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Qualitative study (The influence of immigrant status and acculturation of the development of overweight in Latino families. Journal of  Immigrant Minor Health)

Introduction and Research Questions

This article examines the increasing prevalence of obesity in the United States, particularly focusing on the problem in the Hispanic/ Latino sub-population.  Indeed, national data indicate that Hispanic Americans tend to have higher levels of obesity compared to other ethnic groups; this phenomenon is also observed in the younger generation: The prevalence of Latino children at risk of being overweight is as high as 42.9%.

This study attempts to examine the problem of obesity in the Latino/ Hispanic community through the analytical lens of cultural acculturation.  That is, while Latinos/ Hispanics are normally treated as a homogenous ethnic group, there are actually notable intra-group differences.  One of those (potentially key) differences is acculturation, or the degree to which minorities adopt the majority culture in their everyday practices including eating and exercise.  In the context of the Hispanic/ Latino population, this angle may be quite profitable: Indeed, the “immigrant health paradox” posits that those who immigrated to the US may have better health outcomes, including lower mortality risk and lower low birth weight infants.  Hispanics and Latinos who have lived in the US for a longer period of time show worse outcomes similar to natives that were born here: Overall higher rates of obesity are found in first and second generation immigrants in the Hispanic/Latino community.

The authors posit there is a lacuna in the literature based on this analysis: 1) there has been little research focusing on the impact of acculturation across generations in explaining differences in health behavior and outcomes; 2) existing studies that have looked at the question primarily examined adolescents; however; obesity research shows that critical habits may form much earlier in life to become obese.  Thus, the study wants to fill in the gap to understand the impact of acculturation on the intergenerational Hispanic/ Latino population, particularly focusing on mothers and younger children (under the age of four).

Study Methods

The data and selection for this qualitative study essentially piggy back off an existing study: The Latina Mothers’ Child Feeding Practices (LMCFP) study that focused on mothers’ feeding practices and perceptions of infant weight status and children’s food intake.  The study used three main qualitative methods to understand sociodemographic, sociocultural, and feeding environment influences on the mothers and their decision for care: 1) focus groups; 2) one-to-one interviews; 3) surveys.  The participants in the focus group and interviews were purposively sampled from the existing participants of the randomized study- a non-probabilistic sampling technique, that focuses on selection of a certain characteristic, in this case, Latino ethnicity, living in Boston, speaking (primarily) Spanish, and having gave birth over the past four months.   Different participants were chosen for participation in the control group and interviews.

A total of six focus groups were selected with a total of 31 individuals; 20 interviews were carried out over a six-month time period. The focus groups and interview sessions ranged from 60-120 minutes e ach.  Once the focus group and interview sessions concluded, the results were interpreted qualitatively by looking at the transcripts and identifying main themes.  In order to facilitate quantitative analysis efforts, and calibrate the level of acculturation among the Latina mothers, all focus group participants completed the Marin Acculturation Scale, a scale that gives an acculturation score across 12 items each item on a scale of 1-5.

The quantitative component of the study focused on capturing the sociodemographic and acculturation characteristics of participants. In the quantitative analysis, various sociodemographic variables served as the independent variables in the univariate analysis: proportion of years living in US (of an individual’s total life span), duration of years in the U.S., education (continuous), household income (continuous), age, hours of work/ week, and number of children. The dependent variable in the analysis was acculturation based on the Marin Acculturation Scale.  The univariate analysis showed a robust positive correlation (correlation coefficient ) with the independent variables proportion of years living in the U.S. (r=.67), duration of years (r=.62) and household income (-.54) and age (-.18).

The qualitative analysis focused on asking mothers how their current lives differs from that in their native countries. Seven total themes were identified as differences from the interview and focus groups: 1) diet, perceived food quality and availability; 2) food and eating practices; 3) breastfeeding practices; 4) beliefs about food, child feeding and weight status; 5) weight status of mothers and children; 6) physical activity and sedentary lifestyles; 7) social isolation and support.

Discussion and Results

The authors used the quantitative and qualitative results as the main evidence to assess the claim of acculturation as a factor in giving rise to obesity. The calculated result of the dependent variable, cultural acculturation, indicated that this sample of Latino women (a mean score of 2.04) was on the brink of being classified “bicultural” rather than solely identifying with the prevailing Latino culture.  The purpose of the qualitative exercise was then to give greater detail the components of the acculturation process, and how it might impact the health of the mother and child alike.  The authors cited mothers’ response that focused on: dietary quality and intake, physical activity and rising sedentary behaviors, factors previously associated with acculturation and development of overweight.

Mothers further identified increasing dependence on foods prepared outside of the house as a function of being busier, meaning that acculturated Latinos might in fact have adopted a diet more akin towards someone born in America rather than immigrants who, studies have shown, have a higher level of eating fruit and vegetables. The authors also cited decreased physical activity for mothers new to the country as new transportation systems and the watching of television became more common.

Overall, the authors concluded that the findings from their study had broader implications for public health practice and research in childhood obesity.  In particular of all ethnic groups, Latinos have the greatest prevalence of obesity, and are at the highest at-risk compared with other racial and ethnic groups.  In particular, the authors identified maternal cultural beliefs about child feeding and weight status may shape mothers’ caregiving practices for prevention and treatment and child obesity.  Finally, the process of acculturation and immigration are cited as important factors in understanding the obesity epidemic; the authors call for further research on these important concepts.

Assessment of Study

The assessment of this study must depend on the research questions selected and methodology chosen by the authors.   Overall, the authors want to study how the process of acculturation impacts the level of intergenerational obesity: that is, as immigrants spend more time in the United States, they adopt eating, physical activity, and caring habits closer to natives than to individuals in their home country.  The authors’ use of qualitative methodologies was both illustrative and limiting to answer this question.  The focus groups and interviews provided initial evidence that, at least for the sample of Latino women in Boston, acculturation seemed to be a factor in eating more processed food, exercising less, and breast feeding more.  The qualitative methods were used to make a rough statement regarding acculturation, in this sense the study succeeded.

However, this study also had a number of weaknesses.  Although the authors sporadically cited statistics and previous studies, they did not carry out a formal “literature review” that placed the study in the analytical stream of previous findings. Thus, the reader is not specifically aware of the existing literature regarding acculturation, or even different ways of operationalizing it, in either the context of Latino/ Hispanics or other ethnic groups.  This would have been helpful to understand how previous qualitative efforts have supported quantitative efforts to measure it.  In addition, while the authors cite numerous constructive findings of their study, they do not properly identify weaknesses or limitations of their methods. This would have been useful in understanding what the authors’ thought could have improved upon.

Besides these more formal criticisms, there are also questions regarding the generalizability of the study’s results across different Latino populations.  In particular, this study’s sample of Boston Latino women was on the border of being on the “bicultural” axis of acculturation. It is not clear how a predominantly “bicultural” population versus one significantly more “Latino” in orientation would have impacted the results. Indeed, with a significant number of Latinos living outside of the east coast and urban areas, particularly in the Midwest and west, there are questions whether this was the best proxy group to measure acculturation.  Indeed, perhaps the authors picked this cohort because it was an “embedded” cohort in an already conducted study; this would cut down on both expenses and logistical arrangements.  But this decision came at the expense of measuring other cohorts, particularly in rural areas, where the acculturation process may be more intensified (i.e., Latinos deal more within mainstream society) and more interesting to examine how their health habits were impacted. This would also be interesting due to the issue of confounding: rural individuals traditionally eat less healthy and have worse health outcomes than urban inhabitants (at least for most measures of chronic disease). Thus, the sample is not likely generalizable to other populations.  It would have been interesting to cite results from different Latino populations, or different intra-group ethinic populations, in order to understand the potential variation in the acculturation population.

With these suggested improvements, one should also acknowledge the purpose of qualitative research in this context: this qualitative study served as an initial attempt to qualify whether acculturation may potentially explain increasing obesity rates and differential intergenerational obesity rates in ethnic populations.  To this extent, the study provided results that may not only serve for further research (replication) but may also be the base of more quantitative methods to assess longitudinal changes over time.

As a potential advanced nurse practitioner, this article offers numerous points for my practice moving forward.  First, in order to understand why a child may be obese or suffer from less optimal habits, it may be necessary to examine the nexus between the mother and the child.  Indeed, education programs and special efforts to contact the mother may be necessary when dealing with health issues related to the family. Second, obesity should not only be seen as a clinical problem, but should also be viewed as one with significant sociodemographic and socioeconomic components.

References:

Sussner, K.M., Lindsay, A.C., Greaney, M. & Peterson, K.E. (2008). The influence of immigrant status and acculturation of the development of overweight in Latino families. Journal of  Immigrant Minor Health, 10(6), 497-505.