Background
Methods
Rationale and study sample
Study design
Analysis
Results
Age category in years | Sex | Educational level | Household income | Employment status | Marital status | Migration background | Food Bank use | BMI1 category | Diet quality score | Food security status | |
---|---|---|---|---|---|---|---|---|---|---|---|
Participant number | |||||||||||
1 | 45–50 | Male | ISCED 2 | Below basic needs budget | Currently paid job | Two parent household | Moroccan | No | Overweight | 36/ 60 | Food insecure |
2 | 40–45 | Female | ISCED 2 | Below basic needs budget | Currently no paid job | Single parent household | Colombian | No | Overweight | 31/ 60 | Food insecure |
3 | 45–50 | Female | ISCED 2 | Below basic needs budget | Currently no paid job | Single parent household | Surinamese | No | Obese Class I (moderately obese) | 29/ 60 | Food insecure |
4 | 40–45 | Female | ISCED 5 | Below basic needs budget | Currently paid job | Single parent household | Surinamese | No | Overweight | 33/ 60 | Food secure |
5 | 40–45 | Female | ISCED 2 | Below basic needs budget | Currently paid job | Single parent household | Curacao | No | Obese Class I (moderately obese) | 41/ 60 | Food insecure |
6 | 40–45 | Male | ISCED 1 | Below basic needs budget | Currently no paid job | Two parent household | Moroccan | Yes | Obese Class I (moderately obese) | 35/ 60 | Food insecure |
7 | 35–40 | Female | ISCED 4 | Below basic needs budget | Currently no paid job | Two parent household | Polish | No | Obese Class I (moderately obese) | 31/ 60 | Food secure |
8 | 50–55 | Female | ISCED 1 | Below basic needs budget | Currently no paid job | Single parent household | Moroccan | No | Obese Class III (Very severely obese) | 46/ 60 | Food insecure |
9 | 45–50 | Female | ISCED 7 | Above basic needs budget | Currently paid job | Two parent household | Surinamese | No | Overweight | 32/ 60 | Food secure |
10 | 35–40 | Female | ISCED 3 | Above basic needs budget | Currently paid job | Single parent household | Surinamese | No | Overweight | 43/ 60 | Food insecure |
Theme 1. Health related topics
Perceived healthy and unhealthy eating
Some participants indicated that healthy cooking and home cooking were difficult and laborious compared to unhealthy cooking and takeaway foods, whereas in the opinion of others healthy cooking was not difficult at all, because healthier cooking techniques (like steaming and oven cooking) were considered easier than less healthy techniques (like frying). Some misconceptions about dietary advice were present, e.g. stating coconut oil as being specifically beneficial for health, while saturated fats like coconut oil are usually not recommended in international and national dietary guidelines [29, 30]. Participants mentioned mostly consulting social media or acquaintances for information regarding healthy eating.“Hurry hurry, you know. For example, if you have to go somewhere, for example they have extra lessons in the mosque. Then I notice, quickly baking chips with a minced-meat hot dog and stuff. [ … ] Sometimes you have those empty moments. And then you bake a minced-meat hot dog.” (Participant 1)
Physical and mental health and disease
Participant 6 really regretted his unhealthy eating pattern in the past, which in his opinion had led to diabetes, and he wanted to prevent that from happening to his children:“If children eat healthy, they are not ill. Have fewer problems with everything. With concentration too.” (Participant 7)
Another participant became more aware of her lifestyle after being warned by her physician to lose weight in order to prevent cardiovascular diseases and diabetes. One participant mentioned experiencing poorer mental and physical health because of an unhealthy diet and overeating. Contrariwise, poor mental health was seen as a cause of unfavourable eating behaviour. Participants explained they lacked energy to prioritize healthy eating or cooking when feeling unwell, worried, stressed or depressed.“An example of me. I have always eaten unhealthy and now I have it [disease]. Custard, ice cream, chocolate … [ … ] I should not have done that. But you never knew in advance that you could become a diabetic. If my parents had said that, I would not have done it. But they did not say much. [ … ] They never said ‘that is good and that is bad’. [ … ] It is a pity, but... I did not get it from them.” (Participant 6)
"Everyone has a difficult situation and you are not in the mood, yes then it is easy to get a bag of fries and throw them in [the frying pan] and everyone has fries. Because it requires fewer actions and if you do not feel mentally well, then washing the dishes is really too much. Going to a supermarket uh, getting out of bed even, is just too much." (Participant 3)
Broader health concepts
Some participants mentioned having the intention to exercise more often but not (yet) actually had changed their physical activity level, for example because it was perceived too hard to make time or set one’s mind to it. Costs were not discussed as a barrier for physical activity.“But I think that if you start exercising, that you, that diet is going to change automatically a little bit.” (Participant 2)
Theme 2. Social and cultural influences
Influences by children
Child food preferences also influenced food purchases and dinner choices. Parents mentioned several strategies to broaden their children’s exposure to and taste for healthy food including: repeated exposure to disliked foods so children could get used to the taste and cooking preferred dishes in a healthier way, such as a homemade pizza rather than store bought or hiding vegetables within a (favourite) dish.“I work a lot. Night shifts, day shifts and evening shifts. She [child] is alone, I am there with my aunt, but then I felt guilty and then when I left, she started to cry. When I came back I had cookies for her, ‘mommy has brought you cake’. [ … ] You know, or I went to get her at the babysitter and then she said: ‘I missed you, you should not go to work anymore’. ‘That’s okay, mommy will buy a cake for you okay?’” (Participant 10)
Setting a good example for their child was mentioned as a motivation for healthy eating by some participants. Further, school food regulations positively influenced child-eating behaviour at school and sometimes also translated into healthier eating behaviours at home. For example, at some schools, unhealthy snacks or drinks were not allowed in class, which also made the children and parents reconsider consuming these products at home. Most participants had a positive attitude towards these school food regulations as they considered it a helpful contribution to adopting healthier eating behaviour.“It’s weird, but they [children] do not want vegetables. But yes, if you for example make chili con carne or for example sauce for spaghetti, then you just throw it through that zucchini. But that is how they eat it.*laughing* So yes, that's how you do it.” (Participant 1)
Influences by culture, family and friends
One participant even decided to limit family visits to reduce her child’s exposure to unhealthy eating habits of the family. Another mentioned strategy was to bring healthy products to these gatherings themselves. Positive influences were also mentioned, as friends and family sometimes served as an exemplary role for healthy behaviour or provided guidance about child upbringing:“Well uh, not really influence but they [family] try to force trough their vision or their will and I find that difficult. For example, if I go to my mother, well that she uh thinks he [child] should eat peppers, well, I don’t agree with that.[ … ] After a day at Grandma’s, he [child] goes home and then he ate chocolate, he ate crisps, he ate cake, he ate candy, he ate dinner and preferably ate three other things as well and then also coke and ice cream. Yes, I just think that, I'm really annoyed by that. Really that is just such a frustration.” (Participant 3)
Participants’ cultural background also influenced their eating behaviour, which was reflected in food customs (e.g. providing and consuming large quantities of food at social gatherings) and food choices (e.g. purchasing and cooking traditional foods, mostly indicated to be unhealthy, fatty of sugary foods).“But the bigger she [child] grew, the more rebellious she became and I say, ‘no, this is not going to happen’. Then I went to talk to my aunt and she coached me a bit and told me I should be strong. No remains no. That’s how I started to learn.” (Participant 10)
Theme 3. Influences by the physical environment
Presence of food outlets
The abundance of supermarkets, small food shops (e.g. Turkish shops) and the market were mentioned in this regard. The market was seen as a place to buy large quantities of cheap fruit and vegetables, although some mentioned that these products did not last long enough as they were not fresh. A downside of the abundance of food outlets in the neighbourhood was mentioned to be the food outlets offering unhealthy foods, as participants felt that the presence of these food outlets tempted them into making unhealthy food choices. The food supply at the supermarket checkouts was also considered unhealthy and tempting. Resisting these temptations was especially difficult for children.“Advantages are uhm, yes you can get almost everything here, also from your own culture the groceries. Everything is close by.” (Participant 3)
The school food environment was mostly viewed as healthy by the participants, which is not surprising as most schools adhered to healthy school food regulations. However, as long as the food outlets surrounding the schools offered unhealthy foods, children were tempted to buy those unhealthy foods during the breaks or after school.“I also want to leave this neighbourhood. Because [ … ] you cannot blame [name child] because he walks out and it already starts, that Bulgarian there, the fries shop there. I mean, in the morning at around a quarter past eight, he already has fried chicken. Yes, you go with your child to the market to get watermelon, he is twice in the fight at the Kentucky. And then he looks at me like that again [ … ] and then, yes you have to disappoint him. And as a mother you also get tired of that no, no, no [ … ]. So uh sometimes we have a little fight about this too. [ … ] I just want to live somewhere that if you walk out the first ten minutes you will not come across a single snack something. [ … ] this is really too bad for a child.” (Participant 3)
Liveability of the neighbourhood
Theme 4. Financial influences
Coping
Non-basic needs like a holiday with the family or visiting family abroad were important motivators for saving money.“Yes, I used to be ashamed to buy cheap products [ … ]. I really thought those people would think that I don’t have money. That's how I thought. Some colleagues also said ‘you should not be ashamed, even if all your groceries are premium brands, it's all the same’. It's just another package, just look, it's all the same. I used to buy Cornflakes of 3 euros while I could also get Cornflakes of 1 euro.” (Participant 10)
Financial perception
Some participants felt discontented about that and indicated that lowering healthy food prices would be a great help in achieving healthier eating behaviour in the population.“Well then you go and look and the healthy things are actually really expensive. Yes then you are inclined, [ … ] we better take a sausage roll, you almost want to say that.” (Participant 3)
However, it was mentioned that using the right strategies (e.g. coping strategies for dealing with a limited budget like buying frozen vegetables) it was possible to buy healthy foods despite having a limited budget. Participants generally felt in control over their grocery shopping behaviour and felt this was not greatly influenced by external factors. Participants demonstrated a conscious attitude towards their financial situation, as reflected in their coping strategies for dealing with a limited budget, knowingly buying products that were a bit more expensive if they lasted longer, and prioritizing basic needs over luxury needs.“But the worst help there is are all those sweets in the shops. Those are cheap and the ones that you need are expensive. That is the worst thing they can have. And then some people think: ‘Yes, that is cheap?’ That is why we have a lot of children with obesity here, too many children. Children from 4 years and older, some children are only 5, all teeth are rotten. Wherever you go, [for] 50 cents you have a bag full of candy. You are not going to have a bag full of vegetables for 50 cents. You do not have that. So if you turn that mentality around, it would be better.” (Participant 5)
Financial stress
However, as also indicated in the theme about mental health, financial stress was a barrier for healthy eating behaviour, as participant 8 indicated about the time when she was in debt:“For me, money is not everything. For me it is that I can get up every day, that I can breathe every day, that I thank my god. Every day of my life because not everyone can do that and I think that's the best you can do as a person, especially when you get up. Because we cannot buy that, not with any money.” (Participant 5)
Regarding basic needs like food and clothes, participants clearly prioritized their children over themselves. For example, participants mentioned to rather skip a meal themselves than that the child would be short on something.“I did not really buy healthy food then, I just bought what was cheap. I only want to live because you are in the cramp, it’s not possible, it’s difficult.” (Participant 8)
Food insecurity was mostly mentioned in reference to the past or to others and not to the participants’ own current experiences, i.e. mentioning past experiences of having insufficient money for food due to debts, or knowing others that were unable to afford sufficient food. Interestingly, participant 1 was classified as food insecure according to the previous questionnaire, but during the interview he specifically mentioned not to worry about going hungry:“I do not care because I prefer [caring for] them [children] rather than myself. I can do with a few slices of bread and peanut butter and then I go to sleep. But they can’t.” (Participant 6)
He made a clear link with the quantity aspect of food security for himself and his family:“So, you always have to pay close attention and put everything in order when it comes to finances. For the rest just happy. I mean, my family also. I mean, I'm not worried about, for example, that I'm going to starve, not that.” (Participant 1)
“Healthy eating for me and my family means ensuring that there always is food. Yes. That is first of all healthy, that you have to eat. And secondly, yes, that you pay attention to your diet." (Participant 1)
Existing and proposed solutions to reduce food-related financial strain
Other proposed solutions to reduce financial strain and improve dietary habits were providing free meals for those in need, increasing healthy food supply in the neighbourhood (specifically limiting unhealthy snacks at supermarket checkouts and decreasing the number of fast-food outlets) and lowering healthy food prices.“The only thing they [Food Banks] don’t have is social contacts.” (Participant 6)
Barriers for using resources included feeling ashamed, thinking not to belong to the target group, not being eligible for the desired resources, finding it too difficult to register for resources or not knowing where to find the right information. Further, dietary advice provided by dieticians was mentioned to be insufficiently suitable for different cultural backgrounds:“What would help me? To eat healthier? If the store prices of those things drop a little, that would be super helpful. Not just for me but for many people.” (Participant 5)
Several participants felt that resources like Food Banks and allowances were often misused by people who did not need it and that people who actually needed help not always asked for or accepted help.“For dietary advice, it's just hard in such a neighbourhood as this because you have different cultures. [ … ] I also experienced that at the dietician, yes okay I do get the dietician but I don’t eat all that. And you can’t expect that if it is in your roots not to eat certain things that you just change it.” (Participant 3)