N14002: Overcoming barriers to a healthy food choice in girls from low income and minority groups

Study Duration: October 2003 to June 2006

Contractor: London Metropolitan University

Anecdotal evidence suggests that the likelihood of having a low birth weight baby is substantially greater for mothers in specific ethnic groups and confounded by low income, compared with those in higher socio-economic groupings and of white ethnicity. Research is needed to specifically address the barriers to food choices made by those in minority and low income groups.

Issues to be addressed will therefore be those related to the facts, life skills, social influences, access, and inhibitors to behaviour change as they relate to ethnic minority groups and low income populations.

This project aims to:

• determine and quantify factors that inhibit a healthy food choice in girls 14-18 years from low income and/or ethnic minority groups
• evaluate a community intervention programme aimed at overcoming the barriers to increasing fruit and vegetable and complex carbohydrate intake in these groups

This project will target school girls aged 14-18 years. Barriers to fruit and vegetable and complex carbohydrate intake in girls of specific ethnic groups will be qualified and be used in the design of a two-part tailored community intervention, which will include a computerised personalised leaflet and a practical skills workshop.

Participants will be tested pre-intervention and at follow-up to measure changes in intake, attitudes to fruit, vegetables and complex carbohydrates, social influences and perceived dietary control. The success of a sustainable and culturally appropriate intervention will be ascertained.

The aim of the project was to develop and evaluate a tailored intervention designed to increase the intake of wholemeal bread, wholegrain cereal, fruit and vegetables in adolescent girls from ethnic minority and low-income groups. Originally the aim was to develop a community intervention programme however community groups approached in the early stages of the project were unable to commit to participating in the study. Schools were able and willing to take part and therefore it was decided that the study should take place in the school setting.
The project was carried out in three stages using quantitative and qualitative methods.
Study 1: the objective was to assess the psychological factors which promote or prevent consumption of wholemeal bread, wholegrain cereal, fruit and vegetables. A cross-sectional survey of 634 adolescent girls (14-15 years old) from ethnic minority and low-income groups was carried out in order to determine psychological predictors of dietary intake of the target foods. The data were used to investigate the usefulness of the Theory of Planned Behaviour (TPB) as a theoretical basis for the tailored intervention. The data were also examined to determine the role of ethnicity in dietary intake and the relationship between ethnicity and psychological components of the TPB.
The results showed that the constructs from the TPB accounted for between 26% and 41% of the variance for intention and between 17% and 37% of the variance for dietary intake. Ethnic group was found to be a significant predictor of dietary behaviour independently of psychological factors for wholegrain cereal, fruit and vegetables but not for wholemeal bread.
Study 2: the objective was to identify factors that act as barriers to eating healthy foods for girls in ethnic groups therefore in-depth focus groups were used to expand data collected in Study 1. Four key themes were identified using an interpretive phenomenological approach: perceptions of healthy eating; barriers to healthy eating; benefits of unhealthy eating; and social influences on food choices.
Perceptions of healthy eating were linked to knowledge about the health benefits of different foods as well as factors such as personal appearance and weight. Barriers to healthy eating included external factors such as availability, variety, presentation and quality; cost was also an issue. In some cases, unhealthy foods were perceived to be better value for money than healthy ones and more easily available; girls also had a high preference for such foods. Social factors were very important in making decisions about food: peers were influential at school but girls respected their parents’ beliefs and standards at home. The role of the media was also perceived as important.
Study 3: the objective was to develop, and test the efficacy of, a tailored intervention leaflet in increasing the intake of wholemeal bread, wholegrain cereal, fruit and vegetables. The primary outcome measure was dietary intake of the target foods based on 2-3 dietary recalls. Psychological outcomes included constructs of the TPB including behavioural, normative and control beliefs as well as intention. Readiness to change behaviour (stage of change) was also assessed.
This study used a randomised, controlled, cluster trial to compare dietary intake and psychological factors from the TPB in 406 girls who received a tailored intervention leaflet and 417 girls who received a generic leaflet. Girls were recruited in schools in London and the West Midlands and were randomised by school class. Three, 24-hour dietary recalls were used to assess dietary intake at baseline and at three month follow-up.
In the intervention group, computer-generated leaflets were tailored to individual participants’ current dietary behaviour, behavioural, normative and control beliefs about food and stage of change. Participants in the control group received a generic healthy eating leaflet based on government guidelines and which was the same for all individuals.
Baseline results showed low levels of intake of all the target foods. Only 2.5% of participants consumed five servings of fruit and vegetables/day; less than 16% ate wholemeal bread daily and less than 6% ate wholegrain cereal daily. The majority of the girls had positive views on general attitudes, cognitive and affective beliefs about food. Most girls regarded themselves as being in the ‘maintenance’ stage of behaviour change therefore motivation to change behaviour by eating more of the target foods was relatively low.
Results at three months showed a significant increase in intake of wholemeal bread - by less than one slice/week - in the intervention group. However, there was also a small but significant increase in intake in the control group. Differences between the groups at baseline meant that it was not possible to draw firm conclusions about the efficacy of the intervention. There were no positive changes in intake of wholemeal cereal or vegetables in either group; fruit intake decreased in both groups.
For psychological factors there were some minor positive changes to cognitive beliefs for wholemeal bread, wholegrain cereal and fruit in the intervention group compared to the control group however there changes were not consistent between foods. Those in the intervention group displayed positive changes to their stage of change for wholemeal bread only; these girls were more likely to move from the ‘contemplation’ to the ‘preparation’ stage. Overall, the changes in dietary intake could not be explained by changes in TPB factors suggesting that either the intervention had a direct impact upon behaviour or that the assessment may not have been sensitive to changes in psychological factors.

*The final report is available from the Agency’s Information Centre.
To obtain a copy, please contact the Enquiry Desk, Information Services, Food Standards Agency (tel: 020 7276 8181/8182 or email: infocentre@foodstandards.gsi.gov.uk)

For any enquiries concerning this research project, please contact the relevant Programme contact or email: science@foodstandards.gsi.gov.uk