Improving access and quality for ethnic minority women— panel discussion

Abstract

Inequalities in healthThe World Health Organization defines health as a “state of complete physical, social, and mental well-being and not merely the absence of disease or infirmity.”1WHO Regional Office for EuropeSecond consultation to develop methods and instruments for health interview surveys. WHO Central Bureau of Statistics, Copenhagen1990Google Scholar The main arguments in both papers presented are developed on the prevailing reductionist, disease-orientated approach to health. Furthermore, many ethnic minority groups living in both the U.K. and the U.S. have different and complex belief systems about health that do not fit comfortably into the biomedical approach that still dominates much Western policy and practice.Both papers point to the great variety and diversity within and across minority groups in terms of levels of integration, generation, linguistics, socioeconomic status, culture, religion, and lifestyles. However, we often forget to acknowledge those areas where ethnic minority women do better than average, or skirt over the areas where there are major differences between certain ethnic groups. For example, studies in the U.K. show that Indian women have reasonably good overall health. In some conditions, such as lung cancer and breast cancer, ethnic minority women have half the incidence rate of the general population, and they fare better than the general population with regard to respiratory diseases.Coronary heart disease (CHD) is 43% more frequent in South Asian women when compared to the general population of England and Wales, but Caribbean and Chinese women have lower rates than the general population. Nevertheless, the papers do show a number of areas of commonality, such as diabetes, HIV/AIDS, CHD, and obesity in these populations.Marilyn Gaston states that “disparities in health status for women of colour persist across both low-income and high-income groups.” Veena Bahl argues that “much of the variations in health between and within different ethnic groups is related to socio-economic status.” The question then arises for the U.S.: are public policy interventions such as improving the education and income prospects for ethnic minority women of limited value in terms of health gain? This whole area warrants further investigation, as it may have significant implications for how we take any joint work forward.Most of the panelists agree that a strong sense of community, particularly for ethnic minority women, is absolutely essential to help deal with the impact of racism and crime, to overcome social isolation, and to build dignity, self-esteem, and autonomy. In fact, the relationship between social capital (ie, the benefits to individuals and communities of social networks, strength of community organizations, neighborliness, and a host of other factors) and health and well-being, especially for ethnic minority groups, is only now beginning to be properly examined.2Health Education AgencyBlack and ethnic minority groups in England. Health Education Agency, London (UK)2000Google Scholar, 3Health Education AgencyHealth and lifestyles of the Chinese population in England. Health Education Agency, London (UK)1999Google ScholarLet me expand. Almost 70% of ethnic minorities in the U.K. live in the larger conurbations, and this can have a positive impact on health. (The main exception to this are Chinese people, who experience problems identified with dispersed minority communities.) But even people in well-established communities rely on friends, family, and local networks to understand how services work. This is particularly true for older people in South Asian, Chinese, and Vietnamese communities, many of whom came to the U.K. later in life and do not speak English as their main language of communication.The barriers to accessing equitable health and social care have been made worse with the introduction and phased implementation of the 1999 Immigration and Asylum Act. The interim dispersal scheme introduced in December 1999 in London and the South East has the aim of alleviating accommodation shortages; therefore, people are being dispersed purely on the basis of available housing without regard to whether the area of enforced settlement has a relevant, existing ethnic minority population.This means that only the lucky few will be able to access local voluntary and community groups for information, reassurance, and support in an alien environment. Such support is crucial, as the evidence consistently shows that many refugees and asylum seekers do not receive even their basic entitlement to services, and few are given information on the available services and how to access these. For example, in one part of London, 93% of survey respondents said they had been given no information on how to register with a family doctor, and 97% said they had been given no information on how to use hospital services. In another study, it was found that 40% of refugees encountered problems registering with a family doctor, and in a third survey, some patients reported being asked for their passports when trying to register.4Gammell H. Ndahiro A. Nicholas N. Windsor J. Refugees (political asylum seekers). College of Health, London, (UK)1993Google Scholar, 5Islington Zairean Refugees GroupIslington Zairean Refugees Survey Report, Healthy Islington 2000. Lambeth, Southwark and Lewisham Health Authority, London (UK)1998Google Scholar, 6Lambeth, Southwark and Lewisham Health Authority. Lambeth, Southwark and Lewisham Refugee Outreach Team Annual Report; 1997/98.Google ScholarInequalities in information about healthIn the U.K., we are severely hampered by the inequalities in information and research about diseases and treatments relating to ethnic minority women. More comprehensive research and better information sources, standards, and databanks are being developed; however, it will take some time before public policy decisions reflect this. Even so, I am not convinced that the proposed changes will lead to effective models for gathering, collating, and acting on data concerning key health issues for ethnic minorities. And, I see no prospect of an R&D strategy for ethnic minority health, let alone ethnic minority women’s health.At the moment in the U.K., much of what is known about the health disparities in ethnic minority populations is based on country of birth data as recorded on death certificates. These statistics cover immigrants, yet over half of the ethnic minority population were born in the U.K. In fact, 90% of ethnic minorities under age 35 were born in the U.K. and all ethnic minority populations have a younger profile than the white population, with about one-third under age 14 (compared to a fifth in the general population).These percentages led me to think about some of the current and more pressing needs of younger women. The papers pay little attention to improving the quality of life for younger women. Recently in the U.K., there have been widely publicized debates on teenage pregnancy, transcultural adoptions, young people and the use of recreational drugs, young women and girls’ poor self image, and homelessness, to name but a few. I could pose a series of questions relating to the health needs and outcomes on each of these for younger ethnic minority women on both sides of the Atlantic.I will limit myself to two issues. First, the debate on low self-esteem of girls and young women in the U.K. has centered on waif-like fashion models appearing in the magazines and advertisements read by young women of all ethnic groups. But even if we judged eating disorders among young women to be only of concern to white middle-class people, why are we not discussing recent studies in the U.K. relating to deliberate self-harm, the disturbing increases in suicides, and the increased rates of depression, particularly among some groups of Asian young women? Second, isn’t teenage pregnancy also a major public health issue for certain ethnic minority groups in the United States as well as in the U.K.?At the other end of the age spectrum, we have recently had a lengthy debate about long-term care issues in the U.K. Statistics from the London Research Centre show that among ethnic minority communities, numbers of people over age 60 will increase by 100% to 200% over the next 15 years. The “over 60’s” currently comprise 6% of the ethnic minority population (compared to 21% in the general population) and over half of these are women. The Policy Research Institute on Aging and Ethnicity at the University of Bradford, among others, is calling for a radical rethink of health and social care services to meet the needs of this group, and has been critical particularly of services to people with dementia.Veena Bahl looks at women’s health “in the context of black and minority ethnic health generally;” however, Marilyn Gaston is explicit about the fact that ethnic minority women share many of the same health issues as white women. The latter is an important point. We tend to overlook the ethnic minority perspective on many common areas of concern by focusing on the things that separate us, at the expense of the things we have in common. Whether we are concerned with breast cancer, the number of unnecessary hysterectomies (about one-fifth of British women have hysterectomies before the age of 65 years), the medical management of menopause, or general maternity services, ethnic minority women have views on these and many other issues, and research and service agencies should be encouraged to seek their views and respond to their needs.Inequalities in access and quality of servicesAre we really concerned with equity of access, equity of health care treatment, or equity of health care outcomes? When we measure access we are looking at whether or not, in general, people with “equal” health needs use the same level of health care services. We need to be clear about what our objective is because 1) it does not necessarily follow that more care will mean better care and, 2) the type of solutions we put forward will depend on what we are trying to achieve.Education and training is another area that needs attention. I chair the U.K. Council for Education and Training in Social Work (CCETSW). CCETSW’s policy on education and training has antidiscriminatory practice as an integral part of the curriculum. The policy states that: “Students and candidates will accept and respect individual rights and circumstances and understand how these affect the delivery of services for children and adults, families, and communities. They will learn how to counter discrimination, racism, poverty, disadvantage, and injustice in ways appropriate to the situation and their role.” The policy further states that: “Providers of social work education and training (and this includes universities equally) will eliminate unfair discrimination and disadvantage in all aspects of their work regulated by the Council and they will demonstrate this consistently through the Quality Assurance process.” We must continue to lobby for change in clinical education and training so that antidiscriminatory practice and cultural competence become mainstream issues, as they are in social work.Also in the U.K., general skills courses tend to be run by nonspecialist in-house staff or independent training contractors. There are no nationally recognized qualifications or accredited programs on antidiscriminatory practice, managing diversity, or cultural competence. As a consequence, quality standards, content, and outcomes vary widely.In their discussions of promotoras and linkworkers, Gaston and Bahl have presented a Health Advocacy model to improve both access to and quality of health care services. In London, the King’s Fund charity has earmarked £1m to continue the development of advocacy services in London, with the hope that this pump-priming money will lead to mainstream implementation over time. Let me quote from the King’s Fund report on Advocacy which will be launched next month:Advocacy is about helping people to say what they want, obtain their rights, represent their interests, and gain the services they need. The fundamental emphasis and focus of advocacy is that it sees things from the service users’ perspective and recognizes that the user or patient is in an unequal power relationship with the service provider… Reviews of interpreting and linkworker schemes across health and social services highlight that while many of these schemes were developed to address communication difficulties, many have needed to extend their remit to include “advocacy” roles, such as promoting better health and making health care systems more accessible.7King’s FundMapping the provision of health advocacy for black and minority ethnic communities in London. King’s Fund, London (UK)2000Google ScholarWhile we continue to work on more equitable public health policies and influence the development of better education, training, and development, one of the other main avenues for change will be in the ethnic minority-led health and social support voluntary sector, particularly their work in advocacy, patient empowerment, and health promotion. The range of roles and activities of the ethnic minority-led health and social support voluntary sector include direct service delivery, translation, interpretation, information provision, education and advocacy services, outreach support, local research into needs, community development, counseling services, and training for statutory professionals. These volunteers are good at encouraging take-up of main-stream services, promoting understanding of available services through information provision in appropriate languages and formats, designing and delivering training programs for professionals to help them deliver culturally competent services, campaigning for more culturally competent services, and building social capital within their communities.In one area of London, health service planners have created a “Charter of Access.” They ask all commissioners of new or restructured services to agree that a certain percentage of the total service will be set aside for advocacy provision. (This could be 1% or it could be 10%). The planners realize that this may not necessarily increase the total amount of money available for advocacy, but it does draw attention to access issues.The center of the health disparities conundrum should be the individual woman, not the health care system. The extent to which individuals engage in health promoting behaviors and are prepared or able to modify risky behaviors will depend to some degree on how they assess their own health behaviors, on their awareness of what healthy behavior is, and on their awareness of the relationship between their behavior and health or illness.The 1999 Health Survey for England has an ethnic minority “focus.” This will allow a proper comparison of ethnic groups on the main health status measures in the survey and analysis of inequalities, as well as issues relating to specific health conditions, for example, cardiovascular disease, diabetes, accidents, and mental health. Inequalities in healthThe World Health Organization defines health as a “state of complete physical, social, and mental well-being and not merely the absence of disease or infirmity.”1WHO Regional Office for EuropeSecond consultation to develop methods and instruments for health interview surveys. WHO Central Bureau of Statistics, Copenhagen1990Google Scholar The main arguments in both papers presented are developed on the prevailing reductionist, disease-orientated approach to health. Furthermore, many ethnic minority groups living in both the U.K. and the U.S. have different and complex belief systems about health that do not fit comfortably into the biomedical approach that still dominates much Western policy and practice.Both papers point to the great variety and diversity within and across minority groups in terms of levels of integration, generation, linguistics, socioeconomic status, culture, religion, and lifestyles. However, we often forget to acknowledge those areas where ethnic minority women do better than average, or skirt over the areas where there are major differences between certain ethnic groups. For example, studies in the U.K. show that Indian women have reasonably good overall health. In some conditions, such as lung cancer and breast cancer, ethnic minority women have half the incidence rate of the general population, and they fare better than the general population with regard to respiratory diseases.Coronary heart disease (CHD) is 43% more frequent in South Asian women when compared to the general population of England and Wales, but Caribbean and Chinese women have lower rates than the general population. Nevertheless, the papers do show a number of areas of commonality, such as diabetes, HIV/AIDS, CHD, and obesity in these populations.Marilyn Gaston states that “disparities in health status for women of colour persist across both low-income and high-income groups.” Veena Bahl argues that “much of the variations in health between and within different ethnic groups is related to socio-economic status.” The question then arises for the U.S.: are public policy interventions such as improving the education and income prospects for ethnic minority women of limited value in terms of health gain? This whole area warrants further investigation, as it may have significant implications for how we take any joint work forward.Most of the panelists agree that a strong sense of community, particularly for ethnic minority women, is absolutely essential to help deal with the impact of racism and crime, to overcome social isolation, and to build dignity, self-esteem, and autonomy. In fact, the relationship between social capital (ie, the benefits to individuals and communities of social networks, strength of community organizations, neighborliness, and a host of other factors) and health and well-being, especially for ethnic minority groups, is only now beginning to be properly examined.2Health Education AgencyBlack and ethnic minority groups in England. Health Education Agency, London (UK)2000Google Scholar, 3Health Education AgencyHealth and lifestyles of the Chinese population in England. Health Education Agency, London (UK)1999Google ScholarLet me expand. Almost 70% of ethnic minorities in the U.K. live in the larger conurbations, and this can have a positive impact on health. (The main exception to this are Chinese people, who experience problems identified with dispersed minority communities.) But even people in well-established communities rely on friends, family, and local networks to understand how services work. This is particularly true for older people in South Asian, Chinese, and Vietnamese communities, many of whom came to the U.K. later in life and do not speak English as their main language of communication.The barriers to accessing equitable health and social care have been made worse with the introduction and phased implementation of the 1999 Immigration and Asylum Act. The interim dispersal scheme introduced in December 1999 in London and the South East has the aim of alleviating accommodation shortages; therefore, people are being dispersed purely on the basis of available housing without regard to whether the area of enforced settlement has a relevant, existing ethnic minority population.This means that only the lucky few will be able to access local voluntary and community groups for information, reassurance, and support in an alien environment. Such support is crucial, as the evidence consistently shows that many refugees and asylum seekers do not receive even their basic entitlement to services, and few are given information on the available services and how to access these. For example, in one part of London, 93% of survey respondents said they had been given no information on how to register with a family doctor, and 97% said they had been given no information on how to use hospital services. In another study, it was found that 40% of refugees encountered problems registering with a family doctor, and in a third survey, some patients reported being asked for their passports when trying to register.4Gammell H. Ndahiro A. Nicholas N. Windsor J. Refugees (political asylum seekers). College of Health, London, (UK)1993Google Scholar, 5Islington Zairean Refugees GroupIslington Zairean Refugees Survey Report, Healthy Islington 2000. Lambeth, Southwark and Lewisham Health Authority, London (UK)1998Google Scholar, 6Lambeth, Southwark and Lewisham Health Authority. Lambeth, Southwark and Lewisham Refugee Outreach Team Annual Report; 1997/98.Google Scholar The World Health Organization defines health as a “state of complete physical, social, and mental well-being and not merely the absence of disease or infirmity.”1WHO Regional Office for EuropeSecond consultation to develop methods and instruments for health interview surveys. WHO Central Bureau of Statistics, Copenhagen1990Google Scholar The main arguments in both papers presented are developed on the prevailing reductionist, disease-orientated approach to health. Furthermore, many ethnic minority groups living in both the U.K. and the U.S. have different and complex belief systems about health that do not fit comfortably into the biomedical approach that still dominates much Western policy and practice. Both papers point to the great variety and diversity within and across minority groups in terms of levels of integration, generation, linguistics, socioeconomic status, culture, religion, and lifestyles. However, we often forget to acknowledge those areas where ethnic minority women do better than average, or skirt over the areas where there are major differences between certain ethnic groups. For example, studies in the U.K. show that Indian women have reasonably good overall health. In some conditions, such as lung cancer and breast cancer, ethnic minority women have half the incidence rate of the general population, and they fare better than the general population with regard to respiratory diseases. Coronary heart disease (CHD) is 43% more frequent in South Asian women when compared to the general population of England and Wales, but Caribbean and Chinese women have lower rates than the general population. Nevertheless, the papers do show a number of areas of commonality, such as diabetes, HIV/AIDS, CHD, and obesity in these populations. Marilyn Gaston states that “disparities in health status for women of colour persist across both low-income and high-income groups.” Veena Bahl argues that “much of the variations in health between and within different ethnic groups is related to socio-economic status.” The question then arises for the U.S.: are public policy interventions such as improving the education and income prospects for ethnic minority women of limited value in terms of health gain? This whole area warrants further investigation, as it may have significant implications for how we take any joint work forward. Most of the panelists agree that a strong sense of community, particularly for ethnic minority women, is absolutely essential to help deal with the impact of racism and crime, to overcome social isolation, and to build dignity, self-esteem, and autonomy. In fact, the relationship between social capital (ie, the benefits to individuals and communities of social networks, strength of community organizations, neighborliness, and a host of other factors) and health and well-being, especially for ethnic minority groups, is only now beginning to be properly examined.2Health Education AgencyBlack and ethnic minority groups in England. Health Education Agency, London (UK)2000Google Scholar, 3Health Education AgencyHealth and lifestyles of the Chinese population in England. Health Education Agency, London (UK)1999Google Scholar Let me expand. Almost 70% of ethnic minorities in the U.K. live in the larger conurbations, and this can have a positive impact on health. (The main exception to this are Chinese people, who experience problems identified with dispersed minority communities.) But even people in well-established communities rely on friends, family, and local networks to understand how services work. This is particularly true for older people in South Asian, Chinese, and Vietnamese communities, many of whom came to the U.K. later in life and do not speak English as their main language of communication. The barriers to accessing equitable health and social care have been made worse with the introduction and phased implementation of the 1999 Immigration and Asylum Act. The interim dispersal scheme introduced in December 1999 in London and the South East has the aim of alleviating accommodation shortages; therefore, people are being dispersed purely on the basis of available housing without regard to whether the area of enforced settlement has a relevant, existing ethnic minority population. This means that only the lucky few will be able to access local voluntary and community groups for information, reassurance, and support in an alien environment. Such support is crucial, as the evidence consistently shows that many refugees and asylum seekers do not receive even their basic entitlement to services, and few are given information on the available services and how to access these. For example, in one part of London, 93% of survey respondents said they had been given no information on how to register with a family doctor, and 97% said they had been given no information on how to use hospital services. In another study, it was found that 40% of refugees encountered problems registering with a family doctor, and in a third survey, some patients reported being asked for their passports when trying to register.4Gammell H. Ndahiro A. Nicholas N. Windsor J. Refugees (political asylum seekers). College of Health, London, (UK)1993Google Scholar, 5Islington Zairean Refugees GroupIslington Zairean Refugees Survey Report, Healthy Islington 2000. Lambeth, Southwark and Lewisham Health Authority, London (UK)1998Google Scholar, 6Lambeth, Southwark and Lewisham Health Authority. Lambeth, Southwark and Lewisham Refugee Outreach Team Annual Report; 1997/98.Google Scholar Inequalities in information about healthIn the U.K., we are severely hampered by the inequalities in information and research about diseases and treatments relating to ethnic minority women. More comprehensive research and better information sources, standards, and databanks are being developed; however, it will take some time before public policy decisions reflect this. Even so, I am not convinced that the proposed changes will lead to effective models for gathering, collating, and acting on data concerning key health issues for ethnic minorities. And, I see no prospect of an R&D strategy for ethnic minority health, let alone ethnic minority women’s health.At the moment in the U.K., much of what is known about the health disparities in ethnic minority populations is based on country of birth data as recorded on death certificates. These statistics cover immigrants, yet over half of the ethnic minority population were born in the U.K. In fact, 90% of ethnic minorities under age 35 were born in the U.K. and all ethnic minority populations have a younger profile than the white population, with about one-third under age 14 (compared to a fifth in the general population).These percentages led me to think about some of the current and more pressing needs of younger women. The papers pay little attention to improving the quality of life for younger women. Recently in the U.K., there have been widely publicized debates on teenage pregnancy, transcultural adoptions, young people and the use of recreational drugs, young women and girls’ poor self image, and homelessness, to name but a few. I could pose a series of questions relating to the health needs and outcomes on each of these for younger ethnic minority women on both sides of the Atlantic.I will limit myself to two issues. First, the debate on low self-esteem of girls and young women in the U.K. has centered on waif-like fashion models appearing in the magazines and advertisements read by young women of all ethnic groups. But even if we judged eating disorders among young women to be only of concern to white middle-class people, why are we not discussing recent studies in the U.K. relating to deliberate self-harm, the disturbing increases in suicides, and the increased rates of depression, particularly among some groups of Asian young women? Second, isn’t teenage pregnancy also a major public health issue for certain ethnic minority groups in the United States as well as in the U.K.?At the other end of the age spectrum, we have recently had a lengthy debate about long-term care issues in the U.K. Statistics from the London Research Centre show that among ethnic minority communities, numbers of people over age 60 will increase by 100% to 200% over the next 15 years. The “over 60’s” currently comprise 6% of the ethnic minority population (compared to 21% in the general population) and over half of these are women. The Policy Research Institute on Aging and Ethnicity at the University of Bradford, among others, is calling for a radical rethink of health and social care services to meet the needs of this group, and has been critical particularly of services to people with dementia.Veena Bahl looks at women’s health “in the context of black and minority ethnic health generally;” however, Marilyn Gaston is explicit about the fact that ethnic minority women share many of the same health issues as white women. The latter is an important point. We tend to overlook the ethnic minority perspective on many common areas of concern by focusing on the things that separate us, at the expense of the things we have in common. Whether we are concerned with breast cancer, the number of unnecessary hysterectomies (about one-fifth of British women have hysterectomies before the age of 65 years), the medical management of menopause, or general maternity services, ethnic minority women have views on these and many other issues, and research and service agencies should be encouraged to seek their views and respond to their needs. In the U.K., we are severely hampered by the inequalities in information and research about diseases and treatments relating to ethnic minority women. More comprehensive research and better information sources, standards, and databanks are being developed; however, it will take some time before public policy decisions reflect this. Even so, I am not convinced that the proposed changes will lead to effective models for gathering, collating, and acting on data concerning key health issues for ethnic minorities. And, I see no prospect of an R&D strategy for ethnic minority health, let alone ethnic minority women’s health. At the moment in the U.K., much of what is known about the health disparities in ethnic minority populations is based on country of birth data as recorded on death certificates. These statistics cover immigrants, yet over half of the ethnic minority population were born in the U.K. In fact, 90% of ethnic minorities under age 35 were born in the U.K. and all ethnic minority populations have a younger profile than the white population, with about one-third under age 14 (compared to a fifth in the general population). These percentages led me to think about some of the current and more pressing needs of younger women. The papers pay little attention to improving the quality of life for younger women. Recently in the U.K., there have been widely publicized debates on teenage pregnancy, transcultural adoptions, young people and the use of recreational drugs, young women and girls’ poor self image, and homelessness, to name but a few. I could pose a series of questions relating to the health needs and outcomes on each of these for younger ethnic minority women on both sides of the Atlantic. I will limit myself to two issues. First, the debate on low self-esteem of girls and young women in the U.K. has centered on waif-like fashion models appearing in the magazines and advertisements read by young women of all ethnic groups. But even if we judged eating disorders among young women to be only of concern to white middle-class people, why are we not discussing recent studies in the U.K. relating to deliberate self-harm, the disturbing increases in suicides, and the increased rates of depression, particularly among some groups of Asian young women? Second, isn’t teenage pregnancy also a major public health issue for certain ethnic minority groups in the United States as well as in the U.K.? At the other end of the age spectrum, we have recently had a lengthy debate about long-term care issues in the U.K. Statistics from the London Research Centre show that among ethnic minority communities, numbers of people over age 60 will increase by 100% to 200% over the next 15 years. The “over 60’s” currently comprise 6% of the ethnic minority population (compared to 21% in the general population) and over half of these are women. The Policy Research Institute on Aging and Ethnicity at the University of Bradford, among others, is calling for a radical rethink of health and social care services to meet the needs of this group, and has been critical particularly of services to people with dementia. Veena Bahl looks at women’s health “in the context of black and minority ethnic health generally;” however, Marilyn Gaston is explicit about the fact that ethnic minority women share many of the same health issues as white women. The latter is an important point. We tend to overlook the ethnic minority perspective on many common areas of concern by focusing on the things that separate us, at the expense of the things we have in common. Whether we are concerned with breast cancer, the number of unnecessary hysterectomies (about one-fifth of British women have hysterectomies before the age of 65 years), the medical management of menopause, or general maternity services, ethnic minority women have views on these and many other issues, and research and service agencies should be encouraged to seek their views and respond to their needs. Inequalities in access and quality of servicesAre we really concerned with equity of access, equity of health care treatment, or equity of health care outcomes? When we measure access we are looking at whether or not, in general, people with “equal” health needs use the same level of health care services. We need to be clear about what our objective is because 1) it does not necessarily follow that more care will mean better care and, 2) the type of solutions we put forward will depend on what we are trying to achieve.Education and training is another area that needs attention. I chair the U.K. Council for Education and Training in Social Work (CCETSW). CCETSW’s policy on education and training has antidiscriminatory practice as an integral part of the curriculum. The policy states that: “Students and candidates will accept and respect individual rights and circumstances and understand how these affect the delivery of services for children and adults, families, and communities. They will learn how to counter discrimination, racism, poverty, disadvantage, and injustice in ways appropriate to the situation and their role.” The policy further states that: “Providers of social work education and training (and this includes universities equally) will eliminate unfair discrimination and disadvantage in all aspects of their work regulated by the Council and they will demonstrate this consistently through the Quality Assurance process.” We must continue to lobby for change in clinical education and training so that antidiscriminatory practice and cultural competence become mainstream issues, as they are in social work.Also in the U.K., general skills courses tend to be run by nonspecialist in-house staff or independent training contractors. There are no nationally recognized qualifications or accredited programs on antidiscriminatory practice, managing diversity, or cultural competence. As a consequence, quality standards, content, and outcomes vary widely.In their discussions of promotoras and linkworkers, Gaston and Bahl have presented a Health Advocacy model to improve both access to and quality of health care services. In London, the King’s Fund charity has earmarked £1m to continue the development of advocacy services in London, with the hope that this pump-priming money will lead to mainstream implementation over time. Let me quote from the King’s Fund report on Advocacy which will be launched next month:Advocacy is about helping people to say what they want, obtain their rights, represent their interests, and gain the services they need. The fundamental emphasis and focus of advocacy is that it sees things from the service users’ perspective and recognizes that the user or patient is in an unequal power relationship with the service provider… Reviews of interpreting and linkworker schemes across health and social services highlight that while many of these schemes were developed to address communication difficulties, many have needed to extend their remit to include “advocacy” roles, such as promoting better health and making health care systems more accessible.7King’s FundMapping the provision of health advocacy for black and minority ethnic communities in London. King’s Fund, London (UK)2000Google ScholarWhile we continue to work on more equitable public health policies and influence the development of better education, training, and development, one of the other main avenues for change will be in the ethnic minority-led health and social support voluntary sector, particularly their work in advocacy, patient empowerment, and health promotion. The range of roles and activities of the ethnic minority-led health and social support voluntary sector include direct service delivery, translation, interpretation, information provision, education and advocacy services, outreach support, local research into needs, community development, counseling services, and training for statutory professionals. These volunteers are good at encouraging take-up of main-stream services, promoting understanding of available services through information provision in appropriate languages and formats, designing and delivering training programs for professionals to help them deliver culturally competent services, campaigning for more culturally competent services, and building social capital within their communities.In one area of London, health service planners have created a “Charter of Access.” They ask all commissioners of new or restructured services to agree that a certain percentage of the total service will be set aside for advocacy provision. (This could be 1% or it could be 10%). The planners realize that this may not necessarily increase the total amount of money available for advocacy, but it does draw attention to access issues.The center of the health disparities conundrum should be the individual woman, not the health care system. The extent to which individuals engage in health promoting behaviors and are prepared or able to modify risky behaviors will depend to some degree on how they assess their own health behaviors, on their awareness of what healthy behavior is, and on their awareness of the relationship between their behavior and health or illness.The 1999 Health Survey for England has an ethnic minority “focus.” This will allow a proper comparison of ethnic groups on the main health status measures in the survey and analysis of inequalities, as well as issues relating to specific health conditions, for example, cardiovascular disease, diabetes, accidents, and mental health. Are we really concerned with equity of access, equity of health care treatment, or equity of health care outcomes? When we measure access we are looking at whether or not, in general, people with “equal” health needs use the same level of health care services. We need to be clear about what our objective is because 1) it does not necessarily follow that more care will mean better care and, 2) the type of solutions we put forward will depend on what we are trying to achieve. Education and training is another area that needs attention. I chair the U.K. Council for Education and Training in Social Work (CCETSW). CCETSW’s policy on education and training has antidiscriminatory practice as an integral part of the curriculum. The policy states that: “Students and candidates will accept and respect individual rights and circumstances and understand how these affect the delivery of services for children and adults, families, and communities. They will learn how to counter discrimination, racism, poverty, disadvantage, and injustice in ways appropriate to the situation and their role.” The policy further states that: “Providers of social work education and training (and this includes universities equally) will eliminate unfair discrimination and disadvantage in all aspects of their work regulated by the Council and they will demonstrate this consistently through the Quality Assurance process.” We must continue to lobby for change in clinical education and training so that antidiscriminatory practice and cultural competence become mainstream issues, as they are in social work. Also in the U.K., general skills courses tend to be run by nonspecialist in-house staff or independent training contractors. There are no nationally recognized qualifications or accredited programs on antidiscriminatory practice, managing diversity, or cultural competence. As a consequence, quality standards, content, and outcomes vary widely. In their discussions of promotoras and linkworkers, Gaston and Bahl have presented a Health Advocacy model to improve both access to and quality of health care services. In London, the King’s Fund charity has earmarked £1m to continue the development of advocacy services in London, with the hope that this pump-priming money will lead to mainstream implementation over time. Let me quote from the King’s Fund report on Advocacy which will be launched next month: Advocacy is about helping people to say what they want, obtain their rights, represent their interests, and gain the services they need. The fundamental emphasis and focus of advocacy is that it sees things from the service users’ perspective and recognizes that the user or patient is in an unequal power relationship with the service provider… Reviews of interpreting and linkworker schemes across health and social services highlight that while many of these schemes were developed to address communication difficulties, many have needed to extend their remit to include “advocacy” roles, such as promoting better health and making health care systems more accessible.7King’s FundMapping the provision of health advocacy for black and minority ethnic communities in London. King’s Fund, London (UK)2000Google Scholar While we continue to work on more equitable public health policies and influence the development of better education, training, and development, one of the other main avenues for change will be in the ethnic minority-led health and social support voluntary sector, particularly their work in advocacy, patient empowerment, and health promotion. The range of roles and activities of the ethnic minority-led health and social support voluntary sector include direct service delivery, translation, interpretation, information provision, education and advocacy services, outreach support, local research into needs, community development, counseling services, and training for statutory professionals. These volunteers are good at encouraging take-up of main-stream services, promoting understanding of available services through information provision in appropriate languages and formats, designing and delivering training programs for professionals to help them deliver culturally competent services, campaigning for more culturally competent services, and building social capital within their communities. In one area of London, health service planners have created a “Charter of Access.” They ask all commissioners of new or restructured services to agree that a certain percentage of the total service will be set aside for advocacy provision. (This could be 1% or it could be 10%). The planners realize that this may not necessarily increase the total amount of money available for advocacy, but it does draw attention to access issues. The center of the health disparities conundrum should be the individual woman, not the health care system. The extent to which individuals engage in health promoting behaviors and are prepared or able to modify risky behaviors will depend to some degree on how they assess their own health behaviors, on their awareness of what healthy behavior is, and on their awareness of the relationship between their behavior and health or illness. The 1999 Health Survey for England has an ethnic minority “focus.” This will allow a proper comparison of ethnic groups on the main health status measures in the survey and analysis of inequalities, as well as issues relating to specific health conditions, for example, cardiovascular disease, diabetes, accidents, and mental health.