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The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
The Mental Health and Well Being of Black and Minority Ethnic Elders
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The Mental Health and Well Being of Black and Minority Ethnic Elders

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  • 1. 
 
 .
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CSIP
West
Midlands
 The
Mental
Health
and
Well
Being
of
Black
and
 Minority
Ethnic
Elders:
A
Foundational
Report
on
 the
Research
Literature
and
a
Mapping
of
National
 Resources.
 
 
 
 
 
 
 
 
 
 
 Dr
Pauline
Lane
 Sue
Hearsum
 1st
draft
July
2007
 
 
 

  • 2. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Contents
 
 
 Introduction
 
 Terminology
 
 Part
One:
Key
issues
in
BME
elders
mental
health
and
well
being
 
 Part
Two:
Issues
for
specific
BME
elder
communities
 
 Part
Three:
Improving
our
practice
and
developing
cultural
competence
 
 Part
Four:
A
national
mapping
of
projects
for
BME
elders
to
support
their
mental
health
well­ bring
.
 

  • 3. 
 
 Introduction:
This
foundational
report
forms
part
of
a
larger
national
project
for
CSIP
and
the
 Department
of
Health
OMPH
programme;
it
is
a
one
year
project
that
is
being
developed
to
promote
the
 mental
health
and
well
being
of
black
and
minority
(BME)
ethnic
elders
and
to
improve
access
to
mental
 health
services.


 The
one
year
project:
The
one
year
project
aims
to
produce
practical
resources
to
improve
the
access
 and
quality
of
mental
health
and
care
services
for
black
and
other
ethnic
minority
elders
and
their
 families/
cares
on
the
issues
of
depression,
dementia
and
delirium.
The
resources/
materials
will
be
 developed
in
partnership
with
four
voluntary
sector
organisations
who
will
consult
with
community
 groups
to
encourage
diversity,
creativity
and
participation
in
order
to
develop
materials
(text/
film/
 audio)
that
support
the
specific
needs
of
BME
elder
service
users
and
their
carers
in
different
 communities
(but
the
materials
would
have
national
application).
It
would
be
important
not
to
create
a
 ‘one‐resource–fits–all’
approach
but
to
identify
a
range
of
resources
that
may
be
beneficial
to
different
 communities
/
individuals.
(All
materials
should
be
led
by
need
and
not
simply
by
diagnosis).
The
one
 year
project
aims
to:
 
 Produce
a
short
participatory
film
on
BME
elders
living
with
 depression
with
voice‐
over
available
in
several
different
languages.
 The
film
will
be
directed
by
the
project
lead
but
work
in
participation
 with
the
partnership
organisation
and
black
and
other
ethnic
 minority
elders
and
their
families/
cares
together
with
a
filmmaker.
 
 Establish
a
base
line
of
information
to
inform
the
development
of
 community
based
resources
that
will
aim
to
improve
the
 understanding
of
mental
health
needs
of
BME
elders
and
to
promote
 understanding
and
access
to
mental
health
services.
 
 Contribute
towards
the
development
of
the
Guidance
for
 Commissioners
of
OPMH
services:
Working
with
BME
Older
peoples
 
 Contribute
towards
the
development
of
Guidelines
for
Health
 Practitioners
and
Voluntary
Agencies
Working
with
BME
Older
 peoples
 
 
 As
we
grow
older
we
want
to
 have
good
health
and
a
good
 quality
of
life.
We
want
to
be
 respected
for
continuing
to
 make
a
valued
contribution
to
 society.
People
of
whatever
age
 or
background
wish
to
maintain
 their
dignity:
to
have
self
 respect,
to
have
their
essential
 identity
and
independence
 preserved.
Where
mental
 and/or
physical
illness
 intervenes,
it
is
the
job
of
health
 and
care
services
to
support
 people
in
maintaining
their
 dignity,
autonomy
and
 independence.

 
 Older
people
with
mental
health
 problems
also
want
to
exercise
 control
over
their
lives
and
to
 make
choices,
including
 decisions
about
their
own
care.
 They
also
need
to
be
able
to
 trust
care
staff
with
their
 mental
well‐being
as
well
as
 their
physical
care.
 
 Everybody’s Business. Integrated mental health service for older adults: a service development guide (DH/ CSIP 2005)

  • 4. 
 
 The
project
builds
upon
a
range
of
policy
and
guidance
documents
that
actively
seek
to
promote
and
 support
the
mental
health
and
well
being
of
elders.

These
include

 • A
new
ambition
for
old
age:
next
steps
in
implementing
the
NSF
for
older
people
(DH
2006a)
 • Let’s
Respect
(CSIP
2006)

 • A
sure
start
to
later
life:
ending
inequalities
for
older
people
(ODPM
2006)

 • Promoting
mental
health
and
wellbeing
in
later
life
(UK
Inquiry
into
Mental
Health
and
Well‐Being
 in
Later
Life
2006)
 • National
service
framework
for
mental
health
–
five
years
on
(DH
2004)
 • National
service
framework
for
older
people
(DH
2001a)
Mental
wellbeing
in
older
people
 • National
service
framework
for
mental
health
(DH
1999)

 • 
Our
health,
our
care,
our
say:
a
new
direction
for
community
services
(DH
2006b)

 • 
Making
it
possible:
improving
mental
health
and
wellbeing
in
England
(DH
2005a)
 • Independence
wellbeing
and
choice:
our
vision
for
the
future
of
social
care
for
adults
in
England(DH
 2005b)

 • 
Securing
better
mental
health
as
part
of
active
ageing
(DH
2005c)

 • Fair
access
to
care
services
(DH
2002)

 • 
Building
capacity
and
partnerships
in
care
(DH
2001b)

 • 
Everybody’s
business
–
integrated
mental
health
services
for
older
adults
(DH/
CSIP
2005)
 • Opportunity
age
–
meeting
the
challenge
of
ageing
in
the
21st
century
(DWP
2005).

 
 
 This
report:

 This
initial
report
is
the
first
step
in
the
one
year
project
and
it
seeks
to


 a)
Examine
some
of
the
key
debates
in
the
field
of
BME
older
people’s
mental
health
and

 
b)
To
map
key
mental
health
projects
and
resources
for
black
and
minority
ethnic
elders
across
England.






























  • 5. 
 
 Terminology
:
It
is
useful
to
have
some
clarification
about
some
of
the
key
terms
being
used
in
the
 report.
 
Ethnic/
ethnicity/
ethnic
minority:
Ethnicity
is
a
term
that
is
open
to
much
debate
and
one
that
often
 causes
great
confusion.
The
word
'ethnic'
is
derived
from
the
Greek
word
'ethnos',
and
simply
means
 'nation'
or
'people'.
Certainly
most
definitions
of
ethnicity
imply
a
shared
culture,
religion,
traditions
or
 heritage
and
language
and
geographical
origins
(Helman
2000:2).

For
many
people,
their
ethnicity
is
not
 a
static
but
a
fluid
identity
and
this
may
change
over
time.
Certainly
there
are
many
definitions
of
 ethnicity
 
 • One
definition
of
ethnicity
suggests
that
ethnic
minorities
are
individuals
with
a
culture
that
is
 distinct
from
the
majority
population.

(Manthorpe
&
Hettiaratchy
1993).
However,
this
generic
 approach
ignores
some
of
the
experiences
and
inequalities
within
minority
white
populations,
 such
as
travelers,
Irish
communities
and
other
white
minority
communities
where
cultural
 differences
may
not
be
so
obvious.
 
 • It
is
also
important
to
recognize
that
some
people
may
prefer
to
place
emphasis
on
their
 religious
allegiance
(e.g.
Buddhist,
Hindu,
Muslin
etc)
rather
then
their
cultural/
ethnic
origin
 (Mizra
et
al
2007),
although
many
people
will
identify
themselves
through
both
religious
and
 cultural/
ethnic
alliances
(such
as
Gujarati
Muslims).
 
 • The
research
on
refugee
ethnic
identity
is
conflicting,
with
some
authors
suggesting
that
people
 may
seek
to
reinforce
their
traditional
cultural
identities
and
origins
(see
Eriksen
2002,
Barth
 1996).
Other
research
suggests
that
refugees
are
prone
to
loose
their
original
cultural
identities
 as
patterns
of
behaviour
that
sustained
them
in
their
country
of
origin
are
no
longer
applicable
 in
the
country
of
asylum
(Mallki
1995).

 
 In
addition,
it
should
be
recognised
that
even
though
people
may
identify
with
an
ethnic
 group/community
this
identity
may
change
over
time
and
research
suggests
that
many
temporary
 migrants
may
become
unexpected
settlers.
For
example,
in
the
1960s,
many
Bangladeshi
migrants
from
 Sylhet
expected
to
return
home
after
amassing
some
capital.
But
many
people
could
not
save
as
much
 as
anticipated
and
became
settlers
in
a
country
with
very
different
traditions
to
their
own.
For
some
 people,
this
cultural
difference
contributed
to
a
heightened
awareness
and
value
of
their
own
heritage,
 which
may
provide
structure,
stability
and
meaning
to
their
lives
(Ahmed
2005:
195‐196).
However,
in
 contrast,
many
second
generation
migrants
may
reject
their
parents
cultural
traditions
and
language,
 and
some
researchers
have
suggested
that
migrants
may
assert
their
Britishness
as
a
way
of
gaining
 acceptance
and
minimising
discrimination
(Abbas

2005:9)
 
 Therefore,
when
addressing
the
mental
health
needs
of
older
black
and
ethnic
minority
people,
it
 important
to
recall
that
we
all
belong
to
an
ethnic
group
but
each
of
us
are
unique
and
we
all
have
 differing
needs.
We
need
to
recognise
the
diversity
of
BME
older
peoples
experience
and
mental
health
 needs,
understanding
that
individual
voices,
as
well
as
community
experiences,
need
to
be
heard.
We
 therefore
need
to
move
with
caution
when
we
start
to
talk
about
‘BME
communities’
as
if
they
are
a
 homogeneous
group
and

recognise
the
differences
within
and
between
BME
communities
as
well
as
 among
individuals.


In
addition,
we
need
to
ensure
that
we
do
not
over
focus
on
cultural
factors/
 differences
and
remember
to
take
into
account
wider
institutional
factors
(such
as
discrimination,
 poverty,
housing,
etc.)
as
they
affect
the
lives
and
health
of
an
individual.


  • 6. 
 
 
 In
this
study,
we
shall
use
the
terminology
used
in
the
specific
research
finding
as
they
relates
to
BME
 elders
and
in
the
community
consultations
that
are
to
be
conducted
later
in
the
national
project,
we
 shall
use
a
self‐definition
approach
to
ethnicity,
that
is
to
say
we
shall
be
working
with
community
 groups
who
have
defined
their
own
ethnic
boundaries
(e.g.
Chinese
older
peoples
community
group).

 
 Elders/
older
people:
Although
much
of
the
literature
focuses
on
the
problems
and
challenges
of
old
age
 it
is
important
to
remember
that
for
many
elders
it
can
also
be
a
positive
time
which
is
not
necessarily
 linked
to
decline
and
dependency
and
while
it
is
important
not
to
underestimate
the
material
and
 resource
needs
of
BME
elders
,
it
is
also
necessary
to
challenge
negative
stereotyping
and
examine
the
 possibilities
for
pursuing
satisfying
lives.

There
is
a
need
for
health
practitioners
to
build
upon
and
 support
the
reliance
of
BME
elders
their
families,
carers
and
communities.

 The
World
Health
Organisation
has
suggested
the
model
of
Active
Ageing
that
incorporates
a
whole
life,
 whole
person
approach
to
ageing.
This
model
incorporates
the
experiences
of
the
unavoidable
changes
 we
all
face
as
we
age,
alongside
a
positive
sense
of
continuing
to
strive
for
and
achieve
fulfillment
of
a
 range
of
hopes
and
aspirations.

While
this
report
embraces
the
WHO
concept
of
ageing,
it
also
applies
 the
terms
elder/
older
person
to
anyone
of
State
Pension
Age.
 
 
 Part
One:
Key
issues
in
BME
elders
mental
health
and
well
being
 Demographic
trends
and
BME
elders:
 It
is
recognised
that
we
are
living
in
an
increasingly
ageing
population
and
by
2020,
one
in
five
UK
 citizens
will
be
aged
65
plus
(DH
2005).
According
to
the
Office
of
National
Statistics
(2001)
currently
 only
a
small
proportion
of
older
people
in
Great
Britain
(4
per
cent)
are
from
non‐White
ethnic
minority
 groups.
In
2001,
15
per
cent
of
people
from
non‐White
ethnic
minority
groups
were
aged
50
and
over
 (around
672,000
people).
This
compares
with
33
per
cent
of
the
overall
population.
 
 Age
distribution:
by
ethnic
group,
April
2001,
GB
(Office
of
National
Statistics
2001

  • 7. 
 
 o The
Census

(2001)
suggests
that
the
population
in
England
aged
65
and
over
was
 predominately
White
(97.08%).
Of
the
White
group
aged
65
and
over,
around
2%
were
 White
Irish
and
under
2%
were
White
Other.
The
BME
group
made
up
2.92%
of
the
total
 population
of
over
65s
in
England,
of
which
Asian
or
British
Asian
was
the
largest
group
at
 118,816
(1.52%),
followed
by
Black
or
Black
British
at
73,256
(0.94%).
The
number
of
older
 people
in
the
remaining
two
groups
was
comparatively
small:
with
18,556
(0.24%)
in
the
 Mixed
group
and
17,531
(0.22%)
Chinese
or
other
ethnic
groups.
 o Whilst
there
is
currently
a
lower
percentage
of
people
over
60
within

black
and
minority
 ethnic
(BME)
communities,
compared
with
the
white
population,

over
the
next
decade
 there
will
be
a
significant
increase
as
middle
aged
people
from
these
groups
reach
 retirement.
 o Research
suggests
that
currently
the
highest
concentrations
of
BME
older
people
are
in
the
 South
East,
particularly
London
where
over
7%
of
the
BME
older
people
belonged
to
the
 Asian
group;
6%

to
the
Black
group
and
around
1%
to
the
Chinese
and
Mixed
groups.
The
 second
largest
concentration
of
BME
older
people
is
in
the
West
Midlands
where
Asians
 accounted
for
3%,
Black
2%
and
Chinese
and
Mixed
groups
less
than
0.5%
of
the
local
 population.
(Age
Concern
England
2007).
 o The
vast
majority
of
BME
elders
live
in
large
metropolitan
or
inner
city
areas
and
only
a
 small
minority
live
in
rural
areas
of
England.
There
is
an
over‐representation
of
people
from
 BME
communities
living
in
poor
housing
–
BME
households
are
less
likely
to
live
in
decent
 homes
–
40%
live
in
non‐
decent
homes
compared
to
32%
of
white
households
(2001
 English
House
Conditions
Survey,
Office
of
the
Deputy
Prime
Minister).
 
 o 
It
is
widely
accepted
that
problems
experienced
by
BME
people
living
in
inner
city
areas
are
 closely
linked
to
the
problems
of
deprivation
in
many
inner
city
areas
where
resources
and
 services
are
particularly
stretched
(Age
Concern
England
2007).

 
 o Problems
for
those
who
live
in
rural
areas
or
areas
with
much
smaller
BME
populations
are
 often
compounded
by
social
isolation
and
the
lack
of
recognition
of
their
needs
by
service
 providers.

 o According
to
the
2001
Census,
differences
in
mortality
rates
mean
that
women
aged
65
and
 over
normally
outnumber
men.
This
can
clearly
be
seen
in
the
White
(with
58
per
cent
 women),
Mixed
(55
per
cent)
and
Chinese
ethnic
groups
(54
per
cent).
However
for
some
 ethnic
groups
this
has
been
affected
by
differing
immigration
patterns.
This
is
particularly
 evident
in
the
Bangladeshi
group
where
only
one
third
(34
per
cent)
of
those
aged
65
and
 over
were
women.
Similarly,
for
the
Pakistani
group,
women
made
up
45
per
cent
of
the
65
 and
over
age
group.
 
 
 

  • 8. 
 
 Some
of
the
health
challenges
for
BME
elders
 While
many
elders
will
live
into
a
healthy
old
age,
research
suggests
that
many
BME
elders
consistently
 experience
poorer
health
especially
in
the
rates
of
mental
ill
health
(NIMHE,
2003,
PRAIE
2005).
 Research
suggests
that
the
social
determinant
of
health
over
a
person’s
life
time
may
have
a
 considerable
impact
on
the
health
of
BME
elders
and
it
has
been
suggested
that
ethnic
elders
face
a
 ‘triple
 whammy’
in
terms
of
age,
ethnicity
and
socio‐economic
 deprivation
(Rait
at
al.
1996).
Research
 suggests
that 
 o There
is
a
substantial
gap
in
income
and
wealth
and
 housing
conditions,
between
older
people
in
the
white
 community
and
ethnic
minority
groups
and
this
often
 impacts
on
health
and
well
being
over
a
life
time.

 o White
and
BME
women
tend
to
be
located
among
those
 receiving
a
state
pension
only,
this
is
often
because
their
 patterns
of
work
and
family
care
responsibilities
resulting
 in
sufficient
payments
to
a
pension
scheme.
Managing
on
 a
low
income
can
have
consequences
over
and
above
the
 difficulties
of
maintaining
a
basic
standard
of
living.
For
 example,
this
may
impact
on
social
functioning
including
 the
capacity
to
maintain
relationships
with
friends
and
 family
and
can
result
in
social
isolation
(Nazroo
2002).
 o Ethnicity
may
have
a
significant
bearing
on
quality
of
life.
 White
elders
tended
to
report
better
levels
of
health
and
 higher
incomes
than
other
ethnic
groups.
At
the
same
 time,
many
BME
elders
view
the
process
of
growing
older
 more
positively.
(Fisher
et
al
2006)

 o For
all
older
people
practical
and
emotional
support
is
 most
often
provided
by
families
and
friends,
but
for
 minority
ethnic
elders,
voluntary
organisations
play
a
vital
 role
in
providing
support
in
terms
of
information
and
 advice
(Fisher
et
al
2006
).
 o The
impact
of
migration
may
mediate
individual
 components
of
quality
of
life,
such
as
social
support
 (Brockmann,
2002).
 o BME
elders
are
more
likely
to
describe
their
health
status

 as
poorer
than
the
total
population
(PRIAE
2006;
Age
 Concern,
2002:
3).
 o Although
many
older
people
from
black
and
minority
ethnic
groups
are
registered
to
and
 use
General
Practitioner
services,
the
usage
of
community
health
services
among
black
and
 minority
ethnic
elders
tends
to
be
low
(Age
Concern,
2002:
3).
 ‘’
It
is
widely
reported
that
people
 with
mental
health
problems,
black
 and
minority
ethnic
communities
 and
older
people
as
separate
groups
 experience
social
exclusion.
It
 follows,
then,
that
black
and
 minority
ethnic
older
people
with
 mental
health
problems
are
a
 particularly
vulnerable
group
at
risk
 of
social
exclusion,
which
could
lead
 to
depression
as
well
as
 exacerbating
other
mental
health
 problems
that
may
go
untreated.
 Unfortunately,
access
to
mental
 health
services
for
black
and
 minority
ethnic
older
people
and
 their
carers
remains
problematic.

 Barriers
include
issues
of
language,
 knowledge
of
what
services
are
 available,
and
the
attitudes
and
 practices
of
service
providers,
as
 well
as
cultural
factors
in
the
 perception
and
understanding
of
 mental
illness’’.
 Everybody’s Business. Integrated mental health service for older adults: a service development guide (DH/ CSIP 2005
 
 
 
 

  • 9. 
 
 
 o People
from
minority
ethnic
groups
are
less
likely
to
use
health
and
social
care
services
and
 are
often
less
aware
of
what
help
is
available
(Ahmad
et
al
2000).
 o The
Health
Survey
of
England
(1999)
reports
that
South
Asian
men
and
women
as
well
as
all
 Black
Caribbean
women
aged
55+
report
relatively
high
levels
of
limiting
longstanding
illness
 compared
to
the
general
population
(Patel,
2003:
21
cited
in
PRAIE
2007).
 
 o Differing
religious
and
cultural
practices
appeared
to
affect
the
way
in
which
participants
 were
prepared
to
comment
negatively
on
their
current
quality
of
life.
This
may
be
especially
 noticeable
among
some
Muslims
who
might
emphasise
that
there
was
a
divine
purpose
 behind
an
event
(Fisher
et
al
2006
 
 Ageing
and
culture



 Interestingly
the
literature
of
ageing
and
culture
addresses
the
issues
of
‘cultures
of
ageing’
as
well
as
 ‘ageing
within
different
cultures’
 Cultures
of
ageing.

 There
is
an
extensive
literature
on
cultures
of
ageing
and
much
of
this
focuses
on
how
becoming
older
in
 itself
creates
a
different
cultural
identity.
This
literature
/
research
reflect
the
demographic
changes
as
 we
start
to
become
an
increasingly
ageing
population
and
it
embraces
ideas
about
how
culture
shapes
 our
experiences
of
ageing
(Torres
1999,
Twigg
2004).
There
are
many
theories
of
ageing,
although
most
 of
them
seem
to
be
Eurocentric
in
focus.
 • The
1950s
saw
beginnings
of
theoretical
debates
about
ageing
and
society
and
in
particular
 about
people’s
loss
of
role
following
retirement
and
how
this
presented
a
problem
for
society
 (Jones
1993).
One
influential
theory
was
‘disengagement
theory
‘
that
suggested
how
older
 people
should
disengage
from
work
roles
and
prepare
for
the
ultimate
disengagement
of
death
 (Cumming
and
Henry
1961).

 • Later
political
economists
such
as
Walker
and
Townsend
(
1981)
saw
age
in
relation
to
advanced
 capitalist
economies
and
how
the
experiences
of
different
elders
related
to
their
class
positions
 during
their
working
lives.
Walker
in
particular
was
interested
in
how
the
State
created
a
 situation
of
dependency
for
working
class
elders
and
this
was
seen
as
a
reflection
of
the
 inequalities
of
class
and
employment
opportunities.

 • Other
debates
in
gerontology
examined
the
construction
of
age.
The
work
of
Gubrium
(1975)
 was
important
in
his
analysis
of
Alzheimer’s
disease
in
the
USA
and
the
establishment
of
 boundaries
between
‘normal’
and
pathological
aging,
where
old
age
is
seen
as
a
"mask"
which
 conceals
the
‘essential’
identity
of
the
person
beneath.
Later
these
ideas
were
extended
by
 Featherstone
and
Hepworth
who
suggested
that
age
should
be
viewed
as
fluid.
They
also
 critiqued
the
medical
model
of
ageing
as
a
process
of
decline
(1993).

  • 10. 
 
 • In
the
late
1980s
and
1990s
feminism
was
to
 influence
the
debate
on
ageing.
In
part
this
critique
 was
an
extension
of
the
political
economist’s
 position
as
feminists
examined
how
womens
role
in
 the
work
place
impacted
on
their
old
age
(Acker
 1988
cited
in
Arber
and
Ginn
1991).

In
addition
 there
was
a
rising
debate
about
the
construction
of
 womanhood
in
older
age
and
how
age
was
seen
to
 have
negative
connotations
for
woman.
 • It
is
only
in
the
past
few
years
that
gerontology
has
 started
to
look
at
ageing
as
culture‐specific.
More
 recent
research
of
BME
elders
ageing
has
started
to
 look
at
how
people
are
simultaneously
influenced
 by
two
or
more
cultures
(Torres
2001).
 
 Ageing
within
 different
 cultures
 There
is
a
substantive
literature
on
how
different
cultures
 perceive
old
age
(Gozdiak,
1988).

Most
cultures
instils
in
its
 communities

ideas
of
what
successful
aging
means,
of
the
 kind
of
respect
due
to
an
older
member
of
society,
and
of
 the
types
of
relationships
that
should
exist
between
an
 elderly
parent
and
his
or
her
child.

Age
is
defined
by
society
 therefore
the
definition
of
age
may
be
may
be
varied
across
 cultures
(Gozdiak,
1988).

In
some
societies,
old
age
is
 defined
in
functional
terms,
based
on
one’s
ability
to
 perform
certain
activities,
for
example,
when
the
body
 looses
physical
vigour
needed
to
work
or
carry
on
 demanding
everyday
tasks.
In
other
societies,
ageing
is
defined
in
formal
terms
based
on
external
 events,
such
as
retiring
or
becoming
a
grandparent
(Hatzidimitriadou
2005).

 Cultures
differ
in
their
attitudes
towards
their
elderly
members
and
the
expectations
of
older
people
as
 well
as
the
status
attributed
to
old
age
(this
includes
issues
such
as
a
persons
lifestyle
expectations
and
 the
roles
and
responsibilities
they
anticipate
for
themselves).

However,
research
suggests
that
for
many
 elderly
migrants,
it
can
be
difficult
to
adapt
cultural
expectations
and
this
can
create
individual
and
 family
stress
(Desai

1990).
 
 Culture
and
mental
illness
 When
looking
at
BME
elder’s
mental
health,
it
is
important
to
emphasis
the
nuances
of
'culture
and
 mental
health'
and
how
individuals
interact
within
these.

It
is
important
to
avoid
stereotypical
 generalisations
and
at
the
same
time
it
is
necessary
to
guard
against
unsubstantiated
'cultural'
 explanations
of
differences
in
health
or
health
behaviour
(Howlett
et
al
1992).
 
 
 Black
and
minority
ethnic
elders
do
 not
enjoy
the
same
quality
of
life
as
 their
peers,
continue
to
have
many
 unmet
needs,
from
care
to
quality
of
 life
issues,
which
reduce
 their
potential
for
participation,
have
 witnessed
changing
family
structures
 and
are
growing
old
in
a
country
 that
many
of
them
thought
they
 would
not
remain
in
after
their
 ‘working
period’.
These
experiences
 are
in
addition
to
a
lifetime
where
 discrimination
and
disadvantage
 have
often
been
an
everyday
part
of
 their
experience”
 
 (Policy
Research
Institute
on
Ageing
and
 Ethnicity
cited
in
A
Sure
Start
to
Later
 Life
ODPM
2006) 
 

  • 11. 
 
 One
of
the
key
issues
in
mental
health
is
the
cultural
specificity
of
expressing
illness
(often
known
as
 idioms
of
distress)

For
example,
it
has
been
suggested,
that
some
groups
may
experience
particular
 "culture‐bound"
syndromes

that
is
a
cluster
of
symptoms
that
is
restricted
to
a
particular
culture

such
 as
"sinking
heart"
often
described
by
Punjabi
people
(Krause
1989).

 Some
people
may
be
more
likely
to
somatise
mental
illness
(i.e.
locate
mental/
emotion
stress
within
 the
physical
body)
that
is
they
experience
and
describe
psychological
distress
more
in
terms
of
physical
 symptoms,
which
are
less
likely
to
be
identified
as
mental
illness
in
both
epidemiological
research
and
 clinical
practice
who
may
be
using
biomedical
/
Eurocentric
assessment
processes
(Rack
1982,
Livingston
 and
Sembhi
2003).
Some
researchers
suggests
that
the
reliance
on
a
biological
definition
of
disease
 crucially
undermines
an
understanding
of
how
different
the
culturally
shaped
illness
may
be,
including
 symptoms,
help‐seeking
behaviour
and
the
course
of
illness
(Kleinman
1987,
Gilliam
1989)
 An
additional
dimension
of
help
seeking
behaviour
and
the
medical
encounter
is
the
importance
of
 language
(see
Tribe
and
Raval
2002
for
a
detailed
discussion
on
this
subject).

This
relates
to
both
the
 use
of
interpreters
in
the
therapeutic

encounter

as
well
as
the
terminology
commonly
used
to
describe
 mental
distress
such
as
"depression",
"stress",
"anxiety",
being
"mentally
ill",
or
"mentally
disturbed".
 Western
biomedical
terms
may
not
relate
to
other
cultures
systems
of
health
beliefs
and
language.
 While
some
cultures
have
terminology
that
might
indicate
a
shared
meaning
such
as
the
Bengali
terms
 "dorchita"
(meaning
feeling
anxious)
"oshanti"
(having
no
peace)
and
"shorill
shanti"
(something
being
 stressful).
But
in
many
cultures
mental
experiences
are
expressed
in
terms
of
the
physical
pain
and
for
 others
it
can
be
seen
to
be
linked
to
spiritual
beliefs,
such
as
the
Somalia
concept
of
the
jinn
(spirit)
 causing
mental
distress.
 
However,
it
is
not
possible
to
generalise
about
the
specific
beliefs
 held
by
an
individual
and
a
sensitive
 inquiry
about
beliefs
should
 be
an
essential
part
of
taking
a
history,
whatever
the
patient's
 ethnic
 background.
 
 It
is
important
to
stress
that
while
cultural
understanding

is
significant
to
providing
good
care
to
BME
 elders,
it
is
also
important
to
recognise
that
a
number
of
structural
or
organisational
issues
that
go
 beyond
language
and
culture
can
affect
health
and
access
to
health.
These
include
issues
such
as
the
 social
determinants
of
health
(e.g.
poverty,
poor
housing,
racism,
employment
opportunities
etc)
as
well
 as
the
institutional
organisation
and
delivery
of
care
and
related
policies.
 
 
 The
mental
health
of
BME
elders
 Before
looking
at
some
of
the
issues
concerning
BME
elders
and
their
carers
in
relation
to
mental
health,
 it
is
important
to
recognise
that
the
experiences
of
migrants
in
the
UK
has
influenced
the
current
health
 of
BME
elders
today.
The
historical
experiences
of
living
in
a
‘racialised
culture’
where
many
people
have
 had
to
fight
for
their
rights
and
they
have
had
to
struggle
for
employment,
housing,
education
and
the
 right
to
be
recognised
as
equal
citizens.

As
Boateng
and
Patel
(1999)
suggest,
BME
elders
are
not
just
 ‘passive
or
powerless’
 
 ‘The
BME
elders
of
today
were
part
of
this
resistance
and
hence
their
struggle
 against
racism
and
exploitation
in
old
age
is
not
new.
Portraying
it
as
new
plays
 into
the
hands
of
those
who
divide
BME
generations
into
'passive'
and
'active'

  • 12. 
 
 categories,
seeing
older
people
as
passive
and
content
to
accept
their
position
in
 British
society,
while
black
youth
are
viewed
as
suffering
from
'culture‐clash',
 alienated etc’. (Boateng
and
Patel
1999) The
social
inherence
of
health
is
significant
for
many
elders
and
research
suggests
that
many
BME
elders
 are
more
likely
to
face
a
greater
level
of
poverty
and
have
lower
incomes
than
white
older
people
and
 are

more
likely
to
live
in
poorer
quality
housing
which
lacks
basic
amenities,
and
this
may
affect
their
 health(Butt
and
O’Neil
2004).
These
points
are
significant
in
the
planning,
development
and
delivery
of
 mental
health
services
to
BME
elders
and
their
carers.

In
addition,
many
BME
elders
will
not
have
had
a
 positive
experience
of
official
organisations

and
it
is
important

for
health
commissioners,
as
well
as
 service
providers
to
recognise
the
expertise
of
BME
elders
to
identify

and
help
to
plan
for
their
own
 needs
and
care
in
a
way
that
is
appropriate
to
them.
 
 While
there
is
a
substantive
amount
of
national
policy
promoting
the
rights
of
BME
elders
into
mental
 health
care
(see
Appendix
1)

there
is
a
notable
absence
of
national
data
on
the
mental

health
of
BME
 elders.
Most
of
the
research
on
BME
elders
is
based
on
localised
studies
(even
the
PRAIE
European
 (2005)
study
drew
on
regional
data
from
three
regions
 for
the
UK
study),
although
much
of
this
localised
and
 community
based
work
is
useful.
For
example,
in
a
 study
by
Seabrooke
and
Milne
Culture
and
Care
in
 Dementia:
A
study
of
the
Asian
Community
in
North
 West
Kent(2004),
found
that

 • There
may
be
little
awareness
of
older
people's
 mental
health
issues
within
black
and
minority
 ethnic
communities,
for
instance,
some
Asian
 languages
do
not
have
an
equivalent
word
for
 dementia
and
symptoms
may
therefore
be
 unrecognised
or
misunderstood.

 • In
some
communities
a
lack
of
understanding
 and
the
stigma
attached
to
mental
illness
may
prevent
families
from
seeking
help.
This
may
 particularly
be
the
case
where
the
community
culture
places
great
emphasis
on
self‐reliance.

 • Language
barriers
may
prevent
people
from
receiving
information
about
what
is
available
and
 how
to
access
help.
Even
where
printed
information
in
minority
languages
is
available,
this
may
 not
help
those
older
people
who
have
a
limited
level
of
literacy
in
their
own
language.

 • Unfamiliarity
with
social
care
services,
which
may
not
exist
in
minority
cultures,
may
prevent
 people
from
requesting
services
or
lead
to
misunderstandings
about
their
role.
Medical
services,
 which
are
better
understood,
and
free
from
stigma,
are
often
considered
more
acceptable
than
 social
care
services.
Low
uptake
of
social
care
services
by
older
people
from
minority
ethnic
 communities
may
lead
to
demand
being
overlooked
or
underestimated
by
commissioners.

 

  • 13. 
 
 • The
lack
of
a
professional
interpreting
service
may
make
it
difficult
for
assessors
who
do
not
 speak
the
older
person's
preferred
language
to
conduct
an
effective
assessment.
The
use
of
 friends
or
family
members
as
interpreters
may
compromise
confidentiality
or
influence
the
 assessment.
Older
people
affected
by
dementia,
who
were
once
able
to
speak
English
as
a
 second
language,
may
lose
the
skill
as
their
memory
deteriorates.
Even
with
good
language
 skills,
cultural
differences
may
result
in
meaning
and
nuance
being
lost.

 • Standard
diagnostic
tests
for
dementia,
or
depression,
may
not
be
culturally
appropriate
and
 may
lead
to
inaccurate
diagnosis.

 • Assessors
may
not
be
able
to
offer
a
sensitive
and
effective
assessment
because
they
are
not
 sufficiently
familiar
with
the
lifestyles,
health,
religious
and
cultural
needs
of
older
people
and
 their
carers
from
minority
ethnic
communities.

 • No
suitable
services
may
be
available
where
the
older
person's
language
is
spoken
and
their
 cultural,
religious
and
dietary
needs
met.

 • Conversely,
assessors
may
make
assumptions
about
the
lack
of
acceptability
of
mainstream
 services
to
older
people
and
their
families,
and
not
offer
them.
 Screening
BME
elders

 While
research
suggests
that
BME
elders
may
have
a
range
of
mental
health
needs,
the
process
of
 identifying
needs
through
standardised
assessment.
There
is
conflicting
research
evidence
on
the
 cultural
appropriateness
of
mental
health
screening
and
assessment
tools.
As
an
example
of
this
 conflicting
evidence,
what
follows
is
an
illustration
of
the
research
based
on
the
Mini‐Mental
State
 Examination
(MMSE),
this
is
a
brief
assessment
instrument
used
to
assess
cognitive
abilities
in
the
 elderly
and
is
the
most
commonly
used
test
for
complaints
of
memory
problems
or
when
a
diagnosis
of
 dementia
is
being
considered.
While
some
research
suggests
that
this
tool
is
culturally
transferable
(this
 includes
when
the
MMSE
has
been
translated
into
different
languages),
other
research
appears
to
 suggest
that
assessment
tools
such
as
the
MMSE
are
not
transferable
across
cultures.
Example
of
these
 studies
include
 • Research
by
Lindsay
et
al
(1998)
aimed
to
evaluate
the
performance
of
a
Gujarati
version
of
the
 MMSE.
The
effect
of
ethnicity
on
MMSE
performance
was
also
examined.
The
results
suggested
 that
the
Gujarati
version
of
the
MMSE
performed
adequately
as
a
screen
for
dementia
in
this
 immigrant
community
population.

 • Research
by
Kabir
and
Herlitz
(2000)
adapted
the
MMSE
for
the
cultural
context
of
Bangladesh
 and
for
use
in
populations
irrespective
of
literacy
skills.
In
the
Bangla
Adaptation
of
Mini‐mental
 State
Examination
(BAMSE),
the
MMSE
items
were
changed
in
such
a
way
that
they
would
be
 applicable
for
illiterate
individuals,
as
well
as
being
culturally
relevant
in
Bangladesh.
To
enable
 comparison
between
the
BAMSE
and
MMSE,
the
literate
elderly
were
tested
with
both
 instruments.
The
results
showed
that,
in
comparison
to
the
MMSE,
the
BAMSE
demonstrated
 satisfactory
test
properties,
although
reliable
differences
were
found
on
some
of
the
individual
 items
when
the
two
instruments
were
compared.
More
importantly,
the
BAMSE
was
found
to
 be
less
sensitive
to
age
and
education
than
the
MMSE.
Finally,
the
results
suggest
that
in
the

  • 14. 
 
 socio‐cultural
context
of
Bangladesh,
irrespective
of
literacy
skills,
the
BAMSE
is
an
instrument
 that
can
be
used
to
assess
cognitive
function
of
the
 normal
elderly.
 • Research
by
Rait
(2001)
aimed
to
assess
whether
 screening
instruments
for
depression
and
cognitive
 impairment
were
acceptable
to
older
African‐ Caribbean
and
South
Asians
in
the
UK.
It
involved
the
 modification
and
translation
of
screening
 instruments
using
community
and
translation
 groups.
The
results
indicated
that
there
was
a
 relationship
between
co‐morbidity,
education
and
 MMSE
score.
The
study
also
illustrated
the
potential
 use
of
adapted
versions
of
existing
screening
 instruments
in
older
people
from
ethnic
minority
 groups
in
the
United
Kingdom
and
the
challenges
of
 cross‐cultural
research.
Significantly
the
researchers
 suggested
that
the
adaptation
process
requires
time
 and
community
participation.
 However,
there
is
also
a
growing
body
of
research
critiques
 current
assessment
instruments.
For
example

 • Research
by
Livingston
and
Sembh
(2003)
suggests
 that
cross‐cultural
assessment
of
dementia
in
older
 people
has
specific
 pitfalls
related
to
language
and
 literacy
skills.

In
particular,
 the
use
of
culturally
 biased
screening
instruments
that
rely
 on
language
 recognition
and
familiarity
with
test
situations
 may
 be
inappropriate
or
misleading
for
people
with
 cognitive
 impairment.

Culturally
appropriate
norms
 are
 also
important
in
the
evaluation
of
dementia.
 Immigrants
may
 be
literate
in
a
different
language
or
 functionally
illiterate.
 Recent
immigrants
from
rural
 areas
may
have
had
little
need
 for
the
concept
of
 complex
maps
and
exact
dates.
As
a
result,
 interpreting
cognitive
testing
without
knowledge
of
education
 and
background
is
likely
to
lead
to
 errors
in
diagnosis.

They
suggest
that
it
 may
be
important,
therefore,
to
validate
and
modify
 instruments
 for
examining
cognitive
function
in
different
ethnic
groups.
 
 • Research
by
Stewart,
Robert
et
al
(2002)
compared
the
normative
data
for
the
MMSE
in
a
UK
 African‐Caribbean
population
and
compare
those
with
norms
for
white
UK‐born
elders.
The
 study
found
that
the
median
value
for
the
distribution
of
MMSE
scores
was
three
points
lower
 in
a
community
African‐Caribbean
sample
compared
to
that
for
a
predominantly
UK‐
born
 population
with
a
similar
age‐range.
Differences
in
score
distributions
were
principally
 explained
by
different
error
rates
for
specific
items
which
could
be
attributed
to
cultural
bias.

 The
report
recommends
that
if
the
MMSE
is
to
be
administered
to
older
African‐Caribbean
 
 Cross‐cultural
assessment
of
 dementia
in
older
people
has
specific
 pitfalls
related
to
language
and
 literacy
skills.

In
particular,
the
use
 of
culturally
biased
screening
 instruments
that
rely
on
language
 recognition
and
familiarity
with
test
 situations
may
be
inappropriate
or
 misleading
for
people
with
cognitive
 impairment
(Lindesay,
1998).
 Culturally
appropriate
norms
are
 also
important
in
the
evaluation
of
 dementia.
Immigrants
may
be
 literate
in
a
different
language
or
 functionally
illiterate.
Recent
 immigrants
from
rural
areas
may
 have
had
little
need
for
the
concept
 of
complex
maps
and
exact
dates.
As
 a
result,
interpreting
cognitive
 testing
without
a
knowledge
of
 education
and
background
is
likely
 to
lead
to
errors
in
diagnosis.
It
may
 be
important,
therefore,
to
validate
 and
modify
instruments
for
 examining
cognitive
function
in
 different
ethnic
groups
 
 
 (Livingstone
and
Sembhi
2003)

  • 15. 
 
 people,
specific
normative
data
should
be
referred
 to
(and
mistakes
on
certain
items
viewed
with
 caution),
or
a
culturally
modified
version
used.
 • Research
by
Richards
et
al.
(2000)
administered
the
 MMSE
to
forty‐five
African
Caribbean
and
forty
‐five
 age
and
gender
matched
white
community
 residents
from
inner
London.
These
participants
 were
administered
the
MMSE
during
a
screening
 interview.
Where
possible,
this
was
followed
up
by
 tests
from
the
CERAD
and
CAMCOG
 neuropsychological
batteries,
a
medical
 examination,
and
a
structured
interview
with
an
 informant.
Based
on
these
data,
a
psychiatrist
blind
 to
ethnicity
independently
rated
86
of
these
 participants
as
cognitively
normal,
cognitively
 impaired,
or
demented.
Of
41
African
Caribbean’s,
 44%
were
rated
as
cognitively
normal,
22%
were
 rated
as
cognitively
impaired,
and
34%
were
rated
 as
demented.
Of
the
45
whites,
87%
were
rated
as
 cognitively
normal,
9%
were
rated
as
cognitively
 impaired,
and
4%
were
rated
as
demented.
African
Caribbean’s
scored
significantly
lower
than
 whites
in
most
cognitive
test
scores,
which
was
not
accounted
for
by
their
lower
educational
 and
occupational
attainment,
or
their
higher
frequency
of
cardiovascular
risk
factors.
African
 Caribbean
elders
in
the
UK
appear
to
be
at
high
risk
of
cognitive
impairment
and
dementia.
 However,
the
researchers
suggested
that
the
influence
of
potential
confounding
factors
such
as
 socio‐economic
position
and
ill‐health,
and
the
effect
of
cultural
test
bias,
cannot
be
ruled
out.
 Certainly
the
research
above
suggests
that
there
is
a
wide
range
of
conflicting
evidence
on
culture
 assessment.

It
is
of
some
concern
to
find
that
there
is
an
absence
of
national
data
as
well
as
a
clinical
 guidance
on
assessing
the
mental
health
of
BME
elders.
 
 BME
elders
and
dementia

 The
National
Service
Framework
for
Older
People
(2001:
standard
7)

suggests
that

in
that
about
5%
of
 the
population
over
65
has
dementia
and,
at
any
one
time,
about
10‐15%
of
the
population
over
65
will
 have
depression.

Dementia,
a
progressive
brain
dysfunction,
leads
to
a
gradually
increasing
restriction
 of
daily
activities.
The
most
well‐known
type
of
dementia
is
Alzheimer's
disease.
Dementia
is
a
specific
 brain
disease
that
is
characterised
by
a
collection
of
symptoms
namely,
progressive
loss
of
memory,
 attention
and
learning
which
restricts
the
individual
from
leading
the
life
they
have
led
before.
It
is
a
 progressive,
terminal
organic
brain
disease
and
the
most
common
types
are
 
 • Alzheimer’s
disease
(accounts
for
62%
of
dementia
in
the
UK)
 • Vascular
–
dementia
associated
with
hypertension
and
strokes
 • Dementia
with
Lewy
Bodies

 ’Existing
instruments
for
screening
 for
depression
and
dementia
 were
 developed
for
use
in
the
indigenous
 white
population.
Western
 ideas
of
 distress
and
symptoms
are
not
 necessarily
true
for
 other
ethnic
 groups,
and
it
is
difficult
to
translate
 emotions
 into
English
even
if
 language
skills
are
honed
or
an
 interpreter
 is
present’’
 
 BMJ
Editorial.

BMJ
1996;
313(7069):1347

  • 16. 
 
 • Fronto‐temporal
Dementia

 
 According
to
the
Alzheimer’s
Society
(2007),
it
is
estimated
that
there
are
about
11,000
people
from
 black
and
minority
ethnic
(BME)
groups
with
dementia,
and
this
represents
1.7%
of
all
people
with
 dementia
in
the
UK.
However,
although
the
proportion
of
older
people
from
ethnic
minority
groups
in
 the
UK
is
small,
they
are
increasing
steadily
as
this
section
 of
the
population
ages
it
is
predicted
that
the
number
of
 people
with
dementia
from
BME
groups
will
also
rise.
 Research
suggests
that
some
differences
have
been
found
 in
the
prevalence
of
dementia
among
different
ethnic
 groups.
Dementia
in
BME
elders
is
not
necessarily
 recognised
and
research
has
shown
that
in
general
Minority
 Ethnic
groups
are
at
far
more
risk
of
misdiagnosis
and
 delayed
treatment
than
other
Mental
Health
Users
(Hare
 2001).
In
particular,
higher
rates
have
been
found
among
 Black
Caribbean
older
peoples
(Livingston
et
al.
2001)
 although

the
recognition
of
dementia
is
lower
among
 South
Asian
and
African
Caribbean
people
than
among
the
 population
as
a
whole
(Adamson,
2001;
Bowes
and
 Wilkinson,
2003).
 
 
 Prevalence
of
dementia
in
BME
populations

 A
number
of
key
measures
must
be
put
in
place
if
the
aims
 of
the
National
Service
Framework
for
Older
People
(NSF),
 particularly
standard
seven
on
mental
health,
are
to
be
met
 for
BME
communities
and
local
service
providers
must
do
 more
to
connect
with
communities.

However,
there
are
no
 national
statistics
held
on
the
prevalence
of
dementia
in
 BME
populations
and
the
Royal
College
of
Psychiatrists
(2001)
noted
that
identifying
dementia
among
 BME
elders
as
an
area
that
has
been
neglected
in
research.



























 The
Alzheimer’s
Society
publication
Dementia
UK
(2007:
36‐37)
has
identified
that
6.1
%
of
all
people
 with
dementia
from
BME
groups
are
living
with
early
onset,
compared
with
only
2.2%
of
the
population
 as
a
whole,
and
this
indicates
implications
for
policy,
commissioning
and
care.
However,
future
 projections
of
Alzheimer’s
among
BME
elders

will
be
much
large
than
the
population
as
a
whole
as
first
 generation
migrants
from
the
1950s
and
1970s
move
into
the
age
risk
for
dementia.
There
is
a
notable
 absence
of
BME
elders
and
dementia
from
much
of
the
national
research
and
policy
guidance
and
even
 national
documents
such
as
the
NICE
Guidance
on
Dementia
(2006)
takes
a
social
inclusion
approach
to


 BME
elders
but
it
barely
addresses
the
issue
of
different
cultural
needs
and
fails
to
address
the
issue
of
 culture
and
assessment
and
culturally
appropriate
care.

 Positive
Practice

 Film:
Dementia
Matters,
Ethnic
 Concerns:
Managing
Care
in
the
 UK,
Netherlands,
Spain
and
 Finland
(1999)
‐
 This

film
contains
important
 information
for
dementia
 sufferers,
their
families
and
 professional
carers
along
with
 mainstream
care
providers,
 minority
ethnic
organisations,
 majority
voluntary
organisations
 and
policymakers,
as
well
as
 students
in
dementia
care.
The
 accompanying
booklet
contains
 key
facts,
issues
and
proposals
on
 dementia
care
and
will
be
helpful
 for
anyone
interested
in
mental
 health
and
ethnicity.
 Available
from
PRIAE
£27
 

  • 17. 
 
 However,
does
NICE
suggest
that
heath
and
social
care
staff
should
identify
the
specific
needs
of
people
 with
dementia
and
their
carers
arising
from
diversity,
including
gender,
ethnicity,
age
(younger
or
older),
 religion
and
personal
care
and
it
acknowledges
that
care
plans
should
record
and
address
these
needs.
 THE
NICE
social
inclusion
approach
suggests
that
managers
and
care
coordinators
should
ensure
that
 care
plans
are
based
on
an
assessment
of
the
person
with
dementia’s
life
history,
social
and
family
 circumstance,
and
preferences,
as
well
as
their
physical
and
mental
health
needs
and
current
level
of
 functioning
and
abilities
(NICE
2006)
however
it
does
not
talk
about
culturally
appropriate
assessments.

 Importantly
it
does
address
the
important
issue
of
language
and
suggests
that
if
language
or
acquired
 language
impairment
is
a
barrier
to
accessing
or
understanding
services,
treatment
and
care,
then
 health
and
social
care
professionals
should
provide
the
person
with
dementia
and/or
their
carer
with
 information
in
the
preferred
language
and/or
in
an
accessible
format
as
well
as
access
to
independent
 interpreters
and
psychological
interventions
in
the
preferred
language.

 Certainly,
dementia
in
BME
populations
appears
to
be
neglected
in
national
research
and
health
and
 social
care
services
for
people
with
dementia
from
black
and
minority
ethnic
communities
need
to
move
 towards
providing
evidence‐based
culturally
appropriate
care.
Responding
to
issues
of
culture
and
 ethnicity
is
not
unique
to
dementia
care
and
there
is
a
need
to
improve
the
quality
of
and
access
to
 services
and
greater
responsiveness
to
individual
need.
Service
providers
need
to
work
with
community
 and
voluntary
 organisation’s

to
plan
the
 development
and
delivery
 of
services
but
this
can
be
a
 challenge
in
dementia
care,
 where
the
stigma
of
 dementia
may
inhibit
 involvement
(Milne
2001).
 Therefore,
service
providers
 also
have
a
role
in
health
 education
and
health
 promotion
among
younger
 communities
as
well
as
 carers. 
 
 
 
 
 BME

Elders
living
with
 depression.
 
 We
all
suffer
from
feeling
down
at
different
points
in
our
lives
but
depression
is
often
indicated
when
 feeling
low/
depressed
don’t
go
away
and
that
those
feelings
are
so
bad
that
they
interfere
with
a
 persons
daily
life.
Major
depression
is
generally
diagnosed
when
a
persistent
and
unreactive
low
mood
 and
an
absence
of
positive
affect
are
accompanied
by
a
range
of
symptoms,
the
number
and
 combination
needed
to
make
a
diagnosis
being
operationally
defined
(NICE
Guidelines
2007),
although
 some
people
show
an
atypical
presentation
with
reactive
mood,
increased
appetite,
weight
gain
and
 excessive
sleepiness
(Quitkin
et
al.,
1991).


Depression
in
later
life
frequently
coexists
with
other
 medical
conditions
(such
as
dementia).
In
addition,
advancing
age
is
often
accompanied
by
loss
of
key
 social
support
systems
due
to
the
death
of
a
spouse,
friend
and
family
and
many
elder
people
become
 isolated
‐
this
can
be
a
key
factor
developing
depression
(ONS,
2000,
Steptoe,
2003;
Jackson,
1991).

 
 Consultations
with
groups
of
older
people
 from
black
and
minority
ethnic
 communities
found
that
older
people
often
 felt
they
had
been
"researched
to
death"
 over
the
past
15
years.

 (Butt
and
O’Neil
2004)
  • 18. 
 
 General
issues
related
to
elders
living
with
depression.
 
 The
presentation
of
depression
varies
with
age,
the
young
showing
more
behavioural
symptoms
and
 older
adults
more
somatic
symptoms
and
fewer
complaints
of
low
mood
(Serby
&
Yu,
2003).
However,
 the
recognition
of
depression
in
old
age
may
be
more
difficult
in
that
symptoms
such
as
poor
 concentration
or
loss
of
interest
in
usual
activities
can
mimic
dementia
(Badger,
1998)
and
some
people
 may
perceive
this
as
a
natural
part
of
ageing
and
both
elders
and

professionals
underestimate
the
 significance
of
late
life
depression
(Manthorpe
and
Iliffe,
2005).
Certainly,
the
consequences
of
not
 offering
support
to
people
with
depression
are
very
serious.
Without
help,
there
is
a
greater
risk
that
the
 depression
may
become
chronic
(Beekman
et
al.2002).
Research
suggests
that
the
frequency
of
 depression
rises
with
age
and
is
more
common
among
people
in
their
80s
and
90s
than
those
in
their
 70s
(Osborn
et
al
2003)
but
here
is

conflicting
evidence
as
to
whether
older
women
are
at
greater
risk
 of
depression
than
older
men
(Beekman
et
al.,
1999;
Osborn
et
al.,
2003).
 Depression
is
extremely
common
among
people
living
in
long
term
care.

(Mann
et
al.
2000
and

Mozley
 et
al.,
2000)
and
there
are
high
rates
of
depression
among
people
living
in
sheltered
accommodation,
 possibly
because
their
move
had
been
precipitated
by
bereavement
and/or
loneliness

(Harrison
et
 al.(1990)
and

Field
et
al.
(2002).


 
 It
is
not
surprising
to
see
that
research
suggests
that
 caregivers
of
dementia
patients
can
experience
various
 emotional
problems
during
the
course
of
the
illness
(Rabins,
 1984)
and

depression

among
carers
is
common
(Harwood,
et
 al,1998).

However,
the
risks
for
carer
giver
depression
have
 been
found
to
be
related
to
a
complex
interrelationship
of
 gender,
age,
health
status,
ethnic
and
cultural
affiliation,
and
 access
to
social
support
(Gruetzner,
2001)
.
 
 
 BME
elders
living
with
depression
 
 There
is
contradictory
research
on
depression
in
BME
elders
and
while
some
studies
of
Black
and
White
 elders
in
the
USA
and
 UK
show
no
difference
in
the
prevalence
of
depression
(Ebrahim
at
al
1991,
Murrrell
 et
al
1991,
Bhatagner
et
al
1997
other

studies
have
found

a
slightly
higher
prevalence
of
depression
 among
BME
elders
(Livingson
et
al
2001,
McCracken
et

al
1997).
However,
other
researcher
such
(as
 Livingstone
and
Sembhi

2003)
suggests
that
BME

elders
are
thought
to
be
particularly
vulnerable
to
 depression
because
of
risk
factors
of
socio‐economic
deprivation,
immigrant
status
and
old
age.
Research
 suggests
that
many
BME
elders
feel

isolated
and
that
this
sometimes
leads
to
high
levels
of
depression
 and
depression
and
mental
health
may

be
a
taboo
subject
in
some
communities,

there
is
a
need
to
 discuss
these
issues
–
‘’but
not
in
a
way
that
left
people
feeling
worried
or
exposed’’(Butt
and
O’Neil
 2004).
 

  • 19. 
 
 Certainly
at
a
policy
level
BME
elders
are
on
the
agenda
and
the
Department
of
Health


‘Delivering
race
 equality
in
mental
health
care:
An
action
plan
for
reform
inside
and
outside
services
and
the
 Government's
response
to
the
Independent
inquiry
into
the
death
of
David
Bennet’
(2005)
identifies
 some
of
the
‘building
blocks’,
that
can
help
to
promote
the
mental
health
and
well
being
of
BME
elders.
 It
suggests
that

 •
More
appropriate
and
responsive
services
–
including
‘to
improve
services
for
specific
groups,
 including

older
people
 
 •
Community
engagement
–
delivered
through
healthier
communities
and
by
action
to
engage
 communities
in
planning
services,
supported
by
500
new
Community
Development
workers;
and
 
 •
Better
information
–
from
improved
monitoring
of
ethnicity,
better
dissemination
of
information
and
 good
practice,
and
improved
knowledge
about
effective
services.
 
 Among
the
points
in
the
Government
document
which
refer
specifically
to
the
needs
of
older
people
 from
BME
communities,
communication
and
language
difficulties
are
acknowledged
as
a
particular
 issue,
and
it
is
recommended
that
all
PCTs
and
local
authorities
should
ensure
that
all
mental
health
 services
take
account
of
the
language
and
interpretation
needs
of
older
people
from
BME
groups.
 
 It
is
also
acknowledged
that
Standard
7
of
the
National
Service
Framework
(NSF)
for
Older
People
 requires
PCTs
to
ensure
that
every
general
practice
is
using
an
agreed
protocol
to
care
for
patients
with
 dementia
or
depression.
It
is
recommended
that
PCTs
need
to
acquire
‘BME
age
specific
expertise’
to
 help
them
develop
services
that
are
responsive
and
appropriate
to
the
needs
of
older
people
from
BME
 communities.
It
is
up
to
local
commissioner
and
practitioners
to
work
in
partnerships
with
community
 organisations,
families
and
individuals
to
improve
mental
health
care
for
BME
elders.
 
 
 Positive
practice:
Identifying
local
needs
 In
2006,
Devon
County
Council
and
Age
Concern
conducted
research
entitled
Removing
the
Barriers:
 meeting
the
needs
of
minority
ethnic
elders
in
Exeter,
looking
into
the
health
and
social
care
needs
of
 local
older
people
from
minority
ethnic
groups.
The
study
found
that
older
people
from
these
groups
 experience
higher
levels
of
general
ill‐health
in
comparison
to
the
wider
community:
68.7%
of
those
 questioned
described
themselves
as
having
poor
physical
health
and
80%
were
taking
medication.
This
 can
be
attributed
in
large
part
to
health
related
behaviour
such
as
diet
and
exercise,
and
is
influenced
by
 the
fact
that
religious
and
cultural
sensitivities
make
most
activities
currently
on
offer
difficult
to
access.

 Another
important
consideration
is
material
circumstances
such
as
inadequate
living
conditions
and
 financial
resources:
62.5%
or
those
questioned
were
not
receiving
benefits
despite
the
high
incidence
of
 poverty
expressed.
Lack
of
money
inhibits
participation
in
a
variety
of
activities,
thereby
increasing
the
 risk
of
isolation
and
this
is
identified
as
an
issue
which
has
a
significant
impact
on
mental
well
being.

 Following
the
study,
a
need
was
identified
for
a
culturally
specific
centre
for
older
people
from
minority
 ethnic
groups.
93.8%
of
those
questioned
agreed
there
was
a
need
for
this
facility,
as
current
facilities
 such
as
those
offered
by
Age
Concern
and
Devon
County
Council
did
not
meet
their
needs.
It
was

  • 20. 
 
 intended
that
the
centre
would
offer
a
venue
where
people
could
access
information
and
advice
from
a
 range
of
professionals,
with
language
support
from
centre
staff.
In
addition
it
would
offer
the
 opportunity
to
mix
with
others
and
reduce
social
isolation.

 A
community
based
pilot
project,
Hikmat,
has
therefore
begun
in
response
to
the
needs
identified.
 Initially
this
service
was
offered
one
day
per
week
to
Muslim
Elders,
but
has
recently
been
extended
to
 offer
a
similar
service
to
the
Chinese
Elder
population.
When
attending
the
centre
male
and
female
 Muslim
Elders
use
separate
rooms,
as
this
is
culturally
appropriate.
The
Chinese
Elders
prefer
to
attend
 in
a
mixed
group.
Both
groups
have
lunch
from
a
local
takeaway,
for
which
they
make
a
financial
 contribution.

 Suicide
and
self
harm
 
One
of
the
worrying
and
negative
outcomes
about
not
providing
the
quality
of
care
for
elders
is
the
risk
 of
self
harm
and
suicide.
There
is
a
growing
body
of
research
literature
on
elders
and
self
harm/
suicide
 but
very
little
research
on
BME
elders.
 The
general
literature
suggests
that
 • Older
people
are
less
likely
than
younger
people
to
talk
about
suicide,
but
more
likely
to
 carry
it
out
(Help
the
Aged
2004)
and
attempted
suicide
should
always
be
taken
seriously
in
 the
elderly
and
is
most
likely
to
represent
a
failed
suicide
bid
rather
than
parasuicide
(Cattell
 2000)

















































 jjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjj
 • Two
of
the
most
commonly
cited
risk
factors
for
suicide
are
older
age
and
male
gender
 (Pearson
and
Conwell
1995).
 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
 • Older
men
aged
75
and
over
have
the
highest
incidence
of
suicide
‐
11
per
cent
higher
than
 the
rates
for
all
males
aged
15
and
over
(Samaritans
1998).
Rates
 for
the
most
elderly
men
 (males
over
85
years)
during
this
period
 remained
fairly
static,
this
group
still
having
the
 highest
 rates
of
any
group
(Cattell
2000). mmmmmmmmmmmmmmmmmmmmmmmmmmm • Evidence
suggests
that
GPs
treating
older
people
for
suicidal
tendencies
overwhelming
 prefer
to
prescribe
medications
rather
than
psychotherapy
(Kaplan
et
al.,
1999)
and
some
 studies
suggest
that
up
to
70
percent
of
older
people
visit
their
clinician
within
30
days
of
 death
(Barraclough,
1971,
Conwell
et
al.,
1991).
 • Suicide
risk
is
often
complex
to
recognise
in
elders
for
two
main
reasons:
co‐morbidities
and
 infrequency
of
contacts
with
mental
health
specialists
Co‐morbid
chronic
illnesses
are
common
 in
older
people,
they
increase
risk
for
depression
and
suicide,
and
they
make
symptom
 presentation
more
complicated
to
disentangle.

(Caine
and
Conwell
1998).
 mmmmmmmmmmmmmmmm
 • Among
the
elderly,
 depressive
illness
is
the
most
important
predictor
 of
suicide
and
this
needs
to
 be
emphasised
(Cattelle
et
al
2000).
Suicide
and
attempted
suicides
are
associated
with
high

  • 21. 
 
 rates
of
depression
(up
to
90%),
with
major
depression
accounting
for
over
50%
and
physical
 illness
being
a
significant
contributor
in
around
60–70%
of
cases

 • The
role
of
social
isolation
as
a
risk
factor
for
elderly
suicide
 has
been
stressed
in
many
studies.
 (Barraclough
1971),
for
 example,

living
alone
as
often
cited
as
the
most
important
social
 variable.
 • Effective
suicide
prevention
models
will
involve
multi
faceted
prevention
strategies
carefully
 designed
to
address
the
needs
of
the
individual
(Diekstra,
R.
F.
W.
1993).

 • Investment
in
supporting
community
outreach
and
voluntary
sector
groups
with
a
prevention
 and
promotion
focus
will
enable
the
overall
needs
of
vulnerable
people
to
be
addressed
and
 thereby
reduce
the
likelihood
of
their
needing
support
from
specialised
mental
health
services
 (NIMHE
and
NatPAct

2005)
The
Commissioning
Friend
for
Mental
Health
Services
 
http://www.natpact.nhs.uk/uploads/2005_Jan/MH_Print_Version.pdf
 
 Suicide
and
BME
elders
 • Burr
(2002)
warns
that
some
times
cultural
stereotypes
have
been
presented
as
scientific
facts,
 hence
the
South
Asian
patient's
experience
of
depression
followed
with
suicidal
thoughts
and
 intent
is
attributed
solely
to
the
person's
culture.
 • In
some
cultures
suicide
may
be
an
acceptable
way
to
avoid
losing
face
and
honour,
in
other
cultures
it
 may
 be
 viewed
 as
 a
 grave
 sin
 that
 will
 bring
 shame
 and
 disgrace
 on
 the
 family
 for
 many
 years
 (Farberow,
1975).

 • Community
education
and
awareness
programs
need
to
take
into
account
these
different
values
and
 attitudes
 towards
 suicide
 and
 present
 information
 and
 support
 in
 ways
 that
 are
 culturally
 and
 linguistically
appropriate.
Farberow
(Ed.)
(1975).

 • Improving
information
and
pathways
to
care,
supporting
self‐help
groups
and
BME
elder
community
 organisations
may
all
provide
early
interventions
that
may
prevent
mental
health
problems
escalating.
 
 
 Spirituality
 For
many
people,
their
spiritual
life
is
significant
to
their
mental
health
and
well
being
and
practitioners
 are
now
recognising
the
value
of
spiritual
life
to
mental
well
being
and
recovery
across
all
different
 cultures
(Cinnirella

et
al
1999,
Larson
1998).

 
 The
Royal
College
of
Psychiatry,
has
identified
that
spiritual
care
can
have
a
very
positive
outcome
for
 many
people,
(
see
also
the
NIMHE
spirituality
project)
and
a
number
of
studies
have
highlighted
the
 importance
of
religious
and
cultural
values
for
minority
ethnic
families.
Beliefs
and
values
are
often
 integral
to
people’s
self‐concept
and
will
affect
their
willingness
to
take
up
any
services
on
offer
(Azmi
et
 al
1997).


 

  • 22. 
 
 Attention
to
cultural
practices
and
religious
beliefs
is
important
in
the
 achievement
of
quality
in
service
provision
and
beliefs
can
offer
many
people
 solace,
and
spiritual
nourishment
as
well
as
a
framework
for
daily
living.

 
 • Working
in
partnership
with
local
religious
and
spiritual
groups
can
be
 an
effective
approach
to
mental
health
promotion.

 
 
 • Spiritual
leaders
are
widely
consulted
by
individuals
experiencing
 mental
distress
and
this
may
reflect
the
help‐seeking
behaviour
in
 many
different
cultures
and
may
appear
more
culturally
appropriate
as
a
first
place
for
 information
and
support.
 
 • A
person’s
spirituality
may
also
inform
their
perceptions
of
experiences
and
an
event,
including
 emotional
distress
and
mental
ill
health
and
it
is
important
that
these
spiritual
needs
are
 recognised
in
the
development
of
culturally
sensitive
services.


 
 • Research
suggests
that
older
people
who
have
a
strong
sense
of
spiritual
belief
and
personal
 meaning
in
life
are
less
likely
to
suffer
from
depression
or
mental
health
problems
even
when
 they
have
lost
a
spouse
within
the
past
year
and
spiritual
practice
may
help
to
support
the
 mental
health
and
well
being
of
elders
who
have
been
bereaved
(Coleman

et
al
2002)
 While
it
must
be
acknowledged
that
culture
(including
spiritual
beliefs)
can
impact
on
a
persons
life
 and
health,
it
is
important
to
recognise
that
the
social
determinants
of
health
other
dynamics
may
 also
prevent
the
use
of
services
on
offer
such
a
language
barriers,
lack
of
understanding
of
services
 available
and
concern
about
stigma.

 
 Accessing
mental
health
services
 People
with
mental
health
problems
pass
through
different
levels
of
‘filters’
before
gaining
access
to
 different
levels
of
mental
health
services
(Goldberg
and
Huxley
1980).
Pathways
to
mental
health
 services
may
be
influenced
by
a
number
of
factors
including
the
cultural
appropriateness
 of
services
 (including
access
to
interpreters
and
health
practitioners
who
can
speak
the
clients
language);
attitudes
 towards
services;
previous
experiences;
 and
culturally

defined
lay
referral
systems(
Goldberg
1999).

 While
much
of
the
literature
on
mental
health
focuses
on
the
medical
model
there
is
a
growing
interest
 in
how
socio‐cultural
factors
may
mediate
the
experience
of,
and
response
to
illness
such
as
dementia
 (Holstein
1998)
and
how
different
cultures
perspectives
may
influence
help
seeking
behaviour
(Radley
 1987)
 
 Some
of
the
barriers
to
accessing
mental
health
services
include:
 
 Communication
 • Research
suggests
that
one
of
the
primary
challenges
facing
BME
service
users
in
trying
to
 access
mental
health
services
is
language
(Tribe
and
Raval
2002)
 

  • 23. 
 
 
 • Although
clients
and
interpreters
speak
the
same
language
they
may
or
may
not
share
the
same
 cultural
origins.

Practitioners
need
to
be
sensitive
to
cultural
issues
such
as
the
religious
 background,
ethnic
group,
political
alliances
or
the
cultural
origins
of
the
interpreter
/
client.

 mmmm
 • These
issues
can
be
complex
to
resolve
as
the
client
may,
or
may
not,
want
the
interpreter
to
come
 from
the
same
background
(e.g.

religious
background).

This
issue
needs
to
be
handled
with
 sensitivity,
as
a
service
provider
needs
to
conform
to
the
Race
Relations
Act
as
well
as
being
 receptive
to
the
needs
of
their
clients.
 
 • A
competent
interpreter
in
mental
health
is
not
only
a
language
broker
but
also
a
cultural
broker,
as
 the
task
of
the
interpreter
is
to
facilitate
communication.

The
interpreter
must
know
not
only
the
 meaning
of
words
in
another
language,
but
must
also
understand
the
meaning
of
concepts
in
both
 cultures.

However,
although
the
interpreter
may
be
asked
about
cultural
background
issues,
the
 practitioner
needs
to
be
aware
that
if
the
interpreter
is
not
from
the
same
clan,
class,
gender,
 religion
or
culture
to
the
client
then
they
may
not
be
able
to
answer
/
support
cultural
 interpretation
issues
(Tribe
and
Raval
2002).


 • Research
suggests
that
it
is
unrealistic
to
imagine
that
people
who
have
reached
a
certain
level
 of
maturity
can
learn
a
new
language
(PRAIE
2005)
 
 • Some

BME
older
peoples
may
not
speak
English
and
a
number
are
illiterate
in
their
own
 language
this
may
be
due
to
work
patterns
and
family
commitments
(McCallum,
1990)
 
 • Deaf
people
are
over‐represented
in
the
mental
health
setting.

A
deaf
person
may
have
limited
 opportunitiesto
get
to
know
where
and
how
to
get
help
for
mental
health
problems.

There
may
 be
cultural
differences
in
the
way
mental
distress
manifests
in
people
who
are
deaf,
compared
 to
those
who
are
not.
One
difference
in
working
with
a
deaf
client
is
that
the
interpreter
is
 usually
hearing,
so
will
not
share
the
same
cultural
background
as
a
deaf
person.

This
can
bring
 the
issue
of
mistrust
towards
both
the
interpreter
and
the
mental
health
professional.


It
may
 be
difficult
to
find
an
interpreter
for
the
deaf
in
the
language
for
some
BME
service
users. 
 
 
 Stigma
 • Research
by

Seabrooke
and
Milne
(2004)
in
Kent
explored
the
service‐related
needs
of
Asian
 older
people
with
dementia
and
their
carers.
Currently
Asian
elders
and
their
carers
are
only
 willing
to
use
services
where
their
cultural
and
linguistic
needs
are
met.
Unfortunately
such
 services
are
generic
and
are
neither
appropriate
nor
resourced
for
managing
people
with
 dementia.
GPs
also
have
difficulty
with
diagnosing
dementia
in
Asian
elders,
and
families
are
 reluctant
to
come
forward
for
treatment
due
to
community
stigma.
 
 • Research
suggests
that
there
is
a
lack
of
awareness
regarding
definition
and
recognition
of
 dementia
in
BME
communities
and
a
greater
need
for
community
education
to
reduce
stigma
 and
myths
(
Hare
2001).


 
 • It
is
possible
that
levels
of
stigma
about
mental
health
are
higher
in
some
communities
than

 others
(Ng,
1997;
Marwaha
and
Livingston,
2002;
Bowes
and
Wilkinson,
2003).

  • 24. 
 
 
 • Some
BME
communities
may
not
access
services,
due
to
a
 belief
that
the
rest
of
their
community
might
think
they
are
 not
capable,
lacking
as
a
family
or
seeking
charity.

There
is
a
 also
a
lack
of
awareness
among
some
BME
people
concerning
 of
the
role
of
the
GP
as
a
source
of
information
and
support
 for
mental
health
problems
(Jacob
et
al,
1998).
 
 • People
express
their
distress
and
pain
in
different

ways
and
 hold
diverse
beliefs
about
the
body,
healing
and
sickness
(see
 culture
section
above)
 
 
 Attitude
of
service
providers
 • Research
by

Odell
suggests

that
GPs
by
are
less
likely
 to
 identify
psychological
symptoms
in
ethnic
minority
patients
 (Dell
et
al
1997)
and
there
may
be
a
tendency
among
some
 GPs
to
perceive
the
health
needs
of
their
minority
ethnic
 patients
on
the
basis
of
negative
stereotypes
(Ahmad
et
al,
 1991).
 
 • Research
suggests
that
black
and
Asian
ethnic
minorities,
 access
to,
utilisation
of

 and
treatments
prescribed
by
mental
 health
practitioners
differ
from
 those
for
white
people
(Lloyd
 and
Moodley
1992).
 
 • Like
all
elders,
research
suggests
that
BME
elders
wish
to
 being
treated
with
respect;
feel
safe
and
comfortable;
having
 their
dignity
respected;
and
be
supported
by
professionals
 who
behave
with
integrity
(PRAIE
2005).
However,
practitioners
may
need
to
consider
how
 these
attributes
are
interpreted
and
experienced
across
cultures.

 
 
 BME
service
users,
families
and
carers. Service
users
and
their
carers
are
the
most
important
people
in
the
health
service;
involving
them
in
service
 planning
and
delivery
is
one
of
the
main
ways
we
can
make
sure
that
we
offer
patients
the
highest
quality
 care.
Patient
and
Public
Involvement
is
about
making
improvements
to
patient
care,
by
enabling
patients
to
 have
a
say
in
how
they
are
treated
and
how

services
are
run.
Under
the
NHS
Plan,
health
trusts
now
have
a
 legal
duty
(under
Section
11
of
the
Health
and
Social
Care
Act
2001)
to
consult
patients
and
the
public
in
the
 planning
of
services.
Patients
and
the
public
should
be
involved
and
consulted
from
the
very
beginning
of
any
 process
to
develop
or
change
health
servicesi .
This
will
increasingly
lead
to
a
more
patient‐centred
health
 service
and
improvements
in
the
patients’
experience.
This
is
not
about
new
targets;
it
is
about
delivering
 what
the
patient
thinks
is
acceptable
and
needs.

 ’
Traditionally,
there
has
been
a
 view
that
black
and
minority
ethnic
 communities
do
not
wish
to
use
 services,
as
they
prefer
to
care
for
 elders
themselves.
However,
 research
suggests
that
the
idea
that
 the
extended
family
will
look
after
 their
elders
may
be
a
myth
and
that
 in
many
cases
the
reality
is
that
 family
networks
are
spread
across
 continents
not
counties.

Similarly,
 black
and
minority
ethnic
 communities
are
often
described
as
 a
hard
to
reach
group.
An
 alternative
view
is
that
these
 communities
find
services
hard
to
 access.

 
 
The
number
of
older
people
from
 black
and
minority
ethnic
 communities
has
risen
sharply
over
 the
past
few
decades
and
is
 projected
to
continue
to
rise.
Black
 and
minority
ethnic
older
people
 with
mental
health
problems
and
 their
carers
need
to
have
access
to
 appropriate
and
responsive
services.
 There
needs
to
be
a
balance
 between
ensuring
access
to
 mainstream
services
and
 understanding
the
nature
and
 extent
of
the
need
for
specialist
 services’’.

 Everybody’s
Business
(DH/
CSIP

 2005)
 
 

  • 25. 
 
 The
Audit
Office
have
estimated
that
there
are
476,000
informal
carer
in
the
UK
and
they
provide
a
service
 that
is
valued
at
5.4
billion
pounds
(Audit
Office
2007),
however
there
are
no
national
figures
on
the
number
 of

BME
carers
in
the
UK
and
despite
recognition
of
the
importance
of
informal
family
care,
there
is
only
 limited

research
relating
specifically
to
BME
families
and
carers
(Atkin
and
Rollings,
1992
cited
in
the
Oxford
 Institute
of
Age

2003)
and
most
of
the
research
is
small
scale
and
local.
 
 Some
of
the
key
finding
on
the
roles
of
BME
carers
suggests
that
 Families
 • There
is
a
need
to
challenge
the
idea
that
black
and
minority
ethnic
communities
have
strong
 family
structures
and
they
always
look
after
their
own.
Research
suggests
that
BME
families
face
 their
own
pressures
of
normal
life,
career
and
childcare
commitments
and
may
be
stretched
 financially,
physically
and
mentally
by
caring
for
an
elder,
especially
if
he
or
she
is
in
poor
health
 (Ahmad
and
Atkin
1996).
 
 • Research
suggest
that
there
is
a
need
to
communicate
with
families
about
their
family
script
and
 family
expectations
(Lau
1986)
if
service
providers
are
trying
to
achieve
a
culturally
acceptable
 form
of
mental
health
support/
care
for
BME
elders.

However,
the
traditional
view
of
family
 entrenched
in
gerontological
research
is
that
‘the
family
‘is
often
portrayed
as
a
resource
and
a
 primary
support
system.
However,
there
are
often
a
number
of
assumptions
made
in
research. • Service
providers
need
to
be
reflective
about
their
own
expectations
and
beliefs
about
families
 and
family
roles, as
the
concept
of
family
and
family
roles
varies
across
cultures
and
people
 from
different
cultures.
The
Western
model
of
mental
health
and
well
being
is
predominantly
 based
upon
an
individualised
approach
that
places
a
strong
emphasis
on
intervention
and
 working
towards
empowering
individuals
and
encouraging
independence.
However,
this
is
not
 appropriate
for
clients
across
all
cultures
and
many
people
do
not
want
to
be
assessed
as
 separate
from
their
family
setting.

 
 • Some
small
scale
studies
have
suggested
that
some
BME
elders
have
expressed
that
their
 children
had
or
would
become
‘westernised’
into
the
uncaring
and
individualistic
attitudes
of
 English
people
towards
older
people).
In
a
study
of
Bangladeshis
living
in
Camden,
north
 London,
discovered
that
a
great
concern
of
older
people
in
the
area
was
the
erosion
of
the
 ‘customs’
and
‘tradition’
of
their
joint
Islamic
and
Bengali
heritage
because
of
the
influences
of
 British
culture
on
their
children
and
grandchildren
Fenton
(1987)
and
Qureshi
(1998)
cited
in
the
 Oxford
Institute
of
Age

2003)

 
 • Much
of
the
current
literature
on
the
family
and
carers
is
based
on
heterosexual
families


 (Novak
and
Campbell
2001)
and
there
is
scarce
literature
on
certain
groups
of
older
people
such
 as
the
never
married,
childless
and
LGBT
people.
Carers
of
a
gay,
lesbian,
bisexual
or
 transgender
person
may
not
choose
to
confide
all
relevant
information
to
professionals
due
to
 fears
of
discrimination.
Similarly,
where
the
individual
cared
for
does
not
seek
to
disclose
his
or
 her
relationship
with
the
carer,
the
identity
and
support
needs
of
carers
may
not
be
met.

 

  • 26. 
 
 • Patients
and
carers
are
not
often
accommodated
in
the
formal
system
of
care
because
service
 providers
believe
that
people
from
minority
ethnic
communities
find
these
services
as
either
 inaccessible
or
inappropriate
to
their
culture
specific
needs
(Forbat
2003)‐
as
a
result
BME
 service
users
and
their
carers
may
become
locked
out
of
care
 • Many
elders
who
live
in
the
UK
due
to
forced
migration
(i.e.
refugees)
may
not
have
any
family
 in
the
UK
(Connelly
2006).
 
 • Research
suggests
that
carers
of
people
with
learning
difficulties
from
minority
ethnic
 communities
are
often
more
affected
than
their
White
peers
by
problems
of
poverty,
bad
 housing
financial
problems
and
racism
(Butt
and
Mirza
1996).
 
 • Some
elders
who
are
unable
to
speak
English
may

be
dependant
on
other
family
members
for
 accessing
the
most
basic
services,
which
can
place
a
strain
on
the
family
and
create
a
sense
of
 loss
of
independence
in
the
older
person
and
some
elders
who
have
used
English
in
the
past
 may
return
to
their
original
language
of
their
childhood.
 
 
 Part
two:
Issues
for
specific
BME
elder
 communities
 Lesbian,
gay,
bisexual
and
transgender
(LGBT)
BME
elders
 As
with
all
community
groups,
lesbian,
gay,
bisexual
and
transgender
 (LGBT)
BME
elders
need
to
be
approach
as
unique
individuals
with
 distinctive
needs.

While
living
life
openly
as
a
lesbian,
gay
man
or
 bisexual
person
is
only
a
relatively
recent
possibility
(Heaphy
et
al.
 2003;
Weeks
1995,
Plummer
1995;
Weeks
et
al.
2001),
policy
and
 service
provisions
for
ageing
LGBT
communities
are
slowly
developing
to
recognise
the
needs
of
the
individual
 within
these
communities.
However,
while
there
is
very
limited
research
on
LGBT
elders,
there
is
even
less
 research
about
BME
LGBT
elders.


 The
general
research
suggests
that
 • Many
of
the
health
and
social
care
needs
of
older
people
who
are
lesbian,
gay,
bisexual
or
 transgender
are
likely
to
be
the
same
as
other
older
people
although
they
may
face
additional
 discrimination.

 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
 • Ageing
can
have
a
significant
impact
on
how
individuals
live
their
lives
as
lesbians,
gay
men
and
 bisexuals
in
a
predominantly
heterosexual
society
and
this
may
contribute
towards
a
sense
of
 isolation
and
loneliness
(Heaphy
et
al
2003).

 
 • Lesbian
and
gay
communities
may
have
an
important
role
in
supporting
non‐heterosexual
 identities
and
ways
of
living.
However,
these
community
supports
are
unevenly
distributed
in
 

  • 27. 
 
 geographical
terms.
Age
itself
can
form
the
basis
of
exclusion
from
community
activities
not
 specifically
targeting
older
lesbians,
gay
men
and
bisexuals
(Heaphy
et
al
2003).

 
 • MIND
suggests
that
ageism
within
society
has
meant
that
elders
are
generally
seen
as
 unattractive
and
socially
boring.
The
'gay
scene'
is
no
exception
and
is
more
often
than
not
 geared
towards
younger
people.
Despite
the
lack
of
social
opportunities
generally,
some
older
 lesbians
and
gay
men
may
have
long‐established
support
networks
while
others
will
be
more
 isolated,
perhaps
due
to
the
deaths
of
partners
and
friends,
lack
of
mobility,
or
simply
because
 they
have
lost
touch
with
others

(MIND
web
site).
 
 • 

Disclosure
of
sexual
orientation
to
health
and
social
care
providers
may
be
difficult
(Cochran.
 1988,
Hitchcock.
1992).




 mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm
 • Some
organisations
working
with
older
people
fail
to
take
into
account
the
fact
that
a
service
 user
may
not
be
heterosexual.
For
example,
sheltered
housing
and
residential
care
is
usually
 mixed‐sex
and
geared
towards
heterosexuals.

While
an
increasing
number
of
voluntary
 organisations
have
recognised
the
needs
of
lesbian,
gay,
bisexual
and
transgender
(LGBT)
elders,
 currently
there
are
only
a
few
organisations
meeting
the
needs
of
specific
LGBT
ethnic
 communities.
However,

community‐based
programmes
may
not
in
themselves
sufficient
to
 meet
the
social
support
and
health
related
needs
of
older
lesbian,
gay,
bisexual
and
transgender
 people
(Davies
et
al
2006).
mmmmmmmmmmmmmm
 • Research
suggests
that
LGBT
individuals
often
have
higher
levels
of
mental
ill
health
than
their
 heterosexual
counterparts

(King
et
al.
2003)
 
 
 LGBT
BME

people

 While
there
has
been
limited
research
into
the
needs
of
elder
LGBT
in
this
country,
there
is
very
limited
 research
on
meeting
the
needs
of
BME
LGBT
elders

(Brockmann.
2002)
 • Mind
suggests
that
black
lesbians
and
gay
men
face
double
oppression
because
of
their
race
and
 their
sexuality.
Some
feel
they
have
been
forced
to
choose
between
the
gay
and
the
Black
and
 minority
ethnic
cultures.
Black
communities
can
be
homophobic,
in
the
same
ways
white
ones
 can
be.
 • According
to
SAFRA,
(a
resource
project
working
on
issues
relating
to
lesbian,
bisexual
and/or
 transgender
women
who
identify
as
Muslim
religiously
and/or
culturally)

most
Muslim
LBT
 women
struggle
to
reconcile
their
sexual
orientation
or
gender
identity
with
their
cultural
or
 religious
identities.
This
internal
struggle
can
result
in
depression,
self
harm
and
even
suicide.
 Coming
out
(or
being
found
out)
can
result
in:
























































































































 o being
rejected
by
family
and
friends
 o intense
pressure
to
get
married,
sometimes
leading
to
forced
marriage
 o domestic
violence


  • 28. 
 
 o homelessness
 o losing
custody
of
children
and/or
abduction
 of
children

 • Homophobia
can
mean
that
an
individual
is
cut
off
 from
support
networks
of
family
and
friends,
which
 are
important
to
enable
a
person
to
develop
a
 positive
black
identity
and
to
counter
the
racism
 faced
on
a
daily
basis.
Black
lesbians
and
gay
men
 therefore
have
to
consider
the
importance
of
 'coming
out',
weighing
the
possible
loss
of
family
 and
community
support
against
the
gains,
 (Hayfield,1995)and
this
may
have
long
term
 implications
for
older
LGBT
people
who
may
lack
 family
/
community
support.


 mmmmmmmmmmmmmmmmmmmmmmmmmm mmmm
 • The
2006
Welsh
Office
report
into
The
Health,
Social
 Care
and
Housing
needs
of
Lesbian,
Gay,
Bisexual
 and
Transgender
older
people
suggests
that
people
 from
diverse
cultures
and
groups
may
be
‘gay’
but
 may
do
not
use
the
term
to
describe
their
life
or
 their
lifestyles
(Davies.
M.
et
al.
2006).

 
 BME
elders
who
are
refugees
 
 The
standard
definition
of
the
elderly
as
being
those
over
 retirement
age
is
not
always
suitable
for
members
of
 refugee
communities.
In
common
with
others
from
different
 cultures
they
may
have
been
used
to
different
lifestyles
and
 experiences
and
to
economic
disadvantages.
Many
will
have
 been
through
traumatic
experiences
and
losses
in
the
course
 of
their
escape
and
subsequent
exile.

 These
factors
can
all
have
the
effect
of
ageing
people
earlier.
 Those
who
were
already
in
later
life
when
they
came
to
the
 United
Kingdom
may
have
been
unable
to
work
and
 therefore
have
adopted
a
retired
lifestyle
earlier
than
is
 usual
here.
In
addition,
dates
of
birth
may
have
been
 calculated
differently
or
recorded
inaccurately
in
transit,
so
 that
some
are
actually
older
that
their
‘official’
age.


 
 (Finlay
and
Reynolds
(1987,
cited
in
Wilson,
1988:
157)
 

  • 29. 
 
 
 Refugees
flee
their
homes
because
of
the
threat
of
persecution
and
cannot
return
safely
to
their
homes
 and
cannot
be
guaranteed
safety
on
their
return.
For
most
refugees,
there
is
considerable
anguish
 regarding
the
final
decision
to
flee
their
family
and
their
homeland
and
they
only
take
this
extreme
step
 in
order
to
survive.


 The
term
refugee
is
often
used
very
loosely.
Generally,
people
use
the
term
refugee
to
mean
people
 who
have
moved
across
an
international
border
in
search
of
protection.
When
people
flee
their
 homelands
as
a
refugee,
they
are
afforded
rights
under
the
1951
UN
Convention
on
Refugees.

This
is
 the
key
legal
document
in
defining
who
is
a
refugee
and
significant
elements
of
the
Convention
include
 • A
refugee
has
the
right
to
safe
asylum.

 
 • International
protection
comprises
more
than
physical
safety.

 
 • Refugees
should
receive
at
least
the
same
rights
and
basic
help
as
any
other
foreigner
who
is
a
 legal
resident,
including
freedom
of
thought,
of
 movement
and
freedom
from
torture
and
 degrading
treatment.
 
 • Economic
and
social
rights
are
equally
 applicable.
Refugees
should
have
access
to
 medical
care,
schooling
and
the
right
to
work
 
 • Governments
establish
their
own
status
 determination
procedures
to
decide
a
person's
 legal
standing
and
rights
in
accordance
with
 their
own
legal
systems.

 
 • Growing
old
in
exile
is
an
inevitable
 phenomenon
for
a
growing
numbers
of
 refugees
and
asylum
seekers
in
the
UK.

Refugees
are
often
among
the
most
deprived
and
 socially
excluded
groups
living
in
European
countries
(Brockmann
2002),
however,
there
is
a
 dearth
of
research
literature
on
elder
refugees.

 
 
 General
research
on
refugees
suggests
that
 
 • Refugees
often
carry
the
burden
of
a
health
inheritance
from
their
home
country
that
may
 include
trauma,
loss
and
possibly
torture,
the
health
impact
of
the
refugee
journey
that
may
 include
long
periods
of
mal
nutrition,
violence
and
destitution
and
the
asylum
seeking
process
in
 the
UK.
Yet
refugee
older
peoples
are
often
a
neglected
population


(Hatzidimitriadou
2005).
 
 • Most
refugees

face
considerable
problems

during
resettlement
in
a
new
country;

these
may
 include
poor
housing
conditions,
financial
insecurity,

loss
of
family

and
culture,
lack
of
 familiarity
with
the
health
care
system,
fear
and
mistrust

of
officials
due
to
past
experiences
 

  • 30. 
 
 (Wasp
et
al
2004,
Derges
and
Henderson,
2003
 South
London
and
Maudsley
NHS
Trust
2001,
Scott
 and
Bolzman,
1999)

 
 • Refugees
often
face
problems
in
accessing
health
 and
this
is
often
due
to
language
barriers
and
some
 times
discrimination
by
health
professionals.
 (Cowen
2001,
Ager
and
Strang
2004).

 
 • Women
may
face
particular
problems
due
to
 experiences
of
sexual
violence,
trafficking
and
 prostitution
(Cowen
2001)
and
women
are
more
 likely
than
men
to
report
poor
health
and
 depression
due
to
isolation
(Burnett
and
Peel

 2001).
 
 • Many
elderly
refugees
report
having
persistent
 headaches
and
stomach
aches.
Others
complain
of
 back
and
chest
pains.
While
some
of
these
 symptoms
are
clearly
signs
of
physical
problems,
 many
are
attributed
to
stress
and
to
"survivor's
 grief"
as
well
as
to
worry
about
the
future
(Gozdiak

 1989).
 
 • Many
service
providers
are
unfamiliar
with
the
full
 range
of
entitlements
of
disabled
people
within
 refugee
and
asylum‐seeking
communities
and
many
 people
find
themselves
denied
access
to
services

 (Roberts
et
al
2002).
 
 
 Elder
Refugees
 • Elder
refugees
may
experience
ageing
faster,
due
to
 past
traumatic
experiences
(Ditscheid
2004).

 
 • Older
refugees
may
be
resistant
to
approaching
public
authorities
for
assistance
due
to
their
 experiences
in
exile,
or
of
discrimination
in
their
country
of
settlement
(Saunders
2004).

 
 • Refugee
elders
may
also
be
at
risk
from
social
isolation
because
of
dispersal
policy,
distance
 from
a
place
of
worship
and
a
poor
knowledge
of
available
welfare
services
(
McCarthy

1995).
 • Due
to
the
refugee
experience
many
BME
refugee
elders
are
without
any
family
support
 (Connelly
2006).
 • The
loss
of
community,
history
and
tradition
leaves
people
without
a
context
within
which
to
 exist.
Elder
refugees
can
draw
on
traditions
to
sustain
their
sense
of
self
and
hope
for
the
future
 and
they
have
the
knowledge,
skill
and
ability
to
hold
communities
together.
They
can
draw
on
 Positive
Practice

 Older
Refugees
and
Asylum‐Seekers
 Project
(2006‐2007)
 
Age
Concern
England
and
the
Refugee
 Council,
also
involves
Age
Concern
 London
and
the
Association
of
Greater
 London
Older
Women
has
developed

a

 two‐year
joint
programme
which
aims
to
 promote
greater
involvement
of
refugee
 elders
at
all
levels
of
society,
through
 listening
to
their
voices,
and
raising
 awareness
of
their
experiences,
needs
 and
capabilities.
It
seeks
to

 Review
of
existing
literature
and
research
 on
older
refugees
 Survey
Refugee
Community
 Organisations
and
other
organisations,
 including
local
Age
Concerns,
working
 with
older
refugees
and
asylum‐seekers
 Conduct
3
regional
‘listening
events’
with
 older
refugees,
the
results
of
which
will
 all
be
brought
together
in
conference
a
 
It
is
hoped
that
one
of
the
outcomes
of
 the
Older
Refugees
Programme
will
be
to
 identify
opportunities
for
local
 partnership
working
in
meeting
the
 needs
and
aspirations
of
older
refugees
 
 
 

  • 31. 
 
 many
past
experiences
and
memories
to
remind
their
people
that
they
have
surmounted
other
 difficulties
and
survive
(Goveas
2002).
 
 
 BME
elders
in
rural
localities
 Very
little
research
has
been
conducted
on
the
mental
health
needs
of
BME
elders
living
in
rural
 locations.

Although
the
proportion
of
older
people
in
England’s
and
Wales’
rural
areas
is
significantly
 higher
than
in
urban
areas,
most
BME
elders
tend
to
be
located
in
urban
areas
(National
Census
2001)
 and
therefore
BME
elders
living
in
villages
and
other
rural
settings
may
find
themselves
quite
isolated
 and
without
access
to
culturally
appropriate
community
resources
and
the
needs
and
perspectives
of
 the
white
ethnic
majority
often
become
defined
as
the
norm
(Ubuntu
2004).

 • The
term
BME
covers
a
wide
range
of
individuals
and
groups
including
established
communities,
 individual,
migrant
workers
as
well
as
refugees
and
asylum
seeker
elders
and
combined
with
 rural
distances
and
isolation
it
often
means
that
there
may
be
no
factors
in
common
which
 cause
people
to
network
spontaneously.
 • Without
access
to
communities,
many
individuals
may
find
themselves
isolated
(this
is
also
true
 for
white
elders
living
in
remote
and
rural
locations)
and
service
providers
many
find
it
difficult
 to
include
their
needs
in
service
planning
without
BME
community
representative
structures.
In
 addition,
many
BME
elders
may
face
discrimination
(MIND) . 
 BME
elders
living
with
learning
difficulties
 Research
in
the
field
of
elders
with
learning
difficulties
is
very
limited
and
the
scoping
for
this
report
was
 unable
to
identify
any
specific
research
on
BME
elders
living
with
learning
difficulties
in
the
UK.
This
 clearly
is
an
area
that
requires
further
research.
However,
the
general
literature/
research
on
BME
 communities
living
with
learning
difficulties
may
also
apply
to
elders
(although
much
of
the
literature
 focuses
on
children
with
learning
difficulties)
and
there
is
a
limited
amount
of
research
specifically
on
 elders
with
learning
difficulties.
Certainly,
the
social
and
medical
factors
leading
to
the
increase
in
 longevity
for
the
general
population
have
significantly
increased
the
life‐span
of
people
with
learning
 difficulties
(Hogg
2000
and
1988).
While
research
suggests
that
people
with
severe
or
profound
 intellectual
disability,
multiple
disabilities
(e.g.
cerebral
palsy,
epilepsy,
severe
motor
handicap,
etc.),
 and
people
living
with
Down
syndrome
(Hayeman
et
al.

1989,
Eyman
et
al
1999)
still
have
a
reduced
life
 expectancy,

age‐specific
mortality
rates
among
people
with
mild
intellectual
disability
and
adults
within
 the
general
population
in
developed
countries
are
comparable
(Eymen
1987,
Zigman
1991)
 
 General
research
on
ethnicity
and
learning
difficulties
suggests
that
 
 • There
is
a

higher
prevalence
of

people
living
with
learning
difficulties
in
South
Asian
 communities
has
been
linked
to
high
levels
of
material
and
social
deprivation

and
is
up
to
three
 times
higher
than
in
other
communities
(Azmi
et
al
1996)
but
prevalence
within
other
minority
 ethnic
groups
is
not
as
well
documented
(Mir
et
al
2001).

  • 32. 
 
 
 • People
with
learning
difficulties
from
minority
ethnic
communities
experience
simultaneous
 disadvantage
in
relation
to
race,
impairment
and,
for
women,
gender.
Negative
stereotypes
and
 attitudes
held
by
service
professionals
contribute
to
the
disadvantage
they
face
(Mir
et
al
2001).
 
 • Studies
show
that
socio‐economic
disadvantage
and
financial
insecurity
may
add
significantly
to
 the
stress
that
carers
experience
(Atkin
and
Ahmad
2000a,
Chamba
et
al
1999).

 
 • An
understanding
of
independence
that
emphasises
individuality
may
run
counter
to
the
values
 of
collectivism
and
close
family
relationships
that
exist
in
some
communities.
The
role
of
family
 and
community
networks
needs
to
be
taken
into
account
when
planning
services
for
individuals
 (Mir
et
al
2001).
 
 • 
Empowerment
requires
information,
choice
and
involvement
in
decision‐making.
Support
 groups
can
increase
participation
and
control
for
minority
ethnic
people
with
learning
difficulties
 and
their
carers,
as
well
as
providing
emotional
support.
However,
such
groups
are
generally
 small‐scale
and
isolated
and
may
be
unable
to
 provide
progression
to
other
provision
if
 cultural
needs
are
not
recognised
in
other
 services
(Mir
et
al.
2001)
 
 • Service
providers
should
be
alert
to
the
fact
 that
people
who
have
difficulty
in
verbalising
 their
health
problems
(due
to
intellectual
 impairment,
communication
difficulties
and
/or
 language
barriers
will
need
access
to
 assessment
and
treatment
should
prevent
 secondary
conditions
(Nothard
1993).

 
 • There
is
evidence
of
a
failure
to
provide
 information
to
carers
about
services
in
 appropriate
languages
and
locations
and
this
 particularly
affects
those
carers
who
have
least
 access
to
provision
(Azmi
et
al
1997,
Steele
et
al.
2000
cited
in
Mir).
 
 • It
is
important
not
to
underestimate
the
ability
of
people
with
learning
difficulties
to
be
involved

 and
without
consultation,
services
will
remain
inappropriate
and
culturally
inappropriate
(Mir
et
 al
2001).
 
 Elders
with
learning
difficulties
 
 • The
ageing
process
in
people
with
learning
 disability
brings
changes
in
the
rates
of
physical
and
 mental
 health
problems
similar
to
those
found
in
people
without
pre‐existing
 developmental
 disabilities
(Holland
2000).
 
 • Research
by
Cooper
(1997)
with
elder
people
with
learning
difficulties
suggests
that
elderly
 people
with
learning
disabilities
have
a
greater
prevalence
of
 psychiatric
morbidity
than
younger
 

  • 33. 
 
 controls
(68.7
v.
47.9%).
Rates
for
 depression
and
anxiety
disorders
were
higher,
and
dementia
 was
common:
there
 were
equal
rates
for
schizophrenia/delusional
disorders,
autism
and
 behaviour
disorders
in
the
two
groups.
The
research
concluded
by
stating
that
there
was
higher
 psychiatric
 morbidity
among
elderly
(compared
with
younger)
people
with
learning
 disabilities
 and
this
has
not
previously
received
adequate
recognition.

 
 • Research
 has
been
to
investigate
the
extent
to
which
cognitive
decline
 and
dementia
occur.
 Many
studies
have
now
confirmed
that
age‐related
 cognitive
decline
and
dementia
affecting
 people
with
Down's
 syndrome
occur
30‐40
years
earlier
in
life
than
in
the
general
 population
 (Holland
2000).
 
 • Sensory
impairments
 characteristically
associated
with
later
life
are
found
to
a
 greater
extent
in
 those
people
with
learning
disabilities
aged
 over
65
(Janicki
et
al
1985
cited
in
Holland
2000).
 
 • Differences
in
the
structure
of
the
life
of
a
person
 with
learning
disabilities
can
often
lead
to
a
 failure
of
care
services
to
recognise
and
help
to
plan
for
old
age.
For
example,
many
people
with
 learning
disabilities
the
death
of
parent
is
associated
with
not
only
the
loss
of
a
family
member
 but
possibly
also
information
about
the
person
 themselves.

 
 • The
lack
of
evidence
concerning
the
mental
health
of
BME
elders
with
learning
difficulties
 suggests
that
there
is
a
pressing
need
for
further
research
and
the
incorporation
of
the
 perspectives
of
users
and
 carers
in
the
planning
process
is
an
essential
 pre‐requisite
to
 developing
effective
services
for
BME
elders
with
learning
difficulties.
 
 Part
three:
Improving
our
practice
and
developing
cultural
competence
 Cultural
competence
is
about
adapting
mental
health
services
to
meet
the
needs
of,
and
offer
an
 appropriate
service
to,
service
users
from
all
cultures
and
communities.
The
needs
of
diverse
 populations
and
individuals,
maybe
very
different
and
one
standard
model
is
unlikely
to
meet

the
needs
 of
everyone.
But
cultural
competence
is
more
than
simply
looking
to
provide
services
for
minority
 communities,
it
also
involves
practitioners
in
being
reflective
in
their
own
practice
and
acknowledging
 their
own
cultural
values/
bias
and
reflecting
on
how
this
might
inform
their
daily
interaction
with
 clients.
 Certainly,
developing

knowledge
of
diverse
communities
and
their
needs
can
help
towards
promoting
 equality
of
access
and
culturally
appropriate

services
and
there
are
a
number
of
approaches
that
help
to
 improve
cultural
competence.

These
include
 • Working
in
partnership:

BME
elder
community
groups
and
service
users
can
speak
for
their
 communities
as
well
as
about
them
and
represent
a
huge
pool
of
volunteer
expertise
that
would
 otherwise
be
wasted.
Consulting
and
working
in
partnership
with
BME
elders
local
community
 groups
is
important
in
to
both
sharing
cultural
knowledge
and
information
as
well
as
developing
 appropriate
mental
health
services.


However,
any
consultation
must
be
aware
that
community
 leaders
may
not
be
speaking
for
all
members
of
their
community
and
service
providers
should
 make
a
special
effort
to
communicate
with
more
excluded
members
(e.g
some
women,
people
 with
disabilities
such
as
people
living
with
deafness).

  • 34. 
 
 • Provide
appropriate
information
to
BME
elders:
It
is
important
that
organisations
impart
 information
to
BME
elders

regarding
the
services
they
offer.
The
information
needs
to
include
 the
details
of
the
goals
and
expectations
of
the
service
offered
by
the
organisation
as
well
as
 policy
statements
and
procedures.
This
also
needs
to
cover
issues
such
as
confidentiality
and
 information
should
be
provided
in
a
range
of
formats
and
be
available
in
the
appropriate
 language
for
the
service
user.
When
possible,
the
information
also
should
be
discussed
verbally
 and
any
questions
answered
prior
to
any
service
being
given.
This
enables
all
service
users
to
be
 aware
of
the
services
they
are
being
offered,
to
know
what
to
expect
and
helps
avoid
 misunderstanding.
Information
also
promotes
engagement
with
the
service
and
helps
to
build
 trust
in
the
services
being
offered
as
well
as
the
organisation
and
should
be
developed
in
 consultation
with
local
community
groups.
 • Provide
appropriate
training
and
information
for
practitioners:

Organisations
/
employers
need
 to
provide
staff
offering
mental
health
services
appropriate
and
regular
training,
supervision
and
 leadership
if
they
are
to
give
all
their
patients
culturally
sensitive
and
safe
care.

Training
and
 information
needs
to
include
information
from
research
and
practice
issues
relating
to
other
 cultures;
this
could
incorporate
cultural,
social,
psychological,
political,
economic,
religious
and
 historical
material
specific
to
ethnic
groups.
Perceptions
of
mental
health
differ
in
cultures
and
 there
maybe
issues
of
stigma
or
issues
relating
to
the
attribution
of
mental
illness
such
as,
 supernatural
or
religious
ideas.
The
value
of
medical
treatment
and
responses
to
health
issues
 and
treatment
may
also
vary.
 • Awareness
of
own
cultural
background:
Cultural
issues
will
influence
the
way
practitioners
offer,
 organise
and
deliver
services
and
it
is
helpful
for
practitioners
and
health
care
staff
to
be
 reflective
in
their
work
to
facilitate
cultural
competence.
This
involves
being
able
to
critically
 evaluate
our
own
strengths
and
weaknesses
in
working
with
people
from
different
cultures
and
 ethnic
backgrounds1 .

For
example,
Western
cultures
tend
to
focus
on
the
individual,
whereas
in
 some
cultures
the
healing
practices
are
centred
on
the
family
and
/
or
the
community.
Western
 cultures
also
tend
to
view
religious
beliefs
and
practices
as
private
and
separate
from
any
 health/
healing
/
treatment
being
offered.
In
many
cultures
their
is
a
strong
relationship
 between
health
and
spirituality
(
however,
the
role
of
spirituality
s
becoming
increasing
 recognised
as
playing
an
important
role
in
health
 • Maintaining
an
individualised
approach:
It
is
essential
that
the
services
should
maintain
a
client
 centred
and
an
individualised
approach,
it
should
not
be
assumed
that
because
an
individual
is
 from
a
particular
culture
or
ethnic
group
that
they
will
think
and
behave
in
a
particular
way,
 require
a
specific
service
or
hold
a
particular
belief.

Cultures
do
not
have
clearly
defined
 boundaries
but
are
multi
layered,
multi
faceted
and
influenced
by
a
range
of
different
factors.

 
 • Integration
across
the
services:
Cultural
competence
needs
to
be
integrated
in
each
stage
of
the
 service
offered,
for
example,
at
the
most
basic
level,
residential
care
needs
to
take
into
account,
 linguistic
and
spiritual
needs,
as
well
as
a
practical
issues
such
as
food,
accommodation
and
 gendered
space
as
well
as
issues
such
as
personal/
spiritual
hygiene
practices
and
family
contact
 needs.

 
 



























































  • 35. 
 
 • Promoting
a
culturally
diverse
staff
team:
It
is
important
that
organisations
establish
a
culturally
 diverse
staff
team
and
recruitment
initiatives
need
to
attract
individuals
from
all
parts
of
the
 local
community,
aiming
to
build
a
workforce
that
reflects
the
diversity
of
the
local
population.

 This
should
include
all
departments
of
staff,
from
receptionists
across
to
clinicians
across
to
 executive
managers.
Organisations
/
employers
need
to
offer
ongoing
education
and
training
for
 all
staff
–
administrative,
clinical,
support
and
managerial,
recruitment
of
staff
from,
and
 representative
of,
local
communities
is
the
most
effective
longer
term
strategy
to
build
cultural
 competence.
A
diverse
staff
team
will
also
have
cultural
needs
and
this
should
be
addressed
by
 the
organisation
in
order
to
meet
these
staff
needs.
For
example,
a
prayer
room
or
space
for
 meditation
maybe
required
or
religious
holidays
need
to
be
respected.

 
 • There
is
a
high
number
of
care
home
staff
without
English
as
first
language
and
this
may
result
 in
communication
problems.
(Communication
skills
are
a
requirement
of
the
Common
Induction
 Standards
which
all
staff
should
complete
(National
Audit
Office
2007)
 
 • Improving
communication:
To
develop
cultural
competence,
effective
and
clear
communication
 is
required
from
staff
at
all
stages
of
the
mental
health
care
process
to
ensure
that
BME
elders
 know
what
is
happening,
to
avoid
misunderstandings
and
inform
people
of
their
rights
and
 choices2 .
Many
clients
and
carers
will
need
access
to
trained
interpreters
as
well
as
access
to
 appropriate
language
materials.

However,
practitioners
need
to
recognise
that
interpretation
 and
linguistic
access
is
not
sufficient
as
the
sole
criterion
for
cultural
competence.

Good
 communication
is
especially
significant
when
care
staff
are
supporting
elder
people
who
are
 confused
and
interpreters
should
be
used
as
require
and
it
is
beneficial
to
use
the
same
 interpreter
as
this
promotes
continuity
for
the
elder.


 
 • Staff
need
to
be
able
to
recognise
the
importance
of
non‐verbal
cultural
influences
to
ensure
 good
communication
with
BME
elders.
This
includes
awareness
of
differences,
such
as
 expression,
gesticulation,
non
verbal
communication
as
well
as
nuances
in
speech
patterns
and
 communication
styles.
For
example,
many
cultures
do
not
shake
hands;
others
do
not
make
/
 maintain
eye
contact
during
conversations.


 Positive
Practice
 NIMHE
and
the
Sainsbury
Centre
for
Mental
Health
have
developed
The
Ten
Essential
Shared
 Capabilities
for
Mental
Health
Practice
 Working
in
Partnership.
Developing
and
maintaining
constructive
working
relationships
with
service
 users,
carers,
families,
colleagues,
lay
people
and
wider
community
networks.
Working
positively
with
 any
tensions
created
by
conflicts
of
interest
or
aspiration
that
may
arise
between
the
partners
in
care.
 Respecting
Diversity.
Working
in
partnership
with
service
users,
carers,
families
and
colleagues
to
 provide
care
and
interventions
that
not
only
make
a
positive
difference
but
also
do
so
in
ways
that
 respect
and
value
diversity
including
age,
race,
culture,
disability,
gender,
spirituality
and
sexuality.
 


























































 

  • 36. 
 
 Practicing
Ethically.
Recognising
the
rights
and
aspirations
of
service
users
and
their
families,
 acknowledging
power
differentials
and
minimising
them
whenever
possible.
providing
treatment
and
 care
that
is
accountable
to
service
users
and
carers
within
the
boundaries
prescribed
by
national
 (professional),
legal
and
local
codes
of
ethical
practice.
 Challenging
Inequality.
Addressing
the
causes
and
consequences
of
stigma,
discrimination,
social
 inequality
and
exclusion
on
service
users,
carers
and
mental
health
services.
Creating,
developing
or
 maintaining
valued
social
roles
for
people
in
the
communities
they
come
from.
 Promoting
Recovery.
Working
in
partnership
to
provide
care
and
treatment
that
enables
service
users
 and
carers
to
tackle
mental
health
problems
with
hope
and
optimism
and
to
work
towards
a
valued
 lifestyle
within
and
beyond
the
limits
of
any
mental
health
problem.
 Identifying
People’s
Needs
and
Strengths.
Working
in
partnership
to
gather
information
to
agree
health
 and
social
care
needs
in
the
context
of
the
preferred
lifestyle
and
aspirations
of
service
users
their
 families,
carers
and
friends.
 Providing
Service
User
Centred
Care.
Negotiating
achievable
and
meaningful
goals;
primarily
from
the
 perspective
of
service
users
and
their
families.
Influencing
and
seeking
the
means
to
achieve
these
goals
 and
clarifying
the
responsibilities
of
the
people
who
will
provide
any
help
that
is
needed,
including
 systematically
evaluating
outcomes
and
achievements.
 Making
a
Difference.
Facilitating
access
to
and
delivering
the
best
quality,
evidence‐based,
value
based
 health
and
social
care
interventions
to
meet
the
needs
and
aspirations
of
service
users
and
their
 familieand
carers.
 Promoting
Safety
and
Positive
Risk
Taking.
Empowering
the
person
to
decide
the
level
of
risk
they
are
 prepared
to
take
with
their
health
and
safety.
This
includes
working
with
the
tension
between
 promoting
safety
and
positive
risk
taking,
including
assessing
and
dealing
with
possible
risks
for
service
 users,
carers,
family
members,
and
the
wider
public.
 Personal
Development
and
Learning.
Keeping
up‐to‐date
with
changes
in
practice
and
participating
in
 life‐long
learning,
personal
and
professional
development
for
one’s
self
and
colleagues
through
 supervision,
appraisal
and
reflective
practice.
 
 
 



























































  • 37. 
 
 




























































































































































































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