Transplantation Proceedings
Volume 35, Issue 1 , Pages 21-23, February 2003

Developing culturally competent renal services in the United Kingdom: tackling inequalities in health

  • G Randhawa

      Affiliations

    • Institute for Health Services Research, University of Luton, Luton, England, United Kingdom
    • Corresponding Author InformationAddress reprint requests to Gurch Randhawa, Principal Research Fellow, Institute for Health Services Research, University of Luton, 15-17 George Street, Luton, England, LU1 2AF, United Kingdom.

Article Outline

 

“To improve the health of the worst off in society and to narrow the health gap.”1

“Equity in health care would be to ensure equal access and use of available health care for equal need, with equal quality of care for all.”2

These two quotes are summative of the shift in focus of policy during the last 20 years in which there has been a growing interest in the health of minority ethnic populations in the United Kingdom (UK). We have seen the inclusion of a question seeking to identify ethnic group in the 1991 census. This has aided, to some extent, the examination of health status for different ethnic groups. Government strategy papers such as Health of the Nation and the more recent Our Healthier Nation have highlighted the specific health problems faced by minority ethnic groups in the UK and the need for an urgent course of action to reduce health inequalities.1, 3 The Department of Health established the NHS Ethnic Health Unit in 1994, which aimed to promote health and healthcare for minority ethnic groups.4 The Health Education Authority (HEA) has carried out two health and lifestyle surveys of black and minority ethnic groups to highlight information regarding health behaviours and health status.5, 6 Most recently, the Fourth National Survey, conducted by the Policy Studies Institute (PSI) and Social and Community Planning Research (SCPR), included an extensive section on health among minority ethnic groups.7

Throughout this period, the provision of diabetic services for minority ethnic groups has become a particularly important area of debate. This is in part due to the observation of high rates of end-stage renal failure (ESRF) (as a result of diabetic nephropathy) among South Asian populations in the UK and the disproportionately higher numbers of South Asians represented on transplant waiting lists.

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South Asians and diabetes/renal disease 

Inequalities in health and poor access to services have been well documented as common experiences for South Asians in the UK. South Asians have a high prevalence of type 2 diabetes; recent studies indicate a prevalence 4 times greater than those who are white. Significantly, the high rates of diabetes occur within all groups of the South Asian population. It has been reported that 20% of Asians aged 40 to 49 years have type 2 diabetes, and by the age of 65 the proportion increases to one third.8

A further complication is that diabetic nephropathy is the major cause of ESRF in South Asian patients receiving renal replacement therapy (RRT).9 Nationally, the relative risk of ESRF secondary to diabetes is 5.8 times greater in South Asians than in whites.8 Data from Leicester show that South Asians with diabetes are at 13 times the risk of developing ESRF compared to those who are white.10 Thus, not only are South Asians more prone to diabetes than those who are white, they are more likely to develop ESRF as a consequence. Importantly, the South Asian population in the UK is relatively young compared with the white population. Because the prevalence of ESRF increases with age, this has major implications for the future need for RRT and highlights the urgent need for preventive measures.9 The incidence of ESRF has significant consequences for both local and national NHS resources. The National Renal Review estimated an increase over the next decade of 80% in the 20,000 or so patients receiving RRT and a doubling of the current cost, about £300 million a year of providing renal services.8

The World Health Organization (WHO) study group on diabetes notes that resources should be directed to improving the quality of preventive care in primary care settings and to public health interventions for controlling diabetes. Education, early diagnosis, and effective management of diabetes is important for safeguarding the health of susceptible populations and for long-term savings for the NHS.8 Most encouragingly, recent studies from the United States (US) and Finland have demonstrated that modest lifestyle changes can reduce the risk, by more than 58%, of developing overt type 2 diabetes in susceptible groups.11, 12 Furthermore, various interventions, such as blood pressure control, effective use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor (ATR) blockers, and blood sugar control can significantly delay the progression of diabetic nephropathy.13, 14, 15, 16, 17, 18

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Access to services 

The recently published Diabetes National Service Framework ([NSF] government policy document) in the UK within its 11 standards of good practice highlights the importance of access to services and places particular emphasis on meeting the needs of minority ethnic groups.19 The working draft of the Renal NSF is also focusing on “renal disease complicating diabetes” and, again, particular attention is being paid to the inequalities being experienced by minority ethnic groups.20 However, the HEA’s Second Health & Lifestyles Survey among black and minority ethnic groups.6 and the PSI’s fourth national survey of The Health of Britain’s Ethnic Minorities7 both indicate that knowledge of diabetes and its complications is poor among South Asians. The vast majority of treatment for diabetes in the UK is provided at general practitioner (GP) surgeries (primary care centres) and by referral to hospital-based diabetic clinics. Preliminary evidence, however, suggests that the quality of health care for South Asians is inadequate and compliance is poor.6, 8 This situation is compounded further with the low uptake of hospital-based diabetic services. There is also growing evidence that South Asians are subsequently referred later to nephrologists or, having been referred, are more likely to be lost to follow-up.21

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Developing culturally competent services 

Major undertakings for researchers and clinicians in the UK will be to explore access to and the progression through the diabetes and “renal disease complicating diabetes” care pathways and to identify health beliefs and experiences associated with diabetes and diabetic renal complications among South Asian groups. A systematic exploration of these would provide a valuable resource for health professionals working with these groups and allow for the development of a culturally competent diabetic and renal service, which is sensitive to the needs of South Asians.

Specifically, gaps are as follows: (1) identification of cultural beliefs and practices relevant to diabetes and diabetic renal disease self-management, including attitudes to medication and attendance to GPs, diabetic services, and nephrology services for routine monitoring; (2) examination of referral patterns to hospital-based diabetic services, and subsequent attendance; (3) exploration of referral patterns to nephrology services; and (4) exploration of the relevance of current renal complications education programmes for South Asian groups.

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Identifying good practice 

Attempts to trace material reporting on, and evaluating, initiatives to improve access are likely to prove disappointing. Although such reports do exist,22, 23 the evaluation is often little more than an account of a particular initiative, from which it is difficult to generalise. Similarly, the attempt to identify “barriers” to equal access frequently generates a lengthy list of possibilities, which do not add substantially to the many reports that have been issued by various health authorities and health care agencies in both the US and the UK. This is highlighted in a review of research on the effectiveness of health service interventions to reduce variations in health undertaken by the NHS Centre for Reviews and Dissemination in the UK.24 The review included 94 studies, 68 were from the USA, 19 from the UK, and 7 from other countries.

Delivery methods and content features that appeared to have potential to contribute to the reduction of variations in health included the following: a multifaceted approach, a multidisciplinary approach, face-to-face interactions, prior needs assessment, culturally appropriate interventions, peers to deliver intervention, appropriate support materials, skills development, provision of material support and resources, prompts, and reminders for use of health services.

Although lists of this kind may act as sensitising prompts, suggesting places to start looking in a particular area, there is nothing that can be seen as an authoritative account of the “causes” of unequal access, or a definitive strategy for reducing it. The implication is, one might suggest, that any health service provider wishing to make a serious effort to combat the disadvantaging of minority ethnic groups will have to analyse the situation in each specific area, and formulate a specific plan, capable of addressing the factors demonstrably at work in that location.

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Conclusion 

In summary, the majority of work related to inequalities in access highlights the following areas that need to be addressed by service providers: (1) lack of awareness of unequal access to services and of services available; (2) lack of understanding of local demographics and diversity of communities; (3) lack of understanding of culture, religions, and languages and how they can impact access to health services; (4) lack of awareness of quality standards relating to services for minority ethnic communities; (5) stereotyping; and (6) Euro-centric assessment tools and advice. It is only when these issues are addressed adequately will we begin to see renal services that truly meet the needs of a multi-ethnic and multi-faith population within the UK.

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References 

  1. Department of Health . Saving Lives: Our Healthier Nation. London: HMSO; 1999;
  2. Whitehead M: In Benzeval M, Judge K, Whitehead M (eds): Tackling Inequalities in Health: An Agenda for Action. London: The King’s Fund; 1995, p 22
  3. Department of Health . On the State of the Public Health. London: HMSO; 1992;
  4. NHS Confederation: Composite Directory of NHS Ethnic Health Unit Projects. Birmingham: NHS Confederation; 1998
  5. Rudat K. Black and Minority Ethnic Groups in England: Health and Lifestyles. London: Health Education Authority; 1994;
  6. Johnson M, Owen D, Blackburn C. Black and Minority Ethnic Groups in England: The Second Health and Lifestyles Survey. London: Health Education Authority; 2000;
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  17. Lightstone L. Preventing Kidney Disease: The Ethnic Challenge. Peterborough: National Kidney Research Fund; 2001;
  18. UK Prospective Diabetes Study (UKPDS) Group . Lancet. 1998;352:837
  19. Department of Health . National Service Framework for Diabetes: Standards. London: Department of Health; 2001;
  20. Department of Health: National Service Framework for Renal Services. Department of Health web site, 2001
  21. Jeffrey RF, Schlossen D, Prabhu P: Pattern of Referral of Indo-Asian Patients With Chronic Renal Failure to Nephrology Services. London: Renal Association; October 1999 (abstract)
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PII: S0041-1345(02)03879-4

doi:10.1016/S0041-1345(02)03879-4

Transplantation Proceedings
Volume 35, Issue 1 , Pages 21-23, February 2003

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