Health Promotion International Advance Access published January 5, 2015 Health Promotion International doi:10.1093/heapro/dau105

© The Author 2015. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]

Adapting health promotion interventions for ethnic minority groups: a qualitative study JING JING LIU1*, EMMA DAVIDSON1, RAJ BHOPAL1, MARTIN WHITE2, MARK JOHNSON3, GINA NETTO4 and AZIZ SHEIKH1 1

SUMMARY Adaptation of health interventions has garnered international support across academic disciplines and among various health organizations. Through semi-structured interviews, we sought to explore and understand the perspectives of 26 health researchers and promoters located in the USA, UK, Australia, New Zealand and Norway, working with ethnic minority populations, specifically African-, South Asian- and Chineseorigin populations in the areas of smoking cessation, increasing physical activity and healthy eating, to better understand how adaptation works in practice. We drew on the concepts of intersectionality, representation and context from feminist, sociology and human geography literature, respectively, to help us understand how adaptations for ethnic groups

approach the variable of ethnicity. Findings include (i) the intersections of ethnicity and demographic variables such as age and gender highlight the different ways in which people interact, interpret and participate in adapted interventions; (ii) the representational elements of ethnicity such as ancestry or religion are more complexly lived than they are defined in adapted interventions and (iii) the contextual experiences surrounding ethnicity considerations shape the receptivity, durability and continuity of adapted interventions. In conclusion, leveraging the experience and expertise of health researchers and promoters in light of three social science concepts has deepened our understanding of how adaptation works in principle and in practice for ethnic minority populations.

Key words: ethnicity; health; adaptation; intervention

INTRODUCTION Growing evidence documenting considerable and persistent health inequalities with respect to ethnicity has led to increasing sensitivities to the delivery of health interventions. Members of certain ethnic groups in economically developed countries where they make up the minority, experience substantially higher rates of obesity, diabetes and cardiovascular disease (CVD) in comparison to

White European-origin populations (Sproston and Mindell, 2004; Bhopal, 2009). Improving access to and participation in health promotion interventions has the potential to reduce the burden of long-term conditions and reduce ethnic health inequalities (Department of Health, 2010; Scottish Government, 2010). Culturally adapting interventions is one strategy that has garnered increasing support across a number of health disciplines (Castro et al., 2010). Adaptation can help ensure Page 1 of 11

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Edinburgh Migration, Ethnicity and Health Research Group, Centre for Population Health Sciences, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK, 2Institute of Health and Society and Fuse, UKCRC Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK, 3Faculty of Health and Life Sciences, De Montfort University, Leicester, UK and 4Institute of Social Policy, Housing, Environment and Real Estate (I-SPHERE), Heriot Watt University, Edinburgh EH10 5AN, UK *Corresponding author. E-mail: [email protected]

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LITERATURE REVIEW We begin by outlining what we mean by adapting interventions and how we come to understand how they will benefit the health promotion efforts with ethnic minority populations. We include only a short discussion on ethnicity and culture, emphasizing salient elements of particular import

to our study, as much has already been written on these respective topics (see Bhopal, 2006; Lee, 2009; Bradby, 2012). Building on our definition of ethnicity, we employ three key concepts, intersectionality, representation and context, to underscore how health promoters and practitioners come to understand the lived experience of ethnicity, and how adaptations work or do not work in light of these experiences. These three concepts were selected as we felt that drawing on the theoretical novelty and strength of concepts originating from disciplines outside of health promotion could enrich and enliven the conversations within health promotion around an often taken-for-granted category such as ethnicity. Culturally adapted interventions Cultural adaptation has been defined as ‘a planned, organized, iterative and collaborative process that often includes the participation of persons from the targeted population for whom the adaption is being developed’ (Castro et al., 2010). Seminal work by Resnicow et al. (Resnicow et al., 1999) delineating surface and deep structures has shaped the last decade or so of empirical studies as well as models and theories crafted to guide cultural adaptation. Surface structures are described as the ‘observable, “superficial” characteristics of [a] target population’ (Resnicow et al., 1999), while deep structures are the cultural, social, historical, environmental and psychological forces that influence behavior. Both have different functions and benefits: addressing surface structures increases ‘receptivity’ and ‘acceptance’, and is achieved by delivering messages and programs through appropriate channels—using people, places, language, music, food brands and clothing preferred or familiar to the target population (Resnicow et al., 1999). On the other hand, addressing deep structures increases ‘salience’ and efficacy, and requires pretesting and direct questions on perceived differences between the target group and mainstream group (Resnicow et al., 1999). Ethnicity and culture A brief pause on what we mean by ‘culture’ and ‘ethnicity’ is warranted. Ethnicity can be regarded as part of a person’s ‘cultural mosaic’, alongside demographic variables such as age and gender (Chao and Moon, 2005 in Castro et al., 2010). Equally valid is a treatment of culture as subsumed

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health initiatives sufficiently reach and are relevant to address the needs and preferences of ethnic minority groups to improve health outcomes and redress inequities (Nielsen and Krasnik, 2010). This study builds on a comprehensive review of adaptation literature, which in part involved systematically identifying and critically appraising interventions for smoking cessation, physical activity and healthy eating that have been adapted for African-, South Asian- and Chinese-origin populations (Liu et al., 2012). To complement this rigorous body of work, we sought to explore and understand the perspectives of health researchers and promoters working on health promotion interventions to reduce smoking, increase physical activity and healthy eating in African-, South Asian- and Chinese-origin populations around the world, as these populations account for the majority of the diversity documented in many economically developed countries. It should be noted that in some of these countries, the indigenous groups might also face similar health disparities; they were, however, not the focus of our present study. We chose to speak directly with researchers and health promoters as we felt firsthand accounts would best bring into focus the complexity of the constituent parts encompassed by the term ‘ethnicity’ in the course of adaptation work (Bradby, 2012). However, despite interest in studying adapted interventions, there has been little consideration of the experiences of health researchers and promoters who are conceptualizing, implementing and evaluating these adapted interventions, although there are studies that have focused on the health researcher or practitioner perspective in other contexts (Kendall et al., 2007; Nair et al., 2008; Laberge et al., 2009; Rankin et al., 2009). We identified one study that conducted interviews and reviewed case studies to probe the processes undertaken by community-based organizations to culturally adapt their tobacco cessation materials and programs (Lettlow, 2008); however, limited information on the undertaking was provided.

Adapting health promotion interventions for ethnic minority groups

Intersectionality Feminist theories have contributed to the concept of intersectionality, a non-reductionist approach to examining the impact of various biological, social and cultural categories simultaneously and on multiple levels (McCall, 2005), rather than ‘one category at a time’ (Phoenix and Pattynama, 2006). While we acknowledge the centrality of factors such as gender, ‘race’, class, sexual orientation and other axes of identity on ethnicity, in the health research setting, we tend to treat them as additional to ethnicity (Bredstrom, 2006), rather than having a cumulative impact or synergistic effect and, moreover, on how identity is lived and expressed. For example, this tendency is quickly evident in the kinds of information solicited by hospital intake forms or queried by healthcare service satisfaction questionnaires. While we also recognize that gender, age, ethnicity and religion have associated inequalities, we infrequently note newly generated or enduring inequalities at the intersections of these factors in adapted interventions. An intersectional perspective in this study highlights both the mutually constitutive positive and negative effects these factors have on the social identities of members of ethnic minority populations, and their health practices and outcomes (Bowleg, 2012). Furthermore, a focus on how multiple factors intersect can simultaneously highlight that not all positionings are equal in their contribution to producing inequality (Ludvig, 2006), for example, in our study, noting the differing impact of age on ethnic women. As theorists in this field contend, studying simultaneous intersections allow more complex and dynamic understanding to unfold than a focused

examination of one category, for example, ethnicity alone (Brah and Phoenix, 2004). Representation Sociologists understand representation as ‘the form an object takes and the meanings encoded in that form, [such that] meaning isn’t inherent in the object itself but is socially constructed’ (Curtain and Gaither, 2007). This understanding further specifies a producer and a target, meaning that ‘representing’ is often a purposeful undertaking, such that ‘the content, the format, and even the method of distribution communicate an intended meaning’ (Curtain and Gaither, 2007). In this study, the concept of representation is used to show how in adaptation work, ‘ethnicity’ and its component parts (for example, culture, religion, language, ancestry and physical features) may be too narrowly conceived to capture real-life experiences. Or, put another way, their symbolic meaning may eclipse the more variable material, or lived, meaning (Hall, 1997). More nuanced understandings can take into account how and when religious practices are observed or include country of birth or citizenship as proxies for ancestry, or consider what language(s) are spoken at home and elsewhere and with what level of proficiency (Australian Bureau Statistics, 2006). With this knowledge in mind, we can come to appreciate that ethnicity as representation works in, or rather, works for health interventions precisely, because it presents concrete opportunities to act, alter and affect its component parts. However, the categories that make up ethnicity are not durable facts and we must also recognize that when we act upon ethnicity in adapted interventions we are acting on representations (or how we come to know what ‘ethnicity’ is) rather than ethnicity itself. Ethnicity then can be thought of as a moment of production in the context of interventions, not always ‘consumed’ as intended (Hall, 1997). Context Human geographers have alerted us to the influence of space and place in our lived experiences. The term ‘ethnicity’ should ideally be used with reference to the context in which adapted interventions take place. Context here refers to the experience of space and place through time. In particular, we are referring to relative space, which includes perceptions of distance and proximity, feelings toward demarcations and boundaries, and

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within the definition of ‘ethnicity’, alongside religion, language, ancestry and physical features (Davidson et al., 2010). Both definitions are commonplace, and for the most part, they depend on academic discipline or health organization, and their respective epistemological orientations. We tend to opt for the latter orientation, encouraged by the literature in support of a more flexible definition of ethnicity that is multidimensional (Ford and Harawa, 2010). Furthermore, we have opted to use the term ‘culturally adapted’ to describe these modes of accommodation while recognizing that interventions may also be described as culturally ‘sensitive’, ‘tailored’ and ‘targeted’ to capture such changes, and that each term may carry different meanings.

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METHODS Ethics approval Ethical approval was obtained from The University of Edinburgh’s School of Health in Social Science Research Ethics Committee. Written consent was obtained from all participants.

Sampling From the systematic review we conducted (Davidson et al., submitted for publication), studies published after 2005 were used to create a sampling frame to recruit researchers for interviews. We employed purposive, maximum diversity sampling aiming for 20–30 participants by devising a three-by-three recruitment approach (see Liu et al., 2012) to ensure we included participants with different roles, working with the three populations and three intervention types of interest. We anticipated that these numbers of interviews would allow us to achieve saturation on the issues at the heart of our inquiry. We sampled researchers designing and evaluating adapted interventions for smoking cessation, physical activity and healthy eating for African-, Chinese- and South Asian-origin groups. We were, in addition,

also interested in hearing the perspectives of individuals involved in delivering the intervention, such as counselors and health educators/promoters. We also approached the interviews with the explicit aim of capturing a range of opinions and perspectives. Participant selection and recruitment We initiated four interview recruitment waves. Each wave satisfied a different sampling goal, namely piloting, generating interest, maximizing diversity and ensuring representativeness. We continued to interview until we reached saturation (Bauer and Aarts, 2000), that is, as we iteratively coded interview transcripts, no new codes were generated with the last few interviews. Data generation Semi-structured interviews with participants were conducted either by telephone or by face to face. These interviews provided an opportunity to build rapport, elicit detailed accounts and explore new topics as they arose while keeping focused on the topic of interest. The interviews were structured around a topic guide, which was first piloted and refined through expert consultation. Interviews were conducted in English by either J.J.L. or E.M.D., or jointly by both researchers and were digitally recorded and transcribed. All transcripts were subsequently checked for accuracy and completeness by one of the two researchers (J.J.L. or E.M.D.). All participants completed a demographics questionnaire. Data analysis Analysis was comparative and iterative to synthesize the body of data (Noblit and Hare, 1988; Pope et al., 2000). A coding frame was developed drawing on initial read-throughs of the interview transcripts, and themes were identified from the theoretical literature (Airhihenbuwa, 1994; Ashley, 1999; Davis et al., 1999; Resnicow et al., 1999; Hugo, 2000; Burnet et al., 2002; Fitzgibbon and Sánchez-Johnsen, 2004; Appel et al., 2005; Davis et al., 2005), along with a list of 46 unique adaptations (Liu et al., 2012). This list was compiled through a synthesis of adaptations undertaken in a systematic review of 107 adapted interventions—one component of our multi-method study (Liu et al., 2012). The coding frame was independently piloted by two coders (J.J.L. and E.M.D.);

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attitudes on interactions and relations (Gupta and Ferguson, 1992). Space, then become invested with ‘richly symbolic, aesthetic, moral and importantly, identity-relevant meanings’ (Durrheim and Dixon, 2005). A related concept, place, refers to the local, cultural and personal experiences formed through interactions with and within sites, over time (Yuan, 2001). Why a context-oriented perspective matters is that often, in adapted interventions, the context is treated as secondary, for example, acknowledging neighborhood effects on food availability (Campbell et al., 1999) and location-based opportunities for physical activity (Yancey et al., 1999). We should also bear in mind that spaces and places can facilitate certain social practices while disallowing others (Lefebvre, 1991); it can enable or constrain interactions (Durrheim and Dixon, 2005) depending on occupants’ relationships with that space. We should therefore think of the context not just as a neutral backdrop. Similarly, we should also be wary of purporting an ‘unproblematic link between identity and place in conversations and accounts of ethnicity’ (Gupta and Ferguson, 1992).

Adapting health promotion interventions for ethnic minority groups

RESULTS We approached 37 participants and 26 agreed to be interviewed; one of the interview session included two participants. Interviews were conducted between 2009 and 2010. The majority of declines were implicit, as the participant did not respond to our e-mail request. Those who responded cited time constraints as the reason why they were unable to participate; some of them referred us to their colleagues. Our maximum diversity sampling captured a wide range of participants of varying ages, occupations and working with different populations around the world. The majority of participants were between 46 and 55 years of age (36%). Participants were located in the USA (n = 14), UK (n = 7), Australia (n = 2), New Zealand (n = 2) and Norway (n = 1). The participants’ occupation ranged from community outreach workers and consultants (n = 5) to research associates (n = 4), while the majority were university professors (n = 17). It should be noted that a participant’s self-identified ethnicity was not always matched to the ethnicity of the target group with whom the researcher had previous working experiences, although this was true for the majority of the interview participants. Across the interviews, an eclectic mix of approaches, various settings and multiple activities

and actors were reportedly used in interventions. Similarly, a diverse group of participants were included, with a mix of generations, genders and ethnicities reported. Groups ranged from 10 participants in small pilot studies to thousands of participants in a citywide survey. There was no obvious model intervention for adaptation considerations. We present here three main themes that bring into focus the complexity of adapting health promotion interventions for ethnic minority groups: the intersections of population demographics with ethnicity, the representational elements of ethnicity and the contextual experiences of ethnicity.

FINDINGS AND DISCUSSION The intersections of population demographics with ethnicity In adapted interventions, researchers spoke of the effect of population demographics, such as age and gender, on ethnicity. These intersections were found to significantly influence the way that ethnicity became relevant in the intervention. For example, ethnicity-associated preferences for intervention facilitators were found to interact with genderand age-associated preferences. Sensitivity to existing health problems related to age was seen to potentially affect participation in an intervention for a group of African American women in midlife: It was just as important to these [Black] women in [midlife], in the focus groups when we started, they said now don’t bring in here as our fitness expert a 20-year-old that weighs 110lbs and is perky right. They don’t understand what we’re going through with our back problems, our knee problems. (P23, physical activity and nutrition, USA)

For a group of South Asian participants in the UK, ability to participate and partake in physical activity revealed an ethnicity-contingent gendering of seemingly neutral technological aids to exercise, in concordance with varying levels of adherence to traditional dress: Women couldn’t get them on their saris, the saris not the best thing for a pedometer so they were trying their knickers and, and things like that. The men of course had no trouble on their belts. (P6, healthy eating and physical activity, UK)

Another example of interaction between ethnicity and gender was reported in a smoking cessation

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disagreements were resolved by discussion, or where necessary, a third coder (A.S.). The two authors independently coded all transcripts using the NVivo 8 qualitative data analysis software (QSR International Pty Ltd, Doncaster, Australia). Multiple independent coding allowed for discussion of new and emerging insights and, importantly, the transparent documentation of how analysis developed (Barbour, 2001). Thematic analysis (Attride-Stirling, 2001) was used to analyze text: inductive and deductive codes were applied to the text and then grouped according to conceptual clusters. These clusters formed basic themes, which were further grouped into organizing themes. These themes were further abstracted into three global themes. This systematic method of building up the themes was grounded in the text-linked codes and helped to identify consensus or conflict across themes, as well as the absence of expected themes (de-Graft Aikins, 2004), to explore how researchers talked about ethnicity in their adaptation work.

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intervention, such that, for Chinese participants, gender seemingly dictated the level of social support quitters thought they could expect: The Chinese population prefer, the men, the men like to become smoke free and then celebrate it back with their family so they won’t lose face if they relapse. (P7, smoking, New Zealand)

So it took me about two years to get permission to open up the swimming pool for these women at on the weekly basis, for few hours, which was just women only, and I had to go through many, many steps. (P9, physical and nutrition, Australia)

These activities, for example, were perceived as time-consuming, but also absolutely necessary to work with ethnic minority populations. Furthermore, these lived experiences call into question the distinction between ‘surface’ and ‘deep’ structures outlined by Resnicow et al. (Resnicow et al., 1999). While age and gender may be considered ‘observable’ and therefore ‘surface’ level, the intersection of age, ethnicity and gender may speak to ‘deep’ socio-cultural influencers that affects the circumstances in which older African American women, for example, feel comfortable in health-promoting activities. Furthermore, the intersection of the same variables of age, gender and ethnicity reflects potential social and historical barriers to physical participation for South Asian women and emotional support for Chinese men. The representational elements of ethnicity The features identified as targets of adaptation in the interventions encompassed dimensions of ethnicity most immediately familiar to us; these included such elements as ‘culture’, food, language, religion/spirituality and ancestry. In practice, researchers discovered that these constitutive

They view within their home that healthy food isn’t acceptable, either to themselves or their family, or visitors, they come over and say oh those were horrible cause we know we recommend for instance bake your samosas and the women are like oh wait a minute, I would be considered a horrible hostess. (P8, nutrition, UK)

Interventions for some African American groups and South Asian groups often engage religious institutions and leaders, as spirituality and religion were thought to enhance the intervention through increased uptake and salience. Despite common assumptions about their compatibility, this approach was met with mixed reception: some advocated for integration of spiritual and health elements, and others called for secular health-promoting activities. For example, in the case of a smoking cessation intervention for a Bangladeshi community in the UK: So they, people will put it off until the first Ramadan to set a quit date, then those will be, then Ramadan is such a busy month, everybody’s focused on the spiritual aspect of fasting, and family life. And then you’ve got Eid and then people will say well we’ll do it after Ramadan, give me the patches. (P6, smoking, UK)

Furthermore, while shared ethnic background may be seen to bind communities together, it can also act as a source of tension as ancestral ties can limit participation in an intervention for fear of making public private health practices and behaviors. This speaks to the potentially negative impact of an assumed ‘community’, one that was identified as an important intervention design concern for a group of Bangladeshi women attempting to quit smoking: We can’t do it in groups, again for confidentiality issues because if a community is quite close knit, you have to make sure that they don’t, you know, they’re not in a group where somebody knows them from Bangladesh, back home, so there’s a lot of village ties, so they don’t really want, somebody older wouldn’t want somebody younger than them knowing about their personal issues and why they smoke. (P6, smoking, UK)

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As we can see, the intersections of ethnicity with what are traditionally perceived as ‘population demographics’, for example, age and gender, can alter the way people interact, interpret and participate in adapted interventions. A view to the intersections between these variables rather than as add-ons to a defined ‘ethnic group’ can help to capture the lived experiences in groups of individuals who are distinct in their own right. Researchers therefore emphasized their commitment to these lived experiences by demonstrating their in-depth knowledge of the pertinent issues through the active development of long-term relationships:

elements or representations of ethnicity were further complicated by additional nuances. For example, a dietary intervention for a group of South Asian women did not anticipate that distinctions would be made between daily food and hospitality food, the latter seemingly refractory to intervention:

Adapting health promotion interventions for ethnic minority groups

[take] lay people and [up skill] them rather than taking people and trying to skill them in the community. (P7, smoking, New Zealand)

To achieve this end, researchers across interviews attempted to ‘match’ staff to participants in terms of their ethnicity, gender, language, etc. This assumes that the representational elements of ethnicity are consumed in non-precise ways, which are often unpredictable. Employing members of the target population can achieve resonance with these conceptual categories through proximity to the lived experience. This study shows that ethnicity, as theorized, tends to fall short of said lived experience, because representations of ethnicity are already removed, in a matter of speaking, from the experiences of living as an ‘ethnic’ person. Researchers therefore prioritize the consumed aspect of ethnicity in practice, for example, the double-edged implications of a close-knit community, which may be disconnected, partially or entirely from how ethnicity is symbolically defined in intervention research proposals. The contextual experiences of ethnicity While features such as culture norms, spiritual/ religious orientation and shared ancestral ties are folded into the fabric of interventions to increase their salience for ethnic minority groups, the experience of ethnicity in context was also reported to moderate the effects of the intervention. ‘Context’ here refers to those accumulated experiences that operate in the background, often outside of the intervention itself, and brought into the foreground in the presence of an active

intervention. Researchers discussed the influence of past experience with health care or research, embodied social roles and responsibilities, and sociospatial settings of interventions as critical and often unexpected drivers and barriers for behavioral change in ethnic minority populations. Particularly in underserved populations, past experiences with health care or research were thought to affect the way participants perceived the present intervention and influenced their level of interest and involvement. We can consider this impact using examples of two extreme cases reported by researchers: the systematic exclusion of certain populations from public health efforts, for example, to reduce smoking behaviors, and the over-reliance of certain members of ethnic minority groups, leading to research fatigue. In the context of adaptation, seemingly a balance is needed to ensure acceptable participation. In the first case, in New Zealand, information on smokefree environments was in the main advertised through mainstream media and was thus perceived to exclude a group of Chinese-origin people from accessing the same health information: Back in 2003 New Zealand brought in the smokefree environments legislation. What we found is that a lot of the communities that weren’t accessing mainstream media weren’t getting those messages across about to take the smoke outside and about the fact that it was now, you know legislated against smoking in public places, bars, restaurants and things like that, so there was a whole section of the New Zealand population that kind of missed that message. (P7, smoking, New Zealand)

On the other hand, there was concern about the possibility of ‘intervention fatigue’ for key gatekeepers and community figures who were regularly tapped to act as representatives or participants. For example, a researcher working with the African American community on healthy eating recognized this danger: There’s a danger of intervention fatigue and particularly where you keep turning to the same natural helpers over and over again. So we find that a lot of times people keep nominating the same people, you know and they are the doers and they’re very well connected but they can get overwhelmed by how many interventions they’re supposed to be helping with and how much they’re supposed to do and how much time they and especially if they’re being asked to be volunteers. (P22, healthy eating, USA)

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The above accounts challenge and complicate how we come to understand the so-called familiar representational elements of ethnicity, in particular, how we apply them in interventions and how we expect them to function. Namely, additional complexity is associated with mobilizing changes to food practices in the name of health, increasing salience through linkages with religious or spiritual elements, or capitalizing on a collective orientation among those with a shared ethnic identity. These examples showcase how conceptual understandings of ethnicity components are frustrated by their actual experiences within populations in practice. Therefore, in practice, intervention personnel, including principal investigators, tend to originate from the target population, as it was felt to be more appropriate to:

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Among some ethnic minority populations, emphasizing one’s roles and responsibilities to family and community was seen as a pivotal motivator in nutrition and physical activity interventions. We consider these roles to be socially embodied such that they reside with or are attributed to the entire ethnic group, rather than being particular to any one individual. For example, in an intervention for a group of African American women, the intention was to appeal to this embodied social character to purposefully mobilize its associated sentiment as a motivational strategy:

Researchers’ also noted the effects of the sociospatial settings in which interventions are delivered. The visibility of an intervention in a close-knit community can heighten awareness of the intervention objectives in that space. For example, the density of Bangladeshi participants in a socio-spatially demarcated community area in the UK not only solidified intervention presence and continuity, but also created cessation cues that informally reinforced learning outside of the formalized portions of the intervention. One interesting things like elderly people give up the smoking yeah and after six month they start again and he, he just saw me that passed the road and his hand is smoking, he’s just hiding smoking like he’s, he’s seventy year old man but when he saw me, just then say oh I’m sorry, sorry Bhateja we call Bengali like, you know, like a son, we say Bhateja, sorry Bhateja, then we said don’t worry Uncle, if you want please come back. (P4, smoking, UK)

Furthermore, the visibility of activity in the shared physical space inhabited by members of the targeted ethnic minority group can influence other non-participants, with potentially positive knockon effects. For example, in the case of a walking intervention, a circuit was set up in public view: The higher risk group persons, at least some of them, very successful in change their behavior, started to walk in the district every, every evening, every afternoon or evening, attend the classes

A contextual orientation to ethnicity recognizes the potentially linked experiences of ethnicity with space/place, and that these accumulated experiences surround and infiltrate each and every intervention, shaping its receptivity, durability and continuity. Strengths and limitations This qualitative component was developed alongside an extensive and rigorous systematic review (Davidson et al., submitted for publication). Leveraging the studies included in the review provided us with access to information that was either not yet published, or in some cases to information that may never be published. It was particularly important to learn about the processes associated with adapting interventions, as there are few papers in the published literature. This access provided unique insights far beyond what a reader (ourselves included) could glean from only accessing peer-reviewed journal articles on the same study and was a major strength of this study. Another strength was the opportunity to speak to those positioned to provide practical insights on adapting health promotion interventions for ethnic minority groups. Studying academic researchers and health promoters, however, raises its own ethical issues, which have been carefully examined by Wiles et al. (Wiles et al., 2006). Some of these issues include ownership and publishing of the data discussed, challenges of accessing ‘private rather than public accounts of research practice’ (Wiles et al., 2006; Nair et al., 2008) and wrestling with how to approach information obtained outside of the interview context, for example, through knowledge of their work and informal discussions (Wiles et al., 2006). Furthermore, there was a risk of introducing bias given that our sample was skewed towardsm researchers. However, we found that the researchers were both critical and reflexive of their own work, and welcomed the opportunity to reflect and discuss. Another issue that arises with speaking only to researchers and health educators about adapting health promotion interventions is the absence of the intervention participant voice and thus represents a potential limitation of this work. We therefore tried to exercise caution when

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As these are women, we always hook it into if you don’t change your behavior you’re going to see in your grandchildren the statistics of women dying prematurely from preventable deaths. So we really try to do both, I mean we, we focus on expanding their sense of responsibility to themselves in terms of health but we always link it to how, if they change, it can help in terms of their community, in terms of their family and, and the rest of their community. (P23, nutrition, USA)

walking classes which walked in the district and, and some of them lose weight so that anyone could, anybody could see that. They became very important role models for the others. (P19, physical activity, Norway)

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interpreting researchers’ views on ethnic groups, particularly when presenting the target community’s acceptance and satisfaction with the intervention, as these opinions were filtered through the lens of their own values and thinking. Overall, researchers were willing to share some of their shortcomings, as well as successes, with the explicit goal of advancing the field. CONCLUSIONS

accumulated contextual experiences shape the receptivity, durability, and continuity of interventions. Interventions that respect past positive or negative experiences, communicate shared community sentiments or capitalize on the possible synergistic effects of distinct socio-spatial settings, can improve the appropriateness and effectiveness of adapted interventions. These qualitative findings thus present three additional ways we can think about how ethnicity in adapted interventions work and contribute to the conversation around framework building and modeling of adapted interventions. Since Resnicow, other models and frameworks for adaptations have been developed and reviewed (Castro et al., 2010), and observed to share some core commonalities (Zayas et al., 2009; Castro et al., 2010; Card et al., 2011; Rodriquez et al., 2011). These usually involve sequential steps such as assess the risk factors specific to the population, select the best evidencebased intervention and determine whether and which components need to be adapted, pilot the adapted intervention through preparation of relevant materials and training of staff, implement intervention and monitor, and evaluate for adaptation fidelity and intervention outcome. The concepts of intersectionality, representation and context can help understand how ethnicity functions at each stage and perhaps shed light on why it works and in what ways. For example, intersectionality can help determine risk (e.g. cluster risk as an amalgam of factors—age, gender and ethnicity), while the representational understanding of ethnicity can help decide staffing issues (e.g. speak to how constitutive elements of ethnicity are experienced), while contextual notions of ethnicity can help with evaluation (e.g. consider the impact of intervention setting and relationships people have with space and place). Our qualitative study, undertaken alongside a systematic review of adapted interventions, was indispensable in teasing out the processes and thinking around ethnicity that underpin adapted interventions for ethnic minority populations. Mapping these concepts, processes and relationships has both practical applicability and analytical value both for intervention delivery and analysis.

REFERENCES Airhihenbuwa, C. O. (1994) Health promotion and the discourse on culture: implications for empowerment. Health Education Quarterly, 21, 345–353.

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Many of the findings on adaptation complement what is already known about working with ethnic minority populations, for example, the importance of community engagement and building trusting relationships (Rooney et al., 2011), matching personnel and using preferred methods to deliver messages and materials (Hugo, 2000), and building linkages with existing organizations (Yancey et al., 1999). Furthermore, much of the reported thinking around ethnicity in this study echoes understandings evident in the literature, recognizing that it is a concept that is moving away from describing at times what appears to be entrenched and immutable characteristics attributed to persons or groups, to more dynamic thinking, while also capturing, more or less, the common sense usages prevalent in healthcare and health research. Across these interviews, we have been sensitized to the different ways of knowing and working with ethnicity within adapted interventions from a researcher’s perspective. We have chosen to highlight three areas in this article. First, locating the intersectionality of ethnicity and other factors, such as age and gender, can significantly alter the way people interact, interpret and participate in adapted interventions. It calls to attention that unique intersections should be recognized as potential subgroups within interventions for ethnic minority groups. Second, looking at the constitutive elements of ethnicity as representations highlight some of the tensions that exist in common assumptions underpinning adaptation work for ethnic minority populations. Bringing about behavior change by tapping into cultural norms, religion or spirituality, or shared ancestry, for example, can often be met with additional complexity as these elements represent conceptual, rather than experiential understanding. Finally, the context of space and place surround the experience of ethnicity such that these

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Adapting health promotion interventions for ethnic minority groups: a qualitative study.

Adaptation of health interventions has garnered international support across academic disciplines and among various health organizations. Through semi...
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