Barriers and facilitators to the uptake of healthy eating messages
Research type
Research Study
Full title
Barriers and facilitators to the uptake of healthy eating messages by pregnant African immigrants living in the UK: perspectives of women and midwives.
IRAS ID
268646
Contact name
Aniebiet Ekong
Contact email
Sponsor organisation
Bournemouth University
Clinicaltrials.gov Identifier
NCT04009395, Clinical Trials
Duration of Study in the UK
0 years, 6 months, 15 days
Research summary
Sumary of Research
Obesity is on the increase and black Africans in the UK make up a significant part of this population (32%). Weight retention after pregnancy is considered as one of the leading causes of obesity. African women living in high income countries have been found to experience more weight retention after pregnancy than Caucasian women.
Healthy eating guidelines have been provided in pregnancy in the UK (National Health and Care Excellence) and midwives have been placed to provide healthy eating advice in pregnancy, but some studies have identified that African migrants in the UK often eat and prepare food in a different way to the traditional British approach. It has also been observed that the recommended advice for pregnant women, for example the Eatwell plate and start4life are focused on traditional British foods and cooking patterns and do not include food that would be familiar to African migrants. This may impact on the meaningfulness of such guidance to African women. Therefore, this research aims to understand what prevents healthy eating or makes healthy eating easier for pregnant African migrant women in the UK. This would include understanding how healthy eating is interpreted, the cultural factors that are considered important in healthy eating, the current sources of nutrition information and midwives view on providing healthy eating advice to this population.
Eligibility
• Pregnant African migrant women (18 and above) attending ante-natal clinics in NHS hospital sites.
• Midwives who provide ante-natal advice to pregnant Africans
Where
Study sites will be hospitals covered by the Epsom and St Helier University trust, London North West University Healthcare NHS trust and the Lewisham & Greenwich NHS trusts.
How
The study will involve one-one-one interviewing with pregnant women and midwives using hospital spaces provided by the hospital. Focus group discussions with midwives will be attempted depending on logistics. The interviews are expected to last about one hour to one and a half hours. Interview sessions will be audio-taped with the permission of the participants. Data collection is expected to last for 6 months.Summary of Results
Thesis title: Barriers and Facilitators to the uptake of healthy eating messages by Black African Immigrant pregnant women living in the UK: Perspectives of women and midwivesBackground: This study explored the perspective of Black African immigrant pregnant women living in the United Kingdom (UK) on the uptake of healthy eating advice offered during pregnancy. The study also explored midwives’ views around offering healthy eating advice to these women.
Pregnancy nutrition is vital for improving child health outcomes and protecting women’s health during and after childbirth. Inadequate or excess intake of maternal nutrients can lead to adverse consequences for the foetus and the mother including affecting foetal programming which may predispose children to metabolic diseases later in life. Excess maternal intake of macronutrients such as carbohydrates may lead to maternal hyperglycaemia which might lead to foetal macrosomia and an increased risk for caesarean delivery for mothers. Foetal macrosomia is also a predisposing factor for obesity in later life. Additionally, excess maternal weight gain can lead to postpartum weight retention, leading to overweight and obesity. Obesity has been termed as a public health concern and postpartum weight retention has been indicated as the leading cause of obesity amongst women of childbearing age. With the consistent increase in maternal obesity rates worldwide and in the UK, it has become important to vital to attach importance to maternal nutrition.
Black women in the UK make up about 66.6% of the obese population in pregnancy in the UK. Black African pregnant women especially from West African countries like Nigeria and Cameroon have an increased risk of developing iron deficiency, coupled with the increased burden of vitamin D deficiency in pregnancy. Black African immigrant population face inequalities in health such as higher prevalence of obesity, gestational diabetes, gestational hypertension, and an increased risk of mortality, morbidity and adverse outcomes in pregnancy. The recent Maternal, Newborn, and Infant clinical Outcome Review (MBRACCE) report indicated that Black African women living in the UK are five times more likely to die in pregnancy from all causes than their Caucasian counterparts. Considering that behavioural/lifestyle factors such as healthy eating modification may improve these outcomes, it became essential to explore health behaviours such as dietary and physical activity behaviours that have the potential to mitigate these adverse circumstances. This study focused solely on gaining an insight into the factors that influenced Black African immigrant pregnant women’s engagement with healthy eating advice.Methodology
Sample characteristics: twenty-six women were recruited to the study. Ethnicity was self-reported by Black African Immigrant women. Exclusion criteria for pregnant women included Black African immigrant pregnant women who were less than 18 years, women who had chronic conditions that required dietary management, women who were able to communicate in either English or creole. In addition, Black African immigrant pregnant women who lacked the capacity to consent were excluded from the study.
Midwives who were not directly involved in the care of Black African immigrant pregnant women were excluded from the study.
Recruitment: pregnant women were mostly recruited from two NHS trust and the community in the south of London using convenience sampling and snowballing. Other methods of recruitment earlier indicated in the protocol such as notices posted on social media sites were largely unsuccessful. The difficulty of recruitment for this group has been written up and published in MIDIRS midwifery digest.
Midwives were recruited from two NHS trusts in London Data collection : Although the study protocol had earlier indicated that in-depth interviews would be conducted either in the hospital or at any location of the participants choosing, the COVID -19 pandemic and subsequent amendment to the protocol meant that one-to-one interviews were impossible. Therefore, virtual interviews were conducted. In-depth virtual interviews for pregnant women and in-depth virtual interviews with some focus group discussions were conducted for midwives. The interviews lasted between 60 and 90 minutes for pregnant women and 30-60 minutes for midwives. Interviews were conducted via either Microsoft Teams, Zoom or telephone.
Data analysis: The methodological principles of constructivist grounded theory using constant comparative analysis was used towards the development of a substantive theory. Transcribing and data analysis for constructivist grounded theory was an iterative process which involved three coding techniques: initial coding, focused coding and theoretical coding towards the development of a theory. The process of theory building also involved memo writing, reflexivity and theoretical sensitivity. A substantive theory was developed which increased understanding around Black African women’s engagement with healthy eating advice.
Ethical approval: A favourable ethical opinion was obtained from the London Brent Research Ethic Committee Local Research Ethics Committee and the HRA Health and care Research Wales (HCRW). This was in addition to an approval from the Bournemouth University Research Ethics committee.Results
Twenty-six women including seven pregnant women and nineteen midwives participated in twenty-two in-depth interviews and two focus group discussions. The focus group discussions consisted of two midwives each. The challenges of the pandemic did not allow for more than two midwives per focus group discussion, although many midwives had earlier expressed interest to attend. The interviews lasted an average of 60-90 minutes for pregnant women and 30-60 minutes for midwives. Twenty-three interviews were conducted via either Microsoft teams or zoom, and the remaining interview was conducted half by telephone and the remaining half by zoom.
All participants met the study’s inclusion criteria. All participants could also communicate in English, therefore there was no need for a translation. All pregnant participants spoke of their experience of interacting with healthy eating advice in the context of the UK, while midwives spoke on their experience of providing healthy eating advice to pregnant African immigrant women living in the UK.
Theoretical categories: Category development in constructivist grounded theory focuses on generating understanding about the experiences of individuals in the phenomenon that is being studied using their narratives and observations. Words were fit into categories with properties that best captured their meaning. Theoretical sampling then followed, which allowed for further exploration of the categories that had emerged.
Pregnant women: Four categories emerged from the analysis of interviews with pregnant women which reflected the barriers and facilitators to the uptake of healthy eating advice. Although the questions asked were about healthy eating, the answers provided reflected BAIP women’s perception of the antenatal care system in general.
a.) Navigating a shifting cultural landscape: showed the difference in cultural understanding between what Black African immigrant pregnant women understood as healthy eating. It showed how this understanding did not seem to fit into what the society in which they were living in or the midwives to which they had interactions with, seemed to portray or tell them. Black African immigrant pregnant women’s culture was the context to which the concept of healthy eating was understood and maintained. The entrance of the pregnant women into the society through the antenatal care system brought to fore the difference in cultures. This category reflected how Black African immigrant pregnant navigated between their culture and the culture in the society to which they had been introduced.
b.) Blending in: This theoretical category was used to reflect Black African immigrant pregnant women’s attempt to become a part of the society. Children were the primary reason that these women tried to blend in with the society.
c.) Negotiating for help: Previous categories highlighted that BAIP women had acknowledged that they needed to change their eating habits for the sake of their health. This category acknowledges the change the women required and the processes to which they negotiated for this help that they required.
d.) Meeting my healthy eating needs: This category captured answers to specific responses about the barriers and facilitators to the uptake of healthy eating messages. Women talked about mainly pregnancy, family and society as being primary determinants to healthy eating in pregnancy.
Midwives: Three categories emerged from the analysis of interviews with midwives.
a.) There are cultural needs: some midwives acknowledged that BAIP women had unmet cultural needs. Midwives reflected on their lack of or minimal understanding of the existing cultural dynamics. Midwives also reflected on the cultural gaps that existed with the National Health Service (NHS). Gaps relating to the cultural unsuitability of the healthy eating advice offered in pregnancy, unmet cultural needs and lack of knowledge.
b.) Hard to engage: This theoretical category reflected midwives struggle with engaging with BAIP women. Midwives felt that BAIP women did not want to be engaged, neither did they ask for help nor communicate. This communication experience was not central for all midwives. Black midwives and midwives who had many years of experience found that their experience was different. They were able to engage with BAIP women. Additionally, this category reflected the unconscious thought processes that existed within the maternity care system, which seemed to influence midwives’ interaction with BAIP women. These thought processes ascribed an identity to the BAIP woman, for instance, being “hard to engage”.
c.) System: This theoretical category reflected on the problems that existed within the NHS, which made healthy eating discussions an uphill task. For instance, healthy eating was not considered a priority in the NHS. There were also discussions regarding the lack of resources within the NHS to accommodate immigrant women.
Discussion
Discussion for the study was centred on improving understanding around the BAIP woman and her maintenance of her cultural identity. The developed theory “the concept of identity- the black immigrant woman” tried to explain the processes to which BAIP women made sense of the healthy eating advice that was offered, the antenatal care system and the society. Meaning was culturally developed. Additionally, the theory was used to explain how communication and engagement was more successful with midwives that acknowledged the cultural differences.
Recruitment
Recruitment started in January 2020 and ended in January 2021REC name
London - Brent Research Ethics Committee
REC reference
19/LO/1308
Date of REC Opinion
20 Nov 2019
REC opinion
Further Information Favourable Opinion