Physical activity among South Asian women: a systematic, mixed-methods review
© Babakus and Thompson.; licensee BioMed Central Ltd. 2012
Received: 25 April 2012
Accepted: 6 December 2012
Published: 20 December 2012
The objective of this systematic mixed-methods review is to assess what is currently known about the levels of physical activity (PA) and sedentary time (ST) and to contextualize these behaviors among South Asian women with an immigrant background.
A systematic search of the literature was conducted using combinations of the key words PA, ST, South Asian, and immigrant. A mixed-methods approach was used to analyze and synthesize all evidence, both quantitative and qualitative. Twenty-six quantitative and twelve qualitative studies were identified as meeting the inclusion criteria.
Studies quantifying PA and ST among South Asian women showed low levels of PA compared with South Asian men and with white European comparison populations. However making valid comparisons between studies was challenging due to a lack of standardized PA measurement. The majority of studies indicated that South Asian women did not meet recommended amounts of PA for health benefits. Few studies assessed ST. Themes emerging from qualitative studies included cultural and structural barriers to PA, faith and education as facilitators, and a lack of understanding of the recommended amounts of PA and its benefits among South Asian women.
Quantitative and qualitative evidence indicate that South Asian women do not perform the recommended level of PA for health benefits. Both types of studies suffer from limitations due to methods of data collection. More research should be dedicated to standardizing objective PA measurement and to understanding how to utilize the resources of the individuals and communities to increase PA levels and overall health of South Asian women.
KeywordsHealth inequalities Sedentary time Self-reported physical activity
Low levels of physical activity (PA) (defined as movement of the body requiring energy expenditure) and increased sedentary time (ST) (no energy expenditure above that required at rest) are major independent risk factors in the development of cardiovascular disease, and are recognized as key contributors to other chronic conditions such as type 2 diabetes and obesity . As such, PA and ST are potentially modifiable health behaviors that can be changed to reduce risks for morbidity and premature mortality resulting from various chronic diseases [2–4]. It has been shown that those who are physically active can reduce their risk of developing cardiovascular disease by up to 50% . The World Health Organization, US Department of Health and Human Services and the UK Department of Health agree that 150 minutes of moderate intensity PA or 75 minutes of vigorous activity per week are recommended to achieve health benefits [5–7].
South Asian women (SA) are disproportionately affected by chronic diseases [2, 8, 9] and large cross-national surveys of many western nations such as the UK, Australia and the US have consistently reported that SAs report lower levels of PA than their white counterparts [10, 11]. Cardiovascular disease (CVD), which includes heart attack and stroke, accounts for 16.7 million deaths globally each year . CVD is the leading cause of death in the UK and nearly half of all deaths in Europe are caused by CVD . The UK has one of the highest rates of CVD in the world, with more than 190,000 deaths in 2008 . In the UK 33% of all mortality in South Asian women and 25% in men 2008 was caused by cardiovascular disease . As insufficient PA is recognized as a significant, independent risk factor for CVD and other chronic diseases, it is important to gain a better understanding of the PA levels of SA and the factors influencing PA among this population to help inform the development and delivery of culturally appropriate interventions and policy .
Researchers have recently focused on quantifying and contextualizing PA and ST among groups such as SAs living in industrialized countries who are at the greatest risk for cardiovascular and other chronic diseases such as type 2 diabetes and hypercholesterolemia when compared to the general populations of those countries . The objective of this systematic mixed-methods review is to assess what is currently known about levels of PA and ST in SA. Research questions are: 1) What is known about the volume, intensity, duration and type of PA/ST that SAs engage in, 2) What is known about the context in which these behaviors occur in SA, and 3) What is the quality of the evidence on PA/ST in SAs?
After careful consideration of the methods that would be most appropriate for answering the research questions, a combination of the EPPI-Centre mixed-methods systematic review and an integrative review were used. This review uses the EPPI-Centre methods for systematically searching the literature, rigorously assessing the quality of studies, and synthesizing quantitative and qualitative studies into one report. As in the integrative method, many types of studies were considered for inclusion in order to meet the objective of the review . These included randomized and non-randomized controlled trials, observational studies and qualitative studies. The adaptation of the mixed-methods review and integrative review allowed for a systematized and rigorous review while including the appropriate studies to fully answer the research questions.
A search was performed in online databases (MEDLINE, The Cochrane Library, EMBASE, PsychInfo, CINAHL, AnthroSource and Sociological Abstracts from 1980 to July 2012), grey literature, hand searches of journals over the previous twelve months (MSSE, Journal of Physical Activity & Health, Journal of Aging and Physical Activity), and reference lists of articles to identify studies. Search terms included combinations of PA, ST, physical exercise, physical fitness, exercise, sport, physical training, physical training, recreation activity, MVPA, LTPA, leisure activities, physical inactivity, sedentary behavior and South Asian/immigrant. Inclusion criteria were: Randomized and non-randomized controlled studies, observational and qualitative studies; studies that include data on PA and/ or ST; studies on SA; studies published from 1980 on to obtain the most current data; studies with data on adult women aged 18 and older; studies published in English. Exclusion criteria included: Studies without adult data and studies focusing on migrant groups instead of permanent immigrants, and studies on children.
Quality of studies was assessed using validated checklists developed from the Critical Appraisal Skills Programme (CASP) [16, 17]. The checklist for quantitative studies was used to assess quality of study design including methods selection, identification of biases, appropriate use of statistical methods, and clarity of reporting . Studies were accepted for inclusion if they addressed each of these through justification of choices made in each quality category. The checklist for qualitative studies assessed strength of studies for inclusion, ranking studies on a continuum from weak to strong . Consideration was given to rigor (thorough and appropriate key research methods), credibility (findings well presented and meaningful), and relevance (how useful are the findings) . Qualitative studies were acceptable for inclusion if they were categorized as at least of moderate quality. Study eligibility was confirmed by two researchers and quality assessment and data extraction were performed by the principal investigator (WSB) and confirmed by a senior researcher (JLT).
Findings from quantitative studies are described numerically and textually to provide a summary of evidence on PA and ST performed by SA since heterogeneity of methods and measures of PA and ST precludes the use of meta-analysis. Qualitative data was synthesized and analysed thematically using NVIVO in three stages: 1) line-by-line coding of primary studies; 2) organising codes into themes; and 3) development of analytical themes . The final integrated synthesis consists of narrative commentary, combining the results of quantitative and qualitative syntheses.
Summary of included quantitative studies
Location of fieldwork
Participants & sample recruitment
Physical activity measures
Dogra et al., 2010
N = 347,229
Self-report: 3 month recall of PA (metabolic equivalent calculation based on Canadian Fitness and Lifestyle Research Institute cut-offs
SA less likely than Whites to engage in walking, endurance, recreation, and sport activities (SA: walking = 56.7%, endurance = 29.7%, recreation = 38.3%, sports = 24.3%; Whites: walking = 68.3%, endurance = 34.6%, recreation = 60.0%, sports = 28.8%). SA report more inactivity: 18.7%, Whites = 10.5%
N(male White) = 10729
N(female White) = 114,965
N(male SA*) = 1,708
N(female SA) = 1,576
Health Education Authority, 2000
N = 4,444
Self-report: survey piloted and revised for clarity
Translated into 7 languages
% reporting taking ‘regular exercise:
N(Indian) = 1,111
Indian = 71%
N(Pakistani) = 1,111
Pakistani = 63%
N(Bangladeshi = 1,111
Bangladeshi = 65%
N(Afro-Caribbean) = 1,111
% females reporting ‘very active’:
National Survey of Ethnic Minorities
Indian = 17%
Pakistani = 18%
Bangladeshi = 17%
Hine et al., 1995
N = 547 (women only)
Translated into 7 languages
% currently doing exercise to keep healthy:
N(Pakistani) = 79
Pakistani: 1%, Indian: 6%, Bangladeshi: 12.5%
N(Indian) = 52
N(Bangladeshi) = 21
Identified from Family Health Services Authority and Electoral Register
Jonnalagadda & Diwan, 2002
N = 237 Asian Indian men and women
Self-report: survey based on Kriska et al, 1997
% reporting engaging in 1 or more of the 3 activities from PA index:
Identified from 10 community organizations
South Indian = 70%
North Indian = 56%
West Indian = 65%
Kolt et al., 2007
N = 112
Objective measurement: New Lifestyles NL2000 pedometer
48% of total sample classified at sedentary (<5000 steps/day)
N(Asian Indian men) = 50 N(Asian Indian women) = 62
33% classified as active (>10,000 steps/day)
Identified from Auckland-based Asian Indian community organizations
Lean et al., 2001
N = 259
18% of Migrant SA performed sport and exercise
N(Scotland general population) = 50
30% of British-born SA performed sport and exercise
N(immigrant SA ) = 63
N(UK-born SA ) = 56
N(immigrant Italians ) = 39
N(UK-born Italians ) = 51
Lip et al., 1996
N = 232 (women only)
Self-report of regular exercise
Translated into 3 languages
Lower proportion of exercisers among South Asians (X2 = 22.34, df = 2, p < 0.001)
N(White ) = 84
N(SA) = 72
N(Afro-Caribbean ) = 76
Recruited from City Hospital, Birmingham
Mahajan & Bermingham, 2004
N = 250
Self-report: Based on the National Heart Foundation Risk Factor Survey
Total exercise hours/week: Men in Australia:17.3+/-25.5
N(SA Indians in Australia ) = 125
Men in India: 18.9+/-29.4 Women in Australia: 17.1+/-20.6
N(familial relatives in India ) = 125
Women in India: 33.5+/-36.9 (P < 0.001 referring to country of residence stratified by gender)
Recruited from Indian community centres in Sydney and referred familial relatives in India
McKeigue et al., 1992
N = 3,399
Completed questionnaire checked by bilingual fieldworker
Age-adjusted mean leisure time:
N(European men) = 1,506
SA: 3.0 MJ/week
N(SA men) = 1,360
European: 4.2 MJ/week P < 0.001
N(European women) = 245
N(SA women) = 288
Recruited from general practitioner’slists and industrial workforces in West London
Misra et al., 2005
N = 56 SA Indian immigrants
Self-report: Minnesota LTPA*** questionnaire
Total activity mean in min/week
N = 31 men
N = 25 women
Recruited via general practitioner’s offices, community centres and media releases
N = 261 Gujarati Asian Indian immigrants
Self-report: revised Health Promotion Lifestyle Profile II
53.3% Follow exercise regime
N(men ) = 180
56.4.% of men
N(women ) = 81
52.5% of women
Significant difference between men and women (X2 = 14.1, p = 0.001)
Mohanty et al., 2005
N = (White) 87,846
Self-report: any vigorous activity 10-20 min at least once per week
80.4% in1997, 73.9% in 1998, 69.6% in 1999, 72.1% in 2000
% reporting never being active or active less than once/week:
N(SA Indian) = 555
White = 59.3%
National Health Interview Survey years 1997-2000
Asian Indian = 67% (p = .004)
O’Laughlin et al., 2007
N = 2033 (42.2% male)
Self-report: ≥20 min. LTPA at least twice/week for 4 months
% inactive (95%Confidence Interval)
N(French Canadian) = 575
French Canadian = 71.5% (67.6-75.1)
N(Portuguese) = 294
Portuguese = 80.5%(75.5-84.9)
N(Italian) = 122
Italian = 78.3%(69.9-85.3)
N(Eastern European) = 51
Eastern European = 58%(43.2-71.8)
N(SA) = 42
SA = 76.2%(60.6-88.0)
Data available from adult parents of children participating in an intervention in Montreal
Palaniappan et al., 2002
N = 210
Years of regular exercise Caucasian: 6.2+/-4.0
N(Caucasian 0 = 67
African American: 4.0+/-4.2 SA Indian: 4.2+/-4.3 P = 0.0013
N(African American ) = 69
N(SA Indian ) = 70
Patel et al., 2006
N = 537 total
Objective Measurement: Caltrac accelerometers
Bilingual fieldworkers conducted measurements
67% in Sandwell, 65% in Navsari
Measured physical activity in Kcal/day (95% CI): Men in India:1820(1630-2000)
N(SA Indian men in UK ) = 119
Men in UK: 2350(2200-2490)
N(SA Indian men in India) = 139
Women in India: 1680(1540-1810) Women in UK: 1750(1640-1870)
N(SA Indian women in UK) = 123
N(SA Indian women in India) = 155
Recruited from community directories and local primary care registries in UK, from electoral roll from India
Pomerleau et al., 1999
N = 839 (women only)
Bilingual fieldworkerscollected data and translated during interview
SA women walked least for transport compared to European and Afro-Caribbean: 22% vs 44% and 40%, respectively. 1% of SA women participated in sport and none cycled
N(European ) = 246
N(SA) = 291
N(Afro-Caribbean ) = 303
Data from 2 large cross-sectional studies, Southall and Brent surveys
Riste et al., 2001
N = 919
Self-report: validated questionnaire(Was hburn et al, 1990), PA reported over the past week
Punjabi and Urdu interviewers available
% physically active defined as 3X20min/week (95% CI):
N(European ) = 471
Pakistani men = 6.8%(0-13)
N(Pakistani ) = 132
Pakistani women = 5.2%(0-11)
N(Afro-Caribbean ) = 316
European men = 37.8%(23-53)
Sampled from registers from local health centres
European women = 29.4%(13-46)
N = 2,619
Indian = 77%, Pakistani = 80%, Bangladeshi = 9 1% successful as% of screened eligible respondents
% reporting any activity: Indian = 46%, Pakistani = 41%, Bangladeshi = 37%
N(SA Indian ) = 1017
N(Pakistani ) = 935
N(Bangladeshi ) = 667
Sample available from 1981 census
Sinnapah et al., 2009
N = 122
Self-report: 24-hour recall
Energy expenditure in Kcal +/-SD: SA Indian men: 2615+/-417
N(general population men) = 25
SA women: 2264+/-465
N(SA Indian men) = 27
Controls men: 2921+/-608
N(general population women) = 32
Controls women: 2481+/-627
N(SA women) = 30
Sampled from those workers who came in to attend annual medical check-up
Williams et al., 2010
N = 15,413
Self-report: 4 week recall
Questions translated into 5 languages
% reporting no weekly physical activity(unadjusted):
N(White) = 13,293
White = 28.1%
N(SA Indian) = 1,244
Indian = 37.1%
N(Pakistani/Banglade shi ) = 876
Pakistani/Bangladeshi = 56.7% (p < 0.001)
Data available from Health Survey for England years 1999 and 2004
Williams et al., 2010a
N = 1,948
Self-report: Based on IPAQ****
Questionnair e available in English and Punjabi
% reporting more than 3 hours sedentary/day:
N(White) = 818
SA = 45.6%
N(SA) = 1130
White = 47.5%
Recruited from London Life Sciences Prospective Population(LOLIPOP) study
% reporting some physical activity:SA = 73.2%
White = 79.4%
Williams et al., 1994
N = 173 SA
Bilingual interviewer and questionnaire available in 4 languages
% reporting ever taking vigorous exercise: SA Males = 46%, Male general population = 59% SA females = 38%, Female general population = 44% SA less likely to report ever taking vigorous exercise, difference statistically significant in men (p < 0.05)
N by sex unspecified
Sampled from electoral and valuation rolls in Glasgow
Yates et al., 2010
N = 5,474
Self-report: Short version of last seven-day self administered format of IPAQ
92% of white European, 69% of SA
% in activity level category:
N(White men) = 2033
White Men: Low = 22%, Moderate = 28%, High = 50%
N(SA men) = 604
SA Men: Low = 37%, Moderate = 25%, High = 38%
N(White women) = 2277
White Women: Low = 27%, Moderate = 33%, High = 32%
N(SA women) = 560
SA Women: Low = 40%, Moderate = 28%, High = 32% (all significant at p < 0.01)
European -baseline data from ADDITION-Leicester study
Yates et al., 2012
N = 505
Self-report: Short version of last seven-day self administered format of IPAQ
Total hours sitting time (hours/day):
N(White European Men) = 220
Men = 6.0(4.0-8.8)
N(White European Women) = 188
Women = 5.0(4.0-7.0)
N(South Asian Men) = 52
p for difference between genders <0.01
N(South Asian Women) = 45
Total MVPA + (METhours/week:
From subsample of the ADDITIONLeicester study from 2004-2007
Men = 46(17-108)
Women = 34(17-106)
p for difference between genders <0.01
Ye et al., 2009
N = 77,267
% reporting physical inactivity(unadjusted):
N(White) = 74,424
White = 37.2%, Asian
N(SA Indian) = 534
Indian = 41.8%, Other
N(Other Asian) = 1,117
Asian = 41.0% (X2 = 16.27, p = 0.04)
Aggregated data from the National Health Interview Survey 2003 to 2005
Measurement of physical activity and sedentary time
Sixteen studies focused on PA prevalence [4, 8, 10, 19, 21, 22, 24, 27, 29, 30, 33, 34, 38–40, 42]. Two studies used a questionnaire to estimate both PA and ST among male and female SAs in the UK [36, 39]. Fourteen focused on the prevalence of PA among SAs in comparison to the white or general population of the host country. Kolt et al. (2007) did not make this comparison . Methods of assessing PA prevalence varied greatly between studies. Four studies measured prevalence of PA in the week prior to completion of the survey [10, 29, 34, 39], two asked respondents broadly if they participated in PA but did not specify a timeframe [21, 40], two assessed the prevalence of participating in regular PA [24, 30], one dichotomized PA by asking respondents if they were either active or inactive , one assessed prevalence of PA based on the number of kilometres walked or cycled per hour/week , one assessed the prevalence of ever taking vigorous PA , one used a scale (highly to ‘never-routinely’) , one study assessed the prevalence of performing PA by number of times/week , one assessed the prevalence of physical inactivity only , and one assessed PA using pedometer steps per minute measured over 7 consecutive days . All studies that assessed prevalence of PA in comparison to the white or general population found that SAs performed significantly less PA than the comparison group [4, 8, 10, 24, 29, 33, 39, 40, 42, 44].
Three studies assessed duration of PA [25, 27, 31]. Misra et al. (2005) report total PA duration in mean minutes per week . SA Indian men performed an average of 45 (+/−44) minutes while women performed 16 (+/−48) minutes of PA, less than half of the minutes of PA that the men did per week . Majahan et al. (2004) reported total exercise in hours over a two-week period . This study compared SA Indian women living in Australia or India, and found that women in Australia were performing just over half of the hrs/2 weeks of PA (4.8 +/5.3, p < .003) than the women in India (9.2+/− 9.1, p < .003) . Palaniappan et al. (2002) reported regular exercise in number of minutes per week , and found that SA Indian women performed nearly 5 minutes less regular exercise overall than their white counterparts (42 +/− 20.7 vs. 46.5 +/− 21.5) though this result was not significant. Two studies assessed PA in terms of energy expenditure with both finding that SA expended less energy in PA that their white and SA male counterparts [26, 35]. The one study that measured both PA and ST reported that on average, 70% of SAs in the study did some PA and that an average of 50% of participants were sedentary for more than 3 hours per day .
Eighteen studies assessed LTPA [8, 10, 19–21, 24–31, 33, 34, 40, 41, 45], three assessed home, work and leisure physical activity combined [4, 37, 38], two assessed active commuting [8, 27], two did not specify mode of activity but instead measured energy expenditure [32, 35], one assessed occupational physical activity , one study did not specify mode of activity but focused on intensity of the activity , one study assessed steps but did not specify the mode of activity , and one study looked solely at physical inactivity with no mode specified . In studies that assessed LTPA in both SA and white European groups, SA consistently reported less LTPA than their white European counterparts [4, 8, 10, 24–26, 29–31, 33, 34, 40, 41]. In the study by Dogra et al., 55.8% of SA respondents reported actively commuting to work versus 53.1% of the white European respondents (not significant) . Misra et al. (2005) report that 12.5% of SA men reported actively commuting to work while no women reported doing so . Pomerleau et al. (1999) indicate that 62.5% of SA and 49.0% of white Europeans reported walking more than sitting at work (p < 0.01) .
Summary of qualitative studies focusing on South Asian women and physical activity
Author, publication date& quality rating
Darr et al., 2008 -Strong+
To examine and compare illness beliefs of South Asian and European patients with CHD about lifestyle changes
N(Pakistani/Muslim men) = 10
Perceptions: Vigorous PA* seen as unnecessary, just keep mobile to achieve adequate PA levels
N(Pakistani/Muslim women) = 10
Barriers: Lack of time and uncomfortable walking alone
N(Indian/Sikh men) = 7
N(Indian/Sikh women) = 5
N(Indian/Hindu men) = 9
N(Indian/Hindu men) = 9
N(Indian/Hindu women) = 4
N(European men) = 10
N(European women) = 10
Age range: 40-83
Galadas et al., 2012 - Strong
To describe Punkabi Sikh patients’ perceived barriers to engaging in physical exercise following myocardial infarction (MI)
N(Punjab men) = 10
Perceptions: Difficulty determining safe PA levels
N(Punjab women) = 5
Informal exercise versus structured PA in a gym would be better
Age range: 48-80
Social networks disrupted after migrating to Canada and therefore difficult to make friends with whom to do PA with
Barriers: Fatigue and weakness after MI
Grace et al., 2008 -Strong
To understand lay beliefs and attitudes, religious teachings, and professional perceptions in relation to diabetes prevention in the Bangladeshi community
Focus groups for lay SA religious leaders
N(lay SA men) = 37
Perceptions: ‘Namaz’ is term used to refer to exercise
N(lay SA women) = 43
PA is seen as way to care for the body and for controlling weight
N(Religious leader men) = 14
Walking best form of activity to maintain modesty
N(lay religious leader women) = 15
PA central to Muslim way of life
Mean age: 35 +/-2 standard deviations
Horne et al., 2009 -Weak/moderate
To identify salient beliefs that influence uptake and adherence to exercise for fall prevention among community dwelling Caucasian and SA 60-70 years old
Ethnographic participant observation, focus groups, and semi structured interviews
FG: N(White men) = 14
Perceptions: PA not considered necessary if a person is healthy
N(White women) = 44
Barriers: Limited knowledge of PA and its benefits
N(SA men) = 16
Unaware of benefits of PA such as balance and improved mobility
N(SA women) = 13
Fear of injury if participate in PA Lack of confidence to do PA
N(White men) = 9
N(White women) = 14
N(SA men) = 7
N(SA women) = 10
Mean age range: 65.2-66.1
Kalra et al., 2004 -Strong/moderate
To gather information on the perceptions of cardiovascular risk within the Asian Indian community and to identify opportunities to design health promotion and intervention programs
N = 57 Asian Indian men and women
Perceptions: Urban dwellers more likely to want to do PA in a gym
FG size and sex unspecified
Rural dwellers knew to walk and caretaking was PA
Lawton et al., 2006 -Strong
To explore perceptions and experiences of undertaking physical activity as part of diabetes care
N(SA) = 32
Perceptions: Should do PA
N(Pakistani men) = 11
Encouraged by health professional to walk
N(Pakistani women) = 11
Barriers: Lack of time, fear to go out alone, no culturally sensitive facilities, domestic duties take priority over PA
N(SA Indian men) = 4
N(SA Indian women) = 5
Mohan et al., 2008 - Moderate
To report lifestyle factors of Asian Indians in Australia in relation to CHD and explore factors that could inform health education and cardiac rehabilitation programs in achieving lifestyle behavior changes
N = 8
Barriers: Family is a higher priority than PA; loneliness and lack of support after migration
N(SA Indian men) = 5
N(SA Indian women) = 3
6 born in India, 2 born in Fiji
Age range: 41-80
Pollard & Guell, 2011 -Moderate
To explore the facility and confidence with which women were able to recall information on PA, as required by questionnaires
Semi-structured interviews, 24-hour PA recall and accelerometry
N = 22 (British Pakistani women only)
Recall of PA: Women unlikely to accurately quantify time or intensities of daily PA
Age range: 24-61
Commonly used questionnaires unlikely to accurately capture PA levels
Sriskantharajah & Kai,2006 -Strong
To explore influences on, and attitudes towards, physical activity among SA women with CHD and diabetes to inform secondary prevention strategies
N = 15 (women only)
Barriers: Uncertainty of what activities to do
N(SA Indian) = 5
Selfish to take PA
N(Pakistani) = 4
N(Bangladeshi) = 1
Modesty an issue
N(East African Asian) = 2
N(Sri Lankan) = 3
Age range:26- + 70
Walseth 2008 -Moderate
To explore social network dimension of social capital, and whether participation in sport leads to accumulation of social capital for young women with an immigrant background
N = 15 (women only from Pakistan, Turkey, Morocco, Iran, Syria, Gambia, and Kosovo)
Perceptions: Sport clubs strengthened established friendships
Age range: 16-25
Focus on similarities among each other rather than differences
Knowledge of physical activity and its benefits
Nine studies highlighted participants’ knowledge of PA and its benefits [23, 41, 46, 48–51, 53, 58]. In three studies respondents reported awareness that they should be participating in regular PA and that it has some general health benefits [23, 50, 58]. In the study by Horne et al., participants reported not being aware of the health benefits of PA . Although there was a general awareness, five studies reported that there was confusion as to what types and how much PA to perform as well as confusion about specific health benefits [46, 48, 49, 53, 58].
Barriers to participating in physical activity
Nine studies reported barriers to PA participation among SA [23, 46, 48–53, 58]. Major barriers were those due to cultural differences with the dominant society and structural barriers. Five studies reported that SA as well as their families and communities would view taking time out to participate in PA as a selfish act [23, 48, 51, 53, 58]. Women reported that in SA culture, a woman’s focus is meant to be on the family and she should perform domestic duties over all other activities [23, 53]. Those women who participated in PA or wanted to, were concerned about the stigma that might come from others in their community [23, 48, 58]. Moreover they reported that caretaking duties left them with no time for PA [23, 46, 58]. Five studies cited culturally inappropriate facilities as a barrier to PA participation in this population [46, 48, 52, 53, 58]. Examples included mixed-sex facilities such as swimming pools that do not consider the women’s requirement for modesty, and the use of male instructors [23, 48, 58]. Four studies found that women were less likely to participate in PA outside their home if they had difficulties speaking English, the language of the wider society [23, 48, 52, 53]. The concept of fatalism or the idea that health is Allah’s will was expressed in two studies [48, 49].
Structural barriers such as fear for personal safety were cited in five studies [23, 46, 49, 52, 53]. Many women were worried for their safety if they were to go out into the neighborhood unaccompanied [23, 46], while others were fearful of exacerbating an illness or disability by doing too much PA or becoming too tired while out in the neighborhood alone [46, 49, 53]. Three studies cited poor weather as the main barrier for low PA participation [23, 46, 52]. Finally, lack of time [23, 46, 58], money , and access to open spaces  were additional structural barriers noted.
Facilitators to participating in physical activity
Facilitators to PA participation emerged in four studies [23, 48, 49, 53]. A common facilitator seen in all studies was motivation to participate in PA as a way to care for the health of the body and to prevent or alleviate illness and disease [23, 48, 49, 53]. Two studies offered solutions to lack of PA motivation in SA [23, 48]. Having exercise equipment in the home was seen as one way to motivate people to be physically active and eliminate several barriers to participation . Education about Muslim faith was also seen as a way to motivate the South Asian community since PA was seen as central to the Muslim way of life .
Final synthesis & discussion
The quantitative studies included in this review broadly indicate that SA’s PA levels are lower than the general or white population of their host countries, though SA Indian women generally had higher levels when compared to other SA women (Bangladeshi and Pakistani women) of the host countries [4, 10, 19, 20, 41]. There were no randomized controlled trials available for inclusion in this review, which may indicate that there is not enough high quality evidence on PA or ST in this population from which to draw conclusions. Self-report surveys were used to measure PA participation in all but two studies [22, 32]; it is recognised these measures have limitations such as recall bias and misinterpretation of questions [14, 59]. Eight studies reported using questions on PA from a validated questionnaire, though these have been validated on white populations, not SA populations [25, 27, 28, 34, 36, 37, 39, 42]. The study that used an accelerometer to measure PA levels chose to use a device that is often used in conjunction with a heart rate monitor and is typically used to measure the energy expenditure (in kcals) of PA . The findings that women of SA origin perform little PA based on their energy expenditure are similar to other studies that have used the Caltrac to assess PA in other ethnic minority women such as African American women in the US .
This device is known to overestimate energy expenditure of activities such as walking and running and therefore may not be the best choice of accelerometer . Other accelerometers that are commonly used are the Actigraph and the ActivePAL . These can be worn without the use of a heart rate monitor and are widely used to measure the intensity and duration of PA . More high quality studies with rigorous study designs and methods are needed to assess levels of PA and ST in this population.
Heterogeneity within SA groups based on country of origin/birth and diversity of socioeconomic status (SES), religious beliefs and cultural practices make insights from these studies difficult to generalize and should be interpreted with caution [61, 62]. Of the 26 quantitative studies reviewed only 13 included any information on SES and a range of markers of SES were measured across studies [4, 8, 19–21, 28–30, 33, 34, 36, 38, 39, 42]. Measures of SES included household income [4, 8, 21, 34, 36, 42], education level [4, 8, 19, 20, 28, 30, 33], and deprivation indexes such as Index of Multiple Deprivation scores  and the Townsend Deprivation Index . Other potential mediating or confounding factors such as employment status [18, 28], disease status [4, 22, 32, 38, 39, 41], religion [19, 36], stress levels  and racial discrimination [20, 36] were reported and controlled for in physical activity analyses, although these were not collected in all studies.
Conclusions from these studies are based on the limited and often missing information on sampling, methods and findings obtained from papers. Most studies gave minimal or no information on the translation of surveys into the appropriate languages. As the qualitative studies reviewed here have indicated, English language skills are limited in this group and efforts should be made by researchers to make the translation and interview process more transparent. Measurement and definition of PA varied widely, making it difficult to quantify activity across all studies. Moreover terms such as PA, vigorous, moderate, exercise, etc. have different meanings in the English language, making them challenging to understand by those whose first language is not English . As evidenced by this review, ST is largely overlooked within the current research on SA. Only two studies reported ST and this was self-reported data [36, 38]. Based on the evidence indicating low levels of PA, this population is likely to have high rates of ST and sedentary behaviors. Future research is needed to assess levels of ST and contextualize sedentary behaviors since these have been identified as important independent risk factors for CVD. Additionally, it is difficult to compare PA across studies since the domain of PA measured, and the methods used to assess PA, varied across studies. The majority of quantitative studies measured LTPA. It may be the case that SA women do not engage in LTPA but do engage in more household or occupational activities. There may be considerable amounts of PA that are not being captured by the currently published studies, therefore more investigation is needed into the type of PA that SA women currently engage in.
The qualitative studies reviewed for this paper varied by methods, sample size, and research focus. While most studies reported that they chose themes or interview questions a priori, there was little description of how these were chosen. Mays & Pope (2003) recommend using the presence of a theoretical framework as one aspect of assessing quality of qualitative studies . However only three studies in this review [15, 47, 51] identified and reported the theoretical framework that underpinned the study.
Knowledge of PA and its benefits was found to be lacking among SA. Horne et al. (2009) found that there was disagreement on the understanding of the difference between exercise and PA . This misunderstanding can be compounded by health practitioners or health promotion professionals giving only general recommendations, and failing to provide detail on what activities should be performed, at what intensity and for what duration . Awareness of specific health benefits of PA such as falls prevention, cardiovascular health, and stress relief was low among many SA [23, 49, 52, 58]. Of those respondents who knew about the benefits of PA and had knowledge of which activities to participate in, few reported that they were successful in actually performing any activity [23, 46, 49, 58] or did not believe that they needed PA for their own health [46, 49, 52, 58]. In contrast, Kalra et al. (2004) found that most respondents (who were all of SA Indian descent) did do some PA .
While the majority of the qualitative studies addressed barriers and facilitator to PA, there was little agreement in the findings. There are several possible reasons for this. The term “South Asian” is used to group together people from the India, Pakistan, Bangladesh, and Sri Lanka, but this grouping is one of convenience and fails to address the differences that may be found between these diverse countries and cultures. The studies were also guided by different research goals. For example, some focused on PA in SA with type 2 diabetes [23, 48] or heart disease [47, 51–53, 58], and others on falls prevention for older SA . Finally, the method of data collection, i.e. individual interviews vs. focus groups, may provide information on individual’s thoughts and perceptions (interviews) or reveal the thoughts and perceptions of the collective (focus groups) . Some common themes across these two methods were identified. These included barriers to PA due to differences of the host culture and the SA culture, structural barriers such as neighborhood safety, and facilitators such as the use of faith and education to encourage activity.
Put in the context of global PA and ST among ethnic minority groups, the findings from this review are consistent with those of many previous studies on other ethnic minority groups. Examples include studies on African Americans and Hispanics in the United States where researchers have found similar barriers to those of the SA reviewed here, including cultural barriers such as proper dress for PA and lack of time, money and facilities for PA [1, 57, 64]. Studies on Muslim minority groups have also found comparable results to these, referring to an incongruence of the minority culture and the host population as a main barrier to PA behaviors . Future research should focus on improved methods of working within minority cultures to reduce barriers to PA and discourage ST. While there are similarities in the barriers to PA, the solutions to low PA among these groups may be varied due to the specific characteristics of individuals and communities. These should therefore be explored further and employed to promote increased levels of PA and reduce ST among SA.
This review has built a detailed description of all the evidence published since 1980 on SA and PA from both quantitative and qualitative sources. This method of synthesizing both types of studies has some limitations. There is currently no standardized way of extracting data or assessing the quality of both types of studies , therefore more than one method was used. This analysis suffers from a lack of detail from some papers on the sample, methods, and findings. Publication and researcher bias are also a consideration, although efforts were made to procure all studies, published or unpublished, and to use multiple researchers in the identification of studies, data extraction and assessment of quality. Finally, due to a lack of randomized controlled trials and significant heterogeneity between studies, a meta-analysis of results was not possible.
Although not a traditional systematic review, this review has closely followed the rigorous standards of conducting systematic reviews. The strengths of this review include transparent methodology and the inclusion of all types of research to produce the most comprehensive narrative evidence on PA and SA. This review updates and improves upon previous work through integration of study types to provide the most comprehensive picture of existing evidence in this area [63, 66]. This systematic synthesis of studies also allows for the development of more informed recommendations for future research needs and intervention strategies.
These findings have implications for researchers, policy specialists and health practitioners. It is clear from the findings of this review that there is little standardization of PA measurement or terminology used to describe SA groups across studies. This reduces the ability to compare findings across studies and to make any useful generalizations. It is recommended that researchers use objective measures of PA (e.g., accelerometers) more widely among ethnic minority groups. Only two of the 26 quantitative studies [20, 22] in this review used objective measurements and only one of those used accelerometers . While there are other objective measurements that might be considered to be the gold standard, accelerometers offer the ability to accurately and consistently monitor PA and avoid recall bias, translation issues, and have a high degree of reliability over time [22, 59]. The wider use of this technology will help to standardize PA measures and allow for better comparisons across studies. While objective measurement is recommended, it is not always a practical option. Therefore when self-report methods must be used in lieu of objective measurement, it is recommended that researchers used the IPAQ in order to standardize measurement across studies . The IPAQ can be translated into a range of languages and dialects and used for a wide variety of participants, [38, 59, 67]. Additionally, this review illustrates the need for more theory-based research to better understand the social, structural, economic, and cultural factors contributing to the PA and ST in this group. Moreover, there is currently not enough data to ascertain whether there is a consistent difference between women of various SA subgroups, and if there is, what that difference might be.
Policy specialists should consider the alarmingly low rates of PA among SA and press for more evidence-based interventions and programs aimed at this population. The results reported here suggest that healthcare and health promotion practitioners need to provide more detailed guidance on the type, frequency and duration of PA for their patients and clients in this population. There is also concern among SA that participating in PA will aggravate current disease or illness and practitioners should promote education on the benefits of PA even for those with disease. The use of translators and leaders in the faith communities may assist in disseminating these messages.
This review has identified the quantitative and qualitative studies on PA among SA. All quantitative studies showed a trend toward low activity levels in this group, though outcome measures varied widely. Although findings were limited, they suggest that barriers to PA may be overcome by working within cultural norms and to provide more education on the safety and benefit of PA. The evidence base for these conclusions is limited and it is recommended that more research be done in this area to close gaps in knowledge and provide the information needed to develop and disseminate culturally appropriate interventions that increase PA and reduce ST in this population.
We thank Ms. Julianne van der Berg for her assistance with the study selection process.
No funding was received.
- Eyeler AA, Matson-Kaffman D, Young DR, Wilcox S, Wilbur J, Thompson JL, Sanderson BK, Evenson KR: Quantitative study of Correlates of physical activity in women from diverse racial/ethnic groups. Women’s Cardiovascular Health Network Project introduction and methodology. Am J Prev Med. 2003, 25: 1-14.
- Eapen D, Kalra GL, Mercharnt N, Arora A, Khan BV: Metabolic syndrome and cardiovascular disease in South Asians. Vasc Health Risk Manag. 2009, 5: 731-743.
- Gill JMR, Malkova D: Physical activity, fitness and cardiovascular disease risk in adults: interactions with insulin resistance and obesity. Clin Sci. 2006, 110: 409-425. 10.1042/CS20050207.View Article
- Williams ED, Stamatakis E, Chandola T, Hamer M: Physical activity behaviour and coronary heart disease mortality among South Asian people in the UK: an observational longitudinal study. Heart. 2010, 97: 655-659.View Article
- UK Department of Health: Physical activity guideline for adults (19–64 years). 2011, 1.
- US Department of Health and Human Services. http://www.health.gov/paguidelines/contact.aspx .
- World Health Organization: Global recommendations on physical activity for health. 2010, Switzerland: World Health Organization, 1-60.
- Dogra S, Meisner BA, Adern CI: Variation in mode of physical activity by ethnicity and time since immigration: a cross-sectional analysis. Int J Behav Nutr Phys Act. 2010, 7: 75-85. 10.1186/1479-5868-7-75.View Article
- Dunnell K: The changing demographic picture of the uk national statistician’s annual article on the population. Population Trend. 2007, 130: 9-21.
- Hayes L, White M, Unwin N, Bhopal R, Fishcbacher C, Harland J, Alberti KGMM: Patterns of physical activity and relationship with risk markers for cardiovascular disease and diabetes in Indian, Pakistani, Bangladeshi and European adults in a UK population. J Public Health. 2002, 24 (3): 170-178. 10.1093/pubmed/24.3.170.View Article
- Hosper K, Deutekom M, Stronks K: The effectiveness of “Exercise of Prescriptio” in stimulating physical activity among women in ethnic minority groups in the Netherlands: protocol for a randomized controlled trial. BMC Public Health. 2008, 8: 406-453. 10.1186/1471-2458-8-406.View Article
- British Heart Foundation Web site. http://www.bhf.org.uk/heart-health/statistics/mortality.aspx .
- Banda J, Hutto B, Feeney A, Pfeiffer K, McIver K, Lamonte MJ, Blair SN, Vena J, Hooker SP: Comparing physical activity measures in a diverse group of midlife and older adults. Med Sci Sports Exerc. 2010, 42: 2251-2257. 10.1249/MSS.0b013e3181e32e9a.View Article
- Caperchione CM, Kolt GS, Mummer WK: Physical activity in culturally and linguistically diverse migrant groups to Western Society. Sports Med. 2009, 39: 167-177. 10.2165/00007256-200939030-00001.View Article
- Walseth K: Bridging and bonding social capital in sport- experiences of young women with an immigrant background. Sport, Education and Society. 2008, 13 (1): 1-17. 10.1080/13573320701780498.View Article
- Critical Appraisal Skills Programme: 10 questions to help you make sense of qualitative research. 2006, England: Public Health Resource Unit
- Polgar A, Thomas SA: Chapter 22. Introduction to Research in the Health Sciences. 1995, Melbourne: Churchill Livingstone, 1-2.
- Thomas J, Harden A, Oakley A, Oliver S: Integrating qualitative research with trials in systematic reviews. Br Med J. 2004, 328: 1010-1012. 10.1136/bmj.328.7446.1010.View Article
- Health Education Authority: Black and ethnic minority groups in England: the second health and lifestyles survey. 2000, London: Health Education Authority, 1-6.
- Hine C, Fenton S, Hughes AO, Velleman G: Coronary heart disease and physical activity in South Asian women: local context and challenges. Health Educ J. 1995, 54: 431-443. 10.1177/001789699505400406.View Article
- Jonnalagadda S, Diwan S: Regional variations in dietary intake and body mass index of first-generation Asian-Indian immigrants in the United States. J Am Diet Assoc. 2002, 102 (9): 1286-1289. 10.1016/S0002-8223(02)90283-X.View Article
- Kolt GS, Grant SM, Rush EC, Oliver M, Chadha NK: Body fatness, physical activity, and nutritional behaviours in Asian Indian immigrants to New Zealand. Asia Pac J Clin Nutr. 2007, 16 (4): 663-670.
- Lawton J, Ahmad N, Hanna L, Douglas M, Hallowell N: ‘I can’t do any serious exercise’: barriers to physical activity amongst people of Pakistani and Indian origin with Type 2 diabetes. Health Educ Res. 2006, 21: 43-54.View Article
- Lip G, Luscombe C, McCarry M, Malik I, Beevers G: Ethnic differences in public health awareness, health perceptions, and physical exercise: implications for heart disease prevention. Ethn Health. 1996, 1 (1): 47-53. 10.1080/13557858.1996.9961769.View Article
- Mahajan D, Bermingham MA: Risk factors for coronary heart disease in two similar Indian population groups, one residing in India, and the other in Sydney, Australia. Eur J Clin Nutr. 2004, 58: 751-760. 10.1038/sj.ejcn.1601873.View Article
- McKeigue PM, Pierpont T, Ferrie JE, Marmot MG: Relationship of glucose intolerance and hyperinsulinaemia to body fat pattern in South Asians and Europeans. Diabetologia. 1992, 35: 785-791.
- Misra KB, Endemadd SW, Ayer M: Leisure time physical activity and metabolic syndrome in Asian Indian immigrants residing in Northern California. Ethnicity & Disease. 2005, 15: 627-634.
- Misra R, Gupta R: Predictors of health promotion behaviours among Asian Indian immigrants: implications for practitioners. Int. J. Sociol. Soc Policy. 2004, 24 (12): 66-86. 10.1108/01443330410790821.View Article
- Mohanty SA, Woolhandler S, Himmelstein DU, Bor DH: Diabetes and cardiovascular disease among Asian Indians in the United States. J Gen Intern Med. 2005, 20: 474-478. 10.1111/j.1525-1497.2005.40294.x.View Article
- O’Laughlin J, Maximova K, Tan Y, Gray-Donald K: Lifestyle risk factors for chronic disease across family origin among adults in multi-ethnic, low-income, urban neighborhoods. Ethnicity & Disease. 2007, 17: 657-663.
- Palaniappan L, Anthony MN, Mahesh C, Elliott M, Killeen A, Giacherio D, Patel JV, Vyas A, Cruickshank JK, Prabhakaran D, Hughes E, Reddy KS: Cardiovascular risk factors in ethnic minority women aged ≤ 30 years. Am J Cardiol. 2002, 89: 524-529. 10.1016/S0002-9149(01)02291-3.View Article
- Patel JV, Vyas A, Cruickshank JK: Impact of migration on coronary heart disease risk factors: comparison of Gujaratis in Britain and their contemporaries in villages of origin in India. Atherosclerosis. 2006, 185: 297-306. 10.1016/j.atherosclerosis.2005.06.005.View Article
- Pomerleau J, McKeigue PM, Chaturvedi N: Factors associated with obesity in South Asian, Afro-Caribbean and European women. Int J Obesity. 1999, 23: 25-33. 10.1038/sj.ijo.0800750.View Article
- Riste L, Khan F, Cruickshank K: High prevalence of type 2 diabetes in all ethnic groups, including Europeans, in a British inner city. Diabetes Care. 2001, 24 (8): 1377-1383. 10.2337/diacare.24.8.1377.View Article
- Sinnapah S, Antoine-Jonville S, Donnet JP, Hue O: Asian Indians of Guadeloupe are less physically active that their island counterparts. Scand J Med Sci Sports. 2009, 19: 222-227.View Article
- Williams ED, Nazroo JY, Kooner JS, Steptoe A: Subgroup differences in psychosocial factors relating to coronary heart disease in the UK South Asian population. J. Psychosom. Res. 2010, 69: 379-387. 10.1016/j.jpsychores.2010.03.015.View Article
- Yates T, Davies MJ, Gray LJ: Levels of physical activity and relationship with markers of diabetes and cardiovascular disease risk in 5474 white European and South Asian adults screened for type 2 diabetes. Prev Med. 2010, 51: 290-294. 10.1016/j.ypmed.2010.06.011.View Article
- Yates T, Phunti K, Wilmot EG: Self-reported sitting time and markers of inflammation, insulin resistance, and adiposity. Am J Prev Med. 2012, 42 (1): 1-7. 10.1016/j.amepre.2011.09.022.View Article
- Ye J, Rust G, Baltrus P, Daniels E: Cardiovascular risk factors among Asian Americans: results from a national health survey. Ann Epidemiol. 2009, 19: 718-723. 10.1016/j.annepidem.2009.03.022.View Article
- Lean MEJ, Han TS, Anderson AS, Bradby H, Williams R: Ethnic differences in athropometric and lifestyle measures related to coronary heart disease risk between South Asian, Italian and general-population British women living in the west of Scotland. Int J Obes. 2001, 25: 1800-1805. 10.1038/sj.ijo.0801823.View Article
- Rudat K: Black and minority ethnic groups in England. 1994, London: Health Education Authority, 1-178.
- Williams R, Bhopal R, Hunt K: Coronary risk in a British Punjabi population: comparative profile of non-biochemical factors. Inter J Epidemiol. 1994, 23 (1): 28-37. 10.1093/ije/23.1.28.View Article
- Minio AM, Xu J, Kochanek KD, Tejada-Vera B: Death in the United States, 2007. NCHS Data Brief. Hyattsville, MD: US Department of Health and Human Services. 2009, 1-8.
- Ridgers ND, Salmon J, Ridley K: Agreement between activPAL and ActiGraph for assessing children’s sedentary time. Int. J. Behav. Nutr. Phys. Act. 2012, 9: 15-22. 10.1186/1479-5868-9-15.View Article
- Whittemore R, Knafl K: The integrative review: updated methodology. J Ad Nursing. 2005, 52: 546-553. 10.1111/j.1365-2648.2005.03621.x.View Article
- Darr A, Astin F, Atkin K: Causal attributions, lifestyle change, and coronary heart disease: illness beliefs of patients of South Asian and European origin living in the United Kingdom. Heart Lung. 2008, 37 (2): 91-104. 10.1016/j.hrtlng.2007.03.004.View Article
- Galadas PM, Oliffe JL, Kang BK: Punjabi Sikh patients’ perceived barriers to engaging in physical exercise following mycocardial infarction. Public Health Nurs. 2012, n/a: 1-8.
- Grace CB, Begum R, Subhani S, Kopelman P, Greenlaugh T: Prevention of type 2 diabetes in British Bangladeshis: qualitative study of community, religious, and professional perspectives. Br Med J. 2008, 337: a1931-a1940. 10.1136/bmj.a1931.View Article
- Horne M, Speed S, Skelton D, Todd C: What do community-dwelling Caucasian and South Asian 60–70 year olds think about exercise for fall prevention?. Age Ageing. 2009, 38: 68-73.View Article
- Kalra P, Srinivasan S, Ivey S, Greenlund K: Knowledge and practice: the risk of cardiovascular disease among Asian Indians. Results from focus groups conducted in Asian Indian communities in Northern California. Ethn Dis. 2004, 14: 497-504.
- Mohan S, Wilkes L, Jackson D: Lifestyle of Asian Indians with coronary heart disease: the Australian context. Collegian. 2008, 15: 115-121. 10.1016/j.colegn.2007.03.001.View Article
- Siddiqui FR, Ur-Rahman M, Bhatti MA, Mirza I, Shahid A: Knowledge, attitudes and practices to lifestyle risk factors for coronary heart disease(CHD) and diabetes amongst South Asians in North Kirklees, England- A focus group study. Pakistan Armed Forces Journal. 2008, 3: 1-9.
- Sriskantharajah J, Kai J: Promoting physical activity among South Asian women with coronary heart disease and diabetes: what might help?. Family Practice. 2007, 24 (1): 71-76.View Article
- Pollard T, Guell C: Assessing physical activity in Muslim women of South Asian origin (forthcoming). J. Phys. Act. Health. 2011, n/a: n/a
- Sani MU, Wahab KW, Yusuf BO, Gbadamosi M, Johnson OV, Gbadamosi A: Modifiable cardiovascular risk factors among apparently healthy adult Nigerian population - a cross sectional study. BMC Research Notes. 2010, 3: 1-7. 10.1186/1756-0500-3-1.View Article
- Swan PD, Byrnes WC, Haymes EM: Energy expenditure of the Caltrac accelerometer for running, race walking, and stepping. Br. J. Sports Med. 1997, 31 (3): 235-239. 10.1136/bjsm.31.3.235.View Article
- Evenson KR, Sarmiento OL, Ayala GX: Acculturation and physical activity among North Carolina Latina immigrants. Soc Sci Med. 2004, 59: 2509-2522. 10.1016/j.socscimed.2004.04.011.View Article
- Farooqi A, Nagra D, Edgar T, Khunti K: Attitudes to lifestyle risk factors for coronary heart disease amongst South Asians in Leicester: a focus group study. Fam Pract. 2000, 17 (4): 293-297. 10.1093/fampra/17.4.293.View Article
- Ham SA, Ainsworth BE: Disparities in data on healthy people 2010 physical activity objectives collected by accelerometry and self-report. Res. Pract. 2010, 100: S263-S268.
- Keyserling TC, Samuel-Hodge CD, Ammerman AS: A randomized trial of an intervention to improve self-care behaviours of African-American women with type 2 diabetes. Impact on physical activity. Diabetes Care. 2002, 25 (9): 1576-1583. 10.2337/diacare.25.9.1576.View Article
- EPPI-Centre: EPPI-Centre methods for conducting systematic reviews. 2007, London: EPPI-Centre, Social Science Research Unit, Institute of Education. University of London, 1-18.
- Cochrane Handbook for Systematic Reviews of Interventions. http://www.cochrane-handbook.org .
- Fischbacher CM, Hunt S, Alexander L: How physically active are South Asians in the United Kingdom? A literature review. J Public Health. 2004, 26: 250-258. 10.1093/pubmed/fdh158.View Article
- Wolin KY, Colditz G, Stoddard AM, Emmonsc KM, Sorensen G: Acculturation and physical activity in a working class multiethnic population. Prev Med. 2006, 42: 266-272. 10.1016/j.ypmed.2006.01.005.View Article
- Strandbu A: Identity, embodied culture and physical exercise: stories from Muslim girls in Oslo with immigrant backgrounds. Young. 2005, 13: 27-45. 10.1177/1103308805048751.View Article
- Daniel M, Wilbur J: Physical activity among South Asian Indian immigrants: an integrative review. Public Health Nurs. 2011, 28: 389-401.
- International Physical Activity Questionnaire website. http://www.ipaq.ki.se/ipaq.htm .
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