WP 9

Developing behavioural and nutritional interventions in Europe in South Asians: systematic review and qualitative research

WP leaders:  Trisha Greenhalgh and Khalid Khan

The aim of this study was to gain a greater understanding of the illness experiences of South Asian women with gestational diabetes (living in London), and to inform the theorization and design of behavioral and nutritional interventions. The study consisted of narrative interviews [1] and focus groups with 45 women of Bangladeshi, Indian, Sri Lankan, or Pakistani origin aged 21– 45 years with a history of diabetes in pregnancy, recruited from diabetes and antenatal services in two deprived London boroughs about their diabetes.

Analysis of the focus groups and narrative interviews revealed that there were three key storylines (over-arching narratives) that recurred across the accounts of all the women who took part in the study: short-term storylines, medium term storylines and long-term storylines.

The short-term story lines depicted the experience of diabetic pregnancy as stressful, difficult to control, and associated with negative symptoms, especially tiredness. Taking exercise and restricting diet often worsened these symptoms and conflicted with advice from relatives and peers. Many women believed that exercise in pregnancy would damage the fetus and drain the mother’ s strength, and that eating would be strength-giving for mother and fetus.

These short-term storylines were nested within medium-term storylines about family life, especially the cultural, practical, and material constraints of the traditional South Asian wife and mother role and past experiences of illness and healthcare, and within longer-term storylines about genetic, cultural, and material heritage – including migration, acculturation, and family memories of food insecurity. Moreover, when reflecting on what information and knowledge was used to inform understanding and action peer advice was often considered to be familiar, meaningful, and morally resonant. In contrast health education advice from clinicians was usually considered to be unfamiliar and devoid of cultural meaning.

As demonstrated by the narratives described above diabetes in this group (and arguably all groups) has substantial anthropological and public health dimensions: its onset and course are strongly patterned by cultural practices and social determinants of health, including the material, cognitive and socio-cultural effects of poverty, migration, education and social capital.  These findings chime with social ecological approaches [2] that view health-related behaviours as the result of influences at multiple levels: intrapersonal, interpersonal, organizational, community, and public policy. Glass and McAttee [2], propose a ‘stream of causation’ flowing over time from upstream (in utero and early life exposures and windows of vulnerability) to downstream (later life manifestations). They further propose a nested hierarchy of systems from genes, to cells and organs, the psychology of behaviour choices, the influence of social networks and groups and the local and global environment and a series of feedback loops and cross-level influences between these.

By using a using a narrative approach this research illuminates how this nested hierarchy influences can inflect the health related behaviours of the women that in turn shape their health outcomes. That is, that narratives collected and analysed have helped surface explanations about the reciprocal relationship between the different levels in the nested hierarchy, including how human agency (behaviour ‘choice’) is dynamically influenced by both the distal structural contingencies (external ‘chances’) and embodied biological and psychological drivers (e.g. physiological status, genetic predispositions, bodily sensations and personality traits

Based on these findings it is claimed that ‘Behaviour change’ interventions aimed at preventing and managing diabetes in South Asian women before and during pregnancy are likely to be ineffective if delivered in a socio-cultural vacuum. Individual education should be supplemented with community-level interventions to address the socio-material constraints and cultural frames within which behavioural ‘choices’ are made [2].


1. Wengraf T: Qualitative Research Interviewing: Biographic Narrative and Semi-structured Methods. . London: Sage; 2001.

2. Glass TA, McAtee MJ: Behavioral science at the crossroads in public health: Extending horizons, envisioning the future. Social Science & Medicine 2006, 62(7):1650-1671.

3. Greenhalgh T, Clinch M, Afsar N, Choudhury Y, Sudra R, Campbell-Richards D, Claydon A, Hitman GA, Hanson P, Finer S: Socio-cultural influences on the behaviour of South Asian women with diabetes in pregnancy: qualitative study using a multi-level theoretical approach. BMC Med. 2015 May 21;13:120. doi: 10.1186/s12916-015-0360-1