Reducing Health Inequalities: A focus on Pelvic Health
Dr Rebekah Davis is a GP working in Bedfordshire, and a current East of England Trailblazer Fellow. She has a keen interest in health inequalities and deprivation, as well as maternal health. She kindly shares with us some of the work she is doing locally on pelvic health, particularly within the BLMK community.
For many women the process of pregnancy and childbirth is a time of excitement and empowerment. However, maternity health outcomes in women from black, asian and minority ethnic communities are far poorer than in their white counterparts (1). For this reason, maternity health has been identified in the Core 20 plus Five as one of the key areas to focus on (2).
I’m a trailblazer GP working in Luton where there is a large ethnic minority population, particularly from the Indian subcontinent. I’m also a relatively new first-time mum. Finding a project relating to maternal health piqued my interest and I have been fortunate to be able to join the BLMK Perinatal Pelvic Health project with a focus on reducing health inequalities and integrating with primary care. Encouraging and maintaining good pelvic health is critical to prevent prolapse, urinary and bowel problems both in the immediate post-partum period and for later life.
The challenge is how to engage ethnic minority groups, who have previously been under-served, by developing a new service and avoid creating barriers that may stop women accessing help in a timely manner. There is currently little evidence base or documented similar projects looking at pelvic health in these groups. Therefore, I have considered what barriers women from ethnic minority backgrounds may face in accessing pelvic health, in order to develop appropriate interventions to help remove those barriers.
1: Language Barriers
For ethnic minority women for whom English is not their first language, a challenge lies in explaining the importance of pelvic health and the complications that can occur during and after pregnancy.
Health care staff will often use translators and here problems can arise in having health-literate translators. This is particularly important in relation to pelvic health: many women will not know what or where the pelvic floor muscles are. If their translator also doesn’t know it will be very difficult for them to accurately impart the information to the patient!
2. Lack of awareness of service provision or how to access services
Ethnic minority patients who are relatively new to the UK may not understand their rights or the healthcare system in general (3). Alongside this they may also have insecure housing or social situations. There may be frequent changing of addresses and contact numbers and limited access to access computers, mobile phones and internet services (5).
3. Cultural barriers
Cultural barriers exist around access to female healthcare staff for women or embarrassment with unknown male medical staff so that patients feel unable to bring up pelvic health issues. Studies have indicated that women of Muslim faith can feel that health care practitioners can hold unhelpful assumptions and lack of understanding of the relationship of the Muslim culture towards maternity (3).
Women from ethnic minority backgrounds may also be more likely to having caring roles, for example having other children or older relatives to look after (6). This can make it difficult for them to have the time or opportunity to attend appointments. They may also be less likely to drive which can make it inconvenient and expensive for them to travel to appointments that are not close to their home. In some ethnic minority cultures, women are less likely to be computer or IT literate which may cause issues in accessing resources and appointments.
4. Previous poor experience with healthcare
Due to the above issues (and others!) women may have had poor previous experiences with healthcare which may make them less likely to seek help in the future (3). Direct and indirect discrimination (5).
So what interventions may improve access to pelvic health for ethnic minority women:
High quality language resources: pelvic health literate female interpreters, translated materials, infographics (1). Ensuring that enough time is allocated in consultations that require an interpreter to enable adequate information sharing and to reduces pressures on patient and clinician (4).
Community based care can increase awareness and accessibility to healthcare (1). Considering where women will feel most at ease discussing pelvic health and where is it easy for them access appointments. Information and advertisements in community centres, community clinics and places of worship may increase awareness of health issues and services. Appointment options that are closer to home may make it easier for women with other caring responsibilities or without their own means of transport to engage.
Providing enhanced care: e.g group antenatal care or additional Health Visitor support. Consideration should be given to how best provide culturally appropriate care and whether health care practitioners from similar cultural backgrounds would improve engagement and outcome. The aim is to increase opportunities for patient contact, raise awareness and engagement in services and also to enable healthcare professionals to gain trust, impart relevant information and pick up problems as they arise (1).
Peer support can provide culturally relevant and sensitive support for women within their own community (1). This could be via support groups, peer befriending or trained volunteers. In planning and implementation of the pelvic health service it will be important to have ethnic monority patient representatives to provide insight.
Cultural competency training specific to pelvic health for healthcare professions may improve communication and understanding between healthcare professionals and patients (1,4).
Tailored patient education: adapting education and intervention to the individual patients need rather than a one size fits all approach (1). Some patients may need more support than others. For example, providing easy access to health and well-being services or mental health services where appropriate.
Enabling easy access to female health care staff and interpreting staff. Giving patients the choice. Ideally these clinicians should have relevant cultural and pelvic health training (4).
These measures may reduce barriers for women in accessing pelvic health services. It remains to be seen how practical they will be to implement and what their impact will be. It will be important to incorporate a regular process of review and adjustment as the service is rolled out will to establish how successful any implemented measures are.
Public Health England: ‘Maternity high impact area: Reducing the inequality of outcomes for women from Black, Asian and Minority (BAME) communities and their babies’
Higginbottom et al; Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review. Available at https://bmjopen.bmj.com/content/bmjopen/9/12/e029478.full.pdf
Higginbottom GMA, Evans C, Morgan M, Bharj KK, Eldridge J, Hussain B. Experience of and access to maternity care in the UK by immigrant women: a narrative synthesis systematic review. BMJ Open. 2019;9(12):e029478.
Adrienne Yong & Sabrina Germain (2022) Ethnic minority and migrant women’s struggles in accessing healthcare during COVID-19: an intersectional analysis, Journal for Cultural Research, 26:1, 65-82, DOI: 10.1080/14797585.2021.2012090