African Americans and members of other minority groups are disproportionately affected by overweight and obesity [1
]. Recent data suggest that, although obesity rates in the US have stabilized in the general population, rates of obesity continue to increase among minority groups, specifically non-Hispanic black women and Mexican American women [3
]. Obesity rates are highest among African Americans, affecting 45.0% of non-Hispanic Blacks, as compared to 36.8% of Mexican-Americans, and 30.6% of Whites [5
]. Half of African American women and 37% of African American men are obese [6
]. African Americans also have one of the lowest rates of physical activity among all ethnic groups in the US [7
] and are also 38% less likely to meet recommendations for fruit and vegetable consumption as compared to White Americans [9
]. Understanding the factors that contribute to these disparities in health and health behaviors is an important part of developing effective preventions. (Note that, in this paper, we use the term “health behaviors” to refer to the broad range of behaviors related to food intake and physical activity.)
It is widely recognized that culture can shape people’s food intake and physical activity [10
] because culture represents set of values, social norms, traditions, and ways of doing things and engaging with the world that are transmitted across generations and influence behaviors [13
]. In particular, culture shapes health related values, norms, beliefs, and behaviors through people’s connection to their social and physical environments [14
]. Given that individuals’ social and physical environments change, the influence of culture and culture itself can change as well. Thus, it is also important to recognize that culture embodies not only fixed but also fluid qualities [13
]. Some aspects of culture are fixed (e.g., the collectivistic or individualistic focus of a given culture) in that they are transmitted over generations, but other aspects are fluid in that they evolve as the social environment becomes increasingly diverse (e.g., culturally preferred foods that evolve as immigrants come and bring their “own culture” to an existing culture) [15
Most research in the area of culture and health has focused exclusively on the influence of individuals’ ethnic culture on their health behaviors [16
]. Here we consider ethnic culture to reflect a group of individuals of the same ethnic background sharing similar values, norms, and engaging in similar practices or behaviors. For instance, Airhihenbuwa et al. [16
] explored African Americans’ perceptions about positive and negative cultural food practices and the contexts in which they occur. Their participants reported that, not only does ethnic culture affect individuals’ food choices, but culture also influences how the food is prepared and the context in which it is consumed by creating social norms surrounding these practices.
In addition to exploring the influence of individuals’ ethnic culture, the health practices of African Americans also need to be also considered in the context of their mainstream culture (i.e., the most popularized or typical beliefs, norms, and practices—including health related trends surrounding food intake and physical activity—common within American culture). Because African Americans belong to both their ethnic and mainstream cultures, they are exposed to two sets of cultural norms surrounding food intake and physical activity. These multiple cultural norms can potentially have positive or negative influences on individuals’ health behaviors. The negative influence is related to the idea that norms of different cultures can be in conflict with each other. Given that cultural norms affect health behaviors, bicultural groups, such African Americans, may be simultaneously exposed to discrepant cultural lifestyle-related norms, and these norms may adversely affect their food intake and physical activity. A few previous qualitative studies explored the relationship between cultural norm discrepancy and health behaviors [18
]. For example, in one of these qualitative studies, participants reported feeling conflicted between culturally informed eating habits, body size image, and mainstream culture dietary guidelines [21
]. Such conflicting norms can contribute to poor health behaviors [11
]. For example, they may confuse individuals with regard to what constitutes healthy lifestyle and make it more difficult for them to actually follow any of the norms promoting healthy behaviors that each culture has to offer. Furthermore, the confusion caused by conflicting norms might itself trigger inaction. The exact processes involved in cultural norm conflict and health behaviors, however, are yet to be identified.
There is also a potential positive influence of ethnic and mainstream cultures on one’s health, and this is related to the idea that bicultural individuals may have more access to, and more knowledge about, health behaviors that are valued in each of these cultures and that shape their health practices. To date, however, there is very little research examining the ways in which African Americans perceive positive aspects of both cultures influencing health and the ways in which they can capitalize on health enhancing qualities of each culture. Thus, it is important to expand the exploration of culture on health and health behaviors by examining the simultaneous influence of African Americans’ ethnic and mainstream cultures, particularly in terms of the positive factors contributing to better health.
The idea that belonging to two different cultures can positively influence one’s actions, such as health behaviors, is supported by research on Bicultural Identity Integration [16
]. According to this construct, exposure to two cultures provides people with an opportunity to learn and benefit from their rich cultural environment [17
]. Embracing both parts of one’s culture can enhance people’s lives [18
]. For instance, bicultural identity integration was found to increase individuals’ creativity [20
] and their wellbeing [18
]. In the context of health, exposure to two cultures affords individuals two sources of information about health trends and practices common in each culture, and these different sources of influence can shape individuals’ own health behaviors. For example, one can be exposed to behaviors common in mainstream American culture such as the trend toward healthy eating, and behaviors common in ethnic African American culture such as consuming foods at home with one’s family. As a result, individuals can have a broader range of healthy behaviors to choose from while pursuing their healthy lifestyle. These potential benefits of being exposed to two cultures highlights the value in examining the simultaneous influence of African Americans’ ethnic and mainstream culture on their health behaviors.
Of course, the influence of culture on individuals’ health behaviors cannot be separated from their immediate social context and broader physical environment [12
]. For example, research has shown that, because African Americans value collectivism and togetherness, family and friends play an important role in shaping their health behaviors [27
]. Furthermore, the health behaviors of African Americans are often the result of health and economic disparities among this cultural group. African Americans (and many other minority groups) are disproportionately more likely than White Americans to experience factors such as compromised access to healthy food [29
], limited access to safe places for physical activity [31
] and low affordability of healthy foods [32
], and these factors can impact their likelihood of engaging in health behaviors. Thus, the health behaviors of African Americans need to be examined in the context of personal factors, individuals’ immediate social environment, and their physical environment [33
The Present Study
There are a few gaps in the previous research on culture and health that the current study attempted to address. First, previous studies have focused on the relationship between culture and African Americans’ health behaviors only in the context of African Americans’ ethnic culture [11
]. These studies did not take into account the simultaneous influence of individuals’ mainstream and ethnic cultures on their health practices. Given that African Americans are simultaneously exposed to both their ethnic and mainstream American cultures, the present study examined the role of both cultures in individuals’ food intake and physical activity.
Second, there are relatively few studies directly examining the interplay between culture and other psycho-socio-environmental factors that collectively affect individuals’ health practices [11
]. Because the opportunities to engage in healthy behaviors among African Americans depend on the myriad of interconnected personal, social, and environmental factors, the present study explored the influence of culture on African Americans’ food intake and physical activity in the context of these factors. Adopting a qualitative methodological approach can help develop a richer understanding of the role of culture and other psychological, social, and environmental factors in African Americans’ health behaviors [11
Third, most recent studies have focused exclusively on unhealthy norms related to food intake and physical activity, omitting the healthy aspects of individuals’ cultures. This approach represents a “deficit model,” which, according to previous research, can be counterproductive in health promotion programs [36
]. Therefore, in addition to the examination of health compromising (or unhealthy) factors connected to individuals’ cultures, the present study focused predominantly on healthy behaviors from both cultures that may optimize African Americans’ health and explored how receptive African Americans are to the idea of picking and choosing
healthy behaviors from their ethnic and mainstream cultures as a means of optimizing their health.
The specific goals of the present qualitative study were to examine: (1) what is the role of people’s ethnic and mainstream culture in shaping their health behaviors; (2) how do individuals perceive the idea of picking and choosing healthy behaviors from their ethnic and mainstream culture to optimize their health; and (3) what psycho-socio-environmental factors optimize the positive influence of culture on African Americans’ food intake and physical activity?
The present study explored: (1) the role of people’s ethnic and mainstream cultures in shaping their health behaviors; (2) how individuals perceive the idea of picking and choosing
healthy behaviors from their ethnic and mainstream culture to optimize their health; and (3) psycho-socio-environmental factors that optimize the positive influence of culture on African Americans’ food intake and physical activity. The findings illustrate the importance of both ethnic and mainstream cultures in African Americans’ food intake [11
] and physical activity [17
]. In particular, the present study found that African Americans position both their ethnic and mainstream culture as important influences on their health behaviors. Thus, the present findings extend previous research by highlighting the simultaneous influences of both African Americans’ ethnic culture and mainstream American culture on their food intake and physical activity and by emphasizing the importance of taking the advantage of “the best of both worlds” (that is, combining cultural and mainstream approaches to health).
With respect to their ethnic culture, and consistent with previous research, participants often mentioned resilience [33
], reliance on spirituality [11
], dance and music [43
] and social support [28
] as important health-enhancing qualities endorsed in their African American culture. In contrast, traditional “soul food” cuisine was reported as one of the most important cultural factors that compromises healthy food intake within African American communities [43
]. This finding may explain why preparing healthy makeovers
of some of the less healthy traditional African American dishes appealed to participants in the present study. The importance of healthy makeovers
identified in this study is consistent with previous research [11
] and suggests that African Americans may embrace the idea of preparing healthier versions of some of the unhealthy traditional dishes in order to improve their health yet maintain connect with their cultural traditions.
With respect to individuals’ mainstream culture, participants indicated that “healthy lifestyle trends” popularized within their mainstream culture and the importance placed on physical activity are two the most important salutogenic qualities of their mainstream culture. In contrast, and consistent with previous research [44
], the experience of discrimination within one’s mainstream culture was reported as one of the biggest health compromising factor. All these findings suggest that ethnic and mainstream cultural norms and behaviors around food intake and physical activity can be important in shaping African Americans’ health behaviors.
Given that African Americans belong simultaneously to their ethnic and their mainstream cultures, the current study also examined individuals’ reactions to the idea of picking and choosing
, that is incorporating the healthy elements of both cultures into their lives. Most participants reported engaging in picking and choosing
healthy behaviors related to food intake and physical activity from both cultures to which they belong. They also perceived picking and choosing
these behaviors as a way to optimize their health. The potential benefits of incorporating normative behaviors from one’s ethnic and mainstream cultures is consistent with the concept of Bicultural Identity Integration [22
], which is associated with greater wellbeing, creativity, problem solving, and coping strategies [23
]. In the context of current study, one possible explanation as to why engaging in behaviors from both cultures may be beneficial for African Americans’ health is that doing so provides individuals with a wider range of health behaviors to choose from as opposed to relying on just one source of information about health and wellbeing. Belonging to more than one culture exposes individuals to a broader range of norms, values, and beliefs on the basis of which they can govern their behaviors [13
], including their health behaviors.
There are also a variety of practical considerations (environmental and personal factors) that participants described as influencing their opportunities to engage in healthy behaviors from both cultures. Consistent with previous research, participants in the current study reported that affordability [45
], access to healthy food [30
], health knowledge [46
] and personal factors [47
] are important in determining African American’s health behaviors. The current study, however, builds on previous research by examining these psycho-socio-environmental factors in association with individuals’ ability to incorporate healthy behaviors from both their ethnic and mainstream cultures (i.e., to pick and choose
and to consume healthy makeovers
of unhealthy dishes). For example, the willingness to consume fruits and vegetables, which are heavily promoted within mainstream culture, depends on a proper access to these types of foods. This finding suggests that the influence of ethnic and mainstream culture on African American’s health behaviors should be examined in the relation to their broader psycho-socio-environmental context (consistent with ecological models of health behaviors, such as the PEN-3 model [10
The results of the present study may have some implications for planning and designing health promotion programs for African Americans. First, the fact that participants show favorable attitudes toward picking and choosing
and toward healthy makeovers
suggests that they are open to taking advantage of healthy behaviors promoted in both their ethnic and mainstream cultures. Although there is the potential for both positive and negative influence of ethnic and mainstream cultures on health, these findings further suggest that health interventions could focus on positive health enhancing behaviors already celebrated within individuals’ cultures [12
], rather than focusing solely on eliminating health-compromising behaviors. Shifting from a deficit model to a strength-based model empowers ethnic minority groups and validates their experiences without unnecessarily pathologizing their health practices [16
]. Of course, research is needed to determine the extent to which incorporating practices from both cultures (including picking and choosing
and consuming healthy makeovers
) is an effective means of improving the health and wellbeing of African Americans. Additionally, given that cultural practices and norms can be in conflict with one another and contribute to unhealthy behaviors surrounding food intake and physical [18
], future studies should simultaneously examine the impact of positive cultural influences, negative cultural influence, and cultural conflicts on individuals’ health behaviors.
Second, by providing an opportunity for individuals to decide which behaviors are important to them, the picking and choosing
approach resembles the “cultural tailoring” framework of health promotion [14
]. This health promotion model is directed toward individuals and cultural subgroups, and acknowledges within-culture differences among people, taking into consideration personal choices and preferences. The autonomy and freedom to make a choice is one of the most fundamental human needs affecting individuals’ performance, relationships, and wellbeing [48
]. Being able to make a choice increases individuals’ intrinsic motivation and self-efficacy, which further enhance adherence to behavioral change goals [50
]. Overall, having the opportunity to choose health behaviors that individuals want to pursue is gratifying, desirable, and important from health promotion perspective.
Third, there were a number of psycho-socio-environmental factors that were associated with the likelihood of picking and choosing
. Targeting these factors in health interventions for African Americans could potentially increase the effectiveness of these interventions. For example, health promotion programs could design interventions that teach individuals how to select or pick and choose
healthy behaviors that both of their cultures have to offer. Such a self-efficacy building approach to health promotion is empowering, and fosters ownership of individuals’ behaviors, which can further increase the likelihood that they will engage in a variety of healthy behaviors [52
Finally, the effectiveness of tailoring dietary messages may depend on individuals’ connection to their cultures [53
] as well as on differences within the culture [54
]. For African Americans, this means that their willingness to pick and choose
health behaviors from their ethnic and mainstream cultures, and their willingness to consume healthy makeovers
, could depend on their level of connection to both their ethnic and their mainstream cultures. As Kreuter et al. [54
] noted, African American culture does not comprise of a monolithic cultural milieu, and people’s relationship to their culture can vary [54
]. Therefore, health promotion programs for African Americans need to consider these variations and individuals’ connections to their culture in the design and delivery of effective health promotion programs. For instance, in order to optimize the effectiveness of such programs, the focus and the content of health intervention can be tailored to individuals’ level of connection to their ethnic and mainstream cultures. Moreover, these programs should also target personal factors such as motivation for leading healthy lifestyle because these factors are potentially important in triggering healthy behaviors.
Although this study revealed some important insights regarding African Americans’ food intake and physical activity, there are some limitations that should be considered. First, the convenience sample consisted of African American students or alumni from Columbia University, or community members predominantly living in the Columbia University area. The sample is, therefore, not representative of the entire African American population. Living in an urban area as opposed to in the rural community can affect African Americans health behaviors differently. For example, these two groups may differ substantially in their access to healthy food and recreational spaces, as well as socio-economic status affecting their health behavior choices. Second, the participants in the study consisted of predominantly educated individuals, and mostly women. Interviews with individuals representing different educational levels and with more men as well might have yielded different conclusions given that both of these characteristics can affect food intake and physical activity. Third, the way participants perceive their African American culture and their mainstream culture may be tied to their level of education and their socioeconomic status, which were relatively high among the research participants in this study. Individuals with higher socioeconomic status might be more connected to their mainstream culture and therefore more willing and able to engage in healthy lifestyle practices common in their mainstream culture. Unfortunately, we did not collect comprehensive demographic and socioeconomic data, which limits our ability to fully understand the sample characteristics and how they relate to participants’ responses. Therefore, future studies should clarify how socioeconomic status affects African Americans’ perceptions of food intake and physical activity common in their ethnic and mainstream cultures. Fourth, most questions designed for this study explored participants’ perceptions of other African Americans’ health behaviors in the context of their ethnic and mainstream cultures; many fewer questions addressed participants’ perceptions of their own behaviors. Because different processes can be involved in perceiving one’s own versus others health behaviors, it would be important for the future research to distinguish these two types of views—of one’s own beliefs and behaviors and those of others. Finally, in terms of our conceptualization of the influence of culture on individuals’ food intake and physical activity, the current study has focused on only two dimensions of this influence (i.e., barriers and facilitators of healthy lifestyle). The rationale for this choice of dimensions is that it reflects the study’s research questions; it has not been examined before in the context of individuals’ ethnic and mainstream cultures; and it has implications for health promotions programs. However, there are many other ways in which the influence of African Americans’ culture on their food intake and physical activity could be conceptualized, and future research would benefit from exploring those dimensions. Despite these limitations, the present research contributes to broadening the understanding of how African Americans make sense of their own experiences in relation to food intake and physical activity.