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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





























































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
.







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)





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.


































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.








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





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.











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















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).





• 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)








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'





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.








• 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





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)





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





• 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







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)




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).







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





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





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).









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)









• 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).







• 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)









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.








• 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







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


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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