Communities of Interest

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Different groups in society may experience avoidable, unfair and systematic differences in health, known as health inequalities. This may involve differences in health status, access to care, quality and experience of care, behavioural risks and wider determinants. Those at higher risk include socio-economically disadvantaged, those with protected characteristics, socially excluded groups, and particular occupations. The national Inclusion Health Guidance highlights key population groups who may experience inequalities, and this has been combined with local intelligence to compile the communities below. 

Understanding the unique health and wellbeing needs of people from different communities of interest can be a challenge due to limitations of knowledge, data and evidence. However, we do know that some of these groups are predisposed to certain health conditions whilst others face challenges in accessing services to support health and wellbeing (due to cultural barriers, stigma or language differences for example). It is important across all of the JSNA topic areas that we are mindful of potential additional challenges in understanding, access and outcomes our Lincolnshire Communities of Interest might experience, and that we adapt accordingly to avoid the exacerbation of health inequalities. 

Communities of interest in Lincolnshire include: 

Ethnic Minority Groups

An ethnic group is a category of people who identify with each other based on similarities such as a common ancestry, language, history, society, culture or national origin. ‘Ethnic minorities’ is used to describe people of non-white British descent.  

Determining the profile of the local ethnic minority population is challenging. National mid-year population estimates are published annually but lack any ethnicity data. Hence, Census data remains the most recent and reliable data source for this purpose.  

Pre Covid-19, life expectancy among ethnic minority groups was higher than white and mixed groups, however disability-free life expectancy is estimated to be lower among several ethnic minority groups. The Covid-19 pandemic had a disproportionate impact on ethnic minority communities, who experienced higher infection and mortality rates. Covid-19 has therefore reversed the previous picture for some ethnic minority groups, which now have higher overall mortality than the white population (Source: BMJ).  

Research by the Black Health Agency for Equality (2013) found that black and other ethnic minority groups experience inequalities relating to mental health, cancer, heart disease and related illnesses such as stroke, HIV, Tuberculosis and Diabetes. The prevalence of most health conditions differs between groups and long-standing health conditions are most commonly reported by black Caribbean men (45%), white British men (40%) and Pakistani women (49%) (Source: NHS Digital).  

Multiple factors such as deprivation, environmental, physiological, health-related behaviours and genetic predispositions contribute to ethnic health inequalities. Structural racism, for example in housing, employment and the criminal justice system, can also have a negative impact on health. Access to primary care is generally equitable for ethnic minority groups, but this is less consistently so across other health services (Source: King’s Fund).  

Lincolnshire NHS hold listening events to ensure that everyone in the community can be heard, this has included a Race Equality Event. They also produce a Lincolnshire System BAME & Allies Newsletter. Eligibility thresholds for some commissioned services, such as One You Lincolnshire’s weight management pathway, have been lowered for certain ethnic minorities to reflect the increased risk of related health conditions. Local services such as the BAME Inclusion Service, supports and encourages families from different backgrounds to access Early Years and Family services.   

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Lesbian, Gay, Bisexual and Transgender

Despite substantial social and legal improvements in the UK Lesbian, Gay, Bisexual and Transgender (LGBT) communities, people continue to face disadvantages and inequality based on their sexual orientation or gender identity (Source: National Institute of Economic and Social Research).  

Trans people often experience bullying or harassment in schools and workplaces, thus impacting educational attainment and employment status, both of which tend to correlate with poorer health outcomes. However, of those who do stay in education, 34% of trans people obtain a degree or higher degree later in life, compared with the national average of 27% (Sources: Stone wall and The Equalities Review). The Lesbian and Gay Foundation (2010) identified poor personal health, sexually transmitted infections, problematic drug and alcohol use and smoking all disproportionately affect LGBT populations.  

Research has found that LGBT people face issues with housing (particularly young LGBT), harassment and violence, domestic abuse and difficulty accessing appropriate services. A third of LGBT people were apprehensive about accessing public services, such as leisure, housing, transport, education, social care or housing, because of previous negative experience or fear of discrimination (Source: Stonewall Scotland).  

Local agencies are working to ensure that service provision, employment practices and policy making does not disadvantage LGBT communities. One example of this is the Lincolnshire NHS LGBT+ Patient User Group, which has been established to improve local services.  

There are limited official figures for the number of LGBT people. The range of national estimates vary considerably however the Government use a figure of 5-7%. There is no accurate data on the number of people who are transgender and/or have a non-binary agenda in Lincolnshire (Just Lincolnshire), reflecting a national problem with accurate statistical analysis. However, a report by the Gender Identity Research and Education Society suggests a figure of around 0.6% (Source: GIRES) and other research shows 1% of the population had gone through some part of a gender reassignment process (Source: Equality and Human Rights Commission).  

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    Military Families and Veterans

    Individuals currently or previously serving in the armed forces, along with their family members, may experience unique challenges related to military life and culture. This population can be particularly transient, be dispersed from support networks, experience disruptions in continuity of care and may have experienced unique combinations of life events.  

    Common issues include mental health and wellbeing, understanding and challenging stigma towards help-seeking behaviours, social isolation and loneliness, and resettlement and reintegration into civilian society (Source: University of Sunderland). Whilst serving, social connection and peer support tends to be strong, however a loss of this when transitioning out of the military can be a risk factor for mental health issues (Source: Kings Centre for Military Research). 31% of the ex-service community live alone compared to 19% of UK adults (Source: Royal British Legion, 2006). Increasing research regarding veterans indicates links to alcohol abuse, physical disability or injury, homelessness and crime. Evidence shows that serving personnel and reservists who have been in conflict zones, are more likely to engage in risky behaviours such as drinking excessive alcohol, smoking and risky driving (Source: Occup Med). However more recent evidence does suggest that drinking cultures are changing and alcohol consumption reducing (Source: Journal of the Royal Army Medical Corps). 

    There are several military bases within Lincolnshire and service personnel may remain or return to the area upon discharge. However, it can be difficult to obtain data to help understand the needs and wellbeing of military families and veterans. 

    A range of national and local organisations offer support to military families and veterans, such as Veterans’ Gateway, the Lincolnshire Veterans Support Service, Lincolnshire SSAFA and OpCOURAGE, the veterans’ mental health and wellbeing service. Early intervention from services, such as employment and housing advice, could help facilitate a smoother transition into civilian life for former military personnel. Local initiatives, such as the Lincolnshire Maternity & Neonatal Military Care Programme, aim to collaborate with military families to improve service design and equitable provision.  

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        Offenders

        An ‘Offender’ is someone who has encountered the criminal justice system because they have committed a crime. Offenders can often be more socially isolated or marginalized than the general population and have broader health concerns.  

        Offenders have high rates of mental ill health, alcohol and drug misuse and smoking. They are more likely to take their own lives. People with learning disabilities are overrepresented in the offender population. There are high levels of educational need and offenders have increased difficulty accessing employment and housing. Where offenders have identified health needs, continuity of care can be disrupted due to admission, movement between prisons and release.  

        Improving the health of offenders reduces the chance of them re-offending, which in turn reduces the future impact on themselves, their victims and the families of both. 

        Organisations such as Lincolnshire Action Trust focus on the care, resettlement and rehabilitation of offenders and those at risk of offending, as well as supporting the welfare of their families and dependents. Victim Lincs provide help and support for victims of crime.  

        Further information about children and young people in touch with Lincolnshire’s criminal justice system can be found here.  

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          Refugees, Asylum Seekers and International Migrants

          A refugee is a person who has been forced to leave their country to escape war, persecution, or a natural disaster. An asylum seeker is someone who has left their home country as a political refugee and is seeking asylum in another. An international migrant is someone who changes their country of usual residence. Migration is driven by numerous reasons, including economic, family reunion, study, humanitarian reasons or human trafficking. 

          Significant international immigration has occurred within Lincolnshire over recent years.  In Boston, Lincoln and South Holland particularly, individuals have migrated from several eastern European countries, predominantly to seek employment in the care, agricultural and food production industries.  

          Studies show most Eastern European migrants reside in private rented accommodation, often accepting poor and overcrowded conditions, in a sector which is more difficult to regulate and already under strain (Source: Joseph Rowntree Foundation). These conditions can contribute to the spread of communicable diseases.  

          Immunisation programmes may differ between countries. It is therefore important to promote the benefits of the local immunisation offer, to help protect vulnerable newly arrived communities against certain diseases.  

          Health problems in these groups can develop due to difficulty accessing services, lack of awareness of entitlement, administrative issues and language barriers. Only a third of Eastern Europeans know how to register with a GP and less than a fifth understand the UK’s health system, resulting in inappropriate use of hospital and A&E facilities (Source: Joseph Rowntree Foundation). 

          It is important to consider the cultural norms, beliefs, vulnerabilities and hereditary factors of immigrants when designing and delivering interventions. The Empowering Healthy Communities Programme in Boston is one example initiative to improve engagement with diverse communities; improving access to services, greater cultural awareness and more culturally sensitive communications. 

          Provision for newly arrived communities is variable depending on their circumstances and support available from central government.  

          • Individuals who migrate to Lincolnshire of their own accord, such as those who move here to reside with family, are not necessarily known to the local authority. Therefore, they are unlikely to receive structured support on arrival and may have ‘hidden’ needs.  
          • Asylum seekers are generally supported into temporary accommodation whilst their settlement status is assessed. In the first instance, asylum seekers are usually housed in Initial Accommodation Centres before being re-located to long-term temporary accommodation, however due to demand exceeding capacity, a network of Contingency Accommodation has been procured to provide temporary full-board accommodation on an interim basis. Asylum seekers are unable to access public funds (benefits and housing assistance), unless an exception applies. The number of asylum seekers residing in Lincolnshire is likely to increase due to a drive from the Home Office to disperse these individuals into private sector accommodation, more evenly across the country. The Lincolnshire Resettlement Partnership provides a cross-agency package of support to ensure the health and wellbeing needs of asylum seekers can be met, and that appropriate fire safety, food safety, and health protection standards are in place. 
          • In given situations central government launch support schemes for refugees which enables more structured support to be given, such as the recent Homes for Ukraine scheme. Under such schemes, coordinated by Lincolnshire County Council, the Lincolnshire Resettlement Partnership have mobilised processes and packages of support to help ensure appropriate accommodation is sought, link individuals into health, care and education services, advise on benefit applications and encourage community integration through things like provision of ESOL courses. Although these individuals are known to the local authority, emerging health needs of these cohorts are not yet known.  

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            Sex Workers

            Sex workers are adults who receive money or goods in exchange for consensual sexual services or erotic performances, either regularly or occasionally. 

            Evidenced based information about sex workers is rarely depicted within publications by national health organisations (Source: Putnis & Burr), making it difficult to fully understand the health and social inequalities, stigma, social and economic exclusion and marginalisation that they incur. There is particularly limited research relating to male and transgender sex workers.   

            Sex workers are at increased risk of HIV, sexually transmitted infections, drug related harm, violence and other human right violations, and significant unmet sexual and reproductive health needs. Stigmatising and discriminatory treatment by healthcare workers have a negative impact on sex workers, undermining their wellbeing and access to care. Conversely, positive interactions empower sex workers, affirm dignity, and foster healthier behaviours and improved health outcomes (Source: Goldenberg et al.). 

            It is important to collaborate, build trust, and ensure equitable access to sexual health screening and treatment services, safer working environments and legally enforceable rights to occupational health and safety protections for sex workers.   

            There is a consensus amongst partner organisations in Lincolnshire, that further information and understanding of the local sex worker industry would be beneficial and could be used to help address some of the health needs highlighted above. 

            Transient Populations / Temporary Residents

            Lincolnshire has a very transient population, due to people migrating for study, work and tourism for example. Much of our health data is obtained from GP practice registers, yet a large proportion of the transient population may not be registered with a local GP and so their health needs may not be fully understood. Even where temporary residents are captured, given the seasonal fluctuation any needs assessment will only provide a snapshot in time which may not accurately reflect the situation from one month to the next. 

            Individuals may experience issues with continuity of care due to transitory living arrangements, being unfamiliar with local services, and medical records not being easily transferable between different health trusts.  

            The demand surge on services during peak tourist season can be difficult to predict and resource, thus affecting access for local residents as well as those in temporary residence. There are also specific challenges, such as the movement of transient populations contributing to the spread of communicable diseases and the increase in homelessness during the tourist season.  

            Park home and mobile caravan residents have varying health needs depending upon their age and duration of their stay, therefore access to medical and pharmaceutical services can be a challenge to predict. Some caravans are temporarily home to holiday makers or seasonal workers. Others serve as a more permanent home to residents who tend to be older and experience higher rates of poor health than the general population (Source: Sheffield Hallam University). Many patients remain registered with their ‘home’ GPs while visiting, as the growth of electronic prescribing and repeat dispensing enables patients to manage their prescriptions remotely.

            University students make up a significant proportion of the county’s population, particularly in Lincoln and near other Higher Education settings. Students have their own discrete constraints in terms of accessing services and preferred communications channels. For many students this is the first time they may have lived independently of their families, which can result in an increase of risky behaviours such as alcohol or substance misuse, smoking, poor diet, and unsafe sex. For some students, the transition to university life may cause poor mental health, isolation or stress. However, resilience can be developed through innovation, improvements to students’ social and living environment and peer support (Source: Unite Students). 

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                Travellers

                The term “Traveller” is used to describe a wide variety of cultural and ethnic groups that either are, or have been, traditionally associated with a nomadic lifestyle. The two main groups of Travellers in the UK are Gypsies and Travellers of Irish Heritage. These two groups are recognised ethnic minorities and thus afforded protection under the Race Relations Act. 

                11.7% of the Gypsy or Irish Traveller community live in areas that are amongst the 10% most deprived in the country, higher than the national average of 9.9% (Source: English indices of deprivation). This population exhibit worse health outcomes, have poorer access to and uptake of services and are more likely to experience social issues compared to the general population. Several studies report a disparity of 10-12 years in life expectancy between Travellers and the settled population. UK studies have also shown high perinatal and infant mortality, high rate of childhood accidents, higher death rates from cardiovascular disease, and a higher incidence of asthma (Source: BMJ). Irish Travellers exhibit a greater prevalence of congenital anomalies, possibly related to a higher incidence of first cousin marriages in the Traveller population; 19% compared with 0.16% in a settled population (Source: Barry & Kirke). Traveller communities experience disproportionately high rates of poor mental health, have the lowest economic activity of any ethnic group, and have greater susceptibility to infectious disease due to poor access to sanitation amenities and low vaccination rates (Source: OHID). Many Gypsy sites are situated in hostile environments that are deemed unsuitable for any other development, such as old waste tips. They invariably lack adequate basic facilities and are situated well away from other habitation and local amenities.  

                Gypsies and Travellers’ health beliefs demonstrate a cultural pride in self-reliance, so there is more trust in family carers than professionals. Gender roles are strictly defined, meaning that women’s access to health services could be restricted (Source: Parry et al.). Many Travellers experience severe educational disadvantage and poor literacy levels, therefore audio communication may be more useful. Their access to healthcare is also impacted by being refused registration, discrimination, lack of cultural sensitivity, stigma, language and digital barriers (Source: OHID). 

                Local systems aim to provide appropriate accommodation and support to Gypsies and Travellers in accordance with the Gypsy and Traveller Sites Policy, the Public Sector Equality Duty and Secretary of State’s legal duty. Services such as Lincolnshire Traveller Initiative and the Ethnic Minority and Traveller Education Team are available locally to support members of this community. 

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                    Victims of Modern Slavery and Human Trafficking

                    Modern slavery is the illegal exploitation of people for personal or commercial gain. It covers a wide range of abuse and exploitation including sexual exploitation, domestic slavery, forced labour, criminal exploitation and organ harvesting, and is a crime under the Modern Slavery Act 2015 . Labour and criminal exploitation are the most prevalent forms of modern slavery in the UK, and the number of child and male victims has increased, however the hidden nature of the crime means it is challenging to produce an accurate measure (Source: Gov). A drive for cheap products means forced labour can be common on farms, in construction, shops, bars, nail bars, car washes and manufacturing (Source: Anti-slavery).  

                    Modern slavery disproportionately affects people in more vulnerable circumstances, such as children and young people, undocumented migrants and people living in poverty (Source: PHE), although anyone can be a victim, even if they do not recognise themselves as this. They are tricked or threatened into work and may feel unable to leave or report the crime through fear or intimidation. Stigma, fear of law enforcement and experiences of discrimination may influence their trust in statutory services. 

                    Lincolnshire is particularly vulnerable to modern slavery, given the deprivation along the coast and rates of child poverty across the county. Children in areas with a lack of sufficient youth services and support are a particular future risk. Trafficking into crime is a particular issue amongst children, such as being forced into County Lines drug trafficking. Organised criminal groups exploit vulnerable people, such as children and those with poor mental health or addiction issues, to redistribute drugs from cities into smaller towns and rural areas.  Lincolnshire’s rurality also provides risk for modern slavery and human trafficking relating to cannabis farms located in secluded, sparsely populated locations, and to exploitation in rural industries such as farming. 

                    Strategic assessment, undertaken by Lincolnshire Police between April 2021 and March 2022, highlighted the following findings and risks: 

                    Key Findings

                    Key Risks
                    • MSHT offences in Lincolnshire have increased by 263% over the last five years (from 19 to 69 offences) and 19% in the last year (from 58 to 69 offences) 
                    • Criminal exploitation was the most common type of modern slavery in Lincolnshire (57% of all offences), followed by labour exploitation (30%) and sexual exploitation (12%).  Victims were frequently, but not exclusively, exploited by people with the same nationality as themselves. 
                    • Key areas of MSHT exploitation in Lincolnshire are related to: 
                    • Drug dealing, both local and county lines activity involving both children and adult victims  
                    • Vietnamese and Albanian nationals forced to work at cannabis farms 
                    • Foreign nationals brought to the UK with the promise of work, then charged high rents for poor quality, unlicensed HMO accommodation 
                    • Foreign nationals who are in the country illegally and/or with no right to work in the UK, used as labour in nail bars (exclusively Vietnamese victims) and takeaway food businesses, for little or no pay.  
                    • Exploitation of Romanian and Bulgarian females forced into sex work 
                    • Exploitation of females under 18, often by slightly older female ‘friends’, into visiting different areas of the country to meet males where sexual exploitation occurs.   
                    • Adults represented 56% of all victims and were primarily victims of labour exploitation, and criminal exploitation.  Children represented 44% of victims (a decrease from 57% the previous year), with the majority suffering criminal exploitation. 
                    • British nationals accounted for the highest proportion of victims, followed by Vietnamese, Albanian and Bulgarian nationals.   
                    • Males accounted for 72% of all victims. 
                    • 55 victims were referred to the NRM. 6 referrals were related to sexual exploitation, all for female victims, five of whom were aged under 18, and four referrals were related to County Lines criminality all of which involved males under 18. 
                    • It is highly likely that ongoing MSHT criminality involving ethnic Vietnamese organised crime groups and Vietnamese nationals will continue to impact Lincolnshire.  The UK is perceived as an attractive destination by Vietnamese migrants who are at risk of exploitation both en-route to and on arrival in the UK.  Exorbitant fees charged by traffickers for each part of the journey result in debt bondage, and exploitative working conditions for victims in both legal sectors, such as nail bars, and illegal activity, such as cannabis cultivation.  
                    • It is highly likely that exploitation of children in the care system in Lincolnshire will continue.  The Commission on Young Lives report (2021) warns a shortage of suitable residential places, a failure to identify those at risk of exploitation, and cuts to funding for early intervention programmes are all cited as contributing to the crisis.   Some vulnerable teenagers are being moved to placements In Lincolnshire to remove them from the previous exploitation environment, only for them to be re-exploited by a new group of perpetrators once they arrive.   The care population is getting older and 16 and 17-year-olds with acute needs now make up 23% of children in care.  Teenagers also form the highest proportion of child exploitation victims. 
                    • Following the substantial expansion of the seasonal worker scheme, the visa route has expanded from 2,500 places in 2019 to 30,000 in 2022, with the option of recruiting a further 10,000 workers if required. The increases the likelihood of migrant agricultural workers being exposed to exploitation in this key area of industry for Lincolnshire. 

                     

                    Modern slavery has a range of serious health consequences at an individual and population level. Victims may experience malnourishment, injury, anxiety and depression, fatigue, trauma or post-traumatic stress disorder, sexually transmitted infections, late presentation for maternity care, self-harm, dental pain, psychiatric and psychological distress, back pain, stomach pain, skin problems, headaches, dizziness and poor personal hygiene (Source: Lincs Police & RCN). Victims may be living in poor quality, crowded, accommodation which can increase the risk of infection and communicable diseases.  

                    Awareness raising, training, earlier identification by statutory services and partnership working all help towards the prevention of slavery. The National Crime Agency organise Operation Aidant, to regularly focus operational activity on different aspects of modern slavery. Locally, Lincolnshire Police work closely with Immigration, Trading Standards, gangmasters and others to tackle modern slavery, particularly in targeted areas of the county.  

                    Potential victims of modern slavery can access information and advice from Lincolnshire Police and can be referred into the National Referral Mechanism or via the Duty to Notify process.  

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