© 2014 Springer Publishing Company

Hispanic Health Care International, Vol. 12, No. 1, 2014

http://dx.doi.org/10.1891/1540-4153.12.1.43

Using the PRECEDE-PROCEED Model to Assess Dietary Needs in the Hispanic Population in Northeastern Pennsylvania Diana Cuy Castellanos, PhD, RD University of Dayton, Ohio Katie Abrahamsen, MA Marywood University, Scranton, Pennsylvania Research shows that as Hispanic immigrants spend more time in the United States and/or become more assimilated to the U.S. culture their diet begins to mimic that of a Western diet. A dietary needs assessment was conducted in the target population of low income, first-generation Hispanics in the greater Scranton, PA, area to identify nutrition problems and inform culturally appropriate nutrition intervention development. The PRECEDE-PROCEED model was used to guide the assessment. Interviews with key informants and a focus group as well as demographic and dietary-related ­questionnaires were completed with the target population to identify health and nutrition needs in the community and factors regarding dietary behaviors. Behavioral and environmental objectives were developed and led to a culturally tailored nutrition intervention. Las investigaciones muestran que a medida que los inmigrantes Hispanos pasan más tiempo en los EE.UU. Se vuelven más asimilados a la cultura y su dieta comienza a imitar la de la dieta occidental. Se llevó a cabo una evaluación dietética en la población Hispana de primera generación, de bajos recursos, la mayoría en el área de Scranton, PA para identificar los problemas de nutrición e informar sobre el desarrollo de una intervención de nutrición culturalmente apropiada. El modelo PRECEDEPROCEDE fue utilizado para guiar la evaluación. Se realizaron entrevistas con informantes claves y un grupo de enfoque, así como cuestionarios demográficos y relacionados a la dieta con la población blanco para identificar las necesidades de salud y nutrición en la comunidad, así como los factores con relacionados a los hábitos alimenticios. Se desarrollaron objetivos conductuales y ambientales los cuales llevaron a una intervención nutricional culturalmente adaptada. Keywords: Hispanic; nutrition intervention; culturally tailored; PRECEDE-PROCEED

A

ccording to the 2010 U.S. Census, the Hispanic population, which includes recent immigrants and those of Hispanic background, increased from 35.6 million in 2000 to 48.9 million in 2010. The U.S. Census Bureau projects that the Hispanic population will continue to increase and will reach 59.7 million by the year 2020. By 2050, it is forecasted that Hispanics will constitute 24.4% of the U.S. population. In particular, the state of Pennsylvania experienced a 35% growth in the Hispanic population between the years of 2000 and 2010, with the

Hispanic population in Lackawanna County growing 261% between 2000 and 2010 (U.S. Census Bureau, 2011). This population represents 5% of the total Lackawanna County population and 10% of the population in the city limits of Scranton, which lies in the county (Pew Hispanic Center [PEW], 2011). In terms of education and income level, the Hispanic population in Lackawanna County mirrors that of the overall U.S. Hispanic population. This population group is less educated and has a higher poverty rate when compared to non-Hispanics (U.S. Census Bureau, 2011). 43

Castellanos and Abrahamsen

Furthermore, health disparities and risk factors such as high rates of diabetes and obesity as well as low physical activity and unhealthy dietary behaviors affect the Hispanic population residing in the United States (Centers for Disease Control and Prevention [CDC], 2010; Elder, Ayala, Parra-Medina, & Talavera, 2009). Factors ­associated with these health disparities include but are not limited to lack of health care access, low health and nutrition literacy, poverty, and acculturation (Elder et al., 2009; Goel, McCarthy, Phillips, & Wee, 2004; Lara, Gamboa, Kahramanian, Morales, & Hayes Bautista, 2005). With the rapidly increasing Hispanic population in Lackawanna County, it is important to assess their nutrition and health-related needs and develop community-oriented interventions that address health disparities affecting this population. With the growing prevalence of chronic disease, community-based interventions that address nutrition behaviors and overall health status are needed. Interventions that are culturally tailored and target identified influencing factors are shown to be successful in this population (Lorig, Ritter, & Gonzalez, 2003; Mier, Ory, & Medina, 2010; Pérez-Escamilla, ­ Hromi-Fiedler, Vega-Lopez, Bermudez-Millan, & Segura-Perez, 2008). However, Mier et al. (2010) note that many of the current interventions with the Hispanic population only target behavioral factors related to health and nutrition and fail to address related environmental factors; possibly ­limiting their effectiveness. The PRECEDE-PROCEED model has been used extensively in the health arena to assess health needs and guide intervention development, implementation, and evaluation specific to a certain population (Green & Kreuter, 1999). The model is outlined in Table 1 and includes nine phases. First, the PRECEDE portion of the model assesses

the health or nutrition needs of a particular population and the predisposing, reinforcing, and enabling (PRE) factors associated with an identified need. This leads to the development of an intervention that targets the identified need through addressing the PRE factors. From here, the PROCEED portion includes the ­implementation and evaluation of the intervention. The purpose of this research was to assess the nutrition-related issues in a Hispanic population residing in a metropolitan city in the northeastern United States. The information gained from the assessment was used to inform the development of a culturally appropriate intervention. In this article, the needs assessment process and results are reported as well as the implications to future practice.

Methodology Procedures The PRECEDE-PROCEED model guided the development and implementation of the needs assessment. The core research team consisting of the primary investigator (PI), project research assistant, and bilingual research assistant completed most of data collection and analysis procedures. Dietetic interns affiliated with a local university assisted in a portion of the data collection. Different data collection methods were used to (a) determine the target diet-related need within the population, (b) develop behavioral and environmental objectives to address the need, and (c) identify influencing dietary factors associated with each objective. The data collection methods included a review of current research and demographic, social and health data, key informant interviews, a focus group interview, and demographic and dietary-related questionnaires completed by a sample of the target population. These methods are described in the ­following section. This study was approved by the Marywood University Institutional Review Board.

TABLE 1.  PRECEDE-PROCEED Model PRECEDE Phases Phase 1

Social assessment

Phase 2

Epidemiological assessment

Data Collection Methods

Phase 3

Behavioral and environmental assessment

Phase 4

Educational and ecological assessment

Phase 5

Administration and policy assessment

Secondary Data. The research team gathered ­information from the U.S. Census Bureau, the CDC, the Department of Health and Human Services as well as primary literature. This data was organized into tables based on the topics presented in the Hispanic Health Needs Assessment document developed by The National Alliance for Hispanic Health (2001). These data were then used to identify and compare findings related to the nutrition and health needs of the target population. Key Informant Interviews. The research team, with the assistance of the dietetic interns, identified community members who worked closely with the Hispanic community in the target county. Each key informant was 18 years of age or older. The identified key informants were contacted by the primary research assistant or ­dietetic intern

PROCEED Phases Phase 6

Implementation

Phases 7, 8, and 9

Process, impact, and outcome Evaluation

Green, L., & Kreuter, M. (1999). Health promotion planning: An educational and environmental approach (3rd ed.). Mountain View, CA: Mayfield. 44

Dietary Needs in the Hispanic Population

TABLE 2.  Key Informant Questions Adapted From the Hispanic Health Needs Assessment (N 5 8) Topics

Key Informant Questions

Health issues

  1. What do you perceive as the major health concerns within the Hispanic community here in Scranton and the surrounding areas?   a.  What do you believe are the major causes of these health concerns?   2. Look at the list in front of you. Choose three that you believe are the most important for Hispanics in our community. (Give participants a minute to look then ask if anyone would like to share.) What are your reasons for choosing these conditions?   a.  In your opinion, how could these conditions be reduced or eliminated?   3. Now look at the list of health factors you have on page 2. Select at most five factors that you perceive as most important to Hispanics in the local community.   a. In your opinion how can these conditions be reduced or eliminated?   4. What health promotion services are currently doing a good job of reaching Hispanics in the ­community?   5.  What programs are most needed in the community?   6. We would like your opinion on which methods listed on page 3 are effective for purposes of health education/promotion services.   a.  Which do you believe are most affective and what are your reasons?   b. Do you know of specific places in the area (specific churches, stores etc.) that we may be able to access?

Nutrition issues

Now we would like to have your opinion on nutrition in the Hispanic community.   7. How do you believe that what you eat plays a role in different health issues affecting this community?   8.  How is hunger affecting the local Hispanic community?   a.  What are reasons for hunger in the community?   b. What needs to be done in the local community to address hunger in the local Hispanic population?   9.  How is obesity affecting the local Hispanic community? (children, adults etc.)   a.  What are reasons for obesity in the community?   b.  What needs to be done to address obesity in this community? 10.  Where do most people from this community access their food? 11.  What nutrition programs do you think would be beneficial to the local Hispanic community?   a.  Which do you think would be good organizations to implement these programs? 12. Is there anything else you would like to tell us about the Hispanic community and their ­nutrition needs?

The National Alliance for Hispanic Health. (2001). Hispanic Health Needs Assessment: A community guide for documenting health status and establishing priorities (3rd ed.). Retrieved from http://pdf.hispanichealth.org/hhna2001_1.pdf

and asked to participate. If the key informant agreed, a time and place was determined for the interview. The key informant interviewees consisted of three English as a second language (ESL) teachers, three health care ­workers, one priest, and a university student and all resided and worked in the target county. The primary research assistant or dietetic intern administered the interviews in English. First, the key informant read and signed the informed

c­onsent before the interview proceeded. The key informant interview guide used to collect information consisted of questions adapted from the Hispanic Health Needs Assessment Instrument (Table 2) and related to health and nutrition factors affecting the local Hispanic community (The National Alliance for Hispanic Health, 2001). The interviews lasted between 25 and 60 min and each participant received a $5 gift card to a local grocery store. 45

Castellanos and Abrahamsen

Table 3.  Focus Group Question Guide Understanding food choices

What are some main factors that currently influence your daily food intake?

Food supply and availability

What stores or places do you obtain your food from?

Income and food prices

How is the cost of foods in the United States different than in your country of origin?

Sociocultural factors

How do you think your family background has affected the way you currently eat?

Tradition

What are some traditional foods that you continue to consume in the United States? What are some differences in these foods here compared to in your country of origin?

Food preferences, cognitions, and attitudes

What foods do you tend to choose the most? What are the reasons you choose these foods?

Health beliefs and practices

Probe: Fast food, traditional foods, homemade foods, convenient foods, etc.What ­connection do you believe food and disease have?

Living and working ­conditions

How does your home environment affect the way you eat?

Children

What are some of your children’s favorite foods? ranged from “strongly disagree” to “strongly agree.” The questionnaire was divided into two subscales: diet-related psychosocial factors and diet-related environmental factors. The Cronbach alpha correlation coefficients were .0.70 for each subscale indicating acceptable internal reliability. The demographic questionnaire included items regarding participants’ age, years in the United States, civil status, education, and income. The instruments were pretested with four people from the target population for item comprehension and wording changes were made based from the participant’s feedback. Each questionnaire was translated from English into Spanish and back translated to insure accuracy. Fruit and Vegetable Screener. The Fruit and Vegetable Screener was developed by Wakimoto, Block, Mandel, and Medina (2006) and showed acceptable reliability with a Hispanic population sample (r 5 .64). It was used to describe fruit and vegetable intake in the participant sample. The screener includes seven different categories of fruits and vegetables. Each participant indicated the number of times each fruit or vegetable was consumed within a month’s timeline. The screener was used to calculate the average amount of fruits or vegetables consumed daily (Wakimoto et al., 2006). The screeners are available in Spanish and English. The demographic, diet-related influencing factors questionnaire and Fruit and Vegetable Screener were selfadministered with a convenience sample of first-generation Hispanics, 18 years of age or older who resided in the target county. If a participant was illiterate or did not ­ want to complete the questionnaires on his or her own, the primary researcher or the bilingual research assistant interview–administered the questionnaires. The research team recruited participants from a local health clinic and a Hispanic Catholic Church. Furthermore, each participant in the focus group also completed the questionnaires. Informed consent was obtained from each participant before data was collected. Each participant received a $5 gift card for completing the questionnaires and $10 if participated in

Focus Group Interview. The focus group interview guide (Table 3) was adapted from a previous guide exploring dietary-related factors with a Hispanic population (Cuy Castellanos et al., 2013; Falk, Sobal, Bisogni, Connors, & Devine, 2001). The guide included the following categories: understanding food choices; food supply and availability; income and food prices; sociocultural f­actors; food preferences, tradition, cognitions, and attitudes; health beliefs and practices; living and working conditions; and children and children influence on food. The guide was pretested with four people of the target population for item comprehension. Items were changed based on the pretest feedback. The guide was translated from English into Spanish by the PI who is bilingual and then back translated into English by the bilingual research assistant. A key informant interviewee recruited the focus group participants. There were 11 participants between the ages of 18 and 55 years with 4 males and 7 females. All participants were Hispanic; foreign born; and had immigrated from either Mexico, Honduras, Dominican Republic, or Ecuador. The PI conducted the focus group in Spanish. The PI read the informed consent form in Spanish and received signed consent from each participant before proceeding. At the end of the focus group, each participant completed the demographic and dietary-related questionnaires described in the following text. A $10 gift card to a local grocery store was provided to compensate for the participants’ time. Demographic and Psychosocial Dietary Questionnaires. The demographic and dietary-related influencing factor questionnaires were developed using data from a primary research study assessing dietary influencing factors in a Hispanic population (Cuy Castellanos et al., 2013). The dietary-related influencing factor questionnaire included 31 statements relating to behavioral and environmental dietary-influencing factors (Table 4). Each item was placed on a 5-point Likert-type scale with the participant indicating his or her level of agreement for each item, which 46

Dietary Needs in the Hispanic Population

Table 4.  Psychosocial and Environmental Dietary Factor Questionnaire Items and Responses Psychosocial (N 5 49)

Mean

SD

  1.  It is important to me to eat a diet that is made up of traditional Hispanic foods.

2.96

  2.  It is important to me to choose foods that are healthy.   3.  It is more important to me to like the taste of foods than whether the foods are healthy.   4.  I believe that foods that are part of a typical U.S. diet are mostly processed.   5.  I believe that women are responsible for food preparation.   6.  believe that men are financially responsible for their families.   7  I prefer traditional Hispanic foods over U.S. food.   8.  I prefer food that is healthy over food that is not.   9.  I read the food labels on foods before I purchase them. 10.  I consider health information before buying a food. 11.  Traditional Hispanic foods taste better than typical U.S. foods. 12.  I believe that what a person eats can affect his or her risk of getting heart disease. 13.  I believe that what a person eats can affect his or her risk of getting diabetes. 14.  I believe that what a person eats can affect his or her general health.

3.47 2.27 2.92 2.04 2.18 2.80 3.37 2.35 2.57 2.90 3.33 3.20

1.34  .96 1.38 1.11 1.41 1.30 1.31  .95 1.39 1.34 1.19 1.07 1.17

3.31

1.18

Environmental Factors (N 5 46)

Mean

SD

  1.  Sometimes it is hard for me to find foods that I like in the United States.

2.37

1.44

  2.  In the United States, most ingredients used in food preparation are processed.   3.  In the United States, it is hard to find some fruits and vegetables.   4.  In the United States, it is hard to find traditional Hispanic ingredients.   5.  I have access to fresh fruits and vegetables.   6.  Processed foods are readily accessible in the United States.   7.  Fruits and vegetables are expensive in the United States.   8.  Meat is expensive in the United States.   9.  Processed foods are expensive in the United States. 10.  It takes a lot of time to prepare traditional meals. 11.  I have the skill to prepare traditional meals. 12.  I have the skill to prepare healthy foods. 13.  My diet is influenced by people I live with (spouse, children, or roommates). 14.  I like that foods in the United States are quick and easy to prepare. 15.  The prices of foods I like are within my budget. 16.  I have transportation to the markets that have the foods I like to buy. 17. I eat more fast food because it is more available to me in the United States than in the c­ ountry where I am from. 18. In the United States, I have more money to spend on food than in the country where I am from.

2.85 2.02 2.15 2.74 3.24 2.87 2.57 2.09 2.50 2.85 2.80 2.48 2.07 2.11 3.00 1.54

1.21 1.50 1.44 1.24 1.14 1.31 1.34 1.33 1.43 1.23 1.67 1.43 1.14 1.14 1.38 1.44

2.54

1.39

the focus group as well. The following provides a description of how each measure was incorporated into the PRECEDEPROCEED model to inform intervention development.

target nutrition issue, the following analysis occurred. The interviews and focus group were audio-recorded and transcribed verbatim by a member of the research team into the language in which they were administered. The PI, primary research assistant, and bilingual research assistant used thematic analysis to analyze the data from the transcriptions. First, each researcher did line-by-line ­coding for the key informant interviews and the focus group.

Data Analysis Phases 1 and 2. To assess the social and epidemiological factors related to the target population and identify the 47

Castellanos and Abrahamsen

Codes were extracted and discussed among researchers and then defined to create a code book. Based on the core codes, the researchers identified major social and epidemiological themes. The themes were put into an outline. The demographic questionnaire and Fruit and Vegetable Screener were analyzed using SPSS 19.0 and descriptive statistics were generated for each. The secondary data identifying socioeconomic and disease prevalence in the Hispanic population and the descriptive statistics from the demographic questionnaire and Fruit and Vegetable Screener were incorporated into the outline to further define the identified social and epidemiological themes. The research team identified and discussed nutritionrelated health issues affecting the target population and came to a consensus on the main nutrition issue affecting the local Hispanic community. A main target issue was identified leading to Phase 3. Phase 3. During Phase 3, the research team used the data to identify environmental and behavioral factors relating to the target nutrition-related health issue and determined the importance and changeability of each factor. The team used focus coding to identify the behavioral and environmental factors relating to the nutrition-related health issue as described by the key informants and focus group participants. The focus coding involved each researcher reexamining the transcriptions and using the main codes identified during open coding and therefore leading to the identification of behavioral and environmental influencing factors in terms of the nutrition-­related target issue. These factors were included into the original outline. From here, the diet-related influencing factors questionnaire was analyzed using SPSS 19.0. Means and standard deviations were determined for each item. The possible range for each item was 0–4 with the lower indicating disagreement and the higher indicating agreement for each item. The data from the questionnaire and information from secondary data (literature review) relating to the behavioral and environmental factors was incorporated into the outline. The research team then discussed the importance of and changeability of each identified factor. The team determined one behavioral and one environmental factor that was of most importance and deemed changeable in terms of the target issue. Operational objectives were developed. The purpose of these objectives was to guide intervention development and evaluation. Phase 4. During this phase, the research team returned to the transcriptions and prior extracted codes, secondary data and the diet-related influencing factors questionnaire to identify PRE factors relating to each objective. These factors were used to guide the development of a culturally appropriate intervention to address the behavioral and environmental objectives and therefore the nutritionrelated health issue identified during Phase 2. Phase 5. During Phase 5, the research team identified from the key informant interviews and secondary data different possible collaborations and funding opportunities

as well as available resources and appropriate measures to assist with intervention implementation and evaluation.

Results Sample Table 5 outlines the socioeconomic and demographic variables of Hispanics compared to non-Hispanics residing in the target county. The values were determined from secondary data and the demographic q ­ uestionnaire that was completed by 50 local Hispanic residents. Furthermore, during the key informant interviews (N 5 8) and the focus group (N 5 11), multiple nutrition-related and health issues that affect the Hispanic population were identified and are outlined in the following text. The key informant interviewees consisted of three ESL teachers, three health care workers, one priest, and a university student. All participants work and serve the Hispanic ­ community in the target county. The focus group consisted of 11 local Hispanic residents. Furthermore, there were 50 Hispanic participants that completed the demographic and diet-related influencing factors questionnaires and Fruit and Vegetable Screener. The 11 focus group participants also completed the demographic and diet-related influencing factors questionnaires and are therefore accounted for in the sample, N 5 50. The average age of the participants was 36.41years (SD 6 12.06). Participant average time spent in the United States was 10.61 (SD 6 9.92) years. About 51% of participants were of Mexican origin with 39.2% emigrating from Central America and the remaining participants migrating from Puerto Rico, Dominican Republic, or Ecuador. Furthermore, 49.0% were married and 78.4% had children. Table 5 compares the education and income of the sample Hispanic population (N 5 50) to the overall county population.

Phases 1 and 2 The following were dietary-related themes that emerged from the data (secondary data and focus group and key informant interviews) to inform the dietary-related social and epidemiological factors of the target population. Diabetes. Among the eight key informant interviews, diabetes was one of the top five health concerns reported in the local Hispanic population. According to the CDC, Pennsylvania has one of the highest rates of diabetes in the nation with Lackawanna County having a diabetes rate greater than 8% (Nissley, 2011). In 2009, diabetes was the fifth leading cause of death among Hispanics in the United States (CDC, 2009). Overweight and Obesity. Key informants identified overweight and obesity as a major health concern in the population. Identified causes were nutrition and low rates of physical activity. According to the CDC 48

Dietary Needs in the Hispanic Population

Table 5.  Demographics of the Hispanic Population Compared to the Overall Population in Lackawanna County, PA Lackawanna County

Hispanics Lackawanna County

Sample Hispanic Population ­(questionnaire respondents; N 5 50)

9.80%

40.00%

31.40%

  High school degree/GED

32.20%

21.70%

25.50%

  Vocational/trade school

8.30%

2.20%

3.90%

  Some college

13.70%

19.60%

15.70%

  Bachelor’s degree

24.10%

2.20%

21.60%

  Graduate degree

11.90%

4.30%

2.00%

  Less than $25K

32.80%

87.90%

84.30%

  Greater than $25K

67.20%

12.10%

15.70%

  Working full time

42.00%

34.70%

 Retired

25.90%

4.10%

  Working part time

14.50%

20.40%

 Homemaker

12.60%

16.30%

 Unemployed

9.40%

20.40%

  Unable to work/disability

5.80%

4.10%

  Working more than one job

5.40%

6.10%

 Student

3.80%

6.10%

Education   Less than high school

Annual household income

Employmenta N/A

aEmployment

status was not determined in the participants from this study. Tripp, U. (2010). Healthy Northeast Pennsylvania initiative: 2009–2010 healthy needs assessment. Retrieved from http://healthynepa.org/PDF/Needs_ Assessment_2010.pdf

compared to other ethnic groups (Sharma, Gernand, & Day, 2008; Woodruff, Zaslow, Candelaria, & Elder, 1997), which has been associated with negative dietary behaviors and health outcomes (Fitzgerald, Damio, Segura-Perez, & Perez-Escamilla, 2008; PEW, 2011; Sharma et al., 2008). In terms of dietary intake, the focus group participants indicated that since moving to the United States, their intake of fruits and vegetable had decreased and intake of meat and processed foods had increased, therefore decreasing dietary quality. Also, they felt that their diet and meal patterns are unhealthier in the United States compared to when they resided in their country of ­origin. This was also reflected in the results of the Fruit and Vegetable Screener. The average daily intake of fruits and vegetables for the participants who completed all questions in the screener (n 5 36) was three servings a day, although the recommendation of the Dietary Guidelines for American is five servings a day. These factors and dietary behaviors are similar to those identified in prior nutrition studies with the Hispanic population (Dixon, Sundquist, & Winkleby, 2000; Gregory-Mercado et al., 2007; Mazur, Marquis, & Jensen, 2003; Montez & Eschbach, 2008;

(2009), 29.2% of adults aged 20 years and older in the state of Pennsylvania were categorized as obese or overweight by body mass index standards. The 2009–2010 Healthy Needs Assessment for Lackawanna County found 75.0% of the Hispanic population to be overweight/obese (Tripp, 2010). According to The National Health and Nutrition Examination Survey (NHANES) data, this large percentage is caused by several factors, which include easy accessibility to fast foods and unhealthy nutrition choices such as low intakes of whole grains, fruits, and vegetables and high intakes of foods high in saturated fats (Fryar, Wright, Eberhardt, & Dye, 2012). Of the Hispanic participants who completed the demographic questionnaire, 69.5% indicated weight gain because of immigrating to the United States. Dietary Factors. Key informants and the focus group participants indicated lack of nutrition and diseaserelated knowledge as a key health issue affecting dietary intake in the population. The key informants viewed this as a large barrier to disease prevention. Furthermore, research has shown that the overall Hispanic population has the lowest health and nutrition literacy when 49

Castellanos and Abrahamsen

Neuhouser, Thompson, Coronado, & Solomon, 2004; Norman, Castro, Albright, & King, 2004). Physical Activity. Low rates of physical activity have been associated with the Hispanic population (CDC, 2008). During the key informant interviews and focus group, low physical activity rate was mentioned as a concern within the population. Moreover, prior research indicates that Hispanics have the lowest physical activity rates compared to all other ethnic groups (Marquez & McAuley, 2006). Other Themes. Furthermore, health and nutrition-­ related social aspects affecting the local Hispanic population that were extracted from in the key informant interviews included lack of health care access because of lack of insurance, cultural beliefs, and language barriers. One of the main social needs found is the necessity for proper medical care for this population as many do not have health insurance. In addition to the lack of health insurance, the language barrier and lack of culturally appropriate health care prevents many Hispanics from seeking medical and nutrition care when needed. Identified Need. After reviewing the data collected, the research team identified a major dietary-related theme in Phase 2: Nutrition Quality. Nutrition quality directly relates to diabetes and obesity prevention and control and is therefore important to address. Furthermore, the team determined this issue as being changeable in terms of the social, human, and monetary resources available.

Phase 3 The main behavioral codes that were extracted relating to nutrition quality were physical activity and social support, connecting obesity to disease, cultural beliefs around nutrition and obesity, importance of healthy cooking and eating, lack of nutrition literacy and knowledge, and fatality. The environmental codes were lack of accessibility to nutritious foods, lack of healthy cooking skills, time constraints to cook healthy meals for families, feeling uncomfortable in new food environment, and the language barrier. Table 4 presents the means and standard deviations for each behavioral- and environmental-related item from the dietary influencing factor questionnaire. Relating to the behavioral aspects, the questionnaire indicated that participants connected disease to dietary intake (Table 4: Psychosocial Items 11–13) and valued eating a healthy diet (Table 4: Psychosocial Item 2); however, they scored the items of “reading nutrition labels before purchasing foods” (Table 4: Psychosocial Item 9) and “considering health information before buying a food” (Table 4: Psychosocial Item 10) lower, indicating a possible lack in nutrition literacy. Nutrition literacy is defined as the “capacity to obtain, process and understand nutrition-related information” (Zoellner, Connell, Bounds, Crook, & Yadrick, 2009, p. 128). Bivarate correlations between the three disease-related belief questions: “I believe that what a person eats can affect his or her

risk of getting heart disease,” “I believe that what a person eats can affect his or her risk of getting diabetes,” and “I believe that what a person eats affects his or her health in general” were positively correlated with “considering health information before buying food” (p , .05). The behavioral factors that were determined to be most changeable and important in the target population were cooking skills and nutrition-related literacy. The environmental factor was food accessibility. Behavioral Objective. Increase nutrition literacy and therefore nutrition quality over a 6-month time period in a sample of the Hispanic population in the target county. Nutrition literacy has been positively associated with nutrition quality in prior research (Fitzgerald et al., 2008). Environmental Objective. Increase accessibility to fresh produce through local farmer’s markets and food vouchers leading to an increase nutrition quality over a 1 year time period in a sample of the Hispanic population ­residing in Scranton, PA.

Phase 4 The PRE factors were determined for each behavioral and environmental objective. The factors are outlined in Table 6.

Phases 5–9 During this phase, the research team contacted local organizations that work closely with the local Hispanic population and were identified through the key information interviews. Collaborations between the different entities have begun and funding acquired to implement the following plan. The needs assessment led to the development of a nutrition intervention plan culturally tailored for the Hispanic population residing in Lackawanna County, PA. The plan has two parts. The first is that local food producers have collaborated to begin a farmer’s market in the zip code with the highest Hispanic population in the county to increase fresh food availability. At the farmer’s market, there will be cooking demonstrations and recipes will be provided that are culturally appropriate and incorporate produce available through the market (increase nutrition literacy). Food vouchers will be provided to people attending local Hispanic churches to help with cost of foods and farmers will have the ability to accept Women, Infants and Children food vouchers. Moreover, the research team developed a 6-week nutrition literacy program and partnered with two local Hispanic churches to implement it with interested members.

Discussion The importance of identifying factors that influence dietary behavior to inform the development of appropriate interventions cannot be overstressed. The PRECEDE-PROCEED model provided a framework that allowed for a system50

Dietary Needs in the Hispanic Population

Table 6.  Predisposing, Reinforcing, and Enabling Factors Associated With the Targeted Behavioral and Environmental Objectives Behavioral Factors Predisposing

Enabling

Reinforcing

Low nutrition knowledge

Limited nutrition resources

 isconnect between nutrition and D physical consequences

 alues associated with traditional V cooking and foods

 ack of ability to cook with new, L ­foreign (U.S.) ingredients

Listen to family for nutrition advice

 erception that nutrition is P ­unimportant

 hildren’s influence on what to cook C for family meals

Ability to connect disease to n ­ utrition Fatality Environmental Factors Predisposing

Enabling

Reinforcing

Valuing fresh foods

High cost of fruits and vegetables

 egative perception of U.S. foods by N peers

Valuing traditional foods and meals

Low cost of meats

 ccessing foods at certain stores as A enforced by community

 egative attitude toward trying and N using U.S. foods

 ack of fresh markets in their L ­communities

S ocial community not accepting of new foods

Apathy to lack of access

Lack of income

There are several limitation of the present research. First, this study is not intended to be generalized onto the U.S. Hispanic population. It is to just provide a framework to assess health needs on a community level of a population leading to effective intervention. Second, although several methods for data collection were used, they were limited in that the sample of Hispanics was small (N 5 50) and only descriptive and bivariate correlation statistics were used. Prediction of dietary behaviors could not be assessed. Furthermore, although all participants in the focus group and those who completed the diet-related influencing factors questionnaire indicated being Hispanic, they were from different countries and regions throughout Latin America. Each country and ­ ­region has its own subculture and as health practitioners, we need to be careful to not generalize the findings onto each individual but use the findings to inform development of population-level interventions.

atic assessment of the behavioral and environmental factors affecting the health of the target population. The Hispanic population is growing faster than any other ethnic group in the United States. However, this population as a whole has a lower education level and higher poverty rate when compared to non-Hispanics and is experiencing numerous nutrition-related health disparities such as type 2 diabetes and obesity (U.S. Census Bureau, 2011). The present assessment determined a need for fresh food accessibility and an increase in nutrition literacy to encourage higher nutrition quality. As the Hispanic population continues to grow in the target county, addressing these influencing factors through interventions that are culturally tailored and target ­ identified dietary-related influences and through collaborative means is critical for positive outcomes (Mier et al., 2010). The proposed nutrition intervention addresses the identified behavioral and environmental objectives with a goal of increasing nutrition quality for the Hispanic population. It aims to educate the target Hispanic population on these concerns so they have the ability to make better nutrition and diet decisions as well as increase fresh food accessibility and, therefore, can avoid the future health complications associated with poor diets. Furthermore, the proposed intervention goes beyond only addressing behavioral factors related to nutrition quality and addresses environmental factors; factors that are often omitted from interventions (Mier et al., 2010).

Implications for Practice As the Hispanic population increases across the United States, different environmental and behavioral factors may influence the health of this population. Each community is different and therefore the factors that may influence the Hispanic population in one community may be different for another community. Some communities have recently begun to experience the increase of the Hispanic 51

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population which is contrary to other areas (Midwest vs the Southwest). In the midst of health disparities apparent in this population (Elder et al., 2009), it is important that health professionals, from public health nurses to medical staff in a local health care facility, are working to assess and appropriately address health issues and influencing factors within this population on a community level. Furthermore, guided health needs assessments allow health professionals to culturally tailor interventions to the specific target population. The present research provides an example of how the PRECEDE-PROCEED model can be implemented to identify health-related issues that can be addressed by health professionals within a ­community. In conclusion, although this research is limited in that the results of the needs assessment cannot be generalized onto other Hispanic populations in other communities, it does provide a framework for assessing dietary needs and developing culturally tailored and theory-based interventions. As our society becomes more preventive and intervention driven, it is essential that we continue to provide evidence of successful methods that can then be translated into practice.

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Correspondence regarding this article should be directed to Diana Cuy Castellanos, PhD, RD, University of Dayton, Health and Sport Science, 300 College Park, Dayton, OH 45469-1210. E-mail: ­dcuycastellanos1@ udayton.edu 

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