The Relationship of Stress to Health-Promoting Behaviors of College-Educated African American Women

Abstract

Background:

More research has been done involving obese and overweight African American women who have low and middle socioeconomic status (SES) and have a high school education or some college. Fewer studies have involved African American women who have completed college, and even fewer numbers of studies have involved African American women of middle and high SES with bachelor's and graduate degrees.

Methods:

Quantitative analysis, using analysis of variance (ANOVA), Pearson's product moment statistics, and stepwise multiple regression, was performed. Utilizing Pender's health promotion model, the relationships among weight, body image, self-efficacy, stress, and health-promoting behaviors were determined in a purposive sampling of 167 subjects who were members of an organization of women in the Metropolitan Washington, D.C., area, whose membership consists primarily of college-educated African American members. These participants were compared for the association of weight, body image, self-efficacy, and stress in relation to increased commitment to engage in health-promoting behaviors, such as increased physical activity and consumption of healthy foods.

Results:

Among these women, low levels of stress were likely to influence a participant's decision to adopt health-promoting behaviors. The results showed a significant negative relationship (r = −.365, p < .05), indicating that among these college-educated African American women, low levels of stress were likely to influence one's decision to adopt health-promoting behaviors; and there was no significant difference in any of the mean scores (F(2,163) = .854, p > .05) of health-promoting behaviors between those who were normal weight, overweight, or obese.

Conclusions:

In this cohort, levels of stress were found to negatively influence a participant's decision to adopt health-promoting behaviors. Further, positive body image and positive self-efficacy were related to intent to engage in health-promoting behaviors. Information from this study can enable nurses and other health care providers design culturally and educationally sensitive interventions aimed at helping such women achieve and maintain a healthier lifestyle.

Introduction

Little is known about the interrelationship of health-promoting behaviors, overweight status, and obesity in college-educated African American women. More research has been done involving obese and overweight African American women who have low and middle socioeconomic status (SES) and have a high school education or some college.¹ Although a few studies have involved African American women who have completed college, fewer numbers of studies have involved African American women of middle and high SES with bachelor's and graduate degrees.^2–4 Most research of African American women includes those of low socioeconomic class (SEC) with high school or some college, and few studies include solely participants with a bachelor's degree or higher. It is important to note that for Caucasian women, achievement of a college education is a protectant for being overweight or obese, whereas overweight and obesity are present in overwhelming numbers in African American women, no matter what their education.⁵ This represents a disparity in obesity and health promotion that is not usually considered.

Many African American women acknowledge stress as a major influence on their well-being. Stress plays a major role in family interactions, relationships with friends and coworkers, work productivity, use of leisure time, marital status, and career mobility.⁶ The purpose of this article is to report the results of a previous study⁷ that examined the role stress plays, as well as its correlates to weight and health-promoting behaviors, in a group of college-educated African American women.

Review of the Literature

Stress impacts life events continuously. Our response to stress varies from individual to individual. One possible reason for obesity is one's inability to manage or control the elements of stress in one's life, defined as self-efficacy.⁸ Stress is mediated by self-efficacy.

Lazarus and Folkman⁹ define psychological stress as a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being. Present research indicates there is a positive correlation between body weight and stress.^10–12 African American women who are overweight experience more stress. Stress has the ability to negatively effect weight control.^10,13 Major stressors for African American women include occupational stressors related to racism, sexism, and workload.^10,14 Negative exposure to life experiences may occur equally to African American women at all levels of education, and not decrease related to greater educational attainment.⁵ Further, Strickland, Giger, Nelson, and Davis found “that overweight and obese African American women were less likely to directly confront problems in their lives than women who are normal weight.”¹⁵

Contrary to other studies related to eating disorders, Perez, Voelz, Pettit, and Joiner¹⁶ studied the interactive effects of acculturation stress and body dissatisfaction in predicting bulimic symptoms, particularly in nonwhite females, and found that among minority women who report low levels of acculturation stress (stress of adaptation related to assimilation into a culture different to one's own culture), body dissatisfaction and bulimia were not correlated. However, among minority women who reported high levels of acculturation stress, body dissatisfaction and bulimia were highly and significantly correlated. Participants of this study, 118 European American (51%), Hispanic (19%), and African American (30%) female undergraduate university students, completed questionnaires about their personality, emotions, self-concept, and stress.

Research indicates that African American women are less likely than Anglo-American, Mexican, or Puerto Rican women to engage in stress reduction activities.¹⁴ This finding is the result of a descriptive, exploratory study (which used triangulation methodology) consisting of a purposive sample of 94 middle-income African American (36), Anglo-American (24), Mexican American (921), and Puerto Rican (16) women between the ages of 23 and 75 years of age who were members of community service and professional organizations. The purpose of the study was to solicit the types of stressors experienced in the workplace, directly from a culturally diverse group of women. Unique stressors of Mexican Americans, Mexicans, and African Americans included the added workload of serving as translators for Mexican, Mexican American, and Puerto Rican women, and the dual burden of racism and sexism experienced by African American and Puerto Rican women.¹⁴

Combining employment with home management and childcare can result in high stress levels.¹⁷ In their qualitative study of 16 African American women (ages 35 to 50 years) who participated in focus groups in an urban area of western Tennessee, Nies, Vollman, and Cook¹⁷ concluded that a commitment to understanding the psychological determinants (such as stress) of physical activity, as well as a supportive environment, is required for African American women to increase their activity levels. Stress reduction was viewed as the primary goal of physical activity, and exercise was identified as a reducer of stress.

Chronic stress exists in the form of daily hassles, perceived racial discrimination, and financial strain often leading to emotional responses that are believed to affect both the systolic and diastolic blood pressure. Chronic stress and emotional responses may not have the same negative effects on blood pressure for high-income, middle-class African American adults as they do for low-income, lower-class African American adults.¹⁸ This disparity was noted in an exploratory study that examined the relationship among socioeconomic position, chronic stress, emotional responses, and cardiovascular response of elevated blood pressure in a convenience sample of 211 African American men (64) and women (147), ages 25 to 79 years, who resided in southeastern Michigan. Seventy-four percent of the participants reported having completed some college, and 61% reported having completed bachelor and/or graduate degrees. Though the average Body Mass Index (BMI) was 28.5 kg/m², the BMI ranged from 17.9 (underweight) to 49.60 kg/m² (extreme obesity). The women in this study had higher incomes and were more likely to be employed in white-collars jobs than the men in the study. They also had higher negative affect scores than men, “reflecting more anger, contempt, fear, and nervousness” (p. 509). The negative affect did not increase the diastolic or systolic blood pressures for men or women; in fact, women's diastolic blood pressure averaged 4 mm/hg lower than men's.

Materials and Methods

A descriptive correlational design was used to describe the relationship among the individual variables (weight, body image, self-efficacy, and stress) to health-promoting behaviors in African American women who obtained a bachelor's degree or higher. Participants were a convenience sample of 167 subjects who were members of an organization in Metropolitan Washington, D.C., whose membership is college educated and primarily African American. This organization has a national membership of over 200,000 women.

In this study, college-educated African American women were compared on variables of weight, body image, self-efficacy, and stress as they relate to increased commitment to engage in health-promoting behaviors, such as increased physical activity and consumption of healthy nutrition. Power calculation of three groups determined a target sample size of 159 subjects, using a probability value of .05, an effect size of .25, and a power of .80. This probability and power level were chosen to ensure adequate sample size.¹⁹

Eligibility criteria for the study included women of all ages and weight categories, who through self-report indicated that they are healthy. Additionally, each subject met the following criteria: (1) The subject had completed a 4-year college baccalaureate degree, and (2) the subject indicated via self-report that she is African American.

Six instruments were used in this study. Five were paper-and-pencil surveys, and one was a body measurement taken by the researcher. It took each participant approximately 30–45 minutes to enter and complete all phases of this research. All participants were given a pedometer with a pulse meter. The instruments were as follows

The Body Mass Index (BMI) measures weight status in adults. BMI, which describes relative weight for height, is significantly correlated with total body fat content. BMI is the measure of weight in relation to height.²⁰ Anthropometric measures were taken using a stadiometer (Seca 214 Portable Height Rod), also referred to as a height rod, and weight was taken using a digital scale with a remote display (Health O Meter 320KL Digital Medical Scale). The digital display on the scale was visible only to the researcher and could also be displayed to the participant. This was discreet and maintained confidentiality of the participant's weight. It is important to note, for adults over 20 years old, that BMI is placed in one of the following weight status categories: (1) Below 18.5 is underweight, (b) 18.5–24.9 is normal, (c) 25.0–29.9 is overweight, or (d) 30.0 and above is obese.

The Body Image Quality of Life Inventory (BIQLI) is a 19-instrument designed to quantify the impact of body image on aspects of one's life. The item content reflects domains or contexts in which body image has been found to be consequential. Subjects rate the impact of their own body image on each of 19 areas, using a 7-point bipolar scale from −3 to +3 (reporting negative, positive, or no impact). It measures effects on feelings about self and life in general emotional states, same- and other-sex relations, eating and exercise, grooming activities, sexual experiences, and family and work or school. The range of possible scores is from −57 to 57. High scores indicate positive body image.²¹ The internal consistency (Cronbach's alpha) was .95, and the test–retest reliability of the mean scale (over a 2–3-week period) was .79.²¹

The General Self-Efficacy Scale (GES) aims at a broad and stable sense of personal competence to deal effectively with a variety of stressful situations. The GES measures one's belief of his or her ability to deal efficiently with a variety of stressful situations; it uses a 4-point Likert scale, ranging from 1 to 4, with responses ranging from not at all true to exactly true. High scores indicate high self-efficacy. The range of possible scores is 10 to 40. The Cronbach's alpha was .75 to .90.²²

The Perceived Stress Scale (PSS) is used to assess stress. The PSS is a 10-item instrument designed to measure the degree to which situations in one's life are appraised as stressful. It uses a 5-point Likert scale, from 0 to 4, with responses that range from never to very often. The range of possible scores is 0 to 40. High scores indicate high levels of stress. Reported Cronbach's alphas have ranged from .84 to .86.²³

The Health-Promoting Lifestyle Profile II (HPLP-II), a 52-item, 4-point Likert scale, contains six subscales: health responsibility, nutrition, physical activity, stress management, interpersonal relations, and spiritual growth. All of the items are scored from 1 to 4 (1 = never to 4 = routinely) with a range of possible scores from 52 to 208. A composite score and individual subscale scores are obtained. The Cronbach's alpha for the total HPLP-II is .943, and for the subscales as follows: health responsibility, .861; nutrition, .800; physical activity, .850; stress management, .793; interpersonal relations, .872; and spiritual growth, .864 (S. N. Walker, personal communication, April 4, 2004).

The Personal Profile is a form designed to record self-reported demographic data; it requests information about participants' age, education, number of children in the household, ages of children in the household, race and ethnicity, parents of other races or ethnicities, marital status, religion and faith, and income.

The following stress-related research questions were addressed:

What is the relationship between stress and health-promoting behaviors among college-educated African American women?

Among college-educated African American women, how much of the variance in health-promoting behaviors can be explained by weight, body image, self-efficacy, and stress?

Can the relationship among weight, body image, self-efficacy, and stress predict the adoption of health-promoting behaviors of college-educated African American women?

Subjects were recruited at their regularly scheduled chapter meeting. In response to a letter to three chapters of the organization, announcements, and posters placed in strategic locations, interested participants were directed to come to a designated area. All women (all sizes and ages) attending the organization's meetings who had completed a bachelor's degree or higher were recruited to participate in this study of health-promoting behaviors. Including participants of all ages captured women who were beginning their career, as well as those who were retired or about to retire. Any failure to recruit women of all body sizes was examined in the analysis of this study.

Results

Factors associated with commitment to engage in health-promoting behaviors by college-educated African American women were explored. Following descriptive analysis of the data, correlations of weight (as assessed by BMI), body image, self-efficacy, stress, and health-promoting behaviors were analyzed using Pearson's product moment correlations. ANOVA was used to evaluate the mean variance differences among normal-weight, overweight, and obese participants. Variables that were correlated with health-promoting behavior were further analyzed, using stepwise multiple regression to determine their ability to predict health-promoting behavior.

Variables correlated with health-promoting behavior were further analyzed using stepwise multiple regression to determine their ability to predict health-promoting behavior. All analyses were performed using SPSS, version 11.5.

Sample

The mean age of the participants was 47 (SD = 15.04). Participants ranged between 22 and 86 years old. Almost half of study participants had attained a master's degree (49%), and nearly 12% had completed doctoral degrees (7%), law degrees (4%), or medical degrees (1%). Most of the women enrolled in this study were married (42%), although a sizable percentage was single and had never been married (38%). Most of the participants were Protestant (57%), followed by “other” (34%) and Catholic (8%). Generally, participants were upper middle class income in terms of income. The largest portion of the sample (25%) had household incomes of $75,000 to $99,999, followed by 18% who had household incomes of $100,000 to $124,999. Twenty percent of subjects had household incomes of $50,000 to $74,999, and 17% had household incomes of $125,000 to $149,999. Table 1 contains further demographic information about the sample.

Table 1.

Demographic Characteristics of Participants

	N	%		N	%
Educational			Race or ethnicity of participant's parents
Bachelor's degree	65	38.9	Both are African American	160	95.8
Master's degree	81	48.5	One or Both are West African	1	.6
Doctoral degree	12	7.2	One is Native American	2	1.2
Law degree	7	4.2	One or Both is West Indian	4	2.4
Medical degree	2	1.2
Income			Marital status
Less Than $25,000	3	1.8	Married	69	41.3
$25,000–34,999	5	3.0	Single (Divorced)	24	14.4
$35,000–49,999	11	6.6	Single (Never Married)	63	37.7
$50,000–74,999	33	19.8	Single (Widowed)	9	5.4
$75,000–99,999	42	25.1	Single (Separated)	2	1.2
$100,000–124,999	30	18.0
$125,000–149,999	14	8.4
$150,000 and Over	28	16.8
Number of children in household			Religion or faith
0	113	67.7	Catholic	14	8.4
1	31	18.6	Islamic	1	.6
2	19	11.4	Jewish	2	1.2
3	4	2.4	Protestant	93	55.7
			Other	57	34.1

The findings of the stress-related research questions in this study are explained as follows. The relationship between stress and health-promoting behavior was examined utilizing Pearson's product moment correlation. The results showed a significant negative relationship (r = −.365, p < .05), indicating that among these college-educated African American women, low levels of stress were likely to influence one's decision to adopt health-promoting behaviors. Conversely, high levels of stress may influence one's decision not to adopt health-promoting behaviors. Table 2 shows the correlation between BMI (weight), body image, self-efficacy, stress, and health-promoting behavior.

Table 2.

Correlations of Body Mass Index, Body Image, Self-Efficacy, Stress, and Health-Promoting Behavior

Variables	1	2	3	4	5
Body mass index	—	—	—	—	—
Body image	−.278(^**)	—	—	—	—
Self-Efficacy	−.106	.398(^**)	—	—	—
Perceived stress	−.003	−.315(^**)	−.348(^**)	—	—
Health-Promoting behavior	−.023	.413(^**)	.324(^**)	−.365(^**)	—

Note. ^**Correlation is significant at the 0.01 level (2-tailed). Body Mass Index assessed weight.

A one-way ANOVA was utilized to determine differences between the normal-weight, overweight, and obese participants' health-promoting behaviors. The results indicated that there was no significant difference in any of their mean scores (F(2,163) = .854, p > .05). That is, all three groups were equal in their health-promoting behaviors. Additionally, there was no significant difference in health-promoting behaviors between those who were normal weight, overweight, or obese. Table 3 shows the differences between the normal-weight, overweight, and obese participants, as determined by ANOVA.

Table 3.

Differences Between the Normal Weight, Overweight, and Obese Participants, as Determined by ANOVA

Source	SS	df	MS	F	p
Between groups	963.453	2	481.727	.854	.428
Within groups	91,924.023	163	563.951	—	—
Total	92,887.476	165	—	—	—

Stepwise multiple regression analysis was utilized to ascertain whether weight, body image, self-efficacy, and stress predicted the adoption of health-promoting behaviors among these college-educated African American women, and to estimate a model that best predicted the adoption of health-promoting behavior. The results of the stepwise analysis revealed that in two of the four factors (with a beta of .36; p < .05), body image emerged as the strongest predictor of health-promoting behaviors, accounting for 19.1% of the variance in health-promoting behavior. The next strongest factor was stress (β = –.26, p < .05), which accounted for an additional 5.6% of the variance in health-promoting behavior. Adoption of health-promoting behavior appeared to be a function of positive body image and low levels of stress among these college-educated African American women. Table 4 shows a summary of stepwise multiple regression analysis for variables predicting health-promoting behaviors. The results of correlation of the other variables are reported elsewhere.²⁴

Table 4.

Summary of the Stepwise Multiple Regression Analysis for Variables Predicting Health Promoting Behaviors

Variable	B	SE	β
Step 1
Total body image	.238	.038	.443
Step 2
Total body image	.194	.038	.360
Total perceived stress	−.020	.005	−.260

P < .05.

Discussion

Utilizing Pender's health promotion model,²⁵ which incorporates social cognitive theory as the conceptual framework, the descriptions and correlations of weight, body image, self-efficacy, and stress related to health-promoting behaviors of college-educated African American women were established. Despite media attention, more access to exercise, and healthy food, the rate of obesity has changed only minimally.

Consistent with Pender's model, each participant possessed unique demographics or attributes in terms of age, education, number of children in the household, ages of children in the household, and race and ethnicity. Varying marital status, religion and faith, income, unique experiences (including experiences of some prior behaviors), and personal characteristics were all represented in the study. Prior related behavior shaped the participants' behavior-specific cognitions and affects. Child bearing, physical activity and nutrition practices, management of stress, association of body size to body image, experience with weight control, and self-efficacy (experience with accomplishing what one plans to) were the prior behaviors accounted for in this study. According to Pender (2002), prior behavior can affect one's likelihood of participating in health-promoting behavior through perceptions of self-efficacy, benefits, barriers, and activity-related affect. In this study, prior levels of physical activity and nutrition along with personal factors of weight status and stress influenced cognitions, affect, and health behaviors of the identified perceived benefits of action, perceived barriers of action, perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences including body image.

Behavior-specific cognitions and affect were major motivators. Measurable change in body image, a variable in this category, influenced changes in commitment to engage in or the occurrence of health-promoting behaviors. Commitment to a plan of action may be an important factor, since this type of behavior has the ability to help women initiate physical activity and healthy nutrition.

Interestingly, positive body image and low stress predicted the adoption of health-promoting behaviors in this group of college-educated African American women. Body image and levels of stress accounted for one quarter of the variance in health-promoting behavior, while 75% was influenced by other, yet-to-be-determined factors. The present research leads to the conclusion that studies that take into account the impact of race, gender, and class are needed for health disparity research involving women of color, so that health disparities can be eliminated. This approach provides for cultural sensitivity that will enable a better understanding of why women of color experience poorer health outcomes.²⁶

Demographic data indicated that the participants were primarily African American women who ranged in age from 22 to 86. These women were typically married and had no children living in the household. Most held graduate degrees and were middle to high income, with earnings of $75,000 or more (68%). A full 17% of participants earned $150,000 or more annually. Though the participants held a variety of occupations, most were educators, followed by managers and analysts.

Among these college-educated African American women, weight did not influence the decision to adopt health-promoting behaviors. Likewise, the extent to which health-promoting behaviors were adopted did not influence weight in college-educated African American women.

Among these college-educated African American women, a positive body image may influence the participants' decision to adopt health-promoting behaviors. Feeling good about one's body encourages adoption of health-promoting behaviors that will enhance or maintain positive perceptions and attitudes related to body characteristics.

Among these college-educated African American women, a positive self-efficacy or belief that one had the ability to carry out a specific behavior or course of action positively influenced the participant's decision to adopt health-promoting behavior.

Among these college-educated African American women, high levels of stress appeared to influence the participant's decision not to adopt health-promoting behaviors. Likewise, low levels of stress were likely to influence one's decision to adopt health-promoting behaviors. Jones, Tucker, and Herman conclude that older African American women experienced more stress, as they achieved higher levels of employment and earned higher incomes, both outcomes of higher levels of education.²⁷ Additionally, they were also found to distance themselves from family resources as they took advantage of employment activities.

Among these college-educated African American women, there was no significant difference in health-promoting behaviors between those who were normal weight, overweight, or obese. All of these women, who were normal weight, overweight, or obese, had similar health-promoting behaviors.

Among these college-educated African American women, the adoption of health-promoting behavior appeared to be a function of positive body image and low levels of stress, indicating that the adoption of health-promoting behavior is a function of positive body image and low levels of stress among these women.

The limitations of this study were as follows: (1) The convenience sample was not randomly selected, and therefore generalizability was limited; (2) the findings could be generalized only to the specific sample of college-educated African American women who participated in this research; and (3) the study was limited by the use of participants of a national organization of college-educated women in the Metropolitan Washington, D.C., area.

Conclusions

It is hoped that this study will bring added knowledge concerning the lack of understanding of the cultural perspectives and beliefs surrounding the obesity of African American women. The findings of this study indicate that among this group of participants, weight did not significantly correlate to health-promoting behavior; however, body image, self-efficacy, and stress did.

Though bariatric surgery was not a variable in this study, when asked about previous surgeries along with other demographic data, no participants in this study reported a history of bariatric surgery. This finding is consistent with studies involving African American women that indicate a lower likeliness than other women to participate in bariatric surgery, which is often related to fear.^28,29

Based on the aforementioned findings of the present research, several recommendations are in order. First, since body image was significantly correlated with engagement in health-promoting behaviors (such as exercise), using counseling targeted at improving body image may provide a positive strategy for those who are overweight or who do not engage in health-promoting behavior. Nurses with psychiatric or mental health training and education are well equipped to provide such services, particularly in light of nursing's strong emphasis on health promotion and disease prevention.

Stress was another variable that was significantly correlated with engagement in health promotion behaviors. Contemporary research has begun to focus on an arsenal of techniques that can be used to decrease stress. Such stress reduction techniques as biobehavioral feedback, therapeutic massage, yoga, and other “nontraditional” methods to reduce stress warrant serious consideration in terms of interventions for college-educated African American women. From a research perspective, further investigation is needed to determine whether implementation of these methods may positively impact health promotion behaviors.

Another potential method to improve health-promoting behaviors may be the utilization of “buddy groups” of African American women of similar and different ages and levels of education to support each other in adopting and continuing health promotion behaviors. While some African American women prefer to interact with women of similar background, others may prefer to be in a “sisterly” or “motherly” role, interacting with women of dissimilar backgrounds and sharing resources. Since so many of the participants in the present study were educators, a very familiar theme for encouraging health-promoting behaviors could easily be “each one, teach one.”

Education about the relationship between chronic illnesses and the adoption of health-promoting behaviors needs to be given in a manner that is culturally appropriate and utilizes multiple media sources of delivery. College-educated African American women are often engaged in multiple, simultaneous activities related to family, work, and household responsibilities. As a result, any future health-promoting nursing interventions will need to be sensitive to their limited amount of free time. Since a number of the participants in the present study were educators, future nursing interventions may want to focus on education and activities that are school based, where the participants are already present and interventions are more readily accessible. Nursing activities to promote healthy behaviors could be offered during faculty “free periods” or immediately after school.

Initiation of a campaign that increases the amount of culturally relevant health-related advertisements and provides appropriate health promotion cues to all women is needed in a variety of teaching–learning modes. This information should be available in lay magazines, television, radio, and the Internet. Media sources of health information, including CDs, DVDs, podcasting, and video streams, should be made more widely available.

Informing more African American women of programs, such as the Weight Watchers, the Red Dress Program of the American Heart Association, and the Small Steps Program of the U.S. Department of Health and Human Services, which have subscription services that send health promotion materials and information by mail or e-mail, is also recommended.

Still another strategy involves partnering with community recreational facilities and businesses that will provide incentives for increased physical activity and healthy nutrition, such as bonus time to use facilities and exercise equipment, and cost reductions on recreational supplies and equipment maintenance. Such incentives help to remove any barriers, real or imagined, that might diminish health-promoting behaviors, especially if they involve other family members or friends.

Focus groups are yet another opportunity to impart health information. Starting with preexisting organizations in the community, providing information at regularly scheduled meetings and activities can be an entrée to additional health-promoting ventures. Faith-based organizations have already begun to partner with local health departments to provide health-promoting interventions and direct care. Volunteers from faith-based organizations provide community-based assistance, direct health care, and health education information to low-income, uninsured residents. I see more opportunities for this type of venture in other communities, since costs are reduced by the use of volunteers and donations in these partnership programs.

More knowledge about health promotion and disease prevention of African Americans is crucial to decrease the prevalence and incidence of disease complicated by obesity. Recognition and management of triggers such as stress and anxiety impeding health promotion are important in the prevention of overweight and obesity,^30,31 as well as in preparation and follow-up care for bariatric surgery.

Despite resources and access to weight reduction programs and fitness facilities, college-educated African American women have not adopted health-promoting behaviors in a manner that protects them from the increased risks of chronic illness associated with overweight and obesity status. It is imperative that a message related to the immediacy of adopting and maintaining health-promoting behaviors be delivered, heard, and acted upon. These women must be empowered to reverse the trend. Failure to receive this message will lead to African American women's increased vulnerability to increased morbidity and premature death among a group of women who are major contributors to this society.

Additional recommendations for future studies include the following:

Increased longitudinal studies of college-educated African American women on a large scale, addressing health concerns of women at all levels of educational attainment.

Promotion of more nursing research using randomized samples of college-educated African American women.

Utilization of interventions that promote confidence in research participation by college-educated African American women, such as the provision of increased opportunities for participants to learn about the research process and health policy, with emphasis on informed consent, bioethics training of researchers, and procedures in place to decrease the incidence of bioethical exploitation and abuse.

Increased use of research incentives that add value and quality to the lives of their participants, such as the pedometer with the pulse meter that was used in the present study.

Consideration of the impact of acculturation stress among college-educated African Americans. The topic of acculturation stress has historically been reserved for immigrant samples, but this concept may also be of relevance in the context of upwardly mobile African American women.

Information obtained in this study can assist nurses and others gain insight into cultural perspectives and beliefs, weight, body image, self-efficacy, and stress issues from the perspective of African American women who are college educated, allowing for the implementation of interventions that are culturally and educationally sensitive and aimed at helping such women achieve normal Body Mass Indexes and the maintenance of healthier lifestyles. More research that takes into account the impact of race, gender, and class is needed for health disparity research involving women of color, so that health disparities can be eliminated.

Footnotes

Acknowledgments

This study was partially funded by a research grant from the Kappa Chapter of Sigma Theta Tau International and an award from the District of Columbia National Black Nurses Association.

This study was conducted while I was a doctoral candidate at the Catholic University of America. I wish to thank members of my dissertation committee, Dr. Patricia McMullen, Sr. Mary Elizabeth O'Brien, and Dr. Guardia Banister, for their guidance and support. I also wish to thank Dr. Jan Hinkle for review of this article.

Disclosure Statement

No competing financial interests exist.

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