Background
Cultural adaptation
The Healthy Beginnings program and the current study
Methods
Design and context
Framework for the cultural adaptation process
Stage 1: initial considerations
Stage 2: information gathering
Stage 3: preliminary cultural adaptations
Financial costs of the cultural adaptation process
Results
Stage 1: initial considerations
Rationale for culturally adapting Healthy Beginnings
Program theories and worldviews
Program core components
Stage 2: information gathering
Findings from literature reviews
Findings from qualitative consultations with local community members and staff
Domains and sub-themes | Arabic speaking mothers | Chinese speaking mothers | Health professionals |
---|---|---|---|
Domain 1: Beliefs and practices related to infant feeding, active play, sedentary behaviours, sleep | |||
Confinement practices important for recovery after birth | x | x | x |
Breastfeeding as part of the social norm and expected | x | x | |
Not enough breastmilk and formula use for reassurance | x | x | |
Feeding as helpful for weight gain, sleep and settling | x | x | x |
Confusion with ideal timing of complementary feeding | x | x | x |
‘Tummy time’ as a new concept | x | x | x |
The floor is not seen as a place for new babies to play | x | x | x |
‘Tummy time’ as a risk for new babies | x | x | |
Interactions/play with babies as natural | x | x | x |
Dilemmas of screen use | x | x | x |
Screens to distract baby while feeding | x | ||
Domain 2: Perceptions related to child weight | |||
A bigger baby as a healthier baby | x | x | x |
Infant overweight as not a concern | x |
“It depends on the mother themselves whether they follow the guideline here or that in their own country. You know, they will feel different here.” - Multicultural community health worker, 6 years, Mandarin and English
"Frankly, non-one advised me to bottle-feed, all people encouraged me to breastfeed." - Arabic speaking mother, Focus group 4
"At that time, my mother was helping me with the baby, so when the baby was hungry, you would not necessarily have enough breast milk." - Chinese speaking mother, Focus group 1
"If they whinge, you give them food or milk because they will stop complaining, even if they might be crying over something else." - Child and family health nurse, 23 years, English
“You can then puree this thing for him to have a taste. If the child shows no interest, then you can maybe wait. If he shows interest at a fairly early stage, you can try it early with him.” - Chinese speaking mother, Focus group 1
“We don’t put the baby on the floor [in Syria]. …This is the first time I know about it” - Arabic speaking mother, Focus group 5
“At the early stage, his eyes are still developing, it will have a bigger impact, so you should try to delay [using screens]. Then again, there are many apps that are really helpful to their study. However, the later you introduce this the better.” - Chinese speaking mother, Focus group 2
“The weight is important. It’s healthy. If they are skinny, then people will ask is there anything wrong with the baby.” - Child and family health nurse, 16 years, Cantonese and English
Stage 3: preliminary cultural adaptation
Culturally adapted Healthy Beginnings delivery features
Mainstream Healthy Beginnings – English speaking mothers | Culturally adapted Healthy Beginnings - Arabic and Chinese speaking migrant mothers | |
---|---|---|
Recruitment | ||
Promotional material | Flyer in English developed by project staff. | Flyer adapted by bi-cultural project staff, with culturally relevant images and translated text focussing on infant growth and development. |
Strategies | Recruitment via flyers at antenatal clinics and promotion from midwives. | Recruitment face-to-face with bi-cultural research staff and medical professional translator at antenatal clinics and groups. |
Delivery features | ||
Program components | ||
Nurse phone calls | Participant-led discussion including goal setting, with script/prompts based on program key content, infant age and developmental milestones, individualised to each mother. Call script/prompts developed by health professionals for Australian mothers. | Participant-led discussion including goal setting, with script/prompts based on program key message, infant age and developmental milestones, individualised to each mother. Call script/prompts culturally adapted and translated by health professionals, bi-cultural workers, translators. Script/prompts adapted to cultural factors (identified in information gathering stage) and bi-cultural nurse experience. |
Written Healthy Beginnings booklets | Healthy Beginnings information booklets aligned with key content areas and timing of nurse calls. Developed by health professionals for Australian mothers and families. Mailed to home address with option to email. | Healthy Beginnings information booklets aligned with key content areas and timing of nurse calls. Adapted and translated by health professionals, bi-cultural workers, professional translators and Arabic and Chinese community members. Adapted to cultural factors (identified in information gathering stage). Mailed to home address with option to email. Additional breastfeeding promotional poster sent. |
Written complementary material | Relevant supporting resources available in English (e.g. physical activity and healthy eating guidelines for children). | Relevant supporting resources available in Arabic and Simplified Chinese (e.g. translations of Australian Guide to Healthy Eating, local Arabic or Chinese play groups). |
Phone text messages | Aligned with staged calls with opportunity for mothers to reply. SMS sent twice per week for 4 weeks. Personalised by name, according to age and feeding mode. Developed by health professionals for Australian mothers and families. | Aligned with staged calls with opportunity for mothers to reply. SMS sent twice per week for 4 weeks. Personalised by name, according to age and feeding mode. Adapted and translated by health professionals, bi-cultural workers and translators. Key content retained but adapted to cultural factors (identified in information gathering stage). |
Delivery staff | Female child and family health nurse, in English language. | Female bi-cultural child and family health nurse, in Arabic or Chinese languages. |
Program audience | Individual mothers | Individual mothers |
Program location | Phone calls to participant’s home | Phone calls to participant’s home |
Program duration | 24 months | 6 months |
Session number | 8 staged intervention phone calls, with additional calls as required | 4 staged intervention phone calls, with additional calls as required |
Session frequency | One call during the third trimester of pregnancy, then at infant age 1, 3, 5, 9, 12, 18 and 24 months | Once call during the third trimester of pregnancy, then at infant age 1, 3, 5 months |
Culturally adapted Healthy Beginnings content
Timing and key content areas / Behaviour targets | Main content | ||
---|---|---|---|
Mainstream Healthy Beginnings program [36] | Culturally adapted Healthy Beginnings – Arabic speaking migrant mothers | Culturally adapted Healthy Beginnings – Chinese speaking migrant mothers | |
Antenatal (third trimester) Sustaining breastfeeding / best-practice formula feeding | ▪ Breastfeeding guidelines ▪ Health benefits of breastfeeding and strategies to overcome barriers associated with breastfeeding | ▪ Breastfeeding guidelines. Reinforce with support of community ▪ Benefits of breastfeeding and colostrum; Breastmilk production in first weeks. ▪ Family and social support ▪ Information about accessing free health services and interpreters | ▪ Breastfeeding guidelines. ▪ Benefits of breastfeeding and colostrum; Breastmilk production in first weeks; address concerns of not enough breastmilk for baby. ▪ Family and social support ▪ Information about accessing free health services and interpreters |
0–2 months Sustaining breastfeeding / best-practice formula Timing of solid food introduction Promote active play ‘Tummy time’ Response to child cues: hunger, satiety | ▪ Rapid response to women with problems initiating breastfeeding after childbirth, especially women who delivered by caesarean section ▪ Advice on establishment of breastfeeding pattern ▪ Management of feeding problems ▪ Infant feeding cues ▪ Baby feed, play, sleep cycle ▪ ‘tummy time’ for babies | ▪ Rapid response to women with problems initiating breastfeeding ▪ Advice on establishment of breastfeeding pattern ▪ Management of problems ▪ Reinforce no other fluids or foods needed until around 6 months (e.g. formula and water) ▪ Infant feeding cues ▪ ‘tummy time’ for babies; with increased information about what, why and how ▪ Baby feed, play, sleep cycle; infant crying is normal. ▪ Family and social support; sharing care with fathers and family, and emotional support ▪ Information about accessing free health services and interpreters | ▪ Rapid response to women with problems initiating breastfeeding ▪ Advice on establishment of breastfeeding pattern ▪ Management of problems – addressing any concerns of milk quality and/or quantity. ▪ Reinforce no other fluids or foods needed until around 6 months (e.g. formula and water) ▪ Infant feeding cues ▪ ‘tummy time’ for babies; with increased information about what, why and how. ▪ Baby feed, play, sleep cycle; infant crying is normal. ▪ Family and social support; sharing care with fathers and family and emotional support ▪ Information about accessing free health services and interpreters |
2–4 months Sustaining breastfeeding / best-practice formula Timing of solid food introduction Promote active play ‘Tummy time’ Response to child cues: hunger, satiety | ▪ Advice on establishment of breastfeeding patterns ▪ Management of problems ▪ ‘tummy time’ for babies ▪ Introduction of solids at around 6 months ▪ Encourage mothers going back to work to continue breastfeeding | ▪ Advice on establishment of breastfeeding patterns ▪ Management of problems; describe signs that baby is getting enough breastmilk ▪ ‘tummy time’ for babies ▪ Introduction of solids at around 6 months ▪ Baby feed, play, sleep cycle; Sleep and settling techniques ▪ Family and social support ▪ Parenting; looking after mother and father’s emotional health ▪ Information about accessing free health services and interpreters; introduction to family child health nurse | ▪ Advice on establishment of breastfeeding patterns ▪ Management of problems; describe signs that baby is getting enough breastmilk ▪ ‘tummy time’ for babies ▪ Introduction of solids at around 6 months, emphasise includes water/fluids too ▪ Encourage mothers going back to work to continue breastfeeding and offer strategies. ▪ Baby feed, play, sleep cycle; Sleep and settling techniques ▪ Family and social support ▪ Parenting; looking after mother and father’s emotional health ▪ Information about accessing free health services and interpreters; introduction to family child health nurse |
4–6 months Solid food introduction Healthy food choices Promote active play ‘Tummy time’ and no screen use | ▪ Reinforce breastfeeding pattern, Management of problems ▪ ‘tummy time’ for babies ▪ Introduction of solids from 6 months ▪ Encourage mothers going back to work to continue breastfeeding | ▪ Reinforce breastfeeding pattern ▪ Management of problems ▪ ‘tummy time’ for babies ▪ Introduction of solids from 6 months; visually illustrating age-appropriate food textures ▪ Learning to eat and making a mess ▪ Following hunger and fullness cues ▪ Encourage mothers going back to work to continue breastfeeding and offer strategies ▪ Family and social support ▪ Parent-child interactions; importance of play for mental & emotional development ▪ Information about accessing free health services and interpreters | ▪ Reinforce breastfeeding pattern, Management of problems ▪ ‘tummy time’ for babies ▪ Introduction of solids from 6 months; visually illustrating age-appropriate food textures ▪ Learning to eat and making a mess ▪ Following hunger and fullness cues ▪ Encourage mothers going back to work to continue breastfeeding and offer strategies ▪ Family and social support ▪ Parent-child interactions; importance of play for mental & emotional development ▪ Information about accessing free health services and interpreters |