Understanding the complex interplay of barriers to physical activity amongst black and minority ethnic groups in the United Kingdom: a qualitative synthesis using meta-ethnography

BackgroundTo conduct a meta-ethnographic analysis of qualitative studies to identify barriers to Black and Minority Ethnic (BME) individuals engaging in physical activity in the UK context.MethodsA qualitative synthesis using meta-ethnographic methods to synthesis studies of barriers to engaging in physical activity among BME groups in the UK. A comprehensive search strategy of multiple databases was employed to identify qualitative research studies published up to October 2012. The eleven searched databases included ASSIA, MEDLINE, EMBASE, CINAHL, Health Technology Assessment (HTA), NHS Scotland Library, Physical Activity Health Alliance (PAHA), PsyINFO, Social Services Abstract, Sport discuss and Web of Science. The Noblit and Hare’s meta-ethnographic approach was undertaken to develop an inductive and interpretive form of knowledge synthesis.ResultsFourteen papers met the inclusion criteria. The synthesis indicated that barriers to physical activity among BME individuals were influenced by four main concepts: perceptions; cultural expectations; personal barriers; and factors limiting access to facilities. BME individuals had different understandings of physical activity were influenced by migration history, experiences, cultural and health beliefs. This in turn may have a disempowering effect on BME individuals in terms of adopting or maintaining physical activity. These barriers to physical activity were explained at a higher conceptual level by a socio-ecological model. The social construct ‘individual perception and understanding of physical activity’ was particularly relevant to theoretical models and interventions.ConclusionInterventions to promote engagement with physical activity need to address perceptions of this behaviour. The elicited concepts and contexts could be used to enhance the development of tailored effective health promotion interventions for BME individuals.

Related papers:

title: Assessment of physical activity levels in South Asians in the UK: findings from the Health Survey for England
abstract: Asians in the UK experience high rates of coronary heart disease compared with other ethnic groups. Behavioural risk factors such as physical inactivity have been explored as possible explanations for this trend. However, there have been few comprehensive accounts describing physical activity levels of this ethnic group.  Data from the Health Survey for England (1999–2004) on 5421 South Asians and 8974 white participants aged 18–55 years were used to compare physical activity levels. Analyses of covariance tested the association between ethnicity and self-reported total physical activity metabolic equivalents of task (MET) scores, adjusting for age, sex, self-reported health, adiposity and socioeconomic status.  Total MET-min/week were consistently lower in UK South Asians than in white participants (973 vs 1465 MET-min, p<0.001). This ethnic group difference was consistent across sexes, age groups and subgroups and was independent of covariates. South Asians born in the UK reported higher levels of physical activity than those born elsewhere (p<0.001). Variables such as urbanisation and psychological distress were associated with physical activity; however, despite their inclusion in the models, ethnic group differences remained, indicating that physical inactivity in South Asians was not attributable to area or individual sociodemographic factors.  Physical activity levels are very low in UK South Asians; this is consistent across all examined population subsets. Physical inactivity is likely to contribute to their high risk of coronary heart disease. Increasing physical activity in all UK South Asians should be a public health priority for health professionals.

title: Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy
abstract: Strong evidence shows that physical inactivity increases the risk of many adverse health conditions, including major non-communicable diseases such as coronary heart disease, type 2 diabetes, and breast and colon cancers, and shortens life expectancy. Because much of the world's population is inactive, this link presents a major public health issue. We aimed to quantify the eff ect of physical inactivity on these major non-communicable diseases by estimating how much disease could be averted if inactive people were to become active and to estimate gain in life expectancy at the population level.



For our analysis of burden of disease, we calculated population attributable fractions (PAFs) associated with physical inactivity using conservative assumptions for each of the major non-communicable diseases, by country, to estimate how much disease could be averted if physical inactivity were eliminated. We used life-table analysis to estimate gains in life expectancy of the population.



Worldwide, we estimate that physical inactivity causes 6% (ranging from 3·2% in southeast Asia to 7·8% in the eastern Mediterranean region) of the burden of disease from coronary heart disease, 7% (3·9-9·6) of type 2 diabetes, 10% (5·6-14·1) of breast cancer, and 10% (5·7-13·8) of colon cancer. Inactivity causes 9% (range 5·1-12·5) of premature mortality, or more than 5·3 million of the 57 million deaths that occurred worldwide in 2008. If inactivity were not eliminated, but decreased instead by 10% or 25%, more than 533 000 and more than 1·3 million deaths, respectively, could be averted every year. We estimated that elimination of physical inactivity would increase the life expectancy of the world's population by 0·68 (range 0·41-0·95) years.



Physical inactivity has a major health eff ect worldwide. Decrease in or removal of this unhealthy behaviour could improve health substantially.

title: ETHNIC DIFFERENCES IN CARDIOVASCULAR DISEASE
abstract: People of non-European origin form around 7% of the total UK population. Most of these are of South Asian (that is, from the Indian subcontinent) or Black African (that is, from the Caribbean and West Africa) descent. For these migrants, as for virtually all population groups living in the western world, cardiovascular disease (CVD) is the main cause of death. But there are striking ethnic differences in CVD risk. Disease presentation may differ, challenging diagnostic skills, and therapeutic requirements and responses may also not be uniform. The study of ethnic differences in CVD has provided valuable aetiological clues, not just for ethnic minority groups but also for the majority population.

Migrants of South Asian descent worldwide have elevated risks of morbid and mortal events because of ischaemic heart disease (IHD).1 In the UK, mortality from IHD in both South Asian men and women is 1.5 times that of the general population (fig 1),2 and South Asians have not benefited to the same extent from the general decline in deaths caused by IHD over the last few decades. These ethnic differences are greatest in the youngest age groups.



 Figure 1 
Standardised mortality ratios (SMR) for heart disease and stroke in South Asians and African Caribbeans compared to Europeans, age 20–69, from 1989–92. Adapted from Wild and McKeigue,2 with permission from the BMJ Publishing Group.



These ethnic differences have been extensively studied, and while classical risk factors, such as smoking, blood pressure, obesity, and cholesterol vary substantially between subgroups of South Asians—such that in some cases, levels are equivalent to, or lower than, a comparable European population—levels of glucose intolerance, central obesity (as measured by waist to hip ratio), fasting triglyceride, and insulin are uniformly elevated compared to Europeans (table 1).3 As the elevated risk of IHD is shared by …

title: Joint Prevalence of Diabetes, Impaired Glucose Regulation, Cardiovascular Disease Risk and Chronic Kidney Disease in South Asians and White Europeans
abstract: Multiple vascular risk factors may confer very high risk, but the degree of commonality between risk factors is unclear, particularly among ethnic minorities. Furthermore, it is unknown what impact this commonality will have on the UK-based NHS Health Check Programme; a vascular disease prevention programme that screens individuals aged 40–74 years. We estimated the joint prevalence of diabetes, impaired glucose regulation (IGR), high cardiovascular disease (CVD) risk and chronic kidney disease (CKD) among White Europeans and South Asians who would be eligible for the Programme.  Cross-sectional data were analysed for 3707 participants (23.6% South Asian) in a screening study set in Leicestershire, UK. Diabetes and IGR were screen-detected. CKD may have been diagnosed previously. IGR was defined as impaired fasting glucose and/or impaired glucose tolerance, and high CVD risk as 10 year risk greater than 20%.  Among males, South Asians had higher prevalence than White Europeans of diabetes (9.0% vs. 3.9%, respectively, p<0.001), IGR (12.5% vs. 9.2%, p = 0.06), and high CVD risk (39.1% vs. 33.1%, p = 0.03), but lower prevalence of CKD (1.5% vs. 4.6%, p<0.01). Among females, South Asians had higher prevalence than White Europeans of diabetes (7.4% vs. 3.3%, p<0.001), but lower prevalence of CKD (3.7% vs. 13.0%, p <0.001) and CVD risk (2.4% vs. 4.6%, p = 0.03), and a non-significant difference in IGR prevalence. At least one risk factor was diagnosed in 34% of participants, and all of them in 0.4%, suggesting that 723,589–734,589 more individuals each year will require monitoring following implementation of the Health Check Programme.  The collective prevalence of risk factors for vascular disease in this population was high, but there was little overlap between the risk factors, and prevalence differed by ethnicity. This has implications for service delivery and resources, and should be considered when planning screening and intervention programmes.

title: Incidence and case fatality rates of stroke subtypes in a multiethnic population: the South London Stroke Register
abstract: To identify sociodemographic differences in the incidence of the subtypes of first ever stroke in a multiethnic population.  A prospective community stroke register (1995–8) was developed using multiple notification sources and pathological and clinical classifications of stroke. Standardisation of rates was to European and World populations and adjusted for age, sex and socioeconomic status in multivariate analyses. A multiethnic population of 234 533 in south London, of whom 21% are black was studied.  A total of 1254 cases were registered. The average age of stroke was 71.7 years with black patients being 11.3 years younger than white patients (p<0.0001). The incidence rate/1000 population was 1.33 (crude) (95% CI 1.26 to 1.41), 1.28 (European adjusted) (95% CI 1.2 to 1.35) with a 2.18 (95% CI 1.86 to 2.56) (p<0.0001) age and sex adjusted incidence rate ratio in the black population. Radiological diagnosis was confirmatory in 1107 (88.3%) with 862 (68.7%) infarction, 168 (13.4%) primary intracerebral haemorrhage, and 77 (6.2%) subarachnoid haemorrhage. Of the cerebral infarction cases 189 (21.9%) were total anterior circulatory, 250 (29%) partial anterior, 141 (16.4%) posterior (POCI) and 282 (32.7%) lacunar infarcts. The black group had a significantly higher incidence of all subtypes of stroke except for POCI and unclassified strokes. The incidence rate ratio (IRR) for men compared with women was 1.34 (95% confidence interval (95% CI) 1.19 to 1.50; p<0.001). The IRR for manual versus non-manual occupations in those aged 35–64 years was 1.64 (95%CI 1.22 to 2.23; p<0.0001). There was a borderline significant increase in adjusted survival at 6 months in the black group 95% (CI 0.61 to 1.03, p=0.078) with a hazard ratio of 0.79 after adjustment and stratification.  Although the black population is at increased risk of stroke and most subtypes of stroke, this is not translated into significant differences in survival. Hence black/white differences in mortality are mainly driven by incidence of stroke. There are striking demographic inequalities in the risk of stroke in this multiethnic inner city population that need to be tackled through interagency working. Although the reasons for the increased risk in the black population are unclear, demographic factors such as socioeconomic status do seem to play a significant independent part.

title: American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise.
abstract: The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.

title: Conducting a meta-ethnography of qualitative literature: Lessons learnt
abstract: BackgroundQualitative synthesis has become more commonplace in recent years. Meta-ethnography is one of several methods for synthesising qualitative research and is being used increasingly within health care research. However, many aspects of the steps in the process remain ill-defined.DiscussionWe utilized the seven stages of the synthesis process to synthesise qualitative research on adherence to tuberculosis treatment. In this paper we discuss the methodological and practical challenges faced; of particular note are the methods used in our synthesis, the additional steps that we found useful in clarifying the process, and the key methodological challenges encountered in implementing the meta-ethnographic approach.The challenges included shaping an appropriate question for the synthesis; identifying relevant studies; assessing the quality of the studies; and synthesising findings across a very large number of primary studies from different contexts and research traditions. We offer suggestions that may assist in undertaking meta-ethnographies in the future.SummaryMeta-ethnography is a useful method for synthesising qualitative research and for developing models that interpret findings across multiple studies. Despite its growing use in health research, further research is needed to address the wide range of methodological and epistemological questions raised by the approach.

title: Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ
abstract: BackgroundThe syntheses of multiple qualitative studies can pull together data across different contexts, generate new theoretical or conceptual models, identify research gaps, and provide evidence for the development, implementation and evaluation of health interventions. This study aims to develop a framework for reporting the synthesis of qualitative health research.MethodsWe conducted a comprehensive search for guidance and reviews relevant to the synthesis of qualitative research, methodology papers, and published syntheses of qualitative health research in MEDLINE, Embase, CINAHL and relevant organisational websites to May 2011. Initial items were generated inductively from guides to synthesizing qualitative health research. The preliminary checklist was piloted against forty published syntheses of qualitative research, purposively selected to capture a range of year of publication, methods and methodologies, and health topics. We removed items that were duplicated, impractical to assess, and rephrased items for clarity. Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement consists of 21 items grouped into five main domains: introduction, methods and methodology, literature search and selection, appraisal, and synthesis of findings.ConclusionsThe ENTREQ statement can help researchers to report the stages most commonly associated with the synthesis of qualitative health research: searching and selecting qualitative research, quality appraisal, and methods for synthesising qualitative findings. The synthesis of qualitative research is an expanding and evolving methodological area and we would value feedback from all stakeholders for the continued development and extension of the ENTREQ statement.

title: Perceived barriers to exercise in Hispanic adults by level of activity.
abstract: National data show that Hispanics report low levels of physical activity. Limited information on barriers to exercise in this population exists in the literature.



Surveys were administered to 398 Hispanic participants from two colonias in South Texas to investigate self-reported levels of and perceived barriers to exercise. One-way ANOVA by level of activity and t tests by gender were conducted. Exploratory factor analysis was used to examine patterns by level of activity.



Results show that 67.6% of respondents did not meet physical activity recommendations of at least 150 minutes per week, as compared with 55.6% nationally. Overall, the most frequently reported barriers included "lack of time," "very tired," and "lack of self-discipline" to exercise. An exploratory factor analysis of the barriers reported by participants not meeting physical activity recommendations resulted in a 3-factor structure. A unidimensional scale was found for participants meeting recommendations.



Findings suggest that future interventions should be specific to gender and exercise level to address the high prevalence of inactivity in this population.

title: Evaluation of an Asian women’s healthy eating and exercise group
abstract: A healthy eating and exercise group for Asian women was established in April 1996. A community dietitian, fitness instructor and link worker took part in running the group and funding was provided by Trafford Healthcare NHS Trust and Trafford Metropolitan Borough Council. The group was run as a 14-week pilot project, however, due to a positive response the group was continued. 
 
 
 
 To follow up participants in the programme and examine their perceptions of the programme and changes in weight. 
 
 
 
 Thirteen of the 15 overweight or obese women who attended the initial pilot group were followed up and qualitative evaluation was undertaken using a semistructured interview. Measurement of weight change was also made. 
 
 
 
 Formal methods of recruiting participants appear to have had little impact. Verbal recommendation of the group by the Link Worker and participants appear to have been effective routes for recruiting. Respondents suggested that the group fulfilled social and weight loss functions, both functions being interrelated and affecting weight. Important reasons for no longer attending the group seem to include difficulty getting to the venue and prioritization of the needs of the family over the women’s own needs. 
 
 
 
 Some implications for the group are that women should be encouraged to walk to the group with others and it should be stressed that coming to the group and learning about healthy eating and exercise is important for the women’s health and also that of their families. Exercise was a popular aspect of the group and it is recommended that exercise sessions are held more frequently for a trial period. The resulting effects on attendance could then be assessed. All women could relate their weight change to diet and exercise in some way. The women who reported that they would definitely re-attend the group were generally those with a higher BMI (body mass index).

title: Promoting physical activity in South Asian Muslim women through "exercise on prescription".
abstract: Printed copies of HTA monographs cost £20 each (post and packing free in the UK) to both public and private sector purchasers from our Despatch Agents. Non-UK purchasers will have to pay a small fee for post and packing. For European countries the cost is £2 per monograph and for the rest of the world £3 per monograph. You can order HTA monographs from our Despatch Agents: – fax (with credit card or official purchase order) – post (with credit card or official purchase order or cheque) – phone during office hours (credit card only). Additionally the HTA website allows you either to pay securely by credit card or to print out your order and then post or fax it. NHS libraries can subscribe free of charge. Public libraries can subscribe at a very reduced cost of £100 for each volume (normally comprising 30–40 titles). The commercial subscription rate is £300 per volume. Please see our website for details. Subscriptions can only be purchased for the current or forthcoming volume.  Paying by cheque If you pay by cheque, the cheque must be in pounds sterling, made payable to Direct Mail Works Ltd and drawn on a bank with a UK address. Paying by credit card The following cards are accepted by phone, fax, post or via the website ordering pages: Delta, Eurocard, Mastercard, Solo, Switch and Visa. We advise against sending credit card details in a plain email. Paying by official purchase order You can post or fax these, but they must be from public bodies (i.e. NHS or universities) within the UK. We cannot at present accept purchase orders from commercial companies or from outside the UK. Please use the form on the HTA website (www.hta.ac.uk/htacd.htm). Or contact Direct Mail Works (see contact details above) by email, post, fax or phone. HTA on CD is currently free of charge worldwide. The website also provides information about the HTA Programme and lists the membership of the various committees. Health Technology Assessment is indexed in Index Medicus/MEDLINE and Excerpta Medica/ EMBASE. Copies of the Executive Summaries are available from the NCCHTA website (see opposite). T he NHS R&D Health Technology Assessment (HTA) Programme was set up in 1993 to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care …

title: Effective heart disease prevention: lessons from a qualitative study of user perspectives in Bangladeshi, Indian and Pakistani communities.
abstract: Coronary heart disease (CHD) has a high mortality, incidence and prevalence among Indian, Pakistani and Bangladeshi communities in the UK, indicating the need for effective heart disease prevention initiatives for these communities. This paper considers how service user perspectives can be used to develop effective, culturally focused CHD prevention interventions for these target groups by addressing identified barriers, including deeply held cultural beliefs.



A qualitative research study, using a longitudinal action research approach.



This was a community-based study in Edinburgh. Six focus group discussions--two for each community--were organized with participants from these communities at the beginning of the project. A further six focus group discussions for the same communities were organized six months later.



Over the period examined, participants reported varying changes in levels of knowledge relating to the nature, causes and symptoms of CHD. Some participants reported taking slight to significant steps to reduce or prevent heart disease, while others did not. The project was viewed as helpful in increasing knowledge about CHD and preventive measures and encouraging healthier lifestyles. However, persistent barriers to change were also identified, requiring changes to the project that involved not only matching intervention materials and messages to observable, superficial characteristics of the target population, but more fundamental changes that address the cultural, social, historical, environmental and psychological forces that influence health behaviour.



CHD prevention initiatives need to identify and respond to deep-rooted influences on health-behaviour in 'at-risk' groups, in addition to superficial characteristics of the target populations. It is important for specific prevention initiatives to be linked into wider CHD frameworks to ensure transferability of learning and integration within wider service provision.

title: Attitudes to lifestyle risk factors for coronary heart disease amongst South Asians in Leicester: a focus group study.
abstract: South Asians have a significantly higher risk of mortality from coronary heart disease (CHD) compared with the general population in the UK. There is a lack of evidence on attitudes to and knowledge of risk factors for CHD amongst South Asians. Such information is important for the provision of effective health promotion services.



The aim of the study was to identify key issues relating to knowledge of and attitudes to lifestyle risk factors for CHD amongst South Asians aged over 40 years in Leicester, UK.



A qualitative focus group analysis was carried out using randomly selected South Asians from GP lists and South Asians attending community centres. Group discussions were taped, translated and transcribed. The transcripts were analysed using qualitative methodology to identify key issues and themes.



Participants expressed a range of attitudes to and different levels of knowledge of lifestyle risk factors for CHD. Barriers to improving lifestyle with respect to diet and exercise were identified; these included lack of information (e.g. of how to cook traditional Indian food more healthily) and cultural barriers, such as lack of women-only exercise facilities. Participants perceived stress as an important cause of CHD, and stress directly related to ethnic minority status was described frequently. Language was identified as a key barrier to accessing health services.



Health professionals need to provide individually tailored health promotion for South Asians which avoids stereotyping, but recognizes potential cultural obstacles to change. The issue of stress amongst South Asians requires more research and needs to be recognized as an important issue by health professionals. South Asians still face problems accessing health and leisure services due to language and cultural issues.

title: Promoting physical activity among South Asian women with coronary heart disease and diabetes: what might help?
abstract: People of South Asian origin have higher mortality and morbidity from coronary heart disease (CHD) and diabetes than those of European origin. However, physical activity, of established value in primary and secondary prevention, appears lower among South Asians.



To explore influences on, and attitudes towards, physical activity among South Asian women with CHD and diabetes to inform secondary prevention strategies.



Exploratory qualitative study with women aged 26-70 years of varying South Asian ethnicity, religion and socio-economic background with CHD and/or non-insulin-dependent diabetes were recruited from primary care practices in the UK.



The beneficial use of physical activity to improve and limit progression of their disease was largely unrecognized by the women interviewed. They were uncertain what type and level of physical activity was appropriate and safe for them. They operated their own threshold for physical activity in relation to their condition, which they were afraid to exceed. Specific guidance from health professionals was lacking. Respondents emphasized the cultural importance of being active day to day, rather than the 'Western' concepts of organized exercise. However, women's principal motivations and attitudes towards physical activity, to loose weight, socialize and maintain independence, were culturally similar to 'majority' populations.



Better health professional guidance on appropriate physical activity, its health benefits and its safety is needed for this highly at-risk group. Promoting informal moderate-intensity physical activity may help. Strategies should avoid any tendency to overemphasize cultural barriers noting greater similarities than differences between cultural groups.

title: 'I can't do any serious exercise': barriers to physical activity amongst people of Pakistani and Indian origin with Type 2 diabetes.
abstract: Type 2 diabetes is at least 4 times more common among British South Asians than in the general population. South Asians also have a higher risk of diabetic complications, a situation which has been linked to low levels of physical activity observed amongst this group. Little is known about the factors and considerations which prohibit and/or facilitate physical activity amongst South Asians. This qualitative study explored Pakistani (n = 23) and Indian (n = 9) patients' perceptions and experiences of undertaking physical activity as part of their diabetes care. Although respondents reported an awareness of the need to undertake physical activity, few had put this lifestyle advice into practice. For many, practical considerations, such as lack of time, were interwoven with cultural norms and social expectations. Whilst respondents reported health problems which could make physical activity difficult, these were reinforced by their perceptions and understandings of their diabetes, and its impact upon their future health. Education may play a role in physical activity promotion; however, health promoters may need to work with, rather than against, cultural norms and individual perceptions. We recommend a realistic and culturally sensitive approach, which identifies and capitalizes on the kinds of activities patients already do in their everyday lives.

title: Cultural negotiations in health and illness: the experience of type 2 diabetes among Gujarati-speaking South Asians in England
abstract: Diabetes has become a global health problem, with both physical and psychosocial effects on people’s lives. The South Asian communities in the UK have been identified as high-risk groups, with high rates of type 2, non-insulin-dependent diabetes (NIDDM). This paper reports on an exploration, based on qualitative methods, of South Asian Hindu Gujaratispeaking people’s experiences of type 2 diabetes. Participants were recruited through purposive and snowball sampling, and a grounded theory framework that while health science discourse in a variety of forms has constructed a type of South Asian diabetic risk, alluding to a particular relationship between health and ethnicity, the participants in the present study expressed active resistance to this construction, through their accounts of diabetes management. By exploring the biographical, historical and socially embedded contexts of diabetes, the participants constituted culture and ethnicity as dynamic entities, contingent on social and personal contexts.There were four major themes in the study, namely notions of familiarity with the illness through family and social connections, the management of physical exercise and activity, the personal and social moderation of food and nutrition, and the use of complementary remedies. This paper argues that it is these active and dynamic constructions of cultural and ethnic identity which health science discourse needs to acknowledge in order to understand how people manage their diabetes, and where help and support might best be channelled.

title: Effectiveness of physical activity and dietary interventions in South Asian populations: a systematic review.
abstract: Physical activity and dietary change interventions can prevent or delay a range of chronic disease. Little is known in primary care about their effectiveness in South Asian populations, who are often at higher risk of developing such diseases.



To assess evidence for effectiveness of primary care based physical activity and dietary interventions in South Asian populations, and identify methods to inform future intervention development.



Systematic review.



Intervention studies conducted in developed countries that reported data for South Asian adults were sought by searching electronic databases, trial registries, and conference proceedings. Following wider screening of titles and abstracts, 119 full articles were reviewed.



Of the 119 articles, four studies met the inclusion criteria and evaluated community-based interventions with South Asian individuals. Methodological quality was poor overall. Interventions appeared generally effective in promoting a decrease in weight, with some positive changes in blood pressure and biochemical outcomes, such as cholesterol. There was limited evidence for effects on behaviour. Theoretical frameworks were not identified and evidence on attitudinal or knowledge-based outcomes was sparse. The inclusion of individual feedback and community workers in communities of deprivation appeared important to the acceptability of the interventions. Information distinguishable for South Asian individuals within intervention studies of general populations was lacking.



Physical activity and dietary interventions with South Asian populations show modest promise but, given the paucity of controlled evaluations or use of objective measures, outcomes are difficult to interpret. Potential insights may be missed if experience concerning South Asian groups within studies is not reported. Further development of culturally appropriate interventions that are theoretically informed and assessed in experimental designs are required.

title: Correlates of physical activity: why are some people physically active and others not?
abstract: Physical inactivity is an important contributor to non-communicable diseases in countries of high income, and increasingly so in those of low and middle income. Understanding why people are physically active or inactive contributes to evidence-based planning of public health interventions, because effective programmes will target factors known to cause inactivity. Research into correlates (factors associated with activity) or determinants (those with a causal relationship) has burgeoned in the past two decades, but has mostly focused on individual-level factors in high-income countries. It has shown that age, sex, health status, self-efficacy, and motivation are associated with physical activity. Ecological models take a broad view of health behaviour causation, with the social and physical environment included as contributors to physical inactivity, particularly those outside the health sector, such as urban planning, transportation systems, and parks and trails. New areas of determinants research have identified genetic factors contributing to the propensity to be physically active, and evolutionary factors and obesity that might predispose to inactivity, and have explored the longitudinal tracking of physical activity throughout life. An understanding of correlates and determinants, especially in countries of low and middle income, could reduce the eff ect of future epidemics of inactivity and contribute to effective global prevention of non-communicable diseases.

title: Intergenerational continuities of ethnic inequalities in general health in England
abstract: Previous research strongly suggests that ethnic minority groups are more likely to suffer a poorer health profile compared with the overall population, although it is not clear whether these inequalities persist over generations. This study aimed to establish the degree to which ethnic inequalities in health are transmitted from the first to the second generation, and to determine the extent to which intergenerational changes in socioeconomic status and health behaviours might explain any variation that exists.  Data from the 1999 and 2004 Health Surveys for England assessed the prevalence of fair/poor general health across first (n = 4492) and second (n = 5729) generations of six ethnic minority populations. A white population was selected as reference (n = 18 407). The risk of fair/poor general health was estimated by applying logistic regression models and stepwise inclusion of demographic, socioeconomic and behavioural variables. Generational movement relative to the white baseline was assessed for all ethnic groups adjusted for age and sex.  No significant differences in levels of reported fair/poor general health were observed between generations. After adjusting for improved socioeconomic position, the second generation became more likely to report worse health, whereas adjusting for differences in health behaviours had no effect. The Bangladeshi population showed significant intergenerational improvement in general health relative to the white reference, showing a reduction in the odds ratio (95% CI) from 2.75 (2.14 to 3.56) for the first generation to 1.58 (1.17 to 2.13) in the second generation.  Ethnic minorities in England report consistent rates of fair/poor general health across generations, despite the health benefits resulting from upward social mobility. These health inequalities are unaffected by changes in health behaviours. Understanding these intergenerational pathways will have important public health policy implications as the migrant population not only ages, but also reproduces.

title: Socio-Demographic Patterning of Physical Activity across Migrant Groups in India: Results from the Indian Migration Study
abstract: To investigate the relationship between rural to urban migration and physical activity (PA) in India. Methods 6,447 (42% women) participants comprising 2077 rural, 2,094 migrants and 2,276 urban were recruited. Total activity (MET hr/day), activity intensity (min/day), PA Level (PAL) television viewing and sleeping (min/day) were estimated and associations with migrant status examined, adjusting for the sib-pair design, age, site, occupation, education, and socio-economic position (SEP).  Total activity was highest in rural men whereas migrant and urban men had broadly similar activity levels (p<0.001). Women showed similar patterns, but slightly lower levels of total activity. Sedentary behaviour and television viewing were lower in rural residents and similar in migrant and urban groups. Sleep duration was highest in the rural group and lowest in urban non-migrants. Migrant men had considerably lower odds of being in the highest quartile of total activity than rural men, a finding that persisted after adjustment for age, SEP and education (OR 0.53, 95% CI 0.37, 0.74). For women, odds ratios attenuated and associations were removed after adjusting for age, SEP and education.  Our findings suggest that migrants have already acquired PA levels that closely resemble long-term urban residents. Effective public health interventions to increase PA are needed.

title: What are the barriers and facilitators to exercise and physical activity uptake and adherence among South Asian older adults: a systematic review of qualitative studies.
abstract: The objective of this study is to synthesise views and experiences of South Asian (SA) older adults in relation to exercise and physical activity (PA). It was anticipated that this work would identify barriers and facilitators that could inform interventions aimed at promoting PA among this population.



A systematic review of qualitative research was conducted. Six electronic databases were searched for relevant papers published from January 2000 to October 2011. Studies were appraised and data extracted by two reviewers. A synthesis was undertaken using framework analysis. Of 26 papers read in full, 11 were included in the review.



An overriding concept derived from the synthesis was the influence of empowering and disempowering contexts on PA levels of SA participants. It was supported by the following themes: communication (e.g. relying on relatives for translation of information, lack of understanding); relationships (e.g. social support from family, friends, community), beliefs (e.g. not culturally appropriate to exercise, fatalism) and environment (e.g. lack of accessible recreational areas/facilities).



Drawing on community resources to generate group norms appears to be important when trying to increase exercise and PA among SA older adults. Implications of the results for PA promotion and provision are discussed.

title: Accessing primary health care: a meta-ethnography of the experiences of British South Asian patients with diabetes, coronary heart disease or a mental health problem
abstract: To develop an explanatory framework of the problems accessing primary care health services experienced by British South Asian patients with a long-term condition or mental health problem.  This study used meta-ethnographic methods. Published qualitative studies were identified from a structured search of six databases and themes synthesized across studies to develop a new explanatory framework.  Initial searches identified 951 potentially relevant records from which a total of 27 articles were identified that met inclusion and exclusion criteria. Twelve of these articles were chosen on the basis of their quality and relevance. These 12 articles described themes relating to the cultural, spatial and temporal dimensions of patient experiences of accessing and using health care. Our interpretive synthesis showed that access to primary care among British South Asians with diabetes, coronary heart disease and psychological health problems is co-constructed and negotiated over time and space along the key domains of the candidacy model of access: from help-seeking to interactions at the interface to following treatment advice. In the case of each condition, British South Asians’ claims to candidacy were constrained where their individual as well as broader social and cultural characteristics lacked fit with professionals’ ways of working and cultural typifications.  Interventions that positively affect professionals’ capacity to support patient claims to candidacy are likely to help support British South Asians overcome a broad range of barriers to care for physical and mental health problems.

title: Evidence-based intervention in physical activity: lessons from around the world
abstract: Promotion of physical activity is a priority for health agencies. We searched for reviews of physical activity interventions, published between 2000 and 2011, and identified effective, promising, or emerging interventions from around the world. The informational approaches of community-wide and mass media campaigns, and short physical activity messages targeting key community sites are recommended. Behavioural and social approaches are effective, introducing social support for physical activity within communities and worksites, and school-based strategies that encompass physical education, classroom activities, after-school sports, and active transport. Recommended environmental and policy approaches include creation and improvement of access to places for physical activity with informational outreach activities, community-scale and street-scale urban design and land use, active transport policy and practices, and community-wide policies and planning. Thus, many approaches lead to acceptable increases in physical activity among people of various ages, and from different social groups, countries, and communities.

title: Review of barriers to engaging black and minority ethnic groups in physical activity in the United Kingdom
abstract: The lower physical activity levels in Black and Minority Ethnic (BME) groups as comparedwith general population in the United Kingdom (UK) could relate to barriers to engaging these groups in physicalactivity. Hence, the aim to conduct a review to examine UK primary studies reporting barriers to engaging BME groupsin physical activity.  This is a narrative review of literature from 1970 to 2008. The search looked for Englishliterature from five bibliographic databases (MEDLINE, Embase, CINAHL, PsyINFO, Ethnicity and Health). Broadsearch terms ‘physical activity and minority’ were used and views from BME groups were considered in this review. The search yielded 391 studies and 18 were finally included in the review. Our review identified20 barriers clustered among four broad themes of: (a) perceived personal barriers; (b) socio-economic barriers; (c)cultural barriers; and (d) environmental barriers. Overcoming these barriers in these broad areas is important indevelopment of sensitive multicultural health promotion addressing physical inequalities.

title: Should We Exclude Inadequately Reported Studies From Qualitative Systematic Reviews? An Evaluation of Sensitivity Analyses in Two Case Study Reviews
abstract: The role of critical appraisal of qualitative studies in systematic reviews remains an ongoing cause for debate. Key to such a debate is whether quality assessment can or should be used to exclude studies. In our study, we extended the use of existing criteria to assess the quality of reporting of studies included in two qualitative systematic reviews. We then excluded studies deemed to be inadequately reported from the subsequent analysis. We tested the impact of these exclusions on the overall findings of the synthesis and its depth or thickness. Exclusion of so-called inadequately reported studies had no meaningful effect on the synthesis. There was a correlation between quality of reporting of a study and its values as a source for the final synthesis. We propose that there is a possible case for excluding inadequately reported studies from qualitative evidence synthesis.