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NutritionRelated Knowledge, Attitudes, Practices AndNeedsof

IndianImmigrantsand Famil yMembersinNewfound la nd

by Suja Vargh ese,B.SC.RDt

Athesis su b m itt ed to the Scboolor GraduateStu d ies

inpartialfulfilmeot of the requirementsrortbedegree or

Mast er of Sdem:e

Dn-bioaorCom m unity Health Mem o rial Uon-enity ofNewfouo d la n d

JUDe,1999

St.Jobo's Newfoundland

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Abstract

This study was a comprehensive nutrition related needs assessment of Indian immigrants andfamilymembersinNewfoundland.Itwas also designed toanswerquestions such as whether this ethnic group had acculturated to Canadianfood habits and whether their dietary practices were influenced by their knowledge. attitudes and demographic characteristics.Across sectional survey utilizing a selfadministeredmailed questionnaire wasconducted.A random sampleof 132 subjects,both malesand females,aged 10-65+

took partinthestudy.

Itwas found that the respondents were fairly knowledgeableabout healthy eating guidelinesinCanada. Regarding attitudes towardfood selection. they were frugal, non-food explorative,butsociable!hospitab lewitha strong concern for social status. They valued nutrition as fundamental togoodhealth. Thefoodconsumption pattern revealed thatthey were somewhat acculturated to Canadianfoodhabits. Althoughthe overall likelihood of following healthy life stylepracticeswas good, consumption ofgrainsand vegetablesIfrui ts wasnot atparwiththe recommendations of Canada'sFood Guide.Itwas observed that healthy lifestyle practices weremore consistently associated with the attitude to'nutrition isimportant'ratherthanwithnutrition relatedknowledge.The demographic characteristics revealed thatthisethnicgroupwashighly educatedwith higherthanaverage income,well establishedinNewfoundlandandhadfewlanguageproblems .Inspite of these unique characteristics, the majority of respondents ratednutrition servicesavailablein

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Newfouodland as cultundlyinappropriate.Thedesireto koow moreabout the nutritional qualityof their traditiooaldiet,provision ofethnicfoodsregularlyinhospitalsand a...ailabili.ty of ethnicall ytailorednutrition educationmaterialsweresomeof the~ needs ofthisethnic group.

Thefindingsofthis studyreinforce theneedfocmore cultun1lyappropriatenutrition servicesinNewfoundlandhospitalsand communities.Thefindingthatkoowledge was not sufficient in inducin ghealthyeating practicescallsfo r new strategies for dietary modifications. Becauseof the unique characteristics of this study population,resultsarc not generaliza bleto otherimmigrants in NewfoundlandortoIndianimmigrantsin otherparts of Canada. More studieson other immigrants arc needed to understandtheimpact o f cu1ture on nutrition relatedissues.

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I dedicate my thesis to all immigrant women who had weathered

the storms of adjustment to a new culture with patience and

perseverance.

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Acknowledgments

Iacknowl ed gewithsincereappreciation theguidance,encouragementandsupport given tomebymy supervisorDr.Robin Moore-Orr.I sincerely thankDr.veereshGadag for helpingmewiththe:studydesignandstatisticalanalysisaDdfor givingso freely ofhis time fortbisproj ect.Ialsoextend my specialthankstoDr.SharonBuehlerandDr.Walid Aldoo ri, members of my superviso rycommittee,fortheirinvaluable commentsand suggestions.

I acknowledgethe comments and suggestions of externalvaJidators,especiallyDr.

Debra Reid and Ms.HelenYeung.I amgratefulto the studentsofMr.Gerry Baird (Association ofNewCanadians) andDr.BarbaraRoebothan(MemorialUniversity) as well asto the dietitians at theHealthCare Corporation, St.John'sfortakingpartinthevalidity testi ngof myquestionn aire.Isincere ly thank mem bers of theSeniorBridging Cultures ClubinS1.John'swhoinspiredmetoconductthis study.[owemyspecialthanks to organizersofthe SeniorBridging CulturesClub foram:nginginterpretersforseniorswho badlanguagedifficul ties. Finally,IthankallIndianimmigrantsinNewfoundlandwho participatedinthe study.without wbom,thisprojec twouldnothave been possible.

Aboveall,I amindebtedtomychildren, SonyaandShawnandmy husband.

Varghese. whomade it possiblefor me to devote my timeto thisproject.

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4.6. IRe~::.===~

^••...^{. .}^.^{. . . .}^{.. .. .}^{. .}^.⁷²

4.6.2Attitude to'nutri tionisimportant'knowledge level and

bealthybehaviors 73

4.6.3Attitudes and food selectionbehavior... ... .... .. . • .75 4.7 NeedsAssc:ssn1ent...• . . ... . . ... . . ...

n

4.7.1 Nutritio ninformationneeds•••••.•••• .••.••••••• • • •..••• .

n

4.7.2Aware ness.utilizationandperceivedappropriateness ofnutri tion relatedservices•.• . • • • ••••.. .•••.• • •.••..• •. •.78

4.7.2.1 Comm uni tyservices 78

4.7.2.2Hospital nutrition services. .. . . 79

4.7.3 General healthcondition/pro blems . 80

4.704Ethnicfoodavailability . 81

4.7.5Changes infoodprep aration practices . 82 4.7.6Nutritionrelatedconcerns...• .. ... . .. ... .. .... . ...82 4.7.7Comments andsuggestions forbetternutrition services .83

5.0 Discussion . . .. ... ... . . 85

5.1Nutritionknowledge . 85

5.2Attitudes... . ... . ... . . . . • . . 87 5.3Dietary practices .... . ..• • . . • . ... ... ... . ... ....88 504Nutrition relatedknowl ed ge,attitudesanddietaryprac tices:

Ioterre lationshi ps . 92

5.5Needsassessment. . ..93

5.6Limitations.. .... . 94

6.0SummaryandConclusions

7.0 References .

..%

98

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List of Tables

Table 3.1 Sample Sizeandselection..•...

Table3.2 Perceived attitude indexes and statements . Table 3.3 Response rate

Table 4.1 Sample characteristics .

Table 4.2 Percentage of respondents identifying reasons for practicingvegetarianism

Table4.3 Percentage of respondents who made recent Changesinthe diet.

.. ..Pg.31 .Pg.37 . .. Pg.42 Pg.48

Pg.50

... .. .. Pg.52 Table 4.4 Percentageof respondents identifying reasons for

making recent changesinthe diet . . Pg.52

Tahle4.5 Foodacculturationpattem Pg.57

Table 4.6 Consumption offoods which have adversenutritional effects Pg.58 Table4.7 Distribution of respondents by reported numberof servings

from eachfood group ... .Pg.59

Table 4.8 Distribution of respondents byadherence to

Canada's Food Guide Pg.59

Table4.9 Distribution of respondents by likelihoodoffollo wing Canada'sGuidelines toHealthyEating. Table4.10 SwnmaryofAttitudinaIResponses.

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... Pg.61 Pg.62

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Table4.11 Distribution,?~respondentsby nutritionknowledgescore Table4.12 Cross-tabulationsand Chi-squarevalues between

knowledgeleveland selected demographiccharacteristics.. Table4.13 Association between demographiccharacteristics and nutrition

relatedbehaviors .

...Pg.66

.Pg.68

..Pg.71 Table 4.14 Cross-tabulation and Chi-squarevalues between knowledgeand

'attitude to'nutrition is important'

Table4.15 Interrelationshipsamongnutrition knowledge,attitude to 'nutrition is important"andhealthy nutrition related practices ..

Table 4.16 Distribution of respondents who identifiedfrequently

... Pg.n

.. Pg.76

used sources of nutritioninfonnation Table4.17 DistributionofRespondents who identified

nutritionrelated topics of interest

Table4.18 Distribution ofrespondents who suggested changes forimprovementofhospital food services Table4.19 Distributionof respondents who suggestedchanges

for Improvementof outpatient nutritionclinics

... ...Pg78

.Pg.79

... . . .. Pg.80

Pg.81

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Figure4.1 Figure 42 Figure 4.3 Figure4.4 Figure4.s

List of Figu res

Breakfast Acculturation Pattern .. . . . ... .... • . ....• ..Pg.S3 Lunch AccuJturation Pattern... ....•.... .Pg.S4

SupperAcculturationPattern . . ....Pg.SS

Snad:Acculturati onPatterns.. . . __._._. . . ..Pg.S6

LevelofNutrition Knowledge Pg.6S

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List of Appendices

AppendixI Questions on demographiccharacteristics. • ... ...•. pg.106 Appendix 2 Questions on dietarypractices... .•. • . •. •. Pg.110 Appendix 3 Questionsonattitudes towardfood selection Pg.liS Appendix4 Questionson nutritionrelatedknowledge Pg. 118 Appendix 5 Questions onneeds assessment. . .•. . _Pg.121 Appendix 6 Canada'sFood Guidcto HealtbyEating... . Pg.127

Appendix 7 Canada'sGuidelinestoHealthyEating.. . ... Pg.129 Appendix8 Examples of approximatevolumepee-serving•••• .. Pg.131 Appendix 9 Tablel-C ross--tabuJation and chi-squarevalues between

attitudesandselecteddemographiccharacteristics . . . • .. Pg.133 AppendixLO Tabl e2 -Cross-tabul aticnandChi-square values between

nutritionrelatedbehaviors andselecteddemographic

characteristics.. . •. . . .. . .Pg.136

Appendix II Tables3 (a)&(b) Cross-tabulationand Chi-squarevalues ofrelationships among knowledge. attitud eto'nutritio n is important' andnutrition relatedpractices _... .. •.. .. '" Pg.143 Appendix12 Table 4-Cross-tabulatio oand Chi-square values of

relationshipbetween knowl edge andbehavior _.. .... Pg.146

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Appendix l3 Table5-Dismbutionof respondc nts byreported

general health conditions.. ..Pg.148

Appendix 14 Table6-Distributionof respoodentsbyreported

frequencyofethnic food substitutions.... ... ... ...•.•••••... Pg.150 Appendix 15 Human InvestigationCommitteeapproval

Appendix16 Sampleof Coverletter toadults• Appendix17 Sampleof cover letter tominoes . Appendixl8 LettertoExternalvalidators . Appendix19 Sample of a nutrition knowledgequestionnaire

usedfordiscriminantvalidity . Appendix 20 Previous presentatio ns .

xii

.. ...Pg.152 .. .Pg.154 .... .•... .Pg.1 57 . .. ...Pg.l60

..•... ..Pg.163

. Pg.l66

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Preface

Asanimmigrantwoman bom and broughtupina traditional Indian orthodoxsociety , settlingdowninStJohn' sandattemp ting toadjusttotheNewfound culturewasa tremendous challen ge.Ittook severalyears for metogetaccustomed to theway Newfound1aDdcrsspeak.tothe way they dress,tothewide variety ofNewfoundl andfoods and, not to mention.tothe wea therinStJohn's.

Oneoftbe experiencesduring theearly stagesaf mylifeinStJobn' sthatstilllingers inmymindisgettingadmittedto aHospital.(hadtoface manyproblems suchasnot knowin gwhat the appropriate food combinationsare and whatto order fromthemenu sheets distributed by thedietary staff.Ifeltthattherewas alackofunderstanding on the partof the dietarystaffabout thecultural differences in foodhabitsand food preferences. Eating improper combinationsorhesitation toeatunfamiliar food resultedinstomach ailmeots and hunger.Thisexperiencesparked an interestinme to studymore aboutnutritio nrelatedissues of immigrants.IhaveDOWLivedinStJohn's formorethantwo decades.Ihave a wid e circleof friendsfromdifferentnationalities and have workedextensivelywithimmigrants.

Mydec ision to choose a thesis on nutritionrelat edissues of a groupofimmigran ts arose from myown andotherimmigrants'experiences.

Ibelievethis researchhasshedlight tosomeoftherelevantissues relatedto immigrant nutrition. As apracticingregistered dietitian [ benefittedimmenselyfrom this research.Lno w bavea better appreciationof the fact that foodisa sourceof one'sidentity

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reflecting one'spreferences, cultural traditions,religionandsociallifc.Inow uodcrstaod better- thecomplexi tiesofeating bebevice.Thisresearchreinforcedinmethe importance ofconsidering the relevant needsof eachindi vid ual when providingnubitional care and counseling.

Iwouldlike to seemoreresearch in thisareainfuture.

xiv

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1.0 Introduction

Canada is aland of inunigrants where multiculturalism flourishes.Accordingto StatisticsCanada (1996)reports,immigrants constitute17.6%oftheCanadi an population and thisshare had remained at around15%to 16%between 1951and 1991.While theratio offoreign bomto Canadian born basremained constantatabout onetosix, countriesof origin ofrecentimmigrants have changed.The proportion ofinunigrants comingtoCanada from Europebasshrunk and mostimmigrantsnow originatefromAsia, LatinAmerica.

Africa and the Caribbean (Bader1993).These immigrantshavebroughtwiththem their diversecultures, languagesandfood habits.Accordingto one report from StatisticsCanada (19 89),there are 80 different cultural groups and atleast 100differentlanguages spo kenby variousethnic groupsinCan ada . Thewidevarietyofethnic foods nowreadily available acrossCanadaarcleg acies of immigrants.

ImmigrantswhocometoCanadawiththeir establishedcultural, linguistic , religious and dietary norms might face many challenges when they attempt to adjust to anew culture.

They arcinanew foodenvironment bombardedwithmanynewfoodsand differen tfood customs.Unfamiliarity with Canadian supermarketsand foods,unavailabilityof traditional foods, and lack of knowledge about the nutritionalvalueof foods availableinCanada could impose added stresses on immigrants (Yeung1995).Food ispartofone's cultural heritage.

Itis vitaltoone's physicalandmental health.Nutrition educators havea respon sibilityin enco uraging immigrants to keeptheir traditionaleating patternsifthey are nutritionally

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soundand in enabling them to makeinformed decisionsaboutthe wide varietyofDeWfoods.

Theincreasingethnicdiversityimposesadditional cbaIIc:ngeson nutritioneducato rs when theyattempt to promotc bcalthyeatinghabits or whentheytrytochange ormodify eatingbehavior.Ifnutritio n educationprogramsarctobe: cffectiveandmeaningfulto immigrants. suchprogramsshouldbe:cu1twallysensitiveandshouldtakeintoconsideration the diversi tyin cultmaI.,lingui sticand dietarycharacteristicsinCanada.

Despite themajorpopulationchanges and theconsequentcultunildiffcrencesin food patterns,studiesonissuesrelatedtoimmigrantnutritionarcsparse.Apreliminary study conductedinSt. John'samong a group of ethnicseniors revealed thatnutrition services availablctherewere notculturallyapprop ria te(Varghese1995).Nutrition educators' inadequateinformation relatedtothc cultural determinants of food habits maybeonereason forthislac kof culturallyappropriateservices.Anotherreasonmaybe:that, comparedto othercitiesinCanada.St.John' shas fewimmigrants;theseimmigrantsarc marginalized outside themainstreamculture and invisibletoserviceprovidcrs(Auger.1993).

The present studywas undertaken to assessthedietary practicc:sandnutrition related occdsof lodi animmigrantsand their familyme:mbc:rs in Newfoundland.POSS1"blepredicto rs of dietarypractices such as nutrition knowledge, attitudes,anddemographic characteristics werealso examined. Tbclodianethnicgroupwas selected. for this studybecause thcy were the largestsegmen t ofthcimmigrant populationinNewfoundland(Nakcooc zmy, 1996 ).

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Theobjecti vesof this studywere:

I) to assesstheeatingpatternsoflndian immigran tsandfamily members 2)todeterminetheir levelofnutritionknowledge

J)toidentify theirattitudes towardfood selection

4) to determine ifthere are differencesin their dietary practicesbased on their nutrition relatedknowledgeandattitudes

S)toidentify theirnutrition relatedneeds

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2.0 Literature Review

Areviewofliterature related toI)nutritionalconsequencesofmigration2)factors detemrining foodrelatedbehaviorand therationale for choosing psychosocial detc:nninanu (knowledgeand attitudes)and3) relevantpreviousresearchwillbediscussedinthissection.

2.1.Nutri tio nalConsequencesofMigration

2.1.1 Impact ofcultureODfood ",Iatntbehavior

Whenstudying issues related toimmigrantnutrition. an understanding oftbe impact ofculture onfoodrelated behavior is essential.Accordingto Tylo r (187 1) "Culture isthat complexwhole whichincl udesknowledge, belief,art.morals.la w.customs,and any other capabilitiesandhabits acquiredby man as a memberof thesociety." Oras Fieldhouse

(1995 )hasdescribed,cultureis"the sum total of a group'slearned,shared behavior".

Although differentcultures have differentcharacteristics., some common characteristics are applicabletoallcultures(Fieldhouse,1995,Axelson 1986.Foster, I%2).First. cultureislearned Peopleacquirecultural traitsearlyintheirlifeandthey transmitthemfrom one generation to anotherthroughtheprocessof socialization.The primary channelthroughwhiebsocializati on occursistheimmediatefamily whichreinforces appropriate behaviorsandsanctio ns theundesired.

Secondly.culture isnotstatic .Although babitsacquired earlyinLife arc on the whole stable and long-lasting,they are nevertheless subject 10change.Chan ges inthe physicalor social environment,educationalprograms.,medicalinven tio ns,massmediaand advertisin g,

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migration and urbanizationare some factorsthat could induce changesinculturaltraits.

Thirdly, peopleinternalize culturaltraditions so that they become an inseparablepart of their identity.Peopleareunconscious of their cultureand routinelydothings without being evenawarethat therearerules and regulationsgoverning many aspects of their behavior;people are creatures of the cultural traditionsinwhich they are raised.

Fourthly,indi vid ual s or groups of individuals might participate differentlywithin one culture.Inthis respect, Broom et aI.,(1917) havecoined the conceptof a subculture.

They have defined a subculture as a "pattern that isinsignificant respects distinctive butthat hasimportant continuitieswith a host ordominant culture."A subculturemay be based on occupation, area ofresidence, ethnic origin, religion, social class, age, language, diet or other variables.Therefore, one may be a participantinseveral subcultures at one time. Several subcultures may existwithina given locality.

How could these characteristics of a culture or subculture relate to the food habitsof immigrants in Canada?If food habits are acquired earlyinlife and. on the whole,are stable and longlasti ng;ifknowledge,attitudes and customs surroundingfood arepassedon to succeeding generations;ifchanges in food habits couldoccur over timebeca use of changes insocial and physical environment, food availabil ity,mass media advertising or migration;

what happens tothe dietaryhabits of immigrants when they attempt to adjust to another culture? Would they follow their traditional eating patterns and cooking methods? Are all the ingredientsrequiredto follow their traditional dietary patterns availablein their loca tion?

Do they havetomake substi tutionstothe availablevarieties in their new country?Or do

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theyacculturatetothe food habitsofthenewculture?tfthe yacculturatetothenew food habits. wouldtherebe any nutritionalconsequences?'Theseare some questions relatedto immigrantnutritionthat requiremore recognition from nutritioneducators.

2.1.1Dieta ryprllCric:norimmigran ts

Several studieshavelookedat:dietarypatternsofimmigrant groups. Shultz etat..

(1994 ) used a four daywrittenfood record.(3 weekdaysand oneweekend) to study the die tarypatterns of a groupofChinese women in San Diego.Itwas foundthatUS born ChineseAmerican womenwere:moreacculturatedto NOMAmerican foodhabitsthan those who wereborninChina.

Chauetal.,(1990 ) studie d thefoodhabitsof45Chineseelderly (over 60years old) livin g in theSan Fran cisco Bay area utilizing a 24hour dietaryrecall method as wellasa food frequencylist. The food frequencylist consistedof 34fooditemsarbitrarily selec ted torepresent. typical American foods andChinese foods.Hefound that 95%ofrespondents were mostlyeating Chinese staple foods for lunchandsupper.

Hrboticky et aL,(19 &4)studiedchangesin theperceived qualiti esof food suchas flavor,health valueandprestige perception among agroupoffirstand second generation Chinese adolescents livingintheMetropolitanTorontoArea.Usin ga 5 pointLiken.type scalesand 46 typicalCanadian foods thisstudydocumentedhigher hedonicflavor and prestigeratings to desserts, snacksand fast foodsandconcluded thatimmigrantscould accul tura teto food habitsthat have nutriti onal ly undesirabl e effects.

Grivettiet al.,(19 78)founda decreased use of traditionalfoodsbyfirstgenera tion

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ChineseimmigrantsinCalifornia even when thosefoodswere readily available. The researchers utilized a food frequencyquestioonaiIe (often, infrequent and never) and 77 traditional 'Chinese'and nontraditional"American foods" whichwere readily availablein California.

Storyet al., (1989) studied food habits and changesinfood consumptionpatternsof 60 SouthAsian refugee families (Cambodian andHmo ng) living inUnited States.

Frequency ofconsumptionof a food item fromalistoffoods (protein foods,dairyfoods.

grains,fruits/vegetables, fats., sweetsandmisccUancous)was collectedusingascale "daily',

"14 timesa month 'and"rarely' .Also,food preferencesfor 31selected items were assessed usinga scale'most preferred ' ,'leastpreferred'and'unfamiliarfood '.Itwas found that fresh fruits,meat s,and softdrinkswhichwereconsidere dhighstatusfoodsintheirhome countrywere highly preferred and frequen tlyconsumed.

Craneet al.,(1980) used a foodfrequencyquestionnaire (the average number ofdays each week such as twice a week, S-6 times a week etc.)to study the food habitsof Vietnamese refugees livinginNorthern Florida. Changes in food habitswere detennincd by comparing frequency of consumption of a food iteminthe United Stateswiththat in Vietnam.He also used a food preference checklistCIike','accept',"dislike', <never eaten') to collectinformation on the degree of liking for specificAmericanandVietnamese foods.

These Vietnameserefugee s were fotmdtoprefertheir traditional Vietnamesefoods over NorthAmericanfoods.Inthe same studyitwasfound thatsteak, infrequentlyeatenintheir ho meland,was oneof the most preferredfoods .

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From the abovementioned studiesand otherstudiesreviewed(HrbotickyetaI..1984.

Queen,1957.AdamsoneeaJ..1945.Grivettietal.,1978, StoryetaI..1989, Cbauet al..1990.

Yang etal., 1996, Crane etal.•1980),itwasdifficult to geoeralizethedietarypatterns of immigran ts,evenamongone specificgroup. Itappearedthat,ina crosssectionof immigrants,some mightfollo w theirtraditionalfoodhabits, staples.recipes andcooking methodswhereassomeothers mightgraduallyadopt the Canadian food habits.

Whatarethenutritionalconsequencesofsuchdietarypattems?Ifimmigrants follow their traditional food habits completely. unavailability oftraditional ingredients orinability to followtraditionalcooking methodscouldresultin nutritionaldeficiencies.Immigrants whocompletelyfollowtheir traditionalfoodhabitsare alsofoundto have difficultieswhen the y seekhospitalandcomm unitynutrition services,if those services arenot culturally appropriate(Varghese,1995).Ontheotherband,acculturatio ntothe typicalNorth American dietcouldresultin an increased use of animal protein, total saturatedfatandsugar alo ng withdecreaseduse of fiber.Such dietarypatternshave proven to have potentialhealthrisks.

Ttllotson(1973)studied coronary disease,heartdisease, and strokeamongJapanese:living inJapan,Hawaiiand Californiaaod foundhigherincidences oftbesediseases in thosewho adopteda NorthAmericandiet. McKeigueetal.•(1991) has documentedhigher blood pressure,fastingandpost glucose serum insulinconcentration,ce:ntraJ.obesity, higberplasma triglyceridesand lowerHDL cholesterolamon g SouthAsianimmigran tsin Londo n comparedto the native Euro pean group.InEngland and Walesmortalityfrom ischemic heart diseases is found to be the highest among menandwomen who immigratedfrom the

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Indian subcontinent (Balarejan, 1991). Bhatnagaret aI.,(1995) compared the coronary risk factorsin247 migrants from theIndiansubcontinent living in West Londonand117 oftheir siblings livinginIndia. It was found that the West London cohort had a higher body mass index,systolic blood pressure,totalserumcholesterol level, higher fasting bloodglucose level and lowerhighdensity lipoprotein cholesterol.

2.1.3 Sodod emograpbic fact onand dietarypatterns

The type,extentandprogression of changes in dietary patternsare dependenton many sociodemographic factors and a fewstudies havelooked at therelationship between thetwoamong immigrants. Length of exposure to the new cultural envirownent (Chavez etal.,1994),ability tospeakEnglish (Yang et aI.,1979),ability to read English(Chau et al., 1990), educationlevel (Chauet al.,1990),age (TillotsonetaI.,1973),and generation level (Freedmanet a1.,1984)are some of the factorsidentified.Ithas also been pointed outthat the dietary change process is easier formales than females(Katcaa-Apte er al.,1980)and that acculturation proceedsmore rapidlyin familieswithchildren(Story et al.,1989).

Studieson non-immigrant populations had identified other sociodemographic characteristicsthat could influence dietary patterns. ForCalasan ti (1986),the three interrelated variables which could have a major influence on dietary behavior were income, education level and occupational status.These variables could influence a wholerange of nutritionrelated factors from food preferencesand habits to the ability to purchase what one wants,to the likelihood of having proper storage facilities. Davis et al., (1982) reviewedl8 published articleson linkagebetweensociodemographic characteristics and dietary behavior

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and foundthateducatio nlevel(especiallythegeneral educationlevelof thehomemaker), bouseboldsizeandresidentialloeationwereimportantdetenninantsof nutritiooai status.

Anothercharacteristicthatbas an effect onfood consumption pattc:ms isethnic backgrowld.

Inspite of significantblendingof foods fromvarious culturesit isknownthatthereare distin ct dietarypractices amongvariousethnicgroups. Cronin etal..(1982),inan examinationof food consum ptio ndatafrom the USDA 1977-1978 Natio nalFood Cons umptionSurvey,foundthatDOD-whites,relative towhites,atemore rice,legumes, perk,fish,poultryandeggsandlessdairyproductsandbeer

2.1.4 Roleofnutritioneducaton

The effects of immigration and acculturationondietarypatterns anddiseaserisks haveimportant implicati onsfor nutritioneducatorsinCanada. Some ofthcproblcmsthat immigran ts mightfacewhena:lemptingtosecureadequatenutritiousfoodare unfamiliarity withCanadiansupermarkets,foods and foodstoragefacilities, lack. of knowledgcabout nutrition, highcost of theirtraditional foods and coocerns about food safety(Ycung1995).

InCanada"convenience foods"(easytocook,paclcaged,.processed foods), "fast foods"

(readymadefoods fromfastfood restaurants) and"rich foods"(foOCshighintotalfat and simplcsugarssuchaspasnics,pies andrichsauces)areeasily availablc.Advertisingusually prom otesthesefoodswhich are highinfat,sugarandsalt.Itis possible that immigrants, withoutbeingawareoflhchealth risks associatedwithsuchfoods,couldchoose them quitc oftcn (ycung,1995).Also,thc practice of vitaminsupplcmc ntatio nisvery commonin Canada. Despiterecommcndations (HealthandWelfare Canada, 1990)that hcalthy

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individuals should be able to meetalloftbeirnutrientneedsfrom diet,vitaminsupplements arebec:omingverypopular.Studiesshowthatthispracticeisnotlimited totbeelderly,even YOUDgadults andcolleg estudentstakevitaminandmineral.supplementsregularlyinan effort to assurethemse!Vd ofgood health(GarryetaI..1982, Wardlaw etal..1993,Elridge etaI..1994).Would therebeatendencyamongimmigrants toadopt suchpractices because of misleadinginformati on oradvertisement?

Understan ding the special nutritional needsof immigrants,enab ling them toselect nutri tio us foods from thewide variety of new foods and encouragin gthemto adoptheal thy eating patterns are responsibilities ofnutrition educators.Recentlythere has been increasing interestintranslatingCan ada'sFoodGuideintodifferentlangua ges andindevelo ping language andethnic specificnutrition education material s.Howe ver,culturalsensitivityin nutriti onmustgo beyond this.Acco rding to Guthrie (1994 ),understanding the factors influencingdietarypractices,orwhy peopleeatwhattheyeatshouldbefirststepwhen attempting topromotehealthyeatinghabits, Another importantfactorto be considered when developing nutritioneducationprogramsis that peoplereadily internalize concepts and ideas whic harc relevant totheirneedsandinterests. Thismakes a comprehensiveneeds assessment an importantcomponen t ofdevelopingnutritioneducation programs.

Therefore,two essential compo nentsof effectivenutritioneducati on programsare:

1.a study of facto rsdetcnnining foodrelated behavioror whypeopleeatwhatthey oat

2.a comprehensiveneedsassessment ofthe targetpopulation

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2.2 Factors Det ermining FoodRelated Behavio r

Tbestudy ofdeterminants offoodrelated behavior orwhypeopleeatwhat they eat and ways to help people change and improve their eatingpatternshasbeentermed

"q uantitative nutritioneducati on research"(Gillespie etal..1992). Nutrition education researchhelps toanswerquestions suchas «what are likely to be the most successful approaches?'"and""what guidelines shouldbe: followed fordevelopingand evaluating nutritioneducationprograms?"(Gillespie et al.,1992). Guthrie (1994)bascategorized factorsinfluencin g dietary behavio r into fourbroadgroups, namely physio logical, sociodemograp hic,bebavioraland psychosocialfact ors .

Primaryphys iologicaldeterminantsoffood choices are taste,smell and appearance . Althoughgoodnutrition is essential forsurvival,peoplemight not eateven the bestnutritious food.ifthe y don't like the taste.Preferences forcertain taste and specific combinations of foodareinfluencedby previousexperiences(Shannon, 1990)andareshapedduring the early socialint:i.on periodandare thus a product of culture (Fieldhouse:,1995).Sensory evaluation of foodsandtaste testingwithconsumer panelshave become a major area of interestof researchers.with the goal being to get a balancebetweenhealth and taste.

Sociodemographic factors havevaryingimpacton individual'sdietarybehavior(See section 2.1.3).Identification of differences in nutrientintakesamong differentsocioeconomic groupsis an importantpartofnutritio n educationresearch.Results can be used toidentify vulnerablegroupsandtodevelop programs appropriateto the needs ofagiven group.

Thosewhopro m ote abehavioralapproach believethatbehavioris readilyinfluenced 12

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bythe physical andsocial environmentinwhich peoplelive.Shannon et al.,(199 1) and Rodin(1980 )badidentified enviroomenla1.influencessuchastelevisionwatchingand eating atMallyoucan ear"restauranlSasfactorsthatcould trigger overeating.Someofthe strategies thatcouldenable behavior modificationan:identifying environmenla1. factorswhich could triggerovereating, attempting tomodifythese environmentalfacto rs orchangingone ' s responsetoenvironmentalfactors (Guthrie,1994 ).

Thosewhotake the psycho-social approachview behaviorasmedia tedthroughthe individual'scognitionssuchasknowledge,attitudes, beliefsandexpectations(Guthrie. 1994 , Axelson1986).Or.howpeoplebehave (what they eat) isinfluenced by whattheythink (knowledge)andhow theyfeel(attitudes). The rationale behind thisapproach isthat if indivi d ual s increase theirknowledgeand change theirattitudes, desirab lechangesinfood relatedbehaviorwouldresult. Toincreaseknowledge andtochangeattitude sthrough nutri tioneducationprograms, info rmati onrelatedtoindividual' seating patterns,their knowledge and attitudesare required.

No single theory orapproach could encompass a complex behavior such as eating.A5 Hochbaum (1981)haspointed out, thesetheori es are useful in the understanding ofoniy some ofthevastarrayof factorsandforces that may shape eating behaviorand its manifestati ons undercertainconditions or in certain populations.Pio neersinnutrition education researchencourage nutrition interventi onprograms tobe basedonestablis bed theoryandresearch(Gillespie, 1994). Since there areseveral wellestablished psychosoc ial theoretical frameworkssuchasConsumer InformationProcessingTheory,Stages of Change

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Theoryand RelapsePreventionwhich havebeensuccessfully usedinexplaini.ng dietary behavior andsince knowledge.beliefsandattitudesareculturallyembeddedtraits.for the purpose ofthe present studypsychosocialfacto rs (Icoowledgeand attitudes) are explored, 2.3Relevan t previo usresearc h

2.3.1Nutritionkno~ledce

Nutritionknowledgeisascientifi cconstructthat representsindividuals' s cogniti ve processesrelatedto food and nutriti on. This constructhasanimportan t rolein nutrition educatio nbecauseof the assumptio nthat increasingindividualsknowledgeaboutfoodand nutriti on willbring aboutdesiredchangesintheir foodrelatedbehavio r.

2.3.1.1Nutritionknow ledgeanddietarybehavior

To date.no studieshavebeenpublishedthatexami nedtherelations hipbetween nutrition related knowled ge and dietary patternsofimmigrants. However, many investigators have examined thisrelationshi p amongnon-immi gran tpopulatio ns.Using meta-analytic techniques., Axelson eta1...(l98S) reviewedninestudiesandfoundapositive and significant relationshipbetween dietary practices(asmeasured byanoverall dietary qualityscore) and nutritionkoowledge..Krista!etal..(1990)observedsimil arresults when shestudiedtherelatio nshi p betweenknowledgeabout low fat diet and food selectio n behaviorin 97 women aged45-59years . Conversely,nosigni ficantrelationshipbetween nutritionknowled geandnutrientintake was foundina seniorcitizen'sgroup (Grotk owski et aI.,1978).Bergmaneta1.,(I992)found no relationshipbetweencaffeineknowledgeand consum ptionina groupof 47 wome n between 45and 80yearsofage.

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2J.l.2Sodod~mollNlplliccorul tllnof nutritionAnowldg~

Sociod emographicfactors have an influeece on thelevel of nutrition knowledge. Ina sampleof malelife insurance companyemployeesWoolcottetat..(1981)found that higherlevel of nutrition knowledgewassignificantly correlated withhigh er socioeconomic status,higher incomeand increasing age. Fusillo(1977)ina sampleof1664adultU.S.

consumers found that those withlow level ofknowledge tendtohaveless edueation.lower income and lessprestigious occupation.Itwas also foundinthisstudy thatthosewith low nutritionknowledge tendedtobe older rather thanyounger andtobemenrather thanwomen.

Rahnetal., (1984) undertook astudytopredictthelevelofnutritionknowledgeinarandom sampleof 210 urban womeninthe cityof'Guelph. Theyfoundthat age,educa tionleveland socioeconomicstatuswere thepredictorvariables.Mansour et al.,(l994)intheirstudy of thenutri tio n knowledge of 150 pregnant womeninSaudiArabia founda positive relationshipbetween knowledge scoreand educationalleve l. Sims (1976) studiedthe nutrition knowledgeof mothers of 163 preschool children and found that socioeconomic status,younger ageand small familysize differentiated thelevelof knowledgelevel. Snider (1980) identified educationand age as predictorsof nutrition knowledgeina surveyof heallh relatedneeds ofnoninsti tutionalized elderly. Wade (1970)conducted ananalysisof knowledgesurveyscompletedbetween1941 and1962 andconcludedthateducationandsex werethebest predict ors ofhealth related knowledge.

2.1.1.JMeasu rem entof n lltrition knowledge

Therewaslittlestandardizationinthenutrition knowledgeinstrumentsfound in the

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literature.Instruments varied depending on the purpose of the study and the target population. Most of them were composed ofaseriesof multiple choiceor true or false questionsthat therespondentswere asked to answer.Answerstoeachitems were scored for correctness and then summed.These scoreswereusedtorepresentthe respondent'snutrition knowledge.

Nevertheless.Axelson etal(1992 ) hadgivensomerecommendatio ns to prev ent threats to the validity of a nutritionknowledgeinstrument.These recommendations are:

• Reliability

Theinstrument that measures nutrition knowledgeshould meet a minimum standard of reliability-that is,thesame results shouldbeobtained if thetestwas takenagain by therespondents. Reliability increasesthe predictivevalidityof an instrument.

Also,agood estimateoftherelationshi p between nutritionrelated knowledge and dietary practices couldbeaccomplishedonlywitha reliableinstrument. Axelson et al., (1992)reviewed19 studiesand foundthatcommon measures of reliabilityare reliabilitycoefficients such as coefficientalphaforordinal variablesor its variation K-R20fornominal,dichotomous variables.Coefficient alphaorK-R20isthe appropriatestatistic fordetermining reliability based on internal consistency.Internal consistencyestim ates to what extent variousitemsmeasure thesame concept.A modest reliabilitycoefficient ofO. 70 issuggestedby Nunnally (1978).

• Discrimination

When usinga nutrition knowledg etest, the differencein scoresshouldreflectreal 16

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differencesinknowledgeamong individuals.Theless discriminatory the measure, the lesssensitiveitis.

•Dimen s iona li ty

Items used to measure knowledge should beODedimensional-that is, a totalscore derivedfrom summing scores fromseveral questions shouldassess asing le UDderlyingcoostruet.Thisisbecauseknowledge ofcee topic would not necessarily mean knowledge of another.Forexample,ifthepurpo seof a study is to assess the relationshipbetween knowledge and consumption oflow fat foods,the knowledge instrument shouldinclude questi onsaboutfatcontentoffoodsor knowledge about the adve rsehealtheffectsof excessive fat.The use ofonescore torepresent a variety oftopics such as fat, fiberor general healthy eating guidelines wouldcause the effect size estimate or the strength of therelations hip between knowledgeandbehaviorto besmaller thanexpected(Axe!sonet al.,1992).

•Correspondence

Items used to measure knowledgeshould reflect the information required by the individual to makefood choicesandshould correspondtothe dietary behavior that isinvestigated. Forexample,"ifthe researcheris interested in using knowledge to predict some dietary behavior,then the knowledge measure should represent the knowledgerequired to performthatbehavior" (Axelso net al.,1992).

• Rep res e nl ativen ess

Nutrition knowledge constructshouldbedefined explicitly and the itemsonthetest

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shouldrepresent the specifieddomain..

• Conv e rg en ce

Axelsonetat..(I992)havealsocalledfor convergence validity,to ensurethat commonlyusednutrition knowledgetests converge.Forthis,acomparisonof one testofnutritioDknowledge with otber testsisneeded.lfthetests are measuring the same construct, thenthescoresrepresenting the individual 'sknowledge should be highl y correlated.

2.3.2Attitude tow ardsfood selecti on

Theconcept of attitude, likemany abstract concepts,isaconstructusedasatool to describe whatpeople say,think,anddowithsomeorder andconsistency (Henerso n et al., 1987). Rokeach (1%8) bas defined attitudeas a"rela tively enduring organizationof beliefs around an objectorsituation predisposingone to respondinsome prefere ntial manner".

Accordingtohimbehaviorisafunction ofatleast twoattitudes;attitude toward theobject and attitude towardthe situation within which theobjectisencountered. For example.food selectio n couldvary according to thesituati on ata giventime.AsSteelman(1976),bas pointed out. a homemaker may be morec:oocemed withconvenience than with economyon a given occasion. At anothertime.she maybetryingtoimpress guests withfood and food service.Thepossi bility that multiple situationalattitudesexistinadditiontoan attitude towardtheobjectmeansthatinonesituationa given attitude mayprevail while00another occasion adiffere ntattitude prevails.Althoughmany possiblebehaviorpatte rnsmay exist for a givenperson. attitudesare patterned to agreatextent (Steelman,1976).Forexample,

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the atti tude to fiugali tymayprevailnotonlyinselectingfooditems,butalsoinselecting severalotheroon-fooditems.

l J.2.1Altitudes 'I1Iddintlry /Hlravio ,

Amongresearcherswhostudiedthe roleof attitudesindetermining food choice Medaugh-Abemethyet aI..(1994 )observed a significantrelationshipbetweenattitudesand the amountltype offoods consumedina group of36 women aged 65and over.Similarly, Be rgman et aI.,(1992)foundthatcaffeine related attitudes werethestrongest predictorof caffeineintake.Positive and significantrelati onships betweenattitudes and behavior were repo rted byAxelson(1985 )ina meta-analysisandbyKrista!etal.,(1990)ina groupof indepe ndentlyliving elderly women .

2.3.2.2Immigran ts'anilud,stowardfoodsel,clion

Immigran ts cometo Canadawithestablishedfood habits,food customsand underlying attitudes.Anexaminationofdifferent aspects of theirattitudes toward food selecti on wouldenablebcttcI"understandingof their consumptionpatternsandfacilitate more effective interventionstrategies.A literature search on MEDLINE, Current Contents and ClNHAL on'culture'or"immi gran ts"and "attitudestoward food selection"failed to ide ntify anystudiesspecifically on immigrants'attitudes towardfood selection.The literaturesearebidentifiedonly the studybySteelman (1976).She used principal component factor analysisandidentifiedthe foUowing attitudes in a groupof'homemakers belo ngin g to diffe rentreligious subc ultures inNorthernLouisiana:propensi tyto chan ge, conveni ence, frugality,health.socialstatus, andsociability aspects.Nostudies werefoundspeci fically

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on immigrants.

Similar attitudecategories hadbeenidentifiedby several researchers amo ng non- immigrantgroups. For example, Hollis etat,(1986) had identifiedattitudes to'health consciousness' and'food exploratioo'inagroupof 179 menaDd178 womenin Portland Oregon. Axelsonet al.,(1983)exploredfood andnutritioo related attitudesof elderly living alone and identifi ed four attitude categories, namely,'nutritious-bealthful' , 'fnJ.gaJ- utilitarian' ,'soc ial-ad venturesome 'and'qualitative pleas urable'. Krista!et.,(1990) examin ed attitudestowardselectinglo w fat dietsin97womeninWashington state and identified bothpositiv eand negati veattitudesabout dietand health.

Itshouldbepointedoutthatfoodconsumptionhasalways been linkedtosocial prestigeandstatusinallcultures. AsJeliffe (1967)haspoint ed out"allculture shave prestige foodswhicharereservedforimportant occasions or even morefortheillustri ous of the community".Some foods reflectfinancialstress;others symbolizeaffluence.Some foods an:meant to be eatenwithinthefamily circle.only someare openly offered toguestS (deGarine,1976).

Would immigrants continue tomaintaintheir'coocemforsocialstatus'in anew culture or food environment by expressingthemselvesin the type of foods chosenand customsfollowed?Accordin g tode Garine(1976)keep ing culturalauthenticityisthetint stepthrough which social presti ge and status may be observed;itisby consumingthe group'sstaple foodsthatitsmembers display theirsense ofbelongin g to the society.Onthe other hand,Katona-Apte eta1.•(1980) whoexaminedfood habitsand acculturationofEast

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lndians in the United States badhypothesized that thereisadirectrelati onship betweenthe [OOians'desire togainstatusamong.and.acceptancebyAmericans and the extent andspeed oftbe acculturation to American food habits.

Similarly, do they have:afavorable attitude toward'food exploration' ?Food exp lorative attitude wouldbe suggestive of flexibility in trying new foods or recipes and willingness to changefood habits.This couldalsomean lower adjustment problemsina new food environment.

2.3.2.3 Sociodemographiccorrelatesofattitudes

Veryfew studieshavelookedat the impact of sociodc:mographic factorsonnutrition relatedattitu des. Kinsey(1994)hasidentified income andsexaspred ictorsof nutri tion related attitudeswhereasJa lsoetal.,(1965) foundthat age was inversely relatedto nutrition relatedattitudes. Ina study among the elderlyGrotkowski et al.,(1978)found that socioeconomic status computedonthe basis of educationalleve l. former occupationand sourceof income was stronglyrelatedto the attitude to'nutri tio n is important'_

2.3.2.4 Measu nment ofiJttil udes

Asfor the nuuition knowledge measurethc:rewaslittlestandardizationinthe attitude measuring instruments.Instruments varieddepc:nding on the purpose oftbe study,typesof attitudes studied andthe target populati on.The majorityof instnunentsutilized a survey methodwith a Likerttypeformat. althoughsemantic differentialscales (a series of specific bipolar scalessuchas good-bad,strong-weakand passive- ac tive ) werenot unco mmon .

Todemonstra te validityand reliability of atti ntdemeasures Hen ersonet al., (1987)

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andSims(1981)haveprovidedseveralrecommendations. Differenttypesof validity mcmuressuchas constructvalidity,contentvalidi ty, and predictivevalidity couldbeused toestablish the validityof an attitudemcasuremenLConstructvalidit)'ol refers tobowwell the instrumentmeasureswhatit claims to.Demonstratingconstructvaliditydemands clear definition oftbcconstruct,administeringthesurveyin.fairsettin g(cooughtime allowed andrespoodcntsarcDOCrushedorpressuredto respondinaparticularwa;:y).seekingm:dJ.'ble opinionsfromexperts,and evideocefrom correlationalorcriterio ngrmqp studies,all aimed atruling outalternative explanationsofthe instrument's results(Hcmcrsonera1., 1987).

Content validity isthedegreetowhich thestatemen tsusedin the questiolOJlairerepresent the constru ctunder investi gation. Concurrentval idity iscalculatedwherethe results ofone measureareused[0predict the resultsofanalternate,contempo rarymea-sure.Acco rdingto Sims (198 1),what evide nceisused toestablishtheiosttum ent'svalidli ty dependsonthe obj ecti ves ofthe study.For exam ple,iftbcinvesti gator wishestopredictsomekindof behaviorontbcpartof thcrespondentin the future, tbea predlctivevalidi1lybecomeacrucia1 issue. ITthepurposeofthe research is to intern:1atc attitudes witb. otheraspectSof personality or10integrateand organize some lcindo fbchavioraJ. outco mec,constructvalidity mustbe considered.

Formulationofcharacteristic behaviorstatementsfrom which imferences couldbe madeonrespondents'attitudes is anothercritical stepin themeesuremencofattitudes(Sims, 19 81). Accordingtoherthe"successandfailureof attitude scale construction maydepend upon the specific collection of items "andhas called forstating the itemsUnsimpleand clear

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language,each item being unambiguous containing onlya singl e ideaand avoidingitems whichare irrelcvamtotheattitudeconstructor are likelytobellDSW'Cf"Cd in exactly the same waybypersons havingbothfavorab leand unfavorableattitudes.Also.randomizingtheorder ofpresentati on ofitems intheinsIrumcnt 'WOuldprevent developing a responsesetonthe partofthe respoodcnt (Sims, 1981).

Hencrson (1981) has suggested using several converging questionsrather thana singlestatementtodetectthe presenceor extentofan attitude.Thisisbecause asingleitem isopen to different interpretations .Aquestionnaire which asks about slightlydifferent aspects ofthe samethingseveral timesand usesa combinationof theresultsfromthese questio ns to indicatethepresen ce ofan attitudeislesslikely to be affected byrandomerror and will be more reliable.

HencrsonetaJ.,(1981)hasreinforced thatonlyareliabl eattitudeinstrumentcan supporta strongcase forvalidity and therefore credibility.Reliab ility or theconsistencyof the measurem ent couldbemeasured with a reliab ility coefficient, A reliability coefficient of 0.7is usuallyconsideredrespcctableforanattitude instrument,eventhough lower coefficients aresome times tolerated(HencrsonclaJ.,1981).

1.3 .3 Nu tritionnlatedknowl edge.,attitudes andbehavior

Itshould bepointedout thateven instudies that found positiveandsignificant relationships amongknowled ge, attitudesandbehaviors,the strength ofassociationwas small,r-o.tu and r=O.17,forknowled ge-behaviorand attitude-behaviorrespectively (Axelsonetal.,1985).Shannon et al.,(1988) inathreeyear nutritioneducatio n studydone

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in Pennsyl vaniafoundonly small changesindietary behavior brough t about by nutrition educationprograms. Similarly.Ikcdaetat...(1982 )ina weight controlprogramo bscrvcd that weightchanges achieved werenot stableover time. Thereare several possible exp lanationsfor these results.Oneexplanationisthatnutri tionknowledgeis probably necessary.butnot asufficien tcondition for bcal thful dietarybehavio r.Other factors such as self-dlicacy,peer or familyinfluencesorcnvironmcotalfactorscouldintervenebetween knowledge and behavior.Forexample,Sapp(1991)studiedthe relativeimpactofnutrition knowl edge and attitudes on intentio nsto eatbeefand thefrequencyofconswnptionof beef withsocialsupportsyst ems. Hefoundoutthataltho ughnutrition kno wledgewas not directly relatedto intentions,behavi or orattitudes,itwassignifi can tlyrelatedtosocial supportsystemsthatinflue ncedintentio ns andbehavior.

KristaIetaI.•(1990)andAxelson etaI.•(l98S)havepointedoutmethodological explanationsfor thepoorcorre lationbetweenIcnowledg e and behavior.Acco rdin g tothem, most studies on'nutritionknowledge,attitudes and dietarypracti ces'hadnot defined expli citly the constructsmeasuredandassuchlackspecificityand validityinmeasuranent.

Also,researchers often did notassess thoseaspectsof nutritionknowledgeandattitudes whichwerenecessary for the performanceof the target behavior ofinterest.The weak associations between knowledge-behavior and attitude-be havior reflect the poor correspondence between themeasures ofdietary intakeandknowledge orattitudes(Axelson, 1985). Clarifyinganddefiningdomainsofknowledgeand attitudeconstructs andensuring thatthesemeasurescorrespondwith the dietary behavior studiedwould improvethe effect

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size estimate of the relatio nshi p (Axelson etal..1992,Axelson etaI..1985) . 2.3.4Needs assessment

The goal of anynutrition related needs assessmentis toobtainquantitativeand qualitativeinformation that willidentify nutrition related problemsandopportunities for reducingthoseproblems.Owen(1993)badrecommendedthreetypesof variablesfor a culturallysensitive,valid needsassessment. These variab lesare 'client variables' (demographiccharacteristics,knowledge ,attitudes,dietarypracticesetc), 'environmental variab les'(availabilityofnecessary services,prevalence ofsocialandhealth problems,ethnic foodavailabilityetc.) and'program andprovidervaria bles' (acc essibili tyto available services, culturalapp ropriateness etc).All these variablescould vary depending on the ethnicgroup and locality.Theinvesti gator could not locate any studies intheliterature that exploredtheneeds of Indian immigrants or that metOwen's(1993)criteria.

Sum mary

TIllsliterature review identified someofthe nutritionrelated issues facing immigrantsand pinpointedthe needfor cultural sensitivityin nutritioneducation strategies.

Two essential componen tsofeffective and meaningful nutritioneducationarc:an understandingof the factorsinfluencing dietarypracticesand developingprograms relevant to theneeds ofthe target population.Of the variousapproachesusedinstudying factors influencing dietary practices,psychosocial approach iswidelyused.Therational e behind this approach isthatif individuals increasetheirknowl edgeandchang e theirattitudes,

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desirablechangesinfoodrelated behaviorwould result, Since knowledge.beliefs and attitudesan:culturallyembedded traits, forthe pwposeof the proposed research psychosocialfactorswereexplored. Thereview also provided backgroundinformation on howto conceptualizenutrition related knowledge.attitudes,behaviorsandneeds ofa group ofinunigran tsandhow tomeasure these variableswithmoderatevalidityandreliability.

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3.0 Methodology

J.lObjectiv es

The objectives of this studywere:

1.To assesstheeatingpatternsof Indian immigrantsandfami ly members 2.Todeterminetheirlevelof nutritionknowledge

3.Toidentifytheir attitudes toward food selection

4.Todetermin eifthere are differencesintheirdietarypractices based on their nutrition relatedknowtedgeandattitudes

S.Toidentify their nutritionrelatedneeds 3.2Design

Across sectional surveyusing a self-administeredmailedquestionnairewas conductedforthisstudy.

3.3 Settingof thestu dy

lndian immigrants started settlinginNewfotmdland approximately40 years ago.They are distributed througbout theprovince.even though the majority liveinSLJo hn ' s.Most of theseimmigrants arc professional semployedbyhospitalsacrossthe province and by MemorialUniversity of Newfoundland.

Indian immigrantsinNewfoundl andconstitute a closelyknitsociety.The Friends of India Association represen tstheIndian community in Newfoundland.Themajori ty of

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Indian immigrantspracticeHinduism.1heir nativerelig ion,TheHindus bavebuilta"Hindu Temp le"inSLJohn's forconductingtheirworshi pandceremonies. Anumberofcultural and religious festivities are organized by Indian inunigrants throughoutthe yearindifferent parts ofNcwfouodlaod.

Languageisa sourceof heterogeneity amon g Indian immigrams.Thisis because differentprovincesinIndia ha ve theirown mothertongues.. AlthoughHindi is the designatcdnationallanguageofIndia,tbeofficial languageis stillEnglish,alegacyle ftby theBritishwhoruledIndiaformorethan300 years. Themediumof instructi o nin universitiesand interprovincial/intergovernmental comm unica tio ns isstillcontinued in Eng lish. Most lndian immigrantsfrequentlyspeak theirmoth ertongue in their home s as a waytokeep theirlan gua ge heritageor to passit along to younge rge nerations.

Vegetarianismis a common practiceamo ngIndianimmigran ts. Themajori tyof vegetariansare tecto-evevegetari ans (peoplewhocatplant products, dairy productsand eggs)or lacto-vegetariens(peoplewho eatplant productsanddaizyproducts).althoughpure vegans (peoplewho catplant products only)arenotunco mmo n.

EarlyIndian immigrantswhocametoNewfoundland35or40years ago,were unableto get Indian groceriesnecessaryfortheir traditionalcooking.Theybad to import groceriesfromEngland orother citiesinCanada. Presently,a few Indianrestaurantsand ethnic specialityfood storesareloca tedinSt.John's. Authe ntic Indiandishesandgroceries arereadilyavailabl ein these resta urants andstores. However ,the varie ties of fruits, vegetables,dhals,picklesandsweets availableare a bare minimum compared tothe number

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of varietiesavailableinothcrcitiesof Canada.Also,the:quality of tbcse foodsmaynotbe atparwith whatis availableinIndia and prices arefairlyhigh.[tshould be pointedout that the foods and facilitiesavailabl einSL John'sare DOtfo -und outsideSt.John' s.

ComparedtoCanadiancooking,Indiancooking istime consuming.Man yIndian cuisinesrequirecIaboratcprep<&mtioossuchas soaking owcmight,grindingandfermenting.

Special cooldngequip mentisalsonecessary.In India,itis a common practice toprepare foodsfreshly every day.Peoplepurchasegroceriessuc=hasfresh fruits ,meats , seafoods, vege ta bles anddairy productsdaily.Refrigeratingfoods, cookingahead,orfreezingleft over foods arc notusualpracti ces.Canned and processed,foodsare not readily availableand not generallyused.

3.4Study population

All Indian immigrants andfamily memberslivingi..:.nNewfoundland,both males and femalesover the age oflOwhowere borninIndia orcvbcse parentswerebornin India, constitutedthe study population.

3.5Sample frame

TheFriends oflndia Association(FIA).,whiich isa provincial organization representingtheIndi an community in Newfoundland,was.contactedpriortothestudy.They suppo rtedthe projectand gave permissiontousetheirrmcmbcrshiplistforthisresearch.

Potentialnames were alsoselectedfromthe Chi om 3llya MissionAssociati o n (CMA) directory, a directoryofthepeopleof EastIndi an origin_Thisdirectory is made available

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to allmem bers of theIndian CommunitybytheHindu Tem ple inSL John' s . The International Students'Association(lSA)attheMemorial University provided names ofall studentsfromlOOiawhowerethen attending the University.TheSeniOl"Bridging Cultures Club (SBC). which is an associationof ethnic elderlyinSLJohn's,providednames ofIndian ori gins who were 65+yearsand attending the club.

Peoplewith Indian surnames fromFIA.CMA. ISAand SBC were contacted 10 determinetheir placeof birth. Onlythose who were bominIndia or whose parentswere borninIndiawere includedinthestudy.

3.6Sam ple size

Therewere 27independ ent variablesinthe questionnaire. In orderto get valid informationon these 27 variables with a 5%level ofsigni ficanc e, a samplesize of13 5 was needed,To cover for an estimated 300A, refusal ratean additional40 subjects were included.

Thetotal samplesizewas 175.

3.7Sam pleselection

From 1bc FIA.,CMA. ISAand SBC membership lists,377 persons who were bom inIndiaand/or-whoseparentswereborninIndiawere identified andListed Thislistwas then arrangedinto four sections as follows:

Single and familyhouseholdunits(FIAand CMA)

Children,10-1 9 years of agefromfamily households(FlA andCMA) Stude nts(ISA)

Seniors(SB C).

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Thefinallisl consisted of137 adultmales,123 adult females, 72children (72 households had childrenin10- 19 agegroup).,30stude:ntsand15 seniors for alotalof371.To achieve the calculatedsamplesize of about175,aproportionatesample of approximately50%(Sec Table 3.1)consisting of 60 males, 60 females, 30childrenand15 students was selected.

Application of thiscriterion wouldachieve the calculated samplesizeand allow a distributionof the study samplecomparableto the population. Since seniors were relatively

Table 3.1 SampleSizeand Selecti on

Sin gle&FamilyHou seh olds Students Senion Total Mal es Fem ales Childre n

TotalSamp le 137 123

"

^3. ¹⁵ ³⁷⁷

Proportionate 6. 6. 3. IS

1 1'&1

^18.

Sa m ple

smal linnumbers. it was decided to takeaU15 seniors who were 65+intothe study.

Sampleswereselectedinsuch a waythatineach householdone childandeither husband orwifewouldreceive the questionnaire.To accomplish this,60males were takennmdoml.y from the 137 names;wivesof those selectedwere eliminated from thelistof females.From the remaining list of females,a randomsampleof 60 was selected. This procedure also decreasedthechance of getting morethantwoquestionnairesinone family unitHowever, householdswitha senior could receive threequestionnaires.

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3.8Instrumentdevelopment

Sincethere were no standardized existing instrumentsthatmet the purpose and objectivesofthisstudy, itwasnecessary to develop an instrumentspecificto the project.

Informationwasgatheredinfivecontentareas;demographiccharacteristics.,dietary practice s,nutritionrelatedknowledge,attitude towards food selectionandneeds.Thedraft instrumentwasreviewedbyagroupofexperts.Theseexperts includedasoc iologyprofessor who bad workedamongimmigrants,a Ph.D candidateinPsychologyand dietitians from different parts ofCanadawho had worked among immigrants and/or had previous research experience.

3.8.1.Questions ODsociode mogra p hiccharacte ristics

Demographiccharacteristic sthatcouldinfluenceknowledge,attitudesandneeds wereidentified through literaturesearch.The expert groupfacilitated thefinalselection of variable s.Aseriesof multiplechoiceand open endedquestions wasdevelopedbythe investigatorto collect information (SeeAppendix L-SectionA,AI toAll). The information collected included:

Sex Country of birth Parent'scountry ofbirth Nwn ber ofyears ofstayinCanada Agegroup

Type of household Curren t employmentstatus

Levelof education(yearand countryofcompletion) Languagemostcommonlyusedathome

Language preferredtoexplain health conditions toadoctorordietitian

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Iecome range Religion

18.2.Questionson diet arypractices

Sinceanundemandingofthedynamicsofdietarychangeandlife stylepncticeswould facilitate development of culturallyspecific nutrition educationprograms. for the purpose of thisstudy c:harac:tcristiceating patterns,extentofdietar)' changes.,nutritional quality of dietandlifestyle practiceswereassessed,When choo sing a method for coUectingdietary data for this study,thegoalwas to develop a short diet assessment method thatis easy and cost effectiveto administer, thatcoulddescribe the dietary pattern and dietaryqual ity,but neve rth elesshave validity.AnaJyzingdietaryintakebynutrientsor calorieswas notan objective ofthisstudy.Therefore, a detaileddietary recallmethod orfood frequency methodwasnot used. Block(1982),Roe et al., (1994) andRimmer al,(1992)have established thatshortquestio nnaires whichask.onlythefrequencywith which specificfoods are consumedandusualintake could beadministeredquicklyandhavegoodcorrelationwith moreextensive diethistories.

Toassess c:hanIcteristiceatingpatternssuchas the prevalenceofvegetari anismand recentchangesmadeinthe dietandtofindoutreasonsforfollowing such practices "yes"

or"eo"questionsandrankingtypequestions were used(Appendix2.Section B,BI&82).

A shortquestionnaire centered around thefrequencywithwhichspecific foodswere consumed was developedtoassesstheir level of acculturationtoCanadianfood habitsand theirlevel of acquisitionof food habitswhichhave adversehealth effects (Appendix2-

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Section B,BJ,B4 &. B5). The frequency scale ranged from"often .. (score ofI),

"sometimes"(sco reo( 2). rarely(~re of J)and"neve r" (scoreof4).

For assessing the nutritional quality of diet and life style practices, adherax:e to the recommeodedscrving guidelines ofCanada' sFood Guide to HealthyEating(C FGHE)and likelihoodof foDowingCanada'sGuidelinesto HealthyEating (oollE)were examined(See sectionJ.8.4and Appendices6 and 7forexplanationofCFG HE and CORE).Toevaluate adherence to CFGHE and to facilitatecategorizing subjectsaseither consuming or Dot consumingtherecommended uumber of servings, the questionnaireincorporatedfour food groups and five serving sizes (more than IIservings, 5- 10 servings,2-4servings, one serving andnone)tochoose from(Appendix 2-SectionB, B6) .These servingsizes were similar tothe serving sizes of theCFOHE(A ppendix. 6).Examplesof approximatevolume per serving forvario us [ndianfoodswerealso provided:'one large chappathi...2servings'; .~cup to J!4cup cookeddhaI-Iserving';(See Appendix 8).

ToestimatethelikelihoodofadherencetoCGHE,a numberof questionson healthy lifestylepracticesweredeveloped bytheinvestig ator'(Appendix 2-SectionB,B7).Some items inthissectionareadapted from a previousstudydonebyMarketFacts ofCanada (1979). Respondentswereaskedtoindicate their likelihoodoffoUowinghealthylife style practicesbyusing a ratingscale "verylikely"(score ofI),"somewhatlikely"(scoreof 2),

"oo tvery likel y"(scoreof J).and"not atalllikely"(scoreof4).The practice of vitamin supplemen tatio nwas estimated using the same scale and scoring system(Appendix2- Section B,B7-e).

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When developin gquestionsto assess the dietary practices.effortwasmadetoselect variables insuchawaythatthey would correspondto selectedattitude categoriesand knowledge items.Forexample.for thequestionin the JcnowIedgesection"whatdocs enjoy a varietyoffoods mean?',therewas acorresponding questioninthedietary practicessection 10findoutwbctberthey includ eavariety offoodsintheir dietevery day.Informati on collectedon dietaryllifestyl epractices were:

Practice ofvege tari anis mandreasons forfollo wing vegetarianism Rec entchangesmadeinthe diet and reasonsformakingsuc h changes Food acculturation pattern

Acquisition offood habits which have adversenutritional effects Adhe re nce toCFG HE serving guidelines

Likelihood of followingCOlmguideline s 3.8.3 QUesti ODSonattilu des low. rd foodselection

Personalinte rviews and a focusgroup discussionat the SeniorBridging Cul tures Clubhelpedto confirmthedifferen t attitud ecategoriesidentified through literature search.

Notes fromthediscuss ionandpersonal intervie ws indicatedthattheywerehesitant totry unfamiliarfoodsandthat they enjoyed the convenience of modem cooking cquipmcutsand scmi processedfoods easily availableinCanada. It was evident thattheyvaluedgood nutritionas fundamentaltomaintaining bealth.Theyalsobrought up a strongdesireto cat mealsinthecompanyoffamilyorfriends..Participantsreported thatthr::yandtheirfamilies regul arly tookadvantage of sale flyersand boughtfoods on sale.Thus from the group discuss ionandlite raturereview,itwasdecided 10 measure thefollowingattitude categories;

importanceofnutrition, frugality,food exploration,sociabilitylbospitality,convenienceand