The Khush Dil project: Raising CHD awareness in the South Asian community

It is well documented that people from black and minority ethnic (BME) backgrounds often have worse health than the general population, including a greater risk of type 2 diabetes and coronary heart disease (Petersen et al, 2004; National Diabetes Support Team, 2006; Parliamentary Office of Science and Technology, 2007). Gloucester has a diverse community consisting of a high proportion of people of South Asian origin. The specific health needs and health education requirements of this community played an important role in the development of a  community diabetes service. 

Background
BME communities make up 8 % of the Gloucester population and are concentrated predominantly in the city centre. The South Asian community in Gloucester is almost exclusively Muslim, with the majority originating from Gujurat, Pakistan and Bangladesh.

A Health Needs Assessment undertaken in 2003 demonstrated that residents of Gloucester experienced many health and social inequalities (Gloucester PCT, 2003). In particular, a high incidence of diabetes and heart disease was identified within the local BME populations. As a direct result of the assessment, Community Counts (a local neighbourhood management organisation) funded a community DSN to improve the access to diabetes services for the residents in this area. 

The community DSN is part of the primary care-based diabetes service, which supports GPs and people with diabetes through education sessions and clinical reviews across the whole of Gloucestershire. However, an additional service was needed to address the specific needs of the BME population, whose health education requirements were very different to those elsewhere in the county. 

The community DSN consulted with the local community groups to establish what support was needed to address the specific health requirements of the BME population. The main areas identified included the following.

• Awareness of the signs and symptoms of diabetes and heart disease.
• Culturally appropriate information for healthy eating in diabetes.
• Information on medicine management issues, for example, what tablets are for and how to take them.
• Awareness of the care that people with diabetes should receive.

These views were reflected by the GPs and practice nurses. Additionally, the healthcare professionals requested the following support to aid them in meeting the needs of the local population with diabetes.

• The provision of culturally sensitive and language-appropriate resources.
• One-to-one support for individuals for whom English is not their first language.
• Patient education about adherence to medical regimens and lifestyle changes.
• Promoting the importance of healthy eating and activity within BME communities.
• Staff updates and education sessions in general diabetes management, particularly focusing on healthy eating and insulin management.

The Khush Dil team
The community DSN felt that a multi-agency approach was needed to develop a service that would meet all of the needs listed above. A team was formed with support from Takeda UK Ltd. Takeda not only provided financial support but the local Regional Account Director also became an active team member, providing ongoing project management advice and contributing to the development and roll out of the service. The local diabetes dietitian and a Healthy Living worker provided specialist lifestyle knowledge. The local Health Inequalities Project also joined the team and proved invaluable owing to the project’s role in training local volunteers in health topics to enable them to support members of their own communities. In this capacity, four Asian peer support women volunteers joined the team and introduced another local Asian woman who was qualified to run cookery classes and became an active team member. The team decided on the name Khush Dil (meaning ‘happy heart’ in Hindi) and one of the peer supporters designed a logo (Figure 1).

Structure and aims of the service
The Khush Dil project has two components: practice support and patient lifestyle education. The project aims to enable South Asian people with type 2 diabetes to make cardio-protective lifestyle changes through raising awareness of the risks of cardiovascular disease, and to support practice staff in Gloucester in providing evidence-based diabetes care for this population. 

Practice support
A flexible package of support was offered to the GP surgeries that could be adapted to each individual practice’s requirements. Two practices opted to participate in an in-depth audit of their diabetes population, utilising the Clinical Audit Learning Module (CALM) tool developed by Oberoi Consulting and Takeda UK Ltd (see Box 1). Further details on the CALM tool are available from: www.oberoi-consulting.com/audit_calm.aspx (accessed 27.07.2007).

Ethnicity
Few of the practices in Gloucester routinely record ethnicity and both of the practices that have thus far completed the audit relied upon the receptionists’ knowledge of individuals to identify those of South Asian descent. The Khush Dil team encouraged the practices to record the ethnicity of patients, as evidence suggests that people from South Asia may demonstrate comorbidities related to obesity at a lower BMI than the general UK population (International Diabetes Institute Steering Committee, 2000). Therefore, recording ethnicity can help practices to plan their clinics according to their practice population’s specific needs. 

It is well documented that type 2 diabetes is more prevalent in people of South Asian descent (National Diabetes Support Team, 2006). A recent review suggests that this population accounts for 20% of all cases of type 2 diabetes in the UK (Barnett et al, 2006). There is also evidence that this population should be treated more aggressively than the general population, aiming for lower BMI and waist circumference to reduce the increased risk of insulin resistance – possibly one of the main contributing factors to the metabolic syndrome (Raleigh, 1997; International Diabetes Institute Steering Committee, 2000; Barnett et al, 2006). 

This information is discussed with GPs and nurses at local surgeries, who may then choose to amend their treatment protocols or refine their screening criteria accordingly. Practices are encouraged to refer their patients to Khush Dil patient support activities. These community-based initiatives focus on reducing CV risk by encouraging individuals to increase their activity levels and reduce dietary fats. 

Lifestyle education
The second component of Khush Dil consists of a selection of educational activity sessions aimed at enabling South Asian people with diabetes to make cardio-protective lifestyle changes. The sessions are all locally based, single sex, free of charge and held in English, Gujurati and Urdu – the most commonly spoken local languages. These sessions are also designed to be hands-on and encourage learning through participation. There are currently three different sessions, all designed to complement one another.

Activity sessions
A weekly activity session is held to encourage Asian women to increase their daily levels of activity. The session combines gentle exercise with advice on reducing CV risks factors (Figure 2). The course has had to be adapted to suit the needs of the local Muslim women, many of whom have not taken any exercise for years. 

The exercises are mainly chair based, with participants completing seated exercises during the warm up and using the back of the chair for stability during balance exercises. The goal behind this approach is to enable them to practise at home. The length of the activity session increases each week to build the women’s strength and stamina. Following a request from the group for weight-loss advice, they are now being weighed weekly with monthly glucose, blood pressure and waist circumference measurements.

The session has evolved greatly to accommodate the needs of the group. The women like to dip in and out, frequently not attending every week. They also like to join any given session at varying times, making it difficult to provide structured exercise for them. The peer support volunteers attend each session to assist the women, interpret for the course leader and help with the monitoring and recording of information. Fruit and tea are provided at the end of the session, with the women encouraged to discuss their progress and set themselves targets for increasing their activity levels at home.

Cook and eat
Fortnightly cooking sessions are held at a local day centre. The aim of the sessions is to involve women in cooking traditional Asian meals using healthy ingredients and methods. Although Asian diets vary greatly across the continent, many recipes are based on saturated fats, such as ghee, and often include large volumes of salt. Sweet, fatty desserts are also popular, such as sevre – made from sugar, ghee and condensed milk. Deep-fried snacks are commonly eaten at social events and during festivals: for example, during Ramadan, many people break their daily fast with deep-fried samosas, bhajis and pakoras. 

The Cook and Eat sessions focus on raising awareness of the increased risk of heart disease in South Asians and encourage women to try cooking with oils that will be more cardio-protective, such as rapeseed or olive oil. The food is prepared by the group using herbs and spices instead of salt, and healthier methods of cooking such as grilling and baking are demonstrated (Figure 3). 

The Khush Dil dietitian attends the Cook and Eat sessions. Their role is to join in with the food preparation and to chat with the women while they are cooking to provide informal education about the ingredients and methods of preparation. This approach encourages the group to interact and often leads to discussions about their families, such as what their children like to eat. These topics are then discussed further while the group eat the meal they have prepared. This is perhaps the most valuable part of the session, as the women not only get to taste healthy food they have prepared themselves, but informal group discussions take place about how they could adapt the recipes to suit their families. Conversations such as these have provided the ideal opportunity to discuss the importance of healthy eating for all ages and highlight the risks of heart disease and obesity in children as well as adults. A copy of the recipe is provided to reinforce the education. Many women have reported trying them out with their families. 

Between 5 and 15 women aged between 20 and 40 years attend each session. This is important as it is often the women of this age group who prepare meals not only for their own families but also for their in-laws, who frequently live in the same house. This means that any positive changes to the way they prepare their food have a wide-reaching impact. 

Supermarket tours
To complement the Cook and Eat sessions and reinforce the livestyle messages, Khush Dil has teamed up with the local Asian supermarket. This supermarket is utilised by most of the local community as it is one of the main suppliers of halal meat and Asian vegetables. The supermarket now stocks ingredients used in the Cook and Eat sessions, including rapeseed oil, low-calorie olive-oil spray and an olive-oil based spread. They also distribute leaflets promoting the Cook and Eat sessions to their customers. 

The Cook and Eat facilitator attends the supermarket fortnightly to promote healthy choices available in the shop, encourage shoppers to attend the Cook and Eat sessions and distribute Khush Dil leaflets that outline the main principles of healthy eating in preventing heart disease (Figure 4). This cohesive approach aims to encourage people to shop healthily and also has the added benefit of promoting the Cook and Eat sessions and supporting local commerce.

Meals on Wheels
The Khush Dil team have liaised with the Meals on Wheels organiser for the local Asian community. Her recipes were examined and suggestions were made to make the meals healthier without changing the menus. Unfortunately, she had met with resistance when trying to provide healthy meals in the past, so it was decided to focus on making small but sustainable changes that would not compromise the taste of the meals. Two months after the initial discussion, she reported using less salt, ghee, cream and condensed milk in the meals. Instead, she had started using rapeseed oil and shallow frying rather than deep frying. Most importantly, she received no complaints from her customers! It is difficult to formally evaluate the effectiveness of these changes, but it is reassuring to find that healthy changes can be made without changing the taste of food. 

Conclusion
Attendance at the Khush Dil activities has been encouraging. The local Asian community are enthusiastic about the project and anecdotal evidence suggests health and social outcomes have improved for many Khush Dil attendees. A strong evidence base that demonstrates a reduction in key cardiovascular risk factors for this difficult-to-reach population is anticipated in a full evaluation on the project due to be completed autumn 2007.  

Khush Dil activities were designed originally for women and men, albeit separately – as is required by the Muslim faith. Unfortunately, despite repeated publicity within the community, it has been difficult to engage men in any of the interventions. This is not uncommon in many communities and it is recognised that men access health services far less frequently than women (Office for National Statistics, 2002). To raise awareness of the risks of diabetes and heart disease amongst the male South Asian population, information has been distributed in the local Mosques and on local radio. 

Currently, Khush Dil clinics have commenced fortnightly in an community venue.  Participants have been identified from the patient register at one practice. The clinics involve the DSN and an interpreter/educator who telephones participants twice prior to the initial appointment to discuss the programme and reduce the number of missed appointments.  

It is envisaged that the Khush Dil project will continue to have a positive impact on the local community throughout 2007. It is hoped that by enabling local women to make cardio-protective changes in their cooking and by raising awareness of the importance of increasing activity levels, these key health messages will be taken into local homes. The Khush Dil team anticipate that this will have a positive impact on the whole family and wider community. It is acknowledged, however, that more work needs to be done to address the education needs of the local male population.