Developing a realist informed framework for cultural adaptation of lifestyle interventions for the prevention of type 2 diabetes in South Asian populations in Europe

Abstract

Aims Selected lifestyle interventions proven effective for White‐European populations have been culturally adapted for South Asian populations living in Europe, who are at higher risk of type 2 diabetes. However, a limited theoretical basis underpins how cultural adaptations are believed to augment intervention effectiveness. We undertook a realist review to synthesise existing literature on culturally adapted type 2 diabetes prevention interventions, to develop a framework that shows ‘how’ cultural adaptation works, for ‘whom’ and in ‘what contexts’. Methods We followed the stepped methodological approach of realist review. Our work concluded a European‐wide project (EuroDHYAN), and core studies were identified from the preceding EuroDHYAN reviews. Data were extracted, coded into themes and synthesised to create ‘Context–Mechanism–Outcome’ configurations and to generate a refined explanatory framework. Results We identified eight core intervention papers. From this evidence, and supporting literature, we examined the ‘Team’ domain of cultural adaptation and identified a mechanism of shared cultural identity which we theorised as contributing to strong team‐participant relationships. We also identified four key contexts which influenced intervention outcomes: ‘research setting’ and ‘heterogeneous populations’ (intrinsic to the intervention) and ‘broader environment’ and ‘socio‐cultural stress’ (extrinsic barriers). Conclusions This work instigates research into the mechanisms of cultural adaptation which, if pursued, will allow a more nuanced understanding of how to apply adaptations, and for whom. In practice we recommend greater consideration of heterogeneous and intersecting population characteristics; how intervention design can safeguard sustainability; and how the four key contexts identified influence how, and whether, these interventions work.

Culturally adapting the Mediterranean Diet pattern – a way of promoting more ‘sustainable’ dietary change?

“…Even here it is important to be sensitive to differences within culturally similar groups in terms of dietary preferences, for example, by age (49) , whilst different levels of adherence to MD advice have also been associated with partners' adherence to MD, suggesting a mediation by household members' support and, in particular, family function (94) . Other examples of cultural adaption have occurred in terms of weight-loss interventions in children (95) , lifestyle management in relation to T2D (96)(97)(98)(99) , school-based smoking cessation (100) and weight management in fathers (101) .…”

“…An examination of cultural adaptation of lifestyle interventions for the prevention of T2D in South Asian populations in Europe (97) agreed that a structured approach to understand and advance cultural adaptation is important to develop effective health promotion programmes to tackle inequities in health. The authors acknowledge that their findings do not fully unpack 'how' these interventions work, for 'whom' and in 'what contexts', but they do assist in proposing a structured approach to undertake further 'sense-making' of existing approaches to adaptation, and also highlight some of the key contextual considerations which influence the outcomes of these interventions (97) .…”

“…An examination of cultural adaptation of lifestyle interventions for the prevention of T2D in South Asian populations in Europe (97) agreed that a structured approach to understand and advance cultural adaptation is important to develop effective health promotion programmes to tackle inequities in health. The authors acknowledge that their findings do not fully unpack 'how' these interventions work, for 'whom' and in 'what contexts', but they do assist in proposing a structured approach to undertake further 'sense-making' of existing approaches to adaptation, and also highlight some of the key contextual considerations which influence the outcomes of these interventions (97) . The authors suggest greater consideration of how adaptations fit with heterogeneous and intersecting population characteristics; how intervention design can safeguard sustainability beyond any investigative phase, ultimately becoming embedded in established health service or community structures; and lastly, what broader contextual influences may limit participant capacity for behaviour change and if there is any way to address or mitigate these influences (97) .…”

The acceptability and effect of a culturally-tailored dance intervention to promote physical activity in women of South Asian origin at risk of diabetes in the Netherlands—A mixed-methods feasibility study

“…This study was part of larger project (i.e. EuroDHYAN) [8,19], which aimed to facilitate the development of novel and targeted health promotion strategies to effectively reduce the risk of T2D in SA origin populations in Europe.…”

The power of equality

“…Where more complex stratification or adaptation is required to address health inequalities and optimise outcomes, a methodology is required to approach the challenge systematically. Adapting population lifestyle interventions for ethnic minorities requires a clear framework and this is provided for the first time in this issue 2 in an important piece of work that begins the complex work of ensuring that adaptation takes account of all aspects of people's lives and is not a simple translation of resources aimed at other groups.…”