The UK boasts a culturally diverse population, with ethnic minorities accounting for 14% of the population according to the 2011 census [1]. The health of ethnic minorities is becoming an increasingly important issue globally for all health-care providers as well as for health policy-makers.

As well as the social determinants of health that affect the general population, ethnic minority health is complicated by additional factors, including cultural beliefs and behaviours, education, language barriers, genetic phenotype and poor take-up of health education.

Musculoskeletal health is a significantly important part of ethnic minority health. Most research into ethnic minority health in the UK has been focused on South Asians, as they form the largest ethnic group.

Interestingly, there is some suggestion that ethnic minorities living in the West behave differently in their musculoskeletal health patterns from the population of their originating country. For example, one study reported that non-specific musculoskeletal pain, lower back pain, knee pain and soft tissue pain were more common in Pakistanis living in England than those living in Pakistan [2]. Alongside this, other studies from the UK indicate differences between the immigrant and indigenous populations with regard to back pain, knee pain and widespread pain, which were all more commonly reported by ethnic minorities when compared with the indigenous white population [3]. The mechanisms for these observed differences are not fully understood, but lower levels of vitamin D among the ethnic minorities, studied as a cause of musculoskeletal pains, may form part of the explanation.

Health beliefs have an important influence on ethnic minority health. For example, among patients with cardiac problems, it has been observed that South Asians are more inclined to believe their health is very much in the hands of God and destiny compared with the indigenous population [4].

Ethnic minority groups are often educationally or economically disadvantaged and are often less able to access the available educational resources. In the UK, ethnic minority populations may not even be literate in their own language, let alone literate in English. These issues need to be addressed in the provision of health education for ethnic minority populations. Poor communication may not only influence treatment adherence, but may also contribute to the reinforcement of stereotyping behaviour by health-care professionals. There is a need for culturally competent health-care provision by health-care professionals trained in cultural competence.

We believe that the key to improving ethnic musculoskeletal health is to improve health literacy. The World Health Organization defines health literacy as follows: ‘The cognitive and social skills, which determine the motivation and ability of individuals to gain access to, understand and use information in ways, which promote and maintain good health’ [5]. Maximizing health literacy improves self- efficacy, self-management and adherence to effective drugs.

Self-efficacy is only one aspect of patient empowerment. Self-efficacy relies upon reinforcement through reading and utilization of all of the information available at one’s disposal. The individual needs to be motivated and willing to take responsibility for their own health. Each culture often has a different attitude to pain, illness and drugs, as well as to their relationship with health-care professionals. In a western culture, health education is often seen as giving the medical facts to support independent lifestyles. In certain other cultures, such as South Asian cultures, health is not always viewed as scientifically defined, but is associated with positive interpersonal relationships, spiritual traits and personal worth [6]. Consequently, these cultures place more value on a listening relationship with a person who understands them than on written forms of communication.

Patients with RA of South Asian origin have different views on the necessity for therapy and worse adherence, when compared with White British RA patients [7]. Factors influencing the poorer adherence among South Asians were as follows: patients viewing their symptoms as mild and not serious; lack of acceptance of a long-term disease; wanting a cure; concerns about toxicity over the benefits of disease-modifying agents; a belief that natural remedies are safer; and a poor relationship with health-care professionals. It has been suggested that the use of pictorial representations might improve the understanding of RA by patients, with a common sense fit minimizing misconceptions about the disease. A deeper understanding is necessary, because knowledge alone is rarely sufficient for a change in behaviour. There are several other potential strategies that can be used to address the ethnic minority issues identified and, in particular, to improve health literacy.

In the UK, most health-related information is provided in English. It is possible to translate the booklets, but this has many potential problems, for example: whether it is a direct translation into the second language, or if different words have different meanings in different cultures; and the level of language and literacy of the target audience may also matter. Interpreters are generally expensive and add another layer at which misunderstandings may occur.

We believe that grassroots approaches to health education using community workers may be especially attractive and relevant for ethnic minority groups. It is important to work with the target community in developing the most effective health-promotion strategy and materials. This is labour intensive, but bilingual health professionals liaising with community groups that develop positive relationships and trust could be very effective.

For several years, Arthritis Research UK has been at the forefront of developing patient information and, following expert discussions, literature reviews and widespread consultation, a mind map, an audiotape and a basic leaflet in specific languages to address a range of musculoskeletal conditions were developed. Mind maps are an information resource that provide pictorial representation of the subject matter [8]. The Arthritis Research UK Osteomalacia Mind Map has been digitized and layered into an interactive tool (the OMMIT). The tool comprises three layers: green grants access to the minimal required information in order to make an informed choice; blue provides more in-depth information on osteomalacia; and in the red layer there are links to sources of more information. The simplest layer, green, was translated into the language Urdu.

The effectiveness of the OMMIT tool has been evaluated. The translation was checked by bilingual professionals to ensure that the translation had the same content and meaning in both languages. The tool was then trialled in a focus group of Urdu-speaking males. Baseline knowledge was tested with an Osteomalacia Knowledge Questionnaire. A presentation was given using the tool, after which knowledge was retested and shown to have improved. The participants all enjoyed the presentation on osteomalacia using the OMMIT. Layout and presentation of the tool were appreciated, but it was suggested that not all of the words needed to be translated into Urdu, and that some words should be left in English so that users would learn them and be able to communicate better with their health-care professionals.

Ethnic minorities are underrepresented in these self-help programmes. An important effect of self-management is to give patients the locus of control and to empower them [9, 10]. Preliminary observations suggest that patients who are in ethnic minorities in Europe and the UK find the concept of self-help more difficult than indigenous communities. This is further complicated by the general mistrust that may occur with health-care professionals [6].

In conclusion, ethnic populations are distinct, and those with musculoskeletal conditions require targeted educational strategies for the reasons described above. The use of visual, layered and interactive material is worthy of further evaluation.

Acknowledgements

We wish to acknowledge the members of the Osteomalacia Mind Map Interactive Tool (OMMIT) Study Group (Ade Adebajo, Pam Bishop, Philip Helliwell, Mark Johnson, Kanta Kumar, Anisur Rahman, Karim Raza, Sandra Robinson, Ash Samanta, David Walker and Robin Waxman). This editorial is based on a European League Against Rheumatism 2015 workshop. We also wish to acknowledge Arthritis Research UK for funding our work.

Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.

Disclosure statement: The authors have declared no conflicts of interest.

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