Understanding-health-care-professionals--barriers-and-f_2026_Journal-of-Alle.pdf

Understanding health care professionals’ 
barriers and facilitators to supporting the 
management of food allergy in British South 
Asian adults: Qualitative results from the FAIR 
Study
Gurkiran Birdi, PhD, a,b * Clare Stradling, PhD, c * Tammy-Jae Jaynes, a Julianne Ponan, MBE, d Melissa Singh, MSc, e 
Sarah Baker, BEd (Hons), RGN, RSCN, RHV, f Amena Warner, g Christina J. Jones, PhD, h ‡ and
Mamidipudi T. Krishna, PhD, FRCP, FRCPath b,c ‡ 
Birmingham, Sunbury on Thames, East London, Frimley, Crayford, and 
Guildford, United Kingdom
Background: The burden of food allergy (FA) is greater among 
South Asian (SA) individuals in high-income countries. 
Objective: We sought to investigate facilitators/barriers for health 
care professionals (HCPs) in FA management in SA patients. 
Methods: HCPs involved in the management of SA adults with 
FA were recruited for online, semistructured interviews. 
Interviews were analyzed using thematic analysis.
Results: Interviews were conducted with 30 HCPs (46% White, 
34% Indian, 7% Pakistani, 10% Sri Lankan, 3% ethnicity not 
disclosed). Allergists, immunologists, and general practitioners 
(77%); nurses (13%); dietitians (7%); and 1 pharmacist (3%) 
were interviewed. Three major themes were generated: (1) 
cultural and social influences on health—patient reliance on 
traditional medicine, scepticism toward conventional therapies, 
and strong family influence in decision making; (2) patient 
characteristics and behavior—presence of unique allergens in 
SA diets adding complexity to diagnosis and management; (3) 
health care communication and support—language barriers, 
interpreter limitations, and cultural misunderstandings 
hindering care. Younger patients were regarded as more 
proactive, whereas older patients relied on family members for 
translation and decision making. HCPs highlighted a need for 
multidisciplinary teams, culturally tailored dietary guidance,
and training in cultural competency. They felt constrained by 
limited consultation times and long waiting times.
Conclusion: A multipronged and multidisciplinary strategic 
approach is needed to address inequalities in FA management 
among SA patients targeting some key areas including 
development of culturally tailored multimodality resources for 
patients and their families, education and training for HCPs in 
SA cuisine/allergens and cultural competency, and adaptive 
changes in the health service framework. (J Allergy Clin 
Immunol Global 2026;5:100613.)
Key words: British, South Asian, food allergy, disparity, culturally 
tailored interventions
Ethnicity-based disparities in allergic conditions, including 
allergic rhinitis, asthma, atopic dermatitis, and food allergy (FA), 
have attracted major interest in recent years. Published evidence 
has highlighted health inequalities and poor clinical outcomes 
among patients living in high-income countries such as the United 
Kingdom (UK), the United States, and Australia. 1-4 Studies from 
the United States and Australia showed a higher risk of FA and 
food-induced anaphylaxis among immigrant Asian populations. 5,6 
A study involving emergency department admissions in Birming-
ham, UK, showed a higher incident risk of anaphylaxis among 
British South Asian (SA) patients and that severity of anaphylaxis 
was greater among girls younger than age 16 years. 7 Beyond the 
UK, large survey datasets from the United States show that Asian, 
Black, and Hispanic individuals report higher rates of FA than 
White individuals, highlighting ethnic disparities that extend across 
high-income countries. 8
Ethnicity-based disparities are underpinned by multiple factors, 
including socioeconomic status, health literacy, cultural and religious 
factors, beliefs, and human behavior. 1 This is particularly relevant for 
allergic conditions such as FA and asthma, as clinical outcomes are 
dependent on patient education, acceptance of medical advice, and 
implementation of self-management plans including allergen avoid-
ance measures. 9,10 Legumes/pulses commonly consumed in SA 
cuisines (eg, chickpea/gram flour [besan], lentils/dal, peas) are recog-
nized causes of IgE-mediated reactions among SA individuals. 
Although population prevalence estimates for nonpriority legumes 
are generally <_0.5%, clinical series and UK charity data highlight 
reactions to lentils, chickpeas and peas, and non–top 14 legume al-
lergies can be underrecognized due to labeling gaps. 11
From a the Department of Psychology, Birmingham Newman University, Birmingham; 
b the Department of Immunology and Immunotherapy, School of Infection, Inflamma-
tion and Immunology, University of Birmingham, Birmingham; c the Department of 
Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, 
Birmingham; d Patient and public involvement and engagement representative, Sun-
bury on Thames; e Patient and public involvement and engagement representative, 
East London; f Anaphylaxis UK, Frimley; g Allergy UK, Crayford; and h School of Psy-
chology, University of Surrey, Guildford. 
*These authors contributed equally to this work as joint first authors. 
‡These authors contributed equally to this work as joint senior authors. 
Received for publication June 9, 2025; revised September 1, 2025; accepted for publica-
tion September 24, 2025. 
Available online November 21, 2025. 
Corresponding author: Mamidipudi T. Krishna, PhD, Department of Immunology and 
Immunotherapy, School of Infection, Inflammation and Immunology, College of Med-
icine and Health, University of Birmingham, Edgbaston, Birmingham B15 2TT, 
United Kingdom. E-mail: m.t.krishna@bham.ac.uk.
The CrossMark symbol notifies online readers when updates have been made to the 
article such as errata or minor corrections
2772-8293
© 2025 The Author(s). Published by Elsevier Inc. on behalf of the American Academy of 
Allergy, Asthma & Immunology. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 
https://doi.org/10.1016/j.jacig.2025.100613
1
Black, and Hispanic individuals report lower rates of FA than
Spices and seeds integral to SA cooking can be allergenic. 
Fenugreek (methi) has documented IgE-mediated reactions and 
cross-reactivity with other legumes (eg, peanut, soy, green bean) in 
case series. Mustard seed (sarson/rai) is a regulated major allergen in 
the UK and Europe and has been implicated as a hidden allergen in 
composite foods. 12,13 Current supportive resources for patients and 
carers are largely targeted toward patients with proficiency in English 
and Western-centric diets; they do not factor in cultural, religious, 
and social elements that are particularly relevant for patients from 
ethnic minority groups. Furthermore, little is known about the views 
and perspectives of health care professionals (HCPs) delivering care 
for ethnic minority groups with FA. The main aim of this study was to 
explore facilitators and barriers to the management of FA among SA 
patients from an HCP perspective.
METHODS 
Study design
This study used a qualitative design, consisting of in-depth, 
semistructured interviews to explore HCPs’ views and perspec-
tives on resources that would improve the management of FA 
among SA patients. The study was approved by the Westminster 
National Health Service (NHS) Research Ethics Committee 
(reference 23/PR/0830).
Participants and recruitment
HCPs (eg, consultants, allergy/immunology trainees, general 
practitioners, nurses, dietitians) providing care for SA patients 
with FA were eligible for participation. HCPs were recruited via 
professional networks and organizations (eg, British Society for 
Allergy and Clinical Immunology, West Midlands Allergy and 
Immunology network, Travellers Immunology Group). HCPs 
who responded to recruitment advertisements were e-mailed with 
participant information sheets and consent forms before arran-
ging a convenient time for a one-on-one semistructured interview. 
The target sample size was 30 HCPs. This was determined a 
priori based on guidance for qualitative research suggesting 
that between 20 and 30 interviews are typically sufficient to reach 
thematic saturation in heterogeneous professional groups, while 
allowing diversity of views across clinical roles to be captured. 
Efforts were made to recruit participants working with patients 
from diverse SA backgrounds, particularly SA patients in hard-
to-reach communities, but inclusion was not restricted by the 
ethnic background of the HCPs themselves. Instead, the emphasis 
was on ensuring that interviewees had relevant clinical experience 
with ethnically diverse patient populations.
Interviews
Interviews were conducted online via Microsoft Teams (Micro-
soft Corp, Redmond, Wash). The interviewer (C.S.) used a 
semistructured topic guide that explored barriers and facilitators
to management among SA patients with FA while allowing 
participants to discuss issues of importance to them. Recruitment 
continued until theoretical saturation was achieved. 14 
A preliminary codebook was generated by C.S. during initial 
rounds of transcript review, drawing directly from participants’ 
language and meanings. This codebook was iteratively refined 
through discussion among the research team.
Data analysis
Interviews were recorded and transcribed verbatim. Transcripts 
were inductively analyzed using reflexive thematic analysis, 15 
with the process of identifying themes derived from the data 
rather than deductively by the researchers. The transcripts were 
thematically analyzed following 6 steps, which included 
becoming familiar with data, generating initial codes, searching 
for themes, reviewing themes, defining and naming themes, 
and producing a report. There was flexibility regarding the 
progression through the steps, with further refinement and re-
refinement of themes; the researcher’s assumptions and influ-
ences were also considered. NVivo software was used in creating 
the code book and analyzing the interviews.
The analysis was undertaken by researchers with a professional 
background in qualitative health research and clinical allergy, 
providing complementary perspectives on both methodological 
rigor and subject matter expertise. Reflexivity was maintained 
throughout, with researchers reflecting on their assumptions and 
professional experiences to minimize undue influence on theme 
generation.
RESULTS
Interviews were conducted with 30 HCPs, including 23 
physicians (comprising allergists, immunologists, and general 
practitioners), 4 nurses, 2 dietitians, and 1 pharmacist. The 
majority of HCPs practiced in secondary care (n 5 25) with the 
remaining working in primary care (n 5 5). In terms of their own 
nationality, HCPs identified as British Indian (n 5 10), British 
White (n 5 7), White other (n 5 7), British Sri Lankan (n 5 3), 
and British Pakistani (n 5 2); 1 individual preferred not to 
disclose their nationality. HCPs had been practicing in their 
specialty for 3 months to 25 years. Several HCPs were also fluent 
in their native languages such as Punjabi and Urdu, alongside 
English; a few discussed talking in native languages with patients 
during consultations. Three overarching themes were identified 
through thematic analysis: cultural and social influences on 
health, participant characteristics and behaviors, and health care 
communication and support. Demographic details are listed in 
Table I.
Theme 1: Cultural and social influences on health
Role of cultural and traditional beliefs. HCPs described 
feeling frustrated toward patient reliance on traditional medicine, 
including the use of natural remedies such as ‘‘garlic, turmeric, 
and ginger’’ (HCP 8) to manage their FA. HCPs also recognized 
cultural beliefs surrounding food such as dishes being labeled 
‘‘hot’’ or ‘‘cold’’ (HCP 3) due to their beliefs in Ayurveda (eg, nuts 
would be considered a hot food due to their inherent qualities and 
effects on the body). HCPs also reported patients frequently 
turning to traditional healers or family members for advice and
Abbreviations used
FA: Food allergy
HCP: Health care professional 
NHS: National Health Service 
SA: South Asian
UK: United Kingdom
J ALLERGY CLIN IMMUNOL GLOBAL 
MARCH 2026
2 BIRDI ET AL
Spices and seeds integral to SA cooking will be allergenic.
treatment of their FA and often discounted medical advice in 
favor of community-based knowledge. There was also uncer-
tainty surrounding patient acceptance of preventive strategies; 
HCPs discussed the cultural expectations for curative treatments 
for FA rather than dietary exclusions. They also believed that SA 
patients are more sceptical surrounding their diagnoses and 
approaches of HCPs to managing their allergy; aversion to the 
use of steroids and antihistamines (HCP 2, HCP 9) was cited, as 
these medicines were thought to contradict traditional practices. 
SA patients were also fearful about the long-term effects of using 
medication; they believed that medication would cause them 
more harm than benefit. It appeared that there was an influence of 
family in enhancing the reliance on traditional medicine and 
alternative remedies.
Culturally tailored approach. HCPs expressed the impor-
tance of understanding cultural contexts in SA patients and the 
need for a culturally tailored approach to allergy management 
rather than defaulting to a Western diet–centric approach. HCPs 
also discussed the need for culturally relevant food substitutions, 
such as addressing the use of specific nuts or halal dietary 
requirements, increasing the relevance and acceptability of 
advice. Written and visual resources, such as leaflets, videos, 
and apps in multiple SA languages were deemed crucial to cater to 
diverse literacy and linguistic needs (HCP 11, HCP 12, HCP 14, 
HCP 19, HCP 20, HCP 22). For certain groups, particularly older 
generations, personalized, face-to-face discussions combined 
with online and written resources were discussed as the most 
effective approach. Many HCPs also discussed the need for 
culturally inclusive laboratory tests and dietary assessments to 
include allergens common in SA diets, such as chickpeas, lentils, 
and specific spices. In addition to understanding SA-specific 
allergens, HCPs acknowledged religious beliefs (eg, the
importance of providing advice tailored to patients who 
consumed only halal foods and patients with strict vegetarian 
diets). Patient information also needed to be written at a 
layperson’s level, avoiding technical jargon to ensure clarity 
and understanding.
Role of family and friends/generational influences. 
HCPs acknowledged the importance of family acceptance and 
knowledge when managing FA. They discussed the reliance of SA 
patients on their family members in making important decisions 
surrounding their health; for example, HCP 17 talked about the 
significance of milk in certain cultures and that having a milk 
allergy was a ‘‘family issue’’ as family members needed to be 
accepting and vigilant of it. Many decisions were made after 
discussion with extended family members, particularly when 
these members also acted as caregivers and/or translators for the 
patient. Older generations, particularly grandparents, appeared to 
play a particularly influential role in health decisions (HCP 2, 
HCP 3, HCP 11, HCP 27) and were not in favor of medication 
such as steroids as they had heard about negative long-term 
effects. HCPs were worried that this aversion to medical 
treatments might influence patients’ adherence to medical advice. 
Older SA patients were more sceptical and dismissed FA as a 
modern phenomenon, believing that allergies did not exist in their 
time; they viewed them as trivial or a means to get attention. 
Given the influence that family had on patients, HCPs were 
conscious of misinformation and incorrect advice affecting 
allergy management. HCPs also discussed the close-knit dynamic 
of SA families and the importance of providing emotional and 
logistical support to both families and patients; educating families 
was seen as a key strategy to improving management of allergy, 
given their strong influence on patient decisions and care. 
Anxiety surrounding social and festive situations. 
HCPs discussed the importance of food in social, religious, and 
festive functions and the central role of food in SA culture, often 
tied to celebrations, hospitality, and social gatherings. Patients 
expressed anxiety surrounding these social situations, as rejecting 
or avoiding food could be perceived as disrespectful or rude. 
HCPs were also concerned about accidental exposure to allergens 
through cross-contamination during SA gatherings; a few dis-
cussed the presence of unlabeled buffet-style foods at cultural 
gatherings. The complexity and number of ingredients in SA 
foods made it difficult to identify allergens in social settings. 
HCPs also thought that patients may be uncomfortable about 
others knowing of their FA in social settings. The need for extra 
vigilance in large social situations was emphasized by several 
HCPs.
Theme 2: Patient characteristics and behaviors
Unique nature of allergens in SA patients. HCPs 
discussed the wide variation in diets within different SA 
populations and how this diversity often complicated allergen 
identification and dietary assessments. SA diets often encompass 
ingredients such as legumes, chapatis, curries with multiple 
spices, tilapia fish, and others (HCP 5, HCP 11, HCP 15, HCP 
17, HCP 23, HCP 24, HCP 27, HCP 28, HCP 29), often making it 
difficult to pinpoint specific allergens and understand potential 
cross-reactivity. Certain allergens such as legumes and fish were 
also acknowledged as far more common among SA patients, but 
there was a lack of understanding in dietary management of these 
allergens. This lack of understanding was compounded by SA
TABLE I. Participant sociodemographic characteristics
Characteristic
Value
Gender, no. (%)
Male
15 (50)
Female
15 (50)
Age (y), mean (median) [range]
49 (48) [36 to 60]
Ethnicity, no. (%)
Indian
10 (34)
Sri Lankan
3 (10)
Pakistani
2 (7)
White British
7 (23)
White other
7 (23)
Prefer not to say
1 (3)
Professional title
Allergy and immunology consultant
14 (47)
Pediatrician
3 (10)
Registrar*
2 (7)
General practitioner (family physician)
4 (13)
Pharmacist
1 (3)
Dietitian
2 (7)
Nurse
4 (13)
Experience, range
3 mo to 25 y
Location, no. (%)
Midlands
15 (50)
North
6 (20)
South East England/London
5 (17)
Wales
3 (10)
Scotland
1 (3)
*Equivalent to fellows-in-training in the United States.
J ALLERGY CLIN IMMUNOL GLOBAL 
VOLUME 5, NUMBER 2
BIRDI ET AL 3
individuals being allergic to rarer or lesser-known allergens; 
assumptions about management were often discussed in relation 
to Western diet–focused allergens. HCPs who were familiar with 
SA cuisines, often owing to being of SA heritage themselves, 
acknowledged the difficulty an HCP of another ethnicity might 
face when managing an SA patient. Also, patients were often not 
aware of the name of the allergen in English as it was an allergen 
largely incorporated in SA diets only. HCPs thought that there 
was a need for training and knowledge of SA diets to enable 
proper management of FA.
Older versus younger patients. HCPs discussed several 
differences between ages in managing FA in SA patients. Older 
patients were more likely and willing to take a physician-led, 
paternalistic approach to managing their allergies, whereas 
younger patients were more likely to ask questions and use online 
resources. Younger patients were also more proactive in man-
aging their condition, often blending traditional and Western 
dietary practices. They were more likely to use digital resources, 
such as apps and web-based tools, for managing allergies, 
whereas older patients prefer traditional methods such as reading 
or listening to audio materials. Several HCPs also discussed older 
patients’ reliance on younger family members to translate infor-
mation in clinic settings; there was concern that this translation 
and form of communication may not be entirely accurate.
Risk taking. HCPs were concerned that SA patients took 
more risks in managing their FA than White patients. SA patients 
had issues adhering to their treatment plans, waiting longer before 
seeking professional help and introducing known allergens into 
their diet without medical supervision, despite being aware of 
their allergies. Several HCPs discussed this as more of an issue 
with older SA women with the introduction of common allergens 
early in a child’s life and more food challenges at home. HCPs 
were uncertain about whether this was due to a lack of knowledge 
or a lack of acceptance of potential risks that exposure could 
cause; they felt frustrated about parents and elders introducing 
allergens into children’s diets despite being aware of the adverse 
consequences.
Theme 3: Health care communication and support
Communication between HCP and patient. HCPs 
discussed the comfort and ease that SA patients felt when they 
were fluent in the patient’s native language or wore clothing 
typical seen in SA cultures, with a preference for some patients to 
seek help from an HCP of a similar ethnic background (HCP 13, 
HCP 14, HCP 17, HCP 18, HCP 19, HCP 28). This was 
accompanied by uncertainty surrounding HCPs’ ability and remit 
in speaking to patients in their native languages, as there were 
often differences in dialect. HCPs also thought that patients with 
limited English proficiency may feel intimidated, less confident, 
or anxious when communicating with an HCP and may not 
adequately express their concerns. HCPs who were aware of SA-
specific food items, such as chapati, found that there was a sense 
of relief when they showed knowledge of such food items native 
to SA culture. Most HCPs recognized the importance of under-
standing the SA diet, but were also conscious that they needed 
knowledge and training to attain this understanding. There was 
also a patient assumption that if an HCP is of SA heritage, they 
must be able to speak the patient’s native language. However, 
White HCPs were more concerned about their cultural awareness 
of the needs of SA patients during consultations. HCPs also found
differences in using the correct idioms between English and 
native languages; for example, HCP 4 discussed patient fear when 
they had a negative allergy test with the misconception that this 
had a negative consequence on their health. Several HCPs also 
discussed patients feeling a level of intimidation when they did 
not receive treatment from an HCP of the same ethnicity; they 
acknowledged that this is not a feasible approach to patient care. 
Confidence in interpreters and translators. HCPs 
acknowledged the importance of having interpreters present in 
clinics where patients did not speak English fluently; however, 
many expressed concerns over the quality and accuracy of the 
translation. They believed that interpreters do not often translate 
wholly and leave out pertinent information in their translations 
(HCP 14, HCP 21, HCP 23, HCP 26, HCP 29, HCP 30). This was 
particularly frustrating for HCPs who were able to comprehend 
a patient’s native language and could understand the interpre-
tation. HCPs also discussed the lack of knowledge that in-
terpreters have of the wider context surrounding the patient’s 
diagnosis. Working with interpreters also affected HCPs’ con-
fidence; they often felt uncertain about whether patients had 
fully understood what was being conveyed to them. HCP 21 
discussed this affecting the level and depth of information 
provided to the patient. There were also similar concerns with 
family members interpreting on behalf of patients, as they can 
often distort information conveyed to the patient. HCPs also 
noted the importance of interpreters understanding SA-specific 
idioms, food practices, and specific dietary terminology. 
Despite all these concerns, HCPs thought that it was appropriate 
to have interpreters present for SA patients who did not speak 
English; however, this availability was found to be sporadic and 
unpredictable, delaying consultations.
Importance of multidisciplinary teams. HCPs discussed 
the need for dietitians in providing tailored dietary advice (HCP 
10, HCP 11, HCP 13, HCP 24, HCP 29), particularly important 
for SA patients whose diets are often diverse and entail a variety 
of lesser-known ingredients. They emphasized the importance of 
current dietetic services being trained to cater to the needs of SA 
patients. The importance of appropriate psychological support 
was also discussed (HCP 18, HCP 23, HCP 29), particularly in 
patients whose families were less accepting of their allergies and 
patients who had more severe FA. HCPs acknowledged the 
importance of working together with other teams to provide a 
more culturally tailored and complete service.
Feelings of helplessness. HCPs discussed that despite the 
knowledge of gaps in current health care for SA patients, they 
were not in position to improve this provision. The complexity of 
SA allergies compounded by language barriers needed to be 
addressed by longer consultation times; however, HCPs felt 
frustrated owing to the ‘‘20 minutes per consultation’’ (HCP 13) 
that they were afforded with patients. They also appreciated that 
general practitioners had ‘‘5 to 7 minutes’’ (HCP 4) to assess an 
SA patient who may not be able to communicate properly, and 
waiting times for secondary referral were ‘‘8 to 10 months’’ (HCP 
18). They often conducted consultations via telephone and 
believed this impeded the quality of care and information 
provided for patients with limited proficiency in English. HCPs 
also thought that SA patients need to voice their problems and 
opinions more to receive proper treatment. Similarly, they felt 
discouraged by patients often not trusting their clinical judgment 
and seeking second opinions from different clinicians—often 
abroad.
J ALLERGY CLIN IMMUNOL GLOBAL 
MARCH 2026
4 BIRDI ET AL
HCP 14, HCP 17, HCP 18, HCP 19, HCP 28). This was were in position to improve this provision. The complexity of
TABLE II. Participant quotes corresponding to themes
Theme
Subtheme
Participant quotes
Cultural and social influences on health
Role of cultural and traditional beliefs
‘‘What I don’t know as well is the influence of religious groups 
and things like that and alternative medicines as well, 
whether people use herbal remedies.’’ (HCP 2)
‘‘If people were raised in South Asia where allergy was less 
common and their awareness of allergy is probably less … 
they don’t really let anyone feed their child, they don’t 
understand the allergist’s approach.’’ (HCP 6)
‘‘I feel like they get loads of wrong information from families 
and friends, and they believe it.’’ (HCP 13)
Culturally tailored approach
‘‘We should have leaflets in multiple languages, we should have 
videos in the waiting area in multiple languages, we should 
have [an] interpreter present, not over the phone, because it’s 
not easy sometimes, also that applies in primary care. We 
don’t really make the effort to make their life a bit easier.’’ 
(HCP 6)
‘‘If you find anyone who’s already doing a kind of … 
cinnamon, cardamom, chickpea, and lentil panel, please send 
it.’’ (HCP 17)
‘‘For us it was probably just knowing that the food you’re 
recommending are halal and all the treatment options are 
halal as well, and it also gives confidence to the patient that 
you made sure it was halal for you. For them to know that 
you’ve thought about it goes so far, people are so happy 
that you’ve considered their background.’’ (HCP 28)
Role of family and friends/generational 
influences
‘‘I feel like they get loads of wrong information from families 
and friends, and they believe it. So really, we need to spend 
time to explain, because they have had that impression for a 
long time, if they are allergic to one thing, they believe they 
are allergic to nuts as well, back home in the area I grew up 
they don’t believe doctors a lot.’’ (HCP 13)
‘‘SA families are close-knit, and very rarely you will find 
someone who isn’t comfortable with English come alone to 
clinic.’’ (HCP 18)
‘‘Extended families often influence decisions, but family 
members might filter the information they translate.’’ (HCP 
27)
Anxiety surrounding social and festive 
situations
‘‘If you go to someone’s house, you take some food, it doesn’t 
matter if you’ve been doing the rounds and visiting relatives, 
it’s a little uncomfortable or can be perceived as rude if you 
don’t have something to eat. It’s getting the other party to 
understand that you have an allergy, or you can’t have this or 
you’ve brought your own food that can have some cultural 
negative tones linked in with it.’’ (HCP 3)
‘‘The other thing that worries me about the Asian population is 
when they have a, they do tend to have a large gathering for 
various events and it’s not predominantly displayed about the 
allergies and things.’’ (HCP 10)
‘‘Some patients feel obliged to eat food prepared as a gesture of 
hospitality.’’ (HCP 27)
Patient characteristics and behaviors
Unique nature of allergens in SA patients
‘‘I see Bangladesh patients they report an allergy to 
Bangladeshi fish, here in the UK we know and understand 
cross-reactivity between common fish here, salmon and its 
effects, but if they tell me that Bangladeshi fish, we 
sometimes make an assumption that their allergy is common, 
for example, all white fish share the common allergens.’’ 
(HCP 5)
‘‘The food contains lots of ingredients. It’s not like fish and 
chips—it’s like lots of ingredients, like spices, and the nuts 
can be in it or not in it.’’ (HCP 11)
(Continued)
J ALLERGY CLIN IMMUNOL GLOBAL 
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BIRDI ET AL 5
TABLE II. (Continued)
Theme
Subtheme
Participant quotes
‘‘Not understanding the ingredients that go into common SA 
foods … can make it difficult to provide advice.’’ (HCP 20)
Older vs younger patients
‘‘There probably is more influence from the grandparents in the 
family, often more so I would say living with the family.’’ 
(HCP 2)
‘‘For grannies, for example, for the elderly population, for their 
grandchildren, it’s not easy to get to know this concept of 
allergy. So, it’s a new concept and for them the food is a 
festive thing, it’s not a dangerous thing.’’ (HCP 11)
‘‘With older sort of North Indian and Pakistani, there’s often 
family involved in history taking … a lot of older patients 
tend to be sort of fairly happy to be doctor-led.’’ (HCP 27)
Risk taking
‘‘This lady went home and did her own challenges and did her 
own thing, and took the risk and thought ‘I’ll just get on with 
it,’ and then wrote a letter to say, ‘I don’t need to come back 
to clinic, I’m fine with this, and I know what’s going on,’ a 
bit less caution with their own health feeling they are less 
important, and thinking ‘I’ll just do this and get on with it’ 
and taking that self-risk type of thing.’’ (HCP 8)
‘‘That culture may be a bit more inclined to just say, ‘You just 
eat this,’ or, ‘You can’t be allergic to that.’’’ (HCP 20)
‘‘My aunty and mum say, ‘No go on, you can eat shellfish, 
you’ll be fine,’ and there’s not that fear or awareness.’’ (HCP 
23 reflecting on a patient)
Health care communication and support
Communication between HCP and patient
‘‘When you see they aren’t able to converse or there are certain 
things, like you say chapati or Madura or whatever, and then 
you, if you start speaking to them in Hindi or Urdu, then 
there is such a relief that someone is able to understand and 
they are not then having to second guess in English.’’ (HCP 
14)
‘‘In the beginning as a new consultant, I used to think, 
‘Shouldn’t they be able to converse in English?’ but I’ve 
matured with age. If you slip into mother tongue, there is a 
degree of comfort, they relax.’’ (HCP 18)
‘‘I’m not necessarily saying that every person of ethnic minority 
needs to see an ethnic minority doctor, obviously that’s 
neither feasible nor ethical in some ways, but then there are 
some people who feel intimidated when you don’t speak the 
language very well, then you don’t feel like you have the 
confidence to negotiate the pathway.’’ (HCP 19)
Confidence in interpreters and translators
‘‘I do find working through a translator really challenging 
because you give less information, and you’re not sure if the 
patient is understanding.’’ (HCP 21)
‘‘Some people have expressed that when you get an external 
interpreter in, you then lose some of the context because they 
are just literally translating your words, but they know 
nothing about the family and the context.’’ (HCP 26)
‘‘My heart sinks whenever I see I have an interpreter because it 
just delays the consultation horrendously, but also I have 
found when I have used an interpreter for languages I only 
speak a bit of, not fluently, and it confirms my suspicion that 
the interpreter doesn’t do the job they should do, you will say 
quite a lot and it translates to 2 words.’’ (HCP 29)
Importance of multidisciplinary teams
‘‘Our dietitian is excellent … with ethnic patients who were 
incredibly anxious, I found [the dietitian] very useful.’’ (HCP 
13)
‘‘What I would really like is psychological support and 
counseling, that is a postcode lottery.’’ (HCP 18)
Feelings of helplessness
‘‘I just feel really guilty … an 18-year-old … diagnosed with a 
nut allergy … followed up for 18 years and then they come to 
the adult service and get discharged.’’ (HCP 12)
(Continued)
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6 BIRDI ET AL
Participant quotes pertinent to all themes discussed here are 
presented in Table II.
DISCUSSION
This is the first study to our knowledge to explore the views and 
perspectives of HCPs regarding management of FA among British 
SA patients. Our data highlight the challenges and complexities 
faced by HCPs in the management of FA in British SA patients. 
HCPs expressed concern regarding reliance on complementary or 
alternative therapies among SA patients, and this was further 
compounded by poor awareness of FA among older family 
members and the wider SA community leading to misinforma-
tion, given the close-knit family dynamics and social network 
within the SA community. The cultural expectation of a ‘‘cure’’ 
for FA has also been reported in the context of native South Indian 
patients with asthma, leading to a search for alternative therapies 
and poor acceptance of medical advice. 16 Similarly, reluctance to 
use antihistamines and corticosteroids reported by HCPs in this 
study can be related to poor use of inhaled corticosteroids among 
native Indian patients with asthma, resulting in a very high pro-
portion having uncontrolled disease and poor clinical 
outcomes. 16,17
Poor awareness of FA among the SA community is particularly 
relevant during social events and visits to temples and mosques 
where cross-contamination and accidental exposure to allergens 
could potentially occur, increasing risk of anaphylaxis. Unac-
ceptance of offerings in faith institutes is deemed disrespectful 
and causes anxiety among patients. This strengthens the case for 
raising community awareness via education. Raising awareness 
of asthma among parents and caregivers via community-based 
education has proven beneficial. 18 However, this education needs 
to be culturally tailored and targeted toward patients from the 
lowest socioeconomic strata with poor health literacy to maxi-
mize reach and impact. Culturally tailored interventions have 
been shown to be clinically effective in the context of diabetes 
in African American and Mexican American patients and might 
be worth considering in British SA patients with FA. 19,20
Some unique allergens 21 are implicated in FA among SA pa-
tients, such as lentils, chickpeas, sesame, aubergine, jackfruit, 
certain types of fish, and spices, among other allergens. 
A sound knowledge of SA cuisine and names of the food allergens 
in English and the ability to communicate with patients with 
limited or no proficiency in English are critical to the clinical 
assessment process and counseling regarding allergen avoidance 
measures. HCPs highlighted the importance of training in these
areas and in cultural competency, as well as provision of multi-
modal culturally tailored resources for patients and access to an 
extended food allergen panel for laboratory testing. Some 
changes in NHS service framework were also suggested as 
ways to improve clinical management, including conducting 
face-to-face consultations as opposed to remote consultations, 
availability of interpreters who could provide more accurate 
translations, and extended outpatient consultation times.
The barriers to delivery of clinical care for FA in this study share 
commonalities with those reported in the study of a multifaceted 
intervention program for the management of asthma involving 
HCPs managing asthma in British SA children. 22 This study iden-
tified similar barriers, including limited consultation times; En-
glish language proficiency; issues surrounding quality of 
language interpretations, particularly when family members are 
involved; HCPs focusing more on pharmacotherapy and less so 
on provision of holistic care; challenges in the provision of linguis-
tically and culturally suitable information; expectations from par-
ents for HCPs to fix the child’s problem rather than understanding 
the concept of chronic inflammatory airways disease manage-
ment; and the need to engage with the NHS in the long-term 
care, thereby causing dissatisfaction and a search for alternative 
therapies. 22 Ahmed et al 23 explored the views and perspectives 
of HCPs from a diverse ethnic background regarding self-
management of asthma in British Pakistani and British Banglade-
shi patients. Despite organizational barriers with respect to 
resources and language, participants in their study attempted to 
provide culturally tailored and adapted management plans based 
on their own views regarding the patient’s ability to self-manage. 23 
They recognized the need for training of HCPs and patients via ed-
ucation, group discussions, and culturally relevant action plans. 23 
Our study involved a diverse group of HCPs with respect to age, 
sex, ethnicity, experience, and professional roles from primary 
and secondary care across the UK NHS, contributing to 
generalizability of the dataset. It is plausible that some of the 
lessons learned from the current study could also apply to British 
patients from other ethnic minority groups, although further 
research is needed to gain a deeper insight into nuances. This 
study recruited Indian, Pakistani, and Sri Lankan HCPs; HCPs 
from other SA ethnicities such as Bangladeshi and Nepali and 
Southeast Asians were not specifically represented. This restricts 
the transferability of findings across the full range of Asian ethnic 
minority populations. Further, although English-proficient SA 
HCPs were included as participants, interpreters or translators of 
SA ethnicity could also have been systematically used. This might 
have enhanced culturally relevant interpretation and more nuanced
TABLE II. (Continued)
Theme
Subtheme
Participant quotes
‘‘If they have a language barrier, telephone appointments are 
useless. If they have severe FA, telephone appointments are 
absolutely useless, so many of them once coming face to 
face, didn’t have a clue what happened in the last 
appointment. Definitely if there is a language barrier, face to 
face is really important.’’ (HCP 13)
‘‘You need to put a little pressure on the GP because of resource 
scarcity, and if you’re from a minority ethnic group you may 
be at somewhat of a disadvantage.’’ (HCP 20)
GP, General practitioner.
J ALLERGY CLIN IMMUNOL GLOBAL 
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BIRDI ET AL 7
understanding of dietary practices, food naming, and cultural 
contexts, as has been recommended in cross-cultural qualitative 
work. Finally, although most interviews were conducted online 
due to feasibility constraints, in-person face-to-face interviews 
may have enabled richer insights into participants’ nonverbal cues 
and more detailed understanding of their responses.
In conclusion, the perspectives of HCPs suggest that disparities 
in the management of FA in British SA patients are multifactorial. 
Addressing inequalities and inequities requires a concerted, 
strategic, multipronged, and multidisciplinary approach with a 
focus on raising awareness of FA among patients, their families, 
and the SA community through multimodal education channels; 
developing culturally tailored supportive interventions for pa-
tients; enhancing cultural and professional competency among 
HCPs; and making appropriate adjustments in the current health 
service framework to suit the needs of SA patients.
DISCLOSURE STATEMENT
This project is funded by the National Institute for Health and 
Care Research (NIHR) under its Research for Patient Benefit 
(RfPB) Programme (Grant Reference Number NIHR204048). 
The views expressed are those of the author(s) and not necessarily 
those of the NIHR or the Department of Health and Social Care. 
Disclosure of potential conflict of interest: M. T. Krishna has 
secured research funds from the NIHR, Medical Research Coun-
cil Confidence in Concept, and Food Standards Agency outside 
the work presented in this article. He is College Lead for Equality, 
Diversity and Inclusion for the College of Medicine and Health, 
University of Birmingham. C. J. Jones has received research 
funding from the NIHR, Food Standards Agency, and Innovate 
UK and honoraria from the NIHR, Nutricia, Mead Johnson/ 
Reckitt, and Allergy UK. The rest of the authors declare that they 
have no relevant conflicts of interest.
Key messages
● Cultural and social factors strongly influence FA manage-
ment in British SA patients, including reliance on tradi-
tional remedies, family decision making, and the stigma 
of refusing food in social or religious contexts.
● Unique allergens in SA diets (eg, lentils, chickpeas, spices, 
certain fish) are underrecognized, creating diagnostic and 
management challenges that require culturally tailored 
resources and training for HCPs.
● Language barriers, limited consultation time, and lack of 
cultural competency hinder effective care, highlighting 
the need for multidisciplinary teams, culturally adapted 
education, and systemic changes in the NHS to reduce 
health inequalities.
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