Sara is 15 and pregnant. The father of her child left to go back to his home country early in the pregnancy. Sara is now 28 weeks pregnant and still at school. She is struggling because of her peers' attitudes toward her and her home circumstances. She lives with four siblings in a three-bedroom semi-detached house in a deprived part of the city. Her parents support her, but money is tight. Meeting her needs is a collaborative effort between midwife, GP, social worker, learning support staff and school nurse. Sara's reading age is 6 and has only just been recognised. She becomes more and more disillusioned with school. Her parents decide to take her back to her home country and outcomes remain uncertain. Sara is part of a minority group whose life outcomes are poor due to their circumstances. She is a victim of profound inequalities which are likely to affect not only her but also her child. Improving her care is the subject of this article.
Health inequalities abound in the UK and are getting worse (Marmot et al, 2020). While the focus has been on the disparity in life expectancy between rich and poor, other inequalities tend to get neglected. For many ethnically diverse children, the future can be uncertain. A susbtantial number of these children live in deprived circumstances and child poverty is on the increase (Raleigh, 2023). Outcomes can be seriously affected by a lack of attention to their individual needs. This article is about the complexity of these needs and how school nurses can address them.
‘… at a caseload level school nurses can be pivotal in getting to know their school communities, the nuances within them and tailoring interventions to encompass diversity.’
Ethnic minority groups tend to be lumped together, either identified as doing well or badly. As specialist community public health practitioners, we are tasked with looking at the evidence and making sense of it. Data from the census is presented from the majority perspective. An estimated 81.7% of the population in England and Wales is White (Census, 2021). This means that 18.3% of ‘usual residents’ are from other ethnic backgrounds. They cannot be classed as a homogenous group due to the complexity of ethnicity. It is multidimensional, subjective and individual (Raleigh, 2023). The task of identifying individual population needs and addressing them is enormous. However, at a caseload level school nurses can be pivotal in getting to know their school communities, the nuances within them and tailoring interventions to encompass diversity.
Infant and maternal outcomes
A legacy of ill health and poor health outcomes affects the life chances of ethnically diverse children and young people in minority groups. It begins at birth. The rate of women dying in the UK in 2018–20 during pregnancy or up to 6 weeks after the end of their pregnancy was 3.7 times higher in Black groups than their White equivalents, and 1.7 times higher in South Asian groups (Raleigh, 2023). Babies from Pakistani and Black populations have higher stillbirth and infant mortality rates than the White population (Raleigh, 2023). According to the MBBRACE (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries) report, in 2021 perinatal mortality (i.e. deaths of babies from 20 weeks of gestational age and stillbirths) was 60% higher in Asian babies and 40% higher in babies of Black ethnicity (Draper et al, 2021). Poverty is a major factor in these profound health inequalities. This is seen as a construct of racism which is a key determinant in people's status and power (Esan et al, 2022). Racism is illegal and school nurses have a duty to consider racism as a factor when addressing health inequalities (Equality Act, 2010).
Interventions to improve maternal and infant outcomes are limited (Esan et al, 2022). They include strategies which are embedded in public health practice such as midwifery led continuity of care (Homer et al, 2017), use of link workers (Smith et al, 2004) and therapeutic mother and infant groups (O'Shaughnessy, 2012). Use of culturally adapted cognitive behavioural therapy (CBT) for South Asian mothers linked to the NICE Guidelines on Whooley questions demonstrated the potential to reduce ethnic health inequalities (Khan et al, 2019). However, this was a small study which requires wider dissemination. All these interventions show aspects of early intervention and prevention but seem a drop in the ocean compared to the extent of need.
Physical health
Early childhood experiences shape adult health outcomes. Children from some groups may be more likely to have parents or carers who suffer ill health. Cardiovascular disease is high in South Asian groups compared with the White group or national average (Raleigh, 2023). More people die from heart disease and develop it at a younger age although recent evidence suggests these outcomes are improving (Raleigh, 2023). The causes of this increased risk are multifactorial and include poverty and changes to lifestyle following migration. Black groups are less likely to have heart disease than the majority of the population but more likely to have strokes. Hypertension and obesity are higher in these groups. Access to treatment varies in these populations with less access among Black groups.
The incidence of diabetes is higher in South Asian and Black groups than in the White population and people in these groups develop the condition at a younger age. The risk of developing diabetes is up to six times higher in South Asian groups than in White groups and South Asian groups have higher mortality from diabetes. About 400 000 people of South Asian ethnicity in the UK have diabetes, one-fifth of the UK diabetes population (Raleigh, 2023).
These patterns of morbidity affect children and young people in these communities. Childhood overweight and obesity rates are higher among children in Bangladeshi and Pakistani groups (NHS Digital, 2022). South Asian children have lower levels of physical fitness than children in White European and Black groups, and physical activity levels are lower among children from ethnically diverse groups compared with White groups (Nightingale et al, 2016; Love et al, 2019). This suggests a need for targeted health promotion interventions, particularly in schools to address these preventable risk factors.
School exclusion
School exclusions present another health inequality. Although Bangladeshi, Chinese and Indian children are around half as likely to be excluded as White British children, children from other ethnic groups are more likely to experience exclusion. This particularly affects Black Caribbean, Gypsy, Roma and Traveller children, and pupils of a mixed background (Timpson, 2019). Education is a major factor in tackling disadvantage and school exclusion is likely to seriously affect life outcomes.
Mental health
Serious disparities also exist in rates of mental health issues among ethnic groups. Black people are 8 times more likely to undergo community treatment orders than White people, and 4 times more likely to be detained. Figures from the Race Disparity Unit show there were 306.8 detentions per 100 000 for Black people compared with 72.9 per 100 000 White people (UK Government, 2020). A meta-analysis conducted by Halvorsrud et al (2019) of 28 studies concluded there were significantly higher risks of diagnosed schizophrenia among some ethnic groups, and that they were most pronounced among Black groups (Halvorsrud et, 2019).
Black and Asian people with mental health needs are less likely to be receiving treatment for mental health issues. For example, Black people were less likely to be taking antidepressants than their White counterparts (Cooper et al, 2012). Black groups and South Asian groups were less likely to have contacted a GP about their mental health within the last year. Black people were just 1.3 times more likely than White British people to be receiving mental health care, with the Black African group actually less likely (0.9 times) (UK Government, 2020). ‘We're also reluctant to admit mental health issues, because we lack confidence in the system, which can lead to incarceration instead of mental healthcare, or being classed and treated on the basis of a stereotype’ (Sewell, 2021: 224).
These attitudes to mental health services are passed down through the generations. Ethnically diverse children and young people in minority groups experience worse mental health than White children. Using data from the UK Millennium Cohort Study (MCS) 7-year-old Pakistani, Bangladeshi, and Black Caribbean children experienced significantly more internalizing problems than White children (Zilanawala et al, 2015). Pakistani and Black Caribbean children also had more externalising problems than White children (Zilanawala et al., 2015). This externalizing disadvantage persists into adolescence for Black Caribbean children, but not for Pakistani children and is not reflected in uptake of mental health services. The perceived lack of culturally sensitive services and mainly White British practitioners could be contributing to reluctance to seek support (Bains and Gutman, 2021). Although different ethnic backgrounds are well represented among the total nurse and health visitor workforce (67.4% White, 14.5% Asian and 10.7% Black (Gov. UK, 2023) there is no official breakdown of the SCPHN workforce by ethnicity. However, my personal observation as a course leader of the SCPHN programme is that students attending this course seem overwhelmingly White and the community workforce is not representative of the diversity of many of the communities it serves. This is a concern but the first step in addressing this perceived discrepancy would be to conduct a survey of the ethnicity of the SCPHN workforce.
Adverse childhood experiences
There needs to be a sea change in the way in which we view the health of ethnically diverse populations in order to improve outcomes. Trauma-informed practice offers a new approach to viewing people's life experiences which can be the catalyst for the prevention of harm. A 2014 study on Adverse Childhood Experiences (ACEs) found that 47% of UK adults had experienced at least one ACE, with almost 10% of the population having four or more ACEs (Bellis et al, 2014). Trauma in childhood affects a child's brain and development (van der Kolk, 2014). Adult physical and mental health are also affected with increased incidence of heart disease, depression and risky behaviours such as anti-social behaviour (Sowder et al, 2018). ACEs are associated with poverty and many children from ethnically diverse communities live in areas of disadvantage. Recognition of these factors could result in more empowering, strengths-based approaches to improving outcomes.
Intergenerational trauma has affected Black Caribbean populations who are descended from the Windrush generation (University College London, 2022). Being able to tell their story and appreciation of this history could help in strengthening resilience and resolve to overcome challenges. Trauma informed approaches have been shown to tackle social injustice among the Native populations in America (Robinson-Zanartu et al, 2023). This journey could be supported by school nurses incorporating cultural awareness in every aspect of care planning.
Conclusions
For Sara, interventions by school nurses to address the needs of ethnically diverse communities may have made the difference to her outcomes. Recognition of her identity and potential within school could have meant the life she wanted for her and her child was within reach.