¡Cocinar Para Su Salud! Development of a Culturally Based Nutrition Education Curriculum for Hispanic Breast Cancer Survivors Using a Theory-Driven Procedural Model

Step 1: Decide Behavior(s)

Health literacy is an essential factor in disease prevention and management. However, approximately 41% of Hispanics have “below-basic” health literacy levels compared to 24% and 9% of non-Hispanic Blacks and non-Hispanic Whites, respectively (Kutner, Greenberg, Jin, & Paulsen, 2006). Pilot data from a weight loss intervention among female Hispanic, predominately Dominican, breast cancer survivors in New York City showed that average fruit and vegetable intake was lower and average fat intake higher than the recommended amounts for reducing the risk of breast cancer recurrence (Greenlee et al., 2012). Research team members recognized the need for a tailored curriculum that would address population-specific cultural and environmental norms and barriers associated with healthy diet practices. Drawing on evidence-based dietary guidelines for cancer survivors published by the American Cancer Society and the American Institute for Cancer Research (Kushi et al., 2012; World Cancer Research Fund/American Institute for Cancer Research, 2007), two key behaviors were targeted for change: increasing fruit and vegetable intake and decreasing dietary fat intake. Several dietary guidelines related to fruit and vegetable intake and fat intake have been published. Examples include the Dietary Guidelines for Americans 2015 (U.S. Department of Agriculture & U.S. Department of Health & Human Services, 2015), designed to promote overall health among all individuals ages 2 years and above, and the Diabetes Prevention Program (Diabetes Prevention Program Research Group, 2002), designed to prevent or delay onset of type 2 diabetes. While similar, dietary guidelines for cancer prevention and preventing cancer recurrence provide more detailed evidence-based recommendations focused on the link between specific dietary patterns and cancer risk. For example, while the Dietary Guidelines recommend that individuals increase fruit and vegetable intake overall and limit fat intake, dietary guidelines for cancer prevention emphasize the associations between cancer risk and specific types of fruits and vegetables and specific sources of fat, such as red and processed meats. The goals of this intervention focused on encouraging women to meet the dietary guidelines specific to cancer survivors.

Step 2: Explore Determinants of Change

Observational neighborhood assessments and informal interviews with neighborhood residents were used to identify potential personal psychosocial determinants and mediators of behavioral change and behavioral capabilities unique to Hispanic breast cancer survivors living in Northern Manhattan. This type of qualitative approach is commonly used for educational curriculum development (Bernard, 1988; Gans et al., 1999; Morgan, 1998) and has been previously used to determine eating habits and health beliefs applicable to Hispanic participants (Gans et al., 1999). A total of 8 neighborhood assessments and 16 informal interviews were conducted in Spanish by the community not-for-profit partner, the Hispanic representatives, and one of the Hispanic nutritionists. The goal of the interviews was to identify specific cultural and environmental influences that could potentially shape behavior and increase the research team’s familiarization with the target population’s food environment. Observational neighborhood assessments were chosen because they could provide a deeper understanding of the target community with the goal of developing culturally sensitive material and would enable the collection of both qualitative and quantitative data. Each assessment consisted of team members physically walking through the community, supermarkets, and bodegas and actively observing the social setting and behaviors while taking detailed notes of the availability and quality of healthy food options, the physical arrangement of products, offers, and pricing. Prices of specific foods were collected from a range of neighborhood food retail establishments in Northern Manhattan and were compared. Additionally, team members observed consumer behavior and asked informal questions to assess if customers knew where specific food items were located in each store (e.g., fresh, canned, and frozen fruits and vegetables, whole grains such as brown rice, and legumes). Through the assessment process, team members learned that while healthful food is accessible, it was comparatively expensive and of low quality, and residents were frequently not able to identify where to find it, and the most commonly purchased food items were high in fat and sugar (e.g., processed orange juice, fruit flavored yogurts, breakfast cereals, salami, frying cheese, condensed sweetened whole milk, energy shakes, cookies). Team members observed that meat departments are substantially larger and produce departments substantially smaller in local neighborhood stores compared to those in more affluent neighborhoods in New York City. Additionally, the purchase of larger quantities of high-fat and processed meat was incentivized through low-cost “meat packages,” which were often supplemented with “free” sodas. Informal interviews were conducted with Hispanic women by having casual conversations with women encountered in the field while conducting observational research, and also having conversations with previous Hispanic participants in the Cook for Your Life classes. This methodology was chosen because it was low-cost, convenient, and provided a broad perspective from the target population. In both settings, interviews involved casual face-to-face conversations with single or multiple interviewees, without a structured interview guide. Interviewees were selected based on their willingness to talk to the research team members. Detailed notes of the conversations were taken immediately after each conversation. Through informal interviews, common themes from both neighborhood residents and previous participants were that women preferred “familiar” vegetables, that convincing their families to accept dietary changes would be difficult, and that family responsibilities and time constraints were real barriers to healthful eating. These assessment findings were corroborated by a review of the research literature in terms of potential mediators of change for intake of fruit and vegetables and dietary fat: perceived benefits of taking action, self-efficacy, social support, and skills in preparing healthy foods (Langenberg et al., 2000; Pomerleau, Lock, Knai, & McKee, 2005; Watters & Satia, 2009).

Based on the team members’ findings and the literature, the following mediators of change associated with increased fruit and vegetable intake and decreased fat intake were identified: perceived benefits of making dietary changes, self-efficacy or confidence in making dietary change, perceived barriers to making dietary change, behavioral skills needed to make dietary change, and environmental factors, including social support and mediators related to cultural factors, that could affect the ability to make dietary changes.

Step 3: Select Theory and Clarify Philosophy

Many theories of behavioral change have been developed and used in nutrition education (Baranowski, Cullen, & Baranowski, 1999; Baranowski, Cullen, Nicklas, Thompson, & Baranowski, 2003; Contento, 1995, 2008). Based on identified mediators, the needs of the target audience, the proposed intervention time frame, and the nature of the desired behaviors, a model integrating social cognitive theory (SCT) and the stages of change construct of the transtheoretical model (TTM) was chosen as the theoretical basis for this intervention. Studies have demonstrated the applications of SCT and TTM as successful models for promoting dietary change in diverse populations (Anderson, Winett, & Wojcik, 2007; Di Noia, Schinke, Prochaska, & Contento, 2006). SCT is one of the most widely used theories for designing nutrition education and health promotion programs as it provides a unified conceptual framework for identifying the determinants of behaviors and mechanism of behavioral change (Anderson, Winett, Wojcik, Winett, & Bowden, 2001; Contento, 2015; Miller, Edwards, Kissling, & Sanville, 2002; Mosher et al., 2008). The central concept in SCT is reciprocal determinism, where personal, behavioral, and environmental factors work in a dynamic and reciprocal fashion to influence health behavior. The stages of change construct complements SCT by describing the five stages people move through as they change behaviors: precontemplation, contemplation, preparation, action, and maintenance (Brug, Oenema, & Ferreira, 2005; Chapman-Novakofski & Karduck, 2005; Feldman et al., 2000; Nitzke et al., 2007). By selecting SCT and the stages of change construct of the TTM, specific environmental factors were addressed and lesson-related incentives were identified as possible facilitators.

Step 4: Identify General Objectives

Objectives were identified for each session to target specific mediators and facilitate participants moving from stage to stage (Table 1). Objectives included understand the importance of eating fruits and vegetables and a low-fat diet to reduce the risk of cancer and other diseases; learn new, quick, and easy methods to prepare healthy foods; demonstrate ability to identify dietary risk factors and assess personal risk factors related to current dietary intake; identify potential barriers to meeting recommendations, such as knowledge, social support, cost, and availability of healthy foods; identify approaches to overcome each barrier; demonstrate ability to use new knowledge of nutrition facts and cooking techniques; and identify new ways to include healthy foods into traditional meals. See Table 1 for a complete list of the study specific objectives.

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Table 1.

Mediators and Objectives of ¡Cocinar Para Su Salud! by Stage of Change.

Stage of change	Educational goal	Session name	Mediators	Objectives
Precontemplation/Contemplation	Increase awareness and enhance motivation	Eating More Fruits and Vegetables	Outcome expectations	State the importance of fruits and vegetables and a low-fat diet in reducing risk of cancer and other diseases
				Recognize that healthy cooking methods are quick and easy to prepare and don’t make the food taste dull or different
		Eating Less Fat	Perceived risk	Identify dietary risk factors to breast cancer
		Healthy Cooking 101	Awareness	Assess current intake compared to recommendations
			Procedural knowledge	Accurately estimate recommended serving sizes of fruits and vegetables and fat
			Social support	Identify ways in which support can facilitate or be a barrier to change
			Behavioral capability	Demonstrate an understanding of where to find healthful foods in the grocery store
			Perceived barriers	Analyze the variety in their diet and recommend ways to increase variety
				Identify the lowest fat options for animal foods and processed/prepared foods
			Perceived barriers	Understand barriers to eating more fruits and vegetables and brainstorm ways to overcome those barriers
			Social support	Discuss ways to implement new knowledge in daily life
Action	Facilitate ability to take action	The New Healthy Plate	Self-efficacy	Use suggested guidelines to reach recommended fruit, vegetable, and fat intake
		Food Shopping Field Trip	Perceived barriers	Interpret common barriers to change and identify ways to overcome them
		Using the New Healthy Plate	Outcome expectations	Evaluate how new knowledge can promote good health and prevent disease
			Behavioral capability	Demonstrate how to use new knowledge with new cooking techniques
			Food preferences	Try foods not commonly used before
			Self-regulation	Identify ways to use knowledge to regulate intake and prevent overconsumption
			Self-regulation	Formulate methods of planning ahead to avoid convenience foods over fresh foods
Maintenance	Facilitate ability to maintain action	Keeping it Up!	Perceived benefits	Compare the quality of fresh produce over other vendors
				Describe how to plan meals and create dishes using legumes, whole grains, and fruits and vegetables with little or no meat
		Using your local Greenmarket!	Perceived barriers	Evaluate which traditional dishes can be prepared or adapted to meet newly acquired guidelines
		Vegetable Feasts	Behavioral capability	Analyze prices and understand that fresh produce can be affordable
			Self-efficacy	Recognize it is possible to buy healthful foods in neighborhood markets

Step 5: Generate Plans

The stages of change construct of TTM was used to guide the structure of individual classes and the decision to create a nine-session curriculum (over a 12-week period, to allow for holidays and/or weather-related conflicts) to facilitate the transition from contemplation/preparation (first set of three classes), through activities that encouraged action (second set of three classes), to activities that encouraged maintenance behaviors (third set of classes). The rationale behind this structure was based on the assumption that potential participants would be in the contemplation or preparation stages at baseline based on their willingness to enroll in a nutrition intervention trial. While the curriculum was designed to follow a linear structure, all sessions addressed barriers and facilitators for each stage in order to meet the needs of participants moving forward or back through the stages.

The team developed a set of learning activities for each lesson, designed to meet each of the established theory-based objectives. Activities were tailored to address reasons for changing dietary behaviors, how and where to purchase healthful affordable foods, and how to prepare foods in a healthful way. Specific recipes were developed based on adaptations of traditional Latin American and Caribbean cuisine. Although there are several existing nutrition education programs that include recipes, there are few resources for healthy versions of Dominican and Puerto Rican traditional foods. For example, the recipe for sancocho, a traditional chicken stew, was adapted to be lower in fat and higher in nonstarchy vegetable servings, without compromising traditional flavors. Drawing from expertise of each of the interdisciplinary team’s members, including Hispanic members from multiple ethnic backgrounds and extensive experience with local Hispanic communities, the cultural importance of family was addressed and curriculum activities were further tailored to address potential obstacles of family dissent. Ways to encourage motivation for participants to engage their families as social support were included. The resulting curriculum included four nutrition education sessions (2 hours/lesson), two food shopping + maintenance sessions (2 hours/lesson), and three hands-on cooking lessons (4 hours/lesson) that were culturally tailored, and addressed community and population-specific barriers and facilitators for Hispanic cancer survivors (Table 1).

Step 6: Nail Down Evaluation Plan

An assessment instrument using a 5-point Likert-type scale for responses was developed to evaluate the main behavioral outcomes (increased fruit and vegetable intake and decreased fat intake), mediators of change targeted throughout the intervention (self-efficacy, food preference, cultural acceptability, health beliefs, access, and outcome expectations), stages of change, perception of target behavior importance versus achievability, social support, barriers to finding and eating healthful foods, and life stressors. Questions were based on previously validated questionnaires (Brady et al., 1997; Contento, 2015; Gotay et al., 2007; Wallston, Stein, & Smith, 1994; Weiss et al., 2005; Zigmond & Snaith, 1983).

Formative Evaluation Methods

Two separate focus groups were conducted among Hispanic breast cancer survivors (self-identified Hispanic women, fluent in Spanish, and at least 3 months post chemotherapy, radiation, or surgery) to evaluate curriculum materials and assessment instruments. Focus group members (age range 21-55 years) were recruited from the institution’s breast oncology clinic in October-November 2011. Columbia University Medical Center Institutional Review Board approval was obtained for all focus group activities, and written informed consent was obtained from all focus group members. Both focus groups were led by two bilingual nutrition educators with expertise in conducting focus groups in Spanish. Sessions were approximately 3 hours in duration and recorded on audiotape for subsequent transcription. Extensive notes were additionally collected by the focus group facilitators. At the beginning of each session, facilitators provided a brief introduction and introduced the purpose of each focus group. Focus group members were then provided copies of the draft curriculum materials and instruments. In the first focus group, members were asked scripted, open-ended questions to evaluate lesson materials (including handouts, presentations, and homework cards) for content (e.g., “On Section 2, what additional information should we present?”), language level (e.g., “Using your own words, what do you think we are asking here?”), graphics (e.g., “Which picture do you prefer?”), and cultural relevance (e.g., “How much do you think Hispanic breast cancer survivors will be able to identify with the issues discussed here?”). Probes were used as needed to clarify and expand on participant responses. Participants additionally provided feedback based on questions about proposed activities and Hispanic-specific attitudes (e.g., “Would this activity motivate you to eat more vegetables?”), barriers (e.g., “What are things that prevent you from buying vegetables?”), behaviors (e.g., “How often do you cook a meal at home?”), and knowledge (e.g., “In your own words, what do you understand is the difference between starchy and non-starchy vegetables?”). The second focus group focused on assessing clarity (e.g., “In your own words, what do you think this question is asking?”), format (e.g., “Which design do you prefer?”), degree of difficulty (e.g., “How easy or difficult to understand is this question?”), and overall cultural and linguistic appropriateness of specific questions in the assessment instrument. Following each focus group, recordings were transcribed along with notes to produce reports used to inform curriculum content, activities, and instrument development. Based on input from each focus group, specific materials and content were modified for improvement prior to program implementation.

Feedback on Program Content, Materials, and Activities: Focus Group 1

A total of seven women participated in the focus group discussion on program content, materials, and activities. Overall, the content and aesthetics of the materials were highly rated. Through animated discussions, participants expressed they liked the structure of the intervention, particularly the emphasis on cooking. A major theme that emerged during discussions was participants’ lack of knowledge about starchy versus nonstarchy vegetables. Because of their protective association with cancer risk (World Cancer Research Fund/American Institute for Cancer Research, 2007), specific emphasis was placed on nonstarchy vegetables throughout the intervention. Thus, curriculum materials were altered to clarify the difference between starchy and nonstarchy vegetables. Additional alterations to curriculum materials were based on feedback associated with content (e.g., placing words used in Dominican and Caribbean slang next to formal Spanish to clarify terms that differ across Hispanic subgroups), logistics (e.g., including transportation compensation to reduce the economic burden among potential participants), and format (e.g., modifying homework materials for women with difficulty reading and writing, adding further components related to family support, and adding a “contract” to increase motivation).

Feedback on Assessment Instrument Questions: Focus Group 2

Seven women (n = 4 from previous focus group and n = 3 new participants) attended the focus group discussion. After reviewing specific questions in the assessment instrument, the second focus group members emphasized their preference for an interviewer-administered questionnaire. They reported section instructions were clear, but certain answer options were found to be confusing. Format and aesthetics were highly rated. Based on feedback, modifications to the assessment instrument included simplifying some of the assessment questions, clarifying the difference between starchy and nonstarchy vegetables, and changing language content for appropriateness in terms of language difficulty and Spanish style to make written materials appropriate for women with lower levels of literacy.