Chapter 1:
Literature Review

Ethnic Minority & the Health care
Importance of Parent Education

Asian Women & Parent Education
Research Question

Chapter 2:
Research Proposal

Summary of the Literature Review

Data Collection
Data Analysis
Access to Research Site
Ethics Approval
Dissemination of Findings



Research Plan
Checklist of Resources for Funding

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Ethnic Minorities & the health care

Immigration has been a world-wide phenomenon; especially characterised by its directionality from East to West, or from other countries that are politically/economically unstable and less developed to those promised a better life. The promise of a better life is not always that simple and straight forward. These immigrates will not only be living in a new culture totally different to their own, but will be learning a new language, and also will be accessing the health care service for one reason or another. With culture being so diverse and complex, it remains a challenge for health professionals to deliver a culturally competent care. Not only are health professionals faced with this problem but alongside the challenge there is another obstacle, which remains an overwhelming problem: communication failures not only for the health professional but also for the consumer. Immigration holds with it many problems including racism, negative stereotypes and inequality in health care service (Tang, 1999).

In addition, communication failures become the biggest cause of complaints in the health care (Cortis 1998). This is more so for the people of the ethnic minorities and for those who speak little or no English. The lack of appropriate trained interpreters or maybe a difficulty in accessing their services put health professionals in very difficult positions in delivering effective care and makes it impossible for those people to obtain relevant information. The delivery of culturally competent care is essential in today’s health care environment where patient satisfaction and financial solvency have become imperative (Davidhizar et al, 1998).

Given the changing context of healthcare and the complexity of policy implementation, there are some important issues that administrators might wish to consider when organising such services in their agencies. Firstly, it should be acknowledged that one language will not cover everyone and providing interpreter service for each language could impose a tremendous financial burden on any institution. Firstly, we know resources are limited. Interpreter services should be provided in efficient and cost-effective ways, such as sharing resources among institutions by fostering partnership between them. Secondly, they should identify and deal with factors that may hinder the implementation of multicultural health policies, such as racism and discriminatory attitudes of staff against immigrants and ethnic minorities.

However, to do this, one of the strategies suggested by Tang (1999) is for the institutions to adopt a mandate to provide all services in an integrated and culturally sensitive way. Confidentiality, objectivity, accuracy, proficiency and cultural sensitivity are some of the standards to safeguard the quality of interpretation and to ensure that a message spoken in one language is transferred into another without distorting the meaning.

Smetten (1999) describes a project, which addressed staff attitudes and sought solutions to communication problems with children and families from the ethnic minority groups in paediatric setting. The aim of the project was to improve the quality of care offered to the families of ethnic minorities, to ensure that they receive the same welcome as the majority Caucasian population and to say: "Assalaam-u-Alikaam" (peace be with you). All Muslims, despite their origin, understand this phrase. Her challenge to improve communication with the ethnic minority families was based in North-West England, where there was a significant minority of families of Asian origin. Although not clearly indicated in her work, the project used a purposive sample.

The total population in the area were people from Pakistan, India and Bangladesh. Her article does not go into depth as opposed to who accessed the services but the results of the survey suggest that languages spoken by families were Urdu, Punjabi and Gujerati, indicate that these families were predominately Muslim. The information collected throughout the survey was classified as secondary data. Another survey was carried out, which collected information from the admission records so that a comparison could be made between the survey results and the total admission figures, thus indicating that there was need to improve communication problems between the clients and health professionals.

Smetten mentioned the Indian population, but the title of her article focuses the project more towards the Muslim families, as she uses the greeting Assalaam-u-Alikaam, which makes it questionable. Although the project brought out positive outcomes, she failed to recognise individuality and appeared slightly confused with the terminology used. At a very first, glance at the article it reflects that the project was designed for the Muslim families not the Indians.

Hill (1999) in turn supports in saying that it is essential that our services are sensitive and relevant to each individuals cultural and religious needs. This is not evident in Smetten’s work; she has attempted to group the ethnic minorities’ families under one umbrella (Asian). She needs to be more specific and descriptive about the families background so that a sound analysis and conclusion can be drawn out from her work. Throughout the literature review, research uses interchangeable terms such as Asian, Muslim and Pakistani the student shall use these as and when appropriate.

The admission of a child to hospital is a time of great anxiety for the family. Fradd (1994) argues that good communication between health care staff and the child and family is essential if this stress and anxiety is to be minimised. A holistic approach in meeting the child and family’s needs and providing care and treatment depends on good communication. Smetten recognised that care offered to the families of ethnic minority children was not always the same as that offered to the majority population (Caucasian) thus, giving evidence of racism or perhaps merely disadvantaging these children in receiving quality care. She found that racism did exist amongst staff working on paediatric wards. It may be subconscious and covert, or frankly overt and includes obstruction and denial of facilities, intolerance of customs, exasperation and even derogatory comments. This behaviour is usually due to ignorance or a lack of awareness on the part of the ward staff, rather than deliberate discrimination, and also some lack of understanding by the consumer of the health care service about how the system operates.

As United Kingdom Central Council (UKCC, 1992, P3) states in the code of professional conduct that nurse must:

"recognise and respect the uniqueness and dignity of each patient and client, and respond to their needs of care, irrespective of their ethnic origin, religious beliefs, personal attributes, the nature of the health problem or any other factor".

Schott & Henley (1999) argue that the opposite can be seen on postnatal wards when Asian Muslim women could not eat the food provided because they observed strict dietary laws. They were forbidden to have cooked food brought in by families. The fact that other women had take-away burgers and chips brought in for them was not noticed or perhaps overlooked, until a Muslim midwife joined the staff and pointed out the inconsistency. The work of Bowler (1993), Rooke (1991) and Hill (1999) is also evidence to illustrate how childbearing women are treated when accessing the maternity services, in terms of cultural and religious needs. The authors have a very judgmental and stereotypical attitude and to some extent inequality. For example, both Hill (1999) and Rooke (1991) begin with a broad and generalised statement in that all Asian women have a total lack in knowledge about pregnancy (Rooke 1991) and have no concept about how the body functions, how does the author come to this conclusion, surely not on the basis that some women can not speak the language? Hill (1999) tries to address the Islamic Law in a few paragraphs but it has taken Muslim scholars years and years to research, it is therefore more deeper and complex than a few paragraphs. So therefore, when examining closely, there are many practices that make health services less accessible, less attractive or positively alienating to people of ethnic minority culture or religions (Schott & Henley, 1996). And research itself makes this evident by writing a two page article based on anecdotal evidence about the Muslin practice surely this is questionable, unethical and insensitive? But the student does not dispute the fact that there may be a minority that do have a limited understanding due to lack of education but the danger is that all Asian women may be seen as ‘the same’. This can mask the needs of individual women and lead to poorer service provision (Bowler, 1995 & Proctor & Smith, 1992).

Smettem found that poor communication and negative staff attitude were two problems identified in her project. Her findings reflected that some members of staff saw the provision of translation services as "giving in", and believed that the onus lay with the family to learn to speak English and nothing was wrong with the service they provided. As Henley & Clayton (1982) suggests, we must all understand that we have racial prejudices and realise that ethnic minority Britons have as much right to health care as white, English speaking Britons, whether this is on paediatric or maternity wards. The promotion of change in staff attitude was a personal challenge for Smetten and she started by learning basic Urdu, this in turn was accepted by hospital management, which resulted in training, which enabled staff to engage families in limited conversation in Urdu and emphasised a willingness to communicate. It was also positive to see that changes were made in pre-registration nurse training at University of Central Lancashire by providing an opportunity to undertake a module devoted to trans-cultural nursing. This meant that students were sometimes more aware of cultural issues than qualified colleagues. This in turn can be argued that maybe if midwifery training can encompass more of these modules, then maybe a change in staff attitude can be seen.

Hussain & Gerrad (1999, P19) argue that services for ethnic minority groups have to begin somewhere. Projects can be a beginning but should not be a means to an end. Project workers such as Smetten need support and to be made to feel valued. Change takes time, it is not enough to submit a document that ends up on somebody’s desk to be glanced at and then be forgotten. Services for the ethnic minority groups have to be part of the mainstream and should be delivered equally and sensitively.

Language barriers may be one problem faced by ethnic minority. The report on the Stephen Lawrence Inquiry (1999) provoked mixed reactions. However, it is especially notable for its bold definition of institutionalised racism. This term has been, and in some quarters still is, taken to mean that everyone in the organisation is personally and knowingly racist. These misunderstanding result in anger among those who feel "accused" and prevent any objective assessment of the real issues. The actual meaning of Institutionalised racism is that "organisations may have a culture, policies and procedures which although not intended to be racist, disadvantage people of minority cultures and religions. The main problem with institutionalised racism is that it is so embedded in organisation that it is difficult to detect (Allen et al, 1999, P208).

For example the under representation of black and ethnic minority health professional in higher grades and management is reflected in midwifery practice. However, it is not always clear what action needs to be taken to tackle such problems instead it simply may go unnoticed and institutionalised racism may tacitly be accepted (UKCC, 1999). But to correct this, UKCC will compile the first comprehensive statistics on the number of black nurses in the United Kingdom (UK). A form will be sent out to 637,000 registered nurses, to monitor ethnic identity. These very first comprehensive statistics will give UKCC more credibility and can feed into workforce planning. Another benefit of these statistics will allow UKCC to establish whether the myths surrounding black nurses are thought to be overly represented at lower end of the scale is true or not. Sanjiv Vedi, Union Officer for race equality, said "it is time these figures were brought out but we need to know what grades people are on so we can challenge the National Health Service (NHS) and the government if there is inequality" (P6)

Inequality is not just embedded within the workforce but more so for the consumers of health care, especially within maternity services concerning ethnic minority. The National Conference: Diverse Needs, Diverse Choice which was held in Manchester explored the ways in achieving racial equality in the maternity service provision in the context of Changing Childbirth. They made recommendations for developing ethnically sensitive services and a few were: provide equality training (including cultural/religious awareness) for all staff and incorporate in the curriculum for all health professionals, encourage black and ethnic minority people into all levels of health services employment to achieve equal representation and to promote the role of the midwife among black and ethnic minority population but the issues of retention and recruitment are varied. The last recommendation clearly indicates the need of more black and ethnic minority midwives in the future who can possibly help solve current problems with communication and educate other health professionals about cultural diversity. But these remain recommendations for health professionals and whether they are put into practice yet remains to be seen, although the work of Smetten (1999) and Ramsay (1999) seem to be heading in the right direction.

The issues raised so far are based around communication barriers and lack of cultural understanding on the health professional’s part. Health professionals need to try and overcome this, then maybe we can then see improvement in the care we provide for the ethnic minority, then may be the people of the ethnic minority may also feel comfortable in accessing services. Cowl (1999) argues from the maternity service perspectives that women from black and ethnic minorities are not difficult but diverse, therefore, when services are planned, their individual differences should be addressed rather than focusing on the "difficulties" they may be seen to present.

From the research (Hill, 1999 & Smettem, 1999) it is obvious that health professionals are dismissing/ignoring the needs of the ethnic minorities especially when there is a communication problem. Instead of attempting to improve the services they try to blame someone when things do not go to plan, the blame therefore lies with the ethnic minorities, this can be seen in paediatric and maternity wards. Bowler (1992) says that stereotypes take the form of caricatures which reflect underlying internal models and often a hostile or belittling attitude, thus reflecting that the health service is not immune from individual and institutionalised racism.

There are many areas where the needs of ethnic minority are ignored, repeatedly and health service is one area of concern, this may be due to language barriers and/or lack of cultural awareness. Although, the author acknowledges this, one particular aspect of midwifery care seems to be an issue: parent education for the non-English speaking population. Research by Walker & Pollard (1995) argue that Asian women are poor uptakers of parent education but is there any surprise why this is the case, when researchers and health professionals have repeatedly stereotyped and alienated the ethnic minorities from accessing such services. Cowel (1999) stresses the importance for health professionals of not making stereotypical assumptions about the needs of ethnic minority women and tailoring their response to ensure those women receive a sensitively delivered individualised care. The author again questions the fact that why are Asian women poor uptakers of parent education? We need to question whether it is our poor and ignorant services that we provide which distances them? On the other hand, whether the women just can not be bothered? The first question has been answered throughout the literature review but the second question needs to be explored.

Parent education is not a new subject but an area where midwives seem to be lacking the skills and expertise in recognising Asian women’s needs (non-English speaking Pakistani women). Not one article or research paper has explored the attitudes and feelings in depth as to why Asian women do not attend parent education classes and what it is about the classes that seems to be unattractive? Before the student can go into detail, the importance of parent education needs to be explored.

Importance of Parent Education

"Changing Childbirth emphasises the need to provide a more women centred approach to care. Providing such care presents a tremendous challenge for midwives caring for women who speak languages other then English" (DOH, 1993, P6)

In 1942, childbirth without fear was landmark publication, which increased the demand from women for parent education classes, which would teach them more about how babies were born and how they could make birth easier for themselves. Since the parent education has attracted considerable attention to itself in terms of research interest, professionalisation of teachers and the commitment of educational charities and in turn the women’s network faded away replaced by more teacher centred environment (National Childbirth Trust).

When considering the origins of parent education, it is important to remember that it came into being to meet the needs of middle-class women who had become separated from the women’s network, due to a number of social reasons. This left them with no further opportunities to be present at births, to observe and learn about the course of labour, whilst the working class women continued to build upon their expertise and offered support to families for several more decades (Nolan, 1997a). Hancock (1994) says that the ideal aim of parent education should be to share knowledge with all childbearing women and their support partners, so that they are informed within the limits of their education and understanding, to an extent that they are able to make decisions and choices if they so wish, guided by honest experience of research based midwives.

Mary Nolan neatly summarised the history of parent education, highlighting how women all over the world learnt from experience. Young girls watched women in labour and had learnt what to expect. Industrialisation separated family networks and the need for parent education became popular, the notion of extended families began to fade away in some parts of the world (Nolan, 1997b).

Originally, the aim of parent education was a list of "do’s" and "don’ts" and in the post war years the medical model in obstetrics also influenced the classes (Carter, 1997).

Sheila Kitzinger agrees, describing how parent education has always been available to women through "the women’s network". Women learnt from other women’s experiences, by attending births and taking part in helping rear babies and small children. It was unheard of for men to be present at birth, in the vast majority of cultures; labouring women were often taken to special huts, surrounded by women carers. This network allowed then to become competent in baby care skills and were empowered as mothers and women through processing knowledge which is accessible only to their own sex (Nolan & Hicks, 1997c). As a result, the concept of providing care throughout prenatal period began to grow and gain respectability, due to the reduction of maternal and infant mortality (Maloni et al, 1996)

The importance of parent education in the lives of women and their families is probably best illustrated by the diversity of provision at the end of the 20th Century (women’s network). But gradually with growth of the conurbation and the dispersal of small rural communities, the women’s network began to break down and women were forced to seek knowledge from other sources apart from experienced mothers, families and neighbours (Dick-Reid, 1942)

Parent education changed from learning from experience to class room teaching where little choice became available to expectant mothers and partners but having said this it still remains an important issue for not only for the indigenous population because of their family structure but also for the Asian mothers especially for those whose English is not their first language and speak or understand very little. However, despite these language barriers Changing Childbirth over a dozen of references argued on the importance of informed choice for women during pregnancy and childbirth. It specifically highlights the recommendations that women need to know what is available to them, so that they can make their own decisions, this in turn should be supported by health professionals, furthermore, the women should receive clear and unbiased advice and their rights to make decisions should be respected (Anderson, 1996)

In turn, women who speak very little or no English are also entitled to informed choice, language barrier does not mean lack of knowledge and intellectual abilities. One main problem of parent education that it has always attracted those who have some basic knowledge regarding childbirth. When providing parent education it is important to identify those women or couples who will benefit from these classes and those who need one to one teaching. Vulnerable women probably belong to this latter category (Annefield & Proctor & Smith, 1992, 1990). Parent education is just as important to the ethnic minority community, for those who have started to enter the UK but also for those who have always been in the UK, but it would be naive to assume that it is the language barrier that stop Asian mothers attending but factors such as other commitments and lack of promotion of parent education could also influence attendance.

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