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

Project Code: N14002

30/09/2006

Department of Psychology, London Metropolitan University
Baker, D ;
School of Biological Sciences, University of Plymouth
Rees, G;
STORM, London Metropolitan University
Stanopoulous, D;
Department of Psychology, London Metropolitan University
Bakhshi, S; Surujlal- Harry, A

The overall aim of the project was the development and evaluation of 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. The project was carried out in three stages using quantitative and qualitative methods.

Study 1: Objectives: To assess the psychological factors which promote or prevent consumption of wholemeal bread, wholegrain cereal, fruit and vegetables.

Study 1 used a cross sectional survey of 634 adolescent girls (14-15 years) from ethnic minorities and low-income groups to determine psychological predictors of dietary intake, specifically in relation to wholegrain cereal, wholemeal bread, fruit and vegetables. The data were used to investigate the usefulness of the Theory of Planned Behaviour as a theoretical basis for the tailored intervention. Also the data were examined to determine the role of ethnicity in dietary intake and the relationship between ethnicity and the psychological components of the Theory of Planned Behaviour.

The results from the cross sectional survey showed that the constructs from the Theory of Planned Behaviour accounted for between 26% and 41% of the variance for intention and between 17% and 37% of the variance for dietary intake. This is comparable to other research in the field using the model. In addition ethnic group was also 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
Objectives: The aims of this study were to identify the factors that act as barriers to eating healthy foods in different ethnic groups.

Study 2 used in-depth focus groups to expand the data collected in Study 1 in order to inform the development of the tailored intervention. This involved using an Interpretative Phenomenological Analytical approach to looking at themes associated with barriers and benefits of eating a healthy diet.

Results of the focus groups showed that adolescent girls talked about foods in relation to four key themes: perceptions of healthy eating; barriers to healthy eating; benefits of unhealthy eating; social influences on food choices.

The findings suggest that ethnic groups did not differ in their knowledge about healthy foods although there was some overall lack of practical knowledge about what constitutes a healthy diet. In particular, none of the focus groups highlighted either wholemeal bread or wholegrain cereal as a healthy food. This may link in with the poor intake levels for both of these foods. Participants suggested that access to healthy foods is easier at home than at school where there is a limited choice available. There were also positive beliefs about the convenience and price of unhealthy foods which help to explain why these foods are readily chosen. Girls talked about both control and affective beliefs in relation to food: issues about confidence and taste were important considerations in choosing foods. Lastly social factors were very important in making decisions about food: peers were very
influential during the day at school but girls respected their parents’ beliefs and standards whilst at home. The role of the media on parents, girls and their peers was perceived as very important.

Study 3 Objectives: To test the efficacy of a tailored intervention leaflet in increasing the intake of wholemeal bread, wholegrain cereal, fruit and vegetables.

Study 3 was a randomised controlled cluster trial comparing dietary intake and psychological factors from the Theory of Planned Behaviour in 406 girls who received a tailored intervention leaflet with 417 girls who received a generic leaflet. Participants were recruited from schools in London and the West Midlands and were randomised by class. Data were collected at baseline and three months later at follow-up. Three 24 hour dietary recalls were used to determine dietary intake at baseline and follow-up. Repeated measures analysis compared scores for the two groups across time.

The tailored intervention was a leaflet tailored to participants’ current dietary behaviour, behavioural beliefs, normative beliefs and control beliefs about food and motivation to change behaviour. Leaflets were produced based on the results collected at baseline and generated using computer software. Each participant received their own individualised leaflet. The control group received a generic healthy eating leaflet based on government guidelines and was the same for all participants in the control group.

The main outcome measure was dietary intake based on an average of 2-3 dietary recalls. In addition psychological outcomes included constructs of the Theory of Planned behaviour including behavioural beliefs, normative beliefs and control beliefs as well as intention. In addition readiness to change behaviour as a measure of motivational level was assessed.

Results at baseline showed low levels of intake for all of the target foods. Only 2.5% of participants consumed the recommended 5 servings of fruit and vegetables a day, with less than 16% consuming wholemeal bread daily and less than 6% consuming wholegrain cereal daily. A review of psychological constructs from the Theory of Planned Behaviour indicates that the majority of girls held positive views on general attitudes, cognitive and affective beliefs about food. The majority of participants regarded themselves as being in the maintenance stage of change thus feeling that they have made changes to their dietary behaviour and therefore are unlikely to see a need to do so in the future. Therefore motivation to increase any of the foods was relatively low.

The results at follow up show a significant increase in intake of wholemeal bread by just under 1 slice of wholemeal bread per week for the intervention group (from 0.39 to 0.51 slices per day) (p<0.05). However there was also a small but significant positive change in intake of wholemeal bread in the control group (from 0.28 to 0.35 slices per day). The differences between groups at baseline do not allow firm conclusions to be made about efficacy of the intervention. There were no positive changes to the other foods for either group whilst intake of fruit decreased in both groups. This decrease in intake may be a consequence of changes to diet overall in line with the presentation of the intervention.

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 although these were not consistent between foods. Although the majority of results were not significant for a time × intervention interaction, the intervention group showed increases for the majority of the belief factors. Lastly, girls in the intervention group displayed positive changes to their stage of change for wholemeal bread only. The results show that participants were more likely to move from contemplation to preparation stage in the intervention group than in the control group for wholemeal bread. Overall the changes in dietary intake could not be explained by changes in the Theory of Planned behaviour psychological factors suggesting that either there was a direct impact of the intervention on behaviour or that the assessment may not have been sensitive to change in psychological factors.

Analysis of the subjective evaluation of the intervention showed mixed results. Although those who received the tailored intervention were generally more positive about the leaflet, overall girls do not appear to be using or to have kept the information. However the intervention group were more interested in having a healthy diet and had a greater awareness about what to eat.

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