Exploring obesogenic environments: the design and development of the migrant obesogenic perception of the environment questionnaire (MOPE-Q) using a sample of Iranian migrants in Australia

As early as 1998, the World Health Organization (WHO) declared obesity to be a problem of epidemic proportions in most Westernized countries, contributing to a wide range of health and social consequences [1]. Specifically, over the last three decades, obesity has become a major public health concern across high, middle and some low income countries where Western behavioural and dietary patterns are evident [2, 3]. Migrant populations represent a particularly interesting case because of the similar, but accelerated, nutritional transition which they experience when moving from low or middle income countries to high-income western countries [4, 5]. A growing number of studies in high income countries have demonstrated a stepwise increase in the prevalence of obesity among migrants [5]. In Western societies, migrants are often healthier than local residents at the time of arrival due to the ‘healthy migrant effect’ of the immigration process. That is, people typically have to be in considerably good health to be eligible for immigration. They are therefore generally in better physical health than their hosts. However, typically the health of migrants regresses to the host country’s norm after a some years of residency [6], and a number of studies have reported that the body mass index (BMI) of migrants can quite rapidly increase beyond that of the local population [7, 8]. People’s behaviors are heavily influenced by their physical, social and cultural environments. In terms of obesogenic behaviour, the strength of these influences significantly overwhelms other factors, such as those related to genetics [3, 9]. As such, socio-ecological models, such as the ANGELO (Analysis Grid for Environments Linked to Obesity) framework [10], describe the physical and socio-cultural, economic and policy dimensions of the community in which they live and which influence their diet and physical activity patterns. Specifically, the ANGELO framework broadly divides obesogenic environments into two levels (micro/settings and macro/sectors) and four types (physical, economic, policy and socio-cultural). This model has been used over the past 15 years for many different purposes relating to obesogenic environments and it has proved to be very robust [11‐13]. Thus, the ANGELO is wide in scope, and acknowledges the notion that obesity prevention in migrant populations requires a broad environmental focus on determinants of obesity, beyond the individual level. While there seems to be greater awareness of the need for creating community initiatives aimed at reducing obesity based on comprehensive frameworks such as the ANGELO [12], the evidence base underpinning the knowledge on which particular issues relate to obesity rates in migrant populations is sparse.

As mentioned above, many migrant groups adopt obesogenic behaviours and experience weight gain as they acculturate to their new environment. This experience particularly relates to immigrants from countries with a low or medium human developmental index (HDI) to countries with a high HDI [14]. However, it is not uniform across all migrant groups, and may differ as a result of factors such as country of origin and degree of acculturation [6]. Acculturation relates to the immigrant adoption of the attitudes, values and behavioural patterns of the host culture to which they have migrated. This also includes health behaviours, such as those connected to obesity [4, 15]. A large number of studies show that the relationship between obesity and acculturation differs between specific immigrant groups with various populations demonstrating elevated, reduced, or unchanged weight in relation to the degree of acculturation. For example, Fitzgerald and colleagues found an overall positive association between the degree of acculturation and body weight status in Mexican-Americans [16] – a finding which has been supported by other studies [17, 18]. Further, while there is limited research investigating gender differences in the association between BMI and acculturation, Lee and colleagues found no significant relationship between acculturation and obesity in their female sub-sample [19]. Other studies have found negative or mixed associations, including less obesity in migrant women [20‐22]. This observation reinforces the argument that, in all likelihood, a complex interaction between culture, ethnicity, gender and place of origin impacts on a range of health-related factors, including obesity. That is, the migrant carries personal factors – some fixed like gender, and others which change temporally such as age – across countries which interact with the change in environments between countries. Broad-scale approaches to obesity prevention in migrant populations are thus more likely to succeed if environmental obesogenic factors are understood and used to shape relevant initiatives and interventions. This interaction is what is hypothesized to help explain the variations in changes in diet, physical activity patterns and weight among migrants [23].

In order to develop the evidence base for explaining predictors of unhealthy weight gain post-migration, phenomena such as the ‘healthy migrant effect’, the ANGELO framework and acculturation theory need to be integrated and synthesized. Thus, assumptions about the relative importance of each of the constructs, in terms of obesity-linked behaviour, need to be tested. While most studies have demonstrated that the foreign-born members of the community experience some changes in their BMI post migration, the majority of these studies fail to measure environmental elements that may directly or indirectly affect migrants’ obesogenic behaviour [6]. There are several reasons for this. First, comparison groups often comprise natives of the host country rather than natives living in the country of origin. That is, second- and third-generation immigrants may be used as controls. Second, few studies of international migration contain information about the migrants’ past way of life and social environment, with most focusing solely on migrants’ degree of acculturation. Third, most existing research about acculturation has relied on surrogate measures of acculturation (e.g. place of birth, language, length of residency in the host country) rather than standardized scales of acculturation. Fourth, previous studies show migrants are generally healthier than their local counterparts and attribute this result to the positive selection of migrants on health. Most of these studies, however, do not examine the extent to which migrants’ health varies as a function of pre-migration health environment or their specific reasons for migration (e.g. refugee, family, work force, educational opportunity, etc.) [6, 23].

Thus, while acculturation theories may be useful for predicting migrants’ post-immigration obesity rates, they are largely based on individual migrant characteristics and obesity status, with little understanding of the effects of changing environments on migrant BMI. In light of this, similarities and differences between health-related pre- and post-migration environmental elements should also be investigated to help both improve our understanding of, and inform public health efforts to prevent, obesity. This is especially critical for increasingly multicultural countries like Australia. Thus, systematic research on this topic is required. To do this effectively and empirically, a valid and reliable measure that can distinguish the key obesogenic elements in specific environments, is needed. In previous study, we sought to understand the changes in environment experienced by migrants to Australia and how this may have impacted on their health [23]. Results indicated an emphasis on both individual and environmental factors in this context. In light of this, the current paper describes the design and methodological components of the Migrant Obesogenic Perception of the Environment questionnaire (MOPE-Q). The developed scale also provides a snapshot of how factors in home and host countries have been experienced differently by a sample of Iranian migrants in Australia.

In developing the questionnaire, we conducted a structured approach including, 1) transitional validity tests (i.e. content validity, face validity, and factor extraction), and 2) reliability tests (i.e. equivalence reliability to check the internal consistency of the scale and finally stability reliability, test re-test) [24].

Immigrants experience a range of environmental and social changes as they move between home and host environments. These differences in environments often have the potential to impact directly on the immigrant’s physical health, including for example body weight. This study developed and tested a new scale for measuring the impact on immigrants to Australia of the change in environmental determinants of obesity experienced as they migrate from their homeland (Iran) to their host (Australia) country. Employing both qualitative and quantitative processes was relevant in choosing, reviewing, and extracting items. This was particularly important when attempting to employ items across two different settings that have been experienced by a sample of Iranian immigrants in Victoria, Australia. Furthermore, using qualitative information from previous study [8] on Iranian migrants enabled us to determine different aspects of Iranian migrants’ experiences rather than solely relying on scholars’ theories and guidance from previous obesity and migrants’ health research.

The emphasis on physical activity environments and government liveability policies in Australia as important influences on healthy weight behaviour in Australia was notable. By contrast Iran was perceived by most as an environment promoting physical inactivity. In terms of food environment, the majority of our participants also indicated that the existence of a generally unhealthy food environment in Australia discouraged them from following a healthy diet. The food environment was also a factor in Iran – however, for Iran there were relatively high factor loadings for a healthy food environment. Together, these results underscore the overall importance of food environment and social norms for healthy weight behaviour in both Australia and Iran.

Another factor mentioned frequently by participants related to the media as a silent environmental key factor in Iran and suggested that if the media was positive in terms of health promotion then it could possibly encourage Iranians to have healthier weight-related behaviours. This is particularly interesting as past research has not examined the effect of Iranian media on Iranians body image concern [38]. Our results, however, do not warrant clear conclusions, but encourage future research to investigate this relationship further.

Overall, adding the environmental dimension in assessment of the relationship between acculturation and migrant obesity has undoubtedly increased the complexity of the migration-obesity paradigm. Ultimately, however, it can be argued that considering both culture and environment in this context affords a truer reflection of migrant experiences, and thus a better understanding of the impact of migration on obesity.

The influences of obesogenic environments on behaviours are inherently complex and most models have considered the relationship at one point in time. This study takes account of the changing environments as migrants move from one country to another, and experience changes in the obesogenicity of the different aspects of the environment (including socio-cultural environments), that they need to meld with their own culture of beliefs, attitudes, cuisine and so on. This study has started to construct this dynamic aspect of behavioural-environment interaction to build on understandings of cross-sectional relationships. Thus, the MOPE-Q is the first questionnaire developed to measure perceived environmental changes in the determinants of obesity in migrant populations. The factor analysis provided valuable information in addition to reliability testing and confirmed the MOPE-Q as a valid and reliable instrument to be used among Iranian migrant groups in Australia and could be further tested on Iranian migrants in other countries with the same socio-cultural, economic and policy status. The outcome of rigorous validity and reliability tests for both the Iran questionnaire and the Australia questionnaire revealed that responses were very consistent over time, and thus provided testament to the soundness of the instruments’ psychometric properties.

In future research, this questionnaire may also help develop evidence-based and culturally appropriate obesity prevention in Iran and other similar countries.

Further, insight into obesogenic socio-cultural factors in Australia may also be gained through use of the MOPE-Q. It may have implications for obesogenic factors which are changeable in Australia as well as other societies.

In terms of future research, we will use the MOPE-Q for further study of the effect of environmental determinants of obesity on food habits, physical activity as well as the BMI of Iranian migrants in Victoria, Australia. It is also possible that the instrument could be applied to other ethnic groups, although researchers would need to take into account the cultural relevance, migration experiences, home and host environments, and the perceived diversity of obesogenic factors for each targeted migrant group. Finally, we believe that the MOPE-Q could be modified for application in other high income countries that mirror the socio-cultural and economic environment in Australia.

Dr. Maryam Delavari is a PhD Scholar in WHO Collaborating Centre for Obesity.

Prevention, School of Health& Social development, Deakin University, Australia.

Anders L. Sønderlund is a PhD researcher and research fellow at the School of Psychology, College of Life and Environmental Sciences, University of Exeter, UK.

Dr. Mohammadreza Mohebbi is a senior research fellow in Biostatistics Unit, Faculty of Health, Deakin University, Melbourne, Australia.

David Mellor is a Professor in the School of Psychology and Director of the professional postgraduate programs, Deakin University, Australia.

Boyd Swinburn is a Professor of Population Nutrition and Global Health, University of Auckland as well as Alfred Deakin Professor and Director of WHO Collaborating Centre for Obesity Prevention, Deakin University, Australia.