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Research Article
Issue Date: September/October 2016
Published Online: July 27, 2016
Updated: January 01, 2021
Exploratory Study of the Clinical Utility of the Pizzi Healthy Weight Management Assessment (PHWMA) Among Burmese High School Students
Author Affiliations
  • Fengyi Kuo, DHS, OTR, CPRP, is Visiting Faculty, Department of Occupational Therapy, School of Health and Rehabilitation Sciences, Indiana University, Indianapolis, and Occupational Therapist, LIH–Olivia’s Place Pediatric Services, Shanghai, China; fkuo@iu.edu
  • Michael A. Pizzi, PhD, OTR/L, FAOTA, is Associate Professor, Dominican College, Orangeburg, NY
  • Wen-Pin Chang, PhD, OTR/L, is Assistant Professor, Department of Occupational Therapy, School of Pharmacy and Health Professions, Creighton University, Omaha, NE
  • Sarah J. Koning, MS, OTR/L, is Occupational Therapist, Olympia Transitional Care and Rehabilitation, Olympia, WA
  • Aaron S. Fredrick, MS, OTR/L, is Occupational Therapist, Legacy Healthcare Services, Anderson, IN
Article Information
Health and Wellness / School-Based Practice / Special Issue: Research Articles
Research Article   |   July 27, 2016
Exploratory Study of the Clinical Utility of the Pizzi Healthy Weight Management Assessment (PHWMA) Among Burmese High School Students
American Journal of Occupational Therapy, July 2016, Vol. 70, 7005180040. https://doi.org/10.5014/ajot.2016.021659
American Journal of Occupational Therapy, July 2016, Vol. 70, 7005180040. https://doi.org/10.5014/ajot.2016.021659
Abstract

OBJECTIVE. Immigrant youth in the United States are at greater risk for weight management problems than non-Hispanic White youth. We used the Pizzi Healthy Weight Management Assessment (PHWMA) to capture data on health perceptions and weight management behaviors among adolescent Burmese refugees.

METHOD. We conducted a retrospective descriptive study of 20 Burmese refugee high school students.

RESULTS. The results captured an understanding of health perceptions and weight management behaviors of the program participants. The PHWMA was found to be a valid and reliable tool for use by occupational therapy practitioners.

CONCLUSION. Findings from this study can inform program development and evaluation in outreach efforts to enhance minority youths’ health and well-being.

Childhood obesity has more than tripled in the past 30 yr in the United States. The percentage of adolescents ages 12–19 who were obese increased from 5% in the 1980s to 18.4% in 2009–2010 (Ogden, Carroll, Kit, & Flegal, 2012). Overweight and obesity have consequences for a nation’s health and economy (Cawley, 2010). In the United States, obesity has been linked to chronic diseases and long-term psychosocial impacts, including cardiovascular risk, hyperlipidemia, hypertension, diabetes, sleep apnea, negative body image, and bullying (Dietz, 1998; Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007; Pizzi & Vroman, 2013). Many communities contribute to unhealthy lifestyles by limiting access to healthy food choices and few opportunities for exercise (World Health Organization [WHO], 2016); “these issues affect one’s occupational performance and occupational choices and lead to occupational alienation, occupational deprivation and occupational marginalization” (Pizzi, 2013a, p. 78). Healthy lifestyles, including healthy eating and physical activity, can lower the risk of becoming obese and developing related diseases (Ogden et al., 2012).
Literature Review
Obesity affects not only the U.S.-born population but also immigrant populations. The Centers for Disease Control and Prevention (2011)  reported that “substantial racial/ethnic disparities exist, with Hispanic boys and non-Hispanic Black girls disproportionately affected by obesity” (p. 42). Research has indicated that the rise in obesity is particularly evident among immigrant youth (Balistreri & Van Hook, 2009; Goel, McCarthy, Phillips, & Wee, 2004; Himmelgreen et al., 2004; Labree, van de Mheen, Rutten, & Foets, 2011).
Several studies have addressed the relationship between acculturation and health perceptions for immigrant youth (Gualdi-Russo et al., 2012; Van Hook & Baker, 2010). For example, the prevalence of obesity in non-Hispanic Black and Mexican-American children is higher than in non-Hispanic White children (Suarez-Balcazar, Friesema, & Lukyanova, 2013; Wang & Beydoun, 2007). In addition, Van Hook and Baker (2010)  found that kindergarten-age boys with immigrant parents weighed more and gained weight faster than those with native-born parents and suggested that social isolation and lack of knowledge about American junk food might contribute to weight gain among immigrant youth. This finding, however, did not hold true for girls, which may be related to disparities in expectations of boys and girls in other cultures (Van Hook & Baker, 2010).
In contrast to studies showing high obesity prevalence in immigrant youth, a study by Singh, Kogan, and Yu (2009)  found that the childhood obesity prevalence among 12 U.S. immigrant groups was lower overall than among native-born Americans. The authors indicated that immigrants become more susceptible to obesity as acculturation occurs over each generation (Singh et al., 2009).
Conflicting results regarding body weight comparisons of immigrants and native-born Americans may suggest that specific cultural identities of immigrant youth should instead be considered for comparison. For instance, the Community Energy Balance framework addresses the balance of food intake and energy expenditure for minority groups in terms of historical, structural, and sociocultural influences (Kumanyika et al., 2012). If a person’s history includes experiences of hunger, for example, migrating to a land with a surplus of affordable food may lead to habits involving excessive caloric intake. Flores, Maldonado, and Durán (2012)  concluded that understanding Latino parents’ perspectives on healthy eating, physical activity, and weight management strategies and finding ways to keep traditional food customs alive are likely to yield favorable outcomes in addressing childhood obesity among Latino immigrants.
Several studies have examined the effectiveness of health and wellness promotion programs among immigrant and minority youth. Muckelbauer et al. (2010)  studied the effects of immigrants’ background on the efficacy of a school-based childhood overweight prevention program that promoted healthy weight management through increased water intake and education on hydration. The intervention was more effective for nonimmigrant children than for immigrant children. It appears that cultural differences between the two groups influenced the effectiveness of the intervention (Muckelbauer et al., 2010).
A study by Davidson et al. (2013)  addressed the need to culturally adapt health promotion programs to the targeted population, a need implied by Muckelbauer et al. (2010) . The authors conducted a systematic review of the literature and qualitative interviews with health educators and researchers who had experience working with people of African, Chinese, and South Asian descent. The focus of each part of the mixed methodology was on smoking cessation, healthy eating, and physical activity programs in various cultural contexts. The authors concluded that culturally adapting health and wellness programs requires broad consideration of the population’s context, reflection on the usefulness of adapted programs, and acknowledgment of the methods used to adapt programming. The authors synthesized their findings into a toolkit of adaptation approaches to be used by researchers and practitioners for culturally sensitive health promotion program development (Davidson et al., 2013).
Wang-Schweig, Kviz, Altfeld, Miller, and Miller (2014)  also supported the need for cultural adaptation of health promotion programs. Their approach differed from that of Davidson et al. (2013), however, because they emphasized the importance of using a conceptual framework to guide program adaptation. The authors argued that adapting a program on the basis of cultural characteristics alone is “surface level change” and that applying theory in context provides change at a deeper level that is more effective. The authors outlined four steps for culturally adapting health promotion programs at a deep, structural level and provided an example of the process using their research with Chinese-American families in an alcohol abuse prevention program (Wang-Schweig et al., 2014).
Suarez-Balcazar et al. (2013)  developed a conceptual model for cultural competence based on cognitive, behavioral, and contextual factors. This empirically validated model was generated from a systematic review of the literature that examined culturally competent interventions to address obesity among African-American and Latino children and youth. Suarez-Balcazar et al. (2013)  suggested that multilevel strategies are needed for obesity interventions in order to promote healthy eating, physical activity, and healthy lifestyles.
Purpose of the Study
An understanding of the perspectives of youth and their parents on weight management strategies is likely to promote favorable outcomes in addressing problems related to weight management among immigrants (Flores et al., 2012). Over the past few years, Indiana has become the largest Burmese refugee resettlement state in the United States. We used the Pizzi Healthy Weight Management Assessment (PHWMA; Pizzi, 2013b) to capture health perceptions and weight management behaviors among adolescent Burmese refugees resettled in central Indiana who participated in the Summer Scholars Program, which was coordinated and implemented by a nongovernmental organization, the Burmese American Community Institute (BACI), during the summer of 2013. In addition to describing participants’ health perceptions and weight management behaviors, this study also aimed to provide insight into how assessment of participation and weight management strategies may promote greater engagement in healthy weight management and to guide program development in wellness and health promotion for immigrants and refugees.
Method
Participants
Twenty Burmese refugee high school students participating in the Summer Scholars Program voluntarily completed the PHWMA. Participants included 14 female and 6 male students from two community high schools. Participants were able to read, write, and understand English and had not participated in the Summer Scholars Program in the past; there was no requirement that program participants be overweight or obese.
The Summer Scholars Program was an 8-wk scholarship program that used participatory action research to provide skills building and leadership development to empower Burmese students. The program focused on team building, healthy behaviors, English language development, college preparation, university campus visits, and application of critical thinking. Program participants worked in small groups to identify future educational and career goals. With guided mentorship from community stakeholders and leaders, students conducted research and proposed strategies to address issues related to human rights and social justice with a global perspective. Program participants met 5 days a week during the summer months of June and July for approximately 4–5 hr per day at a local university campus. Program activities were highly interactive, fun, and intensive, and healthy weight management was incorporated into the curriculum.
Design and Procedures
This study used a retrospective descriptive design. A copy of the PHWMA was provided to a convenience sample of 20 Burmese refugee high school students who attended the Summer Scholars Program. The students were asked to complete the PHWMA when attending the module of healthy behaviors at the community classroom hosted for the Summer Scholars Program. The assessment was used as a part of the program to enable participating students to reflect on their weight status, individual healthy weight management strategies, and potential areas for improvement related to health status. The study was reviewed and approved by the Indiana University’s institutional review board in the exempt category. The procedures were reviewed and approved by the BACI education committee and board of directors to be included in the Summer Scholars Program.
Instrument
The PHWMA (Pizzi, 2013b) was developed on the basis of the childhood obesity literature; the International Classification of Functioning, Disability and Health: Children and Youth Version (WHO, 2007); the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014a); and health behavior change theories. The PHWMA consists of two sections: The first section has 24 items identifying health factors related to weight management, and the second section focuses on identification of the top five areas to change. For the first section, each item consists of four domains:
  1. Want to change (self-rated on a 5-point Likert scale, where 1 = do not want to change and 5 = strongly want to change)

  2. Stress level in this area (self-rated on a 3-point Likert scale, where 0 = not stressful at all and 2 = very stressful)

  3. Want to work on (yes or no)

  4. What can be done to improve this area.

Additional qualitative comments can also be provided for each item. Although want to change and want to work on may literally mean the same thing, the latter domain helps assess whether the respondent wants to change.
The second section is based on the list of 24 items in the first section. Participants can provide comments on the top five areas to change. It also includes two open-ended items: (1) reason I want to make this change and (2) type of help I might need to make changes. It also has one yes–no item: “I feel I can make this change by myself without help.”
The PHWMA is the first occupation-centered assessment to include self-reflections, goal attainment, and self-efficacy in weight management. It also examines occupational participation related to weight management and healthy lifestyle. This instrument is intended to help occupational therapy professionals promote engagement in healthy weight management and guide health promotion program development through community partnerships.
During the initial development of the PHWMA, an expert panel of occupational therapy, physical therapy, and social work professionals examined its construction and content. Changes based on their feedback were made for clarity in answering the questions. The revised instrument was returned to the expert panel, who made no further comments. Both content and face validity have been established, and the tool has been found to be clinically useful (Pizzi, 2013a, 2013b).
The PHWMA has two versions: a child/youth version and a parent version. The parent version was used with 8 Orthodox Jewish mothers to explore their perceptions and the occupational needs of their overweight or obese child (Pizzi, 2015). The results showed that adapting to a new culture was a barrier to healthy weight management. For example, the mothers indicated that food, often in large quantities, was part of each week’s cultural and religious rituals (Pizzi, 2015). In the present study, the child/youth version was used.
Data Analysis
The primary data were the participants’ demographics and the 24 items of the PHWMA. Descriptive statistics were used for the primary data. In addition, to explore whether the 24 items measured the construct of healthy weight management and the interrelatedness among the items, the internal consistency measure of Cronbach’s α using the scores of want to change was calculated.
Because participants were asked to answer want to change or want to work on for each item, γ correlation was carried out to explore consistency between the answers. To explore whether there was a relationship between stress level and want to work on and between stress level and want to change, γ correlation and Kendall’s τ-b correlation, respectively, were performed. A positive correlation indicates that two parametric variables are linearly related and change in the same direction, and a negative correlation indicates that two parametric variables change in the opposite direction. Statistical significance was inferred at a 2-tailed p level of <.05. Statistical analysis was performed using IBM SPSS Statistics (Version 22; IBM Corporation, Armonk, NY).
Qualitative data were entered into an Excel (Microsoft Corporation, Spokane, WA) spreadsheet for thematic analysis (Miles, Huberman, & Saldaña, 2014). Data included identification of the top five areas to change. Two researchers individually reviewed the identified areas to change and color coded the data into separate categories.
Results
The 20 participants were ages 16–21 yr (mean [M] = 17.90, standard deviation [SD] = 1.37); 6 were male and 14 were female. Table 1 presents descriptive results for the 24 items of the PHWMA. For want to change, the item spending time with family had the highest mean (M = 3.20/5, SD = 1.64) and able to choose play, fun, or leisure activities for myself the lowest (M = 1.95/5, SD = 1.10). For stress level, keeping a schedule for things I do in my day and being able to study (M = 1.30/2, SD = 0.66) had the highest mean and feeling safe at home the lowest (M = 0.37/2, SD = 0.60). Regarding the area that participants wanted to work on, most (17) identified keeping a schedule for things I do in my day and being able to study (see Table 1).
Table 1.
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)×
ItemDo You Want to Change? M (SD)How Stressful Is This Area?Do You Think You Want to Work on This Area?
M (SD)Not (%)Sometimes (%)Very (%)Yes (n)No (n)
Able to choose play, fun, or leisure activities for myself1.95 (1.10)0.60 (0.60)45505128
Doing play, fun, or leisure activities2.20 (1.20)0.75 (0.79)453520164
Getting ready for school2.95 (1.36)1.10 (0.91)352045164
Keeping a schedule for things I do in my day3.10 (1.29)1.30 (0.66)105040173
My physical health2.70 (1.38)0.65 (0.75)503515146
Eating habits and routines (e.g., in front of the TV, too late at night)2.85 (1.14)1.00 (0.80)304030164
Time I spend in front of the TV or on a computer2.90 (1.12)1.20 (0.83)253045154
Eating junk food and fast food3.05 (1.54)0.74 (0.73)404015910
Eating fruits and vegetables2.60 (1.57)0.50 (0.69)603010137
Being able to study3.05 (1.28)1.30 (0.73)154045171
Being able to learn2.95 (1.23)1.10 (0.85)303040164
Spending time with family3.20 (1.64)0.40 (0.75)751015117
Amount of sweets eaten each day2.75 (1.62)0.65 (0.67)454510109
My weight2.40 (1.14)0.88 (0.76)354525146
My friends2.40 (1.50)0.65 (0.81)5525201010
Feeling safe in school2.10 (1.25)0.75 (0.85)502525614
My happiness2.45 (1.61)0.50 (0.83)701020910
My overall coping abilities (can I deal with things OK?)2.72 (1.27)0.79 (0.71)354515136
Where I live2.00 (1.49)0.55 (0.83)651520511
Feeling safe at home2.11 (1.66)0.37 (0.60)65255810
My ability to deal with change2.53 (1.31)0.95 (0.78)304025107
Doing things I like to do2.65 (1.39)0.80 (0.83)453025135
How much I participate in sports or outdoor activities2.55 (0.95)0.70 (0.73)454015163
How much I sleep2.60 (1.27)1.05 (0.89)352540136
Table Footer NoteNote. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.
Note. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.×
Table 1.
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)×
ItemDo You Want to Change? M (SD)How Stressful Is This Area?Do You Think You Want to Work on This Area?
M (SD)Not (%)Sometimes (%)Very (%)Yes (n)No (n)
Able to choose play, fun, or leisure activities for myself1.95 (1.10)0.60 (0.60)45505128
Doing play, fun, or leisure activities2.20 (1.20)0.75 (0.79)453520164
Getting ready for school2.95 (1.36)1.10 (0.91)352045164
Keeping a schedule for things I do in my day3.10 (1.29)1.30 (0.66)105040173
My physical health2.70 (1.38)0.65 (0.75)503515146
Eating habits and routines (e.g., in front of the TV, too late at night)2.85 (1.14)1.00 (0.80)304030164
Time I spend in front of the TV or on a computer2.90 (1.12)1.20 (0.83)253045154
Eating junk food and fast food3.05 (1.54)0.74 (0.73)404015910
Eating fruits and vegetables2.60 (1.57)0.50 (0.69)603010137
Being able to study3.05 (1.28)1.30 (0.73)154045171
Being able to learn2.95 (1.23)1.10 (0.85)303040164
Spending time with family3.20 (1.64)0.40 (0.75)751015117
Amount of sweets eaten each day2.75 (1.62)0.65 (0.67)454510109
My weight2.40 (1.14)0.88 (0.76)354525146
My friends2.40 (1.50)0.65 (0.81)5525201010
Feeling safe in school2.10 (1.25)0.75 (0.85)502525614
My happiness2.45 (1.61)0.50 (0.83)701020910
My overall coping abilities (can I deal with things OK?)2.72 (1.27)0.79 (0.71)354515136
Where I live2.00 (1.49)0.55 (0.83)651520511
Feeling safe at home2.11 (1.66)0.37 (0.60)65255810
My ability to deal with change2.53 (1.31)0.95 (0.78)304025107
Doing things I like to do2.65 (1.39)0.80 (0.83)453025135
How much I participate in sports or outdoor activities2.55 (0.95)0.70 (0.73)454015163
How much I sleep2.60 (1.27)1.05 (0.89)352540136
Table Footer NoteNote. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.
Note. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.×
×
With respect to the construct of healthy weight management and the interrelatedness of the 24 items, Cronbach’s α using the scores of want to change was .897, which is considered good to excellent reliability. The results of γ correlation between want to change and want to work on showed that only three items—(1) able to choose play, fun, or leisure activities for myself; (2) doing play, fun, or leisure activities; and (3) time I spend in front of the TV or on a computer—showed a significant correlation (Table 2). For the relationship between stress level and want to work on and between stress level and want to change, more items showed a statistically significant relationship between stress level and want to work on compared with stress level and want to change (see Table 2).
Table 2.
Correlations Between Stress Level, Want to Change, and Want to Work On
Correlations Between Stress Level, Want to Change, and Want to Work On×
ItemWant to Change and Want to Work OnStress Level and Want to Work OnStress Level and Want to Change
γpγpτ-bp
Able to choose play, fun, or leisure activities for myself.697.017.806.008.385.048
Doing play, fun, or leisure activities1.000.0061.000.008.207.298
Getting ready for school.308.334.100.850.205.203
Keeping a schedule for things I do in my day.744.102.882.062.127.606
My physical health.627.067.811.013.167.373
Eating habits and routines (e.g., in front of the TV, too late at night).404.326.636.091.541<.0005
Time I spend in front of the TV or on a computer.922.014.918.008.643<.0005
Eating junk food and fast food.0001.0000.912<.0005.239.249
Eating fruits and vegetables.057.8841.000<.0005.386.052
Being able to study.692.302.398.275.138.569
Being able to learn.630.073.625.179.203.268
Spending time with family−.067.8541.000.004.109.584
Amount of sweets eaten each day.452.134.800.005.620<.005
My weight.600.0871.000<.0005.324.139
My friends.302.354.949<.0005.212.266
Feeling safe in school.536.078.556.082.392.024
My happiness.457.141.714.085.018.936
My overall coping abilities (can I deal with things OK?)−.393.3461.000<.0005−.234.296
Where I live.310.547.956.002.055.802
Feeling safe at home.333.4221.000<.0005−.100.621
My ability to deal with change.429.219.818.001.126.556
Doing things I like to do.474.235.875.005.460.004
How much I participate in sports or outdoor activities.150.7951.000.031.149.447
How much I sleep.667.046.971<.0005.319.127
Table 2.
Correlations Between Stress Level, Want to Change, and Want to Work On
Correlations Between Stress Level, Want to Change, and Want to Work On×
ItemWant to Change and Want to Work OnStress Level and Want to Work OnStress Level and Want to Change
γpγpτ-bp
Able to choose play, fun, or leisure activities for myself.697.017.806.008.385.048
Doing play, fun, or leisure activities1.000.0061.000.008.207.298
Getting ready for school.308.334.100.850.205.203
Keeping a schedule for things I do in my day.744.102.882.062.127.606
My physical health.627.067.811.013.167.373
Eating habits and routines (e.g., in front of the TV, too late at night).404.326.636.091.541<.0005
Time I spend in front of the TV or on a computer.922.014.918.008.643<.0005
Eating junk food and fast food.0001.0000.912<.0005.239.249
Eating fruits and vegetables.057.8841.000<.0005.386.052
Being able to study.692.302.398.275.138.569
Being able to learn.630.073.625.179.203.268
Spending time with family−.067.8541.000.004.109.584
Amount of sweets eaten each day.452.134.800.005.620<.005
My weight.600.0871.000<.0005.324.139
My friends.302.354.949<.0005.212.266
Feeling safe in school.536.078.556.082.392.024
My happiness.457.141.714.085.018.936
My overall coping abilities (can I deal with things OK?)−.393.3461.000<.0005−.234.296
Where I live.310.547.956.002.055.802
Feeling safe at home.333.4221.000<.0005−.100.621
My ability to deal with change.429.219.818.001.126.556
Doing things I like to do.474.235.875.005.460.004
How much I participate in sports or outdoor activities.150.7951.000.031.149.447
How much I sleep.667.046.971<.0005.319.127
×
The 20 participants’ responses were grouped into seven major categories of areas to change (88 data points in order of percentage): (1) healthy weight management (27%), (2) education (25%), (3) time management (23%), (4) sleep habits (12%), (5) internal characteristics (6%), (6) social participation (5%), and (7) home location (2%). The subcategories included in healthy weight management were gaining or maintaining weight, increasing physical health, keeping a healthy diet, and continuously engaging in sports and exercise. Many participants reported a lack of satisfaction with their weight, reflected in comments such as “My weight is very low and I look bad,” “I’m fat,” “I couldn’t wear the dress I like,” and “I feel like my health is not [good] enough, and I am hungry at midnight.” They also expressed a desire for change to maintain healthier weight management behaviors.
The subcategories included in the education category were studying and reading; getting ready for school; and improving concentration, language proficiency, and confidence, reflected in the following comments: “I don’t want to be lazy,” “I wanna be smart enough to take care of my family,” “I didn’t prepare myself [enough],” “It’s hard for me to learn and my grades are bad,” “I spend too much [time] on other things,” “[I am] afraid to learn in English class,” and “[I’m always] rushing at the last minute.” Several participants reported a strong desire to study hard to “have more knowledge,” “get a 4.0 [grade point average],” and “be successful in life.”
The subcategories included in time management were keeping a schedule, cutting back on computer and TV time, and having time for leisure. Some participants indicated that they spent too much time on social media and watching TV. As a result, they felt they were not able to focus on other things or did not allocate enough time for things they wanted to do. One participant reported that the amount of TV watching was straining his eyesight.
In the category of sleep habits, several participants identified experiencing imbalanced sleep patterns such as too much or too little sleep. They commented that their imbalanced sleep patterns affected their physical and mental health; for example, they reported feeling sleepy all day, being stressed, and being self-conscious because of dark circles under their eyes.
The subcategories included in internal characteristics involved patience, flexibility, coping ability, and pursuit of happiness. Several students reported a sense of disengagement and lack of confidence; they stated, “wherever I go, I can’t be happy,” “I’m only happy at home,” “I can’t accept change,” “I get mad easily,” and “I can’t do what other people can do because I’m too shy.” Several indicated a desire to improve their psychosocial well-being by commenting about “wanting to be a more positive person.”
The category of social participation included spending quality time with family members and friends. Finally, two participants indicated a desire to change their home location, reporting their living arrangement as noisy and lacking in safety and quality.
Discussion
The results of this study indicate that the PHWMA is able to capture data on health perceptions and weight management behaviors among Burmese refugee youth. Data on self-reflections, goal attainment, and self-efficacy in the process of healthy weight management were also identified. Given the high internal consistency of the 24 items regarding want to change, the PHWMA is a reliable and culturally responsive tool that can assist practitioners in identifying changes among adolescent Burmese refugees when implementing an occupation-based weight management program.
The results provide potential directions for further program development in support of physical health and psychosocial wellness promotion for adolescent Burmese refugees. For example, occupational therapy programming can use the PHWMA to support empowering habit change, making environmental adaptations for change to occur, and implementing occupational therapy psychosocial interventions in the area of empowerment and therapeutic use of self (Pizzi, 2013b; Pizzi & Vroman, 2013; Taylor, 2008). In the Summer Scholars Program the participants attended, occupational therapists focused on health and wellness promotion and interventions addressing participants’ well-being and lifestyle. Community safety and structural influences on obesity in terms of neighborhoods, food insecurity, stress toxicity, crime, and so forth were also discussed as part of the program.
From a systems perspective, the less active and participatory the child, the more likely he or she is to experience a sedentary lifestyle and to be overweight, adversely affecting his or her sense of self, health, and well-being (Pizzi & Vroman, 2013). The ability and the right to participate in meaningful, satisfying occupations not only is important to health and wellness promotion but also is an issue of social and occupational justice (Whiteford, 2000): “Being overweight or obese can restrict or possibly severely limit people’s engagement in occupations, their level of participation in society, and their overall well-being” (Kuczmarski, Reitz, & Pizzi, 2010, p. 253). Occupational justice is “about recognizing and providing for the occupational needs of individuals and communities as part of a fair and empowering society” and “can be described as the equitable opportunity and resources to enable people’s engagement in meaningful occupations” (Townsend & Wilcock, 2004, p. 79).
The findings of this study indicate that the occupational needs of this immigrant population varied related to healthy lifestyle and weight management. Although many participants stated they wished to maintain their current activity participation, health status, and weight, they noted other areas as being stressful. The process of displacement and resettlement results in occupational disruption and deprivation for many refugee youth (Whiteford, 2000), limiting their opportunities and resources to participate in familiar routines and meaningful outdoor activities.
The influence of acculturative stress on immigrant and refugee health is well documented in the literature (Nayar, Hocking, & Giddlings, 2012; Ramaliu & Thurston, 2003; Schisler & Polatajko, 2002). Acculturative stress occurs in three distinct phases in the resettlement process: premigration, migration, and postmigration (Ramaliu & Thurston, 2003). As immigrants and refugees encounter new contexts and circumstances, how they “navigate cultural spaces” (Nayar et al., 2012) and interact with the new environment (Schisler & Polatajko, 2002) may support or challenge their adaptation to a new country and society. To the extent that the resettlement process is stressful for youth, physical and psychosocial sequelae can arise that may lead them to become overweight or obese (Pizzi & Vroman, 2013; WHO, 2016).
Occupational therapy practitioners have the skills, knowledge, and creativity to develop prevention programs for children and youth who lack economic and personal resources for healthy weight management. These programs can focus on the prevention not only of occupational injustice but also of occupational deprivation, alienation, and marginalization.
Considerable racial and ethnic weight management disparities exist among U.S. children and adolescents (Balistreri & Van Hook, 2009; Franzini et al., 2009; Wang & Beydoun, 2007). Health care practitioners need to be aware of populations at risk for weight management issues and to provide preventive strategies and intervention to promote healthy lifestyles through family routines and in the community. As Kumanyika (2008)  stated, “Recognizing the contributions of environmental variables that are rooted in the social structure and, therefore, beyond the control of individuals is key to understanding the nature of solutions that will be needed” (p. 68). Obesity and issues surrounding food, eating habits, and lifestyle are often deeply rooted in culture, and health professionals must keep cultural, ethnic, and racial influences in mind when working with clients and families.
Implications for Occupational Therapy Practice
The results of this study have the following implications for occupational therapy practice:
  • Minority youth in the United States are at risk for poor weight management and unhealthy behaviors.

  • The PHWMA is a valid and reliable tool that examines health behaviors, readiness to change, and the impact of weight on participation.

  • The PHWMA can be used to support health promotion through community partnerships to enhance the health and well-being of minority youth.

Conclusion
The health and well-being of minority youth are vital to American society as ethnic and racial minorities approach the majority of the U.S. population (U.S. Census Bureau, 2012). Empowerment of minority youth to pursue healthier lifestyles, create healthy habits, and engage in self-advocacy regarding their health and well-being has the potential to strengthen the fabric of society. Unhealthy weight management undermines the social, physical, emotional, spiritual, familial, and occupational health of children and youth of all cultures. The youth in this study noted that problems in weight management affected many key occupations in which they engaged. To promote the health and well-being of minority youth, it is incumbent on practitioners to use a systems approach and explore personal characteristics (client factors), the occupations typically engaged in, and the environmental supports and barriers that influence healthy weight management.
It is also incumbent on health care practitioners to always take a client-centered approach (Blain & Townsend, 1993; Taylor, 2008). The PHWMA supports a focus on client centeredness by enabling practitioners to consider how stressful changing health behaviors can be and by enabling clients to self-identify their priorities for health behavior change. Through age-appropriate coaching and empowerment, practitioners can design a health and wellness program that best benefits each individual.
Cultural sensitivity is a crucial aspect of client-centered care. For minority youth to benefit most from an occupation-based health and wellness program for healthy weight management, the program must be developed in accordance with their culture, including food choices; environmental supports and barriers; and religious influences, values, beliefs, and habits (Caprio et al., 2008; Kuczmarski et al., 2010; Suarez-Balcazar et al., 2013). Helping minority youth understand the benefits of changing health behaviors while they are young can create healthier adults in the future, thus also creating healthier communities and a society committed to the well-being of its youth.
This study only includes a small sample of Burmese refugee youth. The health perceptions and weight management behaviors captured by the PHWMA may be different from other minority youth populations in the United States. In addition, this study used only the child/youth version of the PHWMA; parents’ perceptions of their children’s health and weight management behaviors might be different. Therefore, future studies should continue to validate the PHWMA as a tool for weight perception and weight management in both minority and nonminority youth populations. In addition, future studies may include use of the parent version of the PHWMA to gather data on parent perceptions of health, weight management, well-being, and quality of life. Studies are currently under way using the parent version of the PHWMA with people of different cultures.
As stated in the AOTA (2014b)  position paper on commitment to nondiscrimination and inclusion,

We are committed to nondiscrimination and inclusion as an affirmation of our belief that the interests of all members of the profession are best served when the inherent worth of every individual is recognized and valued. We maintain that society has an obligation to provide the reasonable accommodations necessary to allow individuals access to social, educational, recreational, and vocational opportunities. By embracing the concepts of nondiscrimination and inclusion, we will all benefit from the opportunities afforded in a diverse society. (pp. S23–S24)

As occupational therapy practitioners address diversity issues, it is imperative that they also address diversity through occupation- and client-centered assessment. The PHWMA is an occupation- and client-centered assessment that can help equip occupational therapy practitioners to incorporate health and wellness promotion in practice.
Acknowledgments
We express gratitude to Elaisa Vahnie, Ro Dinga, Lian Ceu, and Lian Sang for their leadership in the Burmese American Community Institute’s Summer Scholars Program. We also thank the students who participated in the program and acknowledge partial funding from the Indiana University–Purdue University Indianapolis Center for Service and Learning. We declare no conflicts of interest. The authors alone are responsible for the content and writing of this article.
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Table 1.
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)×
ItemDo You Want to Change? M (SD)How Stressful Is This Area?Do You Think You Want to Work on This Area?
M (SD)Not (%)Sometimes (%)Very (%)Yes (n)No (n)
Able to choose play, fun, or leisure activities for myself1.95 (1.10)0.60 (0.60)45505128
Doing play, fun, or leisure activities2.20 (1.20)0.75 (0.79)453520164
Getting ready for school2.95 (1.36)1.10 (0.91)352045164
Keeping a schedule for things I do in my day3.10 (1.29)1.30 (0.66)105040173
My physical health2.70 (1.38)0.65 (0.75)503515146
Eating habits and routines (e.g., in front of the TV, too late at night)2.85 (1.14)1.00 (0.80)304030164
Time I spend in front of the TV or on a computer2.90 (1.12)1.20 (0.83)253045154
Eating junk food and fast food3.05 (1.54)0.74 (0.73)404015910
Eating fruits and vegetables2.60 (1.57)0.50 (0.69)603010137
Being able to study3.05 (1.28)1.30 (0.73)154045171
Being able to learn2.95 (1.23)1.10 (0.85)303040164
Spending time with family3.20 (1.64)0.40 (0.75)751015117
Amount of sweets eaten each day2.75 (1.62)0.65 (0.67)454510109
My weight2.40 (1.14)0.88 (0.76)354525146
My friends2.40 (1.50)0.65 (0.81)5525201010
Feeling safe in school2.10 (1.25)0.75 (0.85)502525614
My happiness2.45 (1.61)0.50 (0.83)701020910
My overall coping abilities (can I deal with things OK?)2.72 (1.27)0.79 (0.71)354515136
Where I live2.00 (1.49)0.55 (0.83)651520511
Feeling safe at home2.11 (1.66)0.37 (0.60)65255810
My ability to deal with change2.53 (1.31)0.95 (0.78)304025107
Doing things I like to do2.65 (1.39)0.80 (0.83)453025135
How much I participate in sports or outdoor activities2.55 (0.95)0.70 (0.73)454015163
How much I sleep2.60 (1.27)1.05 (0.89)352540136
Table Footer NoteNote. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.
Note. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.×
Table 1.
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)
Descriptive Data on Responses to the 24 PHWMA Items (N = 20)×
ItemDo You Want to Change? M (SD)How Stressful Is This Area?Do You Think You Want to Work on This Area?
M (SD)Not (%)Sometimes (%)Very (%)Yes (n)No (n)
Able to choose play, fun, or leisure activities for myself1.95 (1.10)0.60 (0.60)45505128
Doing play, fun, or leisure activities2.20 (1.20)0.75 (0.79)453520164
Getting ready for school2.95 (1.36)1.10 (0.91)352045164
Keeping a schedule for things I do in my day3.10 (1.29)1.30 (0.66)105040173
My physical health2.70 (1.38)0.65 (0.75)503515146
Eating habits and routines (e.g., in front of the TV, too late at night)2.85 (1.14)1.00 (0.80)304030164
Time I spend in front of the TV or on a computer2.90 (1.12)1.20 (0.83)253045154
Eating junk food and fast food3.05 (1.54)0.74 (0.73)404015910
Eating fruits and vegetables2.60 (1.57)0.50 (0.69)603010137
Being able to study3.05 (1.28)1.30 (0.73)154045171
Being able to learn2.95 (1.23)1.10 (0.85)303040164
Spending time with family3.20 (1.64)0.40 (0.75)751015117
Amount of sweets eaten each day2.75 (1.62)0.65 (0.67)454510109
My weight2.40 (1.14)0.88 (0.76)354525146
My friends2.40 (1.50)0.65 (0.81)5525201010
Feeling safe in school2.10 (1.25)0.75 (0.85)502525614
My happiness2.45 (1.61)0.50 (0.83)701020910
My overall coping abilities (can I deal with things OK?)2.72 (1.27)0.79 (0.71)354515136
Where I live2.00 (1.49)0.55 (0.83)651520511
Feeling safe at home2.11 (1.66)0.37 (0.60)65255810
My ability to deal with change2.53 (1.31)0.95 (0.78)304025107
Doing things I like to do2.65 (1.39)0.80 (0.83)453025135
How much I participate in sports or outdoor activities2.55 (0.95)0.70 (0.73)454015163
How much I sleep2.60 (1.27)1.05 (0.89)352540136
Table Footer NoteNote. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.
Note. Percentages that do not add to 100 are a result of missing data. M = mean; PHWMA = Pizzi Healthy Weight Management Assessment; SD = standard deviation.×
×
Table 2.
Correlations Between Stress Level, Want to Change, and Want to Work On
Correlations Between Stress Level, Want to Change, and Want to Work On×
ItemWant to Change and Want to Work OnStress Level and Want to Work OnStress Level and Want to Change
γpγpτ-bp
Able to choose play, fun, or leisure activities for myself.697.017.806.008.385.048
Doing play, fun, or leisure activities1.000.0061.000.008.207.298
Getting ready for school.308.334.100.850.205.203
Keeping a schedule for things I do in my day.744.102.882.062.127.606
My physical health.627.067.811.013.167.373
Eating habits and routines (e.g., in front of the TV, too late at night).404.326.636.091.541<.0005
Time I spend in front of the TV or on a computer.922.014.918.008.643<.0005
Eating junk food and fast food.0001.0000.912<.0005.239.249
Eating fruits and vegetables.057.8841.000<.0005.386.052
Being able to study.692.302.398.275.138.569
Being able to learn.630.073.625.179.203.268
Spending time with family−.067.8541.000.004.109.584
Amount of sweets eaten each day.452.134.800.005.620<.005
My weight.600.0871.000<.0005.324.139
My friends.302.354.949<.0005.212.266
Feeling safe in school.536.078.556.082.392.024
My happiness.457.141.714.085.018.936
My overall coping abilities (can I deal with things OK?)−.393.3461.000<.0005−.234.296
Where I live.310.547.956.002.055.802
Feeling safe at home.333.4221.000<.0005−.100.621
My ability to deal with change.429.219.818.001.126.556
Doing things I like to do.474.235.875.005.460.004
How much I participate in sports or outdoor activities.150.7951.000.031.149.447
How much I sleep.667.046.971<.0005.319.127
Table 2.
Correlations Between Stress Level, Want to Change, and Want to Work On
Correlations Between Stress Level, Want to Change, and Want to Work On×
ItemWant to Change and Want to Work OnStress Level and Want to Work OnStress Level and Want to Change
γpγpτ-bp
Able to choose play, fun, or leisure activities for myself.697.017.806.008.385.048
Doing play, fun, or leisure activities1.000.0061.000.008.207.298
Getting ready for school.308.334.100.850.205.203
Keeping a schedule for things I do in my day.744.102.882.062.127.606
My physical health.627.067.811.013.167.373
Eating habits and routines (e.g., in front of the TV, too late at night).404.326.636.091.541<.0005
Time I spend in front of the TV or on a computer.922.014.918.008.643<.0005
Eating junk food and fast food.0001.0000.912<.0005.239.249
Eating fruits and vegetables.057.8841.000<.0005.386.052
Being able to study.692.302.398.275.138.569
Being able to learn.630.073.625.179.203.268
Spending time with family−.067.8541.000.004.109.584
Amount of sweets eaten each day.452.134.800.005.620<.005
My weight.600.0871.000<.0005.324.139
My friends.302.354.949<.0005.212.266
Feeling safe in school.536.078.556.082.392.024
My happiness.457.141.714.085.018.936
My overall coping abilities (can I deal with things OK?)−.393.3461.000<.0005−.234.296
Where I live.310.547.956.002.055.802
Feeling safe at home.333.4221.000<.0005−.100.621
My ability to deal with change.429.219.818.001.126.556
Doing things I like to do.474.235.875.005.460.004
How much I participate in sports or outdoor activities.150.7951.000.031.149.447
How much I sleep.667.046.971<.0005.319.127
×