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Abstract

Background: Immigrant families arrive in the US from a variety of nutritional landscapes and educational experiences. Early childhood is a key time to intervene to set children on a healthy path. Creating nutritional education programs tailored for immigrant families may improve nutrition and health outcomes.

Objective: To evaluate the First Foods curriculum as a tool for knowledge and behavior change for new immigrant families of young children.

Methods: Immigrant caregivers of children less than 2 years old were invited to attend First Foods, a 4-class series. Each series was offered in 1 of 5 different languages (Arabic, Dari, Somali, Burmese, and Nepali). Recruitment occurred through community organizations, primary care clinics and Women, Infants, and Children (WIC), and classes were held in King County, Washington. The curriculum was developed and taught by a registered pediatric dietitian with input from general pediatricians, all experienced in the care of immigrant families. Classes were interpreted in the relevant language and course materials were translated. The classes were based on 4 themes -- 1) Child Eating and Development, 2) Eating Together, 3) Food Safety, and 4) Health Living -- and incorporated positive parenting and child development. Attendees completed pre- and post-surveys in their respective languages or in English. Descriptive statistics, chi-squared analyses, t-tests, and a multi-level linear regression model were conducted in Stata v14.0.

Results: Participants in the classes included 47 caregivers (91% mothers). Nearly one-third had previously lived in a refugee camp. They had lived in the US a mean 5.5 years (95% CI: 3.8-7.2 years), attended a mean 8.6 years of school (95% CI: 7.1-10.1 years), and had a mean of 2.8 children (95% CI: 2.3-3.3 children). Classes ranged in size from 5 to 14 caregivers. Caregivers reported an improved understanding of 2 out of 4 methods to decrease risk of dental caries (drinking tap water, p = <0.001; going to the dentist, p=0.02). They reported a decreased use of food as a reward from the pre- to the post-survey (p=0.027). Additionally, the caregivers reported increased frequency of considering sugar content in family foods (p=0.033), and decreased frequency of purchasing food at a convenience store, after participating in the curriculum (p=0.001). Conversely, there were several domains where caregivers did not show a change in their response.

Conclusion: First Foods, a community-tailored, early childhood feeding curriculum for immigrant parents of young children, improved knowledge and behavior among caregivers from a variety of immigrant communities in some domains. In the other domains, there may be opportunities to further optimize the educational messages and approach.

Key Take Away Points

    • The First Foods curriculum improved knowledge of oral health of immigrant caregivers of young children.
    • Caregivers who attended First Foods sessions improved their behavior around the use of food as a reward, considering the sugar content of family foods, and the frequency of their shopping at convenience stores.
    • Lessons learned from supporting immigrant families with young children could inform advice given by health care providers, and existing early childhood programs such as WIC and Head Start, thereby improving programs and policy.

Author Biography

Elizabeth Dawson-Hahn MD, MPH, is an Attending Physician at University of Washington-Harborview Pediatric Clinic, an Assistant Professor of Pediatrics at the University of Washington (UW) and a Principal Investigator at the Seattle Children’s Research Institute. Dr. Dawson-Hahn’s primary goal is to improve the health, growth and development outcomes of vulnerable children and families, with a focus on refugee and immigrant populations. Her community and public health partnered research primarily focuses on refugee and immigrant children and families across the migration continuum. She provides clinical care to children with medical and/or psychosocial complexity and enjoys welcoming new immigrant and refugee families into her primary care practice at Harborview Medical Center. She collaborates with the Centers for Disease Control and Prevention and the United Nations International Organization for Migration to support pediatric capacity building of general physicians and nurses providing care to refugees globally, and in guidelines for the care of pediatric refugees. She volunteers as a pediatric provider for asylum medical evaluations for the Northwest Health and Human Rights Project. Lorren Koceja, RD, CD is a registered dietitian at Harborview Medical Center, where she has been providing nutritional counseling for a decade. She received her degrees from Oregon Health and Sciences University in Portland and Seattle Pacific University in Seattle. She currently works in 5 different clinics at Harborview: International Medicine, Pediatrics, Womenʼs, Liver and GI. Her passion is working with refugees and immigrants to provide culturally sensitive nutrition education. Recently, Lorren developed education materials for the First Foods class focused on early childhood feeding for immigrant families, and was taught in six languages. She is currently in the process of writing a manual for the class for future dissemination. She has also participated in the development of the Diabetes slideshows for Ethnomed.org. She is also in the process of becoming a lactation expert (IBCLC). Abigail Grant, MD is an outpatient pediatrician and medical director of the University of Washington-Harborview Pediatric Clinic. She provides primary care to children of diverse backgrounds including many refugee and immigrant families, and families challenged by complex social and medical conditions. Dr. Grant established the Harborview Cares for Kids Program to support early childhood development which includes developmental toolkits, lactation support, Promoting First Relationships based care, and connection with early learning programs through a medical home-Head Start partnership. She is currently focused on developmental screening for diverse patient populations including qualitative research to culturally adapt and translate a developmental, behavioral, and social screening tool (Survey of Well-being of Young Children) for Somali families and an innovative pilot project combining bilingual family navigators and a text-based app to meaningfully screen and connect families to services. She is faculty for Seattle Children’s REACH (Resident Education and Advocacy for Child Health) pathway and mentors residents interested in child advocacy locally and globally. She is also a trainer to teach Promoting First Relationships to pediatric residents. Anisa Ibrahim, MD is a general pediatrician at University of Washington-Harborview Pediatric Clinic. Dr. Ibrahim has always had a passion for serving vulnerable refugee and immigrant populations through providing patient care and active engagement in the community both as a mentor and a community leader. Dr. Ibrahim’s clinical and community-based practice is focused on refugee and immigrant health. She provides care for newly arrived refugee and immigrants and children with social and medical complexity. Outside of her clinical work, Dr. Ibrahim is the Board President of the Washington State Somali Health Board. She is involved in projects that address barriers to accessing health care for vulnerable populations including culturally adapting educational and screening materials, facilitating focus groups in both English and Somali, and informing community-partnered research practices. Nationally, she is on the Executive Committee of the American Academy of Pediatrics Council on Community Pediatrics, and she has collaborated with experts at the North American Refugee Health Conference to foster advocacy through coalition building and incorporation of migration health into medical education. Beth Farmer is a Licensed Clinical Social Worker and the Director of Refugees Northwest, a suite of programming that partners with refugee individuals, families, and communities for health, justice and hope. Her undergraduate degree is from Texas Christian University and her graduate degree is from University of Washington. Ms. Farmer has spent more than three decades working with marginalized and vulnerable populations and has received numerous awards for her work including being named by the Robert Wood Johnson Foundation as a Community Health Leader. H. Mollie Grow, MD, MPH is a general pediatrician in the Division of General Pediatrics. She is a teaching faculty with the UW School of Medicine Colleges program, and serves as an Associate Program Director for the pediatric residency and Director of Continuity Clinics. She serves as a faculty lead for the Resident Education and Advocacy for Child Health (REACH) Pathway. Clinically, she provides general outpatient pediatric care at UW Roosevelt Center and also supports the obesity treatment clinic at Seattle Children's Hospital. She is an inpatient attending at the University of Washington Newborn Nursery. Dr. Grow's research focus is developing effective programs and policies to promote child wellness and prevent pediatric obesity, particularly through community-based, collaborative partnerships. She has developed expertise in motivational interviewing (MI), and its application in childhood obesity care. Her research has been funded by the NIH, Academic Pediatric Association, and the Robert Wood Johnson Foundation (RWJF). She serves as an advisor on pediatric obesity for the AAP Institute for Healthy Childhood Weight. Sarah Lowry, PhD, MPH has worked for the past 3 years as a Biostatistician with the Biostatistics, Epidemiology, Econometrics and Programming Core at Seattle Children’s Research Institute, within in the Center for Child Health, Behavior and Development. She earned her PhD in Epidemiology from the University of Washington (UW), and has also previously worked at UW on various global health research studies and evaluations. She provides methodological and biostatistical support on a broad range of research projects and program evaluations related to child health, and she is passionate about contributing to meaningful and relevant research in order to improve the health and well-being of children and families. Suzinne Pak-Gorstein, PhD, MD has served on the faculty at the University of Washington (UW) since 2006 and is associate professor in the Department of Pediatrics and adjunct associate professor in the Department of Global Health. She has led several educational initiatives including the Resident Education and Advocacy for Child Health (REACH) program at the Seattle Children’s Hospital which she co-founded in partnership with the University of Nairobi in 2009. She is the co-Director of the Nutrition Think Tank for the Global Center for Integrated health of Women, Adolescents and Children (WACh-NTT). She is the lead author for the current CDC nutrition and growth guidelines for newly arrived refugees in the US. She attends at the University of Washington-Harborview Pediatric Clinic which serves immigrant/refugee children, from where she supports several community collaborations to support refugee families in areas including food security, child development, health screening, and advocacy. She has also carried out work with UNICEF and WHO in program monitoring and evaluation, nutrition surveillance systems, national surveys in several countries including Indonesia, Laos, Nepal, Bangladesh, and India since 1998.

Acknowledgements

We are grateful to the families that participated in this study and to the interpreters, who made the project possible. We are grateful to Zac Eskenazi and Amy Lloyd Wagner at Refugees Northwest a program of Lutheran Community Services Northwest for their collaboration and leadership in the program logistics. We appreciated the partnerships with Refuges Northwest, World Relief, Somali Family Taskforce, the Somali Health Board, Mother Africa, Coalition of Refugees from Burma, and the Bhutanese Community Resource Center that made this project possible. This work was funded by United Way of King County, Rotary International, and the Center for Diversity and Health Equity at Seattle Children’s Hospital. Dr. Dawson-Hahn was an NIH Ruth L. Kirschstein National Research Service Award fellow during this project.

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