CLINICAL SCHOLARSHIP

Using Photovoice to Explore Nigerian Immigrants’ Eating and Physical Activity in the United States Melanie T. Turk, PhD, MSN, RN1, Abimbola Fapohunda, DrPH, MPH, MS2, & Rick Zoucha, PhD, APRN-BC, CTN-A3

1 Epsilon Phi, Assistant Professor, Duquesne University School of Nursing, Pittsburgh, PA, USA 2Consultant, FOB Group, LLC, Monroeville, PA, USA 3 Professor of Nursing, Duquesne University School of Nursing, Pittsburgh, PA, USA

Key words Immigrants, nutrition, physical activity,

Photovoice

Correspondence Dr. Melanie T. Turk, Duquesne University School

of Nursing, 518 Fisher Hall, 600 Forbes Avenue,

Pittsburgh, PA 15282. E-mail: turkm@duq.edu

Accepted: July 19, 2014

doi: 10.1111/jnu.12105

Abstract

Purpose: African immigrants are one of the fastest growing immigrant groups to the United States; there is a crucial need to learn about African immigrants’ beliefs and lifestyle behaviors that may impact health. The purposes of this study were to (a) explore the perceptions and practices of Nigerian immigrants regarding healthy eating and physical activity in the United States; (b) assess the influence of cultural beliefs of Nigerian immigrants on eating and physical activity; (c) describe the role that healthcare providers can play in helping to promote healthy eating and physical activity; and (d) evaluate the feasibility and efficacy of using Photovoice to collect data on the perceptions and practices of Nigerian immigrants regarding healthy eating and physical activity. Design: Qualitative visual ethnography using Photovoice. Methods: Thirteen Nigerian immigrants were recruited. Data were col- lected using photography and focus group discussions at a church. Photovoice methodology and Leininger’s four phases of qualitative analysis were used to analyze photographs, field notes, and focus group transcripts. Findings: Four overarching themes emerged from the data: moderation is healthy, Nigerian ways of living are healthy, acquiring American ways is un- healthy, and cultural context is important to promote healthy behaviors. Conclusions: Photovoice was a feasible, effective methodology for collecting data on the perceptions and practices of Nigerian immigrants. Nigerian partic- ipants believed that adherence to traditional dietary and activity practices are healthy. Nurses and other healthcare providers must make concerted efforts to communicate with and educate Nigerian immigrants about healthful eating and activity behaviors within their cultural context. Clinical Relevance: The number of African immigrants to the United States has increased dramatically. Photovoice is a creative method to learn about the health beliefs and behaviors of the Nigerian immigrant population.

Immigration plays a major role in the growth of the population of the United States, and it is estimated that 82% of the population increase between 2005 and 2050 will be attributable to immigrants and their offspring (Passel & Cohn, 2008). The African-born population in the United States doubled in size from 881,300 in 2000 to 1.6 million in 2010, and one of the most common countries of origin for African immigrants is Nigeria

(U.S. Census Bureau, 2010). Yet, to a large extent, the health and wellness of the African immigrant population remain unexplored (Venters & Gany, 2011). These de- mographic trends indicate a crucial need to learn about African immigrants’ beliefs and lifestyle behaviors that may impact health.

While the African immigrant population has grown exponentially, few studies have examined the health

16 Journal of Nursing Scholarship, 2015; 47:1, 16–24. C© 2014 Sigma Theta Tau International

Turk et al. Using Photovoice With Nigerian Immigrants

of African-born residents in the United States (US), including the impact of acculturation on diet and phys- ical activity. The majority of immigrant health research has focused on Hispanic and Asian populations and sug- gests that, generally, these immigrant groups are health- ier than native-born Americans (Barrington, Baquero, & Borrell, 2010; Singh, Siahpush, & Hiatt, 2011). Limited evidence also shows that African immigrants tend to be healthier than US-born Whites and African Americans (Read, Emerson, & Tarlov, 2005; Singh & Hiatt, 2006; Singh & Miller, 2004). Studies on dietary patterns in groups of immigrant populations show that traditional diets are healthier than the nontraditional diets that have evolved with acculturation (Delisle, 2010; Desilets, Rivard, Shatenstein, & Delisle, 2007). Yet, immigrants may face barriers in maintaining healthy native diets or acquiring healthy physical activity habits in their new countries. Among 5,230 immigrants to the US, 79% re- ported being physically inactive (Koya & Egede, 2007), and only 38% of a sample of African immigrants to the Netherlands said they had engaged in physical activity in the previous month (Beune, Haafkens, Agyemang, & Bindels, 2010).

US national data systems used in monitoring health, mortality, and disease patterns do not identify Africans in the US as a separate ethnic group, and do not rou- tinely report and analyze health data by immigrant sta- tus (Singh & Hiatt, 2006; Singh & Miller, 2004; Singh, Rodriguez-Lainz, & Kogan, 2013). Thus, data for African- born immigrants are often entangled with data for African Americans. An analysis of National Health Inter- view Survey data showed that 58.4% of African adult im- migrants were either overweight or obese in 2002 after residing in the US for 15 or more years (Koya & Egede, 2007). Current statistics of Black US residents, including persons born in the US or elsewhere, indicate that 54% and 38% of Black female and male adults, respectively, are either overweight or obese compared to 33% and 34% of White female and male adults (American Heart Association Statistics Committee & Stroke Statistics Sub- committee, 2014). While diet and activity are key deter- minants of weight, an established contributor to health, little is known about African immigrants’ perceptions and practices around healthy eating and physical activity as they relate to residing in the US.

Photovoice, in which participants use photographs to describe their health and life experiences, is one method that has been used as a health-promoting strategy (Wang & Burris, 1997; Wang & Redwood-Jones, 2001). Initially originated by Wang and Burris (1997) to document the everyday lives of women in rural villages of China, Pho- tovoice is a grassroots approach of community-engaged research that assists people in identifying the strengths

and issues of their community through photography. The Photovoice approach has been used previously with im- migrant groups such as Latino, Chinese, Korean, and Vietnamese immigrants to learn about topics such as hu- man immunodeficiency virus prevention, family plan- ning, mental and cardiovascular health, and the influence of immigration (Fitzpatrick et al., 2009; Garcia & Saewye, 2007; Rhodes & Hergenrather, 2007; Schwartz, Sable, Dannerbeck, & Campbell, 2007; Streng et al., 2004). Pho- tovoice can provide Nigerian African immigrants the op- portunity to express their ideas about eating habits and physical activity within the context of their daily lives in the US.

Purpose

The purposes of this study were to (a) explore the be- liefs, perceptions, and practices of Nigerian immigrants regarding healthy eating and physical activity behaviors while living in the US; (b) assess the influence of cultural beliefs of Nigerian immigrants on eating and physical ac- tivity behaviors after migration to the US; (c) describe the role that healthcare providers can play in helping to pro- mote healthy eating and physical activity behaviors for Nigerian immigrants; and (d) evaluate the acceptability, feasibility, and efficacy of using Photovoice as a technique to collect data on the perceptions and practices of Nige- rian immigrants.

Methods

Design

A qualitative visual ethnography design using Pho- tovoice was employed for this study, and two of the goals of Photovoice identified by Wang and Burris (1997) were highlighted: (a) encouragement of individuals to record their community’s strengths and concerns and (b) fa- cilitation of critical dialogue through group discussions about photos taken by the…