1. Introduction
Acculturation is “the process of cultural change that occurs when immigrants from heritage cultural backgrounds come into continuous first-hand contact with a dominant culture, [as well as the] subsequent changes in the culture of heritage patterns of either or both groups” [
1]. Both culture—defined as the ideas and social behaviour of a particular group of people or society—and ethnicity are recognised determinants of health [
2]. Cultural differences within England might contribute to growing ethnic health inequalities [
3]. The cultural differences around health knowledge for South Asians living in high-income countries may contribute towards sub-optimal timing of complementary feeding. This, in turn, later influences differences in obesity trends [
4]. The theoretical conceptualization of acculturation has changed from a simplified bipolar model to a complex, multidimensional process. This is according to how immigrants deal with the adoption or retention of (or immersion in) the heritage or dominant culture [
5]. Immigrants can relate to, accommodate to and adapt to each other following contact as they carry out their daily lives in culturally diverse societies [
6]. From one culture to another, negotiation and adaptation of heritage or dominant culture results in four modes: assimilation, integration, separation and marginalisation [
7]. First-generation Asians experience acculturation changes in health status and dietary patterns, moving closer to those of the dominant group and the increased fat and caloric intake patterns of the United States. This leads to higher percentage of overweight or obese individuals [
8,
9,
10].
Complementary feeding is the process that begins when breast milk is no longer enough to satisfy the nutritional needs of an infant [
11]. Infants should start receiving an appropriate quality and quantity of solid foods from six months onwards. The period from 6 to 24 months of age is the time when malnutrition and obesity start in many infants [
12]. Inadequate complementary infant and young child feeding practices (CIYCFP) (i.e., improper timing, quality or quantity, and appropriateness) represent major risks to the health and later development of children. These risks include long-lasting effects on cognition, school achievement and increased risks of developing non-communicable diseases, such as obesity, type II diabetes, dental caries and poor cardiovascular health. There is also a risk of the intergenerational transmission of obesity [
13]. Complementary feeding not only depends on the availability of a variety of foods in the household but is also influenced by the feeding beliefs and behaviours of mothers [
12]. The feeding practices of mothers can be categorised into five domains. (a) The laissez-faire mother does not limit dietary quality or quantity of the child and interacts little. (b) The pressuring/controlling mother is concerned with increasing the amount of food the child consumes and soothes child using food. (c) The restrictive/controlling mother limits unhealthy foods and the quantity of food the child consumes. (d) The responsive mother is attentive to the hunger and satiety cues of the child and monitors the dietary quality the child receives. (e) The indulgent mother does not limit the quantity or quality of food the child consumes [
14].
Complementary feeding practices are influenced by the individual’s culture and how they uphold a child’s own eating behaviours [
15]. A recent study has improved recognition of the wider range of complementary feeding practices among ethnically diverse mothers [
14], while some research has indicated that acculturation and ethnicity might impact on children’s food-related beliefs, behaviours and preferences. The mother’s acculturation to the dominant culture influences breastfeeding [
16,
17,
18,
19]. Acculturation is associated with the differences of mothers’ dietary beliefs and behaviours [
9]. A negative finding of acculturation is that a child’s health deteriorates the more they assimilate to the dominant culture [
10]. Malnutrition in the first two years increases the risk of later developing non-communicable diseases, which cause an increasing public health burden [
20]. Establishing CIYCFP beliefs and behaviours in early life is an important health strategy to combat childhood overweightness and obesity [
21].
Little is known about how the acculturation of mothers may influence CIYCFP in minority communities living in England. Findings from a review emphasised the influence of acculturation on Chinese immigrant mothers’ feeding practices [
22]. Chinese immigrants are the fastest-growing ethnic minority population in England [
23], representing approximately 0.5% of the English population [
24]. Yet, Chinese immigrants receive relatively little research attention [
24] given that they exemplify the complexities of ethnicity and acculturation in minority groups for health services. Furthermore, to the best of our knowledge, no study has investigated the association between acculturation and CIYCFP among new Chinese immigrants. Without considering these cultural changes and the context of socioeconomic and environmental influences, public health strategies will remain untargeted and ineffective and lead to growing health inequalities and public expenditure. This is an important omission because current nutrition-specific interventions might be insufficient to optimise IYCF if the acculturation context in which they exist is ignored.
Considering this gap, this mixed qualitative and quantitative study explores the association between acculturation and CIYCFP among new Chinese immigrant mothers living in England. We aim to identify the barriers and facilitators to acculturation influencing CIYCFP in new Chinese immigrants in order to develop a culturally appropriate CIYCFP intervention that may be tailored to the needs of infant and young child.
4. Discussion
The experience of acculturation is important as Chinese immigrants continue to arrive in England. How acculturation influences CIYCFP needs to be further explored. Thinking of acculturation as a force shaping CIYCFP has implications regarding equity of access and culturally appropriate health policy. To our knowledge, this is the first mixed qualitative and quantitative study to present the association between acculturation and CIYCFP among new Chinese immigrant mothers living in England, with the aim of better understanding how acculturation shapes CIYCFP. This study indicated that Chinese mothers who were better integrated were likely to respond to satiety and attention. Those inclined towards being marginalised were more likely to indulge their children, while those who were more culturally separated were more likely to restrict the food quality offered to their children. This study also indicated that Chinese immigrants balanced western and Chinese feeding practices to combat dietary and culture conflict.
Integration is an option open to immigrants that are interested in maintaining their culture of heritage and who are involved in daily interactions with the dominant society. Immigrants can maintain cultural integrity while they seek to be a member of the heritage group but not as an integral part of the dominant society [
5]. Research proposes that the best adaptation will be among immigrants who seek to integrate [
6]. Integration on responsive to satiety is one of the important determinants of CIYCFP [
38]. In this study, Chinese mothers with the highest scores of integration were highly responsive to satiety and attention and highly pressured their children to finish eating. WHO suggest that mothers should be responsive to the child’s clues for hunger and responsive feeding [
12]. A study indicated that responsive satiety might distract infant and young child from satiety by concentrating on the accessibility of restricted foods, while excessive pressuring was believed to improve food intake in the absence of satiety [
39]. Infant and young child should learn to control the amount of food and finish food based on responsiveness to internal satiety and hunger cues [
40]. If children do not control their food intake, they might not regulate their own appetite. Thus, this could increase the risk of being obese later in life [
41]. High integration is understood with mothers who are less authoritarian [
42]; however, the children of authoritarian mothers who are able to balance demand and responsiveness tend to have lower BMIs than children with indulgent mothers [
43].
This study showed that separated mothers had high influence and scores in restrictive diet quality. This result was consistent with a UK study which showed that Chinese immigrants had the highest restrictive feeding scores compared to other minorities [
44]. Separation is when immigrants place a high value on retaining their culture of heritage while simultaneously deliberately avoiding interaction with the dominant culture [
5]. Separated mothers affect their children’s development of dietary preferences and emotional eating atmospheres, which might result in encouraging children to eat [
45]. Furthermore, restrictive access to particular kinds of food might improve children’s dietary preferences, while obliging children to eat certain kinds of food makes them dislike eating that food [
46]. When children are restricted strongly to eat more food, they might experience an absence of hunger [
47] and have fewer positive interactions with healthy eating beliefs and behaviours [
9]. Controlling feeding is often measured in terms of implementing pressuring and restrictive feeding in CIYCFP [
30]. Mothers with high controlling feeding are reported that their children have worse dietary preferences and higher weight [
33]. In this study, high scores of pressuring and restrictive feeding were dissonant with the interview. Chinese mothers have been known to be highly controlling [
48], authoritarian [
49] and ingrained in traditional culture. However, this parenting style was shown to be correlated with positive health outcomes [
50]. Further research is needed to emphasise whether controlling CIYCFP is beneficial or detrimental or to determine what extent controlling CIYCFP is beneficial.
Adaptation is observed as the relatively steady shifts that happen in immigrants responding to external pressures as they gradually adopt the dominant society’s feeding practices [
1]. When acculturating immigrants encounter problems, these experiences result in poor adaptation. Marginalised immigrants have few possibilities for, or interest in, cultural maintenance. This enforces cultural loss, and they also express little interest in active contact with the dominant society [
5]. In this study, Chinese mothers demonstrated less marginalisation. This was correlated with low indulgence scores. These mothers might experience exclusion or discrimination [
5], which might influence them to feed appropriate complementary food. This, in turn might, be a risk factor of childhood obesity [
51]. To attain integration, mutual accommodation between immigrants and the dominant culture is required. This involves the acceptance of feeding beliefs and behaviours of other minorities so that all may live together as culturally distinct groups. This requires minorities to adopt the dominant society’s basic CIYCFP, while the dominant society adapts national health policy and institutions to better meet the needs of minorities.
In this study, there was no expected association between assimilation and domains of CIYCFP. Chinese mothers had low scores in assimilation, which is defined as immigrants not maintaining the culture of heritage and instead seeking contact with the dominant society [
5]. As immigrants tend to assimilate with the dominant society and achieve a greater understanding of the dominant culture, they might decrease authoritative control [
52]. Research conducted in 1977 showed that Chinese immigrants were least assimilated among multiple ethnic minorities and that they did not change their lifestyles to adapt to British social expectations [
53]. These new Chinese immigrants had a different socioeconomic profile from traditional sojourners, and the societies they came from had experienced rapid and significant changes in recent decades. Some immigrants experience prejudice or discrimination, thus, they are reluctant to assimilate in order to be accepted [
54]. This may be a main reason for new Chinese immigrants to express less assimilation. These separated mothers indicated that their children showed assimilation. When children become assimilated, they adopt the behaviours and beliefs of the dominant culture, which may differ from their mothers’ dietary preferences. This results in difficulties in feeding for children and mothers with different food preferences [
55]. With regards to separated mothers of assimilated children who may consume more daily sugary beverages and calories from fat [
55], their acculturation may influence their children’s future acculturation to the dominant culture and diet.
Chinese immigrants have been reported to positively restrict the amount of unhealthy foods their children eat, considering Chinese dietary culture to be healthier than that of the British. This includes encouraging ‘light’ and nutritious food, feeding a variety of foods, maintaining a healthy and balanced diet, eating more vegetables and fruit and avoiding fried foods and sugar [
56]. Other Chinese mothers did not feed their children with traditional Chinese foods supplemented by oil, salt and spices [
57]. The negative acculturation theory interprets integration as follows [
58]. Immigrants are more integrated in the dominant countries, so they adopt more unhealthy diets and norms that increase health risks and reduce health-protective heritage resources [
59]. Immigrants’ preferences change from the heritage to dominant diet, which includes more fat, processed food and meat [
60]. The high rates of obesity in the United States represent a trend that immigrants gradually reflect as they acculturate [
61]. It may be interpreted that the prevalence of obesity in Chinese children is lower than other minorities [
62]. Some positive beliefs and behaviours of CIYCFP were also identified in this study.
Mutual and interactive intercultural relations are reciprocal attitudes among heritage groups in a multicultural society. The process of balancing heritage and dominant culture might influence minorities to deliver complementary foods for their children. Acculturation involves resistance to and attempts to influence the dominant culture itself, which might be matched to an active or passive valence [
5]. New Chinese immigrant mothers actively balance their Chinese and British culture. Acculturation in CIYCFP can be primarily internal, psychological or sociocultural in connecting the immigrants to the dominant culture, improving the reciprocity between immigrants and the dominant culture. Immigrants attempt to cope with the changes of acculturation and, thus, might achieve long-term adaptation of CIYCFP. This long-term adaptation is high variable, from poor to good. Some immigrants may not be able to remain in the dominant society, or some immigrants can adapt their diet to that of the dominant society very well. As immigrants become acculturated, their values, health beliefs and behaviours, such as food preferences, may change. Some acculturational influences on CIYCFP might increase a risk of childhood obesity among Chinese immigrants, which may change and ultimately affect their children’s health [
10].
5. Strengths and Limitations
To our best knowledge, this is the first study to present preliminary findings of the association between acculturation and CIYCFP using the triangulation of quantitative and qualitative analyses. Even at this preliminary level, culturally appropriate understanding can be improved regarding multiple British racial and ethnic groups.
The limitations of this study include the limited data regarding the internal reliability of MIRIPS. MIRIPS was validated in multiple racial and ethnic groups, including the Chinese ethnic group [
5], yet low scores in internal consistency reliability can weaken the association between acculturation and CIYCFP [
63].
A study measuring MIRIPS in people in Hong Kong found that they have higher integration scores (0.70) compared with those we found for our sample from mainland China (0.448). The Chinese are a diverse group with huge differences in political and economic factors, culture and beliefs. Compared to those from mainland China, the cultures of Chinese immigrants from Hong Kong, Malaysia, etc. are more in line with those of western societies, and they may therefore experience less acculturation issues.
The sample of this study was not nationally representative. Though authors attempted to access an extensive Chinese group, participants were recruited through snowball sampling, which limited the generalisability to all new Chinese immigrant mothers living in other parts of England. This limits the conclusions that can be made about the directionality of the relationship between acculturation and CIYCFP.
Though a researcher with proficiency in Mandarin and English was involved, language limitations might have resulted in selection bias. Further research is needed to explore the association between acculturation and CIYCFP within a larger sample size and to corroborate findings with other minorities in England.