Although ethnic coding within Scotland’s health information systems has been consistently identified as a key priority in tackling health inequalities, Scotland was late in collecting data on Covid outcomes by ethnicity. Public Health Scotland first made such information available on 20 May with more complete data provided on 15 July. A further update on 12 August concluded: ‘There is firmer evidence of increased risks of serious illness due to COVID-19 in those of South Asian origin, with a two-fold increase in risk of needing critical care or dying within 28 days of a positive test’.
Early in the lockdown, some reports from England suggested that ‘certain demographics’ in what were described as ‘hotspots of transmissions and deaths’ were struggling to access information due to language barriers, with older Muslims and Sikhs finding it challenging ‘to adhere to government guidelines about physical distancing’. In July, some charities and advocacy groups wrote to the UK Government raising concerns that the unavailability of Covid-19 public health guidance in languages other than English excluded non-English speakers from accessing essential public health messages, thereby ‘limiting their ability to keep themselves, their families, and their communities safe’.
In Scotland, commitments have been made to improving language support not only for recent migrants but also for minority ethnic older people. Covid public health guidance leaflets in 11 different languages appear to have been first made available in Scotland through NHS Inform. In May 2020, I started interviewing people working in the voluntary sector, faith-based groups and statutory services as part of my research on ageing among Pakistani Muslims and Indian Sikhs in Scotland. I draw on these to highlight some key issues concerning Covid-19 messages and BAME communities, with a focus on older adults of South Asian heritage.
An NHS Link Worker in Edinburgh identified language barriers as a key challenge that older Indian and Pakistani adults face in accessing the Health Service. During a Public Health crisis, these become particularly crucial for people with existing health vulnerabilities (see Qureshi et al. 2020: 22-25). Language barriers are not simply about speaking and understanding English, however. According to the 2011 Census, only a small percentage (1.9% Muslims and 1.7% Sikhs) have ‘No Skills in English’. Crucially, there are differences within as well as between South Asian communities. Differences in class status and educational levels mean that some older adults may be non-literate in English and in their own languages, which denies them access to translated written material. Migration trajectories also make for significant differences.
For instance, Bhatra Sikhs began settling in Scotland more than 80 years ago and their ageing adults were born and raised in Britain. Language barriers are thus not generally an issue for them, just as they are not for East African Sikhs. They are, however, a challenge for some first generation post-war Sikh migrants. Furthermore, older first-generation women have generally less exposure to English than men and may have relied heavily on family members to act as their interpreters. Even those who learned English (e.g. through ESOL classes), may still experience issues around proficiency and confidence as English is not their first language (see Modood 1997: 308-13 for details on the use of different South Asian languages in Britain). This, among other factors, in turn affects digital participation.
A manager at an Edinburgh organisation believed that although some thought had been given to the delivery of essential public health messages, it was not a ‘planned approach’ to reach out to those who needed it. She highlighted the difficulties an older minority ethnic person with basic or no English language and digital skills would face in locating the NHS Inform leaflets—and described it as a ‘half measure’ and ‘tick-box exercise’ not delivered alongside the information in English. The link to ‘different languages and formats’ appears in small text in English on the bottom right of the NHS Inform landing webpage. Leaflets in English providing guidance and information on support available were also sent to each household in Scotland and published online in different languages by the Scottish Government in late April. Importantly, even those able to read (whether English or Urdu/Gurmukhi) may find reading detailed guidance in leaflets neither easy nor desirable. Some charities could serve as examples of good practice in providing more accessible information. Widely available audio and video formats in different languages may be a more effective means of communicating the message.
An Edinburgh community worker, a Pakistani older adult himself, and a support worker at an Equalities charity in Glasgow both considered that generally older people of South Asian heritage were unfamiliar with the NHS website. The latter added that part of his work for his ethnic minority Digital Inclusion Project was alerting older people to ‘fake news’, directing them to ‘reliable’ sources of information and supporting them through the process.
Guidance in different languages was cascaded to various community organisations in Edinburgh by NHS Link workers via email and WhatsApp. Similarly, Glasgow City Council provided the Chair of a day centre Board with a list of 100 people who spoke only Hindi, Urdu or Punjabi and needed to be contacted. He added them to his list of 500 older people living alone and/or non-English speakers and asked his volunteers to phone them several times a week. A charity in Edinburgh worked with the Scottish Government to produce the voiceover for infographic videos in three different languages. They acknowledged that even though they looked for multiple channels of dissemination, they were not going to reach everyone. From several of my conversations, however, communication from Public bodies appeared to have been neither comprehensive nor timely.
A Development Officer at a women’s Glasgow charity reported making phone calls to their service users early in the lockdown and finding a ‘significant lack of knowledge’ among BAME Muslims, mostly older women. She found that many knew that they were not supposed to go out of the house but not whether services were available for them if they got ill. Some women they spoke to had Covid and suffered alone. Some were on medications for other things and they did not know that pharmacies were delivering medicines or that local community groups would supply groceries or meals. Likewise, a day centre manager in Glasgow told me: ‘I think people are starting to get the message about masks, but the message is a bit mixed up: what kind of a mask, what thickness?’ She was asked by an older Pakistani woman: ‘If I just wear my veil, will it protect me?’ She was unaware of information on face coverings being available in different languages. This guidance has been made available in one of the 12 Urdu or 14 Punjabi leaflets on NHS Inform. The older woman’s concerns did not necessarily require culturally-specific messaging but rather access to clear and visible information that could have been provided in an easy read, audio or visual format.
The Director of a charity catering primarily to Sikh women in Edinburgh noted that messages might be missed or lead to misinformation if their presentation is unsatisfactory. She stated that although people have known that Vitamin D is very important for BAME communities, they had not taken it on board until Covid. The Vitamin D guidance that came out from the Scottish Government on what dosage should be taken on a daily basis was very clear but it appeared at the bottom of the page of the leaflet. She added that if she was not somebody who read all the time, she would not even get to the bottom of the page. What concerned her was that there were many messages going around on social media about what dosage people should take and how they should take it and some women from their women’s group were circulating them.
Despite such challenges and contrary to claims that BAME, particularly Muslim communities, were not taking the pandemic seriously enough, many older people could access information through their families or friends and adhered to the guidance. For those without such support, voluntary organisations offered advice and support. Places of worship and Asian TV and radio channels were also vital in reaching out to older people. A Gurudwara in Glasgow, for instance, used their text message service to send key messages in English and Punjabi to all their members, and the Sunday morning slot on a local radio station to relay messages from the Gurudwara in Punjabi.
A committee member told me: ‘The Sikh channels also are good because they have been showing footage of Sikhs working and making sure that they are wearing masks and gloves and using hand sanitisers’. A Mosque in Glasgow also disseminated messages in Urdu via community radio to nearly 1000 households, whilst the Imam’s Friday sermons live streamed via Facebook was one means of providing updated guidance on Covid for a mosque in Edinburgh. Several charities also used Facebook, WhatsApp messages and Zoom calls to communicate important information that older people could either access through younger family members or directly themselves if they had participated in Digital Inclusion projects.
This evidence highlights the need for important lessons to be learned not only in preparation for any ‘second wave’ but also in handling future pandemics and essential health messages more generally. Through the NHS and other public bodies, the Scottish government has a responsibility to deliver on its vision of ‘A Fairer Scotland for All’. Among other things, that entails being more enterprising and quick off the mark in getting key public health messages translated into different languages, and most importantly, ensuring that information is easily accessible. Public institutions must work towards building trust among minority ethnic communities who should not have to rely on having their needs met through alternative networks of support.
Modood, T. 1997. Culture and Identity. In Modood, T., Berthoud, R., Lakey, J. et al. Ethnic minorities in Britain: diversity and disadvantage. London: Policy Studies Institute, pp. 290-338.
Shruti Chaudhry is British Academy Postdoctoral Fellow in Sociology at the University of Edinburgh. Her research focuses on the relational lives of older people of South Asian heritage (Pakistani Muslims and Indian Sikhs) in Scotland.
Image: Author’s own