Culture, family, and social group influences on the African American woman's body image and her susceptibility to coronary heart disease
ix TABLE OF CONTENTS Page DEDICATION iii ACKNOWLEDGMENTS iv ABSTRACT OF THE DISSERTATION vi LIST OF TABLES xii Chapter 1. INTRODUCTION 1 CHD Awareness in the United States 2 Present Concern 6 Currently in Research 6 Statement of the Problem 13 Operational Definitions 16 The Specific Purpose 19 Summary 20 2. LITERATURE REVIEW 22 Body Image Perceptions 24 Obesity 37 Susceptibility to Coronary Heart Disease.... 41 The Concept of Social Influence 45 Conceptual Hypotheses 47
x Chapter Page 3. METHODOLOGY 49 Overview 49 Participants 50 Instruments 51 Procedures 57 Hypotheses 61 Analysis of Research Questions and Hypotheses 63 Assumptions 64 4. RESULTS 65 Preliminary Analysis 65 Descriptive Statistics Means, Standard Deviations, and Internal Reliabilities of Scales 68 Hypothesis 1 68 Hypothesis 2 69 Hypothesis 3 69 Summary 73 5. DISCUSSION 74 Results and Implications 76 Clinical Implications 79 Research Limitations 86
xi Page Implications for Future Research 88 Summary and Conclusions 89 REFERENCES 91 APPENDICES 106 A. E-MAIL AND LETTER SENT TO PROSPECTIVE ORGANIZATIONS 107 B. DEMOGRAPHIC QUESTIONNAIRE 109 C. PERMISSION FORM: THE MULTIGROUP ETHNIC IDENTITY MEASURE 112 D. PERMISSION TO USE: THE MULTIDIMENSIONAL SCALE OF PERCEIVED SOCIAL SUPPORT AND THE BODY ESTEEM SCALE 115 E. INFORMED CONSENT FORM 119 F. ORAL GROUP INSTRUCTION TO PROSPECTIVE PARTICIPANTS/INTRODUCTION 122 G. ORAL GROUP INSTRUCTIONS TO PARTICIPANTS 124
xii LIST OF TABLES Table Page 1. Demographic Characteristics of Participants... 66 2. Means, Standard Deviations, and Intercorrelations for Coronary Heart Disease Risk and Predictor Variables 70 3. Hierarchical Regression Analysis Summary for Variables Predicting Coronary Heart Disease Risk 72
1 Chapter 1 INTRODUCTION Coronary heart disease (CHD) is the number one killer of African American women (American Heart Association [AHA], 2008; Centers for Disease Control and Prevention [CDC], 2009a). African American women outranked African American men, European Americans, and Mexican Americans in cardiovascular diseases by up to 20% (AHA, 2008). CHD is largely recognized as an obesity-related disease. The organic mechanisms behind such diseases have been successfully outlined within the scientific and medical fields of research (AHA, 2009b; CDC, 2009b). The impact that psychological contributors, such as ethnic identity, body image, social support, and self-esteem, have on the African American woman's susceptibility to CHD remains a blur. This study attempted to provide medical and psychological health care providers with insight into the roles that peers, family, and social group influences play upon body mass index (BMI) and CHD susceptibility within a population of African American females residing in a rural
2 area of California. A successful outline of the impact an African American woman's social group has on her vulnerability could not have been accomplished without an overall understanding of cardiovascular disease. In the present day, a review of CHD within the African American female population may have proved especially useful during times of economic difficulty that may have had an effect on the United States' overall health care costs. CHD Awareness in the United States Economic Issues The American Psychological Association (APA) and medical care researchers have been particularly concerned with how economic stress might impact a woman's onset of heart disease. At the time of this study, the United States (U.S.) economy was struggling more than since the 1930's Great Depression (Isidore, 2009). Oil prices were at a peak, the housing market was at an all-time low, and consumers were significantly reducing their spending. The U.S.'s national income or gross domestic product (GDP) had decreased rapidly at a percentage this nation had not seen since 1982 ("The 2008 economy . . . worse," 2009). As the
3 consumer market decreased and the principal interest on home mortgages increased, homeowners unable to make their housing payments were being forced to foreclose. Many Americans were aware of the U.S.'s economic status, and as a precautionary matter households were reducing their family's financial budget. Between September and December of 2008, 1.5 million Americans had lost their jobs ("The 2008 economy . . . worse," 2009). The described economic chaos was the basis of many U.S. citizens' experience with stress. Stress has been known as a psychological or poignant strain that can be heightened when an individual remained in a position of constant worry (Ali, 2002). Because stress was significantly related to the onset of a heart attack or cardiovascular disease, the rise in prevalence of coronary heart disease among U.S. citizens was scientifically expected (Kantrowitz & Wingert, 2008). Because of this issue, the American Psychological Association (APA) asserted stress as a major concern within the U.S. In June and August of 2008, the APA (2008) conducted the Stress in America Survey in order to assess the impact of the United States economy on both men and women. The online survey was conducted in major cities across the U.S.
4 Of these major cities, Los Angeles (LA) was geographically closest to the Central Valley area of California, where the participants of this study were recruited. When results from the survey were examined, LA residents identified money, housing costs, and job stability as significant stress contributors much more than did the residents of other major cities (APA, 2008). In the overall study, more women than men endorsed a recent experience of physical and emotional symptoms that were strongly linked to their heightened fear toward the economy (Kantrowitz & Wingert, 2008). Women over the age of 44 conveyed the highest anxiety related to their finances (APA, 2008). According to the APA, prolonged stress increased a woman's susceptibility to heart disease. Older women have commonly discounted their experiences of coronary heart disease symptoms. The Centers for Disease Control and Prevention, the National Institutes of Health, and the American Heart Association are government-funded establishments that aim to increase understanding and heart-healthy behaviors within the United States. Because of the increase in the incidence of heart disease deaths among African Americans, several
5 government-funded organizations adjusted health prevention and awareness programs to match their ethnic audience. For example, as a component of the Healthy People (HP) 2010 project, the National Heart, Blood, and Lung Institute (NHBLI, 2009) planned to deliver vital cardiovascular disease information and resources to high-risk populations. Minority populations, such as African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, were considered high risk. HP 2010's cardiovascular disease-related objectives address heart disease and stroke, nutrition and overweight, physical activity and fitness, and tobacco use as areas that required the most attention within minority populations. Ethnocultural Differences and Cost-Related Concern Diseases of the heart continue to be the leading causes of death in the United States across all racial and ethnicity groups (Weinrauch, 2008). In 2009, heart disease was estimated to cost more than $304.6 billion (CDC, 2009c). This estimate included medical services, medications, and poor job constancy. The African American female population held the highest prevalence of CHD. Therefore, it was
believed that health care providers, government-funded organizations, in addition to risk awareness and prevention programs, would all benefit from this study's analysis of the African American woman's thoughts toward health. Present Concern Research studies have identified more African American women as overweight or obese. Within the combined years 2003 to 2006, the National Health and Nutrition Examination Survey (NHANES) found 51.1% of the African American women within their sample to be obese and 79.6% to be overweight (AHA, 2008). More African American women were considered obese than European American women (Wu et al., 2007), yet Hawkins (2005) found that African American women classified as overweight were not endorsing an overweight weight status. Obesity and CHD have gone hand-in-hand with one another, yet overweight and obese African American women were showing little concern toward their health or recognition of their weight status. Currently in Research Current research suggests that heavy and obese African American women hold more positive body perceptions, despite
7 the fact that they weigh more (Roberts, Cash, Feingold, & Johnson, 2006). In hopes of understanding the African American woman's contentment with her body, researchers have examined appearance satisfaction, cross-gender attractiveness, skin-color variations, self-esteem, and ethnic/racial group standards. The general themes from this research have asserted that African American women expressed culture-specific norms of attractiveness, and this may or may not have been leading to their obesity (Breitkopf, Littleton, & Berenson, 2007). African American women were more often heavier than were European American women, perhaps because of the African American culture's acceptance or desire for larger body types. For instance, African American males have been more attracted to larger body sizes, while European American males preferred a smaller body type (Thompson, Sargent, & Kemper, 1996). The body shape preferences endorsed by African American males was not simply experienced in an African American woman's social surroundings. African American women have received misogynistic media messages with unrealistic body image that consists of a tiny waist, large hips and buttocks, and lighter skin. These messages
8 have been seemingly different than those influencing European Americans (Furnham & Dias, 1998; Schooler, Ward, Merriweather, & Caruthers, 2004). When compared to African American women, the messages received by European American women from family, peers, and the media concerning their body image and health were quite different. African Americans have depended heavily on family and peer influences when shaping their eating habits and health behaviors. Food scarcity, the ability to distinguish good and bad foods, their mother's food obtaining and preparation practices, plus the acceptance of larger body sizes were typical African American orientations toward food and image received from their mothers (Wilson, Musham, & McLellan, 2004). These health and nutrition practices were learned early in life (Lawrence & Thelen, 1995). African American women have practiced unhealthy-heart behaviors that were endorsed early in life, despite the risk of developing CHD. In addition, more African American women than men were dying of cardiovascular diseases. Some researchers have attributed the lack of cardiovascular risk awareness as a contributing factor.
9 The woman's perception of her cardiovascular risk may or may not have predicted her susceptibility for what, in the past, was considered a "man's disease" (Haas, 1996, p. 3). Society's media highlights osteoporosis, menopause, and breast cancer as high risk for women. As a result, women were more prone to recognize such diseases as their main threats. Haas thought that women who presented with coronary artery disease symptoms were being neglected by their health care providers because of the common misperception of heart disease as a man's disease. African American women recognized influential risks of heart disease related to their own race and the stress associated with society's discrimination toward the African American culture when responding to the Cardiac Risk Perception Inventory (CRPI). The CRPI is an instrument designed to measure a woman's perception of cardiovascular disease on the basis of 16 risk factors (Haas, 1996). In the development and validation of the CRPI, women overvalued race, age, and a known diagnosis of coronary artery disease as cardiac risks, with little recognition of the impact of cholesterol, blood pressure, and weight (Haas, 1996). This
10 research study and others like it failed to examine social contributions to an individual's beliefs. Collins-McNeil (2 005) performed a study with two outcome dates at 2 and 10 years, using a sample of African Americans and other ethnic minorities diagnosed with Type II diabetes. In this study, the researcher examined the effect of perceived social support on an individual's future development of cardiovascular or other fatal diseases. Findings in the Collins-McNeil research were unable to validate the idea of social relationships as a predictor of positive health behaviors when the data of men and women were combined. Most ethnic minorities diagnosed with Type II diabetes endorsed heightened levels of perceived social support (Collins-McNeil, 2005). Research studies related to low-, moderate-, and high-perceived social support and coronary heart disease risks among ethnic minorities were limited. There are also generational differences in health practices among African American women. In a study of 608 African American women, women who were retired and approximately 51 years old were practicing the healthiest behaviors (Dewitty, 2007). When an African American woman
11 is assessed on her CHD risks, certain contributors have been endorsed more than others. Stress and family history of illness have been believed by African American women as key contributors to their existing coronary heart disease. African American women with heart disease have commonly practiced cultural coping behaviors. Taking care of themselves typically involved comparing the severity of their disease to members in the family with the same condition and then not worrying in hopes of diminishing stress-related symptoms (Warren- Findlow, 2006). Among these women, social support from friends, family, and religious organizations provided both helpful and harmful results. This study attempted to grasp an understanding of the damaging and useful behaviors African American women demonstrate that are influenced by their ethnic identity and social support system. African American women have been more satisfied with larger body types and, based on research, the satisfaction they express toward their body is easily sustained within the African American society. Monteath and McCabe (1997) asserted that body satisfaction was a product of societal factors, self-esteem,
12 and BMI for all women. Societal factors include the body size perceptions an individual forms based on the messages conveyed within her or his society. These messages were more often received from the public media, but could be easily passed along to individuals within the viewer's social group. Monteath and McCabe declared that a change in societal attitudes must occur before addressing body image disturbances in women. Their findings supported the idea that cultural and social groups may have influenced body image perspectives held by women. Although much of U.S. culture has been concerned with the preoccupation of thinness, the acceptance of obesity within the African American populations suggested that a different body image disturbance may be shared among a large proportion of African American females. Obesity and various harmful health behaviors appear common within the African American culture, and their acceptance is dangerous for the health of African American women. Social influence is a term that describes the ability of an individual's opinion and actions to have an effect on other people (Cohen, 1964). The theory of social group influence is one psychological theory of communication.
13 This concept was more often found in social psychology and more recently organizational psychology than in clinical applications. This theory seemed applicable since the focus of this study was on the evaluation of the impact that an African American's social group has on her further development of CHD. Social groups have often been formed on the basis of similar interest. Social group influences can be powerful toward changing an individual's views toward culture, body image, and even health. Statement of the Problem Ethnic identity is thought of as a component of an individual's self-concept resulting from his or her familiarity or association to a social group, along with the value and emotional importance attached to their commitment (Tajfel, 1981). The term African self-consciousness sums up the attitudes, beliefs, values, interests, and historical knowledge an individual possesses for the African or African American culture (Stokes, Murray, Peacock, & Kaiser, 1994). These two terms were often discussed simultaneously. Ever since the Civil Rights Movement of the 1960s, African self- consciousness has become significantly related to the African American's cultural identity. The importance of
14 ethnic identity to an African American's self-concept has been highly recognized by behavioral science researchers (Phinney, 1992; Rust, 2008). Self-concept is composed of internalized reactions and opinions made by others (Webster & Sobieszek, 1974). Behavioral traits, such as motivation, drives, attitudes, and personality characteristics an individual displays, are the product of these interactional experiences. From this viewpoint, also known as the looking-glass self, the individual maintains some quality of control over his or her actions (Webster & Sobieszek, 1974). Self-concept is solely a reflection of the perspective of others with whom the individual is in direct contact. This theory takes into account the influence of family, peers, and significant others, but discounts the possible impact of media influence and historical contributions. The concept of social influence attempts to understand the role of all people in the development of an individual's beliefs, feelings, and behaviors (Mason, Conrey, & Smith, 2007). Social groups are not limited to family. From this perspective, people are generally unaware of the influence that others have on their personal choices (Cialdini, 2005).
15 Mason et al. (2007) asserted social influence as a process that occurs at a community level over a period of time; each individual serves as both the source of influence as well as a target. African American women seem to be receiving confirmatory messages about being overweight from individuals who share their culture. The differences between ideal body weight, types, and sizes held among African American women may be the product of cultural and social group influences. Body image attitudes are practically woven into every aspect of behavior. Given the higher incidence of obesity among African American women, an investigation of this population's body image perceptions provided insight into their seemingly reduced concern for overall health and physical condition. Women frequently underestimated their susceptibility to cardiovascular disease (Long, Waldrep, Hernandez, & Strickland, 2005). If the African American woman's increased vulnerability to coronary heart disease is a matter of distorted acceptance of obese or overweight body image perceptions, awareness/intervention and prevention programs should address these perspectives.
16 Operational Definitions Definitions important to this study were coronary heart disease (CHD), cardiovascular disease risks factors, body mass index, and body image. Coronary Heart Disease (CHD) CHD was the most common form of heart disease (CDC, 2009c). This medical illness is recognized as a narrowing of the small blood vessels responsible for supplying blood and oxygen to the heart. Blood vessel contraction is associated with an increase in fatty material and plaque that build up on the walls of arteries. As this condition progresses and the coronary arteries become increasingly constricted, the heart's blood flow can slow down or discontinue, causing chest discomfort, shortness of breath, a heart attack, or various other symptoms (Weinrauch, 2008). In the literature, CHD was also referred to as coronary artery disease (CAD), cardiovascular disease, or arteriosclerotic heart disease. Discussions surrounding coronary heart disease were typically focused on its related risks.
17 Cardiovascular Disease Risk Factors According to the American Heart Association (2008), there were both controllable and uncontrollable risks associated with the development of CHD. Growing older in age, gender, and genetics (including ethnicity) were out of the individual's control. Smoking tobacco, hypertension, decreased physical activity, diabetes, and obesity could all be managed (AHA, 2008; CDC, 2009a). With these manageable risks in mind, (a) Hypertension was the highest among African American women; (b) African Americans were less physically active than were European Americans, with women exercising much less than men; and (c) more African American women were classified as heavy or obese than were African American men, European Americans, Mexican Americans, and Hispanics/Latinos (AHA, 2008). Preventing heart disease or lowering the risks of developing CHD can be accomplished with essential health and lifestyle adjustments. Poor dietary habits lead to obesity, which then heightens an individual's chances of developing heart disease (Bryan, 2006). Consequently, the typical treatment approach gives attention to weight loss in hopes of reducing other contributing risks.
18 Coronary heart diseases as well as 30 other medical illnesses were linked to obesity (Bryan, 2006). Obesity was significantly related to increased caloric intake, decreased physical activity, and genetic predispositions in ethnic minorities (Bryan, 2006; Haslam, 2008). The prevalence of obesity has increased within the United States, and some populations are heavier than are others. Racial minorities, women more than men, and women with low socioeconomic (SES) statuses were considered obese populations, and this was more than likely the product of poor eating, socioeconomic- related stressors, and physical activity routines (Bryan, 2006). Body Mass Index (BMI) The difference between obese and overweight has been routinely distinguished using the individual's body mass index (BMI). BMI (BMI = kg/m2) is a numerical method of assessing body weight relative to height and weight (CDC, 2009a). Each derived BMI has an associated weight category. This measurement correlated well with body fat, making it a preferred measurement for researchers and physicians evaluating obesity (Haslam, 2008). Weight concern has been an essential component of body image.
19 Body Image The Encyclopedia of Psychology (Cash, 2000) described body image as "a psychological concept that refers to an individual's mental representation of his or her own body" (p. 436). In ethnic cultures this mental representation was observed as an expansive range of body shapes and personality characteristics (Breitkopf et al., 2007). For the African American woman, body weight was vital to her body satisfaction (Falconer & Neville, 2000). The Specific Purpose African American women have adhered to their culture's attitudes and beliefs regarding physical health and appearance. Obesity, among other poor health behaviors, was found to be highest within the African American culture. Obese individuals made up the bulk of the adult population within the U.S., and higher body mass indexes have been correlated with cardiovascular disease (APA, 20008; CDC, 2009a). African American women's risk had been the product of their complacency about culturally supported larger body sizes, regardless of the potential health risks. Above all, coronary heart disease in the African American female
20 population was rampant, and experts were unsure why that may have been true. Summary The findings of this study provided additional information toward public health care efforts aimed at decreasing obesity-related diseases, such as CHD, among African American women residing in Fresno County, California. Overall, this study demonstrated that BMI, ethnic identity commitment, perceived social support, and body satisfaction predicted CHD susceptibility for African American women residing in a rural area of the U.S. The findings suggest an increased need for prevention and outreach program development to be implemented within the African American communities of Fresno County, California. These increased efforts could serve to decrease the African American woman's susceptibility for developing CHD as well as enhance her physical health awareness. It was the researcher's hope that investigating body image variables that related most to this ethnic group would provide an extensive framework for why African American women were leading the United States adult population in cases of coronary heart disease. Emmons, Barbeau, Gutheil,
21 Stryker, & Stoddard, 2006) asserted that the identification of the various characteristics that made up an at-risk population would help determine the population's behavior patterns. Race, age, and socioeconomic status were among the most common group characteristics when understanding the beliefs and attitudes about weight and CHD within the African American community (Emmons et al., 2006). A review of these, as well as the components of the African American woman's body image perceptions, proved beneficial when grasping why her health behaviors appeared to be somewhat destructive. African American women endorsed attitudes and behaviors that were strongly influenced by members of their social group.
22 Chapter 2 LITERATURE REVIEW Minority women adapt culture-specific norms of attractiveness. Ranges of body sizes, self-presentation, as well as personality factors, were components of attractiveness within many ethnic cultures (Breitkopf et al., 2007). Falconer and Neville (2000) examined the relationship between body weight and body image among 124 working class, African American women. Considering the various culture-specific variables and body image perceptions in their studies, they found body mass, African self-consciousness, and skin color as components of the African American woman's body satisfaction. The individual's culture swayed the presence or absence of weight concern, eating habits, and body displeasure (Akan & Grilo, 1995). When assessed on their body image perceptions, African American women placed emphasis on the cultural aspects involved in their body image attitudes (Harris, 1995). Roberts et al. (2006) explained ethnic differences in beauty standards as products of the individuals' self-esteem,
23 racial identity, and diverse social values (Robert et al., 2006). It seemed safe to assume that African American women were approaching several aspects of their health based on the common attitudes and opinions of those who shared their racial or ethnic background, cultural values, and life experiences. African American women may be upholding common body image perceptions to confirm their conformity, compliance, and obedience to their culture's beauty standards (Cohen, 1964). This notion of social influence takes into account the role of society on an individual's beliefs, feelings, and behaviors (Mason et al., 2007), and identifying the demographic characteristics that define a population can help determine the population's risk patterns (Emmons et al., 2006). Cultural values, age, and socioeconomic status were among the most important group characteristics to review when understanding beliefs and attitudes about health shared within the African American community (Emmons et al., 2006). This review of literature attempted to outline how body image perceptions contributed to an African American woman's seemingly reduced concern with personal health and well-being.
24 Body Image Perceptions Body weight, self-esteem levels, and the individual's self-evaluation of personal appearance all seemed to serve as appropriate measures of body image perceptions in African American females. For instance, African American women were found to weigh more than European American women, but the levels of self-esteem between the two groups showed no notable differences (Snooks & Hall, 2002). The idea of weighing more without feeling insecure may be surprising to women of other cultures. When researchers observed body image perceptions in 150 males and 185 females self-identified as African, Asian, European American, or Hispanic American, they noticed that African American women expressed more positive body perceptions (Altabe, 1998). An African American woman's security with her looks, as well as the satisfaction expressed toward her body, seemed to influence body perceptions interchangeably (Spurgas, 2005). African American women appeared more confident with their appearance regardless of the significant differences in weight and beauty standards that were not likely followed by European American women. Elevated self-esteem was essential toward