The FAV-S Pilot Study

Abstract

The 2012 FAV-S pilot study was developed as a dietary intervention program for low-income Somali mothers grounded in the health belief model. The intervention was geared toward increasing fruit and vegetable intake among participants’ children. The purpose of this analysis was to determine the impact of the FAV-S program on participants’ (1) self-efficacy in ability to serve more fruits and vegetables, (2) knowledge and beliefs about healthy eating, and (3) perceived barriers to accessing healthy foods. Furthermore, this study assessed change in fruit and vegetable intake among participants and their children. The intervention consisted of two small group education sessions addressing nutrition, serving size, and label reading; a cooking session incorporating fruits and vegetables into traditional Somali dishes; and a grocery store session demonstrating best purchasing practices. Self-efficacy, knowledge and beliefs, and perceived barriers were assessed via surveys administered verbally in Somali pre- and postintervention. Paired t tests were used to compare pre- and postintervention survey responses. Twenty-five women participated in the pilot study; mean age was 43.6 years (SD = 12.4). Self-efficacy significantly increased among participants postintervention (p = .01), though there were no significant changes in knowledge and beliefs or perceived barriers. Following intervention, daily servings of fruits and vegetables significantly increased among both women and children (p = .01 to p < .01). Findings suggest that a multistage, culturally tailored, approach is effective at increasing self-efficacy and fruit and vegetable intake in the Somali community. Continued and expanded research is needed to further develop culturally focused dietary interventions.

Keywords

diet health behavior health belief model immigration health maternal and child health nutrition

The health benefits of fruits and vegetables are well documented and widely promoted by experts in the field. Adequate fruit and vegetable intake is associated with reduced risk of many chronic diseases including coronary heart disease, stroke, diabetes, and certain types of cancer (He, Nowson, Lucas, & MacGregor, 2007; Nöthlings et al., 2008; Takachi et al., 2008). Additionally, fruits and vegetables protect against obesity and aid in weight management (He et al., 2007; Nöthlings et al., 2008; Rolls, Ello-Martin, & Tohill, 2004; Takachi et al., 2008; Tohill, Seymour, Serdula, Kettel-Khan, & Rolls, 2004). Despite these known advantages, consumption of fruits and vegetables remains low among Americans, particularly among many immigrant and minority populations (Centers for Disease Control and Prevention, 2009; Dehghan, Akhtar-Danesh, & Merchant, 2011; Grimm, Foltz, Blanck, & Scanlon, 2012; Larson, Neumark-Sztainer, Hannan, & Story, 2007). Specifically, Somali immigrants and refugees, a growing segment of the U.S. population, experience higher rates of inadequate fruit and vegetable intake due to unique social and cultural characteristics (McEwen, Straus, & Croker, 2009). In Hennepin County, Minnesota, home to more than 34,000 Africans and the largest Somali population in the United States, only 21% of African-born Blacks reported consuming five fruits and vegetables per day in 2010 compared with 34% of White and 24% of U.S.-born Black adults (Hennepin County Human Services and Public Health Department, 2011; Migration Policy Institute, 2013). Reasons for this disparity are complex and diverse.

The Somali diet, consisting mainly of rice, pasta, and red meat, is closely tied to cultural identity and tradition. Fruits and vegetables are often associated with poverty due to their abundance and low cost in Somalia, while meat is highly valued as a symbol of wealth and status (McEwen et al., 2009). Additionally, several social and cultural factors influence the Somali diet including religious beliefs and customs, financial constraints, and lack of education on and experience with purchasing and preparing American foods (Dharod, Croom, & Sandy, 2013; McEwen et al., 2009). Most Somali immigrants are Sunni Muslim and follow strict religious dietary practices including only consuming foods considered to be halal, or permissible to eat (Haq, 2003). Monoglycerides and diglycerides in prepared foods are objectionable, making it difficult for Somali immigrants to determine if canned and frozen fruits and vegetables, often the more affordable option, are halal. This issue is compounded by the fact that many Somalis face barriers in reading and understanding U.S. packaging labels due to language differences and low levels of literacy (Dharod et al., 2013; Haq, 2003). Consequently, efforts to increase fruit and vegetable intake within the Somali community must adopt a multistage approach tailored to account for the specific cultural beliefs and needs of the population.

Though it is apparent that inadequate fruit and vegetable intake within the Somali community needs to be addressed, there has been little, if any, work to develop and implement targeted intervention strategies aimed at increasing fruit and vegetable consumption within this population. Therefore, the intervention to increase fruits and vegetables among Somali children (FAV-S) pilot study was developed to test the feasibility and acceptability of implementing a comprehensive dietary intervention program for Somali mothers. With a focus on the previously identified cultural factors influencing the Somali diet, the FAV-S pilot study was implemented as a multistage program consisting of four small group sessions grounded in the health belief model (HBM). Specifically, the intervention was geared toward increasing knowledge and self-efficacy, decreasing barriers, and changing behaviors related to fruit and vegetable consumption through the use of culturally appropriate intervention methods (Rosenstock, Strecher, & Becker, 2006).

The feasibility and acceptability of the FAV-S pilot study were assessed previously (Hearst, Kehm, Sherman, & Lechner, 2014). The purpose of this analysis is to determine the effect of the intervention on (1) participants’ self-efficacy in ability to serve more fruits and vegetables to their families, (2) participants’ knowledge and beliefs about healthy eating, and (3) participants’ perceived barriers to accessing healthy foods. The HBM theorizes that in order for behavior change to occur, individuals must feel threatened by their current behavioral patterns and believe that a specific behavior change will result in a valued outcome at an acceptable cost (perceived benefit). Individuals also must feel self-efficacious to overcome perceived barriers to take action (Champion & Skinner, 2008). Therefore, this study considers three key components of the behavior change process, providing an in-depth examination of the effects of the FAV-S pilot study on Somali women and children. This analysis further assesses fruit and vegetable intake of participants and their children pre- and postintervention, as dietary behavior change is the ultimate objective of the FAV-S pilot study.

Method

Conceptual Framework

The guiding conceptual model for this intervention was the HBM (Champion & Skinner, 2008), which is grounded in the idea that perceived values and expectations guide behavior. Briefly, individuals will engage in a health behavior if they think it will reduce a threat (e.g., poor health outcomes), and if they have the ability to engage in the behavior change. Perceived likelihood and severity of harm influence behavior change in combination with perceived benefits and barriers to changing behavior, and perceived self-efficacy to engage in the behavior (Champion & Skinner, 2008). Cues to action are behavioral prompts that support the behavior change. Figure 1 depicts how the HBM guided the FAV-S intervention aimed at (1) increasing participants’ understanding of the health threat of inadequate fruit and vegetable intake, (2) providing participants with strategies to overcome barriers, (3) increasing participants’ understanding of the benefits of serving additional fruits and vegetables, and (4) providing participants with the skills and self-efficacy to purchase, prepare, and serve additional fruits and vegetables to their children. All components of the intervention were embedded in Somali cultural traditions to increase the likelihood of behavior change.

Figure 1.

Conceptual model for the FAV-S pilot study.

Intervention

Twenty-five Somali mothers were recruited to participate in the FAV-S pilot program. Women were recruited from a predominantly low-income housing complex located in Minneapolis, Minnesota, in 2012. Women were eligible to participate if they were the provider of at least one child, ages 3 to 10 years. Details on recruitment are published elsewhere (Hearst et al., 2014). The intervention consisted of four small group sessions, each lasting about 1.5 hours, held over approximately 6 weeks (average number of days, 47; range, 20-107). The long time frame for some participants was due to the timing of Ramadan, a holy month of fasting, during which activities beyond religious observance slow down.

Group Health Education

The first two sessions were small group educational classes consisting of three to four participants. Sessions were implemented by trained, bilingual Somali community health workers, and were held at a local community center or coffee shop near the housing complex. Sessions were designed using a culturally modified Simply Good Eating (SGE) Curriculum (University of Minnesota Extension, 2007) and supplemental materials from University of Minnesota Extension. SGE lessons employ visuals, use actual foods, and draw on participants’ knowledge and experiences. The SGE curriculum applied to the FAV-S intervention included the importance of fruits and vegetables for a healthy diet, composition of a healthy plate based on MyPlate resources (U.S. Department of Agriculture, 2013) 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 healthy food options. These sessions aimed to increase participants’ knowledge and beliefs about the importance of healthy eating and to improve participants’ self-efficacy in identifying, preparing, and serving healthy meals that incorporate fruits and vegetables to their families.

Cooking Skills and Preparation

The third session of the intervention consisted of a group cooking activity in which participants prepared regionally available fruits and vegetables for cooking and eating and learned how to incorporate additional vegetables in traditional Somali meals. This session was held at a local community center kitchen and consisted of the same small groups formed in the first two sessions. Again, this session aimed to improve knowledge and self-efficacy in preparing healthy meals that incorporate fruits and vegetables.

Field Trip to Grocery Store

The final session of the intervention involved a field trip to a local grocery store typically used by participants. Women were provided with a $50 gift card to purchase fruits and vegetables, toured the store, and were educated on how to identify and select the healthiest halal choice of fresh, frozen, and canned fruits and vegetables from the appropriate aisles in order to decrease barriers and increase self-efficacy in identifying and purchasing fruits and vegetables.

Measures

Survey tools were developed and translated into Somali. Due to limited English proficiency of participants, surveys were administered verbally in Somali by community health workers at the first group session and again after the fourth session following the trip to the grocery store. The survey was designed to capture participants’ demographics including age, income, and household structure, as well as self-reported self-efficacy, knowledge, and beliefs regarding what constitutes a healthy diet, perceived barriers to accessing healthy foods, and personal and children’s average intake of fruits and vegetables.

Self-efficacy was measured using seven survey items assessing participants’ confidence in ability to identify, purchase, and prepare fruits and vegetables as part of family meals. Questions were developed specifically for the FAV-S intervention to assess self-efficacy in dietary behavior change and were vetted by community experts working with nutrition interventions and with the Somali population. Questions included, “I feel confident that I can plan a nutritionally balanced meal” and “I feel confident that I can serve fruits and vegetables as a snack to my kids.” Responses ranged from 1 =Not confident to 5 = Very confident. The seven self-efficacy items were averaged to create pre-intervention (Cronbach’s α = .97) and postintervention (Cronbach’s α = .95) scales. Refer to Table 2 for a complete list of survey items.

Knowledge and beliefs were measured using four survey items assessing how much participants agreed/disagreed with the following statements: (1) “Eating healthily is important,” (2) “I have a healthy diet,” (3) “Eating a variety of foods is important for my child’s health and development,” (4) “My child does not need to eat fruits and vegetables.” Responses ranged from 1 = Strongly disagree to 5 = Strongly agree; Item 4 was reverse coded. The four knowledge and beliefs items were averaged to create pre-intervention (Cronbach’s α = .72) and postintervention (Cronbach’s α = .59) scales.

Perceived barriers were measured using four survey items assessing how much participants agreed/disagreed with the following statements: (1) “I would buy more fruits and vegetables if I knew what to buy,” (2) “I would buy more fruits and vegetables if I knew how to prepare them,” (3) “I would buy more canned or frozen fruits and vegetables if I knew they were halal,” (4) “I would buy more canned or frozen fruits and vegetables if I knew they were healthy.” Responses ranged from 1 = Strongly disagree to 5 = Strongly agree. The four perceived barriers items were averaged to create pre-intervention (Cronbach’s α = .93) and postintervention (Cronbach’s α = .84) scales.

Fruit and vegetable intake was assessed separately for Somali women and children based on responses to the survey questions, “How many servings of fruits do you usually consume?” and “How many servings of fruits does your children usually consume?” (Glasson, Chapman, & James, 2011). Women were asked to report on consumption for only children ages 7 to 12 years. These same questions were asked for vegetable intake; response options ranged from 1 = 0 to 2 per week to 8 = 5+ per day. These intake questions are widely accepted for use in population-based studies, as they are shown to effectively rank individuals (Glasson et al., 2011). For analytic purposes, responses were converted to an 8-point servings-per-day scale. Data were evaluated for skewness, and though fruit and vegetable consumption responses were slightly skewed, no change in statistical significance was observed when medians were analyzed in place of means.

Data Analysis

All 25 participants were included in analyses, though sample size varies across survey items due to missing data. We opted not to exclude women with missing data due to the already small sample size of the pilot study. Paired t tests were used to compare pre- and postintervention survey responses based on a significance level of α < .05 using the two-tailed test. Analyses were conducted using Stata v. 12.1 (StataCorp, College Station, TX).

Results

Table 1 provides demographic characteristics of the study sample. Participants ranged in age from 25 to 67 years, with a mean age of 43.6 years (SD = 12.4). All 25 participants reported an annual household income of less than $20,000, with a majority of women reporting an annual household income of less than $10,000 per year (88%). Participants reported an average of 1.8 (SD = 0.7) children between the ages of 7 and 12 years living at home.

Table 1.

Sample Demographic Characteristics, FAV-S Pilot Study, 2012 (N = 25).

Variable	Value	Mean	SD	Range
Female (%)		100%
Age^a	Years	43.6	12.4	25-67
Income (%)
	<$10,000 per year	88%
	>$10,000 but <$20,000 per year	12%
Household size
	Children 0-18 years	2.6	1.5	1-6
	Children 7-12 years	1.8	0.7	1-3
	Adults >18 years	1.4	0.8	0-3

One observation missing age (N = 24).

Table 2 presents pre- and postintervention responses to survey items assessing (1) self-efficacy, (2) knowledge and beliefs, and (3) perceived barriers. There was a statistically significant increase in reported confidence for all seven self-efficacy questions postintervention. Questions assessing confidence in planning and serving a nutritionally balanced meal had the greatest increase in reported confidence postintervention (p < .01). Overall, the self-efficacy scale increased from 3.0 (SD = 1.5) pre-intervention to 4.0 (SD = 1.0) postintervention (p = .02). There were no significant changes in knowledge and beliefs or in perceived barriers postintervention. Knowledge and beliefs about healthy eating were high at baseline and remained high following the FAV-S intervention. The same pattern was observed for perceived barriers.

Table 2.

Intervention Effects on Constructs of the Health Belief Model, FAV-S Pilot Study, 2012.

Construct/measure	N	Pre-intervention		Postintervention		p value^a
Construct/measure	N	Mean	SD	Mean	SD	p value^a
Self-Efficacy
How confident are you that you can^b . . .
1. Plan a nutritionally balanced meal.	21	2.8	1.7	4.4	1.0	<.01
2. Identify fresh/ripe fruits and vegetables at the grocery store.	21	3.1	1.6	4.0	1.1	.03
3. Read fruit and vegetable labels to determine if halal.	20	2.8	1.6	3.9	1.4	.02
4. Read frozen fruit and vegetable labels if halal.	22	2.9	1.5	4.2	1.1	<.01
5. Add extra vegetables to traditional dishes.	19	2.9	1.5	4.0	1.2	.02
6. Serve fruit and vegetables as snacks to children.	20	2.9	1.5	4.2	1.0	<.01
7. Serve nutritionally balanced meals to children.	21	2.8	1.6	4.2	0.9	<.01
Self-Efficacy Scale (pre, post α^c = .97, .95)	16	3.0	1.5	4.0	1.0	.02
Knowledge and Beliefs
Agree/Disagree^d . . .
1. Eating healthily is important.	20	4.9	0.4	4.8	0.4	.49
2. I have a healthy diet.	19	4.5	0.9	4.7	0.5	.43
3. Eating a variety of foods is important for my child’s health and development.	21	4.6	0.9	4.6	0.7	1.00
4. My child does not need to eat fruits and vegetables.^e	20	1.8	1.4	2.1	1.4	.47
Attitudes Scale (pre, post α^c = .72, .59)	17	3.9	0.4	4.0	0.4	.80
Perceived Barriers
Agree/Disagree: I would buy more^d . . .
1. Fruits and vegetables if I knew what to buy.	22	4.4	1.2	4.8	0.4	.11
2. Fruits and vegetables if I knew how to prepare them.	22	4.6	1.0	4.7	0.5	.67
3. Canned/frozen fruits and vegetables if I knew they were halal.	21	4.6	0.9	4.6	0.8	.86
4. Canned/frozen fruits and vegetables if I knew they were healthy.	21	4.6	0.9	4.5	0.9	.59
Barriers Scale (pre, post α^c = .93, .84)	21	4.5	0.9	4.6	0.6	.71

Paired t test used to test for statistical significance based on α < .05. ^bMeasured based on five response options ranging from 1 = Not confident to 5 = Very confident. ^cCronbach’s alpha. ^dMeasured based on five response options ranging from 1 = Strongly disagree to 5 = Strongly agree. ^eResponses reverse coded.

Table 3 presents pre- and postintervention self-reported daily servings of fruits and vegetables. Overall, average daily servings of fruits and vegetables significantly increased postintervention among both participants and their children. Among participants, average reported fruit intake increased significantly from 0.7 (SD = 1.0) to 1.7 (SD = 1.4) servings per day (p = .01), and average vegetable intake increased significantly from 0.7 (SD = 1.0) to 1.7 (SD = 1.5) servings per day (p < .01). Among children, participants’ reported a significant increase in average fruit intake from 0.6 (SD = 0.9) to 2.0 (SD = 1.8) servings per day (p < .01) and average vegetable intake from 0.7 (SD = 1.0) to 2.0 (SD = 1.5) servings per day (p < .01).

Table 3.

Daily Servings of Fruits and Vegetables Among Somali Women and Children, FAV-S Pilot Study, 2012.

Measure	N	Pre-intervention		Postintervention		p value^a
Measure	N	Mean	SD	Mean	SD	p value^a
Women
Daily servings of fruit	21	0.7	1.0	1.7	1.4	.01
Daily servings of vegetables	21	0.7	1.0	1.7	1.5	<.01
Children
Daily servings of fruit	20	0.6	0.9	2.0	1.8	<.01
Daily servings of vegetables	22	0.7	1.0	2.0	1.5	<.01

Paired t test used to test for statistical significance based on α < .05.

Discussion

Findings demonstrate that the FAV-S pilot study was effective at increasing reported self-efficacy among participants in terms of confidence in ability to identify, purchase, and prepare fruits and vegetables for their families. There was a significant increase in reported confidence for all seven self-efficacy scale questions, suggesting that this type of intervention program is capable of increasing participants’ self-efficacy in several aspects of dietary behavior change. It is important to note that the self-efficacy survey questions were rooted in culturally significant constructs, such as identifying fruits and vegetables as halal and incorporating more vegetables into traditional Somali dishes. Therefore, the success of this program is likely due in part to the efforts made to design the intervention specifically around the beliefs and needs of the Somali community. Accordingly, the FAV-S pilot study not only supports previous findings that self-efficacy can be increased through educational intervention programs geared toward increasing fruit and vegetable consumption (Dalziel & Segal, 2007), but further suggests that this type of program can be successful among diverse communities if actions are taken to ensure the intervention focuses on culturally relevant concepts specific to the target population.

No significant changes were observed in participants’ knowledge and beliefs about the importance of fruits and vegetables and healthy eating. However, knowledge and beliefs were already high prior to intervention, suggesting that these components of the HBM were not the primary factors inhibiting adequate fruit and vegetable intake within the Somali community. Perceived barriers to purchasing fruits and vegetables also did not significantly change following the FAV-S intervention. Participants reported a high level of perceived barriers pre-intervention, and these barriers remained postintervention, indicating that the FAV-S program did not sufficiently eliminate these obstacles.

Despite the lack of change in perceived barriers, results indicate that the FAV-S pilot study was effective at significantly increasing fruit and vegetable intake among participants and their children. Findings are consistent with previous studies that found small group educational intervention programs to be successful at increasing participants’ fruit and vegetable intake (Dalziel & Segal, 2007). Results suggest that multistage, small group, intervention programs can successfully increase fruit and vegetable intake within specific minority communities, such as the Somali immigrant and refugee community, when appropriately adapted for the given population. Because nutrition interventions represent a highly cost-effective strategy for reducing the growing disease burden associated with poor nutrition (Dalziel & Segal, 2007), results from this study are promising as they demonstrate that this type of intervention strategy is capable of producing immediate and measureable results within immigrant and minority communities.

Limitations

As previously identified, a significant limitation to this analysis is the small sample size of the FAV-S pilot study. Therefore, our findings should be considered preliminary, as more work is needed within this area of research to better understand the effects of this type of dietary intervention program within the Somali community. Another limitation to this analysis is the lack of a control group in the FAV-S pilot study design. Again, this implies that results from this analysis are merely suggestive and may not accurately represent the target population. Furthermore, the observed behavior changes may not be due to the intervention alone. A large randomized control study is needed to validate results from this preliminary study and to further describe the effects of this type of intervention program on fruit and vegetable intake. A third limitation is the presence of missing data, which again limits our ability to make accurate conclusions about the effects of the intervention program on the Somali population. Furthermore, though this study used measures of fruit and vegetable intake commonly used in population-based studies, the reliability and validity of these items were not tested within this specific study sample. Consequently, responses may be skewed, and thus a more comprehensive assessment is recommended for future studies. Findings may also be limited by the possibility that the $50 food voucher influenced purchasing behaviors during the fourth session. Therefore, self-reported purchasing of fruits and vegetables captured immediately following the field trip to the grocery store may not accurately represent purchasing habits postintervention. In addition, the focus of the intervention may have resulted in social desirability bias, meaning the participants may have responded greater consumption of fruits and vegetables to please the interviewer. A further limitation to this pilot study is the wide age range of participants, as there may be substantial differences in food practices across the age spectrum of women. Thus, future studies on a larger scale should consider age as a potential modifier of the treatment effect. Additionally, this study did not capture length of residence in the United States, which may further modify the treatment effect. A final limitation to this pilot study is the potential lack of generalizability to other Somali populations in the United States, as this pilot study only occurred in Minnesota. There may be regional differences in food behaviors and practices, thereby limiting external validity. Despite these limitations, this analysis of the FAV-S pilot program has important implications regarding the effectiveness of dietary intervention programs targeting immigrant and minority communities, an understudied area of research. Because there is currently little, if any, empirical data on effective dietary interventions in the Somali community specifically, findings from this pilot study provide valuable insight into effective strategies for improving nutrition standards among this growing segment of the U.S. population.

Implications for Practice

Results from this analysis have important implications for dietary interventions targeting ethnically diverse communities. Our results suggest that a multistage, culturally driven approach is effective at increasing fruit and vegetable intake among participants and their children by promoting methods of behavior change, such as increasing self-efficacy through education and skill building. Findings also indicate that while the intervention was effective at increasing self-efficacy, it was less effective at addressing other components of the HBM, such as perceived barriers. This suggests that different approaches may be required for successfully impacting various components of the HBM. Nevertheless, despite the lack of reduction in perceived barriers, dietary behavior change was observed among FAV-S participants providing insight into the relative importance of each HBM component in promoting behavior change. Findings suggest that some factors, such as self-efficacy, may be more influential in the behavior change process than others.

Ultimately, dietary interventions, such as the FAV-S pilot program, that provide education on the importance of fruits and vegetables and teach practical skills for identifying, purchasing, and preparing healthier food options, present promising avenues for improving dietary intake among minority communities. We believe that this type of intervention model can produce similar results in other minority and immigrant communities if steps are taken to ensure that the program meets the specific cultural and social needs of the target population. Because of the identified need for improved dietary intake within ethnically diverse populations, as well as the current lack of effective behavior change strategies for these communities, results from this analysis are both informative and encouraging. Based on study findings, we advocate for continued and expanded research on culturally focused dietary intervention strategies that can build on our preliminary findings from the FAV-S pilot study.

Footnotes

Authors’ Note

The Obesity Consortium (the funding agency) had no role in the design, analysis, or writing of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors 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 three 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 (NIDDK funded), and the Center for Transdisciplinary Research on Energetics and Cancer (NCI funded).

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