Introduction

Immigrants and refugees often arrive to the United States (US) healthier than the general population [1], but with time, their cardiovascular risks approximate and often exceed those of the US average, including rising rates of obesity [2, 3], hyperlipidemia [4], hypertension [5], diabetes [6], and cardiovascular disease [7, 8]. In general populations, low levels of physical activity are associated with these adverse health outcomes [9–11], and promoting physical activity is a specific objective of Healthy People 2020 [12, 13]. Among immigrants and refugees to high income nations, physical activity is lower than the non-immigrant populations [14–17], and interventions aimed at increasing physical activity within 10 years of arrival may be particularly effective [2].

Reasons for sub-optimal physical activity in these populations are complex and poorly understood [18, 19]. A recent review identified cultural/religious factors, issues of social relationships, socioeconomic challenges, and environmental factors as barriers to physical activity among migrant groups to high income countries [20]. Cultural barriers are necessarily heterogeneous, but may include gender norms that make physical activity difficult for women [21], competing priorities for children (e.g., academics taking priority over sports) [22], and cultural norms that do not promote leisure-time physical activity [23]. Social support for physical activity is relatively low among immigrants and refugees and is a likely mechanism for sub-optimal physical activity [24–26]. For example, Latina women who know positive physical activity role models in their community are more likely to be physically active [27]. Socioeconomic barriers to physical activity include low literacy, low education and poverty [28]. Poverty in countries of origin may beget (initial) poverty in a new country, rendering these populations susceptible to the same economic barriers that contribute to the physical activity gap among racial/ethnic minorities in general [29]. Finally, environmental barriers, including low perceived safety, new climate/weather barriers, and relatively low access to recreational facilities [30, 31] may all contribute to sub-optimal physical activity among immigrants and refugees.

While studies to describe these factors have grown in recent years, there are gaps in knowledge, particularly among non-Hispanic populations [20]. Further, it is important to explore the heterogeneity of experience and norms that contribute to behaviors among immigrants and refugees to high income countries [32]. Development of physical activity interventions requires identification of commonalities between groups in order to be practically implemented, as well as identification of differences so that targeted interventions do not inadvertently exclude subset groups. To address these commonalities and differences, we present an in-depth qualitative study of barriers and facilitators to physical activity among adults and adolescents from heterogeneous immigrant and refugee groups in Minnesota through a community-based participatory research (CBPR) approach.

Methods

CBPR Approach and Partnership

CBPR is a means to collaboratively investigate health topics within a community, whereby community members and academics partner in an equitable relationship through all phases of the research process [33–35]. CBPR is an effective means of approaching health topics among immigrant and refugee populations [36–43].

Our CBPR partnership began in 2004 between Mayo Clinic and the Hawthorne Education Center, an adult education center that serves approximately 2,500 immigrant and refugee community members per year. Between 2005 and 2007, this partnership matured by formalizing operating norms, adapting CBPR principles, and adding many partners to form the Rochester Healthy Community Partnership (RHCP) with a mission to promote health and wellbeing among the Rochester community through CBPR, education, and civic engagement to achieve health for all (www.rochesterhealthy.org). Since 2007, RHCP has become productive and experienced at deploying data-driven programming with immigrant and refugee populations [36, 37, 44]. Community and academic partners conduct every phase of research together.

Setting

This study took place in Rochester, MN, a small metropolitan area in southeast Minnesota. According to 2007–2011 American Community Survey estimates, there are 14,172 foreign-born residents in the metro area. Asia (41.3 %), Latin America (20.2 %) and Africa (17.6 %) ranked highest for world region of birth. Focus groups were conducted to explore barriers and facilitators to physical activity and nutrition among adults and adolescents from diverse participating immigrant and refugee groups in Rochester, MN: Cambodian, Mexican, Somali, and Sudanese. This work is a precursor to a federally-funded, participatory intervention development project through RHCP—Healthy Immigrant Families: Working Together to Move More and to Eat Well. This paper reports on the results pertaining to physical activity only.

Participants

A stratified purposeful sample [45, 46] of immigrant and refugee families was invited by RHCP community partners to participate in focus groups on physical activity. Since the resulting intervention will be family-based, focus groups were conducted among adults and adolescents within each participating group (Somali, Mexican, Cambodian, Sudanese). There were separate focus groups with adult women, adult men, girls, and boys (ages 11–18 years), for a total of 16 focus groups over a 6 month period, July–December 2011. This study was approved by the Mayo Clinic Institutional Review Board.

Data Collection

We developed focus group guides jointly with RHCP community and academic partners based on literature review and consensus. Focus group questions assessed participants’ understanding of physical activity, soliciting description of how participants practice physical activity, barriers to being physically active, and recommendation of how they could be more physically active. Focus group guides were pilot-tested and refined before use [47].

We used social cognitive (learning) theory (SCT) as a framework to develop the focus group questions for the study [48]. This theory addresses the interplay of individual factors (e.g., self-efficacy to become physically active) and social environmental factors (e.g., social support) on behavior change. Low self-efficacy is an influential determinant of inactivity [49], and a socially supportive family environment is an important influence on physical activity in general populations [50, 51], among families with low socioeconomic position [51, 52], and among immigrants [26]. Other key constructs of SCT are outcome expectations or the consequences that result from enhanced physical activity (e.g., weight loss) [53, 54].

Focus groups (n = 16) were conducted at various community locations as arranged by community partners, including Hawthorne Education Center, a Mosque, a church, a temple, and a community center. Food was provided and participants received gift cards. Sessions lasted 90–120 min each and were conducted by moderators from participating community/language groups who underwent RHCP-sponsored focus group training [55] and have experience conducting focus groups in their communities. Note takers were present at each session. Linguistic concordance between moderator and participants was achieved in 13 of the 16 focus groups. For the three focus groups where there was discordance (Cambodian men and women; Mexican women), trained medical interpreters were utilized.

Focus groups sessions were digitally recorded, translated to English (if applicable), and transcribed. Translations were done by native-language speaking focus group moderators; translation integrity was verified by native-language speaking RHCP members. Focus group moderators reviewed transcripts for accuracy.

Data Analysis

Focus group transcripts, transcripts of post-focus group debriefings, and notes were used as materials for analysis. A qualitative analysis team composed of eight RHCP academic and community partners (AM, GA, GB, CF, JR, KT, SM, MW) read all transcripts before reducing the data for analysis. Transcripts were coded independently by two analysts using inductive analysis, resulting in code lists [46]. Discrepancies in code lists were examined, discussed and debated until consensus was reached between all analysts. The final code list was used for paired coding of all materials. Final themes and sub-themes were developed through a deliberative process among analysts. Analytic memos and data tables were created to inform presentation of results. Analysis was facilitated by NVIVO-9 software (QSR International).

Results

A total of 16 focus groups were conducted among 127 participants. Demographics of participants are shown in Table 1. There were three major themes, each containing a series of sub-themes identified as primary areas that participants described as barriers or facilitators to physical activity: knowledge and practice, barriers, and motivation.

Table 1 Demographics of study participants
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Knowledge and Practice

Physical activity was conceptualized and described in many different ways, including intentional exercise, sports, and chores around the house. In general, there was a thorough understanding of how physical activity was related to health. Further, participants conveyed many advantages of being physically active that extend beyond the biomedical (e.g., lower risk of diseases, longevity) to the psychosocial (e.g., enhanced self-confidence, happiness, and lower stress). This sense of wellbeing and self-efficacy was the most prevalent set of reported benefits to physical activity. Finally, participants stated that physical activity and healthy diet were intimately related and that one could not address one without the other. Sub-themes related to knowledge of physical activity and representative quotes are shown in Table 2.

Table 2 Knowledge and practice of physical activity among immigrants and refugees to Minnesota
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The ways in which participants conceptualized and described their knowledge and practice of physical activity was similar between groups. However, there were gender differences; namely, women were more likely to associate physical activity with housework and recreational activities, while men talked about physical labor at work and sports. Similarly, there were generational differences; adults were more likely to equate physical activity with work and recreational activities, whereas adolescents were more likely to associate physical activity with exercise and sports. Adolescent girls talked about social activities like going for walks with friends. Adults often contrasted their activities in the US with activities in their countries of origin. For example, Mexican men spoke about playing organized sports more in Mexico. Women noted more physical labor in their home country in contrast to less physical labor and more indoor work in the US. Adult participants from Cambodian and Somali groups described sweat as an indicator for physical activity (i.e., without sweat, they felt as if they were not physically active).

Barriers

Overall, almost all participants described more barriers to physical activity in the US than in their home countries. Those who had come to the US as adolescents or adults also underlined that they felt as if they still were in a process of transition learning how to overcome the barriers to being physically active in their new country of residence. Participants reported spending more time outdoors in their home countries for both work and social activities than they do in the US and that time spent outdoors tended to result in more physical activity than time spent indoors. Similarly, participants stated that work inside and outside the home required less physical activity in the US than it did in their home countries. Additional barriers described included lack of time, cold weather, lack of transportation to exercise facilities, lack of motivation or interest in formal exercise, competing time spent with electronics, and a lack of places to gather as groups for physical activities that were affordable and linguistically welcoming. Some adult participants stated that there seemed to be more time for physical activity in their country of origin. They explained that in the US, they worked all day—primarily indoors—and they were too tired after work for physical activity. In their countries of origin, they may have walked or biked to work and still had energy for a sport after work.

Importantly, taking the “first step” towards engaging in physical activity for individuals and families in a new country was described as a major hurdle for many of the participants. For example, joining an exercise facility or exploring its programming was seen as insurmountable for many participants. This lack of familiarity with how to effectively and efficiently be physically active in this country was viewed as a fundamental barrier for all groups. However, participants were hopeful that, once these initial hurdles were cleared, they could be more physically active. While this is hypothetical, it supports the difficulties participants described in taking the first steps towards physical activity. Sub-themes related to physical activity barriers and representative quotes are shown in Table 3.

Table 3 Barriers to physical activity among immigrants and refugees to Minnesota
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While our results indicate that immigrants and refugees share common ways to conceptualize barriers to physical activity, we found important generational and gender differences. First, taking the “first step” towards engaging in physical activity (e.g., familiarity with gyms and other facilities, familiarity with US sports, etc.) was not viewed as a barrier for adolescent participants like it was for adult participants. Some adult participants cited a sense of frustration in their perceived inability to optimally impact physical activity in their families due (in part) to these generational differences in familiarity. Second, Somali women said wearing religious and culturally appropriate clothing was sometimes a barrier to comfortable physical activity. Finally, adult and adolescent female participants perceived less flexibility in their schedules to be physically active than men due to their obligations towards children and the household.

Motivation

“Togetherness” and social support from diverse sources were viewed as important motivators for healthy living by all participants. “Being together” was a main theme described as motivating physical activity. First, pursuing physical activity together as a family was described as an empowering experience for parents who saw it as their task to serve as role models for their children to help them live healthier lives. Second, adolescents described physical activity as a rare opportunity to be together with their busy families for something that was seen as important for everybody. Third, adult and adolescent participants acknowledged that they were more likely to maintain physical activity if it was with family or friends. In this sense, togetherness was viewed as an important factor to motivate physical activity through shared accountability. Finally, participants described a sense of community arising from being physically active together (with family or friends) as a positive experience, potentially bearing a synergistic effect on their larger communities.

As discussed above, the concept of “togetherness” was closely tied to the idea of role models. Participants stated that they were motivated by positive role models for physical activity among people from their community. Participants said they were more likely to engage in physical activity if they saw and knew people from their communities who have been successful in striking the balance between life’s obligations and being physically active.

Participants related a balance between “togetherness” and their “individual responsibility”, whereby the individual was described as ultimately responsible for her/his own motivation and health behaviors. It was generally acknowledged that a person has to make the decision to be physically active and stay committed to it. While participants highlighted a social responsibility for encouraging others to engage in more physical activity (e.g. within a family or community), the individual was viewed as main actor and initiator to becoming physically active. In addition, many participants said that these activities were only sustained if they were able to directly link their physical activity to a tangible observed benefit (e.g., weight loss). Sub-themes related to motivation and representative quotes are shown in Table 4. These themes were very similar across cultures, gender, and generations.

Table 4 Motivations to be physically active among immigrants and refugees to Minnesota
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Discussion

In this paper, we described how Cambodian, Somali, Mexican, and Sudanese immigrants and refugees conceptualized physical activity. The similarities in findings between ethnic groups suggest that cultural norms are not the dominant factors shaping physical activity behaviors among immigrants and refugees to developed countries. Instead, these behaviors may reflect, in part, the social, economic, and environmental factors that influence physical activity of all persons living in the US [56]. Indeed, previous studies suggest that socioeconomic position may be the strongest predictor of physical activity among immigrants to the US [57]. Further, we identified key barriers and motivators to being physically active that are unique to immigrants and refugees. While our participants were culturally heterogeneous, they share the experience of immigration to the US with limited English language proficiency and low socioeconomic position. These shared experiences shape their physical activity behaviors in a more significant manner than cultural norms and experiences. Since interventions to promote physical activity in a new country are most likely to be successful prior to a decline in healthy behaviors [2] (i.e., as soon as feasible after immigration), our findings have important implications for intervention development.

Participants had varied understandings of what physical activity meant to them but all agreed that there were benefits to being physically active. This implies that future interventions to promote physical activity among immigrants and refugees should not focus only on education. Instead, interventions should combine education with efforts to strengthen the individual and community-based facilitators to physical activity while mitigating the complex personal, societal, and environmental barriers. Similarly, recent reviews suggest that multi-component interventions (which recognize the sociocultural complexity and extend beyond education) are needed to influence physical activity among immigrants and refugees [20, 58]. For example, our findings of gender differences in practices and barriers suggest that interventions should be intentional about addressing gender-specific migration experiences as it relates to physical activity. This sort of intentional intervention work was demonstrated by a successful gender-exclusive swim program for Somali women in Seattle, WA, USA [59]. Finally, our finding that perceptions of physical activity are closely tied with perceptions of healthy eating suggests that these multi-component interventions should include a dietary component.

Consistent with previous literature, we found several economic (e.g., cost, transportation, competing priorities) and environmental (e.g., weather) barriers to being physically active [20]. However, a consistent barrier in all adult groups was the lack of familiarity with how to be physically active in a new country of residence. Taking this “first step” towards being physically active seems challenging for many study participants. Therefore, intervention work should assure broad immigrant participation to avoid sociolinguistic isolation and embarrassment while guiding them through a wide range of physical activity and exercise opportunities. It is promising that participants were confident that once this “first step” of being physically active in a new country is achieved, then these behaviors could be sustained. Further, our data that describes “togetherness” as a motivator to being physically active relates to existing literature that argue that interventions to promote physical activity should acknowledge the role of social support from friends and families [50, 52, 60].

This study has limitations. First, while the study includes heterogeneous immigrant and refugee groups, it was conducted in a single community with implications for generalizability to other immigrant and refugee communities or ethnic groups. Further, though focus groups were age, gender, and group-stratified, recruitment was based on a convenience sample of participants. Finally, though this was a large study for qualitative inquiry, saturation of themes from each subset group (e.g., adolescent Cambodian females) was insufficient to draw conclusions about each of these subsets. This limitation also extends to the fact that our study included both immigrant and refugee participants. Results of a previous study show that the risk of cardiovascular death may be higher for refugees to high income nations than for immigrants [61]. The role of physical activity in this discrepancy is unclear. Nevertheless, by including both immigrants and refugees in focus groups, we may have missed the opportunity to explore nuances of the refugee experience that is different from the immigrant experience of physical activity in a new country. Similarly, focus groups were not stratified by duration of residence in the US. This precludes an analysis of perceptions according to this variable.

Conclusions

We found similarities in barriers and facilitators to physical activity between heterogeneous immigrant and refugee groups, suggesting that the shared experiences of immigration and related social, economic, and linguistic factors have a significant influence on how physical activity is understood, conceptualized and practiced. While the benefits of physical activity were widely acknowledged, lack of familiarity and comfort with taking the first steps towards being physically active were identified as the most significant barriers to physical activity. Accordingly, participants felt motivated by social support from family, friends, and communities to be physically active. These findings may inform intervention work among immigrants and refugees to the US to promote physical activity.