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Submitted: 14 Mar 2020
Accepted: 11 May 2020
First published online: 12 Jul 2020

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Health Promotion Perspectives, 10(3), 200-206; DOI:10.34172/hpp.2020.33

# Using multi theory model (MTM) of health behavior change to explain intention for initiation and sustenance of the consumption of fruits and vegetables among African American men from barbershops in Mississippi

Jaelrbreiret L. Williams1,*, Manoj Sharma1, Vincent L. Mendy2, Sophia Leggett1, Luma Akil1, Samuel Perkins3

1 Department of Behavioral & Environmental Health, School of Public Health, Jackson State University, Jackson MS, USA
2 Department of Epidemiology and Biostatistics, School of Public Health, Jackson State University, Jackson MS, USA

*Corresponding Author: Jaelrbreiret L. Williams, Email: jaelrbreiret@gmail.com

© 2020 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## Abstract

Background: African American men have poorer health outcomes compared to their white counterparts despite medical advancements and early detection of diseases. The purpose of this study was to determine to what extent the constructs of the multi theory model (MTM) explain the intention for initiation and sustenance of the consumption of fruits and vegetables among African American adult men in Mississippi. Methods: Using a cross-sectional design a valid and reliable paper survey was administered during November and December of 2019. The target population for the study consisted of African American adult men (18 or older) that had not consumed recommended levels of fruits and vegetables within 24 hours of taking the questionnaire. A convenience quota sample of African American men from select barbershops in Jackson, Mississippi, were asked to complete the 40-item questionnaire on preventive health screening behavior (n=134). Results: The mean total number of fruits and vegetables consumed by participants within 24hours of the taking the survey was 1.63 (SD =1.47). The mean intention to initiate consuming 5or more cups of fruits and vegetables per day score was 2.13 (SD=1.17) as measured on a 5-point scale (0-4). Behavioral confidence (β = 0.495, P <0.0001), and changes in physical environment(β = 0.230, P <0.0001) accounted for 40.8% of the variance in predicting the intention to initiate behavioral change regarding the daily consumption of fruits and vegetables. Practice for change (β = 0.462, P <0.001) and emotional transformation (β = 0.215, P <0.0001) accounted for 37.5% of the variance in the intention to sustain fruits and vegetables consumption behavior. Conclusion: Based on data found in the study, MTM appears to predict the intention to initiate and sustain fruit and vegetable intake of African American men. Further research studies of suitable interventions to target African American men are needed.

Keywords: Fruit, Vegetables, African Americans, Mississippi, Behavior

## Introduction

Fruits and vegetables are a source of vitamins, minerals, antioxidants, and phytochemicals, which combat non-communicable diseases.1 According to the World Health Organization )WHO(, in 2019, approximately 1.7 million (2.8%) of deaths worldwide were attributable to low fruits and vegetables consumption.2 One of the top ten risk factors associated with global mortality is low levels of fruits and vegetables intake.2

In the United States, only one in 10 adults consume the recommended daily servings of one and a half to two cups of fruits and two to three cups of vegetables.3 Increased risk of death, vascular disease, and cancer are associated with low consumption of fruits and vegetables.4 Healthy People 2020 has outlined Objectives: “Nutrition and Weight Status (NWS)-14 Increase the contribution of fruits to the diet of the population age two years and older. NWS-15: Increase the participation of total vegetables to the diets of the population aged two years and older”. 5 Even when made aware of the health benefits of consuming fruits and vegetables African American men are less likely to eat fruits and vegetables than their white counterparts.6 In 2018, only 12.2% of US adults met the daily fruit intake recommended, and only 7.3% of US adults met the daily vegetable intake recommended.3 Only 15.8% of African Americans, non-Hispanics, consumed five or more fruits and vegetables per day.7 Additionally, in Mississippi, in 2017, 52% of men consumed fruits less than one time per day, while 23.6% consumed vegetables less than one time per day.8 Lastly, in the same year, 46.9% of African Americans in Mississippi consumed fruits less than one time per day, and 29.2% of African Americans in Mississippi consumed vegetables less than one time per day.8

A major public health initiative focuses on the health and wellbeing of males, but few interventions target or include the health of African American men.9 A few studies have been conducted to promote dietary changes among African American men.10-13 To our knowledge, only one study was specifically designed to promote the fruits and vegetable consumption of African American men and this study utilized the Health Belief Model and the Transtheoretical Model. 12 The study included African American (mostly immigrant) men from New York City in a randomized control trial designed to promote education, awareness, and adoption of fruits and vegetables among them.12

The multi-theory model (MTM) for health behavior change is a fourth-generation theory. MTM is parsimonious, flexible, encourages both one-time change and long-term behavior change, and it is exclusive to health education.14 MTM initiation constructs include participatory dialogue (two-way dialogue of advantages and disadvantages of behavioral change), behavioral confidence (confidence that the behavioral change can be continued in the future), and changes in the physical environment (change physical environment to allow resource readiness). MTM sustenance constructs include emotional transformation (ability to redirect emotions or feelings to accomplish behavioral change), practice for change (constantly thinking of behavior change to overcome barriers), and changes in the social environment (establishment of social support).14 MTM does not have a moderator variable; therefore, it is easily adaptable for various health behaviors. Additionally, MTM allows health practitioners the flexibility to adapt interventions to individual client needs.15 This study provides evidence to help guide future intervention development to promote fruit and vegetable intake of African American men helping to close the gap of knowledge. The purpose of this study was to determine to what extent the constructs of the MTM explain the intention for initiation and sustenance of the consumption of fruits and vegetables among African American adult men in Mississippi.

## Materials and Methods

### Multi theory constructs

Table 2 depicts the descriptive statistics of study variables. For the construct of advantages, the mean score of 14.66 (standard deviation [SD]: 3.52 indicated that the participant’s attitude toward the daily consumption of five cups of fruits and vegetables was rather positive and could be beneficial for their health. The mean score of 8.18 (SD: 4.44) for construct of disadvantages showed that participant’s attitudes toward the daily consumption of five cups of fruits and vegetables leaned toward disadvantages. The mean score of the total participatory dialogue (advantages – disadvantages) was 6.47 (SD: 5.94) demonstrated that participants believed that the advantages outweighed the disadvantages of the consumption of five cups of fruits and vegetables. The mean score for behavioral confidence was 9.73 (SD: 4.77) indicated that the participants were moderately sure of their decision to initiate a change in behavior. The mean score of changes in the physical environment of 7.06 (SD: 3.04) indicated that participants were moderately sure of being able to consume five cups of fruits and vegetables available in their physical environment. The mean score of the intention for initiation of behavioral change 2.13 (SD: 1.17, median 2, range 0-4) indicated that participants were moderately likely to consume five cups of fruits and vegetables in the coming weeks.

 Table 2. Multi theory model construct survey scores of African American men who did not consume at least five cups of fruits and vegetables daily Constructs Possible Range Observed Range Mean (SD) Cronbachα Cups of fruitsa 0-4 0-4 0.74 (0.91) Cups of vegetablesa 0-4 0-4 0.89 (1.00) Total cups of fruits and vegetablesa 0-4 0-4 1.63 (1.47) Initiation 0 to 4 0 to 4 2.13 (1.17) - Participatory dialogue (PD) Overall PDAdvantages – Disadvantages -20 to +20 -8 .00 to 20.00 6.47 (5.94) - PD advantages 0 to 20 2.00 to 20.00 14.66 (3.52) 0.77 PD disadvantages 0 to 20 0.00 to 20.00 8.18 (4.44) 0.80 Behavioral confidence 0 to 20 0.00 to 20.00 9.73 (4.77) 0.86 Changes in physical environment 0 to 12 0.00 to 12.00 7.06 (3.04) 0.72 Sustenance 0 to 4 0 to 4 1.92 (1.22) - Emotional transformation 0 to 12 0.00 to 12.00 7.32 (3.26) 0.88 Practice for change 0 to 12 0.00 to 12.00 5.33 (3.28) 0.85 Change in social environment 0 to 12 0.00 to 12.00 6.37 (3.11) 0.77 aConsumed within 24 hours of completion of survey.

The mean intention of sustenance of consuming five or more fruits and vegetables per day score was 1.92 (SD: 1.22). The mean score of the emotional transformation was 7.32 (SD: 3.26) indicated participants were moderately sure that they could encourage themselves and redirect their emotions/feelings toward a lifestyle modification to sustain the daily consumption of five cups of fruits and vegetables. The mean score of practice for change was 5.33 (SD: 3.28) demonstrated that the participants were slightly sure that they could engage in activities that encourage the maintenance of behavioral change in the daily consumption of five cups of fruits and vegetables. The mean score for changes in the social environment 6.37 (SD:3.11) indicated participants were moderately sure that they would benefit from the support of family members, friends, and health professionals in the effort to consume five cups of fruits and vegetables daily. The mean score of the intention for sustenance of behavioral change 1.92 (SD: 1.22, median 2, range 0-4) indicated that the participants were moderately likely to sustain the daily consumption of five cups of fruits and vegetables every week from now on.

### Initiation model

Behavioral confidence (β = 0.495, P < 0.0001) and changes in the physical environment (β = 0.230, P < 0.0001) were significant predictors for the intention to initiate behavior change regarding fruits and vegetables consumption of African American adult men, F (2, 131) = 46.779, P < 0.0001; R2 = 0.417; adjusted R2 = 0.408. The results of the stepwise regression analysis to predict the intention for initiation of fruits and vegetable consumption are presented in Table 3.

 Table 3. Stepwise regression analysis to explain intention of initiation of fruits and vegetables consumption behavior change in African American men Constructs a Β SE B β P value 95% CI for B Modelb Behavioral confidence 0.121 0.019 0.495 <0.0001 0.083, 0.159 Changes in physical environment 0.089 0.030 0.230 <0.0001 0.029, 0.148 Abbreviations: B, unstandardized coefficient; CI, confidence interval; SEB, standard of the coefficient; β, standardized coefficient. aDependent variable: How likely is it that you will eat five cups of fruits and vegetables every day in the upcoming week? b F (2, 131) = 46.779, P  < 0.0001; R2= 0.417; adjusted R2 = 0.408.

### Sustenance model

Practice for change (β = 0.462, P < 0.0001), and emotional transformation (β = 0.215, P = 0.016), were significant predictors for the intention to sustain behavior change regarding fruits and vegetables consumption of African American men, F (2, 131) = 40.984, P < 0.0001; adjusted R2 =0.375. The results of the stepwise regression analysis to predict the sustenance of fruits and vegetable consumption are presented in Table 4.

 Table 4. Stepwise regression analysis to explain intention to sustain fruits and vegetables consumption behavior change in African American men Constructs a Β SE B β P value 95% CI for B Modelb Practice for change 0.172 0.033 0.462 <0.0001 0.107, 0.237 Emotional transformation 0.080 0.033 0.215 0.016 0.015, 0.146 Abbreviations: B, unstandardized coefficient; CI, confidence interval; SEB, standard of the coefficient; β, standardized coefficient. a Dependent variable: How likely is it that you will eat five cups of fruits and vegetables every day from now on? b F (2, 131) = 40.984, P  < 0.0001; R2 = 0.385; adjusted R2 = 0.375.

## Discussion

The purpose of this study was to examine the utility of MTM of health behavior change in predicting the initiation and sustenance of daily consumption of five cups of fruits and vegetables among African American men from barbershops in Mississippi. The results of the study revealed most MTM constructs were significant in explaining intention for fruits and vegetable consumption in African American men.

### Limitations/Recommendations for future research

There were some limitations to our study. First, this study utilized a cross-sectional design which cannot establish a causal relationship between the independent and dependent variables as the data was are measured at one time (snapshot). Secondly, this study utilized self-reported data, which may have been subject to recall bias, dishonesty, acquiescence bias and other such shortcomings. In addition, this study utilized the intention of behavior change for initiation and sustenance as substitution measures for actual change. The study also did not establish test-retest reliability of the survey. Lastly, random sampling was not utilized; therefore, the results of this survey are limited by the choice of the sample, which limit generalizability.

Future research should be longitudinal and experimental to establish causality between MTM constructs and fruits and vegetables consumption. For future cross-sectional survey research, participants should be randomly selected to improve generalizability. Additionally, researchers should not only utilize self-reported data but measure participants objectively and through observation of fruits and vegetable consumption behavior. Experimental designs should be used to develop and test MTM-based interventions for modifying the constructs identified in this study for promoting fruits and vegetable consumption among African American men. This study paves way for undertaking a series of pilot interventional studies followed by efficacy trials and then possibly effectiveness studies to promote fruits and vegetable consumption behavior among African American men.

### Implications for practice

Results of this study support MTM being operational in designing and evaluating interventions that promote fruits and vegetable consumption among African American adult men. Participatory dialogue can be influenced by engaging in two-way discussions about the advantages of consuming five cups of fruits and vegetables. We can utilize barbershops as a great place to engage in the two-way conversations facilitated by certified health education specialists or other health professionals. We can influence behavioral confidence by having food demonstrations outside of barbershops and providing tips on quick meals and choosing food options that would help men consume fruits and vegetables. Influencing the construct of changes in the physical environment would involve making more fruits and vegetables available (i.e., healthy snack options in the barbershops and in the community through resource mobilization and policy efforts). To help make long-term change of African American adult men consuming five or more fruits and vegetables, participants would need to transform emotions (emotional transformation construct) toward eating five cups of fruits and vegetables. We can accomplish this by discussions regarding goal setting with health professionals about food substitution for fruits and vegetables as well as setting up barbershop talks with community health educators. The practice for change construct can be improved by teaching the African American adult men to monitor their behavior by keeping an electronic journal (e.g. “take a pic before your pick it”) to help them adhere to their goals. We can influence changes in social environment by getting support of family, friends or health professionals and can occur naturally or artificially.

## Conclusion

This cross-sectional study provided evidence in favor of the multi-theory model (MTM) of health behavior change in helping promote change with regard to fruits and vegetable consumption behavior among African American men. We can reify this theory for developing interventions to facilitate fruits and vegetable consumption in African American men. A venue for such interventions can be barbershops.

## Ethical approval

This study was approved by Jackson State University Institutional Review Board (IRB), Protocol #0149-19. All procedures performed in this study were in accordance with ethical standards of the institutional and or national research committee.

None to declare.

## Authors’ contributions

Manuscript conceptualization: JLW and MS; Manuscript writing: JLW, MS, VLM, SL, LA, SP; Literature review: JLW, MS, VLM, SL, LA; Instrument development; MS; Data Collection: JLW; Data analysis: JLW and MS; Data interpretation: JLW and MS.

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