Community based approaches to addressing high blood pressure with black African and Caribbean men

The overarching aim of the project was to address health inequalities through targeted blood pressure awareness and testing in black African and Caribbean males.

The purpose of the project was to develop a community-based blood pressure project and pilot it in two areas (later expanded to a third).

We aimed to improve health literacy through increasing knowledge and awareness of high blood pressure through targeted resources, and to encourage men, where appropriate, to take up the NHS Health Check as a means of detecting if they had high blood pressure.

Targeted resources included a leaflet which enabled the blood pressure reading to be recorded, strut cards and posters. The development of the resources was led by one of the project partners - Men’s Health Forum. They were co-produced with input from African and Caribbean men who have high blood pressure to ensure images, layout, tone, etc. were concordant with what is known to work in health communication with men. Further information on how the resources were developed can be found in our project report (link below).

Evidence shows that high blood pressure disproportionately affects people with a black African or Caribbean heritage and that there is a higher incidence of stroke and end stage renal failure in black people of African or Caribbean ethnicity in comparison to white people (1, 2, 3, 4). Ethnicity as a risk factor was noted in local needs assessments in the three pilot areas (see below). For example, City and Hackney Joint Strategic Needs Assessment makes reference to this around adult illness and notes ethnicity as a risk factor of ethnicity in developing cardiovascular disease, linked to a higher risk of diabetes and hypertension in South Asian, Black African or Caribbean communities (https://hackneyjsna.org.uk/wp-content/uploads/2018/12/Cardiovascular-Disease.pdf). Evidence shows men are less likely to attend for an NHS Health Check than women, missing an opportunity to identify high blood pressure and raise awareness of lifestyle factors that impact on high blood pressure (5). In all three areas, take up of the NHS Health Check was lower for men than for women.

The way NHS Health Check data is presented makes it difficult to assess uptake amongst Black African and Black Caribbean men. However, it is clear that for specific CCG or local authority areas engaged in this project, work needs to be done to increase the numbers of men from these groups taking up the NHS Health Check as a means of detecting high blood pressure and other cardiovascular diseases.

The 10-year cardiovascular ambitions for England aim to increase the numbers of people diagnosed with and managing high blood pressure, either in healthcare settings or in community settings, and this project focused on community-centred approaches (6).

The project initially targeted two geographical areas in London (Hackney and Southwark), both of which have a high population of African and Caribbean communities. We were eventually successful in adding a third area to the project (Brent). Target areas were chosen by considering demographic information, alongside local priorities on cardiovascular disease/high blood pressure and whether there was a focus locally on ethnicity.

The project took place in community settings; primarily barbers shops frequented by African or Caribbean men, but also a black majority church and a bus depot. The inclusion criteria were African and Caribbean men who were aged over 40 (because they would be entitled to a NHS Health Check) although this was not prescriptive. The project started on 1 September 2019 and was completed by 30 March 2020.

We firstly undertook a literature review of screening programmes, engaging men in public health initiatives and identified ‘what works’ to engage black men in health. We carried out pilot blood pressure testing and awareness raising in eight community settings. We identified the areas to work with which had a good population of the relevant black communities and worked with CCG staff, e.g. nurses, a senior pharmacist and an advanced nurse practitioner, to carry out blood pressure testing and provide information on health issues.

The project was informed by a co-production group of partners (including Men’s Health Forum, Faith Action, Clinks, Blood Pressure UK, Pan African Thought, the African Caribbean and African Health Network, and the Community African Network) and men with lived experience of high blood pressure and other long-term conditions. Some of these organisations were engaged through the VCSE Health and Wellbeing Alliance, whilst others had specific expertise in working with African and Caribbean men on either health issues or blood pressure. This approach demonstrates Quality Statement 1 of NICE QS 167 in practice which recommends that people from black, Asian and other minority ethnic groups have their views represented in setting priorities and designing local health and wellbeing programmes.

The co-production group were invaluable in terms of input into the development of resources and factors to consider that impact on African and Caribbean men’s health-seeking behaviour.

The project focused on using a community-centred approach to address health inequalities and high blood pressure as noted in above (point 6). It was informed by the evidence of community approaches for health interventions and specifically related to addressing high blood pressure (7), including work in USA with black barbershops (8).

We wanted community settings that African and Caribbean men trusted, were well attended, and felt comfortable and confident to participate in the project.

The six-month timeline was a notable constraint for the project, however we were able to overcome a number of challenges within this time, such as getting agreement from the relevant CCG/public health teams; building relationships with the community venues for their involvement and getting the right healthcare practitioner to participate. We needed to take a flexible approach to ensure the success of the project, for example, meeting stakeholders at a time acceptable to them outside of office hours/speaking at meetings or an event; acknowledging and accepting the protracted time that one CCG took to commit to the project following initial enthusiasm (the length of time impacted on the engagement in local community settings); and working with committed practitioners and stakeholders.

More information on some of the challenges we faced and how we addressed them can be found in our project report (see below).

We successfully engaged a group of men who are not accessing health care services despite some saying themselves that they were thinking about getting their blood pressure tested or had received their NHS health check letter but had not acted on it. We ran the pilots in three areas, as opposed to the two we were commissioned for. 87 men participated in total of which were 29 African Caribbean and 48 African, with the remaining men being of Bangladeshi, Pakistani, Indian other and other mixed origin.

Individual project team members and health practitioners took time to speak with the men about general health and to raise awareness of high blood pressure and ethnicity as a risk factor. This led to some discussions with some of the men on themes such as medication for blood pressure, being put on tablets for life (and what perceived impact this has on your health), healthy lifestyle and understandings of how you can be affected by high blood pressure. The impact of raising awareness about high blood pressure was evident in the feedback given as noted in the project report (see below). A process evaluation was undertaken as part of this, which found that the men were very positive about the approach and welcomed the opportunity to have their blood pressure measured and find out more about the implications of high blood pressure to their overall health.

There was no cost-benefit analysis undertaken, as this was not in the scope of this project.

• Buy in from the CCG/public health was essential not only in accessing the relevant healthcare practitioners but to see how the project could compliment the priorities the CCG/public health team have for high blood pressure, cardiovascular diseases and any specific focus on black and minority ethnic communities.
• It was important to build relationships within community settings and this took time; to identify the setting, get permission, build a dialogue, work with community stakeholders ensuring there is that element of trust and benefit for their clientele.
• Having a health care practitioner present was key, not only to ensure the blood pressure measurements were taken correctly, but also that participants seeing a medical professional would counter any lack of confidence in community-based checks. The health care practitioner enabled some men to address certain issues, such as medication, blood pressure and healthy lifestyles, with the senior pharmacist.
• The competence of health care practitioner in the different setting was key to engaging with the men and understanding cultural practices or beliefs which might impact on how they addressed high blood pressure.
• Stakeholder involvement was very helpful to get some of the men to participate in the sessions. Some stakeholders had their blood pressure measured e.g. the pastor was the first within the church session. Some encouraged the men to think about high blood pressure, for example the barbers talked to the men before they had their hair cut and encourage their participation.
• Despite trying to have the sessions in a discreet part of the venue, a lack of privacy was mentioned as a concern particularly where a barbershop was small.

The approach we have used is transferable to a number of community settings. The resources developed could be used by others to provide information to black men and record blood pressure readings. A process evaluation was undertaken and is available on our website (see below).

This project came to an end just as the COVID-19 pandemic started to have an effect worldwide. Analysis of the impact of the pandemic so far (9, 10, 11) has further highlighted the stark inequalities faced by black and minority ethnic communities, and a number of recommendations to address structural and health inequalities have come out of this, including support for community participatory research, that can lead to projects being developed into ‘scalable programmes to reduce risk and improve health outcomes’. Using community-centred approaches as with the work detailed in this practice example are an opportunity to work in a different way to address health inequalities.

Ensure there is sufficient time to work with the stakeholders in the community settings and co-produce the approach with men from the target group.

The project was a pilot but the learning could be used to build a methodology and approach which local public health teams and CCGs could consider as part of their wider strategic priorities on high blood pressure and cardiovascular disease. Whilst all the community settings were willing for a longer programme to continue, and repeat sessions were scheduled, this was not possible within the timeframe. We continue to disseminate information about the project and undertake presentations to those who might benefit from this.

References:

1. British Heart Foundation, 2018, Understanding blood pressure
2. Public Health England, 2017, Guidance, Health Matters, combating high blood pressure https://www.gov.uk/government/publications/health-matters-combating-high-blood-pressure/health-matters-combating-high-blood-pressure
3. NICE quality standards and indicators, briefing paper 2015, https://www.nice.org.uk/guidance/qs167/documents/briefing-paper
4. Randhawa, G, 2007, Tackling health inequalities for minority ethnic groups: challenges and opportunities, Better Health Briefing Paper 6, Race Equality Foundation6 Community based approaches to addressing high blood pressure with black African and Caribbean men November 2020 https://raceequalityfoundation.org.uk/wp-content/uploads/2020/07/Community-approaches-to-addressing-high-blood-pressure-in-black-African-and-Caribbean-men-project-report-complete-1.pdf
5. NHS Digital, 2019, NHS Health Check programme, Patients Recorded as Attending and Not Attending, 2012-13 to 2017-18
6. Public Health England, 2019, Health Matters: preventing cardiovascular disease https://www.gov.uk/government/publications/health-matters-preventing-cardiovascular-disease/health-matters-preventing-cardiovascular-disease
7. British Heart Foundation, u.d. Blood Pressure Award Programme https://www.bhf.org.uk/for-professionals/healthcare-professionals/innovation-in-care/blood-pressure-award-programme
8. Ronald, V, Lynch, K, Ning, L, Blyler, C, Muhammad, E, Handler, J, Brettler, J, Rahsid, M, Hsu, B, Foxx-Drew, D, Moy, N, Reid, A and Elashoff, R, 2018, A cluster - randomized trial of blood pressure reduction in black barbershops, The New England Journal of Medicine, pp 1291-1301
9. Race Equality Foundation, 2020, Covid-19 and how it affects Black, Asian and Minority Ethnic people and communities https://raceequalityfoundation.org.uk/health-care/lockdown-2-briefing/
10. Public Health England, 2020, COVID-19: review of disparities in risks and outcomes https://www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes 
11. Public Health England, 2020, Beyond the data: understanding the impact of Covid-19 on BAME groups https://www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities