Diversity & Equality in Health and Care Open Access

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- (2013) Volume 10, Issue 2

Ironies and the iron law of unintended consequences

Mark RD Johnson MA PhD Dip HE (Warwick)1 and Paula McGee PhD RN RNT MA BA Cert Ed2

Editor, Diversity and Equality in Health and Care; Professor of Diversity in Health and Social Care, Mary Seacole Research Centre, De Montfort University, Leicester, UK

Editor, Diversity and Equality in Health and Care; Professor of Nursing, Faculty of Health, Birmingham City University, Birmingham, UK

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All absolutes are imperfect. All too often, however, interventions that are clear and, in the minds of their authors, unequivocal have almost the opposite effect. In the UK, the government continues to seek to deter people from moving to the UK to settle or work. Past experience should surely provide evidence of why this is not a good idea. Leicester City Council famously advertised in the Uganda Argus on 29 September 1972 that the city already had as many Asian people as it could handle, and that refugees from Amin’s terrors in Uganda should not seek to travel there. As they said, in bold type, ‘In your own interests and those of your family, you should accept the advice of the Uganda Resettlement Board and not come to Leicester.’ The outcome today is that Leicester became the first British city to have a minority of its population self-identified as ‘white British’, and a thriving economy based, in large part, on the businesses created by Ugandan refugees. Migrants, determined to make a new life, can revitalise communities that might otherwise be in decline. They bring new perspectives and challenge prevailing orthodoxies. These characteristics are to be welcomed, particularly in a time of economic recession which does not appear to be responding to more traditional solutions.

However, migrants not only unsettle ways of doing business or generating wealth. Their traditions, beliefs and cultures rub against those of their hosts, giving rise to a series of concerns on both sides. On each side there is a reawakening, a reappraisal of what has long been taken for granted. Who are we? What does it mean to be one of us? What do we believe in and value? Accompanying this is the creation of otherness and thus of ‘others’, those who are not ‘one of us’, who are perceived to be different in some significant way. This reappraisal plays out at different levels, from the personal to the societal. In the UK, we currently see attempts to define ‘Britishness’ and proposals to use this as a basis for reforming school curricula in ways that would airbrush out the contributions of earlier migrants. Fortunately, this incurred considerable publicity and the reinstatement of important figures, such as Mary Seacole, after a vigorous campaign which saw over 35 000 signatures to a petition in her defence, and a huge amount of media publicity which probably raised even higher the profile of Seacole and other notable figures such as Olaudah Equiano. Debates about the ‘proper’ content of officially endorsed history will continue, but sadly there are also proposals to limit migrants’ access to certain services. Although we accept that there are current economic constraints, we have concerns about closing doors to people who may in the short term need help, but who in the long term may have much needed expertise to offer.

Irony is best experienced and enjoyed in retrospect of course. Not all unintended consequences turn out to be beneficial, or even on the side of diversity. For example, the label of ‘political correctness’, and the tendency of professionals to shy away from being thought ignorant or insulting towards the cultures of minorities, can have devastating consequences.One example of such a case was the tragic death of Victoria Climbie´ because of a misguided sensitivity to ‘African’ culture or what were thought to be African family values (Department of Health and the Home Office, 2003). The papers in our current issue, notably those dealing with the population of African origin from Somalia and West Africa, provide valuable correctives to this, but on their own are not enough. Cultural sensitivity must not be confused with collusion, and we do need to think carefully about both our attitudes and our behaviours towards those who are seen as ‘other.’ We might well wish that other nations would emulate the approach of the USA in at least one respect. This year, April has been designated National Minority Health Month to help to raise awareness about the health disparities that continue to affect racial and ethnic minorities, and the healthcare law’s groundbreaking policies to reduce these disparities and achieve health equity. This year’s theme, Advance Health Equity Now: Uniting Our Communities to Bring Health Care Coverage to All (https://minorityhealth. hhs.gov/actnow), is a call to unite in striving towards a common goal of improving the health of all US communities and increasing access to good-quality, affordable healthcare for everyone.

In this issue

The health and well-being of those who occupy the margins of society are the dominant theme of this issue. We begin with a guest editorial by Marie O’Boyle-Duggan and Tony Johnson about people with learning disabilities. In these straitened times, people who are not economically productive are easy targets for administrations that want to be seen to be doing something. The notion of the deserving and the undeserving, which we hoped had gone away, seems to be fashionable again in some quarters; the undeserving are, by definition, not worth bothering with. For people with learning disabilities the consequences of this are dire. We hope that this guest editorial will provoke concern, and we would welcome more papers on this issue.

In the research papers section, we open with a study by Kramer and colleagues at the University of Pittsburgh, who report on an intervention in Dallas to tackle the apparent epidemic of diabetes in families of Hispanic origin by group lifestyle education (Kramer et al, 2013). In America, as in theUKand Europe, there is a poor evidence base on adapted and evaluated culturally specific interventions, despite the strong evidence of a need for this (Liu et al, 2012). The paper by Kramer and colleagues highlights, as expected, issues of translation, but also of practical barriers to compliance such as transport, child health concerns and marginal employment. Their intervention, unusually and helpfully, shows a ‘dose–response’-type relationship which is positive, that is, the more exposure there is to the educational programme, the stronger the impact, and a trial which has the desired effect at a statistical level of significance. There are clear implications for the management and support of diabetes prevention programmes in the UK and elsewhere in Europe, Australasia and any other countries where minority migrant populations show increased risks of developing this condition.

Taylor et al (2013) report on behalf of a consortium of European nurse educators about an EU-funded project for vocational education that built on earlier work by Papadopoulos et al (2004). This was probably a unique initiative in inter-country professional education, which has close links to the fundamental European principles of facilitating labour mobility and reducing inequality of treatment of migrants and other vulnerable groups (https://europa. eu/ scadplus/constitution/objectives_en.htm). The team adopted a skill-based approach, rather than merely relying on the provision of information or knowledge, and paid attention to the needs of those delivering the training. Another key factor was recognising the diversity of learners (who of course also provide a valuable resource for teaching diversity; see Zafrir and Nissim, 2011). Skills identified include the ability to work with interpreters, and to be open to differences and uncertainty.

From elsewhere in Europe, Despena Andrioti and colleagues describe an initiative in Greece to meet the needs of the Roma people, who are in fact the largest minority ethnic group in Europe, although they are often ignored in the professional literature (Andrioti et al, 2013). There is an EU-level strategy to address their needs, and this report provides some descriptive data to assist in the production of other local policies and good practice. However, it is important to note that there is no homogeneity among the Roma, who are shown here to come from a diversity of backgrounds while sharing a strong sense of common cultural identity and experiences of exclusion. The picture in Greece has much in common with the situation of Roma elsewhere, and as the authors conclude, a formal evaluation of the effectiveness of this intervention is still required, along with a move to genuine coproduction or planning of services with members of the communities at risk.

We are delighted to carry a research paper from a final-year medical student. It is good to see the next generation of diversity researchers getting active! Tomlinson and her supervisor have tackled a novel issue in another often overlooked group, namely Somali people in the UK (Tomlinson and Redwood, 2013). Conventionally, it has been believed that the minority ethnic groups have been protected from the adverse effects of media scares and moral panic about public health initiatives such as vaccination (Bhopal and Samim, 1988). However, growing levels of acculturation and access to host society media are threatening this. Wakefield-inspired rumours about autism are shown to have led to a significant fall in the uptake of vaccination against measles, mumps and rubella (MMR) among this group in the UK, despite the impact of these diseases ‘back home’ in Somalia. This paper provides some in-depth insights into matters such as Islam and views on the differences between life in the UK and back home, to help to inform future interventions. The inequalities in vaccination uptake between groups have the potential to create serious public health concerns, andwe are pleased to be able to offer a continuing professional development (CPD) update specifically on that topic in our features section towards the end of this issue.

Finally, in our research paper, Emmanuel Ehiwe and colleagues consider another group of fairly recent migrants from West Africa and their perceptions of cancer (Ehiwe et al, 2013). There is a dearth of information on this subject, but growing evidence of inequalities in access to cancer services (ncat.nhs.uk/ our-work/improvement/equality). All too often a failure to provide services, or even to attempt to do so, is based on false presumptions or fears of causing offence by contravening cultural values. This paper shows very clearly how this can be tackled, and that West African migrants would welcome such outreach, even if ‘there isn’t a word for it in our language.’

Last but by no means least, we have our regular features, including a CPD educational module on childhood immunisation, as highlighted above, a challenging Practitioner’s Blog which picks up on themes of violence against women which we have highlighted in recent editorials (McGee and Johnson, 2012), and the usual Knowledgeshare. We extend an invitation to anyone who would like to gain experience in writing for publication, or who has a burning desire to share their insights by contributing to any of these features, and will offer gentle and constructive support when required. We would especially welcome contributions that could enhance professional vocational education, and reviews of less commonly seen publications or media.

Twitter: If anyone wants to Tweet, we now have an @DiversityJnl identity which provides an alternative to contacting us via the email address (dhc@ radcliffepublishing.com). We intend to use the Twitter feed to ensure the widest possible coverage of the journal, and we shall be using it to highlight other issues of concern to our readership. We welcome feedback, and hope that this might make it easier for some of our readers to respond to what they have read in the journal, as well as to ReTweet and spread the word about us.