understanding barriers to fruit and vegetable intake in ... · understanding barriers to fruit and...

Understanding barriers to fruit and vegetable intake inthe Australian Longitudinal Study of Indigenous Children:a mixed-methods approach

Katherine Ann Thurber1,*, Cathy Banwell1, Teresa Neeman2, Timothy Dobbins3,Melanie Pescud4,5, Raymond Lovett1 and Emily Banks11National Centre for Epidemiology and Population Health, Research School of Population Health, The AustralianNational University, 62 Mills Road, Acton, ACT 2601, Australia: 2Statistical Consulting Unit, The AustralianNational University, Acton, ACT, Australia: 3National Drug & Alcohol Research Centre, University of New SouthWales, Randwick, NSW, Australia: 4RegNet School of Regulation and Global Governance, The Australian NationalUniversity, Acton, ACT, Australia: 5The Australian Prevention Partnership Centre, Sax Institute, Ultimo, NSW,Australia

Submitted 26 April 2016: Final revision received 26 September 2016: Accepted 29 September 2016

AbstractObjective: To identify barriers to fruit and vegetable intake for Indigenous Australianchildren and quantify factors related to these barriers, to help understand whychildren do not meet recommendations for fruit and vegetable intake.Design: We examined factors related to carer-reported barriers using multilevelPoisson models (robust variance); a key informant focus group guided ourinterpretation of findings.Setting: Eleven diverse sites across Australia.Subjects: Australian Indigenous children and their carers (N 1230) participating inthe Longitudinal Study of Indigenous Children.Results: Almost half (45%; n 555/1230) of carers reported barriers to theirchildrens fruit and vegetable intake. Dislike of fruit and vegetables was the mostcommon barrier, reported by 329% of carers; however, we identified few factorsassociated with dislike. Carers were more than ten times less likely to reportbarriers to accessing fruit and vegetables if they lived large cities v. very remoteareas. Within urban and inner regional areas, child and carer well-being, financialsecurity, suitable housing and community cohesion promoted access to fruit andvegetables.Conclusions: In this national Indigenous Australian sample, almost half of carersfaced barriers to providing their children with a healthy diet. Both remote/outerregional carers and disadvantaged urban/inner regional carers faced problemsaccessing fruit and vegetables for their children. Where vegetables wereaccessible, childrens dislike was a substantial barrier. Nutrition promotion mustaddress the broader family, community, environmental and cultural contexts thatimpact nutrition, and should draw on the strengths of Indigenous families andcommunities.

KeywordsDiet, food and nutrition

Child healthHolistic health

Health behaviour

Poor diet is the leading preventable risk factor for poorhealth in Australia, estimated to account for more than10% of the total burden of disease(1), including through itsassociation with conditions including cardiovascular andcirculatory diseases, cancer and diabetes. The diseaseburden attributable to poor diet is estimated to be nearlydouble (19%) in the Indigenous population; four of theseven leading risk factors contributing to the gap in healthbetween the Indigenous and non-Indigenous populations

relate to diet (obesity, high blood cholesterol, high bloodpressure, low fruit and vegetable intake)(2).

Australian guidelines recommend that children aged48 years consume 1 servings of fruit and 4 servings ofvegetables daily, increasing to 2 and 5 servings daily,respectively, for children aged 911 years(3). Data from a20122013 national survey indicated that while 78% ofIndigenous children met recommendations for fruit intake,only 16% met recommendations for vegetable intake(4),

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*Corresponding author: Email [email protected]

The Authors 2016. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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consistent with statistics for non-Indigenous Australianchildren(5). Increasing fruit and particularly vegetableintake by Indigenous children could decrease theburden of disease. However, there is limited evidence onthe effectiveness of existing programmes and policy toimprove Indigenous nutrition(6).

Indigenous Australians have a diversity of culturesand live in varied environments(7). About 57% of the Indi-genous population lives in major cities or inner regionalareas (approximately 380 800 people) and 21% in remote orvery remote settings (approximately 142 900 people), com-pared with 90% and 2% of the non-Indigenous population,respectively(8). On average, Indigenous Australians havelower socio-economic status than non-Indigenous Aus-tralians, and are more likely to live in homes that are over-crowded or have infrastructure problems(9,10) and to live inareas of socio-economic deprivation(11).

Food choice is complex and influenced by a broadrange of factors(1215). The ability to purchase fruit andvegetables is influenced by their accessibility, affordabilityand availability; in Australia, basic healthy food items areless likely to be available and more likely to be moreexpensive and of lower quality in remote areas comparedwith urban centres(1618). Food purchasing behaviour isstrongly associated with socio-economic status and isalso shaped by individual preferences and culturalfactors(12,13,17,1922). Connection and commitment toextended family and community members, and com-munity organisations and events have been identified asfactors supporting Indigenous well-being(23,24). Forexample, cultural values and norms about reciprocity andgenerosity encourage Indigenous families to share foodand resources with others(25); many households often feedextra people(12,26,27) and humbugging, wherein relativesor friends request money or resources, is a commonpractice in some communities(25,28). Traditional knowl-edge and food systems are also understood to promoteIndigenous nutrition(29); however, these were disruptedthrough colonisation and its lasting impacts on the Indi-genous population, resulting in profound changes toIndigenous food practices(13,26,30,31). Contemporarily,market foods are estimated to generally constitute themajority of food intake by Indigenous Australians, withbush tucker (hunted and cultivated traditional foods)a minor contributor to intake(29,3234).

Overall, Indigenous children disproportionately facebarriers to fruit and vegetable intake compared withnon-Indigenous children, given the population distribu-tion, lower socio-economic status, and unique historical,political and cultural context. Qualitative research in bothremote and urban settings has depicted how broadersocial, cultural and environmental factors influenceIndigenous Australians food choice(12,13,17,19,20). Thepurpose of the current work was to quantify factors relatedto perceived barriers to fruit and vegetable intake forIndigenous Australian children, in order to understand

why children do not meet recommendations for intake.We have focused on identifying protective (rather thanrisk) factors that facilitate childrens consumption of fruitand vegetables. Within this, we explore variation betweenurban, regional and remote settings, given the vast dif-ferences in food environments, population characteristicsand cultural contexts.

Methods

Mixed methodsThe current study analyses quantitative data from theLongitudinal Study of Indigenous Children (LSIC) andqualitative data from a key informant focus group. Ratherthan relying on quantitative epidemiological analyses ontheir own, we conducted a focus group as part of ourresearch protocol to guide data interpretation(35). Thismixed-methods approach(36) facilitates a more holisticanalysis, considering multiple perspectives and drawingon multiple ways of sharing knowledge(37,38), andenhances the interpretation and contextualisation offindings(35). Our approach was guided by Bronfenbrennerand Morris social ecological model(39) and a conceptualframework applied within the Pro Children project(40,41).

Study populationThe LSIC is a national study managed by the AustralianGovernments Department of Social Services(42). Purpo-sive sampling was used to recruit Aboriginal and TorresStrait Islander children from eleven diverse sites acrossAustralia. The survey design and the implications foranalysis have been described elsewhere(42,43). IndigenousResearch Administration Officers (RAOs) conduct annualface-to-face interviews with children and their primarycarer (the childs mother in the majority of cases, orsometimes the father, a relative or other guardian). Thepresent analysis is based on data collected in 2013, inWave 6 of the LSIC. The primary carer reported all dataincluded in the analysis, with the exception of childrensBMI, which was calculated based on height and weightmeasurements taken by RAOs, and remoteness and area-level disadvantage, which were derived from participantsaddresses.

Focus group methodsIn February 2015, the lead author (K.A.T.), a non-Indigenous woman, conducted a focus group with theRAOs currently conducting LSIC interviews (n 12/12). Asall RAOs are Indigenous and most live in the sites in whichthey conduct interviews, we considered them key infor-mants in these communities, holding pertinent contextualknowledge(35).

The focus group was semi-structured to facilitate thesharing of stories and to allow new issues to emergethroughout the discussion(44); the participants guided the

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depth and focus of discussion on each topic. During thefocus group, K.A.T. presented preliminary descriptiveanalysis of the relevant LSIC data, including: the distribu-tion of carer-reported fruit and vegetable intake bychildren, overall and by remoteness; carer-reportedbarriers to childrens fruit and vegetable intake, overalland by remoteness; examples of carers free-text respon-ses about why their children did not eat more fruit andvegetables; and examples of carers free-text responsesabout how they encouraged their children to eat more fruitand vegetables. For each item, K.A.T. asked RAOs tocomment if this was consistent with the experience theyhad in the site in which they worked, if they thought thefindings were important and what they thought the find-ings meant. RAOs were encouraged to share stories andexperiences from the field.

K.A.T. conducted, transcribed and analysed the focusgroup interview, which was audio-recorded with partici-pants content. The LSIC team reviewed and approved thetranscript; a follow-up discussion was held with the RAOsin 2016 to discuss the interpretation of final results andtheir implications.

Variables in the quantitative analysis

ExposuresChild factors. We examined childrens age at the time ofsurvey, sex, and identification as Aboriginal, Torres StraitIslander or both. We also examined indicators of thechilds well-being: general health, social and emotionalwell-being (low/moderate v. high risk of social andemotional behavioural difficulties according to theStrengths and Difficulties Questionnaire(45,46)), and BMIcategory(47,48).

Family factors. We examined objective and subjectivemeasures of families financial situations: carers relation-ship status, weekly household income, financial strain (runout of money before payday/spending more than earning;enough money to get through to the next payday; cansave a bit/a lot), serious worries about money in past year,food insecurity (going without meals because of a lack ofmoney) in the past year, and carers highest qualificationand employment status. We examined indicators ofresource sharing: being humbugged in the past year, fre-quency of feeding others who dont live at home andpressures to support others in the community.

We also examined carers general health and social andemotional well-being (low or high distress, based on asocial and emotional well-being index(49)) and the numberof negative major life events experienced by the family inthe past year.

We examined whether the family had an evening mealtogether in the past week and carers perceptions of theimportance of passing on cultural knowledge to theirchildren about bush tucker, hunting and fishing. We alsoexamined household size and housing problems (home has

felt too crowded in past year; moved house in past year;problems with fridge and/or cooking facilities; majorelectrical problems at home; security problems at home major problems with locks, windows, doors or screens).

Area-level factors. Geographical remoteness in the LSICis measured using the Level of Relative Isolation scale(50).Areas are categorised as having no, low, moderate, high orextreme isolation; these categories correspond to majorcities, larger regional centres, smaller regional centres farfrom large cities and communities/settlements generallywith a predominantly Indigenous population, respectively.For stratified analyses, we classified areas with no or lowisolation as urban/inner regional (urban/IR) and areaswith moderate or high/extreme isolation as remote/outerregional (remote/OR).

Area-level disadvantage was measured using theIndex of Relative Indigenous Socioeconomic Outcomes(IRISEO)(51), an index calculated specifically for IndigenousAustralians based on nine measures of socio-economicstatus. We categorised areas as having the highest level ofadvantage (IRISEO 810), mid-level advantage (IRISEO 47)and the lowest level of advantage (IRISEO 13).

Carers also reported if they experienced a problem withracially motivated violence, alcohol misuse, and break-insor theft in their community.

See the online supplementary material, SupplementalFile 1, for more details on exposure variables.

OutcomeAll carers were asked if they would like their children toeat more fruit and/or vegetables. Carers responding thatthey wanted their children to eat more were asked toselect up to two barriers to their childs fruit and/orvegetables intake: child doesnt like them or refuses to eatthem, too expensive, not readily available (e.g. shopdoesnt have enough), poor quality of fresh produce,issue with transport (e.g. shop too far away or no car), nofood preparation area or storage, dont know or other.Carers reporting barriers related to accessibility, afford-ability and availability (too expensive, not readily avail-able, poor quality, issue with transport, no foodpreparation area or storage) were categorised asperceiving accessibility-related barriers. Carers respondingthat their children had enough fruit and vegetables wereconsidered to perceive no barriers to intake. Carers whoresponded dont know (04%, n 5/1239) or who specifieda different answer (03%, n 4/1239) were excluded.

To ensure that our outcome variable was meaningful,we validated that carers perceptions of barriers reflectedlow fruit and vegetable intake by their children, and thatthe relationships of exposures to carers perception ofbarriers were consistent with the relationships of theseexposures to childrens low vegetable intake. Thisvalidation was conducted within the sample of children(n 502/1230) who had data on dietary intake (see onlinesupplementary material, Supplemental File 2).

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Analytical methodsRather than looking at factors relating to carers perceptionof any barriers, we separately examined factors related toaccessibility barriers and factors related to childrensdislike of fruit and vegetables, as the factors related tothese two barrier types might vary. It is difficult to interpretdislike if children have limited access to fruit andvegetables, or if they only have access to fruit andvegetables that are of poor quality, so we examined factorsrelated to childrens dislike in the sample restricted tothose without any accessibility barriers.

We calculated prevalence ratios (PR) using multilevelPoisson models with robust variance. Childrensgeographic cluster was included as a level variable toaccount for the within-cluster correlation resulting from theLSICs survey design. We first adjusted these models for agegroup and sex only. We expected that remoteness mightconfound these relationships, given known variation infood availability and sociocultural context across levels ofremoteness, so we repeated the models with additionaladjustment for remoteness and examined how this alteredrelationships. If findings indicated potential residual con-founding by remoteness, we repeated analyses separatelyin the urban/IR and remote/OR groups. We tested if theexposureoutcome relationships varied between urban/IRand remote/OR environments by repeating the models inthe whole sample including an interaction term betweenthe dichotomous remoteness variable and the exposure,with Pinteraction< 005 indicating a significant difference.

Analysis of the qualitative data from the focus groupguided our interpretation of quantitative findings(35). Thequalitative data were analysed thematically(52). Inductive anddeductive codes were developed based on our open-endedquestions and refined as new information was found. Codedtextual segments were grouped into categories and

sub-categories which were then developed into themes(53)

and further refined and cross-checked through discussionswithin the team. The qualitative findings reported in thepresent manuscript reflect the outcomes of the groupdiscussion and the unique viewpoints of RAOs working indifferent settings.

EthicsThe LSIC survey was conducted with ethical approvalfrom the Departmental Ethics Committee of the AustralianCommonwealth Department of Health and from relevantEthics Committees in each state and territory, includingrelevant Aboriginal and Torres Strait Islander organisa-tions. The Australian National Universitys HumanResearch Ethics Committee granted ethics approval forthe quantitative analysis of LSIC data in October 2011(protocol number 2011/510); approval to conduct thefocus group and for subsequent engagement with keyinformants was granted in 2015 and 2016, respectively.

Results

Profile of the sampleInterviews were conducted with 1239 carers in LSIC Wave6, of whom 1230 provided data on barriers to theirchildrens fruit and vegetable intake. Children in theyounger cohort were aged 46 years and children in theolder cohort were aged 710 years; 614 female and 616male children were included in the sample. The majorityof families in the sample were living in urban/IR areas,787% (n 968/1230), with 213% (n 262/1230) living inremote/OR areas. Characteristics of the participatingfamilies are presented in Table 1.

On average, carers reported that children in the oldercohort consumed 21 servings of fruit daily, with about

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Table 1 Profile of families participating in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6, 2013

Remote/OR (N 262) Urban/IR (N 968) Total (N 1230)

% n/N % n/N % n/N

Carer is partnered 580 152/262 547 529/968 554 681/1230Carer has education Year 12 or further 395 92/233 444 399/899 434 491/1132Household income $AU 600/week 473 104/220 637 581/912 605 685/1132Family has not been humbugged in past year 602 157/261 758 733/967 725 890/1228No problem with pressure to support others in the community 510 126/247 798 700/877 735 826/1124Household size 6 members 523 137/262 354 343/968 390 480/1230Households with working fridge and cooking facilities 827 143/173 950 667/702 926 810/875Living in areas in highest tertile of advantage 38 10/262 259 251/968 212 261/1230

Older cohort only (N 495) Mean 95% CI Mean 95% CI Mean 95% CI

Number of usual daily servings of fruit 21 19, 23 21 20, 22 21 20, 22n 99 394 493

Number of usual daily servings of vegetables 18 16, 21 19 17, 20 19 18, 20n 99 396 495

The sample includes those with data on barriers. Data on intake of fruit and vegetables were recorded for the older cohort (children aged 710 years) only.Sample size varies due to missing data on the exposures of interest.Urban/inner regional (urban/IR) areas were defined as those with no or low isolation (major cities and larger regional centres) and remote/outer regional (remote/OR) areas as those with moderate or high/extreme isolation (smaller regional centres far from large cities and communities/settlements generally with apredominantly Indigenous population).

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80% meeting the recommended daily intake for their agegroup. Vegetable intake was much lower in the sample,with less than 5% of children meeting their recommendeddaily intake; on average, carers reported that childrenconsumed 19 servings of vegetables daily. We did notobserve significant variation in intake between remote/ORand urban/IR settings.

Reported barriersAlmost half of carers (451%; n 555/1230) reported abarrier to their childs fruit and vegetable intake (Table 2);175% (n 215) reported barriers to vegetable intake only,41% (n 51) reported barriers to fruit intake only, and235% (n 289) reported barriers to both fruit and vegetableintake. In the following analyses, we have examinedbarriers to fruit and vegetable intake combined.

Childrens dislike of fruit and/or vegetables was the mostcommon barrier, reported by 329% (n 405/1230) of carers.An additional 74% of carers reported barriers related toaccessibility: 41% (n 51/1230) said fruit and vegetableswere too expensive, 32% (n 39/1230) said they werenot available, 23% (n 28/1230) said they were of poorquality, 07% (n 9/1230) reported issues with transport and05% (n6/1230) said that food preparation or storageareas were not available. Few carers (12%; n 15/1230)reported barriers related to both dislike and accessibility.

An additional 67% of carers specified other reasons(n 82/1230 carers providing ninety-four total responses), withthe main themes of: fussy eating and children making theirown choices (n 20); carers cooking and eating habits,including time constraints (n 14); the preparation or appear-ance of fruit and vegetables (n 9); dietary restrictions due todisability or health conditions (n 9); the type or variety of fruitand vegetables available (n 8); running out of fruit andvegetables at home quickly, or not purchasing enough (n 7);and competition from alternatives such as junk food (n 6).

The proportion of carers reporting any barriers to thechilds fruit and vegetable consumption was 481% inremote/OR and 443% in urban/IR areas. Childrens dislikeof fruit and vegetables was the most common barrier in bothsettings, but barriers related to accessibility were morecommonly reported by remote/OR carers (Table 2 andFig. 1). In remote/OR settings, 248% (n 65/262) of carersreported childrens dislike, 240% (n 63/262) reported anyaccessibility barriers and 27% (n 7/262) specified otherreasons. In urban/IR settings, 351% (n 340/968) of carersreported childrens dislike, 29% (n 28/968) reported any

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Table 2 Barriers to childrens fruit and vegetable consumption reported by carers in the Australian Longitudinal Study of IndigenousChildren (LSIC), Wave 6, 2013

Carer-reported barriers to childrens fruit and vegetable intake

Remote/OR Urban/IR Total

% n/N % n/N % n/N

No barriers to intake 519 136/262 557 539/968 549 675/1230Childrens dislike 248 65/262 351 340/968 329 405/1230Any accessibility barriers 240 63/262 29 28/968 74 91/1230Too expensive 115 30/262 22 21/968 41 51/1230Not available 137 36/262 03 3/968 32 39/1230Poor quality 95 25/262 03 3/968 23 28/1230Transport issues 15 4/262 05 5/968 07 9/1230No preparation or storage area 11 3/262 03 3/968 05 6/1230

Other 27 7/262 77 75/968 67 82/1230Dont know or refused 11 3/262 27 26/968 24 29/1230

Remote/OR, remote/outer regional; urban/IR, urban/inner regional.Carers who reported any barriers to their childrens fruit and vegetable intake were allowed to select up to two specific barriers from the provided responseoptions. The table includes data on both of the carers responses if they reported two different barriers; thus, the sum of all responses sums to more than thetotal percentage reporting any barrier.

100

80

60

40

20

0Remote/OR Urban/IR

% o

f car

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repo

rtin

g ba

rrie

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Fig. 1 (colour online) Categories of carer-reported barriers tochildrens fruit and vegetable consumption in urban/inner regional(urban/IR) and remote/outer regional (remote/OR) settingsamong families participating in the Australian LongitudinalStudy of Indigenous Children (LSIC), Wave 6, 2013 (N 1230).Responses were categorised as Child dislike only ( ) if the onlybarrier the carer reported was that the child did not like fruit and/orvegetables; Accessibility only ( ) if the carer only reportedbarriers related to accessibility and availability (too expensive, notavailable, poor quality, transport issues, and no storage);Accessibility + child dislike ( ) if the carer reported childrensdislike and a barrier related to accessibility or availability; orOther, dont know or refused only ( )




accessibility barriers and 77% (n 75/968) specified otherreasons.

Factors associated with accessibility barriersAccessibility barriers were strongly associated with remo-teness. The percentage of carers reporting an accessibilitybarrier increased from 20% (n 7/348) in areas with thelowest level of remoteness to 337% (n 35/104) in areaswith the highest level of remoteness, corresponding to agreater than tenfold increased prevalence after adjustmentfor age and sex (PR= 141, 95% CI 43, 464). The mag-nitude of these differences indicated that simply adjustingfor remoteness might result in residual confounding byremoteness, so we present the analyses stratified byremote/OR v. urban/IR status (see online supplementarymaterial, Supplemental File 3, for unstratified results).

Remote/outer regional areasWithin remote/OR areas, accessibility barriers were sig-nificantly associated with indicators of family financialstatus, resource sharing and housing, as well ascommunity-level factors (Table 3). Remote/OR carerswere significantly less likely to report accessibility barriersif they did not experience food insecurity in the past year(203 v. 593%; PR= 06, 95% CI 04, 09), were nothumbugged in the past year (166 v. 356%; PR= 06, 95%CI 04, 10) and did not have electrical problems at home(214 v. 647%; PR= 07, 95% CI 05, 09). Carers who livedin communities where racially motivated violence was nota problem (232 v. 467%; PR= 08, 95% CI 07, 10), or inareas with higher levels of advantage, were significantlyless likely to report accessibility barriers. Carers whoconsidered it important to teach their children about bushtucker were more likely to report accessibility barriers thancarers who did not consider it important.

Urban/inner regional areasAlthough the absolute prevalence of accessibility barrierswas much lower for carers in urban/IR v. remote/OR areas,we observed pronounced factors associated with accessi-bility barriers within the urban/IR group (Table 3). Advan-tage at both the family and area level was associated with asubstantially lower prevalence of accessibility barriers. Forexample, the risk of accessibility barriers was reduced morethan tenfold for urban/IR carers who reported they usuallycould save money v. ran out of money before the nextpayday (05 v. 67%; PR=01, 95% CI 00, 03) and wholived in areas with highest v. lowest tertile of advantage(12 v. 138%; PR=01, 95% CI 00, 03). We also observeda lower prevalence of accessibility barriers among carerswho were partnered (19 v. 41%; PR=04, 95% CI 02, 08),who had weekly incomes $AU 600 v.

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Table 3 Factors associated with carers perceiving accessibility-related barriers to childrens fruit and/or vegetable intake, according toremoteness, in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6, 2013

Remote/OR Urban/IR

% n/N PR 95% CI % n/N PR 95% CI

Total 241 63/262 29 28/968 Child factorsSexMale 216 27/125 100 37 18/491 100Female 263 36/137 103 078, 137 21 10/477 057 026, 127

Age group45 years 264 14/53 100 41 9/222 10067 years 241 27/112 110 074, 165 25 9/355 060 024, 152810 years 227 22/97 085 057, 126 26 10/391 070 032, 153

Indigenous identification,Aboriginal 291 55/189 100 31 27/881 100Torres Strait Islander 61 3/49 045 008, 249 79 3/38 000 000, 000Both 208 5/24 091 038, 219 61 3/49 052 005, 521

General physical healthPoor, fair, or good 365 42/115 100 48 9/189 100Very good or excellent 143 21/147 062 038, 101 24 19/779 074 037, 149

Social and emotional well-being,High risk of difficulties 313 20/64 100 74 16/217 100Low risk of difficulties 217 43/198 094 064, 137 16 12/748 023 012, 045

BMI categoryOverweight or obese 233 14/60 100 24 8/331 100Normal weight 284 38/134 075 053, 106 32 14/441 141 073, 273Underweight 250 3/12 054 016, 181 500 3/6 200 101, 399

Family factorsCarers general physical healthPoor, fair, or good 278 49/176 100 36 19/529 100Very good or excellent 153 13/85 066 034, 130 21 9/439 074 034, 160

Carers social and emotional well-being,High distress 157 8/51 100 73 14/191 100Low distress 263 55/209 155 069, 348 18 14/769 027 015, 046

Negative major life events in past year39 323 30/93 100 37 11/294 100

children had good physical health and social andemotional well-being; the prevalence of dislike also variedby the employment status of the carer. Carers weresignificantly less likely to report dislike as a barrier if theylived in communities where there was no problem withalcohol use (327 v. 361%; PR= 09, 95% CI 08, 10).

We did not observe significant variation in the pre-valence of dislike by remoteness, or observe materialchanges in the relationship between exposures and dislikeafter additional adjustment for remoteness; thus, there was

no indication for separate examination of these relation-ships in the remote/OR and urban/IR samples.

Contextualisation

Accessibility barriersKey informants provided insight into the meaning ofcarers reported barriers to childrens fruit and vegetableconsumption and their relationship to child, family andcommunity factors. Key informants explained that in

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Table 3 Continued

Remote/OR Urban/IR

% n/N PR 95% CI % n/N PR 95% CI

Had evening meal as a family in past weekNo 158 3/19 100 71 3/42 100Yes 250 60/240 074 034, 162 28 26/924 048 018, 126

Cultural knowledge about bush tucker*,Not important 126 12/95 100 18 13/715 100Somewhat important 250 25/100 117 068, 200 41 7/170 177 078, 401Very important 388 26/67 173 099, 301 98 8/82 379 169, 850

Total number of people in household25 224 28/125 100 19 12/625 1006 255 35/137 079 053, 116 47 16/343 180 071, 453

House felt too crowded in past year,Yes 270 10/37 100 80 9/113 100No 233 52/223 109 051, 236 22 19/850 033 017, 067

Moved house in past yearYes 282 11/39 100 31 6/194 100No 231 51/221 092 071, 121 29 22/769 123 049, 305

Problem with fridge and/or cooking facilities,Yes 300 9/30 100 143 5/35 100No 196 28/143 109 073, 162 24 16/667 017 008, 036

Electrical problems at home*Yes 647 11/17 100 77 4/52 100No 214 52/243 069 051, 092 26 24/915 040 015, 107

Security problems at homeYes 467 21/45 100 89 8/90 100No 195 42/215 076 050, 114 23 20/877 038 016, 088

Area-level factorsRacially-motivated violence*,,Small or big problem 467 7/15 100 56 9/162 100Not a problem 232 53/228 083 069, 099 21 15/729 023 010, 055

Alcohol misuseSmall or big problem 275 53/193 100 49 19/386 100Not a problem 125 8/64 056 028, 113 16 9/552 040 017, 093

Break-ins or theftSmall or big problem 278 35/126 100 37 17/461 100Not a problem 214 27/126 096 069, 132 20 9/455 050 023, 108

Area-level disadvantage*,Least advantaged 393 59/150 100 138 9/65 100Mid-advantaged 29 3/102 011 002, 056 26 17/652 021 006, 076Most advantaged 300 3/10 042 012, 145 12 3/251 006 001, 034

RemotenessNone 20 7/348 100Low 34 21/620 164 055, 490Moderate 177 28/158 100 High/extreme 337 35/104 204 063, 662

Remote/OR, remote/outer regional; urban/IR, urban/inner regional; PR, prevalence ratio.All models are adjusted for age group, sex and remoteness, and take into account the clustered nature of the data set. Pinteraction

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Table 4 Factors associated with childrens dislike of fruit and vegetable intake, among children whose carers who did not report accessibilitybarriers, in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6, 2013

Adjusted for age and sexAdjusted for age, sex and

remoteness

% n/N PR 95% CI PR 95% CI

Total 342 390/1139 Child factorsSexMale 336 192/571 100 100Female 349 198/568 104 086, 125 104 086, 125

Age group45 years 337 85/252 100 10067 years 327 141/431 097 080, 117 098 081, 118810 years 360 164/456 107 088, 129 107 088, 129

Indigenous identificationAboriginal 350 346/988 100 100Torres Strait Islander 274 23/84 078 058, 104 083 059, 116Both 313 21/67 091 065, 127 092 065, 130

General physical health*,Poor, fair, or good 407 103/253 100 100Very good or excellent 324 287/886 080 068, 094 077 065, 092

Social and emotional well-being*,High risk of difficulties 392 96/245 100 100Low risk of difficulties 329 293/891 083 071, 098 083 071, 098

BMI categoryOverweight or obese 355 131/369 100 100Normal weight 352 184/523 100 085, 117 101 086, 119Underweight 200 3/15 018 003, 110 021 003, 126

Family factorsCarers general physical healthPoor, fair, or good 339 216/637 100 100Very good or excellent 347 174/502 103 085, 124 102 084, 123

Carers social and emotional well-beingHigh distress 382 84/220 100 100Low distress 333 303/909 087 073, 103 087 073, 103

Negative major life events in past year39 337 267/792 100 100

remote/OR settings, low incomes, high food prices andpressures to support others compound to prevent carersfrom providing their children with fruit and vegetablesdespite awareness of the nutritional benefits:

A lot of people in the sort of remote communities areon benefits. And if you have got to feed a couple of kids and you have to buy all of this fruit and veg, whereasyou can have a couple packages of chips, or takeaway well, what are you going to do? Even though theymay know its [fruit and veg] really good for them.

Key informants explained how demand sharinginfluenced carers food purchasing behaviours, for

example, discouraging carers from buying certain types offood:

Because if your child walks outside with watermelon,then youve got fifty kids all of a sudden knocking onyour door.

Given the existing barriers to purchasing healthy foods,key informants explained that health promotion efforts toincrease childrens desire to eat fruit and vegetables havethe unintended consequence of disempowering parents:

Because the kids do get, You have to do this, haveto do this, go home and hassle Mum. We need todo this, we need to do that. And theyre [parents

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Table 4 Continued

Adjusted for age and sexAdjusted for age, sex and

remoteness

% n/N PR 95% CI PR 95% CI

Had evening meal as a family in past weekNo 393 22/56 100 100Yes 339 365/1078 086 067, 111 084 065, 109

Cultural knowledge about bush tucker*Not important 368 289/785 100 100Somewhat important 307 73/238 083 066, 106 085 066, 110Very important 235 27/115 064 045, 091 066 045, 095

Total number of people in household25 351 249/710 100 1006 329 141/429 094 080, 109 095 082, 111

House felt too crowded in past yearYes 397 52/131 100 100No 333 334/1002 084 067, 106 084 067, 104

Moved house in past yearYes 301 65/216 100 100No 350 321/917 116 093, 144 117 094, 146

Problem with fridge and/or cooking facilitiesYes 353 18/51 100 100No 360 276/766 102 068, 152 098 065, 148

Electrical problems at homeYes 352 19/54 100 100No 340 368/1082 097 066, 142 098 067, 144

Security problems at homeYes 377 40/106 100 100No 337 347/1030 089 069, 117 088 068, 115

Area-level factorsRacially motivated violenceSmall or big problem 360 58/161 100 100Not a problem 336 299/889 094 070, 125 097 072, 130

Alcohol misuseSmall or big problem 361 183/507 100 100Not a problem 327 196/599 091 078, 105 086 075, 100

Break-ins or theftSmall or big problem 363 194/535 100 100Not a problem 314 171/545 086 073, 102 087 074, 102

Area-level disadvantageLeast advantaged 306 45/147 100 100Mid-advantaged 335 246/734 109 082, 146 100 076, 133Most advantaged 384 99/258 125 092, 172 118 084, 165

RemotenessNone 352 120/341 100 Low 356 213/599 101 082, 124 Moderate 285 37/130 082 058, 114 High/extreme 290 20/69 081 062, 106

All models take into account the clustered nature of the data set.*Variable significantly associated with dislike in model adjusted for age group and sex (P for Wald test

are] already under lots of pressure, stress. So, I thinkif they do those sorts of things [nutrition education],theyve got to do something about the supply.

Another key informant explained how families strug-gled to achieve the Australian dream of providinga healthy diet for their children:

But what can you do? There is the pressure ofeducation youve got to send these kids to school,got to give them healthy lunches. Parents spend but how far that $500 takes them; its not far. There isthis health education; trying to live the Australiandream but you cant.

Key informants also described the limited availabilityand poor quality of fresh produce in remote/OR settings.For example, one key informant depicted the quality offresh produce in remote/OR areas by asking, Have youever eaten frozen lettuce?

Interviewers also commented that the competingaffordability and availability of fast food was a barrier tothe consumption of healthier foods; a key informant froman urban/IR setting explained that:

When somebody told me that veggies were tooexpensive back in my area, it would have beenbecause Maccas [McDonalds] costs a lot less itsjust that there is a cheaper alternative.

Carers time scarcity was also considered an importantbarrier to nutrition, favouring quicker meal options such astakeaway.

DislikeKey informants explained that childrens dislike of vege-tables was a common problem, although many childrenwere happy to eat fruit. One stated:

I came across this same complaint. That was, youcook it, and you prepare it, and they just dont eat it.

Key informants identified childrens lack of familiaritywith some types of vegetables as an important contributorto their refusal to eat them:

Its like introducing it to them You give them abowl of salad and some veggies, and they freak out;they just eat the meat and rice and they push theveggies aside. We tell them, Its good for you but itsort of, it takes time to adjust.

Key informants commented that the expense ofthrowing away was a barrier to purchasing vegetableswhen there was a risk that children would refuse to eatthem. They also explained that carers wanted to providefood that the child wanted to eat; carers food provisionwas more about pleasing the child than it is about whattheyre feeding them at this stage. The ubiquity of alter-natives such as lollies and fast food, particularly in more

urban areas, was considered to contribute to childrenspicky eating and refusal to eat vegetables.

Discussion

In this diverse national sample, almost half of carers reportedbarriers to their childrens nutrition. Barriers to fruit intakewere less commonly reported than barriers to vegetableintake, but both are considered important nutritionally.Multiple barriers restrict Indigenous childrens consumptionof fruit and vegetables. The most commonly reported barrierwas childrens dislike of fruit and vegetables. Problemsaccessing fruit and vegetables were common among carersliving in remote/OR settings and among disadvantaged car-ers living in urban/IR settings; the cost, availability and qualityof fruit and vegetables were substantial barriers to access.Child and carer well-being, financial security, suitable housingand community cohesion promoted access to fruit andvegetables.

Accessibility barriersIn this sample, carers were over ten times more likely toface problems accessing fruit and vegetables for theirchildren if they lived in very remote areas compared withlarge cities. This is consistent with the increased price offresh food in remote areas(18) and the limited availabilityand poor quality of fresh foods, particularly after extendedtransportation(17). These characteristics of the remote/ORfood environment may explain why we observed fewfactors significantly associated with accessibility barrierswithin this group: where the environment itself createssubstantial barriers to access, individual characteristicsmay become less important.

Within the urban/IR group, disadvantaged carers faceda tenfold increase in the relative risk of accessibilitybarriers compared with advantaged carers. Key informantsdescribed how the affordability and availability offast-food outlets in urban/IR areas negatively influencedchildrens consumption of fruit and vegetables. Thesefindings are consistent with the literature(26,54,55) and theincreased availability of fast-food outlets in disadvantagedv. advantaged urban settings(56,57). Additionally, someliterature has also documented reduced accessibility ofhealthy foods in disadvantaged areas of Australia(58),although findings are mixed(15,57,59,60). Thus, for carersliving in both remote/OR and disadvantaged urban/IRareas, the food environment constrained their ability toprovide their child with a healthy diet, despite theirnutritional awareness.

The present work provides quantitative evidence thatmultiple domains of financial security, including reportedincome, financial strain and worries about money, relate tocarers ability to access fruit and vegetables for theirchildren. These findings are consistent with evidencedsocio-economic gradients in dietary intake; healthy diets

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tend to be more expensive than unhealthy diets(22,61) andthe literature describes an increased reliance on energy-dense foods (rather than nutrient-dense foods such as fruitand vegetables) by families with limited financial resour-ces and time(19,62,63).

Our findings provide quantitative evidence on the linkbetween resource sharing and carers ability to purchasehealthy foods. Consistent with previous qualitative find-ings(12,17,21,27,64), our key informants explained that demandsharing encouraged the purchasing of energy-dense foodsand discouraged the purchasing of sought-after foods thatothers are likely to request. Our findings also support theimportance of adequate housing in terms of crowdingand household infrastructure in promoting childrensnutrition(9,21,65,66). Many Indigenous households containextended family members rather than being restricted tothe nuclear family, due to cultural differences in familystructures and obligations to care for family. Lower socio-economic status and limited availability of quality housing(particularly in remote areas) further contribute to largenumbers of household members, which is linked to thebreakdown of housing infrastructure(67,68).

Our study identified a relationship between access to fruitand vegetables and the social and emotional well-being ofchildren and their carers. Key informants indicated thatcarers might experience distress or feel disempowered ifthey are unable to oblige their childrens requests for fruitand vegetables. These relationships may also be partiallymediated by childrens and carers exposure to stressors anddisadvantage. In both remote/OR and urban/IR settings,carers were more likely to report accessibility barriers if theyconsidered it very important to pass on cultural knowledgeabout bush tucker. This might reflect that carers who valuebush tucker reported barriers to accessing traditional fruitand vegetables or, alternatively, that carers who perceiveaccessibility barriers want to teach their children about bushtucker in order to supplement their diet.

We also observed a relationship between measures ofcommunity functioning (racially motivated violence andalcohol misuse) and carers ability to access fruit andvegetables for their children, providing evidence thatcommunity characteristics relate to childrens health(39).The link between community-level racism and access tonutrition is consistent with wider literature linking racismto reduced access to resources required for health(69,70). Incommunities where racism is perceived to be a problem,Indigenous people may be reluctant to go to food outlets;a qualitative study identified that some urban Indigenouspeople experiencing racism within their neighbourhoodadopt an avoidance strategy(71). The relationshipbetween racism and accessibility barriers might bepartially mediated by social and emotional well-being ofthe child and carer(69,72,73) or by area-level disadvantage.Carers were also more likely to report barriers to accessingfruit and vegetables for their children if they perceived aproblem with alcohol use in their community; carers may

avoid shopping at food outlets where they perceive theymay encounter alcohol-related issues, such as being askedfor money to purchase alcohol.

Differences in remote/outer regional v. urban/innerregional areasWe generally observed consistent patterns in the associa-tions between exposures and accessibility barriers inremote/OR and in urban/IR environments. However, therewere some cases in which these relationships werestatistically different. Some of the significant interactionsobserved might result from the high base prevalence ofaccessibility barriers in the remote/OR sample, which putsa ceiling on the possible magnitude of the relative riskswithin this group. This lack of potential for variation andthe reduced sample size in the remote/OR sample limit thepower to detect significant differences within the group.Although the relative risks observed within the remote/ORsample are often smaller in magnitude than thoseobserved in the urban/IR sample, they are still associatedwith a large absolute difference in the proportion of carersexperiencing the outcome (e.g. for financial strain andracially motivated violence). In addition, it is important toconsider that some significant interactions could haveresulted from multiple testing.

DislikeWhere fruit and vegetables were accessible, childrensdislike was a substantial barrier to intake, indicating that itis important to consider multiple barriers when designinginterventions to promote childrens fruit and vegetableconsumption. Further, factors associated with dislike didnot appear to be congruent with factors associated withaccessibility barriers, suggesting that different populationgroups may face different barriers.

One-third of carers reported that childrens dislike was abarrier, with carers predominantly reporting an issue withdislike of vegetables, rather than fruit. These findings areconsistent with comments by key informants, internationalliterature on picky eating(74) and a qualitative study onhealthy eating among Aboriginal families in urbanVictoria(19). There is no accepted definition of picky eating,but it generally encompasses discomfort in eating familiarfoods and/or unfamiliar foods(75), and is considered to beassociated with poorer diet quality, particularly an avoidanceof vegetables, and increased intake of energy-dense snacksand sweets(74). Internationally, the estimated prevalence ofpicky eating ranges from 6 to 50%, with the peak prevalenceamong children aged 3 years (younger than our sample).

There is limited evidence on factors associated withpicky eating. Research from the UK suggests a relationshipbetween picky eating and socio-economic status(74), butwe did not observe a relationship between picky eating(dislike) and measures of socio-economic status in oursample, with the exception of carers employment status.This might have resulted from our restriction of the sample

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12 KA Thurber et al.



to carers who did not face accessibility problems, whichremoved some of the most disadvantaged families fromthe sample.

Our findings support research on the importance offamiliarity and habit in shaping food choice(17); keyinformants identified childrens lack of familiarity as animportant contributor to their refusal to eat certain vege-tables. The preference for familiar foods (such as thosehigh in sugar and processed flour such as white bread) hasbeen considered a lasting legacy of the colonial historythat dramatically altered Indigenous food practices andpreferences(12,13,21,26,76).

The predominance of childrens dislike as a barrier tofruit and vegetable consumption is also consistent with theliterature on traditional views of child autonomy andchildrens ability to make their own choices(17,64,7779).This was supported by our key informants, who describedthe importance carers place on childrens own food pre-ferences. Forcing children to eat fruit and vegetablesconflicts with this cultural value; instead, carers are limitedto influencing childrens food choice by encouraging themto consider healthy choices(13,37,77,78,8082).

Carers were less likely to report dislike for children withgood physical health and social and emotional well-being,consistent with literature on the association between pickyeating and physical, emotional and social impairment(83). Astrategy for overcoming childrens picky eating is torepeatedly expose (at least ten times) the child to thedisliked food(74,84). This approach is not feasible when therelevant foods are not readily available or are of poorquality, or when resources are scarce and there is concernabout food wastage and hunger(19,20), as mentioned by thekey informants. Thus, although we have examined themseparately, barriers related to dislike and to accessibility arelikely to be entangled.

LimitationsThe current study relies predominantly on carer-reporteddata and findings should be interpreted as such. Ouroutcome reflects carers perceived barriers to theirchildrens nutrition, rather than actual barriers; however,previous research has demonstrated that perceivedbarriers are significantly correlated with intake(85,86). Wehave validated that carers perception of barriers wasclosely tied to reported low intake by children, and thatthere was no material difference between the relationshipof factors to low intake and to the perception of barriers.Further, our qualitative findings supported our quantitativefindings, although we acknowledge that these qualitativefindings were also based on the participants perceptionsof these issues. A limitation of our outcome variable is thatit would not serve as an indicator of a childs nutritionstatus in cases where the childs intake of fruit/vegetablesexceeded recommended intake but the carer reportedthat they want their child to eat more, or in cases wherethe childs intake of fruit/vegetables did not meet

recommended intake but the carer reported that they donot want their child to eat more.

We recognise that there may be differences in the typesof barriers reported, and the associated risk factors, inrelation to fruit intake v. vegetable intake. For example,dislike is understood to be a more common barrierto vegetable intake than to fruit intake(75). We haveexamined barriers to fruit and vegetable intake combinedbecause fruit and vegetables play a similar nutritional role,and accessibility barriers for fruit and for vegetables aregenerally similar, as well as for pragmatic reasons.

The LSIC is not designed to be representative of theAustralian Indigenous population; however, the LSIC dataoffer diversity in geography and environmental conditionsand are well-suited for internal comparisons. Our study isbased on cross-sectional data, so we cannot make infer-ences about causality. The potential biases arising frommissing data should be minimal given that over 99%(n 1230/1239) of carers participating in the survey pro-vided data on the outcome and the majority of exposurevariables had less than 1% of data missing.

Grouping environments into discrete categories ofremoteness is likely to have the effect of combining indi-viduals living in areas across a range of remoteness, butthe use of these categories is pragmatic and can definegroups with similarities in life circumstances, such as thedominant social and cultural setting(87).

Conclusions

To our knowledge, the present study is the first large-scaleinvestigation of barriers to Indigenous Australian childrensnutrition across heterogeneous environments. It providesquantitative evidence that a broad range of social, culturaland environmental factors impact nutrition. Dis-advantaged Indigenous families in urban and innerregional settings, as well as those living in remote andouter regional areas, face substantial barriers to accessingfruit and vegetables. Where fruit and vegetables wereaccessible, dislike of vegetables was a common barrier.

Approaches to improve equity in nutrition in Australianeed to address these barriers, through a combination ofpolicy to improve the food environment in remote/OR anddisadvantaged urban/IR settings and culturally relevantprogrammes to promote underlying determinants includ-ing financial security, housing and community cohe-sion(22). Programmes and policies to promote nutritionshould draw on the strengths of Indigenous families andcommunities, and must be conducted in partnership withIndigenous communities and individuals(24,88).

Acknowledgements

Acknowledgements: The authors acknowledge all thetraditional custodians of the lands and pay respect to

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Elders past, present and future. They acknowledge thegenerosity of the Aboriginal and Torres Strait Islanderfamilies who participated in the study, and the Elders oftheir communities. This paper uses unit record data fromthe Longitudinal Study of Indigenous Children (LSIC). LSICwas initiated and is funded and managed by the AustralianGovernment Department of Social Services (DSS). Thefindings and views reported in this paper, however, arethose of the authors and should not be attributed to DSS orthe Indigenous people and their communities involved inthe study. The authors would like to thank the LSICResearch Administration Officers for sharing their viewsduring the focus group discussion and LSIC staff at the DSS(particularly Fiona Skelton) for their support and assis-tance. They would also like to acknowledge staff atApunipima Cape York Council (particularly Cara Polson)for providing guidance. Financial support: This work wassupported by the Australian National University (K.A.T.,University Research Scholarship); the National Health andMedical Research Council of Australia (E.B., grant number1042717), (R.L., grant 1088366), (M.P., grant number9100001 The Australian Prevention Partnership Centre).Conflict of interest: None. Authorship: K.A.T., E.B. andC.B. conceptualised the study. K.A.T., E.B., T.N. and T.D.contributed to the design of quantitative analyses; C.B.assisted with the planning and analysis of the qualitativecomponent. K.A.T. conducted all quantitative analyses,and conducted and transcribed the focus group. R.L. andM.P. provided critical assistance with the interpretation offindings and the framing of the manuscript. K.A.T. draftedthe manuscript; all authors provided feedback.

Supplementary material

To view supplementary material for this article, please visithttps://doi.org/10.1017/S1368980016003013

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http://www.abs.gov.au/ausstats/[email protected]/0/F4302CEC55D5B8EECA2574390014A785?opendocumenthttp://www.abs.gov.au/ausstats/[email protected]/0/F4302CEC55D5B8EECA2574390014A785?opendocumenthttp://www.abs.gov.au/ausstats/[email protected]/0/F4302CEC55D5B8EECA2574390014A785?opendocumenthttp://dx.doi.org/10.1017/S1368980016003013http:/www.cambridge.org/corehttp:/www.cambridge.org/core/terms

Understanding barriers to fruit and vegetable intake in the Australian Longitudinal Study of Indigenous Children: a mixed-methods approachMethodsMixed methodsStudy populationFocus group methodsVariables in the quantitative analysisExposuresChild factorsFamily factorsArea-level factorsOutcome

Analytical methodsEthics

ResultsProfile of the sample

Table 1Profile of families participating in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6,2013Reported barriers

Table 2 Barriers to childrens fruit and vegetable consumption reported by carers in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6,2013Fig. 1 (colour online) Categories of carer-reported barriers to childrens fruit and vegetable consumption in urban/inner regional (urban/IR) and remote/outer regional (remote/OR) settings among families participating inFactors associated with accessibility barriersRemote/outer regional areasUrban/inner regional areasSimilarities and differences in remote/outer regional v. urban/inner regional areas

Factors associated with childrens dislike of fruits and vegetables

Table 3Factors associated with carers perceiving accessibility-related barriers to childrens fruit and/or vegetable intake, according to remoteness, in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6,2013ContextualisationAccessibility barriers

Table 4Factors associated with childrens dislike of fruit and vegetable intake, among children whose carers who did not report accessibility barriers, in the Australian Longitudinal Study of Indigenous Children (LSIC), Wave 6,2013Outline placeholderDislike

DiscussionAccessibility barriersDifferences in remote/outer regional v. urban/inner regional areas

DislikeLimitations

ConclusionsAcknowledgementsACKNOWLEDGEMENTSReferencesReferences

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