Qualitative research article discussion questions

  

After reading the attached qualitative research article, discuss and address the 5 questions below and give each question its full consideration.  What did you like about this article?What would you change about or add to this article?What role does theory play in this article?How are the findings presented? What structures the results?What are the key take-home messages of this article?
scott_wilson_ecoriskobesitydeepsouth.pdf

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VOLUME 8: NO. 1
JANUARY 2011
ORIGINAL RESEARCH
Upstream Ecological Risks
for Overweight and Obesity Among
African American Youth in a Rural Town
in the Deep South, 2007
Alison J. Scott, MS, MHS, PhD; Rebecca F. Wilson, MPH
Suggested citation for this article: Scott AJ, Wilson RF.
Upstream ecological risks for overweight and obesity
among African American youth in a rural town in the
Deep South, 2007. Prev Chronic Dis 2011;8(1). http://www.
cdc.gov/pcd/issues/2011/jan/09_0244.htm. Accessed [date].
PEER REVIEWED
Abstract
Introduction
Few studies have focused on overweight and obesity
among rural African American youth in the Deep South,
despite disproportionately high rates in this group. In
addition, few studies have been conducted to elucidate
how these disparities are created and perpetuated within
rural communities in this region. This descriptive study
explores community-based risks for overweight and obesity among African American youth in a rural town in the
Deep South.
Methods
We used ecological theory in conjunction with embodiment theory to explore how upstream ecological factors
may contribute to risk of overweight and obesity for African
American youth in a rural town in the Deep South. We
conducted and analyzed in-depth interviews with African
American community members who interact with youth in
varying contexts (home, school, church, community).
Results
Participants most commonly stated that race relations,
poverty, and the built environment were barriers to
maintaining a healthy weight.
Conclusion
Findings suggested the need for rural, community-based
interventions that target obesity at multiple ecological levels and incorporate issues related to race, poverty, and the
built environment. More research is needed to determine
how disparities in obesity are created and perpetuated in
specific community contexts.
Introduction
Rural areas in the Deep South have a disproportionately
high prevalence of obesity compared with urban areas of
the United States (1-3), as have African American populations compared with white American populations (4).
Almost one-third of youth aged 2 to 19 years are categorized as overweight or obese (5), and rural youth are more
likely to be obese than urban youth (6,7). However, little
research has focused on the problem among rural African
American youth in the Deep South. In addition, few studies have explored how these disparities are created and
perpetuated in specific rural communities.
Ecological theory, which is increasingly used to inform
public health research and intervention (8,9), can be
applied to complex community contexts and to the exploration of links between social structures, individual
behaviors, and health. Developed by Sweat and Denison
(10), this multilevel approach assesses the interplay
of downstream factors at the individual level (such as
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health
and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.
Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2011/jan/09_0244.htm • Centers for Disease Control and Prevention
VOLUME 8: NO. 1
JANUARY 2011
knowledge and attitudes) and the relational level (such as
family support) with upstream factors in influencing
health. Upstream levels incorporate environmental factors
(such as the built environment), structural factors (laws
and policies), and superstructural factors (social justice
issues such as race and class).
Research that examines how upstream levels of the ecological theory, including superstructural factors such as
racism and poverty, may contribute to disparities in rural
risk for overweight and obesity is scarce. We coupled the
ecological theory with embodiment theory, which argues
that “bodies tell stories . . . about the conditions of our
existence” (11). Embodiment theory asks how the contexts
of our lives are reflected in the health of our bodies. When
used together, these frameworks help to explore how social
factors affect health risks. We explored upstream ecological
factors that may facilitate development of obesity or serve
as barriers to maintaining a healthy weight among African
American youth in a rural community in the Deep South.
Methods
This study was conducted as part of a larger qualitative
community health assessment in a county in rural southeastern Georgia (12). Researchers worked with a citizens’
health collaborative to conduct the study. The institutional
review board at Georgia Southern University reviewed
the study, and all participants provided written informed
consent. The study community was a rural town in southeastern Georgia. Roughly 40% of its 2,200 residents are
African American, and 28% are younger than 18 years.
The median household income is less than $21,000, and
more than half of families with children in the community
live below the federal poverty level ($17,463 for a family of
4 in 2000) (13).
Researchers conducted in-depth interviews (Appendix)
with 18 African American community members ranging
in age from 24 to 70 years. Participants were purposefully
sampled to select those who interacted with youth in varying contexts (home, school, church, socially) to incorporate
a range of perspectives. Tabular summaries of participant
characteristics helped to maximize variability in sampling.
A key informant, the director of the local health department, suggested initial participants; participants were
later identified through snowball sampling and through
referrals from a range of community organizations.
All participants were African Americans who were
longtime residents of the community and who interacted
with African American youth. They included parents,
grandparents, a school board member, teachers, a principal, pastors, the high school band director, the coordinator
of a church-based youth resource center, and the president
of the local National Association for the Advancement of
Colored People, among others. Interviews were conducted
between January and April 2007.
Interviews were conducted in person in the home or
community setting of the participant’s choice and lasted
from 20 minutes to 2 hours. Interview guides were used
to conduct the interviews. Questions addressed the
3 upstream levels in Sweat and Denison’s ecological
model (Appendix). At the environmental level, topics
included the community-built environment and the food
environment. Questions included, “Where do youth go
to get exercise?” and “Where do families eat when they
eat out?” At the structural level, topics included city
governance and community organizations. Participants
were asked questions such as “How inclusive is community leadership?” and “What organizations are key
for youth?” At the superstructural level, topics included
race and class relations. For example, questions included, “Tell me about race relations in the community”
and “Where do people get jobs here?” Interviews were
recorded and transcribed. Content analysis of interview
transcripts and field notes was ongoing during data
collection. Transcripts were coded to identify text segments related to each ecological category, which were
grouped together for analysis by category (14). Themes
were identified and expanded by using reflexive memowriting (15) and through data display in matrices (16).
Ideas that emerged from content analysis were triangulated by having both researchers involved in analysis
and through member checking by sharing results with
community coalition members (17).
Results
Analysis of transcripts revealed that many participants
perceived that although racism was more subtle than in
times past, it was still rampant in their community and
was a stressor for youth independently and in interaction with socioeconomic status (SES). In addition, issues
emerged related to the built environment, including
lack of access to healthful food options and venues for
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the
Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and
does not imply endorsement by any of the groups named above.

Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/jan/09_0244.htm
VOLUME 8: NO. 1
JANUARY 2011
physical activity; these issues, in turn, were reported by
participants as interacting with racism and low SES.
Black and white: race relations as a stressor
Participants described their community as de facto segregated by race; most African Americans live on the south
side of town and most whites live on the north side of town.
The community’s churches and civic organizations are also
mainly segregated. As a case in point, the citizens’ health
collaborative, which was composed of leaders from local
businesses, schools, health care facilities, and city government, requested the larger community health assessment.
The collaborative had no African American members. A
former school board member, the sole African American
representative on the school board at the time, commented
on the racial dynamics:
You stay on your side of the tracks. . . . Change is
slow. . . . It’s black and white, black and white.
A young woman agreed, commenting that white people
came to her neighborhood only to buy drugs:
If you see a white person driving through on this
street, it’s mostly for drugs. Like, white people
don’t just come through here.
This spatial segregation, according to participants,
limited the interaction of black and white community
members.
The public schools, however, being integrated by law,
served as a lightning rod for racial tensions, according to
participants. The middle school and high school have been
the settings of major racial incidents in recent years concerning issues such as the practice of having separate black
and white prom courts, student councils, and class presidents; outcry over the lack of African American teachers;
and a lawsuit challenging an ability grouping curriculum.
(The US Office of Civil Rights ruled that the curriculum
was discriminatory.) As such, African American youth have
been, and continue to be, at the center of the community’s
struggle with race issues. In addition, such experiences of
segregation and racism are carried into adulthood and, at
times, out of the community. A recent alumnus of the local
high school described going to college and being figuratively “slapped in the face” by other African American students
who were appalled at this community dynamic:
Those kids [at college] who came from bigger
schools in North Georgia or other states said,
“Don’t you all know that you all are still segregated?” . . . That was a slap in the face to us, and
we had to hide that here in our hearts. . . . We’re so
far behind. . . . It’s scary.
Although one cannot assume this situation translates
into race-related stress for every African American student, such a community context creates ideal conditions
for such stress.
Without a dream: entrenched low SES as a stressor
Racial issues were intertwined deeply with those of
class in the community. In addition to the strain of racial
tension, many African American youth in the community
endure the stresses of poverty and face a future with limited opportunities to escape poverty as adults. Participants
consistently reported that job options were few in the
depressed local economy, except for fast-food jobs, other
minimum-wage service jobs, and a poultry processing
plant. The community has undergone economic deterioration in the past 30 to 40 years. Farming work was lost as
agriculture became more mechanized and local textile factories closed or relocated. In addition, many participants
shared that as the local economy weakened, illegal drug
activity had exploded, providing a lucrative yet potentially destructive vocation for African American youth.
A pastor saw this choice as an inevitable consequence of
the economic realities faced by black youth as they enter
adulthood:
What you gonna do when you graduate from high
school? What jobs are available? Outside of going
to work in the poultry plant, working at a fast-food
place, what else is there to do? . . . The big business
here is drugs and eventually jail.
In addition, there was consensus that race and nepotism entered into the struggle to find work, which fed the
sense of hopelessness among black adolescents. This was
described as the who-you-know syndrome or the old-buddy
syndrome. Because white community members owned
most local businesses, it was claimed that they controlled
access to the best jobs in town; those who are hired have
the right social connections, it was purported, even if they
do not have the right skills:
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the
Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and
does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2011/jan/09_0244.htm • Centers for Disease Control and Prevention

VOLUME 8: NO. 1
JANUARY 2011
That’s the status quo of every . . . top position here
right now. . . . [It depends on] who you know, your
great-grandfather. They’re not qualified on paper.
They don’t know a hill of beans about the job. . . .
They just got it handed down. This is not fair to the
blacks in the community. . . . We’re so far behind
it’s not even funny, and it’s killing us.
The African American youth, facing barriers and frustrations related to both race and class, were characterized
by an African American pastor who worked with them
as lacking in hope and trust, and as “people without a
dream.” A mother lamented, of African American young
men especially, that “they get lost” as soon as they enter
high school.
Nowhere to go: the built environment
Issues related to the built environment were frequently
voiced by participants. A common complaint expressed by
parents, teachers, counselors, and community leaders was
the lack of accessible venues for youth to be active. As put
by a former teacher:
There’s nowhere for the youth to go, nothing to do.
. . . There’s not one skating rink. There’s not one
bowling alley . . . [to] let them exert energy.
The town is home to a central park. However, in recent
years the park has closed at 6:30 p.m., limiting its availability after school. The early closure, which was sparked
by illegal drug activity in the park, blocks access to basketball courts and playing fields. The community has a recreational center that sponsors sports activities. However,
participants commented that activities had a participation fee and were geared toward younger children. In
addition, this recreational center was constructed several
miles west of the town center in an undeveloped area, off
a 2-lane highway with no sidewalks, making transportation an issue for many families. A middle school principal
summarized:
We really don’t have that thing to do with our middle school-aged kids and our high school students.
. . . [We need] something positive in the community.
Not just something for blacks. Not just something
for whites. . . . We don’t have anything like that.
Multiple
participants
discussed
youth
activities
sponsored by churches that attempted to fill the gap.
However, activities often were short-lived, underfunded,
and available only to youth from the church’s congregation. Participants complained that this fed a divisiveness
within the African American community that hampered
efforts to address the problem. A mother commented:
It’s about 99,000 different churches, and all of ’em
have their own little center, but it’s basically just
for those kids that go to their church. It’s just got
no togetherness.
The community also has limited options for accessing
healthful foods. The town has 1 grocery store and convenience stores that sell packaged food. With the lack of
competition, the grocery store “can set . . . its own prices”
and has limited selections of produce and other healthy,
fresh foods. Restaurant options largely include fast-food
chain restaurants and buffets serving a traditional array
of energy-dense, high-fat foods. In addition, these restaurants provide the most obvious source of employment for
local youth. Many employees are provided discounted or
free food. One mother described how her daughter, who
has type 2 diabetes, had gained weight after she started
working at Hardee’s:
It was when she started working at Hardee’s. She
would just bring a sandwich home and eat it at
night . . . and all of a sudden she picked up all this
weight, and we went to the doctor. . . . I don’t want
her to have to take insulin — not this young.
Intertwined: the built environment, race, and poverty
Findings suggested that issues related to the built
environment interacted with issues of race and class. For
example, for access to more food options, residents with
transportation and money for gas could drive 20 miles to a
Wal-Mart or a Save-a-Lot in a neighboring county. Those
without such resources had to rely on local grocery options,
given the lack of public transportation. A disproportionate
number of African American families are low-income, placing them in the latter situation.
In addition, participants were aware of additional payto-participate recreational opportunities for youth to be
active. A mother said, “There are more programs the
whites can get into because their mama and daddy got
more money than the rest of us.” As for the community’s
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the
Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and
does not imply endorsement by any of the groups named above.

Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2011/jan/09_0244.htm
VOLUME 8: NO. 1
JANUARY 2011
recreational center, some participants perceived racial
bias in the decision to place it outside of town and to
charge fees, which they linked to the overrepresentation
of middle- and upper-class white children in the programs.
A pastor asserted:
We do have a recreational authority and all that
good stuff, but it’s not equal. It’s racially biased.
When you look at the programs and who’s actually
involved, [there aren’t] enough blacks in proportion
to whites. I don’t mind going on the record saying
this. That’s the way it is.
Discussion
Study findings indicated that stressors associated with
racism and low SES are likely daily occurrences for African
American youth in this context. Such environmental
stressors have been shown to be associated with increased
activation of physiologic stress pathways, including the
hypothalamic-pituitary-adrenal (HPA) axis; chronic HPA
stimulation can lead to metabolic disruption that may
contribute to increased risk of obesity (18,19). These
physiologic pathways provide a biological framework for
embodiment theory; external stresses related to race and
poverty can enter the body and be reflected in dysregulation and eventually disease. Epidemiologic studies bear
this out. For example, the Black Women’s Health Study,
a prospective study of 43,000 black women, found a significant association between weig …
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