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

To enable an exploration of women’s health concerns, a qualitative research design underpinned by feminist standpoint theory guided this study. This theory prioritizes thinking from women's or marginalized lives and considers these lives as privileged sites of knowledge production (Van der Tuin, 2016). Therefore, health concerns can be brought to the fore that could not have been otherwise anticipated. To reduce bias during the research process, patient and public involvement (PPI) was undertaken through consultations with experts by experience, who were women that reflected the target population. The following sections will include details about the input from experts by experience.

The study reported in this paper has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The COREQ criteria for reporting qualitative research was followed. A purposive sub-sample of the Born in Bradford Better Start (BIBBS) cohort was selected. The BIBBS birth cohort study commenced in 2016 and recruited mothers and their partners from three of the most deprived wards in Bradford, where large numbers of Pakistani women live. For more information, see Dickerson et al. (2016). As part of the BIBBS study, women were recruited at a routine appointment while awaiting their glucose tolerance test, which is offered to all women in Bradford between 26–28 weeks gestation to diagnose gestational diabetes. NHS ethical approval had already been granted for the BIBBS project and a minor amendment was approved for the current study (Ref no: 15/YH/0455). English speaking and reading (due to time constraints) Pakistani women who were over the age of 18 were approached. and given an information sheet which was also explained to them by HI. Written informed consent was obtained prior to inclusion in the study and in Summer 2018, 21 interviews were conducted in a private room in the clinic by HI.

Seven experts by experience expressed their preference for semi structured one-to-one interviews to discuss their health concerns, which are a suitable feminist data collection method to enable detailed exploration of personal lived experiences and ability to build a close relationship with participants which can lead to richer, more detailed data (Finch, 1984). A further ten experts by experience guided the development of the questions by identifying the domains of exercise, environment, illness/disease and house as aspects of health they felt women would have the most concerns around. These domains were displayed as cartoon sketches to facilitate discussion during the interviews. An interview guide (see Table 1) was developed by HI and MC. The guide used mainly open-ended questions to facilitate discussions. Two other interview guides used in qualitative research with South Asian populations were examined to ascertain the most appropriate terminology to adopt (Brown et al., 2006; Manikam et al., 2017). Five experts by experience reviewed the interview topic guide and further to their suggestions, the guide was iteratively refined. The interview guide was pilot tested on three experts by experience. The findings from the pilot have not been included in the data for this study. Interviews were conducted in person, solely by HI. Fieldnotes were captured in a journal immediately after the interview. Interviews were audio-recorded and lasted between 20–40 min.

Interviews were transcribed verbatim by HI and anonymised by removing names. Inductive thematic analysis utilizing six steps (Braun & Clarke, 2006) was undertaken by HI. This involved line by line coding of 21 transcripts during ongoing data collection to develop an initial coding scheme. A codebook was then created and subsequently refined several times throughout the process by the research team. All authors worked together to create the main themes from the codes. Three representative transcripts were closed-coded by MC to strengthen credibility. Although it is good practice in qualitative research to return transcripts to participants for member checking to verify their accuracy (Loeb & Steffensmeier, 2011), it was not possible to do this due to participants being part of a pre-existing study (BIBBS) and access to them before and after the study was limited.

It was essential that the researchers questioned their own assumptions as is propagated by feminist research as we played a crucial role in data collection and interpretation. The research team are PhD level qualified with expertise in qualitative research in the UK. HI is a British Pakistani Muslim living in Bradford and has an interest in health inequalities faced by South Asian, Muslim women. The other authors are white British women. JW’s research interests include geographical, income and ethnic inequalities and their impact on child health, size and growth. RM’s research focuses on improving the health of families and reducing inequalities. MC’s research interests are ethnic health inequalities (including migrant) in communities. Our different identities and previous knowledge allowed us to unpick the data and question one another’s interpretations.

Most participants expressed a strong desire to be physically active outdoors while pregnant but highlighted a range of barriers which prevented this. These included concerns around the safety of exercising during pregnancy, with some women stating they felt it would increase their chance of injury. Consequently, they stopped engaging in organized sport and physical activity: “I was going to the gym regularly until I got pregnant so now it’s not safe. I’ll start again after baby” (p7). Other women felt that even gentle physical activities were unsafe: “I will start after baby. I don’t feel it’s safe to go for walks yet.” (p1).

Some women overcame this by driving away from their areas and then walking for physical activity, where they were not recognised: “I don’t like to go for walks in my area so I drive into town and then walk around town so I would never walk around my area.” (p9).

Women discussed other safety concerns which prevented them and their children walking in the local parks. This included drug dealing in daylight, the high number of young male teens and adult men loitering in the park on the streets, the presence of people consuming alcohol, exposure to drug needles, and the amount of litter in the area:

Many participants discussed undertaking physical activity indoors and barriers to this. One reason for not engaging in indoor physical activity such as attending the gym when not pregnant, was the lack of female-only swimming classes or female-only exercise classes/gyms: “The other thing is that the gyms are mostly mixed, and I don’t want to exercise and turn around to see my male neighbour exercising next to me. So embarrassing.” (p19).

Others cited religious reasons as a barrier to indoor physical activity engagement, highlighting a lack of facilities that were compatible with their Islamic faith: “If there were facilities for purdah (observation of religious attire) ladies, there must have been a way that I would have come out and done it.” (p12).

Participants discussed difficulties in consuming a healthy diet. This included the heavy presence of local fast-food outlets in their neighbourhood selling unhealthy, cheap food rather than healthy food options: “You only get unhealthy pizza and burger places in my area. They don’t sell anything healthy in these take-outs.” (p6).

Consequently, women felt it was more difficult to promote healthy eating in their household. They remarked that when they had prepared healthy, home-cooked meals, family members purchased calorific food from local takeaways, which meant that home-cooked food often resulted in waste: “I made vegetable curry last time, trying to be healthy, and my son walked in with huge boxes of chicken parmesan. No one ate what I made and I had to throw it out a couple of days later.” (p16).

Due to the lack of healthy food locally, women discussed having to travel to other areas of Bradford to access healthier foods in restaurants and takeaways. Many participants, however, mentioned that even when there were healthy food options in local takeaways, their financial situation meant that they struggled to eat healthily and they consumed inexpensive, unhealthy food rather than healthy, costly food: “Obviously, I can feed us takeout on a fiver, rather than spend a lot more on healthy food they have there that I can’t really afford.” (p15).

Another difficulty with eating healthily was confusion about recommended portion sizes. Women were generally aware of the advised portion guidelines for widely consumed food such as rice and meat, however, they struggled to determine how this equated with traditional Asian food that were regularly consumed as part of their daily diet, in pregnancy and otherwise, such as chapattis and curries: “There should be more help with portion sizes for Asian food and just food generally, just to make you more familiar.” (p5).

This lack of information meant that many women guessed the correct portion size of commonly consumed Asian food they had prepared, admitting their estimations were likely to be incorrect.

Despite being pregnant and having a midwife, there was concern amongst some participants about the lack of information and support available to them on maintaining healthy lifestyles. This included accessing information about consuming a healthy diet: “I don’t know where to go to get information on what a healthy diet is.” (p8).

For some women, the internet was cited as the main place to seek information on how to be healthy due to this lack of knowledge: “I would look on the internet, I actually don’t know where else to ask.” (p1) Some participants received support from their gym, their family doctor (GP), Sure Start centres, and organisations where they worked “I would go to the Dr to find out if I wanted information on how to eat healthy and exercise.” (p9) However, other participants believed that although the GP was the best person to provide advice, they had difficulty making GP appointments:

Participants believed language barriers led to a lack of knowledge and understanding about health promotion messages by some Pakistani women:

To our knowledge, this is the first study that explores the health concerns of pregnant Pakistani women residing in the UK. The qualitative methodology offered a broad insight into women’s experiences, which is important due to the disproportionate poor health outcomes faced by British Pakistani women (Garcia et al., 2017; Insan et al., 2022). A strength to this study was the insider status of the main author who conducted the interviews. Possessing similar characteristics to the participants can assist significantly in rapport building, sharing collective experiences and discussing common features of their lives (Iqbal et al., 2023). This enabled an atmosphere of trust which may have increased the reliability of the findings. Care was taken, however, to diminish any bias that may have emanated from the main authors insider status. This included asking for clarification when participants assumed HI knew what was mean by something because of their shared characteristics.

Non-english-speaking women were not included in the sample due to time constraints. The health concerns identified in this study, therefore, may not reflect a range of experiences. Future research would benefit from obtaining perspectives from a wider demographic. In addition, the location in which the interview was conducted i.e., a clinical setting, may have influenced women’s level of comfort compared to home and the quality of their responses.