Gestational weight gain (GWG) is a very important modifiable risk factor associated with short- and long-term health outcomes (e.g. maternal and child obesity and obesity-related chronic diseases such as diabetes, hypertensions, etc.) for both a woman and her newborn(Reference Herring, Albert and Darden1). Nonetheless, evidence suggests that approximately 40–60 % of women of childbearing age (18–49 years) in the USA experience excessive GWG(Reference Headen, Mujahid and Cohen2).
Pregnancy is a critical life stage for promoting health and preventing diseases(Reference Herring, Albert and Darden1,Reference Headen, Mujahid and Cohen2) . Maintaining or adopting healthy behaviours (e.g. diet, physical activity, etc.) during pregnancy has the potential to prevent excess GWG and associated adverse health risks during pregnancy and beyond(Reference Dalrymple, Flynn and Relph3). Pregnancy is a time when many women are motivated to improve their health behaviours for their infants’ health(Reference Herring, Albert and Darden1,Reference Spencer, Rollo and Hauck4) . It also a time when women are more likely to seek health information to answer questions about pregnancy, their health and that of their offspring(Reference Herring, Albert and Darden1,Reference Spencer, Rollo and Hauck4) . Pregnant women’s access to evidence-based information about GWG, diet and physical activity is key to their achieving healthy GWG, and, ultimately, the prevention of obesity-related diseases for both the mother and her newborn(Reference Willcox, Campbell and McCarthy5–Reference Shieh, McDaniel and Ke7).
Although evidence suggests that pregnant women value advice they receive from their healthcare providers (HCP) the most, recent studies also indicate that many pregnant women are not receiving or receiving inconsistent advice from HCP about GWG, diet and physical activity(Reference Weeks, Liu and Ferraro8–Reference Sayakhot and Carolan-Olah10). A lack of consistent advice from HCP increases the demand for alternative sources of information(Reference Weeks, Liu and Ferraro8–Reference Huberty, Dinkel and Beets11). The internet is one of the most popular sources of pregnancy information for women of childbearing age in the USA as it provides easy and quick access to information about a wide range of pregnancy-related topics that can influence women’s decision-making associated with all aspects of pregnancy(Reference Song, Cramer and McRoy6–Reference Declercq, Sakala and Corry12). According to the Pew Research Center, about 80 % of adult women of childbearing age in the USA use the internet to obtain health information during their pregnancies(13). Studies indicate that pregnant women also rely on interpersonal relationships for information during pregnancy(Reference Shieh, McDaniel and Ke7,Reference Sayakhot and Carolan-Olah10,Reference Declercq, Sakala and Corry12,Reference Souza, da Silva and Nagpal14) .
Brazilians represent a rapidly growing immigrant population in the USA, with the country now being home to the largest population of Brazilians outside Brazil(Reference Granberry and Valentino15). According to the American Community Survey, Massachusetts is the state with the second largest population of Brazilians after Florida(Reference Granberry and Valentino15). Currently, there is a dearth of maternal health research focused on Brazilian immigrant women in the USA. Like many immigrants, Brazilians face many barriers to accessing and utilising healthcare in a new country such as lack of health insurance, financial difficulties, language barriers and lack of interpreters, cultural differences in views about health, health literacy, differences in health expectations and discrimination based on race or accent, etc.(Reference Lindsay, de Oliveira and Wallington16,Reference Lindsay, Le and Nogueira17) . These barriers may influence how Brazilian immigrant women experience healthcare during pregnancy(Reference Lindsay, de Oliveira and Wallington16–Reference Guillory, Niederdeppe and Kim19). Given the importance of pregnancy as a critical life stage for health promotion and disease prevention for women and their newborn, the purpose of this study was to assess sources of information about GWG, diet and exercise among first-time pregnant Brazilian women living in Massachusetts, USA.
Methods
Study design and sample
We conducted an exploratory cross-sectional survey of first-time pregnant Brazilian women living in Massachusetts, USA to assess sources used to seek information about GWG, diet and exercise during pregnancy. Data collection occurred between December 2018 and June 2019 in selected communities in Massachusetts, with large Brazilian immigrant populations. Women were eligible to participate if they: (a) self-identified as Brazilian; (b) were pregnant with their first child (a single birth); (c) were ≥14 weeks gestation; (c) were 18 years of age or older; (d) lived in Massachusetts; (e) spoke Portuguese or English and (f) provided informed consent(Reference Lindsay, Le and Nogueira17).
Recruitment
Study participants were recruited using strategies successfully employed in our previous studies with Brazilian communities in Massachusetts, which included posting flyers at local Brazilian businesses and community-based social and health services agencies and attending events and making announcement at predominantly Brazilian churches(Reference Lindsay, Wallington and Rabello20). Interested individuals called the phone number listed on the flyer or spoke with study staff at church events(Reference Lindsay, Wallington and Rabello20). Participants were also recruited through network sampling, a ‘word of mouth’ or snowball approach of acquiring participants, with participants enrolled in the study asking their Brazilian friends pregnant with first child if they would be interested in participating in the study(Reference Lindsay, Wallington and Rabello20). Research staff, Brazilian immigrants and members of the Brazilian communities participating in the study engaged their personal and community contacts to recruit participants. In addition, women were recruited using social media (Facebook postings). All interested individuals were screened in-person or via telephone by study staff.
Data collection and survey measures
After determining study eligibility and prior to enrolling in the study, eligible participants were read the informed consent form in their preferred language (English or Portuguese) by a trained bilingual, bicultural interviewer. After providing informed consent (written or verbal), participants completed a brief interviewer-administered survey either in-person or via telephone in their preferred language.
The brief survey included fifteen items adapted from a previous study(Reference Smid, Dorman and Boggess21) and additional sociodemographic and acculturation questions. The fifteen adapted items were distributed across five domains: (1) information received during prenatal care (three questions); (2) sources used to seek information during pregnancy (six questions); (3) beliefs about the safety of GWG and weight management strategies (two questions); (4) self-perception of current GWG (two questions) and (5) knowledge and perception about postpartum weight loss (two questions). The survey was translated into Portuguese (Brazilian) for the present study and pilot-tested (four pregnant women who are not included in this study) prior to use. The current study is focused on participants’ responses to questions related to sources used to seek information about GWG, diet and exercise during pregnancy (six questions) and information received from HCP (i.e. doctor or midwife) during prenatal care (three questions).
Sources used to seek information about gestational weight gain, diet and exercise
Participants responded to questions (yes, no and do not know) about information sources (internet, family members and friends) used during pregnancy to learn about GWG, diet and physical activity. The first set of questions asked included: ‘I used the internet to search for information about weight gain during pregnancy’, ‘I talked to family members about weight gain during pregnancy’ and ‘I talked to friends about weight gain during pregnancy’. The same questions were then asked for diet and exercise.
Information received from healthcare providers about gestational weight gain, diet and exercise
Participants also responded to three questions (yes, no and do not know) about information received about GWG, diet and exercise from HCP (doctor or midwife) during prenatal care. The questions asked included: ‘My doctor or midwife recommended how much weight I should try to gain during pregnancy’, ‘My doctor or midwife gave me advice on exercise during pregnancy’ and ‘My doctor or midwife gave me advice on what to eat during pregnancy.’
Sociodemographics, acculturation level and access to healthcare
The survey also assessed participants’ self-identified pre-pregnancy weight status (underweight, normal weight, overweight and obese) and sociodemographic characteristics (age, marital status, country of birth, years of residency in the USA, primary language spoken, educational attainment (<high school, ≥high school) and annual household income (US$ <40 000, US$ ≥40 000). In addition, participants reported if they had regular access to a HCP (yes, no), if they had health insurance (yes, no) and type of health insurance (government-sponsored, private). They also reported if they were enrolled (yes, no) in the Special Supplemental Nutrition Program for Women, Infants, and Children. The sociodemographic questions used in the current study have been used in our previous studies and are similar to those used in several of studies conducted with Brazilian immigrants in the USA(Reference Lindsay, de Oliveira and Wallington16,Reference Lindsay, Le and Nogueira17,Reference Lindsay, Wallington and Rabello20,Reference Lindsay, Wallington and Greaney22,Reference Lindsay, Moura Arruda and Machado23) .
Last, the survey assessed participants’ acculturation level using the Short Acculturation Scale for Hispanics (SASH), a twelve-item scale validated for use in Latino populations(Reference Marin, Sabogal and Marin24). The SASH assesses language use, media use and ethnic social relations. The scale has good reliability (Cronbach’s α reliabilities 0·92–0·89 for the overall SASH scale, 0·89 for language use, 0·88 for media preference and 0·72 for ethnic and social relations)(Reference Marin, Sabogal and Marin24,Reference Ellison, Jandorf and Duhamel25) . Acculturation scores were computed by averaging across the twelve items, measured on a scale of 1 to 5, and scores were then dichotomised (high v. low). The scale developers recommend an average of 2·99 as the cut-point scores equal to or above this point represent higher levels of acculturation and scores below this point represent lower levels of acculturation(Reference Marin, Sabogal and Marin24). We used the recommended cut-point scores to categorise women as having a low acculturation level (SASH < 2·99) or a high acculturation level (SASH ≥ 2·99)(Reference Marin, Sabogal and Marin24). The average time for completing the survey was 15 min. Participants received a $20 gift card at the end of the interview for their participation.
The present study was conducted according to the ethical principles described in the Helsinki declaration. This study received ethical approval from the Internal Review Board at the University of Massachusetts Boston (Internal Review Board no. 2018068). Participants received information about the study, both verbally and in writing. Participation in the study was voluntary, and the participants were informed that they could withdraw at any time without providing a reason.
Data analysis
Descriptive statistics were calculated for all key variables using means and standard deviations for continuous variables and frequencies and percentage for categorical variables. χ 2 and Fisher’s exact tests were used as appropriate to determine if there were differences in the sources used to seek information about GWG, diet and exercise by self-reported pre-pregnancy weight status, sociodemographic variables, acculturation and type of health insurance. Associations between demographic characteristics (i.e. self-reported weight status, sociodemographics, acculturation and access to healthcare) and sources of information were assessed in binary logistic regression analysis. Only those characteristics significantly associated (P ≤ 0·05) with the outcome were adjusted for in binary logistic regression analysis, and OR were calculated. All analyses were performed using SAS 7.1 (SAS Institute).
Results
Sample characteristics
The study sample included eighty-six women. As shown in Table 1, participants had a mean age of 28·3 years old (sd = 4·7; range 19–39 years). The majority of women (96·5 %, n 83) were born in Brazil and reported they had lived in the USA for an average of 10·7 years (sd = 7·3). All women reported Portuguese as their primary language, and 67·4 % (n 58) were classified as having low acculturation levels. Most respondents (96·5 %, n 83) were married, 35 % (n 30) reported completing high school or less, and about half (48·8 %; n 42) reported a household income of <$40 000/year, which is below the federal poverty line(26).
Table 1 Participants’ characteristics
WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; SASH, Short Acculturation Scale for Hispanics; GWG, gestational weight gain; HCP, healthcare providers.
* All women (n 86) were asked to report including the three who reported being born in the USA.
All women were pregnant with their first child, and the mean gestation was 27·5 weeks (sd = 5·6; range 14–38 weeks). Approximately, 73 % reported that they were a normal-weight pre-pregnancy (72·1 %; n 62), while 25·6 % (n 22) reported being overweight and 2·3 % (n 2) being underweight. All women reported having regular access to healthcare, with most (89·5 %; n 77) having government-sponsored health insurance (MassHealth). In addition, more than half of respondent (55·8 %; n 48) were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children programme (see Table 1).
Sources used to seek information about gestational weight gain, diet and exercise
Seeking gestational weight gain, exercise and diet information via the internet
Overall, about two-thirds of the women reported using the internet to find information about GWG (72·1 %, n 62), diet (81·3 %, n 70) and exercise (75·6 %, n 65) during pregnancy. In the binary logistic regression analysis, women who were younger (OR = 1·13; 95 % CI 1·01, 1·26) and those classified as having low acculturation levels (SASH < 2·99; OR = 7·09, 95 % CI 1·53, 32·98) were more likely to seek information about GWG on the internet than women who were older or classified as having high acculturation levels (SASH ≥ 2·99), respectively (see Table 2). In contrast, women who reported having more than high school education (OR = 0·38; 95 % CI 0·14, 1·00) were less likely to use the internet to seek information about GWG than women who had had a high school diploma or less (see Table 2). Similarly, women who reported having private health insurance were less likely to use the internet to find exercise information (OR = 0·20; 95 % CI 0·05, 0·82) than women who reported having government health insurance (MassHealth) (see Table 2).
Table 2 OR and 95 %CI from binary logistic regression analysis predicting seeking information about gestational weight gain (GWG) during pregnancy via the internet and from family and friends
SASH, Short Acculturation Scale for Hispanics; HCP, healthcare providers.
In the binary logistic regression analysis adjusting for age and receiving advice about GWG from HCP, women who were classified as having low acculturation levels (SASH < 2·99) were more likely to seek information about GWG on the internet (OR = 7·55; 95 % CI 1·41, 40·26) than women classified as having high acculturation levels (SASH ≥ 2·99) (see Table 2). Moreover, women who reported having private health insurance were less likely to use the internet to seek information about exercise (OR = 0·19; 95 % CI 0·05, 0·80) than women who reported having government health insurance (see Table 3). There were no other statistically significant differences by sociodemographics, health insurance type or self-reported weight status for women using the internet to seek information about diet or exercise (see Tables 3 and 4).
Table 3 OR and 95 %CI from binary logistic regression analysis predicting seeking information about exercise during pregnancy via the internet and from family and friends
SASH, Short Acculturation Scale for Hispanics; HCP, healthcare providers.
Table 4 OR and 95% CI from binary logistic regression analysis predicting seeking information about diet during pregnancy via the internet and from family and friends
SASH, Short Acculturation Scale for Hispanics; HCP, healthcare providers.
Seeking information from family members and friends about gestational weight gain, diet and exercise
The majority of women reported actively seeking information about GWG (67 %, n 58), diet (71 %, n 61) and exercise (52 %, n 45) from family and friends. In the binary logistic regression analysis, women who self-reported being overweight pre-pregnancy were more likely to seek information about GWG (OR = 2·94; 95 % CI 1·07, 8·06) from family members and friends than women who self-reported being normal-weight pre-pregnancy (see Table 2). In contrast, women who self-reported being overweight pre-pregnancy were less likely to seek information about diet (OR = 0·27; 95 % CI 0·09, 0·75) and exercise (OR = 0·30; 95 % CI 0·11, 0·86) from family members and friends than women who self-reported normal-weight pre-pregnancy (see Tables 3 and 4). In the binary logistic regression analysis adjusting for receiving advice from HCP about diet and exercise, women who self-reported being overweight pre-pregnancy were less likely to seek information about diet (OR = 0·32; 95 % CI 0·11, 0·93) and exercise (OR = 0·33; 95 % CI 0·11, 0·96) from family members and friends than women who self-reported being normal-weight pre-pregnancy (see Tables 3 and 4).
Discussion
To our knowledge, this is the first study to assess sources of information that pregnant Brazilian immigrant women living in the USA use to seek information about GWG, diet and exercise during pregnancy. The women in the study were pregnant with their first child, most respondents were young (31·4 % <25 and 61·5 % ≥25–<35 years of age), more than half were classified as having low acculturation levels and almost 26 % self-identified as being overweight pre-pregnancy. Although our study relied on self-reported data for pre-pregnancy weight status, this finding aligns with estimates from a recent nationwide survey that found that about 24 % of mothers reported a pre-pregnancy weight that, given their height, would be classified as overweight(Reference Declercq, Sakala and Corry12).
Many women in the current study (72·1 %–79·1 %) turned to the internet for information about GWG, diet and exercise during pregnancy. These findings are concordant with a nationwide survey conducted in the USA that revealed that more than three-quarters of women of childbearing age used the internet for information about pregnancy and birth(Reference Declercq, Sakala and Corry12). Our findings are important and combined with prior research have implications for the development of mobile health (mHealth) interventions to increase pregnant Brazilian immigrant women’s access to evidence-based health information during pregnancy. Growing evidence points to the potential of mHealth intervention as a low-cost, easily accessible option to promote healthy GWG among women worldwide(Reference Muktabhant, Lawrie and Lumbiganon27,Reference Herring28) . For example, a recent meta-analysis found that mHealth interventions involving diet, exercise or both reduced the risk of excess GWG, on average, by 20 % (relative risk 0·80, 95 % CI 0·73, 0·87)(Reference Muktabhant, Lawrie and Lumbiganon27). Although additional research is needed, the high percentage of respondents who reported using the internet as source of information about GWG, diet and exercise suggests that pregnant Brazilian immigrant women would likely use mHealth interventions to access health information during pregnancy.
Furthermore, women in the present study classified as having low acculturation levels were approximately 7 times more likely to seek information about GWG using the internet than women classified as having high acculturation levels after adjusting for age and receiving advice from their HCP about GWG. Prior research conducted in the USA has found that women with low acculturation levels face language and cultural barriers in accessing healthcare(Reference Tovar, Chasan-Taber and Bermudez18). Moreover, prior studies also suggest that access to accurate online pregnancy-related information is particularly important for women from socially disadvantage groups (e.g. low-income, immigrant women from underserved racial/ethnic groups) such as those participating in the current study who may face barriers to accessing accurate information during the prenatal care period(Reference Tovar, Chasan-Taber and Bermudez18,Reference Chasan-Taber, Marcus and Rosal29) . As previously mentioned, this finding suggests the potential of mHealth interventions to increase pregnant Brazilian immigrant women’s access to evidence-based health information during pregnancy, and in particular, women with low acculturation levels(Reference Muktabhant, Lawrie and Lumbiganon27,Reference Herring28) .
In addition to actively seeking information on the internet, more than two-thirds of the women in the current study sought information about GWG, diet and exercise during pregnancy from family members and friends. This finding is notable given that a recent cross-sectional study (n 1171) conducted by Souza et al. in Canada found that women who sought or received advice from family and friends about weight during pregnancy were more likely to experience GWG below or above the recommended guidelines than those who did not receive this advice(Reference Souza, da Silva and Nagpal14). The percentage of women participating in our study who reported seeking advice from family and friends (about 67 %) is greater than that found by Souza et al. (34 %)(Reference Souza, da Silva and Nagpal14). This difference could be due to the fact that the majority of women in our study were low-income and nearly all were immigrant women with low acculturation levels.
Moreover, the current study found that women who self-identified as being overweight pre-pregnancy were more likely to report seeking information about GWG from family members and friends than women who self-identified being normal-weight pre-pregnancy after adjusting for receiving information from HCP and other covariates. This finding is important and should be considered when designing interventions to meet the needs of pregnant Brazilian immigrant women(Reference Guillory, Niederdeppe and Kim19,Reference Blackwell, Dill and Hoepner30–Reference Stengel, Kraschnewski and Hwang32) . Finally, future studies should consider assessing Brazilian immigrant women’s digital literacy and perceptions of features for mHealth interventions, which will be important for the development of mHealth intervention designed to meet the specific needs of this growing immigrant population in the USA.
Study findings should be considered in light of several limitations. First, pre-pregnancy weight status was based on self-report. Although previous studies show that self-reported or measured pre-pregnancy weight used to determine pre-pregnancy BMI and weight classification result in identical categorisation for the majority of women, self-reporting of pre-pregnancy weight may underestimate pre-pregnancy weight status and thus bias the findings in unknown ways(Reference Bannon, Waring and Leung33). Furthermore, although data were collected during pregnancy, data on the study’s outcome variables (sources of information about GWG, diet and exercise) also were based on women’s self-report and thus prone to recall bias. Also, the survey instrument was translated into Portuguese and pilot-tested with a sample of Brazilian women (n 4) prior to use in this study, but it was not validated and did not undergo cultural adaptation. In addition, the cross-sectional design, the lack of a priori sample size calculation and the relatively small sample size may have limited the ability to assess the association of covariates (e.g. maternal age, education level, etc.) that have been previously reported to be associated with racial and ethnic minority women’s report of receipt of information on GWG, diet, exercise and physical activity from HCP(Reference Herring, Albert and Darden1,Reference Mercado, Marquez and Abrams9,Reference Blackwell, Dill and Hoepner30) . The setting and the small and unique study sample also limit the generalisability of study findings(Reference Lindsay, Le and Nogueira17).
Study strengths include an understudied ethnic sample of Brazilian immigrant women and the use of an acculturation measure (i.e. SASH). This is important for the design of interventions tailored to meet the sociocultural needs of ethnic minority immigrant populations(Reference Tovar, Chasan-Taber and Bermudez18,Reference Guillory, Niederdeppe and Kim19,Reference Chasan-Taber, Marcus and Rosal29) . Furthermore, although the purpose of the study is not entirely novel, this is the first study to focus on Brazilian pregnant immigrant women living in the USA. Future studies with a larger sample size are needed to further investigate the association between sociocultural variables and pre-pregnancy weight status and HCP’s advice on GWG, diet and exercise/physical activity.
Conclusions
This is the first study to assess sources of information about GWG, diet and exercise among pregnant Brazilian immigrants living in the USA. Findings showed that about two-thirds (72·1 %–81·3 %) of respondents turned to the internet for information about GWG, diet and exercise during pregnancy. Moreover, women classified as having low acculturation levels were approximately 7 times more likely to actively seek information about GWG on the internet than women who were classified as having high acculturation levels controlling for age and receiving advice from HCP about GWG. To our knowledge, currently, no mHealth interventions are available in the USA for pregnant Brazilian immigrant women. Study findings have important implications for interventions designed to promote healthy GWG and suggest the potential for mHealth interventions to deliver culturally and linguistically tailored evidence-based information about GWG incorporating behavioural change practices through low-cost, easy access method to Brazilian immigrant women living in the USA. Nevertheless, additional research is needed to identify and understand the critical features of mHealth interventions to promote healthy GWG among Brazilian pregnant immigrant women. For example, mHealth interventions designed to meet the specific needs of Brazilian pregnant immigrant women should consider health literacy and income levels, interpersonal influences, as well as language as factors influencing access and understanding of prenatal healthcare information.
Acknowledgements
Acknowledgements: The authors are thankful to the women who participated in the study and the faith- and community-based organisations for their support of recruitment efforts for the present study. In addition, the authors are grateful for assistance provided in data collection by Thaís C. Rocha, Luísa M. Rabello and Amanda De Sá Melo Alves. Financial support: This study was funded by the Joseph P. Healey grant, University of Massachusetts Boston. Conflicts of interest: The authors declare that they have no conflict of interest. Authorship: The following co-authors contributed to the work: A.C.L.: designed the study, oversaw data collection, participated in data analysis, led manuscript preparation and review. Q.L.: participated in data analysis, interpretation of findings and manuscript preparation and review. D.L.N.: participated in interpretation of findings and manuscript preparation and review. M.M.T.M.: participated in interpretation of findings and manuscript preparation and review. M.L.G.: contributed to data analysis, participated in interpretation of findings and manuscript preparation and review. All authors read and approved the final version of the manuscript. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research participants were approved by the University of Massachusetts Boston Internal Review Board. Written informed consent was obtained from all subjects. Verbal consent for the audio recording of individual interview was witnessed and formally recorded.
Supplementary material
For supplementary material accompanying this paper visit https://doi.org/10.1017/S1368980021001798
