Incorporating the evidence

The complexity of developing community-based obesity prevention interventions is well established. It arises from the range of socio-environmental influences on changes in weight status at a population level¹ and the subsequent need for multi-level, sustainable strategies in different settings and contexts.² The lack of uniformity in “real-world” settings is increasingly recognized as a challenge for study design, implementation and evaluation.³ This is further complicated by the global increase in population diversity in developed countries.⁴

The evidence on health inequities for minority groups in developed countries is well established and highlights the need for consideration of diversity in obesity prevention efforts. It requires a flexible, culturally competent approach to the design and implementation of interventions (see Box 32.1). Culturally com petent strategies for public health research and interventions have recently been developed to guide this process and are used as the basis for this chapter. ^5,6 These strategies are designed to assist researchers to shift from an expert-driven to a participatory approach with increasing understanding and capa city for accommodating the added complexity inherent in cross-cultural exchanges. The intention is to encourage a culturally reflective process among researchers and health promotion practitioners who are working with minority groups in developed countries. This chapter is particularly relevant to those involved in public health and health promotion community-based research and interventions. The term “interventions” is a research term that potentially has negative connotations to lay readers. Therefore, for the remainder of the chapter the alternative terms, “programs”, “initiatives” and “strategies” are used.

Chapter 17 highlights the socio-cultural influences on eating and physical activity and considers how this might affect community-based obesity prevention programs. In this chapter, we build on these considerations and focus on issues arising as a consequence of the circumstances of many minority groups. For the purposes of this chapter, the focus is on minority groups as defined by ethnicity. Ethnicity has been shown to be a predictor of overweight and obesity, even after taking into account socio-economic disadvantage.⁷ There has been debate about the usefulness of the body mass index (BMI) as a measure of over-weight and obesity across populations without consideration for different body types. A review of BMI for Asian populations determined that the World Health Organization BMI cut-off points for over-weight and obesity should be retained as international classifications.⁸ However, methods were proposed by which countries could make decisions about the definitions of increased risk for their population.

Various inconsistent terms and concepts are used in the health literature to describe a group or individual’s ethnicity.⁹ Terms include: ethnicity, race, culturally and linguistically diverse background, disadvantaged group or under-privileged group. These terms are influenced by biological origins and social groupings and can be misused. They can often be inappropriate, crude, confusing, limited, inaccurate, potentially stereotyping and can prevent generalizability of research. For the purposes of this chapter, ethnicity refers to an individual identifying as belonging to a particular social group with similar country of origin, spoken language, cultural practices and/or religious beliefs. It is acknowledged that ‘ minority ’ can be defined in many different ways and the particular needs of other minority groups such as people with disabilities also need to be addressed but they are not covered in this chapter. There is likely to be a general recognition by public health researchers and practitioners that diversity in ethnicity is often accompanied by diversity in values, beliefs, knowledge and attitudes regarding health.

There may be less awareness of other issues often associated with migration that can impact on health status and health behaviors. These include but are not limited to the following:

• Migration circumstances vary from skilled migration, family sponsored, humanitarian and refugee, and reflect the circumstances of the individuals and families in their home country. The health status of a skilled migrant may be very different from a person who has fled a country affected by famine and/or war. Their visa status may also determine their level of access to employment and support services in their host country.
  
• Relocation to another country is often a period of disruption in terms of housing, employment and secure income. These issues are likely to take precedence over non-critical health considerations.
  
• Lack of health education in home countries and limited family support and social connectedness in the host country may reduce the capacity of families to engage in health promoting practices.
  
• Acculturation can increase awareness and knowledge of healthy lifestyle options in the host country. However, this takes time. In many cases it is the children who acquire this knowledge first, but without the benefit of an adult’s maturity in decision making. Therefore, while they are in a position to inform the family choices, the transfer of knowledge may not take place. This is supported by recent research findings in Australia which show that use of the English language at home is a strong protective factor against overweight and obesity for boys.¹⁰ This suggests that parents with greater proficiency in the main language of the host country may have greater access to nutritional information to support healthy dietary habits.

These are all likely to be issues affecting minority groups and their interaction with obesity prevention research and programs.

Guidelines on culturally competent strategies in health research and programs consistently call for participatory approaches based on developed relationships and partnerships. 11,12 The challenge in implementing this approach is in knowing who the appropriate partner is, that is, who represents the community. This will vary considerably. For new and emerging communities it may be a gradual process of getting to know community members and networks and identifying individuals with capacity and influence in their community who are interested in sup-porting the research and program initiatives. Some minority groups will have established community organizations or community leaders who are expected to take that role. However, there may also be competing interests between different groups within a given cultural community. In these cases it is very important to allow an initial period of time to explore these different roles and to be transparent about who is being consulted. It is also important to determine if the community leaders are able to truly represent the interests of the target community members. For example, is the male religious leader of a community able to represent the daily experiences of a mother trying to provide healthy meals for her family? In these cases, it is clearly valuable to engage mothers but this should be negotiated through the community leader as a trusted and respected community representative. There are many cultural differences in accepted ways to communicate between genders and so the gender of the researcher and the setting of interactions with research or program participants need to be negotiated in advance.

As always, it is important to be aware of potential power differences in research and community program relationships. This is particularly important in interactions with minority groups if previous traumatic experiences or gendered roles have contributed to a feeling of vulnerability, suspicion of perceived authority figures, or lack of experience with research.

The benefits of this considered approach to identifying and engaging community representatives are self-evident. The time involved in building trusted relationships will save time and resources as the research and community program progresses.¹³ However, can this culturally competent approach be supported in a community context with multiple minority groups? In these circumstances it is extremely valuable to conduct preliminary pilot work on the feasibility of the study design and the methodology to ensure appropriate time and resources have been allocated to meet the needs of culturally diverse communities.¹¹

Factors likely to impact on the way in which community groups are engaged in the research and program processes are explored below, and highlight the need for reflection on which aspects of the study design and methodology are fixed and which can be customized to the group and setting.