VIEWPOINT

Nutrition and Health Education for Limited Income, High-Risk Groups:

Implications for Nutrition Educators

JAN C. SINGLETON

United States Department of Agriculture, Extension Service, Food Science and Nutrition, Washington, DC 20250-0925

INTRODUCTION

Nutrition educators have made much progress in educating families about food and its relationship to health, but many families who hear these health messages are not able to make the necessary changes to incorporate them into their life­styles. For families with limited incomes or social patterns that predispose them to high-risk health behaviors, the struggle to cope with life's everyday problems takes prece­dence over health promotion and disease prevention. These families are often at high risk for health problems arising from the abuse of alcohol and tobacco, a lack of exercise, and a poor diet. Youths raised in such families are at particular risk for engaging in a number of negative health behaviors that are linked to chronic disease in adulthood. As the health care gap between the poor and the wealthy continues to widen, nutrition educators are faced with the challenge of meeting the needs of such high-risk families.

Risk factors are individual or environmental hazards that increase one's vulnerability to negative developmental out­comes. 1 They do not guarantee negative outcomes but, rather; increase the odds that problem behaviors will occur. Poverty is one of many risk factors that place families at risk for engaging in poor health and nutrition behaviors2; it is associated with an increased risk for developing cardiovas­cular disease, obesity, and diabetes.3- 6 The Report of the Task Force on Minority Health released in 1985 and 1986 emphasized the need for special attention to be paid to chronic health problems among minorities, whose average annual income is lower than that of white Americans. 7 In an article about blacks in the Mississippi Delta, Clancy recognized poverty as the most overwhelming cause of poor health among minorities.s Further, researchers in a Harlem study found that one third of the deaths that occurred among poor, black Americans would not have occurred if poor, black Americans had the same health status as white Americans with comparable incomes.9

Address for correspondence: Jan C. Singleton, Ph.D., R.D., USDA-Extension Service, Room 3440 South Building, Ag. Box 0925, Washington, DC 20250-0925 101994 SOCIETY FOR NUTRITION EDUCATION

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Families living in poverty often practice social patterns that increase their risk for engaging in negative health behaviors.2 According to Clancy, such social patterns may keep may adults and youths from limited income families feeling fundamentally powerless and unable to control the circumstances of their own lives.s The cumulative effect of the risk factors associated with poverty and those associated with high-risk social patterns can put many youths from poor families at particularly high risk for developing health and nutrition problems. Nutrition educators need to con­sider both poverty and high-risk social patterns (as well as other economic and social factors) when designing and delivering nutrition education programs that target high­risk families.

ADULT ATTITUDES TOWARD HIGH-RISK BEHAVIOR AMONG YOUTHS

In many poor families across America, behaviors that place youths at risk for health problems are not consistently discouraged by adult family members and other influential people in the community. II In some instances, these behav­iors may not always be viewed as inappropriate by adults who influence youths, or they may simply not be discussed fully between adults and youths. The use of tobacco and alcohol, both significant risk factors for chronic health problems, provides a key example. Use of these substances is more prevalent in poor communities and among minori­ties. 12 Youths who live in environments where there is widespread use of tobacco or alcohol by adults are less likely to develop negative attitudes about the use of these sub­stances. However, research has indicated that when there is a clear and consistent message from the adult family and community members that tobacco and alcohol use are unacceptable behaviors, the likelihood that youths will develop negative attitudes about the use of these substances is increased. 12

When influential adults model inappropriate behavior for youths, it increases the likelihood that youths will engage in these same behaviors. 13 This is especially true

154 Singleton/EDUCATION FOR LOW-INCOME, HIGH-RISK GROUPS

when adult caretakers have permissive attitudes about chil­dren's high-risk health behaviors.14

Youths who associate closely with peers who engage in high-risk behaviors are also more likely to adopt these same behaviors. This is especially true of young children for whom the association begins at an early age, before their own identity and values are formed. 15

SOCIAL ISOLATION AND STRESS

Individuals living in poorer communities are more likely to be plagued by a host of social problems that increase stress and exacerbate the health effects of high-risk behav­iors.2 These include such problems as lack of parental involvement, underemployment, unemployment, and so­cial isolation. 16

Adults from limited income families who are underem­ployed or unemployed often become socially isolated and despondent. Feelings of isolation and despondency can make it difficult for these adults to remain actively involved in their childrens' lives. Subsequently, youths from these families may feel that adult family members are not there for them emotionally. Thus, youths may seek the time and attention of their peers to fill the void left by a perceived lack of parental involvement. 16 This may increase the like­lihood that youths will imitate the behaviors of their peers, many of whom are themselves engaging in high-risk behaviors.

Poverty can place enormous economic stress on families and communities. Adult caretakers are often overwhelmed by financial worries, including food, rent, and transporta­tion. Adults caring for young children may worry about the costs of child care, school clothes, and supplies. Often, adult family members are forced to leave to find work. Stress among families in these circumstances can take its toll on both the health and emotional well-being of family members.

SOCIOECONOMIC STATUS AND ACCESS TO HEALTH CARE

High blood pressure, stroke, heart disease, obesity, and diabetes mellitus are more prevalent in poor communities where stress levels are high and access to health care is low.3- 7 These chronic health problems are especially preva­lent among poor minorities. They are, in part, determined by lifestyle factors and heredity; however, health problems that are related to lifestyle factors are often preventable.

There is evidence that chronic disease incidence may be increasing in poor communities, especially among minori­ties. 17 It has been noted that individuals from poorer com­munities are more likely to require health care, but less likely to receive it, when compared to wealthier individuals. This may be due, in part, to lack of health insurance.

Over 33 million Americans under age 65, many of them from poor communities, do not have health insurance.18

Further, studies have shown that poor and under-insured Americans are more likely to receive inferior health care. To make matters worse, poor Americans often wait longer to visit a doctor when they are ill, and are therefore often sicker before they seek help, because of lack of money or inadequate health insurance. 17 Thus, survival rates from chronic disease are lower for poor and under-insured Americans.?

IMPLICATIONS FOR NUTRITION EDUCATORS

Nutrition educators will not be able to solve all the prob­lems facing limited income, high-risk families. The prob­lems are too complex and, indeed, many of them have yet to be recognized. However, nutrition is a field dedicated to human service, whose ultimate goal is to benefit human­kind.19 Thus, it is important that nutrition educators con­sider the complex social problems that plague limited income, high-risk groups when designing and implement­ing nutrition education programs. As nutrition educators begin to have a greater understanding of the social structure of high-risk groups, they will become better able to formu­late intervention strategies that help individuals in high-risk groups cope more effectively with some of the barriers to good health that are caused by poverty, stress, and poor access to health care. Further, educators will become better able to help families and individuals within families to develop problem-solving skills that may keep them from engaging in high-risk behaviors.

PROBLEM-SOLVING SKILLS IN NUTRITION EDUCATION

Educational interventions that help develop good problem­solving skills among individuals in high-risk groups may be one key to designing effective nutrition education pro­grams.20 Good problem-solving skills can help to improve self-esteem and can given individuals a sense that they are in control of their lives. These skills can also help the learner "personalize" aspects of their own health behaviors by becoming actively involved in the decision-making process.

For example, nutrition educators who teach problem­solving skills to high-risk groups involve individuals in the following activities:

1. They help the learner identify and understand the factors that both positively and negatively influence their health behavior.

2. They help the learner identify alternative behaviors that can be implemented to improve health.

Journal of Nutrition Education Volume 26 Number 3

3. They help the learner identify obstacles to improving their health behaviors.

4. They help the learner understand the pOSItiVe and negative outcomes of alternative health behaviors.

5. They help the learner choose from among the possible alternative health behaviors.

6. They help the learner implement the behavior(s) chosen. 7. They help the learner modify health behaviors as cir­

cumstances warrant.

Many learners who successfully develop the problem­solving skills described above experience improved self­confidence and self-esteem.21 Nutrition educators can help these learners choose their own course of action by encour­aging them to be mature decision makers who are respon­sible for their own health and well-being. Learners whose confidence and self-esteem improve are often encouraged to become more involved in their communities, thus in­creasing the likelihood that they will expand their social support networks, both inside and outside of their immedi­ate communities.

The incorporation of problem-solving skills training into educational interventions is rooted in the theory of empow­erment, which has been defined as "the enhancing of people's capacities to control their own lives by defining, analyzing, and acting upon their health and nutrition prob­lems to their own satisfaction."20 According to Rody, em­powerment can help communities, and individuals within those communities, to become more self-reliant and better able to cope with social or health problems that may be encountered.21

In America, many in the medical and health communi­ties believe that the emphasis in health care should shift from one of the treatment of overt illness and disease to one of prevention. But for limited income, high-risk individuals, where even access to primary health care has been re­stricted, the focus on prevention has been sorely lacking. Yet the poor access to primary health care for these indi­viduals only serves to emphasize the urgent need for preventive health and nutrition programs in these commu­nities. Nutrition educators have an opportunity to make a tremendous impact in such situations, but the effort will require a greater knowledge of their target groups and the greater use of intervention techniques that empower high­risk groups to improve their health and nutrition behaviors.

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