Examining Whether the Social Cognitive
Theory Concepts Predict Childhood Obesity
Prevention Outcome Expectations
Dayna S. Alexander1 , Chunhua Cao2, and Moya L. Alfonso1
Abstract
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.
Keywords
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
efforts.10–13
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
Corresponding Author:
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
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0272684X20915383
journals.sagepub.com/home/qch
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
Americans.
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.
Methods
Study Design
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
Sample
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.
Measures
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
perceptions.
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
more detail.
Statistical Analyses
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
significant.
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
statistically nonsignificant.
Alexander et al. 145
Results
Sample Characteristics
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
(M¼4.14, SD¼0.70).
Bivariate Analysis
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
Gender
Female 124 (96.9)
Male 4 (3.1)
Education
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
Theory Concepts.
Correlations
Constructs 1 2 3 4
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