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Nurses can help to tailor public health messages about lifestyle change and preventable disease through collaboration with community and faith leaders
The unequal share of preventable disease borne by hard-to-reach minority communities has complex causes and is a major public health challenge. Multiple factors, including culturally inappropriate care models, language differences and a lack of trust, can work together to place particular populations at higher risk of such conditions.
Nursing Standard. 37, 10, 19-21. doi: 10.7748/ns.37.10.19.s11
Published: 05 October 2022
It does not have to be this way. Health think tank the King’s Fund says providers ‘need to be aware of the specific healthcare needs, risk factors and treatment requirements in different communities and ensure services are culturally tailored’. Nurses are demonstrating that when services make a concerted effort to build relationships with diverse communities, trust and collaboration can follow, in turn opening up access to vital health education and interventions for people at greatest risk.
Working with ‘gatekeepers’ such as community and faith leaders is one way to achieve this.
When children’s nurse Rohit Sagoo set up British Sikh Nurses to raise awareness of physical and mental health issues in the South Asian community, he drew on his own South Asian heritage to engage with temple leaders. The goal was to achieve improvements in areas including vaccine uptake and stem cell donation among the UK’s Sikh population.
‘It’s as vital to get support from community leaders, as it is about representation,’ says Mr Sagoo. ‘Leaders open a whole new arena in areas with inequalities. Most faith leaders are approachable as long as they understand our work for the community or congregation.’
The legacy of negative healthcare experiences can linger, however. And it is here that nurses with a particular understanding of a specific community can capitalise on their experience and the support of community leaders to be, as Mr Sagoo puts it, ‘a trusted voice with the same common traits as the community’.
Advice from nurse and London South Bank University professor of kidney care Nicki Thomas on what she has learned from engaging with different communities:
1. Take time to plan your project You will need at least two months
2. Listen and learn Allow plenty of time to understand the needs of the community
3. Ensure nurses from the community are involved They can bring awareness of cultural or religious practices
4. Co-produce initiatives with community representatives This ensures messaging about events and details, such as time and venue, are appropriate
5. Share positive results to the community This way, they can see the benefit of participation
In Salford, nurses worked in partnership with members of the city’s Orthodox Jewish community as part of a Healthy Communities Collaborative project. This provided them with a ‘passport’ to a group for whom greater interaction with health services is considered vital.
Nurses attended health promotion events in synagogues, where they carried out cancer screenings and offered advice on cardiovascular health. This was a tailored response to a public health need – the community overall records low participation in physical exercise and high rates of obesity.
Involving key members of the community and holding events at culturally relevant venues helped secure much-needed endorsement of the programme, which included women-only health promotion events and discussions about healthy eating hosted by Jewish delicatessens.
‘Most faith leaders are approachable as long as they understand our work for the community or congregation’
Rohit Sagoo, British Sikh Nurses
In 13 months, the project notched up 1,440 health interventions, such as the screenings, 410 lifestyle risk assessments of people aged 40-74, and took 102 opportunities to signpost people to primary care services.
Undergraduate nursing students at London South Bank University (LSBU) are getting practical experience of such public health outreach work. This year, they began raising awareness of kidney disease in the university, the local area, and among Muslim communities in south London through visits to Greenwich Islamic Centre, where they have been engaging with worshippers following afternoon prayers.
LSBU has worked alongside Gift of Living Donation, an organisation that raises awareness of living kidney donation in black communities.
Early on, students met mosque leaders to build up the trust needed to undertake initiatives such as conducting blood pressure checks among worshippers, as well as offering education about other risk factors for kidney disease.
Nurse and professor of kidney care at LSBU Nicki Thomas says: ‘We have a diverse group of nursing students at LSBU, so it seemed to be a fantastic opportunity to involve them in giving health messages to communities at increased risk of kidney disease.’
Deputy head of nursing science at Bournemouth University Vanessa Heaslip is a researcher in promoting health, well-being and health access to people in marginalised communities, including Traveller and other minority groups.
‘Trust is fundamental when working with all groups who are marginalised or under-served,’ she says. ‘Gatekeepers such as faith leaders are great because they have built trust with people in the community and can help nurses with integration.’
Dr Heaslip also highlights the importance of supporting nurses to do this work. ‘Sometimes they may feel out of their depth working with such groups, but my experience is that the title ‘nurse’ often means people are willing to trust and work with us,’ she says. ‘Even so, nurses’ anxiety can have a negative effect – such as doubling up for visits when not necessary.’
Admiral Nurse Cheryl Scarrott, who supports people with dementia in Traveller communities, draws on her own background to build trust with patients.
The estimated 300,000 people in the UK who are part of the Gypsy, Roma and Travelling community often miss out on continuity of care and access to primary healthcare because systems are not geared towards the needs of people who are constantly on the move.
Traditional attitudes of mistrust of ‘outside’ help can create obstacles too. In a survey by charity Friends, Families and Travellers, more than 55% of people in Traveller communities said they would not let someone from outside their community care for a family member who had dementia.
‘The title ‘nurse’ often means people are willing to trust and work with us’
Vanessa Heaslip, deputy head of nursing science, Bournemouth University
For Ms Scarrott, her Traveller heritage has been vital. ‘We don’t have official ‘community leaders’ – rather, prominent members of a family will make the decisions and give advice to relatives,’ she says. ‘I work with the whole family, as well as the person with dementia, to deliver the best possible care.’
Sheffield Health and Social Care NHS Foundation Trust professional lead for nursing Salli Midgley is overseeing work to improve mental healthcare experience and outcomes for the city’s African Caribbean communities. Projects she is supporting include employment of a race equity officer in Sheffield African Caribbean Mental Health Association, to understand and address racial inequalities in the use of restraint on inpatient wards. Engagement with community gatekeepers has been essential.
‘We held meetings with community leaders of African Caribbean groups in Sheffield,’ Ms Midgley says. ‘We heard the anger of the communities, and resolved to do something immediately. A couple of hard conversations led to us developing a race equity plan, delivered through joint work with the trust, the African Caribbean community and our voluntary sector partner Sheffield Flourish.’
Cultural advocates from the community
As well as aiming to reduce use of restrictive practice on wards, the plan seeks to reduce the risk of suicide among young black men by increasing their opportunity to be heard and find support.
‘There are now cultural advocates from the community who talk to our nurses about improving outcomes for African Caribbean and black British citizens on wards,’ Ms Midgley says. ‘This allows nurses to explore the impact on them, and potential cultural stereotypes and biases implicit in practice.’
Taking time is essential for building those bridges between health services and hard-to-reach communities.
A 2015 project to reduce passive smoking in South Asian households in Yorkshire revealed how health professionals can underestimate the time needed to achieve community engagement. In this case, it took time to understand internal community dynamics and build rapport with gatekeepers.
The project’s ultimate success in recruiting people via mosques showed that, when engaging with underserved populations, progress cannot happen overnight. Patience is essential.
Further information
The King’s Fund (2021) The health of people from ethnic minority groups in England tinyurl.com/kf-minority-health
Local Government Association (2017) Working with faith groups to promote health and wellbeing tinyurl.com/LGA-faith-health
British Sikh Nurses sikhnurses.co.uk
Friends, Families and Travellers gypsy-traveller.org