The Movement Prescription

Health for All: Empowering All Patients

• Konijn Podcasts • Season 1 • Episode 16

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Suzy, Lubna, and Dimple discuss the importance of integrating movement into diverse communities to empower patients from ethnic minority backgrounds. Lubna, a clinical specialist pharmacist, stresses a holistic approach in cardiovascular clinics, addressing lifestyle factors beyond diabetes control. Dimple, a GP, underlines the value of creative health promotion through lifestyle medicine pillars. The conversation focuses on cultural sensitivity in healthcare, offering tailored interventions and inclusive community activities to overcome barriers and promote physical activity effectively. Speakers also emphasize the role of language nuances and building trust with patients to improve health outcomes and well-being.

Produced using funding from NHS Tayside Educational Fund and the British Society of Lifestyle Medicine.

Find us at https://themovementprescription.co.uk/

Suzy:

So hello and welcome to the Movement Prescription podcast, the home of conversations designed to inspire more active conversations in primary care. My name is Susie Scarlett, I'm a GP in Edinburgh and I'll be your host for this episode. We're calling this Movement for All. I love talking to people about integrating movement daily lives, it's one of my favourite topics, but often I feel there are groups that I don't do this so well for, perhaps those with cultural differences, especially if there's the addition of the language barriers. So I was thinking, how can I do this better? And what better way than to introduce you to two of my favourite colleagues to help me understand how I can engage and empower my patients, especially from ethnic minority communities, into more joyful movement. Welcome today, Lubna Kerr, a clinical pharmacist and comedian, and my friend Dimple Devadas, a GP with more qualifications than I can pot account count on one hand um and I'd love to bring you both into the conversation at this point hi ladies hi.

Lubna:

Susie how are you.

Suzy:

So I'm going to start with you there Lubna um Lubna you came uh region and uh came we we met at a um a diabetes conference so um love your background once I started to learn more about you and had a conversation with you about your your cardiovascular clinic that's has been running for decades. You've actually been brilliant and come and met my practice and tell us a bit more about the work that you've been doing.

Lubna:

Yes I'm a clinical specialist pharmacist in diabetes. I've been doing that since last century and my focus is on treating people who have high blood pressure and high cholesterol with a special interest in those who come from an ethnic minority background. But as you alluded to in your introduction I also retrained many years ago, to be an actress, writer and comedian. So I have that dual life, shall we say, which I love. I think it brings the yin and yang into everything I do. So my clinics, I run cardiovascular clinics and there's a real, we know that from data, from science, from evidence, the people who have diabetes will go on to get high blood pressure and high cholesterol. And very much in the diabetes clinics, they really do focus on HbA1c, which is the diabetes control, and not enough on HbA1c. Cholesterol the lipids and um and just managing their way and looking lifestyle issues and i have a general interest in in prevention so how can we prevent patients getting worse but also how can we prevent them developing diabetes in the first place and.

Suzy:

I'll come back to you in a minute to tell tell us a bit more about some of the incredible projects that you you have been using perhaps some of the challenges that you faced during those um but dimple um i I would love you to introduce yourself to us a little bit more too.

Dimple:

Sure. So Susie, I'm a GP. I'm also a lifestyle medicine physician. I have an interest in obesity. I am also a behavioural health coach and also a fitness trainer and educator. And And I do a lot of community activities, not just in the UK, but globally. And my passion is to inspire and get people excited and inspired about improving their health through the different pillars of lifestyle medicine. And there's a huge emphasis also on creative health as well. So I do a lot of activities and festivals and I'm doing lots of festivals this year as well in London and the theme is physical activity so I'm excited yeah to be on this podcast to share some of my insights and experiences working with different communities.

Suzy:

And actually Dimple it's your fault that I keep on running these photography photography competitions at work you introduced me to the idea after your 2012 was it the olympic games where you did the photography projects.

Dimple:

Yes i.

Suzy:

Can still see the photograph of your gentleman with type 2 diabetes who did you photograph a set of um escalator steps and call it taking the first step.

Dimple:

Yeah that's right yeah i was a doctor in the medical team for london 2012 olympic and Paralympic Games and then I was also part of a legacy project in the area so I carried out a project with people with type 2 diabetes and brought in photography as well to inspire people to capture their goals and get them moving and inspired to move and take part in activity, So, yeah, that was a brilliant project, brilliant project. We've got some great photographs and the patients really, really... Took to the creative element of it as well so they actually loved that part of it so we got some really good photographs and the patients had a good experience and more importantly we got people doing activity which was meaningful and I think that's kind of an important part of it to, listen to people's constraints what their challenges and do what's meaningful for them And it may not be going to the gym or organized exercise activity, but whether it's, you know, encouraging just functional activities in the house, do it trying to sort of do part journeys or doing things with their family or maybe reengaging with a hobby that they used to take part in before.

Suzy:

Absolutely. Yeah, I absolutely hear those things. Well, I think one of the things that I worry about most, and I don't know if Lubna, you could maybe comment on this, is how to engage, is particularly the mother-in-law. That is the character that I think of as the hardest nut to crack. When I have perhaps some of my South Asian families that come in and the mother-in-law comes in with her diabetes or hypertension. And in my mind, I'm thinking, right, I need to manage the whole picture here, but I don't even know how to begin. How do I approach that patient sensitively with cultural awareness without putting my big foot in it?

Lubna:

Yeah, I think this will apply to all mother-in-laws, not just from those from ethnic minorities. No, you're quite right. So many years ago, I did a project looking at how do we engage with ethnic minorities? How do we get them on board? How do we get them to come to the clinics? How How do we get them to understand what diabetes is? How do we get them to exercise? So I did this research project because I had to get ethics approval where I provided my ethnic minority patients with a very culturally appropriate approach to their lifestyle. And I ran cookery classes for them. I ran exercise classes for them. And then the exercise classes were in a sports centre, but also in the sports centre, I offered them the chance of getting massage and Reiki. They could have a head and neck massage, a whole load of reflexology. But when I invited the patient, it wasn't just the patient that came, it was the whole family that came. So the patient might have been the daughter, but the mother came, the granddaughter came. And that was a fantastic way to actually get everybody involved. And so it's about knowing that there's a family approach to reaching them. And in a South Asian family it it's very much the son who looks after the parents, and if the son is married it's the daughter-in-law whose responsibility is to look after the parents, so it's about giving people their place so the mother-in-law will be the matriarch and she will be the head of the family but she might not do the cooking depending on your age you might not do the shopping so what you really need to find out is what is the environment in that family where she lives who looks after her does she look after herself she might be totally fit she might she might do all the cooking it's about trying to find out what the family circumstances are, and um and then knowing who then speak to because you might speak to the mother-in-law and she doesn't do any of the cooking and she doesn't do any of the shopping and she has no control over what she's getting access to. So it's really about finding out the family dynamics. Before you offer any suggestions. There's like an example I would use is like when I was speaking to my Chinese patients, I don't speak any of the Chinese languages, but I do know that cottage cheese is not their favourite thing to eat. So it's about finding out what it is in those patients' lives, And what their approach to life is, to the lifestyle habits, to what do they do in their day that makes everything work for them. And you're right, the mother-in-law is the matriarch. So speaking to her and finding out what her life is about is really, really important. Oh, by the way, and the research project showed that if you gave people culturally appropriate education, guess what? Their diabetes improved their blood pressure improved their cholesterol improved their weight improved and it wasn't I mean it was lifestyle medicine I was doing I didn't know that that's what it was called and this was early 2000s so um so I wasn't really aware of of that term lifestyle medicine but that is exactly what I was doing lifestyle medicine and so so you have to give people what's appropriate to their culture whatever that is.

Suzy:

So it's about seeking to understand isn't it and and and seeking permission to have these these conversations it's i i guess what we we we try to do well in general practice but maybe i just may i'm over complicated and ask a few more key questions i think um what what about dimple what's your thoughts on on that in in terms of pitfalls to avoid and in the individual, because I know we're gonna come onto communities in a minute, but for the individual GPs and in primary care, what's your sort of experience and what community levers can we use to access the individual?

Dimple:

Yeah, so I think it's, you know, I echo what Lubna mentioned there. But I think that it's all about asking the patient what are their constraints, what are their preferences. And I spoke to an auntie who's in her late 70s. She's very famous. She's called Auntie 72. But she's not 72 anymore. She's in her late 70s. And she is a serial marathon runner and she does marathons all over India, all over the world. And she is just an example of what can be achieved, doesn't matter how old you are. And she said to me some of the big challenges. She's she's from India, Asian community. I am and my family are also from India. There can be some issues with family responsibilities and support especially when the children are small but she talks about the four f's and the f factor so she tries to promote family finance food and fitness so she she talks about the f factor so um she um really is just an an example of an amazing role model. And certainly some of the patients in my previous work, in my previous lifestyle health projects, they have been from ethnic minorities. And again, it's about bringing the family in as well. Can they do things with the family rather than just just trying to do it by themselves. And I think there was kind of also mention of maybe women only options. Things like, you know, dancing and going to the gym are not really suitable for everyone. And it doesn't always resonate with everyone. And so I think it's about, you know, So asking the patients what is appropriate, what they've tried. And trying to look at local activities. I did a recent poll, actually, a quick survey of some of the Asian communities I'm in touch with. And interestingly, yeah, a lot of people were doing... The 150 minutes that the CMO advises, but there were some challenges. People weren't doing balance building or strength activities. Some of the general challenges for getting weekly physical activity. A big majority mentioned lack of time, lack of energy, busy work schedule and busy family, social schedule, and lack of motivation to start and form a habit. And some of the things that they said could help would be having perhaps local family-friendly facilities and activities, free or low-cost facilities, and maybe facilities at work and time during work and motivation and safe spaces as well, and options that they could combine with social interaction. So, that was quite interesting. And a good majority said a personal trainer and a health coach could help so um just a small survey but that was quite useful um information.

Suzy:

So that's really interesting because a lot of what you have have almost reproduced there is one of these articles i was reading in preparation for this podcast it's um it was it's a 2019 article in the preventive medicine reports um journal um barriers and facilitators of physical activity amongst adults and older adults in black and minority ethnic groups in the UK and they identified these these six real key themes one of which was awareness of actually the link between physical activity and health and I wonder if yours was quite a self-selecting bunch they they seem to be doing incredibly well because certainly if I if I did a straw poll in the waiting room of my practice I don't think many people are doing the 150 minutes um as you mentioned there yeah.

Dimple:

They they were they were professional they were professional women so uh with some of the communities i work with yeah.

Suzy:

Okay okay but some of the other things that they mentioned there um was you know your cultural expectations those social responsibilities that you mentioned there suitable environments and i think that you know being aware of um you know certain religious and cultural beliefs where it may not be appropriate to to wear a a swimming costume and they may not have the access to the correct kit facilities or private time. Lubna, I think you were involved in some work that was creating some of those suitable environments for people.

Lubna:

Yes, very much so. When I ran the exercise classes, excuse me, Around the exercise classes, we had to make sure that the venue was culturally sensitive. And it was a privately run gym at that point, which had been taken over by Edinburgh Leisure. And the woman in it, the woman who was the receptionist, was absolutely fantastic. There was windows into the gym. She went away and made very specific curtains for those windows so that anybody coming in wouldn't then actually be peering into the gym. And it made the women who were there, the women and the girls that were there, feel very comfortable. Now, it was really interesting because we had access to a huge gym hall where the older women wanted to play badminton. So we had a badminton net set up. The younger women wanted to play basketball. And then the others who weren't playing either of those would go to the gym. So it was actually having that variety for the women available to them so that they could try a wee bit of everything. Thing we also organized um swimming ladies only swimming sessions at victoria baths that they could go to them on a saturday afternoon as well so it's just really trying to tailor it to the needs of the patient and making sure that what we're offering them is what they want as well because sometimes we make assumptions that actually they want they want x or they want y but actually exactly what you've done dimple is ask them ask them what they want what is it that they want to do and a lot of them like going walking especially in the summer you know they'll be they don't want to go to the gym they want to be out and about get some fresh air as we know walking is great for you so i i try and advocate well no i try i advocate now to my patients that you know i believe had a meal weather's getting better 10 15 20 minute walk after their lunch. And their dinner um and trying to get do some intermittent fasting as well but if they're They're having two meals a day trying to get them out after they've had their meals just to try and burn off some of that excess sugar that they might have consumed via their carbohydrate intake. So yeah, I think it's really important to make sure that, And those classes that I ran in the sports centre were for all women, not just ethnic minorities. So any woman of any cultural background could access them. And it was great.

Suzy:

That sounds excellent because, you know, simple messages are actually the most powerful, aren't they? And profound. And whilst it would be great to be able to offer health coaching and personal trainers on a much wider level, it simply isn't realistic or possible with the sort of the constraints of finances as they are at the moment. But that brings me nicely on to some data, I think, Dimple, that you were mentioning just before from Sport London.

Dimple:

Yeah, there's a thank you to Rob McLean who sent me over that London Sport report. And it was really just a highlight that the data shows that some of the heightened impact of the cost of living crisis on specific communities, including those from ethnic community background. So there were some behavioral changes in response to this, which included things like people changing their behavioural activities, so looking to free activities, walking and cycling, reducing car use, and also perhaps stopping cancelling gym membership and perhaps sporting activities as well. But the sort of message really was to look into how organizations can pivot to free activities, expanding free and accessible ways to move for those most affected and those groups so that people can keep active through this sort of various challenging times. But I think that... It has to be possible also to make sure people know about these activities. So whether that's through social prescribing and local, you know, GPs or health professionals knowing where to direct these people and how people find out about these things. So, there's a lot of things, you know, happening around council, certainly in London, certainly when I've been doing talks on physical activity, a lot of free activities. But people are saying things like in the park, you know, there are concerns, things like safety, going into the park, perhaps people doing shifts and not having the time, people with childcare responsibilities. Other constraints like pain and other sort of concerns, confidence. Confidence so there's a lot of challenges and it's just addressing these challenges, with individual patients and really asking them well what what what is it that you enjoy what can we do to help you to give the confidence and connecting them with people in the community whether it's community leaders social prescribers or charities that can help and looking to the the council as well uh to see what the free activities are um and making sure these are sort of accessible and as inclusive as possible.

Suzy:

Because i mean there are all sorts of incredible groups of people doing you know um specific cycle groups to make people feel included um at various levels i know there's a group in glasgow that that have um ethnic minority groups i know that there is also a real drive to try and help people who maybe don't feel that the mountains are for them too i don't know if either of you know the name of that that group that's really encouraging people from all backgrounds up into the hills and you know it's like mind over mountains but but for, increasing um the pool of people who feel that that is for them and and i think role modeling is so important as you mentioned that auntie auntie 72 i'd actually not come across her so i'll be looking that one up later later on um um so when we spoke previously um one of the three activities that you mentioned, there was dance. And I wanted to go back to that as an activity, because I know that's something you have a huge passion for, dance. Yeah.

Dimple:

Yeah, Susie, yeah. I mean, I've taken part in a lot of community dance events and certainly at some of the community festivals. We were encouraging dance. We had demonstrations, for example, last year, there was a huge London festival at the Great Exhibition Road Festival where we had dancing doctors. Dancing pharmacists, dancing medical students. And we were doing dance demonstrations very light activity very inclusive and we had great crowd participation i also did some work with complicity and dance umbrella um a few years ago where we were doing dancing at different venues across the capital from somerset house croydon box park outside the o2 where um we had great audience and public participation i know that dance isn't for everyone so it may not be culturally appropriate um for certain groups but i think it's again um providing a range of activities so some of the public festivals we've had a range of activities So some people, they prefer just light walking. Others prefer maybe to do things within their home, like gardening and bringing the family into it. So I think dance and music certainly can be a real motivator and it can help with mood and exercise performance. But I think it really depends on the group and the individual. So for me, really, again, it's asking the people and seeing what is appropriate for them and what is possible.

Suzy:

Libna, last time you gave me a few cautionary words not to mention dance in a conversation with, remind me.

Lubna:

Yes, so Zimple's right. Dance is not for everybody. I think I'm Muslim and dance is not one of the things that's really encouraged, not mixed dancing anyway. If it's just ladies dancing together in an excise class in Zumba or maybe some Bollywood dancing, that's absolutely fine. But to social mixing of dancing is something that's quite prohibited because Islam is a conservative religion and modesty is a really, really important part of it. And so you have to be really careful to know the background of the patient that you're speaking to. I remember one time in our GP practice, the GP or whoever the healthcare professional was had said, lovely lovely Indian lady had been back home you know for a visit and she was actually Pakistani so you can imagine how you know if the if if the healthcare professional can't even get, where she's from right then what chance do they have to actually have proper engagement so I think it's really I mean when I speak to any of my patients doesn't matter what ethnic background what where they come from what color what's color of skin they've got what religion and they are nothing. I ask all the same questions because I want to be well informed about my patient who looks after them, who do they live with, who does their cooking, where are they from, what's their religion, everything that I want to know that I feel might influence the way. Or the content of what I'm going to suggest to them. Because there's no point in, you know, in me, you know, saying something and then they're saying, well, actually, I don't follow that. I'm, you know, I'm an atheist. Why did you make that assumption? So it's really important that you find out all the, I know it sounds really common sense, but you'd be surprised how many people don't use that. It's really important to find out as much information as you can about the patient and I'm very lucky in my clinics I have half an hour to do that because it's about building rapport and trust with the patient so the patient thinks you're taking that time to spend with them they will then open up more so yeah just be careful what you're suggesting, if it's not and if you're not sure about their cultural background as people would rather you ask than made an assumption it's like even speaking you know asking somebody's name how do you pronounce your name you know it's so much better to say that than to get it wrong because then you end up if I'm a health professional and I say the name wrong I then end up looking like a fool or the patient might be too respectful and and not say anything that you've pronounced their name wrong but go away thinking well she was an idiot because you didn't even ask me I mean they wouldn't be wrong you know yeah I.

Suzy:

Have to say this morning I had had some very tricky names to to to get my my mouth around to shout in the middle of a very busy waiting room but I always I shout it a couple of times and look for a movement and then I always say how did I do because I've no idea if I've pronounced that right please correct me.

Lubna:

Um I always.

Suzy:

Find that's a really good place to start and it breaks the rapport before you've even left the waiting room um.

Lubna:

Hopefully.

Suzy:

Either that or they just think I'm an idiot, but never mind. You can but try. But I think there's something I really wanted to mention during this podcast, which is the nuances of language that I just think is so important. Within the principles of lifestyle medicine, I try and avoid the words diet and exercise using the words nutrition and physical activity or movement. But when it comes to talking about various communities, I read this really interesting article entitled, I am not hard to reach, because I think it's a phrase that we use so often about the hard to reach, because they're not hard to reach. It's just that maybe we're looking in the wrong way. And Libra, I know you had something to say about that.

Lubna:

Yeah, very much so. They're not hard to reach. They're not reached, I think, is more. is more. I think we as healthcare professionals have that perception that they're hard to reach, but they're not. It's just actually using the right equipment to be able to reach them, the right terminology, the right contacts. So they're not hard to reach, they're just not reached. And that's a shame really, because they have probably more needs coming from a different, you know from a migrant background maybe asylum seekers they have they have different and more, imperative requirements so yeah they're not hard to reach we just need to know how to reach them.

Suzy:

So so what would your advice be then to somebody listening in primary care um thinking right i want to do this a bit better from from your experience because you have had a lot of experience in these cardiovascular risk clinics what do you think we could could do better in terms of engaging people with with physical activity for example or um yeah what what would your advice be.

Lubna:

I would suggest that if you're going to find somebody where you need to have translation services, then you give them a double appointment. Because then you as a healthcare professional are not feeling rushed. Because if something has to go through an interpreter, it takes twice as long. That would be my first suggestion. And I know that takes up more clinic time, but you're then not running late because you know it's going to take longer. It's going to take longer than what they've what they've been booked in for so if they do need interpretation services then book a double appointment and then you're not stressed by keeping other people waiting and then i i also um the the expectation from. Some of the different cultures who who seek professional um advice is they're not usually coming with one problem they're coming with some other problems and what you'll find is that the other problem is probably the cause of the problem that they're coming to you for so if you can delve back into what is what is the issue it's almost like doing a detective story and then you'll actually get to the root cause which if you can help solve that and it could be something simple Simple like they're an illegal immigrant and they don't have the visa or it's been held up the solicitors or they can't walk properly because actually they've got an ulcer and they have diabetes, but they don't know they've got diabetes and that's why they're not walking. Or they can't eat food properly because actually they have diabetes. They don't know it. Their teeth have fallen out and they can't chew food. So there's so many different reasons. So I think it's like a detective story, and it's about being inquisitive, asking questions, finding out. What the lie of the land is with that person why is he here i saw a patient a few weeks ago and she's come from pakistan she comes over once or twice a year maybe three times a year to take the daughter and then she comes here she's registered with the gp here and she doesn't take her medicines she doesn't take medicines because she's she's like into this all um, allopathic medicine which yeah i'm not i'm not against that at all but actually she needs to to take her insulin and you know and it's about convincing her about about that about taking her vitamin d i mean she's deficient her vitamin d levels were like 14 i mean they're in their boots she's used to sunshine and she's coming here in scotland dimple it's not very safe in scotland and and you know her vitamin d and so and so part of the issue is i'm trying to understand what their cultural beliefs are around health and if you get an if you get a handle on that as a health professional understanding where they're coming from because there's a fear of taking tablets it's a huge fear of taking injections you know injections are just like the devil you can't oh you can't do that so if you can understand what their fears are and where they're coming from around medication around lifestyle around you know nutrition then, then I think you're much better placed to actually be able to guide them where you want them to go.

Suzy:

So that's about uh seeking to understand isn't it and and as you mentioned going upstream which is absolutely one of the key parts i think of of the lifestyle medicine approach um dimple just a quick word on on the importance of community because we've spoken quite a lot about individuals but um you know the importance of of community and and sort of that cultural shift within a community and you know what what are your thoughts on that yeah.

Dimple:

I mean i think that um, It's important just, you know, to not assume in terms of someone, you know, may have been in the UK for a long time, so they may have integrated quite well, but they still may have some cultural appropriate needs, women-only classes. Crosses maybe they you know they don't like the idea of going to the gym it's not in their culture they've never tried swimming um you know so modesty swimming costumes and it's just mindful about all of those things and ask them what they've tried don't assume and um see what the the options are, whether it's you that does that or connects them to a local charity, it could be through the social prescriber. So, I had, you know, a variety of patients from the Asian community who, you know, didn't particularly think that, you know, gardening or activities in the house actually um counted towards physical activity so um and it's sort of getting them to reconnect with some of those activities being able to do that with their family and um um seeing what's important what they've tried and some people it's just that you know maybe they're just not confident they've got no one to go with maybe um they're scared to go to the local parks they've They've got shift work. They have very young children and they have different responsibilities. So it's really sort of asking them what's happened. And it could be connecting through the social prescribers to, you know, charities, community leaders. And I think lots of things are, you know, happening, certainly around London and the local community. And it's just kind of bridging the sort of that sort of, you know, GP through to the community, council run activities through social prescribing and keep mentioning it every single consultation, because we know that. Power and the day to show of even brief conversations even of a few minutes to say actually you know um and connect it with all their symptoms and their mood because there's so many so many so many advantages to physical activity and it doesn't have to be the narrative of going to the gym or organized activity could be things that they can do and um make sure connected with So if they don't like the word exercise, because I think linguistics is really important, bringing in something that they resonate with, which is if it's simple movement, if it's not dance, if it's just movement and activity and connecting it with all of the different symptoms, then I think that can be super, super powerful. So if everyone says the same messages, the nurse, the healthcare assistant. If you go to the hospital, if they bring it up, the GP, we know that the increased number of brief interventions and people bring it up, then that's really powerful. And then if they have got any worries like pain or they have other conditions, the Moving Medicines website has got brilliant, brilliant information where you can have, you know, brief conversation of a few minutes. And if you've got longer, you can have these discussions and even just starting a conversation and then perhaps another health professional can continue with this. Um i think if we if we all sort of um you know say the same thing the message and they can be connected to what's happening in their communities well.

Suzy:

Listen both of you talking about uh not having time it's been absolutely delightful to meet you both again um and be able to bring out a few of the really sort of key um conversations really and learn from your experience as well You know, I think I think I've probably been overcomplicating it all this time and really the approach of understanding people and asking them what what matters to them. It's the same for everyone. It doesn't matter which culture you come from. And if you use that coaching approach, actually, that's all you need. So and Dimple, actually, what you would make me think of the World Health Organization, you know, every move counts. What a brilliant line. What a brilliant message that they have sent. I know that Sport England also brought out their guidance on uniting the movement. This is their sort of 10 year vision following COVID to transform the lives and communities through sport and physical activity. And for them, it's all about, you know, doing the simple things well. So I think we are all singing from the same hymn sheet and it's been absolutely delightful to speak to you both.