Punjabi Sikh patients' perceived barriers to engaging in physical exercise following myocardial infarction

Factors facilitating and hindering South Asian immigrant adults from engaging in exercise and physical activity - a qualitative systematic review

BACKGROUND

Exercise and physical activity are key components of management in patients with rheumatic musculoskeletal diseases (RMD), but people of the South Asian communities have a lower level of engagement with these activities compared to their Caucasian counterparts. The aim of this qualitative systematic review was to determine the barriers and facilitators of exercise and physical activity in South Asian communities who have migrated and live in western countries, particularly in those who have RMD.

METHODS

Qualitative studies, published in English between 1999 and 2021 and including evaluation of barriers and/or facilitators to exercise or physical activity behaviour in people of South Asian adult communities who have migrated and/or lived in western countries were identified from Embase, MEDLINE, CINAHL, PsycINFO, Google Scholar and manual searches. The studies were appraised using the CASP checklist. Inductive thematic synthesis was used to identify common and global themes.

RESULTS

A total of 32 studies that discussed barriers and facilitators of physical activity in South Asian communities who have migrated and lived in western countries were used for this review but there were no studies identified that focussed specifically on those with RMD. Following appraisal of the reporting of the studies, 30 studies were included in the pooling of the results. The facilitators and barriers to physical activities were broadly categorized into 'extrinsic' and 'intrinsic' factors. Extrinsic factors such as 'opportunity' included environmental factors such as weather and safety; socioeconomic factors such as education, language and literacy, and support in the form of social, psychological and resources. Intrinsic factors included cultural factors, such as life stages and family influence, beliefs and knowledge, which impacted attitudes and skills.

CONCLUSIONS

This review has synthesised evidence of barriers or facilitators and identified potentially modifiable factors influencing physical activity and exercise engagement, which could form the basis of evidence-based interventions to promote participation in healthy behaviour change. Provision of a safe, comfortable and culturally acceptable environment together with culturally-aligned cognitive strategies to facilitate acquisition of exercise-efficacy skills could help engagement.

REGISTRATION

The systematic review was registered on PROSPERO, registration no. 289,235.

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study

BACKGROUND

The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models.

OBJECTIVE

The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic.

METHODS

Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis.

RESULTS

Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation.

CONCLUSIONS

Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review

Background

There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies.

Methods

We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers.

Results

In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services.

Conclusions

The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding of these factors will allow future interventions to be more evidence based with clear objectives as to how to address the known barriers to improve access.

Limitations

Time limitations constrained the consideration of study quality and precluded the inclusion of additional searching methods such as citation searching and contacting key authors. This may have implications for the completeness of the evidence base identified.

Future work

High-quality effectiveness studies of promising interventions to improve attendance at rehabilitation, both overall and for key patient groups, should be the focus moving forward.

Funding

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HSDR programme or the Department of Health.

Study registration

The study protocol is registered with PROSPERO [CRD42022309214].

Patient-Centered Care Experiences of First-Generation, South Asian Migrants with Chronic Diseases Living in High-Income, Western Countries: Systematic Review

BACKGROUND

First-generation migrants from South Asia account for a considerable proportion of the immigrant populations in high-income, western countries and are at a high risk of developing complex, chronic diseases such as cardiovascular disease and diabetes. Yet, previous systematic reviews have not synthesized information about the healthcare needs and preferences of such migrants and the best ways for health services to provide them with appropriate, culturally sensitive, patient-centered care. The aim of this study is to systematically review the international evidence about first-generation, South Asian migrants' healthcare experiences from the patients' perspectives.

METHODS

Five databases were searched for qualitative, quantitative, and mixed methods studies published between January 1990 and April 2020. Fourteen thousand, six hundred and forty-four papers were retrieved and screened using pre-determined eligibility criteria. Sixty-one papers were included in this narrative synthesis. Relevant qualitative findings from the included papers were thematically analyzed, and quantitative findings were summarized.

RESULTS

Five themes emerged from findings: 1) Healthcare services engaged; 2) the language barrier; 3) experiences and perceptions of healthcare advice; 4) the doctor-patient relationship; and 5) the role of patients' families in supporting access and delivery of healthcare.

CONCLUSION

The findings indicate that communication barriers reduce the cultural and linguistic appropriateness of healthcare. Potential solutions include employing healthcare staff from the same cultural background, training healthcare professionals in cultural competence, and proactively including first-generation, South Asian migrants in decision-making about their healthcare. Future research should explore South Asian migrants' experiences of multimorbidity management, continuity of care, interdisciplinary collaboration, the formation of treatment plans and goals as little to no data were available about these issues.

‘We just don’t have this in us…’: Understanding factors behind low levels of physical activity in South Asian immigrants in Metro-Vancouver, Canada

Background

South Asian immigrants in western countries are at a high risk for metabolic syndrome and associated chronic disease. While a physically active lifestyle is crucial in decreasing this risk, physical activity (PA) levels among this group remain low. The objectives of this study were to explore social and cultural factors that influence PA behavior, investigate how immigration process intersects with PA behaviors to influence PA levels and to engage community in a discussion about what can be done to increase PA in the South Asian community.

Methods

For this qualitative study, we conducted four Focus Group Discussions (FGDs) among a subset of participants who were part of a larger study. FGD data was coded and analysed using directed content analysis to identify key categories.

Results

Participants expressed a range of opinions, attitudes and beliefs about PA. Most believed they were sufficiently active. Women talked about restrictive social and cultural norms that discouraged uptake of exercise. Post-immigration levels of PA were low due to change in type of work and added responsibilities.

Conclusion

Health promoters need to consider social, cultural, and structural contexts when exploring possible behavior change interventions for South Asian immigrants.

A qualitative exploration of perspectives of physical activity and sedentary behaviour among Indian migrants in Melbourne, Australia: how are they defined and what can we learn?

Background

Although perceptions of what constitutes physical activity (PA) may vary between culturally diverse populations, very little research has explored the perceptions of PA among Indian migrants. This study aimed to identify how PA and sedentary behaviour (SB) are defined and describe how these definitions are shaped by cultural background and migration among a sample of Indian migrants living in Australia.

Methods

Using an exploratory qualitative approach, semi-structured interviews were conducted with twenty-one Indian migrants living in Melbourne (10 men and 11 women; age range: 18 to 65 years). Interviews were audio-recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analyses.

Results

Data revealed two emerging themes: 1) Holistic perspectives related to PA, where although the majority of participants described PA as “any sort of movement”, or “physical exercise”, several of these descriptions had interwoven ideas related to the mind (mind-body connect), social, cultural, and to the outdoor environment; 2) Broader perspectives for SB, where descriptions of SB as “not having movement”, “doing nothing” or “being lazy”, were shaped with ideas of purpose and duration. Women spoke about how their perspectives of PA and SB may be shaped by native Indian experiences, particularly the gender roles, social caste, and regional subcultural norms which they perceived were important to consider among women who migrate to western settings.

Conclusions

Cultural background is important in shaping the perspectives of PA and SB among Indian migrants in Australia. Practitioners and researchers should consider the varying perspectives of PA to communicate and promote PA among migrant populations more effectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12099-4.

Factors that influence adherence to treatment plans amongst people living with cardiovascular disease: A review of published qualitative research studies

BACKGROUND

Treatment plan adherence is recognized as a worldwide health issue, particularly important in the management of cardiovascular patients. Healthcare professionals are the primary sources of information and support for people diagnosed with CVD and those who have experienced a cardiac event, yet we know little about how healthcare professionals contribute to the process of adherence to treatment plans that aim to prevent and/or reduce disease and adverse events. Qualitative evidence that explores factors that influence adherence to treatment plans is limited.

OBJECTIVE

This systematic review identified and synthesised the best available evidence on factors that influence adherence to treatment plans amongst people living with cardiovascular disease.

DESIGN

Systematic review and qualitative synthesis.

METHODS

Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase- Non-Medline, Scopus, Cochrane Library, ProQuest Central (Grey Literature). Pre-defined keywords and MeSH terms were used to identify qualitative methods English-language studies published between 2001 and 2018. Quality appraisal of each paper was completed using the JBI Critical Appraisal Checklist and two reviewers extracted the data independently.

RESULTS

Twenty-two articles were included. Eight key themes were identified that related to facilitators and barriers to adherence to treatment plans. Facilitators were identified as engaging in exercise, having support and mentorship, lifestyle modification, and the perceived value of taking medication. Barriers were identified as a perceived lack of support, concerns about taking medication, and lack of engagement in exercise and lifestyle changes.

CONCLUSIONS

The findings highlight the factors that support adherence and healthcare professionals can build on also the areas that can be targeted to support and improve adherence to treatment plans. Nurses can play an important role in enhancing the provision of information pre hospital discharge and support in the community on taking medication, the value of physical activity and dietary changes.

A systematic review and thematic synthesis exploring how a previous experience of physical activity influences engagement with cardiac rehabilitation

BACKGROUND

Exercise-based cardiac rehabilitation is recognised internationally as an effective therapy to improve quality of life and reduce the risk of hospital readmission for individuals diagnosed with acute coronary syndrome. Despite this, half of eligible individuals choose not to engage and the main reason is lack of interest. Furthermore, prior to attending, 40% of eligible individuals report meeting physical activity guidelines. It is unclear whether this influences decisions about engagement.

AIMS

The aim of this review is to examine systematically qualitative evidence describing patients' perceptions and experiences, and synthesise what is known about how a previous experience of physical activity in adults diagnosed with acute coronary syndrome influences engagement with physical activity during cardiac rehabilitation.

METHODS

A systematic review and thematic synthesis was conducted of primary qualitative studies to examine peer-reviewed literature published between1990 and 2017, accessed from database searches of MEDLINE, CINHAL, PsycINFO and Embase.

RESULTS

The initial search produced 486 studies, and of these 12 relevant studies were included in this review. Studies included 388 participants from six countries. For previously active individuals, communication factors, self-perceptions of an exercise identity and experience of cardiac rehabilitation influence engagement in physical activity during cardiac rehabilitation.

CONCLUSION

In adults diagnosed with acute coronary syndrome, communication post event and during cardiac rehabilitation is a source of self-appraisal and creates expectations of cardiac rehabilitation. In addition, perceptions of an exercise identity and experience of exercise-based cardiac rehabilitation influence decisions about engagement. To improve uptake and adherence, health professionals should consider previous physical activity levels and tailor information to optimise physical activity post event.

The Role of Physical Activity Prescription in Cardiovascular Disease Prevention Amongst South Asian Canadians

Unequivocal evidence suggests an increased prevalence of cardiovascular disease (CVD) amongst South Asian Canadians (SACs) compared to other ethnic cohorts, due to a combination of their unique cardiometabolic profile and environmental factors. This unfavorable CVD profile is characterized by an elevated risk of dyslipidemia, high apolipoprotein B/apolipoprotein A1 ratio, hypertension, glucose intolerance, type 2 diabetes mellitus, as well as increased BMI, body fat percentage, abdominal and visceral adiposity. Despite the overwhelming evidence for the effectiveness of physical activity (PA) in circumventing the onset of CVD and in the reduction of CVD risk factors, SACs are among the most physically inactive cohorts in Canada. This relates to a set of common and unique socio-cultural barriers, such as gender, beliefs and perceptions about illness, immigration, unfavorable PA environments, and their high prevalence of debilitating chronic diseases. Several strategies to improve PA participation rates in this high-risk population have been suggested, and include the implementation of culturally sensitive PA interventions, as well as clinician training in PA prescription through workshops that emphasize knowledge translation into clinical practice. Therefore, the purpose of this mini-review is to highlight and discuss: (1) the burden of heart disease in SACs (2) the cardiovascular benefits of PA for SACs; (3) factors affecting PA participation among SACs and how they can be addressed; (4) the impact of culturally sensitive PA prescription on CVD prevention; (5) barriers to culture-specific PA prescription by clinicians, and strategies to improve its use and impact.

Coronary Artery Disease Patient Perspectives on Exercise Participation

PURPOSE

Participation in exercise programs postmyocardial infarction is highly protective against future events and mortality. Unfortunately, uptake and maintenance of exercise participation has been documented as being low. This is thought to be due to a myriad of barriers. Qualitative research is a powerful tool to explain behaviors. We sought to summarize existing qualitative literature exploring patient perspectives of participation in exercise after a cardiac event.

METHODS

We updated and built upon a previous systematic review and meta-synthesis by identifying qualitative literature that was not previously captured. We used grounded formal theory to synthesize the qualitative findings in the selected literature. This process led to the development of a comprehensive conceptual framework for understanding the determinants of exercise participation.

RESULTS

We found that external, internal, and cultural factors work together as umbrella themes to influence exercise initiation and continued participation in patients who have experienced a cardiac event. Internal factors expand into physical, cognitive, and emotional domains, which include fear, motivation, and mood. External factors include the domains of pragmatic and social considerations such as safety, accessibility, and social support networks. Cognitive and social domains were the most frequently cited factors influencing participation in exercise programs.

CONCLUSIONS

The framework we outline allows for a more complete understanding of the factors that influence the exercise behaviors of patients with coronary artery disease. Cardiac rehabilitation programs should consider the key factors and capitalize on this knowledge, making these facilitators rather than barriers to exercise participation.

Fatigue and acute coronary syndrome: a systematic review of contributing factors

Fatigue is a symptom of ACS, but it remains unclear who is at risk and what factors contribute to fatigue. The purpose of the systematic review was to identify factors that influence fatigue in patients with ACS. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature published from 1981 to 2017 was reviewed, and of 983 articles screened, 36 met inclusion criteria. Variables contributing to fatigue fell into 3 categories: demographic characteristics, clinical characteristics, and other factors. More fatigue was found in women than men, and significant differences in fatigue were identified by race. Additionally, sleep deprivation, depression, and anxiety were associated with higher levels of fatigue. The findings highlight the importance of demographic, clinical, and other factors' impact on fatigue in ACS patients. Fatigue is an important symptom in ACS and healthcare providers must recognize how patient variables affect symptom expression.

The effectiveness and experience of self-management following acute coronary syndrome: A review of the literature

OBJECTIVES

To evaluate the effectiveness of interventions used to support self-management, and to explore patients' experiences after acute coronary syndrome in relation to self-management.

DESIGN

Scoping review.

DATA SOURCES

Keyword search of CINAHL Plus, Medline, the Cochrane Library, and PsycINFO databases for studies conducted with adult population and published in English between 1993 and 2014.

REVIEW METHODS

From title and abstract review, duplicated articles and obviously irrelevant studies were removed. The full texts of the remaining articles were assessed against the selection criteria. Studies were included if they were original research on: (1) effectiveness of self-management interventions among individuals following acute coronary syndrome; or (2) patients' experience of self-managing recovery from acute coronary syndrome.

RESULTS

44 articles (19 quantitative and 25 qualitative) were included. Most studies were conducted in western countries and quantitative studies were UK centric. Self-management interventions tended to be complex and include several components, including education and counselling, goal setting and problem solving skills which were mainly professional-led rather than patient-led. The review demonstrated variation in the effectiveness of self-management interventions in main outcomes assessed - anxiety and depression, quality of life and health behavioural outcomes. For most participants in the qualitative studies, acute coronary syndrome was unexpected and the recovery trajectory was a complex process. Experiences of making adjustment and adopting lifestyle changes following acute coronary syndrome were influenced by subjective life experiences and individual, sociocultural and environmental contexts. Participants' misunderstandings, misconceptions and confusion about disease processes and management were another influential factor. They emphasised a need for ongoing input and continued support from health professionals in their self-management of rehabilitation and recovery, particularly during the initial recovery period following hospital discharge.

CONCLUSIONS

Evidence of the effectiveness of self-management interventions among people with acute coronary syndrome remains inconclusive. Findings from the patients' experiences in relation to self-management following acute coronary syndrome provided important insights into what problems patients might have encountered during self-managing recovery and what support they might need, which can be used to inform the development of self-management interventions. Theoretical or conceptual frameworks have been minimally employed in these studies and should be incorporated in future development and evaluation of self-management interventions as a way of ensuring clarity and consistency related to how interventions are conceptualised, operationalised and empirically studied. Further research is needed to evaluate self-management interventions among people following acute coronary syndrome for sustained effect and within different health care contexts.

Fatigue in Older Adults Postmyocardial Infarction

OBJECTIVE

The purpose of this study was to comprehensively examine putative factors that may independently contribute to fatigue and subsequent persistence of fatigue in elderly adults 6-8 months post-myocardial infarction (MI). Studies suggest cardiac function, comorbidities, daytime sleepiness, depression, anemia, interleukins, and social support are correlates of fatigue; however, no studies have systematically examined these factors 6 months post-MI in an aging population.

METHODS

Study participants included 49 women and men (N = 98) ages 65-91 who were 6-8 months post-MI. Data collection included the demographic health status questionnaire (heart rate, blood pressure, body mass index, and medications), fatigue-related comorbidity scale, revised Piper fatigue scale, Epworth sleepiness scale, geriatric depression scale, social provisions scale, and venous blood tests (B-natriuretic peptide, hemoglobin, and interleukin-6).

RESULTS

Fatigue persisted after MI in 76% of older men and women with no difference by sex. Only depression scores (P trend = 0.0004) and mean arterial pressure (P trend = 0.015) were found to be linearly independent predictors for fatigue, controlling for age, Il-6 levels, and body mass index.

CONCLUSION

Post-MI depression and mean arterial blood pressure are important to assess when examining fatigue post-MI in older populations.

A systematic review and metaethnography to identify how effective, cost-effective, accessible and acceptable self-management support interventions are for men with long-term conditions (SELF-MAN)

Background

Self-management support interventions can improve health outcomes, but their impact is limited by the numbers of patients able or willing to access them. Men’s attendance at, and engagement with, self-management support appears suboptimal despite their increased risk of developing serious and disabling long-term conditions (LTCs).

Objectives

To assess the effectiveness, cost-effectiveness, accessibility and acceptability of self-management support interventions in men with LTCs.

Methods

A quantitative systematic review with meta-analysis and a qualitative review using a metaethnography approach. The findings of the two reviews were integrated in parallel synthesis.

Data sources

In the quantitative review, the Cochrane Database of Systematic Reviews was searched to identify published reviews of self-management support interventions. Relevant reviews were screened to identify randomised controlled trials (RCTs) of self-management support interventions conducted in men alone, or which analysed the effects of interventions by gender. In the qualitative review, the databases Cumulative Index to Nursing and Allied Health Literature, EMBASE, Medical Literature Analysis and Retrieval System Online, PsycINFO and Social Science Citation Index (July 2013) were searched from inception to July 2013.

Review methods

In the quantitative review, data on relevant outcomes, patient populations, intervention type and study quality were extracted. Quality appraisal was conducted independently by two reviewers using the Cochrane risk of bias tool. Meta-analysis was conducted to compare the effects of interventions in male, female and mixed-sex groups. In the metaethnography, study details, participant quotes (first-order constructs) and study authors’ themes/concepts (second-order constructs) were extracted. Quality appraisal was conducted independently by two reviewers using the Critical Appraisal Skills Programme tool. Data were synthesised according to a metaethnography approach. Third-order interpretations/constructs were derived from the extracted data and integrated to generate a ‘line-of-argument’ synthesis.

Results

Forty RCTs of self-management support interventions in male-only samples, and 20 RCTs where an analysis by gender was reported, were included in the quantitative review. Meta-analysis suggested that interventions including physical activity, education and peer support have a positive impact on quality of life in men, and that men may derive more benefit than women from them, but there is currently insufficient evidence to draw definitive conclusions. Thirty-eight qualitative studies relevant to men’s experiences of, and perceptions of, self-management support were included in the qualitative review. The metaethnography identified four concepts: (1) need for purpose; (2) trusted environments; (3) value of peers; and (4) becoming an expert. Findings indicated that men may feel less comfortable engaging in support if it is perceived to be incongruous with valued aspects of masculine identities. Men may find support interventions more attractive when they have a clear purpose, are action-oriented and offer practical strategies that can be integrated into daily life. Support delivered in an environment that offers a sense of shared understanding can be particularly appealing to some men.

Conclusions

Health professionals and those involved in designing interventions may wish to consider whether or not certain components (e.g. physical activity, education, peer support) are particularly effective in men, although more research is needed to fully determine and explore this. Interventions are most likely to be accessible and acceptable to men when working with, not against, valued aspects of masculine identities.

Study registration

This study is registered as PROSPERO CRD42013005394.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

I've lost the person I used to be--experiences of the consequences of fatigue following myocardial infarction

Fatigue has been found to be the most frequent and bothersome symptom after myocardial infarction (MI), influencing health-related quality of life negatively. Moreover, fatigue after MI has been described as incomprehensible due to its unpredictable occurrence and lack of relationship to physical effort. The aim of this study is therefore to explore persons' experiences of consequences of fatigue and their strategies for dealing with it 2 months after MI. In total, 18 informants, aged 42-75 years, participated in the study. Interviews were conducted and analysed using constructivist grounded theory methodology. Grounded in the data, the main consequence of fatigue, as illustrated in the core category, was: I've lost the person I used to be. It indicates a sense of reduced ability to manage daily life due to experiences of fatigue. The core category was developed from the four categories: involuntary thoughts, certainties replaced with question marks, driving with the handbrake on and just being is enough. Furthermore, attempts to relieve fatigue were limited. These findings indicate that patients with symptoms of fatigue should be supported in developing relief strategies, for example, rest and sleep hygiene as well as physical activity. In conclusion, the results show that fatigue can be understood in light of the concepts "comprehensibility" and "manageability." They also indicate that, working from a person-centered perspective, health-care professionals can support patients experiencing post-MI fatigue by giving them opportunities to straighten out the question marks and by inviting them to discuss involuntary thoughts and feelings of being restricted in their daily life functioning.

Physical activity among South Asian women: a systematic, mixed-methods review

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.