1078738 research-article2022 WHE0010.1177/17455057221078738Women’s HealthLansburgh et al. Original Research Article Women’s Health Time for themselves: Perceptions Volume 18: 1­–13 © The Author(s) 2022 Article reuse guidelines: of physical activity among first and sagepub.com/journals-permissions DOI: 10.1177/17455057221078738 https://doi.org/10.1177/17455057221078738 second-generation Pakistani women journals.sagepub.com/home/whe living in the Raval, Barcelona Flora Lansburgh1,2,3 , Constanza Jacques-Aviñó1,2 , Mariona Pons-Vigués4,5 , Rosemary Morgan6 and Anna Berenguera1,2 Abstract Objectives: Pakistani women experience higher-than-average rates of certain chronic diseases, including diseases related to sedentary lifestyles. The aim of this study is to explore how first and second-generation Pakistani women living in the Raval, Barcelona, conceive of physical activity, and their barriers and facilitators around participating in physical activity, with the goal of increasing physical activity in this group. Methods: Qualitative research with an intersectional approach. Nine informal interviews with key community informants were conducted from November 2018 to January 2019 to gain background on the topic, using snowball sampling. Eleven individual interviews were conducted from February to June 2019. Seven were with Pakistani women having lived, or currently living, in the neighborhood of the Raval, Barcelona. Four additional interviews were conducted with non-Pakistani women key community informants who have worked extensively with this community. Thematic content analysis was carried out using ATLAS.ti. Results: First-generation Pakistani women generally did not have physical activity present in their daily lives, but by most accounts wished to. Areas that shed light on this included the following: limited economic opportunities and associated living conditions, barriers to social integration, health concepts and access to information, and cultural norms and related gender roles. For the first-generation, gender-related divisions of labor as well as the absence of the concept of self-care were particularly relevant barriers to their participation in physical activity. The experience of immigration-related grief emerged as a transversal theme which overlapped with multiple areas. While both generations expressed a need for the separation of genders during physical activity—as per their cultural interpretation of Islam—the lack of such spaces was highlighted as a principal barrier in physical activity among the second generation. Conclusion: These findings shed light on distinct elements that exert influence in Pakistani women immigrants’ participation in physical activity—among them: social and living conditions, access to public space, and gender-related work distribution and cultural norms—which are in turn influenced by first or second-generation immigration status. Considering the specific needs of both groups when proposing politics and health programs to encourage physical activity is paramount in order to successfully partner with these populations. 1 F undació Institut Universitari per a la recerca a l’Atenció Primària de Corresponding author: Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain Flora Lansburgh, Fundació Institut Universitari per a la recerca a 2 Universitat Autònoma de Barcelona, Barcelona, Spain l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Av. Gran Via 3 Universitat Pompeu Fabra, Barcelona, Spain de les Corts Catalanes 587, àtic, Barcelona 08007, Spain. 4 Servei Català de la Salut (CatSalut), Barcelona, Spain Email: floralnsbrgh@gmail.com 5 Universitat de Girona, Girona, Spain 6 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Women’s Health Keywords migrants, Pakistan, physical activity, qualitative research, Spain, women’s health Date received: 29 August 2021; revised: 14 December 2021; accepted: 20 January 2022 Introduction populations that are poorer than those of the general popu- lation, including higher risks for T2DM and obesity, par- Economic immigration represents one of society’s largest ticularly in women.18–20 The higher rates of obesity in sources of health inequalities. Available evidence demon- Pakistani immigrant women is related to other cardiovas- strates that, compared to non-migrant populations, eco- cular risk factors.21 In Barcelona, gaining information nomic migrants experience a higher prevalence of chronic about physical activity levels within the female Pakistani diseases such as type 2 diabetes mellitus (T2DM) and car- population (either first or second-generation) is impeded diovascular diseases.1–3 Economic migrants also suffer by the fact that data on immigrant populations are limited from a higher prevalence of disease risk factors, including to the sole category of “developing countries.” Data on obesity and higher rates of sedentary lifestyles, which are Pakistani populations, specifically, are not available, nor strongly linked to the development of T2DM, high blood has the available data been disaggregated by sex.22 Factors pressure, and cardiovascular disease.4,5 Vulnerability to related to this group’s increased risks toward various these chronic diseases and disease risk factors, however, chronic diseases related to sedentary lifestyle and partici- differs within immigrant communities.6,7 The health of pation in disease-prevention practices have not been Pakistani women immigrants, for example, is affected by widely studied, nor are there strong data available around an intersection of social stratifiers including, but not lim- prevalence of physical activity among Pakistani women ited to, social class, immigrant status, gender, and age, all in their country of origin.23,24 of which influence their ability and desire to participate in The aim of this study is to explore how first and sec- physical activity, which may help reduce some of the dis- ond-generation Pakistani women living in the neighbor- ease risk factors associated with a sedentary lifestyle. hood of the Raval, Barcelona, conceive of health and Pakistani women’s experiences, including those of immi- physical activity. In light of the information above, we gration, are distinct from those of their male counterparts, sought to learn more about the unique experiences of resulting in different levels of vulnerability to chronic dis- facilitators and barriers toward participation in physical ease among female Pakistani immigrants compared to activity by seeking to better understand how the intersec- male Pakistani immigrants.8 tionality of immigrant status, gender, social class, and Pakistan is one of the world’s countries with the highest age (as well as other factors) lead to variations in experi- emigration rates, and with historically male-dominated ence. Exploring these variations between the generations emigration trends.9,10 This pattern of men establishing was deemed necessary, given that second-generation themselves in their host country and later bringing over Pakistani immigrants comprise an important part of the their wives or families—in addition to changing trends in emerging population in Barcelona. By understanding immigration patterns that include a greater number of their perspectives on and access to physical activity, tai- women emigrating from Pakistan—has resulted in shifts in lored health promotion strategies and interventions can Pakistani immigrant community demographics abroad.11 be created with the goal of increasing physical activity Spain remains one of the top European destinations for within this population, with the potential to positively Pakistani immigrants, even as immigrant populations in affect rates of chronic diseases related to sedentary life- the country have been especially hard hit during the reces- styles and social determinants of health. sion of 2012.12–14 As a consequence of the changing immi- gration patterns of the last 15 years, Barcelona’s population of Pakistani women has more than sextupled, up from 797 Methods women registered in the city to 5390 women in 2018—a Design shift in women’s representation within the Pakistani immi- grant population from 8% in 2003 to 28% in 2018.15–17 This exploratory qualitative study used an intersectionality This shift in immigration patterns, paired with the passage approach, which considers that people and their multiple of time, has resulted in a substantial presence of both first- identities in society are intersectional in nature, not simply and second-generation Pakistani immigrant women in additive.25,26 In the case of immigrant health outcomes, Barcelona. intersectionality theory moves away from a reliance on Studies in the United Kingdom, Norway, and the explanations rooted in cultural elements, to include a fuller United States show health outcomes among Pakistani and more complicated perspective of the factors that Lansburgh et al. 3 influence health among these collectives.27 This approach female. Seven interviews were carried out with first and informed our analysis in our awareness of the interdepend- second-generation Pakistani women. Four additional inter- ence of the multiple social identities of both first and sec- views were conducted with non-Pakistani women who ond-generation Pakistani women. Our understanding of were key community informants and had worked exten- the data, therefore, considered the context of, and intercon- sively with this community. Relationships with the inter- nected influences exerted on, the lives of these women.26,28 viewees were established at the time of the coordination Within this approach, we employed a social-construction- of, and course of the interviews. Coordination was done ism lens—a perspective which considers that social, his- through face-to-face contact as well as through phone. The toric, and cultural processes influence how people create socio-demographic characteristics of the eleven partici- their social reality.29 pants whose interviews formed the basis of the analysis are shown in Table 1. Pseudonyms were used to protect par- ticipants’ identities. Given the social-constructionism lens Study setting and participants that we employed, various Pakistani women participants The study population consisted of first and second-genera- spoke both from a personal perspective, as well as from the tion Pakistani women (18 years of age and older) who cur- perspective of a key informant, owing to their insight into rently live, or have lived, in the neighborhood of the Raval, the population of study, gained through their work in this Barcelona, or who have extended connections to the area, community. as well as key community informants who were chosen Interviews ranged from 35 to 75 min in length and fol- due to their extensive familiarity and involvement with lowed a semi-structured topic guide informed by the infor- this group. The Raval is among the neighborhoods in mal interviews conducted previously, presented in the Barcelona with the least-favorable indices of socioeco- Interview Guide, attached. Participants were informed of the nomic deprivation, which studies have correlated with goal to glean more information around the subject of health poorer health outcomes.30 It was chosen due to its status as in Pakistani women in Barcelona, and in physical activity in the neighborhood with the largest immigrant population in particular. A pilot test was not conducted, but rather specific all of Barcelona, and particularly for representing the heart interview questions shifted gradually across interviews as of the Pakistani community in the city.31 themes in discourse emerged and generally followed the We considered first-generation Pakistani women to be structure of the guide, flowing with the conversation to cover those women who immigrated as head of households,32 the topics referenced, without following a strict order. Our and women whose parents made the decision to immi- topic guide included themes both directly and indirectly grate—whether they themselves were born in Pakistan or related to physical activity: concepts of health, perceptions of Spain—to be second-generation. This category is some- physical activity, explicit and implicit barriers and facilita- times referred to as generation 1.5.33 tors, the role of religion, the influence of Pakistani culture as Participants were selected through purposive snowball the participant perceived it, social networks, housing, moth- sampling.25,29 Recruitment was done through connections ering, and language. The perspective of gender within these made with community associations and primary health topics was maintained throughout the interviews. care centers in the Raval, with members and cultural medi- Nine of the 11 interviews were carried out in Spanish, ators themselves being interviewed, as well as referring with one interview carried out in English, by request of the friends and acquaintances. Non-Pakistani key informants participant, and another in Urdu with the aid of a transla- were included because of the wider lens they offered of the tor. With the exception of the interview translated from context of the community in the Raval, as well as their Urdu, all interviews were conducted by the principal vision of the changes within this community over time. investigator with no additional persons present. Interviews were conducted at a place of convenience determined by the participant. The number of interviews conducted was Data collection and generation techniques determined by reaching saturation of information, ceasing To begin the research process, nine informal interviews when no new remarkable themes entered the discourse.25 with both non-Pakistani and Pakistani key community All interviews were audio-recorded in order to accu- informants were conducted by the principal investigator rately capture the participants’ responses and to ensure from November 2018 to January 2019, in order for the first data quality. Interviews were transcribed by the principal author to gain a better understanding of the context of investigator. Participant-identifying data were anonymized. Pakistani immigrant women living in the Raval. These interviews served to develop the topic guide for inter- Data analysis and quality of data. A thematic content anal- views, and did not form a part of the interviews analyzed ysis of each interview transcription was done with the for thematic content. technical support of ATLAS.ti software, which was used Following this, 11 individual in-depth interviews were to facilitate the organization and coding of the data, car- conducted between January and June of 2019 by the prin- ried out with the principals of thematic content analy- cipal investigator, a graduate student who self-identifies as sis.34,35 The process for analyzing the data was the 4 Women’s Health Table 1. Participant demographics. Participant demographics Name Age Cultural First or second Years in Marital Children From rural range background generation Spain status area or city First and second-generation Pakistani women Aisha 25–30 Pakistan Second 15 Married Yes City Fatima 18–35 Pakistan Second 9 Unmarried No Rural Yasmin 50–53 Pakistan First 22 Married Yes City Nadeema 45–50 Pakistan First 17 Married Yes City Anousheh 30–35 Pakistan Second 16 Married No Rural Ruksana 35–40 Pakistan First 12 Married Yes City Key community informants Andrea 30–35 South America First 5 – Sara 45–50 South Asia First 22 – Mar 65–70 Catalonia – – – Joana 35–40 Catalonia – – – following: interviews were transcribed verbatim; after Within the categories, some themes were loosely multiple readings of the transcriptions, the researcher related to physical activity, or could be inferred, while began to formulate pre-analytical understanding of the others were directly related. The lack of the concept of data; transcripts were coded by the principal researcher self-care, physical space, and limitations of time and based on the identification of relevant texts and topics energy were important barriers to physical activity, while and organized by theme (broader areas that encompassed gender-specific spaces, the desire to lose weight, and the codes) with the assistance of the ATLAS.ti software; education (both higher education and health education) themes were analyzed and grouped into categories based served as facilitators. on the criterion of similarity; categories were chosen Given the intersectional approach in the analysis, each based off of their mutual exclusivity, and each category category should also be considered to be transversal, as the was reviewed by the team; results were discussed among implications of one are not independent of the others. research team members, with different team members Migratory grief (sorrow related to the migratory process), independently analyzing transcripts by theme; results for example, exerted significant influence in many experi- were triangulated between researchers until a consensus ences of first-generation women, although it was placed on categories was reached. Categories were emergent and within the context of the category of “social integration.” inductive in nature.35–37 Likewise, identities around gender and socioeconomic sta- tus were found to be transversal in the influence they Ethical considerations and consent to participate. This study exerted across categories. followed the tenants of the Declaration of Helsinki. Par- ticipation was voluntary, and all participants gave informed Economic opportunities and living conditions written consent. Confidentiality and data protection were guaranteed. The study was approved by the Clinical Socio-economic status played a determining role in dictat- Research Ethics Committee of the Institut Universitari ing the possibility of free time, access to resources, and d’Investigació en Atenció Primària Jordi Gol(2019,19/024- disposition toward participating in physical activity, as P). Participants received a transportation pass worth 10€ in well as Pakistani women’s sense of well-being. In addi- acknowledgment of their time. tion, it had the direct consequence of determining wom- en’s immediate living environment and access to physical space, both public and private. Results Although living in the neighborhood of the Raval The results are classified into four categories, chosen offered the benefits associated with being within the based on the pertinence of these categories on the topic of heart of the Pakistani community in Barcelona, its status barriers and facilitators to physical activity: economic as a neighborhood of socio-economic deprivation was opportunities and living conditions, social integration, felt in its lack of agreeable public space, and/or the dis- health concepts and access to information, and cultural comfort women felt in spending time in public spaces— norms and gender roles. Illustrative quotations of each cat- often stemming from the constant presence of Pakistani egory are shown in Table 2. men in the streets: Lansburgh et al. 5 Table 2. Representation of categories through participants’ quotations. Representation of categories through participants’ quotations Economic “They [Pakistani women] have a lot of economic difficulties, really. That affects things too. Look! You, you have a opportunities good wage, you can live relaxed. You’re excited to go out. To dress well. To . . . learn things. And . . . everyone and living wants to improve their life. But when you fight and no opportunity comes your way, at some point, you stop trying.” conditions (Nadeema, first-generation Pakistani woman) “There in Pakistan families have really large houses. So the women . . . when they first arrive? They feel shut up . . . in their houses. Because here the houses are small. But bit by bit, with time, they get better. But still . . . when they are in Pakistan they feel more free, they are happier . . . because, it’s because they’re happy. They go to see their family, they go to see the people who . . . love them the most. The people that they miss.” (Fatima, second- generation Pakistani woman) “If she has her kids, and has a . . . a house, a good . . . a good apartment, not the small messed-up Barcelona apartments that are 40 meters squared. Not that. If they have a nice apartment . . . and the husband has a . . . a good salary, and she’s completing all of the . . . expectations of a wife, then she’d be happy, no?” (Anousheh, second- generation Pakistani woman) “Yea, lack of confidence and somewhere the thing, the main thing is that when you are dependent on your husband, then you have to ask money for the gym, you have to ask money for the clothes, you have to ask money for everything . . . then somewhere we cannot ask all the time for our husbands to give this, this, this to us.” (Ruksana, first-generation Pakistani woman) “They don’t have a date when they’ll go visit the family, you know? And their husband, in general, have precarious jobs, and likewise, they can’t say, ‘Ok, relax. Every year we’ll spend 3 weeks in Pakistan.’ Their husbands can’t tell them this, because they don’t know. ‘Hopefully next year. If all goes well.’” (Mar, key community informant) Social “My dad speaks Spanish, but my mom doesn’t. My mom speaks Urdu, Punjabi, Sindhi, and other languages, yea. But integration she doesn’t speak . . . English too, because she studied it up until the end of high school. And . . . other languages. But Catalan and Spanish? No. She understands, but when it comes to talking, she doesn’t talk . . . because my mom had a lot of work. With us kids. Because we were six sisters and one brother . . . And of course, with all the work of that, after she’s tired. And she doesn’t have so much . . . it’s not that after she didn’t . . . before she was interested [in learning the language].” (Aisha, second-generation Pakistani woman) “Without this [language] we’re . . . deaf. Mute. Of course, we couldn’t . . . we could only communicate through . . . through drawings, no? Because the first problem, or a basic problem for Asiatic countries, is when they come here to work . . . they don’t know the language. Zero. And after that, there’s also zero cultural knowledge. Because it’s a cultural shock.” (Yasmin, first-generation Pakistani woman) Me, from my perspective? I don’t see them [Pakistani women] as being depressed . . . at least, the older ones, I don’t. The younger ones are the ones that I see as being more depressed . . . I’m not sure if it’s because of the stress of being in a new place, or for fear . . . with the older ones, is like, my belief, right? They’ve accepted what it is, how it is, and what is going to happen.” (Andrea, key community informant) “A lot of women that live here want to work. And in the beginning, they try hard. But when nothing comes of it, when no opportunity comes, then . . . they stop trying. And that also affects things . . . pains, or diseases, or that they no longer want to do a lot of things. No. For example, a woman . . . at first . . . I also have friends, some of them, that have done courses and they tried really hard, but they haven’t found any work, and now they’re a mess. They don’t want to do anything, they say that here nobody helps and we can’t find work, and so, why do we do it? Why do we learn? Why do we take another course if they don’t give us work. Why? It’s true.” (Nadeema, first-generation Pakistani woman) Health “They [the Pakisani women] told us that they felt a generalized body pain . . . eh, that we call the concept of body concepts pain. Because it’s not back pain, or chest pain, or some other pain, but more like, ‘everything hurts . . .’ Well, it’s and access to like an amalgamation of pains. They go to the CAP, and in the CAP normally they do tests and tell them that they information don’t have anything wrong with them, they give them an ibuprofen and send them home. So the women also end up frustrated because it’s like . . . the pain won’t go away.” (Joana, key community informant) “They they that they’ll see. When they already,for example, if a women . . . if, they tell her that if she doesn’t do this thing, she’ll get this disease, she says, “Well, when it happenss, then I’ll see.” (Anousheh, second-generation Pakistani woman) “Physical activity? That you finish all of your household chores. That you’re not sleeping all day. No. That you are able to cook, clean, wash, whatever it be, raise children, help your kids . . . help your family. That’s a physical state.” (Yasmin, first-generation Pakistani woman) “In my country, if, if you are 60 above or 70, we are always on the bed. And all our joints . . . [she shakes her head] because we are not doing exercises in our lives. So I always learn from them that how happy they are, they are trying to make theirselves healthier, and . . . they are doing something for theirselves. It’s very satisfying when you are healthy and you are not dependent on anyone. And I always notice the Spanish woman of age 70s, 80s, their bags, they take off all things, they are putting lotions on their . . . you know? They are giving time to theirselves. This is really important thing, that when you give your best time to yourself.” (Ruksana, first-generation Pakistani woman) (continued) 6 Women’s Health Table 2. (Continued) Representation of categories through participants’ quotations Cultural “If they [Pakistani women] do physical activity, it would be really good. Because that way they’d forget about their norms and problems. But to do that, they need energy. Because they use up so much energy working in the house, dropping off gender roles their kids, picking up their kids, cooking . . . And also from the stress that they have from family problems . . . so for them to have, for them to have energy, it’s really hard.” (Fatima, second-generation Pakistani woman) “But like I said, there are families that . . . where more or less everyone works, they help the woman out a little bit. There are . . . there are families. But you are the daughter-in-law. You have to do everything. And they [the daughter-in-laws] have to . . . they have to take care of the mother-in-law too, for example, if they have pain, they have to give them massages . . .” (Sara, key community informant) “If the kids are small it’s that . . . a lot . . . a lot of kids don’t eat at school. This means that the mom has a double obligation. To drop them off in the morning. At 12 they come and get them. Then at 3 they drop them off, at 4 they have to get them. It means . . . all day you’re coming, going, coming, going. So, that doesn’t allow much . . . many activities.” (Aisha, second-generation Pakistani woman) “Physical activity is . . . they [Pakistani women] need to have time for themselves. No? For their health. This isn’t . . . Pakistani women don’t . . . they don’t see this. They sacrifice, you know? When they’re already . . . when a woman is already married and has kids, she sacrifices for her kids. And doesn’t . . . she doesn’t see her own health. She doesn’t see anything. For her. For example, what I saw in my home, well, at my mom’s home . . . I have my mom as an example. My mother doesn’t see her own health. That was for her children.” (Anousheh, second-generation Pakistani woman) CAP: Centre d’Atenció Primària (primary health care center). Somewhere I don’t feel comfortable in Raval. Because lot of and struggle. Furthermore, the insecurity as to whether Pakistani community there, and they all belongs to the rural (and when) first-generation Pakistani women would return areas. And they have the same habit if you go, if you walk to Pakistan to visit loved ones added to the sense of pre- here, they look like you like from foot to head, “Oh, she’s a cariousness that was felt in their daily lives. The lived Pakistani woman, she’s not wearing hijab, she’s not wearing experience of such challenges was evident in the manifes- the partha . . . it must be that she’s not a good woman.” tation of migratory grief and the challenges of transition- (Ruksana, first-generation Pakistani woman) ing to life in Barcelona. While this need for public space was frequently cited, so too were the positive implications of the pub- Social integration lic spaces that did exist. Plazas were highlighted as act- Social integration (and the lack thereof) was profoundly ing as facilitators toward physical activity, in addition affected by migratory grief as it related to physical activ- to providing a platform for positive cultural shifts ity. Spending time in one’s home, for example, was often among the community: discussed in concert with various assumptions: on the one hand, women who stayed at home were considered Because when you have a space, a well thought-out space “lazy,” while, on the other hand, time spent at home was where you can go, where you can carry out social activities, sometimes seen as being connected to migratory grief and . . . a space where you can move around, without fear, and the lack of desire to engage with the culture outside without . . . risk . . . There, you can walk or fly. Happily. (Yasmin, first-generation Pakistani woman) of Pakistan. This absence of connection outside of the home was often linked to feelings of isolation and sadness. The focus that was placed on public space could be par- In addition, barriers presented by the non-immigrant tially attributed to the living conditions cited in the Raval. community were also evident: Both generations described the shift from a typically large house in a rural area in Pakistan to a shared apartment in In general, yes, they [Pakistani women] are women who are the Raval, offering a stark example of the impact of physi- isolated. They’re women who, once they are able to break cal environment in their daily lives. In the context of apart- their isolation, then have another barrier to overcome which ments of the Raval, physical activity was transformed is really difficult which is the . . . with . . . connecting with from being intrinsically tied to a woman’s daily routine, to the women from here. Ohh, it’s a problem. It’s not that . . . becoming almost obsolete, given the size and scope of the nobody talks about it, but it’s a wall. It’s a wall. (Mar, key household space available to her. community informant) The everyday impact of living in a neighborhood where physical space was limited as a result of socioeconomic Barriers to participation, including lack of work, pur- status was often reported as being a source of unhappiness pose, and interaction with the wider community, were also Lansburgh et al. 7 considered to be barriers to integration and were associ- created for Pakistani girls. Its success was largely due to ated with a subsequent lack of desire to create a life outside the cultural norms that were taken into account: the home: The teams are not mixed. Because they didn’t want that. So A lot of women that live here want to work. And in the the trainer is also a girl, like, it’s a space where they make sure beginning, they try hard. But when nothing comes of it, when that boys don’t go to watch and make comments while the no opportunity comes, then . . . they stop trying. And that also girls are training . . . it’s an intentional space. Not mixed. For affects things . . . pains, or diseases, or that they no longer the girls. And so it’s working really well for them. (Joana, key want to do a lot of things. (Nadeema, first-generation Pakistani community informant) woman) Health concepts and access to information Some Pakistani women never attempted to integrate, and therefore did not experience the negative aspects Concepts of health and lived experiences of disease were related to integration. often presented through somatization: the communication Communication was another barrier for the first gen- and interpretation of psychological distress through the eration. The desire and drive to learn Spanish or Catalan presentation of physical symptoms. The medical attention varied among first-generation immigrant women, but sought at primary care centers for health concerns treated was often influenced by time, energy, family responsi- ailments such as back and muscle pain—possibly associ- bilities, and leanings toward introversion. One partici- ated with somatization—through anti-inflammatories and pant gave the example of her mother, who spoke four muscle relaxers, and by many accounts, ineffectively. languages prior to moving to Spain, but did not have the There appeared to be a distinct unmet need for other ways time and energy to learn Spanish amid the task of caring of addressing these concerns: for six young children. Because second-generation women entered into the Muscle pain. Muscle. You know? Back pain. It’s from the school system as youth, they were exposed to Spanish and stress. They [Pakistani women] always have something, no? Catalan, and typically grew to be fluent in one or both lan- From thinking. Your muscles hurt from thinking so much. guages. This, however, did not preclude negative experi- (Anousheh, second-generation Pakistani woman) ences in the process: Both key informants, as well as women from the They [schoolmates] thought they were better than me. Pakistani community, talked about the utility of programs Because they knew the language, and they didn’t get along designed to address such health issues. The integration of with me. But bit by bit, once I . . . once I started learning the physical activity into these programs was frequently language, I knew how to respond to them, you know? . . . And noted as fulfilling an otherwise unmet need. Many now they’ve become my best friends. (Fatima, second- women wished to have physical activity programs that generation Pakistani woman) included physical therapy to address ongoing health issues. While the primary health care center served some Among the second-generation Pakistani women, of the health needs of the population by being an acces- enrollment in, and completion of, primary and secondary sible and well-regarded health care service, it did not school was common. These girls were raised with the adequately match the education levels, cultural needs, expectation that they would enter the workforce, as well and language barriers of the women seeking care. Cultural as comply with cultural and familial values, and espe- and language mediators were seen by both Pakistani cially those related to the religion of Islam. The need to women and key community informants as being indis- wear the hijab at work was frequently cited by this group pensable, although not always available: as a condition of their participation in the labor force, and the act of working was not perceived as competing Often when they go to the primary health care center, there’s with the desire to have children, and/or a trajectory that not much time. And on top of that they [Pakistani women] included motherhood. don’t . . . they have difficulty with the language. They can’t Integration into the wider community acted as a facili- explain well. (Aisha, second-generation Pakistani woman) tator toward physical activity, as clearly evidenced by the second generation, who participated in gym classes as a Prevention, like health-promotion, was a concept that part of their general schooling and regarded physical activ- was aided by access to education. For first-generation ity as a normal—and desired—part of a healthy lifestyle. Pakistani women, this often took the form of health-educa- Their participation in physical activity changed somewhat tion, while for second-generation Pakistani women, health as they became adolescents, due to the cultural need for the promotion was often integrated into their schooling. separation of genders during physical activity. A modifica- According to many accounts, in the absence of bodily tion that satisfied this need was a cricket league that was pain, steps were seldom taken to prevent disease. Access to 8 Women’s Health health information acted as a catalyst to shift women’s among participants on both a personal and cultural daily activities to include elements of physical activity, or level, transcending intergenerational differences. Self- to begin considering its importance: sacrifice for the sake of one’s children was a notion that was largely embraced and accepted as a condition of They [Pakistani women] are extremely sedentary. Extremely motherhood. Meanwhile, there was also an awareness sedentary. Sedentary, like . . . culturally everything that is that the concept of “time for oneself” was lacking related to physical activity, as a fundamental aspect of health? among mothers, and that its absence in women’s lives It’s not understood. They have not integrated it. (Mar, key was detrimental. community informant) Time for themselves, and the concept of self-care, was described as something that women seemed to want to Participants differed on their perspective as to whether incorporate into their lives, even as this shift was some- Pakistani women wanted to engage in physical activity. times acknowledged as being at odds with the self-sacri- Almost unanimous, however, was the idea that it would be fice that was required and expected—internally and good for them to do more of it, both for their physical externally—of mothers. The lack of physical activity in health, in addition to being a way to manage stress. the lives of most first-generation Pakistani women could, Arguably the strongest motivator for Pakistani women in many ways, be seen as a direct consequence of the in participating in physical activity was to lose weight, absence of the integration of self-care: although the arrival of a disease such as diabetes could also serve as motivation: It’s customs as well, or what they’ve seen. That no family members, no other women do it [take time for themselves]. So every day, or in the morning, I would leave with my mom The grandmothers don’t do it, the mothers, the aunts. I don’t at six in the morning to go walking. Me and my mom. Yes, know, I think it’s a bit like this. (Sara, key community yes, yes. “Got to lose weight, got to lose weight.” (Aisha, informant) second-generation Pakistani woman) Participants agreed that culturally, participating in There was a polarization in the discourse surrounding physical activity would not be poorly viewed, so long as an individual’s motivation to exercise, with many accounts there was separation between genders, as per their inter- both from and about Pakistani women affirming that phys- pretation of Islam. In practice, however, such involvement ical activity was desired. Contrasting with this, discussions was also contingent on continuing to follow the cultural around the theme of “laziness” also surfaced, with norms—including gender norms—in order to be deemed Pakistani women voicing that many Pakistani women sim- acceptable. In response to the question of whether there ply didn’t like participating in physical activity. was a conflict in integrating time for oneself into their cul- Access to information—be it in the form of formal edu- ture, one participant responded: cation (schooling), language or cultural classes, family regrouping information sessions hosted by the Catalan Yeah, of course! Of course. First, I was the best daughter-in- government, or workshops put on by local community law in the family and now I am the worst daughter-in-law! organizations—acted as instigators for changes in behav- (Ruksana, first-generation Pakistani woman) ior. Knowledge acquired about health-related topics was highlighted as promoting these changes. Among first-gen- Time and energy were cited as obstacles to physical eration Pakistani women, the principal demand for health activity by both first and second-generations, even as the information was related to providing good nutrition for second generation had integrated the concept of time for their children, and gaining a greater understanding around oneself. In the first generation, the principal influencing the female reproductive system. factors were responsibilities of child-rearing and house- Second-generation Pakistani women clearly did not hold duties—cultural expectations that were felt by have the same needs around access to information as their Pakistani women, and which they wished to complete. In mothers, due to the nature of their multicultural identities the second generation, such limitations often came from and enrollment in the Catalan school-system. They typi- schooling or work, with some women also highlighting cally pursued higher-education and had concepts around gender-related expectations such as child-rearing and health that included preventive principals. Culturally, household duties: however, they maintained many of the same values as their parents’ generation. A woman has a big responsibility, you know? To have kids, then educate them, then to . . . well, be at home, be a Cultural norms and gender roles housewife, be the queen of the house, no? . . . She has to do everything. And the husband has to . . . how do you say . . . The role of motherhood was hugely important, and the he has to work for their family. (Anousheh, second-generation desire to become a mother was a point of agreement Pakistani woman) Lansburgh et al. 9 This cultural delineation of gender roles was acutely conditions) was a barrier. Migratory grief among first-gen- felt even among the second generation, although Pakistani eration Pakistani women emerged as a transversal theme, women of both generations who were in the workforce clearly affecting additional areas related to health and sometimes described sharing household duties with their behavior, such as participation in the wider community, husbands. rendering it nearly impossible to completely separate chal- Cultural and community expectations heavily affected lenges related to the immigration process with barriers the first generation, including when it came to raising their toward physical activity. own children. These expectations were evidenced by the As in results from a systematic review carried out on pride expressed by parents when children did well, per- intergenerational differences of physical activity in UK haps related in part to the sacrifice of the mother. Gossip South Asians, our results highlighted the variations in from within the community was regarded as being a trait facilitators and barriers between first and second-genera- of the culture, and served as a motivator for parents to tion immigrants, as well as differences in the amount of maintain a tight grip on their children’s social life. The sec- engagement in physical activity between the two groups.38 ond generation talked about the importance of developing Our findings were also consistent with studies finding that trust within the family which, once established, allowed cultural norms strongly influenced women’s participation children to participate more fully with their school-mates: in physical activity.39,40 We were likewise aligned with studies which found that higher education and access to The first thing that we Pakistanis think is, “What will people health education served as catalysts in shifting the younger say?” If we do something good, or bad, we don’t think about generation’s perceptions of gender norms.41 In addition, if we’re going to feel . . . the second generation does . . . But our findings reflected the well-researched role of neigh- the first generation always thinks, “What will people think?” borhood and housing in health inequalities,42,43 and offered (Fatima, second-generation Pakistani woman) insight into some of the specific ways in which housing and neighborhood factors can facilitate or hinder participa- Change was often considered conflictive, especially tion in physical activity. when it was an adaptation of Western values. The second Although we found that social integration played a generation’s position of being culturally Pakistani at home, role in participation in physical activity, we did not make but raised in the multi-cultural environment of the Raval, a direct link to physical activity serving as a facilitator to was cited as both inevitable as well as feared. While edu- social integration, as has been cited in other studies.44 A cation was heralded, loss of Pakistani family and cultural study on physical activity in immigrant children in Spain values was assumed to go hand-in-hand with exposure to found that parental attitudes were highly influential in a Western cultures. child’s participation.45 While our findings did not iden- Outside perspectives and attempts to guide behavior tify a strong link between parental attitudes and physical changes were met with mixed responses. While health activity in the second generation, we did find that cultural concepts that were gained through increased education values were highly influential in determining the accept- were viewed positively, elements that conflicted with ability of the environment in which physical activity was Pakistani cultural values were sometimes met with offense. carried out. Other studies on identity in Pakistani immigrant women have found that understanding ties to their coun- Discussion try of origin was paramount to beginning to understand Experiences related to physical activity differed between the experiences of women and their host country. In par- first and second-generation Pakistani women. In general, ticular, the cultural emphasis on maintaining certain gen- first-generation Pakistani women did not appear to have der norms was emphasized, as was the importance of physical activity in their daily lives, although it was motherhood.46,47 Such lines of thought reassert the need desired, especially in the context of weight-loss. The barri- to better understand factors related to integration— ers around physical activity appeared to be particularly including cultural norms—before being able to compre- impactful on the first-generation women interviewed. The hend health patterns. Public participation could be one topic of gender norms entered into the discourse fre- strategy by which to elicit more information around the quently, heavily influenced by the participant’s genera- needs of this specific population.48 tional status. Key potential barriers toward physical These similarities in findings between other studies and activity were gender-related family and household duties. our own suggest that there are themes that are relevant Cultural norms dictating a separation of genders during internationally when considering the experience of physi- physical activity was an important consideration among cal activity among immigrant populations. While such both generations. Culturally appropriate spaces in which to shared content is valuable, we find that the intersectional- participate in physical activity served as facilitators, while ity approach of our study explores a unique understanding the absence of such space (chiefly due to socio-economic of the context of physical activity specifically among first 10 Women’s Health and second-generation Pakistani women in the Raval, group by tailoring interventions to meet participants’ Barcelona, with themes that may uniquely affect and influ- needs. ence the health needs of this particular population. While An important area of further exploration is the voices of similarities may exist, generalizing about other popula- men in this community. The gender roles and expectations tions based on these themes may not be possible. that affect the daily lives, routines, and health of women in While the nature of migratory grief was transversal in the Pakistani community exert their own influence on the the experiences of first-generation Pakistani women, the responsibilities attributed to men. Given the hierarchical extent of its influence over their participation in physical nature of the culture, men would be important partners for activity is far from clear. A better understanding of migra- engagement when trying to address risk factors for women. tory grief and its phases, as described in Joseba Achotegui’s Finally, this topic of study could benefit from future article on immigration and mental health, may offer fur- research on barriers to integration in Barcelona including ther insight into how to tailor health interventions to be considerations around how to promote economic opportu- most effective.49 The possibility that participating in phys- nities within this collective. Such research could also ical activity might, in turn, have an effect on migratory potentially shed light on experiences of other Indo-Asian grief, highlights the need to prioritize activities that address communities in this city as well as in other cities and coun- the full individual, and the multiple identities that influ- tries with Indo-Asian immigrant communities, and obsta- ence the lives of both first and second-generation Pakistani cles to their integration. women in Barcelona. Limitations Recommendations All but one participant was fluent in Spanish or English, In this study, social integration surfaced as a potential due to difficulty reaching Urdu-only speaking Pakistani facilitator toward promoting physical activity among the women, whose barriers and facilitators toward physical first generation. Providing resources and activities for activity may be distinct. Likewise, all participants of the Pakistani women that take into account the barriers of study had legal status in Spain; it is reasonable to infer that time and energy, as well as schedule restrictions, would women in irregular legal standing face additional barriers be appropriate considerations for any new programs. We in participating in physical activity. suggest that government policies be designed to increase The different age ranges of first and second-generation the availability of culturally relevant community ser- Pakistani women may have resulted in a less direct com- vices, including ones which address barriers toward the parison between factors influencing participation in physi- integration of immigrant communities within Barcelona cal activity. Similarly, all but two of the participants were (and vice versa). Given that medical care and primary mothers, and only one was unmarried. Perspectives of sin- health care centers were cited as serving as an important gle or childless Pakistani women would offer a more com- community resource, supporting increased access to cul- plete vision of the barriers and limitations toward physical tural mediators is fundamental to the health of Pakistani activity in this community. In addition, it is plausible that women in Barcelona. at different ages, distinct barriers and facilitators are pre- Social determinants—particularly economic resources sent, criteria that were not considered within the scope of and the built environment—were cited repeatedly as being this study. influential factors in access to physical activity. Prioritizing Finally, we conducted interviews with both Pakistani the development of green space and playgrounds around and non-Pakistani women. We chose to do this because we the Raval, with an explicit aim to facilitate culturally sought to glean a perspective on the Pakistani community appropriate gathering areas, has the potential to positively from members of the wider community who had years of influence the day-to-day lives of both first and second- experience working with the Pakistani women population. generation Pakistani women by providing access to physi- While this perspective is indeed valuable, its contribution cal activity. means that our results are not strictly from the Pakistani Taking into consideration relevant cultural norms, gen- women immigrant community alone, a consideration der roles, and socio-economic conditions within this com- which must be taken into account when seeking to speak munity when proposing health interventions—especially about perspectives from within the community. those related to physical activity—is paramount. Second- generation Pakistani women, while being raised within the Conclusion geographical and multicultural realm of Barcelona, also need interventions that are designed with their specific This study provides insight into factors that influence societal and cultural context in mind. This study suggests Pakistani women’s concepts of health and attitudes toward that public participation could be a strategy which would physical activity, with the intersectional nature of their increase the social impacts of interventions within this experiences clearly informing their participation in physical Lansburgh et al. 11 activity in complex ways. Facilitators and barriers related to Union ERDF funds (European Regional Development Fund) social integration, socioeconomic limitations, and access to through the Research Network in Preventive Activities and education all play important roles, as do the oft-cited experi- Health Promotion in Primary Care (redIAPP, RD16/0007/0001). ences of migratory grief in the first generation. Perceptions The IDIAP Jordi Gol also supported this work by offering the first author office space and access to the institution’s resources of gender norms and subsequent cultural expectations throughout the research process. appear to weigh heavily on the first generation, while some shifts in this area are evident among second-generation ORCID iDs Pakistani women, especially in their views on exercise and making time for themselves. Flora Lansburgh https://orcid.org/0000-0001-8609-9694 Taking into consideration the unique set of factors Constanza Jacques-Aviñó https://orcid.org/0000-0001-8506- influencing Pakistani women of both first and second gen- 780X erations around the barriers and facilitators they experi- Mariona Pons-Vigués https://orcid.org/0000-0002-7929-3701 ence in participating in physical activity is key in order to Rosemary Morgan https://orcid.org/0000-0001-5009-8470 design and implement successful interventions or health- promotion strategies among these groups. We encourage Availability of data and materials those who are in positions of implementing programs tar- The datasets generated and/or analyzed during the current study geting this population to not only review themes from this are not publicly available. They could be made available from the research and other relevant research to help inform their corresponding author on reasonable request. approach, but also to engage with the population directly, and solicit their participation in developing and informing Supplemental material the programs being implemented. Supplemental material for this article is available online. Acknowledgements References The authors would like to thank each of the individuals who par- 1. Montesi L, Caletti MT and Marchesini G. Diabetes in ticipated in the study, as well as the professionals who guided and migrants and ethnic minorities in a changing world. World J helped them contact the participants. In addition, the authors Diabetes 2017; 7(3): 34. would like to thank the organizations: Tot Raval, Diàlegs de 2. Tu JV, Chu A, Rezai MR, et al. 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