Home Healthy Eating Identifying perceived barriers and enablers of healthy eating in college students in Hawai'i: a qualitative study using focus groups – BMC Blogs Network

Identifying perceived barriers and enablers of healthy eating in college students in Hawai'i: a qualitative study using focus groups – BMC Blogs Network

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This study revealed barriers and enablers of healthy eating in college students in Hawai’i at the four levels of influence in the socio-ecological model. Findings may be used to inform additional research in this population or interventions targeting college students in Hawai’i.Knowledge served as both a key barrier and key enabler on the individual level. This finding is in concordance with previous studies that have identified knowledge as an enabler of healthy eating in college students [11, 17]. To address the lack of knowledge some students described, one possibility is offering a health class to improve nutrition education. This suggestion has been offered in previous studies to improve eating habits of students [10, 17]. However, college students may have widely differing characteristics and levels of nutrition-related knowledge. More research into tailoring classes to address varying levels of nutrition knowledge, psychosocial characteristics, or health risks may result in more effective targeting of diverse groups of college students [18].Attitudes and beliefs toward healthy eating in individuals were identified as both a barrier and enabler. As a barrier, some students viewed healthy eating as something that could be postponed, or a lower priority in relation to their school life. Attitudes found in this population were consistent with a previous study demonstrating that those in earlier life stages placed less importance of healthy eating, while those in later life stages deemed healthy eating of greater significance [19].The perception that healthy food is not convenient food was a common theme. Students often placed healthy food at odds with convenience in stating that healthy food took longer to prepare or required more planning than pre-packaged foods, take-out, or other options. However, convenience food has typically been defined in relation to time and labor required for food preparation; it is not necessarily unhealthy, although preserved or processed foods may have added sugar or salt to preserve flavor [20]. Pre-cut fruits or vegetables and nuts fall within the scope of convenience food definition, and these have been shown to be perceived as healthy snacks by college students [21, 22]. Interventions promoting convenient and healthy food options may be helpful in countering the perception that healthy food is labor-intensive.At the social environmental level, parental control was viewed as both an enabler and barrier to healthy eating. Students reported that healthy food choices were easier with someone creating a healthier environment for them, or monitoring their behavior. Previous research also indicates that parental influence shapes the child’s perceptions of regularity and normal behavior [23]. Findings of the current study also aligned with previous research regarding the desire to rebel and overindulge in forbidden foods when too much parental control and prohibition is exercised [24].Aside from family groups, peer groups were also identified at the social environmental level. Part of this peer group includes friends, acquaintances, or a boyfriend. Through friend groups, behaviors are modeled, which can serve as either a barrier or enabler to healthy eating. In the current study’s focus groups, friends were valued as support for making a lifestyle change together especially with encouragement and keeping each other accountable for performing the desired behavior. However, although social support in these focus groups was a reported enabler, other studies in college students have reported peer groups as a barrier by normalizing stress-related eating behaviors, like eating when bored, bingeing on junk food, or eating at irregular times [25]. In the current study, participants mentioned eating when bored as an individual rather than social barrier.At the physical environmental level, the “all you can eat” style of cafeteria at UHM was deemed both a barrier and enabler of healthy eating, because both healthy and less healthy offerings are provided on an unlimited, regular basis. In order to “get one’s money worth,” some students reported eating beyond satiety. However, with buffet layout, there are ways to reduce mindless overeating or minimize the effect of overeating by portioning food or avoiding more than two different foods on the plate at the same time [26]. Aside from minimizing overeating, placing healthier foods at the front of the cafeteria may increase better food choices in the buffet [27]. A possible intervention could include teaching healthier buffet behavior in conjunction with modifying the physical layout of the buffet.Location of grocery stores in relation to campus, dorms, or living situation was a barrier for students. A previous study in Hawai’i has been conducted to understand food availability and affordability in local communities based on supermarket or farmer’s market offerings and proximity to bus lines for several communities [28]. Future studies could adapt the aforementioned study’s analysis for food availability and affordability in the UHM college and surrounding neighborhood area by examining rent/housing costs, distance to grocery stores or farmer’s markets, cafeteria offerings, and bus line proximity. It is also recommended that future studies measure travel time to grocery stores from campus as travel time is a convenience-related cost that students consider when making food choices [29].In examining barriers at all levels, cost was the most frequently mentioned barrier, which aligns with the findings of previous studies [9, 11, 30]. Previous research has revealed that healthy diets cost more on a daily basis than unhealthy diets [31]. Moreover, the cost of living in Honolulu is the highest in the United States [32]. Shipping, importation, distribution, and other factors in Hawaii are components of the high food cost. Limited interventions in the college environment have been conducted with food cost-lowering measures, and none have been done yet in Hawaii. A previous study found that identifying budget-friendly fruit and vegetable options as a point-of-purchase message was effective in increasing fruit and vegetable selection by college students, and future research could determine if this intervention is translatable to Hawaii’s population [30].Students’ perceived norms played a role in enabling healthy behaviors, as participants perceived health as trendy, especially in social media in the past few years [33]. Some participants regarded social media as a source of health promotion, allowing students to shape their perception of normalized behavior by selecting whom to follow. Students may model behavior seen in social media or use it as reinforcement of healthy behaviors. When healthy behaviors are considered part of social identity, and these attitudes are repeatedly reinforced via social media, students may maintain healthier behaviors through the reinforcing spiral model [34].

Limitations

The study may have been subject to selection bias, because students who participated in the study knew the topic prior to the focus group and may have had an interest in healthy eating. Half of the students who took part in the study were also from nutrition or health-related majors, which means that their eating habits may not reflect those of the broader student population. Findings may not be generalizable to the rest of the population, nor are the identified barriers or enablers quantifiable.

Future directions

Future studies could use triangulation to further explore the barriers and enablers through the mix of qualitative and quantitative method research [35]. Aside from further elucidating the barriers and enablers, questionnaires could be administered to quantify or rank barriers or enablers in relation to each other.
Future studies on the physical environment of the school and students’ living conditions would be helpful in determining how to establish a more supportive environment, especially since the physical environment was a commonly identified barrier. Interventions should be focused on addressing the most significant perceived barriers of cost, institution, and location to build a supportive environment for healthy eating.

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