Self-Efficacy is Associated with Health Behaviors Related to Obesity and Cardiovascular Risk among Hispanic/Latinx and Somali Immigrants to the United States

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Most research examining self-efficacy has been conducted with white young adult populations. This secondary analysis examined the association of self-efficacy (i.e., confidence) for healthy eating and physical activity in two immigrant communities. Methods: At enrollment into the Healthy Immigrant Community study, a clinical weight management and cardiovascular risk reduction intervention set in southeastern [state], 475 participants completed assessments about their confidence for healthy eating and physical activity. Measurements also included self-reports of dietary quality and intake, physical activity, quality of life, and biometric assessments. Study materials were available in English, Spanish, and Somali. Results In total, 450 adults (Hispanic/Latinx = 267; Somali = 183) completed measures at baseline and were included for analysis. Their average age was 45 years (range 18–87) and 59% were female. Confidence for healthy eating was significantly associated with self-report of eating healthy snacks ( p = < 0.0001) and less consumption of high-calorie drinks ( p = 0.02) and regular soda ( p = < 0.0001). Confidence to be physically active was significantly associated with more self-reported physical activity ( p = < 0.01). Conclusions Confidence to eat healthy and be physically active appears to be associated with having a healthier diet and higher levels of physical activity. Given the large sample size and strength of the associations, it also appears that the theoretical model of self-efficacy can be effectively measured and applied within these immigrant populations. Self-efficacy theory may be useful in understanding potential mediating mechanisms when designing future interventions with immigrant communities. ClinicalTrials.gov registration: NCT05136339; April 23, 2022 Health behaviors healthy eating physical activity immigrant communities cardiovascular risk self-efficacy Figures Figure 1 Introduction Identifying mediating mechanisms that facilitate an individual’s ability to improve their health behaviors can be useful in designing and delivering health behavior interventions. One possible mediating mechanism that is a component of social cognitive theory is self-efficacy, which theorizes that an individual’s confidence to engage in a behavior is predictive of the individual engaging in that specific behavior.[ 1 ] Self-efficacy for eating has been shown to improve after participation in behavioral weight management programs,[ 2 ] and in a sample of 1,740 patients seeking bariatric surgery, lower eating self-efficacy was associated with higher rates of binge eating episodes, food addiction scores, night eating syndrome, and negative mood.[ 3 ] While low self-efficacy for eating is associated with higher levels of anxiety[ 4 ] and lower rates of having bariatric surgery,[ 5 ] improvements in self-efficacy after weight loss surgery are predictive of long-term weight loss maintenance.[ 6 ] In a sample of 676 worksite “wellness champions,” high stress level was associated with low self-efficacy for following a healthy diet over a five-year period.[ 7 ] In a sample of over 13,000 members of a wellness center, high stress was associated with low-self efficacy for being physically active.[ 8 ] How self-efficacy theory and measures apply to immigrant populations is a growing area of investigation. A recent literature review called for more research that examines psychosocial factors that impact physical activity level in Black and Latina individuals.[ 9 ] A physical activity intervention based on social cognitive theory demonstrated effectiveness in a sample of Spanish-speaking Latinas,[ 10 ] as did a physical activity pilot project with Somali women.[ 11 ] Our team previously reported that negative mood was associated with lower confidence for eating healthy among 449 Hispanic and Somali immigrants, but found no association between negative mood and confidence to be physically active.[xx] A review of four community health worker-led interventions with Asian immigrants found that self-efficacy and physical activity improved significantly among participants in the treatment groups.[ 13 ] A combined analysis of 176 Latina adults who participated in one of two exercise interventions found higher self-efficacy two months into the program was associated with less relapse.[ 14 ] Additionally, food insecurity was also found to be associated with low self-efficacy and heritage language proficiency among immigrants to the United States.[ 15 ] The current study is embedded within the Healthy Immigrant Community (HIC) study, which is a cluster randomized trial to assess the effectiveness of a social network-informed, community-based participatory research (CBPR) derived health promotion intervention on measures of obesity and cardiovascular risk among Hispanic and Somali immigrant populations.[xx] HIC is a product of [city] Healthy Community Partnership (RHCP), which is a 20-year CBPR partnership in southeast [state] that collaborates with immigrant and refugee populations to co-create interventions that promote health equity for community health priorities.[xx] RHCP is productive and experienced at using a CBPR approach to co-develop and test community-based interventions to reduce the accumulation of cardiovascular risk after immigration.[xx] This study is a cross-sectional analysis of baseline data from the RHCP HIC study. Our hypothesis was that the association between self-efficacy and healthy eating and physical activity behaviors previously described among predominantly white, affluent study populations[ 19 ] would also be found among immigrant communities in the United States. Methods Setting and Participants The [institution name] Institutional Review Board approved the HIC study (NCT0513633) in 2021. All participants provided written informed consent. The study setting and participants were described in previous papers.[xx, xx] Briefly, HIC is set is Olmsted County in southeastern [state] (2021 estimated population: 163,436).[ 20 ] Approximately 11% of the population were born outside of the US, of which 55% have become US citizens,[ 20 ] and 14% of people living in the county speak a language other than English at home.[ 21 ] The study utilized baseline data from the RHCP HIC study. Through this CBPR-informed study, 52 members of the immigrant communities, identified by RHCP community partners, were trained as health promoters (HP) and delivered the 12-month intervention to 472 participants in their existing social networks either immediately following baseline measures or after a one-year delay (delayed-intervention control group). Baseline data was collected in June-August 2022 HIC inclusion criteria included age ≥ 18 years, self-reported Hispanic/Latinx or Somali ethnicity, being a member of a HP’s social network, and being willing to participate in all study procedures. Participants were excluded if they were pregnant at the time of enrollment or had a medical condition or disability that prevented them from being more physically active. Baseline measures obtained by study staff and community volunteers included: 1) biometric measurements such as height, weight, blood pressure, glucose; 2) survey measures assessing dietary quality and intake, physical activity, and quality of life; and 3) demographics. Assessments were carefully translated and available in English, Spanish, or Somali.[ 22 ] Primary Outcome Measures Self-Efficacy : As previously described, participants completed the adapted Patient Centered Assessment and Counseling for Exercise plus Nutrition (PACE+) survey at baseline.[ 23 ] Two items assessed self-efficacy: “How confident are you that you can eat a healthy diet?” and “How confident are you that you can participate in regular exercise or physical activity?” Both items were rated as a percentage interval (0%=not at all confident; 25%; 50%=somewhat confident; 75%; 100%=very confident). Nutritional Behaviors : The Food Behavior Checklist, which is validated for use among diverse communities, was used to assess dietary quality and intake.[ 24 , 25 ] Questions included in this analysis were: “Do you eat fruits or vegetables as snacks?”, “Do you drink fruit drinks, punch, or sports drinks?, and “Do you drink regular soda?”. The items were rated on a 4-point Likert scale (no; yes, sometimes; yes, often; yes, everyday), but “often” and “everyday” were combined on analysis to produce three variables (no; sometimes; often). Participants also completed the Automated Self-Administered 24-hour (ASA24®) Dietary Assessment Tool[ 26 ] on a computer with assistance from study staff and an interpreter if needed. The Healthy Eating Index (HEI) is a score produced by the ASA24® based on 10 recommended dietary components including high intake of fruit, vegetables, protein, dairy, whole grains, and low intake of fats, cholesterol, and sodium. Each component is weighted with a possible score from 0–10 with a maximum overall score out of 100; higher scores indicate healthier diets. Physical Activity The International Physical Activity Questionnaire (IPAQ) short form was used to measure physical activity levels in the baseline survey.[ 27 ] Physical activity was defined as “any activity that increases your heart rate and makes you breathe harder some of the time” including at work, house and yard work, and sports or exercise. “Vigorous” activity was defined as one that “takes much more physical effort and makes you breathe a lot harder than normal” like “heavy lifting, digging, aerobics, or fast bicycling.” “Moderate” activity was one that “takes somewhat more physical effort and makes you breathe a little harder than normal” like “carrying light loads or bicycling at a regular pace.” Participants were instructed to not include walking as “moderate” physical activity. Participants reported separately the total number of days out of the last seven days that they did “vigorous” and “moderate” activities for at least 10 minutes at a time. They also answered the question “On the days you did do [vigorous or moderate] physical activity, how many minutes total did you usually spend on one of those days?” Participants reported how many days out of the last seven days that they walked for at least 10 minutes at a time, including “all types of walking at work and at home” and the total minutes they usually spent walking on one of those days. Lastly, participants were asked about time spent sitting “on weekdays while at work, at home, or any other place.” The total time usually spent sitting on a weekday during the last seven days was reported in hours and minutes. The recommended scoring criteria for the IPAQ contains three categories: Inactive, Minimally Active, and Health-Enhancing Physical Activity (HEPA) Active. The “minimally active” category is defined as “≥3 days of vigorous activity at least 20 minutes/day, ≥ 5 days of moderate-intensity activity or walking at least 30 minutes/day, or ≥ 5 days of activity achieving a minimum of least 600 MET-min (multiples of the resting metabolic rate)/week.” As in our previous analysis,[xx] the “minimally active” and “HEPA active” categories were combined because the criterion for both exceed public health recommendations for physical activity; thus, two variables were analyzed (active, inactive). Data Analysis Kruskal-Wallis tests were used to analyze continuous variables by categorical variables such as race, confidence levels, and IPAQ categories. Analyses were two-sided using 5% type I error rates. Associations between continuous variables were assessed using Spearman correlation coefficients and a t-test was performed for Fig. 1. Analyses were performed using SAS version 15.1 (SAS Institute Inc. Cary, NC, USA). Results In total, 450 participants who identified as Hispanic/Latinx (n = 267, 59%) or Somali (n = 183, 41%) and completed baseline measures were included in this analysis. Of the 450 participants, 261 (59%) were female, the mean age was 45 years (range = 18–87; SD = 14.3), and 167 (37%) had no health insurance plan in the past 12 months. Although missing in 89 (20%) participants, only 38 (11%) reported English as the language they most commonly speak at home, and 248 (55%) reported speaking English “not at all” or “not very well” compared to those who spoke “well” or “very well” (Table 1 ). For the item “How confident are you that you can eat a healthy diet?”, 6 (1%) reported being “0% Not at all Confident”, 27 (6%) were “25%” confident, 131 (29%) were “50% Somewhat confident”, 119 (26%) were “75%” confident, and 167 (37%) were “100% Very Confident”. For the item “How confident are you that you can participate in regular exercise or physical activity?” 17 (4%) were “0% Not at all Confident”, 34 (8%) were “25%” confident, 133 (30%) were “50% Somewhat confident”, 116 (26%) were “75%” confident, and 150 (33%) were "100% Very Confident”. Overall, 407 (90%) reported eating fruits or vegetables as snacks either “sometimes”, “often”, or “every day”. Additionally, 277 (62%) reported drinking fruit drinks, punch, or sports drinks, and 273 (61%) reported drinking regular soda either “sometimes”, “often”, or “every day”. There was no significant difference between Hispanic/Latinx and Somali participants in drinking fruit drinks, punch, or sports drinks ( p = 0.4). Hispanic/Latinx participants were more significantly more likely to report drinking regular soda “sometimes”, “often”, or “every day” than Somali participants ( p = < 0.001), and to report eating fruits and vegetables as snacks “every day” ( p = 0.03). Among the 430 participants who completed the IPAQ, 298 (69%) met criteria as “minimally or HEPA active”, the mean total MET minutes per week was 3,913 (range = 0–40,320; SD = 6,491), and the mean sitting minutes per week was 314 (range = 0–1,300; SD = 277). Confidence and Nutrition Participants who reported being more confident in eating a healthy diet were more likely to report eating fruits and vegetables as snacks ( p = < 0.001) (Table 2 ). No participants who were “not at all confident” reported eating fruits or vegetables as snacks, while 60% of those who were “very confident” ate fruits and vegetables every day. Respondents who were more confident in healthy eating were also less likely to report drinking fruit drinks, punch, or sports drinks ( p = 0.018). Only 3% of respondents who were “not at all confident” reported drinking not drinking fruit drinks, punch, or sports drinks, while 44% of those who were “very confident" reported not drinking them. Additionally, participants who reported being more confident in eating healthy were less likely to drink regular soda ( p = < 0.001). Only 1% of respondents who were “not at all confident” reported not drinking regular soda, while 47% of those who were “very confident" reported not drinking them. Confidence to eat healthy was not associated with gender, income, or education in our multivariate analysis. Confidence to eat healthy was only marginally associated with ASA24 (Spearman correlation = 0.14; p = 0.0026) and was not associated with the number of servings of fruits or vegetables. All three confidence associations were statistically significant among Hispanic/Latinx participants ( p = < 0.0001 for eating fruits/vegetables as snacks; p = 0.03 for drinking fruit drinks/punch/sports drinks; p = 0.02 for drinking regular soda). Among Somali participants, the first two variables approached significance ( p = 0.06 for eating fruits/vegetables as snacks; p = 0.06 for drinking fruit drinks/punch/sports drinks) but was significant for drinking regular soda ( p = < 0.0001). Confidence and Physical Activity Level Confidence to participate in regular exercise or physical activity was significantly associated with IPAQ categories ( p = 0.0013). Sixty-three percent of those who were “not at all confident” were classified as “IPAQ: Inactive” compared to only 22% who were “very confident” ( p = 0.001). Among those classified as “Minimally or HEPA Active,” 78% were “very confident” compared to only 38% who were “not at all confident”. Confidence to be physically active also had moderate Spearman correlations with IPAQ walking (Spearman = 0.25; p = < 0.0001), moderate (Spearman = 0.21; p = < 0.0001), vigorous (Spearman = 0.17; p = 0.0004), and total (Spearman = 0.20; p = < 0.0001) MET-Minutes per week. There was no correlation between confidence and mean minutes sitting per week (Spearman = 0.006; p = 0.93). When confidence was treated as a continuous variable instead of categorical, the mean for participants classified as “IPAQ: Inactive” was 63.45 (95% CI = 58.92–67.97) compared to a mean of 73.74 for those who were “IPAQ: Minimally or HEPA Active” (95% CI = 70.97–76.51; p = < 0.0001) (Fig. 1). The association between confidence and IPAQ category was also statistically significant among both Hispanic/Latinx ( p = 0.03) and Somali respondents ( p = 0.02) with those who were “very confident” more likely to be classified as “Minimally or HEPA Active”. Discussion Self-efficacy theory postulates that an individual’s confidence to successfully perform a behavior is predictive of the individual engaging in that behavior. Numerous studies have reported an association between self-efficacy and health behaviors.[ 2 – 8 ] Previous studies with smaller sample sizes reported an association between self-efficacy for healthy eating and dietary self-report, as well as self-efficacy for physical activity and self-reported physical activity among Latina, Somali, and Asian Americans groups.[ 9 – 11 , 13 – 15 ] This analysis extends those findings to a larger population of adult immigrants in the United States. Thus, including strategies for increasing self-efficacy for healthy eating and physical activity in culturally tailored weight management interventions may help improve the effectiveness of these cardiovascular risk reduction programs with immigrant populations. In terms of the nutritional findings, the relationship between self-efficacy and nutritional intake has been well documented.[ 2 , 4 , 6 ] This report extends previous findings to a larger sample of immigrants to the United States. The finding that self-efficacy for physical activity was associated with self-report of physical activity level has also been previously reported.[ 7 – 11 , 28 , 29 ] Given that confidence for being physically active is associated with actual reported physical activity, interventions designed to promote physical activity in immigrant populations should include strategies for increasing self-efficacy for being physically active. When translating theoretical concepts and measures into other languages and assessing their usefulness for clinical interventions with other cultures, it is important to examine not only the association of the translated measures with other validated measures, but also the range of scores on the measures.[ 22 ] For example, if participants are clustered to one response option on an item, it may indicate that the concept may not apply to that understudied population, or that the translation was done poorly. In this project, careful steps were taken to translate the items, and there was a wide range of responses in line with previous findings. This suggests that the concepts were applicable to these populations and the items were successfully translated. This project has several limitations to note. First, nutritional intake was not directly measured or recorded. More direct measurement of nutritional intake would strengthen the project. Physical activity level was also self-reported, and direct measurement of physical activity level would improve the study. Additionally, this is a baseline report, so how these variables may change secondary to participation in a cardiovascular risk reduction intervention has yet to be assessed. Future research should consider examining changes in self-efficacy levels before and after behavioral interventions and their ongoing association over time. In conclusion, in this large sample of immigrants to the United States, self-efficacy for healthy nutrition was associated with consuming health snacks, lower intake of high calorie beverages and drinking less soda. Self-efficacy for physical activity level was also associated with a higher level of self-reported physical activity. Investigators and clinicians should consider incorporating strategies for improving self-efficacy into weight management interventions that are culturally tailored and co-developed with immigrant communities. Declarations Ethics Approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Mayo Clinic Institutional Review Board (October 19, 2021; #21-009339). Consent to Participate: Informed consent was obtained from all individual participants included in this analysis. Competing Interests Author M. Clark declares IP on the Pheno-Diet: Individualized Lifestyle Intervention for Obesity Management Based on Obesity Phenotypes. No other authors have competing interests to declare. Funding: This work was supported by the National Institutes of Health: National Institute on Minority Health and Health Disparities (P50 MD017342), the Mayo Clinic Center for Clinical and Translational Science: National Center for Advancing Translational Science UL1 TR000135, and the Mayo Clinic Office of Health Disparities Research. Author Contribution All authors contributed to the study conception and design. The study was designed and supported by MLW, IGS, MMC, CAP, AML, LSP, KAZ, SOI, and TMR. Statistical analysis was performed by PJN. The first draft of the manuscript was written by BNT, MMC, and MLW, and all authors commented on and approved the final manuscript. Acknowledgements: Not applicable Data Availability The data that support the findings of this study are available from the corresponding author, BNT, upon reasonable request. References Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191–215. Clark MM, et al. Self-efficacy in weight management. J Consult Clin Psychol. 1991;59(5):739–44. Ames GE, et al. Further statistical and clinical validity for the Weight Efficacy Lifestyle Questionnaire-Short Form. Eat Behav. 2015;18:115–9. Cifuentes L, et al. Association between anxiety and eating behaviors in patients with obesity. Obes Pillars. 2022;3:100021. Ames GE, et al. Guiding Patients Toward the Appropriate Surgical Treatment for Obesity: Should Presurgery Psychological Correlates Influence Choice Between Roux-en-Y Gastric Bypass and Vertical Sleeve Gastrectomy? Obes Surg. 2017;27(10):2759–67. Flolo TN, et al. Changes in quality of life 5 years after sleeve gastrectomy: a prospective cohort study. BMJ Open. 2019;9(9):e031170. Wieneke KC, et al. Development and Impact of a Worksite Wellness Champions Program. Am J Health Behav. 2016;40(2):215–20. Clark MM, et al. Stress level, health behaviors, and quality of life in employees joining a wellness center. Am J Health Promot. 2011;26(1):21–5. Benitez TJ et al. Promotion of Muscle-Strengthening Activity Among Latina and Black/African American Women: A Review of Literature. Am J Lifestyle Med, 2024: p. 15598276241246734. von Ash T, et al. Pasos Hacia La Salud II: A Superiority RCT Utilizing Technology to Promote Physical Activity in Latinas. Am J Prev Med. 2024;67(2):220–30. Murray KE, et al. Testing the feasibility and acceptability of a culturally adapted physical activity intervention for adult Somali women. Transl Behav Med. 2021;11(9):1764–70. xx. Wyatt LC, et al. 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Tables Table 1 Participant demographics at baseline Total (n = 450) Age Mean (SD) Range 44.7 (14.3) (18–87) Gender Missing 5 Male 169 (38%) Female 261 (59%) Other 15 (3%) Ethnicity Hispanic or Latinx 267 (59%) Somali 183 (41%) Education Missing 3 Some high school or less 184 (41%) High School graduate or GED 119 (27%) Some college or technical school 85 (19%) 4-year degree or beyond 59 (13%) Income Missing 25 $ 0 to $ 29,999 228 (54%) $ 30,000 to $ 49,999 111 (26%) $ 50,000 or more 86 (20%) Have you had a health insurance plan in the past 12 months? Missing Yes No 5 278 (63%) 167 (37%) What language do you most commonly speak at home? Missing English Somali Spanish Other 89 38 (11%) 121 (34%) 197 (55%) 5 (1%) How well do you speak English? Missing 7 Not at all 92 (21%) Not very well 156 (35%) Well 97 (22%) Very well 98 (22%) Table 2 Associations between confidence to eat healthy and other nutritional endpoints at baseline 0% Not at All Confident (n = 6) 25% (n = 27) 50% Somewhat Confident (n = 131) 75% (n = 119) 100% Very Confident (n = 167) Total (n = 450) p value Do you eat fruits or vegetables as snacks? Missing 0 0 0 4 5 9 < 0.0001* No 0 (0%) 6 (22%) 9 (7%) 9 (8%) 10 (6%) 34 (8%) Yes, sometimes 5 (83%) 18 (67%) 93 (71%) 63 (55%) 80 (49%) 259 (59%) Yes, often 1 (17%) 1 (4%) 17 (13%) 30 (26%) 31 (19%) 80 (18%) Yes, everyday 0 (0%) 2 (7%) 12 (9%) 13 (11%) 41 (25%) 68 (15%) Do you drink fruit drinks, punch, or sports drinks? Missing 0 0 0 4 3 7 0.0179* No 5 (83%) 6 (22%) 38 (29%) 44 (38%) 73 (45%) 166 (38%) Yes, sometimes 0 (0%) 16 (59%) 79 (60%) 61 (53%) 70 (43%) 226 (51%) Yes, often 0 (0%) 3 (11%) 11 (8%) 7 (6%) 15 (9%) 36 (8%) Yes, everyday 1 (17%) 2 (7%) 3 (2%) 3 (3%) 6 (4%) 15 (3%) Do you drink regular soda? Missing 0 1 1 1 0 3 < 0.0001* No 2 (33.%) 1 (4%) 39 (30%) 50 (42%) 82 (49%) 174 (39%) Yes, sometimes 1 (17%) 16 (62%) 63 (49%) 53 (45%) 71 (43%) 204 (46%) Yes, often 2 (33%) 4 (15%) 21 (16%) 12 (10%) 10 (6%) 49 (11%) Yes, everyday 1 (17%) 5 (19%) 7 (5%) 3 (3%) 4 (2%) 20 (5%) *Kruskal-Wallis test Additional Declarations Competing interest reported. Author M. Clark declares IP on the Pheno-Diet: Individualized Lifestyle Intervention for Obesity Management Based on Obesity Phenotypes. No other authors have competing interests to declare. Cite Share Download PDF Status: Published Journal Publication published 11 Dec, 2025 Read the published version in Journal of Immigrant and Minority Health → Version 1 posted Editorial decision: Revision requested 30 Jul, 2025 Reviews received at journal 26 Jul, 2025 Reviewers agreed at journal 26 Jul, 2025 Reviews received at journal 25 May, 2025 Reviewers agreed at journal 15 May, 2025 Reviewers invited by journal 04 Apr, 2025 Editor assigned by journal 12 Feb, 2025 Submission checks completed at journal 12 Feb, 2025 First submitted to journal 10 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Pardo","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"Suarez","lastName":"Pardo","suffix":""},{"id":414727347,"identity":"ae71fd2b-d8f1-4f3a-9634-acbf53e98fac","order_by":6,"name":"Christi Patten","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Christi","middleName":"","lastName":"Patten","suffix":""},{"id":414727348,"identity":"11a4e0b7-cdad-4d67-94b2-4c30cce126f0","order_by":7,"name":"Sheila Iteghete","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Sheila","middleName":"","lastName":"Iteghete","suffix":""},{"id":414727349,"identity":"58c18295-ad5f-4833-984b-5769f7cf4aaf","order_by":8,"name":"Katherine Zeratsky","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Zeratsky","suffix":""},{"id":414727350,"identity":"ba505c05-4e53-4372-9194-67a00c47e3cc","order_by":9,"name":"Thomas Rieck","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Rieck","suffix":""},{"id":414727351,"identity":"d283d4e2-c1f4-4a7c-ab5b-e61892fb21a8","order_by":10,"name":"Luz Molina","email":"","orcid":"","institution":"Rochester Healthy Community Partnership","correspondingAuthor":false,"prefix":"","firstName":"Luz","middleName":"","lastName":"Molina","suffix":""},{"id":414727352,"identity":"04e32da9-66aa-4beb-b79b-c5df54012266","order_by":11,"name":"Graciela Porraz Capetillo","email":"","orcid":"","institution":"Rochester Healthy Community Partnership","correspondingAuthor":false,"prefix":"","firstName":"Graciela","middleName":"Porraz","lastName":"Capetillo","suffix":""},{"id":414727353,"identity":"05d0acff-242d-4456-93f8-82934b551d5a","order_by":12,"name":"Yahye Ahmed","email":"","orcid":"","institution":"Rochester Healthy Community Partnership","correspondingAuthor":false,"prefix":"","firstName":"Yahye","middleName":"","lastName":"Ahmed","suffix":""},{"id":414727354,"identity":"82981af5-91d6-4089-bae6-7e169a26810c","order_by":13,"name":"Hana Dirie","email":"","orcid":"","institution":"Rochester Healthy Community Partnership","correspondingAuthor":false,"prefix":"","firstName":"Hana","middleName":"","lastName":"Dirie","suffix":""},{"id":414727355,"identity":"130ac411-6dc5-46cb-a22b-3e0019a52862","order_by":14,"name":"Mark Wieland","email":"","orcid":"","institution":"Mayo Clinic","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"","lastName":"Wieland","suffix":""}],"badges":[],"createdAt":"2025-02-10 18:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6001516/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6001516/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10903-025-01812-9","type":"published","date":"2025-12-11T15:59:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":76660907,"identity":"9e25f035-ef90-46d1-b6c0-6766cf36bc83","added_by":"auto","created_at":"2025-02-19 12:02:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63492,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociation between confidence to participate in regular exercise or physical activity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLegend: Mean and 95% confidence intervals based on t-test treating confidence as a continuous variable. LL=Lower Limit (95% confidence limit) for mean; UL=Upper Limit (95% confidence limit) for mean.\u003c/p\u003e","description":"","filename":"Fig1IPAQ.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6001516/v1/90161cedfa508bb5909336dc.jpg"},{"id":98244052,"identity":"2795d843-0052-4e8b-b2af-a5ba953e8bcb","added_by":"auto","created_at":"2025-12-15 16:12:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1075422,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6001516/v1/fa247847-650c-4e72-b610-2a24ca4e89ca.pdf"}],"financialInterests":"Competing interest reported. Author M. Clark declares IP on the Pheno-Diet: Individualized Lifestyle Intervention for Obesity Management Based on Obesity Phenotypes. No other authors have competing interests to declare.","formattedTitle":"Self-Efficacy is Associated with Health Behaviors Related to Obesity and Cardiovascular Risk among Hispanic/Latinx and Somali Immigrants to the United States","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIdentifying mediating mechanisms that facilitate an individual\u0026rsquo;s ability to improve their health behaviors can be useful in designing and delivering health behavior interventions. One possible mediating mechanism that is a component of social cognitive theory is self-efficacy, which theorizes that an individual\u0026rsquo;s confidence to engage in a behavior is predictive of the individual engaging in that specific behavior.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Self-efficacy for eating has been shown to improve after participation in behavioral weight management programs,[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and in a sample of 1,740 patients seeking bariatric surgery, lower eating self-efficacy was associated with higher rates of binge eating episodes, food addiction scores, night eating syndrome, and negative mood.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWhile low self-efficacy for eating is associated with higher levels of anxiety[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and lower rates of having bariatric surgery,[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] improvements in self-efficacy after weight loss surgery are predictive of long-term weight loss maintenance.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] In a sample of 676 worksite \u0026ldquo;wellness champions,\u0026rdquo; high stress level was associated with low self-efficacy for following a healthy diet over a five-year period.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] In a sample of over 13,000 members of a wellness center, high stress was associated with low-self efficacy for being physically active.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHow self-efficacy theory and measures apply to immigrant populations is a growing area of investigation. A recent literature review called for more research that examines psychosocial factors that impact physical activity level in Black and Latina individuals.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] A physical activity intervention based on social cognitive theory demonstrated effectiveness in a sample of Spanish-speaking Latinas,[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] as did a physical activity pilot project with Somali women.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Our team previously reported that negative mood was associated with lower confidence for eating healthy among 449 Hispanic and Somali immigrants, but found no association between negative mood and confidence to be physically active.[xx] A review of four community health worker-led interventions with Asian immigrants found that self-efficacy and physical activity improved significantly among participants in the treatment groups.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] A combined analysis of 176 Latina adults who participated in one of two exercise interventions found higher self-efficacy two months into the program was associated with less relapse.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Additionally, food insecurity was also found to be associated with low self-efficacy and heritage language proficiency among immigrants to the United States.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e The current study is embedded within the Healthy Immigrant Community (HIC) study, which is a cluster randomized trial to assess the effectiveness of a social network-informed, community-based participatory research (CBPR) derived health promotion intervention on measures of obesity and cardiovascular risk among Hispanic and Somali immigrant populations.[xx] HIC is a product of [city] Healthy Community Partnership (RHCP), which is a 20-year CBPR partnership in southeast [state] that collaborates with immigrant and refugee populations to co-create interventions that promote health equity for community health priorities.[xx] RHCP is productive and experienced at using a CBPR approach to co-develop and test community-based interventions to reduce the accumulation of cardiovascular risk after immigration.[xx]\u003c/p\u003e \u003cp\u003eThis study is a cross-sectional analysis of baseline data from the RHCP HIC study. Our hypothesis was that the association between self-efficacy and healthy eating and physical activity behaviors previously described among predominantly white, affluent study populations[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] would also be found among immigrant communities in the United States.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting and Participants\u003c/h2\u003e \u003cp\u003e The [institution name] Institutional Review Board approved the HIC study (NCT0513633) in 2021. All participants provided written informed consent. The study setting and participants were described in previous papers.[xx, xx] Briefly, HIC is set is Olmsted County in southeastern [state] (2021 estimated population: 163,436).[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] Approximately 11% of the population were born outside of the US, of which 55% have become US citizens,[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and 14% of people living in the county speak a language other than English at home.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe study utilized baseline data from the RHCP HIC study. Through this CBPR-informed study, 52 members of the immigrant communities, identified by RHCP community partners, were trained as health promoters (HP) and delivered the 12-month intervention to 472 participants in their existing social networks either immediately following baseline measures or after a one-year delay (delayed-intervention control group). Baseline data was collected in June-August 2022\u003c/p\u003e \u003cp\u003eHIC inclusion criteria included age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, self-reported Hispanic/Latinx or Somali ethnicity, being a member of a HP\u0026rsquo;s social network, and being willing to participate in all study procedures. Participants were excluded if they were pregnant at the time of enrollment or had a medical condition or disability that prevented them from being more physically active. Baseline measures obtained by study staff and community volunteers included: 1) biometric measurements such as height, weight, blood pressure, glucose; 2) survey measures assessing dietary quality and intake, physical activity, and quality of life; and 3) demographics. Assessments were carefully translated and available in English, Spanish, or Somali.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePrimary Outcome Measures\u003c/h3\u003e\n\u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eSelf-Efficacy\u003c/span\u003e: As previously described, participants completed the adapted Patient Centered Assessment and Counseling for Exercise plus Nutrition (PACE+) survey at baseline.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] Two items assessed self-efficacy: \u0026ldquo;How confident are you that you can eat a healthy diet?\u0026rdquo; and \u0026ldquo;How confident are you that you can participate in regular exercise or physical activity?\u0026rdquo; Both items were rated as a percentage interval (0%=not at all confident; 25%; 50%=somewhat confident; 75%; 100%=very confident).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eNutritional Behaviors\u003c/span\u003e: The Food Behavior Checklist, which is validated for use among diverse communities, was used to assess dietary quality and intake.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] Questions included in this analysis were: \u0026ldquo;Do you eat fruits or vegetables as snacks?\u0026rdquo;, \u0026ldquo;Do you drink fruit drinks, punch, or sports drinks?, and \u0026ldquo;Do you drink regular soda?\u0026rdquo;. The items were rated on a 4-point Likert scale (no; yes, sometimes; yes, often; yes, everyday), but \u0026ldquo;often\u0026rdquo; and \u0026ldquo;everyday\u0026rdquo; were combined on analysis to produce three variables (no; sometimes; often).\u003c/p\u003e \u003cp\u003eParticipants also completed the Automated Self-Administered 24-hour (ASA24\u0026reg;) Dietary Assessment Tool[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] on a computer with assistance from study staff and an interpreter if needed. The Healthy Eating Index (HEI) is a score produced by the ASA24\u0026reg; based on 10 recommended dietary components including high intake of fruit, vegetables, protein, dairy, whole grains, and low intake of fats, cholesterol, and sodium. Each component is weighted with a possible score from 0\u0026ndash;10 with a maximum overall score out of 100; higher scores indicate healthier diets.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePhysical Activity\u003c/strong\u003e \u003cp\u003eThe International Physical Activity Questionnaire (IPAQ) short form was used to measure physical activity levels in the baseline survey.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Physical activity was defined as \u0026ldquo;any activity that increases your heart rate and makes you breathe harder some of the time\u0026rdquo; including at work, house and yard work, and sports or exercise. \u0026ldquo;Vigorous\u0026rdquo; activity was defined as one that \u0026ldquo;takes much more physical effort and makes you breathe a lot harder than normal\u0026rdquo; like \u0026ldquo;heavy lifting, digging, aerobics, or fast bicycling.\u0026rdquo; \u0026ldquo;Moderate\u0026rdquo; activity was one that \u0026ldquo;takes somewhat more physical effort and makes you breathe a little harder than normal\u0026rdquo; like \u0026ldquo;carrying light loads or bicycling at a regular pace.\u0026rdquo; Participants were instructed to not include walking as \u0026ldquo;moderate\u0026rdquo; physical activity.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eParticipants reported separately the total number of days out of the last seven days that they did \u0026ldquo;vigorous\u0026rdquo; and \u0026ldquo;moderate\u0026rdquo; activities for at least 10 minutes at a time. They also answered the question \u0026ldquo;On the days you did do [vigorous or moderate] physical activity, how many minutes total did you usually spend on one of those days?\u0026rdquo; Participants reported how many days out of the last seven days that they walked for at least 10 minutes at a time, including \u0026ldquo;all types of walking at work and at home\u0026rdquo; and the total minutes they usually spent walking on one of those days. Lastly, participants were asked about time spent sitting \u0026ldquo;on weekdays while at work, at home, or any other place.\u0026rdquo; The total time usually spent sitting on a weekday during the last seven days was reported in hours and minutes.\u003c/p\u003e \u003cp\u003eThe recommended scoring criteria for the IPAQ contains three categories: Inactive, Minimally Active, and Health-Enhancing Physical Activity (HEPA) Active. The \u0026ldquo;minimally active\u0026rdquo; category is defined as \u0026ldquo;\u0026ge;3 days of vigorous activity at least 20 minutes/day, \u0026ge;\u0026thinsp;5 days of moderate-intensity activity or walking at least 30 minutes/day, or \u0026ge;\u0026thinsp;5 days of activity achieving a minimum of least 600 MET-min (multiples of the resting metabolic rate)/week.\u0026rdquo; As in our previous analysis,[xx] the \u0026ldquo;minimally active\u0026rdquo; and \u0026ldquo;HEPA active\u0026rdquo; categories were combined because the criterion for both exceed public health recommendations for physical activity; thus, two variables were analyzed (active, inactive).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eKruskal-Wallis tests were used to analyze continuous variables by categorical variables such as race, confidence levels, and IPAQ categories. Analyses were two-sided using 5% type I error rates. Associations between continuous variables were assessed using Spearman correlation coefficients and a t-test was performed for Fig.\u0026nbsp;1. Analyses were performed using SAS version 15.1 (SAS Institute Inc. Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 450 participants who identified as Hispanic/Latinx (n\u0026thinsp;=\u0026thinsp;267, 59%) or Somali (n\u0026thinsp;=\u0026thinsp;183, 41%) and completed baseline measures were included in this analysis. Of the 450 participants, 261 (59%) were female, the mean age was 45 years (range\u0026thinsp;=\u0026thinsp;18\u0026ndash;87; SD\u0026thinsp;=\u0026thinsp;14.3), and 167 (37%) had no health insurance plan in the past 12 months. Although missing in 89 (20%) participants, only 38 (11%) reported English as the language they most commonly speak at home, and 248 (55%) reported speaking English \u0026ldquo;not at all\u0026rdquo; or \u0026ldquo;not very well\u0026rdquo; compared to those who spoke \u0026ldquo;well\u0026rdquo; or \u0026ldquo;very well\u0026rdquo; (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFor the item \u0026ldquo;How confident are you that you can eat a healthy diet?\u0026rdquo;, 6 (1%) reported being \u0026ldquo;0% Not at all Confident\u0026rdquo;, 27 (6%) were \u0026ldquo;25%\u0026rdquo; confident, 131 (29%) were \u0026ldquo;50% Somewhat confident\u0026rdquo;, 119 (26%) were \u0026ldquo;75%\u0026rdquo; confident, and 167 (37%) were \u0026ldquo;100% Very Confident\u0026rdquo;. For the item \u0026ldquo;How confident are you that you can participate in regular exercise or physical activity?\u0026rdquo; 17 (4%) were \u0026ldquo;0% Not at all Confident\u0026rdquo;, 34 (8%) were \u0026ldquo;25%\u0026rdquo; confident, 133 (30%) were \u0026ldquo;50% Somewhat confident\u0026rdquo;, 116 (26%) were \u0026ldquo;75%\u0026rdquo; confident, and 150 (33%) were \"100% Very Confident\u0026rdquo;.\u003c/p\u003e \u003cp\u003eOverall, 407 (90%) reported eating fruits or vegetables as snacks either \u0026ldquo;sometimes\u0026rdquo;, \u0026ldquo;often\u0026rdquo;, or \u0026ldquo;every day\u0026rdquo;. Additionally, 277 (62%) reported drinking fruit drinks, punch, or sports drinks, and 273 (61%) reported drinking regular soda either \u0026ldquo;sometimes\u0026rdquo;, \u0026ldquo;often\u0026rdquo;, or \u0026ldquo;every day\u0026rdquo;. There was no significant difference between Hispanic/Latinx and Somali participants in drinking fruit drinks, punch, or sports drinks (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.4). Hispanic/Latinx participants were more significantly more likely to report drinking regular soda \u0026ldquo;sometimes\u0026rdquo;, \u0026ldquo;often\u0026rdquo;, or \u0026ldquo;every day\u0026rdquo; than Somali participants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and to report eating fruits and vegetables as snacks \u0026ldquo;every day\u0026rdquo; (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e \u003cp\u003eAmong the 430 participants who completed the IPAQ, 298 (69%) met criteria as \u0026ldquo;minimally or HEPA active\u0026rdquo;, the mean total MET minutes per week was 3,913 (range\u0026thinsp;=\u0026thinsp;0\u0026ndash;40,320; SD\u0026thinsp;=\u0026thinsp;6,491), and the mean sitting minutes per week was 314 (range\u0026thinsp;=\u0026thinsp;0\u0026ndash;1,300; SD\u0026thinsp;=\u0026thinsp;277).\u003c/p\u003e\n\u003ch3\u003eConfidence and Nutrition\u003c/h3\u003e\n\u003cp\u003eParticipants who reported being more confident in eating a healthy diet were more likely to report eating fruits and vegetables as snacks (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No participants who were \u0026ldquo;not at all confident\u0026rdquo; reported eating fruits or vegetables as snacks, while 60% of those who were \u0026ldquo;very confident\u0026rdquo; ate fruits and vegetables every day.\u003c/p\u003e \u003cp\u003eRespondents who were more confident in healthy eating were also less likely to report drinking fruit drinks, punch, or sports drinks (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018). Only 3% of respondents who were \u0026ldquo;not at all confident\u0026rdquo; reported drinking not drinking fruit drinks, punch, or sports drinks, while 44% of those who were \u0026ldquo;very confident\" reported not drinking them.\u003c/p\u003e \u003cp\u003eAdditionally, participants who reported being more confident in eating healthy were less likely to drink regular soda (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Only 1% of respondents who were \u0026ldquo;not at all confident\u0026rdquo; reported not drinking regular soda, while 47% of those who were \u0026ldquo;very confident\" reported not drinking them.\u003c/p\u003e \u003cp\u003eConfidence to eat healthy was not associated with gender, income, or education in our multivariate analysis. Confidence to eat healthy was only marginally associated with ASA24 (Spearman correlation\u0026thinsp;=\u0026thinsp;0.14; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0026) and was not associated with the number of servings of fruits or vegetables. All three confidence associations were statistically significant among Hispanic/Latinx participants (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 for eating fruits/vegetables as snacks; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03 for drinking fruit drinks/punch/sports drinks; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02 for drinking regular soda). Among Somali participants, the first two variables approached significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.06 for eating fruits/vegetables as snacks; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.06 for drinking fruit drinks/punch/sports drinks) but was significant for drinking regular soda (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eConfidence and Physical Activity Level\u003c/h2\u003e \u003cp\u003eConfidence to participate in regular exercise or physical activity was significantly associated with IPAQ categories (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0013). Sixty-three percent of those who were \u0026ldquo;not at all confident\u0026rdquo; were classified as \u0026ldquo;IPAQ: Inactive\u0026rdquo; compared to only 22% who were \u0026ldquo;very confident\u0026rdquo; (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Among those classified as \u0026ldquo;Minimally or HEPA Active,\u0026rdquo; 78% were \u0026ldquo;very confident\u0026rdquo; compared to only 38% who were \u0026ldquo;not at all confident\u0026rdquo;. Confidence to be physically active also had moderate Spearman correlations with IPAQ walking (Spearman\u0026thinsp;=\u0026thinsp;0.25; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), moderate (Spearman\u0026thinsp;=\u0026thinsp;0.21; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), vigorous (Spearman\u0026thinsp;=\u0026thinsp;0.17; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0004), and total (Spearman\u0026thinsp;=\u0026thinsp;0.20; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) MET-Minutes per week. There was no correlation between confidence and mean minutes sitting per week (Spearman\u0026thinsp;=\u0026thinsp;0.006; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.93).\u003c/p\u003e \u003cp\u003eWhen confidence was treated as a continuous variable instead of categorical, the mean for participants classified as \u0026ldquo;IPAQ: Inactive\u0026rdquo; was 63.45 (95% CI\u0026thinsp;=\u0026thinsp;58.92\u0026ndash;67.97) compared to a mean of 73.74 for those who were \u0026ldquo;IPAQ: Minimally or HEPA Active\u0026rdquo; (95% CI\u0026thinsp;=\u0026thinsp;70.97\u0026ndash;76.51; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (Fig.\u0026nbsp;1). The association between confidence and IPAQ category was also statistically significant among both Hispanic/Latinx (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03) and Somali respondents (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02) with those who were \u0026ldquo;very confident\u0026rdquo; more likely to be classified as \u0026ldquo;Minimally or HEPA Active\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSelf-efficacy theory postulates that an individual\u0026rsquo;s confidence to successfully perform a behavior is predictive of the individual engaging in that behavior. Numerous studies have reported an association between self-efficacy and health behaviors.[\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Previous studies with smaller sample sizes reported an association between self-efficacy for healthy eating and dietary self-report, as well as self-efficacy for physical activity and self-reported physical activity among Latina, Somali, and Asian Americans groups.[\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] This analysis extends those findings to a larger population of adult immigrants in the United States. Thus, including strategies for increasing self-efficacy for healthy eating and physical activity in culturally tailored weight management interventions may help improve the effectiveness of these cardiovascular risk reduction programs with immigrant populations.\u003c/p\u003e \u003cp\u003eIn terms of the nutritional findings, the relationship between self-efficacy and nutritional intake has been well documented.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] This report extends previous findings to a larger sample of immigrants to the United States. The finding that self-efficacy for physical activity was associated with self-report of physical activity level has also been previously reported.[\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Given that confidence for being physically active is associated with actual reported physical activity, interventions designed to promote physical activity in immigrant populations should include strategies for increasing self-efficacy for being physically active.\u003c/p\u003e \u003cp\u003eWhen translating theoretical concepts and measures into other languages and assessing their usefulness for clinical interventions with other cultures, it is important to examine not only the association of the translated measures with other validated measures, but also the range of scores on the measures.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] For example, if participants are clustered to one response option on an item, it may indicate that the concept may not apply to that understudied population, or that the translation was done poorly. In this project, careful steps were taken to translate the items, and there was a wide range of responses in line with previous findings. This suggests that the concepts were applicable to these populations and the items were successfully translated.\u003c/p\u003e \u003cp\u003eThis project has several limitations to note. First, nutritional intake was not directly measured or recorded. More direct measurement of nutritional intake would strengthen the project. Physical activity level was also self-reported, and direct measurement of physical activity level would improve the study. Additionally, this is a baseline report, so how these variables may change secondary to participation in a cardiovascular risk reduction intervention has yet to be assessed. Future research should consider examining changes in self-efficacy levels before and after behavioral interventions and their ongoing association over time.\u003c/p\u003e \u003cp\u003eIn conclusion, in this large sample of immigrants to the United States, self-efficacy for healthy nutrition was associated with consuming health snacks, lower intake of high calorie beverages and drinking less soda. Self-efficacy for physical activity level was also associated with a higher level of self-reported physical activity. Investigators and clinicians should consider incorporating strategies for improving self-efficacy into weight management interventions that are culturally tailored and co-developed with immigrant communities.\u003c/p\u003e "},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics Approval:\u003c/strong\u003e \u003cp\u003e This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Mayo Clinic Institutional Review Board (October 19, 2021; #21-009339).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to Participate:\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all individual participants included in this analysis.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eAuthor M. Clark declares IP on the Pheno-Diet: Individualized Lifestyle Intervention for Obesity Management Based on Obesity Phenotypes. No other authors have competing interests to declare.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was supported by the National Institutes of Health: National Institute on Minority Health and Health Disparities (P50 MD017342), the Mayo Clinic Center for Clinical and Translational Science: National Center for Advancing Translational Science UL1 TR000135, and the Mayo Clinic Office of Health Disparities Research.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. The study was designed and supported by MLW, IGS, MMC, CAP, AML, LSP, KAZ, SOI, and TMR. Statistical analysis was performed by PJN. The first draft of the manuscript was written by BNT, MMC, and MLW, and all authors commented on and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are available from the corresponding author, BNT, upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84(2):191\u0026ndash;215.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark MM, et al. Self-efficacy in weight management. J Consult Clin Psychol. 1991;59(5):739\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmes GE, et al. Further statistical and clinical validity for the Weight Efficacy Lifestyle Questionnaire-Short Form. Eat Behav. 2015;18:115\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCifuentes L, et al. Association between anxiety and eating behaviors in patients with obesity. Obes Pillars. 2022;3:100021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmes GE, et al. Guiding Patients Toward the Appropriate Surgical Treatment for Obesity: Should Presurgery Psychological Correlates Influence Choice Between Roux-en-Y Gastric Bypass and Vertical Sleeve Gastrectomy? Obes Surg. 2017;27(10):2759\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlolo TN, et al. Changes in quality of life 5 years after sleeve gastrectomy: a prospective cohort study. BMJ Open. 2019;9(9):e031170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWieneke KC, et al. Development and Impact of a Worksite Wellness Champions Program. Am J Health Behav. 2016;40(2):215\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark MM, et al. Stress level, health behaviors, and quality of life in employees joining a wellness center. Am J Health Promot. 2011;26(1):21\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenitez TJ et al. Promotion of Muscle-Strengthening Activity Among Latina and Black/African American Women: A Review of Literature. Am J Lifestyle Med, 2024: p. 15598276241246734.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evon Ash T, et al. Pasos Hacia La Salud II: A Superiority RCT Utilizing Technology to Promote Physical Activity in Latinas. Am J Prev Med. 2024;67(2):220\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMurray KE, et al. Testing the feasibility and acceptability of a culturally adapted physical activity intervention for adult Somali women. 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Popul Health Manag. 2017;20(1):66\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003exx.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003exx.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003exx.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSallis JF, et al. The development of self-efficacy scales for healthrelated diet and exercise behaviors. Health Educ Res. 1988;3(3):283\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlmsted County Policy, Analysis and Communications. Olmsted County Community Indicators 2022. 2023 June 15, 2024]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.olmstedcounty.gov/sites/default/files/2023-01/OC%20Community%20Indicators%202022%20Report.pdf\u003c/span\u003e\u003cspan address=\"https://www.olmstedcounty.gov/sites/default/files/2023-01/OC%20Community%20Indicators%202022%20Report.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUS Census Bureau. \u003cem\u003eOlmsted County, Minnesota\u003c/em\u003e. Aug 1, 2024]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.census.gov/profile/Olmsted_County,_Mi\u0026hellip;\u003c/span\u003e\u003cspan address=\"https://data.census.gov/profile/Olmsted_County,_Mi\u0026hellip;\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e g=050XX00US27109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFormea CM, et al. Lessons learned: cultural and linguistic enhancement of surveys through community-based participatory research. Prog Community Health Partnersh. 2014;8(3):331\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalfas KJ, et al. Mediators of change in physical activity following an intervention in primary care: PACE. Prev Med. 1997;26(3):297\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTownsend MS, et al. Selecting items for a food behavior checklist for a limited-resource audience. J Nutr Educ Behav. 2003;35(2):69\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdeyemi-Benson OS et al. Differences in Nutrient Intake and Diet Quality among Non-Hispanic Black Adults by Place of Birth and Length of Time in the United States. Nutrients, 2023. 15(16).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Cancer Institute, Division of Cancer Control and Population Sciences. Automated Self-Administered 24-Hour (ASA24\u0026reg;) Dietary Assessment Tool. 2010 June 15, 2023; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://epi.grants.cancer.gov/asa24/\u003c/span\u003e\u003cspan address=\"https://epi.grants.cancer.gov/asa24/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIPAQ Research Committee. \u003cem\u003eGuidelines for Data Processing and Analysis of the International Physical Activity Questionnaire (IPAQ): Short and Long Forms\u003c/em\u003e 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagliardi AR, Morrison C, Anderson NN. The design and impact of culturally-safe community-based physical activity promotion for immigrant women: descriptive review. BMC Public Health. 2022;22(1):430.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim J, et al. Relationship of perceived environmental characteristics to self-efficacy and leisure time physical activity among Asian immigrants in the U. S Health Promot Perspect. 2020;10(4):366\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant demographics at baseline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal \u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;450)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMean\u0026nbsp;(SD)\u003c/p\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.7\u0026nbsp;(14.3)\u003c/p\u003e \u003cp\u003e(18\u0026ndash;87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e169\u0026nbsp;(38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e261\u0026nbsp;(59%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u0026nbsp;(3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHispanic\u0026nbsp;or\u0026nbsp;Latinx\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e267\u0026nbsp;(59%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSomali\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e183\u0026nbsp;(41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSome\u0026nbsp;high\u0026nbsp;school\u0026nbsp;or\u0026nbsp;less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e184\u0026nbsp;(41%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHigh\u0026nbsp;School\u0026nbsp;graduate\u0026nbsp;or\u0026nbsp;GED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e119\u0026nbsp;(27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSome\u0026nbsp;college\u0026nbsp;or\u0026nbsp;technical\u0026nbsp;school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u0026nbsp;(19%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e4-year\u0026nbsp;degree\u0026nbsp;or\u0026nbsp;beyond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59\u0026nbsp;(13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e0\u0026nbsp;to\u0026nbsp;\u003cspan\u003e$\u003c/span\u003e29,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e228\u0026nbsp;(54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e30,000\u0026nbsp;to\u0026nbsp;\u003cspan\u003e$\u003c/span\u003e49,999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e111\u0026nbsp;(26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan\u003e$\u003c/span\u003e50,000\u0026nbsp;or\u0026nbsp;more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86\u0026nbsp;(20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHave you had a health insurance plan in the past 12 months?\u003c/p\u003e \u003cp\u003eMissing\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e278 (63%)\u003c/p\u003e \u003cp\u003e167 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat language do you most commonly speak at home?\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMissing\u003c/p\u003e \u003cp\u003eEnglish\u003c/p\u003e \u003cp\u003eSomali\u003c/p\u003e \u003cp\u003eSpanish\u003c/p\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003cp\u003e38 (11%)\u003c/p\u003e \u003cp\u003e121 (34%)\u003c/p\u003e \u003cp\u003e197 (55%)\u003c/p\u003e \u003cp\u003e5 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHow\u0026nbsp;well\u0026nbsp;do\u0026nbsp;you\u0026nbsp;speak\u0026nbsp;English?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNot\u0026nbsp;at\u0026nbsp;all\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e92\u0026nbsp;(21%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNot\u0026nbsp;very\u0026nbsp;well\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e156\u0026nbsp;(35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97\u0026nbsp;(22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVery\u0026nbsp;well\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e98\u0026nbsp;(22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations between confidence to eat healthy and other nutritional endpoints at baseline\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u0026nbsp;Not\u0026nbsp;at\u0026nbsp;All\u0026nbsp; Confident\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25%\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50%\u0026nbsp;Somewhat\u0026nbsp; Confident\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;131)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;119)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e100%\u0026nbsp;Very\u0026nbsp; Confident\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;167)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;450)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo\u0026nbsp;you\u0026nbsp;eat\u0026nbsp;fruits\u0026nbsp;or vegetables as snacks?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34\u003c/p\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;sometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003cp\u003e(67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93\u003c/p\u003e \u003cp\u003e(71%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63\u003c/p\u003e \u003cp\u003e(55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80\u003c/p\u003e \u003cp\u003e(49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e259\u003c/p\u003e \u003cp\u003e(59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e(13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003cp\u003e(19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e80\u003c/p\u003e \u003cp\u003e(18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;everyday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41\u003c/p\u003e \u003cp\u003e(25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68\u003c/p\u003e \u003cp\u003e(15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo\u0026nbsp;you\u0026nbsp;drink\u0026nbsp;fruit\u0026nbsp; drinks, punch, or sports drinks?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.0179*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(83%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003cp\u003e(29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44\u003c/p\u003e \u003cp\u003e(38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73\u003c/p\u003e \u003cp\u003e(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e166\u003c/p\u003e \u003cp\u003e(38%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;sometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(59%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79\u003c/p\u003e \u003cp\u003e(60%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e61\u003c/p\u003e \u003cp\u003e(53%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e70\u003c/p\u003e \u003cp\u003e(43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e226\u003c/p\u003e \u003cp\u003e(51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e(9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003cp\u003e(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;everyday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo\u0026nbsp;you\u0026nbsp;drink\u0026nbsp;regular soda?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(33.%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39\u003c/p\u003e \u003cp\u003e(30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003cp\u003e(42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e82\u003c/p\u003e \u003cp\u003e(49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e174\u003c/p\u003e \u003cp\u003e(39%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;sometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(62%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e63\u003c/p\u003e \u003cp\u003e(49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53\u003c/p\u003e \u003cp\u003e(45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71\u003c/p\u003e \u003cp\u003e(43%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e204\u003c/p\u003e \u003cp\u003e(46%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;often\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(33%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e(16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e(10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e(6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e49\u003c/p\u003e \u003cp\u003e(11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes,\u0026nbsp;everyday\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(17%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e(5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*Kruskal-Wallis test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Health behaviors, healthy eating, physical activity, immigrant communities, cardiovascular risk, self-efficacy","lastPublishedDoi":"10.21203/rs.3.rs-6001516/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6001516/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eSelf-efficacy theory proposes that confidence to engage in a health behavior is associated with engaging in that specific behavior. Most research examining self-efficacy has been conducted with white young adult populations. This secondary analysis examined the association of self-efficacy (i.e., confidence) for healthy eating and physical activity in two immigrant communities.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eAt enrollment into the Healthy Immigrant Community study, a clinical weight management and cardiovascular risk reduction intervention set in southeastern [state], 475 participants completed assessments about their confidence for healthy eating and physical activity. Measurements also included self-reports of dietary quality and intake, physical activity, quality of life, and biometric assessments. Study materials were available in English, Spanish, and Somali.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 450 adults (Hispanic/Latinx\u0026thinsp;=\u0026thinsp;267; Somali\u0026thinsp;=\u0026thinsp;183) completed measures at baseline and were included for analysis. Their average age was 45 years (range 18\u0026ndash;87) and 59% were female. Confidence for healthy eating was significantly associated with self-report of eating healthy snacks (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and less consumption of high-calorie drinks (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02) and regular soda (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Confidence to be physically active was significantly associated with more self-reported physical activity (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eConfidence to eat healthy and be physically active appears to be associated with having a healthier diet and higher levels of physical activity. Given the large sample size and strength of the associations, it also appears that the theoretical model of self-efficacy can be effectively measured and applied within these immigrant populations. Self-efficacy theory may be useful in understanding potential mediating mechanisms when designing future interventions with immigrant communities.\u003c/p\u003e\u003ch2\u003eClinicalTrials.gov registration:\u003c/h2\u003e \u003cp\u003eNCT05136339; April 23, 2022\u003c/p\u003e","manuscriptTitle":"Self-Efficacy is Associated with Health Behaviors Related to Obesity and Cardiovascular Risk among Hispanic/Latinx and Somali Immigrants to the United States","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-19 12:02:32","doi":"10.21203/rs.3.rs-6001516/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-30T19:09:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-26T16:48:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205445121679885653425283594671550462182","date":"2025-07-26T15:54:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-25T16:45:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339421652770076396292527419654345525293","date":"2025-05-16T01:23:37+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-04T15:59:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-12T11:11:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-12T11:11:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2025-02-10T18:27:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5894c548-e06c-4ddc-866c-78094644b5ca","owner":[],"postedDate":"February 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:05:37+00:00","versionOfRecord":{"articleIdentity":"rs-6001516","link":"https://doi.org/10.1007/s10903-025-01812-9","journal":{"identity":"journal-of-immigrant-and-minority-health","isVorOnly":false,"title":"Journal of Immigrant and Minority Health"},"publishedOn":"2025-12-11 15:59:28","publishedOnDateReadable":"December 11th, 2025"},"versionCreatedAt":"2025-02-19 12:02:32","video":"","vorDoi":"10.1007/s10903-025-01812-9","vorDoiUrl":"https://doi.org/10.1007/s10903-025-01812-9","workflowStages":[]},"version":"v1","identity":"rs-6001516","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6001516","identity":"rs-6001516","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}