Aamnah is a Psychological Therapist for the Clinical Health Psychology Team at Bradford Teaching Hospitals. This is her story about what she’s doing to reduce inequalities within the South Asian community, when it comes to cardiac health.
Bradford District is ranked as the 13th most deprived local authority out of the 317 in England. At 32% Bradford has the second highest proportion of South Asian residents in England.
Heart Disease is particularly high in Bradford compared to the national average, especially among its South Asian residents. It also has the second highest rate of heart attack in Yorkshire and Humber which is linked to high levels of social deprivation, physical inactivity, unhealthy lifestyles and increased risk from other health conditions such as hypertension, stroke etc.
Around 10% of patients (approximately 90-95 annually) are referred to psychology services from Cardiac Rehab, of whom 40% are of South Asian origin, a significant proportion of whom do not speak English fluently. Despite this representation, historically engagement with the service has had some challenges, with only about half of referred South Asian patients attending a first appointment, and interpreter use was limited.
Based in St Luke’s hospital at Bradford Teaching Hospitals NHS Foundation Trust (BTHFT), together with her team, Aamnah has been involved in a project to address this issue by removing barriers and culturally adapting their clinical psychology service for Urdu and Punjabi speaking South Asian patients.
“Heart attack is a life-changing event, if your heart’s not working, nothing else will. Patients are often in shock, panic, and they’re in emotional turmoil. They are fearful of every little pain or twinge, and there’s a lot of sadness around the fact their life has changed, and they are dependent on others,” said Aamnah. “That’s where psychology comes in because we help people recognise the emotions and types of pains they are experiencing, for their individual situation. Everyone is individual and everyone’s experience is different.”
What action was taken to address this inequality?
Recognising the emotional toll of cardiac conditions, Aamnah and the team wanted to:
- To examine how accessible and appropriate current services are for individuals from a South Asian background by mapping pathways and identify points where a patient may be lost to the service.
- To deliver one to one psychological therapy, (e.g., cognitive behavioural therapy – CBT) in Urdu/Punjabi
- To evaluate the therapy given in the clients first language, using both quantitative and qualitative measures as appropriate
An introductory video was created in Urdu to provide more information about the service. Aamnah, who is fluent in Urdu, also provided therapy to patients without interpreters, resulting in higher engagement and more consistent outcomes.
“A lot of people won’t speak to their family about their health because they don’t want to burden them, so the sessions become their safe space where they can open up and speak about what’s going on for them. The sessions are confidential, and it helps people offload to make sense of their situation. Especially with South Asian men, there is the added layer of shame when it comes to family and hierarchy – often they have a lot of people depending on them, so dealing with the emotions that come with cardiac health is a struggle and it can be isolating.”
“The video in Urdu helped patients in acknowledging the emotions they may have been feeling are normal. Education and information in a person’s first language does help.”
Aamnah continued: “I think it’s important, where possible to work therapeutically in the patients first language as having a shared language not only eliminates a barrier to access but also enhances the therapeutic relationship. I’ve been surprised at the positive comments from service users about how they have benefitted and were able to articulate their thoughts and feelings in their own language without having to rely on others.”
“Mental health is a very sensitive area, so I had some apprehension around working with people who lived in the same community as myself but the importance of boundaries and remaining professional have helped.”
What is the impact of this action?
Because of the action Aamnah and her team took to address inequalities in the service, patients are reporting improved coping strategies, increased confidence, and better emotional wellbeing. The evaluation highlights progress in returning to work, reconnecting with family, and managing stress.
“The evaluation shows that for the people who had a therapy session with an interpreter, the average number of sessions they attended was two. Those who had sessions in their first language, increased to 5.5 attendance.
Key findings from the evaluation show:
- Having a therapist who has a shared language/background can help some people feel understood and in turn, improves engagement (e.g., increased attendance)
- Community outreach is needed to engage different populations, provide culturally sensitive information to reduce stigma and cultural concerns about seeking support
- Appointing therapists who can speak community languages can save on interpreting costs
- Patient-Reported Outcome Measures (PROMS) need to be adaptable/relevant for specific populations
“When you are a professional from the same culture, with the same language you can understand where a person is coming from. Sometimes within cultures, it’s the things that are not said that you can pick up. With me, you wouldn’t have to explain why your culture does things differently, they know I understand and it helps people feel comfortable and takes away the need to explain. I have an idea of some of the underlying cultural and familial issues that are going on for that patient.”
Patients using the adapted service have fed back how they appreciated being heard without judgment and noted the importance of shared language and cultural understanding in building trust:
- “I hope there are more therapists trained in the complex nature of Pakistani families, so they are not judgemental…”
- “Speaking Urdu/Punjabi, I can say how it is. At first time when I saw her, I was very nervous because I though how am I going to open up to her because she was Asian and I didn’t feel comfortable.”
Aamnah’s work has been recognised by the British Association of Behavioural Cognitive Therapists, and she was asked by them to share her learning at their European congress event. Her poster was selected for the inequalities and diversity stream. She hopes that people can replicate the approach and integrate it into other services.
View more inequalities stories below or on our Reducing Inequalities Alliance webpage. To write a blog about inequalities work you’re involved in, please email ria@bradford.nhs.uk
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