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Designing culturally sensitive dietary interventions for African Americans: review and recommendations Jennifer Di Noia, Gennifer Furst, Keumjae Park, and Carol Byrd-Bredbenner Despite consensus that dietary intervention programs should be culturally sensitive, relatively little is known about approaches to developing culturally sensitive interventions. With a focus on African Americans, the present review summarizes the existing literature on cultural considerations when working with this population and suggests strategies for the development of culturally sensitive interventions to modify the dietary practices of African Americans. Interventions to improve dietary behaviors and nutritional status among African Americans are needed urgently in order to reduce morbidity and mortality from diet-related diseases in this population. Findings are intended to serve as a guide for future research and practice on culturally sensitive approaches for effecting such changes. © 2013 International Life Sciences Institute

INTRODUCTION African Americans are disproportionately affected by diabetes, obesity, hypertension, cardiovascular diseases, and cancer,1–5 conditions that are related, in part, to dietary factors.6–8 Interventions to improve the dietary practices of African Americans are urgently needed to reduce morbidity and mortality from diet-related diseases in this population.9 To enhance program relevance and impact, interventions should be culturally sensitive; i.e., they should incorporate into their design, delivery, and evaluation African American cultural characteristics (experiences, norms, values, beliefs, and behavioral patterns) and related historical, environmental, and social influences on behavior.10 Although scholarship on African American culture has flourished, with numerous guidelines published on approaches for effectively working with this population in clinical and research settings (Table 1),10–25 applications to the development or modification of interventions specific to African American dietary practices are lacking. Drawing from previous guidelines, the present review summarizes information on cultural considerations when working with African American audiences and suggests

strategies for the development of culturally sensitive interventions to modify the dietary practices of African Americans. Guidelines from such diverse disciplines as nutrition, psychology, public health, and health communication were included in the review to provide a comprehensive and cross-disciplinary assessment of the literature. Mindful of the lack of research examining cultural influences on African American dietary practices and the effectiveness of approaches for enhancing the cultural sensitivity of dietary interventions designed for African American audiences, the focus is on summarizing the literature rather than evaluating the state of the evidence. Findings are intended to serve as a guide for future research and practice on culturally sensitive approaches for improving dietary practices and nutritional status in this population. CULTURAL CONSIDERATIONS Heterogeneity of the African American population According to Arthur and Katkin, included are “immigrants from Africa, Central and South America, and

Affiliations: J Di Noia, G Furst, and K Park are with the Department of Sociology, William Paterson University, Wayne, New Jersey, USA. C Byrd-Bredbenner is with the Department of Nutritional Sciences, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA. Correspondence: J Di Noia, Department of Sociology, William Paterson University, 300 Pompton Road, Wayne, NJ 07470, USA; E-mail: [email protected]. Phone: +1-973-720-3714. Fax: +1-973-720-3522. Key words: African Americans, cultural sensitivity, dietary intervention 224

doi:10.1111/nure.12009 Nutrition Reviews® Vol. 71(4):224–238

Table 1 Published guidelines on working with African American audiences. Reference Application Content focus Counseling the disabled Family strengths; application of family strengths model to the Alston et al. (1994)11 counseling process Development of health Barriers to communicating health information; strategies for Anderson (1995)12 promotion and disease effective communication development prevention messages Development of clinical trials Approaches to improving cultural sensitivity in clinical trials; Ard et al. (2003)13 for prevention of model for the development of culturally sensitive trials cardiovascular disease Counseling for patients in Cultural influences on behavior; culturally sensitive Artinian & Franklin cardiac rehabilitation counseling strategies (2010)14 Bell-Tolliver et al. Psychotherapy with families Family strengths; strategies to incorporate strengths; (2009)15 importance of using the strengths to achieve successful therapy outcomes Development of nutrition Issues to consider when designing interventions Bronner (1995)16 interventions to prevent coronary heart disease Nutrition counseling for Background and traditions of soul food; comparison of soul Bronner et al. (1994)17 individuals consuming a food intake with dietary guidelines; nutrition counseling “soul food” diet techniques Nutrition counseling for Cultural influences on food habits and diet adherence; Burrowes (2004)18 patients with end-stage cultural food preferences; impact of preferences on the renal disease renal diet; cross-cultural nutrition counseling strategies Participation in research Barriers to participation; strategies to increase participation Huang & Coker (2010)19 Development of health Cultural characteristics; targeted and tailored approaches to Kreuter et al. (2002)20 interventions developing culturally sensitive health interventions Kumanyika et al. (2007)21 Obesity research Culturally sensitive content themes and research methodologies Psychological counseling Afrocentric worldview; treatment issues; treatment Morris (2001)22 recommendations Development of interventions African philosophy and African American cultural precepts; Nobles & Goddard to prevent substance abuse African-centered model of substance abuse prevention (1993)23 in adolescents Development of health Cultural influences on behavior; model for understanding Resnicow et al. (1999)10 interventions cultural sensitivity; application of the model to program development Cross-cultural psychotherapy Influence of oppression and mistrust on psychological Stevenson & Renard functioning; family strengths; therapeutic application of (1993)24 family strengths Recruitment and retention of Barriers to and facilitators of recruitment and retention Yancey et al. (2006)25 research participants

English-, French-, and Dutch-speaking Caribbean nations and their descendants, as well as descendants of slaves and American Blacks who were free during the centuries of U.S. slavery.”26 (p. 29) Although African Americans share common experiences (e.g., racial discrimination and the history of slavery and related sociopolitical legacies for the majority who are US born), there are important differences within the population that affect factors associated with health-compromising behaviors, motivation to change behaviors, and responsiveness to health interventions.19,21 It is important to recognize variations within groups by ethnicity and nativity while assuming differences between individuals.26 Nutrition Reviews® Vol. 71(4):224–238

Historical legacy Scholars have discussed the culture of distrust toward whites, with its origins in slavery, as well as contemporary examples of research abuse and various forms of institutionalized racism that have helped to sustain it.19,21,27 Cultural mistrust influences the likelihood of receiving preventive health services, including dietary counseling; participation in nutrition interventions; trust in healthcare providers; treatment adherence; and satisfaction with care.27–33 Cultural mistrust also is related to concerns about privacy and how personal information will be used,27 beliefs regarding whether experiences with racism 225

will be understood,34 and fear of continued discrimination.35 Greater comfort eating at home than in a restaurant (including preferences for taking restaurant meals out and eating them at home)36 and concerns that many health problems are related to genetic engineering and other food technologies37 may also be related to a sense of distrust. Perceptions of mistrust of scientific investigators, government, and academic institutions limit participation in health-related research.25 Fear of mistreatment and exploitation is common, as are concerns that research findings will be used to advance researchers’ careers and portray communities in a negative light rather than to aid in addressing community health problems.25,38 Slavery is the primary historical circumstance that altered indigenous African food practices.36 The traditional African diet, high in complex carbohydrates and low in meats and fat, was in line with current dietary recommendations.39 During slavery, dietary changes were shaped by such forces as limited time for selection, procurement, and preparation of food; lack of utensils and food-preparation equipment; lack of written recipes for food preparation; lack of adequate storage facilities; the use of spices to flavor unappealing foods and to cover tastes related to spoilage; the need for extended boiling to tenderize tough cuts of meat and wild vegetation; and the practice of seasoning food with fat to make foods more palatable.17 Passed down through several generations, many of these practices are common today, e.g., cooking the ingredients of a meal together or “one-pot” meals, seasoning vegetables with fat and meat, serving the liquid used to cook the greens (“pot likker”), reusing oils, fats, and grease to flavor foods, and the liberal use of spices to create unique flavors.17,36,39 Positive aspects of contemporary diets include a high intake of nutritious foods (e.g., vegetables, fruits, legumes, fish, and poultry) and the family tradition of eating together, whereas negative aspects are related to food-preparation methods (i.e., flavoring food with salt, sugar, and fat; the use of frying and deep-fat frying methods; and the boiling of food for long periods, which lowers the potency of water-soluble vitamins).17,36,40 Contemporary diets also tend to be low in calcium due to low dairy food consumption.41,42 Although this is partially explained by lactose intolerance, culturally determined food preferences and dietary practices also play a role.42 Socioenvironmental stressors The historical legacy of slavery and the ongoing forms of systematic discrimination are linked to added stressors that limit opportunities for African Americans to engage in healthy lifestyle practices.43,44 The limited availability of healthful food, the targeted marketing of unhealthful food, and such socioeconomic stressors as poverty and 226

low literacy influence African American food choices and responsiveness to health interventions. Neighborhood context and media influences. Neighborhood wealth and racial segregation are among the factors influencing access to healthful food.45,46 Higher densities of fast-food restaurants and fewer supermarkets (which tend to offer the greatest variety of high-quality products at the lowest cost)47 are found in predominantly African American neighborhoods as compared with white neighborhoods.45,46,48,49 Relationships are found between eating at fast-food restaurants and higher total and saturated fat and sodium intakes and lower vegetable intakes.50,51 A lack of locally available supermarkets may also encourage families to shop in small corner stores or bodegas, where the price of healthful food tends to be higher.52,53 There is also evidence of targeted marketing of high-calorie foods to African Americans.54,55 Greater numbers of food advertisements are aired during African American television programs than during programs intended for a general audience, and a greater share of the advertisements are for energy-dense foods.55 Exposure to advertising for energydense, nutrient-poor foods may increase consumption of these foods, particularly among children.56 Magazines targeted to African American adults also are dominated by advertisements for low-cost, energy-dense foods and are less likely to contain health-oriented messages.57,58 Such an imbalanced information environment may limit awareness of and the ability to choose healthful foods.59 Poverty. African Americans are disproportionately represented in poverty statistics. Although the poverty rate for the US population is 15.1%, the rate among African Americans is 27.4%.60 The poor often live and work in substandard conditions that may make healthy eating a low priority.16 Their food-shopping practices are shaped by a number of constraints, such as lack of transportation, child care, and time for food shopping, and inadequate food-storage conditions (e.g., lack of adequate refrigeration and pest-free dry storage areas).61 Low-income adults shop less often than do their higher-income counterparts, in part due to the disbursement schedule of supplemental nutrition-assistance benefits (i.e., food stamps) and other income subsidies.62,63 Dietary intakes may therefore be highly variable in response to fluctuations in the household food supply.64,65 Concerns about the risk of waste may also limit willingness to introduce new foods.66 Low literacy. Limited literacy (i.e., the ability to use printed and written information)67 and numeracy (i.e., the ability to use quantitative information, including information in nontext formats, and basic computational skills)68 skills are associated with difficulty in Nutrition Reviews® Vol. 71(4):224–238

comprehending health information (e.g., understanding nutrition labels), decreased use of health information and services, and poor disease knowledge and selfmanagement.69–71 According to the National Assessment of Adult Literacy, African American adults were among the groups overrepresented in the below-basic prose literacy level.67 This translates to difficulties in locating information in short simple texts or documents.67 Historically, African Americans faced a myriad of social and legal restrictions in the realm of education. It is important to understand these experiences and their potential effects on the assimilation of information important for dietary change.16 Some individuals may have deficits that prevent them from applying dietary guidelines and from participating in health interventions.16 Special attention to numeracy skills may be particularly important in light of previous work demonstrating that, despite adequate literacy skills, many individuals still lack adequate numeracy skills.70 Racial/ethnic identity Racial/ethnic identity refers to the extent to which individuals identify with their racial/ethnic group psychologically and socially and includes such elements as affinity for in-group culture (food, media, and language), attitudes toward the majority culture, and the importance placed on aiding others of a similar background.10 Studies of African-descent populations reveal ethnic and regional differences in food intake and variations between US- and foreign-born groups, including preferences for foods not found on standard dietary questionnaires.18,36,40,72–76 It has been suggested that many food practices are culturally defined and are used consciously or unconsciously to affirm group identity.18,36,37 African Americans associate particular foods, cooking techniques, and flavorings with being African American,36,77 and the extent to which they view certain practices as more typically African American is related to the perceived importance and frequency of enactment of such practices.78 There is also evidence that traditional foods have connotative meanings related to preserving or passing on family traditions, providing a sense of familiarity and comfort, and enabling expressions of caring and respect.36,37,79,80 Body image ideals African Americans are more comfortable with larger body sizes and find larger body sizes attractive, even those considered overweight by biomedical standards.81,82 Their greater comfort with larger body sizes has been attributed to a number of factors, as follows: 1) heavier bodies are equated with prosperity in cultures characterized by a scarcity of food, and thus African Americans, Nutrition Reviews® Vol. 71(4):224–238

many of whom have had to struggle with poverty, value heavier weights as ideal83; 2) African Americans develop alternative standards of beauty as a result of their stigmatization in society, thereby allowing them to resist mainstream ideals in favor of more positive selfdefinitions84; 3) women tend to believe that African American men prefer larger body sizes85; 4) women tend to describe themselves as masculine and androgynous, traits associated with higher levels of body satisfaction85; 5) a larger body size is related to adaptive elements, e.g., to convey strength and power and to afford protection from violence21; and 6) cultural ideals often equate healthy eating with eating a lot of food.17 A preference for larger body sizes may be protective against disordered eating, which is less common among African Americans than among whites.86–88 These findings highlight the importance of understanding perceived needs and motives for weight loss when this is a focus of intervention. There may be willingness “to take some weight off” but not to a dramatic reduction in weight.17 Moreover, the desire to lose weight may be driven by motives other than thinness (e.g., to be muscular and shapely, to improve health, or to fulfill important social roles).10,13,37 It has been suggested that programs may first need to identify alternative ways to address underlying concerns regarding weight issues.21

Centrality of women Many African American women are heads of households with respected and influential roles in family, religious, civic, and other social networks, including roles related to food purchasing and preparation.21,37,89 Mothers occupy a central role in caring for families and preserving cultural traditions.89 Families are matrifocal (women-centered); kin are held together through an extended line of women, grandmothers, and daughters.89 “Other-mothers” (women unrelated by blood who take on mothering roles), grandmothers, and community mothers are indispensable in the rearing of children.89 Because family members’ eating habits are influenced by the eating habits of the person who prepares the majority of the family’s meals,90 targeting women in this position may therefore benefit other household members. There is also evidence that female friends and relatives are considered important sources of health information, and that married men rely on wives to make family nutrition decisions.37 The centrality of women in family life highlights the importance of 1) engaging mothers, grandmothers, and other female role models in the design and delivery of dietary interventions, and 2) understanding the perspectives of women on the need for, and the barriers to, dietary change.21 227

Afrocentric worldview The Afrocentric worldview is a set of beliefs, values, and assumptions common among populations of African descent.23,24,91–95 These assumptions operate as a blueprint for individuals to live by and to make sense of the world.95 Although there is heterogeneity among individuals in endorsements of core beliefs, this worldview is assumed to be central to substantial numbers of African Americans.92 Spirituality. This concerns belief in a force greater than oneself95; spirit is viewed as the basis of existence.91 This nonmaterial spiritual reality emphasizes such character traits as integrity, trustworthiness, and compassion.95 Optimal functioning occurs when one is well connected to this life force.24 Spirituality also encompasses aspects of religious involvement, including, for example, organizational participation (e.g., church attendance) and nonorganizational activities (e.g., use of religious media and daily prayer).96,97 Positive relationships are found between dimensions of religiosity and healthful dietary practices.98–100 It has been suggested that religious involvement influences health by advocating a healthy lifestyle, sanctioning against health-compromising behaviors, providing social support and positive affective experiences, and fostering positive self-perceptions.98 Dimensions of African American spirituality (e.g., faith in a transcendent force, personal relationships with God, and expressions of the transformative and consoling dimensions of spirituality) may also provide guidance for maintaining health, increase self-efficacy and feelings of personal control, and promote active coping.101,102 In focus groups with African American church members, the importance of spirituality in guiding health decisions was discussed. Changing dietary practices to be healthier was considered possible with God’s help.103 Collectivism. This is the assumption of interrelatedness and connection to others.92 Emphasis is on prioritizing the goals of the family and ethnic group and collective survival and advancement.20,91 Optimal functioning occurs when one participates in sharing with and supporting in-group members.24 African Americans are more likely than European Americans to hold collectivist beliefs.104,105 Collectivist beliefs and practices such as the importance of kinship relations, a willingness to absorb others into the household, and informal adoption are culturally distinctive features of family life.106 Gatherings with extended family are common, and food is a large part of this tradition.37 Themes pertaining to the functional meaning of food include feelings of duty to provide meals for someone else in the family, belief in the value of 228

bringing family members together through food, and caring for the nutrition and health of family members.107 Strong kinship bonds can benefit families by providing social support for healthy eating practices. Support from family and friends is associated with healthful dietary practices.108–110 Time orientation. This refers to the equal importance given to past, present, and future and time flexibility.95 Events are not considered discrete but instead as flowing into one another, and their timing is not dictated by the clock or by appointments.92 African Americans and individuals of lower socioeconomic status tend to be oriented more to the past and present than to the future.111–114 Compared with European Americans, African Americans are also more likely to use relative time (e.g., not exact or approximate) than mathematical time, which quantifies a time period.115 It has been suggested that orientation toward the present is more salient in African American culture, owing to the following: 1) a perception of time as circular rather than linear and the expectation of a future that is similar to the past, and 2) experiences with institutionalized racism that have served to provide disconfirming evidence of one’s influence on future outcomes.116 Health promotion is future oriented,12 and a future orientation is related to positive health outcomes.117–119 This highlights the importance of increasing awareness among African Americans of links between current dietary practices and long-term health outcomes.14,20 Orality. This refers to the importance placed on knowledge gained and transmitted by word of mouth, including the use of indirect forms of communication (e.g., body movements) to convey ideas.92,93 Reliance on call-andresponse, a spontaneous verbal and nonverbal interaction in which the speaker’s statements are punctuated by responses from listeners, is common; to be quiet and wait one’s turn to speak often implies lack of interest in what is being said.94,120 There is some evidence that African Americans prefer to receive health information via informal channels involving person-to-person contact121–123 and that low-income individuals are less likely to benefit from materials delivered in traditional formats (e.g., written self-help materials).124 In focus groups with African Americans, group education about prescribed dietary regimens, in combination with peer discussion, was specifically requested, and ideas for promoting healthy eating included educational sessions and sharing, with an emphasis on group support.103,123 Sensitivity to affect and emotional cues. This refers to the importance of emotional expressiveness and of being in tune with the feelings and emotional needs of others.24,92 Nutrition Reviews® Vol. 71(4):224–238

Research with African Americans has shown that affect sensitivity is a predictor of empathy,125 a factor associated with prosocial behavior.126–128 The protective effects of emotional expressiveness on physical and mental health outcomes has also been documented.129–132 This may explain the effectiveness of intervention approaches that incorporate emotion-focused activities for exploring feelings regarding dietary change and those premised on the expression of empathy for respondents’ personal needs and concerns.133–135 In a study of adults receiving weightloss counseling from primary-care physicians, Cox et al.135 found that improvements in fat and fiber intake occurred among those who rated physicians higher on empathy. The expression of empathy is also a key tenet of motivational interviewing, an intervention approach found effective in promoting positive dietary change in African American and other populations.136,137 Multidimensional perception and verve. This refers to learning preferences for visual, auditory, tactile, and motor channels simultaneously; rhythmic and creative behavior; and a simultaneous focus on multiple concerns rather than only one.24,92,95 African American parents and children prefer cultural value-based communal and vervistic activities in home and school settings over individualistic and competitive practices reflective of mainstream values.138,139 Exposure to culturally matched strategies enhances academic performance.140,141 Learning is optimized through motion and movement, music, variability in tasks and formats, novelty, and dramatic elements.142–144 Use of vervistic instructional elements (e.g., rhythmic language, gestures with instances of repetition, communication characterized by call and response, variations in pace, opportunities for high emotional involvement, creative analogies, figurative language, and lively discussions with frequent and spontaneous learner involvement)144 may therefore enhance understanding and retention of dietary intervention program content. Harmony. This assumes that all aspects of one’s life (i.e., physical, mental, and spiritual states) must be in balance in order to function optimally, including belief in the importance of contributing to harmonious interactions with others.24,96 Among African Americans, stress and disease are often attributed to a lack of harmony or balance in self or the environment.145,146 Research on cognitive styles reveals that African Americans are field-sensitive (relational) learners; they tend to be global in their views, to rely on cues from the environment and situational context for interpreting meaning, and to thrive when provided with opportunities to share information with others.147–149 African Americans also exhibit a collective coping style that involves reliance on group-centered activities to Nutrition Reviews® Vol. 71(4):224–238

promote harmony and balance for dealing with stressful life situations.150,151 The value placed on harmony suggests the utility of mind-body intervention approaches and program messages emphasizing interconnectedness of body, mind, and spirit.152,153 Learning may be enhanced through relational and group-based instructional approaches emphasizing social interaction, social learning, and the value of working with others.154 A key consideration is the extent to which members of an individual’s social network will support dietary changes and the priority placed on such changes relative to other family and community responsibilities.155 Expressive individualism. This refers to spontaneous expression of self, i.e., one’s stamp of uniqueness in style and behavior.24,156 People are assumed to be interdependent but can demonstrate a style that is uniquely their own.24 Examples include improvisations in movement, music, clothing, walking style, athletic performance, and language.156–159 Expressive individualism is an important component of African American learning styles, with creative, adaptive, novel, and simultaneous stimulation preferred.149 This highlights the importance of using instructional elements that resonate with learning preferences. Creating opportunities for participants to generate unique solutions to problematic aspects of their dietary behavior and to share personal narratives or testimonials that allow for self-expression (e.g., motives for and obstacles to dietary change, and examples of past successful performances) may have added benefits.155 The persuasive value of testimonials over factual information has been documented, in particular, among individuals who lack motivation to change their dietary behavior.160,161 Negativity to positivity. This refers to the value placed on turning a bad situation into a positive one, including the ability to see something good come from something bad.92 This phenomenon has been interchangeably referred to as “benefit finding,” “finding the silver lining,” “positive consequences,” and “positive reframing.”162 There is evidence of associations between the ability to derive positive meaning from negative life events and positive health and mental health outcomes (e.g., improved mood as well as reduced stress, fatigue, and morbidity).163–166 Individuals who exhibit this ability may therefore benefit from program messages and content designed to encourage reflection on beliefs and practices that have enabled prior successful coping to minimize stress, a factor associated with unhealthful dietary practices,167–169 or to overcome lapses in progress toward desired dietary changes, which are common.170 229

Family strengths African American families have been characterized by a number of strengths, notably kinship bonds, role flexibility, and a strong religious orientation, as previously discussed. Families also value hard work and academic achievement, which are seen as vehicles for overcoming societal barriers to upward mobility.15,171,172 Parents instill these values using achievement-oriented teachings and by encouraging children to share family responsibilities, e.g., household and child-rearing tasks.172 Some family members may be encouraged to contribute financially to the cost of another’s education.172,173 The emphasis on personal and academic achievement suggests the utility of goal-directed program messages (e.g., those relating dietary change to the attainment of personal life goals) and goal-directed activities (e.g., setting goals, monitoring progress toward goals, and rewarding goal attainment) shown effective in promoting dietary change.174–176 STRATEGIES FOR DEVELOPMENT OF CULTURALLY SENSITIVE INTERVENTIONS Designing culturally sensitive dietary interventions for African Americans requires awareness of cultural considerations when working with this population. Equally important is an understanding of how to apply this information. Summarized below and grouped according to the cultural considerations discussed in the first part of this review are suggested strategies for enhancing the cultural sensitivity of interventions to modify African American dietary practices. Cultural considerations, definitions, and strategies for culturally sensitive intervention development are summarized in Table 2. Heterogeneity of the African American population Achieve knowledge of the targeted population’s culture. Clearly define the targeted population with respect not only to race but also to ethnicity, nativity, and geographic location. Become knowledgeable of eating patterns and cultural influences on food consumption, including differences by ethnicity and between US- and foreign-born groups.18 This can be achieved by familiarizing oneself with relevant texts and journal articles, attending professional trainings on cross-cultural assessment and intervention, working with well-informed members of the targeted audience, and asking questions of other professionals who are either members of the targeted audience or who work with this group.18 Shopping in neighborhood stores and markets that cater to audience members to learn about the availability and cost of foods also is recommended.18 Because targeted dietary outcomes are often identified a priori (i.e., during the planning stages of 230

a project), assessing the intakes of targeted foods or nutrients is suggested to confirm that intervention is warranted. This may require modifications to standardized measures to capture preferred foods, portion sizes, and preparation methods. Maintain awareness of personal biases. Examine one’s values, biases, worldview, and comfort working with individuals whose cultural backgrounds differ from one’s own.14,18,19 Self-administered tools for assessing culturally competent knowledge, attitudes, and skills are invaluable in this endeavor (see Gozu et al.177 for a review of available tools). Maintain awareness of personal biases through mentorship from and ongoing consultation with professionals who are skilled in working with African Americans.178 Attend workshops and trainings designed to build multicultural competencies.178 Immerse oneself in targeted communities to overcome ethnocentrism and enhance cultural awareness.179 Read educational materials on effectively working with African Americans (e.g., Hampton et al.180). Stay current in best practices via ongoing training and online educational materials and resources181 (e.g., websites of the Office of Minority Health [https://www.thinkculturalhealth.hhs.gov/Content/ ContinuingEd.asp] and the Health Resources and Services Administration [http://www.hrsa.gov/culturalcompetence/ index.html]). Historical legacy Establish and maintain trust. Conduct formative research to explore potential suspicions among community members regarding motives for the planned work, including concerns about taking from and not giving back to the community.19 Acknowledge historical influences on trust, and appreciate that concerns are based in historical reality.19 Become involved in targeted communities through participation in events that are unrelated to the planned work, share motives for the work, and initiate discussions of trust and distrust.19,21,25,182 Design interventions to give back to the community through long-term sustainability and broader diffusion.182 Use community-based participatory approaches to involve community members in all phases of the work.183 This includes participation in setting the goals and focus of the intervention and in program design, implementation, and evaluation.184,185 Community forums and partnerships with local organizations are vital for identifying local priorities and concerns as well as the intervention strategies and levels of organizational involvement necessary for achieving agreed-upon goals.183,186 Participatory approaches are essential for building and maintaining trust with community members, nurturing community strengths and problem-solving abilities, and Nutrition Reviews® Vol. 71(4):224–238

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Table 2 Cultural considerations, definitions, and strategies for development of culturally sensitive interventions. Cultural Definition Strategies for culturally sensitive intervention development consideration Heterogeneity Assumption of differences – Define the targeted population with respect to race, ethnicity, nativity, and geographic location – Become knowledgeable of eating patterns and of cultural influences on food consumption – Assess intake of targeted foods or nutrients – Examine one’s values/comfort working with individuals whose cultural backgrounds differ from one’s own – Maintain awareness of personal biases Historical Influence of slavery and other – Explore concerns regarding motives for the work legacy forms of inhumane treatment – Acknowledge historical influences on trust on cultural distrust and on – Build trust and mutual respect by becoming involved in targeted communities through participation in traditional food practices events that are unrelated to the work, sharing motives for the work and initiating discussions of trust and distrust – Design interventions to give back to the community through long-term sustainability and broader diffusion – Use community-partnered approaches to engage audience members in all phases of the work – Explore meanings of food that may inhibit/facilitate change – Raise awareness of healthful aspects of traditional diets – Encourage moderation in the consumption of less healthful dishes, and promote healthful recipe modifications Socioenvironmental Effects of neighborhood context, – Host activities/events where only healthful food is offered stressors media influences, poverty, and – Provide transportation and food as program incentives low literacy on healthy eating – Build skills for shopping for food on a limited budget opportunities – Develop policy interventions to establish farmers’ markets and supermarkets in underserved areas, to expand food and nutrition assistance programs, to facilitate institutional procurement of local and regional agricultural products, and to limit the marketing of unhealthful foods – Adapt materials for learners with low literacy/numeracy skills – Use low-literacy-oriented nutrition education materials – Ask learners to “teach back” information – Use educators skilled in teaching low-literate groups – Use promising modalities for reaching low-literate groups (e.g., audiovisual materials and interactive multimedia) Racial/ethnic Extent of identification with one’s – Use cultural targeting and tailoring to enhance the relevance of program materials and messages identity racial/ethnic group, both psychologically and socially Body image Comfort with/perception of larger – Raise awareness of relationships between body image ideals and weight-related beliefs and behaviors ideals body sizes as attractive Centrality of Influential role of women in – Include women as a key focus of intervention women family, religious, civic, and – Engage mothers, grandmothers, and other female role models in program design and implementation other social networks, – Incorporate women’s unique needs and perspectives on the importance of and the barriers to dietary including roles related to food change purchasing and preparation

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Importance placed on knowledge gained and transmitted by word of mouth Importance of being in tune with the feelings and emotional needs of others, and importance of emotional expressiveness Learning preferences for visual, auditory, tactile, and motor channels simultaneously Assumption that physical, mental, and spiritual states must be in balance; importance placed on contributing to harmonious interactions with others Spontaneous expression of self; one’s stamp of uniqueness in style/behavior The value placed on turning a bad situation into a positive one; seeing something good come from something bad Belief in the value of education and hard work

Orality

Achievement orientation

Negativity to positivity

Expressive individualism

Multidimensional perception/ verve Harmony

Affect sensitivity

Equal importance given to past, present, and future; time flexibility

– Consider the church/faith community as an important venue and partner for implementing interventions – Explore church-based traditions surrounding food and eating that may influence health

Belief in a force greater than oneself; various aspects of religious involvement Assumption of interrelatedness and connection to others

– Use goal-directed messages, e.g., those relating dietary change to the attainment of personal life goals – Incorporate goal-directed activities (e.g., setting goals, monitoring progress, and rewarding goal attainment)

– Encourage reflection on thoughts and feelings that have enabled prior successful coping to minimize stress and to address lapses in progress toward dietary change goals

– Create opportunities for self-expression (e.g., testimonials, showcase of lessons learned, or unique solutions identified for addressing problematic aspects of eating behavior)

– Use mind-body intervention approaches and messages emphasizing interconnectedness of mind, body, and spirit – Use relational and group-based instructional techniques that emphasize social interaction, social learning in groups, and the importance of working with others

– Use vervistic instructional techniques to optimize learning

– Use emotion-focused activities (e.g., grieving losses, role playing, and psychodrama) to encourage exploration of feelings related to dietary change – Employ empathy-based approaches (e.g., motivational interviewing) premised on “tuning in” to participant concerns as a prerequisite for change

– Encourage the involvement and support of family, extended family, and fictive kin, particularly influential role models who may be unreceptive to dietary change – Nurture the value of collectivism using group modalities – Increase self-awareness of variations in temporal orientation to minimize the potential for the use of flexible and relative time to be viewed as a sign that participants lack motivation or are noncompliant – Help participants make connections between current dietary practices and future health outcomes – Raise awareness of variations in time orientation that may influence health-related decisions and behavior – Use delivery channels involving person-to-person contact – Incorporate narratives, participant talk in learning situations, and activities that rely on talking versus writing

Strategies for culturally sensitive intervention development

Definition

Time orientation

Collectivism

Table 2 Continued Cultural consideration Spirituality

increasing social capital, community capacity, and ownership of health programs.183,184 By design, they ensure a “do with” rather than a “do to” approach to program development that is essential to individual and community empowerment.186 Acknowledge the cultural meanings of food. Traditional food practices are often an important component of cultural identity, and maintaining these practices is seen as a way of sustaining this identity.18 Explore connotative meanings of food, particularly those that may inhibit or facilitate change. Formative research with audience members is recommended for accomplishing this goal.10 Provide education on healthful aspects of traditional food practices and on the health benefits of consuming particular foods or groups (see http://www.nal.usda.gov/ fnic/pubs/ethnic.pdf for cultural and ethnic food and nutrition education materials).187 Encourage moderation in the consumption of less healthful dishes and modifications to meal ingredients and preparation methods to make meals more healthful.17,36 Cooking demonstrations with taste tests may be particularly helpful for enhancing acceptance of suggested recipe modifications.17 Using role models from the community to deliver educational materials may enhance receptivity to this content. The use of culturally appropriate food guides may also be helpful for increasing awareness of intakes of cultural and ethnic foods that are in line with recommendations. Socioenvironmental stressors Improve access to healthful food. Host events and activities where only healthful food is offered.187 Provide transportation and free food as incentives to program participation.37 Build meal-planning and mealpreparation skills, including skills for shopping for food on a limited budget.37 Although beyond the scope of group-based intervention approaches described herein, policy interventions to establish neighborhood farmers’ markets and supermarkets in underserved areas, to make healthful foods inexpensive to procure, to expand food and nutrition assistance programs, to facilitate institutional procurement of local and regional agricultural products, and to limit the marketing of unhealthful foods, particularly to children, are also needed.187,188 Adapt materials for individuals with low literacy and numeracy skills. Simplify language, organize information into logical blocks, use specific rather than general messages, reinforce the most important messages, and frame messages in a personal context, i.e., with a focus on tangible rather than technical or clinical benefits of dietary change.189 Pretest materials and conduct a readability assessment (see http://www.cdph.ca.gov/programs/cpns/ Nutrition Reviews® Vol. 71(4):224–238

Documents/Network-DevelopingLowLiteracyMaterials. pdf and http://www.cancer.gov/cancerinformation/ clearandsimple for guidance on these tasks). Improve literacy and numeracy skills through the educational system or adult literacy programs.70 Use low-literacyoriented nutrition education materials (e.g., http:// www.nal.usda.gov/fnic/pubs/bibs/edu/health_literacy. pdf).10 Ask learners to “teach back” information to confirm understanding.70 Use delivery agents who have specialized training and skills to educate individuals with low literacy and numeracy skills.70 Because reading may play less of a role in the transmission of information, accompany written materials with social interventions.16 Use delivery modalities that show promise for reaching low-literate groups (e.g., audiovisual materials and interactive multimedia).190 Racial/ethnic identity Use cultural targeting and tailoring to enhance program relevance and impact. Cultural targeting is the use of a singular set of program messages that take into account cultural characteristics common among audience members, whereas cultural tailoring encompasses the design of program messages and content to reflect individual differences in the relevant characteristics (for examples of cultural targeting and tailoring approaches to promoting fruit and vegetable consumption, see Kreuter et al.20,191). Several strategies are recommended for developing targeted interventions. Among these are peripheral strategies or the incorporation of pictures of group members, images, and colors familiar to and preferred by group members; evidential strategies or the presentation of statistics on the health problem and its impact on the group; linguistic strategies or the use of the dominant or native language of the targeted group in communication materials; constituent-involving strategies or the identification of key roles for audience members in program planning and decision-making; and sociocultural strategies or the discussion of health-related issues in the context of core values and characteristics.20 Focus groups with audience members are recommended to explore cultural influences on behavior as the basis for content development, as is pretesting of the resulting content.10 During pretesting, it is important to explicitly inquire about format and content that may be perceived as offensive or insensitive.10 Because tailoring is highly individualized to participants, it is often facilitated with the use of computers.192 Typically, participants complete a baseline assessment, and survey responses are entered into a datafile.192 Software algorithms select feedback segments developed for each survey response and assemble them into a predetermined format (e.g., tailored letter or newsletter).192 233

Body image ideals and temporal orientation Raise awareness of links between beliefs and behaviors. Increase understanding of the potential for perceptions about ideal weight to raise risk for obesity or to limit the extent to which efforts to eat healthfully are sustained.81,193 Increase self-awareness of variations in temporal orientation to minimize the potential for the use of flexible and relative time to be viewed as a sign that participants lack motivation to follow recommendations or are noncompliant.115 Help participants make connections between current dietary practices and future health outcomes.14,20 Provide education on variations in time orientation that may influence health-related decisions and behavior.117 Centrality of women and kinship networks Target influential role models. Include women as a key focus of intervention.37 Engage mothers, grandmothers, and other female role models in program design and implementation and incorporate their unique needs and perspectives on dietary change. Encourage the involvement and support of extended family members,14 particularly those who occupy a central role in food-related decisions and who may be unreceptive to dietary change. Appreciate diverse family forms.16,194 Extend the definition of family to include individuals unrelated by blood or marriage who are considered family.93

family members, friends, or individuals from the same faith community. Incorporate strategies that resonate with cultural values and learning styles. Adapt theoretical models and intervention approaches with evidence of effectiveness.81 Incorporate strategies that build upon core values. Examples of such strategies include the following: use of narratives in the form of firsthand experiential or constructed stories designed to motivate behavioral change and to increase participant talk in learning situations and activities that rely on talking versus writing (orality)155,196; empathy-based approaches such as motivational interviewing and emotion-focused activities, e.g., grieving losses, psychodrama, and role playing to explore feelings related to dietary change (affect sensitivity)197; positive reframing (negativity to positivity); holistic intervention approaches and messages emphasizing interconnectedness of mind, body, and spirit (harmony)152,153; activities that encourage self-expression, e.g., testimonials and opportunities to showcase healthy eating habits learned or unique solutions for addressing personal challenges to dietary change (expressive individualism)161,198; and goal-directed messages and activities (achievement motivation). Understanding and retention of the message may be enhanced by the use of instructional techniques that are vervistic and relational and that afford participants opportunities for spontaneous expression of self (see Gay199 for additional information on culturally responsive instructional techniques).

Afrocentric values and achievement orientation Use preferred delivery settings and modalities. The centrality of the church in African American culture suggests that the church is an important venue for implementing interventions.187 Church-based programs can improve access to hard-to-reach populations or to those who may view traditional healthcare channels with distrust.186 Historically, the mission of the church in the African American community has extended well beyond the functions of worship and spiritual growth; as such, the church is an ideal setting for addressing community health problems.186 Assume heterogeneity within any particular church or faith community and explore traditions surrounding food and eating that may influence health.195 Use delivery modalities that resonate with oral/aural preferences, for example, by making use of interpersonal channels involving person-to-person contact and peer groups. Nurture the values of collectivism and harmony by using group versus individual modalities. Requiring participants to meet as a group and follow group standards may help foster collectivism and a sense of community.93 This may also be accomplished by designing interventions to engage intact groups, e.g., networks of 234

CONCLUSION Interventions to improve the dietary practices of African Americans are urgently needed to reduce morbidity and mortality from diet-related diseases in this population. To enhance program relevance and impact, interventions should incorporate African American cultural characteristics and related historical, environmental, and social influences on behavior into their design, delivery, and evaluation.10 African Americans are a highly diverse group, and myriad factors influence diet-related attitudes and behavior. Without minimizing variations between individuals, awareness of salient factors and of strategies for facilitating work with this population provides program planners with a frame of reference or starting point from which to design culturally sensitive dietary interventions. Acknowledgments Declaration of interest. The authors declare no affiliations with or financial involvement in any organization or Nutrition Reviews® Vol. 71(4):224–238

entity with a direct financial interest in the subject matter or materials discussed in this manuscript.

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