This content was originally published on the MEDFASH website as an e-feature on 6 July 2016 and it is reproduced here with kind permission by MEDFASH.
Marion Wadibia is Chief Executive of NAZ, a London-based organisation providing sexual health promotion and HIV support services to Black, Asian and Minority Ethnic (BAME) communities. She joined NAZ in 2012, setting up its policy and research arm and extending its reach through initiatives like the Joyful Noise choir for people living with HIV and the NAZ OSCARS (nOSCARS) which celebrate the work of those championing better sexual health for minority communities in the UK. In this eFeatureMarion outlines four fundamental challenges which need to be addressed to improve the disproportionate sexual health inequalities experienced by black and minority ethnic groups. She calls for a more strategic approach delivered by and targeted at black and minority ethnic groups and proposes a new set of questions that may help move us forward at both policy and practice level.
I have often been asked ‘what are the key policy and practice issues relevant to minority ethnic groups?’ For me, this question incites a muttering of brief sentences or it stimulates an enlightened narrative which turns into many conversations. The simple version is, of course, that the key policy and practice issues relevant to minority ethnic groups are the same policy and practice issues as for the general population. The ultimate aim is to experience good sexual health for everyone. A key building block is increased involvement of minority groups in research, such as research studies exploring the effectiveness of pre-exposure prophylaxis (PrEP). Research has a direct influence on policy and practice and it is only by engaging black and minority groups that sexual health inequalities can be overcome. Thinking from leaders from these communities can help to realise this.
While there have been improvements along the way, worse sexual health outcomes among people from minority ethnic groups have been persistent for almost 20 years. This means that the statistics don’t just highlight the policy and practice issues, the statistics are the policy and practice issues we need to talk about. For example:
- Minority ethnic groups in the UK are experiencing a real public health issue - it’s called inequalities.
- 13% of the UK population are minority ethnic (1), yet they account for 45% of people accessing HIV-related care (2).
- 79% of women accessing HIV-related care in the UK are from minority ethnic groups (3).
- 58% of black Africans diagnosed with HIV in 2014 were diagnosed late, compared with 35% in the white population (4).
- Rates of gonorrhoea in England are four times higher among black ethnic groups compared with their white counterparts (5).
- Rates of chlamydia in England are three times higher among black ethnic groups compared with their white counterparts (6).
- In England and Wales, 48% of black women having abortions in 2014 had previously had an abortion compared with 37% of White women (7).
Of course, these headlines leave us with many more questions than they answer. This is why I prefer the extended version which inspires more conversations. This version takes both a retrospective and prospective approach; it more adequately sums up the ambition, vision, needs and sometimes complementary contradictions of people from minority ethnic groups and plainly states, “I do not have this all figured out, but I do know where we can begin to start the conversation.”
I think there are four fundamental challenges which need to be overcome in order to create a level playing field and begin to address ethnic sexual health inequalities:
1. Leadership -
a focused strategic approach as well as operational leadership and representation from people from minority ethnic groups.
Much has been done at an operational level to ensure targeted campaigns for people from minority ethnic groups. This has included positive imagery, extended language support services, and minority representation on CCGs and other committees. However, leadership is the missing key which can make the jump from operational output to strategic thinking. This must involve the people most affected being the ones to articulate the pace of change. Leadership should not be limited to a specific group of people but should be driven by a wide range of stakeholders. The economic and personal costs of citing the same or similar statistics in a further 10 or 20 years’ time would be the result of systemic failure and not the sole responsibility of a particular sub-group.
2. Language -
the use of terminology that reflects the heterogeneity of the ethnic groups it describes.
Although I have used the categories which I am about to critique, I believe our thinking around sexual health inequalities is limited by our tendency to put all ethnic minorities or people who share the same sexual orientation into one or two categories. I suspect this has evolved from the way data has been historically collected. The UK is world renowned for health and lifestyle surveys, cohort studies and disease surveillance systems, but if we want to maximise the utility of that data, we need to collect and present it in a way that is meaningful at the grass roots level because that is where in practice the majority of targeted sexual health campaigns are delivered. We also need a way to highlight the proportion of individuals that have overlapping social identities and therefore might experience different levels of risk.
3. Landscape –
a multi-disciplinary approach which draws on innovations from the community, social and corporate sectors. In this way, ‘clients’ should be viewed as consumers able to exercise their rights and choose where and how sexual health services are utilised.
In my opinion, in order to disentangle and eventually resolve the public health challenges that we currently face, we need to operationalise the thinking and contacts in disciplines outside of public health. These can include corporate, media, social media and fast moving consumer goods industries. Engaging in new and innovative collaborations necessitates a multi-disciplinary commitment to a longer term strategy that is led by, delivered by and targeted at members of minority ethnic groups.
4. Strategy -
a joined up strategy combining sexual and reproductive health, including HIV prevention, testing and care, which focuses on outcomes for minority ethnic groups over the next 10 years.
During my last four years at NAZ, I have sensed a growing frustration shared by clients and stakeholders about the poor sexual health outcomes experienced by minority ethnic groups. The appetite to come up with a definitive approach on how to move forward however sometimes seems lacking.
While action in the four areas described above moves us in the right direction, I believe it falls short of what is needed - a wellbeing outcome measure for people from all minority ethnic groups, not just Black Africans, which specifically targets their sexual health in a holistic sense. I am very clear on the sensitivities of such a targeted approach and appreciate that the greatest ‘own goal’ will be creating more stigma for the affected groups and making the journey to positive sexual health harder. Nevertheless, we need to juggle this against the data which points to an overwhelming disproportionality in sexual and reproductive health outcomes for people from black and minority ethnic groups.
Instead of asking ‘what are the key policy and practice issues relevant to black and minority ethnic groups?’ I would like to propose a new set of questions.
At a policy level - ‘What targeted outcome measure can we develop to provide a clear benchmark for minimum sexual health outcomes to be achieved for people from minority ethnic groups?’
At a practice level -‘How can we sensitively cultivate a holistic approach which targets a heterogeneous market of people living in the UK who are in need of sexual health services?’
Ultimately - ‘How can we continue having conversations that feed directly into innovative and collaborative work which is led by, delivered by and targeted at people from minority ethnic groups using the experience and resources of the sector?
(1) Office for National Statistics (2011) Census
(2) Public Health England(2014) National HIV surveillance data tables
(3) Public Health England(2014) National HIV surveillance data tables
(4) Public Health England (2014) Sexually transmitted infections (STIs): annual data tables
(5) Public Health England (2014) Sexually transmitted infections (STIs): annual data tables
(6) Public Health England (2014) Sexually transmitted infections (STIs): annual data tables
(7) Department of Health (2015) Abortion statistics, England and Wales