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