Date of Award


Document Type

Open Access Dissertation


Health Promotion, Education and Behavior

First Advisor

Edward A. Frongillo


ntroduction: The coexistence of food insecurity and excess body weight has been wellrecognized by researchers, and it has been documented in women, but not men. Both food insecurity and excess body weight have multiple consequences for physical and mental health. Concerns have been raised about interventions aimed to reduce food insecurity because these programs might contribute to excess body weight, particularly in adult women. Our previous in-depth qualitative research in Costa Rica showed that discouragement was the primary link in the coexistence of food insecurity and excess body weight among Costa Rican women, and that the family and existing gender norms contribute to and compound this coexistence. Building on this knowledge, we aimed to develop, implement, and evaluate an intervention to alleviate discouragement through enhancing women’s capacities that we hypothesized would simultaneously improve food security and reduce body weight. It was also hypothesized that, when compared with the nonintensive arm, women in the intensive arm would have reduced discouragement and anxiety symptoms and improved social support for healthy eating, psychological and economic empowerment, and food and physical activity behaviors (Manuscript 1). According to our conceptual model, the intervention would also change gender norms and gendered behaviors. To evaluate these changes, we conducted a mixed methods substudy with intensive arm’s participants (Manuscript 2) that aimed to answer. First, what were perceived gender norms, attitudes, intentions, and behaviors of women and their vii family and community members in relation to co-responsibility in the household and selfcare at the beginning of the intervention? Second, what changes in these occurred during the intervention period? Third, how did the changes occur? Methods: We conducted a cluster-randomized controlled trial in the Central Canton of the Province of Alajuela. The randomization was at the catchment area of the EBAIS, which is the first level of care in Costa Rica. This 6-month study compared two arms. The intensive arm consisted of activities at the individual (12 two-hour sessions, three follow-up monthly sessions, and one closing session), household (one workshop with the participants’ household and community members, and homework with family participation), and community (two brochures and one workshop) levels. The nonintensive one was comprised of three one-hour sessions about healthy lifestyles. For the sub-study, we used three sources of data: pre-post-test at the workshops, non-participant observation and content analysis of the participant’s comments during the workshops, pre- and post-semi-structured interviews, and focus groups with participating women. Results: A total of 171 participants were enrolled (83 in intensive and 88 in nonintensive arm). At 6 months, the intensive arm had significantly greater decreases in BMI (p= 0.010), waist circumference (p=0.001), and food insecurity (p=0.004) in relation to the non-intensive arm. In the mixed-methods sub-study, the sample was comprised of 62 participating women, 34 women’s family members, and 9 community members. Participating women and their family members changed attitudes, intentions, gender norms, and behaviors related to co-responsibility in the household and self-care. Family relationships were also improved. viii Conclusions: This intervention was effective to simultaneously improve food insecurity and reduce rather than exacerbate excess weight gain. Promoting co-responsibility in the household and self-care was an effective way to improve women’s health and, in turn, the health and well-being of their household members.