Thank you, Mr. Chair, and members of the committee.
I'd like to begin by thanking you for undertaking this important study and I'm especially grateful to Ms. Sidhu for bringing this issue forward. Today I'll be speaking about the Fraser Health Authority South Asian Health Institute and their work engaging the South Asian community to prevent diabetes.
The South Asian Health Institute, SAHI, was established in 2013 to better understand the health needs of the South Asian population in the Fraser Health region, which is home to over 250,000 South Asian residents or 15% of its population. Fraser Health's “South Asian Health Report” found that one of five of these residents do not speak English. The median age is 39 and 79% are immigrants. Twenty two per cent of them have lived in Canada for 10 years or less.
Chronic conditions are higher among the South Asians in Fraser Health. For example, the diabetes rate is three times higher and at least 10 years younger than in the rest of the population. Diabetes and heart disease risk are present for South Asians at a lower BMI threshold than for Caucasian populations and diet is a key contributing risk factor.
South Asians, particularly those born in Canada, report higher fast food and sugary beverage consumption than the overall Fraser Health population. The SAHI Sehat program, which is an innovative health promotion program, was created in response to the higher incidence of chronic disease in the South Asian population.
The outcome is based on health literacy; do people really understand what they're reading and being informed about? It's based on community engagement; people need to feel connected and to believe that you want to help them. And it's based on partnership development; we realize that working with our community partners is important in assisting the population to become more aware of how they can manage their health.
Initially, we defined our problem as how might we enable South Asians in a behavioural change movement to take charge of their own health and quickly realized that we needed to move from telling them what to do to engaging them. We redefined our problem to how might we engage local South Asians in a behavioural change movement to take charge of their own health.
We started to use a client-centred design approach. We flipped the traditional approach, which is built around the health system, and instead put the person at the centre of all of our activities. We created the Apnee Sehat Design Lab, which is a place to develop, test and evaluate new ways to change behaviour.
The first step is to figure out what people care about, engage them where they are, on their schedule, in their language and through their culture. We also became more focused. The team worked with community partners on one health intervention at a time, testing and refining it before scaling it across the region.
We found that whenever we spoke with people, they constantly asked about what to eat and what not to eat. They were interested in food and nutrition. The outputs of the design activities were new materials, nudges such as positive reinforcement, tools and activities. These outputs generated the lab outcomes, which were education and changes in behaviour. We were able to scale our work across the region and people were engaged.
We developed four simultaneous campaigns focused on sugar. Sehat Cooks works with local gurdwaras and temples to assist them in reducing the amount of sugar that is used in the food that is being served. Some examples include reviewing the recipes in the kitchen, looking at the portion sizes and types of donation requests. We created food models of common South Asian sweets and displayed tubes of the amount of sugar in each. We provided healthier options by way of taste tests and provided information through our health booths.
Through our observations, we found that people were eating 56% carbs on their food trays, of which 21% were sweets. We provided information in English, Punjabi and Hindi. We developed our information in a language they can understand, which we found was extremely important. Our whole team spoke the language. We helped them to understand not only about what not to eat but more importantly, what they could eat. We made the information simple and easy to understand.
Our team worked with temple kitchen volunteers who cooked the food. We engaged congregation members through our podium talks and health booths and we worked with temple leaders. In four main sites we saw a reduction in the amount of sugar in their food; it was reduced by an average of 25%. Some of these sites serve 300 to 400 people per day during the week and a few thousand on weekends.
We did this through our taste tests for the leadership and volunteers, our food models and by working alongside the people in the gurdwaras at times making rotis and most importantly by speaking the language and making information culturally relevant.
Sehat works as a collaboration with local businesses to help reduce sugar consumption at work. Through our service design approach, we created road maps where employees were provided information on health care options at various restaurants around their business. We educated them on the importance of drinking more water and reducing sugary beverages and worked with the employer to produce healthy snack bowls such as fruit instead of sugary snacks that staff often eat. After the interventions were introduced, some employees joined a gym, others brought healthier lunches from home and some started going for walks at lunch time.
Sehat at schools is the collaboration with private south Asian schools, including the students, parents and teachers, to develop educational tools in order to engage students to adopt healthier behaviours. Parents told us that the children didn't want healthy lunches and that they needed recipes and ideas on how to make healthier options tastier.
Teachers told us that their concerns were that the students were bringing unhealthy lunches to school and that they were concerned about the lack of understanding of the importance of healthier eating.
Students told us that they didn't like the lunches that their parents made for them, while others felt they were eating healthy. We are currently working with the student leadership to develop educational tools for them to be the schools' champions for healthy eating.
We are also working with school administration on developing a health tab on their website with information on healthy eating.
On Sehat media, we created a culturally relevant social media post in a language that south Asians could understand. Our posts are reached by upwards of 125,000 people. As you can see, we are moving towards a multi-model, multi-setting approach so that consistent messages and supports are received across settings and family members. Our target is the family and not just the individual.
Concerning our results to date, we are in 12 places of worship and two private schools with over 15,000 interactions. We have distributed over 37,000 culturally relevant resources. We have created 90 culturally relevant education resources in two different languages and have conducted 187 health promotion booths.
Some of our insights put the patient, the person or the client first. You need to meet the needs of the client. Community engagement is changing the way the system works. The health system is not set up to engage clients' evenings and weekends for community engagement. This is a 24-7, 365-day per year partnership. Change takes time. In some sites we were there every week for up to eight months before they started to make changes. We needed to create trust and build a relationship. One size does not fit all. Diversity within a population means that biases can exist even among population members.
Impact requires focus, and change requires readiness. The initial program design was too broad and overwhelmed people. Only after focusing on reducing consumption of added sugar did the project make gains.
Practice service design means learning to observe and ask good questions, make work visible, create and share prototypes early and often, build evaluation into daily practice, conduct client-centred design research and define the real problem to be solved.
We challenge assumptions and conventions. When traditional ways don't work, stop using them. Engagement requires trust. People can only be open to those who have demonstrated through action that they are part of the community.
Culture and authenticity matter. Everything must be culturally appropriate and relevant, including team members, materials, activities, language, food and customs. This also enables the project to identify and address unhealthy traditional beliefs and practices.
We develop external partnerships. We found that the lab needed to be able to collaborate openly with service providers such as primary care, non-profits, government, media and sponsors and to access shared resources from those partners to achieve sustainability. No one person or group has the answer to today's emerging complex problems. Open collaboration is the most effective way to resolve such challenges. Partnership building was a critical success factor, a contrast to the previous approach. Specific interventions may vary, but the approach is promising with other underserved populations at increased risk for diabetes.
On the design for engagement, the south Asian population is not homogeneous. Engaging clients proved to be more complex than indicated by existing data. The intention of designing activities and experiences, big and small, was to maximize engagement with the target audience.
Determine what and why before how. You need to know what problems you are solving and why it matters to the clients before starting to design a solution. We often start with a solution without knowing the actual need to be met.
The Fraser Health population and public health program is applying a health promotion approach by identifying meaningful solutions to support physical, mental and social health and well-being.
To help people and communities improve their health, our healthy living team works within Fraser Health and with local municipalities and community groups to help vulnerable groups and neighbourhoods to improve their healthy living initiatives. The team consists of a variety of health care professionals, with expertise in tobacco reduction, healthy eating, food security and physical activity.
We also have a team specifically dedicated to healthy built environments. Built environments refer to human-made or modified physical surroundings in which people live, work and play. The healthy built environment team works with municipalities and other partners to ensure that the health lens is incorporated into a planning process.
A third program under healthy communities is a comprehensive school health program focused specifically on the school setting. Nearly all Fraser Health communities have implemented the Live 5-2-1-0 initiatives. Live 5-2-0-1 initiatives have included workshops, community forums and community practice, and resource material has been developed.
Comprehensive school health is an approach based on the understanding that healthy students are better learners, and better educated students are healthier. This framework is used across Canada, including in B.C. by the ministries of health and education and the Healthy Schools B.C. initiative.