the influence of culture on diabetes self-management: perspectives of gujarati muslim men who reside...

ORIGINAL ARTICLE doi: 10.1111/j.1365-2702.2007.02178.x

The influence of culture on diabetes self-management: perspectives of

Gujarati Muslim men who reside in northwest England

Elizabeth Fleming BSc, PhD, RN

Honorary Senior Lecturer, University of Central Lancashire, Department of Nursing, Preston, Lancashire, UK

Bernie Carter BSc, PhD, PGCE, PGCE, RSCN, SRN

Professor of Children’s Nursing, University of Central Lancashire, Department of Nursing, Preston, Lancashire, UK

Judith Pettigrew MA, PhD, BScOT, DipCOT

Senior Lecturer, University of Central Lancashire, Lancashire School of Health and Postgraduate Medicine, Preston, UK

Submitted for publication: 15 February 2007

Accepted for publication: 30 August 2007

Correspondence:

E Fleming Honarary Senior Lecturer

University of Central Lancashire

Department of Nursing

Preston

Lancashire

PR12HE

UK

Telephone: 01772678109

E-mail: [email protected]

FLEMING E, CARTER B & PETTIGREW J (2008)FLEMING E, CARTER B & PETTIGREW J (2008) Journal of Nursing and

Healthcare of Chronic Illness in association with Journal of Clinical Nursing 17, 5a,

51–59

The influence of culture on diabetes self-management: perspectives of Gujarati

Muslim men who reside in northwest England

Aim. To present the findings of a study which explored the influence of culture on

(type 2) diabetes self-management in Gujarati Muslim men who reside in northwest

England.

Background. This study was informed by an embodied perspective of culture, in

which culture is grounded in the body and self. This contrasts with some contem-

porary health research and policy which adopts an oversimplified perspective,

portraying culture as static and deterministic and being responsible for non-adherent

self-management behaviours.

Method. A case-study approach was used, which combined interview and participant

observation methods. Data were collected from Gujarati Muslim men about their

lived experiences of diabetes self-management. These accounts, along with further

narrative data from ‘significant other’ participants, were analysed over several cycles.

Results. Two central concepts guide the results: embodied culture and dynamic cul-

ture. These concepts reflect the subjective and contextual nature of culture and are

illustrated in the themes ‘past experiences and socio-economic factors’, ‘social and

gendered roles’ and ‘personal choice and contextual factors’. The findings highlight

that the complexity of life means that culture never exists in isolation, but is one of the

many factors that a man negotiates to inform his diabetes self-management.

Conclusion. We draw attention to the dissonance between the way culture is pre-

sented in some government policy and research, and the way it is understood in an

embodied approach. The National Service Framework for Diabetes advocates the

provision of individualized culturally appropriate care, and in this paper, we make

suggestions as to how an embodied approach can be incorporated within the

framework.

� 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd 51

Relevance to clinical practice. Nurses have an integral role in implementing the

National Service Framework for Diabetes. This paper contributes to the debate about

how nurses can best deliver this framework to a diverse patient population.

Key words: chronic illness, cultural issues, diabetes, men’s health, nurses, nursing,

self-management

Introduction

The rising prevalence of type 2 diabetes (Amos et al. 1997)

has resulted in a renewed governmental interest in the

management of this condition. The publication of the

National Service Framework for Diabetes [Department of

Health (DOH) 2001], which identifies self-management as a

fundamental tenet of diabetes care in England, reflects this

renewed interest. This publication, along with others in the

field of health and nursing, identifies a group’s culture as a

factor that may influence the way a person from that group

self-manages their condition. However, often, a reductionist

approach is taken, in which culture is perceived as determin-

istic (for examples of this, see Hjelm et al. 2003, Barnes et al.

2004). Such a perspective has been criticised for failing to

acknowledge the richness and diversity of culture (Ahmad

1996, Culley 2001).

The perspective we take in this paper is an embodied one,

in which culture is perceived as dynamic, contextual and

contested. In taking this theoretical stance, we question the

applicability of a reductionist approach that often results in

culture being wrongly blamed for non-adherent self-manage-

ment behaviours.

Background

Many studies have explored how culture influences diabetes

self-management (see Fleming 2005, for a review of these)

and how they vary in their approach. While some take a

dynamic approach to the study of culture (Chowdhury et al.

2000, Garro 2000, Thompson & Gifford 2000, Poss &

Jezewski 2002), others take a more simplified approach,

which has the risk of reducing culture to a set of uniform

beliefs and behaviours (Hjelm et al. 2003, Barnes et al. 2004).

Those with the most dynamic approach often do not focus

solely on culture, but instead, portray it as one of the many

influential factors in self-management. These studies reflect

the rich context in which socially situated beliefs and

behaviours are constructed. In contrast, adopting a reduc-

tionist approach to the study of culture risks emphasising

differences and otherness (Culley 2001), which could lead to

harmful stereotypes and cultural blaming (Ahmad 1993,

1996). Instead of acknowledging the complexity of health

beliefs and behaviours, groups of people are reduced to their

cultural differences and culture is perceived as fixed and

constraining (Culley 2001).

The tendency to reduce and consequently problematise

minority cultures is evident within current government policy

on diabetes care. For example, in the Audit Commission

Report (2000), a stereotypical account of a South Asian man

with diabetes is presented (pp. 35–36). Within this report and

others (DOH & Diabetes UK 2005), culture is perceived as

only belonging to and being problematic in relation to people

from minority (usually non-white) ethnic groups. Such a

perspective fails to acknowledge that culture is important and

influential in diabetes self-management for all individuals,

regardless of their ethnic background.

Of the studies that have been identified as exploring the

influence of culture on diabetes self-management, none adopt

an embodied approach to the study of culture. Other studies

have used ethno-epidemiology (Thompson & Gifford 2000),

explanatory model approach (Poss & Jezewski 2002),

cultural knowledge and memory theory (Garro 2000), and

in one study (reported in two publications), the authors did

not name a specific theoretical approach, but used a

qualitative exploratory approach which was guided by

anthropological enquiry (Greenhalgh et al. 1998, Chowdhury

et al. 2000). In the study we report in this paper, an embodied

dynamic approach was adopted as this theoretical approach

is equally applicable to the study of culture and self-

management. These experiences are lived and embodied by

the individual; hence, they are symbolised in thoughts, values,

behaviours, interpretations and reactions. Consequently, an

embodied dynamic approach helps to embrace and explore

the connectivity that exists between culture and self-manage-

ment. The approaches taken in previous research do not

provide scope for the detailed study of this connectivity.

In recent years, the embodied perspective has gained

popularity in the study of health, healing and the body

(Britton 1998, Williams & Barlow 1998, Csordas 1994a,

1994b and c, 2002). In this approach, the body is perceived

as a product of culture and the self, and therefore, is

biological and also emotional, linguistic, imaginative and

religious. Hence, the body and the mind co-exist and are

E Fleming et al.

52 � 2008 The Authors. Journal compilation � 2008 Blackwell Publishing Ltd

inseparable. Furthermore, the individual is located in a world

of others, and while his or her perceptions are likely to be

informed by others and the socio-cultural world in which he

or she is located, they are not determined by others as it is

ultimately the individual that constructs his or her own world

(Csordas 2002). Therefore, culture is not something that

exists as an abstract set of rules which determines a group’s

behaviour; instead, it exists in the meanings that individuals

construct in the context of their world.

The study

Aim

The aim of the study was to explore the influence of culture

on (type 2) diabetes self-management in Gujarati Muslim

men who reside in northwest England.

Sample

A convenience sample of five men living with diabetes as

recruited through attendance at luncheon clubs and contacts

with community development workers. They were aged

between 55–72 years, all had type 2 diabetes, lived in an

urban area of northwest England, spoke English and

identified themselves as Gujarati Muslim. Three of the

men had migrated from Gujarat, India, and the other two

from Uganda, East Africa. Men, rather than women, were

chosen as the study group, because preliminary work had

revealed that many older women could not speak fluent

English. Funding and time constraints meant that EF, who

could only speak English, had to undertake the fieldwork.

Gujarati Muslims were selected because research with this

South Asian sub-group is scarce, and no studies in the area

of diabetes self-management were found with this

population.

There were five further participants who have been referred

to as ‘significant other participants’, of whom, four were

Community Development Officers (CDO) who worked

extensively with the Gujarati Muslim population and one

was the daughter of one of the case study participants. Of the

CDO, two were second-generation Gujarati Muslim people

(one male and one female) and one was a first-generation

Gujarati Muslim man. The fourth was a second-generation

Pakistani Muslim woman.

Data collection

A case-study approach was adopted, which involved inter-

view and participant observation data collection methods.

The interview prompts were devised from a review of the

literature and the findings of a preliminary study. All, except

for one of the men, who owing to ill health was able to

participate in only one interview, participated in two

interviews. The second interview enabled deeper insights

into the participant’s world to be gained and provided an

opportunity to check the interpretation of the data collected

previously. Observation was undertaken at the same time as

the interview, and began then ended when the researcher

was driving to and from the man’s home. Following the

interviews, the researcher was often invited to extend her

visit and stay for refreshments. A further two separate

sessions of observation were undertaken with one partici-

pant while he was attending a luncheon club and one

participant participated in a nominal group (Delbecq et al.

1986) in the preliminary study. In total, there were 12

fieldwork sessions with these participants, which equated to

22 data pieces (nine interview transcripts, one nominal

group transcript and 12 sets of observation notes).

Each of the five significant other participants took part in

one interview. The role of this participant group was to

provide further breadth and depth to the case study

data. Data were collected over a 11-month period, from

June 2003–May 2004.

Ethical considerations

This research was granted ethical approval from the Faculty

of Health and National Health Service ethics committees.

Pseudonyms have been used, participant’s personal details

have been generalized and the area in which the research

was undertaken has not been revealed.

Analysis

Topic and analytic coding were used in the analysis process.

Topic coding entails analysing the data for topics and

reflecting on where it fits in relation to the wider analysis

(Morse & Richards 2002). This type of coding was under-

taken before analytical coding, with the intention of it

enabling immersion in the data. Analytic coding is a natural

progression from topic coding (Morse & Richards 2002), as

it involves looking for deeper meanings in the data. Hence,

the analytic codes were more abstract, whereas topic codes

were often more descriptive. Three cycles of analysis were

undertaken, during which, the researcher moved between the

processes of data coding, literature reviewing, theory building

and fieldwork. Hence, the analysis process was a cyclical one,

which required ‘flexibility’ and ‘creativity’ (Carter 2004,

p. 87).

Original article The influence of culture on diabetes self-management


Findings

Participants

The men who migrated directly from Gujarat came to the UK

as economic migrants in the 1950s and 1960s, while the men

from Uganda (who were brothers) arrived following the

expulsion of Asian people in 1972. These men were born in

Uganda and their fathers had migrated from Gujarat to

Uganda in the early part of the twentieth century. Therefore,

although Gujarati was the mother tongue of all the partici-

pants, and all of them identified themselves as Gujarati

Muslims, they came from different backgrounds. Two of the

three men who migrated directly from Gujarat came from

relatively deprived farming backgrounds, while the other

man had attended university and worked in a professional

capacity. The two men who came from Uganda had worked

in various businesses which they either owned themselves or

were family owned. While one of the brothers had continuing

ties with Gujarat, as his wife was from Gujarat, the other

brother had never visited Gujarat and he did not keep in

contact with any Gujarati relatives.

One man and his family now live in a council-owned

property, while the other four live in privately owned houses.

Of these four men, three have bought houses in deprived areas

which have a large South Asian population, while one man

lives in a prosperous area with a small South Asian popula-

tion. Four men have children, while one does not. All five men

worked following their arrival in the UK (all in unskilled jobs,

including the individual who worked in a professional job in

Gujarat); however, four had retired early owing to ill health,

while one man had worked until retirement age. Furthermore,

the men follow different sects of Islam.

There are many parallels between the men’s lives and those

of many older men living in Britain, and therefore, the issues

that are discussed in this paper are not just cultural ones but

are equally issues of structural, material, political, genera-

tional and individual factors.

Embodied culture and dynamic culture

Two central concepts guide the findings: embodied culture

and dynamic culture. Embodied culture represents the sub-

jective experience and emphasises that diversity, and not

uniformity, is central. Dynamic culture reflects the complex

context in which culture is negotiated. These themes are

interwoven as the man’s subjective culture is negotiated and

re-created in association with the shifting context of his life.

Therefore, they should not be viewed as distinct or separate,

because they are entwined. These themes form a framework,

under which the themes, which are discussed next, are

examined.

Three themes are explored in the following passages. The

dual aspect reflects the complexity of self-management

decisions. Hence, analysis revealed that past experiences

and socio-economic factors are entwined as are social and

gendered roles, and personal choice and contextual factors.

Furthermore, to some extent, all the themes overlap and

should not be thought of as isolated or encapsulated. The use

of ‘Shazana’ and ‘CDO’ indicates the instances where

excerpts from interviews with significant others have been

used.

Past experiences and socio-economic factors

Mr Mustafa and Mr Rathod explained that they use allo-

pathic medicine as their guiding healing perspective, while

Mr Khan, Mr Bhopal and Mr Patel, to varying degrees,

demonstrated the use of a combination of allopathic and

complementary therapies (particularly Unanni Tibb).

This divergence links with the men’s past experiences. For

instance, Mr Khan, Mr Bhopal and Mr Patel identify with

complementary therapies, because this type of therapy was,

and still is, readily available in Gujarat. This was reflected in

an interview with a CDO. When asked whether people with

diabetes would access any other healers apart from allopathic

ones in Gujarat, he replied:

Yeah, yeah definitely. I mean there are herbalist, homeopathic and

ayurvedic. They are probably the same skill as the normal [allo-

pathic] medicine thing. That’s very, very common isn’t it, in India … I

mean they got big hospitals there for herbal and ayurvedic. They are

big hospitals they are.

It was highlighted that people’s experiences of healing are

shaped by their financial situation when Mr Bhopal said that

people in Gujarat would ‘usually’ use ‘herbal’, ‘homeo-

pathic’ or ‘ayurvedic’ therapies because ‘those things is

cheaper [than allopathic] and more homely’. His views

reflect the situation across much of South Asia, where it is

common for people to access non-allopathic healers readily

as they are more affordable and accessible, especially in

rural areas, and these healers often share the explanatory

model of their clients (Gardner 1995, Shaw 2000). Further-

more, Mr Khan explained, ‘Those who are first class, they’re

always going to the medicine doctor’, and Mr Bhopal said

that ‘… those people who are the poor one, they usually

using the herbalist system’. This reflects the ability of the

‘first class’ wealthy person to buy into what is increasingly

seen across South Asia as impressive and prestigious

‘scientific medicine’. The cost of allopathic medicine in

Gujarat means ‘…people tend not to go [to the doctor]

unless they have to’ (CDO), and they do not always continue

with prescribed medications:

E Fleming et al.


It depends how rich you are, how much money you’ve got for the

medication … They would go to the doctor but paying for the

medication or being told you will have this and you’ve got to pay this

much every month for a tablet, it’s highly unlikely that they’re going

to stick to that regimen.

In contrast for Mr Mustafa and Mr Rathod, who both grew

up in Uganda, complementary therapies have little resonance

in their diabetes self-management, as these therapies have not

been a significant feature of their life experiences. They

explained that allopathic medicine was the only form of

therapy that they accessed in Uganda, and when Mr Rathod

was asked if he uses any forms of complementary therapy, he

replied ‘No I’m not’ and Mr Mustafa said that he had ‘never’

accessed a complementary therapist. Mr Mustafa went on to

explain that his only contact with a complementary form of

medicine was when he recently bought homeopathic tablets

from a chemist, to try to ease a ‘headache and pain’, when the

tablets prescribed by his general practitioner (GP) were not

effective. However, the homeopathic tablets did not work for

him either.

The approach taken towards the use of complementary

therapies by Mr Mustafa was quite different to that shown

by Mr Bhopal and Mr Patel. Mr Bhopal and Mr Patel both

discussed complementary and particularly herbal therapies

at length, providing direct examples of their integration

of this therapy into their diabetes self-management.

Mr Mustafa, however, talked of homeopathic tablets as a

last resort when his usual choice of therapy had not been

effective. As Mr Mustafa does not appear to be impressed

by homeopathic tablets, his faith in this type of therapy is

not likely to have heightened following the failure of the

tablets.

The divergence in present-day healing perspectives between

the men who migrated from Gujarat and those who migrated

from Uganda, relates to the type of healing systems that were

available to them in these countries. However, past healing

experiences do not only include those prior to migration, but

also post-migration experiences. Hence, although Mr Bhopal

and Mr Patel predominantly accessed complementary ther-

apies in Gujarat, in the UK, the financial and geographical

accessibility of allopathic therapies means that they are likely

to use them more often than they did in Gujarat.

Furthermore, the interplay of socio-economics with the

type of healer accessed and the associated experience of, and

belief in that system, is also influential in the men’s present-

day self-management. Mr Khan spoke of his ‘wealthy’

background and how his higher education meant that he

was able to become a professional worker in Gujarat. In

contrast, Mr Bhopal and Mr Patel were both farm labourers

in Gujarat, and hence, they did not consider themselves to be

wealthy. Of the three men who migrated from Gujarat, Mr

Khan demonstrated the least amount of faith in and knowl-

edge of complementary therapies, and he explained that if he

still lived in Gujarat and was diagnosed with diabetes, he

would go to ‘the doctor, same as in England’.

Although Mr Khan said that he had taken ‘roots’, ‘old

fruits’, ‘berries’ and ‘very small pills’ in the past, he did not

relate these complementary therapies to his diabetes self-

management, and he did not discuss these in the same depth

as Mr Bhopal and Mr Patel. In contrast, Mr Bhopal and Mr

Patel discussed complementary and particularly herbal ther-

apies at length, and they related these directly to their

diabetes self-management. For example, Mr Bhopal spoke

about his use of bitter foods and Mr Patel talked of his recent

visit to a Hakim (practitioner of Unanni Tibb), who advised

that certain foods should be avoided to prevent ‘inflamma-

tion’ and ‘infection’ to the wound of his amputation site (he

had recently had part of his gangrenous foot amputated

owing to complications of his diabetes). It seems likely that

the variance between Mr Khan’s, and Mr Bhopal’s and Mr

Patel’s current day knowledge, beliefs in and use of allopathic

and herbal therapies is linked with their past personal

experiences, which have been mediated by socio-economic

factors. Mr Khan’s relatively prosperous upbringing in an

urban environment has meant that allopathic medicine has

been more readily available to him, when compared with

Mr Bhopal and Mr Patel. Therefore, in current day

self-management, herbal therapies have greater resonance

for Mr Bhopal and Mr Patel, than they do for Mr Khan.

Social and gendered roles

Several participants highlighted that social relationships can

have a significant effect on a person’s use of remedies. For

example, Shazana (Mr Rathod’s daughter) spoke about her

uncle who had diabetes (Mr Mustafa’s and Mr Rathod’s

brother) and highlighted that ‘some people, like my uncle,

‘cause his wife’s family is in India, he gets things [referring to

herbal medicines] sent to him’. Similarly, Mr Patel’s son (who

was present during an interview with his father, but was not a

significant other participant) spoke about his father’s reluc-

tance to take his prescribed allopathic medicines. He ex-

plained that if it was not for his mother’s ‘badgering’, his

father would not take his medications at all. In these exam-

ples, it is apparent that the man’s self-management practices

are influenced by those around him. This reflects the situation

of other people with long-term conditions, where family

support has been identified as a key aspect of living with the

condition (Fleury 1993, Skinner & Hampson 1998, Skinner



et al. 2000). Social influences do not just come from family

members, but as Shazana highlighted, others, such as friends,

have the potential to influence self-management:

… there are people out there who actually do go to them [herbal

therapists] and they will actually say to you, you know if you’ve got

this and if you’ve got that then you should take this. Like for instance

… if you’ve got kidney problem, someone will say, if you have I don’t

know arrowroot and soak it in some water, and then drink the water

or whatever, it’ll help your kidneys. You know it all travels. If one

person goes to a herbalist, they’ll tell another person and then

another person will tell another person, that kind of thing.

Social influences are also apparent in participants’ discussions

about eating and diabetes. For example, as Mr Rathod had a

stroke and developed diabetes over 20 years previously, he is

unable to work. Although he and Shazana told me that

women traditionally take the lead in cooking, in his family his

wife works full time in a nearby factory and is the main

breadwinner. As Mr Rathod no longer works, he now takes a

greater role in cooking than previously. Mr Khan also talked

about the flexibility of who prepares meals. When asked who

does the cooking in his household, he replied ‘My daughter-

in-law’, and then went on to elaborate saying that his

daughters ‘… ask me to come to their houses, you know …especially on Saturday or Sunday.’ He also explained that ‘…the youngest daughter, the oldest daughter, they also under-

stand about everything [regarding his diabetic diet]’ and so

they prepare him a separate dish to the other family members

by ‘… taking all sweet out and … in my dish would be the

sugar-free.’

As food has social meanings and importance, people’s

decisions about what to eat are complex, and at times,

contradictory. Such was the case for Mr Khan, who, during

an interview, portrayed himself as adherent with an allo-

pathic diabetic diet. However, he was observed on several

occasions at the luncheon club eating very high-fat, fried

foods that he had previously said he avoided. Two factors,

the divergence between ideal and actual behaviour and the

social meaning of food and eating, can explain this ambigu-

ity. Mr Khan was aware that the researcher (EF undertook

the data collection) is a part-time diabetes nurse, and it was

during the early stages of their first interview that Mr Khan

portrayed a picture of himself as an ‘ideal patient’. At this

early stage in the data collection, Mr Khan would often slant

his discussions to reflect an allopathic focus, and the

researcher felt that her nursing background, especially in

the early stages of fieldwork, meant he portrayed himself in a

way which did not always reflect his actual behaviours.

Eating at the luncheon club has a social dimension, and

therefore, Mr Khan may feel pressure to eat the types of

Gujarati foods which he had said he now avoids. The

importance of social eating was reflected by a CDO, when he

explained that eating is an integral part of Gujarati social

occasions. Initially, he spoke about Ramadan:

They [Gujarati Muslims] eat like a pig when they break the fast. It’s

festivity sort of thing, everyday and … all rich food. Many of the

small occasions come, again the food is a priority. Food is always the

main thing.

When asked what ‘small occasions’ he was thinking of, he

replied:

Well birthdays, or weddings or you know even no occasion, just yeah

an occasion to eat (laughter). Occasion to eat … they call people,

that’s very normal actually, they call people just to eat, yeah, just to

come down, you know to somebody’s house … Social gathering sort

of thing. Place for food … They come down, they make this, this, this.

The weekly luncheon club could be seen as a ‘small occasion’,

as it is a place for socialising and a means through which

people keep alive and re-create Gujarati culture in a UK

context. Furthermore, at the luncheon club, the researcher

observed a custom which is common in many populations –

that of serving large portions of food to men. When she stood

in the queue with Mr Bhopal, she watched as he strongly

resisted the attempts made by the woman who was serving

him his food, to pile it up high on his plate. When she looked

at Mr Bhopal’s tray, it already contained larger portions than

did hers. The woman serving at the end of the counter gave

all the women half a bread roll and Mr Bhopal resisted when

she tried to serve him two halves. Her observations on that

day, and during future visits to the luncheon club, revealed

that all the men (including Mr Khan) are offered and usually

accept larger portions than the women. This social atmo-

sphere combined with Mr Khan’s desire to continue eating

the foods that he has been accustomed to for much of his life,

means that despite him saying that he alters his eating so that

it is in line with allopathic advice, in reality, his diet is not

always consistent with this guidance.

Personal choice and contextual factors

Self-management decisions and behaviours are always, to

some extent, a product of personal choice. This is reflected in

Koch et al.’s (2004) paper, in which, personal decision

making is portrayed as a central feature of self-management.

This was also summed up by Shazana, when she said, ‘it

depends on what type of a person you are’ in relation to the

type of healing therapy that a person chooses to use. This is

further supported by a CDO’s comment; ‘What I’ve learnt is

it’s the person’s choice. Some people I mean they don’t like

medicine at all and they’re always taking the homeopathic.’

E Fleming et al.


Personal choice is also influenced by contextual factors.

This is reflected in another comment by the CDO:

… but if it comes to operation or something, I don’t know if there is

any problems ‘cause I know the ayurvedic and the homeopathic they

can’t do the operation. It’s only when they, when it comes to minor

sort of ailments they’re happy with it.

One example of this can be seen in the case study of Mr Patel.

Although, during the interview, he expressed his lack of faith

in allopathic medicine, and he explained that he favours

complementary therapies, it is apparent that these beliefs are

not static. His pluralist beliefs are evident in his decision to

have surgery to remedy his gangrenous foot. When Mr Patel

assessed his options in relation to this particular part of his

self-management, he decided that he had the greatest faith in

allopathic medicine. However, during the recovery phase, he

visited a Hakim who advised him not to eat ‘fish’, ‘yoghurt’,

‘lemon’ and ‘certain vegetables’. Regarding this aspect of his

diabetes self-management, Mr Patel made the decision to

access the Hakim, and his wife incorporated this advice into

his diet for four to five months following his surgery. In this

example, Mr Patel negotiates his healing beliefs and does so

because his healing perspectives are formed by interwoven

beliefs in allopathic medicine and complementary therapies.

His healing beliefs involve the co-existence of differing

perspectives, which he uses to inform his self-management

according to the situation in which he finds himself.

Furthermore, enactment of his healing beliefs are interlinked

with the broader context of his life, and therefore, Mrs Patel

became important in enabling her husband to take the

Hakim’s advice.

Discussion

Researchers and policy makers often present an oversimpli-

fied way of thinking about culture (Audit Commission

2000, Hjelm et al. 2003, Barnes et al. 2004, DOH &

Diabetes UK 2005), which can lead to harmful stereotyping

and constrained perceptions. We and others believe (Ahmad

1996, Culley 2001) that in challenging the reductionist way

of thinking about culture, policy makers, practitioners and

researchers need to see beyond cultural labels which act as a

form of ineffective and limiting shorthand. Labels, such as

‘Gujarati Muslim male’, when applied in a reductionist

manner, say less about the individual and more about a

constrained and limited understanding of the notion of

culture. The interplay between self-management and culture

is a unique embodied process which does not lend itself to

uniformity or predictability. As can be seen from this study

and others (Chowdhury et al. 2000, Garro 2000, Thompson

& Gifford 2000, Poss & Jezewski 2002), culture is one

aspect of self-management, which co-exists alongside other

complex dimensions, such as past experiences, socio-

economics, gender, context and personal choice. The body

and the self are always situated within the context of lived

experience, which influences how these factors interplay in

multiple ways to inform self-management. This subjective

and dynamic approach means that Gujarati Muslim male

culture is not homogenous but diverse, and it is impossible

to map specific beliefs and behaviours to all members of this

population. As Cordas highlights, the body and mind are

the vehicle through which individuals live and experience

culture; hence, culture is multifarious as it exists through

perception and interpretation (Csordas 2002). Therefore,

individualised health-care provision that allows the man’s

personal and fluid interpretation of his culture to be

acknowledged would enable a move towards culturally

appropriate care.

Within current government policy on diabetes care, there is

great emphasis on person-centred care (DOH 2001, DOH &

Diabetes UK 2005). This is reflected in standard three of the

National Service Framework for diabetes: ‘To ensure that

people with diabetes are empowered to enhance their

personal control over the day-to-day management of their

diabetes in a way that enables them to experience the best

possible quality of life’ (DOH 2001, p. 21). A central aspect

of person-centred care is the development of an individual-

ised care plan, which is agreed between the person with

diabetes and their health-care team (DOH 2001, 2002a, b).

This care plan should be developed in ‘partnership’ (DOH

2001, p. 14), ensuring that the needs of the individual with

diabetes remain central. It should be used to facilitate goal

setting (DOH 2002b), whereby the practitioner and person

with diabetes discuss and agree on personally meaningful

goals. By negotiating and setting individualized goals, the

person’s self-management, as influenced by their unique

cultural self, could become acknowledged. In this sense, an

individual’s culture would be recognised as an integral aspect

of the context in which he or she negotiates self-management

decisions and behaviours.

The embodied approach is considerably different to that

presented in current policy (DOH & Diabetes UK 2005).

Current policy suggests that specialised programmes of

education and care, which are tailored to meet the cultural

needs of diverse groups of people (such as ‘South Asians’ and

‘African-Caribbeans’), are an appropriate means to develop

and deliver culturally competent diabetes nursing care. On a

pragmatic level, such an approach is appealing; however, we

are concerned that this uniform perspective fails to acknowl-

edge that culture is subjective, and therefore, important in



terms of everyone’s (including people who are part of the

majority ethnic group) health beliefs and behaviours.

Limitations

The researcher plays a central role in shaping the research

process in interpretative research (Coffey 1999). This research

was undertaken as part of EF’s doctoral studies. Therefore,

she has taken the lead in the research process, while BC and JP

provided supervision. Consequently, as a young white English

woman, EF’s identity (and to a lesser extent BC’s and JP’s

identities) has been central in the interpretive process. As

others have highlighted (Gardner 1995), there is always a risk

that incorrect cross-cultural interpretations can be made, and

in this study, we feel that the different researcher–participant

cultures, mother tongue language and ethnicity may have

heightened this risk. By undertaking a member check,

collecting data which are detailed and rich and undertaking

several cycles of reflective analysis, this risk has been

minimized. Ultimately, this paper presents our perspective of

the influence that culture has on diabetes self-management

among older Gujarat Muslim men in the northwest of

England. Furthermore, this study reflects data gathered from

a select group of five English-speaking Gujarati Muslim men,

whose lives have been shaped by a multitude of cultural,

structural, material and contextual factors. Hence, the study

findings are not representative of all diasporic Gujarati

Muslim populations.

Conclusion

This study has highlighted the dissonance between the

approach taken in some government policy and research,

and an embodied and dynamic approach to providing

culturally appropriate care. The reductionist perspective is

theoretically and empirically questionable, and we call for the

inclusion of a dynamic embodied approach. Such an approach

could be used as a basis for developing and delivering

culturally appropriate research, practice and policy.

Acknowledgement

This research was funded by a doctoral bursary from the

Department of Nursing, University of Central Lancashire,

Preston, PR1 2HE, UK.

Contributions

Study design: EF, BC, JP; data collection and analysis: EF and

manuscript preparation: EF, BC, JP

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