The community-based participatory approach

From a methodological standpoint, Arcan et al.⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} showed exemplary concern for the Somali, Latino and Hmong (SLH) cultural communities by insisting on reaching data saturation with sufficient focus groups and by discussing their findings and interpretation with said communities prior to planning public health interventions. The importance of cultural norms and beliefs for each ethnic community was then determined collectively. It adopts a social marketing approach in that interventions are dictated by client needs.

The community-based participatory research (CBPR) approach put forward also implies that researchers recognize that universal public health interventions are oversimplified, given the heterogeneity of their audiences and the complexity of eating behaviour. This concern was highlighted in Canada in a study we conducted on barriers experienced by different partners during the implementation of a healthy eating campaign targeting parents⁽ Reference Fernandez, Desroches and Marquis ^{2 )}. From a social marketing perspective, standards dictate that messages in national campaigns be tailored to different audiences. Although it requires considerable resources, a CBPR approach wherein community members contribute to research will produce local programmes that target specific cultural groups and, it is hoped, reduce health disparities.

Also important to emphasize is that it is imperative that researchers share their data interpretation with end users before public health nutrition interventions are developed. When data cannot be shared with end users, one very efficient alternative is to submit the data to an expert committee, where professionals can share their experiences working with specific clienteles. This can help others avoid developing well intended but less appropriate messages. Such an approach also exposes other experts to the project, so they can eventually spread the word about the interventions.

The challenge of reaching parents

Parents’ programmatic suggestions, such as those solicited in the research by Arcan et al.⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )}, are promising. Recommending family- and community-focused activities highlights the importance and need for social connectedness. In our own work, however, we have sometimes found it difficult to reach parents and it has been useful to address healthy food topics with caregivers who interact with pre-school children on a daily basis, as well as with educators in primary-school settings, and give them suggestions on proper eating practices. To contribute to childhood obesity prevention, we have used different approaches including formal training, a website and videos (French web resource: http://www.nospetitsmangeurs.org/). More recently, we have found that using legal-size posters about nutrition and shared responsibilities between adults and children is a promising tool for communicating with adults who work with children. The posters we have created contain few words and emphasize the behaviour we wish to promote. They avoid any words that could suggest caregivers must act in a specific way, since this could generate guilt or excessive worry. Social media has also enabled us to reach more people than expected, some of whom we hope are parents. In short, it is important to communicate consistent messages across different environments (home, pre-school services, school services, etc.). We expect that the more parents are exposed to the same messages from different sources, the more credible the messages will seem to them, which will either validate their current beliefs and behaviours or convince them to make changes. Again, for these interventions to be effective, we must never forget that they could generate unexpected attitudes or emotions.

Gaining insight into vulnerable family context

Beyond the similarities and cultural differences, Arcan et al.’s qualitative research⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} provided insight into the families’ structural and environmental issues and the daily pressures they face – threat of eviction, tight living spaces and financial constraints. In addition to this rich content, it would be useful to explore the perspectives of young people on daily living constraints as an additional source of information on barriers to healthy behaviour changes. Those data also suggest that training for health professionals must include a better understanding of cultural communities and the daily lives of different clienteles, through internships, literature and shared experiences. For example, at the Department of Nutrition, Université de Montréal, providing nutritionists with internship opportunities within organizations such as food banks that serve underprivileged clients has exposed trainees to a complex range of actions targeting different clienteles. Suggested readings⁽ Reference Bowen, Elliott and Brenton ^{3 )} for interns illustrate the real-life conditions of families struggling to apply our nutritional recommendations and have raised interns’ awareness about living conditions that most have never encountered or imagined. Today, more students come from diverse cultural communities, and we should consider offering them forums where they can share their cultural specificities with other health-care professionals.

The complex topic of parental responsibilities and food practices

On the topic of dietary behaviours, SLH parents in the study by Arcan et al.⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} clearly recognized the importance of their role modelling as well as the influence of the school food offering and media environments including advertising of unhealthy foods. Regarding the family environment, the data also revealed parental feeding practices and food-related messages to encourage their children to eat that relate to the topic of parental responsibilities. Interestingly, many of the reported attitudes are similar to those reported in studies among other populations. More precisely, these results suggest that we need to emphasize the responsibilities of parents and of young people regarding behaviour likely to promote healthy eating. Specifically, there is sufficient evidence on parenting practices to support knowledge transfer that reminds parents of their responsibilities toward their child’s eating behaviour, which can be adapted to the child’s age, but also to emphasize the responsibilities of the child, a concept developed by Satter⁽ Reference Satter ^{4 )}. The parent’s responsibility for what, when and where the child eats, and the child’s responsibility for how much, appear to be central to several concerns reported in Arcan et al.’s⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} paper directly related to food practices that promote healthy eating and healthy relationships with food.

If properly understood and combined with a gradual change in parenting behaviours, this sharing of responsibilities between parents and children is a topic worth discussing with members of different cultures to determine if it is acceptable to them. If accepted, we may then begin with knowledge transfer. The parental responsibilities must then be transmitted as early as possible, starting with the introduction of solids during early childhood. Introducing these notions of parental responsibilities does pose certain challenges, as they touch upon the subject of a parental role model and, indirectly, parental food habits and preferences. This would be a complex agenda that dictates a step-by-step family approach supported by school and community interventions that ideally promote these same messages. Moreover, while addressing parental responsibilities is a promising avenue, it should not lead to interventions that may evoke guilt among parents who are already seriously concerned by other social matters, such as finances.

In terms of parental responsibilities, Arcan et al.’s data⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} suggest some favourable attitudes on topics such as the importance of meal preparation, sharing family meals, snacks, beverage choice and the transfer of cultural practices between generations. However, it appears more difficult to manage children’s influence on what is being offered, to recognize the child’s ability to decide how much to eat and to deal with children’s attitudes towards adults who prepare their meals. These attitudes are inevitably accompanied by parents’ food practices, as reported for Somali and Hmong parents, such as obliging their children to eat, which, while well intentioned, are not conducive to the development of healthy eating habits. While studying Canadian mothers’ use of strategies with their 10-year-old children, we found four different contexts in which children are pressured to eat: food purchasing, food preparation, meal service and food consumption⁽ Reference Marquis and Claveau ^{5 )}. Many of the strategies illustrate the burden of tasks a mother takes on to ensure that her child consumes a particular food, not taking into account the appetite of the child and the undesirable effect of strategies associated with forcing the child to eat. This underscores the importance of interpersonal influences on children’s eating behaviour.

Interestingly, regarding SLH parents’ perceptions of healthy-weight children, Arcan et al.’s findings⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} suggest positive attitudes towards body diversity. Comments on the appearance of the skin and other physical and emotional characteristics as health indicators are also of interest. From time to time, qualitative studies could be used to explore the meaning given to different constructs, such as body image, body weight, and healthy eating or cooking⁽ Reference Wolfson, Bleich and Smith ^{6 )}. This may reveal false perceptions or unexpected associations, or that public health nutrition messages are making headway and being progressively integrated.

Planning, cooking and sharing family meals

It is worth mentioning that Arcan et al.⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} reported few differences in relation to the gender of the young people, or to the division of tasks between mothers and fathers in the home, with regard to menu planning, food purchasing, cooking and cleaning, although only 16 % of participants were men. Overall, taking a closer look at the factors that could help families incorporate practices such as meal planning and cooking into their schedule, we see that time constraints interfere with families’ ability to sustain the desired practices in the long run. Nevertheless, focusing on task sharing in families not only lightens the workload of mothers, but can also carry the added benefit of revealing missed opportunities for young people to learn cooking skills.

Moreover, family meals, valued by Latino and Somali parents, certainly need more attention if they are to be a time when parents and youth can talk without conflict regarding food behaviour, such as obliging children to eat. Previous studies of families with children as young as 4 years old have revealed that mothers find family meals to be a stressful time of the day. The combination of parents wishing their children would eat all their food (although they may not be hungry), discussions with older children and everyone being generally tired is not conducive to the family meal as we have envisaged it.

We have explored cultural differences in Haitian, Portuguese and Vietnamese mothers’ food choice motives (e.g. health, pleasure and familiarity) and how important it was for them to take the time to eat together. Our results confirm that ethnic origin, after migration, remains an important factor in the food choice process and that it continues to be an independent determinant of the importance ascribed to family meals. For example, while health and pleasure factors were overall predictors of the importance of family meals among mothers from all three groups, when cultural origin was considered, health concerns emerged as the only salient motivation among Haitian and Portuguese mothers. In other words, determinant attributes may differ between cultural groups, and developing culturally sensitive strategies to promote the health benefits of family meals would no doubt help us capture the targeted audience’s attention⁽ Reference Marquis and Shatenstein ^{7 )}.

The adolescence challenge

The children’s ages in Arcan et al.’s study⁽ Reference Arcan, Culhane-Pera and Pergament ^{1 )} were quite heterogeneous, ranging from 3 to 12 years. The specificities of adolescents’ dietary behaviours, such as their eventual desire for greater autonomy in selecting and eating food, their financial capacity to buy food away from home and the influence of peers in their expression of food preferences, are beginning to emerge but are not yet major concerns for the parents. These changes related to adolescence will need to be addressed. Our findings with Canadian families reveal that at around 12 years of age, young people still report that their mothers heavily influence their food selection⁽ Reference Baril, Ouimet and Bergeron ^{8 )}. However, their peers have increasing influence over their snack and beverage choices. The physical presence of their parents dictates the expected behaviour at home, but when away from their parents’ watchful eye, these young adolescents are beginning to assert their independence by choosing foods based on their own food preferences and those of their peers, and not according to their parents’ suggestions (M Marquis, A Allaire, C Lebel et al., unpublished results).

Sources of information in cultural communities

Lastly, the sources of information these parents prefer and the credibility they give to practitioners from the same cultures may be interesting avenues to explore. The findings reveal not only their sources of information (e.g. doctors for Hmong parents) but their myths and expectations. From this perspective, it may be useful to encourage young people from cultural minority groups to pursue postgraduate studies in health programmes and/or social sciences, and to consider ways to promote their enrolment in the programmes. Such an approach has been used, for example, to increase the number of students from indigenous communities who are enrolled in medical studies, or students in areas of study not related to health (e.g. the arts) enrolled in science and medical studies.

In short, while studying perceptions of parents from specific cultural groups presents numerous challenges, it does offer public health nutritionists opportunities to review the pertinence of an unsegmented approach and to emphasize the need to integrate different cultural realities into training programmes for health professionals. While there are many common themes among the various family studies, such as parental responsibilities, meal preparation, family meals, etc., evaluating how efficiently future strategies that are culturally sensitive are able to transfer knowledge is a promising avenue of research.