Goal setting for health behavior change: evidence from an obesity intervention for rural low-income women.

INTRODUCTION
Rural, minority populations are disproportionately affected by overweight and obesity and may benefit from lifestyle modification programs that are tailored to meet their unique needs. Obesity interventions commonly use goal setting as a behavior change strategy; however, few have investigated the specific contribution of goal setting to behavior change and/or identified the mechanisms by which goal setting may have an impact on behavior change. Furthermore, studies have not examined goal setting processes among racial/ethnic minorities. Using data from an obesity intervention for predominately minority women in rural North Carolina, this study sought to examine whether intervention participation resulted in working on goals and using goal setting strategies which in turn affected health behavior outcomes. It also examined racial/ethnic group differences in working on goals and use of goal setting strategies.

METHODS
Data came from a community-based participatory research project to address obesity among low-income, predominately minority women in rural North Carolina. A quasi-experimental intervention design was used. Participants included 485 women aged 18 years and over. Intervention participants (n=208) received health information and goal setting support through group meetings and tailored newsletters. Comparison participants (n = 277) received newsletters on topics unrelated to obesity. Surveys assessed physical activity, fruit and vegetable intake, goal-related stage of change, and use of goal setting strategies. Chi squared statistics were used to assess intervention group differences in changes in goal-related stage of change and use of goal setting strategies as well as racial/ethnic group differences in stage of change and use of goal setting strategies at baseline. The causal steps approach of Baron and Kenny was used to assess mediation.

RESULTS
Intervention compared to comparison participants were more likely to move from contemplation to action/maintenance for the goals of improving diet (58% intervention, 44% comparison, p= 0.04) and physical activity (56% intervention, 31% comparison, p ? 0.0001). Intervention group differences were not found for moving from precontemplation to a higher category. At baseline, black compared to white participants were more likely to be working on the goals of getting a better education (p < 0.0001), owning a home (p < 0.01), starting a business (p < 0.0001), and improving job skills (p <0.05). For whites only, intervention participants were more likely than comparison participants to move from contemplation to action/maintenance for the goal of improving diet ( p< 0.05). For both blacks (p < 0.05) and whites (p < 0.0001), intervention participants were more likely than comparison participants to move from contemplation to action/maintenance for the goal of increasing physical activity. For all participants, progression in stages of change mediated the intervention effect on physical activity, but not fruit and vegetable intake. The intervention did not reveal an impact on use of goal setting strategies.

CONCLUSIONS
In this sample of low-income, rural women, the intervention's goal setting component influenced behavior change for participants who were contemplating lifestyle changes at baseline. Racial/ethnic group differences in goal setting indicate the need to gain greater understanding of individual, social, and environmental factors that may uniquely have an impact on goal setting, and the importance of tailoring obesity intervention strategies for optimal, sustainable behavior change.