Developing a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe - a DEDIPAC study
Holdsworth et al. International Journal of Behavioral Nutrition and Physical Activity
Developing a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe - a DEDIPAC study
Michelle Holdsworth 0
Mary Nicolaou 2
Lars Jørun Langøien 1
Hibbah Araba Osei-Kwasi 0
Sebastien F. M. Chastin 7
F. Marijn Stok 6
Laura Capranica 5
Nanna Lien 4
Laura Terragni 9
Pablo Monsivais 3 8
Mario Mazzocchi 12
Lea Maes 12
Gun Roos 10
Caroline Mejean 11
Katie Powell 0
Karien Stronks 2
0 Public Health Section, School of Health and Related Research-ScHARR, The University of Sheffield , Sheffield , UK
1 Department of Physical Education, Norwegian School of Sport Sciences , Oslo , Norway
2 Academic Medical Centre, University of Amsterdam, Department of Public Health, Amsterdam Public Health research Institute , Amsterdam , The Netherlands
3 Present address: Department of Nutrition and Exercise Physiology, Elson S Floyd College of Medicine, Washington State University , Spokane WA 99210-1495 , USA
4 Department of Nutrition, University of Oslo , Oslo , Norway
5 Department of Movement, Human and Health Sciences, University of Rome Foro Italico , Rome , Italy
6 Department of Psychological Assessment and Health Psychology, University of Konstanz , Constance , Germany
7 Institute for Applied Health Research, School of Health and Life Science, Glasgow Caledonian University , Glasgow , UK
8 UKCRC Centre for Diet and Activity Research, MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine , Box 285 , Institute of Metabolic Science , Cambridge Biomedical Campus, Cambridge CB2 0QQ , UK
9 Department of Nursing and Health Promotion Faculty of Health Sciences, Oslo and Akershus University College of Applied Sciences , Oslo , Norway
10 Consumption Research Norway SIFO, Oslo and Akershus University College of Applied Sciences , Oslo , Norway
11 UMR MOISA, Campus INRA-SupAgro de la Gaillarde , Montpellier , France
12 Department of Public Health, Ghent University , Ghent , Belgium
Background: Some ethnic minority populations have a higher risk of non-communicable diseases than the majority European population. Diet and physical activity behaviours contribute to this risk, shaped by a system of inter-related factors. This study mapped a systems-based framework of the factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe, to inform research prioritisation and intervention development. Methods: A concept mapping approach guided by systems thinking was used: i. Preparation (protocol and terminology); ii. Generating a list of factors influencing dietary and physical activity behaviours in ethnic minority populations living in Europe from evidence (systematic mapping reviews) and 'eminence' (89 participants from 24 academic disciplines via brainstorming, an international symposium and expert review) and; iii. Seeking consensus on structuring, rating and clustering factors, based on how they relate to each other; and iv. Interpreting/utilising the framework for research and interventions. Similar steps were undertaken for frameworks developed for the majority European population. Results: Seven distinct clusters emerged for dietary behaviour (containing 85 factors) and 8 for physical activity behaviours (containing 183 factors). Four clusters were similar across behaviours: Social and cultural environment; Social and material resources; Psychosocial; and Migration context. Similar clusters of factors emerged in the frameworks for diet and physical activity behaviours of the majority European population, except for 'migration context'. The importance of factors across all clusters was acknowledged, but their relative importance differed for ethnic minority populations compared with the majority population. (Continued on next page)
(Continued from previous page)
Conclusions: This systems-based framework integrates evidence from both expert opinion and published literature,
to map the factors influencing dietary and physical activity behaviours in ethnic minority groups. Our findings
illustrate that innovative research and complex interventions need to be developed that are sensitive to the needs
of ethnic minority populations. A systems approach that encompasses the complexity of the inter-related factors
that drive behaviours may inform a more holistic public health paradigm to more effectively reach ethnic minorities
living in Europe, as well as the majority host population.
Some ethnic minority groups living in Europe have a
high prevalence of preventable non-communicable
diseases (NCDs), such as obesity, type 2 diabetes and
cardiovascular diseases [
]. Diet and physical activity
behaviours are likely to play a role in their aetiology and
differences in these behaviours compared with host
populations are well documented [
]. However, there are
fewer studies of the differences in the underlying factors
influencing these behaviours [
]. Most studies have
focused either on a small number of minority groups or
are limited to specific European countries, which makes
it challenging to generalise about the nature of any
]. It could be argued that the variation
between ethnic groups is as great as that between the
general European population. Nonetheless, it could be
expected that there are commonalities in people’s lives
who are either first or second generation migrants,
which are distinct from the general population [
Thus, understanding the factors underlying diet and
physical activity behaviours in ethnic minority groups is
a first step to informing the development of public
health interventions that are successful in reaching
minority ethnic populations in Europe.
Existing frameworks are insufficient for prioritising
research or interventions development, as they either
focus on migration and dietary acculturation processes
] or on a specific health outcome, such as obesity in
the whole population [
]. Alternatively, they are
based on evidence of ethnic minority populations living
outside of Europe, for example, of African descent in the
US  or Iranians living in Australia [
]. This may
offer useful insights, even though contextual differences
limit their transferability to Europe. Likewise, focusing
only on obesity has the potential to ignore important
drivers of the complex system of factors influencing
dietary and physical activity behaviours.
A system-based approach has the potential to cast a
holistic analytic lens [
] to developing interventions,
because it is based on the interrelationship of clusters
within a dynamic system. Systems thinking can simply
be defined as ‘looking at things in terms of the bigger
]. Dietary and physical activity behaviours
therefore emerge as a property, which cannot be
resolved from simple, uni-faceted interventions [
are likely to be required within multiple clusters of
factors, even though some of these may only have small
effects on individuals, they have the potential to stimulate
population changes when combined [
]. Therefore, the
aim of the current study was to develop a systems-based
framework of the factors influencing dietary and physical
activity behaviours in ethnic minority populations living
in Europe, to be able to inform research prioritisation
and the development of interventions to reach these
The framework was constructed as part of the
DEDIPACKH (DEterminants of DIet and Physical ACtivity
Knowledge Hub) [
] for European populations. Within the
DEDIPAC-KH, an inter-disciplinary group focused on the
determinants of dietary and physical activity/sedentary
behaviours. The task was undertaken at several steps
involving scholars with varying academic backgrounds and from
different countries (Table 1 for more details).
A total of 89 participants contributed to at least one step
of the creation of the framework. This comprised a team
focusing on the factors influencing the behaviours of
ethnic minority populations (‘DEDIPAC ethnic minority
team’). Other teams in the DEDIPAC-KH focussed on the
factors influencing dietary [
] and physical
activity/sedentary behaviours [
] of the general European
population (‘DEDIPAC general population team’). This
approach followed earlier successful examples of
multidisciplinary partnerships that comprehensively described the
factors influencing obesity-related behaviours .
The method was guided by concept mapping; drawing
on both quantitative [
], and qualitative [
approaches. Traditionally, quantitative concept maps have
been used in health research, yet the case for flexible use
of concepts maps has been advocated for, requiring a
less rigid and more qualitative approach [
Concept mapping is influenced by systems thinking and
involves gathering and analysing different types of data
and integrating these with prior research/experience
. Concept mapping was selected because it can
illustrate how people visualize relationships between
concepts within a map [
] and it can be used for
research prioritisation [
]. The approach was structured
around the four main phases proposed in quantitative
concept mapping [
], but a more flexible mixed
methodology was employed [
]: i. preparation; ii.
generation of factors; iii. Structuring and rating factors into
clusters; and iv. interpretation and utilisation of the
Preparation (terminology, protocol)
The scope and purpose of the study protocol was
developed (Fig. 1- step 1) by the DEDIPAC ethnic minority
team, in consultation with the DEDIPAC general
population team. Consensus was reached on the terminology
for the different behaviours and for defining
factors/correlates/determinants, so that there was a common
understanding across the DEDIPAC-KH. Minority ethnic
populations were defined as ‘immigrants/populations of
immigrant background from low and middle income
countries, population groups from the former Eastern
Bloc countries who migrate to other parts of Europe and
minority indigenous populations in Europe’.
Three criteria were selected to score each factor, for its
priority for future research (‘research priority’) and for
how useful it would be in developing interventions
(‘expected modifiability’; ‘potential effect size on behaviour’).
It was also decided how consultation outside of the
DEDIPAC network could be undertaken, to ensure that a
wide range of viewpoints were considered from diverse
disciplines to encourage ‘buy in’ to the resulting framework
]. The concept mapping process does not stipulate that
all participants have to be involved in every step [
], so it
was agreed that a small group would generate the factors
and a larger group would sort and rate them.
Generation of factors
The next phase (Fig. 1- steps 2 and 3; then steps 4 and 6)
involved generating a set of factors to represent the entire
conceptual domain of the topic area, i.e. the factors that
influence diet and physical activity (incorporating
sedentary behaviours) of ethnic minority populations living
in Europe. This was conducted in parallel for diet and
physical activity behaviours from published ‘evidence’
and expert opinion (‘eminence’). The aim was to
develop wording that was detailed enough to convey the
underlying meaning for each factor without requiring
Published evidence (systematic mapping reviews)
Factors were generated from published ‘evidence’ by
conducting systematic mapping reviews (Fig. 1- step 2)
of the factors influencing dietary behaviours [
physical activity behaviours (incorporating sedentary
] among minority groups living in Europe.
The review methods and protocols were published
elsewhere [PROSPERO database #CRD42014013549/
#CRD42014014575], but essentially primary data from
quantitative and qualitative studies published over the
15 year period preceding data searching (1999–2014)
were extracted. In synthesizing the findings, all of the
factors (63 factors for diet; 165 factors for physical
activity) were listed [
]. Physical activity and sedentary
behaviours were integrated together, as there was a lack
of published research on sedentary behaviours of ethnic
Expert opinion (‘eminence’)
Expert opinion was sought from three sources:
brainstorming within the DEDIPAC ethnic minority team
(Fig. 1- step 3) and by members of the DEDIPAC general
population team (Fig. 1- step 4); and later by
consultation with external experts during an international
symposium (Fig. 1- step 6). Participants (n = 89 in total
throughout the process) were from a range of disciplines
(Table 1), but they were not all involved at every step.
Factors that had not emerged from the reviews, but
could be important, were generated by the DEDIPAC
ethnic minority team (Fig. 1- step 3). Existing
frameworks were also used to extract additional factors [
21, 23, 38
]. An additional 40 factors (to those from the
systematic mapping reviews) were identified at steps 3
and 6 combined (22 for diet and 18 for physical activity).
Structuring, rating and producing a concept map
Sorting and structuring of factors
The emerging factors from the systematic mapping
reviews and expertise within the DEDIPAC-KH were
grouped into clusters, according to how they were seen
to relate to each other. This resulted in 7 dietary
behaviour clusters containing 79 factors and 8 physical activity
clusters containing 176 factors (Additional file 1: Tables
S1 and S2). This process was undertaken in two ways
(Fig. 1- step 4). Firstly, during meetings of the DEDIPAC
ethnic minority team, when the relationships between
factors were collectively debated. Secondly, during a
confirmatory stage involving members of the DEDIPAC
ethnic minority and the general population teams. The
concept map that emerged was discussed collectively,
which led to some changes in wording of the clusters to
enhance clarity and some factors were moved into
different clusters (Fig. 1- step 4).
Scoring the individual factors
All of the factors were scored individually (Fig. 1- step 5)
by DEDIPAC ethnic minority team members and some
general population team members (Table 1) using the
three criteria identified in the preparation phase, i.e.
‘research priority’, ‘expected modifiability’ and ‘potential
effect size on behaviour’. When scoring, individuals were
asked to provide their scores based on their own
professional judgments. The rating focus statement selected
was: ‘Score the following factors for their importance on
a scale of 1 to 5 for dietary behaviour [or physical
activity and sedentary behaviour] in ethnic minority groups’,
where 1 = the lowest importance and 5 = the highest.
These three criteria were added together as a total
measure of the perceived importance of individual factors for
research and interventions. Individuals rated the factors
separately and these scores were subsequently collated
to develop the ranking of factors within clusters. The
mean is the total sum divided by the number of factors,
so a maximum of 15 could be gained for the three
criteria on a Likert scale of 1–5, with 5 as most modifiable,
strongest effect, largest priority. The position that the
factors were ranked in was based on the overall sum
divided by the number of factors in each cluster (Table 4).
International symposium- eminence
Consultation took place during a dedicated symposium
at an international conference (Fig. 1- step 6) [
Symposium participants scored the top 15 factors that had
emerged from step 5 (Fig. 1) using the same three
criteria. The decision to only request scoring of the top 15
factors was for pragmatic reasons as the symposium was
time limited. The symposium also allowed reflection on
the next phase of ‘Interpretation and utilisation’ of the
Interpretation and utilisation
International symposium- eminence
Two invited experts (external to DEDIPAC) in migrant
health gave their views about the draft concept map,
particularly where there were gaps in published
literature and key research challenges for the future. This was
followed by a short interactive discussion drawing on
experiences and views from the audience (n = 44), during
which, ideas were captured from symposium
participants. The discussion resulted in the identification of a
further 13 factors (6 for diet, 7 for physical activity),
which were subsequently incorporated into the
framework. This process led to a summary of the research
challenges and knowledge gaps identified (Fig. 1- step 6).
Finalise systems-based framework
The rating of individual factors and clusters were
assembled for the separate diet and physical activity frameworks.
A face-to-face meeting of the DEDIPAC ethnic minority
and general population teams was held to discuss the
integrated framework (Fig. 1- step 7) and consensus was
sought at the cluster level. It was the final step in the
framework development process to compare the scoring
of factors and ranking of clusters across minority ethnic
populations with the general European population and to
discuss the implications for research and interventions of
the factors and clusters in the final framework.
Frameworks in the general population of factors
influencing physical activity [
] and sedentary behaviour [
separately, as well as for dietary behaviour [
developed in parallel by the general population teams in the
DEDIPAC-KH. While the factors for ethnic minority
populations fed into these general population frameworks,
they were developed in separate processes [
allowed for a post-hoc comparison of clusters identified in
the general population with those identified in the ethnic
Emerging clusters for dietary and physical activity behaviours
Seven distinct clusters (containing 85 factors) were
identified for dietary behaviour of ethnic minority
populations (Additional file 1: Table S1): ‘migration context’;
‘social and cultural environment’; ‘food beliefs and
perceptions’; ‘accessibility of food’; ‘the body’; ‘psychosocial’;
and ‘social and material resources’. The highest number
of factors were identified in the ‘social and cultural
environment’ cluster (20 factors), followed by ‘food beliefs
and perceptions’ (13 factors). The ‘psychosocial’ and
‘accessibility of foods’ clusters had an equal number of
factors (12 factors each). Only five factors were identified
for ‘the body’ cluster.
Eight distinct clusters (containing 183 factors) were
identified for physical activity behaviours (Additional file 1:
Table S2): health and health communication; political
environment; social and cultural environment; psychosocial;
institutional environment; physical environment and
opportunity; social and material resources; and migration
context. The highest number of factors were identified in
the social and cultural environment cluster (53 factors),
followed by the psychosocial cluster (38 factors). Whilst
the lowest number was identified for the political
environment cluster (3 factors).
Priority ranking of factors for dietary behaviour
One-third of the top rated 15 factors for diet were
related to food accessibility (Table 2). These factors scored
highly in all criteria; and three of these factors (food
availability, food policy, food price) were in the top five
overall; indeed food price scored highest for its likely
impact on population behaviour.
The factors in the ‘food beliefs and perceptions’ cluster
that scored highly related to children’s food preferences
and the social role of food and food beliefs; although the
latter two did not score well for modifiability, as they
were seen as difficult to change, presumably because of
their socially engrained nature. The psychosocial cluster
of factors that reached the top 15 were related to
perceived barriers, psychosocial stress and subjective norms
influencing dietary behaviours. Perceived barriers in
particular scored well for modifiability, suggesting barriers
could be targeted in subsequent interventions. Even
though so many factors emerged in the social and
cultural cluster (Additional file 1: Table S1), only two of
these were ranked highly enough across all criteria to be
included in the final list of 15 factors (social networks;
level of acculturation).
Only ‘nutrition knowledge’ scored well amongst the
‘material and social resources’ cluster (Table 2); the other
factors in this cluster scored low on modifiability and
therefore were not seen as imperative to study, e.g.
income. Only ‘immigrant related policy’ in the host
country scored well amongst the ‘migration context’ cluster,
but even then it did not score well as a research priority.
Others in this cluster had low scores for modifiability,
such as the political context in the host country. No
factors in ‘the body’ cluster emerged in the top 15.
Priority ranking of factors for physical activity
Almost one-third of the top rated 15 physical activity
factors were related to the ‘physical environment and
opportunity’ cluster (Table 3). Two factors related to
provision of culturally sensitive and/or women only
facilities (Table 3). Four psychosocial factors were ranked
highly overall, scoring well for modifiability (knowledge
of physical activity, lack of physical activity skills,
expectations of physical activity, attitudes).
‘Physical activity at school’ was ranked first, performing
well in terms of its likely impact on population health, due
to the potential reach that school based interventions can
have, suggesting schools could be a priority setting in
subsequent interventions. Only ‘area deprivation’ scored
highly amongst the ‘material and social resources’ cluster,
as it was seen to have an important impact on behaviours,
but it scored less well for modifiability. Other factors
related to material and social resources, such as income,
scored less well, as they were seen as hard to modify.
Only three factors ranked highly (Table 2) amongst
the 53 factors that emerged in the ‘Social and cultural
environment’ cluster (Additional file 1: Table S2). Two
of these appeared closely inter-related (social influence,
habitus), where habitus was seen as how individuals
perceive and react to the social world around them. The
third factor (parental attitudes) reflects the high ranking
given to children’s physical activity behaviours. Of the 12
factors in the ‘health and health communication’ cluster,
only ‘primary health care’ was ranked highly. The high
rating of primary health care in part stems from the
central role of health professionals conveying the
importance of physical activity, as it was seen as modifiable,
with potential to reach many people through
interventions. Only ‘lack of knowledge of host culture’ scored
well in ‘migration status’, as it was seen as modifiable,
whereas the other factors in this cluster were perceived
as difficult to change. No factors in ‘the political
environment’ emerged amongst those in the top 15.
Cluster ranking for factors influencing dietary and physical activity behaviours
For both diet and physical activity, ‘psychosocial’ factors
was the top ranking cluster, which scored highly on all
Table 3 Ranking of top 15 factors related to physical activity behaviours (presented in table are mean (SD))
Ranka Factor Modifiability Priority for research Effect on Behaviour SUM Cluster name
1 Lack of physical activity at school 3.82 (1.10) 3.53 (0.86) 3.67 (0.77) 11.02 Institutional environment
2 Knowledge of physical activity 4.11 (0.96) 3.08 (1.37) 3.15 (1.10) 10.35 Psychosocial
3 Social influence 2.86 (1.02) 3.60 (1.09) 3.78 (0.88) 10.25 Social and cultural environment
4 Lack of physical activity skills 3.61 (1.04) 3.14 (0.86) 3.39 (0.98) 10.14 Psychosocial
5 Parental attitudes 3.10 (0.68) 3.38 (1.09) 3.61 (0.92) 10.08 Social and cultural environment
6 Lack of culturally sensitive facilities 3.28 (1.07) 3.44 (0.92) 3.33 (0.84) 10.05 Physical environment and opportunity
7 Expectations of physical activity 3.33 (1.08) 3.22 (1.06) 3.45 (1.10) 10.00 Psychosocial
8 Attitudes 3.38 (0.98) 3.27 (1.07) 3.35 (1.03) 10.00 Psychosocial
9 Facilities available 3.05 (1.06) 3.38 (0.78) 3.50 (0.96) 9.94 Physical environment and opportunity
10 Access to a play area 3.23 (0.94) 3.26 (0.89) 3.44 (0.78) 9.93 Physical environment and opportunity
11 Lack of knowledge of host culture 3.72 (0.96) 2.94 (0.87) 3.12 (0.68) 9.78 Migration context
12 Area deprivation 2.50 (0.86) 3.50 (0.92) 3.72 (0.83) 9.71 Social and material resources
13 Lack of women only facilities 3.25 (1.00) 3.20 (1.11) 3.22 (1.00) 9.66 Physical environment and opportunity
14 Primary health care 3.36 (1.14) 3.23 (1.11) 3.05 (1.00) 9.64 Health and health communication
15 Habitus 2.60 (1.14) 3.23 (1.40) 3.63 (1.29) 9.46 Social and cultural environment
All scores on a scale of 1–5, with 5 as most modifiable, strongest effect, largest priority
aPosition that the factors were ranked in from the 183 Physical activity/Sedentary behaviour factors based on the overall scores of the 3 criteria of ‘research
priority’, ‘expected modifiability’ and ‘potential effect size on behaviour’; factors were scored by 20 people for all 3 criteria
three criteria, but particularly as a priority for research
and its likely impact on behaviour (Table 4). The scores
for the remaining clusters were ranked closely behind.
The ‘migration context’ cluster of factors scored lowest,
mainly because it had a low score for modifiability. Social
and material resources were seen to have an important
impact on behaviour, but scored less for modifiability.
Overall, the relatively close ranking of the clusters for both
behaviours suggested that all could have a part to play in
developing interventions and research.
A systems-based framework – A tool for prioritising
research and interventions
Figures 2 and 3 summarise the clusters that emerged
and their priority ranking. The top scoring five factors in
each cluster are highlighted.
An integrated framework for the major clusters of
factors influencing both dietary and physical activity
behaviours and the overlap between them is illustrated in the
overall framework (Fig. 4).
The clusters of factors influencing the different
behaviours were integrated to illustrate both similar and
distinct clusters of factors. Four of the clusters were similar
(psychosocial; social and cultural; social and material
resources; and migration context) for diet and physical
Research priorities for ethnic minorities compared with those for the general host population
Some similarities and differences were observed between
ethnic minorities and general host populations. Similar
sub-categories of clusters of factors emerged in the
general population frameworks for diet [
] and sedentary behaviours [
] combined, except
for those in the migration context (Table 5).
The clusters of ‘health and health communication’ and
‘institutional environment’ did not emerge in the general
population for physical activity; and ‘material and social
resources’ did not emerge as a distinct cluster of factors
influencing sedentary behaviours in the general population.
aThe number of factors here does not include those 6 factors identified at the ISBNPA symposium, as they were not scored. The full list is in Tables 1 and 3
bMean is the total sum divided by the number of factors- so a maximum of 15 could be gained as 3 criteria on a Likert scale of 1–5, with 5 as most modifiable,
strongest effect, largest priority
cPosition that the factors were ranked in based on overall SUM/number of factors in each cluster
The ‘social and cultural’ cluster was ranked first for
overall importance for its influence on physical activity
amongst ethnic minority populations. Even though social
and cultural factors emerged in the general population,
the overall cluster was ranked lower for physical activity
and sedentary behaviour (Table 5). The importance of
psychosocial factors in the general population was
ranked slightly less than for ethnic minority groups, as
they were ranked in second and third position for
sedentary behaviour and physical activity respectively.
The political environment was ranked higher for its
importance in influencing physical activity in ethnic
minority populations than in the general population, where it
was ranked last (sedentary behaviour) or next to last
(physical activity) (Table 5).
For diet, the importance of ‘psychosocial’ factors, ‘food
beliefs and perceptions’, ‘social and material resources’,
and the ‘social and cultural environment’ were all ranked
Matches here are based on overlap of the individual factors included in each sub-categorya or cluster but it should be noted that overlap may only be partial. All
scores were ranked based on criteria including priority for research, modifiability and population-level effect (and relationship strengtha)
There are a total of 51 sub-categories in the general population diet frameworka [
], 6 clusters in both the physical activity frameworkb [
] and sedentary
behaviour frameworkc [
[PA = physical activity and SB = sedentary behaviour]
lower in the general population than for ethnic minority
groups (Table 5). However, the importance of the cluster
of factors relating to the ‘accessibility of food’ emerged
as important across all populations.
A system-based framework was established in this study
to summarise the factors influencing dietary and physical
activity behaviours in ethnic minority populations living
in Europe. This is the first framework developed using a
formal consensus methodology, drawing upon wide
transdisciplinary evidence and eminence. It is envisaged
that the framework will primarily be used as a tool to
stimulate operationalisation and contextualisation for
research and interventions.
There was insufficient evidence from specific ethnic
minority groups, so therefore they were treated together,
as there are shared experiences in the lives of people
from ethnic minority populations that justify grouping
them together. However, as with majority host
populations, it is important to acknowledge the heterogeneity
of ethnic minority populations living in Europe [
different clusters are likely to interact, implying that
factors in a specific cluster operate differently, depending
on the factors in other clusters. In addition, clusters are
highly dynamic, and might change over time as
populations evolve, as the needs of ethnic minority populations
are not static.
Implications for research priorities for ethnic minority populations
The framework highlights key research priorities for
ethnic minority populations. For instance, addressing the
highest rated factors associated with dietary behaviour
would involve consideration of several clusters including
‘accessibility of food’, ‘psychosocial’ and ‘resources/social
capital’. The clustering of factors in this way might
precipitate a shift in the way complex behaviours are
viewed; from a simple approach focusing on individual
level factors, to a more holistic systems approach. In our
study, psychosocial factors were ranked highly overall,
particularly as they were seen as modifiable, which
probably explains why research and interventions tend to
focus on individual psychosocial factors [
The lack of evidence to attribute causation and effect
strength is a major gap and research on causal models and
pathways needs developing. Identifying and visualising
inter-connections between factors remains difficult to do
without data on their relationships, which requires more
research taking a systems approach [
22, 24, 26
qualitative and longitudinal quantitative research provide
useful insights for these inter-linkages and pathways that
lead to dietary and physical activity behaviours [
Practical considerations include the need for
multidisciplinary researchers involved in understanding and
changing behaviours to develop skills to evaluate the
impact of complex, upstream, population-level
interventions on the underlying clusters of factors [
], as well
developing skills in cultural adaptation. Furthermore, in
light of the peak migration in 2015–16 to Europe [
new research regarding the impact of dietary behaviours
on health for these populations is required, particularly
amongst vulnerable migrant populations, including
refugees, unaccompanied children and illegal migrants.
Research on ethnic minority populations often look
through a lens of difference [
], i.e. focussing on what
is different rather than similar with the general
population, which may explain the wealth of social and cultural
factors identified through this process. Although
important, there is also scope for investigating commonalities,
for example, how factors that drive dietary and physical
activity behaviours in the majority population influence
these behaviours amongst ethnic minority populations,
which emphasises the needs for a systems approach
across all populations. For example, one-third of the top
rated 15 factors for diet were related to food
accessibility, including food availability, how food policy shapes
access to food and the price of food, which all emerged
as important areas for research for the general
population too. Interventions targeting these factors will
require a whole population approach.
Most of the factors specific to the ‘migration context’
were not seen as a research priority, possibly because
they would require studies involving several countries to
research populations in different countries, and the
context was seen as hard to change. The converse is also
true, as research in the majority population seldom
sheds light on how social and cultural factors influence
behaviours, which may explain why they were ranked
lower in the general population framework. The
importance of research on collective behaviours, especially on
the social practices that shape social habits and therefore
practices around diet and physical activity is key for all
population groups [
], regardless of their ethnicity.
Implications for developing interventions for ethnic minority populations
The study’s findings have highlighted that there are
unlikely to be quick fixes or tipping points that can be
isolated to change behaviours, rather, several factors could be
targeted to improve diet and/or physical activity
behaviours across the inter-related system of clusters. This
reinforces the need for a systems approach in planning
multifaceted interventions in order to account for the
(sometimes unexpected) interaction between the factors
influencing behaviour. Conventional approaches focusing on
individual level behaviour change are insufficient [
The contextualisation for interventions is crucial too,
which is in contrast with the high priority given to the
individual level psychosocial factors in this study. This
finding is largely a reflection of prevailing perceptions
that these are easy to change. However, changing
individual level factors, whilst the context remains the same,
is insufficient to drive behaviour change, in view of the
socially and culturally embedded nature of dietary [
and physical activity behaviours.
This study’s findings have highlighted much
commonality between the factors influencing the behaviours in
ethnic minority groups and the majority population.
This begs the question of whether interventions are
needed that address factors that are specific to ethnic
minority groups, or whether mainstream interventions
should be encouraged that can reach all groups. The
study suggests that ‘mainstream’ interventions targeting
the general population could address many factors
identified as there was much in common between minority
and host populations, such as food policy, food pricing,
physical activity at school, access to play areas, area-level
deprivation and so forth. However, even if factors are
shared, their importance and focus might differ, e.g. the
need for women only facilities, the social role of food
might be stronger in more collective cultures. There are
specific factors in the context of migration that will need
to be addressed at a higher policy level, including
policies encouraging integration.
Two different approaches for developing interventions
that can reach ethnic minority populations are advocated
]. These consist of either adapting mainstream
interventions for the majority population to be ‘diversity
sensitive’, so that they can be equally effective for all
citizens regardless of their cultural, religious or ethnic
background, or alternatively developing ‘migrant-specific’
interventions by culturally adapting services and
interventions to individual backgrounds of specific minority
ethnic groups. The framework developed could be used
to develop either approach, as well as encourage new
approaches. Most of the evaluations of culturally sensitive
interventions have been conducted in the US [
and may not be transferable. Additionally, evidence has
indicated that evaluations lack explicit information about
the components of cultural adaptation, and little or no
detail is provided regarding how interventions are
cultural adapted . Evaluating interventions in a way that
goes beyond ‘what works’, but also identifies ‘for whom it
works and in what context’, such as realist approaches
] would be well adapted to unravel the underlying
processes. It should also be emphasised that this
framework does not provide ready-made answers for
intervention development. As for the case for ‘majority’
populations, a needs assessment will remain a necessary
part of the process [
An important limitation was that whilst the frameworks
for physical activity and sedentary behaviour followed a
very similar concept mapping approach to determining
clusters of factors, the framework for dietary behaviours
did not include emerging clusters [
]. The dietary
behaviour framework was developed by sorting individual
factors into pre-defined categories with a positivist
topdown process, using a socio-ecological approach [
Whereas a constructivist approach was taken in the
development of the other frameworks, as clusters emerged
from the data. However, both approaches are holistic,
given that the clusters that emerged were so similar with
the different approaches. In addition, factors were rated
in a different manner in the general population’s dietary
behaviour framework as the overall priority for research
was based on a weighted average of ratings for their
modifiability, relationship strength and population-level
Another limitation is that research participants did not
cluster factors as individuals, but collectively as a group,
meaning that clusters could not be created
mathematically using cluster analysis [
]. This approach was
decided against due to time limitations during data
collection for individuals to cluster factors together
separately. Even in the case of individual clustering, the
results of cluster analysis often require visible adjustment
to make them meaningful [
The decision to only request scoring of the top 15
ranking factors in the international symposium may have
introduced bias, as it is unknown if these factors would
be different if other people from within the broader
DEDIPAC-KH or from outside it had participated in the
rating of all factors. However, new/additional factors
were explicitly sought from external participants, in
order to compensate for this limitation.
The concept mapping exercise led to a hypothesised
ranking of factors within clusters, while the systems
approach implies that the interaction of context and
interrelated factors is what influences behaviour [
evidence for links between factors was not found, due to a
lack of research on the underlying mechanisms. Given
this, there remains uncertainty about the specific factors
that are a priority for research. A further limitation was
the profile of participants. The framework was informed
by academic researchers and although some have
extensive experience with ethnic minority and migrant origin
populations, input from individuals from agencies who
work closely with different populations would have
improved its completeness. Academic specialists in migrant
health were invited as experts, enhancing confidence in
the potential utility of the framework presented.
Other limitations included the lack of research
highlighting the drivers of dietary and physical activity
behaviours across the life-course, as most research
targeted adults. There were insufficient studies to
differentiate by age or life-course and further research is
particularly required on children and adolescents, as
they clearly have a role in influencing behaviours of the
whole family. There was limited research on sedentary
behaviour among ethnic minorities. Some ethnic
minority groups were under-represented, particularly recent
migrant populations to Europe, which should also be a
priority for research.
This is the first systems-based framework to be
developed that sheds light on dietary and physical activity
behaviours of ethnic minority populations living in Europe,
drawing on both evidence and eminence. Distinct
clusters emerged for both dietary and physical activity
behaviours, of which four clusters were similar across
behaviours (social and cultural environment; social and
material resources; psychosocial; and migration context),
suggesting that an integrated approach for interventions
across behaviours in these clusters of factors could bring
maximum benefit. Similar clusters of factors emerged in
the majority population frameworks for diet and physical
activity behaviours, but their relative importance differed
for ethnic minority populations, compared with the
Our findings illustrate that innovative research and
interventions need to be developed that are sensitive to
the needs of ethnic minority populations. Dietary and
physical activity behaviours are intransigent and
addressing them will require enormous innovation. A systems
approach may help in shifting the current public health
paradigm towards a more holistic approach that
considers what works for whom and in what context, in
order to ensure that ethnic minorities are included,
alongside mainstream European populations.
Additional file 1: Table S1. Concept map of the 85 factors and 7
clusters that emerged influencing dietary behaviours in ethnic minority
groups. Table S2. Concept map of the 183 factors and the 8 clusters that
emerged influencing physical activity behaviours (DOCX 46 kb)
BMI: Body mass index; DEDIPAC: DEterminants of DIet and Physical ACtivity;
PA: Physical activity; SB: Sedentary behaviour; SES: Socioeconomic status
The preparation of this paper was supported by the Determinants of Diet
and Physical ACtivity (DEDIPAC) knowledge hub. This work is supported by
the Joint Programming Initiative ‘Healthy Diet for a Healthy Life’. The funding
agencies supporting this work are (in alphabetical order of participating
Member State in this paper): Belgium: Research Foundation – Flanders;
France: Institut National de la Recherche Agronomique (INRA); Germany:
Federal Ministry of Education and Research; Italy: Ministero dell’Istruzione,
Università e Ricerca, Italy; Norway: The Research Council of Norway; The
Netherlands: The Netherlands Organisation for Health Research and
Development (ZonMw); The UK: The Medical Research Council (MRC). The
authors would like to thank the entire thematic area 2 of the DEDIPAC
Availability of data and materials
All data generated or analysed during this study are included in this
published article and its Additional file.
All authors conceptualized and designed the study. MH drafted the
manuscript. All authors reviewed draft versions of the manuscript and
provided suggestions and critical feedback. All authors have made a
significant contribution to this manuscript and approved the final
Ethics approval and consent to participate
This study involved experts in virtue of their training and expertise during an
international symposium. Experts have information and knowledge in a
substantive area beyond that of the average person and they regularly share
this information and knowledge through consultation, teaching or public
speaking, or publications and written reports. The Medical Ethics Review
Committee of the Academic Medical Center (Netherlands) stated that ethical
approval was not required (reference number W16_388 # 16.454) because
the Medical Research Involving Human Subjects Act (WMO) did not apply to
our study, as expert participants are not classified as human subjects when
asked to provide opinions within their areas of expertise. No personal
information was collected about the experts, and only their expert opinion
about the factors influencing dietary and physical activity behaviours was
collected in a confidential way.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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