Empowerment as a key mechanism for supporting changes in eating behaviors among disadvantaged immigrant women living with diabetes, obesity or hypertension: a realistic evaluation

Abstract

Background

While interventions aimed at improving the food habits of people living with diabetes, obesity or hypertension have been implemented and proven effective, we know little about how they produce effects. To develop meaningful programs, it is essential to identify the elements that favor or prohibit successful outcomes and the mechanisms at work. Using a realist approach to evaluation, this study aimed to assess a diet support program offered by a community-based organization in the Greater Paris Region to disadvantaged women living with diabetes, obesity or hypertension.

Methods

We carried out a qualitative study using observations and semistructured interviews (n = 12) with women supported by the organization. The data were analyzed thematically and then cross-sectionally. The intervention-context-actor-mechanism-effect (ICAMO) configuration was used to structure the analysis and identify interactions between the various components.

Results

We identified three different types of effects: awareness of the importance of a balanced diet (cognitive change), initiation of changes in eating behavior, and significant changes in food habits. The mechanisms that led to these changes were based on empowerment (strengthening knowledge and skills, self-esteem, participation, and critical awareness). We also identified individual contextual factors that either limited changes in eating behavior (lack of financial resources, culinary habits) or facilitated them (having experienced a critical health event, access to a kitchen).

Conclusion

This study contributes to a better understanding of how support programs for eating behavior change work and can overcome the constraints faced by disadvantaged populations living with a chronic disease. The exploration of ICAMO configurations enables us to identify the intervention’s mechanisms and key characteristics that will be relevant to consider when replicating the program in other contexts or territories.

French abstract

Contexte

Malgré la mise en place et l’efficacité démontrée d’interventions visant à améliorer l’alimentation des personnes vivant avec un diabète, une obésité ou une hypertension artérielle, nous savons peu de choses sur la manière dont ces programmes d’accompagnement produisent des effets. Afin développer des programmes efficaces et adaptés il est indispensable de comprendre comment fonctionne ce type d’accompagnement et d’identifier les mécanismes à l’œuvre. En utilisant une approche réaliste de l’évaluation, l’objectif de cette étude était d’évaluer l’accompagnement à l’alimentation proposé par une association à des femmes en situation de précarité vivant avec un diabète, une obésité ou une hypertension artérielle, en Ile-de-France.

Méthodes

Nous avons réalisé une étude qualitative par observations et entretiens semi-directifs (n=12) avec des femmes accompagnées par l’association. Nous avons fait une analyse thématique puis transversale des données. La configuration Intervention-Contexte-Acteur-Mécanisme-Effet (ICAMO) a été utilisée pour structurer l’analyse et identifier les interactions entre les différentes composantes.

Résultats

Nous avons identifié trois types d’effets différents : la prise de conscience de l’importance d’avoir une alimentation équilibrée (changement cognitif), l’initiation des changements de comportements alimentaires, et le changement notable de l’alimentation. Les mécanismes qui conduisent à ces changements sont basés sur l’empowerment (renforcement des connaissances et des compétences, de l’estime de soi, la participation, et la conscience critique). Nous avons mis à jour des facteurs contextuels individuels qui limitent les changements de comportements alimentaires (le manque de ressources financières, les habitudes culinaires) tandis que d’autres les facilitent (le fait d’avoir connu un évènement grave de santé, l’accès à une cuisine).

Conclusion

Cette étude apporte des connaissances sur la manière dont un accompagnement aux changements de comportements alimentaires fonctionne et peut surmonter les contraintes d’une population défavorisée vivant avec une maladie chronique. L’exploration des configurations ICAMO a permis d’identifier les mécanismes et les éléments clés de l’intervention qui seront pertinents à prendre en compte pour la réplication de ce type d’accompagnement à d’autres contextes ou territoires.

Text box 1. Contributions to the literature

• Diabetes, obesity and hypertension are major public health issues, particularly among disadvantaged populations.

• Reliable knowledge is necessary to develop support programs for these diseases that are tailored to the needs and constraints of the most disadvantaged populations.

• The evaluation of this empowerment-based intervention has shown that providing knowledge and the opportunity to put it into practice, strengthening skills and sharing experiences with a peer group are key elements to support this population in adopting a healthy diet.

Background

Diabetes, hypertension and obesity represent the greatest burdens of disease from a global health perspective [1, 2]. In France, hypertension is the most common chronic disease, affecting 30% of adults [3]. In recent years, obesity has affected 17% of French adults (54% of men and 44% of women were overweight or obese) [4], and diabetes has affected 12% of men and 8% of women (among adults older than 45 years) [5]. These pathologies are associated with a negative social gradient, meaning that their prevalence increases as socioeconomic status decreases [4, 6,7,8], and disadvantaged populations face multiple barriers to changing their health behaviors. In terms of diet, disadvantaged populations have qualitatively and quantitatively poorer food than the rest of the population [4, 9, 10]. They are less likely to follow certain recommendations [11] and have limited access to often very expensive foodstuffs (fruit, vegetables, meat) [12]. For disadvantaged populations, particularly for immigrants, lack of financial resources [10, 13], precarious legal status, residential instability and poor housing conditions are factors that limit the adoption of a lifestyle in line with diabetes, hypertension and obesity (healthy diet and physical activity).

Providing support for these pathologies is a major public health challenge, both now and in the years to come. In France, the medical management of diabetes relies on drug therapy and therapeutic patient education (TPE). TPE aims to “help patients acquire or maintain the skills they need to manage their lives as best they can with a chronic disease” [14]. TPE programs are most often organized within hospital departments or by healthcare networks or civil society organizations. The cost of drug therapy and care can constitute an important barrier to care for people living with chronic diseases. On the one hand, healthcare costs associated with diabetes are fully reimbursed by the French social security system via a public insurance program (100% Affection Longue Durée) dedicated to diseases requiring long-term and often expensive treatment [15]. On the other hand, the costs associated with hypertension and obesity are not covered by a special social security program, increasing out-of-pocket costs [15]. Moreover, while TPE programs are often limited in time and focused on a biomedical approach to pathology, effectively treating these diseases also requires changing patients’ eating habits and increasing their level of physical activity. Helping people change their eating habits is a common and major challenge in the treatment of these three diseases, as is drug treatment. Changes in eating habits are linked to social, psychological and economic factors [13]. Achieving and maintaining these changes is a difficult and slow process [16], especially for disadvantaged populations facing the multiple barriers mentioned above. A person-centered, holistic approach that accounts for people’s resources (socioeconomic status, skills, literacy) and needs is therefore advised to manage these multifactorial diseases. However, few support programs have adopted this approach.

In the scientific literature, intervention research documents the impact of this type of comprehensive support [17,18,19] without analyzing how these interventions produce effects. For example, one impact study highlighted the value of a free, individualized approach for initiating changes in diet and physical activity in a population of disadvantaged women [20]. The study showed a reduction in food portions over the 2 years of follow-up but did not provide any evidence as to why the intervention works, for whom, and in what circumstances. Nonetheless, understanding how this type of intervention works is necessary for professionals in the field and for political decision-makers looking to develop or generalize this type of approach.

These support programs are based on the plurality of interactions between the actors who provide and receive the intervention, the plurality of the actions implemented, and the degree of flexibility and adaptability of the intervention. Thus, the programs and their evaluation fall within the field of complex interventions and the evaluation of complex interventions [21,22,23]. In this context, it is important to conduct research to better understand the “black box” of the intervention.

The realist approach to evaluation addresses the need to understand how an intervention works. Realistic evaluation [24, 25] answers the following question: “What works, for whom, in what circumstances and why?”. By developing and testing a program theory, this approach enables us to explore the causal mechanisms that produce effects in a given setting and are triggered by the interaction of the intervention with its context. The analysis of interactions between context, mechanisms and outcomes is called the CMO configuration. Developed by Pawson and Tilley [24], the CMO configuration analysis tool was expanded into the intervention-context-actor-mechanism-outcome (ICAMO) configuration [26] to account for the “intervention” and “actor” components of how a program works. Mechanisms refer to the behavioral changes caused by individuals’ reactions to the intervention and their line of reasoning [27, 28]. Mechanisms are strongly influenced by the context in which the intervention takes place. The context can be characterized at different levels: individual, organizational, political, social, etc. [25].

Study objectives

Using a realist approach to evaluation, this study aimed to assess a diet support program offered to disadvantaged women living with diabetes, obesity or hypertension by a nonprofit organization in the Greater Paris Region. This study seeks to identify the mechanisms and contextual factors that may or may not lead to changes in eating habits. This study identified the factors that are essential when duplicating the program. In this way, it supports the intervention’s generalization to other contexts and territories and reduces the risk of an “implementation gap” [29], i.e., “the gap between an intervention as planned and one as it actually takes place.”

Method

The Igikali support program

Opened in February 2022 by the community-based organization Ikambere, the Igikali House welcomes and supports women living with diabetes, obesity or high blood pressure in the Greater Paris Region. The center seeks to empower these women by improving their socioeconomic conditions, physical and mental well-being, and personal health literacy. Its support program targets disadvantaged women living in poverty or isolation and with at least one of these pathologies. Most of the women supported by the center are immigrants. The center is open on a week from 9 am to 5 pm and has kitchen-cafeteria, a fitness room and a computer room. At the Igikali House, a multidisciplinary team (a community health counsellor, nutritionist, caseworker, chef) welcomed the participants with kindness and respect and provided them with comprehensive support. The support provided includes individual casework and group activities and is based on 3 axes: health support (nutrition, adapted physical activity, wellness activities), social support (access to a stable legal status and decent housing) and support for professional integration (access to employment). In the context of health support, dietetic support plays a very important role. Every day, home-cooked meals are prepared and shared collectively (among the women and with the team of professionals). Several times a week, group dietetic workshops (practical and theoretical) are led by the dietician, and individual meetings with the dietician are held according to the women’s needs.

A research project has been associated with the opening of this new structure to carry out an evaluation of this experiment. As part of the research process, the organization’s team and the researchers worked together to formulate the program’s initial theory (Appendix 1), which included intervention components (actions implemented) and outcome hypotheses (expected changes). Based on a previous study [30], theory also mentioned the hypothetical mechanisms leading to the expected changes: empowerment, agency and autonomization processes. The initial program theory did not include the contextual factors likely to influence the underlying mechanisms or the effects. The aim of this study is therefore to identify these contextual factors and specify the underlying mechanisms involved.

Conceptual framework

Based on our initial program theory and the literature [13, 16, 18, 30, 31] and following the methodology of realistic evaluation [24, 25], we produced an initial ICAMO model for nutritional support (Fig. 1) to structure our theoretical hypotheses about how the intervention would function. The initial ICAMO model focused on a specific axis of the overall intervention: healthy diet support. We were interested in the different activities implemented around eating behaviors (intervention), the mechanisms that led to changes in eating behavior (outcomes), and the individual contextual factors that influenced the mechanisms and outcomes. We formulated two types of outcomes—cognitive changes and behavioral changes (visible effects)—with the first being a necessary intermediate step before moving on to the second. In terms of contextual factors, we focused on individual contextual elements to explore the influence of sociodemographic characteristics and living conditions on the intervention. With regard to mechanisms, our approach is based on the definition proposed by Lacouture et al., according to which “a mechanism is hidden but real, it is an element of reasoning and reaction of agents in relation to the resources available in a given context to bring about change through the implementation of an intervention, and it evolves in an open space–time and in a social system of relationships” [27].

Fig. 1

Initial ICAMO model for nutritional support at Igikali

Study design, case selection and recruitment

We conducted a qualitative study based on semistructured interviews and participative observations. Data collection and analysis were carried out by the first author. The interviews were proposed to women who had been supported by the organization for several months and with different sociodemographic characteristics and life situations (in terms of health, administrative and socioeconomic status). Women with insufficient knowledge of French or English to conduct the interview were not included in the study. The researcher’s daily presence at the organization helped to build a confident relationship with the participants and to recruit them for the study. The interviews were conducted until data saturation was reached [32].

Data collection

Semistructured interviews

The semistructured interviews took place at the center (face-to-face) and at the women’s convenience between February and September 2023. All interviews were conducted with women who had been supported by Igikali House for several months.

The aim of the interviews was to explore the changes women identified in their health and socioeconomic situation and the mechanisms and factors influencing these changes (Appendix 2). The interviews also considered the following elements: current and past living conditions; history and management of illnesses affecting the participants; eating and physical activity habits; use of the Igikali Center (attendance, type of activity followed, etc.); changes observed; and relationships with other participants.

Participative observations

The researcher observed daily life at the center, group activities and individual interviews with the center’s team. She was immersed in the field [32] daily for a year between September 2022 and September 2023, and her observations were recorded in a field notebook.

Ethical approval

The research was declared to the French National Protection Commission of Personal Data (Commission Nationale de l’Informatique et des Libertés) (n°2222460), and the research team obtained the authorization of the French Personal Protection Committee (Comité de Protection des Personnes) to carry out the study (project n°2021–090, national N°: 2021-A01474-37). In line with the recommendations of the French Personal Protection Committee, all participants received oral and written information about the research, and their “nonopposition” was collected. The interviews were recorded with the participants’ consent and then transcribed and pseudonymized. The audio recordings were then destroyed.

Data analysis

Our analysis began by reading all the transcripts in order to obtain an overview of the data and to identify the preliminary themes linked to the aim of the study. We identified the units of meaning related to the preliminary themes: eating practices and habits and how these practices have changed since visiting the center. Based on these preliminary themes, we used a cross-sectional analysis of the interviews to clarify the relationship between the effects perceived by each woman, the mechanisms that generated these effects, and the context. We then selected citations to illustrate the findings. We then revised our initial ICAMO model on the basis of our empirical data. An iterative process led to the refinement of the initial ICAMO model: the CMO interactions were completed as the data collection progressed and guided the data collection to confirm certain regularities or explore new regularities. This realistic evaluation followed the RAMESES II guidelines [33].

Results

Description of participants

We conducted 12 semistructured interviews with 12 women from different life situations (Table 1). All women were immigrants from a country other than France, notably sub-Saharan Africa. Most of the women did not have a legal immigration status (8), but all had health coverage and received regular medical care. Almost half of the participants were affected by at least 2 of the 3 pathologies (diabetes, obesity, hypertension). All women with diabetes had type 2 diabetes. Almost half (5) of them lived in their own accommodations, while the others had unstable housing conditions (emergency housing or housing by family or friends). Some shared their room with other adults or children; others had no room or bed of their own when housed by a third party. Among the women without their own accommodations, some had no access or restricted access to a kitchen.

Table 1 Sociodemographic characteristics of study participants

Empowerment: a mechanism that leads to changes in eating behavior

The mechanisms we highlighted are based on Ninacs’ dimensions of individual empowerment [31]: knowledge, skills, self-esteem, participation and critical awareness. Based on these mechanisms, we identified the key components of the intervention that led to the observed effects (Table 2).

Table 2 Key elements of the Igikali intervention and corresponding empowerment mechanisms

An approach adapted to women’s practices and literacy levels to improve the understanding and acquisition of information (knowledge strengthening)

The nutrition-related activities at the Igikali House are designed to be adapted and accessible to all the program participants. For example, educational tools (recipe cards, informational posters, games, etc.) are developed by the center’s team to maximize comprehension: omnipresence of images and use of simple words. Moreover, tools and recipes are always created with women’s eating habits in mind. During cooking workshops, the dietician focuses on ingredients commonly used by women and explains the benefits or risks of these foods. The dietician also adapts public health guidelines to foods traditionally consumed by women rather than exclusively focusing on foods widely consumed in France. This approach improves the accessibility and relevance of the information given and fosters the acquisition of knowledge.

“They [hospital professionals] don’t know; they talk about starchy foods in general terms, but they don’t know about “foutou”. Oriane [the dietician] explains, when we talk about “foutou”, she says you can eat “foutou” but in small quantities and with some vegetables on the side. You can eat a small amount, and you can eat a lot of vegetables, and then you have to have dessert; in Africa, we don’t know all that. Once you’ve eaten a lot of starchy foods and your belly is full, the rest...! These are all mistakes we make.”

Individualized and long-term support to encourage knowledge acquisition (knowledge strengthening)

The repetition of information is a key element of Igikali House’s approach. The nutritionist leads practical and theoretical workshops, as well as individual interviews and informal conversations. Mealtime is an ideal moment for the center’s team to discuss food and eating habits with the participants and to lead activities on these themes (games, quizzes). The nutritionist repeats key messages throughout the support period and accords sufficient time to each woman to ensure that she has acquired the knowledge necessary to become aware of her habits and change them. For example, individual consultations can last more than one hour and be repeated as needed.

“Here, Oriane [the dietician] explains the virtues of this or that food. I ask a lot of questions, and she explains things I didn’t know before. I have the opportunity to ask questions, to take the time to determine more. The doctor doesn’t have time; I’m not her only patient. There are a lot of us, a lot of patients, so he can’t (...) I’ve seen a dietician at the hospital, but as I’m not her only patient (...). She takes approximately 10 to 15 minutes and explains things quickly. You go out, and another person comes in. It’s not like here, we take all the time, all morning, we explain everything.”

“If I have a problem, I’ll reach for something to eat because I’m looking for a way out. I wanted to eat something sweet, and I realized it when I was talking to Oriane. We were talking, and she made me realize that it was because I was evacuating something that I was eating something sweet. And I noticed it just recently and said to myself, “Oh yes, Oriane was right!” Now I know that I’m venting my anger through food, I’m trying to change that because eating like this is not good for your health”.

Cooking workshops to break isolation and reinforce knowledge, skills and self-confidence (strengthening self-esteem, skills and knowledge)

Biweekly cooking workshops organized by the nutritionist enable women to learn how to prepare healthy recipes, discover new foods or develop new ways of preparing them. During these workshops, the nutritionist explains the benefits of the ingredients used, gives advice, proposes recipe cards specially created for the session and questions the women on their nutritional knowledge. Moreover, she creates a friendly and pleasant learning environment. During the workshop, the women meet in groups, chat with each other and then share the meal prepared with the other participants and the team. These workshops enable participants to acquire knowledge and skills related to food and meal preparation and help break their isolation. The women have integrated the cooking workshops into their weekly schedules and participate regularly. The women interviewed testify to gradually changing their diets in small steps and within the limits of what they can change; most of the participants are constrained by a lack of financial means to purchase foodstuffs, particularly fruits and vegetables.

“I know what’s best for me; I’ve changed some things I can change. Oils, sugar, the way I prepare meals, new recipes. I’ve got lots of ideas for new recipes, and I always use the recipe cards. The cards are great! I store them in a file. And honestly, it’s great. After that, as I explained to you, we have to make do with what you’ve got in the fridge.

Once a month, the cooking workshop is dedicated to the gastronomy of a particular country. A woman chooses her favorite recipe and reworks it in advance with the dietician so that it meets the nutritional guidelines for diabetes, obesity and hypertension. The recipe is then orchestrated by the woman, who suggested it and cooked it collectively. This participatory approach enhances women’s skills, boosting their self-confidence and self-esteem.

Daily meals to “experience” and develop new habits (participation, skill strengthening)

By regularly coming to the center for lunch, women experience and acquire the habit of eating a healthy meal in terms of composition and quantity. They testify to having a positive experience with this meal. In addition to satisfying a basic need—adding a meal to women experiencing poverty—these meals are an opportunity for participants to have a positive experience eating smaller quantities or new foods.

“The longer we stay at home, the more we eat everything. When we’re at the organization, we’re limited; we can't go overboard with sweets and cakes. When we get home, we’re fine! It’s important to regain your health.

Practical tools used as a lever for sharing knowledge and asserting oneself (critical awareness)

Some women have additional constraints, either because they do not have a kitchen where they live (emergency housing shelter) or because they are unable to cook for themselves due (housed by a third party, cohabitation with a partner or children). However, they sometimes manage to pass on what they learn at the center to their hosts, notably by using the recipe cards. In this way, they occasionally manage to cook a healthy meal in line with the guidelines for their pathology.

“When I give them the cards, they [her host] say it’s good. At first, people said, “Oh no, that’s not good, that’s for sick people”. But as time went by, they began to appreciate it: “Oh yes, since we’re not eating that much, we feel good, we wake up easier”. Even the kids appreciate it.

A place dedicated to preparing and sharing meals: a “home-style” kitchen to reinforce the sense of group belonging (critical awareness)

At Igikali, the kitchen-cafeteria is the central room, the place where women go as soon as they arrive at the center, the meeting point over a cup of coffee. The kitchen is bright and pleasant, on a human scale, “just like home”. It is equipped with all the utensils needed to prepare meals, and thanks to a partnership with a solidarity grocery store and shopping done with the center’s own funds, participants have access to fresh produce and a variety of other ingredients every week. The women have made the House their own. When talking about Igikali, the women often call it their home and their family. It is not uncommon for women to spontaneously pour themselves in a cup of coffee, help prepare meals outside cooking workshops, or help them clean up. For women who do not have their own homes or kitchens, Igikali is a place where they can enjoy a sense of familiarity and comfort. They feel at ease and find a role for themselves in the community, boosting their self-esteem.

Different effects on the diet of the women supported

Analysis of the women’s interviews and observations revealed three types of change: awareness of the importance of food for health (cognitive change), initiation of change in eating behavior, and significant change in eating behavior.

Based on this analysis of our data, we revised our initial ICAMO model. We produced three ICAMO models (Figs. 2, 3, and 4) corresponding to these three groups of participants to illustrate the mechanisms and contextual factors influencing the production or absence of effects. In the following paragraphs, we detail the effects (cognitive and behavioral changes) and how the interaction between contextual factors, mechanisms and the various components of the intervention produces different effects.

Fig. 2

ICAMO model for the “awareness” group of women (Group 1)

Fig. 3

ICAMO model for the group of women who started to modify their diet (Group 2)

Fig. 4

ICAMO diagram for the group of women who changed their diet (Group 3)

Group 1: Awareness

A first group of women [3] (Fig. 2) showed cognitive changes. These women realized that adopting a healthy diet is beneficial to their health. They knew that adopting a balanced diet (rich in vegetables and fruit, limited in fats, sugars and salt) is part of the treatment for their disease. They were motivated to change their habits but had not yet implemented the nutritionist’s advice.

Group 2: Initiating change

A second group of women [6] (Fig. 3) began to modify their food habits. They assimilated the dietary messages they had delivered, such as the different food groups or how to construct balanced dishes and meals. Moreover, they began changing their eating habits within the limitations imposed by their socioeconomic situations. For example, they reduced their food intake or sugar and salt intake. While the changes were gradual and sometimes marginal, the women began acting upon the information received.

Group 3: Notable changes

A third group of women [3] (Fig. 4) significantly changed their diet. These women adopted a balanced diet, increased their consumption of fruits and vegetables, and succeeded in changing certain habits, such as using stock cubes or deep-frying. These changes were associated with a strong awareness of the importance of food choices for their treatment. This group acquired and integrated nutritional guidelines into their daily diet.

Contextual factors that influence effects and mechanisms

Being able to reach workshops is a prerequisite, but it requires availability and a public transportation ticket

We identified contextual factors influencing regular participation in the intervention. We found that all the women participated several times in the meals and nutrition workshops. However, women in the first group attended an average of 1 nutrition workshop per month, compared with 2 workshops per month for women in group 2 and 3 workshops per month for women in group 3. The women in group 1 lack the financial resources necessary to buy their transportation tickets. Their limited mobility prevents them from taking part in the center’s activities on a regular basis. To combat this limitation, the center helps the women access subsidized transportation passes and contributes financially to purchasing tickets when necessary and possible. Similarly, women who work during Igikali’s operating hours can rarely come to the center. Yet, repeatedly hearing key messages and having the time to express oneself and ask questions are crucial elements in bringing about changes in behavior (Fig. 2).

Financial resources and access to a kitchen: essential elements for initiating change

The lack or absence of financial resources is a limiting factor in the process of adopting a balanced diet. Having the means to buy quality foodstuffs (e.g., fruit and vegetables or unprocessed foods) and having the means to cook them are necessary conditions for adopting a balanced diet. Women who have not begun to change their diet lack financial resources and access to a kitchen (Fig. 2). Most of them have no financial resources and, without legal immigration status, can neither work legally nor benefit from welfare. Moreover, their residential situation is unstable: they are housed in emergency shelters or public housing centers or by family and friends. Their nonpermanent and unsuitable accommodations often lack free access to a kitchen. Conversely, most of the women who have changed their diet have a kitchen available to them in their place of residence (Figs. 3 and 4). In both cases, the lack of financial resources limits substantial dietary changes (Fig. 3).

Experiencing a serious health event in the course of one’s life

Women who have experienced an acute illness that has had a major impact on their health or perception of their health tend to have a better awareness of the importance of taking care of their health. Among women who have initiated or significantly changed their diet, the majority have a history of cancer, severe diabetic complications, or HIV (Figs. 3 and 4). Similarly, we note that pregnancy fostered the adoption of a diet in line with diabetes for two women. Conversely, we note that women who have not yet realized the importance of changing their diet or who have only initiated a change are women with no other significant medical history.

Eating habits and culinary practices

Changing one’s diet and adopting new habits are often difficult and time-consuming. The women who have initiated a change in their diet report difficulties in abandoning certain practices (e.g., using stocks, adding sugar to coffee or tea, using large quantities of oil in the preparation of traditional dishes) (Fig. 3). For example, in West African cuisine, industrial stocks are widely used for all culinary preparations; however, they are very salty and contain numerous additives that negatively impact health. Owing to the advice given during the practical and theoretical nutrition workshops, certain women succeeded in limiting or stopping the use of these stocks (group 3). Awareness-raising at the center accounts for women’s cultural habits by using traditional recipes and suggesting adjustments (for example, the use of spices or dried fish or the preparation of homemade stocks). Moreover, women’s repeated experience eating a different diet at the center and then at home has gradually helped them change their eating habits, which are sometimes deeply rooted in their own customs (Fig. 4).

Living together

For the women taking part in the study, cohabitation with family (children and/or spouse) or another third party is a limiting factor in the adoption of a diet in line with their pathology guidelines. The women are obliged to cook for everyone present, not just for themselves. A lack of financial resources or time does not allow them to cook two menus, and the other cohabitants are not always favorable to the changes suggested (e.g., reduced-salt preparations, new recipes that break with eating habits: without stocks, with less oil, etc.).

Discussion

Discussion of the findings

In this study, we provide knowledge on how an intervention aimed at improving diet produces effects on the eating behaviors of disadvantaged immigrant women living with diabetes, obesity or hypertension. We also specify the contextual factors that influence these results.

We have shown that providing knowledge and the opportunity to put it into practice, strengthening skills and sharing experience with a peer group are central elements of healthy diet support. These findings are supported by other works in the literature. A Danish qualitative study [34] that examined the factors limiting and facilitating sustainable weight loss in overweight or obese women planning a pregnancy cited the lack of knowledge and skills in cooking healthy foods as a barrier to adopting a healthy diet. In a Swedish intervention study [35] proposing a new diet for overweight or obese women in the general population, the women said they would like to be able to cook in a group and have more space for contact and sharing with other participants.

In our study, we showed that the difficulty of changing one’s eating habits, the difficulty of managing food in one’s social environment (partner, family, host) and the high cost of food were obstacles to changing one’s eating habits. These findings are echoed in various qualitative studies of weight loss interventions for overweight and obese people [35, 36]. An Australian qualitative study questioned weight loss support program participants (overweight or obese people living with diabetes or hypertension) about their perceptions and experiences of weight management [36]. The study showed that “eating habits and traditions” can be barriers to dietary change and weight loss because they are shared with the family and “rooted and therefore difficult to overcome”. The study also highlighted the social dimension of sharing meals with family and friends and the potential negative consequences for participants who chose to prepare a separate meal for themselves. Additionally, preparing a different meal is more difficult when people are not involved in meal preparation or grocery shopping, as may be the case for people living in shelters. In the Swedish study [35], the high cost of food and difficulties in changing eating habits were cited as obstacles to the introduction of a new diet. Women also mentioned difficulties in implementing the diet for social reasons, both within the home, where for some, “the partner is a major obstacle” when he refuses to share the new diet and when the woman is obliged to cook two different meals; and outside the home, where moments of socialization represent moments of temptation.

We identified health status as a factor facilitating the adoption of positive eating behaviors. This factor was also identified in the Australian study [36], which showed that being affected by cardiovascular disease or another illness strongly motivated participants to lose weight because of the fear of increased risk of complications or death. Conversely, the Swedish study [35] showed that health problems were an obstacle to adopting a new diet.

We have highlighted several key elements of nutrition coaching: knowledge transfer, the opportunity to put knowledge into practice, skills strengthening, experience sharing and practice with a peer group. We find these points in the literature. In the Danish qualitative study [34] that examined the factors limiting and facilitating sustainable weight loss in overweight or obese women planning a pregnancy, lack of knowledge and skills in cooking healthy foods were cited as barriers to adopting a balanced diet. In the Swedish study [35], the women expressed the desire to cook in a group and have more space for contact and sharing with other participants.

Concerning the effects of the support program, we identified cognitive and behavioral changes. We consider cognitive changes to be a first step toward behavioral changes. As emphasized by Bandura’s social cognitive theory and agency theory [37], knowledge of the risks or benefits of certain health behaviors is considered a prerequisite for behavioral change. It is therefore necessary to be aware of one’s own eating behaviors and of the importance of modifying them to take action and initiate a change in behavior and then adopt a healthy diet in the long term. Thus, even in the absence of behavioral change, we can consider that a cognitive change is by itself a positive outcome and is the indispensable first step toward action.

Study interests and limitations

One limitation of our study is the limited length of time the women had been participating in Igikali House’s support program at the time of the interviews. The participants interviewed had been attending the center for a maximum of 14 months, which is not long enough to observe the onset or long-term sustainability of changes in eating habits, which take time to establish [16]. This limitation is due to the fact that Igikali House is a recent experiment (inaugurated in February 2022). A further limitation of the study is the desirability bias associated with the qualitative interview methodology. The close relationship established with the women supported by Igikali facilitated the recruitment of women into the study, as the women equated the researcher with a member of the association’s team. However, this closeness also restricted the women’s ability to express themselves and freely criticize the support offered by the association. In order to ensure the validity and reliability of the data, a cross-referencing process was undertaken with factual data from the monitoring of the centre’s professional staff.

Another limitation of our study is that it focused on a specific element of the multifaceted support offered at the Igikali center. However, all the axes of support (health, social, professional integration), all the activities offered, and the kind and welcoming environment of the center contribute to changes in eating habits. Mental health, for example, is a relevant parameter to take into account, as the Danish study [34] showed that it was also a factor influencing changes in eating habits. Other complementary lifestyle parameters, such as physical activity, employment or access to rights, need to be considered for a more comprehensive understanding of the interactions between all these components.

By providing additional insights into the functioning of a diet support intervention targeting disadvantaged, immigrant women living with a chronic illness, our study is relevant and complementary to the various impact studies that exist in the field of intervention research.

Implications for practice and future research

The mechanisms by which the intervention produces effects on eating behaviors correspond with the different dimensions of individual empowerment [31]: knowledge, skills, self-esteem, participation and critical awareness. We have linked these mechanisms to the corresponding key elements of the intervention. These elements will be important to consider when replicating this type of support in other contexts or territories.

Conclusion

This intervention promotes the acquisition of knowledge, which seems to be a prerequisite for adopting a healthy diet [38]. This study shows us that knowledge alone is not enough: it is also necessary to enable people to experience, acquire skills, develop new habits, participate in a collective, gain self-confidence and have a critical view of the received information. On the one hand, the intervention provides a response to material needs (daily meals offered, hygiene care packages, material aid for transportation) and proposes casework support for legal status and access to healthcare. On the other hand, when administrative and legal difficulties cannot be resolved by the caseworker and the participants are thus unable to access welfare and employment, this type of support cannot completely overcome the economic and material barriers to purchasing low-energy foodstuffs (such as fruit and vegetables, fish, lean meats) and preparing meals (having a kitchen available). To remove these obstacles and reduce social inequalities in health, policies need to ensure that people living with chronic illnesses have access to decent accommodations and quality food. Experiments such as “social food security” (to combat student insecurity) [39] or the distribution of food baskets (to combat endocrine disruptors during pregnancy) [40] are currently being tested in France and seem to complement food coaching to encourage changes in eating habits.