Development, implementation and evaluation of a healthy lunch box intervention for Australian Latino parents
Creators: name: Casado, Francisco J. Crespo
Publisher: name: Australian Catholic University
Year: 2020
Subjects: diet
health behaviours
immigrants

description: Excessive weight gain and obesity, including the non-communicable diseases related to these conditions, are major public health challenges of the 21st century. Consumption of diets rich in sugars and fat, and low in vegetables and fruits, is associated with the development of weight gain and obesity, insulin resistance and other cardio-metabolic diseases. In general, children are not meeting national dietary recommendations and the diet of children has been characterised as being low in fruit and vegetables and high in sweetened beverages, convenience and fast food. Children bring packed lunches to school in many countries, including Australia, New Zealand, the United Kingdom (UK) and the United States (US), and foods brought from home are typically of poor nutritional quality. In addition, foods in lunch boxes are likely representative of eating patterns at home. There are few interventions specifically targeting the preparation of healthful lunch boxes, and these have displayed modest outcomes. It is possible that immigrant children arrive with healthier dietary behaviours, but at least some of these behaviours deteriorate as children acculturate. Some immigrant parents adopt unhealthy dietary habits, which can impact their children’s dietary behaviours, moving away from traditional diets in favour of a Western diet pattern, rich in sugar and saturated fat, thus increasing the risk of weight gain and obesity among their children. Although totalling approximately 3% of the world’s population, immigrants are relatively underrepresented in health promotion research. Latino immigrants in the US are one of the few immigrant groups who have received significant research attention. Evidence suggest that as Latinos adapt to mainstream US culture, they often adopt less healthful eating habits, including decreased frequency of family meals and increased consumption of ultra-processed packaged foods. In 2016, there were 146,180 people born in Portuguese- and Spanish-speaking Latin American countries living in Australia, their numbers having increased by 52% in the period 2006-2016. Several previous studies have indicated that some newcomers to Australia experience difficulties in adapting to the new food system and food-ways, describing how these difficulties affect their dietary behaviours. Some of this literature contains limited information on lunch box preparation practices by immigrant parents, suggesting that sociocultural factors specific to these particular groups can play a key role in families’ dietary practices. There has been a lack of high-quality evidence about the process of dietary acculturation among Latino children in Australia. What is known is that parents play a vital role in the prevention of childhood obesity. Therefore, this research program aims to understand the barriers, facilitators and factors affecting lunch box preparation among Australian Latino immigrant parents, in order to inform the development and delivery of a culturally appropriate intervention that could assist in the preparation of healthful lunch boxes for their children by addressing these factors. This thesis describes three research studies designed to address the overall research aim. The research is underpinned by a pragmatic paradigm. A pragmatic approach was suitable for this research given the complexity of designing a new intervention, and that using both quantitative and qualitative methods is necessary to enable a richer understanding of participants’ perceptions and a quantitative evaluation of the impact of the intervention. A conceptual framework was developed to assist the research process. A pragmatic research approach was used to conduct the research because it is regarded as the most common way to reconcile the opposing positivist and constructivist paradigms. The overall findings of the studies suggest that it is possible to design and deliver a culturally appropriate behaviour change intervention to improve lunch box preparation practices among Australian Latino immigrant parents. A number of factors were identified by parents as affecting lunch box preparation, including parents’ cultural food practices, the food environment, children’s food preferences and aspects of food literacy. However, several barriers to adopting healthier lunch box preparation practices were also reported, such as parents’ lack of food preparation skills and time, and the school environment, suggesting that future work to address these issues is needed. Study 1 involved three distinct systematic reviews of the literature, the aim being to investigate the available evidence on whether lunch boxes provided by Australian Latino immigrant parents to their children were generally of poor nutritional quality. However, none of the available scientific literature included Australian Latino parents. Consequently, two additional systematic reviews were conducted to provide an evidence base for the development of the intervention. Sixteen studies reviewed provided information on children’s dietary intake in Latin America and about the school lunch boxes prepared by Australian parents. In addition, an extensive, but not systematic, review of scientific literature provided information on school lunch provision by other immigrant parents in Australia. Findings from Study 1 also enabled preliminary conclusions to be drawn regarding the potential difficulties of preparing healthful lunch boxes for their children, as well as adapting to Australian food-ways. For example, with time, immigrant parents tend to adopt unhealthy dietary practices, and this is partly due to several sociocultural factors. Study 1 concluded that lunch box preparation by Australian Latino immigrant parents needed to be further explored. The findings of this review informed the development of Study 2. Study 2 involved a qualitative study to explore factors affecting school lunch box preparation by Australian Latino parents. Thirteen semi-structured individual interviews and one group interview were conducted with Australian Latino parents. The findings show that parents need support during lunch box preparation at home. Parents identified some aspects of food literacy, such as food and nutrition knowledge and food preparation skills, as important in the preparation of healthful lunch boxes. They identified numerous barriers to preparing healthful lunch boxes, which had an impact on their practices, such as lack of time and food preparation skills and unsupportive school food environment, including school canteens and not enough time allowed to eat lunch. Importantly, parents reported difficulties in adapting to Australian meal patterns, particularly getting used to the evening meal being the main meal of the day. They also reported lack of familiarity with the Australian school lunch system, and emphasised that children’s lunches are abundant and nourishing in Latin America. The findings of Study 2 informed the development of the third and final study. Study 3 was an uncontrolled before- and after-intervention study, which aimed to evaluate the feasibility of a group-based healthy lunch box intervention to support parents’ preparation of healthier lunch boxes, and used mixed methods to assess processes and outcomes. The intervention was delivered online via a social networking site to reach immigrant Australian Latino parents. The qualitative evaluation consisted of parents’ posts made by participating parents on the group’s wall during the intervention, and five semi-structured evaluation interviews at the conclusion of the intervention to evaluate its acceptability and usefulness. The quantitative evaluation consisted of pre- and post-surveys measuring parents’ food literacy levels. The qualitative component of the study confirmed most of the factors identified in Study 2, and identified barriers to behaviour change, such as children’s food preferences, lack of food preparation skills, and the school food environment, which will need to be considered in future interventions. Parents valued the group support, the experience of sharing and focus on improving in the group. For example, parents reported that learning about how other parents have managed similar situations provided them with a sense of motivation to prepare healthier lunch boxes and helped them to cope with stress and anxiety. The quantitative component of the study found that parents’ food literacy increased post-intervention, suggesting that food literacy may have an impact on parents’ lunch box preparation practices. Collectively, these three studies highlight the feasibility of an intervention and provide preliminary evidence that a culturally appropriate intervention for immigrant parents to improve lunch box preparation practices may be beneficial for parents. The intervention may be refined based on the feedback from the pilot trial and evaluated in a larger controlled trial to determine its effectiveness. For example, it is possible to create culturally appropriate and relevant education materials. This thesis provides a series of insights into culturally appropriate interventions for researchers and practitioners interested in developing culturally appropriate programmes to improve lunch box preparation practices among immigrant parents in order to reduce the prevalence of non-communicable diseases such as childhood obesity.