Caring for Older People: Ethnic eldersBMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7057.610 (Published 07 September 1996) Cite this as: BMJ 1996;313:610
- Shah Ebrahim, professor of clinical epidemiologya
- a Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, London NW3 2PF
Since the 1870s Britain has received large numbers of immigrants from different countries and cultures (fig 1). Migration is due to “push” and “pull” factors. After the second world war, Britain actively recruited labour from Commonwealth countries to aid the reconstruction effort—a major “pull”; many came thinking they would earn enough money to return home and retire in comfort. “Push” factors are poverty, political instability, and oppression.
Immigration policy became much less flexible during the 1980s and led to reductions in the numbers of new arrivals. New migrants arrive daily from some countries (such as Somalia) where political oppression endangers life but not from others (former Yugoslavia). British immigration policies are not consistent.
It is still possible for older people from some countries to resettle in Britain by joining their children. The distribution of ethnic minorities in Britain is strongly biased towards inner city areas of major industrial towns. Bradford, Leeds, Manchester, Nottingham, Wolverhampton, Leicester, Birmingham, Coventry, and London have high numbers of elderly people of different ethnic origins.
Ethnicity is a complex idea. It includes skin colour, culture, language, religion, birth place, food, beliefs, and behaviour. Ethnicity is impossible to define clearly and in most contexts refers to the “otherness” of people who do not belong to the predominant population. The classification used by the Office of Population Censuses and Surveys1 emphasises the “visible” criterion of skin colour, reflecting British views of ethnicity. Not surprisingly, people who share a skin colour do not necessarily have much else in common. It is wrong to assume that people of the same colour should be put together as they will “get on better.” Many of the problems of ethnic elders are common to European, Irish, and other “invisible” groups.
The numbers of people belonging to different ethnic groups are relatively small—about 5% overall. Most people from ethnic minorities in Britain are young compared with white British people; only 5-10% of people of other ethnic origin are over 65 years old.
All the populations of people who arrived in Britain in the 1950s and 1960s in their 20s and 30s are aging rapidly and reaching retirement (fig 2). The numbers of older people from ethnic minorities will increase dramatically over the next two decades.
Ethnic elders are at risk by virtue of old age because of associated ill health and loss of role. They are further jeopardised by the multiple disadvantages due to racism, resulting in poor living conditions, overcrowding, low incomes, and a sense of alienation. They do not make use of many statutory and voluntary services because they perceive these services as being for the majority white population and being insensitive to their needs.2
Disease patterns are broadly a reflection of those experienced by most older people. Rare or “exotic” tropical diseases are seldom encountered, but the diagnosis of heart failure, asthma, or tuberculosis may present a major challenge because of communication problems. With the exception of Chinese people, older people from all ethnic groups seem to have more chronic disease than white British people until very old age (fig 3).1 Explanations for the excess morbidity are poverty, poor housing, and lifestyle (smoking, lack of exercise, diet), all of which contribute to higher risks of cardiovascular disease, diabetes, and other chronic problems. Morbidity may be due to factors operating in the “home” country, selection of who migrates, or the process of adaptation and adjustment.3
Triple jeopardy for ethnic elders
Cultural and racial discrimination
Lack of access to health, housing, and social services
A variety of beliefs can determine our views about causation and treatment of disease. Many older people from ethnic minorities (in common with many white British people) hold contradictory beliefs, ranging from a modern understanding of infectious and chronic degenerative disease, a religious view that it is God's will that disease occurs and that prayer will help, and traditional beliefs in spirits or the “evil eye” that must be dealt with by rituals.
It is not possible to generalise about the specific beliefs held by an individual. Sensitive inquiry about beliefs should be an essential part of taking a history, whatever the patient's ethnicity.
Consultations in primary care
The number of consultations in general practice by older people from ethnic minorities is high (fig 4),4 and this may cause consternation for the general practitioner or nurse. Having excluded anaemia, osteomalacia, tuberculosis, diabetes, asthma, and ischaemic heart disease, what next? Most older people from ethnic minorities consider themselves to be sicker than white British people. This suggests that excess consultation may simply reflect excess ill health.
Common diseases among ethnic elders
Ischaemic heart disease
Non-specific symptoms are common, and ethnic elders with “modern” health beliefs may expect a suitable array of strong medicines (even injections) to deal with them.
The general practitioner must be aware that these patients are likely to have multiple consultations with alternative practitioners and to take drugs obtained overseas, and should ask about these practices. Employing practice staff from a predominant local ethnic minority group is an excellent way of gaining insight into these expectations and practices.
The hospital experience
Hospital admission is a frightening, demeaning, and difficult experience for anyone and is even harder for ethnic elders. Familiarity with hospital routines (which white people gain from watching TV hospital soaps) is non-existent, and language may present insuperable barriers. Staff from ethnic minorities can help make hospitals more sensitive to people's needs. However, it is vital that equal employment opportunities are not limited to menial roles if improvements in equity and accessibility of services are to be achieved.
The process of rehabilitation is not widely understood by many ethnic elders. If you are ill, you should lie in bed until you get better or die. Active rehabilitation may be thought unhelpful and is counterintuitive. Careful explanation and negotiation is required with the patient and family and with community services to establish aims and methods of rehabilitation and to ensure a reasonable outcome.5
Creating a better hospital environment
Interpreters—available for inpatient and outpatient work
Meals—culturally appropriate and likely to be enjoyed by all
Visiting—acceptance of large family groups, particularly after death
Signs—use of direction markings comprehensible to those not literate in any language
Patient information—booklets, cassette tapes, hospital radio in several languages
Discharge and follow up—equity with white population in provision
Equal opportunities employment at all levels—ethnic monitoring, particularly of medical shortlisting and appointments committees
Activities of daily living are widely used to assess progress and determine discharge from hospital and the need for follow up rehabilitation. Aims are culturally specific and differences in customs of dressing, bathing, and eating must be taken into account. These factors may explain some, but not all, of the relative dependency of Asians aged over 75 in Leicester (fig 5).4
Language, religion, and food are the most obvious differences between ethnic groups, but the health service and social services are not responding to these needs in ways that reflect our multicultural society. Provision of trained interpreters, places for prayer, and culturally acceptable food are all needed in hospitals but are seldom found.
Religious beliefs and social customs must be observed to ensure that the processes of dying and bereavement are not made unnecessarily painful. Knowledge of practices of the major religions (box 5) is not widespread. It is always sensible to ask relatives about specific requirements and not to make assumptions.
Death rituals in different cultures
Judaism—Lay out body conventionally; wrap in plain sheet with no religious emblems. Body should not be left alone. Burial within 24 hours. Postmortem examination only in exceptional cases
Sikhism—Belief in reincarnation. Family may wish to wash and dress the body. Cremation within 24 hours. White worn as a sign of mourning
Hinduism—A Hindu priest (pandit) will arrange cremation with variable rituals. Open expression of grief is expected. Postmortem examination is felt to be disrespectful to the deceased
Islam6— Relatives are duty bound to visit the bereaved. Running water is needed for washing before prayers. Family usually carry out rites but local mosque will help. Body should be touched only by Muslims; non-Muslims should wear disposable gloves when touching the body. Burial should be done within 24 hours
Buddhism—Belief in reincarnation. Cremation arranged at an auspicious time determined by monks. No fundamental objections to postmortem examination
Christianity—Family usually wish to see and may watch over the body. Last rites may be arranged by priest before death. Cremation or burial depending on preference. No fundamental objections to postmortem examination
Myths about ethnic elders
Numbers are very small
The family supports old people
No use of services equals no need for services
People from ethnic minorities will return home in old age
It would be better if they spoke English
Family and social factors
The return home in old age was the expectation of many migrants, particularly from the West Indies. For many this hope will never be realised, but some may have the resources and desire to bury their bones on home soil. Arranging for overseas travel for a frail or very dependent person is quite possible and can often result in much happiness. It is vital that the family have clear information to give the airline on the person's disabilities and likely needs during travel. A comprehensive medical, nursing, and treatment summary is also essential for continuity of care once the person gets back home.
The social services have made little progress in adapting to our multicultural society.7 This is a reflection of political pressure to sustain services for the white (voting) majority, assumptions that no use equals no need, and a widely held belief that assimilation into the wider population will occur. Thus the need for specific ethnic services is avoided. In general, social services should now be making contracts for service provision of meals on wheels, home care, day centres, and lunch clubs with local voluntary groups run by ethnic minorities themselves.
The extended family is popularly believed to exist among ethnic minorities and to be capable of coping with almost any chronic disease. Extended family groups work by mutual support through well defined roles. A dementing older person is not able to fulfil a useful role, and supervision and care become major problems when everyone else is out at school and work. To cope successfully, families require advice, support, respite, and practical help with disability and financial benefits.