Universal vs Targeted policies

Our health and wellbeing is influenced by social, cultural, psychological and environmental factors, which can all change as we progress through life. Does this suggest that health promotion policies may need to be tailored to reflect these different factors, including ethnicity and faith?

In general elderly ethnic minority communities are more likely to suffer from ill health than their White counterparts

2004 was the final year when the Health Survey for England oversampled ethnic minority people. The proportion of people aged 61-70 reporting fair or poor health then was 34% for white people but 86% for Bangladeshis, 69 % for Pakistanis and 67 % for black Caribbean people, with the health of white English individuals aged 61-70 comparable to that of Caribbean people in their late 40s or early 50s, Indians in their early 40s and Pakistanis in their late 30s  

More recently, a cross-sectional study analysed data from adults aged 55 years or older who were registered with general practices in England in five waves from 2014 to 2017. The nationally representative English General Practice Patient Survey (GPPS) examined the association between ethnicity and mobility, self-care, usual activities, pain or discomfort and anxiety or depression. It found that indicators were worse for men or women, or both together, in 15 of 17 minority ethnic groups than their White British counterparts. In addition, older people from black and minority ethnic populations were more likely to describe their health status as poor.

This suggests that, in general, elderly ethnic minority communities are more likely to suffer from ill health than their White counterparts – and that action to encourage healthy ageing for these communities is urgently needed.

Some health-related issues for older people may be more universal

Research into loneliness and social isolation among older people (a risk factor for physical and mental illnesses) found the number of over-50s experiencing loneliness is predicted to reach two million by 2025/6. This has been potentially exacerbated by the existing COVID-19 pandemic, which has left many elderly people even more isolated and suggests a greater need for universal policies that target key pressing issues such as loneliness amongst older people.

However, even here, there may be differences suggesting that a more targeted approach may sometimes be needed. For example, people from Asian backgrounds were more likely to live in multi-generational households. Whilst this increased the risk of intergenerational Covid transmission, it also reduced the risk of loneliness compared with elderly White people living alone.

Equipping older people with the right digital skills, to enable them to communicate with family and friends online, can help combat high social isolation figures. However, as we will see below, this may also increase access to disinformation.

The threat of misinformation and the impact it has on ethnic minority communities

The COVID-19 pandemic has highlighted this risk, with many ethnic minority communities exhibiting vaccine hesitancy and experiencing higher excess mortality. Online covid misinformation has been a significant factor here. This suggests it is imperative that relevant stakeholders, including the NHS, run extensive health campaigns in different community languages, to counter common misconceptions about vaccines, featuring members of different ethnic communities in order to reach those most vulnerable to disinformation.

This is important also because research suggests that vaccine hesitancy has had a long-lasting impact on health in some ethnic minority groups, prior to COVID-19. National communications campaigns have not prepared the ground to counter vaccine hesitancy among these ethnic minorities, despite ample historical evidence to suggest resistance to vaccination programmes, including seasonal flu vaccination. Studies on the efficacy of programmes to address vaccine hesitancy among minority ethnic groups are rare, therefore a multi-pronged approach is recommended.

As can be seen, vaccine hesitancy was highest among Black, Bangladeshi, and Pakistani populations compared with people from a White British or Irish, Indian or other Asian ethnic background. This correlates with COVID-19 vaccination data up to 15 January 2021, which indicated significantly lower rates of vaccinations among over 80s in ethnic minority groups, with 42.5% of white people vaccinated, compared with 20.5% of black people.

Conversely, news reports indicate the success of a UK imam who helped change the minds of thousands of hesitant Muslims by convincing them of the vaccines’ safety and necessity. This is a good example of the power of targeted communication by trusted members of a community, who can potentially act as health messengers and community advocates during pandemics – and also help address issues such as public mistrust in the government.

It may also be worth researching further why some ethnic groups, in particular Indians and ‘any other Asian background’ (presumably including people who were Chinese, Korean, Japanese and originally from other parts of South East Asia) had similar willingness to vaccinate compared with White British and Irish. Might different religion, culture or socio-economic status help explain the differences?

Encouraging a healthy lifestyle whilst reducing social isolation levels amongst all ethnic groups

The LinkAge Plus scheme, which has been piloted within the UK since 2008, aims to improve the wellbeing of older people, increase their social networks and tackle isolation by creating stronger partnerships and links between local communities, local governments and the voluntary sector, tailoring programmes to meet the local needs of communities. Examples include social and fitness activities such as Yoga sessions, as well as health promotion education to include talks around diet and nutrition, and falls prevention workshops. The partnerships with different sectors encouraged effective resource allocation and improved access to services. This reportedly ‘facilitated key services to help maintain independence and improve the wellbeing of older people’. While there was no specific targeting of any group, including ethnicity or social class, the scheme offered benefit advice and healthy lunches to participants from low-income backgrounds.

It was also proven to be a cost-effective approach which saved taxpayer money. The net present value of savings up to the end of the five-year period following the investment was £1.80 per £1 invested. The scheme facilitates schemes ‘that are cost-effective in their own right, including reduced falls associated with balance classes and home adaptations.’

Health promotion projects, including any sport related activities, need to be tailored to suit the needs of different communities and reflect cultural diversity. The National Service Framework for Older People states that activities ‘should take account of differences in lifestyle and the impact of cultural/religious beliefs’. This can include conducting more local female-only sport sessions in order to encourage individuals to join, such as practising Muslim women who adhere to modest dress codes.

Other charities, such as Age UK, conduct a variety of local community services to include home help (day to day domestic tasks), IT training, social activities (groups for older people and local leisure activities), handyperson services and help with shopping. This increases people’s ability to continue living in their own homes as they get older, rather than having to move into care homes, with potential health benefits.

Recommendations

1. Effective health promotion plans by the government, NHS and local authorities must involve consultation with local ethnic minority communities and faith groups, to identify and develop health-related activities tailored to meet and support local needs – and to reduce barriers to healthy ageing, including the incidence of dementia being higher in some ethnic minority communities.

2. The government, NHS and local authorities must adapt their public health communication strategies to address underlying issues such as high vaccine hesitancy levels in certain ethnic minority or faith communities, by combating language barriers, Black and Muslim mistrust in the government, and online misinformation. Involving local community leaders in future pandemic mitigation strategies and potentially in national health initiatives should prove helpful here.

3. As loneliness is a risk factor for physical and mental health conditions, the UK governments and other relevant organisations should include measures to reduce loneliness in the future planning and management of pandemics and also in other healthy ageing initiatives.

4. The government, its research councils and other potential funders should commission research to help establish the long-term impact of universal policies on healthy ageing compared with targeted policies, including community-led initiatives, in order to identify ‘what works.’

Sara Meriouma and Maysa Mawalla, December 2021.