A Survey of Health of First and 1.5 Generation Immigrant and Refugee Students in an all Immigrant School

Jennifer Bromberg

Senior Honors Thesis Dr. Kristen Lucken, Advisor

International and Global Studies, Brandeis University

May 5, 2015

1 Abstract

This mixed-methods study was completed to explore how immigrants’ integration correlates to health outcomes. In this paper integration was defined by the interaction with American-born people with American-born parents, and the health outcome measured was Body Mass Index (BMI). The hypothesis was that the integrated students would have a higher BMI, based on previous research that says that the longer an immigrant is in the United States, the higher their BMI is. These data were collected in a middle/high school where all of the students are recent immigrants and refugees. 80 students were surveyed and 6 students were interviewed. The study found that the integrated group of students (n=33) has a mean BMI 2.29 lower than the mean BMI for non-integrated students (n=47) when controlling for demographic variables. This could potentially be due to factors relating to socioeconomic status or because the students are recent immigrants, so they have not been living in the United States for a long enough time to see a substantial change in BMI. Future studies should look at new ways of defining integration, and should also emphasize more research in the beginning stages of integration in the first ten years of an immigrant’s life in the United States.

2 Table of Contents

Abstract

Table of Contents

Definitions

Chapter I: Introduction to Study

Introduction

Literature Review

a. Overweight/Obesity in Immigrant and Refugee Populations

b. Social Determinants of Health in Immigrant and Refugee Populations

c. Barriers to Health in Immigrant and Refugee Populations

d. Education in Immigrant and Refugee Populations

Study Design and Methodology

Chapter II: Context of the Study

a. Health in Columbus and Ohio

b. Immigrants and Refugees in Columbus and Ohio

i. Somali Refugees

ii. Bhutanese/Nepali Refugees

c. Columbus Global Academy

Chapter III: Findings

a. Results from surveys (quantitative data)

i. Demographic data

ii. Health-related data

iii. Combined demographic and health-related data regression

3 b. Results from interviews (qualitative data)

i. Interview 1

ii. Interview 2

iii. Interview 3

iv. Interview 4

Chapter IV: Discussion

a. Demographics

i. Defining country of origin

ii. Religion

iii. Age

iv. Integration (interaction with American-born people with American-born

parents)

b. Health-related data

i. BMI

ii. Meals eaten outside school

iii. School lunches

iv. Fruits and vegetables

v. Physical activity

vi. Hours spent watching TV and playing videogames

c. Regression analysis

Comparison to state statistics

a. BMI

b. Physical activity

4 c. Fruit and vegetable consumption

Limitations

a. Sample size

b. Lack of measurement for socioeconomic status

c. Too short of length of residency

d. Language barrier

Future of the school

Chapter V: Conclusion

Bibliography

Appendixes

A. Student Health Survey

B. Student Interview Questions

5 Definitions

Body Mass Index (BMI): a value used to measure overweight and obesity in adults using height and weight; for most people this value correlates to their amount of body fat (Defining Overweight and Obesity, 2012).

Immigrant Generations:

a. First Generation Immigrant: a person who was born outside of the United States, Puerto Rico, or other United States territories where neither parent is an American citizen; this term may be used interchangeably with foreign born (Pew Research Center, 2013).

b. 1.5 generation Immigrant: a person who arrives into the United States before the age of 10 (Ellis & Goodwin-White, 2006).

c. Second Generation Immigrant: a person who is born in the United States with at least one first-generation immigrant parent (Pew Research Center, 2013).

d. Third and Higher Generation Immigrant: a person who is born in the United States, including Puerto Rico or other United States territories whose both parents were both also born in the United States, including Puerto Rico or other United States territories (Pew Research Center, 2013).

Obese: In adults, being obese is categorized as having a BMI over 30 (Defining Overweight and Obesity, 2012).

Overweight: In adults, being overweight is categorized as having a BMI over 25 (Defining Overweight and Obesity, 2012).

Refugee: a person who is owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it (United Nations High Commissioner for Refugees).

6 Chapter I: Introduction to Study

Introduction

The United States has a rich history of being the end destination for many immigrants and their families. In 2012, approximately 41 million immigrants (naturalized, legal permanent residents, refugees and asylees, international students, and undocumented immigrants) resided in the United States, which accounts for about 20 percent of all international migrants in the world (Nwosu, Batalova & Auclair, 2014). Additionally, in

2012, the number of refugees authorized for admission was 76,000 (Burt & Batalova,

2014). An estimated 11.5 million undocumented immigrants resided in the United States in

2011 (Nwosu, Batalova & Auclair, 2014). Immigrants and refugees come to a new culture and health system, where the environment may differ distinctly from their homeland. This often leads to change in their lifestyle and eating habits that negatively impact various aspects of their health.

One area where this negative impact is particularly evident is in the weight increase among newcomers after living in the United States for a particular length of time. Studies have found that the immigrant population tends to enter the United States at a lower average weight than the average American. However after about a decade of living in the

United States, this weight advantage dissipates and the immigrant weight patterns converge with those of third-generation Americans (Cunningham, Ruben, & Narayan,

2008). The digression in health status is often attributed to acculturation and conforming to some of the cultural norms and habits in the United States that affect health, such as drinking, smoking and developing an unhealthy diet (Viruell-Fuentes, Miranda &

Abdulrahim, 2012). Being overweight or obese can lead to an increased risk for many

7 health complications, such as coronary heart disease, high blood pressure, stroke, type two diabetes, abnormal blood fats, cancer, osteoarthritis, sleep apnea, obesity hypoventilation syndrome, reproductive problems and gallstones (National Heart, Lung, and Blood

Institute, 2012).

These health-related issues are of upmost importance where immigrant and refugee populations are concerned because they are one of many minority groups that face additional barriers to accessing and receiving high quality healthcare. Additionally, several social determinants of health such as race, level of education, socioeconomic status and religion may put immigrants at a disadvantage to living a healthy lifestyle and achieving better health outcomes than they currently have. These specifically will be further discussed in the literature review of the paper.

The primary goal of this thesis is to fill in some gaps in the research regarding immigrant health outcomes after life in the United States. To begin with, this study will explore the overall health of Columbus Global Academy (CGA) students to determine if their health status coincides with outcomes of immigrants and refugees who have regular contact with Americans. What happens when the influence of third-generation Americans is removed from immigrant social life? Will CGA student health outcomes track with other immigrants that conform to average American health outcomes after a particular length of time? At the CGA, all of the students are English as a Second Language (ESL) students.1 This school provides a unique environment that is devoid of ‘mainstream’ American peers. This

1 It is important to note that a few may not fit the specific definition of a first-generation immigrant if they are from Puerto Rico or a different United States territory where English is not spoken, but for the purpose of this paper all of the students will be considered to be first-generation immigrants.

8 paper will explore what the effects of an ‘all immigrant’ environment might be on the health and health practices of the CGA students.

This paper will use interaction with American-born people with American parents as a proxy for integration. By doing this, there is a new variable used in place of length of residency, which is how immigrant health status is usually measured in the literature.

Additionally, this paper has a unique view on integration and health because it studies students in the midst of their integration process rather than studying the health of immigrants after they have been in the United States for a decent amount of time. This study offers a new way of looking at how immigrants integrate into American culture and society made possible by the ESL focus in the school.

Literature Review a. Overweight/Obesity in Immigrant and Refugee Populations

Upon arrival to the United States, immigrants generally exhibit lower BMIs than the average BMI for American-born population, but after approximately ten years of living in the United States, they tend to fall into a BMI range similar to that of third-generation

Americans (Cunningham et al., 2007). A longer period of residence in the United States leads to greater assimilation into American culture, a time during which the average BMI for second and third generation immigrants increases, and some immigrant race groups, such as immigrant Hispanic women, even surpass the average native Hispanic BMI (Antecol

& Bedard, 2006).

Many studies show differences among immigrant groups when measuring BMI on arrival in the country compared to BMI after longer periods of residence in the United

States. Conversely, for foreign-born Asians residing in the United States, a higher level of

9 English language use and longer length of residency were not linked to increased obesity or

BMI (Nguyen et al., 2014). Additionally, Latino groups are usually found to have a higher overall average BMI than white Americans, but because this is such a large and diverse group, these statistics are usually generalized and ignore many factors that influence acculturation and obesity (Sussner et al., 2008). Fewer studies have looked at refugee groups and assimilation through health practices. However, a significant study of Eastern

Liberian refugees found a substantial increase in obesity with their consumption of many different food items upon moving to the United States, including soda, fruit, vegetables and milk (Patil et al., 2008). b. Social Determinants of Health in Immigrant and Refugee Populations

Social determinants of health are the factors that shape health beyond medical care

(Braverman & Gottleib, 2014). These determinants are formed by the environment in which people live, and are shaped by influences from the economy, social policies and the political climate (World Health Organization). Many recent studies have shown that, while medical care is important for keeping a healthy society, outside social and environmental factors also play major roles in an individual’s overall health (Braverman & Gottleib, 2014).

In adolescents specifically, social determinants are important because they affect adolescent health and help form future health habits (Viner, R.M. et al., 2012). One of the most important determinants that forms more positive future health habits of an adolescent is having a safe and supportive school (Viner, R.M. et al., 2012).

Immigrants have a unique set of social determinants of health because they move from one environment to another and many experience a drastic shift in the settings around them. One major social determinant that many immigrants face is that they are

10 racial and ethnic minorities in the United States, which puts them at a socioeconomic disadvantage (House, J. S., & Williams, D. R., 2000). Ethnic origin also strongly affects adolescent health in high-income countries, especially relating to things like mental health, obesity, substance abuse, and sexual health and teenage pregnancy (Viner, R.M. et al.,

2012). Another social determinant in immigrant groups affecting health is that immigrants are more likely to have low family income and maternal education, and they tend to live in places that have a high density of immigrants and lower levels of English being spoken

(Gorden-Larsen, P. et al., 2003). These determinants lead to overall poorer health outcomes and accessibility to health care in the United States. c. Barriers to Health Care in Immigrant and Refugee Populations

There are some major barriers to health care that immigrants in the United States face. The first barrier is that undocumented immigrants do not have access to Medicaid or the Children’s Health Insurance Program (CHIP), because in order to be covered under the

ACA, you must be an American citizen or be lawfully present in the United States (Patient

Protection and Affordable Care Act, 2010). But lawfully present immigrants often face a five-year waiting period for Medicaid or CHIP, even if they are eligible (Kaiser Commission on Key Facts, 2013). Additionally, 23 percent of non-elderly naturalized citizens are uninsured and 46 percent of non-elderly non-citizens are uninsured in the United States

(Kaiser Commission on Key Facts, 2013). 16 percent of children with non-citizen parents are uninsured and 29 percent of non-citizen children with non-citizen parents are uninsured (Kaiser Commission on Key Facts, 2013).

Another key barrier to health care that immigrants face is language. Approximately

18 percent of people in the United States speak a language other than English in their

11 homes (Flores, G. et al., 2005). Additionally, children of parents with limited English proficiency compared to children with English proficient parents are more likely to face health complications and are less likely to access health care (Flores, G. et al., 2005).

Patients who face language barriers in general are less likely to have a usual source of medical care, less likely to engage in preventative medical care, and are less likely to adhere to prescribed medications as instructed (Flores, G., 2006). Language barriers in medical settings can also lead to discrimination against the patients (Flores, G., 2006). d. Education in Immigrant and Refugee Populations

Different immigrant groups tend to put different emphases on education after coming to the United States. For example, Chinese, Korean, Vietnamese and Cuban students had higher academic performances and higher graduation rates than students who immigrated from Mexico and Nicaragua (Portes, A., & Rumbaut, R. G., 2006). Beyond the country from which the students immigrate, there are also many other factors that influence the educational trajectory of a student. These include living in poverty, being in segregated neighborhoods and schools, being undocumented, participating in seasonal migration, English-language acquisition difficulties, and access to higher education after graduating high school (Suarez-Orozco, C. & Suarez-Orozco, M., 2009). New immigrants face high levels of stress just from moving to a new environment, which places them at a higher risk of performing poorly in school (Suarez-Orozco, C., 2011).

12 Study Design and Methodology

This is a mixed-method study with a quantitative and a qualitative section. The data was collected over a two-week period. Eighty students were surveyed and four more in- depth interviews were completed. The interviews are intended to support and illuminate the survey results by giving qualitative data to compare with the quantitative data and analysis. In order to recruit students into the study, a brief announcement was made at the beginning of classes by teachers who volunteered their assistance. The teachers were selected to have their students participate in the study if they were interested and had time. If students were under 18 years of age, they received a parental consent form to bring home for their parents to sign. After they returned it to their teacher, they were given an assent form for minors, which was reviewed before the interview or survey was conducted.

Students over 18 years of age were responsible for signing their own consent forms just before the survey was conducted. The students interviewed were selected from the group of survey students based on their English language proficiency. Of the four interviews completed, two were done with pairs of students, while the other two were completed with individual students. The survey asked basic demographic questions along with questions on health and nutritional habits. In addition to the survey questions, the height and weight of students was taken on site in order to avoid any inconsistencies in data collection or confusion between units.

In order to analyze and review the data, the interviews were transcribed and examined, while the quantitative data was uploaded into STATA. The demographic and health data in STATA was analyzed using bivariate regression analysis to find out the means and P values. Then, multivariate regression analysis was used to analyze the

13 correlation between BMI and integration through three different regressions, with BMI as the dependent variable, integration as the independent variable, and the demographic and health-related variables as possible confounding factors.

14 Chapter II: Context of Study a. Health in Columbus, Ohio

Columbus has a population of 822,553, and Ohio has a population of 11,570,808

(United States Census Bureau, 2014). In the state of Ohio, 35.8 percent of adults are overweight and 29.2 percent of adults are obese (National Center for Chronic Disease

Prevention and Health Promotion, 2012). Additionally, 27.4 percent of adolescents are overweight and 12.4 percent are obese (National Center for Chronic Disease Prevention and Health Promotion, 2012). Delving into these numbers, the prevalence of self-reported obesity among non-Hispanic white adults in Ohio is 29.4 percent, while that statistic for non-Hispanic black adults was 36 percent and 30.9 percent for Hispanic adults (Prevalence of Self-Reported Obesity Among U.S. Adults, by Race/Ethnicity and State, 2011-2013). b. Immigrants and refugees in the city where the school is located

In Ohio, 4.1 percent of the population was foreign born in 2010, compared to 2.4 percent in 1990, amounting to an 81 percent increase between 1990 and 2010 in the foreign born population (The Chicago Council on Global Affairs, 2012). Since 2003, 10,321 refugees have been resettled into Franklin county, which is the county in which Columbus is located. (Columbus Welcomes the World). Notably, 54 percent of these refugees are from

Somalia, 17 percent are from Bhutan and 11 percent are from Iraq (Columbus Welcomes the World). Not surprisingly, Somali and Bhutanese refugees are the two largest immigrant populations at CGA.

In Franklin county in 2007, there was an estimated foreign-born population of

96,589, amounting to 8.6 percent of the total county population (Columbus and Franklin

County Consolidated Plan 2010-2014, 2010). This was accountable for the almost one in

15 ten students in the school district that includes CGA having a native language other than

English, with Spanish speakers as the largest percentage of this population, followed by

Somali speakers (Columbus and Franklin County Consolidated Plan 2010-2014, 2010). i. Somali refugees

Columbus is host to the second highest Somali population in the United States, behind only Minneapolis, Minnesota (Counting the Franklin County Somali Population,

2009). As of 2014, over 45,000 Somali refugees were reported to be living in Ohio, with about 14,000 residing in Columbus in 2007, and these numbers have continued to grow since (Somali Community Association of Ohio, 2005; Counting the Franklin County Somali

Population, 2009). Of the 45,000 Somali refugees living in Ohio, only 25 percent speak

English well enough to get a job (Somali Community Association of Ohio, 2005).

The most recent wave of Somali refugees began leaving the country in 1990 due to

Somalia’s continued anarchy, clan warfare and border disputes, which led to mass violence such as torture and rape (Promoting Cultural Sensitivity, 2008). Because of such traumas that many of the refugees experience, they often come to the United States with mental health issues, including post-traumatic stress anxiety, depression, and somatization

(Promoting Cultural Sensitivity, 2008). Additionally, once coming to the United States, many Somalis experience social isolation, feeling a lack of control over life and social degradation (Promoting Cultural Sensitivity, 2008).

Some additional health concerns to take into consideration when looking at Somali refugees and immigrants are tuberculosis (TB) and female genital modification. Because of the political and social situation in Somalia, TB is easily spread throughout the population.

16 This is because people live close together in crowded areas, and there is poor recognition and treatment of TB symptoms (Promoting Cultural Sensitivity, 2008).

There are also some important social and cultural characteristics of the Somali immigrant/refugee population that may play a role in their health practices before and after coming to the United States. To begin, Somalia is a largely religious country where

99.9 percent of the population practices Islam (Somali Community Association of Ohio).

This means that many of them have dietary restrictions and some of the women dress according to their culture, which includes wearing ankle-length skirts and covering their hair. Additionally, the average family size is 7-8 people (Somali Community Association of

Ohio). This may lead to cramped living spaces for the families, and also may mean that the families have less money to spend on their children for things like clothes and food. ii. Bhutanese/Nepali refugees

Bhutanese refugees are the largest growing refugee group in the central Ohio area, and are currently 17 percent of the total refugee population in Columbus (Columbus

Welcomes the World). An ethnic minority in Bhutan faced violence and persecution from the Bhutanese government, and fled to refugee camps in eastern Nepal in the early 1990’s

(The Kenan Institute for Ethics, 2013). In the camps, life for the refugees is difficult. The refugees build and repair the huts that they live in, and the refugees that have skills work doing things like sewing, metalwork, and carpentry without getting paid (The Kenan

Institute for Ethics, 2013). Moving from these conditions to a developed country can be difficult for many of the immigrants. Because the refugees from Nepal are a recent group to

Columbus, there is little data published about them with regard to the city.

17 Religiously, about 60 percent of the refugees are Hindu, 27 percent are Buddhist, 10 percent are an indigenous religion, and the remaining 3 percent are Christian (Bhutanese

Refugee Health Profile, 2014). Additionally, the refugees follow a caste system that is similar to the one in place in Nepal. In the camps there are 64 castes, groups, and parties

(Bhutanese Refugee Health Profile). Anemia and malnutrition are health issues faced in the refugee camps (Bhutanese Refugee Health Profile). c. Columbus Global Academy

CGA is part of the Columbus City School District. In 2013-2014 in the district, there were 53,327 students enrolled in the schools (Good, J.D., 2015). Overall in the district,

56.05 percent of students were African American, 26 percent were Caucasian, 8.90 percent were Hispanic, 5.50 percent were multi-racial, 3.03 percent were Asian, and 0.2 percent were American Indian/Native Alaskan (Good, J.D., 2015). Additionally, 13.45 percent of students in the district had limited English proficiency and 79 percent of students were economically disadvantaged.

In order to attend the CGA, the student must fit into the following categories: students who are beginner ESL proficiency level between the ages of 11 and 21; students who are recent arrivals to the United States; students who come from a refugee camp or country torn apart by war or natural disaster; students with little or no formal education; students with little or no literacy in their native language; and/or students who have high school transcripts from their home countries who are over 18 but are able to graduate before their 22 birthday (Columbus Global Academy). Other factors that enrollment is based on include that the student has been in the district’s school system for fewer than two years (it is possible to go from a district middle school to CGA) and the students is

18 recommended by the Assessment Center or their previous school (ESL Programs).

Enrollment into CGA must be approved by the ESL department and the students’ parents must agree to it (ESL Programs). The students typically enter the school at the Beginner

Proficiency Level of English, as determined by the English as a Second Language

Assessment Center (Academics).

CGA is unique not only because the students are all immigrants and refugees, but also because the curriculum is tailored to fit this immigrant population. All classes at the school have built in English language support into the coursework (Columbus Global

Academy). This is done by focusing on five areas on language acquisition skills: listening, speaking, reading, writing, and cultural enrichment (Columbus Global Academy). In addition to the classes that all high school students in the district take, the students at CGA also take a course on democratic citizenship (Columbus Global Academy).

CGA’s students represent over 55 countries around the world and they speak many languages (Columbus Global Academy). In order to help the students with learning English, especially the most recent students, most of the classrooms have a bilingual assistant (ESL

Programs). Additionally, CGA has beginner classes for students with little to no English skills (ESL Programs). In addition to focusing on English language learning, the school also had a goal to help students with the acculturation process and familiarizing them with

American society (Academics).

As many of the students come to the United States with little or no education, there are a few programs in place specifically to help them. The first is a reading clinic, where students go if they are identified as below-grade-level readers for 90-120 minutes per week to get help specifically for reading (Academics). Another program that the school has

19 is Response to Intervention (RTI). RTI works with students who need help with reading and math, which is especially important for those who come to the school without a strong educational background (Academics). CGA also allows students to work independently through an online program to recover credits (Academics). The school itself doesn’t have any sports teams, but the students have the opportunity to play for their home school’s teams. A home school is the school that the student would attend if they were not at CGA, and is based on where the student lives geographically.

20 Chapter III: Findings a. Results from surveys (quantitative data)

In order to organize the results from the study, the data were broken down into two categories based on interaction with American students: integrated and non-integrated.

For the purpose of this study, students are considered integrated if they interact frequently with American-born people with American-born parents, and non-integrated is defined as having little interaction with American-born people with American-born parents. The integrated group (n=33) reported interaction with Americans on a daily basis and the non- integrated group reported not interacting with Americans at all (n=47). These two categories, were broken down into two groups of data: the basic demographic data, and data pertaining to health. i. Demographic data

Overall, 80 students at the school were surveyed. They came from 24 different countries, which are highlighted in Figure 1. These countries are Burkina-Faso, Cameroon,

China, Congo, El Salvador, Eritrea, Ethiopia, Gambia, Ghana, Guinea, Iraq, Jordan, Kenya,

Mali, Mauritania, Mexico, Nepal, Nicaragua, Nigeria, Senegal, Sierra-Leone, Somalia, Sudan, and Yemen. The two countries represented by the highest number of students in the group surveyed were Nepal (n=16) and Somalia (n=11). Overall, most students surveyed were from East Africa (n=25) or West Africa (n=23). There were no students who were born in

Europe, although one student did live in Turkey after moving there from Iraq. But, based on conversations with the teachers, there are a few students who are from Eastern Europe in the school that were not included in this study.

21 Figure 1: Map of locations where students are from

Table 1 summarizes the demographic data collected by the surveys, and is broken up into three groups: integrated students, non-integrated students, and total study population. The P-value was calculated using bivariate regression analysis with integration as the dependent variable and the demographic characteristic and the independent variable. None of these values were statistically significant across the integrated and non- integrated groups except for average length of residency. Average length of residency was statistically significant showing that those who are integrated have lived in the United

States longer than those in the non-integrated group. The other demographic variables included in the study to see if there was a statistically significant between the integrated and non-integrated groups were gender, age, and length of time since immigrating to the

United States.

22 Table 1: Bivariate regression analysis with integration as the dependent variable and health-related characteristics as independent variables

All % Integrated % Non-Integrated % P Value Total 80 100 33 41.25 47 58.75 Gender Male 35 43.75 13 39.39 22 46.8 Female 45 56.25 20 60.61 25 53.19 0.51 Age 18.06 - - 17.97 - - 18.13 - - 0.665 Region of Origin Asia 17 21.25 7 21.21 10 21.28 Central America/Mexico 4 5 2 6.06 2 4.25 West Africa 23 28.75 11 33.33 12 25.53 East Africa 25 31.25 9 27.27 16 34.04 Middle Africa 2 2.5 1 3.03 1 2.13 Middle East 9 11.25 3 9.09 6 12.77 0.953 Religion Muslim 51 63.75 21 63.63 30 63.83 Christian 15 18.75 7 21.21 8 17.02 Hindu 12 15 4 12.12 8 17.02 Atheist 1 1.25 1 3.03 0 - - 0.593 Average length of residency 2.725 - - 3.424 - - 2.234 - - 0.018* Average number of hours spent with Americans 1.79 - - 4.348 - - 0 - - 0 *p-value <=0.05 ii. Health-related data

Table 2 summarizes data collected pertaining to the health of the students. This data included BMI, how many meals the students ate outside of school on an average school day, whether they bring their own lunch to school or eat the school lunch, how many times a day on average they eat fruit, how many times a day on average they eat vegetables, how many hours a day they do physical activities, and how many hours a day they spend playing video games or watching television. Most of these values were not statistically significant between the integrated and non-integrated groups. The two notable variables that were statistically significant were the overweight and healthy categories in BMI. The integrated group had a higher percentage of students who were in the overweight BMI category, while

23 the non-integrated group had a higher percentage of students who were in the healthy BMI category.

Table 2: Bivariate regression analysis with integration as the dependent variable and health-related characteristics as independent variables

All % Integrated % Non-Integrated % P Value Total 80 100 33 41.25 47 58.75 BMI (n=79) 0.138 Average 22.24 - - -

Obese 8 10 2 6.06 6 12.76 0.331 Overweight 8 10 6 18.18 2 4.25 0.041* Healthy 49 61.25 16 48.48 33 70.21 0.05* Underweight 15 18.75 9 27.27 6 12.76 0.104 Meals eaten outside of school Mean 1.918 1.969 1.883 0 meals 5 6.33 2 6.25 3 6.38 1 meal 18 22.78 6 18.75 12 25.53 2 meals 35 44.3 15 46.85 20 42.55 3 meals or more 4 5.06 2 6.25 2 4.26 0.95 Brings own lunch Yes 7 8.75 6 18.18 1 2.13 No 59 73.73 21 63.63 38 80.85 Sometimes 14 17.5 6 18.18 8 17.02 0.039* Servings of fruits eaten per day Mean 1.8 - 1.924 - 1.809 - 0 8 10 4 12.12 4 8.5 1 20 25 7 21.21 13 27.66 2 34 42.5 13 39.39 21 44.68 3 or more 18 22.5 9 27.27 9 19.15 0.644 Servings of vegetables eaten per day Mean 1.35 - - - 0 23 28.75 8 24.24 15 31.91 1 18 22.5 8 24.24 10 21.28 2 28 35 10 30.3 18 38.3 3 or more 10 12.5 7 21.21 3 6.28 0.206 Hours doing physical activity per day Mean 0.89 - - - 0.084** 0 33 41.25 13 39.39 20 42.55 >0-1 29 36.25 10 30.3 19 40.42 >1 18 22.5 10 30.3 8 17.02 0.463 Hours of TV/video games (n=79) Mean 1.95 - 1.63 - 2.17 - 0.106

24 0 to 1 29 36.25 13 39.39 16 34.04 0.583 1 to 2 15 18.75 5 15.15 10 21.28 2 to 3 20 25 12 36.36 8 17.02 3 or more 16 20 3 9.09 13 27.66 0.291 *p-value <=0.05 **p-value <=0.10 iii. Combined demographic and health-related data regression

Three multivariate regressions were done in STATA to find correlations between all of the independent variables and the dependent variable, integration, in Table 3. The first regression was done with just the demographic data, not including integration. None of the values here were statistically significant with regard to BMI, so BMI was not correlated to any of the demographic variables. The next regression included the demographic variables, but also included integration. In this regression, integration was negatively correlated to

BMI (Coefficient=-2.2866, P=0.044). This means that the integrated group of students has a mean BMI 2.29 lower than the mean BMI for non-integrated students when controlling for demographic variables. The third and final regression included integration, the demographic data, and the health-related data. When the health-related data was added to the regression, integration had a less statistically significant correlation to BMI (P=0.090).

This makes the health-related data a potential mediating factor for the correlation between integration and BMI.

Table 3: Three multivariate regressions with BMI as the outcome variable

Demographics Demographics and Integration Demographics, Integration and Health Coefficient P-Value Coefficient P-Value Coefficient P-Value

Integration -2.2866 0.044* -2.1086 0.090** Age 0.0296 0.933 -0.0346 0.920 -0.1950 0.594 Male 0.5490 0.634 0.6083 0.589 0.8005 0.546 Christian 5.2680 0.319 4.5786 0.375 4.2542 0.438 Hindu 1.5425 0.756 0.4289 0.930 1.2440 0.818 Muslim 3.8846 0.499 3.2057 0.569 3.3085 0.574

25 East Africa -1.2566 0.700 -1.5276 0.632 -1.2815 0.707 Middle Africa 3.2010 0.431 3.2736 0.410 2.4571 0.557 Middle East -0.8806 0.800 -1.4336 0.674 -1.4838 0.692 North/Central America -1.0737 0.750 -0.7663 0.816 -0.6215 0.861 West Africa 0.1453 0.964 0.2370 0.941 -0.2464 0.942 Length of US residency 0.2014 0.444 0.3427 0.200 0.4442 0.156 TV/video games 0.2045 0.641 Physical Activity -0.2040 0.704 Meals eaten outside school -0.3123 0.625 Sometimes brings lunch to school 3.0894 0.041* Brings lunch to school 0.7241 0.763 Fruit 0.7730 0.191 Vegetables 0.0894 0.876 _cons 17.5893 0.027 20.1201 0.011 20.8222 0.012 R-Squared 0.0978 0.1529 0.2532 Number of Observations 78 78 77 *p-value <=0.05 **p-value <=0.10

b. Results from interviews (qualitative data)

Table 4: Brief summary of interviewed students

Student Average hours spent Country of Age Gender Religion Length of BMI Interviewed with Americans per day origin residency Student A 5 Mauritania 17 Male Muslim 1 year 17.5

Student B 3.5 Guinea 16 Female Muslim 4 years 20.9

Student C 5 according to survey, Somalia 19 Female Muslim 4 years 17.4 0 according to interview

Student D 6 Iraq 18 Female Muslim 7 years 29.9

Student E 7.5 Kenya 17 Female Muslim 11 years 20.1

Student F 0 Senegal 19 Female Muslim 3 years 24.5

i. Interview 1

The first interview conducted was with two students from West Africa. The first, student A, was a 17-year-old male who had lived in the United States for 1 year and immigrated from Mauritania. He was very outgoing, and was known by some of the

26 teachers as a “troublemaker.” Student A is thin and was wearing jeans and a t-shirt. The second participant, student B, was a 16-year old Muslim female who has been in the United

States for four years, and immigrated from Guinea. She was very talkative, and wore jeans, a long-sleeve shirt and covered her hair with a headscarf. She seemed to have a healthy body shape, she wasn’t overweight, but she wasn’t particularly skinny. Because the room where I had been interviewing students was being used for testing, I interviewed the students in the detention room. When we walked in, student B said that she had never been in the room before, and student A responded by laughing, saying that he was very familiar with the detention room.

Both participants fall into the category I call ‘assimilated’ because of their regular interaction with Americans. Before coming to the United States, their diets consisted of typical West African foods, such as rice with either a meat or vegetable dish. These two students reported consuming three meals a day, starting with bread and coffee for breakfast, and a dish with rice and sauce or fish for both lunch and dinner. They mentioned that before arriving in America, their favorite foods were vegetarian stew and peanut butter soup eaten on top of rice. Student B helped cook for her family before coming to the

United States. She claimed this was a “duty” expected of girls, while the male student had never helped cook or prepare meals. Both students played soccer before coming to the

United States.

In the United States, students have picked up new eating habits and now have some favorite American foods. For student B, her favorite food is pizza and student A’s favorite food is now salad. Student B currently eats breakfast at home and brings her own lunch, while student A skips breakfast and only eats lunch when he feels like it. When asked about

27 new foods that they’ve experienced since coming to the United States, student B responded that she has tried hamburgers and student A replied that he had never eaten pizza until he moved to the United States. Student B was surprised to hear that student A had never tried this type of cuisine, since she occasionally ate pizza when she was in Africa. Both students also love Chipotle. When asked if they usually eat three meals a day, student B said yes and student A said “not really.” Student B explained that her mom encourages her to eat healthfully and even wakes up early to cook student B and her siblings breakfast. She also gets food at a mosque on Friday when she goes to pray, while student A explained “I’m supposed to go to mosque every Friday, but I don’t.”

When asked about exercising in the United States, student B explained, “My dad loves walking, he’s really active, so every now and then we--especially us two--we go to walk around the house, around outside, just walking around. So we do that together.”

Student A says that he jogs to prepare for soccer season, and plays soccer for his “home school” in the fall. A home school, he explained, is the school in the district that he would have attended if he was not enrolled in this all-immigrant school based in another area of the city

Student B spends half of her school days at a career center at a “normal” public school in the district, and has made friends with some American students while going there. She also attended a science camp for a week last summer and became friends with an

American student with whom she often talks. Student A only has one immigrant friend, who comes from a different West African country. The rest of his friends are Americans that he met and befriended in his neighborhood. At home, student B speaks both French and English, and said, “we don’t really speak my native language a lot.” At home, student A

28 speaks English, “‘cause I have two little brothers that don’t speak my language” he explained. Speaking English with their parents was not out of the ordinary. As Student B explained, she speaks English with her mom, who’s not fluent, but takes English classes.

Student A also speaks English at home. As he explained, “My dad don’t like the way we speak English at home, but we cannot change it because we all have to communicate with each other, we have to speak English.”

On the topic of how much contact other students in their school had with Americans, both students agreed that it was rare to see their schoolmates hanging out with Americans.

Student B explained that other students don’t have a great deal of contact with Americans, and spend most of their time with other students from the same country. Student groups form, she explained, based on common region and language. Student A agreed, stating, “just like she said--nobody speaks English. We’re all from our countries. People from the same countries stay with each other, nobody talks to each other.” Both students have a television set in their homes; student B does not watch television a lot while student A does. This led to a conversation about television’s role in English language acquisition, since both students have excellent English and both have only slight accents. Student B started by saying, “when we first came here, we were watching TV. I just felt like they were just speaking Chinese, but as I watched it more and more I think it really helped me.” Student A agreed and said, “I watched it with subtitles to see what they’re saying and writing it you will understand more.”

What was surprising was how little either student thought about their health while living in the United States. Neither student thinks about how healthy their food is when they eat, but student B explained that she is a picky eater. If the food doesn’t look good to

29 her, she won’t eat it. Both students use cars as their primary modes of transportation, but student A walks if he’s going somewhere in his neighborhood. When asked what they do on an average day after school, student A said that he plays video games, drinks coffee, and watches a television show called ‘The Big Bang Theory’. Student B explained that she loves to write and read. She said, “I’m in this, like, online thing where you write and you post and people read and comment. It’s really cool.”

To conclude the interview, the students were asked if they had anything to add regarding health in the United States vs. health in West Africa. Student B said that there’s no fast food in Africa. She then continued to explain that the women there cook three times a day; there’s no pre-made food that can be put in a microwave. She also said, “So in Africa if you’re like really, like big, that means you’re rich ‘cause that means you have enough money to buy food. I feel like it’s the opposite here ‘cause like everyone can go to

McDonalds.” She also said that nobody in Africa cared about how much they weigh. She also said that the people she spends time with also don’t care about how much they weigh, and she eats whatever she wants. She also said that people in America are focused on being healthy, which she considered to be a good thing. The conversation continued to go on to why they came to the United States. Student A explained that where he was from there were two races, and his race was discriminated against. He was eventually forced out and had to leave. Student B said her dad was a journalist, and the “government president took him away.” They moved to another West African country, where “they went after” the family there, as well, which is when they came to the United States. Both students seemed happy and neither showed any signs of trauma during the interview.

30 The conversation then shifted to talking about differences in education between

Africa and the United States. Student A went to a French school and student B went to a private Catholic school where “they didn’t practice any religious things.” She explained that when she first came to the United States, her dad said she was going to be going to a public school, and she was very upset, because in Africa going to a public school means you’re really poor. Student A agreed and said that everybody in America goes to public school. ii. Interview 2

The third student, student C, who was interviewed was a female from East Africa and is in the assimilated category according to the survey, but according to her interview she does not interact with American-born people with American-born parents. She had the heaviest accent of the students interviewed, but her English was still pretty good. She spoke in shorter sentences than the other students, and didn’t really elaborate on any of her answers. She was wearing a skirt down to her ankles and a modest long sleeve shirt.

She also wore a hijab. Before coming to the United States she ate “rice and goat meat and pasta,” and her favorite food was pasta. She helped cook before coming to the United States, and made food from the country in which she was born. She did not exercise or play sports before coming to the United States. Now, her favorite food is chicken. She enjoys the school breakfasts and lunches. One food that stood out to her as a new food she’s tried since coming to America is a bagel. She eats at restaurants in the United States, and when asked at which ones she responded, “Wendy’s, Subway, all those restaurants.” She also gets food once a week through a mosque. She doesn’t like sports.

She talks to students in the school from many different countries. When asked which ones she responded with only African countries, and then added she also talks to students

31 from South America. She does not speak English at home, nor does she interact with

Americans. She doesn’t read American magazines, but she does have a television in her home and watches shows such as Prison Break and The Walking Dead. She does not think about how healthy food is when she eats it. Her primary mode of transportation is a car.

Outside of school she enjoys sleeping and watching TV.

Lastly, when asked if there was anything else she wanted to add about the differences between health in Africa and health in the United States, she responded, “yes in

Africa we eat healthy food. I think it’s healthier because it’s like the food that they made it and just it’s new food and in America it’s refrigerated a lot and it’s been for long time. I think Africa food is healthier because they just killed the goat and in United States there’s the refrigerator.” iii. Interview 3

The fourth student interviewed, student D, is from the Middle East. She is in the assimilated category. She was dressed in a light-pink long trench-coat which she never took off during the day. She also wore a long skirt and covered her hair with a hijab. Student D spoke with a slight accent, but it was easy to tell that her English was very good. She lived in Iraq until she was five or six, and then moved to another Turkey. She ate three meals a day before coming to the United States, which mainly consisted of rice, whole-grain bread and lots of vegetables in the second country she lived in, and lots of meat in the country in which she was born. Before coming to the United States she did not cook or help cook any meals. Before coming to America she would play sports “every single day.” She played basketball, went to boxing classes, and did a lot of exercising.

32 Since coming to the United States her favorite food is pasta. She doesn’t eat breakfast at school, but she eats the school lunch. She said that since she’s a vegetarian they make her a special vegetarian lunch, which she likes to eat, such as a veggie burger. Two

American foods she’s tried since immigrating that stood out to her are macaroni and cheese and donuts. She explained that in her country people don’t eat much cheese because it makes you fat. She has started cooking since coming to the United States since she is the only vegetarian in her family. She makes macaroni salad, and cooks vegetables such as broccoli and carrots. Sometimes her mom will make her favorite soup from her country.

She decided to become vegetarian for no specific reason that she could think of. She visited the two countries that she had previously lived in in 2011 and decided she wasn’t going to eat meat anymore, and continued being a vegetarian since then. She eats at Turkish restaurants and Asian restaurants that serve Turkish foods about once a week. When asked if she exercises in the United States, she responded, “I walk, I run sometimes, and I do those sit ups, push ups a little bit, and I do more stuff that are from the phone. Like there’s an app and they do it with you so I do it with them. And I also do yoga but that’s it. I guess that’s an exercise.”

She doesn’t talk to other students from school outside of class because she doesn’t see them, but she does talk in English a lot when she is at the library, which she usually goes to after school. She doesn’t usually read American magazines, but sometimes will online. She owns a television, but does not watch American TV shows. She watches shows from her home country. Sometimes she uses her brother’s Netflix to watch movies, and she used to watch Grey’s Anatomy since she is interested in medicine. When asked if she thinks about how healthy food is when she eats, she responded, “Yes, all the time. And I even say,

33 this is not healthy why am I eating this, but I eat it.” Her primary mode of transportation is driving, but she sometimes takes the bus, too. After school she goes to the library, then comes home, does yoga, and goes to sleep.

To wrap up the interview, she was asked if there was anything else she wanted to add regarding health in the United States versus health in her home country. She explained:

When I came to United States I was really skinny and I was really healthy. I had no health problems at all. When I came to the United States, I became fatter than I used to. I gained a lot of weight, which was unhealthy weight, and I also have a lot of health problems now than I used to because of the things like, you know how we came here, and like, the fast food restaurants. I usually don’t have time to eat food and sit at a table in America, and like there in my country we have to sit, if we don’t that’s disrespectful. You have to sit at a table and eat. Here I just stand up and eat because I don’t have time, but there no, and that’s unhealthy, because, you know, you gain weight because you don’t know what you’re eating since you’re just eating. And so I think I, you know, here my health is worse I guess. iv. Interview 4

The fourth and final interview was with two female students, one from Kenya,

Student E, and one from Senegal, Student F. Student F was wearing skinny jeans and a plain

V-neck t-shirt. She also had an accent, though not a heavy one. Although she is Muslim, she doesn’t cover her hair when she goes to school or leaves her house, but she does cover her hair when she prays. Student E was wearing a long skirt and covered her hair with a hijab.

She does not have an accent at all. She moved to the United States when she was four years old, so she said she does not remember much from when she lived in Kenya, but she did say that she thinks she drank cow’s milk when she lived there. Student F said that she helped cook and made dishes such as rice and fish or rice and meat. She came to the United States when she was 15 years old. When asked if she exercised before she came to the United

34 States she said, “I used to do the, oh my god, the thingy, the Tae kwon do, I used to do that in Africa.”

Because neither student remembered much from before they came to the United

States, the interview then moved on to talk about life after they immigrated. When asked what their favorite food in America is, student F said “pizza,” while student E said, “Oh my god I don’t know, everything is good.” Both students cook and make rice and chicken or rice and meat. Student E said she eats from restaurants everyday, including both before and after school. She also works at a large chain fast food restaurant so she gets food there often. Student F said she does not eat at restaurants much. Neither student gets food from a religious institution. Both students exercise. Student E said she likes to “run around” and student F said she does “the abdominal thing.” When she said this was what she did for exercise, she demonstrated a movement that looked like she was doing crunches or sit-ups.

When asked if the students interact with people who were from other countries and cultures, student E said she does, “Like all the time, all my friends are not from my place, they’re not all from Kenya. Some are from Asia, some are from West Africa or East Africa.”

Student F shrugged at the question, and student E turned to her, saying, “What about me?

I’m from Kenya and you’re from West Africa.” Student F giggled and nodded at student E.

Both students speak English when they’re not at school, but not with their parents.

However, they do both speak in English when they are talking to their siblings. They also said that their parents understand a little bit of English.

Student E interacts with people born in American with American-born parents often because she went to elementary school and middle school in the United States, and also her neighbors are American. Student F does not interact with Americans often. When asked if

35 they thought the other students in the school interact with Americans often, student E said yes while student F said she thinks only some of them do. Student F explained that she thinks a number of students live close to people who are from the same country or region as they are, since this is what she experiences. She explained, “our place, oh my gosh, it’s all

Fulani. We are all Fulani in that place.” “That place” was implied to be the student’s neighborhood or apartment complex where she lives. The students continued that they don’t always think it’s a good thing for people to just live with similar people. Student F said, “you’re not going to improve your English as well as if you live with the American people,” and student E said, “When you, like, go there you talk in your language, you don’t talk in English, so it doesn’t improve your English.” Both students sometimes read

American magazines. Student E reads “magazines that have all of the celebrities.” Both students also have a television in their homes. Student F watches TV about one hour a day, while student E often watches movies on her phone. They both watch American TV shows and specifically like dramas. Both students use cars as their primary mode of transportation. After school student F likes to do her homework or cook, and student E goes to work and likes to sleep.

When asked if they think about how healthy food is when they eat it, they both laughed and said no. Student E said she doesn’t think anyone at the school is unhealthy. The students were then asked if they thought Americans were unhealthy, to which student E responded, “It’s just half and half for both, Americans and Africans. Some Africans are healthy and some are not and some Americans are healthy and some Americans are not.”

This then prompted a question about whether she thought there was a difference between

Africans in America and Africans in Africa regarding health. She said, “I think so, because

36 their health, they might have a higher health problem than us because we have better hospitals, better doctors and everything, and over there it’s like low on doctors and hospitals and medical stuff. So I don’t know the difference, but it’s a little bit different there.”

37 Chapter IV: Discussion

The key findings in this project will be discussed, and are broken down into the following categories: demographics, health-related data, and overall regression analysis results. This section will combine both the qualitative and quantitative research methods to examine the findings of the study, and also delve into the limitations of this study and avenues for future research in the fields of immigration, integration and health. a. Demographics i. Defining country of origin

Although the study shows that where students are from does not make a difference as to whether they are integrated or not, the sample size was very small (n=80), based on the interviews and further observations from being in the school this could be an area for future research and could show a correlation between integration and where immigrants are from. Other than the small sample size, one limitation of the data analysis is that the students were grouped by region of where they were from. By doing this, many assumptions were made that might not necessarily be true, and this is a major limitation and challenge in immigration research in general: how does one create categories for immigrants? This study collected and grouped the students based on the country in which they were born, but this does not always represent where the student grew up or what their perceived national citizenship is. For example, many of the students born in Kenya,

Ethiopia, and Yemen identified as Somali. Additionally, some of the students lived in three or more different countries before the age of 18. One student was born in Guinea, but spent two years in Mali, eight months in Senegal, and another six months in Sierra Leone before

38 coming to the United States. Another student was born in Congo, but then moved to

Rwanda and lived there for 13 years before immigrating to the United States.

When immigrants move frequently for various reasons and spend time in multiple countries, it creates the complication of defining a national identity. For the students who were forced to move, they might not identify with the nationality of the country in which they were born. Or, if the generations before them were forced out of the country, they may identify with their parents’ or grandparents’ nationality. This was seen in the many students who said they were born in Kenya, Ethiopia, or Yemen but still identified as

Somali. For the Somali students who lived in Yemen, this may have skewed the data, because this group was included in the Middle East region as opposed to the East Africa region, even though they identified as East African.

Another complication with looking at immigrants based on the nation of birth is that they may identify more with a cultural group than a nationality. Because of Africa’s history of being arbitrarily divided into countries by European imperialists who disregarded what groups of people were actually living there, some cultural groups span many countries. For example, in Interview Four, student F explained that the people who lived around her were all also of the Fulani tribe, implying that she identifies more with this tribal group than with the nationality of the country in which she was born. The Fulani people are a predominantly Muslim tribe that lives throughout West Africa, mostly in Nigeria, Mali,

Guinea, Cameroon, Senegal, and Niger (Fulani). But, student F might be identifying with the

Fulani language rather than the Fulani ethnicity. This brings up another way of categorizing immigrants: by language. But limitations to this mode of classification would be that

39 immigrants from Africa tend to speak many different languages so defining people by language groups would be a difficult exercise.

Overall, there is no easy way to categorize immigrants, particularly from this specific school, which houses students with multi-layered identities. This poses a unique challenge in immigration research. Further studies could include a larger sample of students from this all-immigrant school in order to create multiple categories to compare health outcome, such as country of origin, parent’s country of origin, nationality the subject identifies with, primary language the subject speaks, primary language the subject’s parents speak, cultural group the subject identifies with, or country in which the subject has lived the longest. It is not always in the best interest of a researcher to group immigrants by region or continent of origin if it can be avoided because this makes many assumptions and may hide differences between immigrant groups within the broader categories. ii. Religion

The majority of the students in the survey sample are Muslim, and there is a strong

Muslim presence in the school. This is seen just by walking through the hallways: many of the female students cover their hair, and even walking by the girl’s bathroom you hear complaints about having a “bad hijab day” rather than having a bad hair day. After surveying and interviewing some of the students, keeping their old religious traditions and fitting in at the school can sometimes be difficult and often comes up as a point of conversation, especially for the Muslim students. For the Nepali students, religion has less of a spiritual presence and there can also be religious divides in the family between Hindu and Christianity.

40 The week I did my research was the week of the homecoming dance, and the students were all very excited. At the end of a class, three students discussed the religious conflicts they had with the dance. One of them explained that going to the dance in general was a sin, but she was going to go anyway. Then they got into a debate about covering their hair at the dance with a hijab. One student who had her hair covered said she wasn’t going to wear a hijab because it was a sin to go to the dance in the first place so it wasn’t a big difference to her to sin again by not covering her hair. The other student asked why she would sin twice if she only had to sin once. This student was planning on going to the dance and was still going to wear her hijab. The third student in the conversation did not cover her hair at school, and only wore a hijab when she prayed. She explained her perspective on the situation: if you make the commitment to always cover your hair, you shouldn’t uncover it for a dance because, in her opinion, it seemed hypocritical. These three Muslim students had three different practices and perspectives when it came to the school dance and religion, illustrating just one of many ways immigrant students balance integration with keeping their cultural and religious traditions.

Another example of this is seen in Interview One with the exchange of dialogue between the two students interviewed. They were asked if they ever receive meals from a religious institution, such as a mosque, and the following brief conversation ensued:

Student B replied first: “yes, ‘cause we go to mosque every Friday so

usually they do send out like food and snacks, so yeah”

Then student A said: “I’m supposed to go to the mosque every Friday but

I don’t”

And student B turned to him and responded: “that’s okay”

41 Both students in the conversation identified at Muslim, but both had different relations with their religion. This conversation is particularly interesting because of what student A focuses on. Rather than answering the question and saying that he does not receive food from a religious institution, he instead explains that he should be going to mosque on

Fridays but doesn’t.

These two situations, though not directly connected to health, show that these students have varying degrees of religiosity and different connections with Islam. This connects to health because in Islam, there is a strict diet that is followed. Halal food, or food that is permitted in Islam, forbids eating blood, meat from pigs, meat from an animal that was already dead, and meat that was killed for idols, and also forbids the consumption of alcoholic beverages (Bonne, K. & Verbeke, W., 2007). Animals that can be eaten must be killed in a specific way, as regulated by Islamic law (Bonne, K. & Verbeke, W., 2007).

Interestingly, although alcohol consumption is punishable by the Quran, it is not seen as bad as eating pork because it can be seen as more pleasurable, even though it is still prohibited to do in Islam (Bonne, K. & Verbeke, W., 2007). When the immigrant students are figuring out how best to connect with and practice Islam in the United States, this includes their dietary habits and also whether or not they will drink alcohol. Students who decide to stop covering their hair or to only sometimes cover their hair may be more tempted to eat meat that is not halal or to drink alcoholic beverages. This also applies to students who don’t go to mosque: they may be more inclined to stray from the dietary restrictions of the Quran. This would be interesting to look into for further research.

As previously mentioned, the Nepali students also struggle to find meaning in religion after and even before coming to the United States. There are Christian missionaries

42 in Nepal and some of the students convert from Hinduism there. Other Nepali students convert to Christianity once they are in the United States. This is not always done as a family decision—it is not uncommon for the children in the family to convert while the parents remain Hindu. Some of these students gain resources from the church, which may be more of an incentive to convert rather than converting for reasons based on belief.

When surveyed, many of the Nepali students paused when asked about religion, and said

Hindu before, but Christian now.

The conversations and observation regarding the students’ relationship with religion are particularly interesting in this study because of what they could say about the broader topic of immigrant adolescent integration. Some students show more malleability and flexibility when it comes to religion than others, which may indicate an increased level of integration. Further studies could look at different levels of religious practices as another measure of integration. For example, are students who still cover their hair less integrated than those who don’t? Or what about the students who usually cover their hair, but then uncover it for school dances? And further, are there differences in the diets and other health practices of students who adhere to stricter religious practices than the ones who don’t?

This study looked at religion as a whole, because it would be difficult to create further subgroups with a small sample size. Further studies looking at immigrant religion should seek to create categories within religious groups, such as whether or not a person attends a religious institution regularly. It would also be interesting to look further into integration with regard to if immigrants practice the same religion after immigration than they did in their home country. Additionally, future research could explore ties between

43 religion and eating ethnic food or shopping at ethnic grocery stores. Are people who adhere more strictly to religious law more likely to eat the same foods they ate before coming to the United States after immigration? It would also be interesting to look at which immigrants adhere more strictly to religious laws after immigrating, and why that might be and how that affects their health. iii. Age

The mean age of the sample group was high for a high school (n=18.06). This is for a few reasons. The first is self-selection bias: because many of the under-18 students didn’t remember to bring in parental consent forms, most of the students who were able to participate were 18 or older. The second reason that the age is so high is that the students are older than they would be in an average school. For some of the students, going to public school in the United States is the first opportunity they have at getting an education.

Additionally, the mean age may not be completely accurate, because it is not uncommon for the students to have a different age on paper than their actual biological age.

Because students must graduate from the school before they turn 22, there is incentive for them to have a different age on paper than their biological age. If a student is

19 and wants to enroll in the school, they would have to complete all of the requirements for graduation within the next two years. This is especially difficult when many of the students enter the school without knowing more than a few words in English. Because of this, many of the students in the school and, most likely in the survey sample, report lower ages than their actual age.

While surveying the students, some had an obvious pause when I asked them for their birthdays, which included the year in which they were born. It took them a few

44 minutes to think about it before they told me. Some of the seniors were 21, barely making the cut-off for staying in the school. Another interesting thing that happened when asking the students for their birthdays was that eighteen of them had the same birthday: January first. This is probably not a coincidence. From this research, it seems that January first is a go-to birthday to put on documentation for the school, and this also means that at least 18 of the students are probably older than they say they are within this sample size.

This could be a limitation because older students may have more freedom with their diets. Some of the students I talked to were married and lived with a spouse rather than a family. Because it is such a personal question, I did not ask this in the interview or survey, but from talking to the teachers and some of the other students, I learned that being married in the school is not uncommon. Some of the male students even spend their school breaks going to their home countries to get married and bring back a wife. Sometimes these students live independently from their parents, and therefore have complete control over what they eat. They also may not make as much money as their parents because they are students and cannot hold a full-time job, so finding the time and money to consume healthy foods may be difficult. Although, because these students get married early and stick to their cultural traditions in this way, they may eat ethnic food more often. This would be an interesting thing to research in the future. iv. Integration (interaction with American-born people with American-born parents)

As seen in table 1, all but one of the demographic variables collected were not statistically significant, so differences between the integrated and non-integrated students were not correlated to their interaction with Americans. The only variable that was statistically significant was length of residency in the United States (P=0.018). This means

45 that those who are spending time with Americans have been in the United States for a longer period of time than those who are not spending time with Americans. Based on additional information from the surveys that was not quantified in the data tables, this could be for many reasons, including that some of the students went to middle school in the

United States before being streamlined to this school. There is also a program in which some of the students go to a career center for half of the day so they are completely integrated with American students through that program. In order to get into this program, the students would have had to have been in the school for a longer amount of time, and therefore would most likely have been living in the United States for a longer period of time.

Five students explained that they spent time with American-born neighbors in the survey. This is interesting because it could mean that these students are not living in an ethnic enclave, like the Fulani group student F discussed in the survey. Looking at whether people live or don’t live in an ethnic enclave could be another way of looking at integration in quantitative research regarding immigration and health. Are people who live in an ethnic enclave less likely to seek primary medical care? Are people who don’t live in an ethnic enclave more likely to pick up an American diet, and therefore have higher BMIs and lower overall health over time?

Six students said that they spend time with Americans when they go to the library.

This would also be interesting to look into. Which students are going to the library to study? There are two assumptions that can be made about these students: first, that they prioritize education and academic achievement, and second, that they can afford to go to the library after school and not go to work. None of the students said that they interact with

46 Americans through both work and the library. Looking at further research, looking at success in school with regard to a health outcome could be interesting. Not just looking at graduation rates, but looking at effort in school. Do students who try harder in school have better health outcomes? This could be measured by hours spent on schoolwork on an average day after school.

Seven students reported that they interacted with Americans through work.

Although not all of them said specifically what they do, some did say they work at restaurants, one said she worked cleaning, and another said he worked at his mom’s shop.

Even though this was such a small part of the data collected, it still brings up some points for further research. It would be interesting to look at immigrant occupation as an independent variable with some kind of health outcome, such as BMI. Do immigrants who work at fast food restaurants have higher BMIs than those who don’t? What about the BMIs of immigrants working in specific careers in comparison to non-immigrants working in the same careers?

Another limitation of this study was the way in which the question about interaction with Americans was asked and how the students interpreted it. It was especially difficult when one student said he interacted with Americans 24 hours a day. Clearly, this was not even possible. Several students said they interacted with their American-born siblings, and if that was the case I prompted the students by asking if they interacted with Americans outside of the family. Because this question was confusing, I decided to change it to a simple yes or no question after collecting my data. This split the groups fairly evenly and gave me a simple way of quantifying integration. Of course, there are many aspects of integration beyond just interacting with Americans. But, this is a good way of seeing if

47 people are leaving their ethnic enclaves, especially when the students are in a school without American-born students. b. Health-related data i. BMI

BMI was broken up into four categories: Obese, overweight, healthy, and underweight. These were based on the CDC’s numeric definitions for this category. As previously stated, all of the students had their height and weight measured at the time of the survey, and the same measuring devices were used for each student. This means that all of the BMIs collected were both precise and up to date.

Two of the four BMI categories were statistically significant when comparing across the integrated and non-integrated groups. In the integrated group 18.18 percent of students were overweight, while in the non-integrated group 4.25 percent of students were overweight (P=0.041). Additionally, in the integrated group 48.48 percent of students were in the healthy BMI category while 70.21 percent of non-integrated students were in the healthy category (P=0.050). This fits with the idea that immigrants who are in the United

States longer tend to have worse health than those who came recently. But rather than looking at amount of time spent in the United States, it looks at interaction with Americans.

This different definition of integration had statistically significant results even with the small sample size, and may be a new way of providing a measurement to be used while looking at immigration and health in research.

One limitation is that when there are so many small groups, it is difficult not just to get statistically significant results, but also to get a representative sample for each of the categories. For example, there were more obese non-integrated students (n=6) than

48 integrated students (n=2). Even though this was not statistically significant, it still goes against what the data about overweight students says, and what the immigrant paradox says. Future research should repeat similar studies looking at some measurement of integration in immigrant populations, such as interaction with American-born Americans, with the outcome of BMI, but these studies should include a much larger sample size. The study could also be repeated by looking at a binary outcome: the student either has a BMI greater than what is considered to be overweight, or they have a BMI that is either in the healthy or underweight category. Of course this has limitations as well, but it may be a better measurement system when there’s a smaller sample size. ii. Meals eaten outside of school

This question was included as a way of seeing how often students ate meals outside of school. It was not just asked to gain more information about the students’ health, but it was asked to also potentially provide information about the students’ socioeconomic status. Based on conversations with a few teachers, some of the students don’t eat outside of school because they cannot afford it. Almost one third of the students ate either one or no meals outside of school. This might suggest that one third of the students are lower socioeconomic status. But, this is complicated. Because some of the students work at fast food restaurants, they might have low socioeconomic status but also be able to eat many meals outside of school. Another factor that complicates this is that the school began this year offering free breakfast and lunch to all of the students. So even if a student is eating one meal outside of school, they may still be eating three meals a day.

The number of meals students eat outside of school was pretty evenly split across the integrated and non-integrated groups, and it was not at all statistically significant

49 (P=0.95). This suggests that integration may not be based on socioeconomic status. Future research should look at better measurements of socioeconomic status within immigrant populations with regard to health outcomes such as BMI. One good way of doing this is looking at the percentage of students at a school who get free or subsidized school lunches.

Because this school specifically had free lunches for everyone this was impossible to do. iii. School lunches

Another health measure included in the survey that also could be some sort of measure for socioeconomic status is whether the students bring their own lunch or not.

This would show that the students and their families have enough money to give up a daily free meal that the school provides. This measurement was statistically significant

(P=0.039). Six of the integrated students said they regularly brought their own lunches while only one of the non-integrated students said they did. This could show that the integrated students have more resources than the non-integrated students. But, similar to the other variables, these are very low numbers. Most of the students, integrated and non- integrated, ate the school lunches. But this is still an interesting thing to look at in immigrant populations. Further studies shouldn’t just look at if students are bringing lunch, but what they are bringing and why they are bringing it.

Another limitation with this question is that it doesn’t ask if the students are eating the lunch. When I asked about the school lunches in the surveys, many of the students made a funny face and explained that the food wasn’t always good. This is supported by the interview with student A, who, when asked about the school lunch, said, “I don’t like it but I don’t have a choice I just have to eat the lunch. Usually I don’t eat it.” Student C said in her

50 interview that she liked the school lunch, but only because they provided her with a vegetarian option since she doesn’t eat meat.

During my time in the school, I did get to go to the cafeteria to look at the school lunches. They looked like normal, American school lunches, and I could tell that there was some sort of an attempt to get healthy food in the lunch by the mandarin oranges on the trays and some wilted iceberg lettuce. On the district website, they list the lunch menus, and list many options for the students. But, in the cafeteria, almost every student had the same things on their trays. This could be because the school is not providing the variety advertised on the district’s website, or because the students are all choosing to eat the same thing.

Hypothetically, a weekly menu at the school should look like this:

51 Figure 2: Example of school lunch menu

The breakfast menu for the district looks like this:

52 Figure 3: Example of school breakfast menu

Additional studies could look at comparisons between what immigrant students are eating from their school lunches and what non-immigrant students are eating. Because immigrants are used to a different diet before coming to the United States, some foods may be more or less appetizing to them than they would be to American-born students. Another way to measure if the students are eating the lunches and what parts of the lunches they are eating would be to go in and see what, if anything, they are throwing away at the end of the lunch period. This could be compared to American students in the same district, since the lunches are all free throughout the district and follow the same menu. iv. Fruits and vegetables

The differences in the amounts of fruits and vegetables consumed in the integrated and non-integrated groups were not statistically significant (P=0.644, P=0.206). But, one thing that is interesting is that across both groups, the average amount of servings of fruit consumed in a day (mean=1.8 servings) was greater than the average amount of vegetables consumed on an average day (mean=1.35 servings). This is the opposite of what is recommended by the government. The mean amount of vegetables consumed by the students both male and female is lower than the recommendations from the United States

Department of Agriculture. The mean amount of fruit consumed is lower than the recommendation for boys, and a little higher for girls. For girls ages 14-18 the

53 recommended amount of vegetables per day is 2.5 cups, and for boys ages 14-18 the recommended amount of vegetables per day is three cups (How Many Vegetables are

Needed Daily or Weekly?). For girls ages 14-18 the recommended amount of fruit per day is 1.5 cups, and for boys ages 14-18 the recommended amount of fruit per day is two cups

(How Much Fruit is Needed Daily?).

If the students choose vegetables or fruit with their lunch, this alone would cover what they eat in a day. No fruits or vegetables are even offered with the provided breakfast.

More research should be done in order to see what fruits or vegetables the students are eating in the school, and then taking measures to make sure those are available every day.

Additionally, if fruits or vegetables are being offered but not consumed, then they should be switched out for a different variety to encourage healthy eating and also to avoid waste.

Overall, the students seem to enjoy fruits more than vegetables. This is evident in the survey data, as 23 students don’t eat vegetables during an average day while only eight students don’t eat fruit on an average day. One recommendation would be to start offering fruit with the school breakfasts to help encourage healthy eating, since most of the students surveyed choose to eat fruits and it is not on the breakfast menu. This would be a healthy addition to eating a bagel.

Another avenue for future research with regard to immigrant fruit and vegetable consumption would be to look at how immigrant students are consuming their fruits and vegetables. For some of the students, fruit and vegetables in the United States might be new to their diets. For example, student D said that before she came to America, she usually ate

“rice and goat meat and pasta.” The same student also said that while she was living in

Somalia she helped cook “all kinds of Somali food like bread, pasta, rice, meat, all that stuff.”

54 Neither of these quotes mention any kind of fruits or vegetables, so it may be that these were never major staples in her diet in Somalia. Additionally, when I spent two months in

Ghana, there were rarely vegetables offered with any meal. People ate a lot of cassava, rice, and other grains, sometimes with a meat stew. Both of these examples show a lack of fruits and vegetables in some international diets, and there may be a gap in immigrant knowledge in how to cook or eat some fruits and vegetables that are not native to their home country.

A lack of fruits and vegetables was not lacking in all of the students’ diets, though.

For example, student C explained the differences in her diet between when she lived in Iraq and when she lived in Turkey: “in Iraq everybody don’t eat vegetables, and like, when you invite someone you don’t eat vegetables. So like, if you invite someone in Iraq, you eat meat, but if you’re in Turkey you eat vegetables. So when I was in Iraq it was all meat, and when I came to Turkey it was all vegetables.” Vegetable and fruit consumption prior to immigrating depends on the home country’s available cuisine.

Based on the data collected in this study, it would be interesting to do further research that looks at what immigrants ate before and after immigrating. A hypothesis based on some of this study’s qualitative research would be that immigrants who have diets rich in vegetables prior to immigration continue to eat vegetables once coming to the

United States, while immigrants who ate mostly starch and protein have diets that are less healthy. This stems from interactions with three students. The first was student B, who said her favorite food before coming to America was a vegetable stew with herbs. She then explained that she really liked it because she could even make it here in the United States.

The second was in Interview Three with student C, who said she eats at Turkish

55 restaurants about once a week, and enjoys the vegetable dishes there. Finally, the last interaction that might support this hypothesis was when I was invited to a student’s apartment for dinner. She has a unique family situation, and lives in a small apartment with her brother who is a truck driver and is rarely there. I went over the day after her dad came to visit, and she had cooked traditional Ethiopian food for him: injera, a potato dish, a cabbage dish and another vegetable dish. She said she loves cooking and often makes

Ethiopian food.

Another topic regarding fruit and vegetable consumption that would be interesting to further research would be use of ethnic grocery stores. Beyond small, Hispanic convenience stores, there are also some very large ethnic grocery stores throughout the

United States. Looking at health differences between those who utilize those stores and those who do not could provide some interesting research on how and at what point immigrants are converging to American health averages. A hypothesis for this kind of study could be that first-generation immigrants are using ethnic grocery stores, while second- generation immigrants are eating from American fast food restaurants. v. Physical activity

The mean amount of hours per day that students engaged in physical activity was

0.89 (P=0.084). Even though the difference between integrated and non-integrated students was not statistically significant, it is close enough to 0.05 to suggest that maybe there could be a potential correlation in future studies. Across both groups, an almost equal percentage of students were inactive and did not engage in any sort of physical activity on an average day (39.39 percent integrated, 42.55 percent non-integrated).

56 The biggest difference between the integrated and non-integrated groups is that the integrated group has a larger percentage of students exercising for more than one hour on an average day (30.30 percent) than the non-integrated group (17.02 percent). This might be because one way in which the students may be “integrated” is through participation in a sports team. The school does not have sports teams, so if the students want to participate in high school sports they go to their “home school,” which is the school that they would go to based on their location within the district. If a student is on a sports team then they are integrated through the team, which is composed mostly of students from their home school. Student A plays soccer for his home school and is also integrated: he spends more time with his neighbors than other immigrants and has almost no accent.

Physical activity seems to be something that the students don’t usually participate in unless it’s through some sort of organized sport. Many students reported sedentary lifestyles. This might be different if the school itself offered sports, rather than the students participating in sports through their home schools. This might also be something based more on socioeconomic status rather than integration. Students who have to work to make money may not exercise as much if they don’t have the time to. The relationship between socioeconomic status in immigrant students and hours spent exercising would be an interesting topic to research further.

Additionally, it would also be interesting to research socioeconomic status before immigration and engagement in physical activity. For example, in the first interview, both students seemed to have come from relatively wealthy families. This is based on their discussion of the schools they went to, and their perception of public schools in the United

States. Student A went to a French school, and student B went to a private Catholic school.

57 Student A explained, “usually here in the United States … everybody goes to public school.

But in Africa if you go to public school that means you’re poor.” Both of these students also said that they exercised before coming to the United States. Student B played soccer on an all girls team, and student A both soccer and tennis. Additionally, in Interview Two, student

C said that before coming to the United States she used to play basketball and go to boxing classes. Student F said she did taekwondo in Senegal. All of these students seem to have come from relatively wealthy backgrounds, and they all participated in some kind of sport before immigration, and continued some level of activity after immigration. On the other hand, student D, who lived in Somalia and Kenya, was not active before or after immigration. She also didn’t say anything during her interview to indicate any form of high socioeconomic status before immigration. Additionally, because she went from Somalia to

Kenya, it is very possible that she was in a refugee camp in Kenya, and would therefore most likely not have access to any kind of organized sport, especially since she is a girl. vi. Hours spent watching television and playing videogames

The mean for hours spent watching television and playing videogames for all students was 1.95 hours; for integrated students it was 1.63 hours and for non-integrated students it was 2.17 hours. Although this was not statistically significant (P=0.106), the P- value is borderline statistically significant and may suggest that could be researched more in the future; there are many possible reasons for this difference between the groups. It is also important to note that during this survey question, very few students reported playing videogames, most responded to the question about watching television. One student said he didn’t watch television or play videogames, but he was always on Facebook. As watching television and playing videogames is a measurement of being inactive, a follow-up question

58 that would have also helped measure inactivity could have been amount of time spent on a computer.

It’s interesting that few students reported playing videogames because that is considered to be something that many high school students, especially male high school students, do in their free time. Many American-born high school students have some kind of videogame console, such as a Wii, Nintendo or Xbox, in their homes. This might be a sign of either some kind of lack of integration when it comes to playing videogames, or just a lack of general awareness for them. Because most of the students came from developing countries, they probably didn’t have access to videogames like children in America do. They also most likely did not see much advertising for them. Because they did not grow up with them, they might not feel the need to play videogames. Another reason for the lack of response regarding videogames is that they can be very expensive. This might show that the students at CGA are lower socioeconomic status that other students who play videogames often. A final thought on videogames is that the lack of videogames played by first generation immigrants could be a contributing factor to why second and third generation immigrants tend to have higher BMIs. Because playing videogames is an activity that doesn’t require much movement it may cause an increase in BMI in second-generation immigrants if they have a higher interest in playing videogames. This would be an interesting topic for further research.

One reason that the non-integrated group watches more television than the integrated group is the role of television in English language acquisition. This theory stems from the first interview, where both of the students explained how watching TV helped them learn English when they first came to the United States. Student B said, “when we first

59 came here, like, we were watching TV, I just felt like they were just speaking Chinese, but as

I watched it more and more I think it really helped me.” Student A added, “I watched it with subtitles to see what they’re saying and writing it you will understand more.” This could be another topic to research when looking at immigration, health and education. Although watching television may be the most accessible and cost-effective way of improving English language in immigrant groups, it is encouraging sedentary behavior. If research shows a strong correlation between these two variables, perhaps and intervention can be put in place, such as subsidized costs for sports teams for immigrant students to participate on teams with American-born children. c. Regression analysis

As can be seen in Table 3, regression with just the demographic characteristic yielded no correlations with statistically significant P-values. This is good for this study because it means that across the integrated and non-integrated groups any demographic differences were no significant. The regression that did have a statistically significant result was when the demographic characteristics were regressed with integration and BMI. This showed a negative relationship between integration and BMI while controlling for all of the demographic variables (coefficient=-2.2866, P=0.044). The R-squared value for this regression is low (R-squared=0.1529), but it still shows an interesting correlation and a possible avenue for future research.

This negative relationship means that when students are integrated, they tend to have a lower BMI. This is the opposite of the traditional immigrant paradox, which states that the longer an immigrant is here, the higher their BMI will be. But this is interesting, because looking at length of residency says nothing about any other measures of

60 integration, and this is a major limitation in immigration research. So why might there be a negative correlation where a positive one would be expected based on the previous research? To begin to answer this question, we need to keep in mind that the R-squared value is low, so this regression only accounts for a small fraction of the variation. This means that there are many other factors that impact the relationship between interaction with American-born people and BMI. But, this is an interesting start to see how interaction during the beginning stages of integration may correlate to BMI. Future studies can look at other factors impacting integration with BMI within the first ten years of an immigrant’s life in a new country.

Comparisons to Ohio statistics a. BMI

In Ohio, self-reported obesity among non-Hispanic white adults is 29.4 percent, while that statistic for non-Hispanic black adults was 36 percent and 30.9 percent for

Hispanic adults (Prevalence of Self-Reported Obesity Among U.S. Adults, by Race/Ethnicity and State, 2011-2013). This study is going to be compared to the adult rates because the mean age for the sample size was above 18 and the adult formula was used to calculate the

BMI of the students. Although the sample size was composed mostly of adults, it can still be compared to the adolescent statistics because this is a more similar group since they are both in school. In Ohio, 15 percent of adolescents are overweight, and 12.4 percent are obese. In the sample size, the rates over overweight and obesity were below the state rates at 10 percent for both overweight and obese students, a combined 20 percent for both measurements. This makes sense because most of the students are relatively recent immigrants, with a mean length of residency of 2.725 years. This would not allow enough

61 time for their health to converge to the health averages of the state and fits with the immigrant paradox. b. Physical activity

Compared levels of physical activity for children and adolescents in Ohio, the students at the school studied were less active than the children and adolescents in the state. In the state, 26.8 percent of children and adolescents were physically active for a total of 60 minutes for the seven days prior to the survey (Ohio: State Nutrition, Physical

Activity, and Obesity Profile). In the surveyed sample from the school, only 22.5 percent of students engaged in at least 60 minutes of physical activity every day. Yet the students have lower BMIs than the state averages for both adolescents and adults. This could be due to two main reasons.

The first reason is that the students have not been living in the United States long enough to converge to the state health averages. It takes time to build up higher-than- average BMIs that are often seen in second and third generation immigrant groups. The second reason is that the students may be doing physical activity during work that was not reported as physical activity in the survey. For example, one student reported that she cleaned people’s houses after school, but also reported that she didn’t engage in physical activity. The misunderstanding of what physical activity is could have made this number lower than what it could or should have been. The students may be living active lifestyles through work or walking places and may not realize it. c. Fruit and vegetable consumption

In Ohio, 73.8 percent of adolescents ate fruits or drank 100 percent fruit juice fewer than two times a day, and 89.4 percent of adolescents ate vegetables fewer than three times

62 a day (Prevalence of Self-Reported Obesity Among U.S. Adults, by Race/Ethnicity and State,

2011-2013). In the survey sample, 35 percent of students ate fruit fewer than two times a day and 87.5 percent of students ate vegetables fewer than three times a day. While the percentages between the groups are similar for vegetables, they are completely different for fruits. This could be because prior to coming to the United States, foods packed with refined sugar and high fructose corn syrup were not staples in the immigrants’ diets like they are in most American’s diets. Immigrants may get the satisfaction of getting something sweet from fruit as opposed to a candy bar or another food high in sugar. This would be an interesting topic to further research.

It’s interesting that the percentages of lack of vegetable consumption are similar, and part of this could be to increased consumption of fast foods, which is seen in the interviews where most of the students report eating at fast food restaurants. Many students during the survey also made a face when I asked about vegetables, hinting that they don’t like them. This may be because the vegetables in the United States are different or prepared differently than what they were used to in their home countries. Additionally, the value of taste of vegetables may decrease in comparison to greasy and salty fast foods, which are also less expensive and require no preparation.

Limitations a. Sample size

There are many limitations that impacted this study. The first that will be discussed is the small sample size, and the reasons for this small sample size. Only 80 students total were surveyed, lower than the goal number of 100, and there are a few reasons for this that were beyond my control. The first was the timing of the research. This research was

63 completed in February, and the weather was bad. The first week that I was gathering data,

Monday was a general off day, and three other days were snow days, leaving me one day in the school. After staying home an extra week I was able to collect more data, even though there were two snow days this second week. This made is especially difficult to get the parental consent forms to the students who were younger than 18, and without a constant reminder and a consistent schedule they often forgot to bring back the form even though they wanted to participate in the study.

Another limitation that affected sample size was that during the weeks I was conducting research there was also standardized testing. This meant that there was a unique schedule and zero consistency between who was in what classroom and when, and the physical location of the classes changed by the day to accommodate test takers. Luckily, the room in which I collected data was not a testing room, but the standardized testing in the school caused many other issues. It made it difficult for me to track down classes that I had recruited for the study, so finding and reminding the under-18 students to bring back their parental consent forms was a challenge. Also, some students who wanted to participate were not able to because they were testing.

The limitation also affected the sample size because I was only able to recruit students through some of the teachers, and the teachers were not always able to give up their class time for me to survey the students, especially because there was a modified schedule for the standardized testing. The teachers that I worked with were mostly teachers for the upperclassmen, so there was a major overlap in students in the classes that

I recruited from. For example, I would go into one classroom to recruit students, only to

64 realize that I had already surveyed most of them. This probably contributed to the high age of the students (mean=18.06). b. Lack of measurement for socioeconomic status

In addition to the small sample size in the study, another limitation is that there was no real measurement of socioeconomic status of the students. This is a problem because socioeconomic status is a variable that could help analyze the data. It is also a variable that has been shown to be connected to education and BMI. It would have been especially difficult to ask about income in this situation because students may not always know how much money their parents make. It is also a sensitive topic, and there are other questions that can be asked to get some idea of socioeconomic status. Asking about free or subsidized lunch would have worked in this situation, but as previously mentioned, the students all get free lunch through the school. But, there are some questions that can be asked in future research. For example, does the student work? Does the family of the student send money to their home country through remittances? What occupations do the parents of the students have? Does the student live with both parents or just one? How many siblings does the student live with? Does the student get resources through outside organizations?

One major variable that can determine a lot about accessibility to jobs and services in immigrant populations is whether an immigrant is documented or undocumented.

Because this is a very personal question and could potentially deter students from participating in the study this was not asked, which is another limitation in the study.

Undocumented immigrants experience more barriers than documented immigrants, and this could potentially impact health because without documentation it is impossible to receive benefits from programs such as Medicaid.

65 c. Too short of length of residency

Perhaps the biggest limitation of this study is that the dependent variable is one that happens over time, and most of these students have not been living in the United States for a long enough period of time for any substantial changes in BMI. It would be interesting to repeat a similar study in an immigrant population that has been living in America for at least 10 years. This would give a better idea of a correlation between integration and BMI.

It would also be great if this study could be repeated with the same population in five, 10, and 15 years. Although it would be difficult to track down the students who participated in the study, it would not be impossible since most graduates stay in the same city after graduation. Repeating this study, or creating another longitudinal study similar to this one, would be beneficial in studying health, integration, and immigration. d. Language barrier

While most of the students that I surveyed had good English language skills, some of them were not yet proficient in speaking English and it was therefore difficult for them to understand the questions. This means that some of the answers could be misinterpretations of what I was actually trying to ask. This was especially true when talking about fruits and vegetables. For some students I had to explain what they were by saying examples, such as an apple for fruit or carrots for vegetables. I’m not sure they completely understood how to conceptualize how many fruits and vegetables they were eating each day, especially if they were mixed into a meal in a different way.

The future of the school

The school is undergoing massive changes after the end of the 2014-2015 academic year. The principal is moving to another school in the district, and a new principal is

66 coming in. More significantly, many of the students are being shifted from the unique and welcoming environment of the school into other public schools in the district where they will be fully integrated. The schools enrollment as of February 2015 was at 825 students, and the maximum capacity of the building in 1,300 students (Bush, 2015). The problem is with the student teacher ratio is the classrooms, which the newspaper reports to be up to

36 per teacher and removing the students who are more proficient in English will cut it down to 20 students per teacher (Bush, 2015).

Students who are at a level 4 or higher English skill level will be reassigned to another school in the district, and levels 3’s will go on a case-by-case basis depending on factors such as how well they did on the reading and writing sections of the state’s standardized tests. Although they can get into the “preferred lottery,” which gives them a better chance of accessing one of the better schools in the district, some of them will end up going back to their home schools, the schools that correlate to where they are geographically in the district. Many of these schools have lower than average graduation rates and standardized test scores, and also have problems with gangs and drugs. This could be a bad influence for some of the students who may not have been exposed to this at the Immigrant School. Another major issue with relocating the students is that over 70 buildings in the district have no programs for non-English speakers. Although the level three and above students speak better English than when they first came to the United

States, they still benefit from an education that has an emphasis on learning English.

The school is also losing its status as a high school and will no longer be able to graduate students. It will be considered to be a program, and the test scores for the students and graduation rates will go back to the home schools for the students. This

67 means that even though the home schools have no interaction with the students at CGA, the students’ success or lack there of will be reflected in their statistics. Additionally, this provides a fragmented education for the students: they will have to switch to a different school once they hit a certain English proficiency level. This gives the students a new environment with new people, and they are moved away from their friends and mentors. It also may make the already complicated situation of moving to a new country and assimilating into a new culture more stressful than it already is.

This also may have implications on the health of the students. As this study has shown, the students who are integrated have a lower BMI than those who are not integrated within the school, and overall the students at the school have lower BMIs than the students within the district. Because CGA is a unique place where students don’t feel pressure to either hold on to or leave their cultural and religious customs, they may not integrate into what the schools culture would be at other schools in the district. These students may make friends with native-born American students and start eating more fast food with them rather than eating ethnic foods with their families. They also might engage in more sedimentary activities such as playing videogames, which are popular among high school students in the United States but were not popular in the sample group surveyed.

Additionally, because the schools they are moving to most likely have relatively poor graduation rates, this may set the students up for worse long-term health outcomes. One study found that immigrants with less than a high school education have higher BMIs than immigrants who have graduated from high school (Sanchez-Vaznaugh, E. V. et al., 2008).

68 Chapter V: Conclusion

This study was interesting because it looked at the health practices of immigrants in the midst of their integration process. Although the sample size was small, there were still statistically significant values from the regression analyses. These pointed to some interesting correlations between health and integrations, especially when looking at average BMIs between the integrated and non-integrated groups. The biggest finding was that the average BMI for the integrated group was actually lower than the non-integrated group. This is the opposite of what most research points to when defining integration as length of residency in the United States. This study shows that there are other ways of defining integration that correlate to help, and overall can help us better understand what specific factors can lead to the decline in immigrants health defined by BMI.

This project is a step in the direction of researching integration during the first ten years after immigration. By researching this specifically, we can pinpoint what unhealthy habits immigrants pick up first, which could point policy makers in the direction on what to change to prevent the decline in health seen in second and third generation immigrants.

Additionally, similar research, if expanded to larger groups, could show why there are variations in ethnic and cultural groups from different countries when it comes to integrating into American culture. Why can some immigrant groups maintain a low BMI while others struggle to do so? By repeating similar studies to this one and repeating them with other variables of integration, we may begin to figure this out.

One of the most important implications of this study and other studies focusing on integration is that it can be generalized beyond just immigrant groups. If we can figure out what unhealthy habits immigrants pick up first, and if these are consistent across different

69 immigrant groups, then we can figure out what policy changes in general can be implemented to better the health of all people in the country. Every native-born American has their own integration process into American culture, but this starts the day they are born rather than the day they arrive in America. Studies on integration could also be implicated when people within the United States move from one state to another. Because each state has a different environment and a different set of state policies, it would be interesting to see how people integrate into living in a new state, and if their health changes. This would lead researchers to figure out what factors that influence health are on an individual scale, and what factors are influenced by environment and policy. This could also be studied in people who move between urban and rural environments.

Overall, more research needs to be done on how people respond to changing environments and how these changing environments impact their health. By learning more about this, especially in the beginning stages of integration, researchers and policy makers can come up with impactful policy interventions to increase the health and wellbeing of not just those who are integrating into a new environment, but for everyone living in the area where the policy is implemented. Of course, there is much more research to be done on this topic, but this study is a start and had the utilized the unique opportunity to study immigrants in an environment where they do not often interact with American-born people with American-born parents.

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75 Appendices

Appendix A: Student Health Survey Appendix B: Student Interview

76 Appendix A Columbus Global Academy Health Survey Jennifer Bromberg, B.A. Candidate Brandeis University Department of International and Global Studies

The information collected will be completely confidential. Your name will not be associated with the information collected. Additionally, if any of the questions make you uncomfortable or you do not want to answer them they can be skipped. This interview may be stopped at any point. If you experience any psychological distress during this interview, you can seek help from the school principal, the teachers or the school counselor.

Gender identification: _____ Height ______Weight ______

Where were you born? ______

What religion do you identify with? ______When were you born? ______

What countries have you lived in? For how long were you in each country? ______

When did you come to the United States? ______

When did you come to Columbus, Ohio? ______

When did you start attending this school? ______

Thinking about the last week, how many hours on average did you spend with non- immigrant/refugees each day? ______

Thinking about the last week, how many hours on average did you spend watching TV/playing video games each day? ______

Thinking about the last week, how many hours on average did you participate in physical activity each day? _____

Thinking about the last week, how many meals outside of school did you eat on average each day? ______

Thinking about the last week, how many times did you bring your own lunch to school? _____

Thinking about the last week, how many times on average did you eat fruit each day? _____

Thinking about the last week, how many times on average did you eat vegetables each day? _____

77 Appendix B

Columbus Global Academy Student Interview Jennifer Bromberg, B.A. Candidate Brandeis University Department of International and Global Studies

The information collected will be completely confidential. Your name will not be associated with the information collected. Additionally, if any of the questions make you uncomfortable or you do not want to answer them they can be skipped. This interview may be stopped at any point. If you experience any psychological distress during this interview, you can seek help from the school principal, the teachers or the school counselor.

Background information: • In what country were you born? • Have you lived in any other countries? If yes, for how long did you live in those countries? • What meals did you eat on an average day before you came to America? • What was your favorite food before coming to America? • Did you cook/help cook before you came to America? If yes, what kind of food did you make? • Did you exercise or play any sports before you came to America?

Diet/Health in America: • What is your favorite food? • Do you enjoy the breakfast and lunch that the school provides? • What are some new foods you have experienced since coming to the United States? • Do you ever cook/help someone else cook? If yes, what kind of food do you make? • Do you ever buy food at restaurants? If yes, what restaurants do you go to? How often do you go? • How many meals a day during a typical week do you eat meals outside of school? Who do you usually eat these meals with? Where do you eat these meals? • Do you ever get food or meals from a religious institution, such as a church or a mosque? • What is your favorite form of exercise? How often do you do this, or other, exercise during an average week?

Interactions with immigrants/non-immigrants • Thinking about the past week, on an average day how often do you talk to students from a different country of origin outside of class? • Thinking about the past week, on an average day how often do you speak English when you are not in school? • Thinking about your time so far in the United States, how often would you say you interact with people who were born in the United States and do not have immigrant parents other than your teachers?

78 • Thinking about other students that you know, how often do you think they interact with non-immigrants who do not have immigrant parents?

Questions about Daily Life • Do you ever read American magazines? If yes, which ones do you read? • Is there a television in your house/apartment? If yes, thinking about the average week, how often do you watch it? What shows do you usually watch? • Do you think about how healthy/unhealthy the food you are eating is? • What is your primary mode of transportation? Do you walk, ride a bike, drive, or take the bus? • What do you like to do after school is over?

Concluding Question • Is there anything else you want to share regarding your health or the health of your classmates that you think would be important for me to know?

79