Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. An exploration of how life events and the social environment affect food behaviours among New Zealand women A thesis presented in partial fulfilment of the requirements for the degree of Master of Public Health At Massey University, Wellington, New Zealand Jordan Crosbie 2016 ii Abstract Background. Food plays a major role in our health. A poor diet is a contributing factor to many diseases, including obesity and its co-morbidities. The literature suggests that the social environment including social relationships, the media and other features of the social context in which one is born, drive food choices and behaviours. However, there is limited research available explicitly investigating how significant life events and factors within the social environment affect food behaviours among New Zealand women. Given the high prevalence of obesity in New Zealand, there is a concerning gap in the literature attending to the development of food behaviours that may help understand the high obesity prevalence. Aim. The aim of this study is to explore how life events and social environments impact the food behaviours of New Zealand women. Methods. This study is informed by phenomenology and used semi- structured interviews for data collection. Nineteen interviews with older women, who resided in Wellington, were carried out. The interviews asked questions regarding the experiences of these women and the development of their food behaviours overtime. Results. Four main themes were identified, the effect of social relationships; the changing role of the media; gender roles; and social osmosis. The results revealed that the participants were highly influenced by social relationships, with the most influential relationships being between the participants and their mothers’. The media was found to play a role in influencing the participants to change their food behaviours. However, the media also caused widespread confusion about the nutrition guidelines. Gender norms appeared to guide the participants in the type of food related skills they learnt over their lifetime. The final theme, social osmosis describes how participants accumulated food- related information from their social environment over their lifetime that contributed to their food and total nutrition knowledge. Discussion. As mothers increasingly join the workforce, children may need additional guidance on food related skills from social environments outside of iii the home to make up for the reduced time mothers spend in the home carrying out roles dedicated to being a homemaker. In addition, there may need to be restrictions on the type of information published in mainstream media to avoid confusion about how to maintain a healthy diet. Overall, the social environment plays a crucial role in the development of food behaviours and the present study gives an indication of how it is influential for New Zealand women. iv Acknowledgements First and foremost I would like to acknowledge and thank the 19 participants who volunteered to take part in this research, without you this would not have been possible. Thank you for inviting me into your home and been so open about your experiences. I wish to thank my two supervisors Dr. Anna Matheson and Dr. Eva Neely who spent a lot of time supporting and guiding me through this process. I would also like to thank my family and friends who supported me on this journey, I am not sure I would have been able to complete this project without your support. Table of contents Abstract………………………………………………………………..……........…ii Acknowledgements………………………………………………………….……iv Table of Contents..………………………………………………….………..……v List of Tables…………………………………………………………………....…vi List of Figures………………………………………………………….……..……vi Chapter One: Introduction……………………………………………..…………1 Aims…………………………………………………………………………..5 Objectives…………………………………………………………………….5 Chapter Two: Literature Review…………………………………………………6 Social relationships……………………………………………………...…..6 The media……………………………………………………..……………18 Gender norms…………………………………..………………………….27 Settings……………………………………………………………………..28 Social determinants……………………………………………………….32 Summary……………………………………………………………………35 Chapter Three: Methodology and Research Methods……………………..37 Epistemology……………………………………………………………….37 Methodology………………………………………………………………..38 Method……………………………………………………………………....40 Ethical considerations……………………………………………………..50 Limitations…………………………………………………………………..52 Chapter Four: Results……………………………...……………………………54 Social Relationships……………………………………………………….55 ii The Changing Social Environment……………………………………….72 Gender Norms……………………………………………………….……..80 Social Osmosis……………………………………………………….…….83 Chapter Five: Discussion………………..………………………………...……87 A Mother’s Influence………………………………………………….……87 Influential Social Environments…………………………………..………94 Social Expectations………………………………………………..………97 The Media, Doctors and Health…………………………………………102 The Invisible Influence…………………………………..……………….105 Further Research…………………………………………………………106 Conclusion……………..……………………………………………….…107 References…………………………………………………………………….…110 APPENDIX 1……………………………………………………………………...132 APPENDIX 2……………………………………………………………………...134 APPENDIX 3……………………………………………………………………...135 APPENDIX 4……………………………………………………………………...139 APPENDIX 5……………………………………………………………………...140 iii List of Tables Table 1: Summary of Major Themes and Sub-themes……………………...…49 Table 2: Summary of the Characteristics of Participants………………………55 1 Chapter One. Introduction Food plays a major role in health and wellbeing. Poor diet accounts for 11 percent of health loss in New Zealanders and increases a person’s risk of being overweight or obese (Ministry of Health, 2015a). In contrast, a healthy diet throughout life can help prevent nutritional deficiencies, help maintain a healthy body weight and reduce the risk of avoidable chronic disease. Therefore a better understanding of the factors that influence eating behaviours should be a public health priority (Bruening et al., 2014; Thornton, Pearce & Kavanagh, 2013). New Zealand has the third highest rates of obesity in the OECD (Organization for Economic and Cooperation Development) (Ministry of Health, 2015d). Therefore, nutrition-related weight gain is a major concern for New Zealanders. Obesity or excessive weight, in both childhood and adulthood, is a prerequisite for a number of health conditions, including Type II Diabetes, cardiovascular and circulatory diseases, some common types of cancer, osteoarthritis, gout, sleep apnoea, reproductive disorders, gallstones and mental health conditions, especially depression (Ministry of Health, 2015c). Cardiovascular disease alone accounted for one third of deaths in 2012, with dietary factors accounting for 29 percent of the health loss from cardiovascular and circulatory disease. In New Zealand extreme obesity is expected to reduce life expectancy by up to 10 years (Ministry of Health, 2015c). In addition, childhood obesity is rising in New Zealand with rates in some areas above 20 percent (Ministry of Health, 2015a). A concerning aspect of obesity in New Zealand is that obesity rates are rising for all ethnicities, birth cohorts and genders. In fact, obesity rates in New Zealand adults have tripled since the late 1970s (Ministry of Health, 2015a). The increasing rates of obesity, and its co-morbidities, prompted the Ministry of Health to invest additional resources to fight the obesity epidemic in New Zealand. The obesity action plan added to the previously released ‘food and 2 beverage’ guidelines to guide health practitioners on how to best manage and advise overweight and obese patients (Ministry of Health, 2015b). Adaptations of the food and beverage guidelines published through various sources of media gave the general public food and health related information in different forms about the amounts and types of foods that should be consumed to achieve and maintain a healthy body weight (Ministry of Health, 2015b). These included the ‘healthy heart visual food guide’ and ‘5+ a day’ health promotions (Heart Foundation, 2016; 5+ a day, 2007). While variations of the New Zealand food and beverage guidelines are available online and distributed in schools, work places, hospitals and medical centers their effectiveness at promoting healthy food behaviour is questionable. Only 41 percent of New Zealand adults meet the Ministry of Health’s guidelines for vegetable and fruit intake. This percentage has decreased from 2011/12 where 44 percent of New Zealand adults met the MOH fruit and vegetables intake guideline. These results are similar to Australia where it is estimated that 48.3 percent of Australian adults are meeting the guideline for daily fruit intake and only 8.3 percent meet the guideline for daily vegetable intake (Australian Bureau of Statistics, 2012; Thornton et al., 2013). These intake patterns are likely to place many adults at risk of obesity and other chronic diseases and do not appear to be reflective of the messages that the government and Non-Government Organizations are trying to send out (World Health Organization, 2003; Thornton et al., 2013). The reasonably low adherence to the New Zealand nutritional guidelines suggests there are barriers to the general public receiving or implementing said information into their daily lives. The literature suggests that this may be due to factors within the social and physical environment such as a low income, ever-changing social relationships and limited access to food stores that supply fruit and vegetables such as supermarkets and green grocers (James, 2004; Turrell et al., 2009; Worsley and Lea, 2010). However, there have been very few New Zealand based studies that explore the barriers to the general public receiving official nutrition related information (Green and Boyle, 2001). 3 In addition to the release of official guidelines to healthy eating, individuals also accumulate food related information and are exposed to other influences that shape or add to their knowledge and, subsequently, affect their food behaviours over their lifetime (Kraak and Pelletier, 1998; McKie, MacInnes, Hendry, Donald and Pearce, 2000). These influences include mainstream media, social relationships and societal norms (McKie et al., 2000). In particular, the increase in media attention to food post World War II (WWII) exposed women to alternative information and guidelines, which affected the foods they consumed and may have been a barrier to the implementation of the official nutrition guidelines (Simunaniemi, Sandberg, Andersson and Nydahl, 2011; Buttriss, 2011). By focusing on women who grew up during and just after World War II, we can explore how food behaviours develop over a lifespan, including how life events, information sources, and environmental changes affect food behaviours. Throughout history women have been the primary purchasers and preparers of food for a typical household (Ilkay, 2013). Close family members often also rely on their mothers, wives, partners or daughters to prepare and cook their food, thereby relying on the information and skills possessed by these women (Lawrence and Barker, 2009). Food behaviours, which for the purpose of this study are defined as the skills and knowledge involved in the purchasing, planning, preparing and cooking of food. Therefore looking at the food behaviours of this group and investigating why these increases may be occurring is important. This retrospective study reflects on a lifetime of experience and may add a different view to the existing knowledge of how the social environment could affect food behaviours and knowledge (Devine, Bove and Olson 2000; Devine, 2005). In addition, whilst research on the influences on food behaviours and sources of food information of women is widely studied, there is little research focusing on New Zealand women. The present study aims to gain information that will help us understand how New Zealand women acquire the knowledge and skills they have and what makes some information 4 more effective in achieving behaviour change. Gaining this information could help better support or provide regulation to common and popular information sources to ensure that more specific, reliable information is available to New Zealand women and this could potentially help to address the comparatively high rates of obesity in New Zealand. 5 Aims and Objectives Aims The aim of this study is to explore how life events and social environments impact the food behaviours of New Zealand women. Objectives Objective one To identify where women access their food-related information and whether the source of information changes over time. Objective two To investigate whether and how specific life events, such as marriage, childbirth and sickness, cause a change in food behaviours. 6 Chapter 2. Literature Review Introduction Given the complexity of food behaviours and their consequences for health, it is not surprising that the last few decades have produced a large amount of literature dedicated to furthering the understanding of the major influences on food behaviours. The literature on the influences on food behaviours comprises information on both the social and physical environment. This review of the literature will focus on the literature about the social environment. The literature for this review was accessed from the Massey University online journal database, Discover. The use of ‘Discover’ required key words, which were developed through trial and error and discussion with supervisors. Examples of search terms included; mothers + food behaviours + childhood; friends + influence + food; Internet + nutrition information + women. The search terms Internet + influence + food behaviours led the researcher to discover the influence of social media on food behaviours which was subsequently explored. The inclusion criteria for the literature in this review was that research should be peer reviewed, published in English or with a translated English version, journal articles in scientific magazines or government based resources such as the World Health Organization (WHO) or the Ministry of Health (MoH). There were no specific inclusion criteria for the date of publishing as this research aims to look at changes over time and therefore research from many time frames was needed. Bibliographies of relevant published research supplied other relevant literature. These strategies were repeated a number of times and different keywords investigated until further searches did not add any more information. It was common for the search terms to lead to new ideas that had not previously been thought of. 7 Search results returned a large amount of literature on the influence of social relationships and the influence of the media on food behaviours, and also returned smaller amounts of literature on the effect of gender norms, social determinants of health and social settings. The literature from this review is mostly drawn from studies based in the United States of America (USA), Canada, United Kingdom (UK), Europe and a small number from Australia and New Zealand. There was some research from other countries but the listed countries contributed to a large portion of the research in this area. The first section reviews the literature on social relationships. The next section reviews the literature that investigates how specific sources of media such as magazines, advertisements and the Internet affect food behaviours. The third section provides a review of the comparatively small amount of literature on the influence of different settings, including the workplace and home setting. Finally, the last section reviews the literature on how social determinants of health such as income and education, affect food behaviours. Social Relationships and their effect on food behaviors Food is central to the human experience. Food goes beyond nutrient intake alone and, in many cultures, is seen as a way of communicating and relating to others (Neely, Walton, & Stephens, 2014). A large amount of literature finds a clear connection between close social relationships and how women choose to eat, the compromises they make to their own diet, and the role of food in their lives. Literature shows that the relationships that exert the most influence on women are those with parents, peers, partners and children. These relationships rarely remain stable over time and are affected by life transitions, such as leaving home, living with a partner or having children (Lawrence & Barker, 2009). A significant amount of the literature focuses on how parental food behaviours can be a predictor of food behaviours in children (Kiefner-Burmeister, Hoffman, Meers, Koball & Musher-Eizenman, 2014; Chen, Moser & Nayga, 8 2015; Van Ansem, Schrijvers, Rodenburg & Van De Mheen, 2014). The literature often mentions both parents providing influence, but not in equal measure. There is significantly more research that shows that mothers specially play an important role in the development of food behaviours, while the role of the father is rarely mentioned in isolation of the maternal role (De Backer, 2013). Maternal influence A common theme in the literature was the dominant influence of mothers on food behaviours. The development of food behaviours usually begins with maternal role modeling, where mothers carry out particular food behaviours, both intentionally and unintentionally, to promote certain food behaviours in their children (Chen et al., 2015). Palfreyman, Haycraft and Meyer, (2013) found that mothers who were more concerned about their own eating habits were more likely to role model positive food behaviours and thus more likely to report that their children ate higher levels of healthier food items such as fruits, vegetables and salad, than mothers who were not so concerned with their own healthy eating habits. Van Ansem et al., (2014) reported similar results, and found that if parents increased their fruit consumption, their children would also increase their fruit consumption. The same rule applied for breakfast consumption (Van Ansem et al., 2014). Conversely, Kiefner-Burmeister et al., (2014) found that mothers might also encourage the intake of unhealthy foods, if they do not consciously restrain their own consumption of unhealthy foods in the presence of their children. Weatherspoon, Venkatesh, Horodynski, Stommel and Brophy (2013) confirms the findings from Kiefner-Burmeister et al., (2014), by finding that the consumption of energy dense foods by toddlers was influenced by the consumption of energy dense food by mothers. The research that looks at the development of healthy and unhealthy food behaviours, as role modelled by mothers, suggests that these behaviours are not mutually exclusive and both 9 can exist at the same time, e.g. children may have a high consumption of both fruit and vegetables as well as sugar sweetened beverages (Kiefner- Burmeister et al., 2014). It appears that this occurs when mothers get caught up trying to promote healthy food behaviours and forget to address or restrict consumption of unhealthy foods (Kiefner-Burmeister et al., 2014). It is not just food consumption behaviours that are passed from mother to child, a mother’s attitude towards her body and attitudes about food can also be passed on. Bazillier, Verlhiac, Mallet and Rouesse (2011) found that if a mother has a negative attitude towards healthy food, this could result in negative attitudes towards food and unhealthy food behaviours in her children. Lewis, Katasikitis and Mulgrew (2015) found that a mother's feeling of dissatisfaction towards her own body image and her tendency to overeat in reaction to stress would commonly be communicated to her daughter, causing similar consumption patterns. While many studies find that mothers play an important role in the development of food behaviours in childhood there are few studies that investigate how mothers can influence food behaviours in their adult children. Wilson, Musham and McLellan (2004) explored the influence of mothers on adult women by asking adult women to recall their experiences with food growing up, and asking if any of these experiences still affected their food behaviours in present day. Wilson et al., (2004), like many other studies, found that in childhood the participants were highly influenced by their mothers. However, Wilson et al., (2004) also found that for those who grew up in poverty, the influence of their mother appeared to be strong in adulthood as well. Wilson et al., (2004) suggested the greater influence of mothers into adulthood was because women who had experienced poverty in childhood had more respect for the ways their mothers prepared, and served food due to the difficulty she experienced. Another study suggested the greater effect was because despite insufficient income to meet food needs, low-income families were more likely to have a strict, structured food management plan with rules and routines (Sim, 10 Glanville & McIntyre, 2011). However these rules and routines may or may not improve the household diet quality as the routines may involve the use of cheaper and often less nutritious foods (Kendall, Olson & Frongillo, 1996). Most of the studies in this review found that in order for mothers to influence their children’s food behaviours, they must be able to be actively observed carrying out food related tasks. Hocking et al. (2002) found mothers could influence their children without needing to live in such close proximity and suggests that a mother’s influence may be passed on through non-oral communication, in the form of recipes. Through this non-oral communication, Hocking et al., found a significant relationship between food behaviours and multiple generations of women in the same family using written rather than oral or observable means. In focus groups Hocking et al., discovered that mothers had passed on food knowledge and traditions through recipes to 33% of the participants. This particular study was important, as it is one of very few New Zealand based studies. If mothers fail to provide their children with a positive role model, children may struggle to form healthy food behaviours. A lack of a role model for healthy food behaviours could have long-term detrimental affects on health. In addition, a lack of emphasis placed on the importance of a healthy diet in childhood could lead children and adolescences to become influenced by the food behaviours of others within their social environment (Palfreyman et al., 2013). Alternative role models may include other social relationships such as that of peers or friends (Palfreyman et al., 2013). Peer influence The previous section describes how mothers have the most influence on the eating behaviours of women. However, Bazillier et al., (2011) contrasts this notion by finding that the influence of friends on eating behaviours was equal to that of a mother during adolescence. Bazillier et al., (2011) reported that wanting to conform to friends' eating norms was a significant predictor of eating intentions in girls. Bazillier et al., (2011) and Bruening et al., (2014) 11 found that while the influence of mothers often promotes the consumption of healthy foods, friends were more likely to increase unhealthy diet habits in children and adolescences. Smith-Jackson and Reel (2012) suggested the reason friends were more likely to influence unhealthy diet habits was because peers could cause females to make body comparisons between themselves and their friends. Carey (2010) agrees, suggesting body comparisons often led to dieting or eating disorders in females if comparisons drawn led to weight concern or body dissatisfaction. Crandall (1988) adds to these findings, suggesting that dieting behaviours such as bulimia are more likely to occur in social groups that place great importance on physical attractiveness and slimness such as sports teams and dance groups - as these groups may encourage body comparisons. Crandall (1988) suggests that the onset of disordered eating follows entrance into such a group, suggesting that social pressure from peers might be an influence to food behaviours. Social pressure may also influence eating behaviours if a member of the social group deviates from the group norm, to bring the particular member back in line with behaviours the group finds important. In addition, Crandall (1988) suggests that the more girls value a social group, the more they are influenced by it. This may be because social groups tell girls who they are, what they should look like, what to think and how to behave. Members of the same social group therefore tend to have similar attitudes and behaviours towards food (Crandall, 1988). In contrast, it may be likely that in social groups where physical attractiveness and body shape are not so important, that these factors do not have the same association with dieting behaviours. However, the importance of physical appearance may be replaced by another value. For example if the group values the importance of vegetarianism, the correlation between social pressure and dieting may be nil but the correlation between social pressure and vegetarianism may be high. Therefore the size and direction of correlations may differ between groups (Crandall, 1988; Wouters, Larsen, 12 Kremers, Dagnelie & Geenen, 2010). Bazilier et al., (2011) also explored the fact that instead of friends influencing food behaviours, that perhaps girls selected friends who already had similar eating behaviours and the congregation of individuals with similar values encourages one to maintain said values. While the relationship between girls and their peers appears to have a strong influence in adolescence, there is limited evidence to show that this influence translates into adulthood (Bruening, 2014; Neely et al., 2014). Trier (1960) and Lev-Ari, Baumgarten-Katz and Zohar, (2014) are two of a few studies that look at peer influences on adult women. Findings from the authors of Trier, a cross sectional study carried out in 1960, found that adult women most open to suggestions about food from their friends, were those who were more aware of their social responsibilities, and those who were well educated. Trier (1960) suggests that well-educated women were more active in their search for food information and were more likely to discuss trends and new knowledge with friends. In contrast, just as the children and adolescences in Crandall (1988), findings from Lev-Ari et al., (2014) suggests that adult women also compare themselves against their peers. Lev-Ari found that viewing a best friend as being thinner than themselves can result in a detrimental view on ones body image. The influence of friends also may not last into adulthood as once women leave school these relationships are often overshadowed by the influence of a male partner or husband (Hartmann, Dohle & Siegrist 2014). Male Partners or Husbands The influence of husbands and male partners appears to affect women's food behaviours regardless of era. The influence of a male partner appears to cause women to move away from her own desired diet towards one that is closer to his preference. The literature shows that often women claim their male partners are the greatest barriers to their own healthy eating (Beagan & Chapman, 2004; Salvy, Jarrin, Paluch, Irfan & Pliner, 2007). 13 Holm and Mohl, (2000) found that many women would be willing to stop eating meat had it not being for the fact that their male partners wanted to eat it. Hartmann et al., (2014) supported previous findings that male partners can cause detrimental changes to a healthy diet. Hartmann et al., (2014) interviewed women who lived on their own as well as women who lived with a male partner, and found that those who lived on their own ate less meat and processed meats than those who lived with a partner. While there may be other factors that affect the meat consumption of those who live alone versus those who live with a partner, both of the authors in Hartmann et al., (2014) and Beagan and Chapman (2004) found similar results. Beagan and Chapman (2004) and Hartmann et al., (2014) suggest the reason women may adapt their eating habits to fit with their husband’s preferences is because women tend to place a higher priority on maintaining social relationships, or wanting to please others through providing enjoyable meals rather than persisting in efforts to provide healthy food choices. This results in a shift towards the male partner's style of eating (Lawrence & Barker, 2009; Beagan & Chapman, 2004; Hartmann et al., 2014). Another suggestion from the literature was that this might also be due to the concerns women have about wastage and costs of introducing new foods that may be rejected by their families (Dye & Cason, 2005). Beagan and Chapman (2004) carried out semi-structured interviews with breast cancer survivors and women who had not experienced a life- threatening disease and compared their answers. The results found that both groups of women had very different experiences with negotiating healthy eating. While husbands did tend to steer women away from healthy food behaviours, if a woman was to experience a serious health condition, their husbands would be willing to change to healthier food behaviours (Beagan and Chapman, 2004). A large portion of the literature on the influence of husbands on women’s food behaviours found that husbands have a negative effect on a woman’s diet 14 while he is alive, by insisting women change their diet to suit their husband’s preferences. However, the loss of a husband or male partner can also have a negative effect on a woman’s diet. This was based on the idea that cooking is central to what women perceive to be their role in the family. The women in Gustafsson and Sidenvall (2002) enjoyed cooking for others, but, once they had lost their partners, most of the joy of cooking was lost as they no longer had anyone to cook for. Women no longer felt like making a fuss over what was cooked and women struggled to adapt to the smaller portions that were now needed, so large amounts of food were wasted. Widowed women would now just pick at food or not make what they considered to be proper meals (Gustafsson & Sidenvall, 2002). The literature found that marriage or moving in with a male partner or husband is the beginning of a new life stage that often eventually leads to parenthood. Becoming a parent and the subsequent influence of looking after a child may override the influence that husbands have on their partners. This notion will be discussed in the following section (Pandey, 2011). Pregnancy and children’s influence A significant amount of literature finds that pregnancy can cause a change in diet. For many women, pregnancy marks the beginning of a new life stage in which women are more motivated to take care, not only of their own nutritional needs, but also of those of the child (Del Bucchia & Penaloza, 2016; Hartmann et al., 2014; Olson, 2005). Both Beagan and Chapman (2004) and Olson (2005) analysed the effect of having children on a woman’s food consumption habits and found that the transition to motherhood was linked to an increase in the healthiness of the diet. Mathur (2003) proposed that, when consumers experience life changes that also affect the roles one plays in the household, such as food related tasks, they may modify their consumption behaviours in an effort to cope with these life changes, new priorities and responsibilities, and new life circumstances (Johnstone & Todd, 2012; Mathur, 2003). 15 Del Bucchia and Penaloza (2016) found that having children inspired mothers to search for information from different sources such as health magazines and doctors on how to provide children with the best diet possible. Mothers often internalised the health discourse and advice from these sources into their daily diet. This made them feel like they were fulfilling their role of providing balanced meals for their children (Del Bucchia and Penaloza, 2016). Olson (2005) found that a healthier diet was often induced by the increase in support pregnant women and mothers received through ante and postnatal healthcare systems. This finding was particularly applicable to women of lower income who may not have had access to food and information sources prior to pregnancy (Olson, 2005). The influx of information brought the importance of a healthy diet to the attention of mothers who were not previously aware of its benefits. This newfound knowledge not only resulted in an increase in the healthiness of their children’s diets, but also resulted in mothers increasing their nutrition knowledge (Olson, 2005; Lawrence & Barker, 2009). The majority of women in the literature reported ante and postnatal support mainly coming from medical practitioners, midwives, family, friends and other pregnant women (Charlick, McKellar, Fielder & Pincombe, 2015). In some cases the media increased a woman’s nutrition knowledge both before and after the birth of a child. On the contrary, Lucas and Coyle (2016) suggests that as information on the ideal diet for children has become so widely available, it allows mothers and their diet choices to be judged by others. Lucas and Coyle (2016) suggests that the influx of information post birth can make new mothers feel an overwhelming sense of pressure from family members and even perfect strangers if healthy diet norms are not followed. This is enough to influence new mothers to make changes to their diet. This can also have detrimental affects on mothers; including feelings of inadequacy and in some cases postnatal depression. Van Ansem et al., (2014) suggests that in an attempt to get their children to consume healthy foods, some mothers intentionally role model behaviours they believe to be beneficial. This may bring about a change in diet for 16 mothers who are aware that their pre-birth eating behaviours are not positive examples. Mothers may therefore avoid engaging in less healthy food behaviours in the presence of their children, instead increasing their consumption of foods considered healthy. Thus, in an attempt to increase the healthiness of their child’s diet, these particular mothers tend to have higher levels of healthier food intake themselves, given that one important element of modelling is for the child to see the parent eating the food that the parent is trying to encourage the child to eat. As children grow older the association between bringing up children and a healthier diet in mothers appears to diminish (Pandey, 2011). One cross- sectional study found that women living in households with children were more likely to consume sweets. This was as a result of increased eating cues triggered by the availability of the children’s sweets in the household as well as increased stress associated with the role of a mother (Hartmann et al., 2014). In addition, the refusal of children to eat certain foods as they grew older despite a mother’s effort to provide healthy options, resulted in mothers having to revise their food ideals (Del Bucchia & Penaloza, 2016). Mothers often resorted to only cooking meals they knew their children would eat, thus compromising the whole family's diet. These mothers describe their children as being picky and feel as though they must base their food choices on prior knowledge of a child’s preferences or risk their child not eating the meal at all (Pandey, 2011; Hartmann et al., 2014). Mothers, who gave into only cooking food their children would eat, often reported a sense of guilt, knowing that they were not cooking the healthiest meals for their children (Del Bucchia & Penaloza, 2016). In addition, the mothers reported that they lost pleasure in eating because they were always cooking the same things and often neglected their own tastes (Del Bucchia & Penaloza, 2016). Conversely, not all mothers let children affect their purchasing and cooking decisions. The literature describes types of ‘mums’ and how the type of ‘mum’ determines the health rating of foods purchased. Mothers, who refuse to 17 accommodate children’s preferences, have been described as ‘healthy food mums’ (Ilkay, 2013). These mothers’ are less inclined to let children influence food purchase decisions and mainly rely on the ingredient list to determine whether snacks are healthy. It is not known from Ilkay (2013) whether the purchasing behaviour of ‘health mums’ is a result of trying to keep their children healthy, or whether they had always purchased and cooked this way. Moreover, a major weakness of the study was that interview questions were answered on the Internet. Further improvements could be made if these questions were asked in person, giving the ability of the interviewer to prompt. This could offer insight into how future health interventions can facilitate and motivate other mothers to purchase food the same way. Most studies that look at how social relationships affect food behaviours in women only look at a snapshot in time rather than how these influences affect food behaviours over a lifetime. These snap shots in time cannot address how different social relationships interact with other aspects of the social environment at different stages in life. Additionally, many of the studies reviewed show women are making purchasing decisions not based on their wants and needs, but on the wants and needs of others. This type of purchasing behaviour makes it hard to explore women’s knowledge of nutrition and food by looking at purchasing decisions alone and without exploring more in-depth. In-depth interviews also allow the researcher to further understand how life events, such as the birth of a child can be a window of opportunity for individuals to change their nutritional strategies towards better food choices. However, the wide spread use of Internet based interviews or surveys suggest details on these experiences may have been missed. In addition, while much of the research attending to the affect of social relationships on food behaviours addresses differences among minority groups in their respective countries, few studies compared findings between different countries. Nor did many studies look specifically at New Zealand women, leaving a gap in the literature. 18 The media A common theme emerging from the literature on the social environment and its effects on food behaviours was the influence of the media. Media, as a vehicle for health and food related information, has been steadily increasing since WWII, but a concern arising from the literature was the quality and reliability of the information from the media. Literature on sources of media based information and the quality of such information will be reviewed in relation to food behaviours in the following sections. A significant feature of the social environment since WWII has been the changes and access to the media. The literature revealed that popular sources of food related information since WWII included magazines and newspaper articles, television, food labels and advertising material (Worsley & Lea, 2003). The evolution of technology and the introduction of the Internet has meant media has played a more prominent role in the development of food behaviours in the past 30 years (Buttriss, 2011). The literature in this section investigates how these popular sources of media have varying abilities to influence the food behaviours of those who are exposed to it (Worsley & Lea, 2003). Print media Print media, including articles and advertisements in magazines and newspapers, are frequently discussed in the literature as being used as a source of food-related information. A common theme is how advertisements containing ideal body images, regardless of their relevance to food, could affect food consumption patterns in women (Hesse-Biber, Leavy, Quinn & Zoino, 2006; Krahé, 2010; O'Mahony, 2007). Both Krahé and Krause (2010) and Hesse-Biber et al., (2006)’s review of the literature found exposure to advertisements and articles in print media, containing images of very slim models, led to restrained eating or the avoidance of high fat foods immediately following exposure. Hesse-Biber et 19 al., (2006) reported that this may be because women perceived these media sources as telling them the preferred weight ideal was significantly less than what they currently weighed. It appears as though women may therefore attempt to reach the ideal physical image internalized by many women, despite the ideal being both unattainable for most, and unhealthy, through self-imposing controls such as dieting and starvation. This is worrying, considering the ideal physical appearance is continuing to shrink as the body sizes of the winners of the Miss America Pageant and the Playboy centrefolds are continually shrinking over time (Garner, Garfinkel, Schwartz & Thompson, 1980). The connotations behind the ideal physical image is that those who achieve it have self-control and power while those who cannot achieve such body ideals are lazy, self-indulgent and lack control, representing moral failure (Hesse- Biber et al., 2006). It is these messages that have created an environment encouraging dieting with an estimated 50 million Americans dieting at one point in time (Chatzky, 2002; Hesse-Biber et al., 2006). Hesse-Biber et al., (2006)’s review of the literature also reveals that disordered eating, or obsession with food is a culturally acceptable or normal way for women to deal with body image issues and is often considered to be normal and therefore a non-issue from a clinical or social perspective. A large amount of the literature on how the media can induce disordered eating thus far has focused on print media. However technological advances since WWII have changed how women receive food related information. In particular the advent of the mass media has meant food-related information has had an even wider reach than was ever possible with print media alone (Hesse-Biber et al., 2006). The Internet The Internet emerged as an influence on food behaviours during the 1990’s. It began as a tool for information dissemination and interaction between individuals, removing the barrier of geographical location. It began slowly but 20 has evolved into an era where a large portion of homes have family or personal computers which are used for information gathering, sharing and social networking (Guo-Qing, Guo-Qiang, Qing-Feng, Su-Qi & Tao, 2008). The number of people using the Internet to search for health and food related information is increasing (McCully, Don & Updegraff, 2013). The Internet's increase in popularity has resulted in an increase in the amount of health and food information available online (McCully et al., 2013). However, a common theme among the literature is that not all of the information published online is completely reliable, meaning much of the food and nutrition information on the internet is not based on scientific evidence or published by those qualified sources. McCully et al., (2013) conducted a US survey of 3500 participants and found that despite more people using the Internet for food and health related information in 2011 compared to 2007, use in 2011 was associated with lower adherence to healthy food behaviours. The authors suggest this may be because in 2007, only those who were truly motivated to make a diet change searched for food related information online. Another explanation for the Internet's lower affect on food behaviours in 2011 was that diet related Internet sites have become less effective and reliable at helping people adhere to a diet. Modave, Shokar, Penaranda and Nguyen, (2014) added to this theory by finding that less than a fifth of websites included accurate nutrition or weight loss information on more than 50% of the key information. Modave et al., (2014) also found that most of the information found by participants on websites used by participants, was inadequate, not because good information did not exist, but because it was harder to locate as most people use a basic search engine such as Google. While the effect of unreliable information on food behaviours for the average person is annoying, from both the public's and a health professional's point of view, it is often harmless. However, this is not always the case Buttris (2011) found that 40% of respondents were prompted to seek health information from new sources, such as the Internet, in response to diagnoses of a life- 21 threatening condition (Buttris, 2011). Gustafsson, Ecblad and Sidenvall (2005) agreed, finding that older women living with the effects of a stroke and Parkinson’s disease tried to improve their health by changing their food habits. Most of the information they took on board was from the media. As no professional diet advice was sought, many of the women misunderstood how the diets should be executed and this had the potential to cause harmful effects (Gustafsson et al., 2005). To prevent unreliable information reaching vulnerable populations, identifying which groups of the population are using the Internet and how are they using it, could be important in designing education programmes and health campaigns highlighting the dangers of online information. Unfortunately, only a relatively small amount of available literature delves into who seeks information from where and what may cause them to seek information from specific sources. In addition, use of the Internet has branched into use of social media (Worsley & Lea, 2003). It appears as though the use of social media is widespread, making it a target for food related information, especially in the form of food advertising (Hesse-Biber et al., 2006). Social media Since the early 2000s, the rise of the ‘social web’, has had an impact on users. The use of social networking by businesses and educational institutions to promote products has enabled the Internet to have greater influence on the population (Walter, 2013). Social media began as a space on the Internet where people could go to connect with friends, peers and role models and has evolved into a phenomenon where by almost anyone can connect with anyone else and share any information they chose to. Social media has become a place where individuals or groups can share information and see the lifestyles of their peers. Social media has become a powerful source of information with the ability to influence a large group of people (Walter, 2013). 22 The influence of social media on the population is growing. Users of social media tend to be younger and therefore have the potential to be more impressionable. While the purpose of social media is not usually a tool for the communication of health and food related information, it appears to have the ability to affect food behaviours in certain population groups (Chrisler, Fung, Lopez & Gorman, 2013). Chrisler et al., (2013) monitored Twitter during a Victoria’s Secret runway show and found that exposure to idealised images of female models caused the young women viewing the show to comment on their ‘need’ to reduce eating after viewing the show. These findings echo recent research by De Vries and Kuhne (2015) that found that the amount of time spent on Facebook was associated with more frequent comparison of one's appearance with that of others. De Vries and Kuhne (2015) findings suggest that social media sites such as Facebook provide opportunities to compare oneself with the appearance of one's friends, acquaintances, and celebrities. They found a potential correlation between time spent on Facebook and judging one's own appearance to be worse than that of close friends or peers, which, in turn, was associated with greater body image concerns (De Vries & Kuhne, 2015) Results from Smith-Jackson and Reel (2012) suggests that young women will diet as a result of comparison between themselves and others, regardless of the presence of social media. However, the introduction of social media sites such as Facebook and as access to Facebook has the potential to be unlimited and therefore comparison can continue even when not in the physical presence of peers (De Vries, 2015). The rise of the Internet and WWW has massively changed how we communicate, form new social connections, obtain education and engage in with others (Walter, 2013). Public Health Campaigns (PHC) 23 PHCs are health related messages often funded by the government usually to help with a particular objective, and can have an impact on our social environment. Because of the governmental backing, the messages within PHCs are often the messages that are reinforced in schools and public medical centres or hospitals and therefore consumption of these messages may even be unintentional or unavoidable (Gray, 2015; Keogh & Osborne, 2014). They often become commonly accepted thought patterns and can be topics of conversation between individuals and their friends, family and health professionals making them a significant part of the social environment. Payne, Capra and Hickman (2002) assessed the ability of potential public health campaigns to influence positive changes in food behaviour in school aged adolescents. One thousand six hundred (1,600). Australian girls aged 9- 15 particpated in a food education programme which lasted one week. After completion of the programme, of those surveyed, 77% felt they had learned something from the health promotion material 94% said they had changed their eating habits to include more core food groups during the camp, and more than 40% stating they had increased vegetable consumption compared with their usual intake (Payne et al., 2002). The success of such trials could result in implementation of a similar programme in schools, thus enhancing the school’s ability to be a contributor in the development of food behaviours. Dyck and Dossa (2007) found that children often share the nutritional information they acquire at school with their mothers, which often results in changes to the family’s diet. One participant in a study by Dyck and Dossa (2007) said that when her children tell her what they learnt in school about what they should eat, the mother went and bought those foods. The women in the study also spoke of how they avoided food that their child had learnt were ‘risky’ through school (Dyck & Dossaa, 2007). It is, therefore important that public health messages taught in schools are both accurate and easily understood by children so they are able to pass on the correct information. The importance of clarity and accuracy also apply to PHCs aimed at adults. A Canadian study evaluated how Canadian consumers reacted to conflicting 24 health messages about fish consumption in mainstream media. They found that too many conflicting messages, or messages that were too complex, caused a reduction in the likelihood of consumers adhering to diet advice. This particular study investigated the conflicting messages in mainstream media regarding fish consumption. While Canadians were aware of the benefits of fish consumption, they became confused when Health Canada advised against frequent consumption of certain species of fish, which contain high mercury levels. The information on the mercury content of fish proved too complicated for lay consumers who, when tested, could not remember which fish species were high in mercury and which were not. Their confusion led to reductions in total fish consumption. In short, consumers had reacted more strongly to information about health risks than health benefits. Roosen, Marette, Blachemanch and Verger (2006), therefore, deemed warning about mercury in the general media to be ineffective due to its complexity. Nickoloff, Saghaian and Reed (2008) suggest that consumers tend to change their purchasing habits more when faced with a novel finding that has not been widely discussed in the media. Therefore, concentrated periods of media coverage concerning a novel risk appear to have a greater effect on purchasing behaviour than do frequent coverage of common risk factors spread out over time. Another reason for the varying levels of concern about certain risks is that some risks are perceived to be more relevant, or dangerous, to individuals over others. Bocker and Hanf (2000) found that the most important elements of individual hazard judgments are the severity of and familiarity with the hazard. Because there was no coverage of any mercury-related fatalities during the duration of the study, the risk of mercury contamination may have been insufficient to evoke a change in consumer behaviour. Nutrition information panels (NIP) are also a government led PHC aimed at increasing the knowledge of consumers at the point of purchase by displaying important nutrition information on foods (Kolodinsky, Green, Michahelles & 25 Harvey, 2008). A large number of literature looks at the effect of NIP on short- term food behaviours. Kolodinsky et al., (2008) reported that two thirds of college students reported changes in their purchases as a result of being exposed to nutrition information labels in a restaurant setting (Kolodinsky, et al., 2008). Many students switched to what they understood to be healthier purchases after exposure to the calorie count of foods they commonly consumed. Conversely, a lack of negative nutrition information on NIP’s at the point of purchase could cause consumers in to choose immediate gratification over long-term goals (Kolodinsky, 2008). This could suggest that there are no long- term effects of nutrition labels on food purchasing behaviours as the participants did not draw on, or ignored, previous exposure to labels, assuming there had been some. Instead they opted to give in to immediate gratification. Kolodinsky's (2008) use of focus groups gave an insight to how the NIPs affected food choice and food attitudes before and after exposure but provides no long-term follow up and therefore gives little insight to the effects of such labelling on participants long-term food behaviours. While there is much literature on the effect NIP’s have on purchasing behaviour, few studies research their effect on food knowledge. Elbon, Johnson, Fischer and Searcy (2014) found that, while displaying negative facts on NIP’s help participants avoid foods or components of foods that have a negative health effects such as fats and sugars. NIP’s fail when it comes to enticing consumers to purchase foods high in positive nutrients. In fact, displaying nutrients perceived positively, such as protein or calcium may be ignored altogether (Elbon et al., 2000; Rizk & Treat, 2014; Hassan, Shiu & Michaelidou, 2010). This could suggest a lack of knowledge or education of these beneficial nutrients within the general public as displaying these positive nutrients on NIP’s does not entice consumption and so does not have any effect on consumer purchasing behaviours. PHC’s are a part of the social environment, as food related messages are often made on a government level and therefore affect all within the target 26 population, regardless of interest in food. However the plethora of public health messages about nutrition and food consumption that appear in a variety of media sources can complicate the relationship between food and health (Nickoloff et al., 2008). The theme from this literature is that messages within PHC’s need to be carefully considered as these are often the messages that can cause a change in food behaviours. Reliability of the media The question emerging from the literature was whether information in the media was reliable. Reliable information is information that can be backed by science and/or written by an appropriate person e.g. a Dietician. Ellison, White and McElhone (2011) suggest that unreliable information could be a rising phenomenon due to the rapidly increasing availability of food information in the media. The International Food Information Council Foundation conducted a national content analysis of food and nutrition reporting in the media throughout 1995. They found that health claims or warnings of specific foods in media sources were rarely backed by science or qualified experts. In addition, most nutrition articles in the media failed to provide the contextual information necessary to judge the relevance of the results (Borra, Earl, & Hogan, 1998). Some of the contextual information left out in articles in mainstream media included dosage information or the populations to which this information was most relevant. Only 31% of statements about the harm and benefits of dietary choices mentioned the amount needed to be beneficial or harmful; only 17% mentioned any population as being more or less at risk; only 7% referred to the frequency of consumption need to affect benefits or harm, and only 1% dealt with any cumulative effects (Borra et al., 1998). Not having sufficient knowledge to judge the relevance of nutrition articles, Gustafsson and Sidenvall (2002), reported that women often felt frustrated by different messages regarding food and health, and did not know whom to believe. In addition they found it difficult to understand conflicting information. 27 Some women gave up and continued cooking in their usual way (Gustafsson & Sidenvall, 2002). It is therefore, not surprising that Jessri, Jessri, Rashid, Khani and Zinn (2010) found that much of nutrition knowledge of participants came from sources that are not suitably qualified to give this information. Other than individually focused policies such as nutrition labelling, or policy to protect children in schools from advertisement of unhealthy food and by ensuring all school foods meet “healthy” criteria there is little to safe guard from the plethora of false information in the media from becoming ingrained in the population. Gender norms A common theme among the literature on the social environment was how gender norms underlie many social processes associated with food including the type of media aimed at different genders and the roles associated with the preparation of a meal. Gender roles are a set of societal norms that dictate the types of behaviours that are considered appropriate or desirable for a person based on their gender. The prevailing ideology has been that cooking and food preparation were not only natural occupations for women, but deeply fulfilling (Kerstin Gustafsson & Sidenvall, 2002). However, in the past 40 years, the societal role of women has become less domesticated and it is acceptable for women to reject many traditional societal roles. A rare New Zealand study uncovered gender norms among Pakeha women (Herda, 1991). The women in this study identified food-related behaviour such as purchasing, preparing and cooking a meal as central to being a woman and mother. Food was seen as a way to care for others and extended beyond the immediate family, with women frequently using food to maintain social connections and their place within society. Hocking et al., (2002) found women in this study identified with being able to offer hospitality to guests as 28 a strong cultural value that motivated them to always have something in the cake tins (Hocking et al., 2002). For the Pakeha women in Herda (1991) preparing food was an expression of competence and a matter of economic survival. Gender norms underlie many processes associated with food preparation and food consumption. Many of these have been previously discussed in other sections, specifically sections covering social relationships and the media. Influential social settings Social settings other than the home such as school and work, makes up a large portion of the literature and can play a significant role in the development of food behaviours at different times throughout ones life. Home Environment The literature finds that the development of food behaviour starts very early in children’s lives, thus the home environment plays an important role in that development. The home is where children receive repeated exposure to foods. Parents or caregivers dictate the food children are exposed to and provide role models for consumption practices (Dwyer, 2016). Van Ansem et al., (2014) and Dwyer (2016) suggested that parents could promote healthy food behaviours in their children by creating an environment that encourages such behaviours. Van Ansem et al., (2014) found that children of parents who had rules around the consumption of fruit and vegetables were more likely to consume fruit and vegetables than children of parents who had no rules about consumption. In addition, children of parents who always had fruit and vegetables available at home were more likely to consume fruit than those of parents who did not have fruit available at home (Van Ansem et al., 2014). Conversely, the presence of high-sugar beverages and high-fat snacks, family norms for eating in front of the television, and a 29 high amount of ‘take-out’ meals have been associated with an obesogenic home food environment (Kegler et al., 2014). The home setting that is not the only area that can affect food behaviours. Accessibility to a greengrocer or a large supermarket may make the purchase of fresh fruits and vegetables easier (Thornton, Lamb & Ball 2013), while greater accessibility to outlets selling fast food may encourage the consumption of fast food at levels that are damaging to health. A similar theory applies to the work place setting (Thornton et al., 2013). School environment While the literature, on the impact of the influence of schools, in regards to friends and peers has already been reviewed, there are other aspects of the school environment, which can have an impact on food behaviours. The school environment can provide students with opportunities to learn about and practice healthy eating as students may have access to foods and beverages in school cafeterias, vending machines, schools stores, classroom, school celebrations, and fundraisers (D’Adamo et al., 2016). Rowe, Stewart and Somerset (2010) and Neely et al., (2015) both suggest that a whole school approach could be most effective in establishing and maintaining healthy eating behaviours. All individuals in the school community can support a healthy school environment by promoting healthy foods options, implementing a nutrition education program, role-modelling healthy eating behaviours, and ensuring that students have access to free drinking water. Another study found that the impact of serving fruit smoothies during school breakfast significantly increases the total fruit consumption among middle school and high school students. The amount of students eating a full serving of whole fruit increased from 4.3% to 45.1% (Bates & Price, 2015). These actions are important as healthy eating has been linked to improved learning outcomes (Lewallen, Hunt, Potts-Daterna, Zaza & Giles, 2015). 30 Dwyer (2016) found that it is easier to increase consumption of fruit than it is to increase consumption of vegetables. While all of these studies show that putting an emphasis on providing nutrition in schools is important for the development of healthy food behaviours, all of these studies were carried out in the USA. Workplace The workplace has been recognized by the World Health Organization (WHO) as a prime environment to influence dietary behaviours given that individuals can spend up to two-thirds of their waking hours at work (WHO, 2013; Geaney et al., 2016). Just like in the home environment, the odds of eating at least two portions of fruit and vegetables per day was positively associated with having supermarkets within 0.8 km of the workplace (Thornton, 2013). However, time constraints and limited space to prepare and consume a proper meal lead employees to either skip lunch or snack at their desks. Given that the range of snacks available at work is often not healthy, there is an overwhelming push to eating poorer quality food (Pridgeon & Whitehead, 2013). A majority (67%) purchase lunch at least once per week and almost 40% purchase lunch three or more times per week (Blanck, 2009). It is common for the foods that are available in work places to be limited in affordable, healthy choices (Pridgeon & Whitehead, 2013). The lack of healthy options means that even those who attempt to ‘be good’ and bring their own lunch or make healthy food choices, may be tempted by the external cues triggered when observing and smelling co-workers consuming palatable food. This may be enough to drive some individuals to purchase similar foods. Unless a work place is located near a supermarket, it is unlikely it will promote healthy food behaviours. 31 In some work places the lunchroom served as place for discussion and exposure to new foods. It was common to see colleagues from other countries offering pieces of their homemade food to their colleagues. This makes the lunch room an area for opportunities not only to get information and knowledge about where to buy food, but also testing new and different dishes (Lindén & Nyberg, 2009). Social determinants Of all the social determinants to health, the literature found income to have the most influence on food behaviours. Income can affect many different aspects of food behaviours, such as purchasing behaviour. However it can also play an underlying role in other aspects of food behaviours. These social determinants will be discussed in the following section. The literature also includes a small amount of research on the effect of education on food behaviours. Education appeared to be an emerging theme in the literature as more women joined the workforce and refocused their attention to a career outside the home since WWII. Income and socioeconomic status Income is often identified in the literature as having a significant influence on food purchasing behaviour in women. A large amount of the literature on income finds that among low income families in particular, their budget is the major barrier to healthy eating with cost of food, saving money and value for money important considerations when purchasing food (Inglis, Ball & Crawford, 2009; Henry et al., 2003; O’Mahoney & hall, 2007). While the effect of income on food purchasing behaviour is well researched, the effect of income on food knowledge and skill is less known. Inglis, Ball and Crawford (2009) carried out an intervention study that attempted to remove income as a barrier to purchasing food in an attempt to identify whether budget affected food knowledge, by giving women of low income (LI) 25% extra and women of high income (HI) 25% less to spend on groceries. Inglis 32 et al., (2009) found that although LI women spent more money than they previously did on health foods after the increase in budget, overall they still purchased significantly more junk food than HI women. As the LI women continued to spend more money than HI women on junk food, this could infer LI women may not have known the negative health qualities of ‘junk’ food, and therefore suggesting income may have an effect on food knowledge. Conversely, a study conducted in 1960 found income had no affect on cost- consciousness (Trier, 1960). Results showed HI women were just as likely to be cost conscious as LI women. Cost-conscious women, in this study, read newspapers to find specials and shifted their purchases accordingly (Trier, 1960). However, it must be noted that Trier was carried out a long time ago, in a time where it was a women’s role in the household to carry out all tasks relating to food preparation and cooking. Therefore the women in Trier (1960) may have had the time to prioritise cost consciousness. In addition it was typically women of higher SES that were able to afford an education and therefore it may have been these same women that were more likely to read up on specials and calculate the savings (Trier, 1960). It is important for a study assessing the effect on income to also investigate food knowledge. Many studies only focus on purchasing behaviour and fail to address knowledge, which can result in misconceptions as to why certain foods are purchased. Cheaper or lower quality food may be purchased irrespective of the nutritional knowledge of those purchasing it (Inglis et al., 2009). Inglis et al., (2009) suggests that this may be because low-income women have little to no choice regarding foods they purchase. They simply purchase what they can afford, not necessarily what they want or know to be healthy (Inglis et al., 2009). A common goal became clear amongst most women in each of the previously discussed studies and that was that regardless of income, women attempted to purchase what they believed to be the best quality food possible within their budget (Inglis et l., 2009). Another finding was that women would ensure their families are fed before they feed themselves (Lawrence and Barker, 2009; Dressler & Smith, 2013). Income can also directly and indirectly affect other 33 aspects of life. A large amount of literature finds that income can be associated with education levels, access to information and the area in which one resides (Turrell et al., 2009; Walters & Long, 2012; De Vriendt, Matthys, Verbeke, Pynaert & De Henauw, 2009). Residents in low socioeconomic areas or those living in poverty were significantly less likely than their counterparts in advantaged areas, to purchase foods high in fiber and low in fat, salt and sugar. It may be that more deprived living spaces are in closer proximity to fast food places and dairy’s where sugar sweetened beverages were sold, which also play a role in the development of food behaviours (Park, Choi, Wang, Colantuoni & Gitlesohn, 2013). There are clear socioeconomic disparities in extreme obesity. Adults living in the most socioeconomically deprived areas are four times as likely to be extremely obese as those living in the least deprived areas (Ministry of Health, 2015a and c). As previously stated this may not be because of a lack of knowledge but a lack of funds. It appeared that childhood obesity rates are much higher in children living in the most socioeconomically deprived areas. Children living in the most deprived areas are 2.5 times as likely to be obese compared to children living in the least deprived areas. Obese children are at a higher risk of developing diabetes and cardiovascular disease (Ministry of Health, 2015a). Van Ansem et al., (2014) agrees that homes with low socioeconomic status (SES) were less supportive of healthy food behaviours. Van Ansem et al., (2014), found that children living in a household of low SES had the lowest fruit consumption, while children with a high SES had the highest fruit consumption. Adults living in the most socioeconomically deprived areas are also less likely to meet the Ministry guidelines, compared to those living in the least deprived areas (Turrell et al., 2009; Lawrence & Barker, 2009). Education Just like households with a higher income, children of mothers with a high educational level consumed more pieces of fruit per day, more grammes of 34 vegetables per day and were more likely to have breakfast on a daily basis than children of mothers with a low educational level (Van Ansem et al., 2014). In addition, MacFarlane, Crawford, Ball, Savige and Worsley (2007) found that children who grew up in a home food environment with mothers with a low educational level had less support for a healthy diet than the home food environment of children of mothers with a high educational level. Adolescents of mothers with a low educational level were more likely to report that unhealthy foods were usually available for them to consume at home, while adolescents of mothers with a high educational level were more likely to report that fruit was always or usually available at home and that vegetables were always served at dinnertime (MacFarlane et al., 2007). Frequent consumption of fruit and vegetables, restrictive rules, verbal praise, negotiation and restraint from negative modeling were all more common among mothers with a high educational level (Van Ansem et al., 2014). Trier (1960) also maintains that better educated women are more discriminating and intelligent in their use of health related information and are also more likely to search for relevant information and therefore make informed decisions when it comes to their diet. The key difference between women of lower and higher educational attainment manifested itself in the way in which they spoke about cooking and eating (Jarman, 2012). Women of lower educational level spoke almost entirely about the importance of feeding others within their family such as their children and their husbands’, whereas women of higher educational levels talked more frequently about their own eating and cooking habits than they did about feeding their families. Women of lower educational level, although none of higher, suggested it was the ‘role of a mother’ to provide food for everyone else first (Jarman et al., 2012). Summary The social environment refers to the social setting in which people live, work and socialise. It includes family structure, culture, employment and level of 35 education. The social environment influences health literacy, social norms, ability to make healthy decisions and the value placed on health (Ministry of Health, 2015a). The literature reveals that all aspects of the social environment influence women’s food behaviours, therefore there can be no single approach to ensuring women develops positive food behaviours. However, some aspects of the social environment are more influential than others and further research on these particular aspects and how they affect New Zealand women is needed. These particular aspects could then be targeted to help ensure healthy food behaviours are developed. However, we need to address gaps in the literature, namely the gaps in the knowledge on New Zealand women. The literature within this review is mostly from studies based in the United States of America (USA), United Kingdom (UK), and a small amount from Australia and a little from New Zealand as this is what the search strategy returned. More research investigating New Zealand women, who may have been exposed to different influences and experienced different social environments to those of commonly researched populations, may help to understand more about how women make the decisions about food that they do. Additionally, there are gaps in the knowledge assessing how changes to factors within the social environment, such as changes in social relationships and progresses in media and technology, can affect food behaviours over a lifetime. Most of the current literature focuses on short snapshots in time. Further information an exploration of media usage between WWII and the present day could help to identify the extent to which the media influences food behaviours and could assist in discovering the type of information women are frequently drawn to throughout their lifetime. Addressing these limitations and providing further investigation into the factors which influence the food behaviours of women could help in designing effective health promotion campaigns. 36 Chapter 3. Methodology and Research Methods This chapter outlines the methodology and methods used to inform and investigate how life events and the social environment influence food behaviours and knowledge of New Zealand women. It will explain the research methodology, including the philosophical worldview and the research methods used. It will also cover the procedures for data collection, analysis and interpretation and conclude with the ethical considerations and limitations for this research. Epistemology This research uses an interpretivist epistemology. One principle of interpretative epistemology is that there is no single truth or reality (Hudson and Ozanne, 1988). Interpretativists believe that our knowledge, or experience, of a phenomenon is a result of viewing the world in a particular place and time and, therefore, there are many possible worldviews and versions of reality that exist simultaneously (Hudson and Ozanne, 1988). The findings from the present research therefore only represent the ‘truths’ of those within the sample and they cannot be generalised without careful consideration of the wider implications. In order to understand and obtain information on the context in which the individuals in a particular sample experience a phenomenon, researchers must study the subjects through extensive engagement (Hudson and Ozanne, 1988). It is from this extensive engagement with participants that the individual ‘truths’ or meanings emerge. The interpretivist approach contrasts with a positivist approach, where only “objective factual” knowledge, gained through direct observation or measurement, is considered relevant (Neuman, Persson, Mattsson & Fjellstrom, 2000; Hudson and Ozanne, 1988). 37 The interpretive nature of this study requires the researcher to be involved in the interpretation of the data and acknowledges that it is impossible for the researcher to completely set aside their own views on the subject during analysis of the data. Methodology This research was partially informed by phenomenology. Phenomenology is concerned with investigating the thoughts and meanings participants assign to a particular phenomena or experience by means of in-depth description (Creswell, 2007; Davidsen, 2013). The use of some of the principles of phenomenology allowed the researcher to examine the actual experiences of the participants within their social context to discover how their food behaviours developed using qualitative methods such as semi-structured interviews. The use of semi-structured interviews allows extensive and prolonged engagement with the participants and helps the researcher develop patterns of meaning within the sample (Creswell 2009). Interviews also allow the researcher to further understand how life events, such as the birth of a child, can be a window of opportunity for individuals to changes their nutritional strategies. The questions in the semi-structured interview schedule were underpinned by phenomenology. As the methodology dictates the type of questions that can be asked, questions were broad and open-ended to ensure they did not override the participants expressed interests and encouraged them to discuss their experiences as freely as they felt necessary (Thompson, 2008). The interview questions, however, had some structure to ensure the researcher was able to uncover influences on food behaviours by questioning who, where and how food and food knowledge was brought, prepared and obtained through different life stages. 38 It is acknowledged that direct access to the thoughts and experiences of others is not possible, which means there will be some interpretation involved during analysis (Eatough and Smith, 2008; Smith and Eatough, 2007; Smith and Osborn, 2003). Traditional phenomenology argues that the researcher should set aside their own views on the subject during analysis in order to find what is actually presented about the experience from the view of the participants (Creswell, 2007). However, an interpretative perspective, acknowledges that it is impossible for the researcher to completely set aside their own views on the subject. Therefore the researcher needs to be aware of their prior knowledge on the phenomena of interest and, instead of setting the prior knowledge of the researcher aside; it should be part of the analytical process (Creswell, 2007; Crotty, 1998; Guba & Lincoln, 1982). Researcher reflexivity. Given the context of the present research, reflecting on my identity as the researcher is important as transparency and disclosure on the part of the researcher contributes to a fuller picture of the process of research and analysis. Human nutrition was my major in my undergraduate degree and I have worked in the field of nutrition since my graduation in 2012. I spend the majority of my working day working with individuals and their diet- related issues, which increased my interest in this area. However, I became frustrated after repeatedly hearing individuals I was working with, misunderstand nutrition advice in the media, practice nutrition myths that held little truth or being unaware of the New Zealand food and beverage guidelines. During my work I have had the chance to explore or ask my clients where they sourced their information and why they were implementing some nutrition-related information in their lives and not others. This experience led me to want to take this very basic ‘research’ further - into a Masters research project. My professional experience has allowed me to gain insight into my participants that allowed for in-depth understanding of the data. I am a 24-year-old female and, although I have not experienced the same gender norm expectations and restrictions as participants in the present study 39 may have been exposed to, I grew up as the only female sibling in a male dominant house. Therefore I have experienced some gender norm expectations related to food preparation. These experiences allowed me to empathise with participants when discussing aspects of food related tasks, which, throughout history, have fallen on the shoulder of females (Chen et al., 2015; Trier, 1960). Engaging in this reflexivity was an important step in the research process and allowed me to acknowledge any prior thoughts on where individuals get their nutrition knowledge from while not letting them bias my results. Methods In order to address the aims of this research, research methods that would allow the researcher to understand the effect of the social environment on food behaviours from the perspective of the participants, were required. Qualitative research methods were considered appropriate as they enable the researcher to achieve contextual understanding of the phenomenon of interest and aim to answer questions about the ‘what’, ‘how’ or ‘why’ of a phenomenon (McCusker & Gunaydin, 2015; Lyon and Coyle, 2007). Data collection Sampling approach The sampling strategy used was purposive sampling, a type of non- probability sampling (Etikan, Musa & Alkassim, 2016). The participants were selected based on those that were easy to contact and those, which fit an inclusion criteria, outlined in the information sheet (Appendix 1). The aim was to interview 20 participants. This number of participants was decided upon for two reasons. The first was that research, which uses extensive engagement to obtain information from their participant’s calls for a relatively small sample size. In addition, due the nature of this research there were time constraints 40 that would only allow the researcher to interview 20 participants (Etikan et al., 2016). Inclusion criteria were not made very specific to facilitate the recruitment of the number of women that were needed for the research. As the sample was a self-selected sample, it may not be representative of all people and their life experiences. These particular participants may have volunteered for this study because they had an interest in food and nutrition. Therefore, results may only reflect the portion of the population who are more active or knowledgeable in their search for food related information. In order to receive the best possible information on life events and different influences within the social environment, women who had lived through most life stages and had been interacting with the social environment for a long time, were chosen as the study population. It was determined that interviewing a younger population would not return the information necessary to assess the influence of the social environment over the life course. In addition the birth cohort born in 1940 was particularly interesting to study as they have the highest obesity prevalence of any birth cohort in New Zealand (Ministry of Health, 2015a). In order to find participants within this particular population, rest homes and retirement villages were contacted. People were defined as living in a retirement village if they lived inside the retirement village itself and any of its surrounding accommodation within the village walls. This included the villas and apartments, however did not include those living within the hospital ward or the assisted living facility of the retirement village as these individuals were considered to a vulnerable population and may have required specific ethical approval. Wellington Retirement Village (WRV) was chosen through purposive convenience sampling due to the researcher’s prior work with this particular retirement village. Alternative retirement homes in the Wellington Region were sought for participation in this research to increase diversity. The names of five retirement villages and rest homes and their contact information were found in an Internet search. Potential retirement villages 41 were called, or emailed if they could not be reached via telephone. Whilst there was some interest in participation in this research, interested potential participants never came to fruition. One of the rest homes contacted only had residents who required a high level of day-to-day care. Residents of this particular rest home were unable able to give consent to be interviewed themselves; consent had to be gained from a family member, and therefore no residents were suitable for inclusion. The other rest homes and retirement villages approached for potential participants did not return calls or emails or were not interested in having their residents included in the research. Independent living participants were also included in the study population. People were defined as living independently if they lived in their own home, or in a rented home or apartment, either by themselves, with a partner or spouse, or with others of a similar age. Those who lived with younger people, including adult children or caregivers were classified as living in ‘assisted living’ and were not included in the present study. Women from both living situations were chosen to ensure that the results were not affected by differences in characteristics of women who live in a retirement village and those who live independently. Women who were living independently were chosen through convenience sampling. Three elderly women known to the researcher were contacted and snowball sampling guided the inclusion of the remaining participants. Independent living participants lived in various areas around the wider Wellington region. Recruitment of participants WRV assisted with the recruitment of participants in retirement villages. WRV is a retirement village which hosts a wide variety of housing options from independent living in a villa, apartment or townhouse, to serviced apartments as well as rest home and hospital level care. WRV is located in Wellington. Approval to interview residents at WRV was gained through the community administrator who advised ethical consideration was not needed to gain access to their residents. 42 Advertisement of research Retirement village. Advertisements were placed in the September 2015 WRV newsletter, which is distributed monthly via letterbox drop to all 211 residents in the retirement village (Appendix 2). The advertisements contained a brief description of the research and were aimed at potential participants within the village who grew up during World War II. No specific age or birth date was defined within the advertisement. The advertisement outlined the nature and purpose of the research and asked for interested parties to contact the Village Administrator by phone or in person. The administrator then contacted the researcher and provided telephone numbers of interested parties. These participants were contacted via telephone by the researcher in the following days. A total of ten contact telephone numbers were received by the researcher, but only nine could be contacted. Independent living. In October 2015 the researcher met with a group of three women previously known to the researcher, aged in their 70s and above. These women were given the research information sheet (Appendix 1) and told to contact the researcher if they were interested. All three women agreed to participate in the research. These participants were then asked to talk to women whom they thought might be interested in participating in the research as well. These participants provided names and telephone numbers of seven additional women. All seven women were contacted via telephone and all seven agreed to participate. These participants all lived in the Wellington Region in suburban areas. Screening of subjects The researcher contacted interested participants and they were screened to ensure eligibility. At this time the researcher also evaluated potential participant’s ability to hear spoken questions and to respond in a way that could be understood by the researcher. 43 On the day of the interview, participants were given the information sheet (Appendix 1) to read prior to commencement of the interview and told they could pull out of the interview process at any time. A digital tape recorder was used to capture the interviews and the information sheet provided the explanation for this. The information sheet also explained that participants had the right to ask for the tape recorder to be turned off at any time and this was verbally repeated to each participant prior to the interview. None of the participants expressed any concern over the tape recorder. It was also explained that the recorded interview would be transcribed and participants had the right to edit the transcript of their interview. None of the respondents requested a copy of the transcript following the interviews and signed a form confirming this decision. The information sheet also included: • The inclusion criteria • The purpose of the research • A brief explanation of what they would be asked • Where and when the interview would happen • How long the interview might take • The rights of participants • Confidentiality • Who was carrying out the research and how participants could get more information about the research • How participants could contact the researcher All participants who put their name forward to be contacted by the researcher were suitable for the research and agreed to the terms of inclusion outlined in the information sheet. The only exception was one participant who could not be contacted, this particular participant was called twice, a message was left and no further contact was attempted. The recruitment and screening process resulted in a sample of 19 participants who were subsequently interviewed one-on-one. The participants 44 Of the participants recruited nine were from a retirement village and ten were living independently. All participants were New Zealand European. This was not intentional, but no criterion was set in place to ensure diversity of participants. A lack of diversity in the ethnicity of participants may be due to the cost of residing in this particular retirement village, which favours those of European ethnicity who on average earn more than Pacific Island or Maori counterparts (Carter, Lanumata, Kruse & Gorton, 2010). Additionally, as most independent living participants were from a similar social circle, participants were of similar ethnicity and socioeconomic status. Further research would aim to have a study population representative of the New Zealand population. There were no inclusion criteria that ensured the selection of women of varying marital status, number of children or origin of birth. However, the participants provided a diversity of household compositions and education levels. Characteristics of the participants are summarised in Table 1 which can be found in Chapter 4. The intention was to interview 20 participants however, only 19 participants were recruited. After 15-16 interviews had been completed it became apparent that further interviews with more participants would not likely generate further variation in the themes that were emerging and it appeared as though data saturation had been reached. The final three interviews confirmed this and the number of interviews remained at 19 (Thompson, 2008). However, had the researcher accounted for women of different ethnicities and ages in our inclusion criteria, more interviewees may have been needed to reach this point. Method Semi-structured interviews were chosen as the method of data collection because it enabled each participant to tell her own story. Semi-structured interviews 45 A semi-structured interview schedule using open-ended questions (Appendix 3) was used to gather information in the respondent’s own words about her life experiences and how these influenced their food behaviours. Participants were informed of the order in which the different question sections were to be asked. These included: • General questions • Present day • Childhood • Early adulthood, before children • Adult hood, with children (if they had any, alternatively late adulthood) • General food based questions Each interview began with a set of general questions about the participant. The aim of these general questions was to get a general idea of each participant’s background and some basic demographic questions. The purpose of these questions was also to build rapport with the participants. After the general questions, the interview moved on to questions relevant to each life stage. Before heading straight into the questions, the life stage to be discussed was briefly described and followed up by a question to set the scene and ensure the participants could focus on the according life stage. For example, the first question in the ‘childhood’ section was “What was your favourite childhood meal?” These were followed by sub-questions about each life stage. The first life stage to be discussed was ‘the present’. This life stage went first as it was predicted that it would be the easiest to recall for the participants, some of whom may struggle with memory due to their age. This was followed by questions on childhood, early adulthood and adulthood, in chronological order to facilitate flow between sections. Participants were probed where necessary through the use of some predetermined and adlib prompts. In the interview schedule in Appendix 3, questions are indicated as bulleted by numbers and prompts are bulleted by letters. Final questions sought to attain who or what the participants believed to be their greatest influence on food behaviours for each life stage. It was expected that probing from these final 46 questions would elicit any uncovered aspects or influences about this life stage. Similar questions were repeated throughout each life stage section of the interview in an attempt to identify patterns between life stages and respondents and to make the analysis of responses easier and results more reliable. Some questions were slightly adjusted according to answers given by the participants in previous sections. For example, in the first section of questions, it is asked how many children the participant had. One participant did not have any children so subsequent questions relating to children were not asked for this particular participant. Use of the words ‘good’ or ‘healthy foods’ were avoided to prevent respondents from describing only healthy food behaviours. However, as the participants knew of the nature of the research, this may have been unavoidable. The aim was to elicit all experiences and overcome any tendency to only tal