Heart-Health and Asians in Britain

Asians living in Britain are more at risk of coronary heart disease than most other groups of the population; an issue which needs to be specifically addressed by those responsible for planning and implementing the various initiatives, whether at national or local level.

We, therefore, decided to gather together a workshop of people concerned with the health of the Asian communities to consider a number of aspects of the problem and to make practical recommendations to enable more informed decision-making.

We are grateful to all those who took part; but in particular to Anne

Heughan and Don Watson of The Coronary Prevention Group, who bore the main burden of organising the workshop and writing the report; and to Dr Ken Grant, District General Manager of City and Hackney Health Authority, for his part in chairing the proceedings.

The views expressed in this report represent those of the Workshop participants and do not necessarily reflect those of the Health Education Authority or The Coronary Prevention Group.

In 1984 The Coronary Prevention Group was the only charitable body in the United Kingdom solely concerned with the prevention of heart disease. It was formed in response to the need for an impartial organisation to provide information to the general public, health professionals and the media as to the cause of heart attacks and action which can be taken to reduce the risks. As a charity it is wholly dependent upon voluntary donations to enable it to continue its work.

© November 1987Published by The Coronary Prevention Group
London, UK

Introduction

Coronary heart disease (CHD) is the biggest single cause of premature death in the United Kingdom. People from the Asian sub-continent living in this country suffer particularly high rates of death from CHD. The mortality rate for Asian men is 20% higher than the average rate for the United Kingdom, and the rate for Asian women is 30% higher. These rates are much higher than those for other immigrant groups in this country. A similar pattern has emerged for Asian immigrants living in other countries. (1)

The main preventable factors associated with CHD are cigarette smoking, an unhealthy diet, high blood pressure (hypertension), obesity, and a lack of physical exercise. Diabetics are also known to have a higher risk of CHD.

Current research findings seem to show that the high CHD mortality rate among Asians cannot be explained by the classic risk factors alone. In 1986 The Coronary Prevention Group, in association with The Confederation of Indian Organisations, produced a report, ‘Coronary Heart Disease and Asians in Britain’, which drew attention to this problem. The report stressed the importance of involving Asian people at every stage of planning, implementing and evaluating health promotion campaigns to ensure that they are relevant to their needs.

In April 1987, the DHSS and the Health Education Authority launched the ‘Look After Your Heart’ campaign – England’s first national campaign to combat heart disease. The campaign aims to raise awareness of how CHD can be avoided and will be supported by a wide range of activities at national and local level. However, the campaign’s initial strategy document published in April 1987 did not address the specific problem of CHD and Asian people.

It was for these reasons that the Health Education Authority and The Coronary Prevention Group organised a workshop on heart-health promotion and Asians in Britain; held in June 1987. The aim of the workshop was to bring together a number of people working on health in the Asian communities to discuss three key issues:

1. What examples are there of materials or good practices which aim to reduce CHD among Asian people in Britain?
2. How should this material and information in general, be made available to the Asian communities and to those who work with them, such as health professionals, local authorities, teachers and journalists, and the voluntary section?
3. What recommendations for local and national action should be made to address the problem of CHD among Asian people in Britain?

The objective of the discussion was to draw up recommendations for action by the DHSS, the Health Education Authority, local health authorities and other key organisations with regard both to the ‘Look After Your Heart’ campaign and to the general promotion of heart-health in Britain. The discussion focussed on five areas: nutrition, exercise, advocacy, stress and current research and epidemiology. This Report provides a summary of the main points made at the workshop, together with the recommendations.

Nutrition

Discussion introduced by Kiran Shukla, Community Dietitian, Newham Health Authority.

Asian people are becoming unsure of their traditional diet, largely because of the links that are claimed between Asian diets and ill health. The problem is compounded by the pressures on immigrants to adopt many of the worse features of the British diet.

The majority of immigrants in Newham, for example, are from rural backgrounds. They are under a great deal of family and social pressure to Westernise, and one consequence of this and their relatively increased affluence is that they consume more fat than was the case before. They bottle feed their babies, buy sweetened, fizzy drinks, and tinned and packet baby foods, many of which are also high in sugar. When the children get older and start to eat outside the home, they acquire a taste for Western food, with the result that two styles of meal are cooked in the family home. Many adults take Western-style packed lunches to work, to avoid harassment in staff canteens. In all these cases ‘junk food’ is becoming a greater part of their diet.

Other factors are influencing this change. Messages from the media and even from health professionals can be contradictory and confused -curries, for example, being equated with ‘fried food’. Only the potential problems of the Asian diet are highlighted and not any of its advantages. The NACNE recommendations (3) are very close to the traditional vegetarian diet of some Asian communities and nutrition education should underline the positive aspects of traditional diets.

Given the already high CHD mortality rates among Asian people in Britain, it is especially worrying to reflect on the future of Asian children now beginning to eat a Western diet. It is important that health professionals give clear nutritional advice and that the value of traditional Asian diets should be positively reinforced.

Exercise

Discussion Introduced by Rohney Maltk, Community Sports Supervisor, London Borough of Hackney.

The problems in promoting exercise are not confined to the Asian communities. Exercise can easily be seen as a ‘chore’ and promoting it as a pleasurable experience is often difficult. These difficulties are heightened when trying to respond to the needs of a culturally and linguistically diverse community. Nevertheless examples of good practice can be found.

Outreach work is probably the most effective way of facilitating the participants of black and ethnic minority communities in sport. Outreach provides face to face contact with the community and allows service providers to gain awareness of that community’s needs and difficulties. It is particularly difficult to identify the exercise needs of communities that are socially and economically disadvantaged, isolated, and for who exercise may not rank as a priority. Even those who wish to participate may lack the information, confidence, or access to the services.

This in turn requires networking, and the necessity to liase between a variety of voluntary and statutory agencies. It is by these means that outreach is achieved.

Schools are a valuable link, for example when mothers are picking up children after school. It is also effective to work with community representatives to form an information network and to act as a consultation forum. Experience shows too that it is useful to work with and through older generations, particularly when trying to involve younger age groups.

Responding to need poses many dilemmas, particularly in relation to the perception of need. It is vital that responses are relevant to the experienced needs, interests and lifestyles of the community. For example sports which are traditionally marginalised within the Asian communities, such as Gharba dance and Kabbuddi (Indian wrestling) can be positively promoted. Another example is spreading awareness among both staff and users of swimming pools that ‘traditional’ swimming costumes are not essential.

Successful participation is dependent on effective publicity and the dissemination of information. Traditional distribution points such as libraries are not always appropriate. Use should be made of multi-lingual leaflets, posters and videos, and in addition to this publicity service providers should also examine transport and crèche facilities. Complaints procedures should be well advertised and include clear guidelines for dealing with racial harassment.

Local authorities should be sensitive to the needs of Asian people when encouraging them to use local sports facilities. For example, many Asian women and girls do not use sports facilities because of fear of racism. These fears can be overcome by arranging separate exercise sessions for women, and, perhaps, by providing transport. It is also important to promote forms of exercise that are culturally acceptable. ‘Low-key’ activities such as walking can be successfully encouraged.

Asian people should be able to have a say in local sports service provision and in the training of staff for local sports facilities. Networks of those working in this area of exercise take-up would be useful as a means of sharing experience and developing expertise. Closer collaboration between health education units and local authority sports workers would also be beneficial.

Advocacy

Discussion introduced by Carol Baxter, Training Officer, Training in Health and Race Project.

Most health education material aimed at ethnic minority communities has either been concerned with ‘fertility and fecundity’ or dealing with specific diseases. There has been little or nothing on active prevention and healthy living in general. There are few positive images of black people in health promotion literature apart from exceptional figures such as Daley Thompson. This creates an impression of campaigns being imposed from the outside. Successful health promotion initiatives, however, will only come from within the black and Asian communities themselves.

The response of the health services to the presence of black and Asian patients was firstly to try to teach them English, then to use interpreters, then to give staff training in communication. None of these have been particularly successful, and so the current emphasis is on advocacy.

Advocacy is based on the recognition that there is an unequal relationship between patients and health stab It is difficult for patients to negotiate what happens to them in hospital on their own terms. This is particularly true for female patients, those from a different culture and those who do not speak English. Advocacy schemes such as the Hackney Multi-Ethnic Women’s Project have been set up to counteract this. The role of the advocacy worker is to find out from the staff the answers to the patients’ questions and to relay the patients’ wishes to the stab

A successful advocacy scheme depends on at least nine key elements:

1. Community involvement. Those who are meant to benefit should be fully involved from the very beginning in discussions about the project’s organisation and objectives, and should participate fully in management decisions.
2. Independent management structure. Advocacy workers need to be closely associated with the management structure of the department where they are working, but should remain independent from it.
3. Active support from, and access to, senior management. These are essential elements if existing procedures have to be reformed. They also facilitate co-operation from first-line managers and junior staff.
4. Challenging racism. This must be recognised as an integral part of the project’s brief. Senior Managers should be seen to take action to challenge racism, even unintentional racism.
5. Emphasis on advocacy. The emphasis should be on advocacy rather than on the availability of interpreters. However, arrangements for interpreters should be organised by the advocacy project to ensure that all interpreters are integrated into the scheme and get appropriate training and support.

6. Training and support. Training needs to be flexible, informal, and designed to meet the specific needs of the community and the workers as they arise. Training should build on the experience of the advocacy workers.
7. Personal qualities. The criteria for selecting workers should be their background and experience, their commitment to their community and willingness to share their knowledge with patients. These qualities are more important than formal qualifications.
8. Promoting the scheme to other health workers. It is crucial to prepare the ground for a patient advocacy scheme through a carefully planned education and promotion programme among all staff who are likely to come into contact with the project. This can help to avoid many misunderstandings.
9. Secure funding. It is essential to secure long-term funding in order to build up experience and to ensure continuity of the advocacy project. The health needs of ethnic minority groups will continue to be seen as marginal until they attract mainstream funding.

Advocacy should be on the agenda in many more areas of the National Health Service, including CHD prevention. Using the experience of advocacy projects, it is possible to outline how a national ‘healthy heart’ campaign could be made relevant to the Asian communities:

• Asian communities need to be involved in local campaign steering groups at all stages including the identification of needs, implementation, management and evaluation. National campaigns are likely to need a lead-in time of at least two years to allow for this consultation.
• Ethnic minorities should be represented on existing national and local planning structures, committees, and relevant DHA working parties. Other models of consultation are being developed also, and their progress should be monitored.
• Health education officers should liase with Asian communities to explain how the national campaign can relate to them, and to report back on the effectiveness of the campaign.

Stress

Discussion introduced by Dr. Ghada Karmi, Specialist in Community Medicine, Paddington and North Kensington Health Authority.

It is difficult to transfer the words and concepts of stress to Asian communities since the conceptual frameworks are so different. There is an understanding of ‘pressure’ but this is not generally related to the broader lifestyle.

Asian people use their leisure time differently from the indigenous population. Positive images of their traditional culture could help to promote health-enhancing behaviour. For example, seeking and giving support to friends and relatives is a valid activity in this context. More data is needed on the new patterns of alcohol consumption in Asian communities and how this may relate to stress and the use of leisure time.

Racism is stressful and an everyday reality for Asian communities. More work needs to be done on the effects of racism on health. It is also important to look at institutional racism, for example the omission from the ‘Look After Your Heart!’ campaign strategy of CHD as it affects Asian people. All Regional and District Health Authority plans and objectives should include action to address racism within the NHS.

The Asian business community works extremely long hours in sedentary occupations, as do many home working machinists. Homeworkers and self-employed do not benefit from the occupational health services provided by large employers and the LAYH campaign needs to be recognise this if it intends to use workplace-based promotions.

Health promotion material on stress should be available in the five major Asian languages. There is also a need for background material to raise consciousness about the issue.

Current Research and Epidemiology

Discussion introduced by Dr. Paul McKeigue, Department of Community Medicine, University College London and Middlesex School of Medicine.

Research on Bangladeshis in East London in 1986 confirms the findings of earlier studies, in Northwest London in 1985 and also the Immigrant Mortality Study published in 1984 (4), that the high mortality from CHD among Asians in Britain cannot be explained by the prevalence of the classic risk factors alone. The East London data is concerned with Moslems rather than the Guiaratis of Northwest London but both groups have a high hospital admission rate for myocardial infarction. Compared with the Europeans in the sample, the Bangladeshi males smoked more, but they tended to be thinner and have lower plasma cholesterol levels. There was a significantly higher rate of adult-onset diabetes among the Bangladeshis, together with a much higher insulin level after a glucose drink, a measurement that has been shown to be a predictor of CHD.

Diabetes and obesity may well be more important risk factors for Asian people than for the indigenous population. If so, it would be helpful to promote exercise more strongly.

There is a clear need for further research on the possible inter-reactions between risk factors, genetic and environmental factors. This should include an analysis of the current as well as the traditional diets of the Asian communities, and of the health consequences of the stress caused by immigration, racism and work patterns.

Future research should be paralleled by studies in India to test these hypotheses. In 1968 a study in the Punjab indicated a similar mortality rate from CHD to that of the USA. However, poor rural areas in India had much lower mortality rates than the affluent areas. It seems that Westernisation is accompanied by an increase in CHD mortality. At the moment there is insufficient data available to say whether this also applies to British-born Asians.

Although the term ‘Asian’ should not be used to generalist about all Asian communities, the evidence from surname analysis shows that each particular Asian community has a high CHD mortality rate. If the only characteristic these groups have in common is the fact that they have emigrated, could it be that the effects of emigration are specifically linked to heart disease? In order to answer this, more research would need to be done to compare migrating and non-migrating groups.

Research on the ethnic origins of patients and citizens needs to be standardised and extended. It would be helpful to include a question on ethnic origin in the next census. However, this issue will have to be treated with great sensitivity.

Recommendations

The DHSS

• Some of the highest rates of death from CHD in the British population are found among the Asian communities. Their omission from the initial ‘Look After Your Heart!’ campaign strategy document must be rectified if that strategy is to be meaningful.

• The most productive way to achieve this is to extend the principles of advocacy into CHD prevention. This means that health authorities should enable the Asian communities to be actively involved in the planning, implementation, management and evaluation of ‘Look After Your Heart!’ initiatives to ensure that these are relevant to them.

• The Workshop noted that Health Education Units believed that they were expected to participate in the campaign largely from within their existing resources, and questioned whether this was realistic.

• The DHSS should consult with Asian health workers to set up a national forum to collect and disseminate material and information on good practice and to monitor the problem of CHD in the Asian communities. The forum should be mainly composed of Asian health professionals working in this field.

• The DHSS should require Regional and District Health Authorities to include in their strategic and short-term plan proposals for ensuring racial equality in service provision and delivery.

• Resources should be allocated to pursue the epidemiology of CHD among Asian people in Britain. This should recognise that ‘Asians’ are not a homogenous group in terms of CHD risk factors and that much remains to be learned about those risk factors. Nevertheless enough is already known to make research recommendations.

• The principal focus of the research should be on the role of illnesses such as diabetes and the inter-action between diet, stress and work patterns. Data should be collected on smoking, cholesterol levels, systolic blood pressure and body mass index among samples of British born Asian people. Where possible, parallel research with relevant epidemiological projects in the Indian sub-continent should be supported.

The Health Education Authority

• The Asian community should be specifically included as a key target group in the ‘Look After Yourself campaign strategy.

• The objectives are to try to contain any rise in the smoking rates among British Asians, to prevent the wholesale adoption of the worst aspects of the British diet and to increase the uptake of exercise.

• Printed material and videos on smoking, nutrition, exercise and stress, in the five major Asian languages, should be centrally available.

• Opinion formers among the Asian communities, including the ethnic press, should be more actively encouraged promoting health. More use should be made of existing cultural networks to disseminate health promotion material.

• Where possible, health promotion messages should be based on positive reinforcement of the value of traditional Asian cultures. This is particularly so in the area of nutrition.

The Sports Council

• The health value of exercise needs to be promoted to the Asian communities.

• Providers need to address the reasons why Asian people do not take up sport and exercise facilities, and to recognise that exercise can be linked to activities which are culturally more acceptable than many forms of sport currently on offer.

• The Sports Council should take the initiative in publishing guidelines and good practice, in consultation with organisations of Asian people and those local authorities with experience in the field.

Health Authorities

• Health authorities should specifically involve Asian communities in planning and implementing health promotion programmed. This will require effective advocacy schemes, using appropriately trained and securely funded advocacy workers.

• The existing cultural networks such as Asian video shops, community groups, the ethnic press, opinion formers and mosques, should be approached with a view to involvement in the dissemination of health promotion material. This would help to ensure that the material is available at appropriate and effective outlets.

• Nutrition education should underline the positive aspects of traditional Asian diets.

• More effective collaboration with local authorities is required to ensure that catering and exercise facilities are appropriate for the Asian community and are well publicised.

• All regional and district health authority plans should include action to ensure racial equality in service provision and delivery.The Voluntary Sector

• Community groups should ensure their advocacy role includes closer links with health and local authority planning structures, health education services, professional training programmed and local media.

• National voluntary sector agencies should take account of the particular heart-health needs of Asians in Britain, and to press for appropriate efforts by statutory bodies in terms of planning, implementation, management and evaluation of heart-health programmed

Notes

1. Coronary Prevention Group and the Confederation of Indian Organisations. ‘Coronary Heart Disease and Asians in Britain’. Coronary Prevention Group, 1986).

2. Ibid.

3. Working Party of the National Advisory Committee on Nutrition Education ‘Proposals for Nutritional Guidelines for Health Education in Britain’ Health Education Council, 1983.

4. Marmot M.G. et al. ‘Immigrant Mortality in England and Wales’. HMSO, London. 1984.