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Culturally Relevant Nutrition Education Improves Dietary Quality Among WIC-Eligible Vietnamese Immigrants
Abstract
To provide culturally appropriate nutrition education to improve the diets of Vietnamese women.
A total of 152 homemakers were recruited to participate in a nutrition education project, with 76 receiving the intervention and 76 serving as the control group.
Non-English-speaking women eligible for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) with incomes below 185% of the poverty level living in 5 California counties.
Bicultural, bilingual Vietnamese-American nutrition education assistants taught 5 to 7 lessons in the Vietnamese language using nutrition education materials written in the Vietnamese language by 2 bilingual, bicultural nutritionists.
Twenty-four-hour food recalls were obtained before and after the 8-week interval on the treatment and control groups.
To examine if there were changes over time in nutrient intake and nutrient density within groups, matched pair t tests were done. Analysis of covariance techniques determined differences between groups. McNemar tests determined if, within groups, there were changes over time in food groups consumed. Chi-square techniques determined changes between groups.
Over time, the number of treatment group participants who had at least one serving from each food group (P <.01), and who had the recommended number of servings from each food group (P <.05), significantly increased in comparison to the control group. Over time, the dietary nutrient density of calcium, riboflavin, and vitamin B6 (P <.05), as well as potassium (P <.01), of treatment group participants significantly improved in comparison to the control group.
With training, bilingual, bicultural women can effectively deliver culturally relevant nutrition education to their peers.
... A few studies on the diet and physical activity of Vietnamese Americans (6-11) have been published. Although 2005 and 2010 dietary guidelines for Americans recommended intake of least 5 servings of fruits and vegetables daily (1,12), a study published in 1995 reported that Vietnamese Americans consumed only 3.5 servings of fruits and vegetables per day (8). Since 2008, US physical activity guidelines have recommended at least 150 minutes of moderate or vigorous physical activity weekly (2,13). ...
... Baseline rates of knowledge and self-reported adherence to recommendations for fruit and vegetable intake were low among Vietnamese Americans; this finding is consistent with published studies of other racial/ethnic groups (25,26). A study published almost 25 years ago reported that Vietnamese Americans in California consumed only 3.5 servings of fruits and vegetables per day (8). ...
Introduction:
Americans have low levels of knowledge of and adherence to recommendations for healthy eating of fruits and vegetables and for physical activity (HEPA). We conducted a cluster randomized controlled trial of a lay health worker intervention to increase HEPA among Vietnamese Americans.
Methods:
We randomized 64 lay health workers to 2 intervention arms. Each lay health worker recruited 10 participants aged 50 to 74. From 2008 to 2013, using flip charts, lay health workers led 2 educational sessions on HEPA (intervention) or colorectal cancer (comparison). We assessed HEPA knowledge and self-reported behaviors by preintervention and postintervention surveys 6 months apart.
Results:
Of the 640 participants, 50.0% were female, 38.4% had lived in the United States for 10 years or fewer, and 71.4% reported limited English proficiency. Knowledge of the recommended intake of fruits and vegetables (≥5 servings daily) increased from 2.6% to 60.5% in the intervention group (n = 311) and from 2.9% to 6.7% in the comparison group (n = 316) (intervention vs comparison change, P < .001). Knowledge of the physical activity recommendation (≥150 minutes weekly) increased from 2.6% to 62.4% among intervention participants and from 1.0% to 2.5% among comparison participants (P < .001). Consumption of 5 or more daily servings of fruits and vegetables increased more in the intervention group (8.4% to 62.1%) than in the comparison group (5.1% to 12.7%) (P < .001). Participants reporting 150 minutes or more of physical activity weekly increased from 28.9% to 54.0% in the intervention group and from 38.0% to 46.8% in the comparison group (intervention vs comparison change, P = .001).
Conclusion:
A lay health worker intervention increased both healthy eating and physical activity knowledge and self-reported behaviors among older Vietnamese Americans.
... Main Theme 8: Use of Culturally-Based and Culturally-Appropriate Programs. Three interventions focused on cultural competency as a critical element of their program (Auslander, Haire-Joshu, Houston, Rhee, & Williams, 2002; Ikeda et al., 2002; Williams, Auslander, de Groot, Robinson, Houston, & Haire-Joshu, 2006). For instance, Havas et al. (2003) used peers as a method of increasing cultural competency of materials and information presented in the nutrition intervention. ...
... Ikeda et al., 2002; Williams, Auslander, de Groot, Robinson, Houston, & Haire-Joshu, 2006). For instance, Havas et al. (2003) used peers as a method of increasing cultural competency of materials and information presented in the nutrition intervention. Each of these interventions resulted in increases in healthy eating among the women participants. Ikeda et al. (2002) targeted their nutritional education program toward Vietnamese women immigrants in the US. A culturally appropriate and culturally sensitive intervention was developed specifically to meet the needs of this population. Educational components were translated into Vietnamese and a particular focus was placed on the healthy aspects of a Vi ...
This article presents a review of the literature regarding nutrition education programs targeting low income women. A total of 15 interventions were found, which met inclusion criteria. Inclusion criteria included publication between January 1, 2001 and January 1, 2007, focus on low income females, focus exclusively on nutrition and improvement of dietary behaviors, publication in English, and intervention took place in the US. The 15 studies meeting the search criteria were, in turn, re-reviewed collectively by the authors. Ten main themes were found: 1) WIC and EFNEP-based interventions, 2) collaborative approaches, 3) theoretical framework, 4) learner-centered, 5) skills-based programs, 6) use of produce coupons or vouchers, 7) computer-based programs, 8) culturally-based interventions, 9) peer teaching, and 10) recommendations to include social support or physical activity. A summary of each was developed and emergent themes were identified. In this manner, effective strategies and lessons learned from the research regarding increasing healthy eating among low income females could be more clearly delineated and discussed. This paper could be quite beneficial to health educators and health researchers interested in increasing healthy dietary practices among low income females.
... An evaluation with 300 participants by Alcalay and colleagues [16] found that the intervention increased knowledge and awareness of cardiovascular disease risk factors and prevention techniques . Due in part to limited outcomes research, culturally-appropriate health education interventions seem to show more success than do culturally-appropriate treatment efforts [36, 37]. ...
... Situations like this call for, first, the recognition of different explanatory models, and second, a cultural broker who understands both the EM and the biomedical aims of the recommended treatment to develop an explanation that is both comprehensible and acceptable to recent arrivals. Diet and nutrition are commonly recognized as culturally-influenced domains of behavior [37] that are particularly relevant to diabetes management and education [78]. However, patients with diabetes may be especially reluctant to modify their eating habits when they feel that the recommended changes ask them to give up culturally meaningful habits and practices. ...
Cultural and language differences and socioeconomic status interact with and contribute to low health literacy, defined as the inability to understand or act on medical/therapeutic instructions. Health literacy is increasingly recognized as an important factor in patient compliance, cancer screening utilization, and chronic disease outcomes. Commendable efforts have been initiated by the American Medical Association and other organizations to address low health literacy among patients. Less work has been done, however, to place health literacy in the broader context of socioeconomic and cultural differences among patients and providers that hinder communication and compliance. This review examines cultural influences on health literacy, cancer screening and chronic disease outcomes. We argue that cultural beliefs around health and illness contribute to an individual's ability to understand and act on a health care provider's instructions. This paper proposes key aspects of the intersection between health literacy and culturally varying beliefs about health which merit further exploration.
... Despite evidence suggesting culinary medicine interventions produce positive health outcomes, there are few combined cooking and nutrition education interventions designed for ethnically diverse individuals with T2DM (35). Given the disproportionate impacts of T2DM in various racial/ethnic groups, there is a need for inclusive and diverse nutrition interventions (36). ...
Virtual culinary medicine education interventions have the potential to improve dietary behaviors, nutrition knowledge, cooking skills, and health outcomes for ethnically diverse individuals with type 2 diabetes. The purpose of this study is to describe the adaptation of the Nourishing the Community through Culinary Medicine (NCCM) program for virtual delivery, and the protocol for pilot testing this intervention. The intervention includes five 90-min virtual NCCM sessions streamed live from a Teaching Kitchen. Feasibility outcomes are recruitment, retention, acceptability, and satisfaction. Short-term effectiveness outcomes are measured through self-administered questionnaires, including perceived health, average daily servings of fruits and vegetables, frequency of healthy food consumption, shopping, cooking, and eating behaviors, cooking self-efficacy, diabetes self-management, perceived barriers to healthy eating, and nutrition knowledge. Demographics and biometric outcomes are sourced from the patient’s electronic medical records including glycosylated hemoglobin (HbA1c), Body Mass Index, and blood pressure. We will conduct a single-arm pilot study to test the feasibility and short-term effectiveness of NCCM program with individuals with type 2 diabetes.
... Gentrification's threat to ethnic foodscapes is an area that warrants further attention (Joassart-Marcelli and Bosco 2020). Just as inadequate access to traditional foods can affect community members' health (Ikeda et al. 2002) and well-being (Wright et al. 2021), Jersey City's increasingly gentrified neighborhoods stress the importance of understanding its existing foodways, and potentially what can be lost or transformed when neighborhoods and cities experience rapid demographic changes. ...
This study explores the contemporary foodscape of Jersey City, New Jersey. Although Jersey City has a long history as a destination for immigrants from a wide range of countries, few studies exist concerning its rich array of ethnic foodways. Analysis of the diverse foodscape of Jersey City identifies risks to sovereignty such as the availability of culturally appropriate foods. The mixed methods research utilizes semi-structured surveys and freelists. The results demonstrate a strong, positive cognitive connection between immigrants and their traditional foodways, manifested in the popularity of fresh vegetables. Spatial representations of traditionally designated food deserts and the distribution of food stores suggest that the presence and roles of ethnic food stores should be more explicitly considered when constructing ideas about access to healthy food.
... 37 Gaps in patient knowledge around disease-specific topics, in particular, could be a focus for patient education, including culturally-relevant nutrition information. [38][39] However, the responsibility to address these gaps cannot fall only on providers who have many competing demands and time pressures. Health care organizations should integrate strategies to ensure patient and caregiver health literacy in typical workflows. ...
Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.
... 14 Previous NPA interventions in Asian Americans have focused on print-15 or lecture-based education alone. 16,17 There has been no RCT that compared an NPA lecture-based intervention to NPA printed materials among Asian Americans. ...
Objectives:
To evaluate the efficacy of an in-language intervention of 2 lectures plus printed materials versus printed materials alone on knowledge and adherence to nutrition and physical activity guidelines among older Chinese Americans in San Francisco, California.
Methods:
From August 2010 to September 2013, we randomized 756 Chinese Americans aged 50 to 75 years to either lectures plus print (n = 361) or print (n = 357). Clusters were the participants recruited by each lay health worker. Intervention outcomes were changes in knowledge of recommended vegetable intake, fruit intake, and physical activity level and adherence to those recommendations from pre- to 6 months postintervention.
Results:
The retention rate was 99%. At baseline, knowledge and adherence to recommendations were low. Print yielded increases in knowledge of recommended vegetable intake and physical activity level and adherence to fruit intake and physical activity recommendations. Lectures plus print had significant increases in all 6 outcomes. In multivariable models, lectures plus print was superior to print for knowledge of vegetable (adjusted odds ratio [AOR] = 12.61; 95% confidence interval [CI] = 6.50, 24.45) and fruit (AOR = 16.16; 95% CI = 5.61, 46.51) intake recommendations and adherence to vegetable intake recommendations (AOR = 5.53; 95% CI = 1.96, 15.58).
Conclusions:
In-language print materials, alone and combined with lectures, increased nutrition and physical activity knowledge and behaviors among older Chinese Americans. (Am J Public Health. Published online ahead of print March 17, 2016: e1-e7. doi:10.2105/AJPH.2016.303111).
... The WIC program provides nutrition education, breastfeeding promotion, referrals to other services, and counseling along with food checks for low-income families living in the US that includes nearly 9 million pregnant and postpartum women, infants, and children up to age five. Many WIC center-based services have expanded beyond nutrition to address a variety of maternal and child health topics, such as smoking cessation, child immunization rates, and health and wellness [10][11][12][13][14][15][16][17][18][19][20][21]. Given that over half of all infants, and one-quarter of all children 1-4 years of age have regular contact with WIC programs, building a curriculum to impact parental participation with their child's doctor about their child's development that can fit within the WIC infrastructure holds great potential for enhancing early identification of developmental delays. ...
The objectives describe a curriculum to support parent-provider communication about child development, and to demonstrate its impact and effectiveness when delivered by staff from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). A curriculum was developed by a university-WIC partnership for a WIC center-based health education class to teach parents about child development and how to talk to their child's doctor about development. During a 90-min training session, university pediatricians used this curriculum and trained WIC paraprofessionals to conduct a 20-30 min center-based education session. WIC paraprofessionals completed an on-line survey to obtain their demographic characteristics, and their attitudes and perceptions about the training sessions and their experiences teaching the center-based health education session to parents. Approximately 500 WIC paraprofessionals received the 90-min training session across 60 centers in the Public Health Foundation Enterprises WIC Program in Southern California. About 250 WIC paraprofessionals completed the on-line survey and over 80 % of WIC staff reported that they had learned new information about child development as a result of the training, and 87 % of the WIC staff reported that the training was sufficient to feel comfortable teaching the class content to parents. We demonstrated the ability to build WIC paraprofessional capacity to promote parental participation in child developmental surveillance and communication with their child's doctor. With appropriate training, WIC staff are interested in supporting population-based efforts to improve parent-physician communication about child development that can complement WIC's existing maternal and child health topics.
... Other articles included studies on asthma, HIV prevention or treatment, weight loss, and fitness and nutrition. 32,33,34,35,36,37,38 Cancer Prevention and Early Detection. Nine studies addressed cancer prevention and early detection in high-risk populations. ...
This report reviews the evidence base for the impact of cultural and linguistic competence in health and mental health care on health outcomes and well-being and the costs and benefits to the system. The authors conducted a structured search of Medline from January 1995 to March 2006 to identify primary research articles on health outcomes and well-being. An exploratory search of multiple databases was performed to identify evidence related to the business case. The review of the health outcomes literature indicated that the field is in the early stages of development, with the preponderance of literature defining the concepts and identifying research questions. Some promising studies support the efficacy of cultural and linguistic competence affecting health and mental health outcomes. Evidence of decreased systems costs is not currently present in the literature. The authors identify key gaps in the current literature and specific methodological and funding limitations to be addressed.
... High levels of self-reported adherence to diet plans among Vietnamese may be the result of higher food security in this population, perhaps due to greater reliance on food stamps and social support, which may mitigate food insecurity (Hanson, Sobal, & Frongillo, 2007). The experiences of the Vietnamese participants in our study, and our findings of widespread food insecurity among Black and Latino participants, point to a need for health care providers to consider the economic barriers to improving diet in low-income, urban populations as well as the health consequences of food insecurity (Drewnowski & Darmon, 2005;Ikeda, Pham, Nguyen, & Mitchell, 2002;Seligman, Laraia, & Kushel, 2010;Shenkin & Jacobson, 2010). ...
Many factors interact to create barriers to dietary and exercise plan adherence among medically underserved patients with chronic disease, but aspects related to culture and ethnicity are underexamined in the literature. Using both qualitative (n = 71) and quantitative (n = 297) data collected in a 4-year, multimethod study among patients with hypertension and/or diabetes, the authors explored differences in self-reported adherence to diet and exercise plans and self-reported daily diet and exercise practices across four ethnic groups-Whites, Blacks, Vietnamese, and Latinos-at a primary health care center in Massachusetts. Adherence to diet and exercise plans differed across ethnic groups even after controlling for key sociodemographic variables, with Vietnamese participants reporting the highest adherence. Food and exercise options were shaped by economic constraints as well as ethnic and cultural familiarity with certain foods and types of activity. These findings indicate that health care providers should consider ethnicity and economic status together to increase effectiveness in encouraging diverse populations with chronic disease to make healthy lifestyle changes.
... These efforts should be encouraged within our society. One method of encouragement is through nutrition education programs, because these programs and other nutrition interventions have demonstrated some success in addressing poor nutrition habits (56)(57)(58)(59)(60). ...
In the United States, 17% of children and adolescents are overweight and 20% live in a food insecure household. Previous studies examining the association between household food insecurity and overweight among children have been inconclusive but are limited insofar as they did not assess child-specific measures of food insecurity and overweight. In response, this study examined the association between food insecurity and child overweight status when these variables were measured for the same child using information on children (n = 1031) aged 10-15 y from the Three-City Study. Approximately 8% of the children were food insecure, whereas 50% were either at risk of overweight or overweight. Bivariate analyses indicated that there were no significant differences in the prevalence of at risk of overweight and overweight between food secure and food insecure children. Gender, race, and income showed similar patterns. Results from logistic regression analyses also indicated that the likelihood of being overweight or at risk of overweight was not significantly different for food secure and food insecure children. Although child-specific food insecurity was not associated with overweight in this sample of low-income children, food insecurity and overweight coexist among these low-income children, because approximately 25% of the food insecure children were overweight. Additional research is needed to explore the potential relationships between food insecurity and overweight and to better inform policy that attempts to address these issues among low-income households with children.
The Mediterranean diet has positive effects on primary and secondary prevention of cardiovascular disease including stroke, yet dietary counseling to stroke patients is under-utilized. This study aimed to develop a culturally adapted Mediterranean diet and introduce it to patients admitted to the hospital for acute ischemic stroke with at least one metabolic risk factor (type 2 diabetes mellitus [DM], hypertension [HTN], high low-density lipoprotein [LDL], low high-density lipoprotein [HDL], and/or body mass index [BMI] > 25). Dietary adherence and nutritional knowledge were measured at baseline and 30, 90, and 120 days post-stroke. Weight, hemoglobin A1C [HbA1C], and triglycerides [TG] were assessed at baseline and follow-up. The study enrolled 54 participants, 50 of whom had sufficient data for analysis. Dietary adherence and nutritional knowledge scores increased in 76.4% of participants, with a statistically significant median increase for each. Additionally, participants had significantly lower weight, HbA1C, and TG at follow-up than baseline. This study showcases the potential to introduce a culturally appropriate Mediterranean diet at the point-of-care, and significantly influence dietary adherence and nutritional knowledge and multiple stroke risk factors.
Because optimal nutrition is vital during pregnancy, there are specific U.S. dietary guidelines and recommendations for pregnant individuals. However, Vietnamese Americans often have insufficient access to dietary recommendations for pregnancy that pertain specifically to their culture and cuisine. Healthful components of the traditional Vietnamese diet include vegetables, herbs, fruits, fish, and some unsaturated fats. Adjustments to the traditional and acculturated Vietnamese diet, such as reduced sodium intake from fermented foods and sauces, less sugar, more diverse carbohydrate consumption, more fiber, and less fat intake, would improve overall health and potentially reduce the common pregnancy complications pregnant Vietnamese women face, including gestational diabetes and certain micronutrient deficiencies. Understanding the traditional Vietnamese diet can help nurses provide culturally competent care to Vietnamese Americans.
Objective
Many breast cancer patients are vulnerable to poor nutritional status and may benefit from nutrition education, but existing materials are not generally tailored to the needs of low-literacy immigrant and minority patients.
Methods
With nutritionist guidance, we developed a nutrition presentation for breast cancer patients. English- (n=29) and Spanish-speaking (n=19) patients were recruited from 5 safety-net hospitals, an academic cancer center, and a Latina cancer support organization. Materials were tested using multiple rounds of cognitive interviewing (with an adapted USDA interview guide), followed by study team reviews and modifications, until saturation.
Results
Seven rounds of interviews per language were needed. Approximately 25% of interviewees had less than a high school education. Changes included adapting to regional lexicons and resolving vague/confusing phrasing. Specific food examples needed cultural tailoring. Text color coding (red/bad, green/good) was requested. Labeled images enhanced participants’ understanding of concepts. Spanish speakers expressed a desire to understand nutrition labelling, and this was emphasized in the Spanish slides.
Conclusion
Cognitive interviews were an important tool for creating a nutrition curriculum tailored to the needs of low-literacy, mostly immigrant patients.
Practice Implications
Cultural and linguistic factors should be considered for nutritional education materials in diverse patient populations.
This systematic review examines whether aids for communication are effective between public services and children and youth, or families with an immigrant background. The researchers analyse relevant studies, and the team included four comparative studies, three for health services and one for education.
There is no clear indication that any particular approach to interpretation works better than others. None of in‐person, telephone, bilingual staff or ad hoc interpreting could demonstrate a clear advantage over other approaches. There is uncertainty about the reliability of this finding because the studies had limitations, including small scale.
One study of the effect of two different training programmes of English as a Second Language (‘ESL’) suggests that an enhanced ESL class (where the course was tailored to immigrant parents) improved parents' involvement in students' schoolwork and parents' English skills more than a regular ESL course. There is uncertainty about the reliability of this finding because the study had important limitations, including small scale. Similar studies of more robust design are needed in order to draw firm conclusions.
Key messages
Over recent decades, the number of immigrants with minority language background has increased. This has occurred in many countries, including those with a tradition of relatively low immigration.
In consequence, a higher share of children, young people and families with minority‐language and immigrant backgrounds may need to communicate with public service providers. In this report, we examine whether interventions to facilitate communication between public services, on the one hand, and minority language children and youth or families with an immigrant background, on the other, are effective. Examples of such interventions are types of interpretation services and foreign language training programs.
We included in this review four studies that addressed families with children or parents with minority language backgrounds; we found no studies exclusively addressing youth with minority language backgrounds.
Three studies conducted within the health services compared the effect of different types of interpretation service (in‐person interpreter, telephone interpreter, ad hoc‐interpreter) or bilingual personnel on different outcomes observed for families. None of these interventions appeared to stand out in favor of another. We were therefore unable to draw any conclusion on the effectiveness one of any particular type of interpretation service.
We identified one study that compared the effect of two different training programs of English as a second language (ESL) on Spanish‐speaking parents' English skills and on parents' involvement in their children's school work. The findings indicate that an enhanced ESL class (i.e., an intervention guided by the theoretical frame on immigrant parent involvement) had a stronger impact on parents' involvement in students' schoolwork and parents' English skills than did an ESL‐course focusing solely on language skills. Although this is a promising finding, it was obtained from a small‐scale study, which had methodological limitations, and further studies with a more robust design are needed to allow firm conclusions on effectiveness to be drawn.
We did not find any studies measuring the effect of interventions on the degree of trust between the respective parties.
Executive Summary/Abstract
BACKGROUND
Over recent decades, the number of immigrants with a minority language background has increased. This has occurred in many countries, including those with relatively low levels of immigration. This increase is especially pronounced in the larger cities. As a result, a higher proportion of children, young people and families with minority‐language and immigrant backgrounds might need to communicate with public service providers. Public services are required by law to offer equal services to all client groups. This can mean an obligation to adjust services to cater to individual needs, e.g. with respect to language proficiency.
Statistics show that immigrant children and their parents receive assistance from child welfare services proportionately more often than those who do not have such a background. Well‐functioning communication is a prerequisite to make such interventions work.
The Norwegian Directorate for Children, Youth and Family Affairs commissioned the Social Research Unit at the Norwegian Knowledge Center for the Health Services to systematically review studies of the effect of interventions to facilitate communication between immigrant children, youth or families with minority language background and the public services. Examples of such interventions are the use of professional interpretation services, cultural interpreters and bilingual case workers.
OBJECTIVES
To systematically review studies on the effect of interventions intended to facilitate the communication between immigrant children, youth or families with minority language background, and public services such as child welfare services or health services.
SEARCH STRATEGY
We conducted a systematic literature search of twelve different databases in March 2013. Additionally, we searched for grey literature on relevant websites and hand‐searched reference lists of included publications.
SELECTION CRITERIA
Two review authors independently assessed the retrieved references (titles and abstracts) for inclusion/exclusion, based on the following inclusion criteria:
• 1) Population: Immigrant children, youth or families (with children under 18 years of age) with minority language backgrounds.
• 2) Intervention: a) Interventions to facilitate verbal or direct communication such as different types of interpretation services, b) interventions to facilitate written communication, such as translation of case documents or information materials, or c) broader interventions where improvement of communication between service providers and service recipients was addressed, such as second language training for parents to improve communication between school and parents.
• 3) Comparison: other active intervention or no intervention.
• 4) Outcomes addressing change in communication, user satisfaction, reported trust, use of services or similar indirect outcomes.
• 5) Study design: studies with control conditions.
DATA COLLECTION AND ANALYSIS
We extracted data from each study and summarized the results in a narrative format by means of tables for each comparison. We did not conduct meta‐analyses because the included studies were too different in terms of comparisons, outcomes and in the way results were reported. In consequence, we synthesized the results of the included studies narratively and in tables, categorized according to comparators and outcomes.
We assessed the risk of bias of the included studies by using the Risk of Bias Tool of the Cochrane Collaboration. The quality of the evidence across all studies was assessed by using the Grading of Recommendation Assessment, Development and Evaluation tool (GRADE).
RESULTS AND DISCUSSION
Of a total of 9 896 references that emerged from the systematic literature search we included four studies, either randomized or quasi‐randomized controlled studies.
One study addressed cooperation between schools and parents; three studies were conducted in the context of the healthcare services. We found no studies addressing children or youth only.
Three studies conducted within the health services compared the effect of different interpretation services (in‐person interpreter, telephone interpreter, ad hoc‐interpreter) or bilingual personnel on different outcomes observed for families. They addressed both subjective (e.g., user satisfaction, self‐reported ability to communicate) and objective outcomes (e.g. words understood). The results indicate that interpretation services have a positive effect on communication. However, it makes little difference whether one chooses bilingual personnel, in‐person interpreter or telephone interpreter to facilitate communication; none of these interventions seems to outperform any of the others. We are unable to conclude on the relative effectiveness of any one type of interpretation service.
One study compared the effect of two different training programs of English as a second language (ESL) on Spanish‐speaking parents' English skills and parents' involvement in children's school work. The findings indicate that an extended ESL Class had a higher impact on parents' involvement in students' schoolwork and parents' English skills than an ESL course focusing solely on isolated language skills. As this was a small‐scale study with methodological limitations, similar studies of more robust design are needed to allow any conclusions to be drawn.
We did not find any studies measuring the effect of interventions on the degree of trust between the respective parties.
There is a need for more randomized studies on a larger scale to address the effect of different interventions aimed at facilitating communication for this population, and particularly in domains beyond the health services. In addition, further studies are needed with control conditions that address the effect of similar interventions on outcomes related to children and youth.
AUTHORS' CONCLUSIONS
In a health service setting, the use of an interpretation service appears to help to increase communication quality, irrespective of the kind of interpretation service chosen. There is a need for additional studies of interventions intended to facilitate communication between the population and public services, particularly for services outside health care, such as child welfare, school and early childcare, work and welfare services, and prison and probation services.
Pika Pamoja (Cook Together) is an eight-session cooking curriculum for Burundian and Congolese refugee families, culturally adapted from the evidence-based iCook 4-H curriculum to address dietary acculturation barriers to and facilitators of food security. The goal of this study was to determine the feasibility and acceptability of implementing Pika Pamoja.
Researchers and a multilingual community aid implemented Pika Pamoja in a pre-post pilot intervention with randomized control (n = 5)/treatment (n = 5) dyads (youth/mother). Feasibility (recruitment/retention, implementation, fidelity testing, and assessment procedures) and acceptability (process and program evaluations) measures were collected.
All 10 dyads (control and treatment) were retained throughout the study. All fidelity measures were 91% or above. The final youth assessment instrument included scales for cooking skills (α = 0.93), cooking self-efficacy (α = 0.90), openness to new foods (α = 0.81), and eating (α = 0.68), playing (α = 0.90), and setting healthful goals (α = 0.88) together as a family. The final adult instrument included scales for cooking, eating, and playing together (α = 0.68), kitchen proficiency (α = 0.89), and food security (α = 0.79). Participant feedback was uniformly positive.
Based on these results, Pika Pamoja was feasible to implement and was accepted by the priority population. Larger scale studies to measure the effectiveness of Pika Pamoja to increase food security among refugee families are needed.
This article examines the design and evaluation of a novel, cross-institutional, classroom-based nutrition intervention program created by a seventh grade science teacher and a university instructor. The collaborative project centered around a unique curriculum-based objective as well as an extracurricular aim for each class. Undergraduates taking the community dietetics course designed, facilitated, and evaluated a tailored, community nutrition intervention. Seventh graders explained how organisms in a biome depend on the available biotic and abiotic resources, and how matter cycles continually among organisms and the physical environment. Additionally, the collaboration aimed to synergistically enhance all students’ academic experience by nurturing dietetics students’ cultural competence as well as by encouraging seventh graders to simultaneously explore their nutrition-related attitudes and make connections among diet and food webs. Following the experience, undergraduates reported that the project positively contributed to their personal growth, civic engagement, and overall academic experience. Seventh graders’ post-project discussions revealed confusion and roadblocks adolescents face related to healthy eating. The results of this study indicate that cross-institutional collaborations provide meaningful experiences within the undergraduate dietetics curriculum and that small-group discussions focused on identifying students’ confusion and barriers can guide health educators to creating relevant and engaging programs for youth.
Objective. To examine existing system-, clinic-, provider-, and individual- level interventions to improve culturally appropriate health care for people with disabilities; lesbian, gay, bisexual, and transgender (LGBT) populations; and racial/ethnic minority populations.
Data sources. Ovid MEDLINE®, PsycINFO®, Ovid Embase®, and the Cochrane EPOC (Effective Practice and Organisation of Care) register; hand searches of references of relevant studies.
Review methods. Two investigators screened abstracts and full-text articles of identified references for eligibility. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and other observational studies with comparators that evaluated cultural competence interventions aimed at reducing health disparities in the formal health care system. Two investigators abstracted data and assessed risk of bias. Given the sparse and patchy literature, which precluded pooling, a qualitative analysis is provided.
Results. Over 37,000 nonduplicated English- language citations were reviewed; 56 unique studies were identified as of June 2015: 20 randomized controlled trials (RCTs) and 5 observational studies for individuals with disabilities; 5 RCTs (6 manuscripts) and 6 observational studies for LGBT populations; and 14 RCTs (15 manuscripts), 4 observational studies, and 2 systematic reviews for members of racial and ethnic minorities. Interventions fell into four broad categories: (1) provider trainings and education; (2) interventions providing alteration of an established protocol, or the delivery of an established protocol, to meet the needs of a target population; (3) interventions prompting patients to interact with the formal health care system or health care providers; and (4) interventions aimed at providing
culturally competent care at the point of service.
Educational programs and trainings to improve professional students’ and providers’ cultural competence behavior are the most prevalent type of cultural competence intervention. Two existing high-quality systematic reviews of provider educational interventions for racial/ethnic minority populations found low-strength evidence that cultural competence training had mixed effects for intermediate outcomes and no effect on treatment outcomes. Sixteen studies aimed at changing provider attitudes and beliefs through training or curriculums were identified for the disability population. Eleven of these studies focused on reducing professional stigma toward people with serious or chronic mental illness; five focused on changing professional attitudes and beliefs about people with physical or intellectual disability. Three educational interventions were identified for the LGBT population. Several
short-term effects were evaluated; however, long- term effects of provider training on provider cultural competence behavior in the clinical setting and subsequent patient health outcomes have not been evaluated for the disability and LGBT populations. Two included studies reported a potential harm from provider training: an increase in negative attitudes or stigma resulting from intervention.
Interventions providing alterations of an established protocol were concentrated in the populations. The 12 studies of culturally tailored health care interventions for racial/ethnic minority populations focused primarily on treatment of chronic physical or
mental health conditions (e.g., diabetes, depression, substance abuse). Two psychological interventions were also tailored for members of the LGBT population.
Another common type of intervention was to provide additional resources to encourage or empower patients to interact with the formal health care system and/or health care providers. The stated aims of these types of interventions were to increase receipt of screenings for which disparities are well documented (e.g., Pap tests for people with mobility impairments or colorectal cancer screening among Latino immigrants) or to help patients engage in medical decisionmaking. These studies met inclusion criteria if the intervention was conducted by a medical professional in a formal health care system. One potential limitation of
these types of interventions is that they rely on strong identification with a common
culture. The population groups highlighted in this review are large and diverse. Creating an intervention for “African Americans” or “women who have sex with women” may be differentially effective for specific subpopulations.
The most common culturally competent point-of-service interventions were documents, similar to a hand-held medical record, that patients carried to their appointments to prompt providers to evaluate areas of known disparity for a specific population. These interventions may be coupled with provider notices or trainings. Virtual interventions were also considered culturally competent point-of-service interventions for some people with disabilities, as they create access in a unique way. These interventions are seen as conceptually parallel to infrastructure changes that improve access for people with physical disabilities.
For the majority of included studies, the risk of bias was high. The most common
methodological problems were lack of randomization to treatment, lack of attention control, little or no followup, and failure to report unintended consequences. Large segments of vulnerable or disadvantaged populations—such as children with disabilities; people who are gender nonconforming or transgender; or numerous racial or ethnic groups, including Native Americans or Alaskan Natives—remain essentially invisible in the cultural competence literature. The issue is compounded for people who are members of more than one priority population.
Conclusions. None of the included studies measured the effect of cultural competence interventions on health care disparities. Most of the training interventions measured changes in professional attitudes toward the population of interest but did not measure the downstream effect of changing provider beliefs on the care delivered to patients. Interventions that altered existing protocols, empowered patients to interact with the formal health care system, or prompted provider behavior at the point of care were more likely to measure patient-centered outcomes. The medium or high risk of bias of the included studies, the heterogeneity of populations, and the lack of measurement consensus prohibited pooling estimates or commenting about efficacy in a meaningful or responsible way. The term “cultural competence” is not well defined for the LGBT and disability populations, and is often
conflated with patient-centered or individualized care. There are many gaps in the
literature; many large subpopulations are not represented.
The growing population of nonnative English speakers in the United States challenges program planners to offer services that will effectively reach limited English proficiency (LEP) audiences. This article presents findings from evaluation research conducted with the Special Supplemental Program for Women, Infants, and Children (WIC) to identify best practices and areas of concern for working with LEP clients. Data were collected through online surveys of 338 WIC teaching staff in 2010 and 65 WIC local agency directors in 2011 as part of an implementation evaluation of client-centered nutrition education. Data identified current practices, facilitating factors, and challenges in working with LEP clients. Facilitating factors included cultural competency, material and translation resources, linguistic competency, professional development opportunities, and rapport with clients. Challenges cited included linguistic challenges, lack of cultural competencies, issues related to the client-staff interaction, and insufficient time, materials, and staffing. Best practices inferred from the data relate to developing linguistic standards for bilingual staff, considerations for translating written materials, interpretation services, cultural competency, and staff training. Findings may help inform the development of this and other linguistically and culturally appropriate health promotion programs.
© 2014 Society for Public Health Education.
This study examined associations between social and cultural capital levels and children's food consumption among Latino, Hmong, and non-Hispanic white parents. A total of 292 parents of K–2 children in Northern California completed a survey. Children's consumption and social and cultural capital levels among Latino, Hmong, and non-Hispanic white parents were measured. Hmong children had significantly higher consumption of vegetables and local produce compared to Latino and non-Hispanic white children. Parents with an open attitude toward food from other ethnic groups fed children significantly more vegetables. Additionally, children of parents with access to professional nutrition education consumed fewer processed and fast foods. Children of parents applying child feeding information from their own family or friends consumed fewer fruits and vegetables and more fast foods. Access to nutrition education from professionals and encouraging bridging cultural capital among parents from different ethnic/cultural groups through local produce promotion may be effective in increasing fruit and vegetable consumption among children.
Effective nutrition education can decrease the incidence of diet-related chronic diseases, including obesity, type 2 diabetes, cardiovascular disease, and hypertension. African Americans bear a disproportionately higher incidence and prevalence of diet –related chronic diseases. African Americans also have a higher attrition rate in research studies. Evaluating effectiveness, retention rates, educator perceptions of nutrition programs, and the perceived need for culturally relevant strategies for African Americans within nutrition education interventions are important aspects for developing acceptable and appropriate interventions to increase positive outcomes for African American participants.
Focus groups and individual interviews were conducted as part of a community needs assessment to determine the perceived needs of an African American community to develop appropriate programming. Using the same community, surveys were distributed to African American participants to assess the perceived need for culturally relevant strategies the African American community. Lastly, focus groups and individual interviews were conducted in this community to assess the implementation of culturally relevant strategies to increase African American participation in Iowa State University Extension programming. Focus groups and individual interviews were also conducted to determine educator perceptions of the use of the Transtheoretical Model of Behavior Change to increase fruit and vegetable consumption in a multi–state study for low income young adults. Data from a multi–state study to increase fruit and vegetable consumption was further analyzed to determine similarities and differences between African American and White participants to predict the characteristics of participant retention. Qualitative data was analyzed using NSR, and quantitative data was analyzed using SPSS, version 15.
Themes from the focus groups and survey indicate that culturally relevant strategies are preferred among African American participants. The educators indicated that the Transtheoretical Model of Behavior Change was a useful tool in providing nutrition education materials via the telephone. Similarities and differences between retained African American and White participants and within African American participants were determined. Future studies should examine preferential differences in receiving culturally relevant nutrition education strategies.
This article examines how nutrition outreach efforts address changing food practices among refugee populations resettled in the United States. Qualitative, ethnographic data for the article is drawn from the author's work with the Food and Nutrition Outreach program for resettled refugees and includes the perspectives of practitioners and refugees. Drawing on anthropological theories on the interplay between social meanings and structures of the political economy, the article examines how social meanings and socioeconomic processes facilitate changes in food practices. Findings on the topics of assessing nutritional needs, defining healthy eating, as well as the social organization and meaning of food practices illustrate the importance of going beyond dietary guidelines to incorporate discussion-based nutrition education between service providers and refugees. The article concludes with both practical and structural suggestions for next steps in nutrition programming for refugees.
Refugees in the United States have higher rates of some chronic diseases than US-born residents or other first-generation immigrants. This may be partially a result of dietary practices in the United States. There is limited information about which factors are related to dietary practices in refugee populations, particularly those who have been in the United States for 10 to 20 years. Research with Cambodian communities may be useful for examining the relationship between refugee characteristics and dietary practices. Two focus groups (n=11) and a survey (n=150) of Cambodian refugee women were conducted in Lowell, MA, from 2007 to 2008. χ(2) analyses, t tests, and analysis of variance tests were used to describe differences in dietary practices (24-hour recall and a targeted qualitative food assessment) by group characteristics. Higher acculturation was related to higher likelihood of eating brown rice/whole grains, and to lower likelihood of eating high-sodium Asian sauces. Higher education was related to higher likelihood of eating vegetables and fruits and to eating white rice fewer times. Nutrition education and receiving dietary advice from a health care provider were related to higher likelihood of eating whole grains/brown rice. Having a child at home was related to a higher likelihood of eating fast food. Among Cambodian refugees who have been in the United States for 10 to 20 years, dietary practices appear to have a relationship with acculturation (positive association), the interrupted education common to refugees (negative association), nutrition education from either programs or health care providers (positive association), and having a child at home (negative association).
To assess the readiness of the Western Region Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) states to implement participant-centered nutrition education (PCE) and to develop a PCE model for WIC service delivery.
Formative research including on-line survey, qualitative in-depth interviews, focus groups, and observational assessments.
WIC clinics within the Western Region WIC states.
State and local staff and WIC clients within 8 states, 2 tribal organizations, and 2 territories.
Readiness indicators of states to implement and expand PCE elements to include in PCE model development.
On-line surveys were collected and analyzed. On-site assessment forms, interviews, and focus group findings were collected, coded, and summarized by themes.
Key themes from state and local findings guided the model development for PCE implementation in the Western Region WIC states. The PCE model must be flexible and systems oriented, contain strong training and mentoring components, and integrate cultural sensitivity to best reach program participants.
The PCE model has the potential to improve WIC nutrition services and enable participants to make positive health-related behavior changes that will influence long-term health issues. Further outcome studies are needed to determine the success of PCE implementation in the Western Region WIC states.
To assess the attitudes, perceptions, and practices of staff of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in providing nutrition education on childhood overweight topics with WIC participants.
Descriptive and correlational study.
WIC clinics in Virginia.
106 employees working in direct contact with WIC participants. MEAN OUTCOME MEASURE(S): Demographic information; comfort level and frequency of discussing childhood overweight-related topics with participants; perception of WIC's ability to prevent and help address overweight among children and adults; body mass index (BMI); and attitudes toward personal weight.
Descriptive statistics, regression, and analysis of variance.
WIC staff in this study reported a lack of comfort, practice, and confidence in addressing and/or preventing childhood overweight with WIC participants, with differences existing based on job title (P < .05). Barriers to implementing programs included perceived attitudes of participants, transportation, time, cultural issues, and childcare. Staff BMIs were significantly correlated to ethnicity, age, feeling overweight, unhappiness with current weight, and comfort level discussing fruit and vegetable intake and physical activity (P < .05).
Staff training, health promotion programs, and culturally relevant educational materials are warranted for WIC staff to build a strong knowledge base and promote self-efficacy about childhood overweight-related topics.
This quasi-experimental study examined the effects of an empowerment-based nutrition promotion program on food consumption and serum lipid levels among hyperlipidemic Thai elderly. Fifty-six experimental subjects received the program; 48 control subjects maintained their habitual lifestyle. The statistical methods used were the t-test, Z-test, and chi2/Fisher's exact test. After the program, the consumption of high saturated fat, cholesterol, and simple sugar diets was significantly lower for the experimental group than for the control group. The percentage change of the serum total cholesterol of the experimental subjects was significantly higher than that of the control subjects. The number of experimental subjects that changed from hyperlipidemia to normolipidemia significantly increased compared to that for the control subjects. The implementation of this program was related to an improvement in food consumption and serum lipid levels among hyperlipidemic Thai elderly and, therefore, has implications for practice.
Dietary nutrient intakes of 91 Cambodian, 37 Laotian, and 59 Vietnamese low-income pregnant women attending a university teaching hospital outpatient clinic in Southern California were measured. The nutrient intakes of the Southeast Asian groups were compared with one another as well as with the intakes of a group of 165 low-income non-Southeast Asian pregnant women of similar height, weight, and age from the same outpatient clinic population. Computerized analysis of the 24-hour recall data showed that there were few differences in nutrient intake between the Southeast Asian groups, except that the Cambodian group consumed significantly less fat, riboflavin, vitamin D, and calcium than the Vietnamese group. However, there were a number of differences between the nutrient intakes of the Southeast Asian groups and those of the non-Southeast Asian group. These included significantly lower intakes of fat, riboflavin, folate, vitamins D and E, calcium, phosphorus, potassium, and magnesium and significantly higher intakes of thiamin, niacin, sodium, and selenium. These findings suggest that low-income Southeast Asian pregnant women have some good dietary habits that dietitians need to reinforce and other dietary habits that need improvement.
The traditional medical treatment model often ignores the emotional, spiritual, social, and cognitive aspects of living with a chronic disease such as diabetes. Empowerment programs address these psychosocial areas by helping individuals develop skills and self-awareness in goal setting, problem solving, stress management, coping, social support, and motivation. Although many diabetes educators have been taught to use an empowerment curriculum to facilitate self-management, there is minimal research concerning the actual process of providing such programs to patients. We evaluated an empowerment curriculum (Empowerment: A Personal Path to Self-Care) with a diverse group of individuals with diabetes to determine the key elements of planning and implementing a successful diabetes patient empowerment program.
Objective This study documents obstacles to successful lactation among Southeast Asian women. Design We assessed the infant feeding practices of 65 Hmong and 57 Vietnamese women. The women were recruited and interviewed at clinics of the Special Supplemental Food Program for Women, Infants, and Children (WIC) and neighborhoods in northern California. Analysis included logistic regression and odds ratios. Results Only 5 of the Hmong women and 3 of the Vietnamese women in our initial sample breast-fed their youngest child. Primary reasons for formula-feeding included convenience, the intent to return to work or school (although few did so), desire to allow others to feed, and the expectation of insufficient milk. In addition, most perceived that formula-feeding was more popular in the United States, and 19 of the Vietnamese women believed formula-feeding was healthier than breast-feeding. Variables positively related to breast-feeding included the number of times the mother was enrolled in WIC (for Hmong women) and the number of children previously breast-fed (for both groups). Breast-feeding was negatively related to the total number of children (for Hmong women), maternal age (for Vietnamese women), and receiving formula at the time of discharge from the hospital (for both groups). Applications/conclusions Promotion of breast-feeding among Southeast Asian women should focus on increasing the number of women who initiate breast-feeding, addressing attitudes regarding the popularity and convenience of formula-feeding, and discouraging hospital practices that may impede breast-feeding.
To characterize dietary intake patterns among Vietnamese immigrants, we developed a Vietnamese-language nutrition survey using items from the Centers for Disease Control's Behavioral Risk Factor Surveillance survey and other sources. We surveyed a random sample of 1011 Vietnamese adults in California using a computer-assisted telephone interviewing (CATI) system. Vietnamese respondents reported consuming a mean of 1.3 servings of fruits or fruit juices daily and 1.8 servings of vegetables daily, for a combined consumption of 3.1 servings of fruits and vegetables daily. Respondents reported frequent consumption of high-fat and high-cholesterol foods and frequent use of a variety of high-sodium condiments. Linear regression analyses showed that earlier immigrants were significantly less likely to consume eggs and salty foods, that younger individuals were more likely to consume beef and fried foods, and that males were significantly more likely to consume fried foods and to drink alcohol. A logistic regression analysis showed that respondents who were older than the median age of 37 years or who were high school graduates were more likely to have consumed five or more servings of fruits and vegetables during the previous 24-hour period. The results underscore the need to collect quantitative data regarding intake of dietary fat, cholesterol, sodium, and fiber among Vietnamese.
American women are not meeting their recommended dietary intake for calcium, with the lowest levels of intake being reported by low-income and minority women. Five focus group discussions were conducted with 34 low-income Vietnamese mothers (ages 25 to 47) to assess their nutrition education needs related to dietary calcium. Using the PRECEDE-PROCEED theoretical model, factors related to increasing dietary calcium intake were identified. Knowledge and attitudes related to calcium sources, barriers preventing recommended calcium intake, and preferred methods of receiving nutrition information were determined. Most participants did not consume the recommended number of dairy foods per day. Barriers to increasing dietary calcium intake were identified including taste, cost, time, unfamiliarity with dairy products, and, to a lesser extent, lactose intolerance. Many mothers did not know the diseases related to a low calcium intake. Misconceptions about the fat and calcium content of dairy products were common. Videotapes and print materials that include pictures of high-calcium foods were identified as desirable delivery methods for nutrition education. Friends, physicians, and the media were common vehicles of nutrition information. Children seemed to have a greater influence on their mothers’ food purchasing and preparation choices than did husbands.
Food habits and changes in food consumption patterns were assessed among 60 Southeast Asian refugee families (Cambodian and Hmong) living in the United States. With the use of a structured interview schedule, in-home interviews were conducted by a Hmong or a Cambodian bilingual staff person with the adult having primary responsibility for family meal preparation. Results indicated that while food buying practices have changed drastically in the U.S., Southeast Asian refugee families have maintained strong ties to their native foods and traditional diets. In the U.S., as in Southeast Asia, rice remains the staple food in their diet. High status foods in Cambodia and Laos, such as fruits, meats, and soft drinks, remain highly preferred foods in the U.S. and are consumed frequently. Although most adults prefer eating their native foods, their children prefer both American and native foods. Thirty percent of the adolescents in the home had major responsibility for evening meal preparation.
The rate of breastfeeding among immigrant Vietnamese women in Western countries is low compared to those in Vietnam. To counteract this trend, a language and culture specific education program was developed. An experimental design was used to test the effectiveness of this program. The sample consisted of 182 prenatal Vietnamese women. Data collection included questionnaires and interviews. Results suggested that the education program had significant effects on knowledge, attitudes, planned and actual behaviour towards breastfeeding. However, the effect did not sustain until 6 months postpartum. Implications for nursing practice and further research are discussed.
This study documents obstacles to successful lactation among Southeast Asian women.
We assessed the infant feeding practices of 65 Hmong and 57 Vietnamese women. The women were recruited and interviewed at clinics of the Special Supplemental Food Program for Women, Infants, and Children (WIC) and neighborhoods in northern California. Analysis included logistic regression and odds ratios.
Only 5 of the Hmong women and 3 of the Vietnamese women in our initial sample breast-fed their youngest child. Primary reasons for formula-feeding included convenience, the intent to return to work or school (although few did so), desire to allow others to feed, and the expectation of insufficient milk. In addition, most perceived that formula-feeding was more popular in the United States, and 19 of the Vietnamese women believed formula-feeding was healthier than breast-feeding. Variables positively related to breast-feeding included the number of times the mother was enrolled in WIC (for Hmong women) and the number of children previously breast-fed (for both groups). Breast-feeding was negatively related to the total number of children (for Hmong women), maternal age (for Vietnamese women), and receiving formula at the time of discharge from the hospital (for both groups).
Promotion of breast-feeding among Southeast Asian women should focus on increasing the number of women who initiate breast-feeding, addressing attitudes regarding the popularity and convenience of formula-feeding, and discouraging hospital practices that may impede breast-feeding.
The objectives were: to provide information about breast and cervical cancer and related screening services to minority ethnic women, to enable them to make well informed decisions and choices; to adopt a health education strategy based on a community development approach, augmented by a local publicity campaign; and to evaluate both the direct and indirect effects of this project. To this end a community development intervention study was made over 18 months from October 1991 to March 1993 in Bradford, a multicultural city with 87,000 residents from minority ethnic groups. The subjects of the study were 1,628 women from minority ethnic groups in three geographical areas of Bradford. A stratified sample of 1,000 women (670 South Asian, 163 African-Caribbean, 96 Eastern European and 71 other) was interviewed at the beginning of the project and six months after the health promotion intervention. Two specifically trained Health Promotion Facilitators from minority ethnic groups undertook community development work within three neighbourhoods in Bradford with the largest minority ethnic populations. There were group sessions in both formal and informal settings, which included health education about breast and cervical cancer and the associated screening programmes. These sessions were in the women's preferred languages and audio-visual material and a specially designed teaching pack were used. There were significant differences in the baseline levels of knowledge about cervical cancer and breast cancer across the different minority ethnic groups. The South Asian women had the lowest levels of knowledge and also showed the most significant improvements. Significant increases in attendance for cervical smear and breast cancer screening were self-reported. These were confirmed by anecdotal views of local health professionals. In addition, a local self-help group for South Asian women was established; also the contacts with other related organisations and professionals has helped to raise the issues of ethnically sensitive services within the voluntary and statutory sectors. A community development approach to health promotion is particularly valuable in communities with low levels of knowledge about a diseases or health service provision. Community development approaches often produce outcomes that had not been predicted. There is a need to conduct a definitive study in this area of health promotion for minority ethnic populations with emphasis on evaluation, cost-benefit analysis and opportunity costs.
To collect information on changes in dietary patterns among Asian students before and after immigration to the United States.
A questionnaire designed to collect information about background, changes in food habits, and frequency of food consumption from a 72-item food list was mailed to subjects.
Potential participants were students of local universities and junior colleges who were born in China, Taiwan, Hong Kong, Japan, or Korea and were aged 18 years or older. All subjects were required to have been residing in the United States for at least 3 months before the start of the study. Questionnaires were mailed to 120 potential participants.
Paired t tests were used to determine differences in eating patterns and frequency of food consumption of subjects before and after immigrating to the United States.
Seventy-one questionnaires were returned. Because of missing information on 8 of these questionnaires, only 63 were used in the analysis, which gave a response rate of 53%. The number of students consuming only 2 meals per day increased significantly; 29 (46%) respondents skipped breakfast because of their school schedules. Despite no significant change in the frequency of snack consumption, a majority (n = 46; 73%) of the respondents were consuming more salty and sweet snack items. Subjects were eating out less often, but they were selecting more American-style fast foods when they did eat out. Significant increases were noted in consumption of fats/sweets, diary products, and fruits, and significant decreases were noted in the consumption of meat/meat alternatives and vegetables after immigration to the United States.
Results of this study could be useful to dietetics practitioners as they observe changes in dietary patterns of Asian immigrants. These health professionals can use this information to plan nutrition education programs for Asian groups so that they can make informed decisions in adapting to new eating patterns and make wise food choices in their new environment. It is important to help Asian immigrants retain healthful food habits from their original country and to encourage them to choose eating patterns of the new culture that are nutritionally sound.
We describe a controlled trial of a community outreach intervention to promote recognition, receipt, and screening-interval maintenance of clinical breast examinations (CBE), mammograms, and Pap smears among Vietnamese-American women.
Over a 3-year period, indigenous lay health workers conducted small-group sessions of Vietnamese women in a low-income district of San Francisco, California. Women in Sacramento, California, served as controls. Lay workers conducted 56 sessions on general prevention, 86 on cervical cancer, and 90 on breast cancer. Surveys of 306 to 373 women were conducted in the study communities in 1992 and 1996.
In the intervention community, recognition of screening tests increased significantly between pre- and postintervention surveys: CBE, 50 to 85%; mammography, 59 to 79%; and Pap smear, 22 to 78% (P = 0.001 for all). Receipt of screening tests also increased significantly: CBE, 44 to 70% (P = 0.001); mammography, 54 to 69% (P = 0.006); and Pap smear, 46 to 66% (P = 0.001). Best-fitting logistic regression models, adjusting for preintervention rates and significant covariates, also showed statistically significant odds ratios for the intervention effect (P < 0.0001).
Trained Vietnamese lay health workers significantly increased Vietnamese women's recognition, receipt, and maintenance of breast and cervical cancer screening tests.
To describe the dilemmas for cross-cultural research in translating study instruments and implementing quality assurance methods, drawing on strategies utilised in the Mothers in a New Country (MINC) Study.
To translation of study instruments in the MINC Study included: forward and back translations, a bilingual group review process, consultation with bilingual content experts, piloting of different versions of translations, a process for exploring unresolved difficulties and caution in interpreting unusual study findings. Interview quality was assessed by: 1. An ongoing review of interviewer-prepared English coding schedules to ensure completeness of data and identify problems with interview administration. 2. Analysis of fully translated transcripts of six randomly selected early interviews to assess the accuracy and consistency with which questions were asked. 3. A comparison of data sources for 45 randomly selected interviews (original language interview schedules, English coding schedules and translated interview transcripts) to determine the rate and nature of discrepancies.
Translation strategies that went beyond simple forward and back translations achieved more reliable and appropriate translations. The complexity of language and cultural differences sometimes still meant less than satisfactory results. Interview tapes played an important quality assurance role, enabling feedback to the interviewers and providing a basis of comparison for identification of data discrepancies.
Ensuring good data quality in cross-cultural research is both critically important and difficult. Open discussion of the problems and concerted efforts to deal with them would benefit future research.
To discuss a range of strategies to address the methodological and practical challenges in designing cross-cultural public health studies.
The Mothers in a New Country (MINC) Study was an interview study of 318 Vietnamese, Turkish and Filipino recent mothers exploring their views of maternity care and the early months of motherhood. It was carried out in Melbourne between 1994 and 1997. Sampling, recruitment, retention and representativeness all pose problems for studies involving non-English-speaking background immigrant populations, as do selection, training and support processes for bicultural interviewers. These issues are discussed with reference to the strategies undertaken to tackle them in the MINC Study.
In the MINC Study, a systematic approach to sampling and recruitment, combined with a flexible and sensitive study protocol were largely successful both in achieving in adequate sample size and a largely representative study sample. Similarly, paying significant attention to the selection, training and ongoing support of the biocultural interviewers employed on the study contributed greatly to its successful completion and enhanced confidence in the study findings.
Both researchers and funders need to take seriously the implications of the many methodological and practical issues involved in designing sound cross-cultural public health studies. In particular, there are major implications for study costs and timelines. However, the benefits to be gained are significant.
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- D Sanjur
- M Rodriguez
Sanjur D, Rodriguez M. Assessing Food Consumption. Ithaca, NY: Division of Nutritional Sciences, Cornell University; 1997.
Nutritional Assessment
- R D Lee
- D C Nieman
Lee RD, Nieman DC. Nutritional Assessment. St. Louis: Mosby; 1996.
Behavioral Risk Factor Survey of Vietnamese-California
- S J Mcphee
- Cnh Jenkins
- S S Hung
McPhee SJ, Jenkins CNH, Hung SS, et al. Behavioral Risk Factor Survey of Vietnamese-California, 1991. MMWR Morb Mortal Wkly Rep.
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Breastfeeding: Investing in America's Future. Report of the Breastfeeding Promotion Committee
California Dept of Health Services. Breastfeeding: Investing in America's
Future. Report of the Breastfeeding Promotion Committee. Sacramento,
Calif: 1996.
Behavioral Risk Factor Survey of Vietnamese California, 1991
- McPhee
Prevalence of lactose malabsorption
- Scrimshaw