Community listening to understand determinants of healthy eating in an Australian priority community

Abstract

Unhealthy dietary behaviour is associated with several adverse health outcomes. However, individual dietary choices aren’t solely the function of personal habits and are influenced by various environmental factors. This study aimed to identify the social determinants of dietary behaviours in a priority Australian community. We utilized community listening to explore the priority community members’ narratives and experiences about the determinants influencing their dietary behaviour. Those determinants were then categorized under the lens of the Socio-ecological Model. The suburb of Inala; a low socioeconomic, multiethnic community in Southwest Brisbane, Queensland, Australia was selected to listen to the voices of community members, health professionals, social workers, teachers, and community service providers. Researchers listened to hundreds of stories from 168 community members throughout the project. Participants identified personal interest in healthy eating, knowledge of healthy food and preparation; and time constraints for healthy food preparation, which were subsequently categorized under individual-level (microsystem) determinants of dietary behaviour. Family support, parental influence, and commitments were identified as other determinants that were categorized under social-environment level (mesosystem) determinants. Availability of fresh fruits and vegetables and ubiquity of fast-food outlets were the other factors identified, which were listed under physical-environment (exo-system) determinants; and finally, cost of living, inculturation, and dissatisfaction with health practitioners were identified and categorized under policy-level (macrosystem) determinants. The complex relationship between personal, sociocultural, and environmental factors with dietary behaviour presented in this study highlights the need for multi-component and culturally tailored initiatives to enable healthy eating in priority communities.

BACKGROUND

Socioeconomic status (SES) is a strong predictor of food consumption patterns and nutrient intake (Heijden et al. 2021). People living in lower SES areas have less optimal food environments and fewer opportunities to source and consume healthy food (Thornton et al. 2016, Bivoltsis et al. 2019, Wallace 2021, Darcy et al. 2022). These conditions, along with presumably other contributing factors, could directly or indirectly contribute to lower consumption of fruit and vegetables and a higher intake of energy-dense food among people living in the lower SES areas compared with those living in higher SES areas (Heijden et al. 2021). Notably, people in lower SES areas may be limited by the availability and affordability of healthy food, despite their wish to make healthier food choices (Wallace 2021, Darcy et al. 2022, Gittelsohn et al. 2022).

The interconnected factors of socioeconomic conditions, power dynamics and social support, collectively known as social determinants of health, play a crucial role in shaping an individual’s health, wellbeing, and quality of life (AIHW 2020, ODPHP 2020). Behaviour change interventions are recommended to adopt frameworks that address various levels of influence through multiple strategies (Sogari et al. 2018, Caperon et al. 2019, ODPHP 2020). The socio-ecological model is one comprehensive conceptual framework that focuses on multiple contexts and levels of influence (individual, social, physical and policy, interactions between these levels, and their contribution to change in behaviour/health outcomes) (Sallis & Owen 2015, Caperon et al. 2019, Wang et al. 2023).

To understand the influences mentioned above and the determinants of human health behaviours, participatory approaches to health initiatives are an effective way, whereby people voice their opinions on matters that impact their everyday living (Santilli et al. 2016). Community organizing is one such structural approach aimed at fostering change within the community. It involves actively engaging community members in dialogues to collectively establish a shared vision, strategies, and develop an implementation plan based on shared ideologies (Douglas et al. 2016). The objective of community organizing is to educate, empower, and mobilize communities by building their social, political, and decision-making capacities to assert their voices, increase influence within their community, and drive social environmental changes, such as change in built environment reflecting community healthy eating priorities (Douglas et al. 2016, Agrusti et al. 2020).

An effectively implemented community-organizing initiative is considered more likely to be effective and sustainable than ‘top-down’, pre-planned health initiatives where the community is ‘acted on’ (Douglas et al. 2016, Santilli et al. 2016). Our recent work suggests that these initiatives could take many different forms, and be based on various frameworks, models, and processes, but despite their diversity could still result in positive health outcomes (Kadariya et al. 2023).

Our work also identified paucity of studies, in the Australian as well as international literature, that have utilized community-organizing approaches to listen to the needs and priorities of community members towards healthy eating. Rather, the search has typically focused on the enablers and barriers of healthy eating in specific demographics groups like young people (Amore et al. 2019), people with diabetes and other chronic diseases (Petroka et al. 2017), and relatively few studies have focused on the general population (Van Dyke et al. 2024). Therefore, this study was undertaken to address the gap in the literature about the utilization of community-organizing approaches in promoting healthy eating among the general population. The study aimed to do so by using community organizing as a means to hear community voices and present those voices within the framework of social determinants of dietary behaviours, in a priority Australian community setting.

METHODS

Overview of community listening

This study was part of a larger community-organizing effort called ‘Nourish Inala’ which aimed to take collective action in food and nutrition to improve the quality of life of people living in a low SES area in Australia. The project adopted Alinsky’s model of community organizing that involves four phases: (i) community listening, (ii) discernment, (iii) action, and (iv) evaluation (Tattersall 2015, Post 2018). This article specifically focuses on the findings derived from the first phase—community listening.

Community listening involves gathering community members and local leaders together to listen to their interests, build trust with them, and develop an understanding of common issues that affect them and matter to them as a community (Tattersall 2015). ‘Relational meetings’ and ‘table talks’ are two components of community listening. Relational meetings are one-on-one semi-structured interviews with the community members and recognized community leaders. Table talks are akin to focus groups, bringing organizational leaders and community members together for group discussions (usually between 6 and 12 participants) (Tattersall 2015).

Study context

This community-organizing project was implemented in Greater Brisbane’s Southwestern suburb of Inala. The suburb is considered one of the most disadvantaged (referred to as prioritized from here onwards) areas within Greater Brisbane due to its low median household income and high unemployment status (Queensland Government 2018). Inala has been ranked the second highest socioeconomically prioritized area in Queensland (QLD) and ranked 1148 out of 1161 suburbs in Australia, with 1161 as the score for being the most disadvantaged (Torrens University Australia 2021). There is evidence that residents from low socioeconomic areas experience higher non-communicable disease risks and this holds true for Inala as the data suggest that Inala residents live with chronic illnesses and mental health issues at a higher rate, and at a younger age than most Australians (Inala Primary Care 2020).

University researchers collaborated with Queensland Community Alliance (QCA), a non-profit organization that unites 35 institutions including churches, mosques, and community organizations. The university researchers attended community-organizing training run by Queensland Community Alliance (QCA) and with QCA’s help connected with community members and local organizations in Inala. These connections were made possible through relational meetings with existing community leaders from local medical centres, primary health care services, Technical and Further Education (TAFE) institutions, private businesses, charities, Inala Primary School, Inala Community House, Blue Care, and private residences. Following the relational meetings, table talks were held, bringing together large, diverse community groups, where the research team heard hundreds of personal stories from 168 community members between September 2021 and November 2021 and grew connections with the local community to drive ongoing communication to inform local action.

Participants

The study participants for the relational meetings and table talks in Inala included health professionals, social workers, teachers, and other community members. These community members or stakeholders (church members, TAFE teachers, medical personnel, and community service providers) had either lived for several years in Inala or had extensive experience working in the area. The study participants were not excluded based on any characteristics such as gender, ethnicity, or age.

Relational meetings

Purposive sampling was used and all community members who were interested in participating after receiving the information about the project were invited to attend the relational meetings—each lasting 45–60 min. The lead community organizer used their strong community network to identify key community stakeholders based on their expertise and approached them to participate in the relational meetings. Altogether 13 such relational meetings were organized.

Table talks

Both purposive and snowball sampling methods were employed for identifying the table talk participants. They were contacted via emails, phones, and verbal conversations following the relational meeting referrals. A series of listening sessions were carried out in the community to gather inputs from community members and stakeholders alike. Each community listening session was conducted for around 60–90 min. Each session was guided by an open-ended questionnaire with one facilitator to guide the talk and one note taker for record-keeping of the conversations.

Along with a series of relational meetings and table talks, QCA also invited key stakeholders and community members through emails, phones, and their community network in November 2021 to a ‘Community Connector Night’. This event was focused on sharing stories and experiences of the community members regarding healthy living in Inala. Approximately 80 community members attended this event including allied health workers, general community members, representatives from partner organizations as well as QCA members active in Inala. This process reasserted the shared interests of agencies and community members in working together to foster healthy eating and healthy lifestyles in Inala. Informed consent was obtained for all the relational meetings and table talk participants including those attending the community connector night.

Data collection

The research team brought diverse professional backgrounds, including nutrition and dietetics, psychology, and public health, which provided a multidisciplinary lens to the study. All researchers were trained in the community-organizing process by experienced community organizers from QCA, equipping them with a solid understanding of the methodology. Additionally, their extensive experience in community-based research supported effective engagement with community members and an appreciation of participants’ knowledge of healthy lifestyles.

All relational meetings and table talks were focused on the broad topic of healthy lifestyle in the local community. For the purpose of this study, the information obtained was used to address the following research questions:

• How does the interplay of personal and non-personal factors influence community dietary behaviours in a priority community setting?

• How do the determinants of dietary behaviours in a priority community setting fit under various levels of the socio-ecological model?

During relational meetings (for an individual) and table talks (for a group of individuals), the facilitator/community organizer used a semi-structured questionnaire as a guideline to lead the conversations. The discussion began with the facilitator outlining the table talk/relational meeting objectives. They then initiated the conversation by asking the participants about their ability to access resources for a healthy lifestyle, and the barriers they faced. The facilitators also shared their own personal stories about adopting a healthy lifestyle, along with the barriers and enablers they encountered for healthy eating. As the facilitator continued sharing, community members started connecting their own experiences and discussed how they were working towards adopting a healthy lifestyle. The facilitator guided the discussion, encouraging participants to share their stories about dietary changes and any efforts they had made towards healthy eating. As they started contributing, the conversation progressed into a meaningful spontaneous discussion about healthy living. Community members actively listened to and appreciated each other’s stories, while also learning about new ways of making positive lifestyle changes. Through these table talks and relational meetings, prospective community leaders/champions were identified based on their potential to: (i) influence change in their community, (ii) empower individuals to unite and invoke actions together, and (iii) create sustainable community-based solutions.

In the presence of experienced community organizers from QCA, trained researchers took field notes that included direct quotes from the participants. The age, gender, and occupation of participants were also collected during the conversation/discussion. The field notes were later transcribed into a Microsoft Word document. De-identified notes were stored securely using the secure data storage service within the university system.

Data analysis

We followed Braun and Clarke’s six-phase process of reflexive thematic analysis in exploring and interpreting the data obtained from the community listening exercise (Braun & Clarke 2021, Braun et al. 2022).

Notes from each session were summarized as field reflections. The first author had already developed familiarity with the data from the time of data collection. This familiarity was made possible by participant engagement, rapport-building, and exploring their stories during the relational meetings and table talks. This in turn was followed by reviewing the field notes, before actively engaging with analysis. These notes and reflections were read and re-read by the first author and immersed themselves into the data which led to the generation of codes.

With the initial inductive coding approach, interesting patterns and categories in the data that were relevant to the two research questions were identified and documented separately. The separate documentation of codes ensured that they captured meaning in a way that could be understood in isolation. Some of the initial codes developed while reviewing the field notes were later revised/refined following discussions among the authors who were present during community listening. This allowed the authors to examine the field notes from an alternative viewpoint, which was useful from a reflexivity perspective.

After the initial coding, the codes were examined for recurring patterns and grouped into potential broader themes to construct coherent meaning. These themes were developed inductively from the participant’s narratives rather than being shaped by predefined categories. The refined codes were further added to the personal reflection notes, where the first author noted down what she noticed about the participants and the ways in which they framed their experiences. Following the code generation, potential themes were subsequently generated by grouping similar codes together (based on the patterns observed across the field notes), and the commonalities in the respondents’ answers.

The process of developing themes involved collating of codes and continuously revisiting the raw reflective notes to further refine themes. Despite each participant’s story being different from that of others, commonalities were present across their experiences. The themes were then reviewed in the context of the dataset (reflexive field notes) and our research questions.

Through iterative reflection of the initial themes, and revisiting of field notes, further ideas about the patterns and themes were refined. Each theme was then clearly defined to establish its core concept and scope about what participants thought about healthy lifestyles, factors affecting their healthy eating practices and enablers to influence them.

In the final stage, to provide further clarity to each theme and to represent the experiences of the participants through their words, S.K., J.P., and L.B. described each theme and categorized them according to the socio-ecological model. This process remained iterative, requiring repeated revisits to earlier phases to ensure that the themes accurately reflected participant perspectives while aligning with the research questions. Relevant participant quotes were subsequently listed under these themes during the writeup to help readers see contextual examples of the participants’ experiences about healthy eating.

As the overarching conceptual framework guiding this study, the finalized themes were presented under the four levels of the socio-ecological model: individual level (microsystem), social-environment level (mesosystem), physical-environment level (exo-system), and policy-level (macrosystem) (see Fig. 1).

Researcher reflexivity in the analysis process

Due to their active engagement with the community starting from the data collection stage, the researchers had developed familiarity with the data and could look at it with the background knowledge and experience of having been present in person while the community consultations were taking place. Participant engagement, rapport-building, and listening to multiple individual stories during the relational meetings and table talks further helped with this process. This was further enhanced by the author’s appreciation for the community members, recognizing their stories and relating them to their own lifestyles. This enabled the authors to listen with empathy and a sense of connection to the experiences shared. The theme development process was aided by that sense of self and an active generation of themes (as opposed to themes emerging on their own). Therefore, the researcher’s own personal experiences helped inform the data analysis to describe and interpret the participants’ responses/experiences about healthy eating.

It is also important to add that all authors recognize the potential biases stemming from their personal/professional backgrounds and training (Olmos-Vega et al. 2022). Additionally, their expertise in health-related disciplines may have shaped their perspectives, potentially leading to an overemphasis on health-related outcomes or the prioritization of specific aspects of healthy lifestyles out of all the issues that came out during community listening. Similarly, the authors’ familiarity with community-based research may have also influenced their expectations or interpretations of participant responses. Reflexivity throughout the research process was essential to mitigate these biases and ensure the voices and experiences of community members were authentically represented.

Ethical standard disclosure

The study participants were provided with study information including the purpose of the study before commencing the table talks and relational meetings. Verbal consent to participate was obtained from all participants before every meeting. Ethics approval for the study was provided by the Griffith University Human Research Ethics Committee (GU Ref No: 2021/672).

RESULTS

All table talk and relational meeting sessions were highly interactive. The participants varied between events, as some sessions were targeted at health professionals, some at general community members, and others at senior citizens. However, they all shared a common goal: improving the lifestyle of their respective communities. As a result, all participants expressed strong opinions about changing the living environment to promote healthier food choices and lifestyles. Most of them expressed a desire for healthy eating for a healthier lifestyle.

The community voices on determinants of healthy eating in Inala are shown in Fig. 1.

Individual determinants of healthy eating

Individual factors play an important role in influencing healthy eating behaviours, shaping both the personal motivation and capacity to make dietary choices. Personal interest, knowledge, and time were identified as individual-level factors that play a role in overcoming barriers and embracing healthier eating practices among the Inala community members.

Personal interest in healthy eating

Personal interest in healthy eating was found to be driven mainly by health goals. Participants shared how motivation to improve health and prevent the early onset of chronic diseases had encouraged healthier choices in them. A number of participants described that they were personally motivated to choose healthier food and prioritized their health over the attraction of takeaway food.

One participant described that her daughter had attempted to improve her eating habits to improve her overall health. Another participant linked it with preventing the onset of chronic disease. Some of the common efforts towards healthy eating adopted by participants included reducing the intake of salt and oil, sugary drinks; replacing white rice with brown rice; and preparing homemade salads for snacks.

Whenever I feel hungry, I have started preparing salad or other healthy alternative snacks instead of running to buy takeaway or processed food. I want to stay fit and healthy. 27-year male, Student

My daughter is aware of her health problems and has started doing physical activity and changed her dietary habits to reduce the risk of diabetes in the future. She had gestational diabetes a few years back. 57-year, female

Instead of the sweet white rice that I was previously accustomed to, I have now started eating brown rice and have also reduced the portion size. I eat more fresh vegetables and fruits now and get them from a place nearby my home. 52-year female

Knowledge of healthy food and its preparation

We found that knowledge about healthy foods and cooking practices also influenced the participants’ ability to make informed choices. Many participants expressed a need for better nutritional understanding and cooking skills, due to the knowledge gap limiting their ability to prepare healthy meals.

People from Inala don’t know how to prepare healthy food - they can easily access fresh food and vegetables but lack cooking skills. 65-year female, community member

Some do not know how to prepare healthy food, and they mostly deep-fry their food. 50-year female, Social Worker

This lack of knowledge of healthy food preparation sometimes also extended to those who knew the importance of healthy eating but couldn’t prepare such food themselves.

Healthy food is important, but most people don’t know what healthy food is and how to prepare it. Too much misinformation in the newspapers and social media is confusing. Need to be taught how to eat healthy. 32-year working female

Discussion with health care and/or support professionals, who shared stories about their clients’ low health literacy and knowledge of healthy eating, revealed that many of their clients managed several challenges around social determinants of health, which had a direct impact on what and how they ate.

Most of my clients have limited [formal]education and nutrition education, and they spend money on smokes [sic] and eating junk food. Often when they get their welfare payments, they spend it all on junk food at the beginning of the week and then go hungry for the rest of the time. Many don’t know how to budget and don’t really want to know. 24-year female, Disability Support Worker

Care providers also reported that it was not easy to teach some of their clients about healthy eating or bringing about dietary behaviour change because in their experience, providing support in food preparation was more important than just focusing on access.

It has been 5 years, but I am unable to convince one of my teenage clients living with obesity to eat healthy food and do regular exercise. 43-year male, Physician

Time constraints for healthy food preparation

Time limitations were reported as another individual-level common barrier to preparing healthy food. Balancing busy schedules and responsibilities often left little time for cooking, making convenience foods a more appealing option despite the intention to eat healthily. Convenience, in terms of time availability to shop and prepare food, was identified as a hindering factor for those with busy family and work schedules. In this context, eating takeaway food and pre-packed meals often took the place of eating home-cooked meals to fit in with their lifestyle.

Most homes have two working parents. Therefore, mums buy packed items as they are not home to pack lunch boxes for their children. The oldest child usually packs the lunch boxes, so processed foods are an easy option. Even when it’s the mum packing the children’s lunch, it is usually easier to give children money to go to the tuckshop. 38-year female, Working Woman

People have a busy schedule and do not have time to prepare food at home. However, they want to go for tasty food and end up choosing unhealthy takeaway options. 49-year male

I wish I could have good and healthy takeaway food on the way back home after a tiring day. I used to enjoy healthy takeaway food back from when I was working in Japan. 36-year female, Teacher

Social-environment determinants of healthy eating

Socio-environmental factors were also found to impact individuals’ eating behaviours, with family dynamics and community support playing key roles. This highlights how relationships, societal norms, and household responsibilities can play supportive or disruptive roles in the adoption of healthy eating practices.

Family support and influence

Several participants mentioned that family support was a key mechanism of change for them to eat healthy, enacted through encouragement and modelling behaviour. The family served in motivating them to prepare healthy food at home either to promote health or to avoid adverse consequences of chronic disease.

I changed my husband’s diet completely into healthy food after he got diagnosed with diabetes. I am adopting moderation as the key to keep my husband’s glucose level on track. My GP has given me the nickname ‘Doctor’. 57-year female

Participants with grandchildren especially expressed their love of cooking for children and grandchildren and found it to be an important factor for opting healthy eating. This was further reinforced by the appreciation for non-Western cuisines by younger family members.

My children and grandchildren still deeply value traditional Vietnamese meals and typically eat home-cooked food. Vietnamese food is heavy on vegetables and is therefore a healthy choice. 67-year female, Retiree

Some participants also expressed the importance of introducing a range of different foods in the family diet during early childhood for promoting and maintaining healthy eating across the younger family members’ life course.

My kids aren’t fussy eaters; they eat vegetables easily, including bitter melon. I think introducing all kinds of food from an early age and maintaining that habit helps encourage the kids to eat better from a young age. It all starts at home. 42-year female, Liaison Officer

My children didn’t always like eating traditional Vietnamese food at home but now they eat it. I couldn’t always afford to provide them money for tuck shops, but Vietnamese food was much more affordable. I used to make many dishes with just one chicken. I am happy that my children are very healthy now. 66-year female, Local Resident since 1971

Some participants highlighted how parents’ own life circumstances or their attitude towards food and social pressure can also adversely affect their children’s dietary choices and overall health.

Some parents use fast food as a low-cost reward for children. Many parents from poorer backgrounds don’t like to deprive their children from ‘treats’ if they can afford them now. 45-year female, Community Family Service Staff Member

I was keeping my children away from chocolates and candies until the age of 4, my neighbours thought that I was doing so due to lack of money because of which the children were not getting sweets at home. That put me under indirect pressure to buy them sweets. 39-year male

Sense of family obligation and personal sacrifice

A sense of family obligation was another major factor that adversely affected healthy eating for many participants, especially women. They tended to prioritize their families’ needs and neglected their own for a healthy lifestyle.

Healthy eating and lifestyle are difficult for me to attain because of recent work commitments and my son being in year 12 this past year. I have sacrificed my time to ensure he is well supported. 39-year female, Liaison Officer

It is difficult for women from the [Vietnamese] community to take some time out for themselves and care about their personal health. It is because they devote a lot of their time taking care of their children and other family members rather than their own. I tried to teach them to be a little ‘selfish’ regarding self-care but found it hard to change their mindset. 50-year female, Professional Woman

Throughout various discussions, the participants, especially women, who were involved in preparing family meals reported that the choice of food they consumed was influenced by who they were eating with. They further commented that they did not eat as healthy as they would like to, instead, they often ignored their own preferences and ate whatever they were preparing for others.

I would skip meals and give myself the unhealthy offcuts of food while giving the best part to my daughters. Vietnamese parents do that – they sacrifice for their children. 45-year female

Physical-environment determinants of healthy eating

Availability and access to fresh fruit and vegetables

Some participants described that the biggest advantage of living in Inala was living close to an open-air fruit and vegetable market. However, despite the market’s presence in Inala, participants were also cognisant of limited access to the market for seniors, as well as those who do not live close enough to the market to walk.

The market provides us with the option of accessing fresh fruit and vegetables locally. However, it is hard for me to get to the market because of my health condition and transportation issues. 65-year male

Many older adults, recent migrants, people from low socioeconomic backgrounds with no access to personal vehicles and those with health concerns had difficulty accessing the market. Irregular and expensive public transport was a deterrent from going to the market to buy fresh groceries to prepare healthy meals.

Although the bus service is there, it is very expensive if you are not a pensioner. 70-year female

I am a wheelchair user and not all places are wheelchair friendly, including the fruit and vegetable market nearby. As a result, I end up going to a distant fruit and vegetable market. 66-year female

Ubiquity of fast-food outlets

Easy access and availability of fast-food outlets were a major physical-environment factor promoting unhealthy eating in the Inala area. The convenience of fast food in the area meant that it was easier for people to be reliant on processed unhealthy food.

Franchises like McDonald’s are intentionally targeting the Inala area because of its socioeconomic condition. They are aware of the low SES people opting for cheaper processed food, which is not healthy at all. 39-year male

Easy access and availability of fast-food corners is another major issue in Inala. There are very few good options for healthy takeaways and dine-in restaurants. 41-year female, Professional Woman

At the same time, some parents wished for a healthy alternative of fast-food takeaways for occasional treats.

I want my daughters to have takeaway foods sometimes in the week when I am very busy or tired to cook, unfortunately we do not have good stores for healthy takeaway. 50-year female, Community Leader

Policy-level determinants of healthy eating

We also identified some higher-level determinants reflecting systemic influences, ranging from cost-related barriers to access and cultural adaptation, to the quality of healthcare support. These determinants reveal the external forces that influence food-related behaviours and challenges at a community level.

Cost of living

Some participants reported that economic pressure made nutritious food less affordable for them. The higher cost of healthy options led families with lower socioeconomic status to prioritize cheaper, less nutritious alternatives, thereby limiting their ability to maintain a healthy diet.

I raised my 8 children as a single mum. I would have loved to buy them fish once a week but could not afford it. Meat was the most expensive part of my food budget, so I cook only with sausages. 67-year female

The unaffordability of fresh and healthy food was not only mentioned by the community members but also by care providers.

My patients, especially those from refugee backgrounds, buy cheaper foods with low nutritional value. It is because fresh food items are expensive to buy, forcing them to opt for cheap processed food. 37-year male, Health Practitioner

One of my clients ate unhealthy takeaway food as his regular meal, which is not good for a diabetic patient. He was not really focused on his health and was instead more focused on housing and social pressures than eating healthy and being healthy. 58-year male, Health Practitioner

One of the participants mentioned that being a single mother and having a low household budget, she has to choose between whether she wants good childcare or healthy food for her children.

The childcare cost is high and that is one of the barriers for having a healthy lifestyle. Sometimes, I need to make a choice between child care or healthy eating. Cheaper childcare options are also available but their menu does not have healthy food options. 40-year female, Professional Woman

Inculturation

Participants discussed how transitioning to new dietary norms into their new host community had created an imbalance, among migrant and refugee background communities, between their traditional eating habits and local food systems, making it harder for them to navigate healthy eating options.

Many migrants had struggled with access to affordable adequate quantities of food before migrating to Australia due to difficult life conditions. As a result, they are availing themselves of cheap processed food items and developing unhealthy eating habits. 37-year female

Some people from the refugee background think that eating ‘Western food’ is more prestigious than eating cultural food. 25-year male

Pacific Islanders eat fried chicken and fried food. They see fried food as extra special because oil in their islands is expensive. Fatty foods are more accessible here compared with their home islands. 45-year male, Multicultural Community Development Officer

Dissatisfaction with health practitioners

Some participants described that their general practitioner and/or dietitian were not adequately meeting their needs. Some were concerned about health professionals not providing them with culturally appropriate food suggestions. As a result, people did not attend their appointments or avoided health services altogether.

Some GPs don’t even pay attention to their patients’ concerns and make us feel not listened to. There are many Vietnamese patients in that area who do not speak English and the GPs just want to hold on to those patients within their own GP practice. 52-year female

Dietitian’s suggestions should be culturally appropriate. They need to make diet plans as per the clients’ cultural background. People with rice as a staple food should not be asked to cut off rice completely. 42-year male, Health Practitioner

Interactions between socio-ecological levels

Reflecting on the socio-ecological model, the interaction between the different levels as described in the result section above—individual, social, physical environment, and policy—provides a comprehensive framework for understanding the complexities of healthy eating behaviours. Each level influences and is influenced by the others, strengthening the depth and breadth of the analysis.

For example, individual determinants, such as interest in healthy eating and time constraints, do not operate in isolation but are shaped by broader social and environmental contexts. A lack of family support or competing family commitments (social environment) may exacerbate individual time constraints for healthy food preparation. Similarly, individual knowledge of healthy food may be undermined by a physical environment where fresh fruits and vegetables are inaccessible or overshadowed by the ubiquity of fast-food outlets.

At the policy level, determinants such as cost of living and dissatisfaction with health practitioners interact with other levels by creating systemic barriers. For instance, even individuals with an interest and knowledge of healthy eating may find their efforts constrained by the rising cost of fresh produce. This is further compounded when policies fail to address inculturation or systemic inequities that disproportionately impact marginalized communities.

The interplay between levels highlights the need for holistic strategies to address healthy eating. Interventions at one level (e.g. increasing knowledge at the individual level) may be less effective without complementary actions at other levels, such as improving access to affordable healthy foods or fostering supportive social environments. This interconnectedness emphasizes that sustainable change requires simultaneous attention to the individual, social, environmental, and policy determinants of behaviour.

DISCUSSION

This study utilized community listening to identify the determinants of healthy eating among community members residing in a priority area in Australia. Unsurprisingly, community members shared rich perspectives on healthy eating, supporting community-organizing action.

Personal motivation for healthy living was identified as an individual-level factor in influencing healthy eating. Well-informed individual preference for healthy eating is an expected outcome because those who can differentiate healthy from unhealthy foods are more likely to be motivated to make healthy selections (Vettori et al. 2019, Willett et al. 2019). Subsequently, poor food literacy and limited cooking knowledge and skills among the participants prevented eating healthy. As a result, community members reported preparing and consuming unhealthy food despite having all the ingredients available for healthy cooking. Confidence in meal preparation and cooking skills has been found to be positively associated with incorporating healthy ingredients in dish preparation and healthy eating (Wijayaratne et al. 2021). Tailoring workshops/classes to impart nutritional knowledge or cooking skills to community members from priority communities is therefore recommended (Mirza et al. 2022).

Being time-poor in preparing healthy food was also identified as an individual-level barrier to healthy eating. Changed labour conditions mean that the working hours of people have been extended, which has changed how, what, and when people eat (Palumbo 2020). As a result, more people are spending less time preparing healthy food at home. In many cases, even the foods consumed at home are increasingly being delivered to households as takeaway foods from ready-to-eat outlets (Poelman et al. 2020, Dana et al. 2021). There is also some evidence that post-COVID working-from-home arrangements could have contributed to some decline in the diet quality due to an unintended overlapping of household duties and work responsibilities, which increased fatigue perception and ultimately increased the consumption of comfort snacks and takeaway food (Palumbo 2020, Sarda et al. 2022), mainly during the pandemic settings. Therefore, any intervention aimed at promoting healthy eating as a public health problem needs to not only focus on trying to reduce unhealthy food consumption through health education but also on making healthier food options more readily available and accessible.

Families can be an important mechanism of change in communities. A parent’s proficiency in food literacy and cooking skills is crucial for the provision of healthy meals for the whole family (Wijayaratne et al. 2021). Conversely, the intergenerational transfer of unhealthy eating habits from parents to their offspring is more likely to lead to unhealthy eating in children and adolescence as it becomes a part of their lives growing up (Rhodes et al. 2016, Berge et al. 2018). Parents on the other hand might have been limited by their own constraints in making poorer choices for themselves, either because of resource limitations or lower priority placed towards their own self-care and healthy living (Lev-Ari et al. 2021). Therefore, adopting a multi-pronged approach to promoting healthy food while also addressing families’ socioeconomic concerns could prove helpful, and this is likely to extend beyond a familial-level responsibility and require policy-level intervention.

The presence of a fresh fruit and vegetable market in the immediate neighbourhood was found to be a physical environmental motivator for a small number of participants to eat more fresh and healthy options. There is evidence that opening up a local farmers’ market in an underserved community not only improves access to fresh produce (Sadler 2016) but also reduces grocery prices (Newing et al. 2023). This adds strength to the argument that when provided with an option, members from priority communities are likely to opt for healthier options. However, the study not only identified limited access to healthy options in the community but also easy accessibility to fast-food outlets. Spatial access to these food outlets played an influential role in hindering healthy eating and encouraging more unhealthy eating habits among many community members, and this finding aligns with those from previous studies (Petroka et al. 2017, Bivoltsis et al. 2019).

Food environments in areas with low socioeconomic status are usually less enabling of healthy eating in terms of access and affordability (Darcy et al. 2022). In addition to general grocery stores offering more unhealthy food options in these priority areas, takeaway outlets that sell relatively more unhealthy and cheaper foods are also present in significantly higher numbers (Erpecum et al. 2022). As a result, people are more likely to be exposed to, purchase, and consume energy-dense unhealthy meals in these areas (Goffe et al. 2020). However, there is also evidence of counterargument in the literature, from the Australian state of Victoria, that the development of an additional fast-food chain restaurant in one’s direct residential environment may not always lead to automatically increased consumption of unhealthy food, especially if the residential environment is already saturated with similar other fast food outlets that the locals have already been frequenting (Thornton, Ball, et al. 2016). The double-barrelled situation of limited access to healthy options and easy access to unhealthy ones means that it is important for community planners to adopt place-based approaches in priority communities, where the services are placed in convenient and easy-to-access locations. These place-based approaches are known to help promote population health and health equity by addressing social determinants of health (McGowan et al. 2021).

Addressing broader social determinants of health (beyond the public health/health promotion sector) should be at the centre stage of addressing healthy eating in the priority communities. Previous studies have shown that the perception among community members that the cost of healthy food is higher than that of unhealthy food served as a barrier to eating healthily (Sogari et al. 2018, Amore et al. 2019).

Acculturation was also found to influence people’s choice of food and eating habits. Some migrant and refugee community members reported having had to opt for cheaper and unhealthy options due either to affordability issues or an inclination towards a more novel Western-style diet. Other studies conducted in Australia and the USA also found that people from migrant backgrounds, especially those with low SES are bound so much with the demands of settlement and social stressors that it reduces their ability to focus on healthy lifestyle behaviours, resulting in the establishment of unhealthy lifestyle habits in host countries (Bertoni et al. 2011, Cyril et al. 2017). In addition, migrants are more exposed to ‘Western food’ in the host country which ultimately adversely affects their health (Gallegos et al. 2020).

As in the case of a study among culturally and linguistically diverse (CALD) populations in Victoria, Australia (Cyril et al. 2017), participants in this study also identified a lack of car ownership, poor public transportation, and the need to travel long distances as transportation-related deterrents for healthy eating. Not having access to a personal automobile has also been found elsewhere to impede one’s access to fresh produce (Hammelman 2018). In the context of Inala, this might be because the residents found the hot weather prohibitive to walk to the shops. This could also be because of a higher proportion of older adults in Inala, who have problems with mobility. This further highlights the need for place-based approaches.

Support from general practitioners is crucial not only in treating diseases but also in promoting healthy lifestyles and is therefore an important lever for change. However, there may be a lack of motivation to visit health professionals due to cultural and language barriers, an important issue across the Australian health system (Cyril et al. 2017). Limited English proficiency and a fear of not being able to communicate their symptoms to their general practitioner or to understand their medical instructions are recognized as major barriers to accessing healthcare (Guirgis et al. 2012, Cyril et al. 2017). In addition, Australian health service providers have been described as employing a ‘one-size-fits-all’ approach to delivering health services, without considering the cultural differences among people, which also further exacerbates the situation (National Health and Medical Research Council 2013). The participants recommended health professionals should be trained to listen to their patients’ health problems thoroughly and provide them with culturally appropriate suggestions.

CONCLUSION

Multiple, interrelated determinants of healthy eating exist in this low SES, high-priority community in Australia. Several micro, meso, exo, and macro determinants including knowledge, time, and cultural influences were reported to influence healthy eating. Listening to the stories of the community enables better preparation for delivering culturally appropriate and tailored healthy eating strategies. Future community-based initiatives aimed at promoting healthy eating should extend beyond individual behavioural changes and consider the influence of other socio-ecological factors. More community-based, community-accessible, and community-owned solutions are required to have a viable chance at promoting healthy eating in these communities. The complex relationship between the personal, cultural, and environmental factors and eating behaviours presented in this study highlights the need for multi-level factors consideration while developing healthy eating initiatives in priority communities.

ACKNOWLEDGEMENTS

We would like to acknowledge and express our sincere gratitude for the unwavering support and collaboration extended to us by Queensland Community Alliance members. Without their guidance and coordination, our efforts would not have been as effective or impactful. We are sincerely thankful to all the community members who directly or indirectly participated in this research. Their willingness to share their personal experiences, insights, and stories on healthy lifestyles has not only enriched the data but also provided a deeper, more authentic understanding of the challenges and successes in promoting healthy eating within the community. We also appreciate the valuable assistance provided by other Nourish Inala team members in contributing to project activities.

AUTHOR CONTRIBUTIONS

S.K. conceptualized the manuscript, collected and analysed the data, and took the lead role in writing the manuscript. L.B. and J.P. oversaw and supervised the study and contributed critically to the manuscript development. J.M. contributed to the data collection and made valuable suggestions and comments on the manuscript. All authors read and approved the final manuscript.

CONFLICT OF INTEREST

The authors declare that there is no conflict of interest.

FUNDING

This work was supported by the Menzies Health Institute Queensland, which enabled our partnership with Queensland Community Alliance. LB’s salary was supported by a National Health and Medical Research Fellowship (APP 117346).

DATA AVAILABILITY

The data underlying this article will be shared on reasonable request to the corresponding author.

REFERENCES