Welcome to the first issue of Diversity in Health and Care in 2011. This is the beginning of our eighth volume, and we are pleased to inform our readers that the journal is continuing to develop as planned. Nearly half of our papers now come from countries outside the UK, demonstrating that our journal is considered relevant to people in different societies across the world. From our perspective, this is most encouraging because we have tried hard to promote the view that notions of diversity can, and do, encompass a very wide range. Any situation in which individuals are regarded as ‘different’ by the majority is one in which prejudice and discrimination are likely to arise. Examining perceived differences and finding practical, workable solutions to rectifying the many inequalities that are so often identified as a result are essential steps towards equity and fairness for all. To this end we welcome papers which address any or all of the following topics:
• health and social care in relation to race or racism and racialised communities, culture and ethnicity, sexual orientation, gender, migrants, carers, disabilities (including physical, communication and learning), religion and spirituality, age and agerelated inequalities, and other underserved, marginalised or stigmatised populations
• consideration of specific health states and care issues as they relate to the populations identified above
• the equitable provision of health, care and services for members of diverse social groups, health and care economics, and changes in and management of services and staffing issues.
Papers may report on qualitative or quantitative research, put forward arguments for debate, or discuss educational and training matters. We particularly encouragemulti-professional perspectives and a focus on the views of service users and carers. Papers exploring the international dimensions of diversity across and within cultures are also most welcome. Authors are encouraged to critically examine concepts and theories in the field, and to develop new paradigms for practice.
Papers may take the form of:
• research papers that address any aspect of diversity, including evaluative studies and methodological or theoretical debates
• practice papers that provide examples of culturally competent practice, or which address the practicalities and policy, economic or managerial aspects of delivering services to members of diverse groups
• education papers that are concerned with improving or evaluating the education or training of health and care professionals in order to address diversity concerns, whether in initial training or as part of continuing professional development
• debate papers that address key issues in diversity or that focus on under-researched topics
• feature items such as the Did You See? section, the Practitioner’s Blog and Knowledgeshare, which includes reviews of books, meetings, websites, videos and other resources, and papers about specific initiatives to improve practice.
We also wish to encourage our readers to consider the topics that we have outlined here within the context of public health, because this adds weight to the achievement of social justice through protecting and improving health and health-related services.
In the UK, the new approach to public health is to be ‘owned by communities and shaped by their needs ... have ring-fenced funding ... [be] professionally led, focused on evidence, efficient and effective’ and provide ‘protection against current and future threats to health’ (Department of Health, 2010, p. 6). Directors of public health will work in partnership across the state, voluntary and independent sectors. A new service to protect health and respond to emergencies will be phased in during the coming year. Time will, of course, tell whether or not this is all merely political rhetoric, but it does appear to be in keeping with international trends. For example, the World Health Organization regards public health practice as essential in providing a systematic approach to the eradication of preventable suffering and death. At least 13 million people die each year as a result of diseases and illnesses caused by environmental factors such as exposure to hazardous chemicals, contaminated water supplies, poor sanitation and air pollution (www. who.int). As we have noted elsewhere, some of these problems can be resolved at very low cost (e.g. through the provision of mosquito nets to prevent malaria, or stoves that carry smoke away from the person who is cooking) (McGee and Johnson, 2010). What is needed is the will to make such changes happen.
Women and their children bear the brunt of many health inequalities (see, for example, Longinotto and Ayisi, 2005; World Health Organization, 2008; McGee, 2009;UnitedNations Children’s Fund, 2009). Throughout the world women are considered inferior to men in every aspect of life and have to live within restrictions that men would never tolerate. The title of this editorial is taken from an observation made by a hospital cleaner as the female editor of this journal lay in bed recovering from a miscarriage. Access to education that might help to improve female lives is increasing, but at a global level the numbers of girls in school still lags behind the number of boys. Lack of education, as well as early marriage and childbearing trap women in poverty and poorly paid agricultural work. Those who are able to find employment in other sectors are usually paid less than men. It therefore comes as no surprise that the third Millennium Development Goal is to ‘eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education, no later than 2015’ (www.un.org/milleniumgoals).
In our guest editorial, Elaine Denny expands on these gender issues, highlighting the continuing unacceptably high and preventable rate of maternal deaths.Manywomenhave little power tomake decisions about health or to access services without recourse, first, to male relatives to obtain their permission. The articles in this issue take up some of the points that Elaine Denny raises, in both research and debate. Thus, the issue concludes with two debate papers that consider the implications of scientific progress for women and reproductive health in an international context. LeezaOsipenko andAla Szczepura focus on the tests available to determine the sex of an unborn child, and their potential for abuse. Once the sole preserve of hospitals and their laboratories, some of these tests can now be accessed via the Internet from companies that market directly to the public. These tests are simple and easy to use, and the risks associated with them are nowhere near as high as those associated with amniocentesis or any other invasive procedures. Whilst some parents desparately need to find out the gender of their baby in order to prevent the suffering associated with some hereditary conditions, others simply do not want to have girl babies. This speaks volumes about the status of the women in these couples, and it is anyone’s guess who either parent imagines will bear the children of their precious sons in the future. As Osipenko and Szczepura point out, gross discrepancies between the number of boys and girls are already apparent in certain societies, causing a raft of other social problems, and this situation could well get worse.
Secondly in our Debate section, the ethics involved in assisted conception are the subject of Sigal Gooldin’s paper. Our attention is drawn away from the right to avoid girl babies and children one does not want, to a perceived right to have as many children as onewishes, irrespective, it seems, of any ability to care for them properly. In Israel, having children is regarded as an essential part of life. In this context, women who do not wish to become pregnant or who cannot do so are less valuable and lessworthy than their peerswho have one baby after another. Demonstrating fertility is culturally important in many societies (Culley et al, 2007, 2009; Denny et al, 2010), and there is a tendency to regard this pro-natalism positively, even in developed societies where women tend to have more choices (‘The XX just love children, they’re wonderful’), but being pro-natal is not the same as being pro-child. In India alone, an estimated 11 million babies are abandoned each year because their mothers cannot feed them. Schemes for rescuing these unwanted children can only scratch at the surface of the problem(Nelson, 2009).
We begin, however, with new insights from research, and in the first Research paper, Iolo Madoc- Jones and Karen Roscoe consider an approach to combat domestic violence. Even in so-called developed and liberal societies it is still acceptable to engage in violence towards women because they are wearing the ‘wrong’ clothes, answer back, iron the wrong shirt, or are simply there and ‘ask for it’ (Lee, 2004; Walker, 2011). Whatever they do or do not do, women end up as the punchbags for the rest of the human race. Domestic violence does not have to be physical. The constant fear of what might happen and the unpredictability of their partner’s behaviour render women powerless. Shame, the feeling that it is somehow their fault, and the difficulties involved in accessing help mean that women become isolated. This is of course what many women’s partners want. If no one knows, as Madoc Jones and Roscoe report, ‘To be honest there’s no point reporting stuff because, so yeah they come and speak with him and if you’re lucky they take him away, but two, three hours later he’s back, he’s told them some sob story and that he’s sobered up so right, bail.’ Introducing another person, who is there for the woman, clearly helps to open up these claustrophobic domestic situations. Being there for the woman from themoment that a crisis arises clearly enables her to reclaimher dignity and begin to change her life.
Monir Mazaheri et al introduce another perspective, that of caring for elderly relatives. The majority of carers tend to be women and, although this research shows that some women find this a fulfilling activity that they are happy to perform, the ensuing costs can be high. The realisation that former relationships have gone for good, and the discovery that a partner or parent no longer knows who you are, can be very hard to cope with.
In our practice paper we return to the subject of pregnancy as Yana Richens and Debbie Smith take us through some of the issues that may arise when researching pregnant women who are deemed to be ‘at risk.’ In doing so they reveal how challenging it can be to locate some women, let alone recruit them into a research project. This paper highlights the need for flexible research strategies that are based on a realistic understanding of women’s circumstances, particularly for those who live in marginalised communities.
Finally, we present our regular features. Did You See? discusses an article about teenage mothers and the psychological processes that may influence their behaviour. Mothers are also the subject of our Practitioner’s Blog, in which Mary Dawood and KimBains reflect on a situation in which a mother tried to find help for her children. Finally, our Knowledgeshare section includes links to reports such as guidance from the Royal College of Obstetricians and Gynaecologists on caring for pregnant women who have recently arrived in the UK, or those who have little or no knowledge of the English language, and a ‘landmark’ review by the Equality and Human Rights Commission which compiles the available evidence on equalities in England, Scotland and Wales against 40 indicators agreed by that body. Readers should contact Nisha Dogra ([email protected]) if they wish to contribute to Did You See?, Mary Dawood ([email protected] imperial.nhs.uk) if they wish to write a Practitioner’s Blog, or Lorraine Culley ([email protected]) if they wish to contribute to Knowledgeshare.