Research on racial and ethnic health disparities has continued to grow over the past decade, but disparities in cancer morbidity and mortality between racial and ethnic groups (Frohlich & Potvin, 2008; Geiger, 2006; Griffith, Moy, Reischl, & Dayton, 2006; Sankar et al., 2004) and between men and women continue to persist and, in some cases, widen (American Cancer Society, 2009). While there has been progress in our understanding of racial differences in health status, there remains considerable disagreement on why disparities persist and what should be done to eliminate them. More research is needed that helps to identify how and where to intervene to eliminate racial and ethnic disparities in health, particularly for cancer disparities (Adler, 2006).
The health behaviors and disparate health outcomes that are of primary interest to social scientists are rooted in historical and contemporary inequalities in education, justice, social and political power, and economics (Griffith et al., 2006). These factors not only directly affect health behaviors and health outcomes, but the ecological contexts in which these outcomes occur. Investigators, however, tend to examine health disparities by fragmenting contributing factors into separate contextual and individual-level components (Williams & Jackson, 2005). While this yields needed information on unique relationships and disease pathways, it provides an incomplete picture. Achieving the goal of eliminating racial health disparities in the United States requires research that synthesizes available knowledge and provides a more comprehensive understanding of racial differences in health outcomes (Adler, 2006; Moy, Arispe, Holmes, & Andrews, 2005). Health disparities are created and maintained through multiple and varied pathways that must be understood and addressed holistically.
Increasingly, health behavior interventions and the theories that inform them have considered how multiple levels and dimensions of the social ecological contexts of health may influence risk, behaviors, and outcomes (McLeroy, Bibeau, Steckler, & Glanz, 1988). Although these approaches have become more systematic in considering the influences of race and ethnicity on health, few have considered how race and ethnicity intersect with gender, particularly male gender.
While it is critical to continue focusing on eliminating racial and ethnic disparities in cancer, it is not clear that race and ethnicity are the most important characteristics affecting cancer risk behavior. Men are more likely than women to engage in over 30 behaviors that have been known to increase the risk of injury, morbidity, and mortality, many of which are behavioral risk factors for cancer (Courtenay, 2000); this suggests that there is a potential benefit of examining gender, particularly male gender, in combination with other risk factors for understanding and addressing cancer disparities. While sex refers to biologically determined factors, gender refers to differences between men and women that stem from social and cultural origins (Payne, 2006). While cultural sensitivity is generally recognized as a necessary component for effective health promotion programs, it has typically been utilized to address racial and ethnic differences, and in a way that has been consistently more successful at engaging women (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999). Incorporating the gendered nature of culture, particularly for men, may be essential for interventions focused on reducing men’s health risk behaviors to be successful. Gender influences health and intersects with other known determinants of health to play an important role in health behavior, particularly in exacerbating and mitigating men’s health behaviors and cancer outcomes.
In this topic, we argue that attending to male gender in addition to race and ethnicity in population-based interventions is vital to improving health and eliminating cancer disparities. We will briefly review the cancer epidemiology of African American men. We will then provide an overview of an existing culturally sensitive, research-tested intervention, Body and Soul, which we are adapting to more effectively engage and change the behavior of African American men. We chose to adapt Body and Soul as it has demonstrated success in improving our behaviors of interest—healthier eating and physical activity—in multiple efficacy and effectiveness trials with African Americans, albeit primarily with women (Resnicow et al., 2004). The remainder of the topic describes the process that we developed and are currently employing to adapt the core components of Body and Soul into a more male-gender-sensitive intervention called Men 4 Health (M4H). We conclude with a brief discussion of lessons learned and recommendations for adapting interventions to be more male-gender sensitive.
THE CANCER EPIDEMIOLOGY OF AFRICAN AMERICAN MEN
Men in the United States have slightly less than a 1 in 2 lifetime risk of developing cancer, and that risk is dramatically higher for African American men (American Cancer Society, 2004). African American men have approximately a 37% higher death rate from cancer than White men (Powe et al., 2009). For African American men aged 45 and older, cancer is the first or second leading cause of death (American Cancer Society, 2009; Taylor et al., 2001). Between 1975 and the early 1990s, the disparity in cancer death rates between African American and White males widened, and today it remains larger than it was in 1975 (Ward et al., 2004). In addition, African American and White disparities in cancer mortality rates are greater for African American men than African American women (American Cancer Society, 2009).
Of all cancers, prostate, lung, and colon cancers have both the highest incidence and mortality rates for African American men (American Cancer Society, 2009). Together, these three cancers comprised 60% of all cancer incidence and 54% of all cancer mortality for African American males in 2009. For these cancers, African American men are less likely than White men to undergo screening tests, have their cancer diagnosed at early or localized stages, and have access to appropriate and timely cancer treatment (American Cancer Society, 2009). When compared to White men, African American men have higher incidence and mortality rates for prostate, lung, and colon cancer, and lower 5-year survival rates (American Cancer Society, 2009).
The health behaviors of African American men seem to contribute to their high rates of colon, lung, and possibly prostate cancer (Koh, Massin-Short, & Elqura, 2009). The evidence linking physical activity and cancer is strong for colon cancer and suggestive for many other types of cancer including lung and prostate cancers (Friedenreich & Orenstein, 2002; Gotay, 2005). Consumption of foods that are high in fat from animal sources, red meat, and processed meats and low consumption of fruits and vegetables also tend to increase colorectal cancer risk, as does obesity (Schneider, 2009). Approximately half of African American men in the United States report no leisure time physical activity (Ward et al., 2004). African American men aged between 35 and 50 years eat, on average, only 3.5 of the 9 recommended daily servings of fruits and vegetables, fewer than any other racial or ethnic group (National Cancer Institute, 2002). Approximately one fourth (24.4%) of African American men are obese, which is second only to the obesity rate for American Indian/Alaska Native men (Ward et al., 2004). These patterns of disease suggest that race and gender play an essential role in cancer morbidity and mortality of African American men, and need to be more effectively considered to eliminate racial and gender disparities in cancer.
AN OVERVIEW OF BODY AND SOUL
Although several studies have examined factors associated with obesity among African Americans in general and African American men in particular, little is currently known about how to effectively intervene to improve dietary practices and rates of physical activity of African American men. Body and Soul is one of only two community-based, research-tested intervention programs recognized by the National Cancer Institute (NCI) has been found to be efficacious with African American populations, and that is available on the NCI’s Cancer Control Planet. The Body and Soul intervention was developed by combining methods from previous evidenced-based research on dietary behavior change in African Americans with theory-based research identifying social and cognitive variables associated with health behaviors (Resnicow et al., 2004). Despite the success of Body and Soul at improving healthy eating and physical activity, it has thus far failed to enroll and retain significant numbers of African American men: over 70% of each sample has been female.
The Theoretical Foundations of Body and Soul
Body and Soul utilizes constructs from social support theory (Israel, 1985; Israel & McLeroy, 1985), social cognitive theory (Bandura, 2001), and selfdetermination theory (Ryan & Deci, 2000). Social support theory emphasizes the importance of social influence and social support in shaping and maintaining health behavior, and several studies have found that behavior-specific social support is related to healthy dietary practices (Ammerman, Lindquist, Lohr, & Hersey, 2002). Social cognitive theory incorporates both psychosocial factors influencing health behavior and strategies for promoting behavior change. Social cognitive theory posits that behavioral capability (i.e., knowledge and skill to perform a given behavior) and self-efficacy (i.e., the belief that one is capable of performing a behavior) are important causal factors related to healthy eating and physical activity (Steptoe et al., 2003). Selfdetermination theory focuses on social and contextual conditions that facilitate self-motivation and healthy psychological development (Ryan & Deci, 2000). Ryan and colleagues (1997) found evidence of a relationship between intrinsic motivation and long-term changes in physical activity; specifically, the people who reported higher intrinsic motivation were more likely to sustain higher rates of physical activity than those with lower rates of intrinsic motivation (Ryan, Frederick, Lepes, Rubio, & Sheldon, 1997). Trudeau and colleagues found evidence of a relationship between intrinsic motivation and fruit and vegetable intake in a cross-sectional study (Trudeau, Kristal, Li, & Patterson, 1998).
Intervention Components of Body and Soul
Body and Soul includes four basic components: church-wide activities, organizational policy change, motivational interviewing, and self-help materials. As a condition for participating in the project, individual churches agree to carry out several core components, including holding a kickoff event, establishing a project committee, hosting at least three church-wide nutrition events, and having at least one additional event involving the pastor. The churches also agree to make at least one policy change (e.g., offer healthy food in addition to traditional options at church-wide events). All individuals enrolling in Body and Soul receive the Eat for Life (EFL) cookbook as well as several American Cancer Society educational pamphlets. Finally, peer counselors are trained in motivational interviewing, which is a counseling approach that helps individuals work through their ambivalence about behavior change, overcome their own barriers, and explore potential untapped sources of motivation. In our efforts to adapt Body and Soul to more effectively engage men, we examined the setting (faith-based organizations vs. other organizations), contextual and psychosocial factors, and motivations to engage in healthy eating and physical activity.
FOUNDATIONS OF THE INTERVENTION ADAPTATION AND DEVELOPMENT PROCESS
While there is consensus that health promotion programs should be culturally sensitive, there has been surprisingly little conceptual work defining cultural sensitivity and testing the effectiveness of culturally sensitive interventions (Resnicow et al., 1999). Cultural sensitivity is the extent to which health promotion materials and programs incorporate ethnic/cultural characteristics, experiences, norms, values, behavior patterns, consumer preferences, and beliefs of a focus population as well as relevant historical, environmental, and social forces in design, delivery, and evaluation (Resnicow et al., 1999).
Developing Culturally Sensitive Health Promotion Interventions
According to Resnicow and colleagues (1999, 2004), cultural sensitivity is composed of two dimensions: surface structure and deep structure. Surface structure involves matching intervention materials, messages, and events to observable, "superficial" (although nonetheless important) characteristics of a focus population. Surface structure may involve using people, places, language, music, food, locations, product brands, and clothing style familiar to, representative of, and preferred by, the target audience. Surface structure also includes identifying what channels (e.g., media) and settings (e.g., churches, schools) are most appropriate for delivery of messages and programs. With regard to cultural competence, or interpersonal sensitivity, this generally entails using ethnically matched staff to recruit participants as well as deliver and evaluate programs (Resnicow et al., 1999). In effect, surface structure refers to the extent to which interventions appear to fit within a culture. Surface structure is generally achievable through expert and community participation, as well as the involvement of the focus population in the intervention development process.
The second dimension, deep structure, has received less attention and can be more elusive, yet is an essential aspect of determining relevance and effectiveness. Deep structure refers to the cultural, social, historical, and psychological forces that influence the target health behavior in the proposed focus population, as well as the population’s unique environmental and psychological barriers and enabling factors. Whereas surface structure generally increases the receptivity or acceptance of messages, deep structure conveys salience. Surface structure is a prerequisite for feasibility, whereas deep structure determines efficacy. Deep structure involves understanding how particular sociodemographic and ethnic populations differ from other groups, as well as how ethnic, cultural, social, environmental, and historical factors may influence specific health behaviors within that population (Airhihenbuwa, DiClemente, Wingood, & Lowe, 1992). This entails understanding how members of the focus population perceive the etiology and treatment of a particular illness or behavioral risk factor (Airhihenbuwa et al., 1992). Culturally tailored interventions need to address and accommodate cultural values and historical beliefs to have credibility.
One strategy that has been used to tap into deep structural elements of interventions is ethnic mapping (Resnicow et al., 1999; Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000). This process has been used to provide valuable information for tailoring interventions by asking focus groups of the population of interest to classify aspects of the target behavior along a continuum. Most often, because cultural sensitivity has been operationalized as ethnic or racial sensitivity, participants have been asked to rate foods or types of physical activity on a continuum of race and ethnicity (e.g., mostly for Blacks; equally for Blacks and Whites; mostly for Whites).
Limitations of Cultural Sensitivity
While using a culturally sensitive approach to developing interventions is considered an important aspect of health behavior interventions, there is little agreement on how we might operationally define cultural sensitivity. What constitutes aspects of surface and deep structure, for example, and how should other aspects of identity (e.g., age, gender) be considered? The process of ethnic mapping provides a useful example of this challenge.
Ethnic mapping implicitly assumes that race and ethnicity are the most salient aspects of identity that are relevant to behavior change. We, however, posit that gender is an equally important aspect of identity that may influence health behavior. Consequently, the challenge becomes: How do we adapt the mapping process for use with African American men? Do we first ask men to rate items or activities along a racial/ethnic continuum, and then ask them to do the same along a gender continuum (e.g., mostly a male thing; equally a male and female thing; mostly a female thing)? Do we challenge men further by inviting them to rate items in a more complex matrix, maybe crossing race/ethnicity and gender (e.g., mostly for Black males; mostly for White females; equally for Black males and Black females)? This conundrum highlights a few critical challenges in adapting and developing behavioral interventions:
• How do we decide what aspects of identity (and other factors) are most relevant to health behavior?
• Who is best positioned to determine how aspects of identity intersect?
• Are psychosocial factors (i.e., social support, cultural norms, stressors) equally relevant for different behaviors, such as eating behavior and physical activity?
Toward an Intersectional Approach to Developing Behavioral Interventions
A broad conception of health that incorporates social relations and institutions and situates health within communities and families is becoming more prevalent in the social sciences (Weber & Parra-Medina, 2003). This approach calls for research that simultaneously addresses the intersection of several key aspects of identity that affect health and health behavior: race/ ethnicity, gender, class, socioeconomic status (SES), sexual identity, age, rural-urban, address, and region (of country, state, and city), among others. Because these dimensions are all socially constructed, they simultaneously and more accurately reflect the complex array of factors that influence health and health behavior. The goal of this approach is to consider how individual agency and choice, contextual and environmental influences, and physiological and biologic factors combine to impact health (Rieker & Bird, 2005). An intersectional approach helps us to consider how the multiple levels of influence included in a social ecological model (individual, interpersonal/ social network, organizational, community, and environmental and policy) combine with critical aspects of identity (race, ethnicity, gender) to influence health and health behavior.
The intersectional perspective to research on health behavior remains in its infancy (Mullings & Schulz, 2006), and it has rarely, if ever, been used with African American men. Health promotion interventions have remained focused on the aspects of identity that are most congruent with the disease epidemiology (i.e., we should focus on ethnic identity because people’s health outcomes vary significantly by ethnicity), rather than considering personal characteristics that also may influence the behavior of interest (i.e., gender, age, religiosity). Research in health behavior has recognized that these factors influence health behavior, but they have yet to be incorporated effectively into more comprehensive and complex theoretical, conceptual, or framework approaches to understanding the multilevel factors that influence how and where we intervene to address health behavior.
In the remainder of this topic, we outline the strategy we have used to disentangle the complex array of factors that influence the eating behavior and physical activity of African American men. We argue that we can use health behavior theory and other scientific literature to guide this work, but that critical first steps are: (1) Marshalling a team that can help us to see blind spots and assumptions we may unintentionally make about the determinants of health behavior and the most important and plausible places to intervene; and (2) Conducting exploratory research to gain the perspectives of our population of interest, urban African American men, and those who know them best on what factors influence their health behaviors and their relative importance compared to other life priorities.
THE FOUNDATIONS OF MEN 4 HEALTH
Step 1: Use a CBPR Approach
Our approach to systematically adapting and developing interventions begins with a community-based participatory research (CBPR) approach (Israel, Eng, Schulz, & Parker, 2005; Minkler & Wallerstein, 2003; Viswanathan et al., 2004). CBPR is a collaborative research approach that is designed to ensure and organize the participation of communities affected by the issue being studied, representatives of organizations, and researchers in all phases of the research (Bowman, 1989, 2006; Geertz, 1973; Griffith et al., 2007, 2008; Johnson et al., 2009; Zimmerman et al., 2004). CBPR can enhance the capacity of a project to: bring together diverse partners with multiple skills, expertise, and sensitivities to examine and address complex problems in culturally appropriate ways (Butterfoss, Goodman, & Wandersman, 1993; Israel, Schulz, Parker, & Becker, 1998; Minkler, 2004); increase the relevance, usefulness, and applicability of intervention research (Israel et al., 1998; Schulz et al., 1998); and enhance the quality and validity of intervention research by integrating the knowledge and theory of the local partners involved and tailoring interventions to the local community context (Israel et al., 1998; Kerner, Dusenbury, & Mandelblatt, 1993). Kerner, Trock, and Mandelblatt assert that "only efforts to involve these high-risk populations as partners in cutting-edge cancer research can ensure that the research findings will be accepted by the community and that the interventions tested have a reasonable chance of proving themselves cost effective and sustainable after the research funding has ended" (Kerner, Trock, & Mandelblatt, 2004).
The participation of community members is integral to our approach. To ensure community participation and oversight, we created and regularly convene with a Community Steering Committee that guides, reviews, and provides insight on M4H activities throughout the research process. The Community Steering Committee is composed of community leaders, representatives of community-based organizations, project personnel, and university researchers, but led by one of our community outreach staff members. M4H’s outreach staff is composed of African American men who are from, and currently live in, the cities of interest. They also have experience and reputations of being actively involved in addressing men’s health issues in these communities. They strategically attend events and utilize their interpersonal skills, membership in social and faith-based organizations, and informal social networks to raise awareness about the study, distribute flyers, and recruit a diverse sample of men and women in the focus population of the study. Their local knowledge and ability to build upon existing interpersonal relationships help to gauge community needs and interests while assessing issues that are meaningful in the lives of African American men.
Step 2: Conduct and Analyze Focus Groups
In addition to engaging key community members, we conducted exploratory focus groups to examine individual and collective perspectives on the broad social, cultural, and environmental barriers and facilitators to African American men’s healthy eating and physical activity. Of particular interest was how intersections of race/ethnicity, gender, life stage, and social and environmental contexts influence these men’s health behaviors. Focus groups provided the ideal strategy for examining how individual skills, motivation, and knowledge intersect with social and environmental factors to influence physical activity and eating among African American men. Qualitative methods are effective for capturing emergent and unanticipated responses, providing participants with an opportunity to voice their perspectives, and understanding interactions and relationships between variables for theory development and intervention planning (Banyard & Miller, 1998; Geertz, 1973; Zimmerman et al., 2004). Women were included as focus group participants to examine the barriers and facilitators that they perceived for men, to gain their perspective on the stressors that influenced men’s health and health behavior, and to capture the role they saw themselves playing in promoting men’s healthy eating and physical activity.
Focus group participants were recruited by snowball sampling via word of mouth, fliers, and the extensive social networks of the project’s outreach staff and Community Steering Committee partner organizations. The focus population for the male focus groups was African American men, ages 35 years and older, living in the Flint, Ypsilanti, and Detroit metropolitan areas of Southeast Michigan. The participants in the female focus groups were women who had close relationships with men meeting the criteria for the male focus groups and included men’s spouses, sisters, daughters, and friends. Focus groups were conducted separately with men and women. One hundred fifty-four African American men participated in 18 focus groups: 10 groups with a total of 63 men from Flint; 4 groups with a total of 42 men from Ypsilanti; and 4 groups with a total of 49 men in Detroit. Half of the men’s focus groups concentrated on eating behavior and half on physical activity. Seventy-seven women took part in 8 focus groups: 5 groups with a total of 50 women in Flint; and 3 groups with a total of 27 women in Ypsilanti. Our data organization process of chunking and assigning codes to text was similar to the methods used by Griffith and colleagues (Griffith et al., 2007, 2008). We sought to confirm the accuracy of our findings and interpretations by conducting three member checking groups—two with men and one with women. These groups also helped us to consider environmental and historical contextual issues relevant to the geographic locations.
Step 3: Interpret Focus Group Findings Using a CBPR Approach
In this section, we briefly discuss selected but key findings that describe the factors that our population of interest suggested influenced their behavior. We juxtapose what we anticipated to find based on the literature with what we found from the data. We also discuss what we learned from our Community Steering Committee and Community Outreach team.
Barriers to Healthy Eating and Physical Activity
One of the major barriers to African American men’s consistent and sustained healthy eating and physical activity appears to have more to do with competing priorities in their lives, and less with issues of masculinity or health. While the literature on men’s health highlights how men’s gender socialization and resultant beliefs and attitudes about masculinity are major factors that influence behaviors associated with increased cancer risk (e.g., overeating, consuming fatty foods and few fruit and vegetables, physical inactivity) (Courtenay, 2000), African American men participating in our focus groups articulated "competing priorities" or a "hierarchy of responsibilities" that pose barriers to them prioritizing their own health and health practices. These African American men described how their roles as providers, parents, spouses, and community members were more important than taking care of their personal health. This prioritization also was reinforced by spouses, extended family members, and employers, who expected men to attend to work, family, and community roles and responsibilities, even if it meant taking time away from engaging in regular physical activity, preparing or purchasing healthier food, and engaging in other health behavior (e.g., sleeping or seeking medical care). Health is often considered a low priority for men until poor health impairs some aspect of their lives (e.g., sexual relationships, job) or roles (e.g., provider, father, spouse) that is considered a higher priority (Bowman, 1989, 2006).
