Individuals living in the UK who are from ethnic minority communities have a higher risk of heart disease and strokes than white individuals. This risk arises from the social determinants of health. These include lifestyle factors such as diet, physical activity and smoking. Improving these lifestyle factors in individuals is an essential part of reducing the chances of heart attacks and stroke. Patients may have diets and lifestyles arising from their cultural and religious backgrounds but receive advice which is not aligned to their own customs and experiences. Receiving advice which is not relevant to their own types of diet and lifestyle customs may create difficulties for patients in managing their heart and circulation health. Moreover, the dissonance between advice given and patient-specific relevance may lead to poorer adherence to the recommendations made to manage their condition. This can lead to poorer health outcomes for these patients. In addition, they may be advised to adopt diets and behaviours which are not appropriate to their cultures and may be also difficult to put into practice. This is important because lifestyle advice aligned to a patient's existing diet, behaviours and cultural beliefs leads to improved control of these health conditions. Learning to provide dietary and lifestyle advice relevant to individual patients needs is an important skill for the clinicians caring for them.

Background The experience of patients from ethnic and differing cultural backgrounds may range from unempathetic to discriminatory. Treatment and management pathways may be contrary to patients' cultural beliefs and values. Lack of awareness of cultural differences among individual clinicians and healthcare organisations contributes to racial disparities in health. The risk of cardiovascular disease is higher in ethnic minorities in developed countries than for white populations. This is reflected in patients of South Asian and African Caribbean heritage living in the UK. Lifestyle factors including diet and physical activity contribute to the social determinants of health which place some communities at a disadvantage relative to others.

Support with self-managing chronic disease can be individual, from family and friends, the wider community as well as from local primary and secondary care services. Social stigma and dietary challenges are significant barriers to effective diabetes management in South Asian patients. The role of family members and religious observance can be important in optimising diabetes management. Adherence to recommended diet is the most significant challenge for diabetes management. While media from healthcare professionals, leaflets and magazines can be valuable, it needs to be culturally attuned. This includes the preferred language of communication for patients. The role of family members in supporting dietary adaptation and adherence is significant.

Cardiovascular risk factors apply across all populations in all regions and include lifestyle factors. Management of lifestyle factors is important in both primary and secondary prevention of cardiovascular disease and requires patient adherence to recommendations. Lifestyle modification programmes can improve patient knowledge, self-care behaviours and glycaemic control when tailored to patient experience, psychosocial characteristics, culture, and worldview. Guidelines should account for patient's daily routines, with cultural and familial expectations of different ages and genders as well as facilitators and barriers for each group. Patients are aware of the facilitators and barriers to behavioural change affecting them though this may not apply to their clinicians and healthcare providers.

Clinicians and organisations providing care to minority ethnic patients with chronic cardiovascular disease need to be aware of the facilitators and barriers to self-management of cardiovascular disease. This includes engendering a sense of personal vulnerability and empowering self-efficacy among individuals to achieve optimal self-care.

Whilst there is existing research on this topic, it is often focussed on self-management of diabetes. Diabetes is itself a risk factor for cardiovascular disease. This study will consider patients' experience of dietary advice and facilitators and barriers to adherence in the context of a diagnosis of cardiovascular disease. Cardiovascular disease is defined as any condition relating to the heart, blood vessels and blood supply to the brain in which the management of risk factors including lifestyle is relevant to preventing the progression of the disease. Studies of risk factors in diverse populations highlight the impact of cross-cultural differences in diet or lifestyle resulting in variation in disease patterns. Diet is very influential on primary prevention of cardiovascular disease. Dietary interventions require tailoring to specific ethnic minority communities. The determinants of food choice include the nutritional environment, economic, cultural and individual factors. As well as the lack of time and motivation affecting white populations, ethnic communities may have issues around cultural commitments including extended family and faith events. Lack of access to culturally relevant information may prevent dietary change. Adjustment of cultural traditions in adaptation to the host country (acculturation) may affect health and dietary habits. In particular for dietary advice, a lack of support post intervention may lead to return to prior habits.

Main research question What are the perspectives and experiences of patients from minority ethnic communities on advice provided on diet and lifestyle advice in management of their cardiovascular disease?

Supplementary question Is the dietary and lifestyle advice provided to ethnic minority patients with cardiovascular disease appropriate to their dietary culture and background?

Data collection methods

Data for the study will be collected using a mixed methods approach and will involve:

1. One-to-one interviews exploring the lived experience of ethnic community patients and the facilitators and barriers to making recommended changes to diet and lifestyle. This will be using a phenomenological approach exploring patients' dietary and lifestyle changes following diagnosis of cardiovascular disease and how these have been facilitated by healthcare providers.

Summary of known and potential risks and benefits The benefits include an increased level and understanding among healthcare staff, trainees, and educators of the lived experience of minority ethnic individuals with cardiovascular disease. It may also increase confidence and belief among the volunteers in the study of a willingness of healthcare staff and future doctors in wishing to engage, support, and help ethnic minority patients with chronic diseases in which lifestyle and social factors are relevant.

It will assist the student researchers' understanding of communicating sensitively with ethnic minority patients and their possible experiences around dietary and lifestyle advice as well as the facilitators and barriers to change in self-managing their condition.

Interviews may include topics that might be sensitive, embarrassing or upsetting either to the patient volunteers or to the students experiencing similar feelings in their own lives or family and friends. It is possible that other disclosures (e.g. previous unprofessional behaviours by healthcare staff) requiring action could occur during the study.

Description of the population to be studied and special considerations

The study population will be ethnic minority volunteers with a history of established cardiovascular disease. They will be participating to discuss their healthcare experience particularly around dietary and lifestyle advice. Special considerations will be ensuring all participants are fully informed prior to consent regarding the use of data for analysis and storage. Patients from these communities may have previously experienced or witnessed adverse healthcare experiences which may affect their confidence in participating or sharing their thoughts and opinions. Psychological safety should be provided to participants and compliance with University safeguarding procedures should be in place in the event of participant distress.

Inclusion Criteria:

• Patients over the age of 18 years with a personal history of minority ethnicity (non-white) and a diagnosis of cardiovascular disease

Exclusion Criteria:

• Patients with a personal history of white ethnicity Patients without a history of cardiovascular disease

UK-based volunteers living in the community who have a personal history of non-white ethnicity and of cardiovascular disease

The participants include vulnerable individuals. Even where data is anonymised, it would be appropriate to request IPD only after the study is completed and they have reflected on their experience of participating in the project and had further opportunity to discuss IPD.