526204 research-article2014
HPPXXX10.1177/1524839914526204Health Promotion PracticeKeller et al. / Addressing The Demand for Cultural Relevance in Intervention Design
Cultural Competence
Addressing the Demand for Cultural Relevance in Intervention Design Colleen S. Keller, PhD1 Kathryn Coe, PhD2 Nancy Moore, PhD1
This article describes the development of a model to promote physical activity in Hispanic women that embeds a life course perspective and culture to enhance comparative effectiveness in intervention design. When working with diverse cultural groups, researchers often struggle with intervention designs and strategies to enhance cultural relevance; they do so based on the assumption that this will enhance efficacy and make interventions more sustainable. In this article, the authors discuss how the model was used in two interventions designed for younger and older Hispanic women. These interventions were guided by a life course perspective, incorporated social support, and included salient elements from the women’s culture. Three considerations underpinned the development of the model: (a) infusing concepts and values of a culture and tradition into the interventions, (b) viewing participants through a life course perspective to assess how an intervention can build on developmental transitions, and (c) determining how social support operates within two groups that, although sharing history and thus some cultural practices, diverge widely in those practices. The authors propose that by incorporating elements of this model into their interventions, researchers can increase program efficacy and effectiveness. Keywords: intervention design; Hispanic women; social support; physical activity; culture; life course perspective
Health Promotion Practice September 2014 Vol. 15, No. (5) 654–663 DOI: 10.1177/1524839914526204 © 2014 Society for Public Health Education
Introduction >> In Hispanic women, obesity is a particular concern, with 78% of Mexican American women overweight or obese, compared with 60.3% of non-Hispanic White women (U.S. Department of Health and Human Services, 2012). Although limiting energy intake is important, increasing physical activity (PA) has been used successfully to manage weight across the life span. However, despite the known benefits of PA, 46% of Hispanic women of all ages report no leisure time exercise (McGruder, Malarcher, Antoine, Greenlund, & Croft, 2004). In this article, we discuss the rationale underpinning the development and implementation of two interventions, Madres para Su Salud (Mothers for Health, hereafter referred to as Madres) and Mujeres en Acción por Su Salud (Women in Action for Health, hereafter referred to as Mujeres), designed to increase walking and reduce body adiposity among Hispanic women. These innovative interventions reflected, through formative work and continued participant cultural review factors salient to women, critical transition, life stages and cultural values. Toward that end, a new model, illustrated here (Figure 1), was developed that embedded social support, a life course perspective, and cultural elements, all of which may be critical 1
Arizona State University, Phoenix, AZ, USA Indiana University–Purdue University, Indianapolis, IN, USA
2
Authors’ Note: Funded by NIH/NINR 1 R01NR010356-01A2 (Madres para la Salud (Mothers for Health) and NIH/NINR 1 R21 NR010126-01A1 (Mujeres en Acción: Walking in Hispanic Women). Address correspondence to Colleen S. Keller, Center for Healthy Outcomes in Aging, College of Nursing and Health Innovation, Arizona State University, 500 N. Third Street, Phoenix, AZ 85004, USA; e-mail: [email protected].
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Older women: Increased traditionalism may manifest as increased stress during postmenopause if family members no longer honor those traditions. Older women may experience increased stress due to more kinship obligations (e.g., with grown children, grandchildren, and partners) and other changing relationships, while having to deal with less social support, which may lead to weight change.
Younger women: In reproductive period, fat stores before and during pregnancy protect fetus. Women likely to maintain weight gain, particularly when cultural values encourage rounded figures and when family urges eating well and resting during pregnancy. Women may have heightened stress due to more childcare obligations while having to maintain kinship ones.
Personality & Developmental milestones
Machismo and marianismo: Hispanic women are socialized to place an emphasis on male as protector/female as nurturer and moral guide.
Colectivismo: Hispanic women are socialized to participate in a social system that is cooperative & to value social interdependence.
Personalismo: Hispanic women are socialized to consider friends to be a source of strength as well as information.
Familismo: Hispanic women are socialized to sacrifice and work for the benefit of the family by exhibiting altruism, generosity, & strong loyalty. Church replicates kinship model and requires same loyalties, etc.
Respeto: Hispanic women are raised to understand hierarchies and their place in hierarchical relationships and to respect authority figures.
Culture or Traditions Respecto: One end: Valuing and being comfortable with people of different ages. Opposite end: Valuing decisions made by others more than valuing one’s own decisions or ability to make decisions. Social skills: One end: Finding it easy to engage in activities involving others (manifesting personalismo). Opposite end: Tending to stay involved or spending more time being social than in other types of activities that also may be important. Altruism/Simpatía: One end: Being willing to help others who need help and working to get other involved (manifesting colectivismo). Opposite end: Helping others at the expense of one’s own health (possibly manifesting negative aspects of familismo, if family discourages PA). Machismo and marianismo: One end: Fulfilling traditional roles in the family (e.g., for male, engaging in behavior that protects family; for female, being committed to children and the vulnerable). Opposite end: Being overprotective (for males), thus inhibiting activities; being likely to acquiesce (for females).
Two Ends of the Continuum: Social Application & Effect
Figure 1 A Traditional Woman: Maintains Behaviors Inherited From Ancestors, Through Parents
Environment, including physical and social
Biology, including Genes
Design elements minimizing perceived negative effect: Anticipate that some aspects of a culture or environment could dampen achievement of desired outcomes • Sessions discussing such potential cultural impediments such as the influence of machismo in their lives and their ability to engage in PA. • Problem-solving the effect of multiple family obligations (e.g., taking children to school, an issue especially for younger women). • Aids such as maps to help women plan safe walking routes; walking in groups also to help them feel safe and thus promote PA and social support.
Design elements enhancing positive social effect: Build on sources of support • Promotoras who facilitated and reinforced group persistence and overcoming barriers. • Time management as specific strategy to help women (especially younger women) find time for PA. • Training and booster sessions to help women articulate specific weight-loss goals and motivations (e.g. be attractive to husband and be well for families for younger women; enhancing companionship and caregiving for older women). • Role-playing of support during walking sessions. • Pedometers, maps, weekly calendar as ways to measure and share progress.
Intervention
in intervention development across many diverse women. Three considerations underpin this model: (a) infusing concepts and values of a culture and tradition into the interventions, (b) viewing participants through a life course perspective to assess how an intervention can build on developmental transitions, and (c) determining how social support operates within two groups that, although sharing history and thus some cultural practices, diverge widely in those practices.
Background >> The Role of Culture and Tradition: Social Support Despite important biological similarities among all women across the life trajectory, there are other important differences, often related to culture. Researchers recognize that individuals who are members of different ethnic groups will diverge in significant regards and that culture involves shared, not idiosyncratic, behavior. As Kreuter, Lukwago, Bucholtz, Clark, and Sanders-Thompson (2003) suggest, the issue is to identify, in any distinct population, the visible expression of shared values, namely, the behavior. As anthropologists have long noted, although there are variations in culture, the heart of any culture is kinship. The value of kinship, or familism, in the case of Hispanic women, can be observed as activities devoted to care and nurturing of the family. However, it also can be seen in the expansion of kinship relationships to nonkin who are referred to using kinship terms (e.g., sister, brother) and often treated as if they were close kin. The point here is that social support is often associated with a kinship model—when kinship terms are used either actually (to refer to biological kin) or metaphorically (e.g., calling friends “sister” or “mother”), those social relationships tend to be very supportive (Coe, 2003; Coe & Keller, 1996). Indeed, a curious feature of humans is that we regularly associate different kin terms with different roles and responsibilities. A mother does not and is not expected to behave the same way that a sister or aunt does. However, both mothers and aunts are expected to provide social support. Social support from family and friends has been positively related to initiating and maintaining PA across races and ethnicities; it is the most commonly reported correlate to higher levels of PA for Hispanic women (Barrera, Toobert, Angell, Glasgow, & Mackinnon, 2006; Van Duyn et al., 2007). Among Hispanic women, interviews show that demands for social support (e.g., overwhelming family responsibilities), a lack of an effective structure for support (e.g., for child care), and poor
time management are the most significant barriers to engaging in PA. Strengthening supportive social resources would enhance PA by ensuring that a woman could exercise while still managing to meet other obligations (Gonzales & Keller, 2004; Martinez, Arredondo, Perez, & Baquero, 2009). Traditions teach kinship terms and outline associated duties and responsibilities. A woman’s current values are, in the case of many Hispanic women, still built on core traditional values that are deeply embedded in her consciousness and practices. These values play a role in guiding activities of daily living, including daily practices of PA, and despite acculturation, values are transmitted through behavioral modeling to the next generation of kin (Coe, 2003). These traditions also guide all social interactions, the type and quantity of social support a woman feels that she needs (and indeed does need), and the support she feels an obligation to provide and to whom she needs to provide it. Modernization, migration, and experience living in a historically and predominately non-Hispanic culture are events that are rapidly transforming the traditional culture of Hispanics. As many traditions have been lost through the process of acculturation, program planners often are uncertain what, if any, focus should be placed on traditional culture and the values at its foundation. The important point is that through the interplay of multiple factors, Hispanic women, like all women, are continually reconstructing their ancestral traditions (Castro, 1997). Evidence indicates, however, that although change does occur, traditions continue to shape both Hispanic women’s social organization, which is still built on a kinship model, and their behavior, which is influenced by deeply held, and less likely to change, traditional values of familism, altruism, and duty to others, especially to kin (Castro, 1997). Traditions, therefore, cannot be ignored when developing any intervention for Hispanic women, particularly if that intervention is built on social support. Culturally tailored interventions reflect and address unique participant characteristics (Kreuter et al., 2003). The design of culturally tailored interventions has two critical requirements: (a) that cultural tailoring be developed based on clear and salient constructs relevant to the culture, especially kinship, and (b) that both constituent-involving and sociocultural strategies be deployed to encase interventions in the context of cultural values and characteristics (Kreuter et al., 2003). Life Course Perspective In the development of interventions for either young women, who are in the reproductive stages of life, or
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older women, who have completed menopause, a life course perspective is important as it places a focus on transitions across a woman’s life span. This perspective suggests that numerous factors converge at passage points such as childbearing (as fat storage and fertility are linked in human females; Power & Schulkin, 2007) and menopause (related to a relatively sedentary lifestyle in modern populations), which contribute to weight accumulation in women (Keller et al., 2010). Furthermore, an understanding of human development over the life span and knowledge of the way biology and the environment interact offer a research and research application paradigm that can be successfully used to promote healthy development not only over a lifetime but also across generations (Fine & Kotelchuk, 2010). This emerging paradigm can guide the development of interventions that address critical periods in development during which interventions can be more effective and focus on risk and protective factors that may have cumulative and long-term effects (Fine & Kotelchuk, 2010). The model we developed embedded two distinct developmental transition times, pregnancy and perimenopause. Because of contextual factors that surround adjustment to the transitions, these times can contribute to a woman’s weight gain, retention, and engagement in PA. Childbearing can be an important contributor to the development of obesity. Although a moderate weight gain supports the development of the large and expansive brain of the fetus and helps prepare the woman’s body for meeting the demands of pregnancy and lactation, pregnancy weight is often retained for a lifetime and may contribute to obesity-related risks and diseases (Asbee et al., 2009). Furthermore, postmenopausal women often put on weight, as they are more likely to engage in a sedentary lifestyle (Duval et al., 2013). The interaction among many contributing factors likely determines an individual’s propensity for excess energy intake, sedentary behavior, patterns of fat distribution, and risk of developing obesity. For some older women, in addition to the social and biological changes associated with menopause, changing relationships with parents, children, and partners can be disruptive to well-being during midlife. As women age, they change their investment in their families and their occupations and begin undertaking activities as such assuming child care responsibilities for grandchildren. These changes not only can contribute to overweight and obesity, because being distressed can change health behavior (Keller et al., 2010; PerrigChiello, Hutchison, & Hoepflinger, 2008), but also can influence the amount of time these women have for self-care, including PA.
Method >> Preliminary work for Mujeres was predicated on focus group work that included three focus groups of 3-4 women each in San Antonio, Texas. The participants were asked open-ended, descriptive questions that included, “What factors you perceive as facilitating physical activity, or that you perceive as barriers to PA?” (Gonzales & Keller, 2004). In Phoenix, Arizona, women between the ages of 18 and 60 participated in a photo-elicitation study of social support for PA and were interviewed during group discussion of their photographs (Keller, Fleury, Perez, Belyea, & Castro, 2011). Participants were provided with disposable cameras and instructed to photograph their PA, including housework/yard work, throughout the day. Follow-up focus groups were conducted in which each woman shared her photos and discussed ways that she engaged in PA and ways that her family and friends might help or hinder her efforts at increasing PA. From these preliminary focus groups, the Mujeres intervention was developed for older Latinas and subsequently refined for younger postpartum Latinas. Finally, women who were pregnant or who had recently given birth were invited to review the draft of the Madres intervention for cultural relevance (data were field notes taken by study investigators, as well as data bits from formative work; see Table 1). Collectively, these preliminary discussions and critiques described Latina preferences for social support strategies that emphasized cultural tailoring based on the age-groups selected for intervention development and refinement. Mujeres for older Hispanic women (age 45-70 years) was a feasibility study that evaluated the efficacy and acceptability of a theory-driven, social support intervention program; was grounded in prior research with ethnically diverse women; and aimed at initiating and maintaining regular PA and reducing overweight among older Hispanic women. The Mujeres intervention was conducted weekly for eight groups of two to four women and led by trained promotoras. This intervention included (a) emotional support as a way to initiate and sustain walking; (b) instrumental support, including the use of pedometers in monitoring regular walking and maps showing safe walking areas; (c) appraisal support, including self-monitoring with women recording their progress (pedometer step counts, number and duration of activity bouts); and (d) informational support, including education materials developed to negotiate neighborhood safety and avoid musculoskeletal injury. We examined the effects of the Madres program on health outcomes among postpartum Latinas. The study
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Table 1 Operationalization of Cultural Themes by Age-Group and How They Translated Into Specific Intervention Strategies
Concept Time management
Respeto
Familismo
Personalismo
Selected Comments From Madres Participants (Age 18-40 Years), as Recorded in Field Notes
Selected Comments from Mujeres Participants (age 45-70 Years), as Recorded in Field Notes
•• Participants really liked doing the 7-day schedule. They mentioned that they were able to manage time better. They said that some of the setbacks were not scheduling baby time for feeding, bathing, and lulling to sleep. Participants mentioned that they were going to continue doing the 7-day schedule.
•• “I put my children first. I would never be able to tell my family to ‘take responsibility’ because I need time for myself. They need me. I put myself to the side and then I’ll make time for myself.”
•• Women stated they wanted a “onebaby body, not a 5-baby body.”
•• “I just need to exercise. That’s what the doctor said.”
Intervention Design Element •• Younger women (Madres): Time management as specific strategy, encouraging short “bouts” of walking; training and booster session discussions showed that women desired to lose postpartum weight to be attractive to husband and be well for their families; role-playing of support during walking sessions. •• Older Latinas (Mujeres) were encouraged to walk on their own but had scheduled walking times 1 day a week. • Trained promotoras to advocate safe walking, offer reinforcement; women were scheduled to walk with promotoras one day each week. •• 12 sessions and 2 booster sessions that include strategies for walking with family members, children, spouses, their mothers; strategies for time management to help set specific opportunities for walking.
•• Formation of walking groups to encourage socialization and share goals, progress, strategies, and resources
•• For younger women, this was less important: Strategies were developed to incorporate family activities and outings in walking; older women valued the development of group activities and often met each other to walk outside of scheduled times
•• Participants shared in group session •• “I have a grandson . . . he is they wanted to be role models for full of energy . . . and so it health for their families and children. depresses me that I cannot keep up with him the way that •• “Doing this program is not just about he wants me to. But I can do it, the weight anymore. I have so many it’s just that I’m too heavy. family members with diabetes and That’s when I said I’m going to high blood pressure who are in and do something about it.” out of the hospital and have to take many medications. I am doing this to be healthy too!” •• One mentioned her son really pushes her to walk and that she has discovered that her baby really likes when she walks. He always comes back sleeping. •• Cohort 1 started in June and cited •• “I would stop and say good heat as their main barrier to walking. morning, how are you? And I Promotora and women problemwould stop and talk and that solved alternatives. would break my routine . . . Well, it’s rude not to accept •• Two participants made a goal of and things like that. I figured I losing 30 pounds each for the new better start going by myself in year and set short-term goals together. another direction.” •• Participants in one cohort called each other and set walking/play dates with their grandchildren during the week. They walked in place at the playground while kids play.
(continued)
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Table 1 (continued)
Concept Colectivismo
Machismo and marianismo
Selected Comments From Madres Participants (Age 18-40 Years), as Recorded in Field Notes
Intervention Design Element
Selected Comments from Mujeres Participants (age 45-70 Years), as Recorded in Field Notes
•• Use of pedometers in monitoring •• regular walking, maps showing safe walking areas around participant neighborhood, walking groups and walking shoes and weekly activity calendars ••
•• “I’m not afraid to go out there and walk, it’s just trying to get somebody to go with me.”
•• Emotional support operationalized by formal training sessions that incorporate the notions of marianismo and machismo; for younger women, specific intervention sessions are developed and delivered for the partners/spouses of Hispanic women in the study to explore that the Latina participants can be helped to stay walking for the study, how walking will help their energy level and caregiving ability, and the support that their partners can provide. • Older women (Mujeres): Sessions •• voicing that husbands could facilitate PA, enhancing companionship and caregiving; formation of walking groups capitalized on social support; pedometers, maps, weekly calendar provided ways to measure and share progress; roleplaying of support during walking sessions
•• “When my husband first retired, we started walking after breakfast.”
Participants walked in place for 5 minutes and a couple of them said that now that they had done it like that, they will be walking in home some of the days. The women said they put their calendars on the refrigerator, and it was a great reminder for their walking that week. •• One husband said, “This program is helping to bring healthier habits to our culture.” • One participant said that machismo was a barrier for her to go out and walk, but she managed to take her husband with her to walk.
•• “I think having someone to motivate you really helps me.”
One participant was surprised to learn about marianismo because she had never heard the term; she said she would do more for herself so she could be healthy.
aims were to examine the effectiveness of the Madres intervention for (a) improving (i.e., reducing) the distal outcomes of percent body fat and fat tissue inflammation among postpartum Latinas compared with an attention control group and (b) determining the relationship between the immediate outcome of walking (minutes walked per week) and changes in the distal outcomes. This study used a prospective, randomized, controlled experimental design with assessments at baseline, 6 months, and 12 months after initiation of the intervention. We enrolled 139 women who were randomized to either the intervention or the control group. Full descriptions of these studies and methods
are in print (Keller, Fleury, et al., 2011; Keller, Records, et al., 2011).
Results >> Differences in Operationalizing Social Support for PA Specific elements from the preliminary focus groups, photo elicitation, and field notes of the intervention structure and strategies underpinned the operationalization of interventions, held in common across the two generations, with similarities more numerous
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than differences. Nevertheless, by using a life course perspective, the investigators could appreciate the nuances, differences, and variations between the groups of younger and older women in how each group managed weight and PA initiation and maintenance. Three significant areas of focus were developed that differentiated the intervention components between the generations of Hispanic women: (a) time management, (b) the cultural values that influenced traditional roles for Hispanic women, and (c) the strategies developed for sources of support and family involvement. Table 1 gives sample comments that show how the women verbalized the strategies needed for tailoring the intervention in these areas. Time Management for PA. Time management differed between generations. For older women, the burden of child care was lessened, except for those women who cared for grandchildren. Strategies for these women included developing new relationships with women who shared their culture through group walking sessions and planning to walk on weekends with spouses. For the younger women, the investigators included time management in the intervention as a specific support strategy, as the women in the study often felt overwhelmed with family and household obligations, which were compounded when the women worked outside the home. Strategies for them included ways to manage time, which coincided with routines of work, household chores, and child care. Informational support was developed as specific time management planning—helping women carve out in advance their times for “bouts” of walking, such as when they walked their children to and from school or to walked to the market, and anticipating family care resources to use. The Cultural Values That Influenced Traditional Roles for Hispanic Women. The expression of cultural values varies, but the place where the extreme ends of the continuum of behavior may be most obvious is in the concept of machismo. Machismo is associated with behaviors that range from extreme forms, in which the male is overly protective, has a propensity to engage in high-risk behavior, and treats those below him in the social hierarchy with disdain, to more benign forms characterized by features such as being family oriented, hardworking, brave, proud, interested in the welfare and honor of his loved ones (including providing for, protecting, and defending his family), romantic, and self-assertive (Torres, Solberg, & Carlstrom, 2002). Equally, the expression of marianismo, although a phenomenon that is less frequently studied, is associated with ideas of feminine moral superiority, including a
deep concern for the well-being of the vulnerable, with her children among the vulnerable for which she is responsible. Machismo in its extreme form was shown to be a significant barrier to PA in the two studies if a male insisted that his wife or partner focus on caring for their home and children. These behaviors were reinforced by marianismo, even when the behavior was at the expense of the woman’s health and particularly if the time she took to care for her health involved activities outside the home. The investigators and promotoras used open discussions in both English and Spanish with women during intervention development focusing on these “traditional” male–female values and subsequent role enactments and engaged in dialogues that addressed ways to engage in walking that did not contradict these roles. The aspects of traditional machismo (Torres et al., 2002) were discussed with women to identify ways to capitalize on the important characteristics of machismo: responsibility for family welfare and protection of the family. The investigators focused on ensuring that husbands, regardless of the degree of machismo they displayed, were well aware of the activities and the reason for them and that the women’s child care and homemaking responsibilities were fulfilled. For the younger women, who were more likely to be married to men who expressed only mild forms of machismo, a strong motivator for walking to manage postpartum weight was physical attractiveness, which was an important part of their desired selfimage—and that of their husband—and the need to remain attractive for their partner or spouse. In essence, therefore, no matter if the traditional male roles associated with protecting his wife and family (machismo) expressed themselves in mild forms or more exaggerated forms, the desire of a woman to please her husband or significant other had an important influence on her decisions about engaging in health behaviors. Social Support Social support is assistance through social relationships and interpersonal transactions, and includes four types of support: (a) emotional support, including expressions of empathy, trust, and caring; (b) instrumental support, including tangible aid or service; (c) appraisal support, including information that is used for self evaluation; and (d) informational support, including advice, suggestions, and information (Heany & Israel, 2002; Keller, Allan, & Tinkle, 2006). Social support from family and friends has been consistently and positively related to PA (Keller et al., 2006). Qualitative methods have further strengthened the rationale for social support as a theoretical and culturally
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proficient construct. Keller and colleagues (Keller & Cantue, 2008; Keller & Trevino, 2001; Gonzalez & Keller, 2004) analyzed focus group data, photo elicitation, and qualitative interviews with Mexican American women in community health settings to identify specific parameters contributing to sociocultural resources used in walking and specific culture-bound supports used in walking and PA. Strategies Developed for Sources of Support and Family Involvement. The prior focus group work with Hispanic women had indicated that regardless of age, Hispanic women’s source of support for PA includes family, friends, and neighbors (Gonzales & Keller, 2004; Keller, Records, et al., 2011). For the younger and older generations in both interventions, the open discussions attested that family influenced attitudes and commitment toward PA and walking for health. For older Hispanic women, husbands were viewed as facilitating PA through encouragement, acknowledgement of their efforts, and helping care for the grandchildren, which enhanced a sense of companionship. The younger Hispanic women valued their role as mother and as caregiver and felt that they needed to stay healthy and able to care for their children and husbands.
Discussion >> The investigators show how taking a life course and culture-based perspective, focusing on explicit social and behavioral changes that occur during milestone developmental transitions for all women (Brown, Heesch, & Miller, 2009; Engberg et al., 2012), helped in creating a model that employed strategies relevant to both the culture and the developmental milestone. The perspective allowed investigators to see that concerns about time management, influence of cultural values and traditions, and sources of support and family involvement affected younger and older Hispanic women alike but in different ways. The investigators tailored these two interventions in a way that heeded the ages, experiences, culture, traditions, and values of the Hispanic women. Imbedding a Social Support Intervention in Cultural Values Important Latino cultural values include familismo, simpatía, respeto, personalismo, colectivismo, and machismo/marianismo. As observed above, even during the process of acculturation, many of these values remain strong. As long as they remain strong, failure to adhere to them may be associated with consequences such as losing face in the extended family (Delgado, 1983) and
depression (Hovey, 2000), particularly in women, as they are more vulnerable than men to interpersonal conflicts (Lorenzo-Blanco, Unger, Baezconde-Garbanati, RittOlson, & Soto, 2012). These consequences affect overall family functioning (Lorenzo-Blanco et al., 2012). As humans are a highly social species, social relationships are of critical importance; these relationships promoted our ancestors’ ability to survive and to thrive (Coe, Palmer, Palmer, & DeVito, 2011). In many parts of the world, all social relationships are established on and bound by kinship ties (Coe, 2003; Coe et al., 2011). Although social support is critical, Hispanic women uniquely possess specific traditional skills for maintaining those relationships. When compared with women of other ethnic groups, greater social support in Hispanic women is associated with higher levels of PA (Eyler et al., 2003; Thornton et al., 2006; Voorhees & Rohm Young, 2003). Social support is generally used to refer to the extent and conditions under which the context of interpersonal ties and different types of support might be provided by people holding different roles (e.g., a mother vs. a sister, biological or metaphorical). These roles, in turn, are associated with certain social obligations and linked to determinants of well-being. Although Barrera and Ainlay (1983) refer to the concept of social support as “elastic”—as it is used to describe multiple definitions and characteristics of social support (e.g., interpersonal ties, actions involved in resource provision, and affective responses to support received)—common to all definitions is that “social support” always describes positive, and giving, aspects of social relationships All key aspects of Hispanic traditions are interconnected: They all encourage harmony in interpersonal relationships and provide strategies for avoiding interpersonal conflict (Triandis, Marín, Lisansky, & Betancourt, 1984). These values are the core of a cultural script that outlines the ways that individuals are to interact in order to maintain strong social relationships (Triandis et al., 1984). Familism is characterized by reciprocal family obligations, perceived support from the family, and the use of the family as a referent to decide one’s path in life and make decisions about actions (Garza & Watts, 2010). Marín and Marín (1991) highlighted familism as a value that is critical in promoting health. The investigators incorporated all these concepts into both interventions in the following ways: They used implementation strategies that emphasized group cohesion and reliance on other group members to encourage attendance at walking groups, intervention sessions, and support for walking (colectivismo). Familismo was enacted within intervention content and implementation strategies that planned for walking,
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included supportive family and kinship members, and made time for family and household obligations that incorporated “bouts” of walking. Incorporating familismo thus reinforced how an intervention that involves one individual can benefit an entire family. Each critical input of the intervention and intervention delivery included respeto and personalismo: During group activities, women role-played and practiced negotiations for mutual support from one another and from family and kinship members to assist them with walking and encourage these supportive persons to accompany them while walking. Knowledge about family issues and cultural values (“mi familia viene primero” [my family comes first], a phrase they repeated often) underpinned the intervention components that assisted women with time management by supporting the woman’s walking (Gonzales & Keller, 2004).
Final Thoughts on Developing >> Interventions
The extensive intervention work developed as prelude to Mujeres and Madres led to the model proposed here (Figure 1). Instilling social support, culture, and tradition into the intervention design helped the traditional Hispanic women in Mujeres and Madres engage in new, healthful behaviors to counter obesity. The approach helped a participant see, for example, how social skills, culture, and traditions interacted in ways that were beneficial if others participated with her in PA; it also helped her see that these same social skills might, on the other hand, have led her to spend more time in being social than in engaging in more PA behaviors that would decrease body adiposity. Simply appreciating the crucial role that life course, culture, and social support play within all social groups is insufficient to guarantee its successful application in any intervention; investigators must determine precisely how these factors operate within groups of participants who share a common history but are at varying levels of acculturation, have disparate cultural practices, and/or are at different stages of the life course. Thus, we argue that interventions aimed at improving health outcomes hold the greatest potential to be effective if they incorporate culture and traditions and yet are also mindful of ways that culture and traditions might work against improved outcomes. The responsibility of the investigator is to identify which aspects of culture and traditions are salient to the participants in an intervention and to make those aspects integral to the intervention design and implementation.
References Asbee, S. M., Jenkins, T., Butler, J., White, J., Elliot, M., & Rutledge, A. (2009). Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: A randomized controlled trial. Obstetrics and Gynecology, 113(2 Pt. 1), 305-312. Barrera, M., Jr., & Ainlay, S. L. (1983). The structure of social support: A conceptual and empirical analysis. Journal of Community Psychology, 11, 133-143. Barrera, M., Jr., Toobert, D. J., Angell, K. L., Glasgow, R. E., & Mackinnon, D. P. (2006). Social support and social-ecological resources as mediators of lifestyle intervention effects for type 2 diabetes. Journal of Health Psychology, 11, 483-495. doi:10.1177/1359105306063321 Brown, W. J., Heesch, K. C., & Miller, Y. D. (2009). Life events and changing physical activity patterns in women at different life stages. Annals of Behavioral Medicine, 37, 294-305. Castro, M. J. (1997). Making Pan Latino: Latino pan-ethnicity and the controversial case of the Cubans. Harvard Latino Law Review, 2, 179-197. Coe, K. (2003). The ancestress hypothesis: Visual art as adaptation. New Brunswick, NJ: Rutgers University Press. Coe, K., & Keller, C. (1996). Health protective behaviors of young African American women: Should we be using a kinship model to teach health behaviors? Journal of Human Ecology (Human Ecology Special Issue 4), 57-66. Coe, M. K., Palmer, A. L., Palmer, C. T., & DeVito, C. L. (2011). Culture, altruism, and conflict between ancestors and descendants. Structure and Dynamics, 4(3), 1-17. Delgado, M. (1983). Activities and Hispanic groups. Social Work With Groups, 6, 85-96. Duval, K., Prud’homme, D., Rabasa-Lhoret, R., Strychar, I., Brochu, M., Lavioe, J.-M., & Doucet, É. (2013). Effects of the menopausal transition on energy expenditure: A MONET Group Study. European Journal of Clinical Nutrition, 67, 407-411. doi:10.1038/ejcn.2013.33 Engberg, E., Alen, M., Kukkonen-Harjula, K., Peltonen, J. E., Tikkanen, H. O., & Pekkarinen, H. (2012). Life events and change in leisure time physical activity: A systematic review. Sports Medicine, 42, 433-447. Eyler, A. A., Matson-Koffman, D., Young, D. R., Wilcox, S., Wilbur, J., Thompson, J. L., . . . Evenson, K. R. (2003). Quantitative study of correlates of physical activity in women from diverse racial/ethnic groups: Women’s Cardiovascular Health Network Project—introduction and methodology. American Journal of Preventive Medicine, 25(3 Suppl. 1), 5-14. Fine, A., & Kotelchuk, M. (2010). Rethinking MCH: The life course model as an organizing framework (Version 1.1). Rockville, MD: U.S. Department of Health and Human Services. Garza, Y., & Watts, R. E. (2010). Filial therapy and Hispanic values: Common ground for culturally sensitive helping. Journal of Counseling & Development, 88, 108-113. Gonzales, A., & Keller, C. (2004). Mi familia viene primero (my family comes first): Physical activity issues in older Mexican American women. Southern Online Journal of Nursing Research, 5(4), 1-21. Heany, C. A., & Israel, B. A. (2002). Social networks and social support. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health
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behavior and health education: Theory, research and practice (3rd ed., pp. 185-209). San Francisco, CA: Jossey-Bass. Hovey, J. D. (2000). Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultural Diversity & Ethnic Minority Psychology, 6, 134-151. Keller, C., Allan, J., & Tinkle, M. B. (2006). Stages of change, processes of change, and social support for exercise and weight gain in postpartum women. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35, 232-240. Keller, C., Fleury, J., Perez, A., Belyea, M., & Castro, F. (2011). Mujeres en acción: Design and baseline data. Journal of Community Health, 36, 703-714. Keller, C., & Cantue, A. (2008). Camina por Salud: Walking in Mexican American women. Applied Nursing Research, 21, 110-113. Keller, C., Larkey, L., Distefano, J. K., Boehm-Smith, E., Records, K., Robillard, A., . . . O’Brian, A. M. (2010). Perimenopausal obesity. Journal of Women’s Health 19, 987-996. doi:10.1089/ jwh.2009.1547 Keller, C., Records, K., Ainsworth, B., Belyea, M., Permana, P., Coonrod, D., . . .Nagle-Williams, A. (2011). Madres para la Salud: Design of a theory-based intervention for postpartum Latinas. Contemporary Clinical Trials, 32, 418-427. doi:10.1016/ j.cct.2011.01.003 Keller, C., & Trevino, R. P. (2001). Effects of two frequencies of walking on cardiovascular risk factor reduction in Mexican American women. Research in Nursing & Health, 24, 390-401. Kreuter, M., Lukwago, S., Bucholtz, D., Clark, E., & SandersThompson, V. (2003). Achieving cultural appropriateness in health promotion programs: Targeted and tailored approaches. Health Education & Behavior, 30, 133-146. Lorenzo-Blanco, E. I., Unger, J. B., Baezconde-Garbanati, L., RittOlson, A., & Soto, D. (2012). Acculturation, enculturation, and symptoms of depression in Hispanic youth: The roles of gender, Hispanic cultural values, and family functioning. Journal of Youth and Adolescence, 41, 1350-1365. Marín, G., & Marín, B. V. (1991). Applied social research methods series: Vol. 23. Research with Hispanic populations. Thousand Oaks, CA: Sage.
Martinez, S. M., Arredondo, E. M., Perez, G., & Baquero, B. (2009). Individual, social, and environmental barriers to and facilitators of physical activity among Latinas living in San Diego County: Focus group results. Family & Community Health, 32, 22-33. McGruder, H. F., Malarcher, A. M., Antoine, T. L., Greenlund, K. J., & Croft, J. B. (2004). Racial and ethnic disparities in cardiovascular risk factors among stroke survivors: United States 1999 to 2001. Stroke, 35, 1557-1561. doi:10.1161/01.STR.0000130427.84114.50 Perrig-Chiello, P., Hutchison, S., & Hoepflinger, F. (2008). Role involvement and well-being in middle-aged women. Women & Health, 48, 303-323. Power, M. L., & Schulkin, J. (2007). Sex differences in fat storage, fat metabolism, and the health risks from obesity: Possible evolutionary origins. British Journal of Nutrition, 99, 931-940. doi:10.1017/S0007114507853347 Thornton, P. L., Kieffer, E. C., Salabarría-Peña, Y., Odoms-Young, A., Willis, S. K., Kim, H., & Salinas, M. A. (2006). Weight, diet, and physical activity-related beliefs and practices among pregnant and postpartum Latino women: The role of social support. Maternal and Child Health Journal, 10, 95-104. doi:10.1007/s10995-005-0025-3 Torres, J. B., Solberg, V. S. H., & Carlstrom, A. H. (2002). The myth of sameness among Latino men and their machismo. American Journal of Orthopsychiatry, 72, 163-181. Triandis, H., Marín, G., Lisansky, J., & Betancourt, H. (1984). Simpatía as a cultural script of Hispanics. Journal of Personality and Social Psychology, 47, 1363-1375. U.S. Department of Health and Human Services. (2012). 2012 National healthcare disparities report (Table T2_10_1_7-2b). Retrieved from http://www.ahrq.gov/research/findings/nhqrdr/ nhqrdr12/10_lifestylemodification/T2_10_1_7-2b.html Van Duyn, M. A., McCrae, T., Wingrove, B. K., Henderson, K. M., Boyd, J. K., Kagawa-Singer, M., & Maibach, E. W. (2007). Adapting evidence-based strategies to increase physical activity among African Americans, Hispanics, Hmong, and Native Hawaiians: A social marketing approach. Preventing Chronic Disease, 4(4), A102. Voorhees, C. C., & Rohm Young, D. (2003). Personal, social, and physical environmental correlates of physical activity levels in urban Latinas. American Journal of Preventive Medicine, 25(3 Suppl. 1), 61-68. doi:10.1016/S0749-3797(03)00166-1
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HPPXXX10.1177/1524839914526204Health Promotion PracticeKeller et al. / Addressing The Demand for Cultural Relevance in Intervention Design
Cultural Competence
Addressing the Demand for Cultural Relevance in Intervention Design Colleen S. Keller, PhD1 Kathryn Coe, PhD2 Nancy Moore, PhD1
This article describes the development of a model to promote physical activity in Hispanic women that embeds a life course perspective and culture to enhance comparative effectiveness in intervention design. When working with diverse cultural groups, researchers often struggle with intervention designs and strategies to enhance cultural relevance; they do so based on the assumption that this will enhance efficacy and make interventions more sustainable. In this article, the authors discuss how the model was used in two interventions designed for younger and older Hispanic women. These interventions were guided by a life course perspective, incorporated social support, and included salient elements from the women’s culture. Three considerations underpinned the development of the model: (a) infusing concepts and values of a culture and tradition into the interventions, (b) viewing participants through a life course perspective to assess how an intervention can build on developmental transitions, and (c) determining how social support operates within two groups that, although sharing history and thus some cultural practices, diverge widely in those practices. The authors propose that by incorporating elements of this model into their interventions, researchers can increase program efficacy and effectiveness. Keywords: intervention design; Hispanic women; social support; physical activity; culture; life course perspective
Health Promotion Practice September 2014 Vol. 15, No. (5) 654–663 DOI: 10.1177/1524839914526204 © 2014 Society for Public Health Education
Introduction >> In Hispanic women, obesity is a particular concern, with 78% of Mexican American women overweight or obese, compared with 60.3% of non-Hispanic White women (U.S. Department of Health and Human Services, 2012). Although limiting energy intake is important, increasing physical activity (PA) has been used successfully to manage weight across the life span. However, despite the known benefits of PA, 46% of Hispanic women of all ages report no leisure time exercise (McGruder, Malarcher, Antoine, Greenlund, & Croft, 2004). In this article, we discuss the rationale underpinning the development and implementation of two interventions, Madres para Su Salud (Mothers for Health, hereafter referred to as Madres) and Mujeres en Acción por Su Salud (Women in Action for Health, hereafter referred to as Mujeres), designed to increase walking and reduce body adiposity among Hispanic women. These innovative interventions reflected, through formative work and continued participant cultural review factors salient to women, critical transition, life stages and cultural values. Toward that end, a new model, illustrated here (Figure 1), was developed that embedded social support, a life course perspective, and cultural elements, all of which may be critical 1
Arizona State University, Phoenix, AZ, USA Indiana University–Purdue University, Indianapolis, IN, USA
2
Authors’ Note: Funded by NIH/NINR 1 R01NR010356-01A2 (Madres para la Salud (Mothers for Health) and NIH/NINR 1 R21 NR010126-01A1 (Mujeres en Acción: Walking in Hispanic Women). Address correspondence to Colleen S. Keller, Center for Healthy Outcomes in Aging, College of Nursing and Health Innovation, Arizona State University, 500 N. Third Street, Phoenix, AZ 85004, USA; e-mail: [email protected].
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Older women: Increased traditionalism may manifest as increased stress during postmenopause if family members no longer honor those traditions. Older women may experience increased stress due to more kinship obligations (e.g., with grown children, grandchildren, and partners) and other changing relationships, while having to deal with less social support, which may lead to weight change.
Younger women: In reproductive period, fat stores before and during pregnancy protect fetus. Women likely to maintain weight gain, particularly when cultural values encourage rounded figures and when family urges eating well and resting during pregnancy. Women may have heightened stress due to more childcare obligations while having to maintain kinship ones.
Personality & Developmental milestones
Machismo and marianismo: Hispanic women are socialized to place an emphasis on male as protector/female as nurturer and moral guide.
Colectivismo: Hispanic women are socialized to participate in a social system that is cooperative & to value social interdependence.
Personalismo: Hispanic women are socialized to consider friends to be a source of strength as well as information.
Familismo: Hispanic women are socialized to sacrifice and work for the benefit of the family by exhibiting altruism, generosity, & strong loyalty. Church replicates kinship model and requires same loyalties, etc.
Respeto: Hispanic women are raised to understand hierarchies and their place in hierarchical relationships and to respect authority figures.
Culture or Traditions Respecto: One end: Valuing and being comfortable with people of different ages. Opposite end: Valuing decisions made by others more than valuing one’s own decisions or ability to make decisions. Social skills: One end: Finding it easy to engage in activities involving others (manifesting personalismo). Opposite end: Tending to stay involved or spending more time being social than in other types of activities that also may be important. Altruism/Simpatía: One end: Being willing to help others who need help and working to get other involved (manifesting colectivismo). Opposite end: Helping others at the expense of one’s own health (possibly manifesting negative aspects of familismo, if family discourages PA). Machismo and marianismo: One end: Fulfilling traditional roles in the family (e.g., for male, engaging in behavior that protects family; for female, being committed to children and the vulnerable). Opposite end: Being overprotective (for males), thus inhibiting activities; being likely to acquiesce (for females).
Two Ends of the Continuum: Social Application & Effect
Figure 1 A Traditional Woman: Maintains Behaviors Inherited From Ancestors, Through Parents
Environment, including physical and social
Biology, including Genes
Design elements minimizing perceived negative effect: Anticipate that some aspects of a culture or environment could dampen achievement of desired outcomes • Sessions discussing such potential cultural impediments such as the influence of machismo in their lives and their ability to engage in PA. • Problem-solving the effect of multiple family obligations (e.g., taking children to school, an issue especially for younger women). • Aids such as maps to help women plan safe walking routes; walking in groups also to help them feel safe and thus promote PA and social support.
Design elements enhancing positive social effect: Build on sources of support • Promotoras who facilitated and reinforced group persistence and overcoming barriers. • Time management as specific strategy to help women (especially younger women) find time for PA. • Training and booster sessions to help women articulate specific weight-loss goals and motivations (e.g. be attractive to husband and be well for families for younger women; enhancing companionship and caregiving for older women). • Role-playing of support during walking sessions. • Pedometers, maps, weekly calendar as ways to measure and share progress.
Intervention
in intervention development across many diverse women. Three considerations underpin this model: (a) infusing concepts and values of a culture and tradition into the interventions, (b) viewing participants through a life course perspective to assess how an intervention can build on developmental transitions, and (c) determining how social support operates within two groups that, although sharing history and thus some cultural practices, diverge widely in those practices.
Background >> The Role of Culture and Tradition: Social Support Despite important biological similarities among all women across the life trajectory, there are other important differences, often related to culture. Researchers recognize that individuals who are members of different ethnic groups will diverge in significant regards and that culture involves shared, not idiosyncratic, behavior. As Kreuter, Lukwago, Bucholtz, Clark, and Sanders-Thompson (2003) suggest, the issue is to identify, in any distinct population, the visible expression of shared values, namely, the behavior. As anthropologists have long noted, although there are variations in culture, the heart of any culture is kinship. The value of kinship, or familism, in the case of Hispanic women, can be observed as activities devoted to care and nurturing of the family. However, it also can be seen in the expansion of kinship relationships to nonkin who are referred to using kinship terms (e.g., sister, brother) and often treated as if they were close kin. The point here is that social support is often associated with a kinship model—when kinship terms are used either actually (to refer to biological kin) or metaphorically (e.g., calling friends “sister” or “mother”), those social relationships tend to be very supportive (Coe, 2003; Coe & Keller, 1996). Indeed, a curious feature of humans is that we regularly associate different kin terms with different roles and responsibilities. A mother does not and is not expected to behave the same way that a sister or aunt does. However, both mothers and aunts are expected to provide social support. Social support from family and friends has been positively related to initiating and maintaining PA across races and ethnicities; it is the most commonly reported correlate to higher levels of PA for Hispanic women (Barrera, Toobert, Angell, Glasgow, & Mackinnon, 2006; Van Duyn et al., 2007). Among Hispanic women, interviews show that demands for social support (e.g., overwhelming family responsibilities), a lack of an effective structure for support (e.g., for child care), and poor
time management are the most significant barriers to engaging in PA. Strengthening supportive social resources would enhance PA by ensuring that a woman could exercise while still managing to meet other obligations (Gonzales & Keller, 2004; Martinez, Arredondo, Perez, & Baquero, 2009). Traditions teach kinship terms and outline associated duties and responsibilities. A woman’s current values are, in the case of many Hispanic women, still built on core traditional values that are deeply embedded in her consciousness and practices. These values play a role in guiding activities of daily living, including daily practices of PA, and despite acculturation, values are transmitted through behavioral modeling to the next generation of kin (Coe, 2003). These traditions also guide all social interactions, the type and quantity of social support a woman feels that she needs (and indeed does need), and the support she feels an obligation to provide and to whom she needs to provide it. Modernization, migration, and experience living in a historically and predominately non-Hispanic culture are events that are rapidly transforming the traditional culture of Hispanics. As many traditions have been lost through the process of acculturation, program planners often are uncertain what, if any, focus should be placed on traditional culture and the values at its foundation. The important point is that through the interplay of multiple factors, Hispanic women, like all women, are continually reconstructing their ancestral traditions (Castro, 1997). Evidence indicates, however, that although change does occur, traditions continue to shape both Hispanic women’s social organization, which is still built on a kinship model, and their behavior, which is influenced by deeply held, and less likely to change, traditional values of familism, altruism, and duty to others, especially to kin (Castro, 1997). Traditions, therefore, cannot be ignored when developing any intervention for Hispanic women, particularly if that intervention is built on social support. Culturally tailored interventions reflect and address unique participant characteristics (Kreuter et al., 2003). The design of culturally tailored interventions has two critical requirements: (a) that cultural tailoring be developed based on clear and salient constructs relevant to the culture, especially kinship, and (b) that both constituent-involving and sociocultural strategies be deployed to encase interventions in the context of cultural values and characteristics (Kreuter et al., 2003). Life Course Perspective In the development of interventions for either young women, who are in the reproductive stages of life, or
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older women, who have completed menopause, a life course perspective is important as it places a focus on transitions across a woman’s life span. This perspective suggests that numerous factors converge at passage points such as childbearing (as fat storage and fertility are linked in human females; Power & Schulkin, 2007) and menopause (related to a relatively sedentary lifestyle in modern populations), which contribute to weight accumulation in women (Keller et al., 2010). Furthermore, an understanding of human development over the life span and knowledge of the way biology and the environment interact offer a research and research application paradigm that can be successfully used to promote healthy development not only over a lifetime but also across generations (Fine & Kotelchuk, 2010). This emerging paradigm can guide the development of interventions that address critical periods in development during which interventions can be more effective and focus on risk and protective factors that may have cumulative and long-term effects (Fine & Kotelchuk, 2010). The model we developed embedded two distinct developmental transition times, pregnancy and perimenopause. Because of contextual factors that surround adjustment to the transitions, these times can contribute to a woman’s weight gain, retention, and engagement in PA. Childbearing can be an important contributor to the development of obesity. Although a moderate weight gain supports the development of the large and expansive brain of the fetus and helps prepare the woman’s body for meeting the demands of pregnancy and lactation, pregnancy weight is often retained for a lifetime and may contribute to obesity-related risks and diseases (Asbee et al., 2009). Furthermore, postmenopausal women often put on weight, as they are more likely to engage in a sedentary lifestyle (Duval et al., 2013). The interaction among many contributing factors likely determines an individual’s propensity for excess energy intake, sedentary behavior, patterns of fat distribution, and risk of developing obesity. For some older women, in addition to the social and biological changes associated with menopause, changing relationships with parents, children, and partners can be disruptive to well-being during midlife. As women age, they change their investment in their families and their occupations and begin undertaking activities as such assuming child care responsibilities for grandchildren. These changes not only can contribute to overweight and obesity, because being distressed can change health behavior (Keller et al., 2010; PerrigChiello, Hutchison, & Hoepflinger, 2008), but also can influence the amount of time these women have for self-care, including PA.
Method >> Preliminary work for Mujeres was predicated on focus group work that included three focus groups of 3-4 women each in San Antonio, Texas. The participants were asked open-ended, descriptive questions that included, “What factors you perceive as facilitating physical activity, or that you perceive as barriers to PA?” (Gonzales & Keller, 2004). In Phoenix, Arizona, women between the ages of 18 and 60 participated in a photo-elicitation study of social support for PA and were interviewed during group discussion of their photographs (Keller, Fleury, Perez, Belyea, & Castro, 2011). Participants were provided with disposable cameras and instructed to photograph their PA, including housework/yard work, throughout the day. Follow-up focus groups were conducted in which each woman shared her photos and discussed ways that she engaged in PA and ways that her family and friends might help or hinder her efforts at increasing PA. From these preliminary focus groups, the Mujeres intervention was developed for older Latinas and subsequently refined for younger postpartum Latinas. Finally, women who were pregnant or who had recently given birth were invited to review the draft of the Madres intervention for cultural relevance (data were field notes taken by study investigators, as well as data bits from formative work; see Table 1). Collectively, these preliminary discussions and critiques described Latina preferences for social support strategies that emphasized cultural tailoring based on the age-groups selected for intervention development and refinement. Mujeres for older Hispanic women (age 45-70 years) was a feasibility study that evaluated the efficacy and acceptability of a theory-driven, social support intervention program; was grounded in prior research with ethnically diverse women; and aimed at initiating and maintaining regular PA and reducing overweight among older Hispanic women. The Mujeres intervention was conducted weekly for eight groups of two to four women and led by trained promotoras. This intervention included (a) emotional support as a way to initiate and sustain walking; (b) instrumental support, including the use of pedometers in monitoring regular walking and maps showing safe walking areas; (c) appraisal support, including self-monitoring with women recording their progress (pedometer step counts, number and duration of activity bouts); and (d) informational support, including education materials developed to negotiate neighborhood safety and avoid musculoskeletal injury. We examined the effects of the Madres program on health outcomes among postpartum Latinas. The study
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Table 1 Operationalization of Cultural Themes by Age-Group and How They Translated Into Specific Intervention Strategies
Concept Time management
Respeto
Familismo
Personalismo
Selected Comments From Madres Participants (Age 18-40 Years), as Recorded in Field Notes
Selected Comments from Mujeres Participants (age 45-70 Years), as Recorded in Field Notes
•• Participants really liked doing the 7-day schedule. They mentioned that they were able to manage time better. They said that some of the setbacks were not scheduling baby time for feeding, bathing, and lulling to sleep. Participants mentioned that they were going to continue doing the 7-day schedule.
•• “I put my children first. I would never be able to tell my family to ‘take responsibility’ because I need time for myself. They need me. I put myself to the side and then I’ll make time for myself.”
•• Women stated they wanted a “onebaby body, not a 5-baby body.”
•• “I just need to exercise. That’s what the doctor said.”
Intervention Design Element •• Younger women (Madres): Time management as specific strategy, encouraging short “bouts” of walking; training and booster session discussions showed that women desired to lose postpartum weight to be attractive to husband and be well for their families; role-playing of support during walking sessions. •• Older Latinas (Mujeres) were encouraged to walk on their own but had scheduled walking times 1 day a week. • Trained promotoras to advocate safe walking, offer reinforcement; women were scheduled to walk with promotoras one day each week. •• 12 sessions and 2 booster sessions that include strategies for walking with family members, children, spouses, their mothers; strategies for time management to help set specific opportunities for walking.
•• Formation of walking groups to encourage socialization and share goals, progress, strategies, and resources
•• For younger women, this was less important: Strategies were developed to incorporate family activities and outings in walking; older women valued the development of group activities and often met each other to walk outside of scheduled times
•• Participants shared in group session •• “I have a grandson . . . he is they wanted to be role models for full of energy . . . and so it health for their families and children. depresses me that I cannot keep up with him the way that •• “Doing this program is not just about he wants me to. But I can do it, the weight anymore. I have so many it’s just that I’m too heavy. family members with diabetes and That’s when I said I’m going to high blood pressure who are in and do something about it.” out of the hospital and have to take many medications. I am doing this to be healthy too!” •• One mentioned her son really pushes her to walk and that she has discovered that her baby really likes when she walks. He always comes back sleeping. •• Cohort 1 started in June and cited •• “I would stop and say good heat as their main barrier to walking. morning, how are you? And I Promotora and women problemwould stop and talk and that solved alternatives. would break my routine . . . Well, it’s rude not to accept •• Two participants made a goal of and things like that. I figured I losing 30 pounds each for the new better start going by myself in year and set short-term goals together. another direction.” •• Participants in one cohort called each other and set walking/play dates with their grandchildren during the week. They walked in place at the playground while kids play.
(continued)
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Table 1 (continued)
Concept Colectivismo
Machismo and marianismo
Selected Comments From Madres Participants (Age 18-40 Years), as Recorded in Field Notes
Intervention Design Element
Selected Comments from Mujeres Participants (age 45-70 Years), as Recorded in Field Notes
•• Use of pedometers in monitoring •• regular walking, maps showing safe walking areas around participant neighborhood, walking groups and walking shoes and weekly activity calendars ••
•• “I’m not afraid to go out there and walk, it’s just trying to get somebody to go with me.”
•• Emotional support operationalized by formal training sessions that incorporate the notions of marianismo and machismo; for younger women, specific intervention sessions are developed and delivered for the partners/spouses of Hispanic women in the study to explore that the Latina participants can be helped to stay walking for the study, how walking will help their energy level and caregiving ability, and the support that their partners can provide. • Older women (Mujeres): Sessions •• voicing that husbands could facilitate PA, enhancing companionship and caregiving; formation of walking groups capitalized on social support; pedometers, maps, weekly calendar provided ways to measure and share progress; roleplaying of support during walking sessions
•• “When my husband first retired, we started walking after breakfast.”
Participants walked in place for 5 minutes and a couple of them said that now that they had done it like that, they will be walking in home some of the days. The women said they put their calendars on the refrigerator, and it was a great reminder for their walking that week. •• One husband said, “This program is helping to bring healthier habits to our culture.” • One participant said that machismo was a barrier for her to go out and walk, but she managed to take her husband with her to walk.
•• “I think having someone to motivate you really helps me.”
One participant was surprised to learn about marianismo because she had never heard the term; she said she would do more for herself so she could be healthy.
aims were to examine the effectiveness of the Madres intervention for (a) improving (i.e., reducing) the distal outcomes of percent body fat and fat tissue inflammation among postpartum Latinas compared with an attention control group and (b) determining the relationship between the immediate outcome of walking (minutes walked per week) and changes in the distal outcomes. This study used a prospective, randomized, controlled experimental design with assessments at baseline, 6 months, and 12 months after initiation of the intervention. We enrolled 139 women who were randomized to either the intervention or the control group. Full descriptions of these studies and methods
are in print (Keller, Fleury, et al., 2011; Keller, Records, et al., 2011).
Results >> Differences in Operationalizing Social Support for PA Specific elements from the preliminary focus groups, photo elicitation, and field notes of the intervention structure and strategies underpinned the operationalization of interventions, held in common across the two generations, with similarities more numerous
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than differences. Nevertheless, by using a life course perspective, the investigators could appreciate the nuances, differences, and variations between the groups of younger and older women in how each group managed weight and PA initiation and maintenance. Three significant areas of focus were developed that differentiated the intervention components between the generations of Hispanic women: (a) time management, (b) the cultural values that influenced traditional roles for Hispanic women, and (c) the strategies developed for sources of support and family involvement. Table 1 gives sample comments that show how the women verbalized the strategies needed for tailoring the intervention in these areas. Time Management for PA. Time management differed between generations. For older women, the burden of child care was lessened, except for those women who cared for grandchildren. Strategies for these women included developing new relationships with women who shared their culture through group walking sessions and planning to walk on weekends with spouses. For the younger women, the investigators included time management in the intervention as a specific support strategy, as the women in the study often felt overwhelmed with family and household obligations, which were compounded when the women worked outside the home. Strategies for them included ways to manage time, which coincided with routines of work, household chores, and child care. Informational support was developed as specific time management planning—helping women carve out in advance their times for “bouts” of walking, such as when they walked their children to and from school or to walked to the market, and anticipating family care resources to use. The Cultural Values That Influenced Traditional Roles for Hispanic Women. The expression of cultural values varies, but the place where the extreme ends of the continuum of behavior may be most obvious is in the concept of machismo. Machismo is associated with behaviors that range from extreme forms, in which the male is overly protective, has a propensity to engage in high-risk behavior, and treats those below him in the social hierarchy with disdain, to more benign forms characterized by features such as being family oriented, hardworking, brave, proud, interested in the welfare and honor of his loved ones (including providing for, protecting, and defending his family), romantic, and self-assertive (Torres, Solberg, & Carlstrom, 2002). Equally, the expression of marianismo, although a phenomenon that is less frequently studied, is associated with ideas of feminine moral superiority, including a
deep concern for the well-being of the vulnerable, with her children among the vulnerable for which she is responsible. Machismo in its extreme form was shown to be a significant barrier to PA in the two studies if a male insisted that his wife or partner focus on caring for their home and children. These behaviors were reinforced by marianismo, even when the behavior was at the expense of the woman’s health and particularly if the time she took to care for her health involved activities outside the home. The investigators and promotoras used open discussions in both English and Spanish with women during intervention development focusing on these “traditional” male–female values and subsequent role enactments and engaged in dialogues that addressed ways to engage in walking that did not contradict these roles. The aspects of traditional machismo (Torres et al., 2002) were discussed with women to identify ways to capitalize on the important characteristics of machismo: responsibility for family welfare and protection of the family. The investigators focused on ensuring that husbands, regardless of the degree of machismo they displayed, were well aware of the activities and the reason for them and that the women’s child care and homemaking responsibilities were fulfilled. For the younger women, who were more likely to be married to men who expressed only mild forms of machismo, a strong motivator for walking to manage postpartum weight was physical attractiveness, which was an important part of their desired selfimage—and that of their husband—and the need to remain attractive for their partner or spouse. In essence, therefore, no matter if the traditional male roles associated with protecting his wife and family (machismo) expressed themselves in mild forms or more exaggerated forms, the desire of a woman to please her husband or significant other had an important influence on her decisions about engaging in health behaviors. Social Support Social support is assistance through social relationships and interpersonal transactions, and includes four types of support: (a) emotional support, including expressions of empathy, trust, and caring; (b) instrumental support, including tangible aid or service; (c) appraisal support, including information that is used for self evaluation; and (d) informational support, including advice, suggestions, and information (Heany & Israel, 2002; Keller, Allan, & Tinkle, 2006). Social support from family and friends has been consistently and positively related to PA (Keller et al., 2006). Qualitative methods have further strengthened the rationale for social support as a theoretical and culturally
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proficient construct. Keller and colleagues (Keller & Cantue, 2008; Keller & Trevino, 2001; Gonzalez & Keller, 2004) analyzed focus group data, photo elicitation, and qualitative interviews with Mexican American women in community health settings to identify specific parameters contributing to sociocultural resources used in walking and specific culture-bound supports used in walking and PA. Strategies Developed for Sources of Support and Family Involvement. The prior focus group work with Hispanic women had indicated that regardless of age, Hispanic women’s source of support for PA includes family, friends, and neighbors (Gonzales & Keller, 2004; Keller, Records, et al., 2011). For the younger and older generations in both interventions, the open discussions attested that family influenced attitudes and commitment toward PA and walking for health. For older Hispanic women, husbands were viewed as facilitating PA through encouragement, acknowledgement of their efforts, and helping care for the grandchildren, which enhanced a sense of companionship. The younger Hispanic women valued their role as mother and as caregiver and felt that they needed to stay healthy and able to care for their children and husbands.
Discussion >> The investigators show how taking a life course and culture-based perspective, focusing on explicit social and behavioral changes that occur during milestone developmental transitions for all women (Brown, Heesch, & Miller, 2009; Engberg et al., 2012), helped in creating a model that employed strategies relevant to both the culture and the developmental milestone. The perspective allowed investigators to see that concerns about time management, influence of cultural values and traditions, and sources of support and family involvement affected younger and older Hispanic women alike but in different ways. The investigators tailored these two interventions in a way that heeded the ages, experiences, culture, traditions, and values of the Hispanic women. Imbedding a Social Support Intervention in Cultural Values Important Latino cultural values include familismo, simpatía, respeto, personalismo, colectivismo, and machismo/marianismo. As observed above, even during the process of acculturation, many of these values remain strong. As long as they remain strong, failure to adhere to them may be associated with consequences such as losing face in the extended family (Delgado, 1983) and
depression (Hovey, 2000), particularly in women, as they are more vulnerable than men to interpersonal conflicts (Lorenzo-Blanco, Unger, Baezconde-Garbanati, RittOlson, & Soto, 2012). These consequences affect overall family functioning (Lorenzo-Blanco et al., 2012). As humans are a highly social species, social relationships are of critical importance; these relationships promoted our ancestors’ ability to survive and to thrive (Coe, Palmer, Palmer, & DeVito, 2011). In many parts of the world, all social relationships are established on and bound by kinship ties (Coe, 2003; Coe et al., 2011). Although social support is critical, Hispanic women uniquely possess specific traditional skills for maintaining those relationships. When compared with women of other ethnic groups, greater social support in Hispanic women is associated with higher levels of PA (Eyler et al., 2003; Thornton et al., 2006; Voorhees & Rohm Young, 2003). Social support is generally used to refer to the extent and conditions under which the context of interpersonal ties and different types of support might be provided by people holding different roles (e.g., a mother vs. a sister, biological or metaphorical). These roles, in turn, are associated with certain social obligations and linked to determinants of well-being. Although Barrera and Ainlay (1983) refer to the concept of social support as “elastic”—as it is used to describe multiple definitions and characteristics of social support (e.g., interpersonal ties, actions involved in resource provision, and affective responses to support received)—common to all definitions is that “social support” always describes positive, and giving, aspects of social relationships All key aspects of Hispanic traditions are interconnected: They all encourage harmony in interpersonal relationships and provide strategies for avoiding interpersonal conflict (Triandis, Marín, Lisansky, & Betancourt, 1984). These values are the core of a cultural script that outlines the ways that individuals are to interact in order to maintain strong social relationships (Triandis et al., 1984). Familism is characterized by reciprocal family obligations, perceived support from the family, and the use of the family as a referent to decide one’s path in life and make decisions about actions (Garza & Watts, 2010). Marín and Marín (1991) highlighted familism as a value that is critical in promoting health. The investigators incorporated all these concepts into both interventions in the following ways: They used implementation strategies that emphasized group cohesion and reliance on other group members to encourage attendance at walking groups, intervention sessions, and support for walking (colectivismo). Familismo was enacted within intervention content and implementation strategies that planned for walking,
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included supportive family and kinship members, and made time for family and household obligations that incorporated “bouts” of walking. Incorporating familismo thus reinforced how an intervention that involves one individual can benefit an entire family. Each critical input of the intervention and intervention delivery included respeto and personalismo: During group activities, women role-played and practiced negotiations for mutual support from one another and from family and kinship members to assist them with walking and encourage these supportive persons to accompany them while walking. Knowledge about family issues and cultural values (“mi familia viene primero” [my family comes first], a phrase they repeated often) underpinned the intervention components that assisted women with time management by supporting the woman’s walking (Gonzales & Keller, 2004).
Final Thoughts on Developing >> Interventions
The extensive intervention work developed as prelude to Mujeres and Madres led to the model proposed here (Figure 1). Instilling social support, culture, and tradition into the intervention design helped the traditional Hispanic women in Mujeres and Madres engage in new, healthful behaviors to counter obesity. The approach helped a participant see, for example, how social skills, culture, and traditions interacted in ways that were beneficial if others participated with her in PA; it also helped her see that these same social skills might, on the other hand, have led her to spend more time in being social than in engaging in more PA behaviors that would decrease body adiposity. Simply appreciating the crucial role that life course, culture, and social support play within all social groups is insufficient to guarantee its successful application in any intervention; investigators must determine precisely how these factors operate within groups of participants who share a common history but are at varying levels of acculturation, have disparate cultural practices, and/or are at different stages of the life course. Thus, we argue that interventions aimed at improving health outcomes hold the greatest potential to be effective if they incorporate culture and traditions and yet are also mindful of ways that culture and traditions might work against improved outcomes. The responsibility of the investigator is to identify which aspects of culture and traditions are salient to the participants in an intervention and to make those aspects integral to the intervention design and implementation.
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