Lifecourse, immigrant status and acculturation in food purchasing
and preparation among low-income mothers
Tamara Dubowitz1,*, Dolores Acevedo-Garcia2, Judy Salkeld2, Ana Cristina Lindsay3,
SV Subramanian2and Karen E Peterson2,3
1RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213, USA:2Department of Society, Human
Development and Health, Harvard School of Public Health, Boston, MA, USA:3Department of Nutrition, Harvard
School of Public Health, Boston, MA, USA
Submitted 24 February 2006: Accepted 9 October 2006
Objectives: This study investigates how lifecourse, immigrant status and acculturation,
and neighbourhood of residence influence food purchasing and preparation among
low-income women with children, living in the USA. This research sought to
understand physical and economic access to food, from both ‘individual’ and
Design: This study used qualitative methodology (focus groups) to examine the
mechanisms and pathways of food preparation and purchasing within the context of
daily life activity for US- and foreign-born women, living in the USA. The study
methodology analysed notes and verbatim transcripts, summarised recurring
responses and identified new themes in the discussions.
Setting and subjects: A total of 44 women were purposively sampled from
two metropolitan areas in Massachusetts, USA, based on (1) neighbourhood of
residence and (2) primary language spoken. All focus groups were conducted in
community health centres and community centres co-located with offices of the
special supplemental nutritional programme for Women, Infants, and Children.
Results: Analysis of key response themes suggested that scarcity of food and physical
access to food purchasing points did not influence food purchasing and preparation
as much as (1) limited time for food shopping, cooking and family activities; and (2)
challenges in transportation to stores and childcare. The study results demonstrated
differing attitudes toward food acquisition and preparation between immigrant and
US-born women and between women who lived in two metropolitan areas in the
western and eastern regions of the state of Massachusetts, USA.
Conclusions: The findings illustrate ‘hidden’ constraints that need to be captured in
measures of physical and economic access and availability of food. US policies and
programmes that aim to improve access, availability and diet quality would benefit
from considering the social context of food preparation and purchasing, and the
residential environments of low-income women and families.
Food purchasing and preparation
Neighbourhoods and health
Residential neighbourhood characteristics, such as trans-
portation, number of food stores present and measures of
physical safety, are increasingly recognised to affect diet
and diet-related disease among populations1–3. Research
has suggested that limited transportation options, lack of
shops and variety of foods available, and higher prices in
low-income neighbourhoods are among the factors that
have contributed toward suboptimal dietary intake among
the poor4–6. Energy-dense diets high in added sugars and
fats may be more affordable, and are consistent with lower
food expenditures, low fruit and vegetable consumption
and lower-quality diets in the poor and food-insecure7.
has been hypothesised to be associated with differential
neighbourhood effects by race on diet, demonstrated by
varying reliance upon local food purchasing venues by
race6. In the case of immigrant populations, understanding
venues and use of local venues may allow us to better
understand the pathway between local food environments
and diet for different populations.
Food security, immigrants, and maternal and child
In the USA, household food security has been predomi-
nantly captured as the fiscal ability of a household to meet
‘basic food needs’ such that food insecurity causes ‘the
uneasy or painful sensation caused by a lack of food’8.
Food security as measured by the United States Depart-
ment of Agriculture is defined as ‘access by all people at all
*Corresponding author: Email email@example.com
q The Authors 2007
Public Health Nutrition: 10(4), 396–404
times to enough food for an active, healthy life’, and is
recognised as one of several conditions necessary for a
population to be healthy and well nourished9. This
conceptual perspective has not taken into account
neighbourhood factors such as physical access to and
geographic location of food purchasing venues. In other
words, measuring only an individual’s economic ability to
buy food assumes that the physical and socio-cultural
process of food acquisition is consistent from person to
person and neighbourhood to neighbourhood. In
contrast, the Food and Agriculture Organization of the
United Nations (FAO) defines food security reflecting an
understanding of the global distribution of food and
resources. According to the FAO, food security exists
when all people, at all times, have access to sufficient, safe
and nutritious food to meet their dietary needs and food
preferences for an active and healthy life10.
This study focused on a population of predominantly
Latina and foreign-born (i.e. immigrant) women with
young children living in the USA. Since 1990, the
immigrant population in the USA has increased by 43%
and accounts for the highest proportion of the total
population since 1930. In 2002, 40% of the Hispanic
population was estimated to be foreign-born and 61% of
Hispanic children have at least one foreign-born parent11.
Moreover, the majority of Latina women in the USA
between the ages of 25 and 39 years are mothers12.
Immigrants to the USA face cultural adaptations from
language acquisition to basic changes in daily life and
residence. While variation exists throughout the world as
to ‘the immigrant experience’, many newcomers to the
USA may experience changes in food variety, accessibility
and availability. Limited research exists concerning
changes in the way food is acquired, prepared and eaten
by immigrants, and whether immigrant status has an
impact on dietary intake, adequacy and quality.
Lifecourse experiences and family and social roles have
been found to contribute differently toward dietary intake
in low- to moderate-income adults13. The period following
birth of a child is a time of exceptional transition in
psychosocial and physical needs, time and role conflicts,
and self-care and physical health for mother and child14.
Changes in lifestyle and child-rearing responsibilities,
alongside increased risk for social isolation and poor
health status, can exacerbate already suboptimal dietary
intake among low-income women14. Research has high-
lighted the obstacles many low-income mothers face, with
limited social support such as childcare, access to
transportation, time management skills and feelings of
depression compared with that of middle-aged employed
This qualitative study examined whether and how
structural constraints (e.g. availability of food purchasing
places within the neighbourhood of residence; individual
accessibility to public transportation facilities; and access
to childcare) influenced food purchasing and preparation
among low-income, predominantly Latina women resid-
ing in two urban areas in the northeastern USA.
Focus group discussions were used to elicit an under-
standing of the beliefs, preferences and behaviours of low-
income women, and to capture their perceptions of the
economic and sociodemographic contexts in which they
live16–18. All women recruited into the study had
completed a 12-month period of participation in a
randomised controlled intervention trial (RCT) of a
nutrition and physical activity educational programme
Boston and Springfield/Holyoke, Massachusetts, USA14.
Eligibility criteria for the RCT (and therefore all focus
groups) were: (1) income eligibility to receive Women,
Infants, and Children (WIC) programme benefits (i.e.
household income #185% of the US federal poverty level
the US federal poverty level was US$18400 for a family of
four, so 185% of the US federal poverty level was
US$34040per annum)); and (2) birth of an infant who
was ,20 weeks old to women at the time of enrolment.
RCT participants in both the ‘intervention’ and ‘control’
treatment arms who had completed the follow-up survey
were recruited for the qualitative study; at the time of the
focus groups, women had children aged 13–18 months.
Focus group participants were purposively sampled
geographically and by language spoken in order to build
upon our main inquiries concerning immigrant status and
neighbourhood of residence. Women were recruited
based on (1) expressing an interest in participating in
the focus groups at their RCT final survey interview; or (2)
responding to letters of invitation sent to women whose
RCT final interviews did not include the additional option
of focus group participation. The study protocol of the
RCT and the qualitative study reported here were
reviewed and approved by the Institutional Review
Board of participating institutions.
After women (n ¼ 58) expressed interest in participat-
ing in the focus groups, all residential addresses were
plotted, or geocoded, to a map of Massachusetts, and each
point was labelled according to primary language spoken
by the participant (English or Spanish). Appropriate
locations to hold the discussion groups were chosen,
based on the spatial distribution of potential participants,
geographically and by language. All women were
contacted by phone to invite them to participate in
discussion groups. Women were also sent reminder flyers
with directions. A standard US$35 incentive as well as free
childcare was offered for participation in the focus groups,
reflecting local research practices in the study area.
Seven focus groups of 1.5–2hours duration each were
held over a 6-week period among immigrant Spanish-
speaking women (n ¼ 24) and US-born English-speaking
Food acquisition among low-income mothers 397
(n ¼ 20) women from the Boston and Springfield/Ho-
lyoke metropolitan areas. Groups were diverse in age,
parity and educational level. All focus groups were
conducted in community health centres co-located with
WIC programme offices.
Focus group guidelines and process
The focus group protocol followed open-ended questions
probing the location of neighbourhood food purchasing
sites, food acquisition and food preparation. Additionally,
questions were asked regarding whether and how access
to transportation and childcare influenced food purchas-
ing and preparation. Questions were developed with the
assistance of Spanish- and English-speaking data collec-
tors and staff of the RCT, capitalising on the knowledge
and insights they had accumulated through administration
of the surveys during the RCT. All seven focus groups were
audio-taped and had a designated note-taker. All
participants gave informed consent for tape recordings.
Facilitators were trained in focus group moderation and
facilitation to ensure implementation of a systematic
protocol across focus groups. Training included review of
the function and goals of the focus groups and guidance
for the facilitator to maintain objectivity throughout the
focus group. For Spanish-speaking groups, a native
Spanish speaker moderated all groups; the lead author
(T.D.) moderated all English-speaking groups. Spanish-
note-taker, and one of the authors (J.S.) took notes for
English-speaking groups. Following each focus group,
notes were typed and audiotapes were fully transcribed.
Transcripts from Spanish-speaking focus groups were
translated into English by the bilingual group facilitator
who led the group. Basic demographic characteristics of
participants were obtained from linking to their RCT
survey, used solely for purposes of obtaining these
descriptive statistics of women who participated in the
Transcriptions of focus group were summarised and then
manually coded for emerging themes in a data index
format. Notes were used to confirm the coded themes.
Transcripts and notes were analysed by identifying
recurring, emergent themes using the constant compari-
son method19,20. This qualitative method analyses data in
stages, most notably (1) comparing incidents applicable to
each category; and (2) integrating categories and their
properties. This process undergoes continuous refinement
throughout the data collection and analysis process,
feeding back into the process of category coding. After
noting patterns and cross-cutting themes throughout (time
and childcare constraints, cultural role of food preparation
and ‘meals’, social support) and clustering them by
conceptual grouping (food preparation, acquisition and
immigrant status), emergent relationships were identified
across categories based upon the original research
questions. Themes are presented textually, with quotes
illustrative of emergent and cross-cutting themes.
Demographic characteristics of focus group participants,
shown in Table 1, were consistent with purposive
sampling; half were from the Boston metropolitan area
and half were from western Massachusetts (Springfield/
Table 1 Demographic characteristics of focus group participants
First-generation immigrant to the USA (foreign-born)
Mean age (years)
Some high school
Completed high school
Married/living with partner
T Dubowitz et al.398
Holyoke). In Boston, 19 women were born outside the 50
United States (first-generation immigrant). Five women
from western Massachusetts were first-generation
immigrants and 11 had at least one of two parents born
outside the USA (second-generation immigrant). All
foreign-born women from Boston were Spanish-speaking
and came from several locations in the Caribbean and
Central America, including Puerto Rico, the Dominican
Republic, El Salvador, Cuba and Mexico.
Figure 1 displays emergent themes and cross-cutting
influences concerning ‘time’ and ‘obstacles’ from analysis
of focus group data. There was also intersection between
the social and geographical aspects to food purchasing
and preparation and immigrant status: foreign-born
women were less likely to perceive physical barriers to
purchasing and preparation of food. For purposes of
presentation, responses were grouped and compared
within each topic area principally by women’s immigrant
status (foreign-versus US-born) and by geographic region
of residence (western Massachusetts versus Boston
The social and geographical aspects of food
Most women, regardless of neighbourhood or immigrant
of monthly or bi-monthly trips to ‘no frills’ stores that have
advertised coupons or sales for large and/or staple foods.
For small or necessary items such as milk or butter, women
relied more upon convenience and proximity to a food
store. Transportation to and location of grocery stores
within neighbourhoods differed between western Massa-
chusetts and Boston. Women in western Massachusetts
relied much more on cars for transport and had a more
limited choice of food stores. Women in Boston, on the
types of transportation in order to get there.
Among women from all groups, price was described as
a key factor in choice of shopping locations.
‘We are fans of watching the prices and of the savings.
Since my husband is the only one working, when he gets back
from work, we look at the specials and we compare the
price... We use coupons. We look for specials and see if we
can stretch the money’.
Geographical access and food availability
Some of the differences between foreign- and US-born
women emerged through discussion of physical access to
food purchasing places and its impact on food acquisition
and preparation. US-born women were less inclined than
immigrant women to travel great distances to grocery
stores. Foreign-born women, however, spoke about their
experience in the USA compared with that in their native
country and many felt that food acquisition was easier for
them in the USA.
‘I think that the transportation here is easier. It’s different
also in regards of food, here the poorest person it does not
matter how educated they could be or not be it does no matter
Fig. 1 Emergent and cross-cutting themes from focus group discussions
Food acquisition among low-income mothers 399
what they do, there is always dollars to buy food. In our
country it’s not like that, people make $100 a month and
can’t buy good food, here you can’.
Many of the immigrant women said that produce was
better, cheaper and easier to find in the USA. However,
many immigrant women also felt that although food was
cheaper and more plentiful in the USA, it was of lower
‘The biggest difference is the meat and the chicken. Here,
we need to put a lot of spice so it will have more flavor, instead
the chicken in my country is exquisite’.
‘It’s the chemicals they use to conserve it, so it lasts longer.
Over there they kill the cattle twice a week so you know it and
you buy it fresh’.
Most women agreed that smaller stores in their
neighbourhoods were very expensive and they fre-
quented them only ‘in emergencies’ or for everyday
items. Women spoke about the quality of products at these
‘Food is older there. I had the experience with the yuca and
avocado that it was very expensive and rotten, and I said I
won’t buy there any more. I’m wasting my time, my money
and getting bad things’.
In some focus groups, the difficulty of shopping with
children was discussed:
‘I take the bus to Stop and Shop and to take the kids is a hassle.
I’m by myself so I have to take the first one and make sure she
gets on the bus and I’m like, “don’t touch anyone, please”.
And then the second one, I have to bring him up. Then, to
come back with the bags. It’s hard’.
Convenience and time
Although many women reported buying ready-made food
or meals once or twice per week, nearly all women were
concerned with the cost of ready-prepared food. Many of
the Spanish-speaking women questioned the taste and
preparation of the foods. Foreign-born women, compared
appropriate and familiar ingredients as opposed to ‘fast
food.’ By contrast, even within the Spanish-speaking
were more likely to buy already prepared food, either
‘ready-to-serve’ microwave meals or meals from fast-food
restaurants or take-away establishments, than to travel to
purchase different ingredients and goods from different
stores. Yet many Spanish-speaking US-born women spoke
about their preference for ‘Spanish’ restaurants over fast-
Many of the English-speaking US-born women, on the
other hand, were more willing to frequent fast-food outlets
and purchase ready-prepared food, primarily because of
convenience. The quality or nutritional value of the food
was not as important to them. As explained by one US-
‘... If we’re somewhere and they’re hungry ... how can I not?
You know, we can stop off at McDonalds and get a
cheeseburger and French fries. It’s like a dollar’.
Food preparation in daily life
Food preparation practices ranged from a woman who
reported that she does ‘not think about’ what she prepares,
daily basis (rice,beansandeitherchicken or beef).Themes
and factors that impinged on food preparation included
time, convenience and children as ‘picky’ eaters.
Most women reported that they were the primary
person responsible for food preparation and shopping.
One woman said that she and her fiance ´ share all
responsibility, and another woman, whose husband was a
chef, explained that she did food purchasing and her
husband did the preparation. Still, many women talked
about difficulty cooking ‘entire’ meals. As a native-born
woman from the Springfield area described:
‘I don’t really have time to eat. I’ll just make them [the children]
something or I’ll get take-out orders for them because I don’t
have time. I’ll eat something like a granola bar’.
The influence of the length of the workday on food
preparation emerged as a theme from respondents in all
focus groups irrespective of language, nativity or
immigrant status. As one woman said:
‘I work three days a week. I don’t have time – for me. I
get home late and I don’t want to think about cooking’.
On the other hand, there were women who said theyate
more nutritiously and were more conscious about eating
fruit and vegetables and salads since having children.
Almost all women talked about time and convenience,
especially those constrained by working or attending
school. Women discussed the difficulty of cooking and
caring for children at the same time. As one US-born
woman from western Massachusetts described:
‘My son ... sometimes it’s just hard because he [my child]
won’t let me just cook ... It’s just that he feels like that is his
time. I don’t know’.
Family and social aspects of food
Both immigrant and US-born women consistently men-
tioned social ties around eating. Family structure and
composition emerged as an important theme with respect
to cooking. Many women discussed eating at extended
T Dubowitz et al.400
family’s homes. Single mothers in the groups, irrespective
of immigrant status or neighbourhood of residence,
explained that preparing full meals was not worth the
time it took in households with fewer members.
‘I go to my mom maybe twice a week. And then I go to my
sister’s once per week. It’s just me and my daughter’.
Discussion around economic aspects of household food
security was more difficult to elicit. Of the 44 women in the
focus groups, just one woman, who was a single mother
and native-born, grew up in one Boston neighbourhood
and currently lives with her aunt in another neighbour-
hood, explained that even though geographic access to
food was not a problem, household food distribution was
‘I live with my aunt now and she lives in Roxbury. I’ve been
living there since August ... Everything is right there. The
store, the hospital, bus stop ... The McDonalds is right there.
Save A Lot is right there. Church is right there. Laundromat is
down the street’.
She goes on to explain that the reality of her situation at
home, however, makes it difficult to think about having a
‘It’s hard to think about what’s healthy. You just want to eat
and do what you gotta do. If you’re on the run, you can’t stop
and think about healthy this or that. You think about some
bread, meat, cheese, mayonnaise and then you’re out’.
Themes defined by ‘time’ and ‘family’ in the USA were
brought up repeatedly by women in the Spanish-speaking
‘Here, life is always running, especially for us. We have 3
children in different schools so life is complicated and if you
do not try to distract your mind you’ll end up stressed out or
Relationships between nativity, duration of US residence,
acculturation and diet have been demonstrated in both
national and community-based studies conducted in the
USA. Despite lower socio-economic status than second-
generation or White non-Hispanic women, first-gener-
ation Mexican-American women have demonstrated
healthier dietary intakes21. Being born in the USA and
reporting a preference for speaking English at home have
been significantly associated with greater consumption of
convenience foods and salty snacks, as well as greater
frequency of eating higher-fat foods, overall22. While this
research sought to examine the pathways through
which access and availability influenced food purchasing
andpreparation among immigrantand US-born
low-income mothers, many emergent themes were
intertwined. For example, relationships between accul-
turation, lifecourse experiences, social contexts and
physical context were demonstrated to be not only
important in daily life activity, but especially central to the
cultural phenomena of diet, food preparation and eating.
Other research has highlighted differences in how food
security is conceptualised and experienced in different
populations. Wolfe and colleagues demonstrated how the
experience of acquisition, affordability and preparation of
food influenced elders’ experience of food security23. An
augmented instrument of the food security survey module
was developed for use among Spanish-speakers in the
USA24. Still, this study demonstrated that ‘food security’, as
measured in the USA primarily as economic access to
food, may not capture some of the most important
mechanisms associated with food acquisition, including
lifecourse factors such as childcare and the need to work
to make ends meet.
In focus groups with low-income Latina families in
California, for example, it was found that women tend to
reduce their food intakes during the winter in an attempt
to spare other household members from experiencing
hunger25. Research in the UK has additionally shown how
economic and physical access to food differs by variation
in demographic groups (e.g. mothers of younger children
versus the elderly)26,27.
In the present study, women shared many of the same
obstacles in finding time to shop and prepare food.
Immigrant women, however, were more apt to view food
preparation as an essential daily activity. US-born women,
including second-generation immigrants, were morelikely
to consider at-home food preparation to be a choice and
spoke more about buying ‘take-away’ foods and fast food,
and eating at relatives’ houses. In this way, one could
expect that the context of the neighbourhood, specifically
the quality and quantity of prepared food purchasing
venues (such as take-away restaurants and fast-food
establishments), would have more influence among US-
born women and second-generation immigrants (and less
effect on immigrant women). Likewise, US-born women
were less likely to speak about going to different food
stores and generally did their shopping at one or two
places. Again, this would imply that US-born women are
more vulnerable to neighbourhood constraints such as
limited variety or quality of food choice in the
Many immigrant women explained that weekends were
a time for family and friends in their country of origin, but
in the USA this time was used for necessary household
activity, such as food preparation and purchasing. In this
way, food preparation and meals might be a central family
function in their country of origin but a secondary activity
in the USA – which could translate into lower-quality
meals. For example, prepared and processed foods are
nutritionally less optimal, but faster and more convenient
Food acquisition among low-income mothers 401
to prepare. In an unpublished study with Hispanic women
in Durham, North Carolina, fast food accessibility was one
of the reasons cited regarding their families’ diets
deteriorating in quality28. Among other findings, this
study confirmed that time constraints had a strong
influence on the decision to purchase ready-made ‘fast
In this study, there were varying degrees to which
women relied upon their ‘neighbourhood’ of residence.
For example, immigrant women living in the Boston
metropolitan area described travelling from one end of
the city to the other in order to acquire different
ingredients. Similarly, women in western Massachusetts,
who by and large had access to personal cars, reported
travelling to the ‘better of the two’ grocery stores. Yet US-
born women were less likely to spend time travelling
long distances to acquire ingredients. Varying factors that
might come into play include household size and access
One of the limitations in this research was the geographic
division of women – between immigrant status and
between metropolitan areas. Many of the immigrant
women lived in the Boston metropolitan area. Thus, the
research was unable to disentangle fully whether, for
example, food shopping practices were linked with
immigrant status or with neighbourhood of residence.
This division of women into neighbourhoods and
immigrant status is partly the result of the complex nature
of neighbourhood segregation, immigrant enclaves and
urban history, and was largely unavoidable with this
methodology. The research was designed so that women
who lived in the same neighbourhood and spoke the same
language participated in focus groups together.
The incentive of US$35 given to all women who
participated may have been appealing to women who
were more ‘in need’ of money, making them more eager
to attend, or to those who who were resourceful.
Because participants in the parent RCT were all low-
income women with infants, it is more likely that
women’s capacity to participate in focus groups was
limited by social responsibilities and roles, and those who
attended had more social support, had fewer children
and/or did not work at a part-time or full-time job outside
A further limitation of this work concerns the cultural
and linguistic challenges English-speaking researchers
face in conducting research with Latina women, many of
whom speak Spanish. Information derived in Spanish may
have a different cultural connotation and meaning from
information derived in English. Yet because the focus
groups were semi-structured (meaning discussion and
conversation helped lead the order and types of questions
that were asked), women were encouraged to express
themselves in their native language and words. Verbatim
transcripts were translated prior to analysis.
This research contributes to the development of a more
complete definition of ‘food security’. The research
questions sought to understand food security in a broader
context, in order to draw attention to immigrant health and
the effect of neighbourhoods on health. In this way, food
programmes, research and policy can start to take both
neighbourhoods and specific populations into account
when designing and implementing their efforts. Addition-
ally, evaluation of such programmes should capture their
operation in the varying contexts and levels within which
If food security is defined as physical and economic
access to an adequate and healthy supply of food, these
notions – of space and/or time – must be conceptualised
as part of the way food security is evaluated and improved.
Still, it is important to recognise that differences in place
(i.e. neighbourhood) characteristics matter. In this light,
policymakers must consider the social context of
individuals, within places, when initiating health pro-
This research demonstrated that in order effectively to
measure and influence household food security, neigh-
bourhood factors must be considered. With this, food
policy and programmes can more productively act on the
very purpose they serve. Efforts can be made on a local
level – such as promoting the use of establishments that
are geographically accessible and supply a variety of
foods. On a state level, officials can devote more attention
to the importance of neighbourhoods in health and
These findings have potential implications for the
design and implementation of multilevel environmental
intervention studies. Social context, as described through
this research, may provide an additional way of examining
the connection of neighbourhood residents to the food
environment. Further, this work highlights the need for
more qualitative research in this area, which has the ability
to highlight the mechanism and pathways by which ‘place’
and ‘health’ are connected. For example, this research was
able to uncover how food purchasing points or other
services used by certain groups, general willingness and
ability to travel for groceries, and specific priorities might
influence the decisions and behaviours of different
Immigrants comprise one in nine US residents and
one in four low-wage workers29. The immigrant
population is central to the economy of the USA and
their health and well-being is of fundamental import-
ance. This study and others have established that the
physical and social characteristics of neighbourhoods
influence nutritional behaviour. Thus, food policy and
T Dubowitz et al.402
programmes that seek to address food security and
improve diet would become more effective with
consideration of people and of their residential
environments. After all, improving food security is not
limited to improving fiscal access on an individual level,
but should include minimising the social, cultural and
environmental barriers to a healthy diet.
Sources of funding: This work was supported generously
by the Department of Maternal and Child Health at the
Harvard School of Public Health (Maternal and Child
Health Bureau training grant MCHB 5T76 MC 00001); the
Vitamin Settlement Grant, State of Massachusetts; the
intervention trial, Reducing Disease Risk in Low-income,
Postpartum Women 1 R01 HD37368-01 (NICHD)
(Peterson, PI); the Ruth L Kirschstein National Research
Service Award (NRSA) F31-NS046161-02 Pre-doctoral
Fellowship; and the Center for Minority Health, University
of Pittsburgh Graduate School of Public Health export
Conflict of interest declaration: The authors declare no
conflicts of interests with respect to this research.
Authorship responsibilities: T.D. conceptualised and
designed the study, attended all focus groups, performed
the analyses, and wrote the manuscript. J.S. helped
organise focus groups and participated in conceptualis-
ation of the research. A.C.L. helped with conceptualisation
of the research. D.A.G., S.V.S. and K.E.P. helped with
conceptualisation of the study, guidance of the analysis
and interpretation of the results.
Acknowledgements: The authors wish to thank each of
the women who took the time and effort to share their
stories in the focus groups. We also wish to thank Carrie
Hardwick and Aidana Baldassarre for their painstaking
and generous effort with organisation, implementation
and facilitation of focus groups. In addition, Aidana
Baldassarre was responsible for all translation of groups
and of notes from Spanish to English.
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