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Factors Related to Physical Activity in Hispanic Women

Keller, Colleen PhD, RN-C, FNP; Fleury, Julie PhD, FAAN

The Journal of Cardiovascular Nursing: March-April 2006 - Volume 21 - Issue 2 - p 142-145
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Hispanic women are more likely to be sedentary than the general population. Increasing physical activity in this at-risk group is an important challenge in the prevention and management of coronary heart disease. This article reviews research conducted with Hispanic women in whom physical activity was the primary focus of study or the primary outcome of interest. Computer and manual searches were performed to identify articles published from 1990 to 2005. Factors that influence physical activity in Hispanic women include self-efficacy, having a concern for own and family health, social support and norms for physical activity, serving as a role model to others, and perceived neighborhood resources. Despite significant efforts to understand and promote physical activity among Hispanic women, much work remains to be done in this area. Future research should include attention to cultural, social, and contextual resources in understanding and promoting physical activity.

Colleen Keller, PhD, RN-C, FNP Professor, School of Nursing, University of Texas Health Science Center, San Antonio, Tex.

Julie Fleury, PhD, FAAN Hanner Professor, College of Nursing, Arizona State University, Tempe, Ariz.

Funded in part by a grant from NIH/NINR R55 NR04888-01A2 (Colleen Keller, PI).

Corresponding author Colleen Keller, PhD, RN-C, FNP, Professor, Arizona State University, College of Nursing, Tempe, AZ (e-mail: colleen.keller@asu.edu).

Hispanic Americans are the second largest ethnic minority group in the United States, accounting for 12.5% of the total population.1 By the year 2010, Hispanics will make up the largest minority group in the United States (34%), yet Hispanic Americans remain a seriously understudied population.2 This population is also predicted to be the youngest, the most likely to be poor, and the most likely to be without health insurance.3

The term "Hispanic" refers to a number of genetically heterogeneous and culturally diverse populations, including Mexican Americans, Puerto Ricans, Central and South Americans, and Cubans. The classification of Hispanic was developed by the US government to describe members of many minority groups.4 Thus, providing healthcare to Hispanic groups requires recognition of unique sociocultural and economic factors contributing to the health status of each subpopulation of Hispanics.5

Across studies, mortality from cardiovascular disease (CVD) has been reported to be lower among Hispanic Americans than among non-Hispanic whites in the United States, in spite of having higher rates of diabetes, obesity, and physical inactivity.6,7 However, Hispanic-American women studies have been found to have mortality rates from CVD comparable to non-Hispanic white women, thus refuting what has been termed "the Hispanic Paradox."8 Two primary factors contributing to the rates of CVD in Hispanic-American women are the prevalence of overweight and obesity (71.9%),9 and lack of leisure-time exercise (74%).10 The older Hispanic-American woman is at particular risk; after 60 years of age, Mexican-American women show marked declines in leisure-time physical activity.10

The purpose of this article is to critically review the research available on the factors related to physical activity in Hispanic-American women. Understanding the relationships between individual, social, and cultural factors and physical activity in Hispanic women will provide a basis for interventions to increase activity in this vulnerable group.

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Physical Activity Among Hispanic Women

The evidence that physical activity is causally and inversely related to CVD incidence and mortality has been substantiated with both retrospective and prospective data.11 Physical activity reduces CVD risk factors in women by improving lipid profiles, lowering blood pressure, reducing body fat, and increasing metabolic rate. Despite the known benefits of physical activity for reducing obesity and other cardiovascular risks, 74% of all Hispanic women report no leisure-time physical activity.

Relatively few studies have focused on the initiation and maintenance of sustained physical activity in Hispanic women.12-19 These data suggest the need to consider new or alternative strategies, built upon current knowledge of physical activity in Hispanic-American women. The positive relationship between physical activity and improved health has prompted widespread research into the initiation and maintenance of sustained physical activity in minority populations as a means of eliminating health disparities. However, among Hispanic women, the factors that contribute to physical activity are not well defined. In order to appropriately promote physical activity among Hispanic women and other minority populations, a greater depth of understanding regarding specific influences on physical activity behavior will facilitate movement toward achieving national health objectives.

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Methods

Using journal scans and computerized literature database searches, we identified studies that incorporated perspectives central to understanding physical activity in Hispanic women published between May 1990 and May 2005. Computerized searches of the English-language literature were conducted in Psychinfo, Medline, PubMed, and CINAHL using the following search terms: physical activity, exercise, inactivity, qualitative research, descriptive research, intervention research. Findings were categorized consistent with the stated purpose and methods of the research. Our primary inclusion criterion was the identification of empirical indicators of physical activity among Hispanic women. Only studies that assessed some physical activity behavior(s) as an outcome variable were included. Due to the small amount of research in this area, studies that used exercise or physical activity for weight reduction or cholesterol reduction were included. Studies that included Hispanic women as part of multiple ethnic groups were included if they analyzed findings by ethnic group.

Thirty-one studies met inclusion criteria. Findings were grouped by study results indicating the individual, social, and cultural influences on physical activity in Hispanic women. Given the early stage of the research, no attempt was made to integrate findings into a comprehensive synthesis. Instead, this article presents a descriptive review of literature to increase understanding of physical activity among Hispanic women.

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Findings

Individual Influences

A large number of survey research reports describe the level of physical activity in Hispanic women, as well as the relationships of factors thought to be related to activity.20 Broad categories of correlates have been identified, including self-efficacy, social support, barriers to physical activity, health concerns, attitudes toward physical activity, marital status, number of children, and normative beliefs.21,22 Self-efficacy and social support were the most commonly reported factors specific to Hispanic women.23-25 Barriers to physical activity include being too tired, receiving discouragement from others, self-consciousness, women's multiple roles, and lack of time.26,27 Among older women, self-efficacy was positively related to physical activity.28 Among young Central and South American Hispanic women, religious service attendance and belonging to community groups were related to higher levels of physical activity.29

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Social Influences

Social supports have been shown to be especially relevant among Hispanic women compared to other ethnic groups, and corresponded to higher levels of physical activity.30-32 In data presented from the Women's Cardiovascular Health Network, salient correlates of physical activity among Hispanic women included social norms, or knowing and observing others who engaged in physical activity, and attending religious services, although these factors were negatively correlated among younger Hispanic women.23,29,33,34 Both healthcare providers and community supports were reported to be physical activity facilitators in older Hispanic women.35 Across studies that measured environmental variables such as neighborhood safety, few of these factors were correlated with physical activity.33

Castro et al13 used a behavioral counseling intervention to increase self-efficacy and social support for walking and showed increases in perceived social support but not increases in walking.36 Culturally relevant intervention strategies that both enhanced retention and fostered positive outcomes included the use of informal leadership, social support in the form of "buddies" to facilitate the change process, and family involvement in physical activity.12,18

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Cultural Influences

Across studies, investigators found that family obligations, family attitudes, positive perceptions of weight (eg, equated with marriage and motherhood), cultural norms of overweight, fatigue, safety, cost, and lack of environmental resources served as primary barriers to physical activity.37 Although women voiced primarily positive attitudes toward physical activity, many did not directly relate physical activity to their health status, or viewed physical activity as prescriptive rather than preventive.38 The majority of studies noted family obligations, or commitment to their family, as primary barriers to engaging in physical activity.39-41 In contrast, family obligations also were seen as an enabler to physical activity in that women felt that their family members were proud of them for participating in activity, and that taking care of their health was something that women could do for their family.15,42 Cultural expectations and values related to weight and exercise influenced physical activity among immigrant Mexican-American women.43,44

Posting culturally relevant signs in public places, such as the airport, increased the use of stairs among Hispanic women.45 The use of community advisory committees, walking clubs, and informal structure for exercise has been shown to contribute to walking increases in Hispanic communities.16 Social support and behavior modification contributed to achieving weight loss with physical activity, although not defining the culturally appropriate intervention.19 Traditional values also served as a barrier in some studies. For example, Melilo et al35 found that within the Mexican-American culture, physical activity was considered inappropriate in for older women.

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Implications for Practice

Few of the studies reviewed included a cultural-specific intervention or described the cultural relevance of the findings. For example, most surveys of Hispanic subgroups (eg, South and Central Americans, Mexican Americans) employed predetermined factors thought to be important in relationship to physical activity. The results of these studies are equivocal, with strong or weak relationships of self-efficacy, social support, and neighborhood influences, depending upon the Hispanic subgroups surveyed.23,29,33 These findings illustrate 2 important aspects of cross-cultural research: (1) the notion that ethnic groups cannot be considered heterogeneous based upon a common language; and (2) the likelihood of socioeconomic influences on health behavior.

Eight studies employed focus groups to examine barriers and supports for physical activity in Hispanic women27,35,37,39-41,43,44 These data point specifically to the need for social supports to assist women in physical activity, the importance of family obligations and ethnic women's roles that preclude physical activity. It may be that sedentary behavior is imbedded in subjective interpretations of cultural values, such as familism. Therefore, it is important for researchers and healthcare providers to understand that the health consequences of sedentary behavior and other risky behaviors may be a part of this group of women's daily lives. Interventions designed to increase physical activity in Hispanic women without understanding how sedentary behavior is integrated into their lifestyles and determined by social and cultural expectations will not be successful. Hispanic women may be more responsive to programs promoting physical activity participation as a strategy to improve their roles as caregivers and mothers.44

A number of factors provide direction for practice, including individual self-efficacy, having a concern for one's own and family's health, social support and norms for physical activity, serving as a role model to others, and perceived neighborhood resources. These factors can be used to guide strategies in clinical practice to encourage the initiation and maintenance of physical activity.

Research designed to promote regular physical activity among Hispanic women must be socially and culturally specific and recognize social, cultural, and contextual factors, including individual and community resources, values, strengths, and goals. Research is greatly needed to generate a more complete understanding of how individual, social, community, and organizational factors interact to determine physical activity in Hispanic women.46

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Keywords:

cardiovascular risk reduction; health promotion; Hispanic women; physical activity

© 2006 Lippincott Williams & Wilkins, Inc.