A report on the
health/health promotion
needs of the Black and Minority Ethnic
Communities
in North Wales
Author: Hilary Nicholas Public Health Practitioner, Conwy &
Denbighshire Local Public Health Team, Public Health Wales
Date: 9th June 2010
Version: 1
Publication/ Distribution:
 Betsi Cadwaladr University Health Board (BCU HB)
 Public Health Wales Local Public Health Teams
Purpose and Summary of Document:
To inform BCU HB and Public Health Wales Local Public Health Teams of
the health needs of Black and Minority Ethnic Groups in North Wales,
health promotion approaches to address these needs and
recommendations for improving equity of access to health promotion
services.
Recommendations include the need to:
 establish more effective methods of engaging with BME communities
through links with the voluntary sector, the North Wales Race Equality
Network and other local BME networks
 provide cultural awareness training for staff and identify opportunities
for joint training, networking and the development of joint initiatives
 identify existing examples of good practice and opportunities to raise
awareness of health promotion activities and health issues
 consider joint approaches to health promotion and health needs
assessment between Public Health Wales, BCU HB, local authorities and
the voluntary sector.
Contents
1
Summary
3
2
Introduction
3
3
Methodology
4
4
Demographic data
5
5
The health needs of BME groups
6
6
Access to health promotion services
8
7
Conclusions and recommendations
10
References
12
Public Health Wales
1
Improving access to health promotion for BME communities
Summary
Demographic and health needs data on black and minority ethnic (BME)
communities in North Wales is limited. Evidence from wider studies
suggests that the health needs of BME groups are similar to those of the
majority white population, especially in relation to common health
problems, although some conditions are more common in BME
populations. Research has shown that approaches to health promotion
may not adequately meet the needs of BME communities and that further
consideration should be given to methods of engagement and
communication in relation to health promotion activity. It is suggested
that a muliti agency approach is taken to identify opportunities for
engagement with BME communities to promote physical and mental
wellbeing.
2
Introduction
This report has been produced in response to the following action set out
within Denbighshire Local Health Board’s Race Equality Scheme Action
Plan 2008 – 2011:
Take account of the health needs of racial groups in the
development of health promotion and disease prevention
programmes and establish appropriate health promotion and
disease prevention programmes.
The report provides a brief overview of:
 local demographic data on Black and Minority Ethnic (BME)
communities
 common health problems and lifestyle issues amongst BME groups
 access to health promotion and disease prevention services
 guidance and recommendations that may be used to inform health
promotion and disease prevention activities.
The report does not include the health needs of white migrant groups nor
the health needs of Asylum Seekers/Refugees and Gypsy Travellers. A
recent publication from the National Public Health Service (NPHS) provides
updated guidance for healthcare planning relating to the latter population
groups1.
During the preparation of the report it was considered reasonable to
extend its geographical focus beyond Denbighshire for the following
reasons:
Date: 9 June 2010
Version: 1
Page: 3 of 12
Public Health Wales



Improving access to health promotion for BME communities
Issues highlighted in the report are likely to be of general relevance to
North Wales
Relevant statistical data for Denbighshire is limited
The recent formation of Betsi Cadwaladr University Health Board
(BCUHB) takes a North Wales approach to health service planning and
delivery, including the delivery of actions to promote health and
wellbeing.
It is intended that the recommendations from this report may be used to
inform the Upstream Prevention and Wellbeing activities of Public Health
Wales and BCUHB and in the preparation of local Health, Social Care and
Wellbeing strategies.
3
Methodology
Two themes were used for literature searches:
 The health needs of Black and Minority Ethnic (BME) groups in Wales
 Health promotion and illness
specifically at BME groups
prevention
programmes
targeted
Consultation with Public Health Wales’ Library, Knowledge and Information
Service highlighted a small number of reports produced by respected
bodies. Of specific interest and relevance were the following publications:
 Welsh Assembly Government (2005) Health ASERT Programme Wales
Enhancing the Health Promotion Evidence base on Minority Ethnic
Groups, Refugees/Asylum Seekers and Gypsy Travellers
 Equality issues in Wales: a research review (2009) Equality and Human
Rights Commission. The Bevan Foundation
 Gill, P. et al, Health Care Needs Assessment Third Series (2007) Black
and Minority Ethnic Groups, University of Birmingham
Additional information was gathered from local demographic data, needs
assessments and from consultation with the North Wales Race Equality
Network (NWREN), a regional organisation that supports BME communities
in North Wales.
For consistency the term ‘health promotion’ is used throughout this report
to refer to services and interventions in the community that aim to
promote physical and mental wellbeing, encourage the uptake of ill health
Date: 9 June 2010
Version: 1
Page: 4 of 12
Public Health Wales
Improving access to health promotion for BME communities
prevention services such as screening and immunisation and encourage
participation in self-help approaches to condition to condition
management.
4
Demographic data on BME communities
The most reliable source of demographic data for local BME populations is
the 2001 Census. However, this does not take account of recent changes
in migration of population groups. Different datasets and population
projections have been developed since 2001 but these show a lack of
consistency with definitions and categories of racial groupings2.
Based on 2001 Census figures the non-white BME population of the
BCUHB region is 1.2% of the total population. This compares with a
population of 2.1% for Wales and 7.9% for the UK as a whole. A more
recent report produced by Conwy Local Health Board and North Wales
Race Equality Network (NWREN)3 suggests that the entire BME population
of North Wales has risen by between 30 - 50% since 2001. The diversity
of ethnicity in the area, including white minority groups, is represented in
the diagram below based upon 2001 Census figures:
BME population and makeup of North Wales3
The BME population in North Wales is dispersed widely in both rural areas
and towns. BME populations are clustered also in parts of the University
City of Bangor along with Cardiff, Central Newport and parts of Swansea4.
Date: 9 June 2010
Version: 1
Page: 5 of 12
Public Health Wales
Improving access to health promotion for BME communities
The development of Wrexham as a University town may also suggest a
presence of higher numbers of BME groups. NWREN states also ‘the BME
population of North Wales is not a homogenous entity and the potential for
isolation and /or rural racism is evident’5.
5
The health needs of BME groups
As with the majority white population group, the health status of BME
populations is influenced by a range of wider factors including age,
gender, disability, lifestyle, cultural issues and socio-economic and
environmental factors; all of which should be taken into account when
interpreting epidemiological data. For the BME population it is
acknowledged also that experiences of discrimination and racism may
contribute to health inequalities and poorer health outcomes.
Reliable, health specific information on BME communities in Wales is
limited. The evidence referred to below relates to the BME population
generally and is included with the assumption that it is relevant also to
population groups in Wales.
5.1
Health status
Data 6 7 8 suggest that BME groups suffer from the same common health
conditions as experienced by the majority white population i.e. cancers,
circulatory diseases, diabetes and mental illness. However of these
diseases and conditions some are more common amongst BME groups
than amongst the indigenous population and which have implications for
lifestyle and health promotion interventions. These include:
 Diabetes Mellitus. This is much more common in Afro-Caribbean and
South Asian minority groups than in the population as a whole.
Diabetes UK9 suggests that it is up to six times more common in people
of South Asian descent. Causes of the high rates are likely to be a mix
of genetic, lifestyle, environmental and socioeconomic factors.
 Coronary Heart Disease. This is moderately higher in South Asian
groups than in the population as a whole, with increasing evidence that
the poorest groups of Pakistani and Bangladeshi origin have the highest
rates. Reasons for this are not fully understood but evidence suggests
that socio-economic and lifestyle factors are important. Coronary heart
disease is also a main cause of mortality in other ethnic groups,
including Afro-Caribbean and Chinese, even though the rates are lower
than in the population as a whole.
Date: 9 June 2010
Version: 1
Page: 6 of 12
Public Health Wales
Improving access to health promotion for BME communities
 Stroke. This is highest in Afro-Caribbean men but rates are relatively
high in the Chinese and South Asian groups. The major known
associated risk factor is high blood pressure, which is extremely
common in Afro-Caribbeans.
 Lung cancer; cancer of the liver; cancer of the prostate. Overall,
cancers tend to be less common in BME groups than in the ‘white’
comparison population but should still remain a consideration. Lung
cancer remains the top ranking cancer in men, particularly in South
Asian groups where smoking rates are higher than the majority
population.
 Infectious diseases such as tuberculosis and malaria. The likelihood is
that these are linked to travel, migration, immunity and living
conditions in the UK.
 Mental Illness: Data on prevalence of mental illness amongst BME
groups is conflicting particularly when trying to distinguish ethnic
differences linked to psychoses and neuroses. In the United Kingdom
African-Caribbeans have higher admission rates to psychiatric units and
receive a diagnosis of schizophrenia more often than do members of
other ethnic groups. Studies on the use of treatments have suggested
that African-Caribbeans have low rates of depression and South Asians
have low rates of all mental illnesses. Mental Health Race Equality
Schemes developed in North Wales provide a more detail account of the
local situation and how it is monitored.
 Nutrition. Studies have shown that Black and Asian women are more
likely to have calcium intakes below recommended levels, compared
with white women. Other diet-related problems that are more common
in BME groups include vitamin D and iron deficiencies amongst South
Asian children under 2 years.
5.2
Lifestyles
As with other areas of health there is limited data and research on
lifestyles of ethnic minority communities10. For example, the Welsh Health
Survey provides information on mortality, morbidity and lifestyles but
does not capture large enough groups to merit analysis by ethnicity.
In relation to smoking prevalence, self reported smoking amongst
Bangladeshi men was 44% in the 1999 Health Survey for England
compared with 27% in the general population7. Gill et al6 suggest that a
Date: 9 June 2010
Version: 1
Page: 7 of 12
Public Health Wales
Improving access to health promotion for BME communities
smaller proportion of BME population groups have given up smoking
compared with the majority population.
Research on diet and nutrition8 has shown that the average Body Mass
Index (BMI) of BME groups from South Asia and China was lower generally
than that of the majority white population. Amongst the Afro Caribbean
communities the BMI is higher. Use of salt in cooking was higher in most
minority ethnic groups than among the majority population and knowledge
of the links between diet and cardiovascular and other specific diseases
was poor in general, particularly among Bangladeshi people.
6
Access to Health Promotion Services
Evidence suggests that BME population groups experience the same range
of common health problems as the majority white population. This
suggests that the health promotion needs of BME groups may be very
similar to the majority population. To improve equity of access to services
Gill et al6 suggests that the methods for targeting and delivery may
require a different, flexible approach.
6.1
Barriers to accessing health promotion
Of the limited research available, the health ASERT study7 explores the
evidence base for health promotion services for BME populations,
identifies barriers to access and suggests solutions to issues of inequity.
Themes are consistent with those identified by Gill et al6 and include:
 Policy and strategy development
Obstacles to developing policies and strategies relate in the main to lack of
consistent data, insufficient assessment of health promotion needs, small
numbers of BME populations or the lack of knowledge about how to
engage with BME communities.
It is suggested also that services are
reticent to invest in specific and or small communities.
 Communication
Approaches to communication require the same generic considerations in
common with the majority population. For example, the importance of
being given time, listened to and being offered advice and information
appropriate to cultural and linguistic needs. Other areas of concern
include the availability of interpretation services for face to face or
telephone conversations and opportunities to talk with health professionals
in a shared language.
Date: 9 June 2010
Version: 1
Page: 8 of 12
Public Health Wales
Improving access to health promotion for BME communities
 Provision of information
Health related information can be provided in a number of different ways
for example: leaflets, books, letters, T.V., video, internet, face to face, or
phone. Fluency in English, literacy levels and access to various forms of
media must be considered when disseminating both targeted and generic
health promotion information. Provision of information in community
languages may be also be appropriate.
 Physical access to services
As with the majority population, services need to be physically accessible
in terms of location and disability access. A preference for community
based services has been stated amongst groups for whom cultural and
religious factors should be taken into account. Gill et al6 refer to two
randomised trials on the uptake of breast and cervical screening and
although results may not be generalisable there is evidence that home
visits were effective.
 Cultural competence of service providers and health
professionals
Health professionals’ awareness of cultural issues is important in all areas
of service delivery including the delivery of health promotion
interventions. An example given by Winckler10 shows that diabetes health
promotion amongst BME groups is more effective if dietary advice
accorded with their usual or traditional diet.
6.2
Improving access to and uptake of health promotion
programmes
Summarised below is a range of solutions for improving local access to
health promotion activity by the BME population, identified by both the
Health ASERT research programme.
Develop a stronger evidence base to support action:
 Ensure that new approaches to health promotion are based upon
existing evidence where available
 Approaches and methodology should be evaluated for effectiveness
 Encourage individuals and communities to participate in research,
evaluation and needs assessment activities
 Establish the community’s views and aspirations on health promotion
and lifestyle issues
 Strategies and policies to address health promotion needs should
straddle all public services
Date: 9 June 2010
Version: 1
Page: 9 of 12
Public Health Wales
Improving access to health promotion for BME communities
Communication:
 Consider providing health information in diverse media that are
favoured by local BME communities
 Use existing communication methods and networks within local BME
communities
 Health promotion information could be made more accessible by using
local networks and trusted individuals or ‘champions’
Cultural competence:
 Ensure that staff receive relevant training aimed at enhancing cultural
competence. This should be delivered in addition to mandatory equality
and diversity training.
It should be acknowledged here that the suggestions referred to above are
applicable equally to the delivery of all healthcare services for BME
populations and have been recognised to a great extent within Race
Equality Schemes of the former Local Health Boards and NHS Trusts of
North Wales and in the current Single Equality Scheme of BCU HB.
7
Conclusions and recommendations
Population figures for BME groups in North Wales are relatively small
compared with other areas of Wales and the UK. Discussions and research
suggest that this may create a barrier to both recognising and
understanding the local BME population’s health needs. Data collection on
disease and ethnicity appears to be limited and inconsistent therefore
measuring the effectiveness of interventions will be problematic until the
quality and completeness of the data improves. Gill et al suggest that the
challenge for health service planners is interpreting and using the existing
data in ways that benefit the population.
The BME population should be seen not as an homogenous group but as
people with diverse needs based not only on ethnicity but also on
disability, gender, sexual orientation, religion and wider social and
economic determinants. Rather than concentrating on specific health
issues relevant to one particular group in the community attention should
be placed upon equitable service provision.
Based upon both the available research and discussions locally with
NWREN the following recommendations are made for consideration to
improve access to health promotion interventions for BME communities in
North Wales:
Engaging with BME communities in North Wales
 Make the best use of expertise in the voluntary sector to access
community groups
Date: 9 June 2010
Version: 1
Page: 10 of 12
Public Health Wales
Improving access to health promotion for BME communities
 Strengthen links with the North Wales Race Equality Network (NWREN)
to identify opportunities for communicating with local groups in ways
that do not over-burden the community with consultation
 With NWREN, identify existing local groups and networks through which
to promote services and to identify preferred methods of delivery
 Consider the use of NWREN website to communicate on health related
information and services
 Recognise that some individuals within the BME community also use
Welsh as a first language
 When working with targeted groups on specific projects translation of
materials should be considered
 Promote the use of language line to facilitate improved access to
services such as smoking cessation.
Workforce training
 Equality and diversity training provides staff with a broad knowledge of
equalities issues and legislation and the importance of equality impact
assessment of projects and strategies. Additional training should be
considered locally to build confidence in cultural awareness and
culturally sensitive issues
 Public Health Wales teams in North Wales should liaise with BCU HB to
identify opportunities for networking, joint training and development of
joint initiatives.
Identify existing examples of good practice and opportunities for
joint working
 Liaise with Screening Promotion Services to raise awareness of other
activities and health issues e.g. smoking cessation, breast feeding,
sexual health services and opportunities for promoting mental wellbeing
 Local agencies including Public Health Wales, BCU HB, local authorities,
other public bodies and the voluntary sector should consider joint
opportunities for health promotion activity and needs assessment work
with BME communities.
Date: 9 June 2010
Version: 1
Page: 11 of 12
Public Health Wales
Improving access to health promotion for BME communities
References
1. National Public Health Service for Wales, (2009). Healthcare planning
and service development guidance for specific vulnerable groups in
Wales. 2009 Update.
2. Public Health Wales (2009) Demography Profile
3. Conwy Local Health Board & NWREN (2007) ‘Race Equality in Practice’
Resource Pack
4. National Public Health Service for Wales, (2004). A Profile of the health
of children and young people in Wales.
5. http://www.nwren.org.uk/english/info-population-allwales.htm
6. Gill, P. et al, Health Care Needs Assessment Third Series (2007) Black
and Minority Ethnic Groups, University of Birmingham
7. Welsh Assembly Government, (2005) Health ASERT Programme Wales
Enhancing the Health Promotion Evidence base on Minority Ethnic
Groups, Refugees/Asylum Seekers and Gypsy Travellers
8. Stockley, L. (2009) Review of Dietary Intervention Models for Black and
Minority Ethnic Groups. Food Standards Agency, Wales.
9. http://www.diabetes.org.uk/Professionals/Conferences_and_events/Te
aching_aids/Diabetes_awareness_toolkit
10.Equality issues in Wales: a research review (2009). Research Report
Equality and Human Rights Commission ed. Winckler, B. The Bevan
Foundation
Date: 9 June 2010
Version: 1
Page: 12 of 12