Barriers to Healthcare Seeking and Provision Among African American Adults in the Rural Mississippi Delta Region: Community and Provider Perspectives.

Barriers to health care access and utilization are likely to be perceived differently for receivers and providers of health care. This paper compares and contrasts perspectives of lay community members, volunteer community health advisors (CHA), and health care providers related to structural and interpersonal barriers to health care seeking and provision among African American adults experiencing health disparities in the rural Mississippi Delta. Sixty-four Delta residents (24 males, 40 females) participated in nine focus groups organized by role and gender. The constant comparative method was used to identify themes and subthemes from the focus group transcripts. Barriers were broadly categorized as structural and interpersonal with all groups noting structural barriers including poverty, lack of health insurance, and rurality. All groups identified common interpersonal barriers of gender socialization of African American males, and prevention being a low priority. Differences emerged in perceptions of interpersonal barriers between community members and healthcare providers. Community members and CHA fears of serious medical diagnosis, stigma, medical distrust, and racism emerged as factors inhibiting health care utilization. All groups were critical of insurance/regulatory constraints with providers viewing medical guidelines at times restricting their ability to provide quality treatment while community members and CHA viewed providers as receiving compensation for prescribing medications without regard to potential side-effects. These findings shed light on barriers perceived similarly and differently across these stakeholder groups, and offer directions for ongoing research, outreach, clinical work, and health care policy.

"We Need Help in the Delta".

The purpose of this study was to better understand the barriers to health promotion among African American older men living in the rural Mississippi Delta. A qualitative, intrinsic case study approach was used to explore the phenomenon of health and the barriers to promoting men's health within the unique context of the Delta. Data included one key informant interview and two focus group interviews with 14 men, with the majority between the ages of 41 and 55 years. Focus group participants were lay community members as well as members of a volunteer community health advisors men's group. Findings underscore the extensiveness of the term "health" and the importance of attending to structural barriers in addressing men's health. Three overarching themes emerged: "men don't talk about health," "health care is not just the issue, everything is," and "we need a strong male to lead." Implications for future research and health promotion efforts are provided.

Mississippi Communities for Healthy Living: Implementing a nutrition intervention effectiveness study in a rural health disparate region.

BACKGROUND: Intervention research in rural, health disparate communities presents unique challenges for study design, implementation, and evaluation. Challenges include 1) culturally appropriate intervention components, 2) participant recruitment and retention, 3) treatment cross-contamination, 4) intervention delivery and data collection, and 5) potential measurement reactivity. PURPOSE: The purposes of this paper are to 1) detail the methods of the MCHL study and 2) report baseline demographic characteristics of study participants. The secondary aim is to determine if study participants were engaging in behavior changes after enrollment and prior to intervention initiation. METHODS: MCHL was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). Intervention components were based on Roger's diffusion of innovation attributes that promote adoption of a new innovation as well as on the psychosocial constructs of social support, self-efficacy and decisional balance. Rolling enrollment data collection was used to acquire sufficient sample size and a second data collection just prior to intervention implementation assessed measurement reactivity effects. Participant outcomes included diet quality, blood pressure, weight status, and quality of life. Cluster stratified assignment to one of two treatment arms was utilized to minimize cross contamination. Generalized linear models were used to compare enrollment measures between the two treatment arms while mixed model linear regression was used to test for changes in diet quality outcomes from enrollment to pre-intervention baseline. RESULTS: There were no significant differences in participant demographic, anthropometric or clinical measures between the two treatment arms at enrollment. With the exception of total vegetables, none of the diet quality indicators were significantly different between enrollment and baseline timepoints. CONCLUSIONS: Conducting nutrition intervention research in a rural health disparate region requires flexibility in adapting the recruitment, retention, and data collection procedures while maintaining a high level of scientific rigor. Negligible research participation effects, such as measurement reactivity, were noted in this population. However, further research is needed to identify methods to successfully recruit and retain Caucasian females to participate in community-based nutrition interventions in this region.

Using the RE-AIM Framework in formative evaluation and program planning for a nutrition intervention in the Lower Mississippi Delta.

OBJECTIVE: Identification of prominent themes to be considered when planning a nutrition intervention using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. DESIGN: Qualitative formative research. SETTING: Women's social and civic organizations in the Lower Mississippi Delta. PARTICIPANTS: Thirty-seven (5 white and 32 black) women with a college degree or higher. PHENOMENON OF INTEREST: Impact of dietary and contextual factors related to the Lower Mississippi Delta culture on intervention planning. ANALYSIS: Case analysis strategy using question-by-question coding. RESULTS: Major themes that emerged were "healthy eating focus" and "promoting a healthy lifestyle" when recruiting organizations (Reach); "positive health changes" as a result of the intervention (Effectiveness); "logistics: time commitment, location, and schedule" to initiate a program (Adoption); "expense of healthy foods" and "cooking and meal planning" as barriers to participation (Implementation); and "resources and training" and "motivation" as necessary for program continuation (Maintenance). The "health of the Delta" theme was found across all dimensions, which reflected participants' compassion for their community. CONCLUSIONS AND IMPLICATIONS: Results were used to develop an implementation plan promoting optimal reach, effectiveness, adoption, implementation, and maintenance of a nutrition intervention. This research emphasizes the benefits of formative research using a systematic process at organizational and individual levels.

Energy density, nutrient adequacy, and cost per serving can provide insight into food choices in the lower Mississippi Delta.

OBJECTIVE: To compare differences across food groups for food cost, energy, and nutrient profiles of 100 items from a cross-sectional survey of 225 stores in 18 counties across the Lower Mississippi Delta of Arkansas, Louisiana, and Mississippi. METHODS: Energy, nutrient, and cost profiles for food items were calculated by using Naturally Nutrient Rich methodology and converting price per 100 g edible portion to price per serving. Foods were grouped into 6 food groups. Mean differences were compared with ANOVA. RESULTS: Significant differences existed by food group for each measure. Energy density was highest for fats/oils/sweets, whereas nutrient density was highest for vegetables. Price per serving was lowest for fats/oils/sweets and highest for meats. CONCLUSIONS AND IMPLICATIONS: Educational messages focusing on a complete diet should consider the role of food costs and provide specific recommendations for increasing nutrient-dense foods by replacing a portion of the meat serving at meals with culturally acceptable lower-cost nutrient-dense foods.

Meaningful messages: adults in the Lower Mississippi Delta provide cultural insight into strategies for promoting the MyPyramid.

OBJECTIVE: To explore cultural perceptions of the MyPyramid key messages and identify factors that may impact adoption of these recommendations. METHODS: Systematic content analysis of transcripts from in-depth, structured interviews with 23 adults, primarily African American females, residing in the Lower Mississippi Delta. RESULTS: When asked to identify good reasons to follow the MyPyramid key messages, nonspecific references to improved health were most prevalent (n = 130); however, participants also acknowledged the importance of getting vitamins and nutrients (n = 81), and the impact food choices have on health conditions (n = 77) and organ systems (n = 65). Individual-level factors (n = 211), such as dislike for food items and tradition or customs, far outnumbered environmental-level factors (n = 48), such as cost and availability, as perceived reasons preventing community members from adhering to the key messages. The most frequently mentioned suggestion for helping community members eat according to the MyPyramid were to raise awareness (n = 93), provide information (n = 65), and improve the taste of or provide opportunity to taste (n = 49). CONCLUSIONS AND IMPLICATIONS: This study captured participants' cultural perspectives of the MyPyramid key messages. Results indicate that both social marketing campaigns and intervention efforts focused on individual-level factors are needed to promote the MyPyramid in this disadvantaged Delta region.

Nutrition literacy status and preferred nutrition communication channels among adults in the Lower Mississippi Delta.

INTRODUCTION: The objective of this cross-sectional study was to examine the nutrition literacy status of adults in the Lower Mississippi Delta. METHODS: Survey instruments included the Newest Vital Sign and an adapted version of the Health Information National Trends Survey. A proportional quota sampling plan was used to represent educational achievement of residents in the Delta region. Participants included 177 adults, primarily African Americans (81%). Descriptive statistics, chi2 analysis, analysis of variance, and multivariate analysis of covariance tests were used to examine survey data. RESULTS: Results indicated that 24% of participants had a high likelihood of limited nutrition literacy, 28% had a possibility of limited nutrition literacy, and 48% had adequate nutrition literacy. Controlling for income and education level, the multivariate analysis of covariance models revealed that nutrition literacy was significantly associated with media use for general purposes (F = 2.79, P = .005), media use for nutrition information (F = 2.30, P = .04), and level of trust from nutrition sources (F = 2.29, P = .005). Overall, the Internet was the least trusted and least used source for nutrition information. Only 12% of participants correctly identified the 2005 MyPyramid graphic, and the majority (78%) rated their dietary knowledge as poor or fair. CONCLUSION: Compared with other national surveys, rates of limited health literacy among Delta adults were high. Nutrition literacy status has implications for how people seek nutrition information and how much they trust it. Understanding the causes and consequences of limited nutrition literacy may be a step toward reducing the burden of nutrition-related chronic diseases among disadvantaged rural communities.