Culturally sensitive health care
systems in our multi-ethnic Europe:
insights from Scotland
Raj Bhopal
CBE, DSc (hon)
Professor of Public Health, University of Edinburgh
Honorary consultant, NHS Lothian
Acknowledgements
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Colleagues including Rafik Gardee, Hector MacKenzie, Laurence
Gruer, Aziz Sheikh, Gill Matthews, Vincent Laurent
People supplying slides-Smita Grant (MEHIS, Lothian NHS),
Judith Sim (Lothian NHS), Michelle Lloyd (Equally Connected)
IOM for migration slide
Members of the Edinburgh Ethnicity and Health Research Group
The conference organisers
Objectives of the presentation
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Share insights from an 16 year, ongoing
journey trying to develop culturally sensitive
health systems, 11 in Scotland
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Reflect these internationally, especially
Europe
Core concepts for the lecture
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Migration-internal and international
Ethnicity
Health systems
Inequality
Inequity
Migration-key to culturally sensitive
healthcare systems
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Fundamentally human
Reasons –
commerce,
work,
education,
ambition,
refuge
curiosity &
change
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Europe- progressed with migration
Nothing to be ashamed of-for individuals or nations
Lifting the stigma is a top priority
Migrating populations, 1990-2000:
175 m. in 2000 (4-fold increase cf. 1975)
230 m. predicted by 2050
Sources: Population Action International 1994, IOM 2003
Ethnicity
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The group you belong to, or are perceived to
belong to, because of your
culture (language, diet, religion),
ancestry,
and
physical textures
Ethnicity incorporates race, and country of
birth
Scotland’s ethnic composition-not
untypical of Europe
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Shaped by migration
Emigration historically overshadows immigration
Scotland has recently welcomed migration
1850-1950 Irish, Lithuanians, Jews, Italians, Poles
immigrate
1950-2000 Indians, Pakistanis, Bangladeshis,
Chinese immigrate
2001-present Asylum seekers, refugees, Eastern
Europeans, and students immigrate
2001 Census (non-White populations
doubled since 1991)
%
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White Scottish
Other White
South Asian
Chinese
African/Caribbean
Mixed
Other
88
10
1.1
0.3
0.15
0.25
0.2
Country of birth of mothers of babies
born in Scotland
Country of birth 1991
2007
United Kingdom
63702
51432
EU – pre 2004
countries
770
1100
EU – post 2004
countries
885
2388
Other
2437
3961
Forces - ethnic health inequalities
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Culture and lifestyle
Social, educational and economic status
Environment before and after migration
Early life development
Generational effects
Genetics
Access to and concordance with health care advice
Quality and quantity of healthcare
Perceived status in society
Discrimination/bias/inequity
Inequity and inequality
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Consider whether any of the following are
inequities:
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The lower prevalence of smoking in Chinese
women compared to White women
The higher rate of colo-rectal cancer in White
people compared to S. Asians
The lower life expectancy of African Americans
compared to White Americans
What do you think?
Multiplicity of challenges for a culturally
sensitive healthcare system
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health behaviours, beliefs and attitudes, and diseases
varying
diagnosis, treatment, intervention, adherence to the
intervention, and outcomes varying
language and cultural barriers
requirements based on religion
lack of information and research
lack of leadership
personal biases, stereotyped views, individual racism
institutional (health system) bias, and laws against it
laws requiring equal opportunities in employment and
other walks of public life
Legal Framework and Policy Consensus
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In 1997 EU Member States approved the
Treaty of Amsterdam
Article 13 - powers to combat discrimination on
sex, racial or ethnic origin, religion or belief etc
Implemented in each European nation e.g. the
UK has:
 Race Relations Amendment Act 2000
(building on 1976 act)
 Public sector duty to promote equality and to
demonstrate this
Major recent achievements in Scotland
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HDL (2002) 51 –Fair for All policy
 Energising the Organisation
 Demographics
 Access and Service Delivery-equity
 Human Resources-equality in employment
 Community Development-strengthening communities
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National Resource Centre for Ethnic Minority
Health (NRCEMH) 2002-2008
Major achievements in Scotland 2
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Integration of the equality strands in the
Planning and Inequalities Directorate in NHS
Health Scotland-2008
Information-responsibility and funding
embedded in ISD: promotion of ethnic coding
in routine information systems
Linkage of Census ethnic codes to mortality
and hospitalisation databases providing
health status by ethnic group
Ethnic Health Research Strategy
Six priorities for research-Scottish strategy
1. Ethnic coding of health information systems
>80% by 2013
2. Data linkage work is developed
3. Ethnically boosted health survey
4. Coordinated research on major problems
5. Audit of health and social care services
6. Coordinating and monitoring research by
Implementation group
NHS Board level action plans: e.g. main areas of
Lothian Health’s plan (2003-2008)
1 Mainstreaming minority ethnic health
2 Advocacy and action against racism
3 Appropriate, culturally sensitive, high quality and
accessible healthcare
4 Involving people and communities
5 Interpretation and translation services
6 Health and healthcare information for minority ethnic
groups
7 Provision of advocacy and facilitation services
8 Training for staff
9 Employment
10 Patient profiling; monitoring of ethnicity
http://www.nhslothian.scot.nhs.uk/news/documents/equalitydiversity_strategy.pdf
Research and surveillance-health status of
ethnic minorities in Scotland
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Ethnicity not recorded on birth and death certificates
Ethnic coding for:
 5-10% of hospital admissions
 18% cancer registration data
 Unknown forprimary care data
 60% of Scottish Diabetes Register
So, unable to assess differences in mortality and
morbidity routinely
High-level managerial activity to resolve these problems
So country of birth, name search and linkage methods
used
Using name search, country of birth, and
linkage methods
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In Tayside
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Compared with those born in Scotland,
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diabetic care for people with South Asian names had equal
care but key outcomes poorer
all-cause mortality lower among those born in England and
Wales, Pakistan, Bangladesh, India (men), China, and rest
of world
Linkage-heart attacks much more common in those
reporting to be South Asian after 2001 census
More work being done on cardiovascular disease,
cancer, maternal & child health and mental health
Anonymised Linkage of Health
Databases to Census Databases:
conceptualising the procedure
Census Database
Health Database
Record Linkage
Encrypted
CHI
Number
Personal
Identifiers
Personal
Identifiers
Encrypted CHI Number
Encrypted
Census
Number
Encrypted Census Number
(Look-up Table)
Death & Hospitalisation from
Health databases
Ethnicity from Census
http://www.biomedcentral.com/1471-2458/7/142/abstract
Directly age standardised incidence rates
per thousand for first AMI (principal diagnosis)
Sex/Ethnicity
Female
Non SA
SA
Male
Non SA
SA
Person
years
Age
95%
adjusted confidence
rate
interval
4,557,730
24,762
2.56
4.86
2.51 – 2.60
3.05 – 6.67
3,905,224
25,885
5.00
7.71
4.93 – 5.08
5.68 – 9.75
A trial for primary prevention of type 2
diabetes in South Asians (PODOSA)
Principal research questions
 does a family-based weight loss and physical activity
programme, reduce the incidence of type 2 diabetes in
South Asians?
 what is the cost effectiveness?
 what factors will lead to greater participation in the trial?
 the trial will report in 2013
 pending research results we need service action
http://www.podosa.org/index.html
Practical activities at service delivery level
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Interpreting and translation funded for inpatient and
outpatient services (including general practice)
Spiritual services in hospital for every religion-by
creating multi-faith spaces and facilities
Food in hospitals – appropriate choices
Trained staff support minority patients and
communities (Minority Ethnic Health Inclusion
Service-MEHIS)
Several community organisations supported to
provide appropriate services
Ideas tested out using specific projects
Impact of a cardiovascular risk control project for
South Asians (Khush Dil) (JPH, 2007)
• Khush Dil - Edinburgh 2002
•Create a culturally sensitive service for CHD/risk factors
among South Asians
•140 people had screening-6 months after baseline
•Risk factor profiles improved, e.g. reduction in
cholesterol, and reported changes in behaviour
•Khush Dil had an impact
•Extremely difficult to continue funding locally
•Eventually, national budgets partially rescued it (Keep
Well).
Minority Ethnic Health Inclusion Service
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1994 Generic Mental Health Worker
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1999 MEHIP (Minority Ethnic Health Inclusion Project,
Pilot)
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2001 MEHIP-Core Service
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2006 Keep Well
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2006 Diabetes & Hypertension Pilot-3 practices
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2008 Khush Dil incorporated into MEHIP
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2009 MEHIP to MEHIS / Mental Health / Keep Well
MEHIS Link Worker Model
Patient
Link Worker
Health
Professional
Maternity services-some sensitive
adaptations are required.
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Polish people in Scotland
Medicalised understandings of pregnancy
Simultaneous participation in Polish and UK health
systems
‘Best practice’ may not be perceived to be so
Past experiences and expectations matter
Educational DVD for staff on the
experiences/expectations of Polish migrants
Producing culturally sensitive materials on antenatal
screening and diagnostic testing for patients
Maternity service projects-some sensitive
adaptations are required.
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Scottish guidance - male partners welcomed in
parenthood education sessions to help reduce
inequalities (McInnes, 2005).
Urdu, Bengali and Arabic-speaking women presence of men was the prime reason given for not
attending
A policy to reduce social inequalities can increase
ethnic inequalities
Equally connected community project
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Community development approaches to learn
from minority ethnic communities about
attitudes to, and experiences of, mental
health
Gypsy/Traveller women – collecting individual
case-studies and running a programme of
exercise and wellbeing workshops.
Some obstacles on the culturally sensitive
healthcare pathway
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Implementation
Insufficient monitoring
Sparse budgets
Competing priorities
Insufficient information
Mainstreaming projects into routine service problematic
Maintaining engagement between the statutory and
voluntary sectors difficult
Altering service delivery
Winning hearts and minds
Examples of obstacles
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People haven’t heard of/read law or policy
Key recommendation of Fair For All HDL-an
Ethnic Health Forum within each health
board-scarcely applied
Ethnic coding- largely ignored
Training events- attendance abysmal
Practitioners not confident
Patients not served properly
One exemplary obstacle-end of life study
“Policy directives aimed at improving access to
services and standards of care for ethnic
minority groups in Scotland are laudable. It
seems, however, that end of life services for
South Asian Sikh and Muslim patients remain
wanting in many key areas”.
Worth et al BMJ
http://ukpmc.ac.uk/articlerender.cgi?accid=PMC2636416
Conclusions 1
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Scotland’s progress incremental, incomplete and difficult,
but still comparatively strong
Comparing policies to tackle ethnic inequalities in health:
Belgium 1 Scotland 4
Built on partnership by a government and institutions
promoting equality, and justice
Achieved within a strong NHS
Underpinned by research and information
Involving ethnic minoritiy groups and individuals as
instigators, leaders, service personnel and users
Conclusions in international context 2
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USA: health systems consume vast resources-despite long
recognition, culturally sensitive healthcare not achieved
Europe: patchy progress, subject to political change. Progress
largely in service delivery, rather than governmental policy.
New Zealand: innovative, and effective work in relation to Maorispolitical power and will has been instrumental
Australian work on aboriginal health-challenge has been
somewhat overwhelming.
Multi-ethnic countries in Middle East, China, India etc: much to
do, but issue seems mostly unrecognised
Conclusions 3: the future in Europe
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Health systems in our multi-ethnic
societies-challenging, interesting, with potential
for great advances
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Sharing experience across Europe means
faster progress.
We must remember our ultimate goal-a
healthy society
Further reading
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Gill PS, Kai J, Bhopal RS, Wild SH. Health Needs
Assessment for Black and Ethnic Minority Groups 2002
(online) and 2007 (in print) (book chapter –PDF available
online at
http://www.hcna.bham.ac.uk/documents/04_HCNA3_D4.pdf
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Bhopal RS. Ethnicity, race, and health in multicultural
societies; foundations for better epidemiology, public health,
and health care. Oxford: Oxford University Press, 2007, pp
357.
http://www.oup.com/uk/catalogue/?ci=9780198568179
Some URLs for organisations/policies
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National resource centre for ethnic minority
healthhttp://www.healthscotland.com/about/equalities/raceresources.aspx
Planning and Equalities Directorate integrating equality strands
http://www.healthscotland.com/about/equalities/raceresources.aspx
Information
http://www.isdscotland.org/isd/5826.html
Fair for All
http://www.sehd.scot.nhs.uk/mels/HDL2002_51.pdf
Ethnicity and health research strategy
http://www.healthscotland.com/documents/3768.aspx
Lothian NHS board
http://www.nhslothian.scot.nhs.uk/news/documents/equalitydiversity_strategy.
pdf
MEHIS
http://www.saferedinburgh.org.uk/DOSDetails.cfm?ID=75
Equally connected
http://www.healthscotland.com/equalities/mentalhealth/equally-connected
Comparing Belgium and Scotland policies
http://eurpub.oxfordjournals.org/cgi/content/full/ckq061)