The South Asian community health education and empowerment (SACHE) in diabetes programme

Following the success of the South Asian community health education and empowerment (SACHE) programme for cardiovascular health, it was decided that a similar programme would be developed for South Asian people with diabetes. The programme targeted a high-risk population in 7 major cities in the UK and broke down cultural barriers by taking important diabetes education out into the communities, including schools, community centres and places of worship. The programme also involved embedding health ambassadors in schools and recruiting local pharmacists as diabetes education champions.

Community events
A total of 11 events were delivered in a variety of community centres, including mosques, gurdwaras, temples and schools, reflecting the need for settings that were culturally most acceptable to the attendees. Events were advertised in the local communities through posters in family practice centres, through the networks of local community leaders and also through direct contact with people registered as having diabetes. Emphasis was placed on extending the invitations to the wider family group to reflect the need for wider family engagement in improving self-management, since carers have such a major impact on health outcomes in those with non-communicable disease.

Event programmes
Although the specific content of the events varied, each event followed a broadly similar approach.

The sessions started with a bilingual introductory session led by the South Asian Health Foundation (SAHF; www.sahf.org.uk) healthcare professionals and specialist guest speakers on the nature of diabetes and its complications, screening services and other NHS diagnostic approaches.

There was a focus on the positive self-management of diabetes and topics covered included medicines compliance and the importance of diet and exercise. The section on lifestyle changes was supported with the showing of the short film “Meethi Baatein” or “Sweet Talk”, both in Hindi and English. This video, which was produced by SAHF and Pink Sequin Productions focuses on the risk factors and complications of type 2 diabetes.

An important aim of the sessions was to dispel myths, such as those surrounding injectable insulins reflecting terminal aspects of care for people with diabetes.

Each event culminated in question and answer sessions which, for the most part, generated positive and useful debate, exploring some potentially sensitive issues, such as fasting, through to more obvious issues around engaging the wider family in lifestyle change.

Copies of the DVD were distributed at each event alongside support material. All of the educational materials were available in English, as well as the main South Asian languages, such as Punjabi, Gujarati, Urdu and Hindi.

Event evaluation
A simple questionnaire was created to establish attendee knowledge at the beginning of each event and this was then completed again at the end of each event (Box 1). The aim was to assess the extent to which the event itself was effective in increasing knowledge and dispelling some of the common myths.

Ensuring high levels of questionnaire completion was always going to be a challenge, even with assistance offered. In practice, questionnaire completion rates were high at the start of the events, but for various reasons (largely people needing to get home or having other commitments) completion fell away after each event, in some cases significantly.

Results
Figure 1 shows the questionnaire data about attitudes and beliefs before and after the programme. The results highlight that there was consistent and positive learning throughout the events. The most striking finding was the significant shift in beliefs from people thinking they will inevitably die once prescribed injections for diabetes. These beliefs decreased by as much as 33% after the events.

We have been delighted with the impact of these events and we have successfully reached out to vulnerable South Asian men and women with diabetes, demystifying some commonly held beliefs. The main outcomes and lessons taken from the programme are described below:

• Powerful and significant attitudinal change can be witnessed in areas of significant educational need.
• The success of self-medication and self-care can be influenced by confusion and concerns over compliance. In particular, we identified concerns over the side effects of certain drugs, such as statins, with diabetes medications.
• Tapping into strong parental responsibility across the community is likely to be a highly effective means of generating behaviour change in children’s diets.
• Positive messages to reduce unhealthy behaviours can be used as a starting point for some people, rather than actually stopping them. This is especially the case among those of Bangladeshi origin and men in general.
• There is an encouraging and noticeable shift in the willingness of the South Asian community to admit to having problems with diabetes.
• There is a need for advice, specifically around fasting. It is vital to reinforce the importance of medication and to avoid fasting for long periods of time. This also applies to those of Hindu religion, who may also fast.
• Simple visual aids and images can have a profound impact in both men and women’s attitude to adopting a healthy lifestyle, for example, bodies with obvious central obesity, and showing images comparing healthy and smoke-damaged lungs.
• Women can play a key role in influencing positive dietary changes through small and gradual changes made through their traditional role and duties of preparing tasty, but often unhealthy food for themselves and the wider family.
• Physical activity among those practising Islam can be encouraged with greater ease if promoted through their regular and daily religious prayers.
• Some women do not know or recognise the symptoms of diabetes and that being overweight increases the risk of diabetes.
• Programmes need to be multifaceted, covering not only blood glucose, but also blood pressure and cholesterol. Tackling wider determinants of health enables a potentially wider impact on health outcomes for those with non-communicable diseases.
• Provision should be made for women to ask questions in private.
• Co-ordinating education with prayer times would maximise audience reach and impact.
• Travelling abroad can be seen as a reason to temporarily abandon medication, or be less compliant, so specific messages should reiterate the importance of continuing medication at all times.
• Some people with diabetes did not have a good understanding of the lifetime nature of the condition.
• The perceived efficacy of herbal remedies needs to be dispelled.
• Hearing others’ case histories and being able to share coping strategies can be a powerful driver for behaviour change.
• More work is required to drive home the message that children can be at risk of diabetes.
• Alcohol intake among Punjabi men was identified as a big area for improvement, but convincing male family members to change behaviour can prove challenging. Equally, encouraging this group to eat at least five portions of fruit per day can be difficult.
• Messages about diet control needs to be broadened to overcome the perception that reducing sugar/sweet intake is the key factor to reducing risk.

Summary
Powerful attitudinal changes were achieved in areas of significant educational need. The feedback received was positive and we were delighted to receive the BMJ award for an innovative programme improving diabetes care and addressing inequalities simultaneously.

As mentioned previously, the main challenge of the programme was to collect questionnaire data. In practice, questionnaire completion rates were high at the start of the events, but were poor after each session. There were various reasons for this, but it was largely because attendees needed to get home or had other commitments.

Funding was provided from Novo Nordisk for the community training events and resources.