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Assessing CHD and hypertension in minority ethnic communities

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VOL: 99, ISSUE: 16, PAGE NO: 26

Mohammed Memon, MB, BS, LRCP, LRCS, LRCP&S, MPH, MBA, is professor of ethnicity and community health, Preston Primary Care Trust

Farha Abbas, PhD, BSc, is research coordinator, Preston PCT;Breda Memon, RGN, is a student at the Bolton Institute.

According to the 1991 census, minority ethnic groups made up about six per cent of the UK population. The 2001 census suggests this figure is now around 7.9 per cent (4.6 million) (Office for National Statistics, 2003).
According to the 1991 census, minority ethnic groups made up about six per cent of the UK population. The 2001 census suggests this figure is now around 7.9 per cent (4.6 million) (Office for National Statistics, 2003).

People from minority ethnic communities often have special health needs due to a range of factors. Many are socially excluded due to illness, disability, poverty, language barriers or racism, and such exclusion can contribute to physical and mental ill health. Disease patterns and presentation may be different to those in the general population, and mortality and morbidity from diseases such as coronary heart disease (CHD), cerebrovascular disease, hypertension and diabetes mellitus are higher than average (Memon et al, 2002; 2001; Raleigh, 1997).

The government has recognised the need to address inequalities in the health of local populations, and has set out its expectations in terms of equality, diversity and social inclusion through the equalities framework for the NHS. It states that new ways of thinking, working and behaving must be considered that recognise the health needs and rights of all sections of society (Department of Health, 2000). The aims of the framework include:

- Delivering services that are fair, accessible, appropriate and responsive to different groups and individuals;

- Making a difference to the life opportunities and the health of local communities, especially those that are excluded or disadvantaged (Department of Health, 2000).

If the NHS is to achieve equality in its service provision, morbidity and mortality rates of local communities need to be determined and their health needs must be understood. Health-needs assessments can help services to meet these requirements.

Health-needs assessment

A number of approaches can be taken to assessing the health needs of a population:

- Population profile - structure, environment (general, work, housing), lifestyles, cultures and religions;

- Measurements of disease and disability;

- Service utilisation (Memon et al, 2002);

- Effectiveness of intervention - promotion, prevention, screening, treatment and rehabilitation;

- Measurement of perceptions and expectations (of both general population and health care professionals);

- Social values;

- Political philosophy.

A comprehensive health-needs assessment provides opportunities to identify, prioritise and act to reduce mortality and morbidity among specific populations.

Health among minority ethnic groups

There are large differences in health between different groups, although a common factor is that many communities are disadvantaged and socially excluded in respect of CHD and stroke. Health differences include:

- Afro-Caribbean adults are up to six times more likely to die from hypertension-associated illness than white adults (Memon et al, 2002; 2001; Raleigh, 1997).

- Mortality from CHD is 55 per cent higher than the UK average in the Asian population (Memon and Abbas, 1999), and these inequalities are growing;

- In British south Asians the mortality rate from hypertension is 1.5 times higher than the national average (Memon et al, 2002; Raleigh, 1997).

- The risk of CHD is not uniform among south Asians, and there are important differences between subgroups. Bangladeshis have a high death rate from stroke (Cappuccio, 1997), while those from the Indian subcontinent have a higher death rate from CHD (Bhopal, 2002);

- In Afro-Caribbean people, blood pressure and weight are important factors in the high stroke rate (Cappuccio, 1997), while black Africans also have a high death rate from stroke.

A local health-needs project

A health-needs assessment project was undertaken in Preston and Blackburn to determine the prevalence of undiagnosed and asymptomatic hypertension in ethnic minority groups. The project surveyed 698 individuals over the period 1999-2000. The project was undertaken for the following reasons:

- It related to the requirements of the national service framework for CHD to prevent CHD in high-risk patients (Department of Health, 2001);

- It related to Health Improvement Programmes and priority settings and to the aims of the equality framework for the NHS (Department of Health, 2000);

- The outcomes of the project may provide evidence that can be used to improve the health and well-being of the population studied and to reduce health inequalities and incidence of conditions affecting minority ethnic groups;

- It would enable the researchers to establish a network and rapport with general practices in the area;

- It would assist health care commissioners in developing and delivering improved, appropriate services.

According to the 1991 census, minority ethnic groups form about 10 and 14 per cent respectively, of the Preston and Blackburn populations (Table 1).


Screening for undiagnosed/undetected hypertension was carried out on minority ethnic adults aged 35-65 at 10 general practices. Screening was undertaken by practice nurses, using standardised blood-pressure monitoring equipment. Patients were also interviewed to collect demographic, lifestyle and family history details. Height and weight were also recorded. Patients with a known history of hypertension were not screened.

Main outcome measures included age-adjusted prevalence of hypertension and associated demographic and lifestyle factors such as: smoking, alcohol consumption and diet.


Preliminary results of the survey indicate:

- The prevalence of undiagnosed/undetected hypertension among minority groups was 32.49 per cent;

- Severe obesity levels (body mass index >30) were higher in the newly found hypertensives than in the normotensives (P<0.01).>

- Preliminary results indicate that in minority communities, age, obesity, possibly gender and a high fat diet may play a pivotal role in the development of hypertension.

Possible strategies to improve health care

A number of strategies may be undertaken to improve health care and reduce health inequalities among minority groups. These are applicable to all localities with a high population of south Asian and Afro-Caribbean origin. These proposed strategies aim to improve awareness among both the community and health care professionals, and to facilitate early identification and better management of the condition:

- Health-needs assessment for minority ethnic groups should be undertaken, and must take into account the diversity within these populations.

- Health improvement programmes should be devised to provide opportunities to assess the total population as well as minority ethnic groups;

- Primary and secondary prevention of CHD should be increased through the improvement of appropriate interventions at the appropriate general practices;

- Hypertension screening and control among minority communities, particularly older south Asian females, should be considered a priority and intervention strategies should be developed;

- Follow-up of individuals identified with hypertension in respect of compliance, treatment and outcomes should be undertaken.

Despite the documented ill health experiences of minority ethnic communities, little progress has been made in addressing these issues, as factors other than those related to direct care provision have not been addressed. These factors include: language and communication difficulties; cultural attitudes; abstract and lateral thinking; different ways of doing things; patterns of disease; presentation of illness; how health and disease are perceived; access to services; racism; encounters with care service providers - including receptionists and clerks; use of alternative medicines; religion and beliefs and lifestyle and cultural practices.

In order to achieve the benefits of improving mortality and morbidity among local minority communities, the following strategies are worth considering:

- Undertake health-needs assessment in collaboration with local community members to help shape service provision and reconfigure initiatives that target minority communities;

- Assess the health impact of agency policies with regard to meeting the needs of minority communities;

- Involve minority communities in service development, planning and delivery to address issues of access, barriers and cultural sensitivity;

- Invest resources to address specific disease patterns;

- Promote cultural sensitivity training among NHS staff and commissioners - this should address barriers to accessing health services, racism and racial stereotyping, staffing in the NHS, and factors affecting access to services such as religion and culture;

- Supporting and empowering staff who wish to manage change to develop culture-specific practices;

- Invest in research and service developments in specific areas of care to meet the needs of minority communities;

- Employ more female staff in areas with large minority communities to improve access by women to health care, and make positive efforts to recruit staff from minority backgrounds;

- Support and promote equal opportunities for staff from minority ethnic backgrounds;

- Support health-related religious practices such as male circumcision;

- Address communication and language barriers.
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