Examining Whether the Social Cognitive
Theory Concepts Predict Childhood Obesity
Prevention Outcome Expectations
Dayna S. Alexander1 , Chunhua Cao2, and Moya L. Alfonso1
The social cognitive theory (SCT) has been used to explain and promote childhood obesity prevention behaviors. We examined
whether the SCT concepts predicted outcome expectations of childhood obesity among the children of African American caregivers.
Caregivers (n ¼ 128) completed the childhood obesity perceptions paper-based survey. A multiple linear regression was conducted to
determine the direct effects of moral disengagement, environment, self-efficacy, and behavioral capability on outcome expectations
(p<.05). A mediation analysis using a bootstrapping bias correction method was used to test whether self-efficacy and behavioral
capability mediated the effect of moral disengagement and environment on outcome expectations. Caregivers reported high levels of
moral disengagement (M¼4.13; standard deviation [SD]¼0.70) and self-efficacy (M¼4.26; SD¼0.64) and moderate levels of behavioral
capability (M¼2.83; SD¼0.75) and environment (M¼2.92; SD¼0.74). Findings indicated the hypothesized relationships in the
SCT were not fully supported. In addition, the indirect effects of environment on outcome expectations were not statistically
significantly mediated by behavioral capability. This research warrants more attention in testing the SCT concepts for the development
of childhood obesity prevention efforts that prioritize African American families in rural communities.
childhood obesity, African Americans, rural health, social cognitive theory
In the United States, the burden of obesity remains high
among African American children.1,2 Using the Centers for
Disease Control and Prevention body mass index categories,
approximately 22% of African American children are categorized
as obese,3,4 defined as age- and sex-specific body
mass index 95th percentile.5 Childhood obesity is the
result of multiple micro- and macro-factors, such as caregiver
behavioral habits, presence of food deserts, neighborhood
safety, and lack of physical structures in the rural environment.
1,6 A variety of interventions (e.g., programs,
health communication campaigns, etc.) have been
developed and implemented to prevent and reduce childhood
obesity.7–9 Some of these efforts have targeted specific behaviors
(i.e., healthy eating and physical activity) of children
and caregivers. In addition, health behavior theories
have been utilized as guiding frameworks for the design
and evaluation of the aforementioned efforts. The literature
indicates the social cognitive theory (SCT) as the most commonly
used theory for childhood obesity prevention
The SCT is an interpersonal theory that posits human
behavior as the outcome of bidirectional interactions (i.e.,
reciprocal determinism) between personal, behavioral, and
environmental factors. Thus, the SCT explains how a
child’s or caregiver’s behavior is influenced by their environment
(e.g., availability and accessibility to resources that promote
the health behavior), behavioral capability (i.e.,
knowledge and skills to perform the health behavior),
moral disengagement (i.e., ways of thinking to accept harmful
behaviors), self-efficacy (i.e., level of confidence to
1Department of Community Health Behavior and Education, Jiann-Ping Hsu
College of Public Health, Georgia Southern University
2Department of Rehabilitation, Human Resources and Communication
Disorders, College of Education and Health Professions, University of Arkansas
Dayna S. Alexander, Department of Community Health Behavior and Education,
Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro,
GA, United States.
Email: [email protected]
International Quarterly of
Community Health Education
2021, Vol. 41(2) 143–151
! The Author(s) 2020
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perform the behavior), and outcome expectations (i.e., the
anticipated consequences of the individual’s actions before
performing the behavior).14,15 This theory demonstrates the
importance of acquiring the knowledge, performing the
skills, and accomplishing the targeted behavior to prevent
the health outcome. Consequently, the SCT is a comprehensive
theory that includes concepts from the social ecological
model.15 The SCT consists of several concepts, including
environment, situation, behavioral capacity, outcome expectations,
outcome expectancies, self-efficacy, collective efficacy,
observational learning, reinforcement, facilitation, selfregulation,
and moral disengagement.14,15 The aforementioned
concepts have guided the development of multiple
programs and interventions that prevent and reduce chronic
conditions.16–18 However, there is a paucity of research on
the utilization of these concepts in the design, implementation,
and evaluation of childhood obesity efforts for African
In Heerman et al.,19 parenting self-efficacy was defined as
parent’s confidence to make good decisions to support
healthy childhood growth. Findings indicated that parenting
self-efficacy was not statistically significantly associated with
child physical activity and diet among African American and
Hispanic/Latino children.19 An additional study, conducted
in neighborhood corner stores in African American communities,
examined food purchasing patterns and preparation
methods in relation to SCT concepts (i.e., behavioral intentions,
self-efficacy, and outcome expectancies).20 In this
study, food-related (e.g., healthy food purchasing) behavioral
intentions decreased, whereas food-related outcome expectancies
increased among African American youth. Yet, no
significant impact of the intervention was observed on selfefficacy,
healthy food purchasing and preparation, and
unhealthy beverage consumption among participants.20 In
contrast, African American mother–child dyads experienced
an increase in self-efficacy for diet and behavior changes (e.g.,
consumption of more fruit and vegetables in- and outside of
the home and participation in more physical activity) after
participation in an eHealth intervention.21 Similarly, African
American families discussed an increase in self-efficacy to
start and sustain positive weight-related behaviors after participation
in the Families Improving Together randomized
controlled trial.22 Other empirical studies have found relationships
between self-efficacy and behavioral capability
and self-efficacy and outcome expectations.23,24 Thus, studies
have demonstrated that the concepts of SCT are predictors
for childhood obesity prevention and have been applied
across other chronic conditions and populations. However,
none of the aforementioned studies prioritized African
American families residing in rural communities.
Because the SCT has not been applied widely in a rural
setting among African Americans,12,25 it is useful to examine
how specific behaviors among this priority population can
prevent childhood obesity in a rural environment.
Although, the SCT is difficult to operationalize entirely and
it has not been exhaustively tested like other health behavior
theories.15 This study provides guidance on the utility of the
SCT concepts in the development of childhood obesity
efforts for African American families in rural communities.
Study findings contribute to the body of knowledge on the
interrelationships and testing of the SCT concepts. The existing
literature indicates that, on average, only one to two SCT
concepts are employed in interventions to explain the childhood
obesity-related behaviors.19,21,22 Thus, the results of the
study will assist public health professionals and others in
more effectively using the SCT theory to design interventions
targeting childhood obesity within rural, predominantly
African American settings. Finally, this study promotes the
importance of operationalizing, measuring, and applying the
SCT concepts within the context of childhood obesity.
The objective of this study was to examine whether moral
disengagement, environment, behavioral capability, and selfefficacy
predict childhood obesity prevention outcome
expectations among African American families. The authors
specifically investigated whether moral disengagement and
environment directly affected childhood obesity prevention
outcome expectations or whether they are mediated via
self-efficacy and behavioral capability in two different
models. Based on the relationships postulated in the SCT,
it was hypothesized that higher levels of moral disengagement,
environment, self-efficacy, and behavioral capability
would be statistically significantly associated with higher
childhood obesity prevention outcome expectations. The
authors also hypothesized that behavioral capability and
self-efficacy would statistically significantly mediate the positive
effects of moral disengagement and environment on
childhood obesity prevention outcome expectations.
The study design was cross-sectional. Data for this analysis
came from the Preventing Childhood Obesity study,26 which
examined and explored childhood obesity perceptions (COP)
among African American caregivers in rural Georgia.
Setting and Population
The participating elementary school is located in a rural
county in Georgia. There are five public schools in the
county including the participating elementary school.
However, the school was chosen because it contained a
high population of African American students, and it was
centrally located in the county. During the 2014 to 2015
study, approximately 595 African American students were
enrolled in third to fifth grade. At the time of this study,
there was a total population of 23,125 county residents
(49% African Americans) with a $32,188 median household
income.27 Approximately 52% of county residents self-
144 International Quarterly of Community Health Education 41(2)
identified as females and 30% of county residents had a
bachelor’s degree or higher.27
For this study, a caregiver was defined as an individual who
had legal guardianship of the child. A convenience sample of
caregivers was recruited using multiple strategies, such as
study invitational letters.26 The inclusion criteria for the caregivers
included (a) self-identification as an African American
or Black, (b) residence in the targeted Georgia County, (c)
the ability to read and write in English, (d) 18 years or older,
and (e) a third to fifth grader enrolled in the targeted elementary
school. If the caregiver had two or more children attending
the school, the caregiver completed the COP survey on
the child with a higher self-reported weight status. Informed
consent was obtained from all study participants. This study
was approved by the Georgia Southern University
Institutional Review Board and County School Board.
Caregivers completed a paper-based COP survey and interview.
26,28 For this study, we only examined the COP survey
data. The COP survey assessed sociodemographic characteristics
and information about childhood obesity perceptions
using SCT Concepts. Caregivers responded to items using a
5-point Likert-type scale: 1¼strongly disagree, 2¼somewhat
disagree, 3¼neither, 4¼somewhat agree, and 5¼strongly
agree. Summary subscale scores were created by averaging
item responses. Higher scores indicated greater levels of
Sociodemographic Characteristics. Caregivers answered seven
demographic items on the COP survey. Only three demographic
items: age (in years), gender, and education (less
than high school, some high school, high school diploma or
GED, some college or an associate degree [2 years], college
degree [bachelor’s], and some graduate degree study or completed)
were included in the study analyses.
SCT Concepts. SCT concepts were assessed using the validated
and reliable COP survey.28 The 59-item COP survey contains
five sections: childhood obesity risk factors, health complications,
weight status, barriers and facilitators in the built environment,
and prevention strategies. The SCT concepts used
for the 59-item survey included: outcome expectations (e.g.,
Parent’s eating habits influence a child’s risk for obesity),
self-efficacy (e.g., I can help my child have a healthy lifestyle),
behavioral capability (e.g., My child is the appropriate
weight for his or her age), reinforcement (e.g., My child’s
doctor discusses my child’s weight with me), environment
(e.g., My child feels safe in my community), and moral disengagement
(e.g., Limit high calorie foods). To measure
moral disengagement in this study, positively stated behavioral
indicators were used instead of negatively stated
behavioral indicators. Thus, in this study, higher levels of
moral disengagement represent healthier, more engaged
obesity prevention behaviors. The authors conducted an
exploratory factor analysis. More than half of the survey
items loaded highly (0.60–1.00) on their respective factors.
Items were kept if its rotated factor loading on its primary
factor was greater than 0.35; six survey items were deleted
because they loaded on <0.3 on the primary factor.29,30
Twelve items were removed because they had a factor loading
>0.27 on any secondary factor. In addition, two items
were discarded because of their nonalignment with their
respective theoretical concept. Twenty items were deleted,
which resulted in the final 39-item total measure. The six
factors were outcome expectations (n¼12; a¼.85;
M¼41.03; standard deviation [SD]¼7.72), moral
disengagement (n¼7; a¼.82; M¼28.78; SD¼4.84),
environment (n¼8; a¼.74;M¼23.81; SD¼5.62), behavioral
capability (n ¼5; a¼.79; M¼13.26; SD¼5.02), self-efficacy
(n¼4; a¼.70; M¼17.20; SD¼2.25), and reinforcement
(n¼3; a¼.75; M¼10.83; SD¼2.69). Alexander et al.,28
described the psychometric properties of the COP survey in
Descriptive statistics were used to characterize the sample
and variables of interest using the Statistical Package for
Social Sciences version 22.0. Mediation analysis was conducted
using Mplus 7.1.31 Bivariate analysis was used to
examine the associations among key study variables. All
assumptions (i.e., normality and homoscedasticity) were
met before conducting a multiple linear regression. The
regression model was conducted to examine the direct effects
of moral disengagement, environment, behavioral capability,
and self-efficacy on childhood obesity prevention behaviors
(i.e., outcome expectations). The regression controlled for
caregivers’ demographic characteristics including age,
gender, and education. Education was a categorical
variable in this data set; therefore, five dummy coded
variables were created using the lowest education level as
the reference. P values <.05 were considered to be statistically
A bootstrapping approach was used to run two mediation
models to explore whether behavioral capability and selfefficacy
mediated the effects of moral disengagement and
environment on childhood obesity prevention perceptions
(i.e., outcome expectations). The bootstrapped method
resampled 1,000 samples from the study sample.32 The mediation
model controlled for age, gender, and education. Biascorrected
95% confidence intervals were used to determine
whether the point estimates for each indirect effect were significant.
Confidence intervals that contained zero were considered
Alexander et al. 145
A total of 135 participants completed the survey; however,
only 128 participants were included in this analysis because
they had complete data for all variables examined in this
study. This resulted in a 22% response rate. The average
age of the participants was 34.31 years (SD¼7.77); 97% of
the participants were female. Twenty-two percent of the participants
had a high school diploma or GED, whereas 38%
had some college or an associate degree, respectively (see
Table 1). The mean of the five concepts varied with outcome
expectations (M¼3.42, SD¼0.63), self-efficacy (M¼4.26,
SD¼0.64), behavioral capability (M¼2.83, SD¼0.76),
environment (M¼2.92, SD¼0.74), and moral disengagement
Pearson correlations between the five SCT concepts indicated
that outcome expectations were statistically significantly correlated
with self-efficacy (r¼.31), environment (r¼.29), and
moral disengagement (r¼.33) at .01 a level. The correlation
coefficients were positive, which indicated that higher outcome
expectations reflected higher levels of self-efficacy,
moral disengagement, and rural environment. The correlations
between self-efficacy and moral disengagement
(r¼.35) and between environment and moral disengagement
(r¼.18) were also statistically significantly. In terms of directionality,
the correlation coefficient indicated a positive association
where self-efficacy scores increased as moral
disengagement increased. In addition, environment had a statistically
significant, positive effect on moral disengagement.
The pairwise correlations between the five concepts are listed
in Table 2.
Linear Regression Analysis
Table 3 presents linear regression results for outcome expectations
(adjusted R2¼.20). The adjusted R2 implies that 20%
of the variance in outcome expectations can be accounted for
by the other SCT concepts and caregiver’s age, gender, and
education. Only moral disengagement (b¼.23, p¼.01) was
statistically significant associated with outcome expectations
after controlling for the other SCT concepts and the participants’
gender, age, and education. Self-efficacy (b¼.13,
p¼.15), behavioral capability (b¼.02, p¼.78), and environment
(b¼.16, p¼.06) were not statistically significant predictors
of the outcome expectations. None of the covariates
(i.e., age, gender, and education) were statistically significant
with outcome expectations.
Table 1. Sample Characteristics (n¼128).
Characteristics MeanSD or n (%) Minimum–maximum
Age, years 34.317.7 10.0–65.0
Female 124 (96.9)
Male 4 (3.1)
Less than high school 11 (8.6)
Some high school 14 (10.9)
High school or GED 28 (21.9)
Some college or an associate degree 49 (38.3)
Four-year college degree 10 (7.8)
Some graduate education or completed degree 16 (12.5)
Social cognitive theory constructs
Outcome expectations 3.410.63 1.0–5.0
Self-efficacy 4.260.64 1.0–5.0
Behavioral capability 2.830.75 1.0–4.6
Environment 2.920.74 1.0–4.5
Moral disengagement 4.130.70 1.0–5.0
Table 2. Correlations Between Social Cognitive
Constructs 1 2 3 4 5
1. Outcome expectations 1.00 – – – –
2. Self-efficacy .31a 1.00 – – –
3. Behavioral capability .09 .04 1.00 – –
4. Environment .29a .13 .15 1.00 –
5. Moral disengagement .33a .35a .16 .18b 1.00
aCorrelation is significant at the .01 level.
bCorrelation is significant at the .05 level.
146 International Quarterly of Community Health Education 41(2)
It was hypothesized that self-efficacy and behavioral capability
mediated the direct effect of moral disengagement on outcome
expectations (see Figure 1). The 95% confidence
interval (corresponding to the 2.5th and 97.5th percentiles
from lowest to highest ranked estimates calculated from the
1,000 samples) of the two indirect effects (ac: the effect of
moral disengagement on outcome expectations mediated by
self-efficacy, and bd: the effect of moral disengagement on
outcome expectations mediated by behavioral capability)
were not statistically significant at the .01 a level while controlling
for age, gender, and education (see Table 4).
Bootstrap with bias correction method analysis results
indicated that the indirect effects (eg: the effect of environment
on outcome expectations mediated by self-efficacy and
f h: the effect of environment on outcome expectations
mediated by behavioral capability) were not statistically significant
at the .01 level controlling for age, gender, and
education. The 95% confidence intervals of the two indirect
effects included zero; therefore, the mediation analysis was
nonsignificant (see Figure 2). The direct and indirect effects
of environment on outcome expectations were not statistically
Current research on childhood obesity has employed SCT as
a theoretical framework to assist in intervention development
12,33; however, there is a paucity of literature on the
testing of SCT concepts.34,35 The authors tested whether
SCT concepts (i.e., moral disengagement, environment, selfefficacy,
and behavioral capability) predicted and mediated
Table 3. Result of Multiple Linear Regression With Outcome
Expectations as Dependent Variable.
Variables b p Adjusted R2
Intercept 1.01 .08 .20
Self-efficacy .13 .15
Behavioral capability .02 .78
Environment .16 .06
Moral disengagement .23 .01
Age .14 .09
Female .00 .98
Some high school .06 .63
High school or GED .02 .86
Some college or an
Four-year college degree .13 .26
Some graduate education
or completed degree
Note. Boldface values represent a statistically significant result.
Figure 1. Modeling the Indirect Effects of Moral Disengagement on Outcome Expectations. The model controlled for caregiver’s age, gender, and
education. Dashed lines indicate insignificant relationships and solid lines indicate significant relationships. *p<.005. **p<.01. ***p<.001.
Table 4. Mediation Results for the Direct and Indirect Effect Using
Bootstrap With Bias Correction Method.
Self-efficacy on moral disengagement (a) .008 .045
Behavioral capacity on moral
Outcome expectations on self-efficacy (c) .023 .375
Outcome expectations on behavioral
Outcome expectations on moral
ac (indirect effect) .004 .007
bd (indirect effect) .040 .014
Self-efficacy on environment (e) .000 .311
Behavioral capacity on environment (f) 14.034 .003
Outcome expectations on self-efficacy (g) .045 .425
Outcome expectations on behavioral
Outcome expectations on
eg (indirect effect) .119 .000
fh (indirect effect) .000 .057
Note. Age, gender, and education were controlled for in this model. Boldface
values represent a statistically significant result.
Alexander et al. 147
childhood obesity prevention outcome expectations. The
authors hypothesized that higher levels of moral disengagement,
environment, self-efficacy, and behavioral capability
would be associated with higher childhood obesity prevention
outcome expectations among African American caregivers
and that the effects of self-efficacy and behavioral
capability would statistically significantly, positively mediate
the effects of moral disengagement and environment on outcome
expectations. The bivariate analyses demonstrated that
childhood obesity outcome expectations are associated with
all of the SCT constructs.
Moral disengagement, according to Bandura36 is the interaction
between social and cognitive factors that enable individuals
to rationalize their unhealthy or damaging behaviors
in order to protect their self-image. In this study, results
suggested moral disengagement, which was assessed using
positive (healthy) behavioral indicators, was associated with
higher childhood obesity prevention outcome expectations
among African American caregivers. These results provide
a finer explanation as to caregivers being morally disengaged
and anticipating positive outcomes for their child while
engaging in obesity prevention behaviors. For example, caregivers
limiting their child’s portion sizes or providing healthy
snacks to prevent childhood obesity. In addition, our findings
are similar with previous studies, which also found that
higher moral disengagement was associated with higher
self-efficacy among children who were being bullied in
school settings.37,38 A most recent study demonstrated that
when mothers acquired the self-efficacy of how to prepare
nutritious and affordable foods for their child this reduced
childhood obesity outcome expectations.39
The study findings specifically the mediation analyses did
not highlight the significance of the SCT concepts for promoting
childhood obesity prevention outcome expectations
among African American families. The analyses demonstrated
no support for the indirect effect of moral disengagement
on outcome expectations mediated by behavioral capability.
Moreover, the author’s did not find support for the indirect
effect of environment on childhood obesity prevention outcome
expectations mediated by behavioral capability.
Yet, qualitative research is warranted to examine how caregiver’s
behavioral capability about childhood obesity
increases moral disengagement strategies and addresses physical
structures in the rural environment.
Moral disengagement and the rural environment are factors
in childhood obesity and should be examined comprehensively
in future obesity prevention efforts with a larger
sample. Therefore, both SCT concepts require a qualitative
approach. It would be essential for public health and healthcare
professionals, school personnel, and others to assess
how these factors impact African Americans obesity prevention
behaviors using focus groups or in-depth interviews.
Both methods would allow professionals to gain an indepth
understanding of African Americans knowledge, attitudes,
and behaviors in managing and reducing childhood
obesity in a rural setting. Similarly, behavioral capability
and self-efficacy are essential factors that public health professionals
should directly address among caregivers by providing
credible obesity-related information while assessing if
caregivers have the knowledge, skills, and resources necessary
to prevent obesity among their children. Childhood obesity
information should be tailored to align with African
Americans geography, demography, socioeconomics, and
culture. In addition, it would be helpful if African
American members of the community were trained to deliver
the information in a trusted community-based organization.
The linear regression analysis demonstrated that moral
disengagement was the single most important predictor of
outcome expectations. This reveals to public health and
health-care professionals that caregivers were knowledgeable
of childhood obesity preventive strategies. However, interventions
must go beyond knowledge and help families start
and maintain obesity prevention behaviors. In the African
American community, interventions should utilize community
assets such as schools and faith-based organizations to
increase family involvement and alleviate the stress of engaging
in a new health behavior. Although behavioral capability,
self-efficacy, and environment did not show any statistically
significant associations in the multivariate analyses, future
studies should continue to examine and test the SCT
Figure 2. Modeling the Indirect Effects of Environment on Outcome Expectations. The model controlled for caregiver’s age, gender, and education.
Dashed lines indicate insignificant relationships and solid lines indicate significant relationships. *p<.005. **p<.01. ***p<.001.
148 International Quarterly of Community Health Education 41(2)
constructs on the outcome expectations of childhood obesity.
More research is needed to unravel the indirect and direct
effects of the SCT constructs on obesity prevention efforts,
particularly those in rural communities.
In rural settings, behavioral interventions developed for
African Americans should be targeted toward modifying
the child and caregiver’s behavioral capability, self-efficacy,
and moral disengagement to prevent childhood obesity. The
modifications should be tailored for behavioral determinants
of health, family characteristics (e.g., number of family members
living in the household and one- or two-parent household),
religious commitment (e.g., religious attendance,
religious salience, and consolation), and social cohesion of
the rural community. These aforementioned modifications
ensure the concepts are personalized for families, which
may help us better understand the dynamics between each
concept and the rural environment. More empirical evidence
including mediational analyses is needed about the environment
to ensure future researchers and evaluators obtain a
comprehensive understanding of the setting before program
or intervention design. Interventions should be implemented
by a community champion/gatekeeper, which may increase
behavioral capability and self-efficacy among African
American families to prevent childhood obesity. Formative,
process, and summative evaluations should be conducted on
the program or intervention to assess the utility of the SCT
concepts, cultural appropriateness, and priority population
needs and priorities.
Limitations and Strengths
The limitations of the study’s findings must be considered
when interpreting the results. First, the study design was
cross-sectional. Thus, the study design limited our ability to
truly test whether mediation occurred, although the SCT
posits the relationship between self-efficacy and outcome
expectations are bidirectional. Second, the confidence intervals
in the mediation analysis were borderline including zero;
therefore, they were not statistically significant based on
established criterion.32 Third, the use of a small convenience
sample limits the generalizability of the results. Future studies
should recruit a larger representative sample to examine
the study hypotheses and ensure generalizability of study
results. Fourth, participants self-reported on moral disengagement,
environment, outcome expectations, self-efficacy,
and behavioral capability concepts, which may have led to
recall and misclassification bias. Having objective measures
such as direct observations of caregiver’s childhood obesity
prevention strategies may provide valid data to assess the
study’s purpose. Fifth, measurement bias was introduced in
the study because items were removed from the survey scales,
although all scales had an acceptable Cronbach a.40 The
authors removed items from the scale that had a low factor
loading. The results of the regression analysis showed that
only moral disengagement was a statistical significant
predictor of outcome expectations. Finally, the COP survey
items used to measure moral disengagement did not adhere
to Bandura’s36 original definition.
Despite the study limitations, the results contributed to
the body of literature on childhood obesity and SCT specifically
in rural areas. Self-efficacy and moral disengagement
are two SCT concepts that have been repeatedly measured
and validated; however, this study attempts to fully test the
SCT concepts. This research also addressed a population that
is dramatically affected by childhood obesity, indicating that
moral disengagement strategies (e.g., limit high calorie foods)
predicted accurate outcome expectations among African
American caregivers. In addition, this study could be expanded
as groundwork for future childhood obesity efforts in
Childhood obesity can result in adverse health complications
for the child and high health-care expenses for the caregiver
and the United States. Our study findings indicate that caregivers
with higher moral disengagement (healthy behaviors)
strategies have better childhood obesity prevention outcome
expectations. Thus, public health and medical professionals
may want to increase caregiver’s moral disengagement and
behavioral capability in childhood obesity interventions and
treatment plans in rural environments. Our findings also
show that caregiver’s self-efficacy negatively mediates the
effects of the rural environment on childhood obesity prevention
outcome expectations. To increase self-efficacy in caregivers,
public health professionals should identify barriers
that caregivers and children encounter when attempting to
modify their lifestyle habits and teach them how to incorporate
and sustain healthy lifestyle habits in their home, school,
and community environments. In addition, it is essential that
caregivers are assisted in locating safe and accessible recreational
parks and facilities within close proximity of the child’s
home environment to reduce built environment barriers and
encourage physical activity.
In conclusion, no support was found for the applicability of
the SCT concepts in explaining childhood obesity outcome
expectations among African American caregivers. It is evident
in the literature that SCT has been utilized as a theoretical
framework for childhood obesity programs and
interventions; yet, there is limited literature on the testing
of SCT concepts. It is critically important that future studies
test and evaluate the SCT concepts for the development of
childhood obesity prevention efforts.
This work would not have been possible without the participation of
the caregivers, school officials and staff, and County School Board.
Alexander et al. 149
Thank you to the research staff who contributed to the data collection
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This
study was supported by the Georgia Southern University
Graduate Student Organization (grant number 1378924576).
Dayna S. Alexander https://orcid.org/0000-0003-4590-9560
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Dayna S. Alexander, DrPH, is currently an adjunct professor
at Concordia University Chicago and a health scientist at the
Centers for Disease Control and Prevention. She earned a
Master of Science in Public Health from the University of
North Carolina at Charlotte and a Doctor of Public Health
in Community Health Behavior and Education from Georgia
Southern University. Dr. Alexander has over 10 years’ experience
successfully designing, implementing, and evaluating
health disparity and inequity initiatives in academic-, clinical-
, faith-, and government-based organizations. Her research
interests include sexual and reproductive health, rural health,
patient-provider communication, and chronic conditions
(HIV, diabetes, and obesity). In addition, she has expertise
in conducting community-based participatory research, collecting
and analyzing qualitative and quantitative data, and
engaging stakeholders in program planning and implementation.
Furthermore, she has published scholarly articles in
peer-reviewed journals and presented her research at national
and international conferences. She strives to inform and
empower community members so they can adopt and sustain
healthy lifestyle habits and thereby create healthier
Chunhua Cao, PhD, a teaching assistant professor at
University of Arkansas, focused her research in multilevel
modeling, structural equation modeling (SEM), Bayesian
estimation, and program evaluation using mixed research
method. She has published some articles about assessment,
SEM in some top journals in educational measurement and
research methodology. She participated and presented in
some international, and national conferences, for example,
American Educational Research Association, American
Evaluation Association, National Council of Measurement
in Education, and Florida Educational Research
Moya L. Alfonso, CEO and founder of Southeast Change,
founded a consulting firm in 2019 dedicated to building nonprofit
and community-based organization capacity to prevent
and address the effects of trauma, including child abuse, substance
use/abuse, and mental illness. In addition, she is a
senior grant writer for the Children’s Home Society of
Florida. Prior to these roles, she was an associate professor
of Health Policy and Community Health at the Jiann-Ping
Hsu College of Public Health, Georgia Southern University.
She has had an interdisciplinary training in psychology,
public health and educational research and evaluation and
has received formal training in project/program evaluation.
She has conducted formative and summative program evaluations
for numerous nonprofits, school districts, and community-
based organizations. Prior to coming to Georgia
Southern University, Dr. Alfonso served as co-director of
the Methods and Evaluation Unit for the CDC funded
Florida Prevention Research Center at the University of
South Florida. During her tenure at the Prevention
Research Center, Dr. Alfonso used her community organizing
and prevention research training to assist a number of
communities with building capacity to improve community
health. She is a dedicated and passionate public health professional
with 20 years of experience serving the underserved.
She has served on the SEA Board for several years and currently
serves as president.
Alexander et al. 151
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