understanding the relative influence of attitudes and societal norms on dietary intentions among...

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The Social Science Journal 50 (2013) 583–590 Contents lists available at ScienceDirect The Social Science Journal journa l h om epa ge: www.elsevier.com/locate/soscij Understanding the relative influence of attitudes and societal norms on dietary intentions among African-Caribbean women Eugene S. Tull a , Malcolm A. Cort b,, Jerome Taylor c , Tissa Wickramasuriya d a Minority International Research Training Program (MIRT), Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, United States b Department of Behavioral Science, Athens State University, Athens, AL 35611, United States c Department of Africana Studies, University of Pittsburgh, Pittsburgh, PA, United States d School of Clinical Medicine and Research, University of the West Indies, Cave Hill, Barbados a r t i c l e i n f o Article history: Received 1 April 2013 Received in revised form 8 October 2013 Accepted 8 October 2013 Available online 9 November 2013 Keywords: Caribbean women Diet Normative forces Dietary intentions a b s t r a c t This study applies the theory of reasoned action (TRA) to understand the relative influence of personal attitude (AT) toward three chronic diseases (diabetes, heart disease, and hyper- tension), and social normative (SN) groups (family, friends, and church), toward intention to engage in dietary behaviors associated with obesity and chronic disease risk. The sample consists of N = 183 women, aged 18–55 years, in Barbados, West Indies, selected through a stratified cluster sample technique. The instrument includes demographic and anthropo- metric variables and components of the TRA. Analyses using structural equation modeling (SEM) indicate that the TRA explains 22%, 35% and 19% of the variances in intention to consume high-fat foods, alcohol, and fruits, nuts and vegetables, respectively. SN is a pre- dictor of all three dietary intentions, while AT predicts only intention to eat fruit, nuts, and vegetables. In the models, social pressure from family is relatively more important than friends and church in influencing dietary intentions. It can be concluded that social nor- mative influences have a stronger effect on intentions to consume fatty foods, alcohol, and fruit, nuts and vegetables than do personal attitudes. © 2013 Western Social Science Association. Published by Elsevier Inc. All rights reserved. 1. Introduction In many countries, rates of obesity and chronic illnesses, such as diabetes, hypertension, and cardiovascular disease for which obesity is a primary risk factor, are increasing as technological advance contributes to more sedentary lifestyles and consumption of larger amounts of refined foods that are high in fat and calories (Zimmermann- Belsing & Feldt-Rasmussen, 2004). The island nations of the Caribbean reflect this global trend with high obesity Corresponding author at: Department of Behavioral Sciences, Athens State University, 300N Beaty Street, Athens, AL 35611, United States. Tel.: +1 256 233 5609. E-mail address: [email protected] (M.A. Cort). rates reported on several islands (Earland, Campbell, & Srivastava, 2010; Snih et al., 2010), particularly among women aged 25 years and older (Ragoobirsingh, Jeffrey, Morrison, Johnson, & Lewis-Fuller, 2004). There has also been a concomitant increase in the frequency of chronic diseases, such as diabetes mellitus, throughout the Caribbean region (Ferguson, Tulloch-Reid, & Wilks, 2010). On the island of Barbados, where energy from fat as a per- centage of total energy intake rose from 19% in 1961 to 28% in 2003 (Sheehy & Sharma, 2010), there is much interest in identifying dietary strategies to reduce obesity and chronic disease risk (Fraser, 2003; Gaskin, Broome, Alert, & Fraser, 2008) The World Health Organization (WHO) has called for the development of national strategies to reduce body weight through diet modifications in the Caribbean and 0362-3319/$ see front matter © 2013 Western Social Science Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.soscij.2013.10.007

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Page 1: Understanding the relative influence of attitudes and societal norms on dietary intentions among African-Caribbean women

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The Social Science Journal 50 (2013) 583–590

Contents lists available at ScienceDirect

The Social Science Journal

journa l h om epa ge: www.elsev ier .com/ locate /sosc i j

nderstanding the relative influence of attitudes and societalorms on dietary intentions among African-Caribbeanomen

ugene S. Tull a, Malcolm A. Cortb,∗, Jerome Taylorc, Tissa Wickramasuriyad

Minority International Research Training Program (MIRT), Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA,nited StatesDepartment of Behavioral Science, Athens State University, Athens, AL 35611, United StatesDepartment of Africana Studies, University of Pittsburgh, Pittsburgh, PA, United StatesSchool of Clinical Medicine and Research, University of the West Indies, Cave Hill, Barbados

a r t i c l e i n f o

rticle history:eceived 1 April 2013eceived in revised form 8 October 2013ccepted 8 October 2013vailable online 9 November 2013

eywords:aribbean womeniet

a b s t r a c t

This study applies the theory of reasoned action (TRA) to understand the relative influenceof personal attitude (AT) toward three chronic diseases (diabetes, heart disease, and hyper-tension), and social normative (SN) groups (family, friends, and church), toward intentionto engage in dietary behaviors associated with obesity and chronic disease risk. The sampleconsists of N = 183 women, aged 18–55 years, in Barbados, West Indies, selected through astratified cluster sample technique. The instrument includes demographic and anthropo-metric variables and components of the TRA. Analyses using structural equation modeling(SEM) indicate that the TRA explains 22%, 35% and 19% of the variances in intention toconsume high-fat foods, alcohol, and fruits, nuts and vegetables, respectively. SN is a pre-

ormative forcesietary intentions

dictor of all three dietary intentions, while AT predicts only intention to eat fruit, nuts, andvegetables. In the models, social pressure from family is relatively more important thanfriends and church in influencing dietary intentions. It can be concluded that social nor-mative influences have a stronger effect on intentions to consume fatty foods, alcohol, and

tablesocial S

fruit, nuts and vege© 2013 Western S

. Introduction

In many countries, rates of obesity and chronic illnesses,uch as diabetes, hypertension, and cardiovascular diseaseor which obesity is a primary risk factor, are increasings technological advance contributes to more sedentaryifestyles and consumption of larger amounts of refined

oods that are high in fat and calories (Zimmermann-elsing & Feldt-Rasmussen, 2004). The island nations ofhe Caribbean reflect this global trend with high obesity

∗ Corresponding author at: Department of Behavioral Sciences, Athenstate University, 300N Beaty Street, Athens, AL 35611, United States.el.: +1 256 233 5609.

E-mail address: [email protected] (M.A. Cort).

362-3319/$ – see front matter © 2013 Western Social Science Association. Publittp://dx.doi.org/10.1016/j.soscij.2013.10.007

than do personal attitudes.cience Association. Published by Elsevier Inc. All rights reserved.

rates reported on several islands (Earland, Campbell, &Srivastava, 2010; Snih et al., 2010), particularly amongwomen aged 25 years and older (Ragoobirsingh, Jeffrey,Morrison, Johnson, & Lewis-Fuller, 2004). There hasalso been a concomitant increase in the frequency ofchronic diseases, such as diabetes mellitus, throughout theCaribbean region (Ferguson, Tulloch-Reid, & Wilks, 2010).On the island of Barbados, where energy from fat as a per-centage of total energy intake rose from 19% in 1961 to 28%in 2003 (Sheehy & Sharma, 2010), there is much interest inidentifying dietary strategies to reduce obesity and chronicdisease risk (Fraser, 2003; Gaskin, Broome, Alert, & Fraser,

2008)

The World Health Organization (WHO) has called forthe development of national strategies to reduce bodyweight through diet modifications in the Caribbean and

shed by Elsevier Inc. All rights reserved.

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elsewhere (WHO, 1998). However, there are limited datafrom Caribbean-based studies that can be used to designstrategies to promote dietary changes that may facili-tate weight loss among the populations in the region.Moreover, while studies in other populations show thatdietary intervention programs achieve short-term suc-cess (Daly et al., 2006; Langer et al., 2009), long-termweight loss maintenance and dietary changes are diffi-cult to achieve (Rössner, Hammarstrand, Hemmingsson,Neovius, & Johansson, 2008; Wu, Gao, Chen, & van Dam,2009). As a result, if such interventions are applied in theCaribbean, efforts to design intervention programs basedon models used in other populations may result in mis-use of limited resources, or, at the best, only short termbehavior change.

2. Literature review

2.1. Intentions and weight control behavior

Behavior change for weight control is investigated frommany angles. Examples include race-specific weight per-ception correlates and weight control behaviors (Phelanet al., 2009), the prevalence of unhealthy weight-controlbehaviors and their possible long-term negative conse-quences (Eisenberg, Neumark-Sztainer, Story, & Perry,2005; Petrov, 2009; Stice, Presnell, Shaw, & Rohde, 2005;Stice, 2002), and the feelings of intense dissatisfactionwith one’s physical self and the consequences of theseperceptions for physical and emotional health (Ge, Elder,Regnerus, & Cox, 2001; Jones, 2001; Ricciardelli & McCabe,2001; Tang & Wetter, 2007). Of greater interest is thebody of research that explores the link between intentionsand weight control behavior using the theory of reasonedaction (TRA) outlined in Fishbein and Ajzen (1975). Thisbody of research supports the view that intention is thebest predictor of health behavior (Conner & Godin, 2007;Morrison et al., 2002; van Osch et al., 2010; Wiedemann,Schüz, Sniehotta, Scholz, Schwarzer, 2009; Ajzen, 1991).Building on investigations such as these, efforts to developcommunication strategies for intervention programs topromote health behavior change, especially in the area ofweight control, have also utilized the TRA with great suc-cess (Eisenberg et al., 2005; Mackey & La Greca, 2008). It isimportant to note here that the theory of planned behavior(TPB), an extension of the TRA in which the basic TRA com-ponents are thought to be influenced by perceived control,has been applied with equal success to predict a range ofhealth behaviors (Godin & Kok, 1996). However, the TRA,which requires less data to be collected, is used in the cur-rent investigation, as this is easier to implement as a nestedstudy within a larger data collection effort.

2.2. Utilizing the theory of reasoned action

The TRA considers factors a priori to intentions inthe causal chain that culminates in health behavior per-

formance. Factors such as personal attitudes and socialnorms are important to consider when designing inter-vention programs involving recommendations for dietarychange. The TRA permits an assessment of the influence of

urnal 50 (2013) 583–590

attitudes and social norms on individual behavior andshows remarkable versatility in predicting an array ofhealth behaviors, including early teen sexual behavior(Doswell et al., 2003), dental care (Syrjala, Niskanen, &Knuuttila, 2002), compliance with treatment for breastcancer (Hill, Shriver, & Arnett, 2006), UV protection use,condom use, and smoking cessation (Albarracin, Fishbein,Johson, & Muellerleile, 2001; Gibbons, Houlihan, & Gerrard,2009).

Moreover, the TRA postulates that a given behavior isguided by intentions to engage in or refrain from behav-iors, and that intentions are determined by attitude towardthe behavior, and subjective norms to engage or refrainfrom behaviors (Fishbein & Ajzen, 1975). The value of theTRA as a guide for designing interventions is its utilityfor assessing the relative effect of personal attitudes andsocial norms on behavioral intentions (Sayeed, Fishbein,Hornik, Cappella, & Ahern, 2005). However, little researchfocuses on how the TRA is used to identify the relativeinfluences of competing social reference groups on dietaryintentions. In addition, little attention is given to TRA uti-lization to examine the relative importance of beliefs aboutmajor chronic illnesses like heart disease, hypertensionand diabetes for shaping attitudes to dietary intentions.For instance, for ethnic groups like African-Americans,churches have long been viewed as important venues forimplementing community-based dietary and other healthinterventions (Campbell et al., 2007; Markens, Fox, Taub, &Gilbert, 2002). However, understanding the relative valueof various combinations of church and family or friendsin intervention models remains weak. In addition, littleattention is devoted to TRA utilization to examine the rel-ative importance of beliefs about major chronic illnesseslike heart disease, hypertension, and diabetes for shapingattitudes to dietary intentions.

While weight control is important for both males andfemales, research suggests that body image dissatisfac-tion and its health consequences is more pronouncedamong females (Bearman, Presnell, Martinez, & Stice, 2006;Mooney, Farley, & Strugnell, 2009). The current study,therefore, focuses on the dynamic of intentions and itsconnection with weight control behavior among women.Three issues are considered. First, to apply TRA to under-stand the relative influence of social norms and individualattitudes on dietary intentions related to intake of high fatfoods, alcohol, and fruit, nuts and vegetables in a sampleof African-Caribbean women. Second, to determine whichof three social reference groups, family, church or friends,has greatest influence on intention to engage in a dietarybehavior. Third, to assess whether attitude to a dietaryintention is shaped more by beliefs about heart disease,hypertension, or diabetes.

3. Method

3.1. Sample

The data used for the current assessment are part of alarger study of obesity among African-Caribbean womencollected over a 4-month period. The study population con-sists of 183 African-Caribbean women aged 18–55 years

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E.S. Tull et al. / The Social S

rom the parish of Christ Church, Barbados. Christ Churcharish covers an area of approximately 57 km2 on theouthern end of the island of Barbados and has the sec-nd largest population among the 11 parishes on thesland. This parish is included in the study because, com-ared to other areas of the island, it contains areas ofajor tourist activity that include high fast food establish-ent density that are known to contribute to increase fat

nd calorie intake. The study participants were recruitedrom households selected through a two-stage samplingrocess. First, district #6 was randomly selected frommong the seven health districts into which the Christhurch Parish is divided. Next, a systematic sample ofouseholds was chosen from the Lodge Road, Wotton,nd Plum Grove neighborhoods in district #6. Every thirdome on alternating side of streets was selected. Theseouseholds were then visited to determine if an eligible

emale was in residence, and one participant was ran-omly selected from each household. The neighborhoodsf district #6 were among the higher socioeconomic sta-us neighborhoods in the Christ Church Parish, and studyepresentatives visited each home at different times dur-ng the day to increase the likelihood of finding someone atome. Women with a history of diabetes are excluded fromarticipation because another aspect of the study involvedssessments for undiagnosed diabetes mellitus. Of the eli-ible contacted women, 74.4% agreed to participate. Eacharticipant signed a consent form approved by the ethicaleview committee of the Barbados Ministry of Health.

Data for the study were collected in participant’s home.he questionnaires include items that assess attitude (AT),ubjective norms (SN) and intentions related to threeietary behaviors (eating high fat foods, drinking alcohol,nd eating fruits, nuts, and vegetables), which are often theasis for dietary recommendations to reduce obesity risknd improve health. The participants were provided withxamples of high fat foods, including foods available at fastood restaurants and local food preparations.

.2. Variables

Questionnaire items to assess attitudes include thoseoncerning beliefs about specific dietary behaviors to threehronic diseases (heart disease, high blood pressure, andiabetes) and items that assess subjective adversity (howuch an individual believes that diseases affect him/her).n example of a consequence belief item is the phrase “eat-

ng fruits, nuts and vegetables will help to prevent a heartttack”. This item is scored on a seven-point Likert scaleanging from −3 (extremely unlikely) to +3 (extremelyikely). The corresponding subjective adversity item (“For

e, having a heart attack is:”) is scored on a seven-pointikert scale ranging from +3 (favorable) to −3 (unfavor-ble). Questionnaire items for subjective norms assessormative beliefs regarding family, church, and friends’iews about dietary behaviors and motivation to com-ly with the views of the normative group. The results

f focus groups conducted prior to the start of the cur-ent study identified family, church, and friends as thehree most prominent normative groups in the study pop-lation. ‘Church’ refers to the teachings and practices of

urnal 50 (2013) 583–590 585

the church rather than personal relationships within thechurch community. For the items on this questionnaire,each participant is asked to rate his/her family’s beliefabout his/her eating fruit, nuts, and vegetables, with pos-sible responses ranging from +3 (I should) to −3 (I shouldnot). Motivation to comply with what the family thinks isassessed by response items ranging from +3 (I tend to goalong) to −3 (I do not tend to go along). For behavioralintentions, each participant is asked to evaluate his/herintent to participate in the dietary behaviors of interestwithin the next week, using a scale ranging from +3 (Iintend to) to −3 (I do not intent to). A one week test–retestreliability coefficient based on a sample of 25 Barbadianwomen was greater than .80 for the attitudinal, subjectivenorm, and intentions components of the TRA question-naire.

In addition to the TRA constructs, information wascollected for age, education, and perceived health sta-tus. Anthropometric measurements including height andweight were also performed. Weight was measured on anelectronic digital scale with subjects in light clothing andno shoes. Height was measured with a wall mounted ruler.Body Mass Index (BMI) was calculated as weight in kilo-grams (kg) divided by height in meters squared (kg/m2).Classification of overweight is based on a BMI ≥ 25 kg/m2

according to WHO criteria (WHO, 1998).

3.3. Statistical analysis

Attitude toward performing each dietary behavior iscalculated by multiplying each consequence belief aboutheart disease, hypertension, and diabetes score by the cor-responding subjective adversity score. The score for thesubjective norms for each dietary behavior is calculatedby multiplying the expectation of the family, friends, andchurch referent group belief score by the motivation tocomply score with the expectation of the referent group.Therefore, three attitude scores and three subjective normscores are calculated for each dietary behavior. The rela-tionships of age, education, BMI, and self-rated health tothe components of the TRA are assessed with Spearmancorrelation correlations, and partial correlations are usedto determine if significant correlations are independentof potential confounders. Structural equation modeling(SEM) is used for relationships between TRA componentsfor each dietary behavior (Bentler & Wu, 1995). In SEM,latent variables can be constructed from indicator vari-ables, and the unequal contributions of indictor variablestoward the measurement of latent variables can be deter-mined. The structural equation models fit only when theindicator variables associated with any one latent variableare valid indicators of that trait. The models fit best whendirect indicators of fit including Bentler–Bonnet NormedFit Index [(BBNFI)-value range 0–1], and Comparative FitIndex [(CFI)-value range 0–1] are high, that is, values over.90 indicating acceptable fit the model Chi-square (�2) islow, and its corresponding p-value is high (p > .05) (Bentler

& Wu, 1995). In the current study, the structural equationmodels of the TRA provide an estimate of the relative con-tribution of attitude about heart disease, hypertension, anddiabetes to the influence of a latent variable “attitude” on
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0.76*

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Fig. 1. SEM relating attitude and subjecti

dietary intentions. Likewise, the relative contribution ofsubjective norms from family, friends, and church to theinfluence of the latent variable “subjective norms” on thedietary intentions is also estimated. All non-SEM analy-ses are performed with Statistical Analysis System (SAS)software (SAS Institute, 1990).

4. Results

The mean age of the sample is 35.8 years ± 9.1; 89.9%completed high school. Fifty-three percent of the womenare overweight. Correlation analyses show no significantrelationships between age, education, BMI, or self-ratedhealth and the attitudinal or subjective norms componentsof the TRA model. However, both BMI (r = −.19, p = −.010)and age (r = −.20, p = .009) are inversely related to inten-tion to eat foods high in fat. In partial correlation analysis,the relationship of BMI to intention to eat high fat foodsremains significant (r = −.15, p = .048) after adjusting forthe effects of age, self-rated health and the attitudinal andsubjective norms components of the TRA. Likewise, ageremains significantly related (r = −.16, p = .032) to intentionto eat high fat foods after adjustment for BMI, self-ratedhealth, and the attitudinal and subjective norms compo-nents of the TRA. The percent of the variance in intentionto consume high fat foods that is explained by BMI and ageis 2% and 5%, respectively.

Fig. 1 shows the best fitting structural equation modelrelating attitude (AT) and subjective norms (SN) to inten-tion to consume high fat foods. The model explains 22% ofthe variance in intention to consume high fat foods withSN being the significant contributor to intention. For theSN component, social pressure from family (� = .80, p < .05)is relatively more important than church (� = 42, p < .05)or friends (� = 39, p < .05) in influencing intention to con-sume high fat foods. In this model a co-variant relationshipbetween AT and SN is significant (� = 36, p < .05).

The best fitting model relating AT and SN to intention toconsume alcohol is shown in Fig. 2.

Approximately 35% of the variance in intention to con-sume alcohol is explained by the model, with SN (� = 57,

s to intention to consume high fat foods.

p < .05) being the major influence on intention. AT doesnot have a significant influence on intention to consumealcohol. Subjective norms from family (� = .74, p < .05) andfriends (� = 67, p < .05) play a larger role than church (� = 36,p < .05). In this model a co-variant relationship between ATand SN is significant (� = 42, p < .05).

In Fig. 3, the structural equation model explains approx-imately 19% of the variance in intention to eat fruit, nuts,and vegetables.

Both AT (� = 23, p < .05) and SN (� = 31, p < .05) play sig-nificant roles in shaping intention to eat fruit, nuts, andvegetables, with SN contributing slightly more than AT.Beliefs about the relationship of eating fruit, nuts, andvegetables to reduce the risk of each of heart disease, hyper-tension, and diabetes figure equally into shaping overallattitude. For the SN component, family (� = 88, p < .05) is arelatively more important influence than friends (� = 38,p < .05) or church (� = 33, p < .05) in influencing inten-tion to eat fruit, nuts and vegetables. In this model aco-variant relationship between AT and SN is significant(� = 28, p < .05).

5. Discussion

This study among African-Caribbean women on theisland of Barbados uses the theory of reasoned action (TRA)to assess the relative importance of attitude and socialnorms on dietary behaviors. Demographic factors suchas age, education, and BMI are not significantly related tothe attitude or social norm variables in the study. Thus,while the study sample was not randomly selected fromall areas of the island, this result suggests that key findingsin the current study relative to attitude and social normsmay have implications for African-Caribbean womenoutside particular parish and neighborhoods from whichthe study participants were recruited. In contrast to theirlack of association with attitude and social norms, age and

BMI are independently and inversely associated with theintention to eat high fat foods and account for 7% of thevariance in this dietary intention. This inverse associationof BMI with intention to eat foods high in fat among the
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E.S. Tull et al. / The Social Science Journal 50 (2013) 583–590 587

0.72*

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church

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Fig. 2. SEM relating attitude and subje

arbadian women who are gaining undesired weightight be responsive to recommendations for restricting

at intake. Conversely, the inverse association of age withntention to eat foods high in fat, independent of BMI,

ay signal the need for greater focus on finding wayso increase awareness among younger women about themportance of restricting fat intake to prevent overweightr reduce chronic disease risk. This notion is supported byonclusions from another study on Barbados which sug-ests that ignorance with respect to diet and appropriateody size are among the factors contributing to obesitymong youth on the island (Gaskin et al., 2008).

It is noteworthy that in the current study attitude, socialorms, or dietary behavioral intentions are not correlatedith perceived health status. The reason for this finding isnclear. Studies in other populations have found an asso-iation of perceived health status with dietary behaviorsBecker, Glascoff, Mitchell, Durham, & Arnold, 2007; Piko,

007). It may be that dietary intentions are not specificnough to measure a significant relationship with self-eported health status. Future studies in African-Caribbeanopulations might better elucidate this relationship.

0.86*

0.92*

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0.28*

0.33*

0.88*

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Heart disease

Hypertension

Diabetes

church

family

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Fig. 3. SEM relating attitude and subjective norms to in

rms to intention to consume alcohol.

Among the study participants, intentions to eat foodshigh in fat and to consume alcoholic beverages are bothinfluenced by supportive social norms but not by per-sonal attitudes. The normative influence from family ismost strongly associated with intention to eat foods high infat, whereas social pressures from both family and friendsare equally important in influencing intention to consumealcoholic beverages. One implication of these findings isthat the efforts some investigators (Sheehy & Sharma,2010) claim are needed to obtain a reduction in dietary fatintake among Barbadian women might require the inclu-sion of supportive social norms from family to be mosteffective. In contrast, the current study suggests that strate-gies to reduce dietary fat intake by altering attitudinalconstructs such as individual beliefs about the relation-ship of proscribed behaviors to a disease outcome or theindividual’s feeling of susceptibility to a disease associatedwith dietary fat are less likely to be successful in Barbadian

women.

In recent years, increased intake of fruit, nuts, and veg-etables has been encouraged as a means of reducing therisk of chronic diseases (Bazzano, Serdula, & Liu, 2003;

0.23*

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tention to consume fruits, nuts, and vegetables.

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Lairon et al., 2005; Passi, Manchanda, Suri, Chandari, &Kalra, 2004). In the current study the intention to eatthese foods is influenced significantly by both attitudeand subjective norms related. Among the study partici-pants, the attitude to the three referenced diseases appearsto contribute equally to intention to eat fruits, nuts, andvegetables. One suggestion from this result is that effortsto promote increased intake of these food choices mightachieve equal success by focusing on the relationship of thisdietary intake to reductions in frequency of any of the threereference diseases. The significant relationship of subjec-tive norms to intention to eat fruits, nuts, and vegetablesis a further indication of the importance of including fam-ily members as part of any intervention effort to improveeating habits among adult women in Barbados. More-over, they complement the findings of Gaskin et al. (2012)which highlight the importance of the family in shapinglifestyle factors associated with weight gain in Barbadossociety.

It is interesting that in the study population, church wasless important than family or friends as a social influenceon dietary behaviors. Many church organizations, despitebeing venues for promoting health behavior changes, maynot have incorporated health principles into their creed.Data from Barbados show that, for example, among mem-bers of the Seventh-Day Adventist Church, an organizationwith an integrated health promoting creed, those who fullyadhere to the church’s health recommendations are lessobese with lower incidents of hypertension and diabetesthan those who only partially adhere and those who donot adhere (Brathwaite, Fraser, Modeste, Broome, & King,2003). More study is needed to better understand how toincorporate health messages into church doctrine or utilizecross-cutting strategies with friends and family to make thechurch’s health promotion more effective.

While the TRA appears to have utility as a behavioralmodel for understanding dietary related behavioral inten-tions among adult women in Barbados, its explanatoryvalue in the current study is modest. This observationis entirely consistent with the results from other studiesusing the TRA in a similar fashion. For example, in The OsloYouth Study follow-up reported in 2005, Kvaavik, Lien, Tell,and Klepp (2005) found that perceived social norms andbehavioral control were predictive of fruit, vegetable, andfat intake among women. Budd and Spencer (1984) foundin a sample of 53 women that the TRA explained 22% of thevariance in intention to consume alcohol. In another study,Pender and Pender (1986) showed that the TRA accountedfor slightly less than 18% of the variance in intention to eata diet conducive to attaining or maintaining recommendedweight.

An unexpected finding in the study is that struc-tural equation models fit best when a level of covariancebetween attitude and social norms is included, but thereason is unclear. The TRA assumes that attitude and sub-jective norms are independent constructs. However, it maybe that in Barbadian society communal expectations and

individual beliefs are more similar than they are in othersocieties that celebrate individual freedom over communalclaims. These observations need to be replicated and testedin other Caribbean populations.

urnal 50 (2013) 583–590

6. Limitations

There are limitations to the study. The study is cross-sectional which naturally precludes any inference ofcausality between dependent and independent variables.Analysis of household income, an indicator of economicpurchasing power, was not used in the current study asincome and education are highly correlated; the latter wasdeemed a better measure of socioeconomic status amongwomen in the study population. Moreover, given the lackof an association of education with attitude or subjectivenorms for the various dietary behaviors, it is unlikely thathousehold income would have confounded the results ofTRA models found for the dietary behaviors in the currentstudy. The study did not include adolescents; a popula-tion group in Barbados for whom overweight and obesityare an increasing problem (Gaskin et al., 2008). However,replication of the study for children younger than age 18 isrecommended.

7. Conclusion

The noteworthy results in the current study show thatstructural equation modeling can be used to expand theutility of the TRA to provide better understanding of therelative influence various social normative groups have ondietary intentions. Moreover, the SEM models help explainhow competing beliefs about various diseases might shapedietary intentions in the context of the TRA. Informationof this sort is useful for the development of strategies toimprove patient compliance to dietary prescriptions madein the physician’s office and in population-based interven-tion programs in Barbados and elsewhere.

Acknowledgements

This research was supported in part by a Minority Inter-national Research Training grant, NIH 5T37 TW00038-03,from the Fogarty International Center, National Institutesof Health, USA. We wish to thank the following indi-viduals who assisted in gathering information for thisproject: Tamu Brown, Juleen Christopher, Dietra Furgusen,Ehmonie Haney, and Monique Spurill.

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