Project Aims Summary:
This project will use a mixed-methods approach that includes quantitative and qualitative methods, to measure dietary intakes and explore the barriers and facilitators to healthy eating in Māori participants. Participants will engage in critical reflection and act as their own change agents, and to empower them as holders of knowledge that could help them modify their dietary behaviours.
The objectives of this project are to use photovoice and accompanying wānanga and pūrākau to a) determine the effectiveness of photovoice in capturing data on dietary intake and influencing nutritional behaviour change, b) identify key barriers and themes related to food security, c) determine its effectiveness in capturing data on household dietary intake, d) build community relationships. The project will undertaken by Māori researchers, Māori participants and Māori educators, increasing the capacity and capability of the Māori and Pacific health research workforce.
Cardiovascular disease (CVD) is the leading cause of mortality worldwide (WHO, 2014). In 2017, an estimated 17.8 million deaths worldwide were attributed to CVD (Mensah, Roth, & Fuster, 2019), and it is anticipated that CVD will result in approximately 23 million deaths by 2030 (Mathers & Loncar, 2006). Inequalities in CVD prevalence and cardiovascular outcomes are evident between countries, and disparities according to gender, ethnicity and socio-economic status are supported by research evidence.
Inequities in CVD for Māori are well recognised. Coronary heart disease is the single most important contributor to avoidable deaths in Māori and Pacific people with approximately 6–7 years difference in life expectancy between Māori and Pacific, compared with non-Māori non-Pacific people (Cameron et al., 2012; Brewer et al., 2021). Māori have a significantly higher prevalence of CVD risk factors, and are more likely to develop and die prematurely from CVD (Brewer et al., 2022). Māori men are 1.7 times more likely, and Māori women twice as likely, to be obese than non-Māori men and women (Ministry of Health, 2011a). Raised blood pressure, a significant contributor of CVD, is more prevalent in Māori than non-Māori, and approximately 37% of Māori men and 17% of Māori women exceed the healthy cut-off of <4.5 of total to high-density lipoprotein cholesterol (HDL-C) (Ministry of Health, 2011a). Māori are affected to an even greater degree by diet-related metabolic disease than their urban equivalents and Māori based in rural areas have been found to have higher rates of obesity, hypertension, dyslipidaemia, and type 2 diabetes mellitus (Cameron et al., 2012).
Nutrition has been shown to be the most important behavioural factor in preventing and reducing CVD death and disability, surpassing smoking cessation and physical activity (Casas, Castro-Barquero, Estruch, & Sacanella, 2018). Consuming a healthy diet is determined by a number of factors including food security. Food security entails people having, at a minimum, the availability of nutritionally adequate and safe foods, and an ability to acquire foods in socially acceptable ways (Anderson, 1990). The three pillars of food security are (i) food availability and sufficient quantities of food, (ii) food access and having sufficient resources to obtain foods for a nutritious diet and (iii) food use based on a knowledge of basic nutrition and care, as well as adequate water and sanitation (WHO, 1996). Conversely, food insecurity refers to a social and economic problem associated with lack of food because of resource constraints. The availability and accessibility of different foods may also influence dietary patterns (Franco et al., 2009).
Dietary intake information is key to understanding nutrition-related outcomes. However, the accurate assessment of dietary exposure is challenging due to differences between populations and the amount and kind of food consumed, which varies day to day between and within study participants, and over the life course (Bailey, 2021). Dietary intake can be assessed by subjective self-report such as food diaries, recalls or food frequency questionnaires (FFQs), with each different assessment approach having its own limitations. Key challenges for self-reported dietary assessment tools (DATs) relate to measurement error and validation of methods, and it has been acknowledged that none of the dietary assessment methods available for measuring dietary intake are totally free of error (Bailey, 2021). Researchers may choose a particular instrument for practical reasons, such as cost. However, results may be misleading and do not reflect how the availability and accessibility of different foods may also influence dietary patterns.
An understanding of the wider set of social meanings attached to food and going without food is required to develop strategies to improve food security. Traditional outside expert approaches in research to address community health issues are often unsuccessful in their effectiveness (Hergenrather, Cowan, Bardhoshi, & Pula, 2009). In order to understand and eliminate and/or reduce health disparities, research methods emphasising community involvement through partnership are integral to the research process. Community-based participatory research (CBPR) ensures community members are involved throughout the research process to produce data that are authentic to the community experience and action (Hergenrather et al., 2009).
Photovoice is a form of participatory research within CBPR. Photovoice was specifically developed to open avenues for politically marginalized populations to identify important places and issues where they live and to communicate and share their experiences (Wang & Burris, 1997). Participants share their opinions and work collaboratively to find solutions to community problems. Because research participants (not researchers) identify what is important in their experiences, data directly reflect the research populations' views (Martin, Garcia, & Leipert, 2010; Wang et al., 1997; Adams, Burns, Liebzeit, Ryschka, Thorpe, & Browne, 2012). This places greater control in the hands of the research population, giving insight into unique perspectives and experiences. A number of benefits have been identified for Indigenous peoples using this method, such as, balancing power between researchers and participants, creating a sense of participant ownership, increasing trust between communities and academics, building skill and capacity and providing responsiveness to cultural preferences (Castleden et al. 2008; Adams et al., 2012). The individual effects of participation include feelings of increased self-confidence, empowerment, and self-efficacy to advocate for one’s community (Wang et al., 1997).
Photovoice has the potential to produce meaningful information for Māori, since it captures their experiences through visual materials and accompanying narratives. In addition to this, photovoice provides and opportunity to provide a more holistic and balanced approach to the quantification of nutrient intakes within a Māori population, and how the availability and accessibility of different foods may also influence dietary patterns.
Adams, K., Burns, C., Liebzeit, A., Ryschka, J., Thorpe, S., & Browne, J. (2012). Use of participatory research and photo‐voice to support urban Aboriginal healthy eating. Health & Social Care in the Community, 20(5), 497-505.
Bailey, R. L. (2021). Overview of dietary assessment methods for measuring intakes of foods, beverages, and dietary supplements in research studies. Current Opinion in Biotechnology, 70, 91-96.
Brewer, K. M., Grey, C., Paynter, J., Winter-Smith, J., Hanchard, S., Selak, V., ... & Harwood, M. (2022). Protocol: What are the gaps in cardiovascular risk assessment and management in primary care for Māori and Pacific people in Aotearoa New Zealand? Protocol for a systematic review. BMJ Open, 12(6).
Cameron, V. A., Faatoese, A. F., Gillies, M. W., Robertson, P. J., Huria, T. M., Doughty, R. N., ... & Pitama, S. G. (2012). A cohort study comparing cardiovascular risk factors in rural Māori, urban Māori and non-Māori communities in New Zealand. BMJ open, 2(3), e000799.
Casas, R., Castro-Barquero, S., Estruch, R., & Sacanella, E. (2018). Nutrition and cardiovascular health. International Journal of Molecular Sciences, 19(12), 3988.
Franco, M., Diez-Roux, A. V., Nettleton, J. A., Lazo, M., Brancati, F., Caballero, B., ... & Moore, L. V. (2009). Availability of healthy foods and dietary patterns: the Multi-Ethnic Study of Atherosclerosis. The American Journal of Clinical Nutrition, 89(3), 897-904.
Hergenrather, K. C., Rhodes, S. D., Cowan, C. A., Bardhoshi, G., & Pula, S. (2009). Photovoice as community-based participatory research: A qualitative review. American Journal of Health Behavior, 33(6), 686-698.
Jani, R., Rush, E., Crook, N., & Simmons, D. (2018). Availability and price of healthier food choices and association with obesity prevalence in New Zealand Maori. Asia Pacific journal of clinical nutrition, 27(6), 1357-1365.
Martin, N., Garcia, A. C., & Leipert, B. (2010). Photovoice and its potential use in nutrition and dietetic research. Canadian Journal of Dietetic Practice and Research, 71(2), 93-97.
Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine, 3(11), e442.
Mensah, G. A., Roth, G. A., & Fuster, V. (2019). The global burden of cardiovascular diseases and risk factors: 2020 and beyond. Journal of the American College of Cardiology, 74(20), 2529-2532.
Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health education & Behavior, 24(3), 369-387.
World Health Organization. (2014). Global status report on noncommunicable diseases 2014 (No. WHO/NMH/NVI/15.1). World Health Organization.
Project lead: Dr Lillian Morton, Chief Science Officer - Mānuka Performance