reviewarticle - pdfs.semanticscholar.org
TRANSCRIPT
Hindawi Publishing CorporationJournal of ObesityVolume 2013, Article ID 827674, 13 pageshttp://dx.doi.org/10.1155/2013/827674
Review ArticleHeath Beliefs of UK South Asians Related toLifestyle Diseases: A Review of Qualitative Literature
Anna Lucas,1 Esther Murray,1 and Sanjay Kinra2
1 School of Psychology, Faculty of Life Sciences and Computing, London Metropolitan University, 166-220 Holloway Road,London N7 8DB, UK
2Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine,London WC1E 7HT, UK
Correspondence should be addressed to Anna Lucas; [email protected]
Received 12 October 2012; Accepted 26 December 2012
Academic Editor: Jamy D. Ard
Copyright © 2013 Anna Lucas et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To review available qualitative evidence in the literature for health beliefs and perceptions specific to UK South Asianadults. Exploring available insight into the social and cultural constructs underlying perceptions related to health behaviours andlifestyle-related disease. Methods. A search of central databases and ethnic minority research groups was augmented by hand-searching of reference lists. For included studies, quality was assessed using a predetermined checklist followed bymetaethnographyto synthesise the findings, using both reciprocal translation and line-of-argument synthesis to look at factors impacting uptake ofhealth behaviours.Results. A total of 10 papers varying in design and of good quality were included in the review. Cultural and socialnorms strongly influenced physical activity incidence and motivation as well as the ability to engage in healthy eating practices.Conclusions. These qualitative studies provide insight into approaches to health among UK South Asians in view of their social andcultural norms. Acknowledgement of their approach to lifestyle behaviours may assist acceptability of interventions and deliveryof lifestyle advice by health professionals.
1. Introduction
People of SouthAsian origin in theUK (people with ancestralorigins from Pakistan, India, Bangladesh, and Sri Lanka)manifest obesity-related diseases more frequently and earlierthan other groups, [1, 2] at lower levels of body mass indexto European populations [3]. Genetic factors are important,however the increased incidence of these diseases is stronglyassociated with rising obesity in this group [4] where lifestylechanges can reduce risk factors such as a sedentary lifestyle,diet, smoking, stress, and depression.
In the UK, South Asians are the largest ethnic minoritywho now comprise themajority ethnic group in several urbanlocations from the latest UK Consensus. They are also atconsiderably higher risk of diabetes than the general UK pop-ulation [5] and have a mortality rate from coronary heartdisease at approximately 40% greater than the general pop-ulation [6]. Despite this, there remains little evidence ofsuccessful interventions among South Asian groups and
theories of health behaviour only specify a limited subset ofcognitive determinants that are assumed to bemost proximalto the general population’s behaviour. Health research hasfocused on the differential occurrence rate of specific diseasesin ethnic minority groups in relation to indigenous UK pop-ulations. Ethnicity is not just a question of language andresearch exploring cultural differences, including how expe-riences and health beliefs reflect health behaviors (an actiontaken by a person tomaintain, attain, or regain good health toprevent illness), is still limited among people of South Asiandescent. Given the elevated risk of lifestyle-related diseasein South Asian communities, there is a need to identifybeliefs that may contribute to health risks and current healthbehaviours exploring psychosocial risk factors for ill-health(e.g., socioeconomic status, diet, family conflict, attitudes/beliefs, health-related behaviours, and work patterns). NICEguidelines (National Institute for Health and Clinical Excel-lence) recommend advice on lifestyle change is tailoredfor different groups particularly minority groups as their
2 Journal of Obesity
uptake of health information is lower than other groups andunderresearched.
There is some consensus that addressing deep-rootedinfluences on health behaviours in “at-risk” groups, includingcultural influences, is important [7–9]. Culture is a complexinteraction of amultitude of factors that give people an ethnicbelonging and also impacts on their lifestyle and predisposi-tion to chronic disease. For any intervention to be successfulon meeting the needs of the target community, providersneed to be informed by an understanding of a group’s life-styles, attitudes, and beliefs. A more complete explanation ofparticular health behaviours is necessary by extending theo-ries to include other relevant determinants. Investigation ofthese variables by qualitative research provides insight intofactors that may be mediators of motivation to changebehaviour such as cultural and social norms. Qualitativeresearch can be used to inform strategy for the promotionof healthy lifestyles and recognised as increasingly importantin developing the evidence base for public health. Thesemethodologies are especially appropriate for understandingindividuals’ and groups’ subjective experience whilst, beingsensitive to the contextual, social, economic, and cultural fac-tors which influence health beliefs and behaviours [10].Theseare difficult to access using quantitative approaches as suchmethods do not give us an adequate understanding of thefactors involved. The inductive nature of qualitative researchallows for theory to emerge from the lived experiences ofresearch participants rather than the predetermined hypothe-ses testing of quantitative approaches.
1.1. Objective. A review of UK literature was carried out toidentify available evidence on the perceptions around lifestyledisease and health behaviours among UK South Asian popu-lations. Investigating what is known about awareness, knowl-edge, perceptions, and misconceptions about living a healthylifestyle for UK South Asians enhancing our understandingof social and cultural constructs among this group. Further,to identify key themes emerging from research, helping guideintervention programmes and future research.
2. Methods
2.1. Selection of Articles. Articles for inclusion (see Table 2)were scientific articles written in English and studies explor-ing health behaviours among UK South Asians aiming tocapture the nature of their behaviours and lifestyle choices.
Three electronic strategies were used (using thesaurusterms, free-text terms, and broad-based terms) for searchingacross bibliographic databases (see Figure 1). A wide rangeof databases (i.e., Medline, Web of Knowledge, CochraneLibrary, PsyINFO, and EMBASE) and public health websites(i.e., WHO, DH, and HPA) including government websites;NHS Scotland Library, Health Technology Assessments(HTA), and National Institute of Health and Clinical Excel-lence (NICE) were searched. To ensure inclusion of paperswhich may not be submitted to peer review additional web-sites searched include Diabetes UK; NHS Evidence specialistcollection for Diabetes; NHS Evidence specialist collection
= 433 study abstracts were read for direct relevance studies from electronic search excluded (aJer evaluation of abstract text) 332 excluded
= 954 studies identified and screened for relevance potentially relevant citations identif ied aJer liberal screening of the electronic search. citations excluded as either (a) irrelevant to the topic or (b) use of quantitative methods
Review question “Investigating what is known about awareness, knowledge, beliefs, perceptions, and misunderstandings a bout living a healthy lifestyle for South Asians”
= 101 studies fully read for relevance studies from electronic search excluded (aJer evaluation of full text)
74 studies excluded for (a) it focused on ethnic minorities as one group, (b) the research question too specific (c) the non-UK South Asians
methodological quality criteria17 excluded. articles excluded (a) participant samples grouped South asians with other ethnic minorities or focused on child samples (b) use of mixed methods (c) focus on evalua tions of interventions, treatment adherence or experience of healthcare
= 10 Relevant studies included in the systematic review
Figure 1
for Ethnicity and Health. Relevant references from publishedliterature were followed up and all potentially relevant articlesand titles and abstracts of articles were screened and full-textcopies of potentially relevant articles were reviewed.
As the terms South Asian, health beliefs and healthbehaviour have many synonyms, these terms were not alwayspresent in the research objective/s. Examples of outcomesinclude the following in Table 1. Where possible, the appro-priate indexing term was used for each database. The searchresults are shown in Figure 1.
2.2. Quality Appraisal. The criteria outlined in Table 3 is achecklist established by Munro et al., [11] based on commonelements from existing criteria for qualitative study qualityassessment [12–16] and has been used to guide the reviewand evaluation of the elements of each particular study,given its context and purpose. Articles were examined formethodological quality and all clearly defined their purposegiving adequate descriptions of sampling and justificationfor data collection. However, details for sample validationand assessment of generalisability were less clear with limitedevidence of triangulation. Various qualitative methodologieswere used with few justifying their reasoning for the chosenmethod and detail of analysis. All studies clearly identifiedexperiences inherent among this group, with interpretations
Journal of Obesity 3
Table 1: Search terms.
Criteria topics Search terms
Ethnicity South Asian, Asian, UK South Asian, Bangladeshi, Indian, Pakistani, Sri Lankan,and Nepalese
Lifestyle related health problems Type II Diabetes, diabetes, obesity, CHD, health, lifestyle, and diseaseDietary choices Diet, dietary, food, and nutritionPhysical activity Exercise, activity, fitness, and physical activityApproach to using healthcare Accessing healthcare, adherence, and help-seeking behaviourFormation and maintenance of health behaviours Adherence, motivation, initiation, self-efficacy, and formation
Set inclusion criteria
Search and retrieve
eligible studies
Quality assessment
of included studies
Identify primary
themes and conceptsIdentify secondary
themes
Compare primary and
secondary themes
Identify key themeswith narrative
summary
Determine how thestudies are related
Translate studiesinto one another
Synthesise
translations
Figure 2: Metaethnography process, Noblit and Hare [17].
Table 2: Inclusion criteria.
Studies which met the following criteria were included(1) Primary research, of which the sole or major focus is toexplore health behaviours, beliefs, and perceptions.(2) The sole or major participant group is UK South Asians adultsdefined as people of South Asian origin (people with ancestralorigins from Pakistan, India, Bangladesh, and Sri Lanka) living inthe UK of any age.(3) The study is conducted using, solely or as a major part, aqualitative methodology.
that could serve to further the understanding of the partici-pant’s experience and in view of these criteria all ten studieswere included due to evidence of good rigour.
2.3. Method of Synthesis. The findings, context, and analysisof the ten included studies were used as data in the presentstudy. A metaethnographic approach described by Noblitand Hare [17] the steps of which are (outlined in Figure 2)taken to synthesise themes and patterns identified by readingand rereading the included studies. This systematic approachtranslates ideas, concepts, and metaphors across differentstudies and is increasingly seen as a favourable approach tosynthesising qualitative health research.
Once themes were identified an attempt was then madeto translate these into each other. In this process, primarythemes or first-order constructs are understood as reflectingparticipants’ understandings, as reported in the includedstudies (usually found in the results section of an article). Sec-ondary themes or second-order constructs are understoodas interpretations of participants’ understandings made byauthors of these studies (and usually found in the discussionand conclusion section of an article).
Translation involves the comparison of themes acrosspapers and an attempt to “match” themes from one paperwith themes from another, ensuring that a key theme capturessimilar themes from different papers from the reciprocaltranslation a table was constructed showing each theme.When synthesising translations to develop an overarchingframework (or third-order interpretation), translated themesare used to develop hypotheses into a “line-of argument”synthesis. Line-of-argument syntheses create new models,
4 Journal of Obesity
Table 3: Munro et al. [11].
Quality criterion Met criterion Did not meet criterion UnclearIs this study qualitative research? 10Are the research questions clearly stated? 9 1Is the qualitative approach clearly justified? 4 4 2Is the approach appropriate for the research question? 9 1Is the study context clearly described? 8 2Is the role of the researcher clearly described? 7 2 1Is the sampling method clearly described? 7 1Is the sampling strategy appropriate for the research question? 7 3Is the method of data collection clearly described? 8 2Is the data collection method appropriate to the research question? 10Is the method of analysis clearly described? 5 1 4Is the analysis appropriate for the research question? 7 3Are the claims made supported by sufficient evidence? 10
theories, or understanding rather than a description of thesynthesised papers.
2.4. Methodological Reflections. Included articles had to pre-sent an acceptable and justified qualitative research method(based on the criteria in Table 3) but few provided enoughdetail to judge this accurately and a variety of methods andparadigms were presented. However, it was accepted thatthe main interest of the studies was of the experience thatwas being explicated. This paper incorporates the conceptsidentified in the primary studies into a more subsumingtheoretical structure. This structure may include conceptswhich were not found in the original studies but which helpto characterise the data as a whole and take into account dif-ferent settings and subgroups. All reported data were recog-nised as the product of author interpretation. Although thefoci of the studies were not all directly comparable, a numberof recurring first- and second-order constructs were identi-fied.
2.5. Study Characteristics. Although inclusion of evidencewas not restricted by study type other than use of qualitativemethods, there was a focus on study designs that elicitedviews around health behaviour rather than views on treat-ment programmes and health services.The studies employedmethodologies that range from case studies to semistruc-tured interviews, and in-depth interviews to focus groupdiscussions. Taping with transcription of data was the mostcommon method used to demonstrate credibility. Ethni-cally matched interviewers, peer debriefing, and multipleresearchers were also common. All the studies explored insome manner health beliefs and perceptions associated withlifestyle. Of these (see Table 4), three were based on thematicanalysis, one used framework analysis, a form of critical the-ory of phenomenological and sociological approaches, andfour stated that they used grounded theory. Qualitative dataanalysis software packages were used by four studies but onlyone used this as their sole method of analysis. The studieswere all conducted in England and the combined sampleof participants across studies included 377 (153 males, 224
females) South Asian adult participants with a wide agebracket for all studies with participants aged from 21–82 yearsof age. The populations investigated were either South Asianin general or specified group of Indian, Pakistani, or Ban-gladeshi groups.Three studies had small control/comparativegroups of European,White British, or Afro-Caribbean. Sevenstudies looked at those with either Type I or Type II Diabetesor CHD and three looked at “healthy” population samples.
3. Results
The studies investigated a variety of research questionsexploring elements of health beliefs and behaviours specificto this group.The studies’ research questions can be separatedinto the following groups.
(i) Knowledge, understanding, and beliefs of lifestylerelated disease (Type II diabetes or CHD) (6).
(ii) Dietary intake and physical activity related to diabetescare (2).
(iii) Health perceptions and the role of diet (1).(iv) Barriers and attitudes to physical activity (1).
Different studies used methodological and epistemologi-cal approaches to analyse data however a number of consis-tent findings emerged and a broad range of contributors wereidentified regarding the uptake of “healthy” behaviours froma South Asian perspective. This paper looks at the evidence,focusing on the identified main themes in Table 5.
The results have been grouped under two categories to bediscussed furtherwithin this paper.Understanding healthanddisease, and barriers to engaging in health behaviours.
4. Understanding of Health and Disease
4.1. Lack of Personal Risk. Difficulty identifying aspects oflifestyle that contribute to the development of lifestyle-relateddisease [19, 21] with diabetes suggested as causing obesity
Journal of Obesity 5
Table4:Stud
ycharacteris
tics.
Lead
author,yearo
fpu
blication
Research
questio
nParticipantsam
ple
Metho
dof
data
collection
Analytic
strategies
Them
esfro
mresults
Chou
dhuryetal.
2009
[18]
Exam
inethe
understand
ingand
beliefsof
peop
lewith
diabetes
interm
softheircond
ition
,its
causes,prevention,
and
managem
ent
n=14
4male,10
female,aged
26–6
7yrs:B
angladeshi
Allwith
type
2diabetes
Structured
interviews
Datatranscribed
and
analysed,cod
edby
two
independ
entresearchersusing
wordandexcelfollowingthe
presetqu
estio
ns
(i)Cause
ofdiabetes
(ii)P
reventingdiabetes
(iii)Diabetesd
iagn
osis
(iv)M
anagem
ento
fdiabetes
(v)Informationfro
mhealthcare
professio
nals
(vi)Ph
ysicalactiv
ity(vii)
Inform
ationfro
mfamily/fr
iend
sand
use
oftradition
almedication
(viii)D
iabetese
ducatio
n
Darre
tal.2008
[19]
Tocompare
illnessbeliefsof
SouthAs
ianandEu
ropean
patie
ntsw
ithCH
Dabou
tcausal
attributions
andlifestylechange
n=65
Pakista
niandIndian:26
males,19females,aged40
–82
European:10males,10
females,aged42–83
Allwith
CHD
Interviews
Fram
eworkapproach
analysis
[20]
Causalattributions
andlifestylechange
(i)Family
histo
ry(ii)Th
eroleo
ffate
(iii)Stress
(iv)T
obacco
smok
ing
(v)P
hysic
alactiv
ityandexercise
(vi)Dietary
intake
(vii)
Stressmanagem
ent
Farooq
ietal.
2000
[21]
Toidentifykeyiss
uesrela
tingto
know
ledgeo
fand
attitud
esto
lifestyleris
kfactorsfor
CHD
n=44
24male,20
female
SouthAs
ians
aged
40+yrs
Focusg
roup
sTh
ematic/con
tent
analysis
(i)Diet
(ii)E
xercise
(iii)Sm
oking
(iv)A
lcoh
ol(v)A
ccessib
ilityof
health
services
(vi)Stress
Grace
etal.2008[22]
Toun
derstand
laybeliefsand
attitud
es,religiou
steachings,and
professio
nalp
erceptions
inrelationto
diabetes
preventio
n
n=137
54males,83females;
80Ba
ngladeshilay
peop
le(37
females,43males,m
eanage
35),29
Islamicreligious
leaders,28
health
professio
nals
Focusg
roup
s,3
sequ
entia
lphases
(vignette
s)
Them
aticanalysiswith
useo
fNVIV
O,m
ultileveltheoretic
alfram
ework,andcriticalfi
ction
techniqu
e
(i)Layun
derstand
ingof
diabetes
(ii)L
ivinga“
healthy”
life
(iii)Re
spon
sibilityford
iabetesp
revention
(iv)F
atalism
(v)S
ocialroles
andexpectations
(vi)Structuralandpractic
alconstraintsto
healthylifestylechoices
(vii)
Health
literacyandEn
glish
fluency
Greenhalghetal.
1998
[23]
Toexplorethe
experie
nces
ofdiabetes
andun
derly
ingattitud
esandbeliefsystemsw
hich
drive
thatbehaviou
r
n=50
40Ba
ngladeshi(17
males,23
females),8whiteBritish,2
Afro
-Caribbean
aged
21–80
Allwith
diabetes
not
distinguish
which
type
Semistructured
interviews
AnalysedusingNUDIST
softw
are
(i)Bo
dyconcepts
(ii)O
rigin
andnature
ofdiabetes
(iii)Im
pactof
diabetes
(iv)D
ietand
nutrition
(v)S
moking
(vi)Con
ceptso
fbalance
(vii)
Exercise
(viii)P
rofessionalroles
(ix)D
iabetic
mon
itorin
g
6 Journal of Obesity
Table4:Con
tinued.
Lead
author,yearo
fpu
blication
Research
questio
nParticipantsam
ple
Metho
dof
data
collection
Analytic
strategies
Them
esfro
mresults
Lawtonetal.2008
[24]
Tolook
atfood
andeatin
gpractic
esfro
mthep
erspectiv
esof
thosew
ithtype
2diabetes,
barriersandfacilitatorstodietary
change,and
socialandcultu
ral
factorsinformingtheira
ccou
nts
n=32
15male,17
female;aged
33–71,
Pakista
niandIndian
Allwith
type
2diabetes
Topic-gu
ided
interview
Con
stant
comparativ
emetho
dof
analysis[10]
inlin
ewith
Groun
dedtheory
approach.
QSR∗
NUDISTused
(i)Inform
ationfro
mhealthcare
professio
nals
(ii)P
erceptions
ofSA
food
s:badforh
ealth
;good
forself
(iii)Settlem
ent,sharing,andcommensality
(iv)S
trategiesfor
passing:cutting
outo
rcutting
down
Chou
dhuryetal.
2009
[18]
Patie
nts’perceptio
nsand
experie
nces
ofun
dertaking
physicalactiv
ityas
partof
their
diabetes
care
n=32
15male,17
female;Pakistani
andIndian
patie
ntsa
ged33–71
Allwith
type
2diabetes
Interviews
inform
edby
atopicg
uide
Con
stant
comparativ
emetho
dof
analysis[10]
inlin
ewith
Groun
dedtheory
approach.
QSR∗
NUDISTused
Roles,no
rms,andrespon
sibilitie
s:(i)
Lack
oftim
e:ob
ligations
toothers
(ii)F
eara
ndsham
eEx
ternalconstraints:
(i)Lack
ofcultu
rally
sensitive
facilities
(ii)C
limaticcond
ition
sPerceptio
nsandexperie
nces
ofdisease:
(i)Com
orbiditie
s(ii)A
ccou
ntso
fcausatio
n;perceptio
nsof
future
health
(iii)Diabetestrig
gersirr
eversib
ledecline
(iv)P
hysic
alactiv
itycanengend
eranxiety
Activ
ities
andactiv
erespo
ndents:
(i)Sh
ort-term
goals
Ludw
igetal.2011
[25]
Explored
health
perceptio
ns,diet
andthes
ocialcon
structio
nof
obesity
andho
wthisrelatesto
theinitia
tionandmaintenance
ofah
ealth
ierd
ietinUKPakistani
wom
en
n=55
Pakista
niwom
enaged
23–80
Semistructured
interviewsu
seof
fictio
nalvignette
sandbo
dyshape
images
Analysis
using
phenom
enologicaland
sociologicalapproaches
Phenom
enologicalanalysis:
(i)Diabetessym
ptom
s(ii)R
easons
foro
verw
eight
(iii)Health
actio
n(iv
)Motivationto
change
Sociologicalanalysis:
(i)Identitydeconstructio
n:Muslim
,Pakista
ni,and
British
(ii)F
amily
Emergent
them
es:
(i)Risk
awareness
(ii)U
rban
versus
Ruralbackgroun
d(iii)Clim
ate
(iv)F
oodtradition
s/expectations
(v)E
nglishversus
Pakista
nifood
(vi)Obesityandhealth
Journal of Obesity 7
Table4:Con
tinued.
Lead
author,yearo
fpu
blication
Research
questio
nParticipantsam
ple
Metho
dof
data
collection
Analytic
strategies
Them
esfro
mresults
Srisk
antharajah
and
Kai2007[26]
Toexplorethe
influ
enceso
n,and
attitud
estowards,physic
alactiv
ityam
ongSouthAs
ian
wom
enwith
CHDanddiabetes
toinform
second
arypreventio
nstr
ategies
n=15
(allfemale,aged
26–70)
SouthAs
ian
Allwith
either
CHDand/or
noninsulin-dependent
diabetes
Semistructured
interviews
Transcrib
edandanalysis
inform
edby
Groun
dedtheory
(i)Perceivedharm
thresholdlim
itsactiv
ity(ii)Insuffi
cientguidancefrom
health
professio
nals
(iii)Weightloss,maintaining
independ
ence,
andsocialising
perceivedas
mainbenefits
ofexercisin
g(iv
)Som
eund
ersta
ndingof
benefit
ofexercise
(v)E
xercise
beyond
daily
workseen
as“selfi
sh”a
ctivity
(vi)Disc
omfortwith
exercisin
gin
public
(vii)
Con
strainedby
notb
eing
ableto
speak
English
Ston
eetal.2005
[27]
Toexplorethe
experie
ncea
ndattitud
esof
prim
arycare
patie
nts
with
diabetes
livingin
aUK
commun
itywith
particular
referencetoSouthAsia
nsand
patie
ntem
powerment
n=20
(9males,11fem
ales;aged
33–80;15
SouthAs
ians,5
Caucasian)
SouthAs
ians
Allwith
diabetes
Semistructured
interviews
Transcrib
edandem
erging
them
esinform
edsubsequent
interviews,useo
fThem
atic
analysisusingFram
ework
chartin
g
(i)Th
epatient
experie
nce:attitud
esto
diagno
sis(ii)Th
epatient
experie
nce:difficulties
faced
(iii)Ty
peso
fsup
port:emotionalsup
port
(iv)T
ypes
ofsupp
ort:em
powermentthrou
ghkn
owledge
(v)A
ttitudestoself-managem
ent
(vi)Ba
rriersto
know
ledgea
cquisition
8 Journal of Obesity
[25]. The majority of studies found that South Asian par-ticipants lacked understanding of the relationship betweenlifestyle and disease. Those diagnosed with a lifestyle-relatedconditionwere often unconvinced of the impact their lifestylechoices had on health. Personal disease risk and cause wereoften instead attributed to a range of external influencescommonly stress, heredity, pollution, and too much sugaror fried food in their diet as influential factors on health.A shared assertion by those with Diabetes or CHD was notbeing sure or understanding the root cause of their disease[18, 21, 25]. Indeed, very few related their own lifestyle choicesand behaviours in any direct and obvious way. Lawton et al.[28] reported that first generation participants regarded thedevelopment of diabetes almost universally to factors outsidetheir control suggesting it was the will of Allah/God, genetics,or a change in climate and environment brought about bytheir migration to the UK. The mention of an imbalanceof bodily fluids (based on humoral medicine) [26] andimbalances of sugar in their blood [18] were reasons given fortheir condition.
Many were able to recall and quote lifestyle advice fromhealth professionals but the relative importance of these riskfactors did not appear to influence beliefs or translate tobehaviour change. For example, Males understood smokingto be linked with disease but few were convinced thiswould impact on their health [21]. Increased risk of diseasewas often not linked with likely risk factors, that is, beingoverweight.Whilst, stress was more commonly cited as causeof disease development [23, 25]. Where weight loss had beenadvised, this advice was confounded by beliefs that carryingextra weight was not an indication of being unhealthy or ahealth problem but quite the opposite indicating good health,weight, or status and reduced incentive to engage in weightloss behaviour [23, 25]. Similarly, physical activity was notreadily identified as a risk factor although low impact activitysuch as walking was related to general well being. Physicalactivity was considered as negatively impacting health orexacerbating illness by increasing physical weakness [19,26, 28]. Uncertainty over the type of exercise needed andduration for impact appeared a common barrier to formingintentions and across studies more clarity on the risk factorsand preventive actions were desired.
Personal and familial risks of diabetes and CHD wereobservedwithout concern and few linked such diseases speci-fically with risks related to their ethnicity. One study [22] didhowever find knowledge of risk factors for developing TypeII diabetes high (Bangladeshi sample) and this awareness wasprimarily described due to experiences of diabetes by relativesor friends. When discussing prevention of diabetes partic-ipants believed fear of the devastating impact of diabeteswould motivate preventive action across the Bangladeshicommunity. Others, felt diabetes was so widespread in theircommunity and (implicitly) something not to be too con-cerned about. Often, it was not until diagnosis of CHDor diabetes that signalled the need to adopt a healthierlifestyle [21, 22]. Some described how their own experienceof developing disease complications, that of similarly affectedrelatives and friends, or fear of needing extensive treatment(such as insulin injections) had encouraged them to engage
in exercise. However, these perceptions also acted as a demo-tivational effect as far as the uptake or maintenance ofphysical activity once diagnosed with diabetes [26]. Lifestylechanges were often focused on diet rather than physicalactivity, which researchers suggested was due to their focusof diabetes and CHD on imbalances, sugar or fat intake allrelated to diet rather than physical activity.
Physical degeneration and weakness were viewed as vir-tually synonymous and an inevitable consequence of ageingwith the belief that little, if anything, can be done to reverseor delay this process [23, 28]. For some the perception of illhealth being due to age was borne out of their exposure tothe high number of family and fellow community memberssuffering from numerous health problems [28].
4.2. Fatalistic Beliefs. A belief in control over individualhealth status was contradictory as accounts of understandingthat food and activity choices influence health. However,many reasoned an individual’s role in their health was exter-nally influenced if not controlled inducing a more passiveapproach to health.
“We have much fear of this disease, once thisdisease is developed, there will be no way to saveyourself ” [26].
Grace et al. [22] compared South Asians withWhite pop-ulations and found South Asians more likely to externaliseresponsibility of diabetes, reporting general life circum-stances as central to cause in comparison with internalisedresponsibility by White groups. However, both groups citedbeliefs that they had been fated to suffer CHD or diabetes[19, 21]. This demonstrates beliefs around disease occurrencemay be common to people with these conditions however,fatalism did appear stimulated by South Asian religiousbeliefs [22]. Fatalistic views have often been associated withSouth Asian cultural and religious beliefs, and many of thesestudies found evident expressions that ill health was fate.Religious fatalism was often suggested as just among olderrelatives rather than the participants themselves and attribut-ing illness to events or agents outside of the body ratherthan to primary failure of an organ within it was evidentamong older generations [23]. However, even those withfamily history of diabetes and those with understanding oftheir role in health status often mentioned the idea of God,and not the individual, as being ultimately responsible forhealth [19, 23]. Fatalistic views were reinforced by beliefsthat health, illness, and death are preordained by Allah/Godbut family experience of disease and experiences by relativeswere also significant. Farooqi et al. [21] reported healthconditions were often viewed as the will of God but theindividual still had a responsibility to look after their health.Illness could be described as an indication from God thatthey had not looked after their health and a sign thatchanges needed to be made to their lifestyle. Ludwig et al.[25] found female participants expressed a strong sense offatalism with regard to personal health risks and weightgain related to the ageing process described as normal andinevitable. Causal attributions were influenced by fatalistapproaches to health and the uptake of health behaviours
Journal of Obesity 9
Table 5: Identified key themes and subthemes.
Themes and subthemes Study1 2 3 4 5 6 7 8 9 10
Beliefs about origins/cause of CHD or type II diabetes × × × ×
Fatalist approaches to health × × ×
The role of diet in preventing/managing disease × × × × ×
Relationship between physical activity and health × × ×
Role of the individual in health/disease management × × × × × × ×
Sociocultural influence on physical activity × × × × × ×
Sociocultural influence on food and eating practices × × × × × ×
Perceptions of “a healthy weight” and a healthy body × × × ×
Prioritising individual health versus prioritising others × × ×
but not always defined by cultural or religious beliefs andthose with a strong family history of diabetes tended toview their diagnosis as inevitable and accepted it with re-signation [21] feeling like there was nothing that they couldhave done to avoid the onset of their condition [19]. Individ-uals with diabetes and CHD expressed great anxiety abouttheir health and some experienced depression related to theirlack of understanding over why they were afflicted. A lack ofindividual control over health was highly related to feelings ofanxiety and hopelessness regarding their condition [21, 27].
4.3. Sources of Information and Advice. A view prevalentamong the older generations was that management of healthshould be left to qualified health professionals. Specific barri-ers such as language difficulties andmultiple health problemswere described as reasons for their lack of ability/inter-est in understanding their own condition. A number of parti-cipants felt it impertinent to ask questions of their health-care professional and to do “whatever the doctor tells”[18, 23]. Doctors were viewed as busy, authoritative, andknowledgeable, rarely making mistakes and with full under-standing of the individual’s condition. The use of a familymember as translator was necessary for some and they askedfewer questions so as not to appear difficult. Instead, referenceto family networks and history of diabetes among family orfriends [27] created the main informational sources, whichreduced their need to seek additional support. Youngerparticipants expressed a high value on education and learningwith interest in increasing their control over their health [27].However, this was not necessarily matched by action as fewattended organised educational initiatives or support groupsciting excuses relating to lack of time.Health information andadvice was gathered for themost part from health profession-als, peers, and elders, and information was viewed as acces-sible and helpful. Word of mouth was the primary sourcefor delivery and receipt of information [18, 26] playing animportant role in defining the information received.
Health professionals were reported to be sources of adviceand motivation to make lifestyle changes however difficultiesarose when attempting to use advice. Choudhury et al. [18]found South Asian woman were strongly, though passively,influenced by their doctor’s recommendations. It is well
documented that knowledge alone does not always translateto behaviour change and more so for the women influencedby strong family networks prioritising adherence to culturaland social norms. An ability to recall guidance received fromdoctors was apparent [18, 23] but cultural norms acted asa barrier when attempts were made to change behaviour.Importantly, information from nonprofessionals (peers/elder) appeared more influential. Information from peers/elders was viewed with high regard and for those who had afamily history of dealing with diabetes; family was describedas a major source of information. This information wasmore relevant to their cultural norms increasing likelihood ofindividuals internalising the information. Uncertainty aboutinformation from health professionals particularly whenalternate advice was received from peers/elders. Alternateadvice included understanding the main cause of diabetes asbeing high dietary sugar intake and beliefs that Kerala andother “bitter” foods prevent and helpmanage diabetes insteadof considering the larger modifications to their lifestylesuggested by health professionals [18, 23].
One study of South Asian women [26] found in contrastto receiving considerable nutritional advice from dieticians,they typically received cursory and general exhortations, “tojust do more exercise” as part of other health consultationsin primary and secondary care. Rather, what they soughtwas more detailed and specific guidance about appropriateexercise.
“He (health professional) just says. . .just do moreexercise that’s it. . .the doctors and the health advi-sors they do not give you the proper information.They do not push you. . .it would help. . .if (we) hadpeople telling (us) how to do the exercise.” [26]
The need to prioritise engagement in health behaviourssuch as physical activity or dietary modification was clearlyreduced by beliefs common among this group. Advice andsupport from health professionals did not appear to have thesame impact as peers/elders on their enduring health beliefsand behaviours.
10 Journal of Obesity
5. Barriers to Engaging in Health Behaviours
Even though many expressed the need for lifestyle changesto benefit their health, intentions were frequently not madeclear and transforms into behaviour change. Similar barriersto behaviour change arose across studies and a disproport-ionate amount of barriers to leading a healthier lifestylewere described. The idea of preventing disease by a healthylifestyle was not a goal strived for, highly regarded, or priori-tised. Many participants exhibited low perceived behaviouralcontrol [29] in regard to their dietary choices and physicalactivity behaviour. Perceived behavioural control is an indi-vidual’s perceived ease or difficulty of performing a particularbehaviour.
5.1. BeingActive. Therewas no concept or goal of being physi-cally fit or gaining enjoyment from exercise and this relatesto distinct beliefs and behaviours among this group. Basicawareness of physical activity being important for health buta clear lack of putting this into practice [28]. Walking was themost common form of physical activity with few attendingany organised forms of activity. Cultural and social expecta-tions, time constraints, and health problems appeared toreduce the likelihood of physical activity.
Therewas an absence of exercise culture within this grouptogether with a distinctive dislike for most forms of exer-cise offered locally such as gyms [26, 28]. What was acceptedas being healthy (being physically active) was seen as lessimportant than social norms like group socialising, thereligious requirement for modesty, and the cultural rejectionof “sporting” identity or dress [22] and therefore motivationto be active through specific exercise was near nonexistent.The role of cultural beliefs and traditions were displayed asimportant in leisure time choices, influencing motivation toengage in activities such as joining a sports teamor using localleisure facilities as traditionally sports and games are notpursued by adults [28]. Environmental barriersmay also haveinfluence on participation in physical activity as participantsoften lived in urban city environments. Lawton et al. [28]found dislike of outdoor activities, bad weather, and a highusage of cars even for short journeys to the shops meantthat indoor activities were the most appealing. However, twostudies found cultural factors and a lack of awareness of thebenefits of physical activity the biggest impact on behaviour[26, 28].
The notion of “exercise” for oneself–beyond daily work–was perceived by some as a selfish activity, or given littlepriority as expectations by family and community were moreimportant especially by women [25, 26] who prioritisedfamily expectations and needs. The notion of family first wasa key influencer on time-restricting opportunities for individ-ual interests and activities. Forwomen, it remained a functionrelegated to normal daily duties rather than any enjoymentor added provision of time to focus on being physicallyactive. Manymade reference to activity needing to be sociallyrewarding with the appeal being of group rather than indi-vidual activity. Exercise demanded justification or sanctionto occupy one’s time and resources in this way.
The emphasis was on the cultural importance of beingactive day to day, rather than the “western” concept of organ-ised exercise. Physical activity appeared culturally irrelevantin the case of Bangladeshi groups theword physical activity orexercise was noted [23] as not featuring within their nativedialect giving us understanding ofwhy it is viewed as an infor-mal activity predominantly involving walking only. Somereflected on their religious beliefs as encouraging andinstructing them to look after their health by keeping physi-cally fit. Less formal and less obvious forms of exercise werementioned such aswalking and carrying out prayers (Namaz)as worthy and health giving forms of exercise [22, 23].
As a consequence of leading very busy lives men andwomen pointed out this was evidence for them being phys-ically active already as part of their daily duties. Lack oftime was a key barrier to physical activity, yet being activedaily was viewed as a strong cultural obligation. For men theculture of a strong work ethic meant they felt obligated todedicate their time to providing for their family working verylong or antisocial hours often in shops or restaurants [28].Women felt theywere by definition, engaging appropriately inphysical activity from care-giving, house-keeping, and workday activities so extra time for specific exercise (i.e., aerobicsclass) was not acceptable as family duties were their priority[26].
Family concern was described as a motivator to be physi-cally active and as weight gain may compromise the woman’srole as family carer or the man’s role of the wage earnerreference to this rather than individual health gains [25].Women expressed that breathlessness, increased heart rate,and sweating (normal by products of physical exertion) assomething they wished to avoid [25, 26]. Exercise also lackedcultural acceptance in its obvious form of sweating andvigorousmovement.Womendescribed principalmotivationsto walking were relaxation and refreshment from getting outof doors, a change of scenery, and in particular as a form ofsocialising with other women [26].
A couple of studies with women only samples delveddeeper. . .Women cited a variety of externally imposed bar-riers of which they had little or no control over like adheringto cultural expectations that women should walk slowly inpublic not being seen to hurry [28]. Restrictions on womenleaving the home (especially to enter mixed-sex settings) andto remain within the home was a traditional social norm, thisnorm conflicted with efforts at lifestyle change. A few pointedto once a woman is married, she is expected to stay indoors,attending to domestic chores and responsibilities,
“Women cannot go out. . .You have to cook andprovide meals at the right time, so because of thatthere is a restriction. He (husband) goes out whenhe feels like it, but it is different for women.” [28]
Further barriers for women included language, racialharassment, dress codes,modesty, and inappropriate facilities[22, 28]. Gender separated sessions were described as prefer-able, however many had never attempted to attend thesesessions even though they had been recommended to them[25, 26]. Suggestions to increase physical activity includedactivities organised by members of their own community
Journal of Obesity 11
as this would ensure a culturally appropriate environmentwith men and women exercising separately, with separatechanging areas and they would “understand our ways.” Thatsaid, attending fixed time sessions was deemed difficult aspreviously described there are many competing demands ontheir time often with higher priority.
5.2. Food and Eating Practices. Accounts of food and eatingpractices were at least partly informed by concepts andexperiences common to this respondent group. Family expec-tations impacted on dietary choices, food preparation, andconsumption. In relation to food practices the importanceattached to group norms and social values was a themecommon across studies. These norms often acted as barriersto encouraging lifestyle change as lack of knowledge was notthe main barrier but a complex value hierarchy.
A “traditional” South Asian diet presented particularproblems for their health; amount of oil used in cooking, friedfoods, and the high sugar content and popularity of Asiansweets.
South Asian foods were viewed as “risky” by many andthis caused difficulties when adapting their diet. Grace et al.[22] found this belief influenced by health professionals andSouth Asian patients misinterpret or misunderstood healthprofessional’s advice regarding “diet” and “dieting”. Fewmen-tioned cutting out these foodstuffs instead accounts of“restraint” of “risky” Asian foodstuffs was common and con-trasted with White Europeans who were more likely toremove “risky” items completely from their diet [24]. Healthwas a consideration with food practices but was interwovenwith other issues and concerns. Insight came from those par-ticipants with diabetes or CHD who felt changes to their tra-ditional recipes could not be made without having to chooseless appealing, “bland” and “unpalatable” Western food thatlacked acceptability. Some of the authors felt that positiveaspects of traditional food practices should be reinforced,including cooking from scratch using a variety of freshand healthy ingredients, offering fresh fruit and nuts ratherthan sweets with the idea that traditional Asian foods can bemade non- “risky” without compromising taste.
Food and health practices in particular were seen to beinfluenced by peers or elders due to the social and culturalnorms that they recognised [23, 25]. The influence the socialenvironment and, in particular, the views of peers and “signi-ficant others” a theme as engagement in behaviour which ispracticed by and valued by their peers. Consumption of food-stuffs plays an important role in social networks with the ofoffering and receipt of food, the creation of social networks by‘gift-giving’ in the form of luxurious or traditional food, andthe social significance of cooking for guests and of celebratorymeals.This strong hospitality culture was pivotal and the roleof consuming South Asian food viewed obligatory otherwiserisk offence or alienation from the community [24]. Socialexpectations were evidently highly valued and therefore cer-tain standards and food preparation were expected to pleaseguests. Visiting relatives was problematic as healthy choiceswere not available [27]. What is accepted to be healthy (smallportion size, limited rich, and fatty food) was seen as less
important than the social norms of hospitality [22]. Lawtonet al. [24] found most participants continued to consumeSouth Asian foods despite concerns that they may be detri-mental to their glycaemic control. Restraint was the centralmethod used to allow a balance between the risks associatedwith eating traditional food against alienating themselvesfrom their culture, families, and communities. For those diag-nosed with diabetes few suggested ways that they hadchanged or adapted their diet since being diagnosed otherthan when cooking use of Ghee for special occasions only[27].
Males, reportedly, had little or no input into food prepa-ration so were reliant on female household members to cookfood appropriate for them. Grace et al. [22] found some felt“control” of their diet should be imposed and policed byfamily members so through external influences.
Responsibility tomaintain traditional practiceswas felt bymost women and younger women described receiving advice(whether it was asked for or not) from their elders to achievethe correct practice. Women also expressed a moral conflictbetween individualist goals and collectivist goals (e.g., theindividual goal of healthy eating compared with the shameto the family of not providing guests with generous “specialmenu” food). Both first and second generation women strug-gled with these conflicts. However, Grace et al. [22] foundthat although older women felt strong pressure to conformto traditional norms and expectations; younger and second-generation women felt able to resist pressure to conform.
5.3. A “Healthy”Weight. Many experienced considerable dif-ficulties in trying to lose weight and this may be related to theindividual nature of weight loss. As noted with both physicalactivity and dietary modification doing things for oneselfis not highly regarded in this group. The idea of work as aunit makes weight loss difficult, as changes cannot be madewithout inclusion of all household members and having thefamilies support. Some with diabetes described having tohave meals separate from their family who continued withtheir usual diet status [23].
Body image was recognised by many authors as a poten-tial barrier to healthy lifestyle behaviours. Positive personalappearance being related to a larger size is a cultural barrierthat outweighed personal motivation for weight loss, [21] andfor older people weight loss was seen as potentially weak-ening. This may in part be due to the culturally acceptablenature of being of a larger size, weight is not always perceivedas unhealthy and may be viewed as indicating good health,weight, or status [23]. The extent to which importance wasattached to an ideal body size differed by gender, age and itwas not always women that were keen on managing weight[19]. For women, dieting was not common, only if the issuewas raised by a health professional had they considered diet-ing for weight loss [25]. This study also found perception ofownweight was often not correct withmost perceiving them-selves not overweight when body mass index calculationsshowed they were. Weight perception may also be affected bymodesty traditions as some pointed out that a woman dressedin traditional clothing was not always aware of her shape
12 Journal of Obesity
[25]. Women viewed weight gain as an inevitable path in awoman’s life after-children and due to age [24] linked withunderlying beliefs of fate and destiny, which impacted moti-vation to make changes. Although, where there had beenpositive experiences of weight loss seen in a peer or elder thisacted as motivation to diet [26].
6. Discussion
These ten studies provide insight into possible reasons whySouth Asian perceptions may be at odds with individualisticmotivations in commercialised healthy living (e.g., gymmembership) and with current models of behaviour change.Concepts such as self-efficacy or empowerment where em-phasis is placed on individuals and their self-efficacy (e.g.,Health Belief model) may not be readily applicable to SouthAsians along with the current focus on self-management ofdisease. This requires considerable motivation and prioriti-sation of health by the individual but when the benefits ofengaging in health-related behaviours are not readily iden-tified and long-term health not a prioritised goal.
High importance is attached to group norms and socialvalues, so supporting initiatives, which receive communityendorsement, may help to alleviate people’s anxieties takingtime out from their obligations to perform exercise. Deliv-ering education, advice, and support to the whole familygiven the broader role that the shared consumption of SouthAsian food plays in community life is important and mayhelp reduce concerns about not participating in cultural acts.There is also need to consider the nature of social supportnetworks, essential for promoting health behaviour change,that is, extended families living within households as socialsupport from familymemberswill encourage healthy diet andphysical activity adherence.
Lifestyle advice given by health professionals needed to beculturally appropriate to enable individuals to put the infor-mation into practice. Health professionals need to be awaretheir advice can lack acceptability and therefore unlikely to befollowed. Health professionals need to be aware advice lack-ing in acceptability may reduce adherence and so highlightsthe need for sensitivity to patient motivations and culturalcommonality by health professionals. More specifically aneed for strategies focusing on healthy cooking practicesthrough the promotion of lower fat authentic versions oftraditional recipes and understanding different ideas on bodyimage in relation to health risks will likely assist behaviourchange. Consideration of the term physical activity and activ-ities associated, the amount of exercise, physical limits wereoften unknown and questioned. Physical activity was notidentified as amain factor in the aetiology of obesity and poorphysical health; this lack of association should cause concernfor health providers. Lack of knowledge and perceived lack ofcontrol over health, means behaviour modification is likelyto be harder among this group. Walking stood as women’smost popular activity for keeping active as this was easilycontrolled and incorporated into daily routines, accompa-nied by the benefits of meeting other people. Identifying
preferences and activities that are culturally acceptable appearvery important within this group.
Proactive targeting of information is needed, combinedwith specific guidance and reassurance.This should be sensi-tive to South Asian concerns and motivations, such as thoseidentified here and use of community peer education may bean effective way to assist levels of self-efficacy. For now healthpromoters may need to consider working with, rather thanagainst, cultural norms, values, and individual perceptions.For instance, rather than appealing to the promotion of indi-vidual health and personal gain, they might consider empha-sising the benefits of physical activity and dietary changein terms of helping people to maintain their roles withintheir families and to fulfill their obligations to others. Strongfamily networks and frequent history of diabetes appearsto create strong emotional support among South Asiansseeking advice from each other and therefore also means thatthey are unlikely to seek additional support. Emphasis onsupport from family to make changes and high regard frominformal sources of information (peers, elders, etc.) rein-forces that family-based educational interventions are usefulin these communities to build on beliefs, attitudes, andbehaviours already existing. It may be prudent to investenergy and resources in raising general awareness throughgroup and community-based initiatives spread in particularthrough word of mouth as a useful approach for promotion.
Contemporary health promotion is built on assumptionsof individualism and self-investment and may need to berethought for South Asian groups. Typical health promotionis based on education and awareness therefore unlikely thatlarge-scale campaigns are reaching South Asian groups wholook to their peers as role models and advisors. Clearly, anumber of factors give South Asians their unique sense ofidentity and belonging and cultural preferences influenceengagement with different recreational activities and foodchoices. In common with other areas of interest relating topeople of South Asian origin, it is important to bear in mindthe heterogeneity of this broad ethnic group and to be awarethat the attitudes and health beliefs of specific subgroupsmay not be common to all migrant South Asians convertingawareness into action. However, considering their healthrisks, understanding disease risks, and importance of engag-ing in preventive behaviours are imperative for this group.Interventions have previously been based on Westernbehaviourmodels and no information regarding the cultural-appropriateness of these exists.The term “culturally sensitive”has been widely employed to describe initiatives, which havebeen tailored to increase their appropriateness for minorityethnic communities. However, understanding of the factorsto be considered in developing adapted interventions is stilldeveloping, within a wider context of competing theory-based strategies. These studies help us to understand the cul-tural factors responsible for poor adherence to lifestyle advicebut more studies are needed on the cultural acceptabilityof different types of exercise and dietary regimens in SouthAsians. The development of a framework to better under-stand the factors underlying South Asian health behavioursand how this relates to the initiation and maintenance ofa healthier lifestyle would be of use to health professionals
Journal of Obesity 13
and service providers in addressing health inequalities amongthis group.Qualitative research is helping to reveal how socialand cultural forces shape health behaviours and can work toexplainwhy information and programmes alone are often notenough to change it.
References
[1] S. Bhardwaj, A. Misra, L. Khurana, S. Gulati, P. Shah, and N.K. Vikram, “Childhood obesity in Asian Indians: a burgeoningcause of insulin resistance, diabetes and sub-clinical inflamma-tion,” Asia Pacific Journal of Clinical Nutrition, vol. 17, no. 1, pp.172–175, 2008.
[2] A. Misra, L. Khurana, S. Isharwal, and S. Bhardwaj, “SouthAsian diets and insulin resistance,” British Journal of Nutrition,vol. 101, no. 4, pp. 465–473, 2009.
[3] P. Joshi, S. Islam, P. Pais et al., “Risk factors for early myocardialinfarction in South Asians compared with individuals in othercountries,” Journal of the AmericanMedical Association, vol. 297,no. 3, pp. 286–294, 2007.
[4] M. J. Duncan, L. Woodfield, Y. Al-Nakeeb, and A. M. Nevill,“Differences in physical activity levels between white and SouthAsian Children in the United Kingdom,” Pediatric ExerciseScience, vol. 20, no. 3, pp. 285–291, 2008.
[5] Health Survey of England, “The health of ethnic minoritygroups,” 2004, http://www.ic.nhs.uk/pubs/healthsurvey2004-ethnicfull.
[6] V. C. Kuppuswamy and S. Gupta, “Excess coronary heart dis-ease in South Asians in the United Kingdom,” British MedicalJournal, vol. 330, no. 7502, pp. 1223–1224, 2005.
[7] G. McAllister and M. Farquhar, “Health beliefs: a cultural divi-sion?” Journal of AdvancedNursing, vol. 17, no. 12, pp. 1447–1454,1992.
[8] R. J. Pasick, C.N.D’Onofrio, andR.Otero-Sabogal, “Similaritiesand differences across cultures: questions to inform a thirdgeneration for health promotion research,” Health Educationand Behavior, vol. 23, no. 1, pp. 142–161, 1996.
[9] K. Resnicow, T. Baranowski, J. S. Ahluwalia, and R. L. Braith-waite, “Cultural sensitivity in public health: defined and demys-tified,” Ethnicity and Disease, vol. 9, no. 1, pp. 10–21, 1999.
[10] A. L. Strauss and J. Corbin, Basics of Qualitative Research: Tech-niques and Procedures for Developing Grounded Theory, Sage,Thousand Oaks, Calif, USA, 1998.
[11] S. A. Munro, S. A. Lewin, H. J. Smith, M. E. Engel, A. Fretheim,and J. Volmink, “Patient adherence to tuberculosis treatment: asystematic review of qualitative research,” PLoSMedicine, vol. 4,no. 7, pp. 1230–1245, 2007.
[12] M.Dixon-Woods, S. Bonas, A. Booth et al., “How can systematicreviews incorporate qualitative research?A critical perspective,”Qualitative Research, vol. 6, no. 1, pp. 27–44, 2006.
[13] N. Mays and C. Pope, “Qualitative research in health care:assessing quality in qualitative research,” British Medical Jour-nal, vol. 320, no. 7226, pp. 50–52, 2000.
[14] K. Malterud, “Qualitative research: standards, challenges, andguidelines,”The Lancet, vol. 358, no. 9280, pp. 483–488, 2001.
[15] M. Rowan, P. Huston, and J. Murrey, “Qualitative researcharticles: information for authors and peer reviewers,” CanadianMedical Association Journal, vol. 157, no. 10, pp. 1442–1446, 1997.
[16] Critical Appraisal Skills Programme, “Ten questions to helpyou make sense of qualitative research,” 2002, http://www.phru.nhs.uk/learning/casp qualitative tool.pdf.
[17] G. W. Noblit and R. D. Hare, Meta-Ethnography: SynthesizingQualitative Studies, Sage, London, UK, 1988.
[18] S. M. Choudhury, S. Brophy, and R. Williams, “Understandingand beliefs of diabetes in the UK Bangladeshi population,”Dia-betic Medicine, vol. 26, no. 6, pp. 636–640, 2009.
[19] A. Darr, F. Astin, and K. Atkin, “Causal attributions, lifestylechange, and coronary heart disease: illness beliefs of patientsof South Asian and European origin living in the United King-dom,” Heart and Lung, vol. 37, no. 2, pp. 91–104, 2008.
[20] J. Richie and L. Spencer, “Qualitative data analysis for appliedpolicy research,” in Analysing Qualitative Data, A. Bryman andB. Burgess, Eds., pp. 173–194, Routledge, London, UK, 1994.
[21] A. Farooqi, D. Nagra, T. Edgar, and K. Khunti, “Attitudes tolifestyle risk factors for coronary heart disease amongst SouthAsians in Leicester: a focus group study,” Family Practice, vol.17, no. 4, pp. 293–297, 2000.
[22] C. Grace, R. Begum, S. Subhani, P. Kopelman, and T. Green-halgh, “Prevention of type 2 diabetes in British Bangladeshis:qualitative study of community, religious, and professional per-spectives,” British Medical Journal, vol. 337, no. 7678, pp. 1094–1097, 2008.
[23] T. Greenhalgh, C. Helman, and A. M. Chowdhury, “Healthbeliefs and folk models of diabetes in British Bangladeshis: aqualitative study,” British Medical Journal, vol. 316, no. 7136, pp.978–983, 1998.
[24] J. Lawton, N. Ahmad, L. Hanna, M. Douglas, H. Bains, and N.Hallowell, “’We should change ourselves, but we can’t’: accountsof food and eating practices amongst British Pakistanis andIndians with type 2 diabetes,” Ethnicity and Health, vol. 13, no.4, pp. 305–319, 2008.
[25] A. F. Ludwig, P. Cox, and B. Ellahi, “Social and cultural con-struction of obesity among Pakistani Muslim women in NorthWest England,” Public Health Nutrition, vol. 4, pp. 1–9, 2011.
[26] J. Sriskantharajah and J. Kai, “Promoting physical activityamong South Asian women with coronary heart disease anddiabetes: what might help?” Family Practice, vol. 24, no. 1, pp.71–76, 2007.
[27] M. Stone, E. Pound, A. Pancholi, A. Farooqi, and K. Khunti,“Empowering patients with diabetes: a qualitative primary carestudy focusing on South Asians in Leicester, UK,” Family Prac-tice, vol. 22, no. 6, pp. 647–652, 2005.
[28] J. Lawton, N. Ahmad, L. Hanna, M. Douglas, and N. Hallowell,“’I can’t do any serious exercise’: barriers to physical activityamongst people of Pakistani and Indian origin with Type 2 dia-betes,”Health Education Research, vol. 21, no. 1, pp. 43–54, 2006.
[29] I. Ajzen, “The theory of planned behavior,” OrganizationalBehavior and Human Decision Processes, vol. 50, no. 2, pp. 179–211, 1991.