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Keeping the faith: Receptiveness, capacity and acceptability of Islamic religious settings to deliver childhood obesity prevention intervention

Background: Childhood obesity rates among South Asian populations in the UK are significantly high. 10% of childhood population in the UK are of South Asian origin, majority of them follow Islamic faith and attend Islamic religious settings (IRS) daily after school. IRS may be appropriate channels for obesity prevention initiatives; however there is limited evidence for this approach. Methods: Using a qualitative research methodology, we conducted 20 indepth interviews with parents of 5-11 years old children attending IRS, 20 indepth interviews with Islamic leaders, and 3 focus group discussions with 26 managers and workers of IRS in Bradford and Birmingham in the UK. The guides for interviews and focus groups, tailored to each group of participants, were developed from a literature review and prior learning from the results of other work packages in the same study. Interviews and focus group discussions were audio-recorded, transcribed, and analysed thematically. Results: IRS are receptive to delivering a childhood obesity prevention intervention. Most of them have the capacity and the delivery would be acceptable to parents of children attending these settings. All participants viewed Prophet Muhammad’s physical fitness, food and his attitude towards physical activity and maintaining healthy lifestyle as the best role model to follow. Managers and workers in IRS showed willingness to conduct physical activity sessions for South Asian boys and girls and emphasised the need to have female instructors and role models to encourage South Asian girls. Practical barriers for the intervention delivery were poor funding systems and time constraints for managers and workers. Conclusion: IRS can deliver childhood obesity prevention interventions. Interventions

3 should be co-designed, culturally/religiously sensitive and combine the scientific guidelines on healthy living with Islamic narrative on importance of physical activity and healthy diet consumption and should involve local place-based groups for delivery.

Background
Obesity in children is associated with physical, social and psychological health problems, and tracks to adulthood, with subsequent increased risk of chronic diseases (1)(2)(3). 40% of South Asian (mainly Pakistani and Bangladeshi) children (aged 10-11 years) in the UK are overweight or obese compared with 32% within White British children (4). Ethnic inequalities in obesity in the UK result from a combination of metabolic, socioeconomic, cultural and behavioural factors (3,5), with social and environmental factors contributing the most (6).
Dietary practices tend to be less healthy in South Asian young people and second generation migrant families (7). Substantial differences in dietary habits start from infancy, with higher sugar and fat content of foods introduced at weaning in Pakistani compared to white British infants (8). South Asian girls are more likely to skip breakfast and consume more sweetened drinks than their white British counterparts (9). Halal (Islamically permissible) food and meat products are an essential aspect of the diet for South Asian Muslims (10) limiting their food purchasing choices. Average consumption of fruits and vegetables is also lower among the South Asian populations compared to the white British population (11). Low levels of physical activity among South Asian children, particularly girls, is another important contributor to childhood obesity (12). Cultural practices and beliefs, such as preference for driving instead of walking (13) account for some of this behaviour. South Asian children and families are geographically concentrated in deprived areas (14) which further increases risk of childhood obesity. Interventions to enhance physical activity levels of South Asian children in the UK are lacking (15). To our 4 knowledge, only five studies worldwide have tested the effectiveness of obesity prevention programmes in this population (16). These programmes were based in schools with little or no parental involvement and had mixed results (16). Parental and family involvement is particularly important in younger children (13). Obesity prevention programmes for children outside of the school settings have not been explored as much, and may be more promising.
Over two-thirds of British Muslims are of South Asian origin (17). 91% of South Asian Muslim children in the UK go to a mosque or a madrassa (supplementary schools for Islamic learning) after school for Islamic education on some or most days of the week (18).
Islamic religious settings (IRS) such as mosques, madrassas or women's circles to study Islam can be useful venues for targeting South Asian minorities to encourage healthy life styles (19)(20)(21)(22). IRS in the UK are often voluntarily involved in health promotion and are feasible settings for the delivery of an obesity prevention intervention. Their potential can be harnessed if approached with keeping cultural and religious sensitivities in mind and if supplemented with Islamic narrative on obesity prevention (23). Previous research using this approach in relation to smoking cessation has proven to be acceptable and feasible (24)(25)(26). However, to date there is limited evidence on whether a similar strategy could be useful in relation to childhood obesity prevention. We acknowledge the complex and often negotiated relationship that Islamic leaders and communities have with interpreting and approving or disapproving certain health interventions and practices for Muslims (13,20,23,27). However, there is uncertainty on how a health promotion intervention can be delivered by using or involving IRS. The current study addresses this knowledge gap and dearth of literature. The aim of our study was to investigate the receptiveness, capacity, and acceptability of delivering a childhood obesity prevention intervention using Islamic religious settings in the UK.

Methods
We used a qualitative research methodology. Our methods were indepth interviews and focus group discussions and our analysis was thematic. We took an inductive approach where the aim was for the findings to arise from the voices of participants. As such, we did not apply an existing theoretical framework to the dataset.

Participants
In order to grasp the receptiveness and capacity of IRS to deliver childhood obesity prevention interventions, we conducted 20 in depth interviews with Islamic leaders and 3 focus group discussions with IRS workers/managers (n = 26). To determine the acceptability of interventions within IRS for parents, we conducted another 20 indepth interviews with parents of children (5-11 years old) attending IRS. Ethical approval was obtained from research ethics committee of University of Bradford, UK (E645).
We recruited research participants from two English cities with a high density of South Asian Muslim population, Bradford (24%) and Birmingham (22%). Research participants were recruited from three categories of people (Islamic leaders, IRS workers/managers, and parents of children attending madrassa). Purposive sampling sought to include participants with a range of markers of identity like geographical location (Bradford, Birmingham), sex (male, female), ethnicity (Pakistani, Bangladeshi), place of birth (UK or abroad), and first language (English or others).

Researchers and language:
The interviews and focus group discussions were conducted by two researchers (SD and KR). SD is male, fluent in Punjabi, Urdu, Arabic, Persian, and English, and based in Bradford. KR is female, fluent in Punjabi and English, and based in Birmingham. SD conducted interviews with most male participants and KR with mainly female participants 6 in order to facilitate access. All interviews and focus group discussions were conducted in English as this was preferred by participants. Participants used words in Arabic, Urdu, and Punjabi while responding in English, particularly while discussing Islamic rituals or South Asian food habits.
Indepth interview and focus group conduct A topic guide was used. It was developed from a literature review and prior learning from other work packages in the same study, including a scoping review and mapping exercise (23). The topic guides were tailored to each participant group (parents, Islamic leaders, IRS managers and workers) but had substantive components which were similar throughout. We focused on examining attitudes and beliefs in relation to: physical activity, healthy dietary habits, sleep/sedentary time and structural/organisational changes within IRS, and tailored topic guide after team discussed findings from initial interviews. All participants gave written, informed consent to take part in the study. Indepth interviews and focus group discussions were audio recorded and transcribed verbatim. Pseudonyms were used during transcription and data analyses. The duration of indepth interviews was 45-60 minutes and 60-90 minutes for focus groups.

Analysis
Thematic data analysis (28) followed five stages: data familiarisation, theme identification, indexing, charting and mapping the data. NVivo 12 was used to organise coding. SD, KR, SB and LS collaboratively developed the coding framework. SD coded four transcripts against the coding framework. SD, KR and LS fitted the data against the codes and designed the final framework of codes and sub-codes, then iteratively modified it.
After discussing how the data fitted against the codes, we agreed on the final framework of codes and sub-codes for other transcripts.
During coding of interviews, we were aware of overt saturation and repetition of responses from participants. Therefore, the research team decided to code half (20 out of 40) of the indepth interviews transcripts and all 3 focus group transcripts in Nvivo and then read the rest of the transcripts (remaining 20 interviews), only explicitly coding if data was discordant. We ensured that the interview transcripts selected for coding were representative of the dataset as a whole by taking an equal sample from Bradford and Birmingham and an equal split of parents and Islamic leaders, and male and female participants.

Results
Overall, Muslim parents in Bradford and Birmingham informed us that an obesity prevention intervention using IRS would be acceptable to them. Islamic leaders and IRS workers were receptive to the idea of intervention in these settings and explained that IRS would have capacity for delivery. However, willingness to engage with an IRS based intervention had certain caveats. We explored the dominant moderating factors which influence acceptability, receptivity and capacity through three main overarching themes which arose from the data. These moderators are: 1.
The importance of Islamic narrative 2.
The influence of cultural context

Practical barriers and facilitators regarding implementation
Suggestions put forward by participants as to how the intervention could be practically enacted are detailed in appendix 1.

11
Gender of a child and physical activity: Cultural taboos among South Asian communities around physical activity in girls, particularly after reaching puberty, was a frequently cited barrier hindering the scope of activity for South Asian girls. This was partly around the practicality of where they could change clothes, but also related to mixing of girls and boys in unsupervised spaces "Physical activity in same class for 5-9 years old boys and girls in IRS is alright with me, but it should be in separate classes for girls when they are 10 years or above this age" (mother, Birmingham). The majority of participants said that they would prefer physical activity for girls in IRS to be conducted by female instructors. In addition to unstructured sleeping patterns, excessive screen time was also discussed as an issue, leading to less time for physical activity. IRS workers related that younger children have recounted watching TV until 9-10pm. Islamic leaders also acknowledged that parents often buy mobile devices for young children and without parental control, these keep them awake till late at night. "I have witnessed some young mothers giving mobile phones to children to make them finish their meal and others using electronic devices as babysitting tools" (Female IRS worker, Bradford). A potential lever was around collaboration between IRS, schools and the health service. Other perceived barriers related to time, space and funding constraints. Collaboration with external organisations such as schools and the health service presents potential opportunities.

Practical barriers and facilitators to implementation of an IRS based
Mainstream health promotion messages and interventions tend to be uniform and without considering the varying needs and responses of ethnic, religious or other sub-groups (29).
The available data on health behaviours and health inequalities is mostly collected on School based interventions for health promotion have concluded that parental involvement is associated with better outcomes (21). Interventions in IRS will involve parents as well as children and therefore have potential for greater effect. Islamic narrative on healthy living combined with healthy lifestyle recommendations by health authorities in the UK could influence behaviour among South Asian communities. Available evidence shows high reach through IRS where most of health promotion interventions are targeting physical activity already (18,23). Our findings support to view IRS in the UK as a progressive force for inculcating obesity prevention behaviours through promotion of a 'healthy belief system' in these high risk groups. By using IRS, evidence based recommendations on physical activity and healthy diet combined with Islamic narrative on healthy living could be disseminated effectively and in an engaging manner to children, parents, families, and communities as a whole system.
We learned that an intervention to promote obesity reduction in IRS should consider the caveats of each setting. An intervention targeting behaviour change for obesity prevention should relate more with the lived experience of members of the public attending IRS.
Place based groups in these settings, with involvement of local leaders and IRS staff in intervention delivery could result in uptake of activities and ensure sustainability (23). A toolkit or guideline designed specifically for training IRS staff offering educational and informative material to complement the madrassa curriculum using Islamic narrative on healthy living along with obesity prevention recommendations by NHS, PHE and NICE guidelines could prove to be effective.

Limitations
We collected data from parents, Islamic leaders, and managers/workers of IRS separately.

Consent for publication: Not applicable.
Availability of data and material: Data and materials analysed during this study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare that they have no competing interests.