Journal of Public Health Advance Access published online on August 2, 2007
Journal of Public Health, doi:10.1093/pubmed/fdm044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Impact of a cardiovascular risk control project for South Asians (Khush Dil) on motivation, behaviour, obesity, blood pressure and lipids
Gill Mathews, Khush Dil Project Co-ordinator (2002–2006)1
Jill Alexander, Khush Dil Dietetic and Food Advisor1
Taslin Rahemtulla, Research Associate2
Raj Bhopal, Professor of Public Health and Honorary Consultant in Public Health2,
1 Khush Dil Project, Lothian Health Board, Edinburgh, UK
2 Public Health Sciences, Division of Community Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK
Address Correspondence to Raj Bhopal, E-mail: raj.bhopal{at}ed.ac.uk
Background Khush Dil was set up in Edinburgh in 2002 to manage cardiovascular risk factors in South Asians. We assessed its impact in an in-service evaluation.
Methods Between June 2002 and July 2004, 304 South Asians attended health visitor led screening clinics. Measurements included self-report, anthropometry, blood pressure and blood tests. A total 140 subjects attended follow-up screening (henceforth returnees). The outcomes relate to them.
Results In most respects, including ethnicity, family history, medical history and motivational stage, returnees were similar to the non-returnees, but were a little older and were more likely to be women. Between baseline and return visits, returnees reported an increased motivational status (those in the action stage of change increased from 12 to 28%) and increased physical activity (e.g. 45% of women reported improvement at follow-up). Returnees had reduced their risk factor profiles at follow-up in a range of risk factors, e.g. reduction in cholesterol (0.19 mmol/l; 95% CL, 0.1–0.37), in diastolic and systolic blood pressures (3.15 and 3.7 mmHg, respectively) and in weight (0.61 kg; 95% CL, 0.22–1.02).
Conclusions The Khush Dil Project had an impact as indicated by self-report, physical measures and laboratory tests. Such initiatives now need evaluation for cost-effectiveness. Cluster randomized controlled trials warrant consideration.
Keywords: coronary heart disease, diabetes, health promotion, prevention, South Asians
 |
Introduction |
|---|
 TOP Introduction MethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
In the UK there is a high rate of cardiovascular disease among South Asians (i.e. people who have ancestral origins in the Indian Subcontinent; and in the UK and Edinburgh most are Indian, Pakistani or Bangladeshi).1 Compared with the rest of the population, for example, mortality rates in Indian subcontinent born populations living in England and Wales are about 50–60% higher than the standard population, and the incidence of acute myocardial infarction (MI) in South Asians living in Scotland is 60–70% higher.1,2 Developing primary care programmes to identify and manage cardiovascular risk in high-risk populations should, arguably, be a part of strategies to reduce coronary heart disease (CHD).3
The high rate of cardiovascular disease among South Asians1,4 has been studied in relation to a wide range of risk factors,1 including smoking,5 diabetes,6 obesity,6 lack of exercise,7 poor diet,8 lower socio-economic status9 and inequalities in health care.10 As these factors have a complex effect, initiatives aimed at changing the health behaviour of ‘at risk’ populations need to target multiple risk factors in an efficient and culturally sensitive manner.1,6 South Asian minority groups need a range of public health interventions, including screening and health promotion activities, aimed at increasing health awareness and reducing risk of cardiovascular disease,11,12 without increasing health inequalities.
One of several UK-based exemplar initiatives13 is Project Dil,12 which was set up in 1998 in Leicester to reduce CHD in South Asians. Project Dil implemented activities to raise awareness of health in the community and trained 22 primary health care teams that operated within general practitioners' (GPs') practices12. (Other similar projects13 are considered in the discussion.) Project Dil has published information on health knowledge of participants and processes of this project. In autumn 2006, we searched several major scientific literature databases, but found no published data on health outcomes in relation to projects of this kind, although information on procedures, processes and approaches has been published.
Khush Dil (meaning, happy heart) was set up in 2002 on a 1-year health service innovations grant of about £50 000 to develop and test methods for a locally based, culturally sensitive, CHD prevention and control service for South Asians. Details about the processes have been published elsewhere.13,14 Tackling CHD would also tackle other cardiovascular diseases, diabetes and some cancers, because of the shared risk factors.
To evaluate the impact of Khush Dil interventions quantitatively, and to complement the project's consultation procedures and formal qualitative research, the health status of clinic attenders during a follow up visit was compared with their health status as recorded at the initial consultations (hereafter, baseline). This paper focuses on the data on the 140 people examined at baseline and follow-up (returnees). The time span between visits averaged 6–12 months.
|
Methods |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
Target population, background and scope of project, and attenders
The 2001 census identified 55 007 people of South Asian origin living in Scotland (1.1% of the population), with 8150 living in Edinburgh (1.8% of the population).15 About 50% of South Asians in Scotland in 2001 were born on the Indian subcontinent, with the proportion being larger in the older age groups. We did not collect birthplace data in this project, but the general picture for Scotland applies in Edinburgh.
The specified focus of Khush Dil on CHD was to align the project with local health service funding priorities, which emphasized the need to reduce the burden of this disease, but the project tackled cardiovascular risk factors. Khush Dil started in May 2002 with a remit to address healthcare inequalities in respect of CHD in South Asians living within North-East Edinburgh. The project was set up in response to needs identified by local people and as a focused response to national and local health policy objectives including chronic disease management, promotion of minority ethnic health, cross sectoral partnerships and public participation.
Consultation with the local community, and with leaders of similar other projects in the UK, underpinned the approaches taken. A key objective was to identify people with CHD risk factors (including diabetes) for primary prevention and those with established CHD for secondary prevention and then to offer culturally appropriate information and practical support. Community development principles underpinned project planning and delivery. These included multi-disciplinary, cross-sector partnerships and public participation; liaison with the voluntary sector including training of health workers and employment of South Asian community workers as part of the team. Khush Dil included the following service elements:
- Health visitor-led screening to identify and address coronary risk factors.
- Dietetic clinics to provide one-to-one nutritional support.
Box 1 Activities offered via Khush Dil
|
In response to a widely publicized open invitation, 304 South Asians were screened between June 2002 and July 2004, the period of maximum activity of the project. Clinic attendees came for cardiac risk assessment through self-referral, and referral by voluntary organisations, GPs and other health workers. There were no exclusions, i.e. people with (for secondary/tertiary prevention) and without (for primary prevention) pre-existing diseases were included. Although they were not the primary target, where parents were concerned about their children (usually about obesity), young people were also seen. Appendix gives some data on these 304 people. They identified themselves as Bangladeshi (n = 65, 21%), Indian (n = 71, 23%), Pakistani (n = 146, 48%) or other South Asian (n = 22) during the initial consultation. Two-thirds were women. The age of all participants ranged from 13 to 81 years, with the mean age being 44 years.
Clinic screening
Health visitor led screening clinics were run from the project base, worksites and various community venues including local religious buildings, with interpretation and translation supplied via the local council service or South Asian Health Workers. Protocols for the management of hypertension, blood glucose and lipids were based on existing guidelines, e.g. those prepared by Lothian Health Board, SIGN (Scottish Intercollegiate Guidelines Network) and British Hypertension Society, and adapted for the project in collaboration with a local GP. A protocol for referral of clients to the dietetic service was agreed. Training was provided to project staff by a cardiac rehabilitation nurse and the project leader (GM). One-to-one interviews included the CALM heart questions (see below), a validated coronary risk assessment software package based on European Society of Cardiology and Joint British Societies' recommendations and suitable for both primary and secondary health prevention work.16
Participants attended a 30-minute initial screening appointment, including blood tests and the measurements described below, followed by a further 30-minute consultation, usually taking place 1–2 weeks later, to discuss blood tests (see below), individual health profiles and goal setting. This comprised the baseline visit. Those people who were set goals were invited for a follow-up visit, usually 
6 months later. All 140 people who we focus on in this paper participated in both consultations, i.e. baseline and follow-up. Participants were provided with a coloured print-out of their heart health profile produced using CALM heart, identifying CHD risk factors and denoting levels of risk in bar chart form. The risk predictions used were based on the Joint British Society guidelines, which use the Framingham equation, as this works better for South Asians than SCORE.17 The risk was doubled to take into account the fact that this risk prediction model underestimates the outcome in South Asian populations.1,17 The doubling fits with the 70% excess of MI incidence and 100–200% excesses of stroke mortality in South Asians.2,18 At the time of this work, there were no recalibrated risk prediction models for South Asians in the UK.
The following cut-offs for risk factors were used: blood pressure 
140/85 mmHg; cholesterol 5.2 mmol/l; fasting glucose 6.1 mmol/l. No glucose data are given in this paper because samples were not always fasting (see below).
In addition, the CALM package compiled a collective CHD risk rating [0–100] for each person. Accordingly, individuals fell within one of three groupings: low [0–20], moderate [21–50] and high risk [51–100] ratings. This helped promote understanding of CHD risk and created a focus on motivational interviewing and goal setting.
Information was offered on the Khush Dil community activity programme where appropriate and a copy of blood tests with a brief note on the clinic intervention was sent with the participants' informed consent to the GP. Referral to a GP was made when appropriate, for example, for a new diagnosis of diabetes. Minor medical queries were directed to a doctor who offered the project support on a consultation basis. Follow-up appointments were planned 6–12 months later, the interval being dependent on the availability of clinic times and suitability for the participants.
Questionnaire
Questionnaires were given and measurements were taken by one of the Khush Dil team. At baseline, participants completed a questionnaire that included the CALM heart questions,16 which included medical history, health behaviours and motivational stage in relation to CHD and diabetes control. (The questionnaire is available on request from the authors on request and has been lodged with the Journal.) Most of the questions were simple and straightforward. For example, the stress question was ‘how often do you experience stress or anxiety?’, with five options of never, sometimes, often, most of the time and all of the time. Amendments to the questionnaire to increase its face validity for use in South Asians were made, e.g. by including examples of food items relevant to South Asian populations within questions on eating habits. For moderate exercise, in short, we meant physical activity that makes one out of breath but not sweaty. The questionnaire was in English. Translations of the questionnaires using methods for cross-cultural validity19 were not made because such a task, though desirable, was outwith the resources at the project's command. Participants were given the option of being interviewed in their chosen South Asian language. These interviews were conducted by either the attached project community health workers or by trained interpreters. In all cases, interviewers were trained in relation to the Khush Dil questionnaire.
Attendees' stage of change was assessed in relation to their motivation to address lifestyle behaviours, using working definitions derived from the literature on the Transtheoretical Model, a stage model for motivational and behavioural change.20 According to this model, change is a process that involves five stages: pre-contemplation, contemplation, preparation, action and maintenance. Motivation has been identified as important in making lifestyle changes, such as stopping smoking and increasing activity levels.20,21
Anthropometric measurements
Height was measured without shoes to the nearest 0.5 cm using the Leicester height measure. Weight was measured with heavy clothing and shoes removed on portable scales to the nearest 100 g. BMI was calculated as weight (in kg) divided by height (in m2). Waist circumference was estimated at the mid-point of the lowest rib and the iliac crest, using a standard tape measure with the client standing. Equipment was standardized, calibrated and used exclusively by the project staff who were trained in measurement methods.
Clinical measurements
Systolic and diastolic blood pressures were, routinely, measured once per visit in the sitting position after a minimum of 10 min rest. If blood pressure was outwith the normal range (140/85 mmHg), a repeat measure was taken. Repeat measures were also taken at the follow-up visit 1 or 2 weeks later or, alternatively, the person would be referred to their own general practice.
A random (i.e. no time was specified) venous blood sample was taken to assess cholesterol profiles and glucose levels. If glucose was outwith the normal range (>6.1 mmol/l), participants were asked to return fasting for a repeat measure. Full blood count, urea, creatinine, electrolytes and liver and thyroid function tests were done. Both at the baseline and at follow-up, samples were analysed at the Clinical Biochemistry and Haematology Laboratory at the Western General Hospital in Edinburgh.
Follow-up
The same health screening was repeated at follow-up, but blood investigations were limited to glucose and cholesterol profiles, once again taking venous blood (no time was specified). There was no formal data collected on CHD outcomes, as the number of events was expected to be very small. Project workers learned of one death and two heart attacks over the follow-up period.
Analysis of data
The data were coded, entered onto a computer and checked twice for data entry errors. They were analysed using SPSS/PC version 12. Wilcoxon signed ranks test, Chi-square and t-tests were carried out as appropriate. Results are presented using mean values and, when appropriate, 95% CI, calculated using Confidence Interval Analysis version 2.0.
Ethics
Informed written consent for the collection of data was obtained from all participants. Information was collected as an integral part of the clinical service. Data were anonymized by the service providers prior to analysis, by the researchers at Edinburgh University (T.R. and S.R., with R.B.—see ‘Contributorship’). As this was an in-service evaluation, the local research ethics committee was not involved.
|
Results |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
Population characteristics
Of the 304 South Asians who attended the initial screening, 140 returned for follow-up within the period of analysis. We have no follow-up data on the 164 people who did not return, but returnees can be compared with non-returnees (Table 1) and the total group at baseline (Appendix). There were significantly more women among returnees compared with non-returnees. Compared with non-returnees, the mean age was slightly higher in the returnees (borderline statistical significance) and a higher percentage of returnees reported having hypertension (borderline statistical significance). Attendees in both groups were similar in ethnicity, family history, past history of cardiovascular problems and/or diabetes, obesity and medication use. (Only three people had had a stroke so these data are omitted from Table 1, since a comparison between returnees and non-returnees is not valuable.) There was no statistically significant difference between these groups in motivational stage at baseline (in the group that was not followed up, data are missing on 40 people because these data were sometimes collected at the second of the two baseline interviews).
|
Motivational change
Of the 137 returnees with data at baseline and follow-up, 69 (50.4%) reported an increase in their motivational stage, 29 (21.2%) reported a decrease and 39 (28.5%) reported no change in their motivational stage. Table 2 shows that at the follow-up fewer participants were in the early stages (pre-contemplation and preparation) of the model and more in the later stages (action and maintenance) (Wilcoxon signed ranks test, z = –4.81, P = 0.001).
|
CHD health-related behaviours
Table 3 shows that South Asian women self-reported a decrease in their intake of salt, in the consumption of fried foods and stress at follow-up. Most South Asian females reported initially that they did not smoke cigarettes and/or pipes. Little change was seen and the few women who reported this behaviour at follow-up may not have admitted to it at baseline. The same applies to alcohol. There was an increase in moderate exercise levels (such as brisk walking, cycling or swimming). In addition, we collected data on cooking oil use at follow-up but not baseline, and found that 77.9% women reported reducing the amount of oil they used in cooking and 57.7% reported healthier cooking methods such as baking, grilling and steaming. Table 3 also shows similar findings in men (with the exception of smoking cessation, which shows more improvement than with the South Asian women).
|
Anthropometric assessment, blood pressure and biochemistry
Table 4 shows significant reductions in weight, BMI, systolic blood pressure, diastolic blood pressure, total cholesterol, LDL and triglycerides in the follow-up sample.
|
Collective score
For men, the mean collective risk factor score significantly decreased from 28.22 at the initial screening to 18.14 at follow-up (paired samples t-test, t = 6.549, df = 35, P < 0.0005). Similarly, for women, the collective risk factor score significantly decreased from 27.68 to 20.88 (paired samples t-test, t = 7.073, df = 103, P < 0.0005).
|
Discussion |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
Main finding of this study
The Khush Dil intervention led to a reduction in cardiovascular risk factors in South Asians. In addition, participants reported a shift in their motivational status, increasing the likelihood that diet and lifestyle changes are maintained.20,21,22
What is known already?
As noted in the Introduction section, several community health projects have developed processes for controlling cardiovascular risk factors in South Asians, but quantitative outcomes have not been recorded.
Limitations and strengths of the evaluation
We acknowledge potential limitations with this work, alongside its strengths. The strength of the work is that it provides scarce, and possibly unique,13 data on the potential effects of a community-based approach to control cardiovascular risk factors in South Asians. To our knowledge, no other motivational stage or biochemical data are available following this kind of intervention for comparison. Our literature review in autumn 2006 failed to uncover any other reports providing comparable data from cardiovascular risk factor prevention projects on South Asians. In contrast, a considerable amount has been published on processes, which is important to help others set up projects and understand the components of them that might work.12,13,23–25 Indeed, Khush Dil benefited from such reports and consultations with colleagues at the implementation stage.
The scientific weakness of this work is that it is a pragmatic in-service evaluation of a service development, and neither a randomized controlled trial, nor a research project. Other than the impact of Khush Dil, however, it is difficult to explain the changes in the follow-up group, at least in relation to biochemical and physical measures that are not easy to change and that, unlike self-reported information, cannot be explained largely or wholly by reporting/information bias. Regression to the mean is unlikely to be the explanation, because participants were not selected on either low or high initial values (a prerequisite for the phenomenon). This pragmatic approach to evaluation, however, is also a strength, because the findings reflect the reality confronting the staff and users who are developing services of the kind described. The project and evaluation has been done at extremely low cost, with sums that local health authorities can make available for service innovations, i.e. approximately £50 000 per year. In contrast, research costs of a formal scientific evaluation would likely exceed these sums.
The follow-up group provides the primary source of data to support our conclusions. We have no follow-up information on those who came only to the initial consultations. Some of these people were advised that they did not need to return because of their very low cardiovascular risk, others chose not to return (unfortunately, data on the numbers in each category were not collected). In the service context, there is no obligation or requirement for people to return. It is their prerogative to attend only for baseline measurements. Anecdotally, many people were satisfied with the information and advice they received at the initial consultation and did not perceive a need to return. Qualitative research shows the project was highly valued26 so non-return is likely to be for personal reasons rather than faults in the service. In this evaluation, we learned that men were less likely both to attend and to return. That insight has led to more outreach work in the workplace, mosques and temples to reach more men, who are probably deterred from attending clinics because of their working hours. This insight is likely to be generalizable to other geographical areas.
The follow-up period does not permit us to examine whether the impact of the Khush Dil project is long-lasting, or impacts on disease outcomes, although the latter is virtually certain as risk factor–outcome relations are well understood. As with all questionnaires, there are problems with the cross-cultural validity, reliability and the social desirability of responses.27 Questionnaires depend upon accurate recall, a perennial problem to which there is no easy solution. One approach is to see whether different kinds of data lead to the same kind of conclusion. The self-report findings demonstrating beneficial change, although potentially explicable as reporting biases, are compatible with the changes in anthropometric and biochemical measurements that are less prone to such biases. The accuracy of some of these measurements could have been strengthened had two nurses taken each measure or one nurse made repeated measures. Unfortunately, in common with most NHS-funded service activity, and probably services throughout much of the world, this was beyond the resources of the project and only one person, the one on duty, made the measure. This reflects normal health service practice. Systematic bias resulting from observer error is unlikely to explain the beneficial effects in view of the commonality of the findings across the domains of self-reported data, physical measures and laboratory measures. Unlike research projects that select study subjects purposively, sometimes leading to severe selection biases, our participants reflect those who normally will come to, and return to, services. The biases in this selection process reflect the real world rather than the inclusion/exclusion criteria imposed by researchers. The results reflect the experiences that others developing similar services will encounter.
What the study adds
The findings from Project Dil in Leicester and similar projects13,23–25 of successful processes, and the evidence of benefits in risk factor profiles shown in the Khush Dil project here, combine to provide the impetus to develop similar initiatives more widely. The structures and processes adopted by the Khush Dil project14 were partly modelled on Project Dil,12 and other relevant projects,23–25 and these have been described elsewhere. We have focused on intermediate outcomes in this paper. Similar data from equivalent interventions have not been published; so direct comparisons are not possible.
Future initiatives might adopt the key features of these programmes,13 namely, a targeted community approach that is grounded in a practical understanding of the high-risk group, and one that is culturally sensitive, flexible and accessible (run from a familiar environment) and which fosters good relationships with the at-risk community. As the strategy targets multiple risk factors, it is likely to impact on a wide range of chronic diseases and not just CHD, stroke and diabetes. Long-term success of such programmes will inevitably depend on an adequate resource base, including a skilled and dedicated staff team supported by a strong commitment at senior management level. Randomized, controlled trials are likely to be expensive and difficult for multifaceted complex community interventions such as Khush Dil, but need consideration. If such service programmes are to be implemented nationally, and internationally, on a larger scale, we recommend more evaluations to provide rigorous data on effectiveness and cost-effectiveness. The collective experience13 justifies further action, both research and service.
|
Funding |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
NHS Lothian, LPCT Primary Care Development Fund, and Local Health Plan funded Khush Dil. Research staff supported through Professor Bhopal's funds.
|
Conflict of interests |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
G.M. was involved in the initiation of Khush Dil and R.B. acted as an advisor throughout. J.A. is a member of Khush Dil Project staff. T.R., who led in the analysis of data and early drafts of the paper, has no conflict of interest.
|
Contributorship |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
All four co-authors have conceptualized and drafted this paper, with the final version being prepared by R.B. T.R. analysed the data and wrote the early drafts in collaboration with other authors. All co-authors made intellectual contributions to the paper. Snorri Rafnsson checked analyses and undertook additional data analysis. Colin Fischbacher was intimately involved with the data collection components of the project. Rafnsson and Fischbacher's contributions did not meet the criteria for authorship.
|
Appendix |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
Table A Sex, age, ethnicity and medical history of the overall population. Values are numbers (column percentages) unless stated otherwise
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The BMI cut-offs follow the World Health Organisation International Standard for Body Mass Index28 despite the acknowledgment that Asian populations may require a lower BMI as a cut-off for being overweight.29 In addition, in the light of recent research BMI may not be as good as other methods at estimating obesity and therefore the risk of cardiovascular problems.30
|
Acknowledgements |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
We thank Anita Bhatnagar for liaising between the community and project staff; Fulmaya Lama, Neena Agrawal, Shamsad Rahim, Madhu Sharma, Naz Waheed, Trishna Singh, Dalbir Kaur, Rohina Hussein, John Singh, Gurcharn Singh, Ragbir Singh and Wege Singh for developing community links; Dr Sushmita Wiebe for assistance at the early stages of project planning; Dr Duncan McCormick, and Graham Barnes for project planning, monitoring and evaluation; Dr Colin Fischbacher for assistance with the compilation of questionnaires, data entry spreadsheets and advice regarding data analysis; Dr Niall Anderson for his invaluable support and advice regarding the statistical analysis; Snorri Rafnsson for additional data analysis; Jim Forest for managerial support; Lesley Baxter for her marketing support; Dr Peter Ashby for blood sampling and testing; Irene Young for help with training; Dr Azhar Farooqi, Seroj Shah and Kripal Marwa for consultation on implementing similar projects and the University of Edinburgh for infrastructure support. We thank journal editors and referees for their painstaking reviews.
|
References |
|---|
|
TOPIntroductionMethodsResultsDiscussionFundingConflict of interestsContributorshipAppendixAcknowledgementsReferences |
|---|
- Bhopal RS. Coronary Heart Disease in South Asians: the scale of the problem and the challenge. In: The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences—Patel KCR, Bhopal RS, eds. (2004) Birmingham: South Asian Health Foundation. 1–18. http://www.sahf.org.uk/monograph_2004_march_26.pdf (6 June 2007, date last accessed).
- Fischbacher CM, Bhopal R, Povey C, Steiner M, Chalmers J, Mueller G, Jamieson J, Knowles D. Record linked retrospective cohort study of 4.6 million people exploring ethnic variations in disease: myocardial infarction in South Asians. BMC Public Health (2007) 7:142. http://highwire.stanford.edu/cgi/medline/pmid; 17615055.[CrossRef][Medline]
- Pater C. The current status of primary prevention in coronary heart disease. Curr Control Trials Cardiovasc Med (2001) 2:24–37.[CrossRef][ISI][Medline]
- Petersen S, Peto V, Raynor M. Coronary Heart Disease Statistics (2004) London: British Heart Foundation.
- Zaidi Q. Smoking and smoking cessation in South Asian communities. In: The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences—Patel KCR, Bhopal RS, eds. (2004) Bir DsPH mingham: South Asian Health Foundation. 118–25. http://www.sahf.org.uk/monograph_2004_march_26.pdf (6 June 2007, date last accessed).
- Kooner J, Chambers JC. Conceptualising the causes of coronary heart disease in South Asians. In: The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences—Patel KCR, Bhopal RS, eds. (2004) Birmingham: South Asian Health Foundation. 19–47. http://www.sahf.org.uk/monograph_2004_march_26.pdf (6 June 2007, date last accessed).
- White M. Physical activity among South Asians in Britain. In: The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences—Patel KCR, Bhopal RS, eds. (2004) Birmingham: South Asian Health Foundation. 126–34. http://www.sahf.org.uk/monograph_2004_march_26.pdf (6 June 2007, date last accessed).
- Sanders TAB. Nutrition and coronary heart diseases in South Asian communities. In: The Epidemic of Coronary Heart Disease in South Asian Populations: Causes and Consequences—Patel KCR, Bhopal RS, eds. (2004) Birmingham: South Asian Health Foundation. 100–7. http://www.sahf.org.uk/monograph_2004_march_26.pdf (6 June 2007, date last accessed).
- Bhopal RS, Hayes L, White M, Unwin N, Harland J, Ayis S, et al. Ethnic and socio-economic inequalities in coronary heart disease, diabetes and risk factors in Europeans and South Asians. In: Journal of Public Health Medicine (2002) 24:95–105.
[Abstract/Free Full Text] - Feder G, Crook AM, Magee P, et al. Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography. BMJ (2002) 324:511–6.
[Abstract/Free Full Text] - Luscombe C, McCarry M, Malik I, et al. Ethnic differences in public health awareness, health perceptions and physical exercise: implications for heart disease prevention. Ethn Health (1996) 1:47–53.[Medline]
- Farooqi A, Bhavsar M. Project Dil: a co-ordinated primary care and community health promotion programme for reducing risk factors amongst the South Asian community in Leicester. (2000) Leicester.
- British Heart Foundation, NHS. Heart Disease and South Asians—Delivering the National Service Framework for Coronary Heart Disease (2004) London: Department of Health Publications.
- Mathews G. Mobilising communities: the Khush Dil experience. In: Prevention, Treatment and Rehabilitation of Cardiovascular Disease in South Asians—Patel KCR, Shah AJ, eds. (2005) London: TSO. 83–95. http://www.sahf.org.uk/Full_text_version.pdf (23 July 2007, date last accessed).
- Analysis of Ethnicity in the 2001 Census. (2004) Edinburgh: Scottish Executive.
- CALM Corporation Ltd. http://www.pdms.com/clients/casestudies/calm.dpdf (19 August 2005, date last accessed).
- Bhopal R, Fischbacher C, Vartiainen E, et al. Predicted and observed cardiovascular disease in South Asians: application of FINRISK, Framingham and SCORE models to Newcastle Heart Project data. J Public Health (2005) 27:93–100.[CrossRef]
- Bhopal R, Rahemtulla T, Sheikh A. Persistent high stroke mortality in Bangladeshi populations. BMJ (2005) 331:1096–7. http://www.bmj.com/cgi/content/full/331/7525/1096?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Rahemtulla&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT (6 June 2007, date last accessed).
[Free Full Text] - Hanna L, Hunt S, Bhopal RS. Cross-cultural adaptation of a tobacco questionnaire for Punjabi, Cantonese, Urdu and Sylheti speakers: qualitative research for better clinical practice, cessation services and research. J Epidemiol Commun Health (2006) 60:1034–9.
[Abstract/Free Full Text] - Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. J Consult Clin Psychol (1983) 51:390–5.[CrossRef][ISI][Medline]
- Velicer WF, Prochaska JO, Fava JL, et al. Smoking cessation and stress management: applications of the transtheoretical model of behaviour change. Homeostasis (1998) 38:216–33.
- World Health Organisation. Body mass index. http://www.euro.who.int/nutrition/20030507_1 (7 November 2005, date last accessed).
- World Health Organisation Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet (2004) 363:157–63.[CrossRef][ISI][Medline]
- Yusuf S, Hawken S, Ôunpuu S, et al. Obesity and the risk of myocardial infarction in 27 000 participants from 52 countries: a case-control study. Lancet (2005) 366:1640–9.[CrossRef][ISI][Medline]
- Orwin R. Health promotion for Asian patients with CHD. Prof Nurse (1996) 12:170–2.[Medline]
- Netto G, McCloughan L, Bhatnagar A. Effective heart disease prevention: lessons from a qualitative study of user perspectives in Bangladeshi, Indian and Pakistani communities. Public Health (2007) 121:177–86.[CrossRef][ISI][Medline]
- Hunt S, Bhopal R. Self reports in research with non-English speakers. BMJ (2003) 327:352–3.
[Free Full Text] - Fritz T, Wandell P, Aberg H, et al. Walking for exercise—does three times per week influence risk factors in type 2 diabetes? Diabetes Res Clin Pract (2006) 71:21–7.[CrossRef][ISI][Medline]
- Akhtar S, Feather C. Summerscales N. Interventions to improve heart health in the Asian community. Community Nurse (2001) 13–4.
- Shah S. Preventing coronary heart disease among people of Asian origin. Health Visit (1997) 70:77–9.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||