Wendy Lawrence

Constraints on food choices of women in the UK with lower educational attainment.

OBJECTIVE Women of lower educational attainment have less balanced and varied diets than women of higher educational attainment. The diets of women are vital to the long-term health of their offspring. The present study aimed to identify factors that influence the food choices of women with lower educational attainment and how women could be helped to improve those choices. DESIGN We conducted eight focus group discussions with women of lower educational attainment to identify these factors. We contrasted the results of these discussions with those from three focus group discussions with women of higher educational attainment. SETTING Southampton, UK. SUBJECTS Forty-two white Caucasian women of lower educational attainment and fourteen of higher educational attainment aged 18 to 44 years. RESULTS The dominant theme in discussions with women of lower educational attainment was their sense that they lacked control over food choices for themselves and their families. Partners and children exerted a high degree of control over which foods were bought and prepared. Womens perceptions of the cost of healthy food, the need to avoid waste, being trapped at home surrounded by opportunities to snack, and having limited skill and experience with food, all contributed to their sense they lacked control over their own and their familys food choices. CONCLUSIONS An intervention to improve the food choices of women with lower educational attainment needs to increase their sense of control over their diet and the foods they buy. This might include increasing their skills in food preparation.

Why women of lower educational attainment struggle to make healthier food choices: The importance of psychological and social factors

Women of lower educational attainment are more likely to eat unhealthy diets than women of higher educational attainment. To identify influences on the food choices of women with lower educational attainment, 11 focus groups (eight with women of lower, and three with women of higher educational attainment) were held. Using a semi-structured discussion guide, environmental, social, historical and psychological factors known to be associated with food choice were explored. Audio recordings were transcribed verbatim and thematically analysed. Compared to women of higher educational attainment, women of lower educational attainment had less control over their families’ food choices, less support for attempts to eat healthily, fewer opportunities to observe and learn good food-related practices, more negative affect, more perceived environmental constraints and more ambiguous beliefs about the consequences of eating a nutritious diet. These findings provide a starting point for taking forward the design of an intervention to improve the diets of young women.

Health-Related Behavior and Beliefs of Pregnant Smokers

To determine the association of smoking with other health-compromising behavior and beliefs during pregnancy, a cross-sectional survey of 1,203 women in the United Kingdom assessed smoking status, stage of change, fetal health locus of control, alcohol consumption, folic acid intake, and use of vitamin and iron supplements. Twenty percent were current smokers, and 33% were alcohol users. Pregnant smokers (especially those in the precontemplative stage) were less likely to increase folic acid intake, less likely to take vitamin and iron supplements, and less likely to feel personally responsible for the health of the fetus. Infants of smokers may be placed at an intrauterine disadvantage, not only in terms of smoking, but also in terms of nutrition.

Development of a 20-item food frequency questionnaire to assess a ‘prudent’ dietary pattern among young women in Southampton

Objective:To develop a short food frequency questionnaire (FFQ) that can be used among young women in Southampton to assess compliance with a prudent dietary pattern characterized by high consumption of wholemeal bread, fruit and vegetables, and low consumption of sugar, white bread, and red and processed meat.Methods:Diet was assessed using a 100-item interviewer-administered FFQ in 6129 non-pregnant women aged 20–34 years. In total, 94 of these women were re-interviewed 2 years later using the same FFQ. Subsequently, diet was assessed in 378 women attending SureStart Childrens Centres in the Nutrition and Well-being Study (NWS) using a 20-item FFQ. The 20 foods included were those that characterized the prudent dietary pattern.Results:The 20-item prudent diet score was highly correlated with the full 100-item score (r=0.94) in the Southampton Womens Survey (SWS). Both scores were correlated with red blood cell folate (r=0.28 for the 100-item score and r=0.25 for the 20-item score). Among the women re-interviewed after 2 years, the change in prudent diet score was correlated with change in red cell folate for both the 20-item (rS=0.31) and 100-item scores (rS=0.32). In the NWS a strong association between the 20-item prudent diet score and educational attainment (r=0.41) was observed, similar to that seen in the SWS (r=0.47).Conclusions:The prudent diet pattern describes a robust axis of variation in diet. A 20-item FFQ based on the foods that characterize the prudent diet pattern has clear advantages in terms of time and resources, and is a helpful tool to characterize the diets of young women in Southampton.

The Southampton Initiative for Health: A complex intervention to improve the diets and increase the physical activity levels of women from disadvantaged communities

The Southampton Initiative for Health is a training intervention with Sure Start Children’s Centre staff designed to improve the diets and physical activity levels of women of childbearing age. Training aims to help staff to support women in making changes to their lifestyles by improving three skills: reflection on current practice; asking ‘open discovery’ questions; and goal-setting. The impact of the training on staff practice is being assessed. A before and after non-randomized controlled trial is being used to evaluate the effectiveness and cost-effectiveness of the intervention in improving women’s diets and increasing their physical activity levels.

A review of factors affecting the food choices of disadvantaged women

The diets of young women are important not just for their own health but also for the long-term health of their offspring. Unbalanced unvaried diets are more common amongst poor and disadvantaged women. If the diets of these women are to be improved, it is first necessary to understand why they make the food choices they do. Influences on womens food choices range from the global to the individual: environmental factors, such as difficulty in acquiring and affording good-quality healthy foods; social support and social relationships, such as those with parents, spouses and children; life transitions, such as leaving home, living with a partner or having children; individual factors, such as having low perceived control or self-efficacy in making food choices and placing a low value on health in general and on their own health in particular. These interrelated factors all influence food choice, suggesting that if the diets of disadvantaged women are to be improved, it will be necessary to do more than simply educate about the link between diet and health.

'Making every contact count': Evaluation of the impact of an intervention to train health and social care practitioners in skills to support health behaviour change.

A total of 148 health and social care practitioners were trained in skills to support behaviour change: creating opportunities to discuss health behaviours, using open discovery questions, listening, reflecting and goal-setting. At three time points post-training, use of the skills was evaluated and compared with use of skills by untrained practitioners. Trained practitioners demonstrated significantly greater use of these client-centred skills to support behaviour change compared to their untrained peers up to 1 year post-training. Because it uses existing services to deliver support for behaviour change, this training intervention has the potential to improve public health at relatively low cost.

Educational attainment, perceived control and the quality of women's diets

OBJECTIVE Data from the Southampton Womens Survey have established that women of lower educational attainment have poorer quality diets than those of higher educational attainment. This relationship is strong and graded such that for every increase in level of educational qualification, there is an increase in the likelihood that a woman will have a better quality diet. It is not wholly explained by socio-economic status. Qualitative research carried out in Southampton suggests that women of lower educational attainment may have a poorer diet because they feel they lack control over the food choices they make for themselves and their families. We set out to investigate the relationship between educational attainment, perceived control and quality of diet in a sample of women from Southampton. DESIGN Cross-sectional study using structured interviews in which womens diet, educational attainment and perceived control were assessed. SETTING 19 Childrens Centres and baby clinics in Southampton, UK. PARTICIPANTS 372 women, median age 28 years. MAIN OUTCOME MEASURES Quality of diet assessed by prudent diet score produced from principal components analysis of 20-item food frequency questionnaire, and perceived control assessed by a validated questionnaire. RESULTS Women of lower educational attainment tended to have lower prudent diet scores and lower perceived control scores than women of higher educational attainment. Having a lower prudent diet score was associated with consuming fewer vegetables and vegetable dishes, less wholemeal bread and vegetarian food, and more chips and roast potatoes, meat pies, Yorkshire puddings and pancakes, crisps and snacks, white bread and added sugar. In a regression model both lower educational attainment and lower perceived control were associated with lower prudent diet scores, independent of the effects of confounding factors. However there was an interaction effect such that lower perceived control was only related to prudent diet score in the group of women of lower educational attainment. CONCLUSION Women of lower educational attainment perceive themselves to have less control over their lives than women of higher educational attainment, and this perceived lack of control is reflected in their diets being of poorer quality. Our findings suggest that level of perceived control over life is a more important predictor of quality of diet in women of lower educational attainment than in those of higher educational attainment. It may be that psychological and social difficulties disproportionately affect the diets of women of lower educational attainment. We are currently exploring variations in quality of diet among women of lower educational attainment in relation to a range of psychological and social factors.

Specific psychological variables predict quality of diet in women of lower, but not higher, educational attainment

Our previous work found that perceived control over life was a significant predictor of the quality of diet of women of lower educational attainment. In this paper, we explore the influence on quality of diet of a range of psychological and social factors identified during focus group discussions, and specify the way this differs in women of lower and higher educational attainment. We assessed educational attainment, quality of diet, and psycho-social factors in 378 women attending Sure Start Childrens Centres and baby clinics in Southampton, UK. Multiple-group path analysis showed that in women of lower educational attainment, the effect of general self-efficacy on quality of diet was mediated through perceptions of control and through food involvement, but that there were also direct effects of social support for healthy eating and having positive outcome expectancies. There was no effect of self-efficacy, perceived control or outcome expectancies on the quality of diet of women of higher educational attainment, though having more social support and food involvement were associated with improved quality of diet in these women. Our analysis confirms our hypothesis that control-related factors are more important in determining dietary quality in women of lower educational attainment than in women of higher educational attainment.

How do mothers manage their preschool children’s eating habits and does this change as children grow older? A longitudinal analysis

The practices mothers adopt in relation to feeding their children have been identified as important predictors of childrens quality of diet. However, most studies of the impact of these practices on quality of childrens diets have been cross-sectional in design, limiting conclusions about change and causality. Previous research has called for qualitative exploration of the way these practices are used in a real-life setting. This study set out to address these gaps in knowledge. At baseline, mothers recruited to a community-based intervention study and who had a preschool child, completed a questionnaire about their use of covert and overt control practices, child food neophobia and demographics. The quality of childrens diets was assessed using a validated food frequency questionnaire. Both questionnaires were repeated with the mothers two years later. Complete data at both time points were available for 228 mother-child pairs. Four focus group discussions were conducted with 29 mothers of preschool children to explore their experiences of feeding young children. Mothers who increased their use of overt control had children whose level of food neophobia also increased (P = 0.02). Mothers who used more covert control had children with better quality diets at both time points (P = <0.01) and mothers who increased their use of covert control over the two year follow-up had children whose diet quality improved (P = 0.003). These associations were independent of confounders such as mothers level of education. In the focus groups, mothers suggested that feeding young children was stressful and that control was often relinquished in order to reduce conflict at mealtimes. Supporting parents to adopt more covert techniques to control their childrens eating habits may be an effective way of improving the quality of young childrens diets.