Understanding the complex interplay of barriers to physical activity amongst black and minority ethnic groups in the United Kingdom: a qualitative synthesis using meta-ethnography

Study characteristics

From the 2,986 references identified, 14 studies satisfied the inclusion criteria
(Fig. 1). The studies were published between 1997 and 2011, and included 175 participants
(18–65 years). The design and focus of the included studies varied. Three studies
evaluated intervention programmes 33]–35], and four explored knowledge and attitudes to lifestyle risk to developing diseases
such as heart disease 36], 37], Type 2 Diabetes 38], 39]. The seven remaining studies explored physical activity experiences of participants
that were unrelated to a specific clinical condition 30], 40]–45].

Five studies were conducted in Scotland 30], 35], 38], 41], 43]; the remaining studies were conducted in England. All studies considered perspectives
of BME groups, although two also included views from health professionals 39], as well as staff from Health Authorities and leisure centres 34]. Ethnicity was described by all studies, with 10 out of the 14 studies restricted
to South Asians who were mainly Indian, Pakistanis, and Bangladeshi 30], 33]–39], 44], 45]. The distinction between first generation migrants and UK born BME individuals were
poorly reported in included studies. Four studies combined mixed populations of South
Asians, majority populations and/or African-Caribbean 40]–43].

Whilst some studies included participants aged over 65 years 37], 38], 42], 44], the mean age in each study was less than 65 years, hence their eligibility for inclusion
in this review. Five of the studies expressed women’s views only and it is important
to note that all of these involved South Asian individuals 34], 36], 37], 42], 43]. Table 2 summarises data from the included studies. Table 3 presents the results of the quality assessment performed on included studies.

Table 2. Study characteristics of papers that were synthesised (continued over two pages)

Table 3. Quality criteria and results

Main themes that emerged from the data synthesis

Four themes emerged from the findings of included studies (i.e. from first and second-
orders). Each theme is described separately.

Perception

There was mixed perception of physical activity either as a formal separate activity
or as part of everyday lives 30], 34], 36]–42] (Additional file 1: Table S1). Some South Asian groups perceived physical activity as inappropriate
or unnecessary or adding no value; to them, physical activity was perceived to cause
harmful effects 41]. For example, physical activity was perceived harmful as a cause more weakness or
disease 35], and as a reflection of selfish activity to abandon other responsibilities 37]. Furthermore, physical activity was perceived among Bangladeshi people as harmful
and cause social sanction of gossip and laughter among women 39]. Physical activity was perceived to be absent from their culture. For example, among
the South Asian groups, physical activity was perceived as “Western” culture which
was external to their own lifestyle and BME individuals were not able to incorporate
it easily into their lives. The requirements of special clothing or undertaking activities
at designated places such as gymnasiums reflected the notion that physical activity
was perceived as formal and separated activity rather than BME cultural activities
39]. This perception of an absence of exercise culture originated from the participants’
country of origin where there was limited childhood exposure or experience of activities
perceived as “Western culture”. Cultural restrictions, lack of role models in physical
activity or sport from BME communities, and the poorly promoted healthy lifestyles
were described to explain their limited exposure in their country of origin 30], 37], 40], 41].

Within the included studies, perception of disease causation or risks and health beliefs
were revealed among individuals from South Asian groups who held strong health beliefs
and perceived that physical activity had no preventive role in diseases 30], 33], 35], 38]–40] (Additional file 1: Table S1). This perception was shared by a variety of individuals with or without
co-morbidities such as diabetes and obesity. For individuals with an Islamic background,
ageing and external locus of control (e.g. God) were considered causes of disease
with little or no control being derived from human activities (including physical
activity) to prevent them 35], 38]. Therefore, some BME individuals would not engage in physical activity either as
a preventive measure or as treatment for specific health conditions.

The perceived fear of racial or religious discrimination among some BME individuals
was a barrier to engaging in physical activity in the UK 30], 34], 35], 39], 41], 45] (Additional file 1: Table S1). For example, some Muslim women, especially from South Asian groups, reported
avoiding facilities which were unfamiliar to them or where they might feel unsafe
because of fear of either personal or institutional racial discrimination from either
the Caucasian population or members of the same BME group 45]. Perceived personal discrimination from members of the same BME group could occur
when their participation in sport was condemned by their own BME community. For example,
females participating in football 45]. Some female participants perceived discrimination from Caucasian groups at public
facilities when traditional clothes rather than formal sportswear were worn 30]. Closely related to this was the fear of crime and physical attack perceived by many
individuals across BME groups and deterring them from outdoor physical activities.
The fear of crime and physical attack was closely related to perceived fear of racial
discrimination living in disadvantaged areas.

Cultural expectations

Within the identified studies, cultural and religious norms were identified as deterrents
to engaging in physical activity 30], 33]–35], 38], 41], 45] (Additional file 2: Table S2). These norms included: maintenance of Islamic or South Asian dress codes;
curtailing movement of women outside the home and female cultural obligations after
marriage. This suggests that the desire to observe these norms by some South Asian
women or Muslim women being stronger than the desire to be physically active. More
so, there was a fear of breaking the rules or acting outside these norms to avoid
condemnation from members of same BME group. The threat of the disappearance of traditional
cultural values was also another reason BME members would desire to observe these
norms. Therefore, individuals from BME groups (especially South Asian women or Muslim
women) found it difficult to meet expectations of their traditions as well as becoming
sport individuals 45]. The lack of culturally-sensitive indoor facilities and services deterred some BME
individuals from engaging in physical activity 30], 34], 38]–41].

Cultural expectations in some BME groups are religious and culturally based. Sometimes,
South Asian individuals expect physical activity facilities to promote or incorporate
their religious and cultural practices, for example, single-sex facilities and same-sex
instructors or life-guards 38], 41]. These cultural expectations were embedded in their religious beliefs of segregated
environment for both genders (as also observed during Muslim prayers). The gender
identity of South Asian women was pronounced as dictated by cultural norms and family
obligations. Emphasis was placed upon South Asian women to stay indoors, attending
to domestic chores, and prioritise family responsibilities over their independence
and freedom 37]–39], 41]. In this way, to the community groups, modesty as expected by religious beliefs was
preserved by both genders in Muslim or South Asian communities. Whilst culturally-sensitive
facilities exist, there was a, lack of awareness among BME groups of their existence
30], 41].

The time constraints produced by competing cultural priorities limited participation
of some BME individuals (both South Asian and African origin) in physical activity
30], 38], 40], 41]. This tended to affect South Asian women more than their male counterparts because
of heavier cultural responsibilities or expectations after marriage 38]. Some BME individuals were unable to understand information or share information
about their needs due to language barriers 34], 36], 39], 41]. This problem was more pronounced among some older South Asian groups and first generation
migrants. Therefore, there were limitations to healthy lifestyle choices (including
physical activity) or decisions that could be made by BME individuals.

Personal barriers

Time constraints due to social and work commitments limited participation in physical
activity among some BME individuals 30], 34], 35], 37]–41] (Additional file 3: Table S3). Greater emphasis was placed on work commitments (e.g. long working hours)
over physical activity for financial stability in the UK especially following migration
30]–41]. For female South-Asian participants, there was pride and priority of family commitment
(childcare and household management) over physical activity. Our interpretation suggests
low priority in having control over personal health and social freedom in these groups.

The influence of health problems on South Asian groups’ participation in physical
activity was reinforced by their health beliefs which focused on the harmful effects
of physical activity rather than its benefits 33], 37], 38], 40]. For example, the belief that excessive sweating and increased heart rate associated
with physical activity was perceived as illness rather than normal by-products of
exercise 38]. Therefore, the fear of provoking physical symptoms rather than reported ill-health
was a pronounced barrier among some BME individuals in engaging in physical activity.

Within the studies, lack of confidence and motivation was common to all BME groups
as personal barriers to physical activity 30], 33], 35], 40]. There was no perceived enjoyment or motivation to participate in physical activity
because it was perceived as a formal and separate activity from BME everyday lifestyles.
The BME individuals exhibited lack of confidence which was compounded by communication
barriers, an alien environment and the lack of social networks for carrying out physical
activity 38], 41], 42]. First generation migrants in particular lacked confidence and faced challenges due
to limited social networks, or lack experience of new services or skills needed for
physical activity that were not familiar to them. As such, initiating the use of neighbourhood
services was perceived as being difficult by BME individuals.

Factors limiting access to facilities

Various external factors were identified that limited participation by some BME individuals
in physical activity in the UK. These included: climate 30], 38], 39], 41], 44], distance to sports facilities 30], 33], 37], 40], 41], lack of information 34], 35], 37], 40], 41], cost 34], 39]–41], lack of childcare facilities 30], 34], 39], 40], and accessing facilities in unfamiliar neighbourhoods 30], 38], 42] (Additional file 4: Table S4). Many of these factors were inter-dependent. For example, access to distant
facilities was constrained by lack of transport, time constraints and the unfamiliar
environment. Individuals also reported that lack of familiarity about their physical
environments exacerbated the feeling of being unsafe and vulnerability among some
female respondents from South Asian and African groups; thus increasing the difficulty
of seeking out information about physical activity. Most of these factors or barriers
under the category of ‘factors limiting access to facilities’ were not specific to
BME individuals. Although the cost of exercise may be more problematic for some BME
individuals (compared to majority population), expenditure on exercise by some BME
individuals was considered wasteful and of low priority 38]. This may be a reflection of socio-economic issue as people from most minority ethnic
groups are generally more deprived in terms of socio-economic status 46]. This behaviour among some BME members might also have been shaped by their experience
of some BME individuals using facilities free-of-charge in their country of origin,
and then contributing to the perception of physical activity being expensive in the
UK.

‘Line of argument’ synthesis

The synthesis provided in this section attempts to construct the interpretation of
over-arching concepts identified from the 14 included studies. The emergent concepts
provide insight into future potential interventions. The overarching concepts derived
in this synthesis indicated that the barriers which influence physical activity behaviour
among BME groups exist at individual, physical environment and organisational levels.
This relates to the socio-ecological framework that proposes many of the determinants
of health are understood as influences within and on individuals by social groups,
environments and larger society of which the individual is a part 35]. Table 4 presents the summary of information on the ‘line of argument’ synthesis.

Table 4. Line of argument synthesis

Individual level barriers

Clusters of studies reported that barriers to physical activity occur at an individual
level and are influenced by BME groups’ socio-cultural backgrounds and interpersonal
relationships 34], 36]–42]. Following migration into the UK, ‘self identity’ played a role in the attitude of
an individual towards physical activity. The attitudes of some BME individuals towards
physical activity were shaped by the collective cultural beliefs and perceptions which
individuals held before migration to the UK 39]–41]. However, this influence from socio-cultural background on individuals would be expected
by researchers to attenuate over a period of time 38]. This synthesis suggests that the degree of socio-cultural barriers to physical activity
exhibited by first generation BME individuals was more pronounced than later generations.
With regard to the influence of socio-cultural background, as a result of poor interpersonal
relationships experienced by BME individuals in the UK and difficulties in communication
with health professionals, BME individuals may be disempowered in participation of
physical activity.

As BME individuals settle into UK communities, their interpersonal relationships may
influence participation in physical activity. Six studies indicated how interpersonal
relationships were affected by language barriers, lack of confidence and poor social
network 34], 36], 37], 39], 41], 42]. Among some BME individuals, there was a problem with self-identity as well as communicating
individual needs in terms of health information and physical activity facilities.
However, the concepts of physical activity among BME individuals played a major role.
The varied concepts of physical activity BME individuals were shaped by cultural factors,
socio-economic background, knowledge and past experience. In view of these differences,
a conceptual model (Fig. 3) was constructed that demonstrates the influence of conceptual understanding of physical
activity among individuals, not merely ‘practical’ understanding of physical activity
barriers. This is a key finding of this study which described the construct when incorporated
into socio-ecological model may be relevant to developing theory or interventions
related to physical activity behaviour among BME individuals.

Fig. 3. Influences on Physical Activity among BME groups, A Conceptual Model. The model describes
influences at individual, community and organisational levels on behaviour towards
physical activity among BME groups. The inclusion of social concept ‘conception of
understanding of physical activity’ into socio-ecological model and its influence
on individual behaviour

Community level barriers

Many barriers to physical activity existed at a community level and were clustered
as either ‘unfamiliar environment’ versus ‘familiar environments’ or as ‘barriers
similar to general population versus barriers specific to BME groups’.

In all the included studies, BME groups focused on the attendance at facilities e.g.
gymnasiums, leisure centres, to engage in physical activity. There was little focus
on participation in physical activity in familiar environments in which BME groups
were likely to carry out their daily activities, for example, school, work and their
neighbourhood. The synthesis suggests that facilities which are outside familiar environments
of BME individuals reinforced the barriers which limit access to facilities. The synthesis
reinforced how BME groups have different perceptions of interventions in the environment
by focusing on carrying out physical activity at mainly recreational centres such
as gymnasiums. This reflects the misperception of physical activity by many individuals
from BME groups as a formal and separated activity rather than recognition of certain
lifestyle activities in their culture. More so, this may translate to a lack of awareness
of interventions at these familiar places such as school, religious centres and workplace.
Some barriers were specific to only BME groups whilst others are similar to those
experienced by the general population 30], 34], 36]–38], 40]. For example, distance, finance, bad weather, and time constraints due to competing
responsibilities were also experienced by the general population. The predominance
of activities related to religious or cultural practices were found among South Asian
populations. In this study, these were barriers at community level that were specific
to a BME group and might not necessarily be found in other BME groups.

Organisational level barriers

Clustered within seven studies were descriptions of limitations of strategies used
by organisations to promote physical activity among BME groups 30], 34], 35], 38]–41]. The authors of these studies perceived that BME individuals were disadvantaged by
problems in organisational structures including inadequate advertising of existing
services and failure to tackle institutional racism. The failure to also embark on
research to help engage BME groups in physical activity existed at organisational
level. In relation to poor marketing of existing services, although there were existing
services, the use of inappropriate channels of communication or poor partnership with
organisations among BME communities influenced the awareness of BME groups of initiatives
that facilitated physical activity 35], 40].

With regard to institutional racism, the non-inclusiveness of services prevented participation
of BME groups in physical activity 39], 41]. Many service providers did not recognise that they might need to offer different
services or use different settings to promote physical activity (e.g. in the community,
workplace or religious settings). The absence of services such as single-sex facilities
and the reluctance of organisations or policy-makers to provide specific information
to help BME groups contributed to institutionalised racism. In another dimension of
barriers at organisational level, BME members and health promoters had not benefited
from research to guide decision making on cultural lifestyles. Health promoters and
professionals might have been inadequately informed on how to address barriers to
physical activity among BME groups. Overall, BME individuals had no immediate control
over the barriers experienced at organisational level.