Foundation module

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Section One: Cultural diversity

Authors: Elizabeth Anionwu, Dave Sookhoo, Jim Adams

Introduction

We are living in an era of rapid social and technological change. These changes are taking place at different rates across the globe. The pace of change in some countries has accelerated with economic growth and development. As for the advances in science and technology, these are making it possible for us to live our lives in ways we want to, they influence where we live, and affect everything that is associated with living in urban as well as rural environments.

In Britain today, we live side by side with people from different ethnic, cultural, social, and religious backgrounds. We are becoming increasingly aware of the fact that we live in a multi-ethnic and multi-cultural society. Depending upon where we live, work, or which services we access in the community, we have probably seen changes to our communities over a period of time. We are increasingly aware of the differences and similarities among ourselves and others, in relation to; age, gender, ethnicity, culture, religious beliefs and practices, social and economic status, educational and occupational backgrounds, disability, sexual orientation, health, and the impact of illness.

In everyday life, we may find our long held ideas about ourselves as well as others challenged when we encounter people from diverse cultural backgrounds. Our levels of understanding about other cultures may vary. In some instances our observations may be superficial and our knowledge less developed, based on media representations or limited encounters with people from different ethnic and cultural backgrounds. In other cases, it may be that through personal and professional contact we have been able to establish over time an understanding of others from diverse backgrounds. In modern urban environments, it is likely that cultural diversity is an obvious reality for all of us, yet we must acknowledge our level of awareness and sensitivity, or lack of it, in order to demonstrate our respect for others.

Valuing diversity is an essential aspect of living and working in a multicultural society. As professionals in health and social care, we need to become aware of the cultural influences on health, health behaviours, and illness and recovery, and translate that awareness into culturally congruent care practice. We need to develop the knowledge, skills and attitudinal responses to meet the health needs of the people in the communities we serve with respect, sensitivity and the competence required.

This section focuses on issues relating to cultural diversity, including the demography and the breakdown of populations by ethnicity, social and cultural factors that influence everyday life of people from diverse backgrounds.

Many words used in everyday life are social constructs; put another way, they are representations of the social reality, as we perceive it, and given expression through the use of language. Language becomes critical to the ways in which we use words in their sociological and political context. The meanings and usage of terms defined in this section have been contested, some more than others. The critical analysis of terms used can be pursued in detail in the relevant referred source.

Multi-Ethnic Britain

Introduction

Given the opportunity to describe themselves in terms of their ancestry, place of birth, history of migration, religion, and how long they have lived in the host culture, people often refer to themselves from perspectives that reveal the complexities of their identities.

The pattern of migration and the reasons for migration determine how people perceive themselves in relation to the new environment, and their experiences within the prevailing culture. As time moves on, children of migrants who are born in the adopted country develop their own identities with respect to the country they live in. Their values, beliefs, experiences and aspirations are in part shaped by the prevailing culture. However, in many instances, migrant adults form 'communities' that reflect some of the collective values, beliefs and lifestyles of the culture they left behind. Communities emerge, centred on the ethnic and cultural identities that people hold. Therefore, children of immigrants are often in contact with different cultural values. Thus, as the Parekh report notes, there are many 'ethnicities' and many 'communities' in Britain today (The Runneymede Trust, 2000). Children born to parents who are from mixed ethnic and cultural backgrounds further highlight the accelerated transitions that ethnic and cultural identities have undergone.

In everyday conversation and the media, one may hear of the 'Asian community' or the 'African-Caribbean community'. These terms are used as though the 'community' being mentioned is homogeneous, whereas in actual fact they hide the diversity with the said communities. Therefore, the term 'Asian community' is quite misleading. As with other communities, the diversity within the 'Asian community' or the 'African-Caribbean', the 'white', Irish, Jewish, African, Gypsy /Traveller, Somali (and many more communities) gets forgotten or not explored further. The 'white' group has within it people as different in their origins and ethnic identities as are those grouped together under the previously stated categories such as the 'Asian community'. Thus, the 'white' group may not acknowledge people who in terms of skin colour may identify themselves as 'white' but whose origins are in the Mediterranean, such as Greece and Cyprus, or eastern Europe, such as Hungary and Yugoslavia. It is more helpful to identify the diversities within these communities since that would reflect the true nature of the diversity within and between communities.

The Parekh Report (The Runnymede Trust, 2000) has considered the transitions that ethnic groups undergo and has acknowledged that there are communities within what has been previously considered homogeneous groups. The use of the term 'community of communities' in the Parekh Report seems to convey the essence of diversity within and between ethnic groups, and the representation of each ethnic group as a community.

Modood and colleagues (1997) suggest that generational shifts in identity have been observed, for example, between the migrant generation and the second generation. They go on to say that 'minority identities are continually changing and reinventing themselves through fusing of majority cultures' (p.338). Identities are potentially less stable.

Culture

Historically, the word culture has been used to describe many aspects of social life.

As a result, the label 'culture' has been attached to many expressions of social life, food, arts, clothing, music, and practices. Culture has also been used to distinguish social groups in terms of language, religious beliefs, education, and other factors. Hofstede (1984, p.21) has suggested that that culture can be defined as 'the interactive aggregate of common characteristics that influence a human group's responses to its environment'. This definition makes a clear association between humans and their environment, established as an important interactive relationship, each affecting the other.

Purnell and Paulanka (1998, p.2) have defined culture as 'the totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, lifeways, and all other products of human work and thought characteristics of a population of people that guide their worldview and decision making.' This definition captures the essence of culture. The transmission is from people to people, and is intergenerational.

Elsewhere, Giger & Davidhizar (1999) define culture as 'a patterned behavioral response that develops over time as a result of imprinting the mind through social and religious structures and intellectual and artistic manifestations' (p3). This definition suggests the action or behavioural orientation of cultural influences. Building on this definition, they advance explanations about culture. Culture is shaped and in turn acts as a means of shaping our thinking and doing.

Race

The term 'race' is no longer used widely in the human and health sciences. It originated in relation to assumed differences on biological grounds with members of a particular racial group sharing certain distinguishing physical characteristics such as bone structure and skin colour (Giger & Davidhizar, 1999). However, as more has become known about biological variations through population and genetics studies, and findings that show that there is little genetic difference between so-called racial groups, the term has been discredited. 'Race, is now widely acknowledged, as a social and political construct, not a biological or genetic fact. It cannot be used scientifically to account for the wide range of differences among peoples. There is more genetic variation within any so-called race than there is between 'races'' (The Runnymede Trust, 2000, p.63).

The term 'race' has no biological consequences (Senior & Bhopal, 1994). Although of no scientific or biological consequence, the term still has negative political and psychological impact. In this resource, the word 'race' is used only to illustrate other concepts by its social and political associations, for example 'racial groups', 'racism', 'race relations' and discrimination.

Diversity

Diversity is a term used to describe and explain difference. Diversity results from differences in gender, ethnic or national origin, religion, age, physical or mental capability, marital status, sexual preference, social background, organisational role and many more other factors which cause people to have different perspectives on the same set of facts or issues (Kandola and Fullerton, 1998).

In describing these differences, sometimes the most obvious and immediately observable features are what we commonly identify and relate to. We are socialised in the process of making these observations as part of our ability to make sense of the world around us. We may note, consciously or unconsciously, how the person looks, whether the person looks young or old, what the person is wearing, how the person talks, and so on. Our observations help us to build on our previous experiences and knowledge.

We also assign specific and general meanings to what we observe, sometimes taking for granted what we observe, and at other times consciously interpreting what we observe in order to clarify our understanding and make subtle adjustments to our thoughts, feeling and actions. We need to be careful about our assumptions, and risks of stereotyping or labelling others.

What are immediately noticeable are personal characteristics such as skin colour, height, weight, gender, and age, any physical disability. The language the person speaks, his/her dietary preferences, religious affiliation, sexual orientation and any intellectual impairment are not necessarily immediately noticeable. Communication with the person may assist in informing about the person in a holistic way. Our understanding of the issues about diversity and the person can only then begin to have any substantive meaning.

However, when considering people from different backgrounds, we should also consider what we have in common, that is those things that we share as human beings. The things that we have in common are known as universals, hence the universality of some values, beliefs, and behaviours that are common across gender, ethnicity and cultures. Across the many social, economic, political and cultural divides, people have far more commonalities than differences.

Valuing diversity in health care incorporates 'acknowledging an individual's culture in its broadest sense, for example a patient's ethnicity, education, socio-economic background, religion, prior health experiences and values' (Kai et al., 1999). The individual level is emphasised in order to prevent stereotyping and prejudice.

Cultural Diversity

Cultural diversity encompasses issues of perceived and real differences with respect to age, gender, ethnicity, disability, religion, lifestyles, family and kinship, dietary preferences, traditional dress, language or dialects spoken, sexual orientation, educational and occupational status, and other factors (Purnell & Paulanka, 1998). In valuing diversity, the awareness of diversity, an understanding of values, beliefs, behaviours and orientations are essential.

Ethnic groups may express differences in language, food preferences, religious beliefs and practices. When caring for people from different cultural background it is important to assess their needs and meet these in a culturally congruent way.

Multiculturalism refers to a plural society where diversity is valued. It advances the desirability of ethnic pluralism, where ethnic or cultural groups can coexist peacefully (Haralambos & Holborn, 1996). Thus the recognition and valuing of diversity is encouraged. Multiculturalism has been used as a tool for policy formulation in many public sectors, particularly in education (Yuval-Davis, 1992). However, multiculturalism has been criticised for its limitations in advancing more than just a superficial understanding of diversity, less an acceptance. As Donald and Rattansi have argued 'its drawback was that a multicultural celebration of diversity tended to reproduce the 'saris, samosas and steel-bands syndrome. That is, by focusing on the superficial manifestations of culture, multiculturalism failed to address the continuing hierarchies of power and legitimacy that existed among different centres of cultural authority' (Donald and Rattansi, 1992, p.2). By emphasising differences, and attributing to cultures the main differences, multiculturalism as observed in the context of Britain and 'English culture' failed to address the uniqueness of the cultures and their position in the relation to assimilation and integration. It did not address the underlying problems of inequalities and power.

Parekh (1997) has argued that neither assimilation nor integration is the answer to the question of the place of minority ethnic groups in society. 'Assimilation refers to total absorption into the wider society's culture, and the concomitant surrender of the immigrant's cultural identity. Contrary to what its advocates have argued, assimilation has nothing to do with identification. The immigrant does not have to become like the rest in order to develop a common sense of belonging with them. Indeed, since assimilation demands a culturally unacceptable membership fee, it provokes resentment, a sense of discrimination and even persecution, and hinders identification. Assimilation is also an incoherent notion, for no society, especially not a liberal one, has a unified cultural structure into which the immigrants can be required to assimilate themselves' (Parekh, 1997, p.ix).

In a multicultural society, integration has been thought of as one of the many ways of dealing with cultural diversity. Integration occurs where there is an interest in maintaining the original culture and in interactions with others. Parekh has pointed out that 'integration is a social concept…defined differently in different societies, and by different groups in Britain, it minimally implies that immigrants should not live in isolated and self-contained communities and cut themselves off from the common life of the wider society, as also that they should acquire the required degree of conceptual competence to find their way around in the society at large' (Parekh1997, ix). Parekh has suggested that immigrants choose to integrate at some levels of society and not others.

Societies maintain and reconcile cohesion, equality and difference through mechanisms of government, and the following five models have been considered (The Runneymede Trust, 2000, p.42).

Procedural - in such a case the state adopts a culturally neutral stance. It does not interfere or intervene, allowing individuals and communities to negotiate freely with each other, and as they wish within certain agreed basic procedures by they have to abide. This is thought of a 'proceduralist view of unity and diversity'.
Nationalist - the state actively promotes a single national culture to which each citizen is expected to subscribe. Those who do not or cannot assimilate are treated as second-class citizens. This model represents a nationalist view.
Liberal - this view is characterised by a 'common political culture' with 'a unified and cohesive political system in the public sphere', and 'substantial tolerance of diversity in people's private lives, and in the internal affairs of distinct communities'. This model illustrates a liberal view.
Plural - this model rejects the distinction between private and public spheres, placing more emphasis on recognition of diversity. It is characterised by unity and diversity in public life and private lives, by the notion of the protection of the rights and freedoms of individuals, and there is visible interdependence and overlap between and within communities. This pluralist view characterises the multicultural society. It represents what has been termed as 'the community of communities' in this report.
Separatist - in this model the state allows and expects each community to remain separate, without any overlap or interdependence, in a kind of federation. Each community has responsibilities for organisation and regulation of their own affairs, with the state having 'no moral status of its own, but simply has to protect, maintain and nurture its various constituent communities, and the distinction between them' (p. 44).

It has been suggested that the five models are not mutually exclusive and that they can be found locally in modern Britain. The emphasis on unity, diversity, and culture varies in each model.

A multicultural society should be based on equal citizenship (Parekh, 1997, p. ix), and five areas have been identified for consideration, and commitment for change:

elimination of discrimination
equality of opportunity
equal respect
acceptance of immigrants as a legitimate and valued part of society
the opportunity to preserve and transmit their cultural identities including their languages, cultures, religions, histories and ethnic affiliations.

Furthermore, multiculturalism should not only aspire to develop shared values but also recognise differences, with an aim to embed these in the vision of a human rights culture (The Runnymede Trust, 2000). In its alternative vision of Britain, this report places much emphasis on the idea of 'a community of communities' and presents a set of aspirations for Britain (The Runnymede Trust, 2000, p.3).

Cultural identity is a subjective interpretation of the individual in relation to the context and is experienced at different levels across situations. Experiences within the culture are important in shaping one's cultural identity. Cultural identity in relation to poverty, diseases and lifestyles may not be derived from ethnicity.

Universality

Although there is such diversity among human groups, the diversity is not infinite. Diversity is not unlimited, and the interactions between nature and culture means that 'human groups, no matter how diverse, comprise a common humanity constituted by universal biological and social characteristics' (Baker, 1997, p4). The transcultural models of nursing all recognise that diversity and universality are not mutually exclusive, that similarities and differences among human groups exist side by side.

Ethnicity

Ethnicity is a common term used in health and related sciences and most definitions include references to place of origin, or ancestry, skin colour, cultural heritage, religion, and language. Ethnicity denotes a sense of kinship, group solidarity, and a common culture. Mackintosh et al., (1998, p.7) define ethnicity as 'the group a person belongs to as a result of certain shared characteristics including ancestral and geographical origins, social and cultural traditions, religion and languages'. We all belong to ethnic groups even though the term 'ethnic' is often incorrectly used in a shorthand way to only refer to individuals from black and minority backgrounds. Individuals may perceive themselves as belonging to particular ethnic groups, and identify themselves with people with whom they feel they share a common sense of identity. Thus, there are objective and subjective facets to ethnicity. The objective facet includes factual and observable characteristics such as ancestry, place of birth, cultural factors, religion, and language - these can be used as objective indicators to examine the concept of ethnicity. The subjective element is important to the individual's perception and identification of his/her ethnicity, and the group that he/she belongs to. In this instance, the individual may assign himself/herself an ethnic identity, an ethnic group affiliation. However, such assignment is a matter of choice and preference, and individuals may equally choose not to state their ethnicity. Ethnic identity is part of cultural identity, it is an interpretation by the individual, and is subjective. In addition, as Culley (2000, p. 133) has explained, 'ethnic identity is overlaid with gender, age, socio-economic and professional identities, each of which may be more or less significant in any specific situation, at any specific moment'. When the sense of ethnic identity is strong, individuals maintain solidarity, ethnic group values, beliefs, language, and culture.

An ethnic group is a social group, and has been defined as 'a community whose heritage offers important characteristics in common between its members and which makes them distinct from other communities' (Modood et al., 1997, p.13). Furthermore, it is necessary that there is a group consciousness among members of the ethnic group in order to express the ethnic identity of the group. As Modood and colleagues (1997, p.14) contend, 'group membership is a matter of opinion, which may change over a lifetime, and from generation to generation'. Ethnicity is not rigid and static; it is dynamic and interactive, shaped by the social, political and cultural relations between the ethnic groups, in part as responses to racism and prejudice.

Modood and colleagues (1997) have considered diversity in terms of three distinct ways - origin, socio-economic status, and lifestyles.

In summary, we all belong to an ethnic group. Ethnic groups may or may not be a minority within a larger community. 'Ethnicity' and 'ethnic group' are two concepts that are significant to how ethnic identities are perceived, and how people describe themselves.

Ethnic Group Monitoring

Data about ethnic groups is gathered for the purpose of needs identification and assessment in health and social care. A useful educational resource concerning its use within the National Health Service is contained within the Department of Health website.

The census data of 1991 included for the first time a question on ethnicity. The following categories were used:

The 1991 Census Ethnic Group categories - Source: OPCS, 1991

White
Black Caribbean
Black African
Black other (please describe) Indian
Pakistani
Bangladeshi
Chinese
Asian other
Any other ethnic group (please describe)

Note:

If the person is descended from more than one ethnic or racial group, please tick the group to which the person considers he/she belongs, or tick the 'Any other ethnic group' box and describe the person's ancestry in the space provided.

The 1991 census categories facilitated the introduction to ethnic monitoring as a tool for measuring health assessment needs and accessibility of services. It has been recognised that discrimination has been more likely to happen to certain groups of individuals because of their skin colour.

There has been much criticism about the categories and their limitations (Aspinall, 1997). It has been argued that the categories were not sophisticated enough to make distinctions within groups, treating them more or less as homogeneous groups, when in reality they were not accounting for a large number of people within the example of terms such as 'Asian' and 'White'. Groups such as Sri Lankans, Cypriots or the Irish and various groups from the Middle East are only subsumed under these terms. The terms 'black African', 'black other' and various 'Asian' groups were deemed not useful for the purpose of monitoring, as they do not distinguish between communities with different cultures, religions, and socio-economic profiles (Aspinall, 1997). It has also been noted that the validity of the 1991 census data for making comparisons is dubious (The Runneymede Trust, 2000: p144).

However limited, it is the only source of information about the breakdown of ethnic groups within the population and therefore provides a baseline for needs assessment in respect to minority ethnic health care. The following are examples of the data that has been obtained from the 1991 census for local authorities where NHS Trusts provide placements for students from Thames Valley University.

Residents by ethnic groupings from the 1991 Census data
London Borough of Brent
London Borough of Ealing
London Borough of Harrow
Royal Borough of Kensington and Chelsea
Berkshire Authority - Reading
Berkshire Authority - Slough

The 2001 census recognises some of the limitations of the 1991 categories. However, the revisions made do not satisfy all the requirements for clarity about ethnic identity as perceived by the respondent. Religion has been included for the first time. It has been argued however that the term Christian should be further subdivided to reflect the reality of the wide diversity of faiths that it encompasses - Anglicans, Roman Catholics, Methodists, Pentecostalists, Seven Day Adventists, Presbyterians and Baptists. Aspinall (2000) has argued that unless the term 'Christian' is broken down further, it will be limiting in its usefulness, and 'suggests a concern with the use of information from the religious question responses to identify ethno-religious sub-groups in the visible minority population only, to the exclusion of majority ethnicity' (Aspinall, 2000, p.505). This is a valid argument given that the majority ethnic group, also not homogeneous, may have their diversity overlooked.

It has been argued that the methods of classifying ethnic groups do not account very precisely and adequately enough for people of mixed parentage (Modood et al., 1997). The analysis based on children aged less than 16 and both of whose parents lived in the same household showed that most people of mixed parentage have one 'white' parent and one minority ethnic parent (Modood et al., 1997, Table 2.8, p. 31).

Classification	% of children with one white parent
Caribbean	39%
Indian/African Asian	3%
Pakistani/Bangladeshi	1%
Chinese	15%

The percentage of mixed family groups origin was broken down as follows:

Origin	Origin % of mixed family groups
White	13%
Black Caribbean	14%
Black African	1%
Black British	15%
Black other	2%
Indian	4%
Chinese	2%
British Asian	5%

(Modood et al., 1997, Table 1.1, p.15).

The 2001 Census

The 2001 Census categories were a response to a greater understanding of these demographic characteristics of the ethnic groups. It began to address the issues that are significant in the ways in which society and communities within it are evolving. The inclusion of an actual category that reflects 'mixed' parentage is seen as valid and useful for the collection of accurate information about ethnicity.

The 2001 Census, England and Wales - Source: The Census Order 2000 (ONS)

(a) White
British
Irish
Any other white background (please write in below)

(b) Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background (please write in below)

(c) Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background (please write in below)

(d) Black or Black British
Caribbean
African
Any other Black background (please write in below)

(e) Chinese or Other ethnic group
Chinese
Any other (please write in below)

As stated earlier, the 2001 Census allowed for the first time the collection of data on religious affiliation (Aspinall, 2000). The following religion question was asked in England and Wales:

England

Wales

What is your religion? Tick one box only

None
Christian (including Church of England, Catholic, Protestant and all other Christian denominations)
Buddhist
Hindu
Muslim
Sikh
Jewish
Any other religion, please write in below

What is your religion? Tick one box only

None
Christian (including Church in Wales, Catholic, Protestant and all other Christian denominations)
Buddhist
Hindu
Muslim
Sikh
Jewish
Any other religion, please write in below

With the introduction of the religion question, it will be now possible to collect further information that is considered important with respect to determining and identifying ethnicity. For example, as with other ethnic groups, it will be possible to identify further the diversity among the 'white' ethnic groups. With reference to health assessment and planning, it may be possible to identify the diversity within the community of communities with respect to spirituality and spiritual needs, and the extent to which this may impact on provision of services in a particular geographical locality.

At this point, it may be worthwhile to compare and contrast the ethnic group categories in the 1991 census and the 2001 census.

It is recommended you visit the 2001 Census website.

Look up residents by Ethnic groupings. Table KS06 and table KS07 show residents by Ethnic Groups and Religion. National and regional rankings are also produced by theme (Ethnicity and Religion).

The scenarios may provide an insight into the issues that emerge when an attempt is made to work out the ethnicity of individuals. The information available is limited, and demonstrates some of the real problems with 'ethnicity' as a variable. At the local level of health planning and assessment, Health Trusts can add categories to the official census categories in order to obtain an accurate demographic profile of the communities they serve. It is important to allow people to choose how they express their ethnic identity.

Although arbitrary and not the way it should be done, and even with the limited information, it is possible to illustrate issues for discussion by considering the ethnic groupings of the persons profiled in the scenarios. You may wish to compare your own responses to the following:

Scenarios	Person	Ethnicity (1991 Classifications)
Conception and pregnancy	Abiola George Megan Taiwo	Black African or Black other - Nigerian White White Black African or other - Nigerian
Child with a learning disability	Amir Baksh Amina	Pakistani Pakistani
Adult with Sickle Cell Anaemia	Mark Jonathan	Black Caribbean' Any other ethnic group' or one that Jonathan might assign himself
Elderly person and bereavement	Maeve Joyce	White White

Given a voice, individuals may not describe themselves as belonging to the categories listed above. They may choose to emphasis particular characteristics over others.

We may have multiple ethnic identities, just as we might have numerous cultural identities.

With the 2001 categories it may be possible to be relatively more specific about our ethnic group. The idea that these are relatively more specific is because in a sense these categories are still restrictive as opposed to individuals being given a choice to express their own ethnic group identification.

Scenarios	Person	Ethnic Group (2001 Classifications)
Conception and pregnancy	Abiola George Megan Taiwo	Black African or Black African Nigerian Christian White British Christian White British Christian Black British African or Black British Nigerian Christian
Child with a learning disability	Amir Baksh Amina	Asian Pakistani or Pakistani Muslim Asian British - Pakistani or British Muslim
Adult with Sickle Cell Anaemia	Mark Jonathan	Black British or Black British Caribbean Mixed - White and … or Mixed - Any other mixed background or Chinese - Any other
Elderly person and bereavement	Maeve Joyce	White Irish Catholic White British - Catholic

Demography And Statistics

The demography of populations in any given region or country can be looked upon as varying over time not just in numbers but also across gender, age, and ethnicity. Within the demographic characteristics, differentiation can be made about the majority and minority (minorities), migration patterns, status of migrants to the host country in terms of workers, students, asylum seekers and refugees and other categories.

Migration itself has as long a history as humanity itself and mobility has been a hallmark in the evolution of human societies. There has been a long history of migration to and from Britain. In an era of globalisation and post-colonisation, there have been many instances of migrations to Britain of people from different parts of the world, for example from Ireland, west Africa and south-east Asia. However, in the recent past, famine, strife and conflicts in some regions of the world have necessitated people to leave their countries and to seek refuge in Britain.

The 1991 census data made it possible for the first time to look at the demographic characteristics of the United Kingdom in terms of ethnic origins of people. As already noted earlier, the categories used were of some help in global terms, they hid information that would have otherwise been more helpful in making sense of the ethnic origins of people born here and in other countries. In summary, ethnic groups were hidden within the broad categories.

The Fourth National Survey (Modood et al., 1997) is a useful source for information on the demographic characteristics of people, and includes an extensive section on health and health related issues, from health behaviours to the use of services.

Ethnocentris

People learn to look at the world from their own particular cultural viewpoint through the process of socialisation in the culture in which people are brought up, and the cultural influences the beliefs and values they hold. Ethnocentrism refers to the tendency of people to perceive their cultural ways to be the best, superior to the cultural ways of others. Purnell and Paulanka (1998) define ethnocentrism as 'the universal tendency of human beings to think that their ways of thinking, acting, believing are the only right, proper, and natural ways…Ethnocentrism perpetuates an attitude that beliefs that differ greatly from one's own are strange, bizarre, or unenlightened, and therefore wrong' (p. 3). Assumptions are made about what is correct and preferable. The other person's cultural orientation and beliefs may be ignored or disregard as unimportant. The person may not be aware of his/her own ethnocentric behaviour. Ethnocentrism is not an acceptable attitude in health and social care because it deters from relationship building between the professional and the patient.

Cultural Relativism

Baker (1997, p. 3) has suggested that cultural relativism is 'an implicit principle underlying the conceptual approaches developed by the nurse to guide cross-cultural caregiving'. Furthermore, cultural relativism refers to 'the perspective that the behaviors of individuals should be judged only from the context of their own cultural system'. Baker argues that although its proponents propose that it allows for openness and flexibility in cross-cultural encounters, and understanding, cultural relativism undermines the inequalities, oppression and violation of human rights. In health care across cultures, care professionals can be drawn into conflicts with certain practices such as circumcision (male or female), although viewed as traditions in some ethnic groups.

Acculturationy

People migrate from one environment to another. When there are distinct differences between the culture from which they arrive to the one in which they settle, individuals give up some of the traits of the culture they left behind, and adopt the traits of the dominant culture in which they now live. The degree to which this happens is termed acculturation. Contact with another culture makes people reassess their orientation and beliefs and values. The presence and direct contact with people from a different culture also impacts on the dominant host culture. Thus, it is possible that over time, a high or low degree of acculturation may occur. Assimilation is a phase of acculturation and occurs when the values, beliefs and lifestyles of the prevailing culture are adopted.

Discrimination And Anti-Discriminatory Practice

Stereotypes are oversimplified or untrue generalisations about social groups (Haralambos & Holborn, 1996, p. 688), and they refer to shared beliefs about others with respect to their personality traits, attitudes and behaviours. Stereotyping others in terms of ethnicity, (as well as age, gender, disability, sexual orientation) can gives rise to negative and positive stereotypes, and this can lead to prejudice and discrimination. The assumptions that are held about people from different ethnic groups need to be challenged.

The Race Relations Act (1976)

Discrimination can be defined as treating a person differently and unfairly from others on the basis of held prejudice about which group the person belongs to i.e. gender, age, ethnicity, and other perceived differences.

Discrimination on the grounds of 'race', disability, gender, sexual orientation and any other, is outlawed by the Race Relations Act, 1976 (Hugman, 1991). Although the 1976 Act prohibited direct and indirect discrimination by public bodies, it did not include all the functions of public authorities. Following the Stephen Lawrence Inquiry (MacPherson, 1999), it became clear that revisions to the Act were needed and long overdue. Organisations such as the Commission for Racial Equality (CRE) pressed for changes. As a result, amendments to the 1976 Act have been enacted by Parliament.

The Race Relations (Amendment) Act 2000

The Race Relations (Amendment) Act 2000 came into effect in April 2001. It removes any exceptions to indirect discrimination by authorities. It also includes different categories of public authorities among which are the NHS authorities and trusts, Higher Education Institutes, Armed Forces and the Police. In the Amendments to the Act, (2000), Section 71 (1) requires these authorities to make arrangements to ensure that they 'eliminate unlawful racial discrimination, and promote equality of opportunity and good relations between persons of different racial groups'. The Act gives powers to impose specific duties on public authorities to ensure that equal opportunity policies are implemented and monitored. Authorities now have to demonstrate that they employ and manage diversity in their workforce, which in turn represents the ethnic and cultural diversity of the population that they serve. Targets for the recruitment of staff from ethnic communities are already being implemented in some authorities, for example the police.

The Commission for Racial Equality were empowered by the Home Office to produce a Health Code of Practice that will assist NHS Trusts understand how they can comply with the duties imposed on them through the Race Relations Amendment Act. The Code will be statutory and will be admissible in evidence in discrimination cases.

Useful resources about this and other legislation such as the Human Rights Act are contained on the Commission for Racial Equality.

Religious discrimination is also prevalent in authorities in England and Wales (Weller et al., 2001). This study undertaken for the Home Office, revealed religious discrimination in the health services as well as many other public services.

The experiences of people suggest that discrimination is still practised. Discrimination is perceived as the outcome of structural disadvantages; in other words, they were due to the factors such as education, socio-economic status, level of skills, and housing.

Racism refers to 'beliefs based on racial prejudice, and to acts of racial discrimination, whether deliberate or unintentional', (Mares, Henley & Baxter, 1985, p.5). Racism is base on the belief in 'race', and one's own 'race' being superior. It is often based on prejudice and power. The pattern of racism in Britain is an institutional expression of white racism which has its roots in Western Europe (Hugman, 1991).

Furthermore, the belief that one culture is better than another has raised the issue of cultural racism. It is assumed that the white British culture is better than any other, for example, that of South Asian Muslims (Modood, Beishon & Virdee, 1994).

The Parekh Report (The Runnymede Trust, 2000)

The Parekh Report (The Runnymede Trust, 2000) uses the plural term 'racisms' to illustrate the different types, focus and targets of racist behaviours and attitudes. Different history, stereotypes, and complexities also mark these. Points are made about anti-black racism and anti-Asian racism, and further examples such anti-Irish, anti-Gypsy and anti-Jewish racism. In recent times, Islamophobia or anti-Muslim racism has emerged as yet another racism.

The Parekh Report (The Runnymede Trust, 2000) describes how racism manifests itself in various forms such as street racism and institutional racism. The targets of racism are people who are seen as different and therefore 'threatening'. The Parekh Report (The Runnymede Trust, 2000, p. 74-75, Box 5.2) outlines the interacting components of institutional racism:

Indirect discrimination
Employment practices
Occupational culture
Staffing structure
Lack of positive action
Management and leadership
Professional expertise
Training
Consultation
Lack of information

These components are described in detail in the report.

Discrimination exists in many sectors: health services, housing, education, employment (HEA, 1994).

Schott and Henley (1996) describe two types of discrimination: direct or intentional, and indirect or unintentional. Direct discrimination involves treating someone less favourably than someone else because of his or her ethnic group (or disability, or age, and others). Indirect discrimination occurs when service provision is the same for everyone but people from various ethnic groups cannot access or gain maximum benefit because of language, religious or cultural reasons. Such discrimination is more subtle, perhaps more widespread and less easy to detect. Schott and Henley (1996), and Henley and Schott (1999) give some examples of where this may be the case in the health care of people from different ethnic and cultural backgrounds:

unacceptable services because of unsuitability
culturally unacceptable and inflexible services
care based on stereotypes
staff lack skills and knowledge about specific needs
Institutional Racism

The Macpherson Inquiry into the murder of Stephen Lawrence defined institutional racism thus:

'The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantages ethnic minority people.

[Racism] persists because of the failure of the organisation openly and adequately to recognise and address its existence and cause by policy, example and leadership. Without recognition and action to eliminate, such racism can prevail as part of the ethos or culture of the organisation. It is a corrosive disease'

(Macpherson, 1999, p.28, para. 6.34).

The report also emphasised that this concept was one relevant to all bodies (e.g. the NHS):

'Racism, institutional or otherwise, is not the prerogative of the Police Service. It is clear that other agencies including for example those dealing with housing and education also suffer from the disease. If racism is to be eradicated there must be specific and co-ordinated action both within the agencies themselves and by society at large, particularly through the educational system, from pre-primary school upwards and onwards.'

(Macpherson , 1999, p.33, para. 6.54).

Institutional racism is linked to organisations where there is racism in relation to policies, procedures and practices. Institutional racism in British institutions such as the NHS, police forces and other organisations is now more explicitly recognised and acknowledged as the first step in eliminating such racism. The Department of Health has taken positive measures in recent years to address the important issues. Alexander (1999) reported on the race equality agenda of the Department of Health, and the Vital Connection (DoH, 2000) has outlined the equalities framework for the NHS.

Cultural Racism

Cultural racism is a concept that refers to the stereotype, and it's associated hostility, where some cultures are thought of as inferior or primitive. It 'is targeted not at non-whites in general, but at certain groups which are perceived to be assertively "different" and not trying to "fit in"' (Modood et al., 1997, p.9). Cultural racism can manifest itself at both individual and institutional levels.