and providing services for the Asian population: a survey of District Health. Authorities. L. J. DONALDSON, M.SC., M.D., F.R.C.S.(ED.), M.F.C.M.,. Senior Lecturer ...
199
The Journal of The Royal Society of Heaa‘Z1 VOLUME 104 NO 6
and
DECEMBER 1984
providing services for the Asian
Planning population: a survey of District Health Authorities
L. J. DONALDSON, M.SC., M.D., F.R.C.S.(ED.), M.F.C.M., Senior Lecturer in Epidemiology and AILEEN ODELL, B.A.(HONS.), Research Assistant, University of Leicester INTRODUCTION S IS THE case with other groups within the popufor example, the elderly, pre-school children, residents of inner cities people belonging to ethnic minority populations have special health needs. Many of the traditional British ethnic health issues have been concerned with infectious and parasitic diseases’~2, nutritional disorders3~4, mortality in early life’,’, or have dealt with special problems (such as Sickle Cell Anaemia). Only latterly have there been attempts to study, more generally, differences in the pattern of disease between ethnic minority and indigen-
lation
-
-
populations’ ,8,9 specific investigations of disease occurrence, routinely available information is necessary to allow the health needs of any community to be assessed and monitored and for health services to be properly planned and provided. These tasks, the responsibilities of District Health Authorities throughout the country, are made difficult, where ethnic minority populations are concerned, by a paucity of such basic data at a local level. The omission of a question on ethnic origin from the 1981 Census’o,
ous
,
Aside from
means
that
even
the determination of the size and struc-
ture of these
populations is not a straightforward matter. The use of systematically collected health records in this
hampered by the fact that few systems include valid information on ethnic group. Given these circumstances, we decided to discover what information bases had been established at a local level, to what extent special services were being provided for the ethnic minority population and whether training and research was taking place on transcultural health issues. We restricted our enquiry to the Asian ethnic minority population, because this population is not only one of the most numerically important minorities living in Britain but also is characterised by sharp cultural differences. It therefore constitutes a group who would be likely to encounter the greatest difficulty in the interface with health services. Work already being undertaken on various aspects of the health of this population had highlighted the problem created by the paucity of sound demographic and health information. We, therefore, wished to determine how widespread this problem was. context is also
METHOD THE STUDY population was all 201 District Health Authorities in England and Wales. A postal questionnaire was sent to these Authorities to elicit information about the following four main subjects relating to the Asian communities within their Districts: (a) Population data the availability and source of information used to estimate the size and composition of their Asian population; (b) Routine health records the extent to which data -
Correspondence and reprint requests should be addressed to :Dr. L. J. Donaldson, Department of Community Health, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, P.O.
Box 65, Leicester LE2 7LX.
-
200 ethnic origin were collected or recorded; (c) Special service provision - whether services were provided to take account of the special needs of the Asian population (e.g. labelling of medicines, dietary needs in hospital, health education and the provision of translated material, use of interpreters in different health service settings); details of in-service (d) Training and research training of medical and other health professionals on on
-
cultural and health issues of Asians and of relevant research projects undertaken concerning the health needs of the Asian population within their District. The meaning of ’Asian’ in this study was a person not of United Kingdom descent who originated from India, Pakistan or Bangladesh or a person of Indian or Pakistani descent who originated from East Africa. Only those Authorities with Asian populations larger than 500 were asked to complete all sections of the questionnaire. The initial point of contact with each Authority was the District Medical Officer. After two mailings a total of 169 authorities (84% of the total) returned questionnaires. However, of those returned, 27 were not completed either because no information was available or there were insufficient resources to complete it. RESULTS FOR THE majority (92%) of responding authorities, estimates of the sizes of their populations of Asian origin were derived from the Census (Table 1). However, 11 % (15 authorities) were working with modified census estimates. These data had been created either by incorporating locally collected information (for example, that produced by the Community Relations Council) or derived by using sources (such as notifications of births, child and school health records) to take account of children born within the district to parents of Asian origin. The remaining 8% (11 authorities) used estimates from sources which did not involve the census data at all. In the main, these data were obtained from local surveysmostly conducted by the Community Relations Council; two authorities used information from the National Housing and Dwelling Survey. Table 1: Sources ofestimates ofAsian population used by District TaM~ Authorities (Percentage using each source)
Health
main agency concerned, other initiatives had included, for example, analyses of electoral registers conducted by the local library service. A slightly higher proportion of authorities (21 %), with more than 500 people of Asian origin, knew further details (other than religion) of the cultural composition of their population, this was mainly the identification of various language speaking groups. The sources of this information were similar to the source of the religious composition data. Authorities were asked if ethnic origin was included as a variable in various health information systems and if so whether it was inferred from country of birth or derived by other means. Where the use of health data incorporated an indicator of ethnic origin, this was mostly inferred from country of birth, the use of methods other than country of birth was most notable in data systems concerned with infant or child health and infectious disease notifications. The most commonly cited methods were judging whether the patient’s name had an Asian appearance or, less commonly, whether the patient himself/herself had an Asian appearance. Almost three quarters (72%) of all District Health Authorities with Asian populations of more than -500 reported that they ran health education schemes directed at their Asian population or distributed health education material in Asian languages (Table 2). smaller proportions provided special services (e.g. clinics) for them (other than interpreters) or had run any in-service training courses for medical and/or health professionals on the cultural and health issues of Asians (31 % and 29% respectively). Most authorities reported that they were able to cater for the special dietary needs of Asians in at least some of the hospitals within their District, 52% said that this was the case in all hospitals and 26% in some hospitals. Very few, however, (6%) labelled medicines in the languages spoken by their Asian population. Table 3 examines the provision made for dealing with language difficulties which may arise in health settings. In the majority of settings a heavy reliance is based upon informal solutions such as the use of lay and volunteer interpreters, usually members of the family, and the language skills of staff. Fewer authorities reported using more formal means such as translated literature and
Much(
employing interpreters. Thirty-one per cent (35) of authorities, with more than 500 Asians, reported that they had carried out, or were in the process of undertaking surveys or projects
popular-(
concerned with the health needs of their Asian tion. The kinds of research which were reported summarised in Table 4.
Table 4 : Research undertaken by District Health Authorities *data
on source were not
obtained from two authorities
Slightly less than half (49 % ) of the 112 authorities with Asian populations greater than 500 were working with estimates which included details of the population by age and/or sex. Twenty-one authorities (19% of this total) reported that they knew details of the religious composition of their Asian populations. However, 8 of these 21 stated that the information was based on guesses or general impressions, the remainder relied on locally-generated ethnic minority information and, whilst the Community Relations Council was again the
*Some Authorities stated
more
than
one
research
topic
are
201 Table 2 : The extent to which various special provisions (other than interpreters) were made for Asians by District Health Authorities with Asian populations greater than 500
f provision made by District Health Authorities (with Asian populations greater than 500) for dealing with communication problems in health settings Percentage of Authorities
Table 3 : Types o
-
DISCUSSION THE APPROACH to the promotion of health, the prevention of disease, the planning and provision of services within the NHS is based heavily on the realisation that the community is not an homogenous entity. It is accepted that groups such as the elderly, pre-school children and the residents of inner cities must be carefully defined if their needs are to be accurately assessed and adequate attempts made to meet them. The same is true for the ethnic minority groups within Britain’s population. There are many areas where cultural differences may have potential implications for health, the risk of disease or the organisation and delivery of health services. Some of them are shown in Table 5.
I Table S: Areas where cultural differences have implications the provision of health services 0 0 0 0 0 0 ·
for health or
Uptake of services Presentation of illness Perceptions of health and disease Life-style and cultural practices Encounters with services Patterns of disease Use of alternative medicine
The results of the survey presented here concern one of these ethnic minority groups. They show that many District Health Authorities do not have available, as a routine, information such as population size and structure or morbidity data to allow them to address the health needs of the Asian population. The fact that a variety of approaches were being used to estimate population size (census data alone, with modification or a non-census source) perhaps most strikingly illustrates the difficulties which Authorities face in assembling even the most basic information necessary. This lack of uniformity of approach would not have been so apparent had an ethnic minority question been
included in the 1981 census’o. Its omission has meant that the main, standard source of nationally-collected demographic data, which can be supplied for local populations, provides only an indirect measure of the size and characteristics of the ethnic minority populations. Thus, since the 1981 census indicates the country in which a person was born, describing people by the country of birth of their head of household provides an approximation of the population of New Commonwealth and Pakistani ethinic origin (NCWP): most will either have been born in NCWP countries or will be children born in the U.K. but be still living with
parents’ 1. Even this indirect measure will lose its value as further
generations arise but, more immediately, it will not be possible to provide reliable estimates for the years beyond the census in 1981. Although, at a national level, the biennial Labour Force Survey12, a sample survey, takes a more direct approach to determining ethnic origin, it can only provide reliable estimates for the country as a whole or for large urban conurbations. It is clear from the data presented here that some District Health Authorities are already making use of locally collected information for planning purposes. This level of detail is essential. The fact that only a minority of authorities surveyed here had information about the cultural composition of their Asian populations poses a serious handicap to rational planning. The populations of Bradford, Birmingham, Southall, Tower Hamlets and Leicester all contain substantial numbers of ’Asians’ but these same populations are very differently composed. Whether an Asian man or woman is a Hindu, a Muslim or a Sikh; whether he or she came to Britain directly from India, Pakistan, Bangladesh or had lived, or been brought up, in East Africa may all be important influences on the kinds of health problems to be expected, and the appropriate approach to the planning and provi-
202 sion of services. The present survey also confirms that Authorities do not have available morbidity data which take account of ethnic origin. Country of birth was incorporated in some systems but, as previously mentioned, this has been shown to be a very unreliable measure: it is unable to identify Asians who were born in this country, and therefore produces a serious underestimate of the number of cases amongst them9. Despite the lack of an adequate information base, we have shown that many District Health Authorities are attempting to provide services which take account of the special needs of their Asian populations. This was most evident in relation to health education schemes and the provision of special diets in hospitals. A high proportion of authorities, also, made attempts to overcome problems of primary communication by the use of interpreters although this was usually by informal means such as using relatives, volunteers or the language skills of staff. The use of translated literature or employed interpreters were less common solutions to this problem. Those Authorities which provided training for staff on transcultural issues were still in the minority. CONCLUSION
long-term, the solution to the absence of adequate demographic data is to redouble efforts to secure the inclusion of a question on ethnic origin in the 1991 IN THE
Census. In the short term, all necessary encouragement (and commensurate financial support) must be given to conducting methodologically sound sample surveys at a local level to provide estimates of the size and structure of ethnic minority populations. It is important, too, that health information systems dealing with morbidity or contact with health services should also be capable of
the study of differences in disease patterns or service use between the different ethnic groups. It is only with such data that Authorities will have the necessary information on which to plan and provide appropriate services to meet the health needs of what, for many, is a numerically important problem. It will be essential, also, to furnish staff with the necessary knowledge, attitudes and skills concerning transcultural health issues. This will necessitate building upon the initiatives in training already in operation within some District Health Authorities.
allowing
.
z
REFERENCES ~
~
~
~
_
_
_
_
_
_
__
1 CLARKE, M., SAMANI, N., DIAMOND, P. Tuberulosis mort idity amongst immigrants: notification and hospitalisation. Community Med. 1979;1: 23-8. 2 STANFIELD, J. P., REID, D. Imported infections in children. J. R. Coll. Physicians Lond. 1980; 14: 232-7. 3 Anonymous. Exotic diets and the infant. Br. Med. J. 1978; i: 804-5. 1978; i: 804-5. 4 Anonymous. Rickets in Asian immigrants. Br. Med. J. 1979; i: 1744.
5 CLARKE, M., CLAYTON, D. G. Quality of obstetric care provided for immigrants in Leicestershire. Br. Med. J. 1983; 286: 621-3.
Asian 6 GARRATT, N. Health Problems of ethnic minorities. In. Smith A
Edinburgh
Recent Advances in Community Medicine 2. Livingstone, 1982: 143-155. Anonymous. Ethnic differences in common diseases. Postgrad. Med. J. 1981; 57: 745-93. 8 Anonymous. Ethnic differences in common diseases. Postgrad. Med. J. 1983; 59: 615-73. 9 DONALDSON, L. J. and TAYLOR, J. B. Patterns of Asian and nonAsian morbidity in hospitals. Br. Med. J. 1983; 286: 948-51. 10 1981 OFFICE OF POPULATION CENSUSES AND SURVEYS. Monitor
(ed).
Churchill
7
—
11
12
Census. London: OPCS, 1980/ (Cen 80/81). Anonymous. Sources of Statistics on ethnic minorities. Trends 1982; 28:1-8. Labour Force Survey 1979. London: HMSO 1982.
Population
