gurkha and nepalese health needs assessment...gurkha and nepalese population in north yorkshire....

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GurkhaandNepaleseHealthNeedsAssessment

March 2017 ProjectTeamDavidBagguley,PublicHealthRegistrar,NorthYorkshireCountyCouncilJudithBromfield,ChiefOfficer,RichmondshireCommunityandVoluntaryActionMartinRamsdale,DentalPublicHealthRegistrar,PublicHealthEngland

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Executive Summary • ThisHealthNeedsAssessmentcombinesanepidemiologicalandcorporate

approach,includingbothananalysisofavailabledataandevidencereviewandtheresultsofsurveysdesignedtocapturetheviewsofboththeNepalesecommunityandhealth,dentalandotherprofessionals

• AreviewofscientificliteraturesuggeststhattheNepalesecommunityareatriskofpoorerhealthoutcomesduetocoronaryheartdisease,kidneydiseaseandstroke,aswellasmentalhealthconditionsduetopsychosocialstressorsassociatedwithmovingtotheUK

• Thecommunitymayalsofacedifficultiesaccessingappropriatecareduetocultural

differences,lackofawarenessofservicesandlanguagebarrier

• Theresultsofthecommunitysurveysuggestrelativelygoodlevelsofphysicalhealthamongstrespondents

• Howevertherearespecificconcerns,informedbyboththecommunityand

professionalsurveys,aroundtherecognitionandprioritisationofmentalanddentalhealth,aswellasappropriateaccesstosmokingcessationanddrugandalcoholtreatmentservices

• Ethnicityispoorlyrecordedinroutinelycollecteddatarelatedtohealthcareactivity,makingdetailedanalysisofserviceusagechallenging

Recommendations

1. EffortsaremadetoraiseawarenessofavailablehealthservicesamongsttheNepalicommunity,perhapsviahealtheventorworkshop,withaparticularfocusonthefollowing:

i. Mentalhealthservicesii. Dentalhealthservicesiii. Smokingcessationservicesiv. Drugandalcoholservicesv. Femalehealth

2. TranslatedadviceonavailableNHSservicesandhowtoaccessthemisprovidedto

newrecruitsandtheirfamiliesonarrivalintheUK

3. Healthcareprovidersimprovetheirrecordingofethnicity,enablingmorecomprehensivedataanalysisandadeeperunderstandingofthehealthneedsofthecommunityinfuture

4. ExistinglinksbetweenMinistryofDefenceandNHSserviceprovisionaremaintained

andstrengthened

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Contents Executive Summary...............................................................................................................1Introduction and Rationale...................................................................................................4Background and Context......................................................................................................6Aims and Objectives..............................................................................................................9Methods.................................................................................................................................10Results of Evidence Review...............................................................................................16

Epidemiological Data...........................................................................................................22Results of Community Survey............................................................................................27Results of Professional Surveys........................................................................................53Currently available services...............................................................................................57Limitations of the Assessment...........................................................................................58Recommendations...............................................................................................................60

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Introduction and Rationale Thishealthneedsassessmentwillaimtoprovideaclearinsightintothehealthneedsofthe

GurkhaandNepalesepopulationinNorthYorkshire.Thiswillthereforeincludenotjust

servingGurkhasoldiers,buttheirfamilies,veterans,studentsandanyotherNepaliresident

withanon-militarybackground.Itwilldosobytakinganepidemiologicalandcorporate

approach.Theepidemiologicalapproachincludesanexaminationofavailablequantitative

data,includingdemographicinformationanddetailsofcurrentlyavailableservices.The

corporateapproachinvolvesastructuredcollectionofknowledgeandviewsof

stakeholders.Itisbasedonthedemands,wishesandperspectivesofinterestedparties,

bothprofessionalandpublic,andthereforerecognisestheimportanceofgaininginsight

fromthosewhohaveaccessedanddeliveredlocalservices.

Thereweremultiplefactorswhichledtotheproject’sinitiation.Firstly,recognitionthat

therewasasizeableNepalesecommunitylivingintheCountyaboutwhosehealthneeds

littlewasunderstood.Giventhedifferencesincultureandhealthserviceprovisionbetween

NepalandtheUK,itmightreasonablybeassumedthatthoseneedsdiffersignificantlyfrom

therestoftheresidentpopulation.

Secondly,overthepastfewyearsGPpracticeswithinRichmondshiredistricthavenoticeda

significantcohortofNepalipatientswhohavehadissueswithaccessingservicesdueto

languagedifficulties.Thishashadtobeaddressedwithchangestoprintedmaterialsand

staffing.

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Thirdly,theuncertaintyaboutarmedforcesdeploymentsmeansthattheremaybe

increasesinthenumberofGurkhasandtheirfamiliesresidingintheCountyinfuture.

Finally,theconcentratedplacementofGarrisonbuildingsaroundCatterickmeansthatthe

servingNepalisoldiersandtheirfamiliesarelikelytolivewithinasmallpocketofNorth

Yorkshire,whichhasthepotentialtocreatepressureonlocalservicesifnotaddressedby

appropriateallocationofresources.

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Background and Context TheBritishArmyhascontainedNepalisoldierssince18151.Thesesoldiersarecollectively

referredtoasthe‘BrigadeofGurkhas’,takingtheirnamefromGorkha,ahistoricdistrictof

Nepal2.Duringtheirservice,theGurkhashavemainlybeenbasedoutsidetheUK,firstlyin

India,andthenlaterBurmaandHongKong3.FollowingthetransferofHongKong’s

sovereigntytoChina,theBrigadeheadquartersandallGurkhatrainingwasmovedtothe

UK4.

Until2004,GurkhashadnorighttoremainpermanentlyinBritain,butunderTonyBlair’s

government,Nepalisoldierswhohadretiredafter1997(thetransferofHongKong

sovereignty)andhadservedfor4ormoreyearswereallowedtosettleintheUK5.Asa

resultofthecampaigntosecuresubstantivesettlementrightsforallGurkhaveterans,in

2009theGovernmentannouncedthatallthosewhohadservedinthearmyfor4yearsor

more,regardlessofwhentheyretired,wereentitledtoBritishcitizenship6.

This,alongwithariseinthenumberofNepalistudentsstudyinginBritain,hasresultedina

significantincreaseinmigrationintotheUKfromNepal7.The2001censusrecorded5,938

1BritishArmy(2017)HistoryoftheGurkhas,Availableathttp://www.army.mod.uk/gurkhas/27856.aspx.Dateaccessed15thFebruary2017.2BBCNews(2010)WhoaretheGurkhas?Availableathttp://www.bbc.co.uk/news/uk-10782099.Dateaccessed15thFebruary2017.3BritishArmy(2017)ibid4SouthChinaMorningPost(2014)TheNepalesecommunityinHongKonglookstopreserveGurkhalegacy.Availableathttp://www.scmp.com/lifestyle/article/1458561/nepalese-community-hong-kong-looks-preserve-gurkha-legacy.Dateaccessed15thFebruary2017.5BBCNews(2010)ibid6BBCNews(2010)ibid7Adhikari(2013)NepalisintheUnitedKingdom:AnOverview,CentreforNepalStudiesUK

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NepaliintheUK8.Thiswaslikelytohavebeenanunderestimateduetothelackofaspecific

Nepaliethnicstatusavailableoncensusforms9.Nevertheless,datafrom2011suggeststhat

around60,000NepaliwereresidinginEnglandandWales,whichrepresentsaconsiderable

riseinpopulationnumbers10.However,thereissomeevidencetosuggestthattherecent

riseinnetmigrationhasdecreasedslightlyinthelastfewyearsduetoareductioninNepali

studentnumbers11.

TheGurkhaCompany,partofthe2ndInfantryTrainingBattalionandbasedattheInfantry

TrainingCentreinCatterick,isoneof7majorunitsoftheGurkhabrigade12.Itisresponsible

forthetrainingofnewNepalirecruitsarrivingintheUK13.Theexactnumberofsoldiers

basedattheCentrevariesdependingonservicerequirementsandannualfluctuations,but

ayearlyintaketypicallyconsistsof200to300soldiers14.

ItshouldbenotedthatwhilstGurkhasoldiers,servingorretired,arelikelytorepresenta

considerablenumberoftheNepalipopulationlivingintheCounty,theyarenottheonly

potentialsourceofmigration.AcommunitystudyexaminingmigrationtotheUKfrom

8ibid9Adhikari(2013)NepalisintheUnitedKingdom:AnOverview,CentreforNepalStudiesUK10OfficeforNationalStatistics(2014)2011Census:SmallpopulationtablesforEnglandandWales.Availableathttps://www.ons.gov.uk.Dateaccessed15thFebruary2017.11Adhikari(2013)NepalisintheUnitedKingdom:AnOverview,CentreforNepalStudiesUK12BritishArmy(2017)BrigadeofGurkhas.Availableathttp://www.army.mod.uk/gurkhas/27784.aspx.Dateaccessed15thFebruary2017.13ibid14GurkhaBrigadeAssociation(2017)Availableathttp://www.gurkhabde.com/category/gurkha-coy/.Dateaccessed15thFebruary2017.

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Nepalfoundanumberofcommonnon-militaryreasonsforUKentry,includingprofessional

work,educationandstudy,andasylum15.

15Sims,J.M(2008)Soldiers,MigrantsandCitizens-TheNepaleseinBritain:ARunnymeadecommunityStudy.Availableonlineathttp://www.runnymedetrust.org/uploads/publications/pdfs/TheNepaleseInBritain-2008.pdf.Dateaccessed15thFebruary2017

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Aims and Objectives TheaimsandobjectivesoftheHealthNeedsAssessmentareasfollows:

Aims

• ToprovideaninsightintothehealthneedsoftheGurkhaandNepalipopulation

livinginNorthYorkshire

• Identifyrecommendationsforhealthserviceplanningandresourceallocationto

improvethehealthandwellbeingoftheGurkhaandNepalipopulationlivingin

NorthYorkshire

Objectives

• Buildawarenessoftheprojectamongstcommunityandgainsupportofcommunity

leaders

• PresentavailabledemographicdatatodescribetheGurkhaandNepalipopulation

livinginNorthYorkshire

• OutlinethecurrentserviceprovisionavailabletotheGurkhaandNepalicommunity

• SummarisehealthneedsoftheGurkhaandNepalipopulationinNorthYorkshire

• Highlightanyareasofcareprovisionwhichcouldbestrengthenedtomeetthe

healthneedsoftheGurkhaandNepalipopulationinNorthYorkshire

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Methods Thereareseveralpossibleapproachestoahealthneedsassessment.Thishealthneeds

assessmentadoptedanepidemiologicalandcorporateapproach.Theepidemiological

approachrequiredanexaminationofavailabledatatounderstandthedemographicsofthe

population,andpresentdetailsofcurrentserviceprovision.

Thecorporateapproachinvolvedastructuredcollectionofknowledgeandviewsofrelevant

stakeholders.ThiswasconductedforboththeNepalipopulationlivingintheCountyand

healthandsocialcareprofessionalsprovidingservicestothecommunity.

TheprojectgroupconsistedofamemberofthePublicHealthteambasedatNorth

YorkshireCountyCouncil,theChiefOfficerofRichmondshireCommunityandVoluntary

Action,andamemberoftheDentalPublicHealthteambasedwithinPublicHealthEngland.

CommunitysupportwasprovidedbymembersoftheBritishGurkhaWelfareSocietyand

theArmyWelfareService.

CommunityConsultation

Structuredquestionnairesweredevelopedandtranslatedtoproduceadual-language

surveywhichcouldbedisseminatedamongstthecommunity.Thisconsistedof60

questions,coveringdetaileddemographicinformation,perceivedhealthstatus,diet,

tobaccoandalcoholuse,dentalhealth,mentalhealth,culturalbeliefs,healthbehaviours,

andhealthanddentalserviceusage.Thelengthofthequestionnairewasdictatedbythe

pooravailabilityofroutinelycollecteddatawhichwasavailableforanalysis,andthe

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requirementtobuildascomprehensiveapictureofthecommunity’shealthneedsas

possible.

Thequestionnairesweredistributedusingasnowballsamplingtechnique,whichreliedon

communityandarmedforcesleadersdisseminatingthesurveystoNepaliresidentsand

soldierswhowerewillingtoparticipate.Thenatureofthesupportorganisationsandthe

locationofcommunitygroupsinvolvedmeantthisactivitywaslargelyfocussedinthe

Richmondshiredistrict,andspecificallyaroundtheGarrisonatCatterick.Forthistechnique

tobesuccessful,asignificantamountoftimewasspentbuildingrelationshipswithkey

communityleaders.

QuestionnaireswerereturnedbyFreepostenvelopetoNorthYorkshireCountyCounciland

responseswereinputtedbymembersoftheBusinessSupportteambasedwithinthe

Council.Questionsrelatingtodateofbirth,surnameandpostcodeweredeliberately

excludedfromthesurveytoensuretheresponseswerenotidentifiabletoanyparticular

resident.

ProfessionalConsultation

Twoquestionnairesweredevelopedtocapturetheviewsandexperiencesofhealthand

socialcareprofessionalsworkingintheCounty.Bothwereinanelectronicformat,and

createdusingSnapSurveysoftware.Onewassenttoregistereddentistsworkingwithin

NorthYorkshireprovidingprimaryNHSgeneralandcommunitydentalservices.Thiswas

achievedwiththehelpofNHSEnglandwhodistributeditbyemailandembeddedhyperlink.

Membersoftheprojectgroupsentthesecondviaemaildirectlytootherhealthandsocial

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careprofessionals,whowereselectedbasedontheirproximitytoRichmondshireDistrict

andCatterickGarrison,andtheirknownfrontlinecontactwiththeNepalicommunity.

Professionalgroupsincludedpharmacists,healthvisitors,midwifes,GPs,police,Citizens

Advice,SocialCareassessorsandLivingWellserviceco-ordinators.

Thecontentofbothwasmuchshorterthanthecommunitysurvey,whichwasreflectiveof

effortstomaximisetheresponserateandalsothenatureoftheinformationtobecaptured.

Inbothquestionnaires,thequestionsrelatedtothehealthstatusofthecommunity,

includingthepopulation’smostsignificanthealthissues,healthbehavioursandbarriersto

access.

Theprojectgroupattendednumerousprofessionalmeetingsinorderraiseawarenessofthe

researchandsecureinterestandparticipation,includingtheArmyCovenant.

EvidenceReview

Inordertoproduceanevidence-basedassessment,andtoguidethedevelopmentofthe

questionnaires,afullliteraturesearchwasconducted.Thisprovidedagreaterinsightinto

thehealthneedsoftheNepalipopulationlivingintheUK.Giventhedifficultiesinaccessing

accurateandreliabledatafortheNepalicommunityinNorthYorkshire,theacademic

literatureandfindingsofresearchstudieswereaparticularlyimportantresource.

ProjectOverviewTheHealthNeedsAssessmentconsistedofthefollowingelements:

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1. InitiationofProject

Aninitialmeetingbetweentheprojectteam,DirectorofPublicHealthforNorth

Yorkshire,ChiefExecutiveofRichmondshireDistrictCouncil,MedicalDirectorof

Hambleton,RichmondshireandWhitbyClinicalCommissioningGroup,Assistant

DirectorofAdultSocialServicesforNorthYorkshireCountyCouncilandChairofthe

localBritishGurkhaWelfareSocietymettodiscussthehealthissuesfacingthe

communityandplansfortheHealthNeedsAssessment.Thecasedefinitionwasalso

consideredanddecidedupon.

2. Examiningavailabledata

Theavailabilityofdatasourceswasestablished,anditwasrealisedatanearlystage

thattheAssessmentwouldnotbenefitfromhealthserviceactivitydataduetothe

poorrecordingofethnicstatusamongstcareprofessionals.

3. Planningconsultationwithpatientsandprofessionals

Allthreequestionnairesweredevelopedinresponsetothefindingsofexisting

researchfindings.Thisstagealsoincludedtranslationofthecommunity

questionnaire.Methodsofsurveydisseminationsandreturnwerediscussedand

developed.

4. Engagementwithcommunityandprofessionals

Thefacttherewasverylittleinformationwhichcouldbederivedfromexisting

sourcesofhealthdatameantthattheAssessmentreliedheavilyonthe

questionnaireresults.Inordertomaximisetheresponserate,theprojectgroup

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spenttimeestablishingrelationshipswithmembersofthecommunityandrelevant

healthandsocialcareprofessionals.

5. Dataanalysis

Analysisofthequestionnaireresponseswascompletedoncetheybecameavailable

totheprojectgroup.Thisstagealsorequiredtheconsiderationoflimitationsofthe

dataandtheimplicationsoftheAssessment’sconclusionsandrecommendations.

6. Developmentofrecommendations

Recommendationsforfuturehealthserviceplanningandresearchwereproducedin

responsetotheresultsoftheAssessment

CasedefinitionThedefinedpopulationforthisHealthNeedsAssessmentwas:residentsoftheCountyof

NorthYorkshirewhowereborninNepalorconsiderthemselvestohaveaNepaliethnic

background.

FundingThetimeoftheprojectgroupwasprovidedbytheirrespectiveemployingorganisations.

AdditionalfundingforthisHealthNeedsAssessment,includingthetranslationofthe

questionnaireandinputtingofquestionnaireresponses,wasprovidedbythePublicHealth

departmentofNorthYorkshireCountyCouncil.

EthicalConsiderations

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ThecommunityquestionnairewasdesignedsothatalldatacapturedduringtheAssessment

wasnotidentifiabletoanyparticularindividual,andallresultsarethereforepresented

anonymously.

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Results of Evidence Review ThereisalimitedamountofacademicliteraturededicatedtothehealthneedsofNepali

livingintheUK.However,anumberofHealthNeedsAssessmentsinotherareasofthe

countryhavebeencompleted,whichprovideaninsightintotheexperienceofcommunities

withasimilargeneticandculturalbackground.Nevertheless,thesupportandservices

availablediffersubstantiallyindifferenthealthandlocalauthorityregions.

Thehealthandwellbeingofmigrantsisanimportantdeterminantoftheirabilityto

successfullyestablishthemselveswithintheirhostcountry.Severalfactorsaffectan

individual’shealthstatus,includingtheirpersonalmedicalhistory,healthbehaviour(i.e.

theirresponsetoill-health)andthequalityandavailabilityoflocalhealthservices.Itisalso

affectedbythecountry’simmigrationandsettlementpolicies,societalattitudeandlegal

protectionaffordednewmigrants16.

ItshouldbenotedthattheGurkha/Nepalipopulationarenotahomogenousgroupand

individualswillhavetheirownuniquepersonalcircumstancesandhealthneeds.Thereare

however,severalgeneralthemesthatappearintheliteraturethatshouldbeacknowledged

andconsidered.

Communicablediseases

16Carballo,M.,&Mboup,M.(2005).Internationalmigrationandhealth.PapersubmittedtotheGlobalCommissiononInternationalMigration.

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TheincidenceofinfectiousorcommunicablediseaseisfarhigherinSouthAsia,and

specificallyNepal,thantheUK17.Thisincludesbothfoodorwaterbornediseases,suchas

hepatitisAandE,andvector-bornediseases,suchasmalariaandJapaneseencephalitis.The

rateoftuberculosisis156casesforevery100,000ofthepopulation,whichismorethan

threetimestheratePublicHealthEnglandclassifiesashighincidence(40per100,000)18.

However,itisestimatedthattheprevalenceofHIVinNepalislowerthanthatoftheUK,

althoughthemortalityrateforthediseaseismuchhigher19.Thisispartlyreflectiveofthe

differentapproachestocasemanagementbetweenthetwocountries,duetotheresources

availablefortreatment.

Studieshaveattemptedtoquantifyprevalencelevelsofsuchdiseasesinmigrant

populationsenteringtheUK,butthishasbeenchallengingduetodifficultieswithsampling.

TheconclusionsmadearethereforenotgeneralisabletoNepaliorGurkhamigrants.

ChronicdiseasesThereisahighermortalityrateamongstmigrantsfromSouthAsiaandtheIndian

subcontinentduetocoronaryheartdisease,renalfailureandstrokethantherestoftheUK

population20.Thisisassociatedwithahighprevalenceofhypertensionanddiabetesinthose

17Zaidi,A.K.,Awasthi,S.,&JanakadeSilva,H.(2004).BurdenofinfectiousdiseasesinSouthAsia.BMJ,328(7443),811-815.18PublicHealthEngland(2015)Tuberculosis(TB)bycountry:ratesper100,000people.Availableathttps://www.gov.uk/government/publications/tuberculosis-tb-by-country-rates-per-100000-people.Dateaccessed18thFebruary2017.19CIAFactbook(2016)FactbookonNepal.Availableathttps://www.cia.gov/library/publications/the-world-factbook/geos/np.html.Dateaccessed15thFebruary201720Ghaffar,A.,Reddy,K.S.,&Singhi,M.(2004).Burdenofnon-communicablediseasesinSouthAsia.BMJ:BritishMedicalJournal,328(7443),807.

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groups21.Thisincreasedriskofdeathfromcardiovascularrelateddiseaseswasobserved

despitealowerprevalenceoftobaccouseandhighcholesterol(traditionalriskfactorsfor

heartdisease)amongstIndo-AsianmigrantscomparedtothegeneralUKpopulation22.

Itisunclearwhethertheoverallrateoflong-termillnessislikelytobehigherinNepali

migrantsthantheUKpopulation.Whilsttheratesofchronicdiseasesamongstmigrants

fromtheIndiansubcontinenthavebeenfoundtobehigherthantheUKaverage,therates

amongstChinesemigrantswerefoundtobelower23.

Whilstseveralstudieshavefoundincreasedrisksofill-health,suchasobesityandobesity-

relateddiseases,inSouthAsianscomparedtowhiteCaucasianslivingintheUK,this

researchisnotmigrant-specificandthereforeitisproblematictogeneralisethesefindings

toNepalimigrantsenteringtheUK.

MentalHealthandEmotionalWellbeingThereisverylittlequantitativedatarelatingtotheprevalenceofmentalhealthconditions

amongstmigrantsingeneral,andtheNepalicommunityspecifically.Nevertheless,thereis

likelytobesignificantstressassociatedwiththechangeinlifestyleassociatedwith

migrationtotheUK,involvingapotentiallossofcommunity,closesupportnetwork,and

21Cappuccio,F.P.,Barbato,A.,&Kerry,S.M.(2003).Hypertension,diabetesandcardiovascularriskinethnicminoritiesintheUK.TheBritishJournalofDiabetes&VascularDisease,3(4),286-293.22ibid23Harding,S.,&Balarajan,R.(2000).Limitinglong-termillnessamongblackCaribbeans,blackAfricans,Indians,Pakistanis,BangladeshisandChinesebornintheUK.EthnicityandHealth,5(1),41-46.

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traditionaleventsandcustoms24.EvidencedoessuggestthatthosebornoutsideoftheUK

havepoorermentalhealthoutcomesthantheUK-bornpopulation,butthisislikelytobe

highlydependentonthecircumstancessurroundingmigration,includingthecountryof

origin25.

Mentalhealthhasalowerprioritythanphysicalhealthinmanylowandmiddle-income

countries26.Ithasbeenestimatedthat4outof5individualswithseverementalconditions

livinginthosecountriesdonothaveaccesstosupportivecare27.Currently,mentalhealth

servicesinNepalarelimited,withonlybigcitiesbenefittingfromspecialistpsychiatric

expertise28.Thishasthepotentialtotranslatetohealthbehaviourwhichdoesnotrecognise

theneedformentalhealthassessment,norseektreatmentincircumstancesofclinical

need29.

DentalHealth

EpidemiologicalresearchsuggestsNepalisoneof15%ofcountrieswheretheprevalenceof

periodontalconditionsanddentalcariesareamongtheworstintheworld30.

24TheMigrationObservatoryatUniversityofOxford(2014)HealthofMigrantsintheUK.Availableathttp://www.migrationobservatory.ox.ac.uk/resources/briefings/health-of-migrants-in-the-uk-what-do-we-know/.Dateaccessed17thFebruary2017.25ibid26Luitel,N.P.,Jordans,M.J.,Adhikari,A.,Upadhaya,N.,Hanlon,C.,Lund,C.,&Komproe,I.H.(2015).MentalhealthcareinNepal:currentsituationandchallengesfordevelopmentofadistrictmentalhealthcareplan.Conflictandhealth,9(1),3.27ibid28ibid29TheMigrationObservatoryatUniversityofOxford(2014)HealthofMigrantsintheUK.Availableathttp://www.migrationobservatory.ox.ac.uk/resources/briefings/health-of-migrants-in-the-uk-what-do-we-know/.Dateaccessed17thFebruary2017.30Helderman,W.,Groeneveld,A.,Truin,G.J.,Shrestha,B.K.,Bajracharya,M.,&Stringer,R.(1998).AnalysisofepidemiologicaldataonoraldiseasesinNepalandtheneedforanationaloralhealthsurvey.Internationaldentaljournal,48(1),56-61.

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SeveralstudiesofNepalesecommunitieslivingintheUKhavefoundalowrateofdental

registration,raisingconcernsaboutthepopulation’soralhealthstatus.Twoseparate

studiesfoundlessthan40%oftheNepalipopulationwereregisteredwithadentist313233.

Thisproportionofthepopulationaccessingdentalcareislowertheaverageforthegeneral

UKpopulation,whichisapproximately46%34,aswellasotherminoritygroupslivingin

Britain35.TheproportionofYorkshireandHumberresidentsaccessingcareisestimatedto

bebetween52%and55%,basedonanassessmentin2015ofthenumbersattendinga

dentistduringa24monthperiodbetween2011and201436.

Thismaybeduetoseveralfactors,includingnotprioritisingdentalcareduetotherelatively

limitedprovisionavailableinNepal,alackofunderstandingaboutthedifferencebetween

publicandprivatedentalprovisionandtheexpenseoftreatment37.

AccesstoServices

Asoutlinedabove,evidencesuggeststhatmigrants,andspecificallyNepalimigrants,areat

anincreasedriskofcertainhealthconditions.Itisthereforevitalthathealthservicesare

abletoaddresstheseneeds,andseektoreduceinequalitiesinhealthoutcomes.31ItshouldbenotedthatdentalregistrationceasedtoexistfollowingchangestotheNHSdentalcontractin2006.Whilstdentistscontinuetomaintainalistofpatientsseenundertheircare,togetherwithdentalrecordsfortheirpatients,andcanacceptnewpatientsforcoursesoftreatmentwhereappropriate,NHSdentalregistrationdoesnotexistinrelationtothecurrentGDSNHScontract.32Adhikary,P.,Simkhada,P.P.,VanTeijlingen,E.R.,&Raja,A.E.(2008).HealthandlifestyleofNepalesemigrantsintheUK.BMCinternationalhealthandhumanrights,8(1),6.33Casey,M(2010)HealthNeedsAssessmentoftheNepaliCommunityinRushmoor.Availableathttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/28116/NepaliHealthNeedsAssessmentOct2010.pdf.Dateaccessed12thFebruary2017.34NHSDigital(2017)DentalStatisticsforEngland-2014/15Availableathttp://content.digital.nhs.uk/catalogue/PUB18129.Dateaccessed5thMay201735Adhikary,P.,Simkhada,P.P.,VanTeijlingen,E.R.,&Raja,A.E.(2008).HealthandlifestyleofNepalesemigrantsintheUK.BMCinternationalhealthandhumanrights,8(1),6.36PublicHealthEngland(2015)OralHealthNeedsAssessmentforNorthYorkshireandYork37ibid

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However,thereareanumberofreasonsaccesstoservicesmaybelimitedinmigrant

communities38.AkeypotentialbarrierfortheNepalipopulationislanguage39.Alackof

Englishproficiencymaytranslatetoalackofunderstandingaboutwhathealthservicesare

providedandwhere.Itcanalsoactasanimpedimenttocommunicationwithcliniciansand

otherprofessionals,whichcanaffectthequalityofcareprovided40.Itmayleadto

disengagementwithservicesanddelaysinappropriatereferraltosecondarycare41.

Thesebarriershavebeenidentifiedinpreviousresearchontheexperienceandneedsof

NepalicommunitieslivingintheUK42.Commonissuesrelatetodifficultieswithtranslation

andcommunication,differencesinhealthbeliefsandconsultingbehaviourandlackof

understandingandawarenessofavailableservices43.

38Jayaweera,H.,&Quigley,M.A.(2010).Healthstatus,healthbehaviourandhealthcareuseamongmigrantsintheUK:evidencefrommothersintheMillenniumCohortStudy.Socialscience&medicine,71(5),1002-1010.39Adhikary,P.,Simkhada,P.P.,VanTeijlingen,E.R.,&Raja,A.E.(2008).HealthandlifestyleofNepalesemigrantsintheUK.BMCinternationalhealthandhumanrights,8(1),6.40O'Donnell,C.A.,Higgins,M.,Chauhan,R.,&Mullen,K.(2007)."Theythinkwe'reOKandweknowwe'renot".Aqualitativestudyofasylumseekers'access,knowledgeandviewstohealthcareintheUK.BMCHealthServicesResearch,7(1),75.41ibid42Casey,M(2010)HealthNeedsAssessmentoftheNepaliCommunityinRushmoor.Availableathttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/28116/NepaliHealthNeedsAssessmentOct2010.pdf.Dateaccessed12thFebruary2017.43ibid

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Epidemiological Data

Nepal

NepalisacountryinSouthernAsia,situatedbetweenIndiaandChina44.Ithasanestimated

populationofjustover29million,withover120differentcastegroupsand123different

languagesspoken45.80%ofNepaliareHindu,withsmallernumbersfollowingBuddhist,

MuslimandChristianfaiths46.Lifeexpectancyforbothmalesandfemalesisjustover70

yearsofage,whichranksasthe155thhighestworldwide,similartotheratesforKyrgyzstan,

BhutanandNorthKorea47.Only5.8%ofGrossDomesticProduct(GDP)isspenton

healthcareprovision,comparedto9.4%intheUnitedKingdom(UK)48.

44CIAFactbook(2016)FactbookonNepal.Availableathttps://www.cia.gov/library/publications/the-world-factbook/geos/np.html.Dateaccessed15thFebruary201745ibid46ibid47ibid48ibid

FIGURE1–POPULATIONPYRAMIDFORNEPAL,201622

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TheWorldBankclassifiesNepalasaLowIncomecountryduetoaGDPofaround$1000per

capita49.ItspopulationdemographicsaretypicalofacountrywithalowGDP;asof2016,

over70%ofNepaliareagedunder40,andonly5%are65yearsofageorabove50.

NorthYorkshire

Coveringover3,000squaremiles,NorthYorkshireisoneofthelargestandmostrural

countiesinEngland,andismadeupofsevendistrictcouncilareasandsixeitherwholeor

partCCGareas51.Thepopulationhavebetteroutcomesrelatedtohealth,employment,

educationandhousingcomparedtothetypicalEnglishlocalauthorityarea,althoughthere

areareasofdeprivation,someofwhicharerankedwithin10%ofthemostdeprivedareasin

thecountry52.

ThelifeexpectancyatbirthofthoselivingintheCountyis83.7yearsforfemalesand80.1

yearsformales,comparedwithanationalaverageof83.01and79.21respectively53.The

populationofNorthYorkshireisageing,andtheimbalancebetweenyoungandoldismore

profoundthanforEnglandasawhole;overthenext20years,thenumberofresidentsaged

65andoverislikelytorise,andinthecaseofthoseaged85andover,risesharply54.A

particularchallengeisaclearunderrepresentationofchild-bearingfemalesresidingwithin

theCounty55.

49TheWorldBank(2016)CountryIncomeGroups.Availableathttp://chartsbin.com/view/2438.Dateaccessed15thFebruary2017.50CIAFactbook(2016)FactbookonNepal.Availableathttps://www.cia.gov/library/publications/the-world-factbook/geos/np.html.Dateaccessed15thFebruary201751NorthYorkshireCountyCouncil(2015)JointStrategicNeedsAssessmentUpdate14/15.Availableathttp://www.nypartnerships.org.uk/CHttpHandler.ashx?id=30660&p=0.Dateaccessed15thFebruary2017.52ibid53ibid54ibid55ibid

24

Figure2showsthepredictedchangeinagedistributionintheCounty,withparticularlyhigh

increasesseeninthenumberofpeoplelivingto70andbeyond.Thoseaged65andoverwill

growinnumberbyanestimated65,000.

TheCountyisrelativelyhomogenousintermsofethnicity;thepopulationis92%white,with

only2%ofresidentsfromanAsianorBritishAsianethnicbackground56.

NepaliinNorthYorkshire

In2011,datafromtheCensusshowedthatonly0.5%ofthepopulationinNorthYorkshire

hadaSouthAsianethnicbackground.Thisethnicgroupingwillincludemorethanjust

Nepaliresidents.

NorthYorkshirehad971residentswhoidentifiedashavingaNepaleseethnicbackground,

theoverwhelmingmajority(88%)ofwhichweresituatedinthedistrictofRichmondshire.

56NorthYorkshireCountyCouncil(2015)JointStrategicNeedsAssessmentUpdate14/15.Availableathttp://www.nypartnerships.org.uk/CHttpHandler.ashx?id=30660&p=0.Dateaccessed15thFebruary2017.

30,000 20,000 10,000 0 10,000 20,000 30,000

0to45to9

10to1415to1920to2425to2930to3435to3940to4445to4950to5455to5960to6465to6970to7475to7980to8485to89

90+

2037Female 2013Female 2037Male 2013Male

FIGURE2–POPUL.PYRAMIDFORNORTHYORKSHIRE,SHOWING2013ANDPREDICTED2307COUNTS23

25

Craven 8(0.8%)Hambleton 13(1.2%)Harrogate 71(6.8%)Richmondshire 929(88.7%)Ryedale 16(1.5%)Scarborough 3(0.3%)Selby 7(0.7%)NorthYorkshire 1,047

TABLE1–NUMBER(AND%)OFNEPALIRESIDENTSBYDISTRICT,CENSUS2011Thiswasthefirsttimecountry-specificcensusdatawasavailabletostudy;priorcensus

questionnaireshadmerelylistedethnicgroups(e.g.SouthAsian),andthereforeanalysing

trenddataIsnotpossible.However,anecdotalreportsfromcommunityleaderssuggestthat

migrationintoNorthYorkshirefollowedasimilarpatterntoelsewhereinthecountry;after

therightstosettlementweregranted,migrationfromNepalincreased.

LookingattheRichmondshiredatainmoredetail,itispossibletoassesstheageandgender

splitamongstthecommunity(seeFigure3).

-100 -50 0 50 100 150

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Numberofresidents

Age Male

Female

FIGURE3-GENDERANDAGEOFRESIDENTSWITHNEPALESEETHNICBACKGROUNDLIVINGINRICHMONSHIRE,DATAFROMUKCENSUS2011

26

ItisclearthattheretheagestructureoftheNepalicommunitydoesnotreflectthatofthe

generalNorthYorkshirepopulationseeninFigure2.TherearefarmoreNepaliresidents

undertheageof40thanover,andtheoppositeistruefortherestoftheCounty.In2011,

78%oftheNepalesecommunitywasundertheageof40.

27

Results of Community Survey Therewere70responsestothecommunitysurvey.Notallquestionswereansweredby

everyrespondenthowever,andsothetotalnumberofresponsespresentedundereach

sectionwillvary.Itisimportanttounderstandthedemographicsofthoserespondingin

ordertoappreciatehowtheresultsgainedmayhavebeenaffectedbytherespondents’age

andgenderdistribution.Italsoallowscomparisonwiththecensusdatatoexaminewhether

thesurveysamplereflectsthatofthewidercommunity.

AgeandGender

Theagesoftherespondentsrangedfrom16to77.Themedianagewas42,themeanwas

42andthemodewas31.

TheasymmetryFigure4demonstratesthevariationintheageandgenderofsurvey

respondents.Inparticular,youngmaleswereverywellrepresented.However,ascanbe

seeninFigure3,thisisnotnecessarilyunrepresentativeoftheNepalicommunitylivingin

-10 -5 0 5 10 15 20 25 30

16-25

26-35

36-45

46-55

56-65

66-75

76-85

Numberofrespondants

Ageinyears

Male

Female

FIGURE4–AGEANDGENDERBREAKDOWNOFRESPONDANTSTOCOMMUNITYSURVEY

28

Richmondshiredistrict.However,itisnoticeablethattherearefewerfemalesrepresented

thanwewouldperhapsexpectgiventhecensusdata.Whilstolderresidents(aged56and

over)arerepresentedinproportionssimilartothosesuggestedbythecensusdata,itshould

benotedthattheseagebandscoveronlyasmallnumberofrespondents.

Levelofeducation

Figure5showsthelevelofeducationalattainmentofsurveyrespondentsbyagegroup.It

suggestsyoungerrespondentshaveahigherlevelofeducationalattainmentthatthosewho

areolder.Forthe26-35ageband,onlyasmallnumberhadnotachievedeithersecondary

schoolorUniversityeducation.Thisstandsincontrasttothe66-75agegroup,forwhomthe

majorityonlyreceivedprimaryeducation.

0 5 10 15 20 25 30 35

16-25

26-35

36-45

46-55

56-65

66-75

76-85

Numberofrespondents

Age

Primary Secondary University

FIGURE5-LEVELOFEDUCATIONALATTAINMENTOFSURVEYRESPONDENTSBYAGE

29

0

5

10

15

20

25

0-2 3-5 6-8 9-11 12-15 >15

Num

bero

frespo

nden

ts

NumberofyearsresidentintheUK

FIGURE7–YEARSRESIDENTINTHEUKBYNUMBEROFSURVEYRESPONDENTS

Figure6showseducationalattainmentbygender.Itsuggeststhattheproportionreceiving

secondaryandUniversityeducationishigheramongmalesthanfemales.Howeverthisis

partlyduetothemoreevenagedistributionoffemalerespondentscomparedtomales.

Yearsofresidence

Figure7showsthatthemajorityofsurveyrespondentshavebeenlivingintheUKformore

than5years,withalargenumberhavingbeensettledhereformorethan10years.

0 5 10 15 20 25 30 35

Female

Male

Numberofrespondents

Gend

er

University Secondary Primary

FIGURE6-LEVELOFEDUCATIONALATTAINMENTOFSURVEYRESPONDENTSBYGENDER

30

EmploymentStatusThemajorityofrespondentswereineitherfulltimeorpart-timeemployment.Therewere

nomalerespondentswhowereunemployedandlookingforwork,andonlyasmallnumber

offemales(4%offemales,2/44)were.

Englishlanguageability

0 5 10 15 20 25 30 35 40

Fullsmeemployment

Part-smeemployment(1-36hrs)

Notemployed,notlookingforwork

Notemployed,lookingforwork

Resred

Student

Numberofrespondents

Male Female

FIGURE8–EMPLOYMENTSTATUSOFSURVEYRESPONDENTSBYGENDER

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Female

Male

Percentageofrespondents

HowwelldoyouspeakEnglish?

Notatall

Notwell

Quitewell

Verywell

FIGURE9–SELF-REPORTEDLEVELOFENGLISHABILITYOFSURVEYRESPONDENTSBYGENDER

31

Figure9showsthenumberandtypesofresponsestothequestion‘Howwelldoyouspeak

English?’brokendownbygender.TheresultssuggeststhatEnglishfluencyishighestamong

males,withthemajorityratingtheirabilityas‘quite’or‘very’good.Conversely,themajority

offemalesreportedthattheyspokeEnglish‘notwell’ornotatall.Thismayreflectatrue

differenceinthelanguageandcommunicationskillsbetweenmalesandfemalesinthe

community,butmayalsoreflectadifferenceinthewaysmalesandfemalesself-ratetheir

ownability.

Self-reportedPhysicalHealthStatus

Figure10showsself-reportedhealthstatusbygender.Thereisnomajordifferencein

proportionofthedifferenthealthstatesbetweenmalesorfemales.Overall,therewere

veryfewrespondentswhoratedtheirhealthaspoororverypoor.

0 5 10 15 20 25

Verypoor

Poor

Fair

Good

Verygood

Numberofrespondants

Self-repo

rted

health

status

Ingeneral,howwellwouldyourateyourhealth?

Male

Female

FIGURE10-SELF-REPORTEDHEALTHSTATUSBYGENDER

32

However,Figure11showshowself-reportedhealthstatusisaffectedbyage.Younger

respondentsweremorelikelytoratetheirhealthasverygoodorgoodiftheywereunder

theageof45,comparedtothoseagedover45.Thereversewastrueofthosereportingvery

poororpoorhealthstatus.

Figure12showstherewerealsoveryfewrespondentswhoreportedhavingachronicillness

ordisability.Thissupportsthenotionthatasignificantmajorityofrespondentsenjoyagood

levelofphysicalhealth.

0% 20% 40% 60% 80% 100%

Verypoor

Poor

Fair

Good

Verygood

Percentageofrespondants

Self-repo

rted

health

status

16-45yrs

>45yrs

FIGURE11-SELF-REPORTEDHEALTHSTATUSBYGENDER

Yes4%

No96%

Doyouconsideryourselftohavealongstandingillness,disabilityorinfirmity?

FIGURE12–NUMBEROFRESPONDENTSWITHALONGSTANDINGILLNESS,DISABILITYORINFIRMITY

33

Lifestyle

Inadditiontoaskingdirectlyabouthealthstatus,thesurveyalsoincludedquestionsabout

lifestylefactorsthatcancontributetohealthandill-health,bothphysicalandmental.

Diet

Respondentswereaskedtoratethehealthinessoftheirnormaldiet,aswellasspecifythe

numberofportionsoffruitandvegetablestheyconsumedaily.

Figure13demonstratesthatwhilstnorespondentconsideredtheirdiettobeunhealthy,

relativelyfewconsumedtherecommendednumberoffruitandvegetablesperday.Whilst

thisisonlyoneaspectofanindividual’sdiet,itisanimportantcomponentofwhat

constitutesahealthydietandcanreducetheriskofhypertension,heartdisease,stroke,and

certaintypesofcancer.

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4 >5

Num

bero

frespo

nden

ts

Numberofporsonsoffruit/vegperday

Fairlyhealthy Quitehealthy Veryhealthy

FIGURE13–SELF-REPORTEDQUALITYOFDIETBYNUMBEROFPORTIONSOFFRUITANDVEGETABLESEATENDAILY

34

TheAdultDentalHealthsurveyof2009classifiesthoseindividualsthatconsumecakes

(cakes,biscuits,puddingsorpastries),sweets(sweetsandchocolate)andsugarydrinks

(fizzydrinks,fruitjuice,orsoftdrinkslikesquash)sixormoretimesaweekashighsugar

consumers.Usingthisproxymeasureforsugarconsumption,50%ofthosethatwere

dentateintheAdultDentalHealthsurvey2009wereclassifiedashighconsumersofsugar.

Whilstdirectcomparisonscannotbemadewiththissurveyasthequestionsvaried,30%of

respondentsdeclaredeatinghoney,syrup,sweetsorchocolatemorethanonceaday.This

wouldbeclassifiedashighsugarconsumptionusingtheAdultDentalHealthsurvey

definition.Inaddition,69%ofrespondentsreporteddrinkingsquash,fizzydrinksorhaving

sugarinhotdrinks.Eventhoughitisnotpossibletoquantifytotalsugarconsumption,this

issignificant.

Smoking

Aslightlyhigherproportionofrespondents(22%)reporteduseoftobaccoproducts

comparedtotheUKpopulationaverage(19%)andNorthYorkshireaverage(16.7%),

althoughthiswaslowerthantheprevalenceinNepal(27%)5758.

However,ofthosethatusedtobacco,thenumberofrespondentschoosingsmokelessor

chewingtobaccowashigherthantheaverageforboththeUKandNepal.

57HealthandSocialCareInformationCentre(2016)StatisticsonSmoking.Availableathttp://content.digital.nhs.uk/catalogue/PUB20781/stat-smok-eng-2016-rep.pdf.Dateaccessed27thFebruary2017.58TheTobaccoAtlas(2013)NepalFactSheetAvailableathttp://www.tobaccoatlas.org/country-data/nepal/.Dateaccessed27thFebruary2017.

35

TheHealthSurveyofEngland(2004)reportedthatthemostfrequentusersofsmokeless

tobaccoproductsinEnglandweremigrantsoriginallyfromtheIndiansub-continent.

Thisispotentiallysignificantastobaccouseinanyformisassociatedwithanincreasedrisk

oforalcancerandsmokingincreasestheriskofperiodontaldisease.

Yes22%

No78%

Doyoucurrentlyuseanytobaccoproducts?

FIGURE14–PERCETNAGEOFRESPONDENTSREPORTINGTOBACCOUSE

Chew47%Smoke

53%

Howdoyouconsumeyourtobacco?

FIGURE15–PERCENTAGEOFRESPONDENTSBYTYPEOFTOBACCOCONSUMPTION

36

Oftherespondentsreportingtobaccouse,73%acknowledgedthatsmokingwasharmfulfor

theirhealth,althoughonly60%hadreceivedsmokingcessationadvicefromahealth

professional.

Alcohol

Inasimilarwaytothequestionsontobacco,respondentswereaskedabouttheirlevelof

alcoholconsumption,aswellaswhethertheyconsidereditharmfultotheirhealth.

Figure16showsthedistributionofrespondents’consumptionandthoseconsideringittobe

harmfultotheirhealth.Itisinterestingtonotethatdespitelownumbersreportingdaily

alcoholdrinking,noneconsideredthisharmfultotheirhealth.

0

5

10

15

20

25

Daily Mostdays 2-3smesaweek

Onceaweek Onlyoccasionally

Num

bero

frespo

nden

ts

Doyouconsideryourcurrentlevelofintaketobeharmful?

No

Unsure

Yes

FIGURE16–LEVELOFCONSUMPTONANDOPINIONONITSHARMTOHEALTHBYNUMBEROFRESPONDENTS

37

InNorthYorkshire,24.1%ofthepopulation59areclassifiedashaving‘increasingandhigher

riskdrinking’withtheEnglandaveragebeing22.3%.Alimitationofthequestionnaireused

forthisHNAisthatitdidnotaskrespondentstospecifytheactualamountofalcohol

consumed.However,thismustbeplacedwithinthecontextofpotentialculturaland

languagebarrierswhichmayhavemadeitdifficulttoelicitanaccurateresponse.If‘2-3

timesperweekormore’consumptionofalcoholisusedasaproxymeasureforpotentially

increaseddrinking(acceptingthatsomeindividualsmayconsumeexcessiveamounts,but

onlyonceperweek)then21/70(30%)oftherespondentsareatrisk,whichishigherthan

theNorthYorkshireorEnglandrates.However,if‘mostdays’isusedasaproxymeasure

thenonly5/70(7.1%)wouldbeatriskofexcessivelevelsofdrinking.As21individuals

providednoresponse,itisdifficulttoaccuratelyquantifythenumbersofthoseatrisk

overall.

Figure17alsosuggeststhattheseresultsmayhavebeeninfluencedbyalackof

understandingaboutthemaximumrecommendedweeklyintakeofalcohol.Norespondent

statedthatthislevelwasmorethantheDepartmentofHealthrecommendedlimitof14

units,withthevastmajoritybelievingthetruesafelimittobesignificantlylowerthanthis.

59PublicHealthEngland(2013)HealthProfile,September2013

38

Figure18showsthelevelofconsumptionbygender.Theresultsmayhavebeenaffectedby

thelowproportionoffemalerespondentswhochosetoanswerthisquestion.Nevertheless,

despiteverysmallnumbersreportingadailyalcoholintake,bothmalesandfemaleswere

represented.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

0-4 5-9 10-14

Percen

tgaeofrespo

ndan

ts

Numberofunits

Howmanyunitsofalcoholisconsideredsafetodrinkinaweek?

FIGURE17–ESTIMATEOFSAFELEVELOFALCOHOLCONSUMPTIONBYPERCENTAGEOFRESPONDENTS

0

2

4

6

8

10

12

14

16

18

20

Daily Mostdays 2-3smesaweek

Onceaweek Onlyoccasionally

Num

bero

frespo

nden

ts

Howouendoyoudrinkalcohol?

Female

Male

FIGURE18–ALCOHOLCONSUMPTIONBYGENDER

39

Asimilarproportionofrespondents(71%)reportedhavingbeenprovidedguidanceabout

theirlevelofalcoholconsumptiontothosebeinggivensmokingcessationadvice(73%).

Dentalhealth

Figure19showsthemajorityofrespondentshavemorethan20naturalteeth,althoughitis

unclearhowmanyhavefullorpartialdentures.

DirectcomparisonswiththeAdultDentalHealthsurvey60shouldbemadewithcautiondue

todifferenceinsurveymethodology;howeveritprovidesausefulcontextforthefindingsof

thisassessment.Itreportedthatofthoseaged16-24yearsoldhadanaverageof28.6teeth,

55-64yearolds23.2teethandthoseaged85yearsandolder14teeth.Despitethelow

60HealthandSocialCareInformationCentre(2011)AdultDentalHealthSurvey2009

0

10

20

30

40

50

60

Noneatall 1-9 10-19 20+ Ihavesomenaturalteethbutnotsurehow

many

Num

bero

frespo

nden

ts

Howmanynaturalteethdoyouhave?

FIGURE19–NUMBEROFNATURALTEETHBYNUMBEROFRESPONDENTS

40

numbersofrespondents,Figure20providessomeindicationoftheestimatednumbersof

teethreportedbyindividualsofdifferentagegroupswithintheNepalesecommunityin

NorthYorkshire.Itshouldbenotedthat7individualswereuncertainofhowmanynatural

teeththeyhadandtheyhavebeenexcludedformthefigurebelow.

FIGURE20–NUMBEROFNATURALTEETHBYAGEOFRESPONDANT

Despitetheseresults,however,asignificantnumberofrespondentsreportedexperiencing

toothacheormouthpain,aswellasfeelingtheirteethwere‘worn’.

0

5

10

15

20

25

16-24 25-33 34-42 43-51 52-60 61-69 70-78

Num

bersofind

ividua

ls

Age(years)

Howmanynaturalteethdoyouhave?

Noneatall

1-9teeth

10-19teeth

20+teeth

0

5

10

15

20

25

30

35

40

45

Never Occasionally Fairlyouen Veryouen

Num

bero

frespo

nden

ts

Overthepast12months,haveyouhadtoothacheorpainfromyourmouth?

FIGURE21–NUMBEROFRESPONDENTSEXPERIENCINGTOOTHACHEORMOUTHPAININPREVIOUSYEAR

41

AshighlightedbytheAdultDentalHealthSurvey200961,responsestoquestionnaires

regardingfrequencyofbrushing,andfrequencyofuseofavarietyofdifferenttooth

cleaningproducts,provideapictureofthemotivationofthoseindividualstoengageinoral

hygienepractices.Theresponsesdonot,however,informusoftheeffectivenessor

otherwiseoftheoralhygienetechniquesundertakenbytheindividuals.

64%ofrespondentsreportedbrushingtheirteethtwiceormoreperdayand36%reported

brushingonceaday,whichislowerthantherateforthegeneralpopulation.TheAdult

DentalHealthsurvey2009found75%ofthosesurveyedinEngland,WalesandNorthern

Irelandreportedbrushingtheirteethtwiceormoreperdayandonly23%onceperday.

61HealthandSocialCareInformationCentre(2011)AdultDentalHealthSurvey2009

Yes31%

No69%

Wouldyoudescribeyouteethasworn?

FIGURE22–NUMBEROFRESPONDENTSREPORTINGWORNTEETH

42

Alloftherespondentsinthissurveyreportedusingatoothbrushandtoothpastetoclean

theirteeth.

Useofdentalservices

Anumberofquestionswereincludedinordertogainanunderstandingofrespondents’use

ofdentalservicesandidentifyanybarrierstoaccesswhichmightexist.Thesewere

incorporatedasaresultofthefindingsoftheevidencereview.

60%ofrespondentsvisitthedentistatleastonceperyear,(incomparisonwith77.4%of

respondentsfromtheNorthYorkshireandYorkPCTareain200862)with40%attendingless

frequentlyoronlyinacuteneed.Thishasthepotentialtoreducetheabilitytoprovide

treatment,preventivemeasuresandregularhygieneadvice.

62HealthandSocialCareInformationCentre(2011)AdultDentalHealthSurvey2009

0 5 10 15 20 25 30 35 40

Atleastonceeveryyear

Lessthanonceayear

Onlywhenhavingtroublewithteeth/dentures

Numberofrespondents

IntheUK,howouendoyougotothedensst?

FIGURE23–ATTENDANCEATDENTISTBYNUMBEROFRESPONDENT

43

Figure23showsthereasonsrespondentsreportednothavingattendedadentistinthe

previous2years.64%failedto‘seethepoint’inattendingthedentist,suggestingthereisa

lackofawarenessamongstsomeoftherespondentsabouttheimportanceofreceiving

regulardentalexaminationsandpreventivecare.

14%ofrespondentsreportedhavingdifficultymakinganNHSdentalappointment(in

comparisonwith20.9%ofrespondentsfromNorthYorkshireandYorkPCTin2008,though

thiswasinrelationtoaccesstotheprovisionofroutinedentalcare),whilstasimilar

proportion(15%)reportedhavinghadtodelaydentaltreatmentduetothefinancialcost.

0 2 4 6 8 10 12 14 16

Idon'tseethepointingoingtothedensst

Itisdifficulttogettothedensst

Ihavehadabadexperiencewithadensst

Iamtooembarrasedtogotoadensst

Itistooexpensive

Ittakestoomuchsmetoorganise

Numberofrespondents

Whichofthese,ifany,arereasonswhyyouhavenotbeentothedensstinthelast2years?

FIGURE24–REPORTEDBARRIERSINACCESSINGDENTALCAREBYNUMBEROFRESPONDENTS

44

Emotionalhealthandwellbeing

Despitethemajorityofrespondentsreportingtheyfelt‘fairlyhappy’,‘happy’or‘very

happy’,therewasstillalmostaquarter(23%)whowere‘unhappy’or‘fairlyunhappy’.When

respondentswereaskedtolisttheirmainworry,changeinlifestylewasthemostfrequently

reportedconcern.

Whatisyourmainworrycurrently?Changeinlifestyle 15

Economichardship 11Lackofsocialsupport 9Health 7Immigrationstatus/visaissues 5Lackoftraditionalfoodandcelebrations 4Other 3GrandTotal 58

TABLE2–CONCERNSREPORTEDVYSURVEYRESPONDENTS

0

5

10

15

20

25

VeryHappy Happy Fairlyhappy Unhappy Fairlyunhappy

Num

bero

frespo

nden

ts

Inthepastfewweeks,howhaveyoubeenfeeling?

FIGURE25–SELF-REPORTEDMENTALHEALTHSTATUSBYNUMBEROFRESPONDENTS

45

Asignificantproportion(44%)ofrespondentsalsoreported‘sometimes’or‘often’feeling

lonely.Itispossiblethatthisisaresultofboththechangeinlifestyleandlackofsocial

networksomeintheNepalicommunityhavefeltsincesettlingintheUK.

UseofhealthservicesThelevelofGPregistrationamongstrespondentswasveryhigh.Males(96%)wereslightly

morelikelytoberegisteredthanfemales(94%),althoughthedifferencewasverysmall.

56%

41%

3%

HowoXendoyoufeellonely?

Never/hardlyever Someofthesme Ouen

FIGURE26–REPORTEDLEVELOFLONELINESSBYPROPORTIONOFRESPONDENTS

0%10%20%30%40%50%60%70%80%90%100%

Female Male

Percen

tageofrespo

nses

AreyouregisteredwithaGP?

Yes

No

FIGURE27–PROPORTIONOFRESPONDENTSREGISTEREDWITHAGPBYGENDER

46

Ofthosethatwereregistered,95%werehappywiththeserviceprovidedbytheirpractice.

RespondentswerealsoaskedwhichGPpracticetheywereregisteredwith,althoughthe

responsetothisquestionwasextremelypoor;onlyHarewoodMedicalPracticeandthe

DefenceMedicalServiceswerelisted.

RespondentswerealsoaskedaboutthenumberofGPandA&Eattendancesintheprevious

12months.

AsFigure26showsthenumberofGPattendancesishigheramongstthoseagedover45

yearsthanunder.Thisisperhapsunsurprisinggiventheincreasinghealthneedsofolder

people,butdoescontrastwiththeverylownumbersreportingchronicdiseaseordisability.

ThereisnoobviouspatterndetectablewhenanalysingGPattendancebygenderorself-

reportedhealthstatus.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-1 2-3 4-5 6-7 8-10

NumberofGPvisitsperyear

HowmanysmeshaveyouvisitedyourGPinthelastyear?

Age16-45yrs Age45+years

FIGURE28–NUMBEROFGPATTENDANCESBYAGEBANDINGANDPROPORTIONOFRESPONDENTS

47

ThemajorityofrespondentshadnotusedanA&Edepartmentwithintheprevious12

months.However,3/32(9%)ofrespondentshadusedit3ormoretimes.Someofthe

reasonsgivenforattendanceincluded‘regularcheck-up’and‘cold/flusymptoms’.This

suggeststheremaybealackofunderstandingaboutappropriateuseofprimaryand

secondarycareservices.

67%ofrespondentshadreceivedasighttestsincearrivingintheUK,whichgiventheage

distributionoftherespondents,isencouraging.Allrespondentsovertheageof55had

receivedasighttest,whichisimportantgiventheincreasingimportanceofsight

assessmentwithadvancingage.However,itisconcerningthatofallfemalerespondents,

44%hadnotreceivedasighttest.Sightlossisanimportantpotentiallypreventablecauseof

restrictionandisolation;ithasbeenestimatedthat50%ofsightlossifpreventablewith

0 5 10 15 20 25 30

0

1

2

3

4

Numberofrespondents

Num

bero

fA&Eaw

ende

nces

HowmanysmeshaveyouvisitedA&Einthelastyear?

FIGURE29–REPORTEDNUMBEROFA&EATTENDENCESBYNUMBEROFRESPONDENTS

48

correctionlensesorophthalmictreatment.Inaddition,nearlytwo-thirdsofpeopleliving

withsightlossarewomen63.

Healthbeliefs

Variousquestionswereincludedinthesurveywhichaimedtogainanunderstandingofany

differenceinhealthbeliefbetweentheNepalicommunityandthegeneralUKpopulation,

whichmayaffectthewaysinwhichservicesareaccessed.

91%respondentssaidtheyfeltcomfortableinseekingmedicalattentionifunwell,and60%

thoughtitwassensibletodoexactlyasmedicalprofessionalsadvise.

63RoyalNationalInstituteofBlindPeople(2016)KeyStatistics.Availableathttp://www.rnib.org.uk/knowledge-and-research-hub/key-information-and-statistics.Dateaccessed20thFebruary2017.

No9%

Yes91%

Doyoufeelcomfortableseekingmedicalawensonifunwell?

FIGURE30–PROPORTIONOFRESPONDENTSWHOREPORTEDFEELINGCOMFORTABLESEEKINGMEDICALATTENTIONIFUNWELL

49

Themajority(74%)feltthatgoodhealthwasthemostimportantthinginlife.Respondents

werethenaskedwhethertheyagreedordisagreedwithanumberofstatementsrelatedto

healthbeliefs.TheresultsofthesequestionsarelistedinFigure29.

Itisinterestingtonotethatthemajorityofrespondentsagreedthatboth‘goodhealthis

generallyamatterofluck’andthat‘ifyouthinktoomuchaboutyourhealth,youaremore

likelytobeill’.Thissuggeststhatasignificantproportionofrespondentsmaynotfeel

empoweredtomakechoicesabouttheirlifestyleorbehaviouronthebasisofhealth

benefit.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

Goodhealthisgenerallyamawerofluck

Ifyouthinktoomuchaboutyourhealth,youaremorelikelytobeill

Sufferingsomesmeshasadivinepurpose

IhavetobeveryillbeforeIgotoadoctor

Peopledon'treallyhavesmetothinkabouttheirhealth

Percentageofrespondents

Howstronglytoyouagreeordisagreewiththefollowingstatements?

Stronglyagree Agree Disagree Stronglydisagree

FIGURE31–PROPORTIONOFRESPONDENTSREPORTINGAGREEMENTORDISAGREEMNTWITHANUMBEROFSTATEMENTSRELATEDTOHEALTHBELIEFS

50

Respondentswerealsoaskedtoconsidertheirlikelyactionsifunwell.Responsestothese

questionsarepresentedinFigures30and31.

RespondentsreportedapreferenceforUKmedicalattentionandtreatment,withonlya

minority‘likely’or‘verylikely’tocalladoctororphysicianinNepal.Thisalsoextendedtoa

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

askafriendorfamilymemberintheUKformedicaladvice

askafriendorfamilymemberinNepalformedicaladvice

useover-the-counterWesternmedicine

usealternasvemedicines

Percentageofrespondents

Ifyoubecameunwellhowlikelyareyouto...

Verylikely Likely Unlikely Veryunlikely

FIGURE32-PROPORTIONOFRESPONDENTSREPORTINGTHELIKELINESSOFANUMBEROFRESPONSESINTHEEVENTOFTHEIRILL-HEALTH

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

seeadoctorintheUK

seeapharmacistintheUK

calladoctor/physicianinNepal

Percentageofrespondents

Ifyoubecameunwellhowlikelyareyouto...

Verylikely Likely Unlikely Veryunlikely

FIGURE33-PROPORTIONOFRESPONDENTSREPORTINGTHELIKELINESSOFANUMBEROFRESPONSESINTHEEVENTOFTHEIRILL-HEALTH

51

preferencefortheuseofWesternover-the-countermedicinesratherthanalternative(e.g.

traditionalChinese)medicines.Morethan70%ofrespondentswerelikelytoaskfriendsand

family,inbothNepalandtheUK,formedicaladviceifunwell.

Socialcare

Approximately10%ofthepopulationinEnglandarecarers64.15%ofNepalirespondents

reportedhavingsomeformofcaringresponsibilityduetolong-termphysicalormentalill

healthordisability,and18%duetohealthproblemsrelatedtooldage.However,onlya

verysmallnumberofrespondentshadtocareformorethan20hoursperweek(2/62,3%).

64TheCarersTrust(2016)Keyfactsaboutcarersandthepeopletheycarefor.Availableathttps://carers.org/key-facts-about-carers-and-people-they-care.Dateaccessed27thFebruary2017.

0 10 20 30 40 50 60

No

Yes-1to19hoursaweek

Yes-20to49hoursaweek

Yes-50ormorehoursaweek

Doyoulookauerorgivesupporttoanyonebecauseoftheirlong-termsphysicalormentalillhealthordisability?

FIGURE34–NUMBEROFRESPONDENTSWITHCARINGRESPONSIBILTIESDUETOCHRONICILL-HEALTHORDISABILITYBYWEEKLYCOMMITTMENT

52

0 10 20 30 40 50 60

No

Yes-1to19hoursaweek

Yes-20to49hoursaweek

Yes-50ormorehoursaweek

Doyoulookauerorgivesupporttoanyonebecauseofproblemsrelasngtooldage?

FIGURE35-NUMBEROFRESPONDENTSWITHCARINGRESPONSIBILTIESDUETOPROBLEMSOFOLDAGEBYWEEKLYCOMMITTMENT

53

Results of Professional Surveys HealthandOtherProfessionalSurveyTherewere9responsestothissurvey,whichwassenttoaround30individualsfromthe

healthsector,aswellasotherprofessionalbackgrounds.Responseswerereceivedfroma

policeofficer,healthvisitor,pharmacist,drugandalcoholservicemanager,socialcare

assessors,andaLivingWellservicecoordinator.

Thesurveyaskedrespondentstorankfactorswhichtheyfeltpositivelyaffectedthehealth

andwellbeingoftheNepalesecommunity,aswellasfactorswhichnegativelyaffected

healthandwellbeing.Iftherespondentwasfromamedicalbackground,theywerealso

askedtorankspecifichealthissueswhichtheyfeltparticularlyaffectedthehealthofthe

Nepalesepopulation.

Giventhelowresponserate,itisproblematictodrawconcreteconclusionsfromthe

findings.Nevertheless,thefollowingisasummaryoftheresults.

ThetopthreefactorspositivelyaffectingthewellbeingofNorthYorkshire’sNepali

populationwerethoughttobe:

1. Senseofcommunity

2. Availabilityoffriendsandfamilysupport

3. Religionandculturalbeliefs.

54

ThetopthreefactorsthoughttobenegativelyaffectingthewellbeingofNorthYorkshire’s

Nepalipopulationwere:

1. Socialisolation

2. Accesstoservices

3. Livinginaremoteandruralarea(linkedtoavailabilityoftransport)

Thethreemostimportanthealthissuesaffectingthehealthofthecommunitywerethought

tobe:

1. Depressionandmentalhealthissues

2. Heartdisease

3. Diabetes

Itisinterestingtonotetheapparentdiscrepancybetweensenseofcommunityand

availabilityofsocialnetworkbeinglistedasimportantfactorscontributingpositivelyto

wellbeing,whilstsocialisolationwasthoughttobethemostimportantfactornegatively

affectingwellbeing.

Thismaybeexplainedbysomeinthecommunity’sresponsetomentalhealthconditions.

Respondents,someofwhomprovidedfurtherqualitativedetailintheirresponses,

suggestedthereisalackofawarenessofmentalhealthissuesamongstthecommunity.

Referencewasalsomadetothead-hocnatureoffamilysupport,whichmaybedependent

onappropriaterecognitionofcertainmedicalconditions.

55

ThegoodlevelofEnglishlanguageabilityamongstthecommunitywasnotedtobeoneof

thereasonsmanyNepalihavesettledwellinNorthYorkshireandbeenwelcomedbythe

widercommunity.However,itwasalsohighlightedthatnoteveryNepaliresidentisableto

understandorspeakEnglish,andthisgreatlyrestrictsaccesstoservices.Thismakescertain

individualsheavilyreliantontheassistanceofcertaincommunitymembers,whooftenact

asgatekeeperstowiderpublicservices.

Itshouldalsobenotedthatthedrugandalcoholservicehadnohistoryofengagementfrom

anyonefromaNepaliethnicbackground.

DentalProfessionalSurvey

Responseswerereceivedfrom25dentalpracticesacrosstheCounty.However,only5

practicesreportedhavingtreatedanyonefromtheNepalicommunity.2ofthesepractices

hadtreatedmorethan20Nepalesepatientsovertheprevious2years.Theresponses

receivedsuggestthatthedentalpracticeswiththegreatestnumbersofpatientsarelocated

intheproximityofthemilitarybaseinCatterickGarrision.

75%ofadultpatientswerereportedtobealmostentirelydentate,with25%beingpartially

dentate.Thetypicaltreatmentprovidedvaried,butmostcommonwasexaminationand

assessment,preventivetreatmentandbasicperiodontalcare.However3ofthe5practices

(60%)reportedthattheaverageNepalesepatientattendedthedentistonlywhen

experiencingtroublewiththeirteethordentures,ratherthanonaregularbasis.

56

ThetypeofcareprovidedwasamixtureofprivateandNHS,with60%ofpracticesreporting

someelementofprivatecareprovision.Only2providedNHScareexclusively.

3ofthe5practiceshadencounteredsomedifficultiesincommunicationwiththeirNepalese

patients,whilsttheothershadexperiencednone.

Allpracticesreportedofferingoralhygieneadvice,includingguidanceontobaccouse,

alcoholuse,anddiet.Thisalsoincludedtheofferofonwardreferraltosmokingcessationor

alcoholmanagementprogrammesifnecessary.However,only50%ofpracticesreported

thatpatientstendedtoacceptsuchreferrals.

57

Currently available services TheInfantryTrainingCentreCatterick(ITC)islocatedinCatterickGarrison.TheGurkha

TrainingCompanyispartofthe2ndInfantryTrainingBatallionandisaccommodatedonthe

HellesBarrackssite.TheArmyMedicalCentreon-siteprovidesaprimaryhealthcareservice

andregularmedicalstothemilitarystaffatCatterick,butdoesnotprovideaservicetonon-

militarystafforfamilies.TheseresidentsareservedbyTheHealthCentreinCatterick,at

whichseveralGPsarebased.

HarewoodMedicalPracticehasemployedaNepalesespeakertoassistwithcommunication

andimprovethecommunity’saccesstoprimarycareservices.Itisoneofanumberof

practicesinNorthYorkshirewithasignificantnumberofNepalesepatientsregistered.

Lifestyleservices,includingdrugandalcoholtreatmentandsmokingcessation,areavailable

Countywideviaprimarycareorself-referral.

SexualhealthservicesinNorthYorkshireareprovidedbyYorSexualHealth,offeringSTI

testingandtreatment.Thereisspecificprovisionaspartofthisserviceforthemilitary

populationonCatterickGarrisonandtheirfamilies.

Mentalhealthtreatmentandsupportisavailableviaprimaryandsecondarycareservices.

TheBeacon,locatedclosetoCatterickGarrison,specificallytargetssingleex-servicemenand

womenwhoaremostatriskofhomelessness.

58

Limitations of the Assessment TherewereanumberoflimitationsassociatedwiththisAssessment.

Firstly,theamountofepidemiologicaldataavailableforstudywasextremelylimiteddueto

thepoorrecordingofethnicity.Thiswastrueofmanypotentialdatasources,particularly

thoserelatedtoprimarycareandhospitalactivity,andinfectiousdiseaseincidence.This

meansthatourcurrentunderstandingofthehealthstatusoftheNepalesecommunityis

heavilydependentontheresultsofthesurveysdevelopedaspartofthisAssessment.These

findingscannotthereforebecorroboratedwithreferencetonationality-specificprevalence

andconsultationdata.Limitedcomparisonshavebeenmadewiththefindingsofthe2015

OralHealthNeedsAssessmentofNorthYorkshireandthe2009AdultHealthSurvey,

althoughasthemethodologyofthereportsvary(typeandstyleofquestionsasked,for

example),theseshouldbetreatedwithcaution.

Secondly,thelackofnationality-specificdatameantthatthedistributionofthepopulation

acrosstheCountywasunknownandnecessitatedarelianceoncommunityleadersfor

accesstomembersoftheNepalipopulationlivinginNorthYorkshire.Thisdidhadseveral

advantages.Itallowedthesurveytobedistributedbythosewhowerefamiliarwiththe

communityandhadthetrustofitsmembers,whichislikelytohaveledtoincreased

engagementwiththeprojectandincreasedresponserates.However,thissampling

techniquemaynothaveproducedarepresentativesurveysample,andledtoimportant

groupswithinthecommunitybeingmissed.

59

Thirdly,despitetheassistanceofcommunitymembers,theresponseratetothesurveys

wasfairlylow.Basedonacomparisonwithcensusdata,theresponserateforthe

communitysurveywasroughly10%oftheCounty’sNepalipopulation.Butdueto

uncertaintiesaboutthesamplingframe(i.e.thetotalsizeofthepopulationwhomighthave

receivedthesurvey)thisisnotdefinitive.Thisambiguitymakesitdifficulttoguaranteethat

ourfindingsarerepresentativeofthecommunityasawhole.Theresponseofthehealth

andotherprofessionalsurveywasbetter(~30%),howevertherewerecleargapsinthe

responsesreceived.Forexample,noGPreturnedthesurvey.Thismeansthefindingsare

missingpotentiallyvaluableinformation.

Fourthly,noqualitativeinterviewswereundertakenaspartofthisassessment.Thiswasdue

toseveralfactors.Alackofcleardemographicinformationandonlylimitedaccesstothe

communitymeantthatafairsamplerepresentativeofthepopulationcouldnotbe

guaranteed.Itwasalsodifficulttodetermineprofessionals’levelofinteractionwiththe

communitygiventheuncertaintyaboutthelocationofthecommunityandthepopulation’s

likelydispersaloverawidegeographicarea.Completingqualitativeinterviewsunderthese

circumstanceswasbeyondthescopeoftheprojectgiventhetimeandfundingavailable.

60

Recommendations

1. EffortsaremadetoraiseawarenessofavailablehealthservicesamongsttheNepali

community,perhapsviahealtheventorworkshop,withaparticularfocusonthe

following:

i. Mentalhealthservices

ii. Dentalhealthservices

iii. Smokingcessationservices

iv. Alcoholservices

v. Femalehealth

2. TranslatedadviceonavailableNHSservicesandhowtoaccessthemisprovidedto

newrecruitsandtheirfamiliesonarrivalintheUK

3. Healthcareprovidersimprovetheirrecordingofethnicity,enablingmore

comprehensivedataanalysisandadeeperunderstandingofthehealthneedsofthe

communityinfuture

4. ExistinglinksbetweenMinistryofDefenceandNHSserviceprovisionaremaintained

andstrengthened