Health Education Research, Vol. 19, No. 2, 165-174,
April 1, 2004
© 2004 Oxford University Press
Reported barriers to eating more fruit and vegetables before and after participation in a randomized controlled trial: a qualitative study
1 Division of Public Health and Primary Health Care and 2 Cancer Research UK General Practice Research Group, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF, UK 3 Correspondence to: S. Ziebland; e-mail: sue.ziebland{at}dphpc.ox.ac.uk
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionReferences |
|---|
This qualitative study compares the barriers to eating more fruit and vegetables reported before and after participation in a 6-month randomized controlled trial in primary care. At the initial intervention appointment of a primary care intervention to promote eating five or more portions of fruit and vegetables a day, participants were asked to identify the barriers that they thought they might encounter. Barriers were discussed again at the final appointment 6 months later. At the end of the study, a purposive sample of 40 of the trial participants was interviewed to explore their experiences in greater detail. Transcripts of tape recordings of the intervention appointments and the semi-structured interview were analysed using qualitative methods. This paper presents the results of a qualitative analysis of these appointment and interview transcripts (results of the trial are published elsewhere). Women reported that children and male partners were obstructive to their attempts to eat more fruit and vegetables, whilst men reported that their partners were supportive of the change. The perception that fruit and vegetables were expensive was a relatively intractable barrier for those with inflexible food budgets. Some barriers, including the problem of getting fruit and vegetables when travelling or when the daily routine is disrupted such as at weekends, were not anticipated and only encountered when participants tried to make changes. However, while all but three of the interview respondents described experiencing at least one barrier to eating more fruit and vegetables, three quarters (29 of 40) reported an increase in intake of between one and five daily portions. This study adds to the existing literature in that it investigates those barriers that were reported at the end of, as well as before, a 6-month trial of a dietary intervention. The findings show that trial participants were not always able to anticipate what might be a barrier to change at the initial intervention appointment. The flexible action plan meant that if participants found their initial plan hard to maintain, they were able to adapt it rather than give up. This suggests that health behaviour interventions that are negotiated and non-prescriptive may be more successful than those that are relatively inflexible.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Diets low in fruit and vegetables have been associated with an increased risk of cancer and heart disease. In 1994, the UK Cardiovascular Review Group recommended a daily intake of five to six portions of fruits and vegetables, twice the average British adult consumption, although patterns vary between different parts of the country and between social classes (Whichelow et al., 1991
; Billson et al., 1999).
Among the many influences on diet are availability, cost and time, which can be seen as ‘external’ to the person. These contrast with ‘internal’ factors such as tastes and preferences (Ziebland et al., 1998). Foremost among the external barriers to eating a healthy diet is cost. Focus groups, surveys and interview studies have repeatedly shown that the relatively high cost of fruits and vegetables is a barrier to healthy eating for people on low incomes (Reicks et al., 1994; Marshall et al., 1995; Treiman et al., 1996). Socially deprived areas may lack local sources of reasonably priced, good-quality fruit and vegetables, causing a vicious circle of poor demand and supply. People on lower incomes have less access to cars and out-of-town shopping centres, and are less able to carry and transport food in bulk (Caraher et al., 1998). Other external factors include availability in the workplace, where many canteens offer relatively poor value for fresh salads, vegetables and fruit compared with high turnover ‘fast foods’ (Anderson et al., 1998; Anderson and Cox, 2000). The perception that fruits and vegetables are time-consuming to prepare is a frequently cited barrier (Treiman et al., 1996; Anderson et al., 1998).
Families exert a strong external influence on diet. Women are much more likely than men to prepare main meals and shop (Warde and Hetherington, 1994), but describe little control over what is eaten, and a need to juggle the tastes of their husbands and children (Charles and Kerr, 1988; McKie et al., 1993). Marshall’s study (Marshall, 1995) demonstrates how foods which are not objectionable to any family member are chosen, resulting in a narrow and repetitive range of fruit and vegetables. Anderson and Cox (Anderson and Cox, 2000) report a focus group study with participants from an 8-week intervention to increase consumption of fruit and vegetables. Respondents highlighted the importance of involving the immediate household, and reported the difficulty of dietary change without family and social support. They also raised the difficulty of persuading children to eat more vegetables. Kilcast (Kilcast, 1996) reports similar findings from a qualitative study in London, Glasgow and Birmingham. Mennell (Mennell, 1996) suggests that the accommodating stance that many contemporary British parents describe towards their children’s food preferences is in sharp contrast to earlier child-rearing advice to parents that children should not be allowed to refuse food. Parents’ recollections of having to eat food they disliked as children may contribute to a willingness to accommodate their children’s preferences, but there is also advice to avoid making mealtimes a battleground. Women are treated as responsible for nourishing their children from the moment they consider pregnancy and are also advised not to make eating an issue for fear of provoking eating disorders: the advice can seem contradictory (Lupton, 1996).
While families and other external factors are clearly influential, many people cite ‘internal’ barriers such as habit, tastes and preferences. Liking the taste of fruit and vegetables is, unsurprisingly, a strong predictor of whether the foods are eaten (Reicks, 1994). A questionnaire survey of 3000 women in America found that one of the most important factors in determining someone’s fruit and vegetable intake was whether the habit of eating lots of fruits and vegetables began in childhood (Krebs-Smith et al., 1999).
Most of the research on barriers to eating fruits and vegetables has explored those that people anticipate would be important, rather than reporting the barriers that are experienced when changes are attempted. An exception is the Take Five study (Anderson et al., 1998) in which respondents completed a structured questionnaire, which included a list of 16 situational barriers, before and after the intervention. Interventions that promote a large increase in intake need to accommodate actual as well as hypothetical barriers. In this paper we discuss how a purposive subsample of 40 participants (from a large trial to increase consumption of fruits and vegetables) anticipated and subsequently became aware of internal and external barriers to eating more fruit and vegetables. This study adds depth to the Take Five questionnaire results through a qualitative study, with 6-month follow-up, of a general practice sample who were not selected as contemplating change. We use data drawn from the transcriptions of the intervention and follow-up appointments, as well as a semi-structured interview after the trial was complete, which enables us to compare the barriers raised in different settings. We use four case studies to demonstrate how awareness of barriers changed.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The Healthy Life Project (HELP) was a randomized controlled trial that investigated the effect of a nurse-led primary-care intervention to increase fruit and vegetable consumption. The results of the trial are published elsewhere (John et al., 2002
). In this paper, we report the results of a qualitative study of the barriers to eating more fruit and vegetables, as reported by participants before and after participation in the trial.
Overview of the randomized controlled trial (John et al., 2002)
In the trial, 690 participants were recruited from General Practice lists, and randomized to intervention and control groups. Everyone attended two appointments, 6 months apart. Intervention group participants received an intervention based on a brief negotiation method, during which they were advised to eat at least five portions of fruit and vegetables a day. Self-reported intake from postal questionnaires showed a highly significant difference in change in fruit and vegetable consumption of 1.4 daily portions (95% confidence interval 1.11–1.56; P < 0.001) between the intervention and control groups, adjusted for gender and baseline intake, bringing the intervention group to an average of just under the recommended target of five portions per day.
The intervention and follow-up appointments
The brief negotiation method (Rollnick et al., 1999) was used for the 25-min intervention. Participants described their current eating patterns, and an action plan to increase fruit and vegetable consumption, based on their preferences, was agreed. During the intervention appointment, participants were asked about any barriers that they anticipated, and were given a tailored selection of materials including leaflets on eating on a budget, storage and preparation, recipe leaflets, information on pesticides, ideas for eating out or when travelling, and a five-a-day refrigerator chart to involve children (Boaz and Ziebland, 1998). Six months later, at the follow-up appointment, participants were asked to describe any barriers to eating fruit and vegetables that they had experienced. Intervention and follow-up appointments took place in the health centre and were audiotape-recorded for transcription.
The semi-structured interviews
Within 2 weeks of their follow-up appointment, a purposive sample (Marshall, 1996) of 42 of the intervention group was contacted by telephone and invited to participate in a semi-structured interview. Two declined to be interviewed. Table I shows the characteristics of the 40 qualitative study participants. The interviews were designed to collect information on the barriers to change that participants had encountered when trying to make changes to their fruit and vegetable consumption. The interview study comprised a maximum variation sample from the intervention arm of the trial, of those who would be likely to have experienced different barriers: men and women; smokers and non-smokers; people living with partners and those who lived on their own; those who reported different levels of self-reported changes in fruit and vegetable consumption during the trial; and people from different social classes. Social class grouping used the classification from the Employment Department Group (Employment Department Group, 1990). No incentives were offered for participation in these interviews.
|
A strength of the semi-structured interview is that it encourages the participant to discuss experiences without being constrained by a limited set of pre-conceived questions. In this study, the interviewer established a rapport with respondents and encouraged them to discuss their experiences in depth. The interviews were conducted at the respondents’ homes at a time of their choosing. The interviewer (J. H. J.) was a postgraduate student not involved in the delivery of the intervention. Interviews lasted 30–50 min, were audiotape-recorded and subsequently transcribed. Respondents were encouraged to describe their experiences in detail, including any barriers they encountered, rather than prompted to discuss specific types of barriers.
Analysis
For each of the participants in the qualitative study, we had three transcriptions available: sections of the intervention and 6-month follow-up appointments in which barriers were discussed, and a full transcription of the semi-structured interview. These were entered, separately, into the software NUD*IST for organization, coding and analysis (QSR NUD*IST, version 4; Sage Publications Software). The transcripts were examined, and each section of text where the interviewee mentioned a barrier to eating more fruit and vegetables was assigned a unique code. Coding was as broad as possible in the first instance. The text units for each code were then gathered together, reviewed, and, in some cases, re-coded and regrouped. Lastly, broader categories were identified and constant comparison ensured that the final categories represented the full range of the data.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
The results are presented in two parts. First, we compare the types of barriers anticipated by the 40 qualitative study participants at the intervention appointment with those that were reported at (1) the follow-up appointment and (2) the semi-structured interview collected after the end of the trial. We then draw on four individual case studies selected to illustrate and discuss how anticipated and experienced barriers differ, and what implications this has for intervention design. Although not atypical, the cases were chosen to illustrate the way that awareness of barriers changed.
Anticipated and experienced barriers
Half of the qualitative study respondents (19 of 40) anticipated a barrier at the intervention appointment. At the 6-month follow-up appointment, 17 of the 40 respondents reported that they had experienced a barrier, while in their home interview 2 weeks later all but five reported a barrier.
There were also differences in the nature of the barriers reported before and after the intervention period. This is demonstrated in Table II where the barriers are presented according to whether they are ‘external’ or ‘internal’ and raised at the intervention appointment, the follow-up appointment or the semi-structured interview at home. All the barriers that were anticipated at the start of the trial were also reported at the end of the trial. Most common among these were household preferences including the reluctance of (male) partners and children to eat fruit and vegetables, and the additional time required to prepare these foods. However, some barriers (e.g. the problem of getting fruit and vegetables when travelling or when the daily routine is disrupted such as at weekends) were only encountered once participants tried to make changes to their fruit and vegetable intake.
|
To illustrate the way that the participants became aware of barriers and made changes during the 6 months we will now discuss in greater detail the experiences of four participants (Table III) chosen to represent the different types of barriers described by the 40 participants.
|
Julie
Julie, is a 39-year-old counsellor who lives with her husband and three young children. Julie anticipated that her partner who ‘won’t eat fruit and...hates vegetables’ and children would make it difficult for her, since they shared family meals.
At the follow-up appointment, Julie again reported the problem that her family’s tastes had presented. She was responsible for the food shopping and preparation for the family and found her children’s dislike of vegetables a particular problem. If she prepared foods that the family did not like, food was wasted, yet she did not have the time to prepare different foods. Two weeks later at the semi-structured interview at home, Julie mentioned additional barriers. She liked pre-prepared foods but found them expensive and felt guilty about spending a substantial proportion of the family food budget on something that only she liked:
If I wanted to buy fresh prepared fruit salad and prepared salad, that could probably add at least ten pounds a week if I were to eat five a day every day. So that’s why I don’t do it because I feel guilty that that amount of money is going on what I like, that I want to try.
Julie said that the intervention research nurse had discussed the option of preparing foods for herself inexpensively. However, she found this time-consuming, and admitted that she was too lazy to prepare fruit and vegetable salads for herself: ‘I’d rather make a cup of tea, get some biscuits and sit back down and do my work’.
The intervention was designed to develop an action plan with the participants, shaped by their preferences. However, Julie had felt that she was being told what to do:
I decided I’m quite resistant to being told what to do...and having anything imposed upon me... I felt it was as if I had to pass some exam almost, not, obviously not quite as bad as that but I had to live up to an expectation that I will try to be something, you know like I was a child.
During the trial Julie’s self-reported fruit and vegetable intake increased from two to three daily portions. The barriers raised in the appointments demonstrate how her family’s preferences influenced her diet. Julie does not want to risk wasting food nor indulging her preference for prepared fruit and vegetable salads if she is the only one who would eat them. It is interesting that the additional barrier of feeling resistant to being told what to do was only raised at the home interview. Participants may offer different explanations in different circumstances or re-frame their experience after reflection. At the intervention Julie may have described her family’s preferences to lower the nurses’ expectations of what she could achieve or (at the follow-up appointment) to explain why she had not reached her target. In her interview at home she may have felt less constrained, and more willing to admit to liking less healthy foods and being resistant to advice.
Carl
Carl, aged 35, lives with his partner and works full-time as a marketing manager. Although he did not anticipate any barriers at the first intervention appointment, at follow-up he reported difficulty because of his busy work schedule. At the interview, Carl elaborated how his schedule was dictated by meetings, which made it difficult to plan food breaks and meant that he would sometimes not eat at all during the day. Carl also spent a lot of time driving, and said that he had found it difficult to get fruit and vegetables when he was on the road.
The nature of Carl’s job and the fact that fruit and vegetables were not readily available meant that he needed to plan ahead if he was going to reach his five-a-day target, but he reported: ‘I find it difficult to be disciplined and say right, I have all this fruit in the car. You can’t seem to buy these things from wherever’. However, despite these barriers, he said he was keen to eat more fruit and vegetables, and had managed to increase his intake from three to five portions a day by eating a piece of fruit and drinking a glass of juice with breakfast.
Patrick
Patrick is a 51-year-old builder who lives with his wife and three grown-up children. Patrick did not usually have a pudding in the week so thought that he could eat a piece of fruit as a dessert. At the follow-up appointment, he reported that this had been easiest during the early weeks of the study but felt that: ‘Five is a high figure if you’re not a fruity person’. At the initial appointment Patrick thought that he would find it more difficult to eat more vegetables than fruit, but at the home interview reported the reverse:
I‘m not a fruit person, I eat a lot of vegetables, it’s very difficult to bring something into your diet that you don’t use normally...like the vegetable bit was no problem... I grow me own anyway so it was easier. The fruit was more difficult because I don’t eat fruit.
Patrick reflected on his reluctance to eat fruit as an adult and suggested it would be easier to eat fruit if he had developed the habit in childhood: ‘...if you started when you were a baby eating an orange a day or something you would continue to eat an orange a day’.
Patrick had had cancer a few years before. He had not managed to stop smoking and expressed doubts that smoking was responsible for his cancer. However, he believed that he could change his diet:
I know I was lucky, but when I went into the hospital, they couldn’t understand why I was still alive and you get over that, beat it, and the doctors and whatever beat it and you think ‘That’s a warning’. I’ll still smoke but then again I’m not a believer that smoking causes cancer. So you try something else [i.e. increasing fruit and vegetables intake]. [Excerpt from interview]
Patrick increased his portions from one to three a day during the trial. He illustrates that the original action plan may need to be substantially revised if it is to be effective. One of the benefits of an intervention where the participants devise an action plan according to their own preferences is that they are well aware how revisions to the plan can be made. Thus, when Patrick had difficulties eating extra fruit, he increased his consumption of home-grown vegetables. Patrick’s story also illustrates how for some people, it may seem easier to change their diet than to stop smoking. Patrick suggested that his history of cancer gave him the added motivation to make the dietary change.
Catherine
Catherine is a 37-year-old single parent who cares full-time for her children aged 6 and 8 years. At the initial appointment, she reported that her meal options were dictated by what her children would eat, but at the follow-up appointment also raised the limited selection of fruit and vegetables available and the increased price in winter as barriers to increasing intake:
I mean in the winter you tend to get stuck on the same old veg and you think ‘oh, not again’... With the winter, the prices tend to go up. And when they do, I have to watch my budget. [Excerpt from follow-up appointment]
At the home interview Catherine again discussed the difficulties of getting fruit and vegetables in the winter within her budget. However,
...meat is expensive and I can’t afford it...vegetables are filling. It was cheaper to do like a vegetable soup than it was to give the kids burgers and chips and it was better for them as well.
The intervention leaflet prepared for people shopping on a budget suggested that bargains might be found at the end of day from market stalls. However, Catherine did not have a car, and found that fruit and vegetables that were available cheaply were usually heavy to carry:
I don’t drive so I have to walk and carry and it’s heavy isn’t it actually. I do it in two or three trips... I mean you get these offers...where you can get, I don’t know, 10 pineapples for a pound or something. [Excerpt from interview]
Catherine was more constrained by external factors such as her budget and access to shops than most of the participants in our study. Internal barriers of taste and preferences were not reported to be an issue for Catherine, who was keen to provide her children with a healthy diet. Her case illustrates the limitations of behavioural interventions for people whose major barrier is inadequate resources. Catherine’s intake remained at three portions a day.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
This qualitative study explores the relationship between the barriers that people reported before and after attempting to eat more fruit and vegetables. The intervention, like many other health behaviour interventions, was designed to include a discussion of barriers that participants anticipated they might encounter. However, we were aware that these might change during the 6-month trial. This was therefore a good opportunity to use qualitative methods to develop an understanding of the role of barriers before and after exposure to an intervention in a general practice population The list of internal and external barriers we identified broadly confirms to the findings of other studies (Cox et al., 1996
; Anderson et al., 1998), and suggests that a sufficient range of materials were developed for our intervention. However, trial participants were not always aware, or perhaps willing to admit at the intervention appointment, what might be a barrier to change. In the trial, participants were given a selection of materials designed specifically to address only those barriers to change that they anticipated, an approach which is more participant-centred than giving everyone an identical and comprehensive set of materials. However, during the first few weeks of the trial the participants become aware of additional barriers. This suggests that dietary interventions, in common with other health promotion interventions (EPPI Centre, 1996, 2001), may benefit from discussing barriers during an early follow-up contact, rather than only providing for those barriers anticipated at the initial appointment. While it might be expected that participants would be aware of more barriers after attempting to change, it is also noteworthy that more barriers were raised at the semi-structured interview than at the follow-up appointment. External barriers such as children’s reluctance to eat fruit and vegetables were more likely to be mentioned at the clinic appointment, whereas some internal barriers, such as being ‘resistant to being told what to do’, were only brought up by participants at the interview. This may be due in part to the different characteristics of the follow-up appointment and the semi-structured interview. The interviews took place about a fortnight after the follow-up appointment so respondents would have had more time to think about the changes they had made and possible barriers they had encountered. Interviews were carried out in the respondents’ homes with a postgraduate student, trained in qualitative interview methods. Respondents may have been more relaxed in this situation than with the nurse in a clinic setting. There was no pressure of time at the interviews, unlike at the clinic appointments, and respondents were able to discuss the subject in more detail.
Among the barriers identified in this study, the reported high cost and lack of access to fruit and vegetables were among the most intractable. Interventions to increase fruit and vegetable consumption among people on low incomes, or living in socially deprived neighbourhoods, may need to include incentives and delivery schemes as well as motivational advice (Anderson et al., 2001).
Other external barriers related to the social context in which food is consumed and demonstrate that where meals are shared, it is difficult for an individual to make changes alone (Anderson and Cox, 2000). Children’s dislike of fruit and vegetables was raised by many of the parents in this study, and has been repeatedly highlighted as an issue in research (Kilcast, 1996). Interventions may be delivered to individuals, but changes in diet are not accomplished in a vacuum. Approaches that recognize the involvement of the whole household may be more likely to succeed.
Parents’ despair at their failure to encourage children to eat fruit and vegetables may be linked to the belief that eating habits are formed early in life. Parents may find themselves caught between anxiety about the long-term effects of unhealthy eating habits in childhood and the worry that if eating becomes an issue the child may be vulnerable to eating disorders (Lupton, 1996). Encouragingly, there is some evidence that school-based interventions to introduce children to a wider range of fruits and vegetables as part of the curriculum or school meals service may help to overcome the impasse between despairing parents and intransigent children (Bangor Food Research Unit, 2001).
In our small qualitative study it was only male partners who were described as obstructing the attempt to eat more fruit and vegetables, while men believed that their female partners would support the change. This may be because of the role that women take in providing nourishment and looking after the health of the family (Charles and Kerr, 1988; McKie et al., 1993). Another explanation is that vegetables and fruits are viewed as feminine foods. In Lupton’s Australian study she concludes:
There is a symbiotic metaphorical relationship between femininity and vegetables: the eating of vegetables denotes femininity and femininity denotes a preference of vegetables. A similar relationship exists for masculinity and meat eating. (Lupton, 1996
In a British intervention study, few participants took up the option of vegetarian meals, preferring to eat fruit as a dessert or snack, or drink fruit juice to attain their target (Cox et al., 1998). For some participants changing to a diet that includes vegetarian dishes may be unappealing.
A final important observation is that although all but three of the respondents in this qualitative study described experience of at least one barrier to eating more fruit and vegetables, three-quarters (29 of 40) reported that they succeeded in increasing their fruit and vegetable intake, as well as giving convincing accounts of how the changes had been made. In the main trial, these reports were backed up by significant changes in blood pressure and serum antioxidants (John et al., 2002). While we cannot be sure why the intervention was successful, we suspect that contributory factors were that it was based on a simple, positive, non-controversial message to increase fruit and vegetable consumption to five or more portions a day; that the action plan was determined by the preferences of the participant; that alternative approaches to reaching the five-a-day target were discussed; and that the intervention was supported by take-home materials including a pictorial portion guide. The accounts from the qualitative interviews suggest that participants adapted their initial plan if it was hard to maintain in practice. These findings support the development of health promotion interventions which offer flexibility rather fixed targets which may not be achievable by everyone.
|
Acknowledgements |
|---|
We would like to thank all the participants in the qualitative study and our colleagues on the HELP trial: Jenny Jay, Andrew Neil, Janet Robertson, Liane Roe and Pat Yudkin.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionReferences |
|---|
Anderson, A. and Cox, D. (2000) Five a day—challenges and achievements. Nutrition and Food Science, 30, 30–34.
Anderson, J.V., Bybee, D.I., Brown, R.M., McLean, D.F., Garcia, E.M., Breer, M.L. and Schillo, B.A. (2001) 5 a day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association, 101, 195–202.[CrossRef][ISI][Medline]
Anderson, A.S., Cox, D.N., McKellar, S., Reynolds, J., Lean, M.E. and Mela, D.J. (1998) Take Five, a nutrition education intervention to increase fruit and vegetable intakes: impact on attitudes towards dietary change. British Journal of Nutrition, 80, 133–140.[CrossRef][ISI][Medline]
Bangor Food Research Unit (2001) Food Dudes Healthy Eating in Schools Programme. Available at: www.fooddudes.co.uk.
Billson, H., Pryer, J.A. and Nichols, R. (1999) Variation in fruit and vegetable consumption among adults in Britain. An analysis from the dietary and nutritional survey of British adults. European Journal of Clinical Nutrition, 53, 946–952.[CrossRef][ISI][Medline]
Boaz, A. and Ziebland, S. (1998) A ‘five-day’ fruit and vegetable pack for primary school children. Part I: development and pre-testing. Health Education Journal, 57, 97.
Caraher, M., Dixon, P., Lang, T. and Carr Hill, R. (1998) Access to healthy foods: part I. Barriers to accessing healthy foods: differentials by gender, social class, income and mode of transport. Health Education Journal, 57, 191–201.
Cardiovascular Review Group (1994) CMAFPC Nutritional Aspects of Cardiovascular Disease 46. Department of Health Report on Health and Social Subjects. HMSO, London.
Charles, N. and Kerr, M. (1988) Women, Food and Families. Manchester University Press, Manchester.
Cox, D.N., Anderson, A.S., Reynolds, J., McKellar, S., Lean, M.E. and Mela, D.J. (1998) Take Five, a nutrition education intervention to increase fruit and vegetable intakes: impact on consumer choice and nutrient intakes. British Journal of Nutrition, 80, 123–131.[ISI][Medline]
Cox, D.N., Anderson, A.S., McKellar, S., Reynolds, J., Lean, M.E. and Mela, D.J. (1996) Vegetables and fruits: barriers and opportunities for greater consumption. Nutrition and Food Science, 5, 44–47.
Employment Department Group (1990) OPCS Standard Occupational Classification. Vol. 2. HMSO, London.
EPPI Centre (1996) Review of Effectiveness of Health Promotion Interventions for Men Who Have Sex With Men. EPPI Centre, University of London. Available at: http://eppi.ioe.ac.uk/EPPIWeb/home.aspx.
EPPI Centre (2001) Young People and Physical Activity: A Systematic Review of Research on Barriers and Facilitators. EPPI Centre, University of London. Available at: http://eppi.ioe.ac.uk/EPPIWeb/home.aspx.
John, J.H., Ziebland, S., Yudkin, P., Roe, L. and Neil, H.A.W. (2002) A randomized controlled trial of a primary care intervention to increase fruit and vegetable consumption: effects on plasma antioxidant concentrations and blood pressure. Lancet, 359, 1969–1974[CrossRef][ISI][Medline]
Kilcast, D., Cathro, J. and Morris, L. (1996) Practical approaches to increasing vegetable consumption. Nutrition and Food Science, 5, 48–51.
Krebs-Smith, S.M., Heimendinger, J., Patterson, B.H., Subar, A.F., Kessler, R. and Pivonka, E. (1999) Psychosocial factors associated with fruit and vegetable consumption. American Journal of Health Promotion, 10, 98–104.
Lupton, D. (1996) Food, The Body and The Self. Sage, London.
Marshall, D., Anderson, A., Lean, M. and Foster, A. (1995) Eat your greens: the Scottish consumer’s perspective on fruit and vegetables. Health Education Journal, 54, 186–197.
Marshall, M.N. (1996) Sampling for qualitative research. Family Practitioner, 13, 522–525.
McKie, L.J., Wood, R.C. and Gregory, S. (1993) Women defining health: food, diet and body image. Health Education Research, 8, 35–41.
Mennell, S. (1996) All Manners of Food: Eating and taste in England and France from the Middle Ages to the Present. University of Illinois Press, Champaign, IL.
Reicks, M., Randall, J.L. and Haynes, B.J. (1994) Factors affecting consumption of fruit and vegetables by low-income families. Journal of the American Dietetic Association, 94, 1309–1311.[CrossRef][ISI][Medline]
Rollnick, S., Mason, P. and Butler, C.C. (1999) Health Behaviour Change—A Guide to Practitioners. Churchill Livingstone, London.
Treiman, K., Freimuth, V., Damron, D., Lasswell, A., Anliker, J., Havas, S., Langenberg, P. and Feldman, R. (1996) Attitudes and behaviors related to fruits and vegetables among low-income women in the WIC program. Journal of Nutrition Education, 28, 149–156.
Warde, A. and Hetherington, K. (1994) English households and routine food practices. The Sociological Review, 42, 758–778.
Whichelow, M.J., Erzinclioglu, S.W. and Cox, B.D. (1991) Some regional variations in dietary patterns in a random sample of British adults. European Journal of Clinical Nutrition, 45, 253–262.[ISI][Medline]
Ziebland, S., Thorogood, M., Yudkin, P., Jones, L. and Coulter, A. (1998) Lack of willpower or lack of wherewithal? ‘Internal’ and ‘external’ barriers to changing diet and exercise in a three year follow-up of participants in a health check. Social Science and Medicine, 46, 461–465.
Received on October 25, 2002; accepted on February 28, 2003
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  L. H. Kushi, T. Byers, C. Doyle, E. V. Bandera, M. McCullough, T. Gansler, K. S. Andrews, M. J. Thun, and The American Cancer Society 2006 Nutrition and Phy American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention: Reducing the Risk of Cancer With Healthy Food Choices and Physical Activity CA Cancer J Clin, September 1, 2006; 56(5): 254 - 281. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. O. Strolla, K. M. Gans, and P. M. Risica Using qualitative and quantitative formative research to develop tailored nutrition intervention materials for a diverse low-income audience Health Educ. Res., August 1, 2006; 21(4): 465 - 476. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Pomerleau, K. Lock, C. Knai, and M. McKee Interventions Designed to Increase Adult Fruit and Vegetable Intake Can Be Effective: A Systematic Review of the Literature J. Nutr., October 1, 2005; 135(10): 2486 - 2495. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||