Cultural influences and individual health beliefs and behaviors played important roles in IYCF. This study integrated qualitative and quantitative data, allowing for the identification of convergent and divergent findings, which demonstrated a deeper understanding of the cultural influences on IYCF among Chinese immigrants. To the best of our knowledge, this was the first mixed methods study to explore the cultural influences on IYCF beliefs among new Chinese immigrant mothers in the UK. Chinese immigrant mothers reported high responsive attention and satiety levels and low indulgence feeding levels; they engaged in advocating healthy dietary beliefs and benefited from the balancing of information sources, although there were cultural conflicts. Chinese mothers reported barriers of first introducing solid foods earlier and language difficulties when accessing health services. In an effort to increase the understanding of the culturally-appropriate and optimal IYCF, the objective was also to learn what a tailored intervention program might look like across minority groups in the UK.
4.1. Summary of Findings
The findings of this exploratory study showed that the beliefs of laissez-faire, pressuring, restrictive, and responsive were more frequently described among Chinese immigrants than a white middle-class population [36
]. Restricting unhealthy foods by preventing access to and/or limiting the amount consumed was a general strategy for improving infants’ diet or reducing the risk of weight gain. The consistent findings of the surveys and interviews showed that new Chinese immigrant mothers believed that the dietary restrictions helped to improve infant and young child health and wellbeing, and hence highlighted the importance of the quality and quantity of food [17
]. In comparison to a cross-sectional analysis of an ethnically diverse sample in the USA [38
], the mean scores of laissez-faire beliefs for attention and diet quality, and pressuring to finish and with cereal were higher than average, while pressuring to soothe was consistent with the sample. The mean scores of Chinese immigrant mothers’ beliefs on restrictive amounts and diet quality were higher than average when compared with a diverse USA sample [38
], which indicated that the mothers engaged in highly restrictive feeding practices aimed at distracting the infant or young child from satiety by concentrating on restricted foods, whereas greatly pressuring was believed to boost eating in the absence of satiety [45
]. Controlling was often measured by pressuring and restrictive to IYCF [35
]. Chinese parents have been described as highly controlling, and even labelled as authoritarian and ingrained in traditional culture [46
]. Commanding mothers balancing demand and responsiveness have been associated with a lower BMI in older children [47
], and positive IYCF beliefs.
Laissez-faire demonstrated that the mothers were lenient (64.5%) regarding what snack foods they gave their children, although most stated that they gave “healthy snacks.” However, restrictive feeding styles may be associated with a poorer self-regulation of appetite and decreased intake of fruits and vegetables [48
], despite being a common strategy to improve children’s diets and reduce the risk of unhealthy weight gain. Fruit and vegetable consumption could be related to obesity prevention [49
], but this may result in children showing a later preference for restricted food and increases in its consumption once the restriction is removed, and therefore also increase the risk of obesity [48
]. In this study, the majority of the Chinese immigrant mothers described feeding their children lots of fruits and vegetables, but restricted both foods and drinks high in sugar; they stated that fruits and vegetables were healthier foods, which is in alignment with national health advice, preventing early tooth decay. Extremely controlling feeding practices have been observed to have a detrimental influence on the regulation of appetite among infants and young children [50
], whilst responsive to satiety has been linked to a reduction of the obesity risk [51
]. Indulgence has been associated with a higher BMI and lower nutrient intake in older children [52
], which included responsive soothing to the children with abundant demands. In this study, new Chinese immigrant mothers engaged in low indulgence, which was higher than a USA sample [38
Though the majority of the Chinese mothers fed children by themselves, the approaches used and the way in which the mothers fed their children were culturally influenced by extended family [17
]. Chinese immigrant mothers explained some differences in their Chinese health beliefs and cultural influences: The majority of them preferred the traditional Chinese diet [17
]. Some Chinese immigrant mothers strictly followed the advice of health professionals; these mothers believed British health beliefs and abandoned Chinese health beliefs, which was inconsistent with an Australian qualitative study on factors influencing Chinese immigrant mothers’ early feeding choices and perceptions of infant growth that was conducted to identify barriers and facilitators to the appropriation of optimal IYCF [17
]. However, the mothers did engage in pressuring their children to eat custom Chinese delicacies, including soup mixed with pork, chicken, or fish, which are all notably high in sodium, and the NHS and SACN strictly advise against foods with a high salt content, in order to prevent kidney problems. During the interviews, there was no mention at all of vitamins for both the mother and baby; national guidelines recommend that is vital for a baby to receive Vitamins A, C, and D every day for optimal growth and development. In addition, more than half of the mothers believed that their toddlers should finish all of the food on their plate, which is not nationally recommended; they pressured their toddlers to eat a certain quantity through the use of a food bowl. In contrast, responsive feeding is both recommended and mutually important for mothers and infants for building a healthy and loving close relationship [5
]. The NHS and policymakers need to focus on engaging with this community pertaining to the parents’ and caregivers’ attitudes, beliefs, and behavior about food and feeding, in order to ensure the safety and optimal nutrition of these children for growth and development.
One study reported that Chinese immigrant mothers were more likely to introduce solids earlier in the USA [54
]. In this study, most of the mothers introduced solid foods between 4 and 6 months, which was influenced by Chinese culture and an early interest in food; this was in agreement with previous studies [54
]. It was shown to be common to introduce solid foods and other non-milk liquids to infants younger than three to four months in some parts of China, which was likely to be culturally linked to this practice [57
]. In this study, the majority of the Chinese mothers introduced solid foods earlier than advised by the NHS guidelines. One important factor influenced by Chinese health beliefs was that the mothers estimated that their children were ready to be fed solid foods within 6 months of age based on Chinese feeding practices. However, the NHS and UNICEF UK strictly recommend that solid foods are not introduced before the infant is able (1) to stay in a sitting position and hold their head steady; (2) coordinate their eyes, hands, and mouth, which will allow them to look at food, pick it up, and put it in their mouth by themselves with ease; and (3) swallow food without spitting it out. However, often, parents may misinterpret that their baby is ready for solid foods by signs such as chewing with their fists, waking up in the night more than usual, and wanting extra milk feeds [5
]. The early introduction of solid foods is dangerous alongside the underutilization of health services or discordance with the advice given by health visitors, because the mothers miss out on key health and safety guidance, such as food preparation, what foods to avoid (i.e., detecting allergies to eggs, nuts, fish, and wheat), and how to detect whether their baby is choking rather than gagging. The NHS and SACN recommend that foods containing allergens not be introduced prior to 6 months of age, and when they are introduced, this needs to be done one at a time, in order to spot any potential reaction. During the interviews, the mothers did not make any reference to food allergens, or if they knew the signs indicating that their baby was choking or if they had experienced it. Doub et al. (2015) found that the early introduction of solid foods was more prevalent among mothers who were younger, less educated, and heavier pre pregnancy, and who breastfed for shorter durations and reported a lower responsiveness to their infants’ hunger and satiety cues and that their infants needed more than milk at <6 months [36
]. Rogers and Blissett (2018) found that mothers with higher scores of laissez-faire feeding behaviors did not keep track of how much milk their infant drank at 3 months, which was associated with the earlier introduction of solid foods [59
]. Therefore, in the development of an intervention, it might be worthwhile to consider a focus on the timing of the introduction of solid foods and safety and hygiene guidance for this community, as well as co-production with the mothers, in order to address their needs from both sides.
The results highlighted the therapeutic and comforting aspects of foods, and how diet and traditional Chinese medicine are inseparable in traditional culture health beliefs, with long-established beliefs that a particular diet has health-promoting or -damaging properties [60
]; this is not only related to nutrients, but also plays an important role in preventing diseases and maintaining health [61
] and diets [62
Findings from this mixed study demonstrated that Chinese immigrant mothers tended to encourage healthy dietary beliefs and identify positive cultural ones associated with IYCF. It became apparent that they were confused by contradictory and conflicting sources of IYCF information [63
]. When the information provided by health professionals was not in line with traditional Chinese health beliefs, they benefited from some form of peer support. Building official online supportive groups might assist Chinese immigrant mothers in achieving optimal IYCF and help health professionals to understand their feeding beliefs and behaviors. In this study, Chinese mothers balanced CF knowledge from different sources of information; they advocated light and healthy dietary beliefs—an explanation for this was that some of the mothers followed the approach of ‘yangsheng
’—and the use of self-healing and nurturing the body to cultivate personal health and longevity [64
Chinese immigrants have consistently underused health care facilities and services compared to other ethnic minorities and white populations in the UK [65
]. In this study, barriers to the uptake of services included linguistic misunderstanding and cultural influences; such beliefs are that English doctors will not understand the feeling of Chinese women, and such women are reportedly scared of seeing or speaking to the doctor or believe that the doctor did not listen to them [66
]. Cultural differences acted as an important barrier to health service uptake among the Chinese population due to individuals’ concerns about their ability to communicate with health professionals [67
]. Traditional culture and health beliefs can produce misconceptions around IYCF beliefs [69
]. Familiarity with Mandarin and understanding of Chinese traditional culture would improve health professionals’ access to new Chinese immigrant groups and help Chinese infants and young children to obtain optimal IYCF. Language difficulties and the avoidance of health services due to poor interactions can have long-term childhood health outcomes, including the delay of social skills, speech and language, visual or motor functioning, and reaching milestones for particular skills at specific ages [70
]. For many minority groups, there are barriers and facilitators that influence the uptake of health services and optimal IYCF, including the income level, lack of knowledge, and incorrect advice [27
]. The first 1000 days of life is a critical window of time for the prevention of both under- and over-nutrition [1
]. Therefore, it is vital to understand what cultural and language barriers exist for this population.
Some of the Chinese mothers had not yet integrated into British society and were also equally far away from the developing Chinese society. Despite living in England for a long time, researchers readily observed isolation, as well as a lack of progress in their routine, daily lives in British society, and updated feeding practices in terms of Chinese feeding practices, which could have been influenced by the fact that the majority of the Chinese immigrant mothers were housewives. Intrinsic features are that Chinese immigrant mothers maintained a Chinese living style in England and habitually still ate Chinese foods and maintained Chinese friendships, language, beliefs, rules, values, etc. It is not a matter of whether these mothers need to “adopt” British ways or feeding patterns or that there may be deficiencies in their practices, but it is vital that there is a way to monitor whether infants and children are reaching their milestones or receiving the correct amount of vitamins; however, this cannot be done if mothers feel discouraged from seeking health advice and using health care services. Through better community engagement and the use of participatory learning action approaches or peer support groups, health professionals can be better educated so that they are aware of Chinese practices and consider the best way to support these families by integrating cultural practices with optimal feeding practices. As the UK continues to be increasingly populated by a diversity of immigrants, culturally competent health services are vital for meeting health care needs and improving health outcomes, patient-provider communication, service delivery, and patient satisfaction.
4.3. Strengths and Limitations
The aim of this mixed methods approach was to obtain a deeper understanding of Chinese culture and health beliefs and their influences on IYCF in the UK. A key strength of this study was that we allowed all of the participants to choose their desired and most comfortable language when they were interviewed. The researcher could speak Mandarin fluently and had first-hand materials of Chinese language and traditional Chinese cultural terms and context. This study has filled a gap, as there was once little data on CF in the UK, particularly in Chinese communities. Despite this gap, CF has been identified as an important and under-prioritized strategy for preventing childhood obesity, but also preventing micronutrient deficiency and fostering lifelong health among Chinese populations in the greater London area. This study demonstrated that interventions for addressing feeding practices need to be culturally adapted to different populations living in the UK and more information about the process of cultural influences upon feeding practices is needed. There were barriers and facilitators to IYCF in alignment with the national guidelines in Chinese populations living in the UK, which can result in long-term health outcomes and development delays. The increased prevalence of various adult chronic diseases among ethnic minority populations requires an investigation of the diet quality of infants to determine whether interventions are needed for this demographic, since early intervention can prevent long-term chronic health complications. The findings contributed to the study of why developing or performing healthy and appropriate feeding practices is important, which may allow, in turn, for the design of intervention programs to target their needs.
However, the limitations of language might have resulted in selection bias. The authors attempted to include a broader targeted Chinese group with traditional cultures and health beliefs, with backgrounds that could inform misconceptions around IYCF beliefs. The main limitation of this study was that the samples were not nationally representative of Chinese immigrants, which limited the authors’ ability to compare them with the broader population of Chinese immigrants living in the UK. Participants were recruited through purposive sampling, which produced a selection bias in that all of the participants had Mainland Chinese origins; this limited the conclusions that can be drawn from the study. The sample size was small and there was no comparison group because the lack of tools that assess IYCF designed for minority ethnic groups in high-income countries limits the ability to make relevant comparisons with other studies considering either low-income countries or European and Western ethnicities. Further study is required to explore the issues identified in this study in more minority groups.