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Equality, diversity and inclusion in women's health

Equality, diversity and inclusion are crucial to providing high quality health care and a supportive workplace.

The National Institute for Health and Care Research's Equality, Diversity and Inclusion Strategy 2022-2027 (NIHR, 2022) aims to reduce inequalities, recognising that inclusive research will contribute to improving the health of the nation. 

This is particularly relevant in women's health. According to research, women spend more time experiencing ill health and disability.

Here at the RCN, we believe that services must be responsive and inclusive, acknowledging that the most vulnerable people in our society often have the greatest need for health care (Inclusion health care, RCN, 2023).

  • We recognise and embrace our gender-diverse society and encourage this guideline to be used by and/or applied to people who are non-binary, transgender or gender fluid.
  • We also recognise that not all those born female or male will use the same gender nouns, but for ease of reading will use the term woman/man, and where appropriate will acknowledge non-binary terms.

Health inequalities and unethical differences in health provision between different groups of people are avoidable. They lead to differences in life expectancy, care experiences and prevalence of health conditions.

Four factors describe the different types of health inequality (these factors may also be combined):

  • socio-economic
  • geography
  • characteristics (including protected characteristics).
  • social exclusion.

Intersectionality explains how discrimination and disadvantages impact individuals or groups. It takes into account peoples’ overlapping identities and experiences to understand health inequalities and prejudices (King's Fund, 2022). 

An intersectional approach recognises that an individual who identifies across multiple ‘protected characteristics’, for example race, gender, sexual orientation, class, physical ability, religion/faith, combined with wider determinants of health (socioeconomical status), is more likely to encounter systems of oppression. This might include racism, sexism, homophobia and systemic discrimination. 

In 2021 the Lancet reported that data analysis on 4.6m pregnancies in seven countries suggests the miscarriage risk for black women is 43% higher than for white women.

An intersectional approach enables nurses to better understand the many factors that contribute to disparities in health care and to develop appropriate care approaches. 

Services should acknowledge barriers to care and make allowances where possible to ensure women can access the care they need safely and acceptably. This could include services such as telemedicine, which has been welcomed in abortion care in England and Wales. 

For vulnerable women, it may be necessary to facilitate outreach services where possible. Outreach services are designed to break down the barriers hard-to-reach groups may experience when trying to access care.

Further resources

Sexual orientation and gender identity should not affect access to the right health care, but some people may face extra challenges in getting the right help and information. Heteronormativity (the assumption that people are heterosexual) can be an obstacle for holistic health care and may make it challenging for people to disclose their sexual orientation.

Lesbian, bisexual and other women who have sex with women (LBWSW) can experience significant health inequalities and barriers to services and support. LBWSW may also face complex and interconnected experiences of social disadvantage linked to their sex, gender and sexual orientation. These negative experiences are often compounded by age, social class, ethnicity, disability and/or faith.

Further resources

Implementing approaches that are anti-oppressive, intersectional, and culturally and contextually adapted can address many factors contributing to the sexual health of LGBTQIA+ people (lesbian, gay, bisexual, transgender, queer or questioning, intersex, or asexual). 

Further resources

Anyone who produces oestrogen and progesterone may experience declining hormone levels. Transgender, non-binary and intersex people may also experience the menopause, either due to age-related hormonal changes or hormone treatments and surgeries. Nurses should provide an evidence-based approach for assessment and management and refer people to specialist services as required.

Further resources

NHS screening programmes aim to prevent ill health, save lives and allow people to make informed choices about their health. But eligible people are not being invited, causing inequalities to remain. 

Cervical screening: All individuals aged 25 to 64 who have a cervix should consider having cervical screening. This includes trans men and people who are non-binary and were assigned female at birth, provided they have not had a full hysterectomy. 

Breast screening: This is offered to anyone between 50-70 years who has breasts, due to either naturally-occurring oestrogen or oestrogen hormone therapy. This includes trans men and non-binary people assigned female at birth who have not had a bilateral mastectomy, and trans women and non-binary people assigned male at birth who have taken feminising hormones.

Further resources

What is a learning disability or intellectual disability?

A learning disability is “a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood” (Department of Health, 2001). Learning disabilities are a life-long condition and affect everyone differently. 

Health inequalities

There is a lower uptake for both cervical and breast screening for women with learning disabilities. A range of factors may affect this. Assumptions made about someone’s capacity to undertake screening; lack of accessible information to help someone decide to have screening or not; no reasonable adjustments in place to maximise appointment success.

Further resources

Reasonable adjustments – cervical screening

Sarah’s story: Sarah had a learning disability and also experienced anxiety and depression. She had two failed attempts to have cervical screening at her GP surgery, despite lots of reassurance from the practice nurse. As a result, the nurse referred Sarah to the Learning Disability Nursing Team for support. 

The learning disability nurse spoke to Sarah and learnt that she did not feel ‘safe’ at the surgery but said she would have the cervical screen if she could have it at home. The learning disability nurse liaised with the surgery, and together with the practice nurse, arranged a joint visit to Sarah’s house. Sarah was able to lay on her bed with her favourite blanket covering her legs. The learning disability nurse held Sarah’s hand, talking her through what was going to happen. With time and encouragement, Sarah was supported to successfully have her cervical screen in the comfort of her own home.

Making simple, small changes (or reasonable adjustments) can make a big difference to the outcome for a patient. Knowing how someone communicates and whether they need accessible information is a good starting point. Other common adjustments that you may find helpful is to allow more time for appointments, including meeting before a test/check to explain what is going to happen and finding a quieter area for someone to wait.

Further resources

Mental Capacity Act/Best Interest process

Nurses should offer women with learning disabilities the same opportunity to attend health checks/tests as we do for any other women. To help women make their own decisions, use information that is easy to understand. Where a woman lacks capacity, the best interest process should be followed. If you're not sure about someone's abilities, you can ask your local learning disability team for help. 

RCN resources 

Accessible Information Standards across health care organisations

Since August 2016, it is a legal requirement (Health and Social Care Act 2012) for all organisations providing NHS care and/or adult social care to follow the Accessible Information Standard. This sets out a 'specific, consistent approach' to make sure that information and communication is easy to understand and accessible to support the 'needs of patients, service users, carers and parents with a disability, impairment or sensory loss'.

A hospital passport is an example of how this can be achieved. This tells any health care professional about the patient’s learning disability or specific needs, their preferred way to communicate and how to make things easier for women to get the care they need. Many trusts have their own version of hospital passports, but you can download your own passport by visiting the Mencap website.

How to ask questions in a positive way

The National Institute for Health and Care Excellence (NICE) provide guidelines for health care professionals on how to improve patient experience to ensure that all patients regardless of their 'physical or learning disabilities, sight, speech or hearing problems and difficulties with reading, understanding or speaking English' have access to making informed decisions about their care.

Neurodiversity is a term used to describe a range of neurological differences, including: 

  • dyspraxia (also called Developmental Coordination Disorder, or DCD) 
  • dyscalculia 
  • attention deficit hyperactivity disorder (ADHD) 
  • autism spectrum condition (ASC)
  • Tourette’s.

These conditions very often co-occur, and many symptoms overlap. All experiences are different and influenced by intersectionality. Neurodiverse groups may be more highly represented in health and social care professions than the general population and are underdiagnosed in women and girls.   

Neurotypical means that the brain learns, functions and processes information in the way society expects and is designed. About 15 per cent of the population are neurodivergent. This means the brain learns, functions and processes information differently. Many of the challenges neurodivergent people experience are due to the barriers caused by the expectations and design of the neurotypical society we live in. Removing these barriers can build a more inclusive society valuing individual strengths and differences.

RCN resources

Limited research exists on the subject of women's health and neurodiversity. However, it is documented that autistic people often have worse physical and mental health, shorter lives, and higher suicide risk than others. 10% of the respondents identified as being autistic or neuro divergent in the Women’s Health Strategy. 

There is evidence that neurodiverse women experience increased difficulties in menstruation and menopause and that they may be less well informed on issues such as the menopause, periods, and sexual health than neurotypical people. Women with learning disabilities and autism are almost four times less likely to go for cervical cancer screening tests (Dimensions, 2023).

Barriers to care include:

  • professionals understanding of needs and misinterpretation of behaviour
  • sensory issues
  • anxiety
  • communication issues
  • issues with transitions/change/organisation.

The Oliver McGowan Mandatory Training on Learning Disability and Autism (NHS England) is the UK government’s preferred and recommended training for health and social care staff.

Reasonable adjustments are a legal requirement to ensure that health services are accessible to people with disabilities. According to the Equality Act 2010, people with disabilities can get reasonable adjustments when using public services. Reasonable adjustments may include:

  • Communication: Ask about preferred methods of communication, use resources such as communication passport, social stories, overlays and appropriate online/written information. 
  • Assistance: Help with reaching out to organisations and advice on taking medication or attending appointments.
  • Sensory issues: Make appropriate adjustments to help people to feel more comfortable, reduce the risk of sensory overload and promote independence.  
  • Environment: Offer home visits or an alternative venue and flexible and longer appointment times. 
  • Involvement: Encourage the involvement of others to advocated and empower relationships. The includes support services, professionals, family and friends.

The 2021 Learning from lives and deaths – People with a learning disability and autistic people (LeDeR) policy now includes autistic people. This means that all autistic adults whose deaths are notified to the programme will be able to have a review. This will help improve health outcomes and provide a clearer understanding of the inequalities autistic people face and the causes for the gap in life expectancy. 

References and resources

Minority ethnic groups include people from Black, Asian, mixed ethnicity groups and other backgrounds such as Gypsy, Traveller or Roma communities.

Evidence suggests that patients from minority ethnic groups face barriers to care within women’s health, and have poorer outcomes overall. We believe the health care sector needs to take more action to address this.

Research shows that:

  • Black women are 3.7 times more likely to die giving birth or in the 6 weeks after birth than white women.
  • Asian women are 1.8 times more likely to die giving birth or in the 6 weeks after birth than white women.
  • Women of mixed ethnic backgrounds are 1.3 times more likely to die giving birth or in the 6 weeks after birth than white women.

Despite being committed to holistic care, midwives have reported barriers for women from minority ethnic groups within maternity services. Obstacles for women included not being listened to or believed by health care professionals and a lack of cultural understanding. 

There is also evidence of systemic racism in maternity care in the UK, and women may feel unsafe, dehumanised, not given adequate choices and disproportionately face structural barriers to their care. The Women’s Health Strategy aims to address these health inequalities and tackle issues with service provision and overall health outcomes for women.

Reports indicate that women from these groups have a lower uptake of health screening. The number of women who do not attend for cervical screening in the UK is much higher. Additionally, many of these women have a low attendance level for breast screening.

Barriers to attending screening include:

  • socio-demographic characteristics
  • health service delivery
  • cultural, religious & language
  • the gap in knowledge and awareness
  • and emotional, and family support.

The option to see a female health care professional for sexual and reproductive health (PDF) is not always available, which can also increase barriers to care.

Research has found that black women’s symptoms are often not taken seriously, despite chronic pelvic pain and abnormal menstrual bleeding being highly prevalent in this population. Black women are also more likely to have endometriosis which remains undiagnosed and are 2 to 3 times more likely to have fibroids than white women.

The Faculty of Sexual and Reproductive Healthcare (FSRH) says that women from minority ethnic groups have poorer access to contraception care and there should be more focus to ensure they receive a higher standard of care.

The COVID-19 pandemic has disproportionately affected those from minority ethnic groups, who experienced higher infection and mortality rates than white counterparts, in large parts due to deprivation, living arrangements and existing health conditions. The pandemic highlighted the need to reduce health inequalities and improve the management of ill health across this group. 

Menopause and women from minority ethnic groups

The menopause transition has a significant impact on a women’s life, with recent reports illustrating profound differences in the experiences reported by black and ethnic minority women. Although women's culture, race, and ethnicity largely shape the way menopause is perceived and understood, there is limited research in the UK to truly understand the differences. 

Download the ‘Menopause in Ethnic Minority Women’ guidance from the British Menopause Society (PDF).

The study Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women’s Health Across the Nation (SWAN) found that black women reached menopause two years earlier than the median age and spend longer periods in the perimenopause phase.

Despite what is already known, ethnic minority women continue to face further barriers when accessing menopause care. Growing evidence suggests that although women are attending services, they are more likely to be given alternative treatments and less likely to be offered hormone replacement therapy (HRT).

Barriers to accessing menopause care include:

  • menopause continues to be a taboo topic and a lot of social stigma exists surrounding it
  • lack of culturally appropriate services
  • fear and mistrust of public services
  • menopause viewed as the loss of fertility and femininity
  • lack of education and knowledge
  • lack of translatable terminology resulting in potential language barriers
  • lack of adequate representation in the media and patient information leaflets.

What can nurses do?

Nurses can make a difference by practicing anti-racism and embracing equity, inclusion, and diversity. Additionally, nurses can:

  • listen to women with a view to understanding their needs, not just waiting to respond
  • include women in decision-making throughout their care journey
  • create an inclusive workplace culture and commit to a diverse recruitment approach
  • prioritise cultural competency training
  • ensure care plans are holistic and culturally aware.

Gypsy, Roma and Traveller ethnic groups

Despite being entitled to the same protection as other ethnic minority groups in Britain under the Equality Act 2010, Gypsy, Traveller, and Roma groups continue to face harassment and discrimination. 

These groups, for reasons including poorer outcomes in health care and education, are among the most disadvantaged people in the UK. Other reasons include:

  • lack of continuity of care and poor inclusion
  • language barriers and low levels of literacy
  • fear and mistrust of public services
  • lack of awareness of cultural taboos within services.

According to statistics, life expectancy for Gypsy, Roma and Traveller groups is 10 years lower than the national average. Mothers are 20 times more likely to experience the death of a child (PDF) than the general population. 

Recommendations for improvement include:

  • mandatory Gypsy, Traveller and Roma inclusive services training for all health and social care services
  • services need to adapt to meet specific social and cultural norms of these ethnic minority groups
  • when discussing information, it is better to use verbal communication instead of issuing leaflets
  • engage with Gypsies, Travellers and Roma people directly to ensure we hear their voices.

For more information download the Tackling Maternal Health Inequalities in Gypsy, Roma and Traveller Communities PDF (Friends, Families & Travellers, 2023)

Further resources

Begum, A. (2023): The Importance Of Diversity, Inclusion, And Equality in Nursing, Nurses.co.uk.

Harlow et al (2022): Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women’s Health Across the Nation (SWAN), Women's Midlife Health.

Although there is no internationally accepted legal definition of a migrant, a migrant may move countries to work, study, and for humanitarian purposes. They may feel they have no other choice due to gang violence, poverty, natural disasters, political unrest or other serious circumstances. 

A refugee is a person who has fled their country in search of safety as they were at risk of human rights violations and persecution. An asylum seeker is someone who has left their country and is seeking protection from persecution and serious human rights violations in another country. They haven’t been legally recognised as a refugee and will be waiting for a decision on their asylum claim.

Both migrants and asylum seekers may have come from countries that do not offer the same health provision as the UK. Migrants and asylum seekers may not know how or where to access care (emergency, acute care and screening), and there may be some concerns regarding entitlement and payment for care. 

It is important to remember that other cultures may have different beliefs or practices around subjects such as menstruation or contraception and a practitioner should aim to explore these properly in order to offer education and advice.  

The Migrant Health Guide (Office for Health Improvement and Disparities, 2021) provides further advice and guidance on the health needs of migrant patients for health care practitioners.

The Women's health: migrant health guide (Office for Health Improvement and Disparities, 2021) outlines 4 important messages:

  • Support women to access sexual health services and maternity care and to understand their entitlements to care.
  • Be aware of possible religious and cultural sensitivities when discussing sexual and reproductive matters.
  • Where language is a barrier in discussing sexual or reproductive matters, offer a female interpreter. It is inappropriate to use children as interpreters for adults, particularly when discussing intimate concerns. 
  • Have arrangements in place for one-to-one disclosure and avoid discussing sensitive topics in front of children.

For further information and resources on supporting migrant health, see the RCN's resource on migrant health.

Principles of good practice: How services adapt to cater for specific needs

Ensure that migrants, asylum seekers and refugees are:

  • aware of how to access health care appropriately
  • aware of their entitlements (free sexual health/contraception)
  • aware of screening in UK (cervical/breast).

Health care professionals can:

  • work with outreach services
  • fully explore beliefs and expectations about women's health
  • ensure use of (female) translators during consultations
  • offer health promotion advice, education and appropriate signposting 
  • use statistics and research, such as health outcomes, physical and mental wellbeing and life choices to develop improvements in care provision.

Individual support and service provision

The blog Supporting our Afghan community to attend cervical screening (Jo’s cervical cancer trust, 2022) outlines a positive report of how immigrant women can be supported and enabled to access cervical screening. Two of the main reasons refugees did not attend cervical screening because of a fear of the unknown and lack of understanding.

Asylum seekers and refugees can also be at increased risk of sexual violence, which can lead to them needing to access sexual health services for infection screening, emergency contraception and abortion care. The British Red Cross provides help for women refugees and asylum seekers facing sexual and gender-based violence.

In terms of gynaecological cancer, awareness of risk factors for and symptoms of cancer, plus socio-cultural and practical barriers such as language, contribute to lower cancer screening rates among ethnic minority groups (The health of people from ethnic minority groups in England, King's Fund, 2023).

Further resources

BMA (2023): Overcoming barriers. Refugee and asylum seeker patient health toolkit.

British Red Cross (2022): Women’s experiences of seeking asylum in the UK.

Royal College of Midwives (2021): Caring for vulnerable migrant women (PDF).

Many homeless or displaced women, including those living in temporary accommodation experience problems and stigma when trying to access health care, in particular primary care services. This is described in detail in The attitudes of homeless women in London towards contraception.

Nurses need to be aware of how they can best support some of the most vulnerable women in local communities. This begins with better understanding the challenges faced by women who are homeless, as well understanding underlying causes, being non-judgemental and considering the specific needs of these women who are often invisible or unseen in health care systems and processes.

The research report aimed to understand more about the health conditions women are facing and how housing issues can affect their health.

Key findings included:

  • Factors causing homelessness – participants had long histories of homelessness in which physical and mental health were contributing factors to their situation.
  • Homelessness was causing significant damage to the physical and mental wellbeing of participants.
  • Participants experienced issues with sleeping, finding enough food, keeping clean, and were affected by addiction and on-going sexual and/or domestic abuse.
  • Health care usage—participants were reliant on the support provided by health care services and not-for-profit services or organisations but highlighted a need for more specialised support.

Further resources

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Page last updated - 07/06/2024

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