Manoj Sharma Shakeyrah Elmore Needs Assessment Using Social Cognitive Theory for Planning Childhood Obesity Intervention for African American Children Manoj Sharma Shakeyrah Elmore

Introduction…1 Childhood obesity is a major public health concern for the United States. Childhood obesity has tripled since 1980 African Americans are disproportionally affected by overweight and obesity. Healthy People 2020 estimates that the rate for the black populations is more than one and a half times the rate which is for their white non-Hispanic counterparts. Childhood obesity amongst African American children ages 2-19 is 35.9%. Obesity has a negative and deleterious impact on the physical, social, behavioral and psychological health of children

Introduction…2 It is estimated that the national health care expenditures related to overweight and obesity has increased by 68.5 billion dollars from 1998 to 2008 to about 147 billion dollars It is evident that more successful health education programs need to be implemented, particularly in the African American community that addresses ethnic and cultural differences. The development of obesity in the African American community is due to a number of influences, including genetic factors, cultural differences, such as those related to diet and social norms, which includes the acceptance of surplus weight

Health effects of childhood obesity Overweight and obesity are likely to persist into adulthood, children who are overweight or obese are more likely than their normal weight counterparts to be overweight or obese as adults. African Americans who are overweight or obese are more likely to have high cholesterol and high blood pressure, and other factors that increase the risk for heart disease and stroke which are the top two leading causes of death in the African American community and diabetes, which is the 4th leading cause of death in the population

Social Cognitive Theory Social cognitive theory provides a useful framework for designing primary prevention interventions to reduce childhood obesity in African American. The major personal level constructs of social cognitive theory include self-efficacy, self-control, and expectations Self-efficacy describes a person’s confidence in completing a particular behavior at a given moment. Self-control describes a person’s capability to regulate their behavior. Self-control includes strategies which encourage proximal and distal goal-setting, and self-rewards. Expectations are the anticipation of the outcome of a particular behavior and the value one places on those outcomes. Different types of expectations include physical outcomes, social outcomes which include approval and disapproval, and self-evaluated positive and negative reactions.

Purpose of the Study The purpose of the study was to examine the extent to which social cognitive constructs (self-efficacy, self-control, and expectations) can predict the four behaviors of limiting television viewing, performing daily moderately intense physical activity of at least 60 minutes per day, increasing fruit and vegetable intake to five or more cups per day, and increasing water consumption in upper elementary African American children.

Population and sample The sample population consisted of 4th through 6th grade African American students. There were 222 students who participated in the study. The sample population came from three public schools in two large Midwestern cities. In calculating sample size, power was set at 0.80 and alpha was set at 0.05, based on previous studies population correlation coefficient was assumed to be 0.20 and that yielded a sample size of 197. An approximate 10% inflation to the sample was done to account for missing values.

Design The design for the study was cross sectional. The dependent variables were the four behaviors and the independent variables for each behavior were the three constructs of social cognitive theory (self-efficacy, self-control, and expectations) along with gender, age and whether they had been taught about physical activity and nutrition in school.

Instrumentation A 56-item scale was developed and validated in a previous study in a two round process by a panel of six experts, which of whom included three university professionals and three experts from the school system. Cronbach’s alpha and test- retest reliability coefficients were found to be over 0.70 and thus acceptable.

Data Collection Data was collected between May and June in 2013. Institutional Review Board (IRB) permission from the parent University was obtained before initiating the study. Permission was also obtained from principals of the schools before distributing parental permission slips. Parent permission was also obtained. Child assent was obtained through an age appropriate brief write-up, which was presented before beginning the instrument. Inclusion criteria for participation in the study were being a 4th through 6th grade student, being identified as African American, having permission from a parent, and giving child assent.

Results…1 Age: Ranged from 9 to 13 years old. 69 (33.2%), were 11 years old, 68 (32.7%), were 10 year olds, 48 (23.1%), were 12 year olds, 16 (7.7%), were 9 years old, and 7 (3.4%) were 13 years old. Gender: An equal amount of male, 104 (50%) & female, 104 (50%). Race: All of the participants identified themselves as African- American 208 (100%). Healthy eating sessions: More than half of the students (53.4%) had been exposed to three or more sessions about healthy eating in school, 51 (24.5%) to two sessions, 35 (16.8%) to one session, and 9 (4.3%) had not been exposed to any sessions about healthy eating in school. Physical activity sessions: One-hundred and twenty-six (60.6%) of the students had been exposed to three or more sessions in school about engaging in physical activity or exercise at home, 44 (21.2%) to two sessions, 25 (12%) to one session, and 10 (4.8%) had not been exposed to any sessions in school about engaging in physical activity or exercise at home.

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Discussion…1 The mean number of glasses of water consumed in a day was 4.33, which is less than the recommendation of 8 or more glasses of water per day. In the case of drinking water, self-control for drinking water (p<0.012) and self-efficacy for drinking water (p<0.047) were significant predictors. These are two important constructs of social cognitive theory and emphasize the need for building behavior specific confidence and self-control to modify water drinking behavior in African American children. These findings are different from the findings done in a study with predominantly white children in which the significant construct was expectations. Perhaps for African American children the constructs of self-efficacy and self-control are more important.

Discussion…2 The mean number of fruits and vegetables consumed for sample population was 4.27, which is slightly below the recommendation of 5 or more servings of fruits and vegetables per day In the case of eating fruits and vegetables, self-efficacy for eating fruits and vegetables was the only significant predictor (p<0.001). The other two constructs of self-control and expectations were not found to be significant predictors. These findings are similar to the findings done in a study with predominantly white children in which also the significant construct was self-efficacy. The most important construct in social cognitive theory is claimed to be self-efficacy and this study is indicating that assertion.

Discussion…3 In the case of physical activity there were no significant predictors. The mean score of physical activity was 73.72 minutes, which is more than the recommendation of 60 minutes per day. These findings are different from the findings done in a study with predominantly white children in whom the significant constructs were self-efficacy and number of times taught in school. In this study we had selected only the personal level constructs of social cognitive theory and did not reify environmental constructs. For African American children the constructs of environment and situational perception are also important. Future studies must focus on these constructs.

Discussion…4 In the case of watching television also there were no significant predictors. These findings are different from the findings done in a study with predominantly white children in whom the significant constructs were self-control and number of times taught in school. Once again in this study we had selected only the personal level constructs of social cognitive theory and did not reify environmental constructs. For African American children the constructs of environment and situational perception are also important. The students in these particular groups may not have access to a TV or cable, which in turn prevents them from watching more TV.

Limitations First, random selection of subjects was not used in this study; this introduces the possibility of sampling bias. Second, to measure primary dependent variables participants were asked to do a 24-hour recall. While this method increases accuracy, student’s answers may not represent a typical day for the participant. Third, self-report was used for the entire instrument, this introduces measurement bias. However to decrease measurement bias and account for varying levels of readability, the instrument was read to the participants. Finally, nothing can be discussed about the temporality of association, because the study was cross-sectional in nature.

Implications for practice According to the results of the study it is apparent that more health promotion and education programs need to be targeted specifically to African American children. An increase in programs that promote limiting television viewing, encouraging daily physical activity, increasing fruit and vegetable intake, and increasing water consumption, also need to be implemented in the African American community. Social cognitive theory offers an excellent framework to design such programs and interventions for African American youth. In order to build expectations the benefits of these behaviors must be highlighted. For developing self-efficacy breaking down each behavior into small steps, using role models, reducing stress and using persuasion must be utilized. For building self-control goal setting and self-rewards are helpful. Interventions can be implemented by health and physical education teachers.