Abstract
Objective: To determine the feasibility, acceptability, and impact of a parent-centered intervention to increase fruit and vegetable servings and consumption among Somali children living in the United States. Design: Pilot intervention that included Somali community health workers who organized groups of 3 or 4 women to participate in 2 initial educational sessions, including topics of health and nutrition, serving size, and label reading. A third session taught interactive cooking to increase skills in preparing fruits and vegetables and increasing the numbers of vegetables included in traditional Somali dishes. The final session was a trip to the grocery store to identify fruits and vegetables, determine ripeness, and explore frozen and canned fruits and vegetables for halal, low-sodium, and low-sugar products. Surveys were completed pre- and post-intervention. Setting: Study participants were recruited from a large housing complex in Minneapolis, Minnesota, with a high population of Somali immigrants. Participants: Somali women (N = 25) with children aged 3 to 10 years. Results: The intervention was feasible and well accepted. In comparing pre- and post-intervention surveys, mothers reported providing their children significantly more frequent servings of fruits and vegetables at dinner, lunch, snack, and breakfast (vegetable only). There was a statistically significant increase in parent-reported intake of fruits and vegetables for themselves and their children. Conclusion: The FAV-S study was feasible and acceptable, and it demonstrated potential for increasing fruit and vegetable servings and consumption among Somali children. A larger-scale randomized trial is needed to assess the impact of this intervention.
Overall fruit and vegetable consumption throughout the United States is lower than what is recommended. 1 African-born blacks are at an even higher risk of inadequate intake. Twenty-one percent of African-born blacks in Hennepin County, Minnesota, the majority being from Somalia, reported consuming 5 fruits and vegetables per day, compared to 34% of white adults and 24% of US-born black adults. 2 This is likely influenced by the complexity of food choice in the United States and cultural diet practices and beliefs among this population.3-6 For example, the traditional Somali diet consists mainly of rice, pasta, and meat. Fruits and vegetables are considered “complementary” foods.6,7 Additional factors contributing to the Somali diet include financial constraints, lack of knowledge on how to purchase and prepare typical American foods, and limitations due to access to transportation and work schedules.6-10 Consequently, addressing fruit and vegetable consumption within the community will require a multidimensional approach that takes into account the specific cultural beliefs and practices of the population.
The purpose of this study was to design a parent-centered intervention that was feasible and acceptable and that increased fruit and vegetable consumption among Somali children (FAV-S). The activities of the intervention included 2 small group sessions focused on increasing knowledge (eg, the importance of healthy nutrition, reading labels, a healthy plate, use of coupons), a session focused on skill development (cooking session), and a guided trip to the grocery store, all embedded in Somali cultural tradition. The hypothesis was that the intervention, delivered by trained Somali community health workers (CHWs) with the partner organization WellShare International, would be feasible and acceptable. The secondary hypothesis was that the parents would increase the amount of fruits and vegetables that they served to their children.
Methods
Study Population
Minnesota has one of the largest Somali populations in the United States. 11 The study population was drawn from Riverside Plaza, a primarily low-income multiunit housing facility in Minneapolis, Minnesota, where 92% are new immigrants, primarily Somali (70%), Ethiopian (14%), and Eritrean (1.4%). Inclusion criteria for this study included being a Somali adult woman with at least 1 child aged 3 to 10 years in the home and whose role is a provider (meal preparation and/or food purchasing) of at least 50% of the child’s (or children’s) meals.
Participants were recruited through a snowball sampling approach. Twenty-five participants were consented and enrolled. Two bilingual CHWs (Somali and English) employed at WellShare International collected contact information and, as 3 to 4 participants consented, scheduled the first meeting at a local coffee shop or community center, for a total of 7 groups.
Intervention
The intervention was tailored to the Somali culture and dietary practices and included 4 sessions over approximately 6 weeks (average number of days, 47; range, 20-107). Preintervention data were collected at the beginning of the first session, and postdata were collected at the end of the fourth (and last) session. The long time frame for several participants was due to the timing of the holy month of fasting, Ramadan, during which activities beyond religious observance slow down.
Group Health Education
The intervention was designed with a culturally modified Simply Good Eating curriculum 12 and supplementary materials from University of Minnesota Extension. The curriculum applied to the current intervention included the importance of fruits and vegetables for a healthy diet, composition of a healthy plate 13 (with examples of traditional Somali foods), benefits and barriers, education of local fruits and vegetables, reading labels, identifying halal foods on English-language labels, purchasing fruits and vegetables on a budget, and taste testing. This portion was conducted over two sessions.
Cooking Skills and Preparation
In the same groups of 3 or 4 participants, 1 cooking session was held at a local community center kitchen. It included demonstration and a hands-on opportunity to prepare and cook a variety of fruits and vegetables, with emphasis on adding regional vegetables in the preparation of traditional Somali dishes, such as suqar.
Field Trip to Grocery Store
The final session was 1 field trip in small groups to a local grocery store with a CHW. The goals of the field trip included identifying local fruits and vegetables, identifying freshness and ripeness, exploration of frozen and canned foods aisles, practice identifying healthiest and halal choices, and shopping on a budget. Participants each received a $50 gift card to purchase food items during the field experience.
Measures
Parent survey items included questions related to education, income, and food security. Parents were asked about their knowledge of nutrition, importance of fruit and vegetables in a diet, barriers related to serving fruits and vegetables to their children, and their self-efficacy related to purchasing, preparing, and serving fruits and vegetables to their children. Parents reported the frequency of serving fruits and vegetables to their children at dinner, lunch, breakfast, and snack, with 5 response options ranging from never/rarely to almost every day. Fruit and vegetable consumption was reported as the number of servings consumed, with 8 response options ranging from 0-2 times per week to 5+ times per day. CHWs read the surveys aloud to the participants at the first session (preintervention) and the fourth (postintervention).
Data on feasibility and acceptability were collected by CHWs after each of the 4 sessions, asking participants if the session met their expectations and if they would refer a friend to the program. Feasibility was documented according to the recruiting efforts and staff time. Three participants were randomly selected to participate in one-on-one qualitative interviews after the intervention, which included a knowledge check on the components of a healthy meal, reflection on the cooking and shopping portions of the intervention, and the necessary forms for pre- and postdata. The intervention was approved by the University of Minnesota Institutional Review Board.
Analysis
Data were analyzed with Stata 11.1 (Stata Corp, College Station, Texas). Descriptive statistics were used to present feasibility and acceptability of the intervention and individual characteristics as well as qualitative summaries of postintervention interviews. Proportions were used to describe if vegetables and fruits were served several times per week or more frequently at breakfast, lunch, dinner, and snack, according to a z test to compare pre- and postdata. Servings of fruits and vegetables consumed by parents and children was compared pre- and postintervention with a Wilcoxon signed-rank z score, a comparison of median values due to potential skewness in the data. A significance level of P < .05 was used.
Results
Data and interviews postintervention revealed that the intervention was feasible and acceptable among participants. There were a total of 96 evaluations returned (25 people for 4 sessions). Of those that responded, 98% (n = 94) indicated that the session met their expectation, and 99% (n = 95) indicated that they would refer a friend to this program. Feedback illustrated acceptability of the program, including the following statements:
“Because we learn more.”
“Hope you doing this program again. Thank you.”
“We learn actual fruits/veg. Very nice program.”
All 3 participants who were approached agreed to an interview postintervention, and all reported high levels of satisfaction. Participants reported learning novel information, as well as using the new information when cooking for their children. One participant explicitly mentioned the benefit of tasting unfamiliar produce and that after exposure to new fruits and vegetables, she bought and prepared them for her family.
The intervention participants were from very low-income households (see Table 1). Following the intervention, the frequency of parents serving fruits and vegetables to their children several times per week or more frequently at lunch, dinner, and snack increased significantly (see Table 2). Parents also reported a significant increase in the median number of fruit and vegetable servings that they consume (preintervention, 0.3 per day; postintervention, 2 per day) and their children consume (preintervention, 0.3 per day; postintervention, 2 per day).
Participant Characteristics of the Pilot Study, 2012 (N = 25).
Sometimes or always do not have enough to eat.
Ever hungry in past year because cannot afford food.
Servings of Fruits and Vegetables to Children by Parents and Consumption of Fruits and Vegetables by Somali Adults and Children.
Wilcoxon signed-rank z.
Discussion
The FAV-S study was feasible and acceptable, and it demonstrated a potentially successful model for increasing fruit and vegetable consumption among Somali children. Although no claims can be made with this pilot study on the impact on childhood obesity, it is known that immigrants arrive in the United States with a lower prevalence of obesity compared to those born natively, but their risk of obesity increases the longer they are in the country. 14 Obesity rates for immigrants living less than 1 year in the United States was only 8%; immigrants living 15 years or longer in the country have an obesity rate of 19%, which approaches the US-born obesity rate of 22%. 15 The use of a culturally tailored intervention designed to meet the needs of the population early in the acculturation period may be an effective primary prevention effort. An important aspect of the FAV-S intervention was not only the education about the importance of fruits and vegetables and guidelines regarding quantity but the practical application in preparing local fruits and vegetables, identifying healthier choices, reading labels to identify key words, and using store coupons to maximize their resources.
The FAV-S intervention had several limitations. There was a delay in onset, which resulted in intervention delivery conflicts due to Ramadan. The sample size was small, and there was no comparison group, although this was conceived as a pilot study. We did observe differences in behavioral outcomes, but the measures were blunt, and there may be information bias in the postintervention survey. Participants may have responded in a way to please the CHWs, and participants were provided with a $50 gift card as an incentive for the field experience. They were not required but encouraged to purchase fruits and vegetables. The research team agreed that providing the gift card was important given the participants’ low income. Postintervention data collection occurred immediately following the field experience.
Conclusion
The results from this pilot study suggest promise in a culturally tailored intervention among Somali immigrants. Further research is required using a randomized trial and longer-term outcome assessment.
Footnotes
Acknowledgements
We thank the participants of this study and the community health workers who implemented the intervention.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was provided by the Obesity Consortium at the University of Minnesota. The Obesity Consortium links 3 obesity centers at the University of Minnesota, including the Obesity Prevention Center (established through the Healthy Foods, Healthy Lives Presidential Initiative), the Minnesota Obesity Center (National Institute of Diabetes and Digestive and Kidney Diseases funded), and the Center for Transdisciplinary Research on Energetics and Cancer (National Cancer Institute funded). The Obesity Consortium had no role in the design, analysis, or writing of this article.