Practical Opportunities for Health Behaviors in Latinos Using the Capability Approach

Purpose:  Most illnesses and deaths in the United States can be attributed to preventable behaviors such as poor diet and physical inactivity (Mokdad, 2004).    However, the health care system repeatedly fails to gather information about a patient’s ability to function.  To effectively respond to health behaviors, an emphasis has been placed on health literacy and patient self-management.  These approaches do not address the gap between what someone knows they should do, and what someone is actually able to do.  The Capability Approach addresses this gap by considering the practical opportunities or capability people have for healthy choices given their actual resources (Sen, 1995).  Recognizing that disparities in health care exist based on race or ethnicity, and socioeconomic status (Landon, 2007).  The purpose of this study was to develop an assessment tool that measures capability for health behaviors (diet and physical activity) in chronic illness management. 

Methods:  Using a mixed methods approach, the study consisted of two phases.  Phase 1 used a community-based participatory research (CBPR) model to gather information on facilitators and barriers of capability.  Qualitative data was collected from 14 focus groups through a community organization, utilizing a semi-structured interview guide.    Focus groups responses were audiotaped, transcribed, translated, and iteratively coded by two independent authors.  A framework approach was used for analysis.  Phase 2 developed a structured survey from phase 1 themes to generate 120 preliminary questions.  The survey was named the Capability Assessment for Diet and Activity (CADA).  The survey was translated into Spanish and evaluated for conceptual equivalence.  Surveys were administered to 300 clinic patients.  Principal component analysis was used to analyze data collected. 

Results: Phase 1 yielded a sample of 145 participants diagnosed with diabetes mellitus (40%) and obesity (60%).  Participants were all Latino (62% primary Spanish speakers).  Themes identified in phase 1 supported the importance of agency (goals, values and depression), community resources (presence, convenience and cost), and conversion factors (knowledge, support and social norms).  An emerging theme includes the influence of discrimination on health behaviors.  Phase 2 achieved a 95% participation rate (292 respondents).  Participants were diagnosed with diabetes mellitus (57%) and obesity (96%), and 82% were Latino.  Based on eigenvalues and factor loadings, the component analysis contained eight factors with a Cronbach’s alpha of .86, subscale alphas range from .62 to .83.  When questionnaire items were calculated to indicate greater capability, participants identified safety, food insecurity, and accessibility of physical activity as resources that influenced health behaviors.  Conversion factors, such as household power relationships, social norms, and professional support influenced capability for health behaviors.  Development of the CADA was an important product of this research which can be used by other researchers. 

Conclusions and Implications: Focus group data proved to be effective as the basis for developing a reliable and valid scale to assess capability of health behaviors in chronic illness management.  Implications for social work practice and research are discussed in terms of assessment and intervention.