title: Socio-cultural influences on the behaviour of South Asian women with diabetes in pregnancy: qualitative study using a multi-level theoretical approach.
abstract: BACKGROUND
  Diabetes in pregnancy is common in South Asians, especially those from low-income backgrounds, and leads to short-term morbidity and longer-term metabolic programming in mother and offspring. We sought to understand the multiple influences on behaviour (hence risks to metabolic health) of South Asian mothers and their unborn child, theorise how these influences interact and build over time, and inform the design of culturally congruent, multi-level interventions.
  
  
  METHODS
  Our sample for this qualitative study was 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. Overall, 17 women shared their experiences of diabetes, pregnancy, and health services in group discussions and 28 women gave individual narrative interviews, facilitated by multilingual researchers, audiotaped, translated, and transcribed. Data were analysed using the constant comparative method, drawing on sociological and narrative theories.
  
  
  RESULTS
  Key storylines (over-arching narratives) recurred across all ethnic groups studied. Short-term storylines 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. While peer advice was familiar, meaningful, and morally resonant, health education advice from clinicians was usually unfamiliar and devoid of cultural meaning.
  
  
  CONCLUSIONS
  '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.
authors.affiliation: Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Walton St, Oxford, OX2 6GG, UK. trish.greenhalgh@phc.ox.ac.uk.
authors.forename: Trisha
authors.initials: T
authors.lastname: Greenhalgh
authors.affiliation: Blizard Institute, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK. m.clinch@qmul.ac.uk.
authors.forename: Megan
authors.initials: M
authors.lastname: Clinch
authors.affiliation: Community Health and Social Medicine Department, Sophie Davis School of Biomedical Education, City University of New York Medical School, New York, 10031, USA. nur.afsar@gmail.com.
authors.forename: Nur
authors.initials: N
authors.lastname: Afsar
authors.affiliation: Blizard Institute, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK. y.choudhury@qmul.ac.uk.
authors.forename: Yasmin
authors.initials: Y
authors.lastname: Choudhury
authors.affiliation: Department of Diabetes, Newham University Hospital, Glen Road, Plaistow, London, E13 8SL, UK. rita.sudra@bartshealth.nhs.uk.
authors.forename: Rita
authors.initials: R
authors.lastname: Sudra
authors.affiliation: Department of Diabetes, Newham University Hospital, Glen Road, Plaistow, London, E13 8SL, UK. desiree.campbellrichards@bartshealth.nhs.uk.
authors.forename: Desirée
authors.initials: D
authors.lastname: Campbell-Richards
authors.affiliation: Department of Diabetes, Newham University Hospital, Glen Road, Plaistow, London, E13 8SL, UK. anne.claydon@bartshealth.nhs.uk.
authors.forename: Anne
authors.initials: A
authors.lastname: Claydon
authors.affiliation: Blizard Institute, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK. g.a.hitman@qmul.ac.uk.|Department of Diabetes, Royal London Hospital, Whitechapel Rd, London, E1 1BB, UK. g.a.hitman@qmul.ac.uk.
authors.forename: Graham A
authors.initials: GA
authors.lastname: Hitman
authors.affiliation: Department of Diabetes, Royal London Hospital, Whitechapel Rd, London, E1 1BB, UK. philippa.hanson@bartshealth.nhs.uk.
authors.forename: Philippa
authors.initials: P
authors.lastname: Hanson
authors.affiliation: Blizard Institute, Barts and the London School of Medicine and Dentistry, London, E1 2AT, UK. finersarah@gmail.com.|Department of Diabetes, Royal London Hospital, Whitechapel Rd, London, E1 1BB, UK. finersarah@gmail.com.
authors.forename: Sarah
authors.initials: S
authors.lastname: Finer
mesh_terms: D000328:Adult; D044466:Asian People; D003469:Culture; D003920:Diabetes Mellitus / Q000208:ethnology* / Q000628:therapy*; D005006:Ethnicity; D005260:Female; D007722:Health Knowledge, Attitudes, Practice / Q000208:ethnology*; D006801:Humans; D008875:Middle Aged; D011247:Pregnancy; D011248:Pregnancy Complications / Q000208:ethnology* / Q000628:therapy*; D036301:Qualitative Research; D055815:Young Adult