Diversity & Equality in Health and Care

In the UK, Black and Asian Minority Ethnic (BAME) patients are less likely to access palliative care services than their White counterparts. An increasingly diverse population makes this a cause for concern. This paper describes a project in Leicester to discover what members of the BAME communities knew about palliative care and the providers of hospice services; what they thought the barriers were to their use of these services; and how they would like to find out about them. Informal discussion groups were used as the vehicle for information gathering; accessing communities to develop such groups posed specific problems. Two project workers made notes during and immediately after the discussion groups. These were thematically analysed. Findings suggested that knowledge about palliative care was scant, though much valued when understood. Cultural and religious strictures on using palliative care services or a palliative care approach were not demonstrated, though others, including considerable concerns about food when an inpatient, were deemed of importance. The need to know what is locally available, and how to access those services, was uniformly agreed, and the information given warmly welcomed, even by those with reservations.

This paper examines understanding of mental health and the extent to which statutory and voluntary mental health services in Birmingham are meeting the needs of members of a range of black African and African Caribbean communities. Qualitative data were collected through nine focus groups and four individual in-depth interviews. Using a purposive sampling strategy, 25 service users and 24 carers were recruited. Interviews were recorded, transcribed and analysed using Krueger's framework. The participants understood mental illness as a social problem linked with material and social deprivation, racism, and an inappropriate response to the treatment of mental and physical illness. Lack of respect and understanding in relation to religious and spiritual beliefs was a cross-cutting theme. While appreciating the positive aspects of medication, the participants raised concerns about interaction with recreational drugs, the dosage of prescribed medication, and equity with regard to accessing talking therapies. Engaging users and carers in a care pathway, acknowledging users' health beliefs and the importance of spirituality in healing, the provision of alternative interventions and working closely with voluntary organisations and spiritual leaders are recommended for improving clinical outcomes and patient-centred care.

This paper draws on interviews conducted for a wider oral history research project that focused on the experiences of South Asian doctors who worked as general practitioners in the UK's National Health Service (NHS) between the 1940s and the 1980s. It uses the evidence gathered to reflect on what doctors' experiences can tell us about the nature of racism in the NHS today. The doctors' narratives suggest that the discrimination faced by migrant and ethnic minority doctors has been multifaceted and their ability to avoid or challenge it has been underestimated. The existence and persistence of racism in British medicine is a well-documented phenomenon. Little attention has been paid to the understanding that can be gleaned from instances where migrant and BME doctors talk about not having experienced racism or about having been successful in overcoming it. Nor do we have a detailed understanding of the range of experiences of discrimination and racism that migrant and BME practitioners have. The paper draws on theoretical notions of 'heterophobia', understood here as fear of difference, and psychological function to explore these issues. Discrimination affecting migrant and ethnic minority practitioners appears in these narratives as a complex and multifactorial process that is susceptible to disruption by individuals and groups. We conclude that the NHS should be conceptualised as a racist and 'heterophobic' space where difference in a broader sense interacts with race. Closer analysis of how some doctors are able to function in such an environment can advance our understanding of discriminatory processes. Reframing our view of racism in this way and engaging with the experiences of a previous generation of migrant doctors can assist the NHS, organisations representing migrant and BME doctors, and individuals in devising successful strategies to challenge racism, 'heterophobia' and discrimination.

An exploratory qualitative study design was adopted for this study and underpinned by Rex's migrant workers framework (Rex, 1999). Semi-structured interviews were conducted with ten ward managers from four NHS trusts in the north-east of England to gain an insight into their experiences of working with black African nurses with regard to equal opportunities in accessing professional development and promotion. Managers reported that black African nurses experienced racism from patients, racism from colleagues, discrimination and lack of equal opportunities. A unique finding of the study was that managers stereotyped black African nurses as lacking motivation for professional development and promotion. The authors recommend that NHS ward managers receive training in implementing antidiscrimination policies and valuing equality and diversity.

People living with HIV/AIDS face significant psychological and social problems in addition to their physical condition, primarily related to AIDS stigma and discrimination. This stigma is profound in Saudi Arabia as Islam prohibits behaviours associated with risk factors related to transmission of HIV, such as non-marital sex, homosexuality and intravenous drug use. In this study qualitative research methodology using narrative interviews was used to explore the experiences of people living with HIV/AIDS in Saudi Arabia. Data were collected from 18 male and female participants. Interviews were conducted in Arabic and each interview lasted 30 to 60 minutes. The interviews were transcribed, translated and analysed using a descriptive phenomenological approach until saturation of themes was achieved. Data analysis revealed five main themes: stigmatisation, disclosure, fear and vulnerability, lack of psychosocial support, and religiosity. Societal attitudes towards HIV/AIDS were a key factor in stigmatisation, which leads to discrimination and stereotyping. Participants experienced a negative self-image, feelings of shame and a threat to self-worth. Disclosure (when and to whom) of their positive HIV status was a great concern, while non-disclosure was a protective measure against stigmatisation. Confidentiality of HIV status was very important and people feared disclosure by the healthcare team to others. Fear and vulnerability included fear of punishment from God, fear of being discovered as HIV/AIDS-positive and fear of the future and death. Participants experienced isolation and lack of psychosocial and emotional support. In response to their experiences all participants accepted their diagnoses as destiny (ghader) and became more religious, using spirituality as their main coping strategy.

Carers of stroke survivors face significant burdens, and increased carer strain has negative implications for both the stroke survivor and the carer. There are limited data on carer strain in the British Indian UK population. In a prospective cohort of White British and British Indian stroke survivors and their carers, we report the incidence of carer strain in each ethnic group, describe patient and carer characteristics, and identify predictors of increased carer strain. Forty-nine participants and their carers were of White British origin and 24 of Indian ethnic origin, whose first language was Gujarati or Punjabi. Multidimensional outcome measures were used to assess the physical and cognitive function in stroke survivors at one month and 3–6 months (final follow-up) from stroke onset. Levels of carer strain were assessed at the same time points using the Carer Strain Index and the Hospital Anxiety and Depression Scale. Statistical significance for difference in patient and carer characteristics between White British and British Indian groups was assessed. Logistic regression models were used to identify predictors of carer strain. British Indian stroke survivors had poorer scores on cognitive assessment (Mini Mental State Examination median 21, IQR 10.5–26.5 in British Indian, versus median 28.5, IQR 20–30, p=0.001) at one month. British Indian carers were younger, and reported higher levels of anxiety and depression at one month (median Hospital Anxiety and Depression Scale subscore depression 3.5 in White British, versus 7 in British Indian, P=0.002, median hospital anxiety and depression score total 10, versus 14, P=0.012). Twenty-four percent of all carers showed evidence of elevated carer strain (CSI>6) at one month, and 30% at final follow-up. There were no differences in levels of carer strain between the two ethnic groups. These findings will inform future research, and in turn, may help to guide population-targeted interventions aimed at reducing carer strain.

This ethnographic study used an interpretive theory of culture to investigate the principles and factors underlying the delivery of culturally competent nursing care. Initially, a theoretical view was derived from the nursing literature, which led to the development of the Five Steps Model of cultural competence (Quickfall, 2004). This model incorporates organisational values, cultural awareness, cultural sensitivity and cultural knowledge (Papadopoulos, 2006). Study methods included observation, individual face-to-face interviews and focus group interviews to consider how community nurses used cultural competence in their practice with asylum seekers and refugees. The data were analysed for their categorical content. Three major themes emerged from the study as major influences in the delivery of culturally competent care: the need for equitable service provision, the cross-cultural promotion of health as a partnership process and the importance of aiding adaptation to a new social environment. The revised model incorporates these themes.

Breast cancer is one of the most common forms of cancer in the UK, and affects women of all ethnic groups. The psychosocial impact of breast cancer has been well documented. However, research conducted in this area has been primarily focused on white women. There is very little work within the breast cancer literature that captures the experiences of black and minority ethnic (BME) women. The aim of this qualitative study was to explore the experiences of breast cancer diagnosis and treatment in black and South Asian women living in the UK. Individual semi-structured interviews were conducted with 22 English-speaking breast cancer survivors (11 black and 11 South Asian women). Thematic analysis of the data revealed five key themes, namely social support, spirituality, body image concerns, healthcare experiences and life after cancer. The findings showed that although the BME women shared similar concerns to white women, their experiences were also influenced by cultural specific concerns. This study has implications for healthcare professionals and recognises the need to provide culturally sensitive care and support to BME women, tailored specifically to their values and beliefs.

This qualitative study explored the experiences of health visitors working with refugee and asylum-seeking families in central London, and assessed the dimensions of their cultural competency using Quickfall's model (Quickfall, 2004, 2010). In-depth interviews were conducted with 14 health visitors. Data were analysed using Framework, a thematic-based analytical method. The findings revealed that the health visitors demonstrated aspects of culturally competent care in relation to Quickfall's five-step model which was developed from the literature specifically for working with asylum applicants within a primary care setting. Shortcomings with regard to demonstrating cultural competence were related to working for an organisation whose work is governed by external factors such as national legislation and policy. In addition, the complexity of the needs of these vulnerable populations and limited resources sometimes compromised the cultural competence of the health visitors. However, they showed many positive examples of how they provided equity, access and non-discriminatory services, health promotion and socially inclusive services.

An ethnically diverse healthcare workforce is considered beneficial to meeting the needs of an ethnically diverse population. In the UK and the USA, lack of equality and difficulties in communication between co-workers and patients from different ethnic backgrounds is problematic. Little is known about the ethnically diverse healthcare workforce in elderly care settings in Sweden. This paper compares native Swedish and first- and second-generation immigrant healthcare workers' perceptions of diversity in relation to equality and communication in elderly care settings. The study used a cross-sectional design with a survey administered by self-completed questionnaire. The Assess Awareness and Acceptance of Diversity in Healthcare Organizations questionnaire was distributed to healthcare workers in elderly care settings in one municipality in Sweden. Responses from 643 healthcare workers were analysed. A factor analysis was performed on 26 items in the questionnaire. Reliability analysis on the subscales was conducted using Cronbach's alpha. Differences between native and first- and second-generation immigrants were analysed using ANOVA followed by post-hoc tests. The results showed that first-generation immigrant and native Swedish healthcare workers had different views on equality and communication in four of the five subscales, namely care of elderly patients from different backgrounds, equality in the workplace, communication with diverse co-workers, and treatment by family and significant others from a different ethnic background. Second-generation immigrants held similar views to native Swedish healthcare workers on two factors, namely equality in the workplace and communication between co-workers from different backgrounds. There were no differences between the groups with regard to their views on self-awareness in collaboration with co-workers. Differences in the experiences of first- and second-generation healthcare workers should be acknowledged, rather than assuming that they share similar experiences as immigrants. Managers need to promote equality and effective communication among an ethnically diverse workforce.

The 2003 Institute of Medicine (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (National Research Council, 2003) provides, through comprehensive reviews, strong evidence of health disparities in healthcare in the USA. In the article entitled 'A life course perspective on how racism may be related to health inequities', the authors cite the IOM study, in addition to numerous other studies that demonstrate racism's contribution to health disparities, and describe a number of approaches that have been adopted in an attempt to at best eliminate, and otherwise at least diminish, these disparities. In this paper the authors propose a new approach to the study of health inequities which uses a life-course structure that can be helpful in future health disparities research. This structure has the potential to create new and more comprehensive solutions. They also provide an extensive literature review of various approaches taken to combat racialised inequality, and these form a foundation on which to base further study.

A number of reports indicate that cultural barriers may prevent members of ethnic minority groups from accessing diabetes services, but little is known about the specific nature of these barriers. This systematic review of observational studies aimed to identify and explore cultural barriers as a basis for improvements in care. Articles published from inception to September 2011 were retrieved from four databases (Medline, CINAHL, Cochrane and DARE), two National Health Service specialist libraries (Diabetes, and Ethnicity and Health), Warwick Medical School publications and reference lists. Inclusion criteria were qualitative or quantitative studies involving ethnic minority groups with diabetes. Two reviewers independently conducted paper selection and appraisal. A total of 316 studies were retrieved, 22 of which were included in the review. Due to the heterogeneity of the studies, a narrative analysis was undertaken. Eight key cultural issues emerged, namely participants' strong adherence to cultural norms, religious beliefs, linguistic diversity, low health literacy levels, different beliefs about health and illness, belief in expert and professional support, low accessibility of culturally appropriate services/information, and low concordance with western professional advice. These issues compromised the level of diabetes care services received by members of ethnic minority groups. It is recommended that further attention is given to the development of culturally competent interventions for improving access to healthcare and diabetes outcomes for members of specific ethnic minority groups.

Like many other countries, Germany has an increasing number of children who originate from migrant families. Medical facilities are required to care for people from a diverse range of social and cultural backgrounds. A study-specific questionnaire was used to ask 100 child and adolescent psychiatrists about their impressions of how well the mental health needs of the children of migrants are identified and managed by child and adolescent psychiatric practices in Germany. There was a generally positive attitude towards migrant families and their needs, with most of the respondents indicating that they enjoyed working with migrant children and adolescents and their families. However, there was a tendency to focus more on language than on other aspects of culture. Most of the respondents felt satisfied with their training in this area. Individual difference variables, such as age, gender and familiarity with migration, affected their awareness of and sensitivity to migrant family health issues.

There is robust and compelling evidence of the pervasiveness of health disparities experienced by groups with limited English proficiency and other diverse communication needs. These disparities have a significant impact on the quality of care and healthcare outcomes. This paper describes the institutional efforts of the H. Lee Moffitt Cancer Center and Research Institute in responding to the diverse language and communication needs of its patients and their families. Information is presented on Moffitt's approach to the development and implementation of comprehensive language and communication services in a hospital-based setting. Moffitt's Language Services Program is designed to improve access to and care of patients with diverse language and communication needs by offering high-quality, culturally competent and professionally delivered interpretation and translation services, in a centralised and consistent manner. The programme includes face-to-face and telephone medical interpreting, video remote interpreting (VRI) (verbal and signed), and translation (written) at no additional cost to the patient. This Language Services Program provides an example to other healthcare institutions, particularly cancer centres, with regard to building the necessary critical structures and implementing promising strategies to meet the language and communication needs of all patients and family members.

Māori have the right to high-quality, appropriate care in all health settings. This study aimed to determine the perceptions and preferences of Māori for end-of-life care in a hospice. A Kaupapa Māori approach to research shaped this qualitative pilot study. Data were collected using semi-structured interviews with five elders from Māori communities and two focus groups with seven family members of Māori patients who had recently received hospice care. Thematic analysis identified (1) that participants perceived hospice as like a hospital, a place where people died, (2) what they appreciated and wanted from hospice, such as family-centred endof-life care and respect for Māori cultural practices, (3) what they perceived as problems and barriers to receiving hospice care, and (4) their potential solutions to these problems, such as community information seminars about the breadth of hospice services. These findings have implications for how Aotearoa/New Zealand hospices can ensure appropriate care for Māori patients and their families, as well as for clinicians and other hospice staff who aim to provide culturally sensitive care.

Background: Institutional delivery is the key intervention to reduce maternal mortality and morbidity. However, most of the mothers in developing country including Ethiopia are giving birth at home. This study, therefore, aimed at filling the gaps, by attempting to explore the factors which are affecting an institutional delivery service utilization in study area. The main objective of this study was to assess magnitude and factors affecting institutional delivery in women who have antenatal follow up at Hawassa referral hospital, Hawassa, south Ethiopia. Methods: A descriptive hospital based cross-sectional study was conducted among randomly selected 257 pregnant women. Interviewed a structured questionnaire including socio demographic characteristics and factors affecting institutional delivery. Data entry was done by using EPI Info 3.5.1 and exported to SPSS version 20.0 software package for analysis. Results: Among pregnant women 83.2% (n=139) at age group of 15-24 years old mothers give birth at health facilities. While 94.4% (n=17) of the mother at age group of 25-29 years old were give birth at home. Most of the pregnant mothers 76.1% (n=150) were prefer to give birth at home, because of different factors such as, privacy 102 (39.7%). Majority of the mothers 76.7% (n=197) were give their recent birth at health facilities. Most of the time institutional delivery was decided by both husband and wife 78.7 %(n=155). Conclusion: The prevalence of institutional delivery was high. This could be achieved due to high ANC utilization and health education. Therefore, efforts should be made to sustain ANC utilization in the study area. Keywords: Delivery; Institutional delivery; Magnitude; Ethiopia

Background: Occupational Therapy as a profession must diversify its workforce to meet the needs of a diverse population. The recruitment and retention of students of color or racial minorities is necessary for a racially diverse workforce. Faculty of color mentors are integral for the retention and success of students of color. This research explored the lived experiences of a recent graduate of color and a faculty of color in a mentoring relationship. Method: Semi-structured interviews were developed to gain insight into the assets, challenges, and environment of the mentee and mentor of color. A phenomenological approach was utilized with a convenience sample of two participants from a health science university in the United States of America. The data was analyzed using the Kawa model as a lens. Results: Four common themes arose from the interviews: (a) racial, cultural, and class backgrounds were strengths, (b) sympathetic supports needed for validation, (c) lack of representation were barriers, and (d) predominantly white institutions may not be inclusive and may also contribute to the maintenance of health disparities. Conclusion: The findings of this study focus on the need for quality mentorship, spaces and opportunities to dialogue about race and racism, and institutional structural support for the recruitment, retention, and success of both students and faculty of color in academia. Keywords Afro Latina; alumna; alumni ; mentoring; non-dominant; people of color

Human Trafficking is becoming increasingly recognised as a global public health epidemic with an estimated 45.8 million individuals affected by some type of exploitation. The effects of trauma and exploitation have profound health implications and often leave victims isolated from society. Victims of Human Trafficking are commonly associated with vulnerability, comorbidities, poor access to, and engagement with, healthcare services. Given this situation, an exploration of trafficking and access to healthcare was indicated. A focus group explored the experiences of six third sector workers in supporting victims of Human Trafficking. Thematic analysis was used and four overarching themes emanated: a call for improved access to treatment for victims affected by mental illness; improved knowledge and training of health professionals in identifying victims; the challenges for victims navigating two complex systems (National Referral Mechanism/Asylum Process) and victim’s self-identification. The findings highlighted the associated complexities that victims commonly face when accessing healthcare and emphasised the fundamental need for ensuring that equitable services are available. To enable safeguarding and individualised care to become embedded, a shift in culture and a move away from judging healthcare need on immigration status was recognised as a key requirement. Improved access to psychological therapy for victims was also suggested, alongside better education for all health professionals and frontline staff. To improve healthcare for victims of Human Trafficking in the ways recommended would require Government and National Health Service (NHS) support including increased financial and staff resources.

This study describes how research approaches the problems of access to services for children and adolescents. The aim is to identify approaches to 'the multicultural question' in relation to access to service, geographical origin, disciplines and methods. Two main approaches were identified in the review, namely culturally based and rights-based approaches, both equally preoccupied with problems such as the disproportionate representation of minorities. The culture-based approachwas influenced by a 'strong' notion of culture and was inclined to target problems of access at the counter (service delivery). The rights-based approachwas influenced by a notion of culture connected to agency and gave primacy to the gateway (recognition of eligibility). The field could benefit from more attention and possibly from further development of a rights-based approach, which implies a notion of culture that involves a connection to agency, a linking to power, participation and self-representation.

We examined disparities in medical and oral health status, access to care, and use of services in a nationally representative sample of adolescents from non-English primary language (NEPL) homes. Bivariate and multivariable analyses were performed on the 2003 National Survey of Children'sHealth to identify disparities in 40 measures of health and healthcare for adolescents aged 10-17 years (n = 47 159). Among adolescents from non-English primary language homes, sub-analyses compared Latinos and Asian/Pacific Islanders with white adolescents.Comparedwith adolescents from English primary-language (EPL) homes, adolescents from NEPL homes experienced many disparities, including being more likely to have suboptimal health (47% vs. 14%), suboptimal dental condition (65% vs. 31%), no health insurance (32% vs. 7%), nopersonal doctor or nurse (42% vs. 15%), problems obtaining specialty care (44% vs. 22%), never having seen a dentist (5% vs. 1%), and no preventive medical (44% vs. 26%) or dental (17% vs. 6%) visit in the past year. Compared with white adolescentsfrom EPL homes, Latino and Asian/Pacific Islander adolescents fromNEPL homes experienced disparities in medical and oral health status, having a personal doctor or nurse, and dental visits. Most disparities persisted in multivariable analyses. Compared with adolescents from EPL homes, adolescents from NEPL homes experienced multiple disparities in health and healthcare. Among adolescents from NEPL homes, Latino and Asian/Pacific Islander adolescents experienced specific disparities.