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To use focus groups to inform a web-based educational intervention for increased fruit and vegetable (FV) consumption.
Twelve groups (participants =137, aged 21–65) were recruited from four geographically diverse health systems. Four groups were stratified by gender and eight by race (white and African American) and gender. Questions included perceptions of healthy eating, factors that encourage or serve as barriers to FV consumption and features preferred for a web-based educational intervention.
Though knowledgeable about healthy eating, participants did not know how to achieve or always care about healthy nutritional choices. Motivators for FV consumption included being role models and health concerns. Barriers included: lack of time, expense and FV availability. Website preferences included: visuals, links, tailored materials, menu suggestions, goal setting assistance, printable summaries and built in motivation. The developers incorporated nearly all suggestions.
Focus groups provided needs-based tactical strategies for an online, education intervention targeting factors to improve FV consumption.
Focus groups can provide valuable input to inform interventions. Further, web-based programs’ abilities to offer information without time or geographic constraints, with capacity for tailoring and tracking progress makes them a valuable addition in the arsenal of efforts to promote healthy behaviors.
A diet rich in fruit and vegetables (FV) is associated with the prevention of numerous diseases.[1–5] While FV consumption benefits have received attention, studies indicate that most adults do not meet the recommended daily minimum servings[6–10] and knowledge appears insufficient to modify behavior.[11–14] Interventions, including counseling as well as tailored, print-based education, have had some success but are limited due to cost and reach. [7, 15–20] However, internet interventions are unconstrained by time and geographic boundaries.[16, 21–25]
To inform the design of a web-based intervention to increase FV intake, we conducted focus groups in four health systems with geographic and racial diversity. The purpose of this paper is to present focus group findings which informed the web-based intervention for the Making Effective Nutritional Choices for Cancer Prevention: The MENU Study.
This study was conducted as part of the HMO Cancer Research Network, a population-based consortium, funded by the National Cancer Institute and committed to the study of cancer. Four of five collaborating HMOs (Henry Ford Health System/Health Alliance Plan (Detroit, Michigan), HealthPartners and HealthPartners Research Foundation (Minneapolis, Minnesota), Kaiser Permanente Georgia (Atlanta, Georgia), and Group Health (Seattle, Washington) obtained institutional review board permission for these analyses.
All participants were HMO members, aged 21–65, not pregnant, not employed in the health field, and residing in the area ≥ three years. Participants had English as a first language, ate <7 FV servings/day and used e-mail at lease twice a week. Ineligibility included patients undergoing treatment for cancer, taking anticoagulation medications, or having a diagnosis for which diet change was contraindicated.
Anticipating that dietary behavior might vary by gender or race, [28–30] the 12 focus groups were stratified on these factors. Four groups were divided by gender only and eight by race [white versus African American (AA)] and gender.
Recruitment strategies varied by site but included targeted (age, race, sex) random sample mailings and flyers placed in clinics. Prospective participants were contacted by phone, screened for eligibility and scheduled into the appropriate focus group. Approximately 12 people were scheduled per group, with the expectation that eight would attend.
Prior to the focus groups, participants were invited to visit a web-based program (HealthMedia® Nourish™; HealthMedia, Inc.) a prototype for web-based interventions that provided personalized feedback about increasing FV intake.
Each session lasted approximately two hours, followed standardized methods, a scripted discussion, and was facilitated by the same investigator (GA) along with a local HMO staff member. Topics included food preferences, purchasing and preparation, attitudes, beliefs and perceptions on healthy eating, and factors that encourage or serve as barriers to eating FV. Focus groups also discussed the Nourish™ website‘s navigation, design features and educational content. Findings were used to optimize the applicability and appeal of the MENU intervention. Sessions were audiotaped and notes were taken. At the conclusion, participants completed a survey on demographics and received a $50.00 reimbursement.
Audiotapes were transcribed locally and de-identified. Responses were collated by question and thematic analysis by two authors identified common themes. A third author independently reviewed analyzes for final data interpretation . Frequencies were run on all variables and chi-squares were used to assess differences by race and/or gender.
There were a total of 137 participants in the 12 focus groups. Participants were predominantly well educated (post high-school: 59%), ate 3–6 FV per day (60%) and used the Internet frequently (70%) (Table 1).
Most participants (regardless of gender or race) were aware of aspects related to healthy eating. Participants offered numerous recommendations on what to eat, what to avoid and behaviors to adopt (Table 2). When commenting on why women eat more FV than men, both genders felt this was due to women’s increased responsibility for food. Both sexes perceived women as health and weight conscious and as media targets for “messages about nutrition” because they are mothers and family care-takers. They are also more responsible for food shopping (80% women versus 50% men) and preparation (85% versus 25%).
Two primary motivations for FV intake were serving as role models and concerns for personal and family health (Table 2). This was true across sex, race and region. Convenience was also key. Having “grab and go” precut vegetables, while more expensive, was appealing, as were fruits that are easy to peel (bananas), rather than “messy” (oranges) or “get in my teeth” (apples). Participants reported fewer barriers for FV consumption in the summer due to the increased variety, availability, freshness and affordability.
Barriers included: time, expense, inconvenience and lack of concern, particularly if “feeling ok.” Most participants reported not eating enough FV, but only half expressed concern. Men were more complacent than women. They commented that the places they go (work, ballpark, golf course, bar, traveling) did not foster good nutritional behaviors. Men felt less pressure to be thin, paid less attention to health/weight and attributed women’s concern for eating FV to control weight to being “less… physically active than men”.
Using the Nourish™ website as a reference, participants discussed their web preferences (Table 3). They preferred easy access and navigation. Nourish™ was too long, “too dense”, log-on was often slow and its navigation was problematic.
They requested “short and focused” “how-to” information with illustrations showing portion sizes, food preparation and determining ripeness. They recommended links to information and printable summaries usable as daily reminders. Men particularly wanted to self-navigate across program features, selecting topics of interest rather than following a prescribed order.
When asked how a web-based program could encourage FV intake, participants suggested information on daily serving amounts and meal plans, testimonials from people who benefitted by eating more FV and realistic goal setting. They preferred personalized materials and information on the consequences of non-attention to healthy eating. The intervention should motivate them; “wellness is something to look forward to” and monitor progress.
This qualitative study explored attitudes and behaviors related to FV consumption among a gender-balanced, medically-insured, racially and geographically-diverse population, who generally knew about healthy food consumption but not how to achieve FV recommendations. Focus group participant comments were consistent with the literature regarding healthy eating: what to eat, not eat and behaviors to employ. [33–35] Also consistent were motivating factors for eating FV, especially for women.[34, 36, 37] The literature purports, and our findings substantiate, that women are more concerned with food quality, nutrition, weight management and have more self-efficacy for FV intake.[37–39] Women take more responsibility for food purchase and preparation, and are more apt to read materials stressing the importance of healthy eating. The barriers - time, money, and convenience - were also consistent with previous findings. [34, 40–44] Others have also reported on the need for flexibility if programs are to be successful. 51, 55
Participants’ exposure to the sample website prior to focus group participation afforded a rich discussion on website content, appearance and navigation. The MENU developers incorporated most suggestions into the intervention. 34 The resultant web-site was light on text, easy to navigate, included videos on food preparation with printable summaries of ingredients and included requested topics, such as how to select ripe produce and clean it of pesticides, nutritional values, setting reasonable goals, FV substitutions and strategies for getting children to eat FV. The website encouraged participants to try new kinds of FV and provided a large selection of recipes. In-depth information was placed as sidebars and links were imbedded within the content.
Participants were self-selected volunteers, primarily white, over age 31, and with higher-level education. Findings may be limited to our insured, generally healthy adult sample, having access to the Internet and not necessarily representative of the general population. Other weaknesses include the one-time data capture and a fairly high FV consumption at baseline. We also may have enhanced the analysis had we maintained a stronger audit trail and by use of qualitative software for analysis. However, the numerous groups from four health systems with sex, racial and geographic diversity strengthened our understanding of attitudes and behaviors around eating FV. Contrary to our expectations, there were no differences in comments by sex or race. To our knowledge, no other gender and race-stratified focus groups have been reported across multiple geographic regions on FV intake.
Multiple, stratified focus groups informed the construction and content of a multi-faceted web-based intervention designed to improve FV consumption.
Focus groups proved valuable in providing tactical strategies that were incorporated into an online, education intervention targeting factors to improve FV consumption. Further, web-based programs’ abilities to offer information without time or geographic constraints, with capacity for tailoring and tracking progress towards a goal makes them a valuable addition in the arsenal of efforts to promote healthy eating and healthy lifestyles. In addition, once shown to be effective, a web program could be adapted for specific target groups on a variety of topics.
We acknowledge the National Cancer Institute for funding this study, Marci Campbell, PhD, RD for her assistance in directing the focus of the manuscript, and the MENU Study team, including individuals not listed as authors on this manuscript, who all contributed to this success of this study.
This study was funded by the National Cancer Institute (U19 CA79689-030, Increasing Effectiveness of Cancer Control Interventions, Edward H. Wagner, MD, PI
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