There is widespread non-compliance within the NHS, to race relations legislation designed to promote equality and equitable engagement. This is obviously not a systematic and purposeful strategy, but instead underlines the difficulty of engaging black and minority ethnic groups in health and wellbeing initiatives, when the huge proportion of managers are white and middle class.
Ethnic minorities form around seven per cent of the UK population. In London, BME groups total just under 20 per cent of residents, but some boroughs have a significantly higher proportion, such as Newham (61 per cent), Brent (54 per cent) and Tower Hamlets (46 per cent). There are significant pockets too in central Birmingham, Yorkshire, Lancashire and the East Midlands.
Healthcare professionals working on projects that involve communications, involvement and engagement, consistently find it difficult to reach these aptly named “hard to engage” groups. Often these audiences feel excluded and do not want, or have the confidence, to engage in what they see as “officialdom” or the “authorities”.
Health statistics vary but, in general, comparisons between BME groups and their white British counterparts show:
- African-Caribbeans are at least four times more likely to present late, and some faith groups are very reluctant to present on certain conditions such as bowel cancer or sexually transmitted infections
- South Asians in the UK are three times more likely to have Type 2 diabetes, African-Caribbean women seven times more likely, and men 13 times more likely
- African-Caribbeans are eight times more likely to develop glaucoma, a major cause of irreversible blindness, although it is avoidable with early detection and treatment.
Some ethnic groups are more prone to obesity and others have proportionally high rates of coronary heart disease and death from stroke. These facts are compounded, or some may say are the result of, living in low income areas. Around 40 per cent of black and Indian groups and 63 per cent of Bangladeshi/Pakistani groups live in social housing and deprived communities, and there is a marked correlation between premature mortality rates, ill health and deprivation.
In Westminster, there is a gap in life expectancy of nearly 11 years between the men born in Churchill ward (73 years) and those born in Lancaster Gate ward (84 years). For women there is a difference of over nine years between the average life expectancy of those born in Tachbrook (80 years) and those born in Knightsbridge and Belgravia (89 years). Westminster is by no means alone in this disparity. In 2008, WHO reported a shocking 28 year gap in life expectancy around the Glasgow area, with Calton, having an average male life expectancy of 54 years.
Engaging BME and low income groups is an essential element in communications and engagement work on health issues such as obesity, smoking, sexual health and drug and alcohol misuse. On a personal level, I have had wonderful advice from community leaders, listened to groups of residents through interpreters and observed some truly inspiring projects and people.
The seven rules
Initially I thought that good intentions, being bought up in a deprived multicultural community myself and 10 years of behaviour change experience would be enough to successfully engage BME groups. It certainly wasn’t – I have made some horrendous mistakes. Essentially though, it boils down to seven engagement “rules”. These should be inserted in every PCT engagement strategy in the UK, and used as a checklist for every health communication programme:
Rule 1 – Banish your stereotypes
Have you got any cultural, racial or religious assumptions or stereotypes about the groups you are targeting? If so, get rid of them, along with your ego. You have to approach this work with a truly open mind and heart, and you’ll need a good sense of humour. Talk to local community leaders – they will tell you everything you need to know, but you must be prepared to listen carefully and learn from those on the ground.
Rule 2 – Do some homework
Multicultural communities are not one homogenous mass, each will have its own norms, traditions, cultural nuances and language. Even within one group, there will be differences in characteristics and behaviours including whether they are first generation immigrants or are British born. Segment these audiences where possible by attitude, risky health behaviours, lifestage, lifestyle or geographically and do your homework on historic and cultural backgrounds. Targeting messages will become much easier.
Rule 3 – Don’t swoop in and swoop out
The most often repeated mistake is to go into a community asking for assistance on a one-off research project or health initiative, never to return … until the next time you want something. This assumes a moral high ground and is perceived as condescending with the affluent educated class, arriving to help the less fortunate because there is something deficient in the community. Treat leaders and community members as partners, commit to the long term and establish a real willingness to listen and understand over time. Build trust and work collaboratively and always give and discuss feedback on findings and developments.
Rule 4 - Go for engagement not just involvement
When working on health projects, encourage local people to sit on any decision-making bodies, establishing shared authority. Build coalitions and partnerships that allow a free flow of communications both upwards and downwards. Ensure you are not superficially involving people, just so you can say they have been consulted – they’ll know that’s what you’re doing. It’s beginning to be engagement, as opposed to involvement, when community groups start to say “we” and “us” when describing your work programmes.
Rule 5 – Be authentic and act as you claim
Nothing is more irritating than people or organisations shouting about their approach to diversity, their partnership credentials or making bold public claims, only for the reality to be the opposite. Those on the lowest incomes are quick to spot whether you are trying to be authentic or just talk a good game. Your messages must match the actual experience of engaging with your service and staff. Senior executives and the board in particular, must lead by example. The key is to under claim and over deliver, not the reverse.
Rule 6 – Don’t use literal translations
Everyone has seen a literal translation from another language into English, often with hilarious results. The same is true when translating from English. Check that translations aren’t just word for word translations, but convey the overall message and embrace social nuances. Some boroughs have over 100 languages spoken as a first language and providing translation is a constant debate, not least because of the cost. It is more important to ensure the content resonates with the culture and identity of the target audience, understanding how they will interpret not just your messages, but images too.
Rule 7 – Don’t “default” to leaflets and websites
The NHS spends far too much money on leaflets, strewn across GP surgeries and hospital waiting rooms buried under a mass of competing health information. Websites too, are often seen as a “must have” when commissioning social marketing campaigns. However, low income and BME groups are amongst the lowest users of the internet, and often find leaflets confusing with too much text and jargon. Get to know what your audience sees, reads and listens to, and prioritise communication channels that fit in with their day-to-day lives.
Sue Nelson is client service director at Kindred Agency and author of Naked Marketing