Ethnicity and Health care inequalities

Introduction:
UK is a country with rich ethnic diversity, which started with migration from South Asia in 1960s mainly Indians and Pakistani. In 1970s East African Asian and Bangladeshi migrated followed by migration from China in various phases (Ali, 2006). Ethnicity has become a social division which is so difficult to be ignored (Ahmad and Bradby, 2008).There has been a strong association between health status and ethnicity, which is evident from the time when Frederick Engels in 1845 recorded quantitative data regarding poor health and mortality of Irish people in England. Engels also identified that most of the Irish people were living in miserable conditions which was the main reason of their poor health, such as they were economically poor and their living standards were quite poor. John Trask in 1916 published a report in which he mentioned the reason of poor health of blacks in United States; the report showed that blacks had higher death rates as compared to whites because of low socioeconomic conditions (Davy Smith et al. 2000). Ethnicity, social condition and health status have complex interrelationship and a strong area of concern .Official statistics making link between ethnicity and health were established in 1980s (Ali, 2012).

An investigation will be made to show how diseases, disabilities and deaths are among different ethnic minorities as compared to the UK white population. The aim is to uncover the causes of different diseases and the reasons for their distributions in ethnic minorities. There is now some reasonable data available regarding differences in health status among different ethnicities and also in relationship to socioeconomic factors to these differences. Nazroo in 1997 and Sproston in 2006 showed in their surveys that ethnic minorities as a whole were likely to report poor health and poor health started at younger age among different ethnic minorities as compared to white British. An attempt is made to investigate factors responsible for the higher and lower rates of certain diseases distributed among different ethnic minority groups. There are examples of higher rates of certain diseases, diabetes and mental illness among different ethnic groups. Then an inquiry will be made to uncover the variations of poor health within different ethnic groups. This will be concluded with discussions of these approaches, which are taken to analyse and understand these variations of poor health among different ethnicities.

Ethnicity and health:

Africa and West Africa, Indian subcontinental countries (Pakistan, India, Sri Lanka, Bangladesh), Scotland, both Northern Ireland and Republic of Ireland. Here are the tables showing standardised mortality ratios (SMRs) for deaths of men and women for all causes according to the country of birth. All-cause mortality is significantly higher for population born in East Africa, South and West Africa, Ireland, Scotland. Lung cancer and ischemic heart disease are main causes of death; people born in Indian subcontinent are showing high mortality rates due to ischemic heart disease. Ischemic heart disease mortality rates are low in people born the Caribbean. Mortality due lung cancer is lower in all countries except Ireland and Scotland. Mortality due to accident and injuries and is also higher in Ireland and Scotland. Suicide mortality is low in people born in Caribbean countries.

Table 1 SMRs for men (20-64 years), by country of birth, \England and Wales, 1991-93 All causes Total Caribbean West/South Africa East Africa India Pakistan Bangladesh Scotland 100 89* 126* 123* 106* 102 133* 129* Ischemic heart disease 100 60* 83 160* 140* 163* 184* 117* Stroke Lung cancer 100 59* 71 37* 43* 45* 92 146* Other cancer 100 89 133* 77 64* 62* 74* 114* Accident & injuries 100 121 75 86 97 68 40* 177* Suicide

100 169* 315* 113 140* 148* 324* 111

100 59* 59* 75* 109* 34* 27* 149*

Table 2 SMRs for women (20-64 years), by country of birth, \England and Wales, 1991-93 All causes Ischemic heart disease 100 100 69 Stroke Lung cancer 100 32* 69 29* 34* 164* Other cancer 100 87 120 98 68 106 Accident and injuries 100 103 A A 93 201* Suicide

Total 100 Caribbean 104 West/South 142* Africa East Africa 127* 130 Indian 99 175* subcontinent Scotland 127* 127* A: low deaths to undertake analysis *p <0.05, compared to overall rate. (Source: Harding and Maxwell, 1997)

100 178* 215* 110 132* 131*

100 49* 102 129 115 153*

There is another table showing mortality in the first year of life in relation to different ethnic groups, which shows that perinatal mortality (deaths between 28th week of gestation and the end of seventh day after delivery) rates are higher of the infants of non-UK born mothers. Neonatal mortality (deaths of neonates in first twenty seven days of life) rates, post neonatal mortality (deaths after twenty eight days of life but before the end of first year of life) rates and infant mortality (deaths in first year of life) rates are higher among Pakistani, Bangladeshi and Caribbean ethnicities, and they are on the lower side among Indians.

Table 3 Mortality in the first year of life per 1000 births by mothers country of birth, England and Wales, 1996 UK East Africa Perinatal 8.2 12.4 mortality Neonatal 3.9 4.1 mortality Post neonatal 1.9 2.0 mortality Infant mortality 5.8 6.1 (Source: Harding and Maxwell, 1997) Morbidity: Bangladesh India 9.5 11.3 4.2 2.2 6.3 3.9 1.5 5.4 Caribbean 11.5 4.7 3.6 8.4 Pakistan 15.8 6.5 3.6 10.1

According to the census 1991, there has been a higher rate of chronic illness among the ethnic minority groups as compared to the white population. Minority ethnic groups were focussed particularly in the Health Survey for England in 2004 (Sproston and Mindell, 2006). The survey reported that Pakistani and Bangladeshi men and women, and Caribbean women had worse health as compared to general population. Pakistani population was more likely to report acute illness. Prevalence of diabetes was four times among Bangladeshi men and three times among Pakistani and Indian men as compared to the general population. Survey also reported that prevalence of diabetes was about five times among Pakistani women, three times among Bangladeshi and Black Caribbean women and about two and a half times among Indian women when compared to general population. Irish men and Bangladeshi men had high prevalence of self-reported smoking. Bangladeshi women had reported highest use of chewing tobacco (26 per cent). Black Caribbean and Irish men had highest prevalence of obesity. Black Caribbean and Irish women were reported be more hypertensive as compared women in general population.

It is important to recognise that inequalities in health are due to multiple factors which are interlinked with each other and are known to be wider determinants. People with poor

housing conditions, low education, and insecure employment are the ones who suffer poorer health (Randhawa, 2007). Socioeconomic status: Socioeconomic status has been a potent factor to ethnic minority groups in relationship to their mortality rates and especially to Black American as compared to the Whites (Sorlie et al. 1992). Work by Nazroo (1997), Ahmed (1993) and Smaje (1997) in Britain and Krieger (2000) and Williams and his colleagues (1997) in USA, focuses on socioeconomic status, ethnicity and health. There is a complex relationship between ethnicity and social class and its impacts on the outcome of the health (Randhawa, 2007). Fourth National Survey of ethnic minorities provides an important data and focuses on socioeconomic status in relationship to health issues ethnic minority groups are facing (Nazroo, 1997). In the Fourth National Survey morbidity was presented according to household social class and ethnicity. Differences in social classes were seen within majority and minority population for their causes of poor health. People who live in households without a full time worker were involved in many cases of morbidity, than people who lived in households with full time worker (Davey Smith et al. 2000).

In 1971 census, little was explained by occupational social class regarding differences in mortality between different ethnic minority groups (Marmot et al. 1984). According to 1991 census the standardised mortality ratio of 89 for all-cause mortality for Caribbean men is reduced to 82, in relationship to social class, this is because Caribbean men represented manual social class groups, generally Caribbean men have higher mortality compared to nonmanual social class group. In studies related to Irish living in UK, among second generation the standardised mortality ratio for men of working ages is 126 which changes little in relationship to social class adjustment and it becomes 132 (Davey Smith et al. 2000). Perinatal, neonatal, post-natal and infant mortality creates a gradient for all ethnic minority groups, born in the lowest socioeconomic classes generally have the highest mortality rates. Representing each social class, infant mortality rates were high in Pakistani children as in those born in Wales and England, except for those in social class I. Infants who are born to parents from East Africa, West Africa, Bangladesh have lower post-neonatal mortality rates as compared to those infants born to parents from United Kingdom, and Bangladesh also have lower infant mortality rates (Davey Smith et al. 2000).

Health service provision and the social class of service users are closely related to each other, with poor social class have least access to the good health services and at the end suffer poorer health outcomes (Ahmad and Bradby, 2008). This was also explained by Tudor Hart and called it inverse care law (Tudor Hart, 1971). This is evident that socioeconomic status is an important predictor of individual health status of the group which one belongs to (Marmot, 2004). There are variations of health concepts and illness across culture and time to

time (Klienman, 1981). Accessibility to healthcare is strongly related to the seeking behaviour of the ethnic minority groups (Smaje, 1995).

National statistic 2006 show that overall unemployment rates decreased still there are variations by ethnic group and the follwing table is showing those differences. Indian men have levels of unemployment similar to White men. Unemployment for Black Caribbean's, Black Africans, Bangladeshis and mixed race men approximately three times that of White British and White Irish men.Pakistani women have the highest rate of unemployment.

Migration:

When there is a history of migration, it plays an important factor in the creation of self-made ethnic minorities and majorities and this also describes its relationship with different health patterns. The migration of different minorities across the world such as South Asian or African-Caribbean in Europe, Irish in Britain, America and Australia experience at least two economic systems, one in past and the current one, and they also experience two systems of culture as well. This gives them always a continuous feeling of dual experience. The different characteristic of health of migrants are there at the time when they decide to migrate and will have also a strong reflection in their health at the place of their destination (Davey Smith et al, 2000). Migrants health is always explained in relation to their population of birth and usually they enjoy better health if they are from an area of long distance (Marmot et al, 1984). Another side of the migrants health is that, there is sometimes possibility of returning migrants to their own birthplace when sick or wishing to die in their original homes, which

could reduce the mortality of the migrant population. This is known to be salmon bias phenomenon (Abraido-Lanza et al. 1999). This salmon bias is investigated in the US studies in relationship to the reduced level of mortality amongst Latino population, there has been not that much studies in UK regarding salmon bias. In a study there has been low mortality in Irish born people of post-retirement age as compared to population at younger ages, which suggested that there is return of ill people with high mortality risks (William and Ecob, 1999). Various kinds of stress are there which are associated with migration period and lead to worse health. This is transitional phenomenon and improves over time (Hull D, 1979). Ethnicity identity and health: Health and different diseases have often been shown in relationship to the notion of identity and rates of mortality. Different conditions have been presented a stigma to certain ethnic minority groups, for example, cancers, tuberculosis, mental illness, ischemic heart diseases, depression and genetic diseases (Ahmad and Bradby, 2008). South Asian, Caribbean and people from African American have got genetic disease such as thalassemia and sickle cell disease (Anionwu and Atkin, 2001). Overall cancer rates for ethnic minority groups lower than the majority population there are certain cancers where incidence is higher among certain ethnic groups. South Asians have higher rates of liver and mouth cancer. Black men are more likely to be diagnosed with prostate cancer. Incidence of strokes is higher in Caribbean women, Bangladeshi men and women and lowest in Chinese women. Caribbean men are 50% more likely to die of stroke compared to general population. Prevalence of diabetes is five times higher in African, Caribbean and Asian communities. Chinese people have the lowest rate of diabetes but still higher than white majority population. Ethnic minorities are more likely to be diagnosed with a mental illness than White British. Diagnosis of psychosis has been seven times higher for Black Caribbean people than White British, Lowest for Chinese people. There have been highest rates of depression in Indian and Pakistani women but lower for Bangladeshi and Black Caribbean women (Ali, 2012). Culture Beliefs and behaviour: Culture affects health of an individual health through factors such as beliefs, health-related behaviour (e.g. drinking alcohol, exercise, diet, sexual behaviour, smoking, health concepts, lay beliefs and body images) or the kinship and family organisation or communication (important in service use) and language (Davey Smith et al. 2000). According to Office for National Statistics 1996 Smoking is less prevalent among South Asian and Blacks as compared to general population, especially among women, although level of smoking is almost similar among Pakistani and African Caribbean men and getting close to the smoking level to the general population and highest among Bangladeshi men. Alcohol consumption is also on the lower side among South Asians and African Caribbean men and more lower amongst women. There is high level of alcohol consumptions among Sikhs and level is approaching to general population for Hindus (Chochrane and Bal, 1990). Different cultures represent various patterns of diet. South Asian are more prone to ischemic heart diseases and African Caribbean has risk of hypertension and stroke because of their

diet and concerns has been shown that risk factors for ischemic heart disease and hypertension may be needed to reduce by changing their diet (Bush et al. 1998). TB has been connected with low intake of vitamin D and iron in vegetarians. Excess weight which is due to lack of exercise has been noted among South Asian community (Rudat, 1994). Nutritional deficit has been related to the short stature among South Asian and Irish in Britain, as result of nutritional deficit the individuals are more prone to childhood infections (Abbot et al. 1998). Family size and kinship have been studied in South Asian population usually they have larger number of people in their households both in number of children and adults and more involved in relatives than in general population. Caribbean children are more involved in households with their mother as compared to general population (Owen, 1994). Religion plays an important role on health behaviour, religious limits Sikhs from smoking, Protestants and Muslims from drinking alcohol. The smoking pattern of Bangladeshis and Pakistani are high compared to overall South Asian group, although lower for women. Language is one of the influential factors among South Asian community when it comes to the service users; they have difficulty in communications and is one of the causes related to racism (Rudat, 1994). Racism: Nazroo (2003) argues that other forms of social disadvantage e.g. racism are neglected from the list of factors of how health and illness is experienced (i.e. class, gender, disability etc.) He argues that social and economic inequalities, underpinned by racism, are fundamental causes of ethnic inequalities in health (Nazroo, 2003). One in eight ethnic minorities comes across with racism every year. 25% people from ethnic minority groups are fearful of racism (Moddod et al. 1997). Racism could have an effect on the health of an individual in three ways. First is indirect effect, which may be experienced as a result of socioeconomic disadvantage. Second, ethnic minority groups will recognise that relative disadvantage which they face due to discrimination, racism and obvious inequalities that they come across in their lives. This feeling of relative disadvantage may result in a significant effect on the health outcomes. Third is a direct effect on the health as a result of harassment and racism which lead to mental stress and poor health. But it is also evident from Fourth National Survey which shows that racial harassment is not directly proportional to the health across different ethnic minority groups. Bangladeshis are there with poorest health, are less likely to report racial harassment compared to both African Asian and Chinese, who enjoy the best health (Modood et al. 1997).

Access to the Health services and Use There are many factors that ethnic minority groups have got inequalities in accessing health services. Many studies have been done in USA to investigate inequalities in accessing health services, and especially involving US whites in comparison with Africa-Americans (Davey Smith, 2000). This is evident that ethnic minorities have got the lowest rates of accessing the main health services. When seeking health care, people from ethnic minorities may experience barriers at any stage. First at patient level, each individual has different perception of his symptoms and has different level of urgency to get an access to healthcare. Second, physical barriers to access to GP i.e. unavailability of transport, unavailability of appointment at right may be a cause of delay to access healthcare. Third at GP level, whether GP diagnoses the person correctly, which are in relation to patient demographic characteristics, including social class (Davey Smith, 2000). Utilisation of the screening services such as breast and cervical screening services are reported to be low in people, especially South Asian women (Rudat, 1994). This difference has been explained in relation to stereotyping, racism (Chantler et al. 2001), cultural barriers and linguistics (Ali, 2003) and lack of knowledge. Recent research shows that there has been a good improvement in these areas (Bhopal, 2007).

Conclusion:
Ethnic identity is socially constructed and concept of ethnicity has to be studied in connection with gender, age, socioeconomic status and sexuality when it is looked under the heading of ethnicity and health inequalities (Ali, 2012). There is a strong connection between ethnicity and health inequalities. There has not been that much evidence to show a difference of health status between different ethnic minority groups in UK. There is not much data of certain ethnic minority groups such as Chinese and Irish communities. There are some complex reasons for the existence of health inequalities among ethnic minority groups and the health of the ethnic minority groups can be improved by reforming current NHS system and Local Strategic Partnerships and there is not that much data regarding ethnicity and health inequalities, and hence data collection is needed to be improved (Randhawa, 2007). The influences which have been discussed above under each category can clear some of the differentials of health status among different ethnic minority groups. These different influential factors will act at different periods in their lives. There are issues with ways to measure socioeconomic position in relation to its effects on the health outcomes (Davey Smith, 2000), and failure to recognise these issues when considering socioeconomic position in relation to the differences in health status between different ethnic minority groups which then lead to explanations based on genetic and cultural differences. The challenge of researchers in public health is to research and investigate health and ethnicity on consistent basis, and to provide a base for public health practitioners with evidences to ensure equitable healthcare services (Ali, 2012).

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