Demographics
Sample demographics and characteristics are presented in Table 2. The study sample size was 33 across the three focus groups. Participants were 63.64% female with the remainder male. An “other” category was offered but no participants selected it. Mean age was 50.80, with a range of 24 to 71. During the focus groups it became clear that a small number of participants came in pairs as either couples, friends, or relatives, however we did not ask about this in the surveys so cannot state the frequency. The largest racial group was African American, with 48.48% of participants identifying in this category. The next largest group was white (27.27%), followed by Latinx (12.12%), other (9.09%), and then Asian (3.03%). Participants were asked to identify as many categories as applied to them, but none chose more than one race/ethnicity. The majority of participants (60.61%) reported incomes of less than $1000 per month. Almost 20% of participants did not select an income level, so it is difficult to ascertain the true percentages for this question.
Table 2
Participant characteristics
|
Number
|
Percentage
|
Mean (SD)
|
Age
|
30
|
|
50.80 (14.10)
|
Gender
|
|
|
|
Male
|
12
|
36.36
|
|
Female
|
21
|
63.64
|
|
Race/ethnicity*
|
|
|
|
Black
|
16
|
48.48
|
|
White
|
9
|
27.27
|
|
Latinx
|
4
|
12.12
|
|
Asian
|
1
|
3.03
|
|
Other
|
3
|
9.09
|
|
Income source*
|
|
|
|
Employment/job
|
4
|
12.12
|
|
SSI/SSD
|
23
|
69.70
|
|
TANF
|
0
|
0.00
|
|
GA
|
3
|
9.09
|
|
Family
|
4
|
12.12
|
|
SNAP
|
|
|
|
Yes
|
24
|
75.00
|
|
No
|
8
|
25.00
|
|
Health insurance
|
|
|
|
Yes
|
32
|
96.97
|
|
No
|
1
|
3.03
|
|
Monthly income
|
|
|
|
0 - $200.00
|
6
|
18.18
|
|
$201.00 - $400.00
|
2
|
6.06
|
|
$401.00 - $600.00
|
3
|
9.09
|
|
$601.00 - $800.00
|
9
|
27.27
|
|
$801-$1000
|
0
|
0.00
|
|
More than $1,000.00
|
7
|
21.21
|
|
Not sure/declined/missing
|
6
|
18.18
|
|
Overall health
|
|
|
|
Poor
|
8
|
24.24
|
|
Fair
|
14
|
42.42
|
|
Good
|
8
|
24.24
|
|
Very Good
|
2
|
6.06
|
|
Excellent
|
1
|
3.03
|
|
Health problems
|
|
|
|
Diabetes
|
9
|
27.27
|
|
Hypertension
|
26
|
78.79
|
|
Heart disease
|
4
|
12.12
|
|
Obesity
|
15
|
45.45
|
|
High cholesterol
|
12
|
36.36
|
|
Other
|
5
|
15.15
|
|
Number of health problems
|
|
|
|
1
|
13
|
39.39
|
|
2
|
10
|
30.30
|
|
3 or More
|
10
|
30.30
|
|
*Participants could select more than one option |
About twelve percent (12.12%) of respondents were employed, and 69.70% received some form of disability benefits. None received Temporary Assistance for Needy Families (TANF), but 9.09% received General Assistance (GA) for single adults (New Jersey is one of the few remaining states to offer this very limited public benefit for adults without children). About twelve percent (12.12%) of respondents received some amount of financial support from family or friends. Three quarters received Supplemental Nutrition Assistance Program (SNAP) benefits. All but one of the participants had health insurance.
The majority of respondents rated their health as Poor (24.24%) or Fair (42.42%). The remainder rated their health as Good (24.24%), Very Good (6.06%), or Excellent (3.03%). The most frequent health conditions identified by the participants included hypertension (78.79%), obesity (45.45%), high cholesterol (36.36%), and diabetes mellitus (27.27%). The largest group of respondents (39.39%) identified only one health problem, followed by 30.30% identifying two health problems, and 30.30% identifying three or more.
Quantitative results
Program planning questions
Qualitative results
Goals
When participants were asked about health-related goals they readily shared their individual visions for positive change. The most prevalent themes for these goals were diet and weight loss. Among those who wanted to change their diet, many stated that they wanted to eat more fruits and vegetables. Others described foods they needed to eliminate from their diets. One participant illustrated both of these themes:
I need to stop eating such fried foods, everything is like fried. I need to start eating more fruits and vegetables. Like I love spinach and eggs, I can eat that almost every other day, I love ‘em. I need to stop frying and stuff all the time with the oil and it’s greasy, it's no good.
Others wanted to cook more, or gain knowledge about how to prepare and enjoy healthy foods.
Barriers towards meeting health-related goals
We asked specifically about barriers that impacted diet and physical activity. For diet, by far the most frequently mentioned barrier was the cost of healthy food. The next most common factor was distance to vendors that sold healthy food. These issues frequently overlapped, with the nearby options having either no healthy food, or healthy food that was too expensive for the participants to purchase. As one focus group member stated:
If there was a market that just had fruits and vegetables that was reasonable that would be good. But if I could say its variety is not there and the cost is too high and it's like I go to [name of supermarket] and get depressed. Oh God it’s like same thing, it’s like I want something different, you know what I mean, and it's not there.
The next most frequent barrier to eating healthy foods raised by participants was preference, habit, or history. Participants said they just did not like the taste of foods that were recommended to them. They often looked at it as a chore to learn to like these foods: “I don't like salad but I know I have to learn how to– I have to learn how to eat [it].” Others described growing up eating unhealthy foods.
While family was often a support, several participants noted family responsibilities as making it more difficult to stick with a healthy diet. For example, one stated: “It’s just hard-it’s hard sticking to that diet. You know, you can get on a roll but you break, holidays come and, you know, the kids come and you gotta...I gotta cook the fries...”
Only a few participants mentioned lack of knowledge as a barrier to eating better, although several said they would welcome cooking and nutrition information as part of a potential group activity. Providers were viewed as a source of knowledge, but were not described as taking participants’ preferences into account
The most frequent comments about physical activity barriers centered on participants’ health limitations. Participants described a number of health conditions that typically impact physical activity, including orthopedic injuries, chronic pain, respiratory problems, and obesity. One participant shared:
I cannot twist, I cannot bend, I cannot stoop down. So, but I ordered a Tai Chi complete program and whatever I can do because, you know, Tai chi is very slooow…I’m excited waiting for it because I used to do yoga but now I'm going for the Tai chi. And I would invite any one of you who wants to come and join me, you can come.
After health limitations, the most commonly shared barriers were similar to those for improving diet: cost and access. Places to exercise were either too expensive or too far away. Transportation overlapped with access, because participants either did not have cars or could not afford transit fare.
Weather also presented a barrier for those in this group who had no place to exercise indoors. One participant whose main exercise was walking outdoors stated: “You can't get by, you know. Especially when you have a walker, you know, like, and then, all the snow is so piled up all to– all over. I mean there's like... Up, you know. You can't, there's no way.” For these participants, cost and access to indoor exercise locations combined with lack of other resources to make exercise much more difficult.
Several participants mentioned depression as a barrier, and one participant stated that stress lies beneath all of the barriers they experienced: ”See, the real heart of the matter concerning these topics likely, number one, can be summed up, just under stress.”
Coping strategies
Participants were resourceful in identifying many individual coping skills to reduce stress. These included activities such as venting, reading, doing puzzles, watching sports, and going outdoors. Some participants stated that caring for others, or even a pet, could be a source of strength for them. Participants identified a number of sources of support, especially friends and family. For example:
Yes, I go to my sister because I do get stressed and she's the calmer one, she calms me down. [laughter] She's like, ‘It's not that bad. It’s not that–.’ She's like, ‘Breathe, take it easy.’ I'm stressed out and I call her and she gets me back down a level.
A number of participants found faith as a strong source of support in their lives. This took a range of forms, including praying, reading the Bible, and attending a house of worship. One participant stated: “So I go to the Bible a lot and I just read it and it calms me down with the things that I'm going through. I do, I just pray.
Almost all the participants endorsed the idea of a group intervention. They felt that peer support was important, and would help them reach the goals they had shared earlier in the focus group:
Yeah well, if you want to join together as a goal to lose weight and support each other in the goals as part of maybe the exercise part, weigh-ins and the recipe of the week or whatever's a reason to come together, because it's so much easier to do with someone than it is to do, particularly if you live alone, than you do by yourself, you know.
Some participants asked if they could sign up for the program on the spot. During the focus groups, participants asked for and gave each other advice, turning the focus groups into a sort of peer support group. In their comments about a future intervention, participants connected their focus group experience to anticipation of a future program: “Having groups like this, this is wonderful.”
Participants had suggestions for features of the group intervention. For physical activity, yoga was the most common suggestion. Others asked for swimming, tai chi, and group walks. For diet, the most common responses centered on healthy cooking class, nutrition information, recipes, and potluck meals. There were many suggestions for stress reduction, including meditation, music, reading, pet therapy, and art therapy. Some specifically mentioned peer support: “I think support groups like talking like he said, just support.” Participants expressed that stress reduction was an important feature of the planned program. A number of them described stress as being at the center of their issues. As noted above, one participant identified stress as being “the heart of the matter” relating to health risks and barriers.
Self-determination constructs
Table 5 presents participant quotes linked with the SDT core constructs of autonomy, competence, and relatedness. The ability to choose from a range of options that are personally appealing and attainable supports autonomy. When participants described strategies they had developed on their own, that aligned with their own needs and preferences, their statements were positive and change-oriented. In contrast, their quotes about providers who counselled them on actions they “have to” take indicated challenges to adherence. Although Table 5 groups statements according to individual SDT constructs, considerable overlap exists. For example, while the lack of variety in available foods undermines the autonomy to make individual choices, the lack of affordability undermines the competence to buy healthy food at all. Depression was linked to difficulty initiating health behaviors as well. Quotes connecting to relatedness included comments on loneliness and the motivational benefits of peer support. Additionally, participants described interactions with providers that thematically connected to not feeling listened to and recognized as individuals.
Table 5
Self-Determination Theory constructs
Construct
|
Undermines this construct (quotes)
|
Supports this construct (quotes)
|
Autonomy
Definition: The need to choose and pursue goals that are personally meaningful, rather than being given directive advice)
|
“I've learnt to– I'm learning that no, I love rice but then I prepare shredded vegetables with a lick of rice just to, ya know, trick myself. So I have a lick of rice but it’s more vegetables. It’s nice. I've done that three days now. Three days I have been doing that and I’m going to continue, and I do my own recipes, just invent.”
But also, made a deal with myself actually to cook for myself, because I live alone, and I really, even if I only take one day a week to cook some meals.
|
|
|
Note. Bolding added by authors for emphasis |