to place increased attention on reducing risk to CVD via early identification, prevention and treatment of heart attacks, strokes; and other cardiovascular outcomes [27,28].One way to accomplish this is to examine the extent to which individual barriers to fruit and vegetable consumption impact dietary behavior change among African Americans.By doing this, it may be easier to develop and implement interventions that may increase the consumption of servings of daily fresh fruits and vegetables among African Americans.Clearly, targeted efforts are required to improve the nutritional health of African Americans.Based on this premise, we undertook the current study to assess how the influence of a community-based intervention designed to reduce risk to CVDs could be effective in reducing barriers to fruit and vegetable consumption in a sample of African Americans living in a Southern City.

Description of the Target Community
The Atlanta Empowerment Zone/Renewal Community is a federally funded program that provides grants and/or loans to nonprofit or for profit organization to carry out a broad range of human services, safety, housing and economic development programs within target areas in the City of Atlanta.The City of Atlanta's Empowerment Zone is made up of 30 neighborhoods, has a poverty rate of 57.4% and population of 50,000.

Description of the Intervention
The lifestyle interventions were gender specific and covered several components regarding dietary behavior.These included: diet modification, physical activity, reduced salt intake, increased water consumption, reduced fast food consumption, increased consumption of fresh fruits and vegetables and behavioral strategies including self-monitoring, goal setting and problem solving were stressed.Participants met in small groups weekly for the first 6 months and 3 times per month for the next 6 months.These sessions utilized a standardized protocol and focused on diet, physical activity, or social support and were designed to be administered consistently across multiple locations in the AEZ and to allow maximum flexibility, given the heterogeneity of the participants.In addition, it allowed for the intervention to ensure that all participants were taught the same basic information about nutrition, physical activity, and behavioral self-management.In terms of exercise, the intervention stressed brisk walking and other examples of activity walking, including aerobic dance, bicycle riding, skating, and swimming.
Intervention sessions that targeted behavioral issues focused on the psychological, social, and motivational challenges involved in maintaining these healthy lifestyle behaviors in the long term, inclusive of ongoing identification of personal barriers to CVD ISSN: 2469-5793 risk reduction and dietary behavior change.Participants were also encouraged to increase their lifestyle activity by methods such as using stairs rather than elevators, and walking rather than riding.Additional life style intervention components included supervised activity classes, integrated in the intervention that were consistent with the overall goals of health empowerment.This included, stress management, meditation/yoga classes, and SPA days for women participants and recognizing anger as a normal human emotion, helping participants identify triggers to their anger, learning healthy verses unhealthy anger management skills for men.

Method
Data was collected from study participants at two time points: baseline and follow-up upon program implementation and completion.Baseline and follow-up data was collected via survey instrumentation from 258 participants respectively, of which 244 are included in this analysis.The data assessment instrument collected information on participant's demographic characteristics, knowledge of cardiovascular disease risk and health practices regarding physical activity and dietary behavior.Trained interviewers collected data at the intervention sites, after individuals agreed to take part in the intervention and were explained about the purpose of the study.At that time, the interviewer reviewed the data collection instrument with each participant.The instrument was written on a fourth grade reading level and pre-tested prior to actual data collection.
Data were examined with the use of SPSS software version 14.0.Descriptive statistics were employed to present a profile of the participant's demographic characteristics.Chi-square was used to discern linear associations between categorical measures of barriers at both assessment periods.All Chi Square values and associated levels of significance are reported after post-hoc test were conducted to adjust for any possible inflation due to sample size issues (to small and disparity in group category sample sizes).Specifically, Hommel's method was used because it is considered more powerful than Hochberg's [29].
In addition, regression analysis was conducted to determine the rates at which the stated barriers to fruit and vegetable consumption varied according to gender at both assessment periods.Adjusted risk ratios (RRs) with 95% confidence intervals (CIs) are presented along with associated probability values.Although there are studies that examine barriers associated with efficacious dietary practices among African Americans, none look at gender differences or employ a social cognitive framework for examination.The rational for the male and female comparisons and the use of RRs is to compare male perceptions with females, rather than to demonstrate statistical significance.This is based on the fact that gender specific groups were employed in the larger intervention portion of this investigation.Specifics pertaining to the male intervention have been reported previously in the scientific literature [30].

Measures
All Barriers to fruit and vegetable constructs were assessed in terms of consumption prior to intervention and post intervention.
Participants were asked the general question; can you please list all the reasons why you do not eat the recommended five servings a day of fresh fruits?Example follow-up probes included Fruits/ vegetables cost too much; I do not know how to choose ripe fresh fruit/vegetables; and I cannot get good fruit/vegetables at my local store.Response categories for these variables were dichotomous in the form of 1=yes and 2=no.

Findings
A detailed profile of study participants is provided in Table 1.Equal proportions of study participants indicated they were either (31%) or had never been married (34%) with 93 percent of the sample being female.Most study participants indicated they were either employed with wages (64%).The mean highest level of education completed at baseline was 11.57 years (sd=4.9).Moreover, more than 70 percent reported having health insurance with most of the participants being female (93%).The mean household was comprised of approximately three individuals and the majority of participants indicated that their total income for the last year from all sources for all household members was in the range of $20,000 to $29,999 annually.More than 50% indicated they had lived in the target community for five years or more.
Using a chi-square analysis, we found that several barriers were problematic to dietary behavior change related to increasing fresh fruit and vegetable consumption among the target population.Table 2 shows an additional comparison of the distribution of barriers to fresh fruit consumption over the two periods.There was an overall group difference in barriers to fresh fruit intake over the assessment periods for six items.Participants reported increases in barriers that were associated with economic factors including fresh fruits costing too much (p<.05) and having to purchase fruits every few days (p<.001).Additional barriers that seemed to increase in significance to participants at the follow-up period were the length of time it takes to prepare dishes with fresh fruits (p<.009), reporting that their families did not like eating fresh fruits (p<.004) and having problems digesting them (p<.05).Similar findings were observed with respect to barriers to fresh vegetable consumption.Cost (p<.011), spoiling too quickly (p<.019), not being able to get them at their local store (p<.011) and having to purchase vegetables every few days were barriers that seemed to become more problematic over the intervention period (Table 3).
Additional personal factors that appeared to be more of a concern after the intervention included not knowing how to select ripe vegetables (p<.033), having trouble digesting vegetables (p<.016) and families eating fresh vegetables too fast (p<.002).Table 4 presents baseline and post-intervention data regarding self-reported barriers to fruit intake by gender.At baseline Females were 2.3 times more likely than males to indicate that fruits spoiled too quickly (RR 2.3; 95% CI .69,7.8).Females were 1.2 and 1.3 times more likely than males to state that their families did not like fruit (RR 1.2; 95% CI .31,4.6) or that they could not get any god fruit at their local store (RR 1.3; 95% CI .38, 4.4).The analysis also revealed that buying fresh fruit every day (RR 1.5; 95% CI .50,4.8) and that there is too much waste with fresh fruit as being major barriers to consumption (RR 1.5; 95% CI .45,5.3).Other noted barriers to the consumption of fresh fruit included families consuming fruit to fast (RR 1.4; 95% CI .40,5.0), not knowing how to select ripe fruit (RR 1.4; 95% CI .40, 4.6).
At post-intervention, the rate of indicating fruits spoil to quickly was reduced but still reflected women being 2.1 times more than men to suggest this as a barrier (RR 2.1; 95% CI .54,7.9).However, the intervention appeared to have some impact on getting participants to understand that planning may be involved in order to work fresh fruit into their diets (RR 1.9; 95% CI .57,6.8).
Barriers to fresh vegetable consumption were not as prevalent at baseline assessment as presented in Table 5.In fact participants were more likely to indicate that there was too much waste with fresh vegetables (RR 1.3; 95% CI .38,4.4) or that they did not have the skills required to select fresh vegetables (RR 1.2; 95% CI .35,4.0).Post intervention analysis suggests that most barriers were associated with factors aligned with economic circumstances also.For example, needing to purchase fresh vegetables every few days (RR 2.2; 95% CI .71,6.8) and being unable to get fresh vegetables at their local store (RR 1.8; 95% CI .57,5.8) were determined to be significant barriers to the consumption of fresh vegetables.In addition, female participants were 1.2 and 1.4 times more likely than men to state fresh vegetables cost too much and that they take too long to prepare respectively.Other variables in which females indicated higher proportions when compared to men included their family eat vegetables too fast (RR 2.0; 95% CI .61,6.6) and that they have to plan to include more fresh vegetables in their diets (RR 1.4; 95% CI .41,4.4).

Discussion
Our findings suggest the importance of understanding environmental factors and their impact on fresh fruit and vegetable consumption among African Americans.When asked what prevented them from consuming more fresh fruits and vegetables daily, study participants indicate that several factors associated with economics were the most problematic.In addition, the document the difficulty interventions designed to reduce risk to CVDs have when dealing with behavioral factors that appear to be a function of economics as  with the barriers to fresh fruit and vegetable consumption outlined in this paper.Our findings support the observation of many others how note how financial issues can be major barriers to behavioral change associated with dietary practices, especially among underserved and racial/ethnic populations [31][32][33][34][35].
In our study, cost and having to purchase fresh fruit and vegetables every few days was mentioned consistently as a barrier to healthier eating.In fact, cost came up more often than any other barrier with the exception of skills such as being able to prepare fresh fruits and vegetables and being able to select ripe produce.What is evidenced by this study is that interventions that are designed to increase participants' capacity for behavioral change must account for various preconceptions regarding the efficacy of existing behaviors.As observed from the comparison of the baseline and postintervention survey results regarding barriers to fruit and vegetable intake, many people living in the AEZ considered their behavior to be appropriate and did not recognize the risk factors associated with them.Participants generally considered their attitudes toward fruit and vegetable intake to be sufficient.
Post-intervention results indicate that the attitudes of the participants began to reflect the presence of significant barriers to fruit and vegetable intake.Implications are that the economic opportunity costs associated with the perish ability of fruits and vegetables compared to foods with longer shelf lives might be a barrier to consumption.There also is an indication of resistance within the household to shift in dietary patterns required for the effective introduction of fruits and vegetables as regular staples.In addition, perceived constraints associated with the amount of preparation time required to incorporate the necessary amount of fruit servings into the household diet too could act as a barrier to their inclusion.Moreover, healthy lifestyle and healthy eating choices are minimally supported thorough media and culture in African American communities.The success of planned intervention programs toward the adoption of lifestyle modifications is a condition of the ability of the sample population to accept that negative association between current behavior patterns and the risk factors that contribute to the prevailing health disparities.
Even with increased knowledge about risk factors and improved treatment options, heart disease remains the leading cause of death in the U.S. and will likely become an even greater public health concern in the future.However dire the statistics, heart disease is largely preventable and is not an uncontrollable aspect of aging.Because many heart disease risk factors may be managed through lifestyle modification, public education directed at altering personal behaviors remains the most effective strategy for reducing disease risk.Our findings suggest that targeted action can play a key role in enhancing members in the targeted local communities to improve health and reduce risk to CVDs.Aiming at health advocacy through the promotion of skills development by the local population, mostly via the use of community organizations, this approach has proffered to be an effective local level mechanism to tackle the health threats in these communities.REACH efforts not only help jump-start the preventive health activities in the target area but can also play an important part in politically bringing to the table other issues pertaining to health and education.In basic terms, the partners note that improvements need to be made regarding enhancing participants or the target audience's level of interest in correcting problematic health behaviors.
Several limitations of this study should be noted.First, the data are all self-reported measures and not observed behavior.Given this, it is difficult to discern the extent to which statistically significant changes in barriers found in this study represent real changes in consumption patterns.Consequently, more research that uses measures of directly observed behavior would serve to confirm the findings of this study.Another major limitation of our study pertains to sample size, specifically the small sample size of the male group in contrast with the females.Research notes that many behavioral studies may be influenced by the presence of confounding variables [36].Consequently, larger sample sizes are preferred since confounding variables must be controlled for in the analysis.Thus a more complex statistical model may have been required, albeit our goal was compare the ranges of males versus females.Moreover, the value of the statistical significance depends on the standard error of the estimator and the power of the study.Therefore, given the smaller male sample size, our level of power is severely decreased, thus our findings may reflect such in the resulting risk ratios and 95% CIs [37].This has been reported to occur because Logistic regression overestimates odds ratios in studies with small to moderate samples size by inducing systematic bias in a direction away from the null hypothesis away from null (odds ratios shift away from one) [38].
Lastly, this study was not designed to find the relative impact or collect measurable outcome data about the specific trends in the economic environment of the study population, which means we cannot state actual causation with respect to findings.
The consistency of barriers and their impact on fresh fruit and vegetable consumption suggests that it will be very difficult to reduce barriers via health empowerment interventions that target vulnerable populations [30].It is also possible that another reason for the slight differences noted between men and women in our study may be a function of social roles.It well supported that women are more likely than men to be responsible for both preparing and purchasing food for their households [39,40].Moreover, some have asserted that among African American and other minority communities that perception that 'eating healthfully' might be understood as giving up part of one's cultural heritage and/or trying to conform to the dominant culture [41].
Our findings also note how economic and situational circumstance can influence health behavioral change even when interventions are designed to do such.For example, during the period of this investigation, gas prices roses in the target community by more than $1.00.Such an increase will also be incurred at the grocery store and on other necessities required for living including increased cost for bus and rapid transit passes.
Because of the many barriers these patients face, interventions must address how they can improve the socioeconomic status of participants in reference to their environment.This was documented in several recent studies including one examining the extent to which perceived barriers as a construct in Social Cognitive Theory influenced dietary behavior changes among a sample of 1,011 African Americans recruited from 14 churches in Georgia [42].
In closing, disparities in CVD risk and health outcomes in general will continue to prevail if health policy does not focus on the economic impact on the level of disparity in ethnic/racial communities and the barriers they create.This suggest policy focus on expanding the reach of health empowerment interventions that focus on CVD risk reduction via dietary behavior change among racial/ethnically diverse populations as well as economic enhancement and wealth creation.

Table 2 :
Chi-Square Results for Barriers to Fresh Fruit Consumption.

Table 3 :
Chi-Square Results for Barriers to Fresh Vegetable Consumption.

Table 4 :
Risk Ratios (RR) and 95 Percent Confidence Intervals for Barriers to Fruit Intake based on Gender at Baseline and Post intervention.

Table 5 :
Risk Ratios (RR) and 95 Percent Confidence Intervals for Barriers to Vegetable Intake based on Gender at Baseline and Post intervention.