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Volume 4: No.
4, October 2007
ORIGINAL RESEARCH
Perceptions of Diet and
Physical Activity Among California Hmong Adults and Youths
Loan Pham Kim, MS, RD, Gail G. Harrison, PhD, Marjorie Kagawa-Singer,
PhD, RN, MN
Suggested citation for this article:
Kim LP, Harrison GG, Kagawa-Singer M.
Perceptions of diet and physical activity among California Hmong
adults and youths. Prev Chronic Dis 2007;4(4).
http://www.cdc.gov/pcd/issues/2007/
oct/07_0074.htm. Accessed [date].
PEER REVIEWED
Abstract
Introduction
We conducted a qualitative study to inform the design of a proposed community-wide campaign to promote increased physical activity and fruit and vegetable consumption among low-income Hmong families.
Methods
We held eight focus groups with parents of children aged 5 to 14 years and with youths aged 11
to 14 years, interviews with key informants in several Hmong communities, and interviews with professionals who conducted physical activity and nutrition activities in these communities. Sessions were tape-recorded and transcribed.
We organized data using ATLAS.ti
software and then analyzed the content.
Results
Findings suggest that physically active lifestyles and dietary patterns emphasizing fresh foods including fruits and vegetables are valued in
the Hmong culture and perceived as essential to good health. Barriers to a
healthy lifestyle include limited
access to safe spaces, time for adequate physical activity,
access to land to grow fresh produce, and time for home preparation of food. Low incomes and marketing of unhealthy foods, particularly to children, are also problematic. Information on
the healthy aspects of both traditional foods and American foods is needed in accessible formats and delivered through media and trusted community sources.
Conclusion
Like other Asian groups, the majority of Hmong are first-generation immigrants. An increase in nutrition-related chronic diseases can be prevented by encouraging and reinforcing the maintenance of traditional eating patterns and active lifestyles.
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Introduction
Rationale for the study
Almost one-third of American adults meet the criterion for obesity, and nearly two-thirds
are either overweight or obese (1). The prevalence of overweight among children and adolescents has doubled since 1980 (2,3), and the rates of related chronic diseases including cancer, type 2 diabetes,
and stroke
and cardiovascular disease are rising dramatically (4). Improving dietary
quality and increasing levels of habitual physical activity are critical public
health goals for the U.S. population. The most important qualitative aspect of diet for disease prevention is
adequate vegetable and fruit intake (5,6). Physical activity aids in the prevention of weight gain in addition to having other direct beneficial health effects.
Evidence shows that for most
adults, about 1 hour per day of moderate-intensity activity is required to prevent significant weight gain, and as little as 1 to 2 hours per week of fast walking or the equivalent significantly attenuates weight gain in middle age (6-10). Yet only about one-fourth of Americans eat the minimum recommended five servings of vegetables and fruits a day, and fewer than half of American adults
participate in the recommended amount of physical activity (2,10).
Ethnic minority populations have worse health outcomes in every chronic disease category
than do non-Hispanic whites. National efforts and state efforts in California
provide program resources and outreach to address these disparities in African Americans and Latino populations, but no
effort exists nationally or statewide in California for Asian American, Native Hawaiian/and
other Pacific Islander (AA/NHOPI) communities. AA/NHOPIs are the most rapidly growing ethnic group in the United States (11,12). About 70% of AA/NHOPI adults in California are first-generation immigrants. Notably, the limited data on dietary practices and prevalence of overweight and obesity indicate that the rate of increase of obesity among AA/NHOPIs is significant. They have the fastest rate of
increase in overweight and obese youths of all ethnic groups in California. California Pediatric Nutrition Surveillance System data reveal that from 1994 to 2003, overweight prevalence increased
from 7% to 15% for California AA/NHOPI low-income children, more rapidly than for any other ethnic group (13). Although few data are available specifically on
Hmong Americans, a local study in
Wisconsin reported that 65% of Hmong youths were overweight or obese (14).
Realizing the unique opportunity to provide health promotion support to optimize dietary and physical activity practices
among Asian immigrants during the all-important transition from first to second generation, California Department of Health Services and the University
of California Los Angeles (UCLA) School of Public Health partnered in early 2004 to begin the formative work required to devise guidelines for an appropriate
nutrition and physical activity campaign targeting Asian American (AA) communities.
Data on parallel studies among low-income Chinese and Vietnamese immigrants and their children are reported elsewhere
(15).
Hmong Americans
Unlike other groups that have a clear country of origin, the Hmong originate from several
regions in Southeast Asia. A tribal people originally from China, where several million ethnic Hmong still reside, many fled
to Laos to escape persecution in China. During the Vietnam War, many of them fought for the United States in Laos and were subject to North Vietnamese retribution when the United
States left Vietnam. Most who survived then fled to Thailand, where they have lived in refugee camps,
sometimes for many years. Most U.S. Hmong came to the United States directly from Thailand, beginning in 1979.
Approximately 200,000 Hmong now live in the United States, most of whom have settled in Minnesota’s Twin Cities, Wisconsin, and California’s agricultural
central and northern
valleys. About 50% of the Hmong in the United States reside in California.
Hmong are traditionally agriculturalists, with a patriarchal and patrilocal (i.e., new families taking up residence with or near the husband’s family) social structure. Religious beliefs are based in traditional animism
(i.e., the belief that all elements of the earth and its creatures possess spirits or souls that live in harmony when they are satisfied that each
is living with respect and honor for each other). Fertility is high (average family size is 4.5), and the average age of the population
is young. The history of the Hmong language has implications for the design of health promotion programs. The written language was lost during centuries of persecution in China. Christian missionaries developed a Romanized phonetic script, which is not
intuitive for pronunciation, in the late 20th century. An increasing number of materials are being printed in this Hmong rendition, but it remains difficult for most Hmong to read (16).
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Methods
We used qualitative methods to explore knowledge, attitudes, opinions, and reported behavior regarding health and healthy lifestyles, dietary practices (focused on vegetable and fruit consumption), and physical activity among low-income Hmong parents and youths in California. The work was nested in a broader study
that also included first-generation, low-income Chinese and Vietnamese
immigrants, reported elsewhere (15). Interview guides and inductive focus group guides were developed, and interviewers and focus group moderators were
formally trained. A series of key informant interviews and focus group discussions were held. Identification of key informants, recruitment of focus group participants, and facilitation of interviews and discussions were accomplished
in concert with community partners, the Hmong Women’s Heritage Association in Sacramento, and Stone Soup Fresno. An advisory committee (made
up of professionals and community leaders who worked extensively with the study group in the areas of nutrition and physical activity) contributed to the recruitment strategy, which can best
be described as informed convenience
sampling. Recruitment flyers and information sheets were distributed to our community partners, who posted the translated notices at supermarkets, businesses, community-based organizations, clinics, and schools. Key informants were identified and contacted directly by representatives from the community agencies. All materials
(including interview guides, focus group guides, and recruitment
materials) were translated into Hmong and back-translated to ensure integrity and consistency. Focus group moderators and interviewers were bilingual
and bicultural. All aspects of the study were reviewed and approved by UCLA’s Institutional Review Board for protection of human research subjects.
We interviewed five key informants in addition to 44 adults (39 women and 5 men) and 40 youths (18 boys and 22 girls) in eight focus groups in Fresno and Sacramento. Adult focus group participants ranged
in age from 25 to 80 years and were parents of children aged 5 to 14 years. Youths were aged 11
to 14 years. Focus groups lasted an average of 2 hours, with question and
answer sessions following, so the discourse was unhurried. Interviews and focus groups were tape-recorded and transcribed.
We coded and organized the data using ATLAS.ti (ATLAS.ti
Scientific Software Development GmbH, Berlin, Germany) software and then analyzed
the content. The number of respondents noted
in the results is lower than total participants because of the dynamics of the groups. If one person answered and the others agreed, no one else responded. Therefore, according to the focus group leaders, the lower numbers most
likely represent consensus in the group.
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Results
Definitions of health
Adult participants consistently defined health as the absence of health disorders and psychological and emotional stability,
and harmony within the family. Respondents expressed a common cultural belief that being healthy meant being thin — one key informant stated that “Hmong people are
[naturally] small.” Health was characterized by eating foods one desired — to be “proud of what you
eat” — and eating many types of vegetables and fruits. “Balance” between consuming foods from different food groups, such as vegetables cooked with meat, was
noted by adults
as necessary to keep the body functioning optimally. Adults noted that cleanliness and environmental conditions contributed to overall health
and emphasized showering frequently and keeping a
home free of dirt and germs.
Both adults and young people recognized the health benefits of physical activity/exercise and vegetable and fruit consumption. Exercise and vegetable and fruit intake were believed to prevent health risks and illnesses such as elevated cholesterol levels, diabetes, stroke, hypertension, and weight gain. One participant expressed that “people that are not physical[ly] active seem to have more
problems and mental and health problems.” Specifically, low stress levels were deemed to be an essential component of health.
Adults expressed worry about weight gain, diabetes, kidney disease, smoking-related cancers, and pregnancy disorders but with low frequency. Respondents commonly expressed the perception that they were not as healthy in the new environment as
they were before
immigration and that they faced many new health challenges.
Perceptions about diet
Respondents generally agreed that vegetables and fruits are the healthiest types of foods and should be consumed often. Beneficial starches included rice, noodles, and bread. Meat was believed to be necessary for good health, but consumption should be limited to reasonable quantities and
to lean meats, such as fish and roasted chicken, which were reported as most beneficial. Most people explained
that different aspects of Hmong and American cuisine were advantageous — the high volumes and availability of vegetables and fruits in the American diet and the low levels of fatty and oily foods of the Hmong diet.
Meat was named as the single most commonly consumed unhealthy food. Many adults expressed concern that
Hmong Americans eat too much meat after moving to the United States, and they eat fatty varieties, most significantly pork. Adults believed excessive volumes of meat directly caused sicknesses: “stomachache and diarrhea,” “black-out,” and feelings of
carrying “a big load on your back.” A few adults even advised that they stopped eating meat altogether or limited intake to holidays. All individuals advised that intake of fried, oily, and fast foods needed to be reduced. Adults expressed concern that
consumption of these foods needs to be reduced by youths in particular. Consuming too many sweets was considered unhealthy as well.
Almost all participants reported that their diets included both Hmong and American foods, with greater proportions of Hmong foods. Rice remained a dietary staple in all home-cooked meals for
Hmong Americans, complemented by reportedly high
intakes of various vegetables, chicken, fish, beef, and pork. Breakfasts for children were commonly eaten at school and included cereal, milk, juice,
eggs, hash browns, sausage, and fruit such as apples, oranges, and bananas. Frequently mentioned snacks were ice cream, cookies, chips, candy, soda, instant noodles, and common fruits. Youths reported that their schools served pizza, hot dogs, burritos, nachos, tacos, or hamburgers for lunch, all of which they and their parents perceived to be unhealthy. The main vegetables that they reported
eating at school were salads and carrots.
Commonly eaten fruits included guava, mango, pears, pineapple, watermelon, and other melons. Home gardens contained peaches, grapes, oranges, and pears. Schools reportedly serve oranges, apples, and bananas. Youths named bananas, papayas, strawberries, and kiwi as favorites. A handful of individuals said that they missed their homeland fruits of rattan, red and gray banana, and passion fruit leaves,
which are not available in the United States.
Vegetables eaten were beans, cabbage, broccoli, green beans, corn, mustard greens, carrots, peppers, eggplant, peas, squash, celery, bok choy, collard greens, and gourds. Youths expressed a liking for salad but did not distinguish the specific types of vegetables included.
Participants who had home gardens grew and ate cucumber, pumpkin, corn, tomato, mustard greens, lemongrass, collard greens, and
herbs including basil, green onion, cilantro, and mint. Some participants indicated they missed vegetables from their homelands such as palm and cassava leaves.
Hmong American adults repeatedly noted that fresh foods were essential to health. They value fresh foods as healthy because old, dried, frozen, preserved, or canned fruits, vegetables, and meats are believed to cause sicknesses: “Our Hmong people have diabetes and high blood pressure because we do not eat fresh meats. The meats we eat were in the freezer for a long time.” Fresh
foods were defined as meats from recently killed animals, recently caught fish (preferably the same day) or recently picked vegetables and fruits. They regarded fertilizer and pesticides as harmful to the nutritional value of vegetables and fruits. The universal sentiment was, “In our homeland the soils are fertile, and we don’t use fertilizer to grow anything
. . . so, we eat the crops and
we are healthier. . . . In this country, you get sick a lot because fertilizer was used to grow all the vegetables and fruits.
. . . I do not eat much anymore and I am very afraid now.” In addition,
temperature of food was important to the health of women, because cold water and
foods “cause you to not have children” because of “abnormal period[s].” Youths voiced no
similar cultural concerns.
Youths referred to diet sodas as a healthier alternative to regular sodas. All groups encouraged drinking plenty of water. Canned fruit juice and milk were also healthy drinks named. Parents often tried to eliminate or restrict soda consumption, referring to its high sugar content.
Adult participants reported not knowing the definition of a “serving” of fruit or vegetable or had never heard of the word before, whereas youths reported knowing about the concept from school or
the news media. One adult reported that “Hmong people eat until their stomach is full, but food was also limited.”
Still another illustrated that the Hmong concept of a serving was much larger
than the American serving size described in the Dietary Guidelines for
Americans. Of adult respondents, 40% reported that youths ate five or more servings of fruits or vegetables
per day; 60% of youths reported actually eating that amount or more. Almost all youth respondents (89%) said that youths should eat
five or more servings daily, although none of the
parents offered an opinion on how many servings of vegetables and fruits a child should eat
per day.
Hmong American parents try to include vegetables in every meal to balance out the meat dishes. Fruit is consumed usually as a snack. “We don’t eat fruits to fulfill our hunger, and we don’t eat them with our meals.” Adults noted that vegetables and fruits prolong life, protect against the sicknesses and diseases mentioned above, and provide vitamins. Youths
cited that they provide energy and strength and that they “help the body grow.”
Definitions of physical activity and exercise
Interviewees provided varying responses when asked to define the difference between exercise and physical activity. A few replied that there was no difference, but most distinguished the two as different concepts. Exercise was generally perceived as being more structured, as “using your energy” to “sweat,” “make your heart pump faster,” and “tighten up
your muscle.” As one adult participant phrased it, “Exercise is like going to a place or with a group that have machine and do to maintain your balance.” On the other hand, physical activity was more broadly defined as “physically moving” and “using your strength.” It most frequently included active games and sports, as well as chores and housework. A
major health benefit of physical activity noted by adults and youths was prevention or improvement of health disorders. Other benefits stated were increased energy, strength and flexibility, burning of fat, keeping the body “in shape,” maintaining independent living for the elderly, improved circulation, good posture, lowering of heart rate, and decreased risk of mental health
problems.
Adults listed physical activities including walking, Tai Chi, stretching, cleaning house, and gardening. Traditional Hmong physical activities are farming, walking, climbing trees, hunting, fishing, swimming, cooking, and cleaning house. Traditional games include spinning tops, tag, jumping rope, kato
(a very popular game in southeast Asia) and “playing house.” Youths participated in housework by mowing the lawn and cleaning. Youths mostly enjoyed sports as their form of exercise, including basketball, volleyball, soccer, kato, baseball, running, football, tennis, badminton, and kickball. Dancing was also popular.
The average response of the five youth and adult participants who answered the question
about frequency of physical activity among youths was 3.2 times per week. Sixty percent of youths and
66% of adults thought that young people get at least an hour of physical activity per day.
Sixty percent of youths and 13% of adults felt that children should get an hour of physical
activity each day. Most adult respondents said they participated in physical activity or brought their children to parks for physical activity. Two replied that they had enough space in their homes for their children to be physically active. Some indicated that they walked around the neighborhood streets. Most youths reported
that they engaged in physical activity at a park or at school in physical
education classes, during class breaks, or after school. Participants indicated
that schools offer most of the physical activity venues and opportunities available to children,
and a few participants mentioned churches initiating physical activity programs. Two parent participants cited that homework limited the amount of time available to youths for physical activity. Parents and youths reported that youth dedicated several hours
per day
(average 2.2 hrs) to watching television, using the computer, or playing video games. Half reported greater time spent using the
television, computer, or video games during weekends, while the other half reported less time because they increased physical activity during weekends.
Concern about obesity
Many parents expressed concern for their children and themselves about
becoming obese after moving to the United States. The cause was perceived to be increased availability
and intake of food, increased consumption of fatty American foods such as fast foods and fatty meats, and decreased physical activity levels. Before coming to the United States,
“Hmong used to work on farms from morning to afternoon. They exercised all day long. In America, things are different. We are more sedentary and do not exercise as much.” One gentleman cited an apt understanding of the phenomenon: “For example, like a pig. If we caged this pig then he will be fatter than the one that you let it run around. Now we are like this pig that [is] in
the cage.”
Barriers to healthy living
Regarding the traditional Hmong diet, all five key informants reported
changes in the traditional Hmong American diet as this community has adapted to
American life and adopted some unhealthy eating habits. Although most Hmong
Americans grew their own vegetables and fruits in
Laos, many cannot do so in the United States because they live in small
apartment complexes and no longer have their own farm or large plots of land on
which to plant foods and raise animals. As a result, people do not eat as many fresh foods, which
Hmong Americans define as healthy foods, as noted above. One parent reported, “Back in the homeland, there were no fertilizers used on our foods because we grew our own foods so they were healthy for
our body. In this country, the foods grow because of fertilizer and pesticide use and that affects our being unhealthy.”
Although some Hmong American families in Fresno and Sacramento maintain small
gardens in their backyards, the variety of traditional vegetables and fruits
they are able to grow in the United States is less than those grown in Laos. In
addition, concern about the presence of chemicals in produce was expressed by many participants.
One parent cited shifts in dietary practices involving eating more meat: “We were able to eat healthy foods in our homeland, but we didn’t have as much foods available. We can eat more foods in this country because they’re plentiful. . . . For example, there’s more meat such as pork here and people tend to eat more of it.” Other parents agreed that they
also eat bigger portions of food here than they did in their homelands. One parent noted, “We have changed a lot. In this country, some families, every month they will kill a pig and eat for the whole month. In our homeland, we only get to eat meat once or twice each year.”
Although all key informants noted that it is easy to buy many different kinds of vegetables and fruits at the
Asian grocery stores, some Hmong Americans are not eating as many vegetables and fruits because of lack of time and money to purchase the vegetables and fruits
with which to prepare traditional meals with fresh ingredients.
Because many Hmong American households have low incomes and both parents are employed, time and money are two of the greatest barriers to eating healthy foods.
Although vegetables and fruits are readily available, many Hmong American families increasingly are consuming poorer-quality diets including fast foods, fatty meats, and ready-made, frozen, and preserved foods because these options are
readily available and often require less time to prepare and less money to purchase. One mother
said, “We eat outside when I am tired or do not feel like cooking. Sometimes I don’t have time to cook.” Another parent stated, “We eat mostly Hmong food.
. . . But if we don’t have time then we will eat American foods. . . . The children like to eat fast food, like
frozen food that is ready to serve after you microwave because they don’t have the patience to wait for Hmong foods.”
Many families use food stamps, which are often saved to buy meat. One parent revealed that with big families, the food stamps sometimes are not enough to purchase the needed groceries: “The more children you have, the tighter your money is when it comes to buying groceries.
. . . You also worry about food when you have guests come over. There are times you have to use cash to help pay for
groceries along with food stamps.” One parent summed up the financial hardships:
The things that can change the way we eat would be employment and earning a higher income, which would allow us to purchase better foods. It’s hard to eat healthy when you don’t have a lot of money. And when you have financial limitations, you tend to purchase foods that are cheaper and unhealthy.
Barriers to physical activity and exercise
All key informants cited lack of time and money as the major barriers to physical activity and exercise for the
Hmong American community. One key informant stated, “The parent needs to supervise their kids and sometimes they don’t have the time.
. . . Money is a problem if you have to pay to have their children in a program.” Another key informant similarly mentioned time and money
issues and added that parents are sometimes not knowledgeable about what kinds of physical activity programs are available for their children:
Parents are not informed about organized youth activities programs. To participate in sport activity one will need money, and many Hmong people don’t have much money. They also have lots of children. In addition, they do not have time after school to attend to all the children’s sport activities.
Other parents agreed when one mentioned that language barriers hinder parents from knowing about physical activities programs for their children: “It is hard in this country. Many people do not speak English so it’s hard for them to join programs.” Another parent expanded on this issue:
The difficult thing is the age of parents and the language barrier. You don’t know the directions to take your kids to recreational places. It’s difficult to communicate with people you meet there. Also, your children may want to travel out of town but you’re old and you can’t drive far even if you want to. But we do like to be with our kids when we go to nearby
recreational places.
In addition to language barriers, lack of information, time, and money, all key informants cited safety issues as a barrier to physical activity and exercise. One key informant noted:
The majority of Hmongs live in apartments. They tend to stay inside. Instead of exercise, they tend to take the car. Some areas where the Hmong live, it is not safe to be outside. They are afraid of gangs and shootings.
Some parents reported prohibiting their children from joining sports
activities because they do not want their kids to “fool around” and forget
their studies or play away from home too much for fear that playing in
groups in some public areas may lead to encounters with gangs. All the
parents agreed that being physically active is good for children, but they
also agreed when one person added:
Yes. But their physical activities should not take up too much of their time that it has a negative impact on their studies. And you as a parent should not give them full freedom as to being physically active. They may be involved with the wrong group of kids.
Another barrier to physical activity and exercise is the lack of space and organized sports programs. One key informant revealed that, “In the south side of Fresno, there are not many places to exercise. Safety is an issue for many parents. Parents don’t have time, so it’s hard to pick their children up from places like the Boys and Girls Club.”
Some youth focus group participants also mentioned safety as a barrier, saying, “I don’t feel safe around the neighborhood.” Another mentioned that there is “no space to play and they
[the parents] do not let us play in the street.”
Many parents also cited the lack of free public parks and public space where they can take their children to play:
As much as we’d like our children to be
physically active, sometimes it costs money to enter some parks and that
keeps us from taking our children. To encourage them to be physically
active, it costs money to get them into the park. Our Hmong children don’t
get enough physical activity compared to American children because we face
limited money and space.
A few parents were worried that their children, especially their daughters, might get injured (“break their leg or arm”) or do harm to their bodies if they played too much sports. One parent stated, “If the girls play too much, it’s not good for them because when their body is hot and they drink cold water.
. . that will cause them to have abnormal periods.” Some
youth focus group participants also expressed that fear of getting injured, or actually being injured, prevented them from doing some sports activities.
Ideas to encourage and maintain vegetable and fruit consumption
All key informants and parents believed that it is important to involve the whole community in any efforts to encourage healthy lifestyles for children. Foremost is involving the family and parents and educating them about healthy eating practices so that they, in turn, can maintain their own healthy habits as well as learn new ways to encourage their children to eat more vegetables and
fruits. One key informant stated:
I think parents are the key. They need to be educated so they can teach their kids. Parents need to understand the difference between healthy foods and junk foods.
. . . The parents need to be educated about proper nutrition. Parents are the ones that buy the food. I tried not to buy cookies and soda for my kids.
The parents agreed with this assessment when asked what would encourage their
children to eat five or more vegetables and fruits each day. One parent replied,
“I think for the younger children they probably don’t eat, but I think for the
older children if you buy and have it at home then they will eat.” Another
parent revealed how she encourages her daughter to eat more vegetables and
fruits when she shared, “I told her that this is how we always eat. She has to
eat this to help her body, so that she doesn’t have diabetes and high blood
pressure.” This message of eating vegetables and fruits for a healthy body was
emphasized by many parents. One focus group participant shared, “I tell my
child, ‘Eat vegetables so you’ll be strong,’ then he eats it. When it comes to
fruits, if you the parent eats it then they will see it and want to eat it
also.”
Parent modeling of healthy behaviors for children was frequently mentioned.
One parent stated:
The parent has to be the one eating the fruits to model for their children.
Young children will eat fruits when they see parents eating [them]. For example, the
parent eats a banana for breakfast while the young child eats half a banana.
Also, when you eat an apple, you cut it into slices and give it to your child.
To encourage your children to eat fruits, you have to purchase a variety of
fruits and make them available in the home. If you let your child decide
[whether to eat fruits], your child will choose not to eat fruits.
The key informants concurred with this idea and suggested several ways to
encourage eating more vegetables and fruits: “The Hmong depend on their family.
Teaching the parents is very important. Not all Hmong know where to go to get
health information. Nonprofit organizations are a good way to get information
out. The health department is good also. Social events and passing out flyers.”
Many parents agreed that receiving information from community and clan
leaders, as well as from nonprofit organizations, doctors, and teachers would
encourage them to pay more attention to healthy eating practices, including
eating more vegetables and fruits. Notably, parents expressed interest in
participating in educational workshops conducted by community health workers,
doctors, and teachers.
Youth focus group participants also mentioned that they would be more likely
to eat more vegetables and fruits if their parents (especially the mothers,
because they are the ones who often prepare the meals) bought them and
encouraged them to eat them: “Cut [up] fresh, not old fruits or vegetables. If it
smells good, then it will make you want to eat more.” Other youths reported that
they would want to eat five or more vegetables and fruits each day if they wanted
to be healthier or “to lose weight or go on a diet.” Others reported that they
would eat more vegetables and fruits “if we can eat it watching TV,” or “eat
with friends.”
Ideas to encourage and maintain physical activity
Similar to encouraging healthy eating practices, parental involvement is an
important factor in encouraging children to be physically active. Many parents
reported that although they don’t have much time, they do make an effort to play
with their children around the house and neighborhood or take their children to
nearby parks or public recreational areas. Playing with them also allows the
parents to supervise their children. One parent stressed:
As a mother, you should go with children to the parks in order to supervise
their activities so they don’t face problems that may arise. For example, when
you’re with your children, they’re less likely to get involved with at-risk
youth groups and wander off and get into trouble.
Another parent suggested, “We need more safe places for family to enjoy
themselves — like safe parks.” Others also suggested having free after-school
programs supervised by teachers or volunteers. Many parents noted that children
are more likely to engage in exercise and physical activities when they can do
so with other children. One parent explained that, “For those who live in
apartment complexes like ours, the children are always outside and engaged in
physical activities with other children living in the same complex. Children are
more likely to do physical activities with other children and in a group.”
The youth focus group participants also reported that family encouragement
and involvement (e.g., going to the park together and “doing fun things,” or “do
exercise with your family”) would help add more physical activity to their daily
life. They also reported that having school programs, tournaments, and community
services would encourage them to exercise and to be more physically active,
especially if the activities are interesting and fun and done with their
friends. Many of the youth participants understood the health benefits of
exercising (e.g., “be in good shape,” “have more energy,” “it burns your calories,”
“it burns fat,” “if you don’t want to be fat just do exercise”) and said that
they would emphasize these positive aspects in telling their friends about the
importance of doing at least 60 minutes of physical activity each day. Peer
pressure and wanting to be thinner were other factors that the youth reported
as motivators to be more physically active.
Specific strategies and suggestions for information dissemination
Media, television, and radio
All key informants and focus group participants cited the media, especially
Hmong-language radio and television stations, as the best channel for health information
dissemination. One parent elaborated: “The news is very important in the sense
that it has the ability to reach every family’s home. News provided through
radio announcements and on television. We always watch and listen to the news,
especially the Hmong-language radio stations.” Several local radio stations and
television channels broadcasting in Hmong language were cited, but cartoon
channels and the Public Broadcasting Service also received mention.
Most respondents felt that newspapers would not be as good a media channel
for information dissemination because there are few Hmong-language newspapers
and some Hmong Americans, especially older adults, cannot read English or Hmong.
One parent reminded the group:
You have to remember that many Hmong cannot read and write in their own
language. In addition, there will be a new group of Hmong coming to Fresno.
These Hmong might speak Thai. I think videos that are visual will be good. Radio
is also a good way to outreach. Radio talk show and radio public service
announcements are good. We have to outreach to the parents in a way that they
can understand.
Culturally appropriate educational materials
Most participants continually emphasized that any educational materials or
media campaigns should use a lot of visual and audio aids instead of written
materials because many Hmong Americans cannot read. Many parents expressed the
desire to attend more educational workshops or classes on nutrition and physical
activity. They wished that more classes were offered in the community because
they wanted to learn more about these topics. One parent mentioned:
We need educational classes in which the information can be translated to our
language. The use of visual aids is also important, such as having the food
samples and serving sizes. It’s also good to have both visual and audio material
available to us. It’s important to have someone that’s educated about the
nutrition and health field to teach us parents about eating and leading a healthy
lifestyle. Once we’re educated we can help our children to eat healthier. Health
education classes are important and the curriculum should address the specific
foods and their nutritional benefits.
In addition, parents suggested, “We can learn from visual aids like posters
and pamphlets, which should be taught and explained by an educated
professional.” Many also suggested having health videos. One parent emphasized,
“It’s important that the visual aids [be in] the Hmong language so that the
older folks can read it and understand it.” Other educational materials
suggested by the youths included magnets, book covers, stickers, key chains,
flyers, and posters. The youths preferred to have materials with lots of
pictures.
The most popular locations for educational workshops and outreach included
Asian grocery stores, nonprofit agencies, community-based social service
organizations, and health clinics with Hmong-speaking staff. Key informants and
parents also suggested holding educational outreach events at churches, New
Year’s festivals, health fairs, and flea markets.
When asked if they had ever seen the 5 A Day logo, most adults reported that
they had not. The key informants mentioned that they had seen the logo in
American supermarkets, but not in the smaller Asian grocery stores. Many of the
youth focus group respondents, on the other hand, did recognize the logo. They
indicated that they saw the logo on posters at school.
Health information messengers
The youth focus group participants most frequently mentioned teachers and
mothers as the people from whom they get information about eating healthfully and
exercising. Hmong-speaking doctors, community health workers, and community
leaders were frequently mentioned by the adult respondents as people from whom
they would like to receive educational health information. However, one parent
mentioned that the educators did not necessarily have to be Hmong, because “[t]he
ethnicity of the person distributing or teaching the information does not matter to us,
but it is important that the person be educated” in the area he or she is
teaching.
Trust is an important factor in selecting the messenger for health
information. One parent articulated this crucial point by saying:
I believe in doctors and educated individuals. One concern about the
distribution of information is trust. In the past, Hmong people have been given
inaccurate and wrong information about various things (such as life
insurance), and in some ways, they’ve lost trust in those educated individuals.
The best way to distribute information would be . . . agencies . . . that have cultivated a
trustworthy reputation among the Hmong community.
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Discussion
The traditional diet of first-generation Hmong Americans includes many fresh
vegetables and fruits, and the health benefits of physically active lifestyles
are valued and clearly perceived. Study participants articulated the
barriers they face to maintain these healthy lifestyles in the United States and
felt that overweight and ill health are predictable results. These
findings are consistent with other reports of Hmong cultural models of health.
For example, Culhane-Pera et al (17) describe Hmong perceptions of diabetes
causation in the terms of their sense that “we are out of balance here.”
Several themes emerged from the information we collected:
- The general concept of health and healthy lifestyles not only involves eating
healthful and nutritious foods and being physically active but also prominently
includes both individual mental and emotional health and family harmony.
- The concept of “balance” is fundamental to the concept of health: mental,
emotional, physical, interpersonal, and metaphysical.
- The idea of “freshness” is directly related to perceptions of healthful
foods. “Fresh” foods are not frozen, dried, canned, or preserved and are
pesticide- and hormone-free. In the case of meat and fish, recently slaughtered
or caught (same day if possible) items are deemed fresh.
- Physical activity and exercise are generally understood and believed to be
beneficial to the overall health of individuals through increasing energy and
strength, improving physical and mental well-being, promoting weight loss, and
preventing illness. Physical activity is perceived to include not only common
sports and games but also cooking, household chores, and yard work.
- There was a clear theme of parental responsibility for children’s lifestyles
and for modeling healthy behaviors.
The longer the Hmong live in the United States, the more their diet inevitably
will change to include more of the foods most commonly eaten in North America. Parents in our study clearly understood what would be healthier
choices, but lack of time, money, and knowledge about the value-maintaining
aspects of the traditional Hmong diet are all constraining factors. In terms of
physical activity, lack of time, money, and available safe spaces to be active
are the most important perceived barriers. The articulated need for better
education and better jobs to enable them to overcome these barriers is
clear.
In addition to individual and social constraints on making healthy choices
about diet and physical activity, changes in the environment — nutritional,
social, and environmental — are also necessary. Parents and youths
reported that the meals provided for children at school are neither tasty nor
healthy. While the demands of schoolwork and the availability of television,
video games, and computers compete with time devoted to physical activity,
safety concerns and limited access to parks and playgrounds are also preventing
children from getting enough daily physical activity.
There is a clear opportunity to help communities of first-generation
immigrants avoid developing increased burdens of nutrition-related chronic
disease through providing information and addressing structural and
environmental barriers to physical activity and optimal diets. Barriers to optimal diets and physical activity patterns for the
Hmong community are multilevel, and a socioecological framework is therefore
essential as a basis for designing effective interventions.
This study was a small qualitative exploration of current knowledge,
attitudes, and perceptions about vegetable and fruit consumption (and by
inference, diet in general) and physical activity among low-income,
first-generation Hmong Americans and their families in California. There were
several limitations to this study. The study
participants were volunteers. The results are not representative of the
populations from which the participants were drawn and cannot be generalized to
other Hmong Americans. Despite these limitations, this study is among the first
to document the knowledge, attitudes, and practices in
the Hmong community in California on these topics.
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Acknowledgments
We are grateful for the technical assistance of the following individuals and
organizations: Henry Lee, MPH; Tu-Uyen Nguyen, PhD, MPH; Pa Vue; Sandra Ho; Tammy Chin;
Stone Soup, Fresno, California; and the Hmong Women’s Heritage Association,
Sacramento, California. We also thank two anonymous reviewers for this journal
whose comments improved the article.
Supported by grant no. CA 86322 from the National Cancer Institute, through the Asian
American Network for Cancer Awareness, Research and Training (AANCART),
University of California, Davis; and by grant no. 04084704 and grant no. 304084705 from the
California Department of Health Services, Sacramento, California.
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Author Information
Corresponding Author: Gail G. Harrison, PhD, Senior Research Scientist, University
of California at Los Angeles
Center for Health Policy Research, 10960 Wilshire Blvd, Ste 1550, Los Angeles,
CA 90024. Telephone: 310-794-6096. E-mail: gailh@ucla.edu.
Author Affiliations: Loan Pham Kim, Marjorie Kagawa-Singer, UCLA School of
Public Health and UCLA Center for Health Policy Research, Los Angeles, California.
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