Sedentary lifestyles, high-energy diets and improvements in the standard of living are underpinning a worldwide disease epidemic associated with increasing rates of weight gain, overweight and obesity(Reference Cameron, Welborn and Zimmet1, 2). Overweight or obese individuals are at a higher risk of lifestyle-related diseases such as CVD, type 2 diabetes, cancer and other chronic health conditions(Reference Cameron, Welborn and Zimmet1, 3). The percentage of Australian men and women classified as obese doubled between 1980 and 1995(Reference Timperio, Cameron-Smith and Burns4). Using recent prevalence statistics for obesity from Diabetes Australia, it is calculated that the financial cost of obesity for Australia is around $AU8·3 billion per annum(5).
The increasing rates of obesity are not merely a result of an individual’s food and exercise choices(Reference Wang and Brownell6). Instead, changes in the physical and social environments contextualise behaviours and play increasingly important roles in the choices that individuals can make relating to food and exercise(Reference Canoy and Buchan7). While the environment has a considerable influence on eating patterns and activity levels and therefore body weight of an individual, another powerful influence is that of culture(Reference Sobal8). It is acknowledged that an individual’s cultural background impacts on all aspects of their lives, including their values, norms and beliefs about diet and physical activity(Reference Sobal8).
A particular population recognised to be at increased risk of obesity is migrant communities. There are many challenges for migrants arriving into new cultures, as they are placed into new food systems, and new social and built environments(Reference Sobal8). Although migration occurs in most areas of the world, generally people move from less industrialised societies into more industrialised societies(Reference Sobal8). During the acculturation process, migrants who have arrived from so-called developing countries are replacing traditional healthier foods and active lifestyles for the typical higher-fat, higher-density foods and more sedentary lifestyle of the host country(Reference Keller9). Thus, the acculturation process is associated with a higher risk of obesity and overweight(Reference Keller9).
Logan in south-east Queensland is a growing city that, as a favoured settlement area for migrants, hosts an increasing diversity of cultures(10). Between 2001 and 2006 the number of African and Pacific Islanders arriving in Logan increased substantially(10). With the large number of migrants arriving from culturally and linguistically diverse (CALD) backgrounds, Logan must look at new approaches to provide these communities with appropriate health and social services including information on nutrition(Reference Magnusson, Hulthén and Kjellgren11).
While health care is an essential component of efforts to deal with obesity, public health interventions focused on prevention should also be a priority to lessen the impact of the disease on individuals, communities and society as a whole(Reference Wang and Brownell6). A WHO consultation paper(2) identified nutrition and physical activity education for both adults and children as a strategy for obesity prevention. Most behavioural change models for health emphasise the importance of individuals gaining knowledge on specific health issues and incorporating this information into their daily activities(Reference Borzekowski and Rickert12). For new migrants from less industrialised countries, it is often not clear what level of knowledge they possess and therefore what information they need. Accordingly, the present study was oriented on understanding the nutrition information needs of the Pacific Islander and African communities of Logan.
Methods
The research was conducted using a needs assessment framework as an approach for collecting data about major community needs, issues or concerns(Reference Neuman13). Within such a framework of enquiry there are four interrelated types of needs.
• Normative needs: defined by professional experts and are generally a reflection of professional judgements and standards.
• Comparative needs: compare services and resources of similar groups or populations to determine how their needs are being met/not met for similar circumstances.
• Felt needs: identified by community members themselves and often referred to as ‘perceived’ needs related to services, information and support.
• Expressed needs: arise from the translation of a felt need into an action or articulated demand for services(Reference Jones, Katz and Sidell14–Reference Naidoo and Willis16).
Data collection and sampling
Consistent with a needs assessment process, multiple types and sources of data were incorporated into the study to create a rich and multi-faceted picture of the target community’s nutrition information needs. An integrative literature review was undertaken to gather and synthesise information on the comparative and normative needs, while semi-structured interviews were undertaken to collect data on felt and expressed needs. The interview questions were piloted with colleagues, several service providers and members of the target community. The interview protocol comprised open-ended questions structured around utilisation and limitations in available health-related services (expressed needs) and information needs including mode of delivery for the target community (felt needs). Interviews were mostly conducted in person at locations of convenience for the participants, with several being conducted via telephone due to transport or time constraints.
A non-probability method of sampling was used for the semi-structured interviews. A purposive sample was taken of the Logan Pacific Islander and African community members with a total of ten African community members (including Congolese, Ethiopian, Burundian and Sudanese participants) and five Pacific Islander community members (including Samoans, Cook Islanders, Tongans and Māori) participating in interviews. A snowball method of sampling was used to select eight service providers from the local council, government health organisations and non-government community organisations. The principal researcher for the project conducted all interviews to ensure consistency in approach and facilitate depth of understanding of the community’s perspective. The researcher was trained in cultural awareness and interview techniques, which, together with the use of an interview protocol, minimised interviewer bias. Ethics approval for the research was granted through the Griffith University Human Research Ethics Committee.
Data analysis
Data were organised and analysed using several methods. An integrative review of the academic and grey literature pertaining to normative and comparative needs was organised and examined at the international, national, state and local levels(Reference Neuman13). Data from the semi-structured interviews, conducted to examine the expressed and felt needs, were recorded and transcribed verbatim and then thematically analysed using emergent themes and phrases.
Results and discussion
At a broad level, preliminary analysis of the data obtained from the four needs identified two primary categories: nutrition information needs of the African and Pacific Islander communities and the delivery format for information. These categories encompass several interrelated factors, including the content of the information as well as the timing, format and barriers for delivering the information.
Information needs – content of the information
Upon arrival in Australia, the migrants received an overwhelming amount of information in a relatively short space of time(Reference Kelaher and Manderson17). According to the service providers, some migrants have never encountered many of the aspects of life that industrialised countries take for granted, such as cooking with electricity or catching a bus. In addition to enrolling in schools, English classes and establishing an income, they have to adjust to a new culture, new foods and different ideas about cooking methods and food hygiene(Reference Renzaho and Burns18). As one service provider stated:
If you have been given a pan each day with meal, all bland looking colours with a bit of oil and a bit of salt and that’s all you’ve had for 10 years and then you go to Woolworths – you can’t even conceptualise what that might be like.
Consistent with this comment, many service providers indicated that it is necessary to start from the basics as a way of establishing good practices and habits in early settlement to have a positive long-term impact on nutrition behaviours. Food safety was identified as the most immediate information need, to avoid alienation by the wider population and to avoid food-borne illnesses. As one community member suggested:
Teaching them that when they buy chicken from the markets they can’t carry it around in a plastic bag while they talk to people, they need to take it straight home.
Medeiros et al.(Reference Medeiros, Hillers and Kendall19) acknowledge that poor food-handling practices can result in serious illness, making food safety education crucial. They found that information should be constructed around personal hygiene, ensuring adequate cooking time and understanding cross-contamination(Reference Medeiros, Hillers and Kendall19). Cason et al.(Reference Cason, Nieto-Montenegro and Chavez-Martinez20) identified a similar need for skills and information in these areas for migrant workers in Pennsylvania, USA.
In addition to food safety, service providers highlighted the importance of knowing what is available at the supermarkets as another immediate information need:
We know for example that kids have taken tins of dog and cat food to school for lunch… It maybe has a fish… with maybe a cat looking at it and they don’t realise it’s food for a cat.
After this, many migrants need an introduction into the basics of Western-style cooking. This should include direction for using kitchen appliances, identifying and cooking with Australian ingredients, and basic budget strategies. As some community members stated:
I am still confused about some foods such as meat. How to cook it and what is in sausages for example.
There were some things that I didn’t know. There were many vegetables grown in Australia, but we didn’t think they were healthy.
While these comments indicate that there is a desire among the African community members to learn to cook with Australian ingredients, there is also a need for information on the ingredient content and nutritional composition of these unfamiliar foods. Likewise, Kruseman et al.(Reference Kruseman, Barandereka and Hudelson21) found that the main information need of an African migrant community in Geneva was for education on the names, uses and preparation of local foods in the absence of their traditional foods.
The Pacific Islanders acknowledged a need for information on similar topics, such as identifying unhealthy foods and cooking on a budget. However, some of their needs differ from those of the African communities. As one Pacific Islander community member commented:
… It’d be good if someone could do something… where they have easy meals with simple direction, cheap ingredients and variety.
This comment suggests that the Pacific Islanders want to improve their established cooking practices in order to overcome barriers to good nutrition such as convenience and cost(Reference Wang and Brownell6). The Pacific Islander community members also identified topics on portion sizes and incorporating a variety of ingredients in cooking.
The Pacific Islander community members also stated that they would like practical information on creatively presenting healthier foods such as fruit and vegetables for their children. There have been numerous successful interventions that have provided information on healthy eating for children through schools and child-care centres(Reference Carson and Reiboldt22). Although the African community members did not raise this topic as a potential need for information, this comment was made by a community member:
My kids told me what to pack for their school lunches, they said ‘yes you put this and this in’.
This quote highlights a potential latent need for information and education regarding food provided for school lunches. Healthy lunchbox ideas and breakfast choices for children were also requested by the Pacific Islander communities. While resources such as the Dietary Guidelines for Australians are designed to provide information on healthy eating to individuals and families, it would appear from the above comments that a more practical application of the guidelines is needed for CALD communities(Reference Patterson23).
Information needs – stages of need
Many of the service providers suggested the need for a staged approach to information delivery, in which information content is delivered based on length of time in the country. Service providers suggested that food safety and an introduction to supermarkets and the basics of Western-style cooking were the most immediate information needs. After meeting these initial needs, service providers suggested giving individuals or families time to establish their lives before providing them with further information:
… by six months they have orientated themselves to time and place and kids are in school and they might have even started English classes by then. Maybe then we could start talking the basics…
At 6 months the service providers outlined the Australian Dietary Guidelines and the importance of providing healthy lunchboxes for school-aged children as the next basic information needs.
Between 18 months and 3–4 years of being in Australia, service providers acknowledged that migrants understand more about their life in Australia and can relate it to their own health:
…People who have been here for about 18 months. They have a little bit more English, not very much but they feel comfortable, they know they can read street signs to get to places, they know they can catch trains and turn up to events.
According to the service providers this may be the time to discuss chronic health conditions with the community and how nutrition relates to their lifestyle including short- and long-term health.
Delivery of the information – deliverer of information
Kelaher and Manderson(Reference Kelaher and Manderson17) identified four main models of health service and health information delivery: bicultural health worker (BCHW); multicultural health worker; mainstream-cross cultural training; and mainstream. The four models range from a member of a specific ethnic community delivering health education and information for members of that same ethnic group as for the BCHW, to services that are not specifically tailored to address cultural differences such as a mainstream service(Reference Kelaher and Manderson17).
According to the service providers of Logan, African and Pacific Islander migrants have access to a range of mainstream health and social services including hospitals, medical doctors, child health clinics and Centrelink. Although these services are freely available to the whole population, they are not necessarily appropriate for people from CALD backgrounds. Language and cultural barriers can make it difficult for both the client and the service provider(Reference Hornberger, Itakura and Wilson24). As one service provider commented:
They [mainstream services] are not familiar with the interpreter service, they are using white middle class mainstream literature to educate, not being respectful of gender, religion…
This quote highlights the mismatch between services designed to meet the broader community’s needs and the more particular needs of CALD migrants. Furthermore, there is a distinct lack of nutrition-oriented services due to a lack of capacity within the system, with the service providers all agreeing that more culturally appropriate nutrition-related services are required. Previously, the African community members had stated that they received much of their information from non-government settlement services in Logan. As well as this, both African and Pacific Islander community members rely on family and friends within the community network to provide them with nutrition information.
My husband was here when I first arrived so I got lots of friends. So they help me do other stuff so in two weeks time I discover everything what we eat in Africa.
This highlights the peer support that exists within these migrant communities as well as the influence that friends and family have on an individual’s lifestyle. This has been similarly documented in other communities(Reference Green, Waters and Haikerwal25). Although small, these groups have a strong sense of community and tend to associate with those of the same nationality(Reference Dounchis, Hayden and Wilfley26). As social inclusion is very important to many of these groups, they utilise community networking and word of mouth to locate appropriate health and social services. Many service providers confirmed this, with the following comment:
…they will come through somebody’s door if they already know of somebody that has been to that service.
This quote identifies the importance of the ‘grapevine’ within migrant communities for information sharing. This has been suggested as an important strategy in other community development projects(Reference Dounchis, Hayden and Wilfley26). Many service providers felt that the most effective method of delivering information would be to increase the proportion of the workforce with a cultural background, rather than training a current service provider in cultural awareness. This could include a peer-to-peer learning approach in which members of the community are trained to deliver nutrition information:
We have to have people with a multicultural background delivering these programmes. It adds credibility…
…there is usually somebody in the community already and I think those kinds of people are much better at explaining the inner workings than we are.
The Go Girls! intervention used an academic to conduct small education sessions to deliver healthy eating and physical activity messages(Reference Resnicow, Yaroch and Davis27). Upon evaluation of the project it was discovered that delivering the information using a community member as the educator would have been more effective(Reference Resnicow, Yaroch and Davis27). Other projects such as the La Cocina Saludable education programme was successful because it identified established natural educators in the community and provided further training, in order for them to take on a ‘peer educator’ role(Reference Taylor, Serrano and Anderson28).
Delivery of the information – format for information delivery
Information needs to be delivered in a manner that is appropriate for the populations of interest. Several providers suggested a more hands-on and visual approach rather than providing written information:
…because some of the communities are not literate in their own language it needs to be much more visual. And… there needs to be lots of hands-on with them in that early settlement …
Actually being able to demonstrate in a hands-on manner and then having them do it for themselves
These statements indicate that the African and Pacific Islander community members would benefit from more personal styles of communication. Nutbeam suggests personal forms of communication assist people to develop the confidence to act on health knowledge(Reference Nutbeam29).
Delivery of the information – language
A major constraint for delivering nutrition information to African and Pacific Islander migrants is the existence of cultural and language barriers. When health and service providers do not share a common language and culture, the provision of health care can be compromised(Reference Hornberger, Itakura and Wilson24). Wadden and Stunkard(Reference Wadden and Strunkard30) suggested that delivering information to communities from CALD backgrounds requires a client-centred and flexible approach when there are substantial differences in language and cultural background between the information provider and client.
Occasionally, individuals are arriving from ‘new’ countries and there is no one to act as an interpreter. If there are interpreter services, they can be difficult to access, time-consuming to use and many health professionals are unfamiliar with using them:
I have experience being with a client and trying to use Telephone Interpreting Services (TIS). It was extremely hard, especially when you are with a client in a doctor’s surgery and the interpreter is on the phone.
In addition, trained interpreter services are costly and the quality of interpretation can suffer if an untrained interpreter such as a friend or family member is used(Reference Hornberger, Itakura and Wilson24). Likewise, service providers acknowledged that many health professionals lack time, funding and the cultural sensitivity or understanding to provide appropriate services to these migrant communities. Although culturally sensitive health service professionals are available, service providers believe that there is a need for more, as well as a better distribution of the workload.
Conclusions
Education and information are an important component of health promotion(Reference Wadden and Strunkard30). This is more than just receiving a brochure; consumers need access to appropriate health information coupled with sufficient health literacy to utilise this information(Reference Wadden and Strunkard30). Efforts to communicate health information to consumers must also acknowledge the social and environmental influences of lifestyle choices(Reference Wadden and Strunkard30). This project sought to identify the nutrition information needs of the African and Pacific Islander migrant communities of Logan using a needs assessment framework.
The importance of improving uptake of nutrition information by taking the capacities of the target audience into account was a key finding of the present study. The target population identified a preference for greater in-person and visual formats for information delivery, with hands-on demonstrations being particularly appropriate. Furthermore, these methods of information delivery should be undertaken by bicultural or ethnically similar persons to increase community and individual engagement. This would enable health workers to have a more intimate understanding of the African and Pacific Islander communities. This, in turn, would assist in minimising constraints and barriers to accessing nutrition information, such as language and cultural disparities between health workers and community members.
The present study has particularly identified that the content and timing of information should be based on a staged approach for information delivery that tailors information to community members based on their time in the country. Using the findings from the present study, the content of the information could be delivered as follows.
• Within 6 months of arrival: food safety; how to identify, cook and prepare Australian foods, and budgeting.
• Six to 18 months after arrival: information on the Australian dietary guidelines and healthy lunchboxes.
• Eighteen months to 3 years after arrival: education on the diet–disease relationships and how nutrition and physical activity impact on health.
Matching information dissemination strategies to needs and capabilities of target communities is critical for the uptake of the message. The cultural and linguistic diversity of the African and Pacific Islander communities of Logan and elsewhere across Australia presents many challenges for health service and health information delivery. Yet, if these communities are to be meaningfully assisted to integrate into the Australian society then service providers must develop information resources and interventions, including for nutrition, that are sensitive to the cultural norms and needs of the African and Pacific Islander communities.
Acknowledgements
The present study was supported by the Logan-Beaudesert Place Based Initiative of Queensland Health. The authors have no conflicts of interest. E.W. participated in the design of the study, conducted the study and analyses of the results, and participated in the preparation of the final manuscript. N.H. developed the basic idea for the study, participated in the design of the study, supervised the conduct of the study and analyses of the results, and participated in the preparation of the final manuscript.
