UNDERSTANDING HEALTH BELIEFS AND LIFESTYLE PRACTICES IN RELATION TO SOCIAL SUPPORT IN THE PAKISTANI COMMUNITY, WEST MIDLANDS, UK. by FARINA KOKAB A thesis submitted to the University of Birmingham for the degree of DOCTOR OF PHILOSOPHY Institute of Applied Health Research College of Medical and Dental Sciences University of Birmingham April 2016 University of Birmingham Research Archive e-theses repository This unpublished thesis/dissertation is copyright of the author and/or third parties. The intellectual property rights of the author or third parties in respect of this work are as defined by The Copyright Designs and Patents Act 1988 or as modified by any successor legislation. Any use made of information contained in this thesis/dissertation must be in accordance with that legislation and must be properly acknowledged. Further distribution or reproduction in any format is prohibited without the permission of the copyright holder. ABSTRACT South Asians, specifically Pakistanis, living in areas of socio-economic deprivation across the UK, have an elevated risk of cardiovascular disease (CVD). The purpose of this research was to explore how social networks function as a source of support and information (social capital) in creating lifestyles associated with CVD prevention in a migrant, minority-ethnic Pakistani population. Semi-structured qualitative interviews were carried out using an interview guide and the convoy model diagram to elicit participant’s responses on social networks, community interactions and lifestyle choices (diet and exercise). A total of 42 participants across three migrant generations, diverse educational and occupational backgrounds, men and women aged 18 years and above participated. Framework analysis was used to analyse transcripts and organise codes, themes and categories. Findings distinguished a diverse narrative amongst men and women with regards to making lifestyle choices and gaining access to social support within or outside of the Pakistani community. Conclusively, engagement beyond familiar community contexts could provide greater or novel sources of support and information for pursuing (at times) non-traditional, healthier lifestyles. Understanding shifting perceptions of health in relation to religion, culture and ethnic-identity could provide primary care practitioners with a better understanding of how to treat high-risk patients. ACKNOWLEDGEMENTS I would like to express my gratitude towards my supervisors Dr Paramjit Gill and Professor Sheila Greenfield, for their guidance and shared knowledge. I am also thankful to Dr Lynda Tait for her early input towards the research. I appreciate the valuable time given by the participants in this research and for sharing their personal experiences. I am grateful for my family’s support especially from my parents Fehmina and Shaheen, and my brother Zohair, the wonderful advice of Dr Manbinder Sidhu, encouragement from Dr Jafer Qureshi, my family and friends, and colleagues at the Institute of Applied Health Research and across the University of Birmingham. TABLE OF CONTENTS 1.0 INTRODUCTION ............................................................................................................. 1 1.1 RESEARCH FOCUS ....................................................................................................... 1 1.2 BACKGROUND .............................................................................................................. 1 1.3 RESEARCH DESIGN ...................................................................................................... 3 1.3.1 Research characteristics............................................................................................ 3 1.4 OUTLINE OF THESIS .................................................................................................... 4 2.0 BACKGROUND ................................................................................................................ 6 2.1 INTRODUCTION ............................................................................................................ 6 2.2 RESEARCH IN CONTEXT ............................................................................................. 6 2.2.1 Prevalence of cardiovascular disease ....................................................................... 6 2.2.2 Associated lifestyle factors for CVD development .................................................. 10 2.2.2 Prevention and management of CVD ...................................................................... 14 2.3 HEALTH SERVICES AND UK POLICY: ADDRESSING ETHNIC SPECIFIC NEEDS ................................................................................................................................. 15 2.4 SOUTH ASIAN DIASPORA ......................................................................................... 17 2.4.1 Health beliefs of the South Asian diaspora ............................................................. 19 2.4.2 Societal environmental concerns ............................................................................. 20 2.5 PAKISTANIS LIVING IN THE UK .............................................................................. 21 2.5.1 Religious and cultural impact on health choices..................................................... 22 2.5.2 Generational and gender based differences in lifestyle .......................................... 25 2.6 CONCEPTS SURROUNDING HEALTH AND SOCIAL SUPPORT .......................... 28 2.6.1 The theory of social capital ..................................................................................... 29 2.6.2 Social capital and transnational migration ............................................................. 30 2.6.3 Formation of social networks: ethnicity, ageing and health ................................... 32 2.7 THE CONVOY MODEL OF HEALTH ......................................................................... 33 2.8 GOAL PURSUIT AND INSTRUMENTALITY ........................................................... 35 2.8.1 Self-preservation and group membership................................................................ 36 2.8.2 Cultural norms and goal formation ......................................................................... 37 2.8 SUMMARY ................................................................................................................... 38 3.0 THE EXPERIENCE AND INFLUENCE OF SOCIAL SUPPORT FOR CARDIOVASCULAR DISEASE PREVENTION IN THE MIGRANT PAKISTANI COMMUNITY: A QUALITATIVE SYNTHESIS ............................................................. 40 3.1 INTRODUCTION .......................................................................................................... 40 3.2 BACKGROUND ............................................................................................................ 41 3.2.1 Healthcare policy .................................................................................................... 42 3.4 AIMS AND OBJECTIVES ............................................................................................ 43 3.3 SCOPING SEARCH: QUALITATIVE LITERATURE REVIEWS.............................. 44 3.5 SYSTEMATIC SEARCH METHODS .......................................................................... 47 3.5.1 Inclusion criteria ..................................................................................................... 47 3.5.2 Search methods ........................................................................................................ 51 3.5.1 Search terms and delimiting .................................................................................... 51 3.6 QUALITY ASSESSMENT AND DATA EXTRACTION ............................................ 52 3.6 DATA SYNTHESIS ....................................................................................................... 54 3.7 RESULTS ....................................................................................................................... 56 3.7.1 Identification of literature ....................................................................................... 56 3.7.2 Description of studies .............................................................................................. 58 3.7.3 Risk and bias of studies ........................................................................................... 73 3.7.4 Topics of research ................................................................................................... 86 3.7.5 Interpretation of themes........................................................................................... 92 3.8 DISCUSSION .............................................................................................................. 100 3.8.1 Relevance to health policy ..................................................................................... 102 3.8.1 Strengths and limitations ....................................................................................... 104 3.8.2 Summary ................................................................................................................ 105 4.0 METHODOLOGY, METHODS AND ANALYSIS ................................................... 107 4.1 INTRODUCTION ........................................................................................................ 107 4.1.1 Aims and research questions ................................................................................. 107 4.1.2 Epistemological