Beyond individual responsibility towards healthy food choices: A qualitative study among Pakistani women in Hong Kong.

While biomedical understandings of food and diet coupled with discourses on individual responsibility towards healthy food choices are nowadays prominent, other social and cultural meanings attached to food and diet are largely devalued. The limits of such a reductionist approach are more evident when related to the experiences of migrant and ethnic populations, whose alternative knowledge(s) and practices about food and health are especially neglected. A multicultural city with a public healthcare system inherited from the British colonial times and largely shaped by biomedical ideas of health, Hong Kong offers a lens into the limits of such a reductionist approach. Due to their vulnerability in the context of Hong Kong as shaped by intersecting social identities, 72 women from Pakistan were recruited to be our community partners in a community-based participatory action research project to investigate their health needs and concerns. 12 focus group discussions were conducted, exploring their experiences of "healthy" food and overweight especially related to their encounters with the Hong Kong public healthcare system, as these issues emerged as key health concerns within the community. Four major themes emerged: unmet expectations of care, health is beyond the individual, constraints to a healthy diet in the context of migration, and beyond health: food as care for diasporic women. This study highlights the limit of a reductionist approach to healthy food as merely based on nutrition and individual responsibility. It stresses the need of a counter-discourse in the field of public health, emphasizing not only alternative cultural ideas of health and food, but also enlarging the field of health in biomedical terms to embrace "care" and acknowledging the structural constraints shaping migrant and ethnic population's vulnerability in making "healthy" food choices.

Perceived barriers and facilitators to healthy eating among Pakistani women participating in the PakCat program in Catalonia: A qualitative approach.

Immigrant women of Pakistani origin are among the most at-risk groups for type 2 diabetes, obesity, and heart failure in Catalonia. As the incidence of these diseases is associated with lifestyle factors, we approached this community with participatory research and conducted six focus groups (N = 36) among Pakistani women participating in the PakCat Program. The research process of this paper adhered to the COREQ checklist. Through the thematic analysis, we identified six main themes: social beliefs and attitudes, family environment, personal factors, dietary acculturation, traditional dietary patterns, and economic factors. We discovered both facilitators and barriers associated with each theme, but the findings indicated that Pakistani women encounter more inhibitors than enablers to following a healthy diet. The determination of these factors can facilitate the reinforcement of the aspects that help Pakistani women to follow a healthy diet and provide adequate tools to overcome the barriers.

Identifying the Health Concerns of Pregnant British Pakistani Women Living in Deprived Areas: A Qualitative Study.

INTRODUCTION: Pregnant British Pakistani women have disproportionately poorer health than the wider population. Bradford has a strong Pakistani presence and a wide range of public health problems including high levels of gestational diabetes, high obesity rates and a high infant mortality rate, which is highest for babies of Pakistani origin. For women to be healthy, we need to know what concerns they have about their health so they can be addressed appropriately. The aim of this study, therefore, was to explore the health concerns of pregnant British Pakistani women living in deprived areas. METHODS: Semi-structured qualitative interviews were conducted with 21 pregnant Pakistani women in a hospital setting. Data were analysed using thematic analysis. RESULTS: Pakistani women identified safety issues, barriers to undertaking physical activity in the areas where they live, concerns surrounding exercising during pregnancy and cultural and religious constraints that prevented them from engaging in physical activity. They reported issues around food, concerns around a lack of culturally appropriate diet information, the cost of unhealthy food locally, and the lack of healthy food options in their residences. Women were unsure on where to obtain health promotion information and reported a lack of access in obtaining that information. Language barriers in accessing health promotion information were further reported as a concern. DISCUSSION: Researchers, midwives, health providers, local authority and policy makers interested in improving the health of pregnant Pakistani women may use these findings to develop further research and interventions to improve the poor health of this population.

What is already known on this subject? South Asian women have previously identified issues relating to safety in physical activity and cultural barriers to engaging in physical activity but there has been little investigation into the health concern of pregnant Pakistani women.What this study adds? We now have a clearer understanding of the barriers faced by pregnant Pakistani women living in deprived areas when trying to live a healthy lifestyle. This understanding will contribute to the development of strategies for promoting health and improving the outcomes for this population.

Exploring the obesity concerns of British Pakistani women living in deprived inner-city areas: A qualitative study.

INTRODUCTION: British South Asians have a higher prevalence of overweight and obesity than the wider population. Bradford (UK), with its high Pakistani presence and levels of economic deprivation, has exceptionally high instances, especially in deprived areas where many Pakistanis reside. British Pakistani women in Bradford are more likely to be overweight and obese. There is uncertainty on how these women can be aided to manage their weight. Therefore, the objective of this study was to explore the obesity concerns of Pakistani women living in deprived inner-city areas of Bradford. METHODS: Three focus groups interviews were carried out with 23 Pakistani women living in deprived areas of Bradford. Data were analysed thematically. RESULTS: This exploratory study identified a wide range of concerns that women had around managing their weight. Participants disclosed distrust in information given around medication, conflicting dietary information and reported low levels of trust in women-only organized physical activities. Cultural barriers were identified, which included the gender role of the woman, the lack of culturally appropriate dietary advice, cultural misunderstandings of what constitutes a healthy diet and healthy weight, the lack of culturally suitable exercise facilities and conforming to family and community expectations. Other concerns were language barriers around a lack of understanding, the inability to read Urdu and reliance on others to translate information. CONCLUSION: These findings have implications for researchers, local authorities, policy makers and others with an interest in reducing the rates of obesity in this population. Recommendations include training health practitioners to be culturally aware of the diet and eating practices of this community, exploring different ways to support socially isolated women to be more physically active at home, addressing physical activity and diet misconceptions and designing obesity management information materials appropriate for a range of literacy levels. PATIENT OR PUBLIC CONTRIBUTION: Public contributors were involved in the development of the interview guide and design of the research. A pilot focus group with participants not included in the present paper was used to help test and refine the focus group questions. Interview transcripts were member checked by participants, and participants assisted with data analysis.

Developing an obesity research agenda with British Pakistani women living in deprived areas with involvement from multisectoral stakeholders: Research priority setting with a seldom heard group.

INTRODUCTION: British Pakistani women have exceptionally high rates of obesity and yet are seldom heard in a research priority setting concerning weight management. The objectives of this study were (i) to ascertain what multisectoral professionals perceive to be the most pressing unmet obesity needs or topic areas that need more research in relation to Pakistani women living in deprived areas of Bradford and (ii) to determine the top 10 obesity health priorities for this group to develop an obesity research agenda. METHODS: A two-step process was adopted using the following: (i) a survey of a wide range of multisectoral professional stakeholders (n = 159) and (ii) a ranking exercise involving Pakistani women living in deprived areas of Bradford (n = 32) to select and prioritize their top 10 obesity health concerns and unmet needs from a list of 31 statements identified in the survey and previous research. Survey data were analysed using inductive content analysis and themes were identified. Themes were translated into statements to be ranked by Pakistani women. The ranking exercise was conducted by telephone either via voice or video call. Data were analysed using a reverse scoring system. RESULTS: Survey responses were grouped into statements reflecting the following three categories: education needs; healthy behaviour barriers and mental well-being. The highest rankings were given by Pakistani women to statements on mental health and the need for education. The top 10 prioritized statements were developed with members of the public into an obesity research agenda that reflected the target population. CONCLUSION: Actively engaging British Pakistani women in setting research priorities provided a unique opportunity to understand the key areas they think are important for future research. The culminating research agenda can be used by researchers to advance the field of obesity research in Pakistani communities, thus producing research outputs that are relevant to and have impact in this population. PATIENT OR PUBLIC CONTRIBUTION: Participants in the ranking exercise collected data. Public contributors were involved in developing the prioritized statements into a research agenda.

Association of the CYP17 and CYP19 gene polymorphisms in women with polycystic ovary syndrome from Punjab, Pakistan.

BACKGROUND: Polycystic ovarian syndrome (PCOS) is considered the most common multifactorial endocrinopathy. Genetic factors play an essential role in the pathogenesis of PCOS. CYP 17 enzyme is responsible for androgenesis, while CYP 19 enzyme works for androgen conversion into aromatic estrogen. Several studies have reported their association with PCOS. This study was aimed to investigate the association of cytochrome P450c17α gene (CYP17) 5'-untranslated region MspA1/(rs743572) genetic polymorphism and rs2414096 of cytochrome P450 or aromatase (CYP19) gene polymorphism with the susceptibility to PCOS in reproductive-age women from Punjab, Pakistan. METHODS: We performed a case-control association study was conducted, including 204 PCOS patients and 100 controls. Genotyping of SNP rs2414096 (CYP 19 gene) and P450c17α gene (CYP17) 5'-untranslated region MspA1 was performed on genomic DNA using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Statistical analysis was performed to find out the association of phenotypic and genotypic characters in etiopathology of PCOS. RESULTS: The genotype distribution for CYP 17 5'-UTR MspA1 (TT, TC, CC) revealed that the frequency of genotype TC is significantly higher in PCOS patients (54.9%) vs. controls (OR 4.97, 95% CI 2.75-8.33, p<.001) (12%). The genotype distribution for CYP 19 (GG, GA, AA) showed significantly higher frequency of GA (58.%) and AA (23.5%) in patients as compared to cases (18% and 8%, respectively) (OR 5.49, 95% CI 3.61-8.34, p<.001). Body mass index (BMI), waist, hip, infertility and family history of infertility, PCOS, diabetes, and hypertension were found significantly associated with PCOS. CYP 19 genotypes were found significantly associated with PCOS patients having paraclinical traits of infertility and family history of infertility, while CYP 17 genotypes showed no significant association with any paraclinical traits in PCOS patients. CONCLUSIONS: This is the first study on PCOS genotypes from Pakistan and results suggest that CYP 17 5'-UTR MspA1 (rs743572) (genotype TC) and CYP 19 gene (rs2414096) (genotype GA) polymorphisms are significantly associated with susceptibility to PCOS in Pakistani women having the traits of infertility and family history of hypertension.

The introduction of risk stratified screening into the NHS breast screening Programme: views from British-Pakistani women.

BACKGROUND: UK national guidelines suggest women at high-risk of breast cancer should be offered more frequent screening or preventative medications. Currently, only 1 in 6 high-risk women are identified. One route to identify more high-risk women is via multifactorial risk assessment as part of the UK's NHS Breast Screening Programme (NHSBSP). As lower socioeconomic and minority ethnic populations continue to experience barriers to screening, it is important that any new service does not exacerbate issues further. To inform service development, this study explored views of women from underserved backgrounds regarding the introduction of risk stratification into the NHSBSP. METHODS: Nineteen semi-structured interviews were conducted with British-Pakistani women from low socioeconomic backgrounds from East Lancashire, UK. Fourteen interviews were conducted via an interpreter. RESULTS: Thematic analysis produced three themes. Attitudes toward risk awareness concerns the positive views women have toward the idea of receiving personalised breast cancer risk information. Anticipated barriers to accessibility emphasises the difficulties associated with women's limited English skills for accessing information, and their I.T proficiency for completing an online risk assessment questionnaire. Acceptability of risk communication strategy highlights the diversity of opinion regarding the suitability of receiving risk results via letter, with the option for support from a healthcare professional deemed essential. CONCLUSIONS: The idea of risk stratification was favourable amongst this underserved community. To avoid exacerbating inequities, this new service should provide information in multiple languages and modalities and offer women the opportunity to speak to a healthcare professional about risk. This service should also enable completion of personal risk information via paper questionnaires, as well as online.

Culturally-adapted cognitive behavioural therapy based intervention for maternal depression: a mixed-methods feasibility study.

BACKGROUND: British Pakistanis are one of the largest ethnic minority groups living in the UK, with high rates of maternal depression being reported in this population. Evidence suggests that culturally-adapted Cognitive Behavioural Therapy (CBT)-based interventions for depression, may improve clinical outcomes and patient satisfaction. This study was conducted to develop and test the feasibility and acceptability of a culturally-adapted, CBT-based, manual-assisted intervention in British Pakistani mothers experiencing maternal depression. METHODS: A mixed-method feasibility study that included qualitative interviews followed by the development of a CBT-based intervention for mothers with mild to moderate depression. Following the qualitative interviews, a CBT-based intervention called the Positive Health Program (PHP) was developed and delivered consisting of 12-weekly sessions. A before and after design was used to explore the feasibility and acceptability of the Positive Health Programme. RESULTS: A culturally-adapted CBT-based group intervention (PHP) was acceptable to this group and improvements were reported in depression and health-related quality of life. The women's understanding of 'depression' as a general consensus was in physical terms, but with an onset triggered by psychosocial causes. The most commonly reported factors contributing to depression were marital disharmony, lack of social support, and financial difficulties. Past help offered was primarily antidepressants, which were not welcomed by most of the women. A lack of availability of culturally sensitive interventions and the limited cultural sensitivity of NHS staff was also reported. CONCLUSION: This study provides preliminary evidence for the feasibility and acceptability of a CBT-based culturally-adapted group psychological intervention for British Pakistani mothers. TRIAL REGISTRATION: Study ethics registration number: 10/H1005/62 (University of Manchester).

Social support, marital adjustment, and psychological distress among women with primary infertility in Pakistan.

This study aimed to identify prevalence rates of psychological distress among Pakistani women seeking help for primary infertility. The associations of social support, marital adjustment, and sociodemographic factors with psychological distress were also examined. A total of 177 women with primary infertility were interviewed from one hospital in Islamabad using a Self-Reporting Questionnaire, the Multidimensional Scale of Perceived Social Support, and the Locke-Wallace Marital Adjustment Test. The data were collected between November 2012 and March 2013. The prevalence of psychological distress was 37.3 percent. The results of the logistic regression suggested that marital adjustment and social support were significantly negatively associated with psychological distress in this sample. These associations were not confounded by any of the demographic variables controlled in the multivariable regression models. The role of perceived social support and adjustment in marriage among women experiencing primary infertility are important factors in understanding their psychological distress. The results of this small-scale effort highlight the need for social and familial awareness to help tackle the psychological distress related to infertility. Future research needs to focus on the way the experience of infertility is conditioned by social structural realities. New ways need to be developed to better take into account the process and nature of the infertility experience.

Maternity care experience of Pakistani ethnic minority women in Hong Kong.

Background: Persistent inequalities in maternity care experience and outcomes exist globally for ethnic minority (EM) and migrant women. Despite the fact that this is an important research area, no prior study has been done in Hong Kong (HK) to examine maternity care experience of EM women. Objectives: To investigate maternity care experience of Pakistani EM women (both local born and immigrants) during pregnancy, birth and after birth in hospital in HK. An evaluation of their satisfaction and factors predicting satisfaction with care during the three phases of maternity care was included in the study. Methods: A cross sectional survey was conducted among Pakistani EM women who had given birth in HK in last 3 years, using a structured questionnaire by a bilingual interviewer, from April to May 2020. Counts and percentages were used to describe all categorical variables. Association between predictor variables and overall satisfaction was assessed by bivariate analysis and multiple logistic regression. Results: One hundred and twenty questionnaires were completed. Almost 60 percent of the women were very satisfied with the overall care. More than half of the women described the care they received as kind, respectful and well communicated. After adjusting for age and parity, HK born Pakistani women expressed relatively less satisfaction with care, especially during pregnancy and labor and birth, as compared with Pakistan born women. Women with conversational or fluent English-speaking ability also felt comparatively less satisfied particularly from intrapartum and postnatal care in hospital. Education level had a negative association with satisfaction with care during pregnancy. Conclusions: Maternity care providers should take into account the diversity of EM women population in HK. Our findings suggest that effective communication and care that can meet individual needs, expectations, and values is imperative to improve experience and quality of maternity care for EM women in HK.

The mental health of working women after the COVID-19 pandemic: an assessment of the effect of the rise in sexual harassment during the pandemic on the mental health of Pakistani women using DASS-21.

Introduction: The mental health of South Asian women has been observed to be in regression lately, with sexual harassment as one of the major factors accounting for mental health deterioration, especially for women who leave their homes frequently for work and study. The COVID-19 pandemic not only augmented the mental health distress of the general female population but the rise in sexual violence against women is being consistently reported around the globe. Based on this background, we adopted a two-pronged strategy to assess whether working women and students aged 18-55 experienced a rise in sexual harassment in the 18 months after lifting the COVID-19 lockdowns. Secondly, using the well-validated psychometric test, DASS-21, we evaluated the psychiatric outcome of this change on the mental health of those women. Study design: The study was designed as a quantitative, cross-sectional survey-based research. Methodology: A total of 303 women participated in this study. Personal interviews through a specifically designed questionnaire and psychometric test DASS-21 were administered to assess the mental health state of working women and female students, aged between 18 and 55 years old. The mean age of the participants was 37 ± 2.8. The study population was further categorized into two main groups of limited and frequent interactions based on varying levels of the frequency of leaving home and interacting with male strangers in their daily routine. Data were analyzed and the correlation between limited/frequent interaction and DASS-21 total scores and sub-scores of depression, anxiety and stress, and other sociodemographic variables were investigated using the Chi-square test, whereas psychosocial predictors of mental distress were evaluated using multiple linear regression analysis after matching limited and frequent interaction groups using a 1:1 propensity score-matched pair method for sociodemographic covariates. Results: Overall, approximately 50% of our study population experienced changes in the behavior of male strangers that could be categorized as harassment in their daily life interactions, whereas 33.66% of participants experienced relatively more sexual harassment post-pandemic than before it. This observation was significantly correlated with the frequency of male interaction (χ2 = 5.71, p < 0.01). Overall, 34% of our study population scored >60 on the DASS21-total score, whereas 29.04% scored >21 on the depression scale. Alarmingly, >40% of the women in the frequent interaction group scored in the extremely severe range of anxiety and depression. Moreover, in the regression analysis, out of all the factors analyzed, the extent of everyday interaction with male strangers, an increase in fear of sexual crimes, and a self-perceived increase in mental distress during the 18 months post-pandemic were found to be highly statistically significant predictors of mental distress not only for total DASS 21 but also for the sub-scales of depression, anxiety, and stress. Conclusion: In Pakistan, women experienced a rise in sexual harassment cases post-COVID-19. An increase in sexual harassment was found to be a predictor of negative mental health in the form of depression, anxiety, and stress.

Pakistani Women: Promoting Agents of Healthy Eating Habits in Catalonia-Protocol of a Culturally and Linguistically Appropriate Randomized Control Trial (RCT) Based on the Transtheoretical Model.

(1) Introduction: Dietary and lifestyle changes along with the cultural and linguistic barriers convert the immigrant women of Pakistani origin into a risk population for developing metabolic syndrome (MetS) and cardiovascular diseases (CVD). The objective of this project is to evaluate the efficacy of a culturally and linguistically appropriate food education program based on the Transtheoretical model that will allow the participants to become ambassadors of healthy eating habits for their community. (2) Methods: In this community-based RCT, any Pakistani adult woman with residence in Badalona and Santa Coloma de Gramenet will be able to participate. We will use a mixed model approach. From the quantitative perspective, the participants will answer a survey accompanied by a multilingual nutritionist that will help us to determine the sociodemographic, clinical, anthropometric, dietary data, and quality of life. From the qualitative perspective, we will conduct 6 focus groups (3 in each municipality) to determine the cultural and religious beliefs with the aim of tailoring the intervention to the target population. Hereafter, the participants from one municipality will randomly become the control group and from the other, the intervention group. The intervention group will participate in 10 weekly food education sessions based on the Transtheoretical model while the control group will receive 3 general educational sessions on food and health. During the evaluation procedure, we will assess the impact of the intervention considering the outcomes of the study. (3) Discussion: This study will establish intercultural bridges between health professionals and the Pakistani community living in Catalonia. The project will open the door for future interventions, and it will be sustainable in time as the participating women will become health promotion agents for the rest of their community.

Design of Culturally and Linguistically Tailored Nutrition Education Materials to Promote Healthy Eating Habits among Pakistani Women Participating in the PakCat Program in Catalonia.

(1) Background: Pakistani women are among one of Catalonia's most affected groups by obesity and cardiovascular disease. The design of health education strategies for them has become a compelling need. This paper aims to enlighten the elaboration and evaluation procedure of culturally and linguistically tailored nutrition education materials for Pakistani women participating in the PakCat Program, which aims to evaluate the efficacy of a nutrition education strategy allowing the participants to become ambassadors of healthy eating habits for their community. (2) Methods: In this Randomised Control Trial (RCT), 137 Pakistani women (70 from the intervention and 67 from the control group) took part. We conducted 10 sessions for the intervention group and 3 sessions for the control group in the form of small groups. The sessions were conducted in Urdu and Punjabi, and the material was translated into Urdu, Catalan, Spanish and English. For some sessions, we elaborated on new materials and for others, we adapted them from the existing nutrition material in aspects of language and culture. We evaluated the nutritional material from the observation carried out by the dietician who developed the sessions, participants' feedback at the end of the sessions and a satisfaction questionnaire. (3) Results: We summarised the elaborated material in form of two multilingual nutritional guidelines about portion size and heart-healthy foods. We also registered several materials generated for the PakCat program such as an infographic about myths and beliefs related to food, a booklet to read and interpret the food labels, a recipe book for healthy snacks, and an infographic of 10 tips for healthy eating. We also organised a PhotoVoice exhibition of 70 healthy plates elaborated by the intervention group participants. The participants highly appreciated the material in terms of visualization, cultural and linguistic adequacy, and level of comprehension through all three evaluation methods. (4) Conclusions: The design of culturally and linguistically tailored nutrition education material for Pakistani women living in Catalonia is attainable and effective to meet their specific needs. The healthy dietary recommendation can be adapted to them preserving their traditional dietary pattern, and they acquire the confidence to start following a healthy diet.

Better Reporting and Awareness Campaigns Needed for Breast Cancer in Pakistani Women.

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer deaths in women globally. In 2018, 2.1 million new cases were reported, with 627,000 deaths. Pakistan has the highest incidence rate of breast cancer among Asian countries: one in every nine women has a lifetime risk of being diagnosed with breast cancer. By reason of many misconceptions about the etiology of the disease and socioeconomic factors, Pakistani women have very low rates of early detection and diagnose breast cancer at advance stages with fewer chances of survival. The key to cure the breast cancer is early diagnosis. The aim of current review is to highlight the factors leading to the delays in early presentation of breast cancer in Pakistani women and to summarize possible recommendations for educating women about early diagnosis along with palliative care facilities for patients suffering from breast cancer. Furthermore, this study appeals to both the general public and government in the belief that better reporting and awareness campaigns may bring more women to clinics for early diagnosis.

Female Entrepreneurial Intentions in Pakistan: A Theory of Planned Behavior Perspective.

With theoretical underpinnings in the theory of planned behavior, this research aims at investigating how women's entrepreneurial intentions might develop in Pakistan. The survey of 216 female students revealed that psychological capital plays an important role in shaping women's entrepreneurial commitment which in turn results in increased intentions to opt for entrepreneurship as a career. Additionally, it was observed that social support moderates the indirect relation in such a way that in the presence of high social support, the association between psychological capital and intentions via commitment is further strengthened. Because women face comparatively more barriers in paid career, therefore it was necessary to study the mechanism and driver that can improve their entrepreneurial intentions, since they represent an untapped resource that might be utilized to improve the economic prospects of a country. The study bridges a significant knowledge gap in utilizing psychological capital to enhance female's entrepreneurial intentions, who are under constant pressure of juggling multiple roles at work and home.

Barriers and facilitators to cervical cancer screening among Pakistani and Somali immigrant women in Oslo: a qualitative study.

Norway has a low incidence and mortality rate of cervical cancer, which is mainly due to the high participation rate of women in cervical cancer screening. However, the attendance of cervical cancer screening was reported to be low among immigrant women. For this reason, we conducted a qualitative study to obtain better insight into perceived barriers and challenges to cervical cancer screening among Somali and Pakistani women in the Oslo region. A convenient sample of 35 (18 Pakistani, 17 Somali) women were recruited for the study in collaboration with Somali and Pakistani community partners. Focus group discussions were used to explore barriers and facilitators to cervical cancer screening, whereas the Ecological Model was used as the framework for the study. The study found three levels of barriers to cervical cancer screening. The individual level included a lack of understanding of the benefits of the screening. The sociocultural level included the stigma attached to the disease and the belief that women who are unmarried are sexually inactive. The system-related level included a lack of trust toward the health care system. Based on the study results, and using a common denominator approach for the immigrant groups included, the study recommends three communication strategies with the potential to improve women's participation in cervical cancer screening: 1) in-person communication and information material at health centers; 2) verbal communication with women through seminars and workshops to educate them about their risk of cancer and the importance of screening and 3) the initiation of better recall through SMS and letters written in native languages. Finally, an intervention study that compares the aforementioned strategies and proves their effectiveness in increasing immigrant women's participation in cervical cancer screening is recommended.