Bristol PCT ... Tackling major health inequalities
"We found that all patients had pretty low awareness, but amongst South Asians that knowledge was even lower." Natalie Field, Assistant Director of Public Health, Bristol North and Bristol South and West PCTs.
Mohammed Ainul Islam has never smoked a cigarette, but he knows how hard it is to give up. As a Stop Smoking Advisor to Bristol's South Asian community, he has helped dozens of people give up and warned hundreds more of the health risks if they continue. "My role is about mediation," he says. "Ninety-nine per cent of people know that smoking is harmful, but they need somebody to help them find out what services are out there to help them."
The recruitment of advisors such as Mohammed is just one of the ways in which Bristol North and Bristol South and West Primary Care Trusts are working together to address the lifestyle choices, including smoking, that are partly responsible for the high incidence of coronary heart disease in the city's South Asian community.
Nationally, death rates from the disease are up to fifty per cent higher amongst people of South Asian origin than the general population. The Trusts' three-year Health Improvement Performance Scheme is an attempt to tackle this glaring health inequality and improve the health of Bristol's South Asian community, who make up three per cent of the population.
Research
Research has uncovered a number of reasons for the prevalence of the disease in people whose origins lie in India, Pakistan, Bangladesh and Sri Lanka. One is the high levels of tobacco use, a major risk factor for coronary heart disease. Lack of physical activity, a fat- and salt-rich diet, work-related stress and the high incidence of diabetes, a related illness, are also known to play a role in the higher prevalence of heart disease in the South Asian community. Despite the risks, research also shows that people from South Asian communities are less likely to access help at an early stage of illness, which means they are more likely to be admitted to hospital when their condition is serious. Language barriers are one cause.
Before the Trusts could begin work on tackling the issue, they needed to find out the situation on the ground, and in particular whether patients from a South Asian background were receiving equal care to patients of other backgrounds. A major consultation was held to find out about patients' experiences. Questionnaires translated into five languages were sent out to both South Asian and non-South Asian cardiovascular patients. The results revealed poor levels of knowledge and understanding of coronary heart disease. "People were asked a range of questions such as what to do if they experienced severe chest pain," says Natalie Field, Assistant Director of Public Health for the two trusts. "We found that all patients had pretty low awareness, but amongst South Asians that knowledge was even lower." Later the same year, focus-group meetings were held with staff and a clinical audit was carried out to discover what treatments patients were receiving. The results of the audit revealed that services were largely equitable, but it did find discrepancies. Though South Asian patients were as likely to be prescribed drugs as people from other backgrounds, they were less likely to be given lifestyle advice by their GPs.
Findings
"We found that staff described subtle differences between South Asian and non-South Asian patients in the way symptoms of heart disease were presented," says Natalie. "South Asian patients presented in more general rather than specific terms, which led to problems in interpreting symptoms. Staff also highlighted cultural factors as influencing whether patients were given lifestyle advice about how they could improve their health."
The Trusts responded with a variety of measures, showing how they are implementing their strategic commitment to tackling race inequalities in the local area on a practical level. A series of posters and leaflets offering patient information were produced in a variety of languages and distributed to GP surgeries, community centres and local groups. Awareness days for the Asian community were held, attracting hundreds of people. Visitors had the chance to test their blood pressure and blood sugar levels and get advice on diet, smoking and exercise. The idea of peer education was central. It was felt that people from the same communities as those the Trusts were trying to reach were in the strongest position to educate people about risk factors.
Mohammed, now part of the Trusts' mainstream Smoking Cessation Service, has worked individually with 200 clients over the past two years. Originally from Bangladesh, he agrees that it is his links with the community that have helped him make a success of the role - though he admits that even he initially faced barriers. "For this to work there needs to be trust," he says. "Though people knew me, they had a lot of misconceptions. A lot of people were afraid that if they agreed to see me but didn't manage to stop smoking that their hospital treatment would be affected. So I had to make a strong case to people even before I started advising them. But now it works both ways. Now people come to me."