Research Commentary  November 2017
Nov 7, 2017
This review offers innovative approaches to culturally appropriate health promotion for ethnically diverse migrant populations. North American, as well as New Zealand research studies exemplify successful health interventions to improve maternal health, and prevent cardiovascular disease, obesity and diabetes in Asian and other ethnically diverse populations. Critical to success are partnership with communities, tailored and targeted programs and language appropriate facilitation and resources.
Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development
The following articles are reviewed:
Article 1: Effectiveness of a Group-Based Culturally Tailored Lifestyle Intervention Program on Changes in Risk Factors for Type 2 Diabetes among Asian Indians in the United States
Trends in Asian migration between 2006 and 2013 show that the largest increase was from India, bringing the Indian population to 67,176 (Friesen, 2015). This study focuses on the Gujarati community. This article is generalizable to Gujarati groups settled elsewhere. Critical to the success of the programme are the cultural adaptations to mainstream diabetes prevention programs.
The study evaluated the effectiveness of a community-based culturally appropriate lifestyle intervention program to reduce the risk for type 2 diabetes among Gujarati Indians in an urban community in the US. The primary outcomes were reduction in weight and HbA1c and improvement in physical activity. While a significant decline in weight and increase in physical activity was observed in all participants, the intervention group lowered their HbA1c and waist circumference significantly as compared to the control group.
The 12-week lifestyle intervention targeted weight loss, increase in physical activity, increase in fruit and vegetable intake to a minimum of 5 servings per day, and decrease intake per day of foods with saturated and trans fats. An evidence-based modified DPP curriculum, called the National Diabetes Education Program’s (NDEP) Power to Prevent (P2P): A Family Lifestyle Approach to Diabetes Prevention, was used as the basis for the programme. The P2P programme was modified to be culturally tailored for Indian groups. Individuals participated in weekly 75-minute group based lifestyle intervention sessions held at the mandir (Hindu temple) on Sunday afternoons. P2P is available for download from the following site: https://www.ndep.nih.gov/media/power-to-prevent-508.pdf.
A Gujarati American facilitator led each session in Gujarati, with examples of Gujarati colloquialisms, customs, and traditions. Specific barriers to adopting healthy behaviours were addressed through inspirational cultural messaging and visuals. Facilitator led 20 minutes of group physical activity time during 8 of the 12 sessions was provided to reinforce physical activity behaviour change. Experiential methods such as exercise and cooking demonstrations, distribution of sample foods using healthier ingredients, a grocery store tour, and a recipe makeover pot-luck party were used to engage participants.
The findings demonstrated that participation in a culturally tailored, lifestyle intervention programme in a community setting can effectively reduce weight, waist circumference, and HbA1c among Gujarati Indians.
Authors: Patel, R.M., Misra, R., Raj, S. & Balasubramanyam, A.
Citation: Patel, R.M., Misra, R., Raj, S. & Balasubramanyam, A. (2017). Effectiveness of a Group-Based Culturally Tailored Lifestyle Intervention Program on Changes in Risk Factors for Type 2 Diabetes among Asian Indians in the United States. Hindawi Journal of Diabetes Research, 2017, Article ID 2751980, 13 pages.
Article 2: The Social, Cultural and Behavioral Determinants of Health among Hawaii Filipinos: The Filipino Healthy Communities Project
This article has important information for approaches to health promotion for the growing Filipino community in New Zealand. Census 2013 showed that the Filipino population had the biggest percentage rise - 144 per cent since 2006, (up by 22,014, to 37,299) of all Asian groups in New Zealand. The majority born in the Philippines (Friesen, 2015). Although Filipino migrants have settled more widely in New Zealand than most other Asian groups, there, 50 percent of the Philippines-born population live in Auckland. Little has been documented in the New Zealand or international literature about Filipino’s views on health and healthy lifestyles. The Hawaiian study shows that due to acculturation Filipino men have disproportionately high CVD mortality rates and women higher stroke mortality rates than other ethnic groups.
In the study, Filipinos stressed an overall view of healthy communities as family centred, along with having basic necessities for economic well-being, a healthy environment, socialisation, happiness, a sense of community belonging and access to affordable health care. They saw the main barriers as socio-economic ones, along with language barriers, ethnic stereotypes and discrimination, lack of education, traditional beliefs and fear. Filipinos saw the main reason for chronic diseases (diabetes, obesity and heart disease and stroke) as dietary, along with lack of exercise and sedentary behaviour, cultural norms and language, the price of healthy food as a barrier and hard work and stress. Filipinos thought that there needed to be access to more tailored and language appropriate interventions, that the strengths of Filipino families could be tapped into, along with engagement of Filipino community leaders, and Filipino specific demonstration projects.
The practical implications of this project are that there opportunities for health providers in settlement societies to focus prevention efforts with Filipino communities on: targeted smoking cessation strategies, intervention efforts to improve healthy eating and increase non-work related physical activity, increased access to healthcare, and stress reduction. Workplace wellness strategies would be especially valuable for migrant Filipino communities.
Authors: Pobutsky, A., Cuaresma, C., Kishaba, G., Noble, C., Leung, E., Castillo, E. & Villafuerte, A.Citation: Pobutsky, A., Cuaresma, C., Kishaba, G., Noble, C., Leung, E., Castillo, E. & Villafuerte, A.
Citation: Pobutsky, A., Cuaresma, C., Kishaba, G., Noble, C., Leung, E., Castillo, E. & Villafuerte, A.Citation: Pobutsky, A., Cuaresma, C., Kishaba, G., Noble, C., Leung, E., Castillo, E. & Villafuerte, A. (2015). The Social, Cultural and Behavioral Determinants of Health among Hawaii Filipinos: The Filipino Healthy Communities Project. Californian Journal of Health Promotion, 13 (1), 1-12.
Friesen, W. (2015). Asian Auckland: The Multiple Meanings of Diversity. Auckland: Asia New Zealand Foundation. http://www.asianz.org.nz/reports/wp-content/uploads/2015/02/ANZF1033-Auckland-Report-_-FA2.pdf.
Article 3: Acculturation and Nutritional Health of Immigrants in Canada: A Scoping Review
Understanding the relationships between acculturation, dietary behaviours and health transitions is the first step towards the development of appropriate intervention strategies for a multicultural population that requires more and more cultural competencies.
In summary, the review found the healthy migrant effect, in other words, there is an overall negative effect on the health of migrants associated with time since migration to a new country. Dietary habits inevitably change after migration but some migrants tend to maintain their traditional diet which is often healthier that Western diets. South Asian, South East Asian, Latin American and African groups are at a high risk for nutrition related chronic conditions including diabetes and cardiovascular disease. Dietary transition undoubtedly contributes to the health transition among migrants, but diet is one risk factor among many. There is an increasing prevalence of childhood obesity and adolescent onset of type II diabetes in Canada. The availability and accessibility of traditional foods, financial insecurity, and limited transportation are important barriers to healthy eating There tends to be a consensus that culturally appropriate interventions including promoting traditional foods for migrants is important to ensure better health equity.
The studies recommendations to enhance migrant participation in nutrition research are also helpful in terms of culturally appropriate approaches to engaging refugee and migrant communities in health promotion programs, namely: Identifying and involving community champions: peer leaders, community champions and outreach workers; reducing logistical barriers that can hinder migrant participation (transportation, child care etc); providing incentives for taking part (grocery coupons, bus tickets, meals, babysitting etc), implementing appropriate community needs and assets assessment that will inform knowledge, perceptions and practices within the community: “One size does NOT fit all”; building trust with community members; involving community members in programme design from planning to dissemination; building research capacity within immigrant communities; enhancing ownership of the research process, data and outcomes; and using other miscellaneous strategies such as targeting women and other specific trusted groups among the community members.
Authors: Sanou, D., O’Reilly, E., Ngnie-Teta, I., Batal, M., Mondain, N., Andrew, C., Newbold, B.K. & Bourgeault, I. L.
Citation: Sanou, D., O’Reilly, E., Ngnie-Teta, I., Batal, M., Mondain, N., Andrew, C., Newbold, B.K. & Bourgeault, I. L. (2014). Acculturation and Nutritional Health of Immigrants in Canada: A Scoping Review. J Immigrant Minority Health, 16, 24–34.
Article 4: Understanding Health Beliefs and Practices in the Cultural Context: Chinese-Born Immigrant Women in the United States.
Culturally relevant health beliefs about health, health promotion, and health care practice among Chinese-born immigrant women in the United States were investigated using an ethnographic approach. A convenience sample of 15 Chinese-born immigrant women was recruited and a total of 21 interviews and 22 participant observations were completed. Findings indicate that, these women’s health beliefs were highly influenced by the traditional Chinese culture; however, their beliefs were also significantly shaped by the immigration. Although sharing beliefs with the other immigrant groups, these women have their unique health beliefs and practices, relevant to the Chinese culture. Findings also indicate that socializing with friends can be an important mechanism through which the Chinese community influences these women’s health belief and practice. Culturally competent and community based interventions should be developed to promote these immigrant women’s use of health care services.
Participant’s beliefs about health promotion and illness prevention were that socialising with friends, exercise, healthy food, good sleep and being happy were the five main ways to promote health and prevent illness. Of these “healthy food” was the main theme for health promotion and prevention. This meant eating “natural” as opposed to processed foods, including more fruit and vegetables and eating regularly and moderately. Traditional Chinese Medicine emphasises food therapy as a very important avenue to maintaining health. People are nurtured by products from nature and these natural products help keep the balance of Yin and Yang. Following Confucian traditions, good interpersonal relationships were highly valued and participants believed were essential to maintaining good health. Happiness and stress relief were critical methods for health promotion consistent with the holistic Yin-Yang dualism which emphasises the balance between mind and body. Stress and unhappiness influenced not only their own health but also the health of family member’s. Religious beliefs for some were instructive around healthy lifestyles; and provided emotional strength.
Authors: Zhao, M. & Conard, P.
Citation: Zhao, M. & Conard, P. (2015). Understanding Health Beliefs and Practices in the Cultural Context: Chinese-Born Immigrant Women in the United States. Int J of Nursing Didactics, 5, (1) 31-38.
Article 5: Development of a Culturally Tailored Text Message Maternal Health Program: TextMATCH.
This New Zealand study describes how mHealth can provide access to health information, motivation, reassurance, and support in simple programs like TextMATCH. It can also link people to existing community programs for appropriate in-person support. It is important that mHealth programs are designed with the involvement of these vulnerable groups in our populations, and that we take the time and extra resources required to ensure that the programs will be relevant and appropriate for the context of their daily lives.
This study shows that mobile health (mHealth) interventions are well-suited for non-English speaking groups with greater barriers to accessing our health services. Importantly, for others developing health education programs the authors show in detail the process of culturally adapting interventions for multiple ethnic and cultural minorities within a population. This was not simply about translating a program designed for mainstream New Zealanders, as there was no “majority” version of TextMATCH. The research team undertook an extensive process of developing an intervention with Māori, Pacific, Asian, and South Asian communities first.
The objective of the study was to describe the process of developing a culturally tailored text message-based maternal health program (TextMATCH: Text for MATernal and Child Health) for Māori, Pacific, Asian, and South Asian families living in New Zealand. This proved to be an engaging and acceptable method of promoting maternal health. All participants stated that the messages were relevant, culturally appropriate, and easy to understand and most were happy with the specific advice and the language options provided.
New Zealand health populations are super diverse, mHealth is an affordable and accessible means of reaching the many non-English groups in our population. The authors amply demonstrate the importance of an intensive approach to the development of a culturally adapted and tailored mHealth program for multiple different cultural groups within our population.
Authors: Dobson, R., Whittaker, R., Bartley, H., Connor, A., Chen, R., Ross, M. & McCool, J.
Citation: Dobson, R., Whittaker, R., Bartley, H., Connor, A., Chen, R., Ross, M. & McCool, J. (2017). Development of a Culturally Tailored Text Message Maternal Health Program: TextMATCH. JMIR mHealth and uHealth, 5 (4), e49. http://doi.org/10.2196/mhealth.7205.