Immigrating to the US: What Brazilian, Latin American and Haitian Women Have to Say About Changes to Their Lifestyle That May be Associated with Obesity

Study Setting, Participants, and Recruitment

The work completed for this study is part of Live Well, a randomized controlled lifestyle intervention, developed and implemented through community-based participatory research (CBPR) [33, 34]. The central premise is that an appropriately timed intervention, co-created by community partners and academic researchers, can prevent excess weight gain in newly arrived immigrants (<10 years in the US). Participants in our study are mothers with a child between the ages of 3–12, arriving from Haiti, Brazil, and Spanish-speaking Latin American countries (primarily from El Salvador, Colombia, Guatemala, Dominican Republic and Honduras). These three populations constitute the major immigrant groups in the northeast [35, 36]. A steering committee was established at the onset of the project, and consists of a professionally and culturally diverse membership, including project staff; Tufts researchers and students representing different specializations and leaders from five community organizations that work with immigrants in Somerville, MA. The community-university relationships were built prior to Live Well through two CBPR projects in the Somerville area; Shape up Somerville [37] and the Somerville Community Immigrant Worker Health Project [38, 39]. At the end of Shape up Somerville, community partners identified the need to address obesity among immigrant populations.

We conducted three focus groups to inform the Live Well nutrition and physical activity intervention, one in each language (Portuguese, Spanish and Haitian-Creole) yielding a total of 25 women at community agencies in Somerville, Massachusetts, a densely populated, highly diverse city 5 miles north of Boston. Women were recruited for the focus groups via flyers in each of the three target languages posted in community agencies throughout Somerville. Interested participants called the contact number of a bilingual/bicultural interviewer who explained the study aims, and administered a brief screening questionnaire to determine eligibility. Focus group participants were required to meet the following criteria: (1) aged 22–55 years, (2) resident of Somerville, MA, (3) had a child between the ages of 3–12, and (4) immigrated to the US less than 7 years ago from Brazil, Spanish speaking Latin American countries (central/south America) or Haiti. The focus groups were stratified by language/country of origin and included: Portuguese (n = 3), Spanish (n = 11), and Haitian Creole (n = 11). The Tufts University Social, Behavioral and Educational Institutional Review Board reviewed and approved all aspects of the study.

The content of the moderator guide (see Table 1) used to lead the focus group discussions was informed by three key informant interviews with community leaders from Brazilian, Spanish speaking Latin American countries and Haitian communities, and discussions with community partners and university investigators. Focus groups were moderated by trained, bilingual moderators and lasted approximately 1 h. A second research team member took notes, operated the digital recorder, and provided logistical support. During the focus groups, open-ended questions were posed to stimulate discussion. Digital recordings were transcribed verbatim and transcripts translated for analysis. Upon completion of the groups, moderators and note takers convened to debrief and discuss their initial reactions and thoughts. The approach was largely deductive [40]; a priori hypotheses were rooted in current literature which observes that certain obesity related health behaviors change with length of stay in the US. A framework of selective acculturation, that individuals make personal choices about the ways they will or will not change with length of stay in the US, further informed hypothesis formation [41]. We hypothesized that patterns of diet, physical activity, stress, and sleep, all modifiable risk factors associated with obesity, would differ between the US and the home country. Specifically, we expected that some of these behaviors would change and deteriorate following exposure to a more “obesogenic”, fast paced environment. For example, we expected that mothers would report less consumption of fruits and vegetables and higher consumption of energy dense, convenient foods, less time for food preparation, sleep and physical activity and higher levels of stress. The analysis of the transcripts was completed in two phases. First an independent researcher trained in qualitative data analysis identified concepts and themes in the transcribed and translated narratives [42]. In this first phase, a hypothesis driven approach was taken; the coding guide was based on the moderator guide questions. The second phase of the analysis applied a community– based, participatory research approach. Themes and concepts from phase one were reviewed and discussed by the steering committee and additional concepts and themes that could have been missed or miscoded by researchers with less extensive experience with the immigrant communities included. During this process, an additional theme emerged, and was discussed and interpreted, resulting in consensus to add this theme to the results [43].

Response Theme: In the Home Country, Food is “Healthier” Because it is More Natural but There are Issues with Food Safety

Women across all three groups felt the food they consumed in their home countries was healthier because it was less processed and contained fewer chemicals. Women shared their experience of growing their own foods in their home countries, or of buying foods in local markets where produce was fresh and not frozen (like in the US). Although most of the women felt their food was healthier back home because it contained less chemicals, more vitamins and fewer preservatives, they also felt the food in the US was more hygienic and safer to eat. The Spanish speaking Latina women also discussed differences in taste between their home country food and US food. Although they said many of the foods they had in the US were similar to what they could get in their home countries, the food did not taste as good.

Response Theme: There is More Time for Food Shopping/Food Preparation in Our Home Country

Another common theme that emerged around the topic of food was that there was more time for food preparation and food shopping in their home countries. The time constraints due to maintaining a job, taking care of children, and dealing with other pressures in the US does not allow for time to prepare foods or to spend much time food shopping. Also, changes in their job schedules from their home country prevented them from spending time preparing or eating food together. Due to these time restraints women reported eating more convenient and fast food.

Response Theme: There is More Diversity of Foods in the US and Differences in Food Prices Compared to Their Home Country

All of the groups mentioned that there was more food diversity in the US. The Spanish speaking Latina women, in particular, had a lengthy discussion about the differences between the sizes of supermarkets here in the US as compared with their home country, and how they could find so many different types of foods in the US. In addition to greater food diversity in the US, the Spanish speaking Latin American mothers felt that certain foods were more expensive; in particular, the “healthier” foods such as fruits and vegetables. In contrast, the Brazilians felt they had the economic means to buy food in the US, and that food in Brazil was more expensive. The Brazilian women also discussed the greater exposure to fast food in the US and their concerns with obesity related to this.

Response Theme: There is More Work-Related Activity in US (Not Necessarily Perceived as Physical Activity)

Women were asked if they thought there were differences between their level of physical activity in their home country and in the US. The overall theme was that there was less work to be done in their home country, and that the work-related activities they performed in the US were tiring and strenuous. In this context, the types of work-related activities they had were associated with fatigue and exhaustion. The Brazilian women, in particular, most frequently mentioned working to clean houses in the US, but not considering this type of work to be “true” physical activity. For them, this work was often associated with work injuries and inappropriate physical positioning.

Response Theme: The Weather in the US Can be a Barrier to Engaging in Physical Activity

Women from all the groups discussed how in the US they had to think about the weather all of time, especially during the winter. They felt the weather affected both their own and their children’s physical activity.

Response Theme: Women Don’t Sleep as Well in the US Due to Stress or Busy Schedules

The majority of women from all groups mentioned having a decrease in sleep quality and quantity compared to what they experience in their countries. Women attributed this change to their high levels of stress and busy schedules in the US. They also mentioned that the lack of family and social support prevented them from being able to take time off from work or to rest or sleep when they needed it. In addition to stress and busy schedules, the Spanish speaking Latin American women mentioned different work schedules, and that the night shifts interfered with their sleep routine.

Response Theme: There is Less Control Over Their Time in the US, with Higher Levels of Stress and Less Social Support

Throughout the focus group discussions, high levels of stress and lack of time were frequently mentioned by all of the groups. The type of job, the financial obligations and their work hours contributed to the women feeling stressed and not having control over their time. Participants characterized their lives in their home country as not being as busy and as having other people, especially family members, available to help out with different household chores and childcare. Three Spanish-speaking women mentioned how in this environment, they had gained weight. Two Brazilian women also shared their immigration status as a source of stress, and how they lived in fear of being apprehended for immigration violations. Brazilian women also mentioned how they often felt depressed and lonely due to the lack of social support.

Response Theme: Childcare Arrangements, School-Related Activities, and Seeking Services are More Stressful in the US Compared to Their Home Country

Women stated that having children was a source of stress because they were often worried about them, and the type of care that could be provided for them while they were at work. They also felt an enormous burden of taking care of their children on their own without family members, who provided emotional support, like in their home countries.

Another theme that emerged was that school-related activities here in the US may be a source of stress. This stress was discussed in the context of not having a good relationship with the school or lacking relationships with the other parents. One woman shared her frustration with the school due to language barriers. In particular, all of the Haitian women felt annoyed about how the schools were managing their children’s problems compared to their home country. This, they said, created a lot of stress. Women also felt significant stress around receiving services such as the Supplemental Nutrition Assistance Program (SNAP; previously “food stamps”).