Health Beliefs and Practices of African Immigrants in Canada.

587486 research-article2015

CNRXXX10.1177/1054773815587486Clinical Nursing ResearchCooper Brathwaite and Lemonde

Article

Health Beliefs and Practices of African Immigrants in Canada

Clinical Nursing Research 1–20 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1054773815587486 cnr.sagepub.com

Angela Cooper Brathwaite, RN, MN, PhD1 and Manon Lemonde, RN, PhD1

Abstract A purposive sample of 14 immigrants living in Ontario, Canada, participated in two focus groups. The researchers used semi-structured interviews to collect data and five themes emerged from the data: beliefs about diabetes were centered on diverse factors, preserving culture through food preferences and preparation, cultural practices to stay healthy, cultural practices determined number of servings of fruit and vegetables per day, and engaging in physical activity to stay healthy. Findings indicated how health beliefs and cultural practices influenced behavior in preventing type 2 diabetes (T2D). Future research should focus on other high-risk minority groups (South Asian, Caribbean, and Latin American) to examine their health beliefs and cultural practices and use these finding to develop best practice guidelines, which should be incorporated into culturally tailored interventions. Keywords prevention, type 2 diabetes, health beliefs, health practices, African immigrants

Introduction Type 2 diabetes (T2D) is a multifaceted disease and major public health problem for adult Canadians with prevalence rate of 8.7% (Public Health Agency of Canada [PHAC)], 2011). Evidence shows that T2D disproportionally affects 1University

of Ontario Institute of Technology, Oshawa, Canada

Corresponding Author: Angela Cooper Brathwaite, Adjunct Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Oshawa, Ontario, Canada L1H 7K4. Email: [email protected]

Downloaded from cnr.sagepub.com at PENNSYLVANIA STATE UNIV on November 16, 2015

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Clinical Nursing Research

ethnic groups (South Asian, Latin Americans, Hispanics, Native People, and Africans) as compared with European descent (PHAC, 2011). Preventing T2D hinges on self-care behaviors, which are influenced by culturally driven health care behaviors and practices (De Jesus & Xiao, 2014; Hjelm, Berntorp, & Apelqvist, 2011), but there is a paucity of research studies, which explored health beliefs and cultural practices of minority groups in preventing T2D (Brown, Avis, & Hubbard, 2007; Brown et al., 2006; Hjelm et al., 2011; Ochieng, 2011). To date, there are no Canadian studies that examined the health beliefs and cultural practices in preventing T2D among African immigrants. Moreover, previous research studies which assessed health beliefs and health-related practices among African immigrants (Brown et al., 2007; Mbanya, Motala, Sobrigwi, Assah, & Enoru, 2010; Noakes, 2010; Ochieng, 2011) have focused on management of diabetes not prevention of it. Prevention of T2D is far more important than its treatment because diabetes and its complications (stroke, blindness, lower limb amputations, heart and renal diseases) are the leading cause of death in Canada (Canadian Diabetes Association [CDA], 2008) and contribute to personal, social, and economic burdens for the individual, family, and the health care system. The life span of individuals with T2D is shortened by 5 to 10 years (CDA, 2010; Newman, 2009). Thus, understanding health beliefs and cultural practices about T2D is essential to guide the design of culturally relevant interventions to prevent diabetes in high-risk minority groups (Smith, 2011).

Purpose of the Study The aim of the study was to explore health beliefs held by adult African immigrants regarding diabetes and their practices in preventing it. The term African refers to people and their offspring with African ancestral origin who migrated from sub-Saharan Africa to Canada (Agyemang, Addo, Bhopal, de Graft Aikins, & Stronks, 2006). This study addressed two research questions: Research Question 1: What are African immigrants’ health beliefs in preventing T2D? Research Question 2: What are African immigrants’ health-related practices in preventing T2D?

Review of the Literature Diabetes and Immigrants According to Statistics Canada (2011), people of African descent (Black People) were the third largest visible minority group in Canada, accounting for 783,800 or 15.5% of the visible minority population and 2.5% of the total population. Creatore et al. (2010) found that immigrants had a higher


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prevalence rate of diabetes than non-immigrants. After controlling for age, they found that the risk of T2D was elevated among immigrants in Ontario, Canada, for South Asian (odds ratio [OR] = 4.01 for men, 3.22 for women), Latin American and Caribbean (OR = 2.18 for men, 2.40 for women), and sub-Saharan Africa (OR = 2.3 for men, 1.83 for women). The high prevalence rate indicated an urgent need to develop culturally tailored interventions to promote uptake and prevent T2D among African immigrants. Culturally tailored interventions were more effective in preventing and managing T2D in ethnic minorities (Martyn-Nemeth, Vitale, & Cowger, 2010; Nam, Jansen, Stotts, Chesla, & Kroon, 2011; Vincent, McEwen, Hepworth, & Stump, 2014) than interventions with limited cultural content (Davachi, Flynn, & Edwards, 2005; Vincent et al., 2014).

Health Beliefs and Health-Related Practices of African People Several researchers (Brown et al., 2007; Noakes, 2010; Ochieng, 2011; Smith, 2011) explored the health beliefs and practices of African immigrants with T2D in England, Sweden, and the United States, to gain an understanding of how their health beliefs and practices influenced participants’ management of diabetes. Findings showed that participants held specific beliefs and practices about diabetes. Specifically, they believed in the treatment efficacy of herbal medicines, traditional foods, and folk medicines, which were integral to their wellness (Brown et al., 2007; Moodley & Oulanova, 2011). Participants also had strong religious beliefs such as faith healing, prayer, and fasting, and used traditional healers to reduce the severity of diabetes or healed it. Participants reported taking herbs like bitter melon, cinnamon bark, aloe vera, and mauby bark to treat T2D (Abascal & Yarnell, 2005; Brown et al., 2007; Hjelm & Mufunda, 2010; Smith, 2011) as well as some commented on eating fruit, vegetables, natural juices, and milk might prevent diabetes (Skelly et al., 2006). Lastly, most participants believed that lifestyle factors such as physical inactivity and eating high carbohydrates foods (sweets and starches) and stress caused diabetes (Brown et al., 2007; Ochieng, 2011). These findings showed that African immigrants had specific health beliefs and practices that influenced their health and management of T2D, which should be considered in development of interventions (Bhattacharya, 2012).

Engagement in Physical Activity (PA) and Healthy Eating of Ethnic Minorities Ethnicity is associated with behavioral risk factors such as physical inactivity and poor dietary habits (PHAC, 2011). Between 2008 and 2009, ethnic minorities (South Asian, Latin American, and Africans) had higher rates of


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physical inactivity and inadequate consumption of fruit and vegetables (ranging from 56% to 65.5%) as compared with Caucasians. Dogra, Meisner, and Ardern (2010) examined modes of PA among Whites, South Asian, South East Asian, Blacks, Latin American, West Asian, and Aboriginal people in Canada. They found that Whites participated in recreational activities more often than ethnic minorities and immigrants. After controlling for age, sex, basal metabolic index, income, and education, they found that the odds of engagement in PA varied such that all ethnic minorities were less likely to walk except Aboriginal persons (OR = 1.25; confidence interval [CI] [1.16, 1.34]). However, South Asian, Blacks, and Latin Americans were more likely to engage in conventional forms of exercise such as home-based PA, aerobics, and weight-resistant training as compared with Whites. The Canadian Institute for Health Information (2006) and Wolfenden et al. (2010) found that people were not including adequate fiber in their diet and were not eating recommended servings of fruit and vegetables. In the Canadian Institute for Health Information study on health determinants and health status indicators, rural residents exhibited less-healthy eating behaviors than urban residents. Similarly, in a case study on five Caribbean and five African immigrants residing in Ontario, Canada, Cooper Brathwaite (2012) found that participants consumed an average of three servings of fruit and vegetables per day, which were less than the 7 to 10 servings for both genders as recommended in Eating Well with Canada’s Food Guide (Health Canada, 2011). The lower performance of PA and eating habits of African immigrants increase their risk for diabetes. Understanding health beliefs and cultural practices of African immigrants is essential for designing effective interventions to prevention T2D.

Conceptual Framework Purnell’s (2002) model of cultural competence provided direction for the design and content of the interview guide, demographic data form, and research questions for this study. It also assisted in the identification of themes and interpretation of the findings. This model had three macro concepts (global society, community, and person) and 4 of the 12 micro concepts or domains (high-risk behaviors, nutrition, heritage, and health care practices) were relevant to this study. High-risk behaviors, nutrition, and health care practices were used to generate the interview guide and the heritage concept was used to develop questions to assess the demographic profile. Lastly, the model suggests that health care providers and researchers must understand the individual’s and family’s needs in the context of community to integrate cultural information into care and research (Cooper



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Brathwaite & Williams, 2004). According to Purnell, high-risk behavior included lack of PA whereas nutrition comprised of food choices and how food and substances were used during illness, health promotion, and wellness. On the other hand, health care practices focused on acute or preventive, traditional, and biomedical beliefs—the individual responsibility for health and self-medicating practices. The concepts of nutrition, health care practices, and PA were included in the interview guide. Alternatively, the demographic data form comprised of the heritage concept, which was related to country of origin, current residence, economics, and educational status.

Method Study Design This study used focus group interviews to collect data. Two investigators conducted in-depth interviews with participants to solicit information on their health beliefs and practices to prevent T2D. Focus groups allowed breadth of information and were effective in research with ethno-cultural communities examining diabetes (Brown et al., 2007) and were the most indepth exploration of beliefs (Fern, 2001).

Setting and Sample A purposive sample of 14 participants (6 residents and 8 community leaders) was adequate for this study, because no new codes or insights were produced from the last few interviews. In a systematic review of qualitative studies, Marshall, Cardon, Poddar, and Fontenot (2013) found wide variations in determining and justifying sample size and suggested that the maximum sample should be based on saturation, where additional interviews failed to produce substantive new insights. Participants were recruited from the community (community centers, churches, and doctors’ offices). Group interviews were held on the premises of three participating churches located in Durham Region, Ontario, Canada. About 30,055 Caribbean and African residents live in this region (Statistics Canada, 2006). Participants’ eligibility criteria were healthy males and females who had not received formal education on T2D prevention; 35 to 70 years of age; ability to speak, read, and understand English; self-reported of being immigrants to Canada for 5 or more years and self-identification as being from the African community. Exclusion criteria were individuals diagnosed with T2D, renal and heart diseases.


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Procedure for Data Collection The study received ethical approval from the university Research Ethics Board. Two methods were used to recruit participants such as advertising the study on Bulletin in the community and word of mouth by peers, family members, and colleagues to participate in the study. The research assistant (RA) arranged to meet interested persons at participating churches to describe the study and what were expected of them as participants, that is, to complete the demographic sheet and participate in the focus group interviews. Once participants agreed to participate in the study, the RA asked a few questions such as their length of residency in Canada, age of 35 years or older, and belonged to the African community to determine their eligibility for the study. After obtaining written consent, eligible participants were invited to the focus group sessions. At the beginning of the session, each participant completed the demographic data form, which took approximately 5 to 8 min to complete. Participants returned the questionnaire in a sealed envelope to the RA. The investigators facilitated the group sessions using open-ended questions and prompts as needed to elaborate on ideas/points. Data were recorded on flip charts to facilitate discussion within a session, audio-recorded, and transcribed. Field notes were made and kept immediately following the interviews to document non-verbal cues and the social environmental contexts of the interviews. Table 1 has a copy of the interview guide.

Data Analysis The focus group sessions (two) were transcribed and coded using an immersion/crystallization inductive approach (Borkan, 1999) to identify themes and Sandelowski and Leeman’s (2012) approach (using subject and predicate) to formulate themes. Whole transcripts were read several times to immerse the researchers in the data. The researchers independently reviewed the transcripts to develop themes from the data, compared accuracy of findings and interpretation of the data, answered questions, explored and resolved (through consensus) any inconsistencies in coding among them. Segments of data, an idea or word conveying an idea were identified before they were subsumed under a theme. A theme included configuration of segments of data. Five themes emerged from the data, based on participants’ responses and reached saturation. Because the interpretations of the data were grounded in participants’ personal beliefs, practices, and Purnell’s (2002) model of cultural competence and not the investigators’ personal biases and perspectives, the investigators readily came to an agreement on the findings (Lincoln & Guba, 1985).



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Table 1. Questions Used in Survey and Focus Groups. Health beliefs, values, and practices i. Do you have any specific beliefs that protect you from developing T2D? ii. What are your beliefs and values related to T2D? iii. Do you have any cultural practices that help you in selecting and purchasing food for yourself and family? iv. What topics do you want to learn about which will help in preventing the development of T2D? Engaging in physical activity i. What types of PA, exercise, or sports do you engage in to stay healthy? ii. During a regular week, how often do you engage in these PA/sports or exercises? iii. What is your preferred type of PA/sport/exercise? iv. Apart from PA, are there any cultural practices you engage in to stay healthy? Food preferences i. What types of foods do you like? ii. W hat are your preferred ways of preparing meals? For breakfast, lunch, and supper? iii. What is your preferred snack and how often do you have it per day? iv. How many servings of (fruits and vegetables) do you have per day? Note. T2D = type 2 diabetes, PA = physical activity.

Lastly, Lincoln and Guba’s trustworthiness criteria were used to evaluate the rigor of the findings. Confirmability of the data was achieved by members checking, where each participant verified the researchers’ transcripts and themes with supportive quotes, several weeks after the interviews. Members checking allowed participants to clarify any misconceptions, add information, confirm individual points, and ensure accuracy of data. Validity of the data was confirmed from feedback on the transcripts and themes by three pastors and three community leaders of the participating churches.

Results Sample Characteristics Fourteen participants completed the focus groups on exploring health beliefs and health-related practices of African immigrants in preventing T2D. The sample comprised of 11 women and 3 men. Eleven participants were from Nigeria and three from Ghana. Thirteen were employed and one unemployed. Their income was varied with the majority (10 participants) reporting income >US$60,000.00 per year. Eleven had undergraduate degrees and three had graduate degrees. Their mean age was 44.6 years with a mean length of


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residence in Canada of 15.4 years (range = 6-25 years). Seven of them had informal diabetic education and seven of them had no formal diabetic education. Five themes emerged from the data. They were as follows: beliefs about diabetes were centered on diverse factors, preserving culture through food preferences and preparation, cultural practices to stay healthy, cultural practices determined number of servings of fruit and vegetables per day, and engaging in PA to stay healthy. Each theme will be discussed with corresponding quotes in subsequent paragraphs.

Beliefs About Diabetes Were Centered on Diverse Factors Beliefs centered around five causes of T2D. They were lifestyle factors (eating habits and being physically inactive), stress related to adjustment to a new culture and work-related issues, genetic factor, obesity, and inadequate production of insulin. Participants also believed that eating high carbohydrates foods (high sugar and starches) will cause diabetes. The following quotes support this theme. Some participants said, I think we have very high expectations of ourselves. As Africans, we relocated from Africa across the world to Canada and there are many differences here. You are in a different environment and work so hard. Sometimes you forget to think about your body and do not exercise.

“You don’t have time to eat right because you work so hard and eat whatever you could find . . . that might be a major contributing factor to develop diabetes,” said another participant. Three participants believed that genetics and obesity/overweight may cause the disease. They said, “If diabetes runs in your family, it is quite likely you will get it. If your parents or close family member had it, you will get it.” Another participant said, “If your body is not producing enough insulin, you will get it.”

Preserving Culture Through Food Preferences and Preparation Most participants preferred the traditional African cuisine to other types of food. Their diet was high in carbohydrates (starches and sugar) with some protein, which were prepared using several methods. Participants also identified many different food types they enjoyed including carbohydrates, protein, vegetables, fruits, and herbs added to their foods, and different ways of



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preparing meals. Two sub-themes were subsumed under this theme: food preferences and cultural ways of preparing meals. The following quotes supported these sub-themes.

Food Preferences A participant said, “I selected food relevant to my culture. For example, rice was a staple food in my culture. Spinach was something we ate a lot of in my culture.” Another participant said, “I purchased food in relation to its nutritional values: ate less carbs but more greens; my Canadian side.” A third participant said, I liked all kinds of African foods although the food consists of carbohydrates (yams, cassava, tapioca, rice and corn meal). It was not an issue for me because of portion size. The issue was the ingredients you added to the food.

A fourth participant said, “I encouraged my children to eat African soup, which had a lot of grains, dry fish and shrimps. It was high in protein with lots of local spices.” However, another participant said, “Most people ate more carbohydrates than soup.” “I liked yams, potatoes, plantain, beans, rice, broccoli, carrots, peppers, tomatoes, strawberries, apples, pasta, bread, breadfruit and cassava,” said one participant. Another participant said, she liked rice, bread, yams, potatoes, breadfruit, and cassava. Another participant said, “I liked rice, cereal, burgers, fries, pizza, yams, potatoes, egg, cassava, breadfruit, salad, and chicken. I liked African foods.”

Cultural Ways of Preparing Meals Participants identified several ways of preparing meals such as frying, boiling, baking, broiling, roasting, steaming, stovetop, and microwave. The following quotes exemplified this sub-theme. “I used frying, boiling, baking, and broiling to prepare my food,” said one participant. Another participant said, “I enjoyed baking, stovetop, or broiling on occasion.” A third participant said, “I used boiling, frying, steaming, broiling, boiling, baking, and roasting when preparing meals.” A fourth participant said, “I used microwave, boil, bake, fry, and toast bread.” A fifth participant said, “I still fried my stew because I liked the taste. I just used less oil when I fried my stew.” “Eating great healthy food that was cooked at home was my preference,” said another participant while one participant added, “I purchased fresh food items to cook myself. Growing up, I was not exposed to frozen or microwave foods.”


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Cultural Practices to Stay Healthy Participants engaged in a variety of cultural practices to keep healthy, which included taking vitamins and herbs, using African spices, drinking healthy drinks like smoothies and herbal teas, eating fruit and vegetables, drinking water, prayer and faith in God. Most participants believed that prayer and faith in God were complementary measures to reduce stress and aided healing. The following quotes represented this theme. “I ate bitter melon and drank the water from it. It helped with lowering the blood sugar,” said one participant. Another participant said, “I took herbs, drink herbal teas such as lemon and ginger and ate at least two fruits daily.” Another participant said, “I cooked bitter melon and drank the water to stay healthy.” A fourth participant said, “I took healthy drinks like smoothies.” Another participant said, Locus beans, ginger, garlic, cumin, green onions, nutmeg, cloves, bay leaves, thyme, lemon grass, alligator pepper, chili, ground dried cray fish, bitter leaf and uziza leaf were used to enhance the flavor of the food and also had medicinal properties.

Similarly, another participant said, “Sal fruit was good for preventing diabetes and lowering cholesterol.” Many participants said, “Prayer and faith in God complemented biomedical and traditional African medicine to manage type 2 diabetes.”

Cultural Practices Determine Number of Servings of Fruit and Vegetables Per Day Participants described the number of servings of fruit and vegetables they ate per day. The following quotes represented their eating habits: Three participants said they were having two to three servings of fruit and vegetables per day. Similarly, two participants said they were having one to two servings of fruit and vegetables per day. Two participants were having four servings per day and one participant said she was having one serving of fruit and vegetables per day. Another participant said, “My goal for fruit and vegetables consumption was 7-8 servings per day but I ate a minimum of five per day on a good day. Up to seven servings per day were very challenging.”

Engaging in PA to Stay Healthy Participants described the frequency of physical activities they engaged in as well as the type of physical activities they enjoyed. They engaged in walking,



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running, swimming, jogging, playing soccer, and using elliptical machines to exercise. Several participants described walking, swimming, and dancing as their preferred type of exercise. However, male participants preferred soccer, running, tennis, and walking. The following quotes supported this theme and the reality of their experience with PA. One participant said, “I tried to exercise 30 min every day at work.” Another participant said, “I enjoyed walking and occasionally running.” A third participant said that he played soccer 1 to 2 hr per week and another participant said he enjoyed walking, running, and soccer. Two participants said they engaged in exercise three times per week for 30 min on the elliptical machines. Another participant said she exercised four times per week.

Discussion This qualitative study explored health beliefs held by adult African immigrants regarding diabetes and their practices for prevention of T2D. Five major themes emerged from the data: beliefs about diabetes were centered on diverse factors, preserving culture through foods preferences and preparation, cultural practices to stay healthy, cultural practices determined number of servings of fruit and vegetables per day, and engaging in PA to stay healthy. Consistent with previous studies (Brown et al., 2007; Ochieng, 2011; Smith 2011), African immigrants living in Canada held specific beliefs about the causes of diabetes such as lifestyle and genetic factors and obesity, which were held by the dominant culture, indicating that participants may have gained knowledge through informal education on T2D. Alternatively, the majority of people living in sub-Saharan Africa believed that overweight and obesity were associated with prestige, happiness, and good healthy living (Agyemang et al., 2009; Mbanya et al., 2010). They also believed that physical inactivity and obesity were not associated with diabetes, which was mainly caused by excessive sugar intake but can be prevented with bitter drinks (Mbanya et al., 2010). Afro-Caribbean immigrants and their second generation living in England believed that diabetes was caused by lifestyle factors such as obesity and lack of exercise, and family history. However, some of them felt that these factors were exacerbated by adapting from the Caribbean lifestyle to British lifestyle (Brown, Avis, & Hubbard, 2007). Similarly Smith (2011) also found that Afro-Caribbean women believed that diabetes was caused by hereditary and a malfunctioning pancreas. Participants of the present study adhered to their traditional African diet, which was high in carbohydrates (yams, cassava, tapioca, rice, and corn meal). They preferred the traditional African cuisine to other types of foods


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and were not willing to give it up. These findings were supported by Higginbottom (2000), who found that African immigrants held strong beliefs concerning their diet and believed that it was more nutritious than Western foods. Similarly, findings from Brown et al., (2007) and Ochieng revealed that participants in their studies adhered to the African cuisine. Contrary to these beliefs and food preferences, Hjelm and Mufunda (2010) suggested that the dietary habits of Africans should be modified to prevent T2D. Higginbottom explained that some cultural practices such as nutrition and diet were more resistant to change and acculturation than other practices. Thus, African immigrants should be educated on preventive measures such as portion sizes and healthy eating habits to inform and influence health-related behaviors, self-care measures, and care-seeking behaviors. These findings should serve as a prerequisite for public health practitioners to identify the health beliefs and practices of African immigrants to inform the development of effective and meaningful health promotion messages and interventions to prevent T2D (Higginbottom, 2000). Narratives from study participants revealed that they engaged in a variety of practices to keep healthy. These practices included taking vitamins and herbs, drinking smoothies, herbal teas, and water as well as using prayer and faith healing to prevent T2D. They took herbs like bitter melon to prevent the development of T2D. In Brown et al. (2007) and Ochieng’s (2011) studies, participants believed in the efficaciousness of traditional herbs in treating T2D. Fuangchan et al. (2011) and Nerukar, Lee, and Nerukar (2010) found that bitter melon (momordica charantia) helped to control blood glucose levels. Many of these complementary practices were similar in other cultures (Hjelm & Mufunda, 2010; Moodley & Oulanova, 2011). However, religious practices like prayer and faith healing were not unique to the African culture but were found in Caribbean, Asian, and African American cultures (Hjelm & Mufunda, 2010; Moodley & Oulanova, 2011; Noakes, 2010; Skelly et al., 2006). For example, Skelly et al. (2006) found older African American women believed in prayer and God’s intercession to prevent or cure diabetes. They described “curing” as God acting through both the changed behavior of individuals and the work of doctors and other health care professionals. Similarly, Noakes found that Africans and African Caribbean immigrants in England held the belief that God worked through self-care and health care practitioners in their treatment of diabetes. They believed that God provided doctors and nurses with knowledge and skills to help people. In addition, Moodley and Oulanova found that African and Caribbean immigrants in Canada relied on their traditions, which included faith healing and the utilization of plants and herbs to meet their health needs.



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In addition to cultural practices, participants reported how many servings of fruit and vegetables they consumed per day. The majority of participants reported having two to three servings of fruit and vegetables per day. These findings indicated that participants were not having the required number of servings of fruit and vegetables per day according to Eating Well With Canada Food Guidelines (Health Canada, 2011). Adult females and males should have 7 to 10 servings per day. Findings from this study were supported by previous studies (Canadian Institute for Health Information, 2006; PHAC, 2011), which found that minority groups (South Asian, Latin American, and people of African heritage) were consuming inadequate amounts of vegetables and fruit. Similarly, Cooper Brathwaite (2012) found that Caribbean and African immigrants were only having three servings of fruit and vegetables per day. Thus public health professionals should increase community awareness by providing health messages on the required servings of fruit and vegetables per day as well as show the link between unhealthy eating and chronic diseases such as diabetes, cancer, and renal and heart disease (CDA, 2008). Similarly, participants of this study had fewer hours of PA per week. The mean number of sessions was three per week. They engaged in PA such as walking, running, swimming, jogging, playing tennis and soccer, and using elliptical machines to exercise. These findings were contradictory to those of Dogra et al. (2010) who found that ethnic minorities including Blacks were less likely to engage in walking but preferred home-based PA, aerobics, and weight resistance exercises. According to the Canadian Physical Activity Guidelines (2014), adults 18 to 64 years should have 30 min of PA per day, 5 days per week. Lack of PA has resulted in chronic diseases such as T2D, heart disease, and cancer (CDA, 2010; Haskell, Lee, Pate, Powell, & Blair, 2007; Kruk, 2007; Nelson, Rejeski, Blair, Duncan, & Judge, 2007). Thus, there is an urgent need for health care professionals to educate African people about the benefits of PA, because diabetes is a serious complex life-long condition with severe consequences (heart and kidney diseases, stroke, blindness, lower extremity amputations, and mortality; CDA, 2008, 2010). Two new findings emerged from this study: cultural practices to stay healthy and preserving culture through food preferences and preparation. Although participants used a variety of herbs in their diets and engaged in physical activities to stay healthy, their preferred types of foods were high in carbohydrates. These findings were supported by Oniang’o, Mutuku, and Malaba (2003) who reported that the main dishes of people from Nigeria and Ghana were fufu (made of cassava), ugali (made with corn), and fura/fula da nono (a dish made with millet and spices). In addition, their snacks comprised of fried plantain, stewed sweet potatoes, stewed green bananas, and


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yam balls while their side dishes included peanut butter soup, green leaves with peanut sauce, and vegetable stew. These dishes and snacks were high in carbohydrates. People from Nigeria and Ghana use palm and peanut oil in cooking their dishes and snacks (Oniang’o et al., 2003). Consumption of foods high in carbohydrates, fats, and sugar lead to overweight and obesity, which are risk factors of T2D. Moreover, participants prepared their meals by boiling, broiling, roasting, steaming, frying, and baking. Most of these cooking methods were used in other cultures (Chinese, African American, and Afro-Caribbean). However, an African community leader reinforced the fact that boiling and grilling were popular but frying food was the main practice. For instance, at breakfast or snack, the individual African will have a cup of tea/coffee with deep fried African donuts or cupcakes, commonly known as maandazi, vitumbua, samosa, or chapatti. On the other hand, traditional Chinese cooking used more boiling and steaming and less frying of foods with high intake of fruit and vegetables (Li & Hsieh, 2004). However, Wang, Zhai, Du, and Popkin (2008) found a shift in dietary patterns and cooking methods of Chinese people living in China had changed from boiling and steaming to less healthy frying of foods. They also found that Chinese people of higher and lower socioeconomic status engaged in snacking and consuming fried foods. According to Liu et al. (2012), health care professionals should use dietary modification with ethnic minority groups by prioritizing substitution of diet rather than avoidance of culturally relevant foods. Therefore, health care providers should assist African immigrants in modifying their diet by replacing saturated fats like butter and palm oil with olive oil, substituting sugar (glucose, fructose, and sucrose) with low-calorie plant sweeteners such as xylitol, and reducing carbohydrates by replacing them with vegetables, based on the availability and wide selection of foods in Canada. Lastly, participants should reduce sugar content (glucose, fructose, and sucrose) in their diet to less than 10% of total energy intake per day to prevent obesity and diabetes (World Health Organization Guidelines, 2015). Moreover, adaptations to the African diet in conjunction with gender-specific PA should be incorporated into interventions to enhance healthy eating and PA behaviors, thereby preventing T2D among African immigrants.

Limitations Participants were from two different countries (Nigeria and Ghana). Differences between and within countries were not examined. This limitation was addressed by asking pastors and community leaders from Africa to confirm or refute findings by providing feedback on the themes and transcripts: transferability of findings was established (Lincoln & Guba, 1985).



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Participants’ socio-demographic factors may have influenced their responses. They had high incomes (>US$60,000.00 per year) and education levels (11 bachelor and 3 graduate degrees), which may have impacted their behaviors and cultural practices. Barnard, Wexler, DeWalt, and Berkowitz (2015) found that socioeconomic status, particularly income level, was associated with excess diabetes prevention. Although, both men and women were targeted during recruitment, yet fewer men participated in this study. Therefore some of the findings may not reflect the perspectives of all African men and may not be representative of average African immigrants.

Implications of Research The present study adds to the body of knowledge but does not fill the gap in research on health beliefs and health-related practices of African immigrants living in Canada but provides a baseline for better health promotion services for African people who are at high risk for T2D. Findings revealed that participants adhered to cultural practices such as taking vitamins, using spices and herbs in foods, and taking bitter melon to reduce their blood glucose, which were validated by other researchers (Brown et al., 2007; Ochieng, 2011; Smith, 2011). Although these findings may not be representative of all African immigrants, they provide insight into how health belief systems and cultural practices influence behavior. First, health care providers should be aware and sensitive to the diversity of health beliefs and practices among African immigrants for whom they provide care and services. If they understand Africans’ health beliefs and cultural practices in preventing T2D, they will be more effective in promoting health messages on preventing T2D. In addition, health care providers should not assume that health beliefs and practices are diminished following immigration to the host country. Walters, Phytian, and Anisef (2007) found minority groups such as Blacks, Asians, and South East Asians in Canada adhered to their cultural practices up to 55 years post residency in Canada. Similarly, Brown et al., (2007) found Caribbean immigrants in England with 41.3 years of residency there, still adhered to their health beliefs and cultural practices. This study has implications for research, education, and practice. Health care professionals should gain an understanding of the perspectives, traditions, values, practices, and family systems of culturally diverse populations for whom they provide care and services (Douglas et al., 2014). Thus, understanding the contexts where African immigrants make self-care decisions can be used to develop culturally relevant interventions to prevent T2D. They should also gain formal education and training to provide culturally congruent health care and services to immigrants. Future research studies should explore


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the health beliefs and cultural practices of other high-risk immigrants (South Asian, Latin American, and Caribbean). Findings from these studies should be used to develop best practice guidelines, which should be incorporated into culturally tailored interventions for them.

Summary This qualitative study revealed health beliefs, cultural practices, and healthrelated practices (PA and eating habits) of African immigrants living in Canada. Some of the findings were confirmed by previous research results from England, Sweden, and the United States. However, this study added new information to the body of knowledge in nursing: preserving culture through food preferences and preparation, and cultural practices to stay healthy. Findings also indicated the importance of understanding how African immigrants’ health beliefs and cultural practices influenced their behaviors, which should be incorporated into health promotion messages and culturally tailored interventions for African immigrants and other minority groups. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies Angela Cooper Brathwaite is an Adjunct Professor at the Faculty of Health Sciences, University of Ontario Institute of Technology in Oshawa, Ontario, Canada since 2011. She received her PhD in Nursing from the University of Toronto and a Master of Nursing from the University of Manitoba in Canada. Her research interests are in chronic diseases and cultural competence. Manon Lemonde is an Associate Professor at the Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT) in Oshawa since July 2003. She received her B.Sc.N., M.Sc.N and her PhD in biomedical sciences from the Université of Montréal. Her dissertation is titled: Quality of Life of Patients with Advanced Stages of Lung Cancer. Her research interests are in the areas of chronic diseases such as cancer and diabetes particularly focusing on quality of life, selfmanagement, and program evaluation.


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