Diversity & Equality in Health and Care Open Access

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- (2006) Volume 3, Issue 4

Remember: you learned about it here first

Mark RD Johnson MA PhD Cert HE (Warwick)1 and Paula McGee RN RNT MA BA Cert Ed PhD2

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

Editor, Diversity in Health and Social Care; Professor of Nursing, Faculty of Health and Community Care, University of Central England, Perry Barr, Birmingham, UK

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We were cheered that a term, Ubuntu, which as far as we are aware was first aired in the European academic press by our journal (Chinouya and O’Keefe, 2006), was used, if not exactly popularised, by Bill Clinton, sometime President of the USA, at the annual Labour Party Conference in Manchester (Hoggart, 2006). The reporter says that ‘It turns out to mean ‘‘I am because you are’’. No’, he adds, ‘I haven’t a clue either’. This lack of cultural awareness must be very scary for wellinformed people like our readers but also, frankly, should give pause to anyone familiar with the Hindi/ Nepali greeting namaste – which conveys a similar sense of respect between living things.We were told by our guide to Nepali culture that its best equivalent in English would be ‘That which is of the divine in me, salutes that which is divine in you’. It might be worth emphasising that namaste is a two-way street, that the divine is therefore in all of us and the greeting is – or should be – reciprocal. Or in other words, reverting to the rude-boy language of (one of the editors’ native) South London, ‘Respect’. Which is what, in fairly crude terms, we and the campaign for cultural competence and diversity awareness are all about. So, despite claiming some degree of primacy for getting there first, we must thank Bill and the conference for giving the concept a decent airing and highlighting the issue.

In fact, the whole issue of cross-cultural sensitivity has been very topical in the run-up to the festivals of Christmas, Hannukah and Eid-el-Adha, which coincidentally all fall around the same time of year (at least in 1427 ah, also known as 2006 CE/AD). Readers in theUKcannot be the only observers to have become at least irritated by the recent events at the ‘nation’s favourite airline’ regarding the wearing of religious symbols and the utter drivel about nativity plays and Christmas generally. Living a civilised life in a diverse society means respecting one another’s beliefs, and that means knowing something about what others believe. We need to emphasise that cultural competence is not just about rectifying deficits, educating Westerners about those whom they perceive as different from themselves, but much more than this for both or all parties. It is more about creating a society in which people are free to be themselves, pursue their own traditions and beliefs, and feel pride in that. Respect then is surely about helping others to do the same rather than feel they have to apologise for/or are in some way at fault because they don’t fit the ‘norm’. And, as a matter of fact it is worth noting that most Muslims feel it is appropriate to celebrate the birthday of one of their most respected prophets (Isa bin Miriamu, Jesus son of Mary, in English).

On a wider front, there is some mixed comfort for the health and social care service providing community in the government’s 2005 ‘Citizenship survey’ (see Kitchen et al, 2006, Table 37). Five percent or less (fewer than one in 20) felt that the NHS, local hospitals and local general practitioners (GPs) discriminated on the grounds of race, far less than any other public service. It is true that the survey did not ask explicitly about ‘social care’ organisations, but while only 4% of those who were dissatisfied with their local hospital thought it might discriminate on grounds of ‘race’, over a quarter of those dissatisfied with local authority services (28%) thought that the local government services might – and even of those satisfied, 17% were prepared to suspect such discrimination. It is also notable that a significant proportion of Sikhs and Muslims had experienced discrimination on grounds of religion, and about 10% of Bangladeshis thought that hospitals would discriminate against them – food for thought, even if the picture is better for health than for other services. It is also an indication that religious discrimination is clearly perceived as a threat – and that people expect respect for their religious as well as their ‘racial’ or ethnic identity.

In this issue, we lead with a guest editorial from Joy Notter, who draws our attention to the issue of discrimination and exclusion in the world of work. Notwithstanding a long-term legislative requirement and a small mountain of research, NHS bodies are still failing to deploy a truly diverse workforce or to offer the diverse members of their staff equal opportunity and protection from harassment. Yet without this diversity on the supply side, we shall wait for ever for the majority to gain the cultural competence and sensitivity required to deliver the necessary – and more efficient and effective – diversity in services to an evermore diverse user population. But maybe some clues to the reasons behind this are to be found in the paper by Uduak Archibong and her team.

Perhaps too often even academics and readers or writers of research journals take the meaning of terms we use in our professional life for granted. Certainly, we have seen how some of the papers we have published have criticised the use of stereotype and assumption – but then we find that use of technical language (between consenting professionals and experts) may still go unchallenged. Archibong and her team explore and explode the myth that ‘positive action’ is a policy which is understood and that it can be implemented in compliance with human rights legislation. In order to conduct their study of implementation of such policies in practice, they began bymapping all the uses of the term and its reputed synonyms across the dimensions of the new Commission for Equality and Human Rights, and found more confusion than concordance. Their paper lays out the legislation in relation to ‘race’/ethnicity, gender, and disability (and could equally be applied to religion, sexuality and age), and examines its application in our own familiar backyards of higher education and health. A couple of ‘case studies’ of marginal classification illustrate and identify the key characteristics, and show the differences between UK and international understandings of the concept. Hopefully with this background the way is now clear to begin to understand and to implement strategies that will tackle the heritage of discrimination in this not-sosecret garden, following Notter’s exhortations, and provide a lead for wider application across the world of work.

There are two other major themes in this issue – or so it appears to the editors. One is the voice of the researched, the ‘subject’ (or object) of enquiry; the other is the way in which research may itself be a form of therapy or action, with beneficial consequences. Research is not just the ‘democracy of the oppressed’ when it makes public the facts, forms and processes of inequality: it can actually be enjoyed and valued by those who take part in it, and change things. As any student of quantum theory knows, you change the nature of a thing when you measure it (or in a more simply put Chinese proverb, you cannot put your foot in the same stream twice).

These two notions, of the subject of enquiry and the beneficial consequences of participation in research, are evident first in Lloyd and colleagues’ account of conducting ‘knowledge attitude and belief ’ research with people who have a non-English-speaking background. Much healthcare, especially in long-term conditions like diabetes, relies on the guidance provided by responses to standardised questionnaires such as the ‘self-efficacy scale’. These assist healthcare professionals to assess how much more training or information is required, while health-related quality of life or ‘patient-reported outcomes’ questionnaires can highlight emergent health problems and monitor progress through treatment. However, it is increasingly acknowledged that many such instruments (or ‘tools and rules’ in the new NHS jargon) are not culturally competent. Lloyd and her team worked especially with groups whose normal home language does not have an agreed written form, and many of whose members are unable to read in any language. Debriefing interviews with respondents, non-respondents and fieldwork staff revealed a number of issues that conventional survey research would take for granted, and reinforced our understanding that some people actively enjoy and learn from taking part in such research. Translation, it is clear, is not interpretation. The team has now gone on to explore ways of overcoming these difficulties, and we are looking forward to learning some solutions to the issues raised here.

In a second example, Nayar and Hocking provide another perspective from New Zealand, adding to our growing understanding of the wider South Asian diaspora and of societies which, because of historical links, Western Europeans too often assume are like us. The process of migration and cultural adaptation has many implications and is complex. Nayar and Hocking’s paper is illuminating in its focus on the ‘ordinary activities of daily life’ and, using grounded theory and participants’ own words, creates a vivid picture of the stages of that process. Importantly it demonstrates people’s capacity for change and ability to draw from or live in two cultures simultaneously, not being stuck between them. The implications are profoundly practical.

Sheppard’s paper again emphasises the significance of everyday life activities: in this case the role of food and the opportunity to exercise choice. This is very topical. The impact of Jamie Oliver’s television programmes about school meals has attracted a lot of attention, not only in theUKbut also in Australia. The concept of ‘healthy schools’ is now high on the political and media agenda in the UK, despite the efforts of some parents to subvert the efforts of the state to give their children only healthy choices. In case readers missed it, UK TV news bulletins showed mothers collecting chips and pizza from a local takeaway and passing them through the fence of a secondary school which had a policy to offer salad every day in its canteen, and chips only once a week. Sheppard’s article reflects the challenges of providing meals in schools and contrasts these with those of catering for the elderly in care homes. She demonstrates a range of similarities and differences between the two types of institutions, and shows that efforts are being made in Australia to make institutional food a tool for health. She emphasises a commonly overlooked factor in discussing food: the social role of mealtimes. From the other perspective, of course, the role of food or nutrition in preventing ill health, including for example osteoporosis and fractures, is also often overlooked, although perhaps less so in dental care and oral health. Perhaps also worthy of comment is her citation of a study showing that when an identical meal is served in a four-star restaurant it is better received than in either a school or an older people’s care facility! It cannot just be the fine tablecloths and napkins: expectations clearly play a role.

Continuing the theme of an alternative gaze (and of antipodean contribution), Bob Cant and Ann Taket bring British and Australian eyes to bear on a much less often discussed zone of social difference – the experiences of lesbians and gay men in primary care. A number of themes emerge from their interviews, many of which resemble those pertinent to minority ethnic groups, such as communication, migration and mobility, or mental health, while a new dimension is added to the issues of shame, honour and stigma through the discussion of ‘coming out’. Relationships of trust are crucial to ensure quality care, and there are significant problems of continuity and of assumptions being made, leading to potential misdiagnosis or inappropriate advice giving. Equally, and as in the black and minority ethnic sector, relationships with and referrals to (and from) community-based voluntary organisations seem to be both problematic and potentially valuable. Further, stereotypes and lack of respect recur as issues. Cant and Taket are to be thanked for bringing this issue more widely ‘out’ into the open.

Our two final papers in this issue focus on practice in health in social care. Cross-Sudworth, a practising midwife, draws upon her experience and a thorough review of academic, policy and practice-based papers to highlight the implications of infertility in South Asian populations for practitioners. She has put this into an easily accessible but authoritative format and draws out the real requirements for midwives and their community-based colleagues meeting people from these communities in their everyday practice. Further, there are important implications for research and public awareness or education which should not be neglected as affecting the environment in which childless families have to cope. This paper is likely to become required reading for student midwives.

Finally, Uddin and colleagues have helped us to go on meeting our objective to highlight and share better practice as well as reporting on research. The paper does not shy away from intellectual debate, and emphasises questions such as ‘what does home treatment mean?’, as well as illustrating the benefits of a crisis intervention team for socially excluded groups including black and minority ethic populations (even in rural areas). The paper illustrates with some case study examples and real data from internal audit – an undervalued source of insight, it must be said. Since, as Uddin and colleagues observe, the new clinical governance framework expects and requires ever more audit,we hope that this resource-intensive activity can be put to good use by being turned into such practicerelevant articles to share experience and learning.

Finally, as ever, our indefatigable Knowledgeshare editor, Lorraine Culley, has assembled a masala (mixture!) of reviews, reports and resources to assist practitioners, tantalise researchers, and keep teachers and learners at the front of the game. We always welcome more short reports of this type – and encourage people to submit ‘research in progress’ teasers to stop us from wondering why someone has not yet researched a topic and then wasting time writing a research proposal for something that is already being done. We only ask about 300–500 words for these items, and if it spotlights good practice or an underused resource then we (and you, the contributor) will have performed a public service. And in conclusion we should also like to spotlight those unsung heroes of the journal: our gallant band of reviewers who tirelessly and selflessly give their time to read articles that are submitted, and to provide invaluable feedback. If you are one of our published authors, you will know (as many of you have written) how valuable and detailed are the constructive criticisms and suggestions that these good folk provide: if you are not yet so published, be assured that you will have all the help you could ask for to make it the definitive article.