Diversity & Equality in Health and Care Open Access

Key words

ageing, cultural specificity, Irish community, social isolation, social networks, social support

Introduction

Changes in life expectancy and family patterns have resulted in an increased number of elderly people in the UK living alone. One in six of the population is aged over 65 years, in comparison with one in ten in 1961, and one in six of the population over 65 years lives alone (Matheson and Summerfield, 2000). The ensuing isolation can contribute to the onset of mental health problems in addition to physical frailty. About 5% of the population aged over 65 years has dementia and, at any one time, about 10–15%of that age group has depression (Department of Health (DoH), 2003); those living alone are at ‘increased risk of worsening mental health’ (Pendry et al, 1999). Social support is recognised as an important indicator of health and wellbeing, and the Acheson Report (1998) has advocated promotion of social networks to reduce health inequalities.

Acknowledgement of the diverse composition of society means that single approaches to health and social care are subject to criticism. While there is recognition that older people from black and minority ethnic communities need appropriate mental health services, it is also acknowledged that assessments of their needs may be culturally biased (DoH, 2001). Interconnections between ethnicity and other impacting social and economic factors are extensively debated (McKenzie and Crowcroft, 1994; Smaje, 1995), but assumptions about white homogeneity (Hickman and Walter, 1997) have often rendered Irish people invisible in these debates. As Tilki (2002a) argues, ‘the image of ethnicity based on a skin colour paradigm ... forms the basis of policy in the UK’ (p. 1). White minority ethnic groups, such as the Irish, are often assumed to be homogenous with the white English population (Tilki, 2002b), and little sensitivity is displayed towards the cultural specificity of their experience. The Irish constitute 1.2% of the population in England and Wales and one in four of them is over 65 years, compared with 16% for the rest of the population (Office for National Statistics (ONS), 2003). In London, 18% of the population over the age of 65 years was born in Ireland (Lowdell et al, 2000). The 1991 Census showed that the mean age profile of the Irish population in London was older than that of the population of London as a whole (Walter, 1997). Despite the fact that the Irish comprise the third largest minority ethnic group in England and Wales (ONS, 2003), they have a low profile in relation to policy development and targeted service provision and, until the publication of the study Inside Outside (National Institute for Mental Health in England (NIMHE), 2003), they were frequently excluded from wider policy debates on minority ethnic concerns.

Data are available about the particular experiences of Irish people in relation to both mortality and morbidity. Premature death rates among Irish men in theUKare higher than in Ireland and Walter (1999) argues that the ‘migration experience was implicated’ (p. 10) in the deterioration of health. There is a higher than average rate of admissions to psychiatric hospitals for women from the Irish Republic and Northern Ireland than for women from England and Wales (Cochrane and Bal, 1989). The level of suicide rates for people from the Irish minority is higher than for all other minority groups and the population of England and Wales (NIMHE, 2003). Among some groups of Irish people there are interconnections between alcohol problems, mental health and wider patterns of social disadvantage such as isolation, poverty, being single men, employment histories and homelessness (Harrison et al, 1993; Leavey, 1999; Erens et al, 2001). Harding and Balarajan (1996) problematised assumptions about cultural assimilation, by showing that mortality was higher among second-generation Irish people than among the rest of the population.

The Social Services Inspectorate (1998) acknowledged that older people from minority ethnic groups are assumed to have large supportive families, but Tilki (2002b) has argued that this ignores the migration patterns that result in significant levels of singleperson households and social isolation. Hickman and Walter (1997) also demonstrated that patterns of discrimination and disadvantage in education, employment, healthcare and housing continue to mark the experience of Irish migrants in Britain. Many older Irish people cherish a dream of returning to Ireland, and may have made considerable financial contributions to their families in Ireland (Brody, 1973), but changes within themselves, their families and their home society can render that dream problematic (Tilki, 2002b). Debates about the links between health and migration (Bhugra and Jones, 2001) urge mental health clinicians to take into account the experience of migration with clients frommigrant groups, and Chakraborty and McKenzie (2002) argue there is ‘strong evidence of an association between perceived racial discrimination, psychosis and depression in minority ethnic groups’ (p. 185).

The association between social support, on the one hand, and health and wellbeing, on the other hand, is widely acknowledged but not fully understood. Social support can be described as the interactive process through which emotional and instrumental support can be obtained. Social networks are particularly common channels for expressions of social support and can be defined as the web of relationships connecting individuals (Seeman and Berkman, 1988), enabling them to interact with their environment (Dipple and Evans, 1998).The Independent Inquiry into Inequalities in Health Report (Acheson, 1998) offers insights into benefits accruing from participation in social networks.

The Irish Pensioners’ Project

The Irish Pensioners’ Project in this study took place in a London borough which falls within the 5% of districts that are most deprived in the UK (Department of Environment, Transport and Regions (DETR), 2000). It is, according to the Index of Local Deprivation (UK Office of the Deputy Prime Minister, 1998), eighth in terms of indicators of deprivation out of a total of 354 local authorities in England. This Irish population of this borough, with its own history of migration and discrimination, lived in an environment marked by disadvantage in terms of employment, income, health, crime and housing. An Irish-led voluntary organisation ran the project, which provided lunches and recreational activities in a convivial atmosphere, as well as advocacy and befriending services. People accessing the project were known as members, rather than clients or service users.

The cultural ambience of the project was deliberately Irish. The sign at the entrance reads Ce´ad Mı´le Fa´ilte (a hundred thousand welcomes) and traditional taped Irish music was played at most times of the day. While these two things could be interpreted as merely minimal signifiers of Irish culture, the hospitality offered to all visitors was traditionally Irish in an interactive way; everyone was offered a cup of tea and something to eat whenever they arrived. Irish newspapers were available, and there were regular opportunities for traditional ceilidh and set dancing. Funerals and wakes are important within traditional Irish life and there were notices about funerals of former members. These patterns of cultural specificity were part of the everyday life of the project.

Aim and design of the study

A qualitative study was undertaken to explore the nature and extent of unmet mental health needs among Irish pensioners living in the borough. The aim was to explore the extent to which the Irish Pensioners’ Project promoted social support and social networks, and to identify good practice that could usefully be applied to enhancing the mental health and wellbeing of Irish pensioners in similar settings in Britain. A steering group drawn from the Irish Pensioners’ Project met regularly with the researcher to clarify the terms of reference of the research, negotiate principles of access to the project members, and comment on the progress of the project. The study received research ethics approval in 2002 from the Research Ethics Committee of South Bank University.

The literature review drew on sources about the Irish community in the UK, the experiences of migrant communities, social support/social networks and the socio-economic circumstances of the borough; it particularly explored the links between one or several of these factors and experiences of mental ill health. Over a period of six months, data were collected through observation, at different times of the day, of the daily activities, interactions among members and between members, the staff and volunteers. Permission was obtained for access to approximately 20 of the case files of project members, as a source of additional information and insight into their experiences, which included issues related to health, poverty, access to services and social isolation.

A purposive approach to the sampling of memberinformants enabled the study to reflect a range of different mental health needs. The sample included those without any diagnosed mental health problems, those with some diagnosis, and those with a diagnosis of major mental health problems; itwas not possible to recruit anyone currently experiencing severe mental health problems for interview. Selection of the sample was made following observation, access to the case files and advice from project staff and volunteers. Other informants were also recruited purposively to reflect key stakeholder perspectives from within both the project and partner agencies. Other informants included management committee members of the project, staff members, volunteers, local authority staff and staff from local mental health services, so as to obtain perspectives reflecting a variety of relationships with the project.

Semi-structured interviews were carried out using topic guides, developed following examination of member files by the researcher, and his ongoing observation of interactions within the project. These were subsequently discussed and agreed by the steering group. Interviews were tape recorded, with guarantees of confidentiality and anonymity, and partially transcribed. Observation of the project at different times of the day facilitated a culturally sensitive approach to the values of the informants. The researcher also found that recollections of his childhood in a Scottish farming community generated additional empathy with informants, all of whom were originally from rural areas. Two different versions of the topic guide were created: one for project members, the second for other informants. Questions related to experiences of the project, their views of the extent to which it was beneficial, and relations between the project and other agencies in the borough. Four female project members, four male project members, three staff members, two trustees, two volunteers and four staff members from partner agencies were interviewed.

Interviewing was hampered by past experience of stigma. Articulating such experiences can be very difficult and sometimes people would fall silent. However, from an interviewer’s perspective, silence can be mistaken for a lack of experience of stigma because ‘private and personal emotions are not necessarily and straightforwardly expressed in language’ (Huby, 1997, p. 1157). The researcher was told, by several people associated with the project, that some Irish pensioners were ashamed of the fact that they had arrived in this country on cattle ships. They inferred that, after a life of unskilled, low-paid work, Irish pensioners felt ashamed that they had not been as successful as they had hoped and they had consequently allowed ties with their families in Ireland to be weakened or even severed. None of the interviews with members revealed such feelings about themselves, but those with staff members and volunteers acknowledged the long-term damage inflicted on the members by the stigma of living through years of poverty and broken expectations.

Themes of significance were identified from the tapes and project documentation through the use of a grounded theory approach (Glaser and Strauss, 1967; Strauss and Corbin, 1990). This research was particularly influenced by the work of Charmaz (1990), who argued that grounded research is three-fold insofar as it requires researchers to ‘attend closely to the data (which amounts to ‘‘discoveries’’ for them) ..., [to build] their theoretical analyses directly on their interpretations of processes within those data ... [and to] compare their analyses with the extant literature and theory’ (p. 1165). This particular grounded theory approach, far from expecting researchers to be blank sheets, enables them to draw upon ‘general perspectives of their disciplines, their own philosophical, theoretical, substantive, and methodological proclivities, their particular research interests’ (Charmaz, 1990, p. 1170) to engage in dialogue with discoveries in the data. Analysis proceeded alongside the process of interviewing, adapting and adjusting, as new or unanticipated themes emerged in order to explore them further. The starting point of the analysis was an examination of the relationship between the Irish Pensioners’ Project and its members. Discoveries were made throughout the whole process of analysis. Repeated readings were made of the data until saturation was reached and no further interviews were sought.

Findings

The findings are presented in terms of the key themes that emerged from the analysis: experiences of multiple morbidity, social isolation and befriending, the needs of carers, sense of belonging in the project, advocacy, relations with other agencies. Each of these is discussed below.

Experiences of multiple morbidity

All the members of the Irish Pensioners’ Project experienced health problems, and several reported multiple difficulties. One suffered from arthritis, asthma, excessive weight, mobility problems and schizophrenia; another had alcohol problems, depression, heart disease and leukaemia. A third suffered depression, respiratory problems and the consequences of social isolation. One woman cared for her husband who suffered from dementia. She had broken her hip and suffered from anaemia. For most, this accumulation of ill health followed a lifetime of unskilled labour and low pay.

Social support and the opportunity to form friendships and social networks in the context of the project helped the members both to maintain a reasonable quality of life and to avoid unnecessary recourse to secondary treatment and institutionalised care. A stakeholder in a healthcare agency confirmed this, adding that, in his view, the social support and social networks generated by the project enhanced the general health and wellbeing of people suffering from multiple morbidity to such an extent that they were able to continue leading independent lives.

Social isolation and befriending

Sixty-nine per cent of the members of the Irish Pensioners’ Project lived alone and were, therefore, susceptible to the problems associated with social isolation, and the following three extracts from the data illustrate how the project helped them to counter its impact. Mr T was an unmarried man, aged 80, who had become isolated once he had retired as a construction worker and was no longer able to enjoy the company of his workmates. As far as he was concerned:

‘I’ve never looked back. It’s like a home to me.’ (Mr T)

MrsMwas a widow in her late 70s who lived alone. In her view:

‘I’ve been on antidepressants for years but since I’ve been going to the club I’ve met up with people from County XX and I’ve known some of them for 40 years – we sit at the same table now – we all live alone – I enjoy the bingo and the dinners on St Patrick’s Day and at Christmas.’ (Mrs M)

Both of them attended the project regularly and they perceived the social support that they received there as being beneficial to their sense of wellbeing. Neither of them had accessed more specialist services since they started attending the project. Mrs S had been living alone since her three children had left home; she had been recommended to the project after being hospitalised several times with mental health problems. For her:

‘The first time I walked out of here leaving my doors open and I was found wandering the streets by the police. I’ve been in hospital five or six times. I live here on my own. I lost a lot of interest in things since I became ill. I used to do a lot of reading but not any more. When I go to the club I sit down and have tea and have a chat. It takes me out of myself.’ (Mrs S)

Without support from the project, these members would all have experienced severe and potentially debilitating social isolation. The project enabled them to maintain independent living and enjoy the benefits of occasional social interaction with their peers.

Several project members reported serious alcohol problems which they were either currently experiencing or which they had suffered in the past. The project tried to provide them with opportunities to spend time with other Irish people without alcohol being involved in the process. The project provided space for people to talk about their shared backgrounds, make new friends and renew old acquaintances. Informants reported that the friendships and social networks formed at the project and on organised trips had helped prevent feelings of depression and recourse to alcohol as demonstrated in Case study 1.

Befriending was developed to meet the needs of the most isolated members of the project and encourage them to attend the club sessions of the project. Some were clinically depressed, and onemanifestation of that is their refusal to take their prescribed medication. For those suffering from dementia, support from the befriending service enabled them to enjoy the stimulation of the company of other people. Many of those befriended had been in the situation where they were resistant to the suggestion of company, although the resulting isolation might be damaging to their wellbeing. While the befriender might accompany the member to the Post Office or to the hospital, the priority was for them to provide a listening ear rather than offer any service-oriented function. Telephone contact was particularly valuable in the evenings and at the weekends when the project was closed, and people were more liable to feel isolated, depressed and, occasionally, suicidal. As Mrs R explained:

‘There’s always someone to talk to at the weekends – I get lonely then – and they know what I mean.’ (Mrs R) No other local project aspires to support lonely Irish elderly people in as culturally sensitive a manner as this project does.

The needs of carers

The needs of carers emerged as far greater than anticipated. Carers could become isolated and the befriending service could provide a service, for example, through respite, which enabled the carer or the person cared for to spend a few hours aweek in a different environment where they could relax. Alternatively, the advocacy aspect of the Irish Pensioners’ Project could provide assistance in seeking practical forms of support and advocacy as shown in Case study 2.

The project, through its telephone service, has sought to maintain the dignity and wellbeing of both the carer and her elderly mother. The telephone service has enabled Ms W to share her problems with someone who understands the personal and cultural dilemmas of her role.

In another example, the wife of a man with Alzheimer’s disease enjoyed some respite from caring for him on her regular visits to the project. She explained:

‘I also go on a Wednesday to the bingo and I go once a month to the tea dance. I used to go on their day trips. It’s the friendliness and it’s the fact that I can go out and meet people. It’s really the only social life I have.’ (Mrs C)

Both Ms W and Mrs C received support, which prevented further deterioration of their own mental health. As the health of Ms W’s mother and Mrs C’s husband declined, the project assisted the carers in finding long-term solutions that maintained the dignity and wellbeing of both the carer and their dependant.

Sense of belonging in the project

The ambience of the Irish Pensioners’ Project, particularly in terms of its use of Irish cultural features and its welcoming approach, encouraged members to feel that this was a place where they belonged. It is our inference that the ambience of the project acted in ways that helped Irish pensioners relate to other people. For example, all the members used the word ‘club’ to describe the project, as if it was primarily an organisation to which they belonged, rather than one which only provided services.

Shortly after the inception of the Irish Pensioners’ Project, staff became aware that, despite the fact that many elderly Irishmen lived alone in the borough, fewer men than women were members. In an attempt to target men, project staff decided to dedicate one afternoon session to card playing. While there was no bar to women taking part in the cards sessions, there was a noticeable increase in the number of men on that day. The cards sessions helped to familiarise men with the project, enabled them to form networks with one another in an alcohol-free atmosphere, and made it more likely that they would access other services, such as advocacy or benefits advice. The card-playing sessions were, therefore, not only pleasurable but indirectly health enhancing, in that they generated social networks, increased awareness of services and did not promote dependence on alcohol.

The local Roman Catholic Church played a role in the initial development of the project but there was a firm commitment to non-sectarianism. Those responsible for setting up the Irish Pensioners’ Project made a conscious decision to focus on shared elements of the members’ experiences rather than those that might divide them. Individual members of the project doubtless had their different views about the place of religion in Irish community life, but there was an understanding that these differences are not to be aired within the project. There was no religious imagery on the walls or elsewhere. Acceptance of non-sectarianismmeant that the project was accessible to Irish elderly people from a variety of backgrounds.

Advocacy

The advocacy function of the Irish Pensioners’ Project was well embedded in its daily functions and was thus easily accessible. Many members had a multiplicity of problems and benefited from multidisciplinary responses from service providers. While the project did not seek to replace statutory services, it did seek to facilitate opportunities for members to access them because of the stigma associated with claiming benefits and acknowledging the symptoms of mental illness. Volunteers in the projectwere trained inmental health awareness, abuse awareness and benefits rights, so that they were able to offer support in assisting people along pathways to the most appropriate services, particularly in relation to their housing needs, their benefit entitlements and healthcare problems.

Sometimes when members were near death, volunteers provided the bulk of the support either at home or in a hospice. A staff member explained their philosophy:

‘We’re not experts on mental health issues; we’re not experts on substance issues; we’re not experts on benefits issues. What we are good at is remembering somebody’s first name when they walk in the door and seeing if it’s a good day or a bad day for them – seeing if they want a cup of tea. Do they need to be left alone?’

What developed over a period of time was a sense of trust in the project because it was respectful of members’ desire to determine the direction of their own lives.

Relations with other agencies

The age, frailty, isolation, mental health problems, physical health problems and social disadvantage of many members of the Irish Pensioners’ Project created many opportunities for co-operation with other service- providing agencies, with regard to preventative activities. Local contacts helped in identifying Irish pensioners living alone and alerting services as individuals became more frail and isolated. There are occasional referrals to the project by social workers, housing officers, residents associations, mental health workers, general practitioners (GPs) and church workers, but there was nothing systematic and coordinated to ensure that such referrals took place. The multidisciplinary approach of the local mental health team provided a foundation upon which further, closer co-operation could be built. The mental health team tried to be cognisant of the whole context of the patient’s life as well as the stigma involved in seeking mental health treatment. As one mental health professional explained:

‘Very often we look at people with depression and a lot of it is cultural isolation and loneliness ... the first thing you notice when you come here [the project’s premises] you feel you’re in Ireland, and the atmosphere is very conducive to people’s mental health.’

The mental health team acknowledged the benefits of the cultural specificity inherent in the Irish Pensioners’ Project. The mental health team also acknowledged that the project’s work with clients could save major expenditure in institutionalised settings. Practitioners were aware that around 40% of the local elderly population was Irish born, and mental health staff were interested in pursuing possibilities for further, more systematic collaboration. Any such partnership would enable them to complement each other’s work and to provide a stronger, more integrated service to elderly Irish people.

Conclusions and implications

The Irish Pensioners’ Project assisted Irish pensioners in the borough to maintain their quality of life in a culturally sensitive environment that fostered their sense of belonging (Hagerty and Williams, 1999). The non-sectarian approach enabled the project to avoid replication of those cultural elements that might disturb the environment and, by the generation of conflict among members, damage the health and wellbeing of members. The creation of a supportive environment enabled members to form social networks with other people from similar backgrounds. The healthpromoting nature of these networks can be understood as enabling members to live independently and to maintain good mental health; the project’s links withmental health services (DoH, 1998) enabled appropriate referrals to take place when needed. The project can be seen as providing an example of a culturally appropriate health promotion programme that utilised both targeting and tailoring strategies in the sense discussed by Kreuter et al (2003).

The sense of trust in the environment of the project helped members to ask for additional forms of support in relation to housing, benefits and other services; often volunteers provided this support. People who felt particularly isolated and unable to visit the project because of their own health problems could access a culturally sensitive telephone befriending service. The project also began to identify the degree of hidden caring (DoH, 1999) that went on in this Irish community, and offer measures of support to the carers.

The project sought not to establish itself as a substitute for either statutory services or family members, but to enable members to enjoy the benefits of both. When a problem about accessing statutory services arose (Costigan et al, 1999), the project was able to take on a liaison role, acting as go-between for the potential client and the service concerned. Projects such as this provide a model that generates the development of social networks, carrying out important preventative work with minority populations experiencing inequalities and offering insights into the value of multidisciplinary partnership working among providers.

The Irish Pensioners’ Project is an example of a voluntary organisation providing low-cost services to reduce social isolation. Policy makers seek to develop appropriate strategies for the UK’s ageing population (DoH, 2001, 2003; Philp and Appleby, 2005), and as the elderly population of the UK becomes more culturally and ethnically diverse, projects such as this, which generate social interaction and social networks amongst an otherwise marginalised minority community, offer a valuable model of good practice to challenge the impact of inequalities on the health and wellbeing of minority communities. The Irish Pensioners’ Project offers an example of the spectrum of effective intervention that can promote and protect mental health in a community setting. Its work with carers and its volunteer programme also indicate the need for further research into building capacity (NIMHE, 2003) within the Irish population in urban areas in the UK.

CONFLICTS OF INTEREST

None.

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