Barriers and enhancers to dietary behaviour change for Aboriginal people attending a diabetes cooking course

Exploring Healthy Eating Perceptions, Barriers, and Facilitators among Urban Indigenous Peoples in Saskatchewan

Urban Indigenous populations encounter distinctive challenges in maintaining traditional dietary practices, compounded by the complexities of socio-economic and environmental factors and the modern urban lifestyle. This qualitative study explores the perceptions of healthy eating, along with the facilitators and barriers to such practices, among urban Indigenous peoples in Saskatoon, Regina, and Prince Albert. Through virtual interviews, we engage 14 participants from these cities. Utilizing NVivo for thematic coding, we apply inductive thematic analysis to reveal relevant themes. The study highlights a preference for nutrient-rich, natural, and minimally processed foods, with a significant emphasis on incorporating traditional Indigenous foods into diets. These preferences are deeply entwined with cultural identity and underscore the importance of traditional foods in maintaining cultural heritage and promoting well-being. Despite the intrinsic value of these traditional foods, participants face several barriers to healthy eating, including economic constraints, limited access to traditional foods, and the psychological impacts of historical trauma. Nevertheless, facilitators such as community and family support, engagement in traditional food practices, and a growing awareness of nutritional knowledge are identified as being crucial in supporting healthy dietary choices. This research underscores the complex interplay of cultural, economic, and environmental factors in shaping the dietary practices of urban Indigenous peoples.

Feasibility of Cooking Matters for Diabetes: A 6-week Randomized, Controlled Cooking and Diabetes Self-Management Education Intervention

BACKGROUND

Diabetes self-management education and support is the cornerstone of diabetes care, yet <10% of adults with diabetes manage their condition successfully. Feasible interventions are needed urgently.

OBJECTIVE

Our aim was to assess the feasibility of a cooking intervention with food provision and diabetes self-management education and support.

DESIGN

This was a waitlist-controlled, randomized trial.

PARTICIPANTS/SETTING

Thirteen adults with type 1 or type 2 diabetes who participated in Cooking Matters for Diabetes (CMFD) participated in 2 focus groups.

INTERVENTION

CMFD was adapted from Cooking Matters and the American Diabetes Association's diabetes self-management education and support intervention into a 6-week program with weekly lesson-aligned food provisions.

MAIN OUTCOME MEASURES

Feasibility was evaluated quantitatively and qualitatively along the following 5 dimensions: demand, acceptability, implementation, practicality, and limited efficacy.

STATISTICAL ANALYSIS

Two coders extracted focus group themes with 100% agreement after iterative analysis, resulting in consensus. Administrative data were analyzed via descriptive statistics.

RESULTS

Mean (SD) age of focus group participants was 57 (14) years; 85% identified as female; 39% identified as White; 46% identified as Black; and income ranged from <$5,000 per year (15%) to $100,000 or more per year (15%). Mean (SD) baseline hemoglobin A1c was 8.6% (1.2%). Mean attendance in CMFD was 5 of 6 classes (83%) among all participants. Demand was high based on attendance and reported intervention utilization and was highest among food insecure participants, who were more likely to report using the food provisions and recipes. Acceptability was also high; focus groups revealed the quality of instructors and interaction with peers as key intervention strengths. Participant ideas for implementation refinement included simplifying recipes, lengthening class sessions, and offering more food provision choices. Perceived effects of the intervention included lower hemoglobin A1c and body weight and improvements to health-related quality of life.

CONCLUSIONS

The CMFD intervention was feasible according to the measured principles of demand, acceptability, implementation, practicality, and limited efficacy.

Barriers and facilitators to diet, physical activity and lifestyle behavior intervention adherence: a qualitative systematic review of the literature

BACKGROUND

Consuming a balanced diet and regular activity have health benefits. However, many adults have a difficult time adhering to diet and activity recommendations, especially in lifestyle interventions. Adherence to recommendations could be improved if common facilitators and barriers are accounted for in intervention design. The aim of this systematic review was to understand perceived barriers and facilitators to lifestyle (diet and/or activity) intervention guidelines.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies included relied on qualitative methods to explore the barriers and facilitators healthy adults ([Formula: see text] 18 years) experienced in lifestyle interventions. Google Scholar, Cochrane Reviews, Medline, PubMed, and Web of Science were searched from January 2005 to October 2021. Main themes from each paper were thematically analyzed and reported as a barrier or facilitator to adherence at the individual, environment or intervention level using inductively derived themes. Study quality was assessed using the Critical Appraisal Skills Programme.

RESULTS

Thirty-five papers were included. Of these, 46% were conducted in North America and the majority had more female participants (86% in mixed-sex studies, 26% females only). Similar themes emerged across all three levels as facilitators and barriers. At the individual level, attitudes, concern for health and physical changes. At the environmental level, social support, social accountability, changeable and unchangeable aspects of the community. Finally, delivery and design and content at the intervention level. An additional facilitator at the intervention level included fostering self-regulation through Behavior Change Taxonomies (BCT).

CONCLUSIONS

Lifestyle interventions that foster self-regulatory skills, opportunities for social engagement and personalization of goals may improve behaviour adherence. This can be achieved through inclusion of BCT, tapering off of intervention supports, identification of meaningful goals and anticipated barriers with participants.

Healthy lifestyle initiatives for increasing fruit and vegetable intake among Aboriginal and Torres Strait Islander peoples: a rapid review

Adequate fruit and vegetable intake is key to reducing chronic disease risk among Australian Aboriginal and Torres Strait Islander peoples. This rapid review collated evidence on healthy lifestyle initiatives that focused on increasing fruit and vegetable intake among Australian Aboriginal and Torres Strait Islander peoples residing in major cities. Due to limited studies conducted within major cities, we extended our inclusion criteria to regional and remote areas. Sixteen studies were included. Five (31%) studies were rated as good quality (least risk of bias), ten (63%) were rated as fair, and one (6%) was rated as poor (significant risk of bias). Five (31%) studies employed participatory research in the design and/or execution, and seven (44%) studies included minimal community involvement. Only five (31%) studies were undertaken in major cities; four of these combined major cities with regional and/or remote areas. All five studies reported positive findings, such as an increase in fresh fruit availability, usage of fresh vegetables, or self-reported fruit and vegetable intake. This review provides evidence confirming the need for high-quality healthy lifestyle initiatives to increase fruit and vegetable intake targeted at Aboriginal and Torres Strait Islander peoples living in major cities. This evidence will assist community organisations in designing effective health promotion interventions, providing insight into improving the structure and function of such programs. PROSPERO registration number: CRD42020194522 Novelty • Five studies were undertaken in major cities and all reported positive findings; only one study was rated as good quality. • Presented data supports the need for high-quality studies to be conducted among those residing in major cities.

Interventions to address food insecurity among Aboriginal and Torres Strait Islander people: a rapid review

Food insecurity disproportionately impacts Aboriginal and Torres Strait Islander Australians. This review sought to investigate research and evaluations of programs and interventions implemented to address food insecurity among Aboriginal and Torres Strait Islander communities. A rapid review was conducted to collate the available research from 6 databases. The search was conducted in May 2020. Search constructs related to food insecurity, Aboriginal and Torres Strait Islander people, and Australia. Twenty-five publications were included in this review, 24 reported on an intervention, while 9 were evaluations of an intervention. Interventions included behaviour change projects, including projects that sought to change purchasing and cooking behaviours, school-based education programs, and gardening programs. In general, the studies included in this sample were small and lacked a systematic consideration of the factors that shape the experience of food insecurity among Aboriginal and Torres Strait Islander people specifically. Based on the findings of this review, authors suggest greater consideration to the systematic determinants of food insecurity among Aboriginal and Torres Strait Islander communities to have lasting and sustainable impact on food insecurity. This review has been registered with the international prospective register of systematic reviews (PROSPERO: CRD42020183709). Novelty: Food insecurity among Aboriginal and Torres Strait Islander people poses significant risk to health and wellbeing. Small-scale food security interventions may not provide ongoing and sustained impact. Any intervention to promote food security will need to involve Aboriginal and Torres Strait Islander people and be sustained once external parties have left.

Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence

Background

Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples’ concerns and priorities about food and nutrition in order to inform policies to improve health equity.

Methods

MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies–published from January 2008–that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health.

Results

Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture.

Conclusions

Documenting Aboriginal and Torres Strait Islander Peoples’ lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01551-x.

For whom and under what circumstances do nutrition-education cooking interventions work: a realist synthesis

OBJECTIVE

To explore for whom and under what circumstances nutrition-education cooking interventions affect nutrition outcomes in adults.

METHODS

A realist synthesis was undertaken. The CINAHL, Ovid Medline, Scopus, and Web of Science databases were searched for literature published between 1980 and 2019, using the terms "cook" and "intervention" and their synonyms; 5759 articles were identified. Grey literature was sourced for further additional program context. A total of 23 articles (n = 11 programs) met inclusion criteria for analysis. Program data were coded in duplicate for context, outcome, and mechanism configurations, and used to build a refined program theory.

RESULTS

Nutrition-education cooking interventions targeted at low-socioeconomic-status and marginalized populations produced a range of positive nutrition outcomes. Outcomes were observed when the program involved hands-on cooking and a skilled facilitator coupled with individual self-efficacy, knowledge gain, family support, and an expectation of positive health outcomes.

CONCLUSION

These findings highlight key program components to achieve improvements in nutrition and important recommendations for nutrition-education cooking interventions.

Perceptions of Aboriginal and Torres Strait Islander Australians toward cardiovascular primary prevention programs: A qualitative systematic review

OBJECTIVE

To synthesize the best available qualitative evidence on the perceptions of Aboriginal and Torres Strait Islander Australians (hereafter, respectfully referred to as Indigenous Australians) toward participation in cardiovascular primary prevention programs.

BACKGROUND

In 2017, cardiovascular disease was the leading cause of premature mortality in Indigenous Australians, accounting for 11.5% of all deaths. Health risk behaviors such as smoking, physical inactivity, poor nutrition, and obesity largely contribute to this burden of disease.

METHODS

A search using MEDLINE, CINAHL, EMBASE, PubMed, Google Scholar, MedNar, ProQuest and Index to Theses for published and unpublished studies was conducted in January 2020. The methodological quality of the included studies was independently assessed by two reviewers using the Joanna Briggs Institute (JBI) critical appraisal tool. Data extraction and meta-aggregation were conducted in accordance with JBI methodology.

RESULTS

Eleven studies were included. Three synthesized findings were developed (a) social and community support affect participants' experiences of prevention programs; (b) structural drivers and social determinants influence Indigenous Australians experiences and participation in prevention programs and health risk behavioral change; and (c) a personal desire to change behaviors and participate in prevention programs requires development of knowledge regarding healthy lifestyles and creation of new social norms.

CONCLUSIONS

Indigenous Australians participation in primary prevention for cardiovascular risk factors and adoption of a healthy lifestyle are influenced by social support, social determinants, and personal desire. Future programs need to tackle the structural drivers and facilitate a supportive environment to assist in health risk behavior change.

Health-related behaviours in a remote Indigenous population with Type 2 diabetes: a Central Australian primary care survey in the Telehealth Eye and Associated Medical Services Network [TEAMSnet] project

AIM

There is a wealth of data concerning the health behaviours of Indigenous Australians, but the health behaviours of Indigenous Australians with diabetes are not systematically documented. At the clinical level, understanding a person's health behaviours can help identify and address barriers to diabetes care and promote good clinical outcomes.

METHODS

We used a novel survey tool to systematically collect health behaviour data on Smoking, Nutrition, Alcohol consumption, Physical activity and Emotional well-being (SNAPE) from Indigenous Australians with Type 2 diabetes in a remote primary care setting in Alice Springs.

RESULTS

At least one of the five surveys in the SNAPE tool was completed by 210 participants: 30% male, mean age 52.6 years (range 22.9 - 87.4). Fifty per cent of men and 23% of women were current smokers (P < 0.001). None of the participants reported an adequate intake of vegetables. Only 9.6% reported an adequate fruit intake. Some 49% of men and 32% of women consumed alcohol in the past year (P = 0.022), and 46% of drinkers were considered high-risk or likely-dependent drinkers. On average, participants walked 10 min or more at a time 6.0 days a week and spent 4.8 h sitting on a weekday. Mean adapted Patient Health Questionnaire 9 score was 4.61, with 34% of participants having mild depressive symptoms and 11% having moderate-severe depressive symptoms.

CONCLUSIONS

Our SNAPE survey tool results present a high-risk, disadvantaged Indigenous population with Type 2 diabetes. More resources will be needed to sustainably implement interventions with the goal of improving health behaviours and subsequent long-term health.

Geographical analysis of evaluated chronic disease programs for Aboriginal and Torres Strait Islander people in the Australian primary health care setting: a systematic scoping review

BACKGROUND

Targeted chronic disease programs are vital to improving health outcomes for Indigenous people globally. In Australia it is not known where evaluated chronic disease programs for Aboriginal and Torres Strait Islander people have been implemented. This scoping review geographically examines where evaluated chronic disease programs for Aboriginal people have been implemented in the Australian primary health care setting. Secondary objectives include scoping programs for evidence of partnerships with Aboriginal organisations, and use of ethical protocols. By doing so, geographical gaps in the literature and variations in ethical approaches to conducting program evaluations are highlighted.

METHODS

The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a published protocol. This scoping review was undertaken in accordance with the Joanna Briggs Institute (JBI) scoping review methodology. The search included 11 academic databases, clinical trial registries, and the grey literature.

RESULTS

The search resulted in 6894 citations, with 241 retrieved from the grey literature and targeted organisation websites. Title, abstract, and full-text screening was conducted by two independent reviewers, with 314 citations undergoing full review. Of these, 74 citations evaluating 50 programs met the inclusion criteria. Of the programs included in the geographical analysis (n = 40), 32.1% were implemented in Major Cities and 29.6% in Very Remote areas of Australia. A smaller proportion of programs were delivered in Inner Regional (12.3%), Outer Regional (18.5%) and Remote areas (7.4%) of Australia. Overall, 90% (n = 45) of the included programs collaborated with an Aboriginal organisation in the implementation and/or evaluation of the program. Variation in the use of ethical guidelines and protocols in the evaluation process was evident.

CONCLUSIONS

A greater focus on the evaluation of chronic disease programs for Aboriginal people residing in Inner and Outer Regional areas, and Remote areas of Australia is required. Across all geographical areas further efforts should be made to conduct evaluations in partnership with Aboriginal communities residing in the geographical region of program implementation. The need for more scientifically and ethically rigorous approaches to Aboriginal health program evaluations is evident.

Putting urban Aboriginal and Torres Strait Islander food insecurity on the agenda

Food insecurity adversely affects diet quality, physical, mental and social wellbeing and the capacity to act on health advice recommended by primary healthcare providers. In this article, an overview of the neglected issue of food insecurity in urban Aboriginal and Torres Strait Islander communities is provided. Policy and action on food security for urban Aboriginal and Torres Strait Islander people is reviewed, and it is argued that for primary health care to better address food insecurity, an evidence base is needed to understand the experiences of individuals and households and how to work effectively to support food insecure clients.

Mediators and moderators of nutrition intervention effects in remote Indigenous Australia

We conducted a longitudinal dietary intervention study to assess the impact of a store-based intervention on mediators and moderators and consequent dietary behaviour in Indigenous communities in remote Australia. We assessed dietary intake of fruit, vegetable, water and sweetened soft drink, mediators and moderators among 148, eighty-five and seventy-three adult participants (92 % women) at baseline (T1), end of intervention (T2) and at 24 weeks post intervention (T3), respectively. Mediators included perceived affordability and self-efficacy. Moderators were barriers to eat more fruit and vegetables and food security. Mixed-effects models were used to determine changes in mediators and moderators with time and associations between these and each dietary outcome. Perceived vegetable affordability increased from T1 (19 %; 95 % CI 11, 27) to T2 (38 %; 95 % CI 25, 51) (P=0·004) and returned to baseline levels at T3. High self-efficacy to eat more fruit and vegetables and to drink less soft drink decreased from T1 to T3. A reduction in soft drink intake of 27 % (95 % CI −44, −4; P=0·02) was reported at T3 compared with T1; no changes with time were observed for all other outcome measures. Regardless of time, vegetable intake was positively associated with self-efficacy to cook and try new vegetables, no barriers and food security. The dietary intervention went someway to improving perceived affordability of vegetables but was probably not strong enough to overcome other mediators and moderators constraining behaviour change. Meaningful dietary improvement in this context will be difficult to achieve without addressing underlying constraints to behaviour change.

Making dietary changes following a diagnosis of prediabetes: a qualitative exploration of barriers and facilitators

AIM

To explore the experiences of people recently diagnosed with prediabetes and overweight or obese in making dietary changes following a six-month primary care nurse-delivered dietary intervention pilot.

METHODS

Semi-structured interviews were conducted with 20 participants, purposefully selected to ensure a mix of ethnicity, gender and glycaemic outcome. Thematic analysis of interview data was undertaken.

RESULTS

Participants described feeling shocked when they received the diagnosis of prediabetes. Three core themes, each containing subthemes, emerged: (i) supportive factors - determination not to develop diabetes, clear information and manageable strategies, and supportive relationships; (ii) barriers - lack of family support, financial constraints, social expectations around food, and chronic health issues; and (iii) overcoming challenges - growing and sharing food, using frozen vegetables and planning. Challenges related to cultural expectations around providing and partaking of food were more evident for indigenous Māori participants.

CONCLUSIONS

A diagnosis of prediabetes provides a window of opportunity for healthcare professionals to work with those diagnosed and their families to make healthful dietary changes. Dietary guidance is likely to be most effective when individuals' life circumstances are taken into account. Clear information and supportive relationships to facilitate lifestyle change are extremely important. (Clinical Trials Registry No; ANZCTR ACTRN1261500080656).

Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis

Objectives Diet modification is an important part of the prevention and treatment of type 2 diabetes, but sustained dietary change remains elusive for many individuals. This paper describes and interprets the barriers to diet modification from the perspective of people with type 2 diabetes, paying particular attention to the experiences of people who experience social marginalization. Methods A systematic review of primary, empirical qualitative research was performed, capturing 120 relevant studies published between 2002 and 2015. Qualitative meta-synthesis was used to provide an integrative analysis of this knowledge. Results Due to the central role of food in social life, dietary change affects all aspects of a person's life, and barriers related to self-discipline, emotions, family and social support, social significance of food, and knowledge were identified. These barriers are inter-linked and overlapping. Social marginalization magnifies barriers; people who face social marginalization are trying to make the same changes as other people with diabetes with fewer socio-material resources in the face of greater challenges. Discussion A social-ecological model of behavior supports our findings of challenges at all levels, and highlights the need for interventions and counseling strategies that address the social and environmental factors that shape and sustain dietary change.

Critical review of behaviour change techniques applied in intervention studies to improve cooking skills and food skills among adults

BACKGROUND

Cooking and food skills interventions have grown in popularity; however, there is a lack of transparency as to how these interventions were designed, highlighting a need to identify and understand the mechanisms of behavior change so that effective components may be introduced in future work. This study critiques cooking and food skills interventions in relation to their design, behavior change techniques (BCTs), theoretical underpinnings, and outcomes.

METHODS

A 40-item CALO-RE taxonomy was used to examine the components of 59 cooking and food skills interventions identified by two systematic reviews. Studies were coded by three independent coders.

RESULTS

The three most frequently occurring BCTs identified were #1 Provide information on consequences of behavior in general; #21 Provide instruction on how to perform the behavior; and #26 Prompt Practice. Fifty-six interventions reported positive short-term outcomes. Only 14 interventions reported long-term outcomes containing BCTs relating to information provision.

CONCLUSION

This study reviewed cooking and food skills interventions highlighting the most commonly used BCTs, and those associated with long-term positive outcomes for cooking skills and diet. This study indicates the potential for using the BCT CALO-RE taxonomy to inform the design, planning, delivery and evaluation of future interventions.

Testing a Model of Sodium Reduction in Hypertensive Older Thai Adults

Hypertensive older adults will benefit if there is a clear understanding of the factors related to sodium reduction. That would raise awareness of the causes, consequently reducing many health risks, lowering health care costs, and diminishing economic and social burden from high blood pressure. This study explored predictors of urinary sodium excretion. A cross-sectional, correlational study was conducted in 312 hypertensive older Thai adults. Questionnaires related to knowledge, self-care agency, self-care behavior of sodium reduction, and 24-hour urinary sodium analyses were used, followed by the application of structural equation modeling and the Analysis of Moment Structures program. Self-care agency, knowledge, self-care behavior, rural/urban location, and education accounted for 61% of urinary sodium excretion. Self-care agency, knowledge, and self-care behavior were the main predictors in the urinary sodium excretion model. This study suggests establishing supportive educative sodium reduction-related programs that improve knowledge and enhance self-care agency, as well as a comparison of the changes of sodium reduction self-care behavior and urinary sodium excretion over time after the intervention.

Ready, set, go: a cross-sectional survey to understand priorities and preferences for multiple health behaviour change in a highly disadvantaged group

Background

Socially disadvantaged groups, such as Aboriginal Australians, tend to have a high prevalence of multiple lifestyle risk factors, increasing the risk of disease and underscoring the need for services to address multiple health behaviours. The aims of this study were to explore, among a socially disadvantaged group of people attending an Aboriginal Community Controlled Health Service (ACCHS): a) readiness to change health behaviours; b) acceptability of addressing multiple risk factors sequentially or simultaneously; and c) preferred types of support services.

Methods

People attending an ACCHS in regional New South Wales (NSW) completed a touchscreen survey while waiting for their appointment. The survey assessed participant health risk status, which health risks they would like to change, whether they preferred multiple health changes to be made together or separately, and the types of support they would use.

Results

Of the 211 participants who completed the survey, 94 % reported multiple (two or more) health risks. There was a high willingness to change, with 69 % of current smokers wanting to cut down or quit, 51 % of overweight or obese participants wanting to lose weight and 44 % of those using drugs in the last 12 months wanting to stop or cut down. Of participants who wanted to make more than one health change, over half would be willing to make simultaneous or over-lapping health changes. The most popular types of support were help from a doctor or Health Worker and seeing a specialist, with less than a quarter of participants preferring telephone or electronic (internet or smart phone) forms of assistance. The importance of involving family members was also identified.

Conclusions

Strategies addressing multiple health behaviour changes are likely to be acceptable for people attending an ACCHS, but may need to allow flexibility in the choice of initial target behaviour, timing of changes, and the format of support provided.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1701-2) contains supplementary material, which is available to authorized users.

Addressing social determinants of health inequities through settings: a rapid review

Changing settings to be more supportive of health and healthy choices is an optimum way to improve population health and health equity. This article uses the World Health Organisation's (1998) (WHO Health Promotion Glossary. WHO Collaborating Centre for Health Promotion, Department of Public Health and Community Medicine, University of Sydney, NSW) definition of settings approaches to health promotion as those focused on modifying settings' structure and nature. A rapid literature review was undertaken in the period June-August 2014, combining a systematically conducted search of two major databases with targeted searches. The review focused on identifying what works in settings approaches to address the social determinants of health inequities, using Fair Foundations: the VicHealth framework for health equity. This depicts the social determinants of health inequities as three layers of influence, and entry points for action to promote health equity. The evidence review identified work in 12 settings (cities; communities and neighbourhoods; educational; healthcare; online; faith-based; sports; workplaces; prisons; and nightlife, green and temporary settings), and work at the socioeconomic, political and cultural context layer of the Fair Foundations framework (governance, legislation, regulation and policy). It located a relatively small amount of evidence that settings themselves are being changed in ways which address the social determinants of health inequities. Rather, many initiatives focus on individual behaviour change within settings. There is considerable potential for health promotion professionals to focus settings work more upstream and so replace or integrate individual approaches with those addressing daily living conditions and higher level structures, and a significant need for programmes to be evaluated for differential equity impacts and published to provide a more solid evidence base.

Perceived barriers to healthy lifestyle activities in midlife and older Australian women with type 2 diabetes

BACKGROUND

Type 2 diabetes is a leading cause of morbidity and mortality in midlife and older Australian women with known modifiable risk factors for type 2 diabetes including smoking, nutrition, physical activity and obesity. In Australia little research has been done to investigate the perceived barriers to healthy lifestyle activities in midlife and older women with type 2 diabetes.

AIMS

The primary aim of this study was to explore the level and type of perceived barriers to health promotion activities. The secondary aim was to explore the relationship of perceived barriers to smoking behaviour, fruit and vegetable intake, physical activity, and body mass index.

METHODS

The study was a cross sectional survey of women, aged over 45 with type 2 diabetes, recruited from four metropolitan community health clinics (n = 41). Data were collected from self-report questionnaires and analysed using quantitative methods.

RESULTS

Women in the study had average total barriers scores similar to those reported in the literature for women with a range of physical disabilities and illnesses. The leading barriers for this group of women were: lack of interest, concern about safety, too tired, lack of money and feeling what they do does not help. There was no association between total barriers scores and body mass index, physical activity, fruit and vegetable intake or socio-demographic variables.

CONCLUSION

This study contributes to understanding the perceptions of midlife and older women with type 2 diabetes about the level and type of barriers to healthy lifestyle activities that they experience. The participants reported a high level perceived barriers with a range of personal, social and environmental issues identified and described. This study suggests that health promo- tion education and interventions for risk factor reduction in women with type 2 diabetes may be enhanced by explicitly addressing perceived barriers to healthy lifestyle activities.

Wider impacts of a 10-week community cooking skills program--Jamie's Ministry of Food, Australia

Background

Jamie’s Ministry of Food (JMoF) Australia is a 10-week community-based cooking skills program which is primarily aimed at increasing cooking skills and confidence and the promotion of eating a more nutritious diet. However, it is likely that the program influences many pathways to behaviour change. This paper explores whether JMoF impacted on known precursors to healthy cooking and eating (such as attitudes, knowledge, beliefs, cooking enjoyment and satisfaction and food purchasing behaviour) and whether there are additional social and health benefits which arise from program participation.

Methods

A mixed method, quasi-experimental longitudinal evaluation with a wait-list control was conducted. Intervention participants were measured using repeated questionnaires at three time points; before and after the program and at six-month follow-up. Control participants completed the questionnaire 10 weeks before their program and at program commencement. Quantitative analysis used a linear mixed model approach and generalised linear models for repeated measures using all available data. Qualitative methods involved 30-minute repeated semi-structured interviews with a purposively selected sample, analysed thematically.

Results

Statistically significant differences between groups and over time were found for a reduction of take away/fast food weekly purchasing (P = 0.004), and increases in eating meals at the dinner table (P = 0.01), cooking satisfaction (P = 0.01), and the ability to prepare a meal in 30 minutes (P < 0.001) and from basics that was low in cost (P < 0.001). The qualitative findings supported the quantitative results. Repeat qualitative interviews with fifteen participants indicated increased confidence and skills gained from the program to prepare meals from scratch as well as increases in family involvement in cooking and meal times at home.

Conclusions

Jamie’s Ministry of Food, Australia resulted in improvements in participants’ food and cooking attitudes and knowledge, food purchasing behaviours and social interactions within the home environment, which were sustained six months after the program.

Trial registration

Australian and New Zealand Trial registration number: ACTRN12611001209987.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1161) contains supplementary material, which is available to authorized users.

Impact of cooking and home food preparation interventions among adults: outcomes and implications for future programs

OBJECTIVE

Cooking programs are growing in popularity; however, an extensive review has not examined their overall impact. Therefore, this study reviewed previous research on cooking/home food preparation interventions and diet and health-related outcomes among adults and identified implications for practice and research.

DESIGN

Literature review and descriptive summative method.

MAIN OUTCOME MEASURES

Dietary intake, knowledge/skills, cooking attitudes and self-efficacy/confidence, health outcomes.

ANALYSIS

Articles evaluating the effectiveness of interventions that included cooking/home food preparation as the primary aim (January, 1980 through December, 2011) were identified via Ovid MEDLINE, Agricola, and Web of Science databases. Studies grouped according to design and outcomes were reviewed for validity using an established coding system. Results were summarized for several outcome categories.

RESULTS

Of 28 studies identified, 12 included a control group with 6 as nonrandomized and 6 as randomized controlled trials. Evaluation was done postintervention for 5 studies, pre- and postintervention for 23, and beyond postintervention for 15. Qualitative and quantitative measures suggested a positive influence on main outcomes. However, nonrigorous study designs, varying study populations, and the use of nonvalidated assessment tools limited stronger conclusions.

CONCLUSIONS AND IMPLICATIONS

Well-designed studies are needed that rigorously evaluate long-term impact on cooking behavior, dietary intake, obesity and other health outcomes.

‘It still leaves me sixty dollars out of pocket’: experiences of diabetes medical care among low-income earners in Perth

Diabetes prevalence is increasing in Australia, and there are stark inequities in prevalence and clinical outcomes experienced by Indigenous people and low socioeconomic groups compared with non-Indigenous and socioeconomically advantaged groups. This paper explores the impact of Indigenous status and socioeconomic disadvantage on the experience of diabetes care in the primary health setting. Data were collected through focus groups and interviews. The sample, comprising 38 participants (Indigenous and non-Indigenous), was recruited from disadvantaged areas in Perth, Australia. Data analysis was mainly deductive and based on a conceptual framework for the relationship between socioeconomic position and diabetes health outcomes. Most participants reported accessing general practitioners regularly; however, evidence of access to dietitians and podiatrists was very limited. Perceived need, cost, lack of information on available services and previous negative experiences influenced health care-seeking behaviour. Complexity and lack of coordination characterised the model of care reported by most participants. In contrast, Indigenous participants accessing an Aboriginal community-controlled health organisation reported a more accessible and coordinated experience of care. Our analysis suggests that Indigenous and socioeconomically disadvantaged people tailor their health care-seeking behaviour to the limitations imposed by their income and disadvantaged circumstances. To reduce inequities in care experiences, diabetes services in primary care need to be accessible and responsive to the needs of such groups in the community.

Cooking schools improve nutrient intake patterns of people with type 2 diabetes

OBJECTIVE

To determine whether cooking classes offered by the Cooperative Extension Service improved nutrient intake patterns in people with type 2 diabetes.

DESIGN

Quasi-experimental using pretest, posttest comparisons.

SETTING

Community locations including schools, churches, and senior centers.

PARTICIPANTS

One hundred seventeen people with type 2 diabetes, from diverse ethnic and socioeconomic backgrounds.

INTERVENTION

Series of classes for people with type 2 diabetes and their family members that incorporated Social Cognitive Theory tenets. The classes featured current nutrition recommendations for people with type 2 diabetes and hands-on cooking, where participants prepared and ate a meal together.

MAIN OUTCOME MEASURES

Three-day food records, completed prior to attending cooking schools and 1 month after, were used to measure changes in energy intake and selected nutrients.

ANALYSIS

Program efficacy was assessed using the Wilcoxon signed-rank test to compare differences between pre-training and post-training variables. ANCOVA was used to determine whether program efficacy was affected by sociodemographics.

RESULTS

Participants decreased (P < .05) intakes of energy, fat grams, percentage of calories from fat, saturated fat grams, cholesterol (mg), sodium (mg), and carbohydrate grams.

CONCLUSIONS AND IMPLICATIONS

Nutrition education incorporating hands-on cooking can improve nutrient intake in people with type 2 diabetes from diverse ethnic and socioeconomic backgrounds.

Effective nutrition education for Aboriginal Australians: lessons from a diabetes cooking course

OBJECTIVES

To examine the experiences of Aboriginal Australians with or at risk of diabetes who attended urban community cooking courses in 2002-2007; and to develop recommendations for increasing the uptake and effectiveness of nutrition education in Aboriginal communities.

METHODS

Descriptive qualitative approach using semistructured interviews with 23 Aboriginal course participants aged 19-72. Verbatim transcripts were coded using NVivo 7 software, and qualitative analysis was undertaken.

RESULTS

Engagement and learning were increased by emphasizing the social aspects of the program, holding the course in a familiar Aboriginal community-controlled health setting and using small group learning with Aboriginal peers. Partnership with a vocational training institute provided teaching expertise, but there was conflict between vocational and health promotion objectives.

CONCLUSIONS AND IMPLICATIONS

Nutrition programs for Aboriginal Australians should be social, flexible, and held in accessible, culturally appropriate settings and focus on healthful cooking techniques using simple, affordable ingredients.

'You get the quickest and the cheapest stuff you can': Food security issues among low-income earners living with diabetes

BACKGROUND

Diabetes prevalence is increasing worldwide. More than 800,000 Australians live with diabetes, and there are stark inequities in prevalence and clinical outcomes among Indigenous people and low socio-economic groups.

AIMS

This paper focuses on food security issues experienced by low-income earners living with type 2 diabetes in Perth, Western Australia. The results presented here are part of a broader qualitative study exploring the impact of socioeconomic disadvantage on diabetes.

METHOD

Data was collected through focus groups and semistructured interviews conducted from October 2008 to November 2009. The sample, comprising 38 participants ( Indigenous and non-Indigenous), was recruited from areas with high indices of socio-economic disadvantage in Perth. Deductive data analysis identified categories from an existing conceptual framework for the relationship between socio-economic position and diabetes health outcomes, while an inductive approach was adopted to identify new themes.

RESULTS

Participants had a good understanding of their dietary requirements. However, access to healthy food was not always realised, as many participants depended on others for food provision and meal preparation and had little control over their diets. Furthermore, the majority struggled to accommodate the price of healthy food within a limited budget.

CONCLUSION

In this study, low-income earners living with diabetes faced food security issues. Participants reported cost barriers, but also physical barriers relating to functional limitations and lack of transport. This study highlights that the socioeconomic circumstances in which vulnerable populations experience their disease need to be understood and addressed in order to reduce the inequities surrounding diabetes outcomes.