This is an excerpt from ACSM's Worksite Health Handbook-2nd Edition by American College of Sports Medicine.
Addressing Underserved Populations in Workplace Health Promotion: Obesity Prevention and Control
Obesity represents a major public health threat. Addressing obesity as a health concern for underserved populations in the worksite setting is a challenging objective. A discussion on this issue is presented here.
American society, as is true of most developed nations, is obesogenic, or obesity producing, and substantial effort and resources are necessary to achieve and maintain a healthy lifestyle when living in the United States. However, obstacles to healthy eating and active living are concentrated in underserved communities. Ethnic minority or lower-income populations experience monumental economic and cultural challenges to healthy eating, physical activity participation, and many other health protective behaviors. Such barriers are inherent in the physical, social, organizational, and political environments of underserved communities. These barriers are detailed in the following discussion.
Economic factors pose enormous challenges to engaging in healthy behaviors (table 25.1). Geographic proximity to healthy foods and physical activity opportunities is strikingly limited for poorer communities. For example, park space in Los Angeles African American, Asian, and Latino communities is less than 1/100 of that in White communities in the same city (39). Similarly, fewer stores stock fresh or frozen produce, and the selection and quality of produce are much poorer. Conversely, fast-food restaurants are more plentiful in low-income and ethnic minority communities. From the higher proportions of inexpensive refined carbohydrate and fat in the food supply to the ubiquitous availability of brand-name sodas and coffee drinks available from vendors and vending machines, dietary quality reflects the nutrition environment of low-income and ethnic minority communities.
Hazardous neighborhood conditions are common. For example, people in low-income neighborhoods are more likely to be located near pollutants (environmental justice issues), face higher levels of exposure to environmental tobacco smoke, and experience higher rates of both intentional injury (due to gunplay or gang infestation) and unintentional injury (due to fewer pedestrian accommodations such as bridges over streets with high traffic volume, speed bumps, sidewalks, and street lamps in good repair). In addition, commercial marketing (including advertising and promotion) undoubtedly influences consumption preferences and purchasing behaviors. Marketing of health-compromising goods and services is pervasive in the United States, but increased exposure to commercial advertising for tobacco, unhealthy foods and beverages, and sedentary entertainment and transportation-as well as decreased exposure to health-promoting goods and services-has been documented in ethnic minority and neighborhoods, ethnically targeted publications, and Black audience prime-time television. However, attacks on this predatory marketing are not always politically feasible. Minority media, long ignored by most industries, have literally survived financially on culturally targeted fast-food, soda, alcohol, tobacco, film, and automobile ads that present sociodemographically marginalized groups in a very positive light.
Employment characteristics of lower-income workers present obstacles as well. Those who are lower in the work hierarchy have little flexibility to integrate physical activity into their lifestyles. They have little decisional latitude, rigid schedules (time clocks), and highly structured and supervised (assembly line) work processes. Sites employing a majority of low-income workers, such as low-income residential areas, have fewer healthy food options in close proximity and short lunchtimes. Long commuting times and multiple jobs further constrain leisure, despite higher rates of mass transit use and active transportation.
Leisure-time physical activity and foods with high nutrient value and low energy density are costly for individuals from low-income and ethnic minority backgrounds, both in time and money. Home meal preparation may assume a lower priority than meeting basic needs such as earning sufficient income for household expenses, caring for children and elders, religious observance, and relaxing at home. Federal farm subsidies for corn, used in cattle feed and high-fructose corn syrup, depress the cost of burgers and sodas relative to healthier offerings; the latter are already more expensive because of their more perishable nature, shorter shelf lives, and lower sales volumes (also due, in part, to less aggressive marketing). Low levels of enjoyment of physical activity and suboptimal motor skills may result from exposure to poor-quality physical education as youths.
Sociocultural obstacles to healthy lifestyle adherence are no less-and perhaps even more-influential than economic barriers. Culturally grounded norms, perceptions, and values surrounding physical activity and eating, including gender roles and role modeling, govern the ease or difficulty of participating in healthy behaviors. Many negative perceptions of physical activity have cultural origins with historical underpinnings. Commercially or socially marketed exercise fads and trends have traditionally emphasized sports, structured aerobics, or calisthenics that are consistent with the values of affluent Whites, especially males. Consequently, these exercise traditions have often been dismissed as incongruous by nonmainstream cultures. Sometimes these exercise traditions are even ridiculed-for example, jogging is perceived as a bourgeois waste of time and energy in less affluent or ethnic minority communities. In part, this may be attributed to the traditionally arduous lives of people from socioeconomically marginalized groups. The manual labor of the past has perhaps historically programmed an overestimation of daily work-related exertion and ingrained the need for rest after work to manage stress. A corollary misperception is that sweating reflects moderate to vigorous physical activity (when in fact sweating can accompany minimal exertion depending upon fitness level and ambient temperature).
Similarly, perceptions of healthful foods and healthy eating are culturally rooted. Certain foods, recipes, and food preparation techniques have been associated with particular ethnic identities. One example is the popularity of soul food, typified by fried catfish, fatback-seasoned collard greens, and corn bread, among African Americans. These tastes and smells produce positive affective responses summoning connection to family and nationality or culture of origin. The stressful lives of many individuals from socioeconomically marginalized groups also precipitate the use of nutrient-poor foods (comfort foods) as stress management. Job and residential segregation by income and ethnicity, magnified by the concentration of fast-food restaurants and paucity of dining options with a broader range of cuisines, preclude the usual sampling of a variety of foods as youths become more independent. Since most learning optimally incorporates an experiential component, there is little opportunity for multiple exposures associated with developing preferences for certain foods such as fruits and vegetables, whole grains, and low-fat dairy products (8). This may be compounded by the lack of vigorous exercise, which increases consumption of water and water-bearing foods and decreases preferences for highly sweetened beverages. Even the definition of what constitutes healthy foods varies among groups.
Social roles are key elements of identity influenced by culture of origin. Gender roles reflect culturally grounded notions of femininity and appropriate role behaviors. For example, concerns about maintaining a professional appearance (hair and makeup, skirts, high-heeled shoes) may deter women from exercising during the workday. In very traditional societies, vigorous exercise may even be seen as compromising a girl's virginity and negatively affecting her marriageability. Women are less frequently in positions of authority, and even when they are, expectations of acquiescence may decrease their influence on corporate policy. For women and people from ethnic minority groups, few culturally relevant role models may be available. At the same time, substantial social distance between line staff (who are more likely to be overweight or unfit) and management (who are more likely to be active) may persuade the former to reject healthier behaviors as pretentious or irrelevant.
Worksites are captive audiences of adults representing the entire demographic spectrum of a society. They present unparalleled opportunities to leverage organizational policy and practice change to improve the overall health of the workforce and, perhaps, to spur widespread social norm change. However, the promise of worksite health promotion beyond tobacco control has largely been squandered by the differential engagement of younger employees of higher socioeconomic status. The voluntary nature of these interventions, targeted at the individual level, engages primarily the motivated and fit-often fewer than 1 in 20 workers.
Workplace environmental change approaches may be designed to preferentially target ethnic minority and lower-income employees. Particularly, these approaches include push strategies that make physical activity and healthy food choices hard to avoid (23). These approaches tend to reduce health disparities, increasing the likelihood of delivering substantial ROI to employers (and to local governments that bear many of the costs of sedentariness) by engaging the more sedentary and overweight population segments less successfully reached by traditional worksite programs. Push strategies include exercise breaks on nondiscretionary time, healthy food services and procurement, walking meetings, vending and vendor restrictions, nearby parking restrictions, and substantive fiscal incentives for mass transit use. They are potentially more sustainable, as they rely less on individual motivation and initiation-the daunting myriad daily decisions and actions that must be undertaken to acquire and prepare healthy foods, to resist the temptations of highly palatable, widely marketed, and nutrient-poor foods and of sedentary entertainment, and to seek out and take advantage of ways to expend energy.
Changing the workplace-driven sociocultural and organizational environment is much more feasible than changing the built environment in these communities. The former changes obviate barriers such as unsafe or unappealing outdoor surroundings, lack of residential access to high-quality produce and recreational facilities, and copious perspiration and lack of enjoyment associated with longer bouts of strenuous exercise. Innovative indoor architectural design (e.g., skip-stop elevators, nested well-lit stairwells, standing workstations), private development of mixed-use neighborhoods, public construction of walking trails, and commercial location of fitness facilities are unlikely to garner a high priority in areas that cannot even regularly secure such basic services as streetlight maintenance, foliage trimming, and sidewalk repair.
Successful health promotion innovations in diverse work settings may share certain fundamental principles, or ingredients. Many, for example, build on cultural assets such as the normative nature of structural integration of group physical activity, in the form of dance or movement to music in social gatherings throughout the life span; the cultural salience of many plant-based foods; and the collectivist versus individualist values. Key ingredients of culturally proficient approaches are outlined in table 25.2.