Life stage influences on U.S. South Asian women's physical activity.

For individual use only. Duplication or distribution prohibited by law.

Physical Activity; Attitudes; South Asian Women

Life Stage Influences on U.S. South Asian Women’s Physical Activity Swapna S. Dave, MPH, MBBS; Lynette L. Craft, PhD; Promila Mehta, MA; Shilpa Naval, BDS, MPH, MS; Santosh Kumar, BSc, LLB (Hons), LLM; Namratha R. Kandula, MD, MPH Abstract Purpose. South Asian (SA) women in the United States report extremely low rates of leisure time physical activity (PA) compared with women in other ethnic minority groups. This study explored SA women’s perspectives on PA during different life stages. Design. This is a community-based participatory research study that used focus groups. Setting. The study setting was a community-based organization that provides social services to SA immigrants in Chicago, Illinois. Participants. The study team conducted six focus groups (in English and Hindi) with 42 SA women, ages 18 to 71 years. Method. A semistructured interview guide was used to foster discussion about perceptions of, barriers to/facilitators of, and suggestions for PA programs. Discussions were transcribed and independently coded by two reviewers using thematic content analysis and guided by a coding scheme that was developed a priori. Results. Participants said that different life stages strongly influenced their PA. PA decreased after marriage and having children. Chronic diseases constrained older women from more vigorous PA. Barriers to PA among younger women were family disapproval and perceptions that PA is unnecessary if you are ‘‘skinny.’’ Women agreed that PA is not a priority within the culture, and that interventions must take into account cultural, religious, and family context. Conclusion. Sociocultural norms, family constraints, and lack of awareness about the benefits of PA strongly influenced PA among SA women. Culturally salient intervention strategies might include programs in trusted community settings where women can exercise in women-only classes with their children, and targeted education campaigns to increase awareness about the benefits of PA across life stages. (Am J Health Promot 2015;29[3]:e100–e108.)

Key Words: South Asian, Physical Activity, Cultural, Qualitative, Community-Based Research, Prevention Research. Manuscript format: research; Research purpose: intervention development; Study design: community-based participatory qualitative research; Outcome measure: behavioral; Setting: community based; Health focus: physical activity; Strategy: skill building/behavior change; Target population age: adults; Target population circumstances: medically underserved South Asian immigrants, women

INTRODUCTION There is a well-documented need for feasible, effective, and sustainable approaches to increasing leisure time physical activity (PA) levels among vulnerable populations, many of whom are at risk for being overweight or obese1 and at risk for obesity-related chronic diseases. National guidelines currently recommend that all adults achieve at least 30 minutes of moderate-intensity PA, on at least 5 days a week, to improve physical fitness and reduce chronic disease risk.2 The term South Asian (SA) is used to group together individuals from India, Pakistan, Bangladesh, Sri Lanka, Nepal, and Bhutan.3 People of SA descent, including Asian Indians and Pakistanis, are one of the fastest-growing segments of the U.S. population, with population estimates approaching 3.4 million.4 Although physical inactivity, type 2 diabetes mellitus (DM), and coronary heart diseases (CHD) are common in the United States, studies5–9 show that SAs are at even greater risk. SAs have a 3-fold higher risk of DM than nonHispanic whites,6 develop CHD 5 to 10 years earlier,7 and are less physically

Swapna S. Dave, MPH, MBBS, and Namratha R. Kandula, MD, MPH, are with the Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. Lynette L. Craft, PhD, is with the Department of Preventive Medicine, Northwestern University, Chicago, Illinois. Promila Mehta, MA, and Santosh Kumar, BSc, LLB (Hons), LLM, are with Metropolitan Asian Family Services, Chicago, Illinois. Shilpa Naval, BDS, MPH, MS, is with the School of Public Health, University of Illinois, Chicago, Illinois. Send reprint requests to Swapna S. Dave, MPH, MBBS, Northwestern University, Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611; [email protected]. This manuscript was submitted April 15, 2013; revisions were requested July 11 and October 20, 2013; the manuscript was accepted for publication November 3, 2013. Copyright Ó 2015 by American Journal of Health Promotion, Inc. 0890-1171/15/$5.00 þ 0 DOI: 10.4278/ajhp.130415-QUAL-175

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American Journal of Health Promotion

January/February 2015, Vol. 29, No. 3

For individual use only. Duplication or distribution prohibited by law. active compared with many other racial/ethnic groups.10,11 Among Asian American groups, SAs have some of the highest rates of overweight/obesity.12 For these reasons, facilitating and promoting PA interventions for the growing SA population could lead to a substantial impact on their risk of overweight/obesity, DM, and CHD. PA counseling by health care providers,13 individually adapted behavior change programs, and improving access to PA opportunities have shown efficacy in predominantly white populations13,14; however, SA women in particular are not being reached by current PA interventions. Most PA interventions are premised on the voluntary engagement of individuals who are culturally or economically situated to embrace active leisure14; psychosocial, cultural, and economic factors are underrecognized in intervention design.15 There is often a mismatch between the conceptual underpinning of most PA interventions and the way that many SA women construct their identities as members of their family and community.16 Few interventions build on specific cultural norms, values, and traditions to facilitate PA engagement.14,17,18 In addition, community-based PA programs may be more successful than clinic-based interventions because community organizations engage community members through many channels, can deliver culturally salient programs, and can facilitate the support and follow-up that are critical for maintaining PA.19–21 Despite the potential benefits of PA, there is almost no research on how best to adapt interventions for the SA community,2,10,22–24 and specifically for SA women. This qualitative focus group study was the first step of a community-based participatory research (CBPR) project aimed at developing community-based, evidence-based PA interventions for SAs. The CBPR framework meant that the community and academic partners collaboratively conducted research that was relevant and responsive to the sociocultural context and needs of SA women.25 CBPR helped the study team to engage diverse members of the SA community in a trusted community setting and to obtain community input


throughout the study design and implementation process. The focus groups described in the present study were designed to assess SA women’s perceptions of PA, to identify sociocultural and contextual barriers and facilitators related to PA, and to identify potential avenues for future PA interventions.

METHODS Community Setting and CBPR Partnership This study’s focus was on Indians and Pakistanis, who comprise 90% of SAs in the United States and in the Rogers Park neighborhood of Chicago, Illinois,3 where this study took place. Rogers Park is a major entry hub for SA immigrants,3 many of whom face economic, linguistic, and cultural barriers to health care.3 In 2008 the research team and community partners conducted a survey from a convenience sample in Rogers Park to assess the health needs and guide planning of the intervention. The results from the survey showed that 85% of SAs in Rogers Park were overweight/obese, 31% reported no physical activity, and 81% had at least one CHD risk factor.26 Metropolitan Asian Family Services (MAFS) was the partner communitybased organization and study site. MAFS provides social services to 1300 SA families, many of which are medically underserved and of lower socioeconomic status than the general U.S. SA population.3 MAFS had been working with the study’s academic principal investigator (N.K.) since 2005, helping to recruit participants for a study on SAs’ beliefs about cardiovascular disease.26–29 Through that project the study partners began to identify the importance of sociocultural factors on SAs’ health behaviors, and then they collaboratively wrote a grant proposing to use CBPR methods to understand and address physical inactivity in SA women. Community members and the community-based organization were involved in designing the research questions, planning and implementing the focus groups, recruiting SAs from diverse backgrounds as study participants, and helping to interpret and disseminate study results to the local community.

The study partners developed a memorandum of understanding, conducted capacity-building activities (e.g., training on human participants research), and formed a community advisory board (CAB) to provide structure and oversight of the partnership and research study. The CAB members were four SA women who were recommended by MAFS staff. These women were chosen because they were well connected to the community and to different SA religious organizations. CAB members were asked to help recruit SA women from different religions into the study focus groups. The CAB members were also involved in study design, review of study materials, and a semistructured interview guide to ensure cultural equivalence, and they also provided input on future interventions. Conceptual Framework PA is contingent on a multitude of individual, sociocultural, and environmental factors. This study was guided by a socioecologic model30 and explicitly aimed to understand SA women’s perspectives on PA and how their beliefs and behaviors are embedded in a larger social and cultural context, across different life stages (Figure). Study Design and Participants Adult SA women (18 years and older), self-identified as Asian Indian or Pakistani, and who spoke Hindi, Urdu, or English were invited to participate. Women who said they were unable to walk at least five blocks or climb one flight of stairs were excluded because the focus of this study was on PA among generally healthy women without significant activity limitations. The MAFS study coordinator and CAB members used word-of-mouth and community fliers to recruit women into the study. MAFS staff contacted interested participants to complete the eligibility checklist via telephone before recruiting them into the focus groups. A total of six focus groups (four in English and two in Hindi), stratified by age group (18–29, 30–49, and 50–71 years) were conducted from December 2010 to April 2011 with 42 women residing in the Rogers Park neighborhood of Chicago, Illinois. Hindi groups were conducted with women ages 30 to 49 and 50 to 71


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Figure Socioecologic Model to Depict the Conceptual Framework of the Study

years. Focus group size ranged from six to eight women. The first author (S.D.), who is fluent in English, Hindi, and Urdu and has had training in qualitative methods, moderated the focus group discussions, with supervision from the senior author (N.K.). The MAFS study coordinator attended all of the focus group discussions and helped with facilitation and note taking. Participants received a $20 incentive for participating in the focus groups. Focus Group Guide and Procedures A semistructured focus group guide (Table 1) was developed using the socioecologic30 model (Figure) and focused on eliciting participants’ definitions of and experiences with exercise, facilitators and barriers, benefits and costs, and participants’ ideas about potential interventions. We used the term exercise because during pilot testing of the focus group guide, other terms (e.g., physical activity and leisure-time physical activity) were not as clear to participants. Prior to each focus group, participants engaged in the informed consent process with a trained research assistant and completed a one-page demographics questionnaire. Focus group discussions lasted between 60 and 70 minutes, were audiotaped, and were transcribed verbatim. Hindi focus groups were

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transcribed and translated simultaneously into English by a bilingual study staff. Coding and Data Analysis The study team used thematic content analysis,31 guided by the conceptual model (Figure), to analyze qualitative data. A coding scheme was developed a priori (version 6.2.27) using the conceptual framework and extant literature on minority women and PA.32–34 The coding scheme was modified during the focus groups and

coding process if important themes emerged that were not part of the initial coding scheme. Two members (S.D., S.N.) of the study team coded all of the transcripts and independently identified themes and concepts. The transcripts and codes were then discussed by the entire team, and the emerging themes were agreed upon jointly. The initial intercoder reliability (percent agreement across coding categories) was 78%; it increased to 100% after discussion of areas of disagreement. Most of the disagreement about

Table 1 Focus Group Interview Guide 1. What is exercise? 2. What kind of exercise/physical activity do you do? Past and present. 3. How have your exercise patterns changed since you were a child and in different stages of life? 4. What are some difficulties that you face that make it difficult for you to exercise? Are there any difficulties faced by most Indian and Pakistani women which make it difficult to exercise? 5. What do you think will make it easier for you to exercise more? Also what will help people in the Indian and Pakistani community exercise more? 6. Does your family do any kind of exercise either together or individually? Do your family members make time for exercise in their routine? 7. Are there any benefits from exercising? If any, what do you think are the benefits? 8. Are there any harms from exercising? If any, what do you think is the harm? 9. Is there anything in your family or community that prevents you from exercising? 10. What can we do to help you exercise more? What are the needs in the Indian and Pakistani community? Are there certain types of exercise that you do/do not enjoy? 11. Are there places in the community, parks, community centers, where you want to exercise?



Table 2 Participant Characteristics Total participants, No.* 42 Younger (18–29 y), No. 12 Midlife (30–49 y), No. 16 Older (50–71 y), No. 14 No. of years in United States, mean (SD) 13 (11.58) Language of interview/focus group, % English 66 Hindi 34 Education: completed high school or more, % 40 Employment: not employed, % 62 Religion, % Hindu 38 Muslim 54 Other 8 Country of birth, % India 50 Pakistan 26 United States 9 Other 15 * Six focus group discussions.

coding categories was related to coding barriers as social and cultural norms, or family-related barriers. Qualitative data analyses were conducted using Atlas.ti 6.2.28.35 Descriptive statistics on sociodemographic data were calculated using Microsoft Excel 2010 (Redmond, Washington).

RESULTS The results are described under five main headings with the themes and subthemes identified during the analysis of the focus groups: (1) definition of exercise; (2) PA during different life stages; (3) barriers to PA; (4) facilitators of PA; and (5) PA intervention ideas. Sample Characteristics Participants were, on average, age 42 years, and most were immigrants (Table 2). For this analysis we categorized women’s life stages as ‘‘younger’’ (18– 29 years), ‘‘midlife’’ (30–49 years), and ‘‘older’’ (50–71 years). Definition of Exercise Women were specifically asked how they defined exercise. Compared with older women, the younger women


were more specific in how they defined exercise and spoke about the physical benefits of PA: ‘‘Doing physical work, giving some exercise to your muscles. It will definitely increase your heart rate, but taking more oxygen inside’’ (20 years). Midlife and older women’s definitions were more general: ‘‘Exercise is good for your body’’ (44 years) or ‘‘Exercise is a branch in your life, like daily routine. We do exercise because we have to keep fit’’ (60 years). Even though women were able to give examples of types of exercises (walking, yoga) and describe general benefits, participants did not articulate the public health definition and recommendations for exercise.36 PA During Different Life Stages Life stage was an important influence on whether or not SA women perceived benefits from PA and if they had time for PA. Women in all groups said that they did more PA when they were in elementary school. Midlife women reported the least PA, largely because of family responsibilities. Younger and older women were more likely to do PA because they had time and perceived tangible benefits, such as maintaining their body image or helping to control chronic disease, such as DM. A common perception among younger women was that older SA women were not exercising; a 24year-old participant said, ‘‘Exercise is like an unnecessary thing for them. There is a lot of difference between the old and the new generation.’’ However, in discussions older women said they were actually exercising more at this life stage because they had much more time for themselves. For example, a woman in her fifties stated, ‘‘Now my life is relaxed. The kids are grown up now, and I thought that it [i.e., PA] is also important. I should use this time, so I joined yoga and also the dance academy.’’ Barriers to PA Barriers to PA fell into four main categories: (1) family related; (2) cultural and social norms; (3) awareness, perceptions, and beliefs; and (4) physical limitations. Family-Related Barriers. All women discussed how family and household responsibilities often acted as a barrier

to PA; however, the ways in which family influenced PA differed across women’s life course. For younger women, family disapproval of PA was a common barrier. Younger women were often told by their families that they should spend time learning how to cook and on household work, instead of on PA (Table 3). A 20-year-old woman said, ‘‘My aunt said that, ‘You have to do house chores like cleaning, cooking. That will be gym for you. That is the best exercise.’’’ Younger women also said that gender norms related to modesty were another reason that their families discouraged PA, especially outside the home. A 23-year-old said, ‘‘There will be problem from my family if I had to go to exercise. My father says that, ‘You can go only if there are women, otherwise you cannot go.’’’ For midlife women, the main family barrier was not having any time for PA because they were busy caring for their children and households. One 45-yearold woman said, ‘‘I work for my mother-in law, my kids and my husband. I do everything.’’ These women in midlife also expressed the belief that their household work may be enough PA: ‘‘I think ladies, they feel like they are doing household work so it is exercise, and they do not need to do anything extra’’ (35 years). A common perception was that a family’s needs take precedent over an individual’s needs. A woman in midlife stated, ‘‘We never watch for oneself, what we need. We always care about fulfilling their needs and not about us’’ (48 years). The themes of family disapproval and household responsibilities were not as strong among older women. Cultural and Social Norms. Sociocultural norms were perceived as a barrier to PA. Women across all life stages also agreed that leisure-time PA was not normative in SA culture. A comment that many women agreed with was, ‘‘In my community, the women do not do exercise; just cooking and feeding the child and husband’’ (29 years). Women also said that newly married women may have an even harder time exercising because of specific expectations for a new daughter-in-law, which include taking care of her in-laws and cooking: ‘‘But from my husband’s side family, they might say that, ‘This new


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Table 3 Themes and Quotes About Barriers to and Facilitators of Exercise at Different Life Stages

Theme Barriers to exercise Family

Cultural and social norms

Awareness, perceptions, and beliefs

Facilitators of exercise Social support and physician advice

Recognizing the benefits

Intervention ideas

Quotes by Younger Women 18–29 y

Quotes by Midlife Women 30–49 y

Quotes by Older Women 50–71 y

‘‘Yeah especially the older people like the in-laws. They say, ‘you don’t have to go to the gym. You do at home. We never went to the gym.’’’ (27 y)

‘‘Earlier I used to exercise more, like in school I was active, sports and with my mom also I used to help her with outside work. I was more active when kid/young but now with my own kids, it is more tiring.’’ (37 y) ‘‘We never watch for oneself what we need. We always care about fulfilling their needs and not about us.’’ (48 y)

‘‘After marriage I slowed down because of more responsibility. Now my kids are grown up, and I take care of my grandkids now. So now I feel I have more time for myself now.’’ (58 y) ‘‘Because in our culture and family, we never did any exercise, especially ladies.’’(59 y)

‘‘No, I did not know before about exercise. I am telling the truth.’’(35 y)

‘‘When I was a kid, I used to do exercise. But there was no awareness, and there was no importance told to us about why should we do exercise.’’ (64 y)

‘‘Now my kids are grown up and they go to the gym and they tell me, ‘mom you should do exercise. It is good for your health.’’’ (41 y)

‘‘When I go to doctor, he tells me that I have to exercise, so now I make conscious effort to exercise.’’ (71 y)

‘‘I think doing exercise is good you know, it makes your body good.’’ (44 y)

‘‘By doing exercise, your blood pressure remains normal.’’ (66 y)

‘‘People should know what the need is. How much profit exercise does it do to you.’’ (48 y)

‘‘Do seminars like in the community or gathering, then I think people who do not know will get more information.’’ (63 y)

‘‘Even in the modern family, even in my family, I have seen if a girl is from a good family and she goes to the gym as well as does her study and all. But after marriage she is doing nothing.’’ (23 y) ‘‘I think also there is unawareness. I think that’s one of the reasons people don’t exercise. I think that’s the barrier for them to start exercising, lack of awareness.’’ (23 y) ‘‘Like what my husband does is whenever he has a target, he brings one smaller size than him and he adds a goal- like lose this much pound to fit in this dress. That motivates him. He started for me as well- he bought a really small dress for me, that I have to fit in this by this date. This helps because I have to fit in to this dress to wear this at my brother’s wedding, I have to wear it I have to go and work out to fit in to it.’’ (21 y) ‘‘Physical activity to maintain physical fitness, and for health and wellness, and to strengthen muscles and bones, and feel more relaxed.’’ (27 y) ‘‘I think you should have a girlsonly dance zumba class because that would interest a lot of South Asian women. It will get people interested in exercising.’’ (24 y)

girl. She just came, and she started going to the gym’’ (27 years). Older women recognized the potential for cultural and social norms to act as barriers; for example, ‘‘Sometimes, the idea is like the man is the

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boss, and you need to have his permission to go out and do certain things’’ (71 years). Some women talked about religion being a barrier for exercise. A 59-yearold Muslim woman said, ‘‘There are a

lot of religious restrictions, so sometimes I just hide and go to the gym. I tell my daughter-in-law, I am going here and there and visiting someone or buying something.’’ Another 41-yearold Muslim woman said, ‘‘They say that


For individual use only. Duplication or distribution prohibited by law. women should not go out and exercise with other men around.’’ Women also reported barriers related to culturally appropriate clothing. A 23-year-old woman said, ‘‘When I started doing the exercise in burkha [long, loose garment covering the whole body from head to feet], people used to be like this person, she cannot go to the gym. People used to stare at me, and I used to feel awkward. But then they got used to me, and I got used to them.’’ Awareness, Perceptions, and Beliefs. Surprisingly, one strong theme from the focus groups was that the community lacked awareness about the benefits of PA. There were common beliefs that exercising is more important for people with chronic diseases, for older people trying to prevent chronic diseases, and for overweight people (Table 3). For example, ‘‘Control your diet and do exercise regularly. Do yoga which will help make your future life go smoothly’’ (48 years). Very few participants talked about exercise as a way to prevent chronic disease in younger people. Additionally, several younger women stated that their families discouraged them from exercising because they were thin: ‘‘They will say you don’t need to work out if you are so skinny. You are underweight. You don’t need to go to the gym’’ (21 years). SA women, even younger women, perceived PA as a sign of modernity and wealth. For example, one woman said, ‘‘That’s what I feel. If you are working out, then you have all the time in the world. You don’t go to work. You stay home with your Chihuahua and nice, little pretty hair-do. You are modern and you are wealthy to afford gym’’ (24 years). Younger women also said that academic achievement was more important than PA: ‘‘When I go to the gym, I try to bring my study material and try to study on the elliptical. If I don’t have study material, I feel you know, I am wasting time when I could actually work for the test’’ (23 years). Physical Health as a Barrier. For older women, chronic disease was perceived as a limitation to PA. The most common physical health limitation was arthritis, for example: ‘‘But I have so much stiffness, it is very difficult to do


exercise’’ (64 years). Only one participant mentioned that PA could be beneficial for arthritis. Facilitators of Physical Activity Social Support—Especially Children. Women in all age groups said they felt motivated to do PA if they got encouragement from a family member or if they had someone with whom they could do PA. Children were often a source of encouragement to midlife and older women. For example: ‘‘I go to the park daily. My kids insist that ‘Mamma, let’s go to the park’’’ (37 years). Women also talked about doing activities with their children, which was not always perceived as exercise: ‘‘I am not doing any exercise, but I am busy all the time with my kids. And in summer time, my kids ride the bike, and I ride the bike too’’ (42 years). A few of the younger women talked about their spouses as a source of encouragement (Table 3). Recognizing the Benefits. Women in all age groups reported that ‘‘being active’’ was important to overall physical and mental health. However, women in different life stages seemed to be motivated by different benefits. Younger women mentioned that physical benefits, such as losing weight or fitting into a dress, motivated them to do PA. As one woman stated, ‘‘I have to fit in this dress and look good. I started gaining weight, so I started working out just for my sake, you know so I can start losing weight’’ (23 years). The women in their midlife described the benefits of PA more as general well-being and health: ‘‘It will help us to become healthy and stay healthy’’ (38 years). Older women said the main benefit of PA was that it helped reduce their risk for chronic disease and helped to manage stress (Table 3). Physician Advice. For some women, physician advice was also an important facilitator. ‘‘When you go to the doctor and they tell, ‘you have to exercise.’ So now I have to make conscious effort to exercise’’ (71 years). A 37-year-old woman also said that her physician recommended she start exercising. She stated, ‘‘After I got a knee pain and other problems, the first thing doctor

says is to reduce the weight, do exercise, and so I exercise regularly.’’ Physical Activity Intervention Ideas Increase Awareness and Involve Children. Participants were asked about the needs of the community and ideas for PA intervention programs. Almost all women reported that creating awareness about the importance and benefits of PA was essential to the success of the intervention. They also said that educating women about exercise could have benefits for the whole family: ‘‘Especially for ladies, you know. Like if the mom is educated and she knows everything, then she will push her kids that you should do this [exercise]’’ (27 years). Women liked the idea of interventions that involved traditional types of activities, such as SA folk dance and yoga. Women felt that they would be more likely to participate if the activities involved their children and could be done in a trusted community setting. Most SA women said that the community needed women’s-only workout facilities: ‘‘Only ladies, there should be exercise center for ladies and children. They don’t want to go because of some religious restrictions. Even I cannot tell in front of some of my relatives that I am going for exercise’’ (59 years).

DISCUSSION This qualitative study addresses a critical information gap about PA among U.S. SAs, and it provides information about how SA women conceptualize PA and about the barriers and facilitators to PA in this group. Although several studies have found that SAs are less physically active and are at greater risk for DM and CHD than other racial/ethnic groups,37,38 the present study is the first to describe how sociocultural norms and family strongly influence PA in U.S. SA women. The Centers for Disease Control and Prevention (CDC) defines exercise as ‘‘Physical activity that is planned, structured, repetitive, and purposive in the sense that the improvement or maintenance of one or more components of physical fitness is the objective.’’36 When we compared the CDC


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For individual use only. Duplication or distribution prohibited by law. definition to that provided by this study’s participants, younger women’s definitions of exercise were more specific and closer to the CDC definition compared with midlife and older women. In general, very few women in this study were able to articulate the public health definition of exercise, and instead described general benefits of being physically active. When developing PA promotion messages for SA communities, it is important to recognize that some SAs may not define and conceptualize PA and exercise in the same way as public health and biomedical models. PA promotion messages for SAs may be more effective if messages clearly and specifically define the frequency, duration, intensity, and type of PA that leads to health benefits. Using a life stage perspective, we found that family and cultural norms strongly influenced SA women’s PA. Women agreed that PA was not prioritized in SA culture, especially for girls and women. However, there were also some interesting differences in how these influences operated across different life stages. For example, family disapproval of PA was an important constraint among younger women, whereas for middle-aged women, the demands of child and family care were the main reason for not being more physically active. For older women, family and cultural constraints were less important, and health concerns were the main reasons that older women were not more physically active. To the best of our knowledge, this is the first study of U.S. SA women’s PA from a life stage perspective. Because PA habits are often established early in life, future work should focus on ways to encourage young SA girls to participate in more PA, encourage the prioritization of PA for women, and develop tailored interventions for SA women in different life stages. SA women said that they were expected to prioritize family needs above their individual needs, and that PA was viewed as taking time away from the household. A similar finding was reported in a study of SA women in Canada, where women said that taking care of the family was more important than caring for their own individual health.39 A similar theme has emerged in studies of Hispanic women.40,41 Our

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finding suggests the need to link the benefits of PA to something other than just the individual benefit, such as potential benefits to family well-being and health. In addition, SA women in this study suggested that PA interventions should involve the family unit, especially children, as a way to engage women in more PA. The strong emphasis on family well-being and importance of family is a universal SA value42; interventions that include husbands and children should be explored as a way to increase social support for SA women and motivate them to participate in exercise. Another key study finding is that SA women were generally not motivated to do PA to prevent chronic disease, especially during younger life stages. Rather, PA was perceived as important for older women, or for women who already have a chronic disease, or for overweight individuals. In an ethnographic study, others have also found that African-American women were not aware of the link between PA and cardiovascular health.40 These findings are in contrast to findings in studies of white women where the disease prevention benefits of PA are perceived across life stages.41,43 Despite numerous public health campaigns promoting PA as a way to prevent DM, CHD, and other chronic diseases,44 our findings suggest that these messages are not reaching some segments of the SA community. Older SA women described chronic health problems as their main barrier to more PA. Women said that vigorous PA could be harmful and exacerbate chronic health problems. Previous work has shown that older SA women with DM or CHD mostly engaged in low-intensity PAs and felt that more intense PA was unsafe.45,46 These concerns have been found in other older populations with chronic disease and have been successfully addressed with group PA interventions and DVD-based interventions that teach people how to exercise safely and gradually increase intensity.16,47–51 SA women also spoke about their physicians’ advice as a key facilitator of PA, suggesting that physician advice and support can be effective at increasing PA in individual SA patients.52,53 Physicians should address the safety concerns of older SA women

with empathy and provide specific instructions on how to exercise safely. Older SA women may also benefit from structured programs teaching them how to gradually increase the intensity of their PA. Studies have shown that culture and religion play an important role as a facilitator of, and at times a constraint to, ethnic minority women’s PA.16 In this study, we found that most Muslim women and some non-Muslim SA women preferred to exercise in women-only facilities or in the privacy of their home because of norms related to clothing, modesty, and separation of men and women. Many women in this study said they would feel uncomfortable exercising in the presence of men, and that their families would not allow it. An intervention study in the United Kingdom was successful at increasing PA in SA women by offering womenonly time at public exercise facilities, including at the public swimming pool.53 In the present study, women said that in addition to interventions that focus on creating awareness about the benefits of PA, they also wanted opportunities to do PA in women-only classes and with their children. These findings underscore the importance of developing PA interventions for SA women in partnership with SA communities, including religious institutions and community organizations. Community involvement is essential for developing PA interventions that incorporate SA values and preferences. It is also important to deploy PA interventions in trusted settings because of gender norms related to modesty and separation of men and women. Strengths and Limitations Strengths of this qualitative study are the inclusion of SA women across age groups, the inclusion of non-English speakers, and the cocoding of all transcripts by two research staff members. Limitations are the use of a convenience sample of medically underserved SA women, recruited through one community organization and in an urban setting in Chicago. Therefore, these results may not be generalizable to other SA populations in the United States. Also, despite the moderator’s effort to ensure that ev-


For individual use only. Duplication or distribution prohibited by law. eryone had a chance to speak, the discussion setting could have led to bias related to social desirability and outspoken participants dominating the conversation. Conclusion and Future Directions Using a CBPR framework, this study provides formative data for refining and developing community-engaged strategies and interventions to promote PA in U.S. SA women. We found that SA immigrant women had little knowledge about PA recommendations and about the benefits of PA for chronic disease prevention, and that

SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic? Although physical inactivity and type 2 diabetes mellitus (DM) are common in the United States,54,55 South Asian (SA) women are at even greater risk.56 SA women have a 3fold higher DM prevalence than nonHispanic whites57 and are less physically active compared with women from many other racial/ethnic groups.10 Little is known about the barriers and facilitators to PA among SA women in the United States. What does this article add? This study is one of the first to use a community-based participatory research approach and qualitative methods to understand medically underserved SA women’s concepts of and barriers and facilitators to PA across life stages. This study includes the perspectives of SA women who do not speak English, a group that is seldom included in behavioral research. What are the implications for health promotion practice or research? Reducing DM risk in SAs, the second-fastest growing minority group in the United States, is a vital public health priority. This study provides novel information on the social and cultural context of SA women’s PA, which can be used to develop effective, culturally salient PA interventions. Strategies to increase PA in medically underserved SA women might include community-based interventions, culturally salient activities, and exercising with children.


there are important sociocultural barriers that need to be addressed when designing interventions for this group. In addition, this qualitative information provides a starting point for further explorations of whether the themes that emerged in this study vary within U.S. SAs by immigration, country of origin, gender, and socioeconomic status.

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Acknowledgments This project was funded by the Alliance for Research in Chicago Land Communities Seed Grant Program (PI-Dr. Namratha Kandula). An earlier version of this paper was presented at the 4th Annual Minority Conference, University of Illinois at Chicago, Chicago, Illinois, on February 24, 2012 and at the American Public Health Association’s 140th Annual Meeting, San Francisco, California, on October 28, 2012. The authors thank Tejas Rawal for helping with the transcription of the interviews. We are also very grateful to our Community Advisory Board members, Nalini Goyal, Shirin Virani, Tejinder Kaur (deceased), and Nasim Vard for their valuable feedback on the study.

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