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Meeting healthcare needs of ethnic minority groups

Kate Gerrish
BNurs MSc PhD RGN DNCert
Reader in Nursing Practice Development
University of Sheffield

Improving the quality of primary healthcare for minority ethnic communities has become a major policy concern. Recent calls(1-3) for Primary Health Care Teams (PHCT(s)) to become more responsive to the needs of local populations mean that practice nurses need to develop skills to assess health needs and plan appropriate nursing interventions for people from different ethnic and cultural backgrounds.
 
However, one of the difficulties PHCT(s) encounter in assessing the health needs of local populations is that ethnic monitoring in primary care is not mandatory. Without accurate information on the ethnic composition of the practice population it is difficult to plan appropriate services.

Overcoming disadvantages

Practice nurses also need to work towards overcoming the health disadvantages and discrimination experienced by many members of ethnic minority communities.

The recent inquiry into inequalities in health(4)  reported that people from minority ethnic communities are more likely than the white population to find physical access to their GP difficult, have longer waiting times in the surgery, feel that the time spent with them was inadequate, be less likely to be referred to secondary or tertiary care, and be less satisfied with the outcome of consultation.

Moreover, research indicates that practice nurses, together with other community nurses, encounter difficulties in providing culturally appropriate care because they lack understanding of the particular needs of minority ethnic patients and encounter difficulties in communication.(5,6) General practices, therefore, need to consider what mechanisms they have in place for determining that the practice population served know when and how to access the full range of services and that services are equitable and responsive to the needs of all people registered with the practice.(7)

There is now extensive research evidence that demonstrates that certain ethnic minority communities experience a higher incidence of morbidity and mortality associated with several common diseases, such as diabetes, coronary heart disease, hypertension and stroke, than the white indigenous population.(8,9)

Bearing in mind the central role that practice nurses play in chronic disease management, it is important that they consider how they can provide more culturally appropriate services. For example, advice on diet and lifestyle needs to take account of the cultural and religious preferences of individual patients. There is also evidence to indicate that the uptake of health promotion and screening services in primary care is low among some ethnic minority communities, and practice nurses may need to consider how they can encourage greater participation in well-person clinics and the uptake of immunisation programmes.

In order to develop culturally appropriate services, nurses need to understand the diverse lifestyles, beliefs and values of healthcare users from different ethnic backgrounds.
There are a number of manuals outlining the needs of different cultures and religions, but it is essential that nurses do not adopt a 'recipe book' approach. They need to recognise that cultural diversity exists not only between different ethnic groups but also within ethnic groups. Stereotypical assumptions about the cultural or religious practices of specific ethnic groups need to be challenged.

For example, the assumption that South Asian families (ie, people of Bangladeshi, Pakistani or Indian origin) are unlikely to want social care support because they prefer to care for ill relatives themselves fails to recognise that changing family structures and employment practices within South Asian communities means that some patients may not have a supportive family structure that is able or willing to provide care.

Knowledge about the influence of culture and religion on people's lives and attitudes to healthcare requires to be balanced with sensitivity to the individual needs and preferences of patients and their families. Textbook information is helpful, but only if it increases nurses' awareness of possible variations and encourages them to ask patients and families about their needs.

Effective communication
Identifying the individual needs and preferences of patients is dependent on being able to communicate effectively. Yet many patients from ethnic minority backgrounds, especially if they have not been born in the UK, may not be fluent in spoken English.

Reliance on family interpreters is far from satisfactory as it entails a compromise in privacy and confidentiality and may have a detrimental effect on family relationships. Inadequate interpretation may also mean that advice and guidance on critical matters such as compliance with treatment regimens might not be fully understood.(6)

Even people whose conversational English normally appears excellent may be at a loss for words when trying to explain medical symptoms or understand health information, especially where it entails difficult medical terminology.

Patients should, therefore, be given the choice of using a professional interpreter. It is important for general practices to consider what provision there is in place to ensure that patients/families whose first language is not English have access to professionally trained bilingual staff. In support of this, the NHS Plan is committed to ensuring that all NHS Trusts have telephone access to a 24-hour interpreting service by 2004.(3)

However, communicating across cultures is not just an issue of a shared language. Appropriate nonverbal communication varies between ethnic groups: for example, differences in amounts of eye contact can cause serious misunderstanding and antagonism. Nurses also need to be sensitive to different expectations, assumptions and ways of communicating.

In many cultures it is unacceptable to discuss intimate matters with a member of the opposite sex. Moreover, in cultures where individualism and personal autonomy are highly valued, patients are often expected to make their own, largely independent decisions about medical treatment.

In other cultures, family members with more authority and experience may make decisions about medical treatment.(10)

Conclusion
If practice nurses are to play their full part in modernising the NHS, they need to take on board the challenges of working in a multiethnic society. However, effectively meeting the healthcare needs of minority ethnic communities cannot rely on the commitment of individual practitioners.

There is a need for the multidisciplinary PHCT to assess the needs of the local community and consider collectively how they can provide a more culturally responsive service.

It is only through taking such collaborative measures that the health disadvantages and discrimination experienced by many members of ethnic minority communities will be overcome.

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References

  1. Department of Health. The New NHS: Modern, dependable. London: The Stationery Office; 1997.
  2. Department of Health. Our Healthier Nation: A contract for health. London: The Stationery Office; 1998.
  3. Department of Health. The NHS Plan: A plan for investment, a plan for reform. London: Her Majesty's Stationery Office; 2000.
  4. Acheson S.D. Independent Inquiry into Inequalities and Health (The Acheson Report). London: The Stationery Office; 1998.
  5. Pharoah C. Primary Health Care for Elderly People from Black and Minority Ethnic Communities. Studies in Ageing, Age Concern Institute of Gerontology, King's College London. London: HMSO; 1995.
  6. Gerrish K. The nature and effect of communication difficulties arising from interactions between district nurses and South Asian patients and their carers. J Adv Nurs 2001;33: 566-74.
  7. NHS Ethnic Health Unit. Good Practice and Quality Indicators in Primary Health Care: Health care for black and minority ethnic people. Leeds: NHS Ethnic Health Unit; 1996.
  8. Balarajan R, Raleigh, VS. Ethnicity and Health: A guide for the NHS. London: HMSO; 1993.
  9. Smaje C. Health, 'Race' and Ethnicity: Making sense of the evidence. London: King's Fund Institute; 1995.
  10. Henley A, Schott, J. Culture, Religion and Patient Care in a Multi-ethnic Society. London: Age Concern; 1999.

Resource
Transcultural Nursing and Health Care Association, Foundation of Nursing Studies
W:www.fons.org