Promoting a healthy diet in antenatal care: Qualitative studies of barriers to nutrition communication among women of different ethnic backgrounds in the Oslo Area

Background: The nutritional and weight status of the mother influences not only her own health and foetal growth, but also the offspring’s future risk of diet-related chronic diseases. Given the rise in the proportion of pregnant women globally with overweight and diet-related chronic diseases, efforts to promote a healthy diet and weight management in pregnancy are urgently needed. Pregnant women may be motivated to eat healthily and be more receptive for nutrition-related information. However, previous research indicates that health professionals may find it challenging to communicating about a healthy diet and weight management, especially towards a multicultural population. Further knowledge of the receivers’ perspectives and experiences may be valuable to addressing possible barriers to nutrition communication in antenatal care.<br><br>
Aims: The overall aim of this thesis was to identify possible barriers to nutrition communication in antenatal care, based on the experiences of women of different ethnic backgrounds. The specific aim of the first substudy of this thesis was to investigate how female immigrants from African and Asian countries perceived the Norwegian food culture and to identify aspects of their original food culture which might be important to preserve. The specific aims of the second substudy were to explore pregnant women’s perceptions of and experiences with nutrition-related information received in antenatal care, as well as their attitudes toward and motivations for healthy eating during pregnancy and postpartum.<br><br>
Methods: The empirical material of this thesis derived from qualitative, individual interviews conducted in the two substudies. Substudy 1 was conducted among 21 female immigrants from African and Asian countries living in Oslo. Participants were recruited at women’s centres run by nongovernmental organisations and open kindergartens. They varied in their country of origin, age, years of residence and employment status. Substudy 2 followed a longitudinal approach. Interviews with 17 women of different ethnic backgrounds were conducted. Of these, five were ethnic Norwegian and the others had immigration background from African and Asian countries. The participants were interviewed twice during pregnancy and once three months after giving birth. Participants were recruited at Mother and Child Health Centres, where they received antenatal care. They varied in years of residence in Norway and educational background. All of the participants in substudy 2 had a higher risk for the development of diet-related chronic diseases. In both substudies, data collection and analysis were inspired by a phenomenological approach.<br><br>
Findings and discussion: This thesis comprises three papers. Paper 1 presents the findings from substudy 1. The findings from substudy 2 are described in papers 2 and 3. Paper 1 investigated female immigrants’ (n=21) perceptions of and experiences with the Norwegian food culture. Participants perceived the food of the host country as tasteless and boring, simple and time-saving, healthy and sometimes healthier than their original food. Participants emphasised the importance of preserving their original food cultures after migration. However, the continuity with their original food cultures varied and was either strict, flexible or limited. Taste, preparation effort and adherence to religious dietary rules were identified as markers for culturally appropriate meals. Awareness of strategies mentioned by the study participants to enhance the cultural acceptability of meals may improve nutrition communication. Health??care professionals’ knowledge about, understanding of and respect for a person’s cultural values and food practices may be core components of culturally sensitive nutrition communication. Paper 2 explored experiences with nutrition-related information during routine antenatal care among women of different ethnic backgrounds (n=17). Interviews conducted during participants’ pregnancies were analysed for this paper. Participants experienced that they were provided with little nutrition-related information in antenatal care. They perceived that the information was presented in very general terms and that it was focused on food safety. Participants were sometimes unaware that their overweight status and dietary intake during pregnancy may increase their own and the offspring’s future risk of diet-related chronic diseases. Participants with immigrant backgrounds appeared to be confused about information given by the midwife that was incongruent with their original food culture. They experienced that they received nutrition-related information in antenatal care too late. Women actively sought nutrition-related information elsewhere, especially in the beginning of the pregnancy. Participants had to negotiate between different sources of nutrition-related information. The midwife was considered the most trustworthy source of information. Throughout the pregnancy, participants often experienced an overload of other pregnancy-related health information. Paper 3 investigated pregnant women’s (n=16) attitudes toward and motivations for healthy eating. For this paper, the postpartum interviews, which were conducted three months after women gave birth, were also analysed. Three groups of participants were identified: the healthy changers, who considered pregnancy a period to adopt healthier eating behaviour; the temporary healthy forcers, who tried to eat healthily only during their pregnancy; and the temporary vacationers, who perceived pregnancy as ‘time-off’ from healthy eating. Participants’ attitudes could be interpreted as having motivations with different degrees of self-autonomy. For instance, an important motivational factor among the healthy changers was their own health. By contrast, the temporary healthy forcers often appeared to relate their motivation for healthy eating to advice received from health professionals. Women who were unconcerned about healthy eating during pregnancy often expressed experiences of restrained eating and weight management prior to pregnancy. Ethnic Norwegians and participants with immigrant backgrounds were represented in all three groups. Immigrant women emphasised a wish to continue, to a varying degree, with dietary habits and foods from their country of origin. However, culture-specific advice about safe and appropriate food in pregnancy did not appear to influence their motivations for healthy eating. Collectively, the papers described possible barriers to nutrition communication as interpreted from the participants’ accounts. These barriers may be important to address in order to promote a healthy diet in antenatal care. The possible influence of individual’s ethnical and cultural backgrounds on their food practices, experiences of receiving unspecific information and the variety in participants’ attitudes toward and motivations for healthy eating indicated a need for an individualised communication approach. The consideration of individuals’ preferred food culture, their ability to understand the information and their attitudes toward and motivations for healthy eating may be important aspects of tailored nutrition communication in antenatal care. Culturesensitive and nutrition literacy-based communication can be appropriate strategies.<br><br>
List of papers. The papers are removed from the thesis due to publisher restrictions.<br><br>
Paper 1: Garnweidner LM, Terragni L, Pettersen KS, Mosdøl A. Perceptions of the Host Country’s Food Culture among Female Immigrants from African and Asian Countries: Aspects relevant for Cultural Sensitivity in Nutrition Communication. Journal of Nutrition Education and Behaviour. 2012; 44: 335-42. <a href="http://dx.doi.org/10.1016/j.jneb.2011.08.005">doi:10.1016/j.jneb.2011.08.005</a><br><br>
Paper 2: Garnweidner LM, Pettersen KS, Mosdøl A. Experiences with Nutrition-related Information during Antenatal Care of Pregnant Women of Different Ethnic Backgrounds residing in the Area of Oslo, Norway. Midwifery, 2013, <a href="http://dx.doi.org/10.1016/j.midw.2012.12.006">doi:10.1016/j.midw.2012.12.006</a><br><br>
Paper 3: Garnweidner LM, Pettersen KS, Terragni L, Mosdøl A. Attitudes toward and Motivations for Healthy Eating among Pregnant Women of Different Ethnic Backgrounds following routine antenatal care in the area of Oslo, Norway. Under Review