The objective of the current study was to investigate barriers and facilitators of communication between persons with Parkinson’s disease, carepartners, and physicians, specifically in the setting of off periods in Parkinson’s disease. We used a qualitative descriptive approach to analyze interview transcripts and compare themes between participating groups.We interviewed persons with Parkinson’s, carepartners, and physicians  using a semi-structured questionnaire to identify and describe experiences, barriers, and facilitators relating to communication about off periods) factors. Other barriers included the challenging nature of off periods themselves. Positive physician characteristics such as empathy, respect, and taking time to listen were major facilitators of communication regarding off periods. Persons with Parkinson’s, carepartners, and physicians described using various tools  to aid communication regarding off periods but participants identified a need for more formal educational materials.Twenty persons with Parkinson’s and their carepartners and 20 physicians  participated in interviews. Identified communication barriers included patient-level , caregiver-level (e.g. caregiver absence), and physician-level (e.g. distraction by technology, lack of appreciation of the burden of off periods. Further research is needed to identify optimal strategies for communication about off periods and preferred approaches for off period education.Physicians caring for persons with Parkinson’s can improve communication through more patient-centered practice but there is a need for improved educational tools regarding  Numerous studies link patient-physician communication to improved health outcomes . Good coShared decision making (SDM) is a partnership between patients and physicians  which considers patients’ values and preferences alongside the medical evidence to make the best decisions for a given patient in a given scenario. While SDM is lauded as the “pinnacle of patient-centered care” , it reliOnly 36% of persons with Parkinson’s disease (PwP) and caregivers report satisfaction that their physician “listens to each patient and takes the patient’s concerns seriously” . Multiploff periods, however, identified only one study on this topic  you don't realize that the fatigue is there, the antsiness is there, the grumpiness sometimes is there … those are the kind of things it's hard to describe (PwP14).Sometimes people describe this sort of very vague, you know, I just don't feel good in the morning… After lunch I'm this, you know, I need to take a nap and I feel so tired. Or I feel so fatigued, or I feel so weak. So, that's obviously a bit more challenging, cause I mean, who knows? … Sometimes it's very straightforward, they're just saying oh, you know, half an hour before I take my next dose the tremor comes back… I think mostly when people describe their off, or their possible off symptoms as very vague, it makes it much more challenging (MDS4).General neurologists and specialists described that patient recall of symptoms was an additional barrier . DiseaseThe biggest challenge is that sometimes just having Parkinson's, my brain don't want to work right and I forget stuff and, you know, I may forget to tell him about, maybe, certain symptoms (PwP13).PwP admitted that pride, embarrassment, and an unwillingness to admit that something was happening limited what they raised with physicians. While carepartners did not identify many patient-level barriers, they reported that sometimes PwP were unlikely to report symptoms:I tend to be more upfront and let [the doctor] know what’s going on, where he’s more wait and see, let’s see if it gets worse, when we don’t need to let it get worse, we need to just tell the doctor now (CP5).off symptoms was unrecognized by physician participants.The reluctance of PwP to report wearing PwP and carepartners reported that the lack of carepartners at clinical visits was the main carepartner-related barrier . PhysiciYou're running up against the difficulty of talking to someone and someone…and the patient saying one thing and the family member saying something else. And, there could be some disagreement and argument about it (GN6).off periods impact daily life.Physician-level barriers were described by PwP and carepartners but not by physicians themselves . PwP desI guess maybe just drawing the line from the fact that I have these off periods to the fact that I think they're a major impediment to my life, and I think he thinks of them as just normal for Parkinson's patients… It's hard for me to feel heard because what I really would like to do is go back to work, and I can't go back to work when I'm having off periods. And I think he's not thinking about me going back to work… (PwP2).off period experiences:Carepartners felt that physicians do not investigate the depth of patient They're certainly not asking the level of questions you are, that like, you know, what is the impact and extent and severity of these off periods (CP2).Carepartners reported lack of physician engagement of carepartners in clinic visits as a barrier:Well, I think the neurologist should inquire a whole lot more of me. I mean, they obviously need to direct themselves towards my husband as a person with Parkinson’s and all of that kind of thing, but I think they miss and have missed a whole bunch of data and information, and it took me a couple of years, not because I’m not assertive or anything, but it was kind of a new experience to be my husband’s spokesperson. But I used to sit there and think they aren’t getting half the story just listening to how my husband perceives what’s happening with him, and I thought it was odd that, I thought it was really odd that the reaction to the person who is with him 24/7 isn’t more important to these neurologists (CP1).Both PwP and carepartners described challenges from physicians distracted by technology:I feel that he's very distracted by the technology that they use, those computers. And I feel like he has, like, his checklist, and he really does need to get through that before he can really focus on me… They're computerizing everything and he is not… he's not a computer guy… At best he's a two-fingered typist and he has to pay complete attention to the computer or me. He can't do both (PwP2).off periods is itself a barrier to communication. Physicians reported difficulty establishing whether symptoms related to PD, medication timing, or something else.The complicated nature of You know, patients just say they don't feel well all day long. And, so, this is hard to kind of say, "Well, was there a time when it was really different? And, how does it relate to my doses? Is it the beginning of my dose? The end of my dose? And kind of arbitrary?" (GN7).off periods from peak dose dyskinesias:Movement disorder specialists described the difficulty of distinguishing tremors during A lot times patients misinterpret their dyskinesia as tremor and that can be confusing because when they’re really on they think they’re off and they’re worried about that movement when it’s really an on phenomenon (MDS10).off symptoms:Specialists also reported challenges in identifying the presence of non-motor …So much of the time the off-periods are–so there are psychological symptoms, and if they're associated with obvious severe motor symptoms, then that’s not hard to ferret out. But so many patients don’t understand that the motor wearing off might be mild and the emotional symptoms might be much more severe (MDS7).off periods, described by both PwP and physicians.Related to these challenges is the lack of shared vocabulary about I also learned what an off period is, and that's what I'd been describing to my doctor as just the unevenness, I called it the unevenness before (PwP2).Helping PwP understand what to expect, though, can be challenging:All symptoms vary quite substantially between individuals, so it's not sort of where I can say, here's a list of things, you know, more tremor or feeling slower or stiffer or things like that, because I think that people experience off differently (MDS2).Clinical visit time was a barrier described by PwP, carepartners, and general neurologists, but not specialists. Lack of ancillary support (e.g. advance practice providers [APPs]) was a barrier for small general neurology practices.Identified patient- and carepartner-level facilitators were rare, though all groups agreed that having a carepartner present at visits was helpful .PwP valued physician traits such as empathy and respect.Parkinson’s is a very individual disease. And so you need somebody that’s going to, you know, care about that and respect that and listen to you when… there’s something really concerning you. I wouldn’t bring this up if it wasn’t important (PwP8).Physician behaviors such as listening to PwP and carepartners, demonstrating interest and curiosity, and appreciating individual experiences were also identified facilitators:Well, the fact that the doctor actually sat down and took the time to listen and hear what I had to say, really listen to all of the symptoms I was conveying, not just looking at the tremors or trying to figure out the small handwriting or whatever. He was listening to what I was feeling relative to smell and taste and hearing and unsteadiness. He was listening to all of it (PwP3).She actually sits and listens, and she doesn’t try to make you think that something else is happening (CP5).You know, the doctors definitely are open to talking to both of us and, you know, I certainly get the feeling that he’s as interested in what I observe as what my husband observes (CP12).General neurologists described the importance of taking time to listen to PwP and carepartners:I think trying to be cognizant of not being rushed when I'm actually in there… When I see a patient I actually don’t–even though I have an electronic medical record–I actually don’t type or work on EMR when I'm seeing a patient. So, trying to be present with them and having a conversation with them versus trying to do my data entry at the same time I'm talking to them (GN2).General neurologists noted the value of longitudinal relationships over time, using the same questions each visit to facilitate patient understanding, and recognizing the importance of individual preferences . PwP andI still think the face to face conversations where I can ask him questions and he can give me answers or he can, you know, actually grab my arm and feel for rigidity or see how I walk across the room, I think those are the kinds of things that I benefit from the most (PwP3).off periods. PwP and carepartners reported creating a list of concerns prior to clinic visits to guide discussion, sometimes using questionnaires to guide that preparation .I give them kind of language because I think the most important thing is a shared language (MDS8).off periods, often by sketching graphics .One specialist noted the particular importance of educating PwP about non-motor fluctuations. A general neurologist described using the teach-back method to ensure understanding. General neurologists reported using informal online videos to demonstrate symptoms and referring patients to online forums or local support groups. Numerous movement disorders specialists described the value of having allied health professionals and APPs to provide education informally or via scheduled training sessions.off periods. Movement disorders specialists felt that having an educational page to send home with PwP would be helpful, whereas one general neurologist thought that a pamphlet would not be much use given the lack of associated visuals.Both general and specialist neurologists voiced interest in having video resources to teach people about off periods. In a prior study of advanced PD, PwP, carepartners, and physicians also identified lack of information, poor neurologist support, patient cognitive impairment, lack of caregiver involvement, and PwP-caregiver disagreements as barriers to decision-making [off periods is a unique barrier affecting many aspects of PwP-carepartner-physician communication. PwP described difficulty putting their off symptoms into words. Physicians described challenges correlating symptoms with medication dosing and identifying if there is a treatable fluctuation. Both parties highlighted the lack of a shared vocabulary.PwP, carepartners, general neurologists, and movement disorder specialists identified numerous patient-level, carepartner-level, and physician-level barriers and facilitators to communication regarding n-making , consistn-making . While moff periods  [Facilitators of communication described in this study and in the literature include presence of a caregiver for decision support, continuity of care, adequate time, respect, physicians taking time to listen, good communication, provision of information about options, and written decision support , 24. Str periods . Successy motor) , 26. Diay motor) .off periods, lack of shared understanding of the concept between PwP and physicians, and limited physician appreciation of the personal impact of off periods are important modifiable communication barriers. These results are consistent with prior PD research demonstrating lack of education and understanding as barriers to PD care [off periods to improve education and communication, consistent with a known need for better patient education in PD [off period video and print educational tools for use within clinical encounters, in community settings, and for patient and carepartner self-education. Subsequent to the conduct of this study, the Parkinson’s Foundation published “Managing PD Mid-Stride,” a booklet with text and figure-based education regarding off periods that addresses some of the needs identified by study participants [Our results highlight that lack of patient/carepartner education regarding  PD care –10. Physon in PD . These ficipants . Educatiicipants  and mediicipants .off periods, failure to engage carepartners in clinical visits, and distraction by technology impeded communication, physicians in our study appeared largely unaware of the ways they impeded communication about off periods. Opportunities for physicians to improve communication include allowing more time, involving carepartners, active listening, showing interest, asking about the personal impact of wearing off, avoiding distractions from technology, and providing education about off periods and what to expect Click here for additional data file.S1 Interview guideThis file includes the three semi-structured interview guides used for the study.(DOCX)Click here for additional data file.S1 AppendixCoding tables for barriers and facilitators to communication about off periods for PwP, carepartners, and physicians.(DOCX)Click here for additional data file.


Interviews were transcribed verbatim and analysed using directed content analysis. Healthy eating was viewed as more important than, and unrelated to, physical function. Personal, social and cultural/environmental factors were identified as the main factors influencing eating behaviours and physical function, which differed by ethnicity, age, and sex. At 8-month interviews, more men than women reported adverse changes. The study provides unique and useful insights regarding perceived eating behaviours and physical function in a relatively large and diverse sample of older adults that can be used to design new, and adapt existing, culturally-tailored community interventions to support healthy ageing.Ethnic minorities have a high prevalence of non-communicable diseases relating to unhealthy lifestyle practices. Several factors have been identified as influencing unhealthy lifestyle practices among this population; however, there is little evidence about how these factors differ among a heterogeneous sample living in a super-diverse city. This study aimed to: (1) identify and compare factors influencing eating behaviours and physical function among ethnic older minorities living in Birmingham, United Kingdom; and (2) understand how these factors and their association with healthy eating and physical function changed over 8-months. An in-depth interviewing approach was used at baseline ( The population in the United Kingdom (UK) is ageing and becoming more ethnically diverse . In EnglThe limited published evidence examining dietary intake in this population suggests that the diets of ethnic minorities who immigrated to the UK are less healthy than when living in their country of origin, due to acculturation ,8. The iThis has significant social and economic implications for the nation, including increases in health and social care costs, and the costs to individuals, families and communities . As suchTo develop culturally tailored and appropriate interventions, it is imperative to have an in-depth understanding of how the factors influencing dietary behaviours and physical function may differ and interact in this population. There is some published evidence contributing to our understanding of these factors among ethnic minority communities. For example, a study exploring eating behaviours among 36 overweight and obese South Asian men (18–64 years) found cultural factors, lack of time and motivation, and family and other social networks as influencing eating behaviours . SimilarThe present study uses a longitudinal qualitative design to: (1) identify and compare factors influencing eating behaviours and physical function among ethnic older minorities living in Birmingham, United Kingdom; and (2) understand how these factors and their association with healthy eating and physical function changed over 8 months. In addition to building on the existing literature, the findings provide insights and novel information to aid stakeholders, policy makers and health professionals in understanding, designing and implementing effective culturally tailored interventions to support healthy ageing in community-dwelling ethnically diverse older adults. A longitudinal qualitative approach was used to gather relevant data. This design was effective in generating a rich dataset that supported an in-depth examination of lifestyle changes that occurred in the target study sample over eight months, the factors that may account for these changes, and the perceived impact of these changes on eating behaviours and physical function . The guiThe research was conducted in the wider Birmingham area, West Midlands, UK. In this geographic area, ethnic minorities (non-white) comprise 46.9% of the population, with the largest being South Asians (22.6%). The population of ethnic minorities increased in this region by 12.4% from 2001 to 2011, and with the current projected population growth of 7.2% by 2026, the non-white population is expected to make up more than half of the entire population by 2021 ,25.One hundred participants were recruited using purposive sampling coupled with chain referrals and word of mouth. Inclusion criteria were an older adult aged 60 years or older living within the Birmingham area who self-identified as African, Indian, Pakistani, Bangladeshi or Caribbean. Participants were recruited through older age societies, community centres, faith centres and various social events for ethnically diverse older adults across the Birmingham area. Recruitment excluded older adults with a diagnosis of dementia or any cognitive disabilities that might affect their participation in the study. Individuals residing outside of the Birmingham area, institutionalised or hospitalised were also excluded. Maximum variation sampling was employed during the recruitment process to ensure wide representation across older age groups, ethnicities, sexes, religions/faiths and socio-economic groups ,27,28. Several techniques were employed to increase recruitment, obtain quality data and to increase retention in the study. The first author (EAA) established initial contact with community leaders and potential participants before the start of the study. EAA attended church services and other faith centres’ public events to establish rapport with leaders and potential participants. This enhanced trust between EAA and participants. Community leaders who met the inclusion criteria were also encouraged to take part in the study. Acting as role models, this built trust and enhanced credibility of the study . This stThe study received full ethical approval from the University of Birmingham Science, Technology, Engineering, and Mathematics (STEM) Research Ethics Committee (ERN_17_1364). All participants provided written informed consent before data were collected.A constructivist paradigm, with a phenomenological philosophical underpinning, guided this research. As such, the researchers shared an understanding that knowledge is not comprehensively generated without the researcher and the participant ,31. ThisGiven the aim of this study, an ecological model was used to explore and conceptualise the different levels in which factors influencing eating behaviours and physical function operate . This moEating behaviours and factors influencing eating behaviours.Physical function and factors influencing physical function.This interview guide was iteratively revised at follow-up to include: Changes in factors influencing eating behaviours and physical function over the previous eight months.The conceptual framework coupled with the use of relevant literature was used to design the semi-structured guide for the interviews ,12,34. Tn = 19). Interviews were conducted from March 2017 to February 2019 at locations of preference for participants including their home, community centres, or at the University. All interviews were digitally recorded and lasted from 25–110 minutes. Using this interview guide, two in-depth qualitative interviews (baseline and 8-month follow-up) were conducted. The use of this approach was most appropriate as it allowed us to guide the interviews towards important areas that would yield relevant responses . AdditioInterviews were transcribed verbatim during the data collection process. This allowed for the reorganisation of some parts of the interview guide to explore in-depth areas of interest . After tThe directed content analysis approach involved preparation, organization and reporting phases. The preparation phase involved full immersion into the data, where transcripts and field notes were read and reviewed to understand the pattern of the data. During the organisation phase, two categorisation matrices were developed: one regarding factors influencing eating behaviours and the other regarding factors influencing physical function. A complete matrix developed on eating behaviours is shown in To ensure rigour, trustworthiness and the ease of use of the matrices, two researchers (JAA and JLT) independently pre-tested the matrices using preliminary data . Afterwan =4); loss of interest (n = 2); and unable to trace participant to schedule the follow-up interview (n = 5). At baseline, the mean age (SD) of participants was 70.1 (8.1) with 24% living alone. The majority of the sample comprised of Caribbean and Africans (60%), followed by South Asians (34%) and the smallest proportion were participants identifying as ‘others’: a mixture of the two major ethnic minority groups (6%). Over half of the sample had completed at least secondary school education (58%), while participants with no formal education made up 15.2% of the sample. The differing perceptions of healthy eating and physical function.The personal, social and cultural/environmental factors influencing eating behaviours and physical function and how these factors differ among the sample.Perceived changes to eating behaviours and physical function over the 8-month follow-up period.The findings that emerged from the data are presented in detail under the categories below: Perceptions of healthy eating differed by sex, ethnicity, the presence of disease condition(s), religion or age. Among women, less than half (43%) perceived healthy eating as cutting down fat, limiting portion sizes, and healthy cooking methods such as reducing the amount of salt and oil during cooking or opting for steaming and baking as opposed to frying. Similarly, a third of men (34%) shared all these views except perceptions around cooking methods. Across both sexes, home cooked meals were commonly considered to be healthier compared with eating out.“I think for me, less fat in your diet and I’m thinking about my health as well. Less fat, things that are not fried and smothered in fat when cooking, and a little bit more homemade because then you know exactly what’s going into them is better” .Among participants with diabetes, one-fifth (20%) reported healthy eating as cutting down on amounts of food eaten, skipping snacks and avoiding sugary or fatty fats to manage their health condition. Some (12%) also reported fruits as foods representing healthy eating, as they were told by their health professionals to have enough fruits daily to manage their blood sugar. “... I don’t eat…between meals, which is good. So, when I get it, at the right time, I eat and eat everything at a go to help me with my sugar level, to control my sugar” .Religious teachings, mainly among Muslim participants, were reported as guiding their perceptions of healthy eating. This was reported by more than half (51%) of the Muslim participants.“Healthy eating means if you have hunger that much [demonstrating using his hand], you eat only that much [demonstrating using his hand 3/4] and leave that much hunger there [demonstrating using his hand 1/4]. And this is what Islam teaches. They say have a glass of water with [your] meal…No, I don’t want it, because Islam says you don’t eat with water, is not healthy eating” .Across both sexes, traditional foods were mostly considered as healthy foods and tasty as compared to other foods. However, their views appear to differ by ethnicities. For instance, Indian/Pakistani/Bangladeshi male participants with a University/College degree described their traditional foods as being ‘fatty’, ‘greasy’ and “tasty with too much sugar”. In contrast, Caribbean and African participants, across all levels of educational status, perceived their traditional foods as healthier and lower in fat:“…I don’t think it’s very healthy, the traditional Indian diet has got too much sugar in it, too much oil, they fry a lot, it all makes it not healthy” .“That is the pivotal point in the West Indies food. I see it as healthy. It keeps you healthy and even though you might not [be] feeling well like you have the flu or you have the pain and everything, with our food, you are never sick too big to go to the hospital” .Additionally, the satiation properties of food emerged among Pakistani/Indian women as an important factor in considering food as healthy. As one participant described, not feeling hungry even after hours of not eating was considered as being healthy for her. Hence, she considers the traditional foods that could satiate her for longer hours as healthy foods.“That [traditional foods] is healthy eating…. It’s more filling. So, [I] think it’s healthy to eat that, as opposed to feeling hungrier” .Physical function was largely perceived as participation in exercise and general fitness level. It was also labelled as ‘strength,’ which participants viewed as the ability to carry out activities of daily living without difficulty.“Physical function means how active you are. How active, how you can be independent. How you can do things on your own. In terms of flexibility, how you can [be] flexible with your body movement, and all of that” .The study also explored the description of older adults’ physical function levels compared with their colleagues. Of the majority (53%) that commented on this, two-thirds rated themselves as having a high physical function . The remaining participants reported low self-rated physical function and attributed it to increasing age, ill-health and pains as illustrated in the quote below.“I’m maybe below average, I’m not good, but I’m not very poor too, I think with the few aches and pains now I will say I am about three out of 10” .Like healthy eating, the concept of improving physical function to manage health conditions also emerged.“If you want to keep mobile you have to keep your fitness [physical function], I tell you everything is about my blood sugar, it [fitness] does affect your blood sugar and stuff like that” .Across educational status, most men (67%) considered healthy eating to be more important than maintaining physical function. This was attributed mainly to the fact that due to age-related decline in physical function, they believed nothing could be done about improving their physical function levels, hence there was no need to prioritise it above healthy eating. “To eat well is more important, with my age there is no running round about. I don’t bother with the fitness [physical function] now because with my age, but when my daughter cooks me good food, I can still eat well” .In contrast, a few (12%) women thought otherwise and explained that with changes in physical activity level, they prioritised their physical function over healthy eating, as they believed this would help them to maintain their activity level and a healthy weight.“I think exercise is more important these days because you’re not doing any physical work, because one time you used to eat and do physical work and that used to drain you out” . The perceived association between healthy eating and physical function was mixed, in that some participants (34%) believed that they were independent of each other and had no relationship, while a small number of participants (6%) described a relationship between these two factors, stating that healthy eating supports them to maintain a good level of physical function and vice-versa. More women self-identifying as Caribbean or African expressed the latter view as compared to men or women from other ethnic minority groups, as illustrated by the quotes below:“I think eating well helps your physical function, but sometimes eating well, you still have to do something with the physical function. No point in eating well and just sitting around, you have to do both. They both complement each other” .“Between the physical function and eating? There’s no connection between them, just when you’re tired you eat, I don’t see any link” .Personal, social, and cultural/environmental influences on eating behaviours and physical function were reported. Participants’ responses suggested that these influences differed across ethnicity, sex and socio-economic status. Participants highlighted several personal factors influencing their eating behaviours and physical function. As shown in Some participants (24%) reported making changes to their eating behaviours such as changing diet, eating patterns or cooking methods to manage their current health conditions. Others (6%) also reported improving their physical function through walking and gardening to manage their current health conditions. These responses differed by sex and disease severity. For instance, 13% of men reported the influence of health on their diet, stating they avoided sugary snacks and reduced portion sizes. In contrast, women  reported changing their cooking methods, substituting their regular (or staple) foods with healthier options, and reducing portion sizes. “… since I was diagnosed [with] this type 2 diabetes, I watch what I eat in between meals. So, I don’t take anything sugary…I don’t eat between meals. So, when I get it [food], at the right time, I eat and eat everything at a go to help me” . “…. No, I don’t cook with salt, and I don’t fry again, my cooking has changed, and I don’t eat our [traditional] food sometimes…Well, your blood pressure, isn’t it? I’m on blood pressure tablets, so I need to change. I am also diabetic too, I have to change [my diet] now” .The fear of losing independence and other consequences accompanying complications from diabetes and other diet-related non-communicable diseases emerged as motivating factors for some (12% of the sample) to eat healthily and maintain their physical function. As one participant explained:“Because I have type 2 diabetes and I’ve seen, [people] actually suffering. I don’t suffer with it, but because I have seen what it can do and has done to members of my family, and I’m not prepared to go there, that’s my impetus, that’s my motivation, that’s my drive. To eat healthily, take a lot of regular physical activity to keep the complications at bay” .Pain resulting from health conditions was mostly described by participants to be inhibiting them from doing activities to maintain their physical function. “Also, like I’ve got a bit of a dodgy left knee mainly from my arthritis. Sometimes that hinders me from doing a lot of walking… because of my knee pain, so I just stay put” . Pain was also reported to be affecting cooking and shopping, as most could not either stand to cook or go about their regular shopping. A man living alone describes how pain from his knee injury is inhibiting him from preparing traditional meals as they require much attention during cooking, so he has resorted to consuming simple, ready-to-eat meals.“I am not able to have that food [traditional food] as I will like [to]. Now I just have these easy ones  as you can see.... buying it myself, it takes time to cook, it takes time to prepare curry goat [traditional Caribbean soup], and with my bad knees, I would not be able to stand for it” .Body image also emerged as a factor influencing eating behaviours and physical function. More women (23%) reported this as compared to males (8%), describing a healthy and ‘desirable’ weight as a means to good health and a way to manage their health conditions. These were reported to influence their portion sizes, types of foods eaten and enjoyment at meal times.“I don’t eat as much cheese as I used to, I used to love cheese, I used to love crackers, and I very rarely eat that. I mean, you see, another thing, it’s not just eating to sustain me, I’m trying to keep my weight down as well, so there’s that sort of consideration as well” .Maintaining a healthy body weight was also described by some (10%) women participants as a motivator to keep up their physical activities, thus helping them to maintain physical function. “If you walk, your joints are fine; you keep the weight, so you keep your body and your muscles healthy, your physical function will not fall” .Interestingly, of the majority (93%) that reported having a diet-related non-communicable disease(s), very few (8%) reported making efforts to improve their physical function or commented on the importance of maintaining a healthy weight. However, the few that stated making efforts to lose weight shared similar difficulties in achieving their weight loss goals. A third of the participants reported the influence of age on eating behaviours and physical function. Those that recognized a decrease in appetite and decline in physical function attributed it to age.. This participant explains how he is becoming more health conscious with age, hence the need to make certain adjustments for better health.“I think we are getting more health conscious, put it this way. As we get older, nowadays me and my wife, both think before we eat. In other words, restrict, eat smaller portions” .More men living alone than women commonly expressed age-related declines in senses such as taste to be affecting their food intake. As narrated by a man living alone, loss of taste makes eating difficult and less enjoyable.“I realise after spending a full day to cook food [to feed me] for three days, I eat the first day, and there’s no taste left…so it become[s] difficult to eat” .Retirement was commonly identified as contributing to changes in lifestyle, in that participants had more time for cooking, shopping or doing physical activities. Some (28%) participants stated this had substantially changed their eating behaviours as compared to when they were working:“I didn’t have much time to watch what I was eating [while working], and I used just to grab things and go because I was all [the] time working, I probably wouldn’t have bothered with green stuff like spinach, I only used to have spinach occasionally. I have it more often now” .In contrast, a few (5%) of recently retired participants thought otherwise. They described the increased ‘free’ time to be causing them to eat more and resulted in them gaining weight as compared to when they were working: “Probably my style has changed because I’ve retired. When I used to work, I was going to work with a cup of tea and one toast, and I would run away to work. Now I’m a bit relaxed, so I have a good breakfast, a good lunch and a good dinner and that has put on my weight. I’ve got all the time to eat” .Regarding physical function, only a few (15%) retired participants, predominantly women, reported that with the increased amount of time available as compared to their working days, they have time to spend doing activities that could improve their physical function. “Yeah, I was sitting from the car to the office, sit down [through] meetings…I think I’ve lost a bit of weight and fitter since I left work. I bought a bike and now [with] my friend who is retired as well, we’d be out, probably get out in the park” .“Yeah, you know, when you go to work, especially Monday to Friday, and then you sit in the car, it limits your physical function a bit because you aren’t able to exercise your body, but now that I am home that is not an excuse. I have more time and I walk around” .Contrary to this, four women and a man complained of lack of time after retirement, as they have to either care for their grandchildren or have an abundance of social commitments relating to their faith/religion and other social groups. Among participants still in active work, a few (22%) across both sexes reported their work schedules as a hindrance to undertaking activities that might improve their physical function.“It [is] either to do with working too late….and then after I’ve worked, I’m so tired, and after I’ve eaten, then it’s too late to get on the cross trainer or do walking…all I can do is just eat and watch TV” .Social network influences included those of family, friends, and the community. Almost all participants described how meal times were more enjoyable when the family size was large. Participants indicated that reduced network size as they have aged, made it challenging to cook often or to cook a variety of foods, due to greater likelihood of food waste. “I don’t cook a lot ever since I am on my own, it has changed ever since my youngest daughter left home to go to the university. Sometimes, I will prepare food and when I am supposed to eat, and I don’t want it anymore… Because being on your own I am not looking forward, I am not thinking about food…on my own, I will say ’why will I bother?’. So I will go for a fruit or anything and end up freezing the food…” .“I wouldn’t say my eating habits have improved, since the children all left I don’t cook that again, when the children were at home, we used to have a lot of eating times, now it has reduced.....because the excuse is, there’s more to eat when I cook and I don’t wanna waste it” .However, Sunday dinners were described as a special day of the week where children and other family members would visit. Some (30%) said they enjoyed eating and might eat more on these days, as there is a variety of foods available. In contrast, others  reported that the presence or lack of social interactions at meals had no effect on their eating behaviours.“I tend to put in more effort in what I do and what I cook while if I am on own, I don’t do that much. Yeah, I might just cook something simple but when they come [children] I make it more special...I have more to eat when we are all seated” . “I don’t really mind. It’s nice to eat with people, but I’m quite content to eat on my own as well. It’s not an issue whether people are there or not, I eat [the] same” . It also emerged that a few (17%) men preferred the act of commensality, and attributed its importance to the fact that their spouses and children supported them to eat healthily, especially when eating together during the meal:“Yeah, eating with them (family) impacts on my eating, it does, because you can see my wife, she’s not a very big eater, and she’s very conscious of what kind of foods she puts in her body whereas sometimes I’m not conscious. Eating with her I tend to eat healthier, I do, yeah” .Some participants living alone reported that they had regular support with shopping and cooking from their children or friends. They further explained that with a decline in physical function, this was necessary as they could not shop or prepare their meals. “She [daughter] does the cooking and [brings] it over to me...I do breakfast myself. But the cooking I can’t stand that long to do it…my daughter does the shopping once a month for me” .Regarding physical function, a few (11%) participants expressed the support and encouragement received from family and friends as having a positive impact on their physical function. Instrumental support, such as taking them to the gym, paying for personal trainers, buying gym equipment, or providing them with information on how to improve their physical function was highlighted as beneficial. Also, participants that attended community/age-well society meetings considered this engagement as beneficial to maintaining their physical function. At these meetings, some of the activities included leisure activities, board games and occasionally exercise and nutrition classes. “…So, when I joined here, it has help[ed] me [to] socialise, and the group exercise is keeping me active, my [physical] function is improving” . Across all ethnicities and age groups, the influence of various cultural  food practices such as eating certain types of food and the food preparation were commonly expressed by participants. Participants referred to these as their “identity”, “heritage” or “culture” that were important in bringing back memories and providing a sense of comfort and ‘proximity’ to their home country.“I will have to eat Caribbean foods, [it] makes you feel good, and makes you feel as if you are home, [and] that’s part of you. Potatoes are not part of me, chapattis are not part of me. So, I’ve got this [Caribbean foods] as part of me…. Sometimes when you eat it, it brings back memories of certain things, so that’s why I do enjoy it when I cook it. I’ll cook it to remember a lot of things” .It emerged that some participants did not like the format and content of some health education messages relating to their traditional foods. While messages around reducing portion sizes were regarded as feasible, messages involving the removal of their traditional food were heavily criticised. For instance, eight participants  described dietary advice that meant they should stop eating their traditional food completely as not realistic or feasible:“A dietician once told a black woman from the Caribbean to cut out her Caribbean food altogether. You never tell a white person to cut out their potatoes. To deny someone their culture and heritage will not work for me…food is what makes a person what they are….” .The influence of the multi-cultural and super-diverse environment of Birmingham on access and affordability of food was also raised by participants. In general, participants highlighted the diversity in Birmingham as having an important role in ensuring accessibility to, and affordability of, some of their traditional foods which was not the case in cities/areas with less diversity. Besides accessibility and affordability, diversity was also reported as helping them to feel comfortable when buying their traditional foods, as one participant recounted: “It [diversity] has made myself very comfortable, I feel comfortable because I know they are other people also having the same sort of food. At the market, I see people buying food like me. It makes me feel happy and [at] one with the place” .“In Birmingham, you can get anything you want as far as African food is concerned. You can get anything you want here. I think it has made us eat well as we can get yam, gari [flour grains from cassava] or anything at any time” .As revealed above, participants considered themselves to be eating ‘healthily’ because they can access the foods they prefer and value. Also, it was revealed that the diversity in the Birmingham area had encouraged the major grocery chains to sell some traditional foods, thus making it more accessible. Probing further, it emerged that most women, living in the most deprived neighbourhoods per the UK Index of Multiple Deprivation (IMD) scale, described the prices of traditional foods in these supermarkets as slightly more expensive compared with those sold in their local corner shops or the budget market located in the city centre.“Because of the diversity, you can now shop for traditional foods at the Asian shops, at Tesco, at Lidl, at Asda, but it’s a bit dear as compared to the market at Bullring [budget market in the city centre]” .Predominately, more African and Caribbean participants describe their traditional foods as expensive as compared to South Asian participants. These responses were common among both sexes and across the IMD quartiles. However, the influence of traditional food prices on food choices was mixed among this sub-population. While a few (11%) reported that it had no effect, more participants (32%) thought otherwise. As shown in the contrasting quotes below:“Well, another thing again… provided it’s good for you; I never think it’s too expensive. I never question that. It doesn’t matter…. If I’ve seen it, want it, I’ll buy it” .“I don’t eat much of the Caribbean [food], we eat more rice and the other stuff because the Caribbean food is very expensive. Rice is cheaper as compared to green bananas, yams, and sweet potatoes…. Yes, I do enjoy these more, but we just have to manage with that rice, because of the prices” .Exploring the importance of diversity further, a few (6%) of the African and Caribbean women reported that the multicultural nature of Birmingham provides them with a platform to share healthy practices across ethnicities. For instance, they reported sharing best practices with friends and church members on healthy ingredients and other efficient ways to manage and control chronic diseases with food.“Very multicultural…. because especially with the Sikh community, because they tell me about what things are good. My friend, she’ll tell you how to use these powders. So, I think the multicultural [environment], you pick up and share different ideas” .Finally, some (32%) participants highlighted the effect of bad weather, notably increased snow and rain, as making it unsafe and demotivating to participate in usual outdoor activities such as walking or gardening. In general, the cold weather was reported as the main cause of an increase in joint pain, making it more difficult to engage in physical activities.“The only thing that would prevent me from going out is the weather. If the day is a normal day, I’ll visit a friend. Doing something to the car or something like that, keeping fit…but if it’s raining or snowing, my knees start to hurt, I just stay in bed” .Besides the influence of the weather on maintaining physical function, it also emerged that with the cold weather, eating patterns are disrupted as narrated by one participant, as she prefers vegetables in the summer as compared to the winter:“Like with my vegetables, in winter I really don’t like to eat vegetables, I don’t know why. In the summer I will eat any amount of vegetables, but when it comes to winter, my mind just blocks vegetables out. I don’t know why” .At the 8-month follow-up, one-third of the participants reported significant changes in their eating behaviours and physical function. The rest of the participants reported little or no changes. Those reporting significant changes described recent sickness and hospitalisation, falls/accidents, fasting, and changes in the level of support as factors influencing their eating behaviours and physical function. The impact of these changes was mixed, while some (42%) described the changes as positive, that is supporting them to either eat well or improve their physical function, the majority (58%) considered these changes as negative, thus affecting their physical function or eating behaviours. Predominantly, more men reported adverse changes compared with women. “Well, it [eating behaviours] has changed quite a lot, to be honest. Because as I said, I used to have a wife…my wife used to cook, but now I have to do all that myself and it is not easy. I don’t think I am eating that well” .Most men who reported these negative changes were living in the most deprived neighbourhoods as per the UK IMD scores. However, this was not the same trend with most women reporting positive changes, who lived in areas of lower deprivation. There were also differences in responses by age among the men reporting changes. Men who were older than 70 years expressed more negative changes as compared to those aged less than 70 years. However, this trend of responses again did not apply to women, as their responses to experiencing changes were evenly distributed across the age range. Participants who engaged in health education opportunities during the study described these as accounting for their experiencing positive changes over the 8 months. A woman reporting a positive change, explained how her recent visit to a clinic-based health education session during the study period led her to make healthy dietary changes.“To be fair, I have cut out sugar. That’s one of the things I’ve done since I saw you, I did go down from one [teaspoon of sugar] to half. Now, I can drink things. Well, I went to the hospital and the nurse said a group of us who are pre-diabetic, that it will help….” . The introduction of fasting (both religious and non-religious) was also an important change discussed by participants, especially those reporting sicknesses during the follow-up period. As described by one participant, introducing fasting was perceived as an effective way to lose weight and regain fitness:“I’m putting on the weight, because of the drugs or because I was in the hospital or whatever the reason might be. So, now I decided to start fasting. If I’m fasting, I feel lighter with my weight and more energy” . Consistent with the baseline responses, changes in weather were repeated as influencing physical function. Participants interviewed during the summer months at follow-up expressed this as an enabling factor to maintaining their physical function and to getting out of the house, engaging in activities, visiting community clubs and religious groups. In contrast, participants interviewed during the winter perceived it as a barrier to maintaining their physical function as they opted to stay in bed at most times. “The weather, I will say yes. You see, like, when the weather [is] hot and nice [like] now, it makes you want to come out of the house, and find different things to do but when you [researcher] came in the winter, I was always in bed, you don’t want to go out, no, there is no motivation to do anything” . This study found diverse perceptions of healthy eating and physical function among ethnic minority older adults that were in some cases shaped by socio-demographic characteristics. The findings revealed that eating behaviours and physical function were influenced by a wide range of factors, from personal, social to environmental factors. At follow-up, more men reported negative changes to eating behaviours and physical function. The key findings are summarized and discussed as follows. Perceptions of healthy eating differed by sex, ethnicity, age and educational attainment. Common perceptions of healthy eating were a reduction in portion sizes, cutting out fat and not skipping meals. In addition to these, women perceived healthy eating to be related to cooking methods. Some of these findings are consistent with previous studies conducted among ethnic minorities and the white English population ,44,45. HOne of the significant findings is that South Asian women considered healthy eating to be eating more satiating foods. In previous research, South Asian participants preferred traditional foods for their satiating properties, however, they added that these were not healthy . The stuDiffering perceptions about traditional foods were present between ethnicities. Those self-identifying as Indian or Pakistani perceived their foods to be generally unhealthy, whereas African and Caribbean older adults viewed it otherwise. These findings are in contrast to a comparative study of African and Caribbean women in the USA, in which African women were more likely to consider their diets as unhealthy and hence made changes to foods and cooking methods . ConsistMost participants rated their physical function highly and perceived that physical function was related to health/fitness, exercise, and the ability to carry out activities of daily living. The present study found that participants’ self-rated health was in most cases opposite to self-rated physical function. Previous research reported that the social and economic disadvantages experienced over the life course partly accounts for low-self reported health , and thaThe present study found that at the personal level, health conditions, pain, age and retirement were factors influencing eating behaviours and physical function. At the social level, changes in social support, living arrangement and community involvement were identified as key factors. At the cultural or environmental level, superdiversity, the cultural identity of food, and the weather were identified. These factors also differed by socio-demographic characteristics of participants and were in some instances consistent with previous studies ,46,52,53Furthermore, the diverse environment was reported as enabling minority ethnic older adults to share cultural practices. The multicultural nature of these communities was serving as a basket of knowledge for them to share culinary skills and recipes for combating diseases. Thus, it highlights more evidence of heterogeneity among ethnic minority communities. The differences shared among and within these groups could be used in tailoring community-based interventions to give the desired results as proven effective in previous interventions ,18. At the personal level, most of the findings were consistent with previous literature ,56,57. HAt the social level, the act of commensality was described as supporting older adults not only to eat better but to enjoy meals more, and this is comparable with previous literature including white British older adults ,58. Our The regular meetings of ethnic minority older adults at faith centres, clubs and community centres were also reported as significant influences on eating behaviours and physical function. These meeting places were expressed as an avenue to worship, exchange ideas, offer support for colleagues during difficult times and engage in leisure activities with friends. Also, a few of these gatherings offered meals, exercise classes or nutrition talks; these could form part of the ‘active ingredients’ of how social networks influence health outcomes in later life. These findings concur with previous research which found that increased social networks and greater involvement in leisure activities did not only improve diet quality in older adults but also enhanced resilience to cope with lifestyle changes ,59.Given that not all older adults experience the same level of changes in eating behaviours and physical function as they age, this study provided novel findings with regards to perceived changes with time and how these differed within this sample of ethnically diverse older adults. Our results indicated that a third of the participants experienced changes within a rapidly short period. Some of the changes during follow-up were the introduction of fasting , changes in the level of support, sickness, accidents/falls and changes in the weather. Men living in higher areas of deprivation were more likely to experience negative changes perceived to be affecting their diet and physical function as compared to women. Previous literature supports these findings as they suggest that men, especially those with poor cooking skills, are likely to have negative changes to diet after losing their spouse, as most meals were previously prepared by their spouse ,61. Considering that most participants in this study had one or more diet-related non-communicable disease, it was surprising to note that at follow-up only a few participants reported making a positive change to improve their health condition(s). This is contrary to previous findings, where a majority attributed changing their diet due to their health conditions ,62. One Perceived negative changes that affected both men and women were the change of weather. Staying at home during these months may not only affect their physical function, but also makes it difficult for participants to engage in other community activities, thus the likelihood of experiencing declines in social ties. This is a commonly-reported issue affecting the ability of adults to engage in regular physical activity across the lifespan ,63.Our study revealed that community-dwelling ethnically diverse older adults are more likely to consider healthy eating and physical function to be separate entities with no relationship. Furthermore, participants commonly prioritised healthy eating over physical function for general health. While more men prioritised healthy eating over physical function, some women prioritised physical function, mostly for weight management reasons. However, more women than men, especially from African/Caribbean backgrounds, viewed healthy eating and physical function as related. This has implications for how they are likely to understand and adopt healthy lifestyle practices based on the already existing generic health education messages. Considering that this population is more sedentary, with some possibly having poorer dietary habits due to acculturation ,10,11, tGiven the importance of the cultural significance of eating patterns, culturally tailored educational messages about healthy eating using traditional foods as practical examples could be designed by health care providers to ensure proper adherence to dietary advice. Additionally, considering the differing perceptions and influences on eating behaviours and physical function, community health interventions and health messages, when delivered, should consider these heterogeneities between and within ethnicities to avoid broad generalizations and stereotyping, and to celebrate and harness this diversity to develop and deliver programs that can achieve the desired results. Some participants were conscious of their health as they aged and ready to choose healthy lifestyle options. Hence, resources highlighting the nutrient content of traditional foods, such as the Ismaili nutritional data on traditional foods , could bFollowing health education, participants who reported they had been identified as having pre-diabetes made significant efforts at follow-up to change their diet; thus, increased early screening and dietary advice would be beneficial in this population. Also, given that some of the meeting places for ethnic older minorities are willing to support these activities, health authorities could better deliver assessments and health education at these centres to ensure increased access and acceptability.The inclusion of an under-represented population is a major strength of this study . MoreoveAdditionally, the diverse experiences of the research team were an advantage. JLT and CAG are both senior female researchers with vast experience of working with older adults and ethnically diverse communities. EAA is a doctoral researcher with expertise in qualitative research in diverse populations. As a male researcher, he was able to recruit more men than previous studies. However, we must recognise the potential limitations in how we interpret the data due to the younger age, gender, and different ethnic backgrounds of the research team.Likewise, the use of interpreters for 19 interviews could have introduced translation bias. We felt it was essential to utilise trained interpreters to allow for the inclusion of participants with low English literacy to ensure the sample was more representative of the current level of literacy in Birmingham . RecogniThis longitudinal qualitative study found diverse perceptions of healthy eating and physical function among ethnically diverse older adults. Traditional foods were highly regarded as healthy foods by African and Caribbean older adults. The presence of super-diversity was reported as positively influencing accessibility and affordability of traditional foods. Also, diversity supported them to feel comfortable and encouraged to shop, eat and engage with other cultures. More men than women perceived healthy eating and physical function to be unrelated, and prioritised healthy eating over physical function. At follow-up visits, more men than women reported adverse changes such as changes in the level of support , sickness and accidents/falls. These changes were perceived to negatively affect eating behaviours and physical function.


C) for new individuals with a genotype, with and without phenotypes. Computational performance is significantly improved by re-using parts of the coefficient matrix inverse calculations that do not change from one animal to another, in combination with updated calculations for those that do change. This method expedites calculation of accuracy for new individuals with genotypes, without re-doing the whole population, by using the previously calculated matrices.Diagonal elements of the coefficient matrix are necessary to calculate the genomic prediction accuracy. Here an improved methodology is described, to update the inverse of the coefficient matrix ( G) and the coefficient matrix (C), which is computationally demanding. More efficient methods such as APY   required for calculating EBV accuracies. With the increasing speed at which new genotypes are provided, inversion of the coefficient matrix for accuracy calculation is increasingly computationally demanding and time consuming, requiring more efficient methods.In the last decade, technological advances have significantly decreased genotyping costs, particularly for agricultural livestock and cropping species. This reduction in costs has enabled regular genomic best linear unbiased prediction (GBLUP)  for new individuals only, without re-doing the whole population. Using this method, we significantly reduce time and computational demand by updating the accuracy of new individuals and reducing redundancy in the reference population.Here we propose a method to calculate the accuracy of new individuals, with and without phenotypes, by updating the coefficient matrix inverse  isTo calculate the accuracy of individuals with or without phenotypes, each individual can be added to where subscript p and q are core individuals forming the reference population and new individuals respectively. New individuals may or may not have phenotypes.Z′Z becomes G−1 becomes C−1 becomesAs demonstrated in Equation (2), C is computationally demanding, as both G and the entire C should be inverted in each analysis for all individuals. G. This can be performed by the method explained in Meyer et al. (C as well as G. Equation (4) can be converted with the following inversion lemma which is equivalent to the Woodbury's formula  and (3). Inverting r et al. . HoweverC we can consider A = Z′Z, B = −I, D−1 = G−1 and E = αI. Thus C−1 isWith M−1 as (G + α(Z′Z)−1)−1 is used for simplification and is shown below in Equation (8). For the partitioned matrices in Equation (4), C−1 becomeswhere G−1 is not required and we only need to invert the middle matrix (M) in Equation (7). With this simplification M−1 can be updated for each new individual using Cholesky decomposition and multiplying the Cholesky factors, i.e., M−1 = LT−L−1  Therefore, Equation (7) can be written asM the solutions for based on Equation (8) andCqq which is the inverse of Cqq becomesand where “—” is the right division sign (multiplying numerator by inverse of denominator) and Gpq, Gqq, and Only Cqq isFor animals without phenotypes In summary, Equations (14) and (15) can be used to calculate the prediction accuracies of individuals with and without phenotype, respectively.Based on Equations (14) and (15) only M−1 is the largest matrix that was generated in the previous run and can be compressed and stored in binary format to avoid memory issues. The other matrices were small and can be built efficiently by using optimized Linear Algebra PACKage (LAPACK). The equations  were implemented as an R function (by regarding previous assumptions and Equation (8). function  to show function  to assesG) were built by using VanRaden , 1 (AB), and 2 (BB) randomly. The genomic relationship matrices (VanRaden  method 1G and C) was measured. In the second step, the time to build qq was measured. In the third step, the time to calculate cqq by using the initial matrices was measured.To evaluate performance, each set was run in three steps. In the first step, the elapsed time to build the coefficient matrix by using the classic approach . The proposed approach using Z′Z  resulted in shorter time to build the matrices used to update cqq compared to when using the classic approach to calculate accuracies. This method can be extended in order to accommodate fixed effects and dense Z′Z when cqq is updated. Furthermore, the part of C for animals with phenotype (Cpp) must be updated as more individuals are phenotyped.By calculating the accuracy of young individuals using Equations (14) and (15) computational times have been significantly reduced. Computational performance using this method is considerably faster, in comparison with existing methods, as shown in This method could be exploited within routine breeding value estimation for expidited accuracy calculations. Breeding value accuracy is based on an individual's relatedness to the core reference, such that high accuracy indicates high relatedness. This method to calculate accuracy will affect how the genotypes are used, based on how informative they are for the prediction, improving efficiency by reducing redundant information.New individuals with phenotypes and low accuracy can be added to the core population, as it is likely these animals are lowly related. Their addition improves the diversity and informativity of the core reference population, and can further improve imputation accuracy of the missing genotypes, with added diversity into the imputation haplotype library. Individuals with high accuracy are not required to be added to the core, with or without phenotype, as their accuracy indicates their relatives are already included in this reference population, making their addition redundant. New individuals without phenotypes and low accuracy, should have relatives genotyped to improve accuracy and/or should have their phenotypes recorded to improve the core population.It is possible to exploit the accuracy calculation as a type of quality control filter for population data, such that individuals with an expected level of relatedness to the reference population, obtains a low accuracy, this may be indicative of genotyping/sampling error, mis-assigned breed, etc. The rapid accuracy calculation for those individuals without phenotype can provide important context for quickly developing a phenotyping strategy.C for new individuals with and without phenotype, using the method here, is shown to reduce the computational effort significantly. With increasing numbers of genotyped animals in genetic evaluations, computational efficiency is essential for frequent and timely evaluations. This method provides an improved and efficient method to deliver accurate and fast evaluations when few new young individuals are genotyped but may or may not have phenotypes.Updating the inverse of MF developed the method, structured the manuscript, and wrote the method and theory. NC wrote the introduction, result and discussion, and performed major revision. BT gave some comments to improve the final method and article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


I first encountered global health through the writings of Dr. Paul Farmer on his work in Haiti. Farmer argued that inequalities led to infections and criticized “Pathologies of Power,” linking poverty to the causation of disease. In college, I read all things Paul Farmer and would often ask myself, “WWPD?” (What would Paul do?) if he were in my situation. I dreamed that I would study medicine and anthropology and find a place, like Haiti for Paul Farmer, where I could start a clinic in an underserved area, conduct social medicine research, and return at every possible opportunity during my training.I won a yearlong fellowship to study medical anthropology at Oxford and gained admission to medical school at the University of California, San Francisco. I was thrilled. I was following in the footsteps of Farmer. I planned to research food insecurity and the human immunodeficiency virus (HIV) in rural Kenya. My Asian tiger parents, although thrilled that I would be a doctor with pedigree, were horrified that I would be living in a “third world” country. My dad e-mailed me daily U.S. State Department updates about violence, terrorism threats, and disease outbreaks in Kenya before my departure. A week before I was set to leave for Kenya, he discovered emerging cholera outbreaks around Lake Victoria, where I would be staying. Alarmed, my parents flew from Los Angeles to London before my departure, bringing an entire suitcase full of water treatment methods to ensure I did not die from cholera and diarrhea. We practiced each step of the handheld water filtration pump in detail every day. We reviewed protocols for requesting air evacuation from my insurance plan in case of emergencies.The journey from Oxford to Mfangano Island, Kenya, took 2 days. After a 7-hour flight to Nairobi, I made a connecting flight overlooking the savannah plains of the Maasai Mara National Reserve on a loud rickety propeller plane, and then took a bumpy bus ride on roads of cracked pavement followed by a glide on a worn wooden fishing boat, arriving to the island at dusk. I rode on the back seat of a motor bike grasping my water treatment–filled suitcase for dear life, feeling insects accrue on my face as we whisked through swarms of buzzing mosquitoes.The island lacked electricity, Internet, telephone lines, paved roads, and running water. Each morning, I accompanied my host mother, Akeyo, on the 2-mile-long journey through tortuous footpaths to the shore of Lake Victoria to gather our daily water. Whereas I only needed to carry the plastic jug that I would drink from throughout the day, Akeyo balanced a massive vat on her head that provided sustenance for her entire family—including eight children—and all of the cooked meals for the day. Like Wonder Woman, she traversed the return journey with a neck of steel in a sapphire sarong and sandals worn down to the sole. After we returned to our thatched roof, mud-walled home, Akeyo boiled the water over a wood fire. When my ration of water was boiled, I let it cool and then started my hand-pumped filtration system. To the filtered water, I dissolved one chlorine tablet, followed by two drops of iodine, as if I were in a chemistry laboratory. All in all, the water cleaning process took 3 hours each day.Akeyo chuckled with a singsong laugh as she watched my daily ritual, but also encouraged me to use all of the techniques because she did not want me to get sick under her watch. Otieno, my sinewy host father, returned home for lunch from farm labor as I finished my water ritual. Beads of perspiration trickled down his skin, wrinkled from decades of the sun’s abuse. With his calloused hands, he pumped the water filtration contraption a few additional times. I offered to treat my host family’s water as well.Otieno declined, saying, “Our stomachs are accustomed to the lake water.” He grinned, revealing his bright white teeth, adding, “Your stomach is weak!” It felt wrong that the water I drank was more disinfected than the water my host family consumed. But I also realized that the period when I could offer my filter and disinfectants represented only a short blip in their lifetime exposure to water-borne diseases. To my host parents’ credit , I never once had any gastrointestinal problems during my 2-month stay in Kenya.I realized that with all of the time I spent guarding against possible water-borne tropical diseases, I only had a couple of hours each afternoon to actually conduct my research interviews. From these interviews, I learned that virtually all people with HIV on the island experienced food insecurity and worried about how they would feed their families. Without access to basic requirements for survival such as food and water, it is difficult to ascend the ladder of Maslow’s hierarchy to other domains of life.I returned to Oxford in time for the formal dinner celebrating the beginning of the spring Trinity Term. Young men donned tuxedos with long black robes, called “sub-fusc,” whereas young women revealed their tans from exotic destinations under low-cut gowns. The Hogwarts-style dining hall bustled with excitement. I talked about the water situation in Lake Victoria, the doctoral student seated on my left discussed Palestinian geopolitics, and the fellow seated on my right critiqued neocolonialism in Myanmar. Amid the chatter, nobody finished the servings of their four-course meals. We were offered four types of sparkling water; my neighbor across the table returned her Perrier because she felt it was too flat. I excused myself from dinner, feeling sick with indigestion through the transition from eating with my hands with Akeyo and Otieno to the crème brûlée dessert at a formal hall. I went to the loo, threw up in the marble toilet, and had diarrhea for the first time in 2 months.Transitions between different contexts, time zones, and cultures were more difficult than I had anticipated. During his preclinical years of medical school, Paul traveled from Harvard to Haiti so often that he acquired the nickname “Paul Foreigner,” while still managing to excel academically. When I started medical school the following year, I initially dreamed that I too would be jet-setting across the globe every long weekend. However, I soon gave up on that romantic notion. Medical school was exhausting, and catching up on sleep debt during breaks was more essential than accruing more financial debt from international travel, dealing with layovers and jetlag, and having to worry about clean water.Although I realized that the Paul Farmer lifestyle could not be sustainable for me, I still wanted to find a way to engage with global health throughout my medical training. I began to relate more to his partner in crime, Dr. Jim Kim. Jim had practical Asian immigrant parents, similar to mine. When Jim had decided after his first semester of college that he would be studying politics and philosophy, his father said, “After you finish your medical residency, you can do whatever you want.” Jim’s career took the more pragmatic approach, and he was able to effectively advocate for global health issues through leadership with the World Health Organization, Dartmouth College, and the World Bank. I began to ask myself: “WWJD?” (What would Jim do?). I even crashed Dartmouth College alumni events to have the opportunity to meet Jim, even though I had no affiliation with the university.I began working on systematic reviews with the World Health Organization that informed HIV guidelines from the carrels of my university library. I also conducted secondary analyses of Kenyan data, evaluating nutrition interventions for people living with HIV and trying to understand the complex relationships between undernutrition and HIV, work that built on my master’s fieldwork but that did not require frequent travel. Given advances in modern technology and social media, I could easily schedule conference calls with Kenyan research colleagues and keep up with my host family’s updates on Facebook. Although I sometimes felt like a “limousine liberal,” doing global health research from the comfort of my home, it was the only way that I could engage globally while balancing the grueling clinical demands of medical training.I am writing this essay on a flight to Kenya, my first visit after an 8-year hiatus. The faces and stories of Akeyo, Otieno, and the interview participants I encountered years ago remain fresh in my memory. As I complete my training and launch my professional career this year, I wonder to myself, “WWJD?”