James Nazroo

The Structuring of Ethnic Inequalities in Health: Economic Position, Racial Discrimination, and Racism

Differences in health across ethnic groups have been documented in the United States and the United Kingdom. The extent to which socioeconomic inequalities underlie such differences remains contested, with many instead focusing on cultural or genetic explanations. In both the United States and the United Kingdom, data limitations have greatly hampered investigations of ethnic inequalities in health. Perhaps foremost of these is the inadequate measurement of ethnicity, but also important is the lack of good data on socioeconomic position, particularly data that address life-course issues. Other elements of social disadvantage, particularly experiences of racism, are also neglected. The author reviews existing evidence and presents new evidence to suggest that social and economic inequalities, underpinned by racism, are fundamental causes of ethnic inequalities in health.

Cohort Profile: The English Longitudinal Study of Ageing

The English Longitudinal Study of Ageing (ELSA) is a panel study of a representative cohort of men and women living in England aged ≥50 years. It was designed as a sister study to the Health and Retirement Study in the USA and is multidisciplinary in orientation, involving the collection of economic, social, psychological, cognitive, health, biological and genetic data. The study commenced in 2002, and the sample has been followed up every 2 years. Data are collected using computer-assisted personal interviews and self-completion questionnaires, with additional nurse visits for the assessment of biomarkers every 4 years. The original sample consisted of 11 391 members ranging in age from 50 to 100 years. ELSA is harmonized with ageing studies in other countries to facilitate international comparisons, and is linked to financial and health registry data. The data set is openly available to researchers and analysts soon after collection (http://www.esds.ac.uk/longitudinal/access/elsa/l5050.asp).

Socioeconomic status and health: the role of subjective social status

Studies have suggested that subjective social status (SSS) is an important predictor of health. This study examined the link between SSS and health in old age and investigated whether SSS mediated the associations between objective indicators of socioeconomic status and health. It used cross-sectional data from the second wave (2004-2005) of the English Longitudinal Study of Ageing, which were collected through personal interviews and nurse visits. The study population consisted of 3368 men and 4065 women aged 52 years or older. The outcome measures included: self-rated health, long-standing illness, depression, hypertension, diabetes, central obesity, high-density lipoprotein cholesterol, triglycerides, fibrinogen, and C-reactive protein. The main independent variable was SSS measured using a scale representing a 10-rung ladder. Wealth, education, and occupational class were employed as covariates along with age and marital status and also, in additional analyses, as the main independent variables. Gender-specific logistic and linear regression analyses were performed. In age-adjusted analyses SSS was related positively to almost all health outcomes. Many of these relationships remained significant after adjustment for covariates. In men, SSS was significantly (p<or=0.05) related to self-rated health, depression, and long-standing illness after adjustment for all covariates, while its association with fibrinogen became non-significant. In women, after adjusting for all covariates, SSS was significantly associated with self-rated health, depression, long-standing illness, diabetes, and high-density lipoprotein cholesterol, but its associations with central obesity and C-reactive protein became non-significant. Further analysis suggested that SSS mediated fully or partially the associations between education, occupational class and self-reported and clinical health measures. On the contrary, SSS did not mediate wealths associations with the outcome measures, except those with self-reported health measures. Our results suggest that SSS is an important correlate of health in old age, possibly because of its ability to epitomize life-time achievement and socioeconomic status.

Effects of self-reported racial discrimination and deprivation on Māori health and inequalities in New Zealand: cross-sectional study

BACKGROUND Inequalities in health between different ethnic groups in New Zealand are most pronounced between Māori and Europeans. Our aim was to assess the effect of self-reported racial discrimination and deprivation on health inequalities in these two ethnic groups. METHODS We used data from the 2002/03 New Zealand Health Survey to assess prevalence of experiences of self-reported racial discrimination in Māori (n=4108) and Europeans (n=6269) by analysing the responses to five questions about: verbal attacks, physical attacks, and unfair treatment by a health professional, at work, or when buying or renting housing. We did logistic regression analyses to assess the effect of adjustment for experience of racial discrimination and deprivation on ethnic inequalities for various health outcomes. FINDINGS Māori were more likely to report experiences of self-reported racial discrimination in all instances assessed, and were almost ten times more likely to experience discrimination in three or more settings than were Europeans (4.5% [95% CI 3.2-5.8] vs 0.5% [0.3-0.7]). After adjustment for discrimination and deprivation, odds ratios (95% CI) comparing Māori and European ethnic groups were reduced from 1.67 (1.35-2.08) to 1.18 (0.92-1.50) for poor or fair self-rated health, 1.70 (1.42-2.02) to 1.21 (1.00-1.47) for low physical functioning, 1.30 (1.11-1.54) to 1.02 (0.85-1.22) for low mental health, and 1.46 (1.12-1.91) to 1.11 (0.82-1.51) for cardiovascular disease. INTERPRETATION Racism, both interpersonal and institutional, contributes to Māori health losses and leads to inequalities in health between Māori and Europeans in New Zealand. Interventions and policies to improve Māori health and address these inequalities should take into account the health effects of racism.

Genetic, Cultural or Socio‐economic Vulnerability? Explaining Ethnic Inequalities in Health

Most work on ethnic inequalities in health in the UK has focused on genetic and cultural difference, ignoring issues relating to class disadvantage. However, more recent work, and that conducted in the US, suggests that material disadvantage might be crucial. Nevertheless, the wider sociological literature illustrates that ethnicity and ‘race’ cannot simply be reduced to class. This paper uses data from the Fourth National Survey of Ethnic Minorities to examine three alternative approaches to ethnic inequalities in health. Epidemiological approaches are driven by empirical findings and make little explicit acknowledgement of theoretical understandings of ethnicity, but they carry the assumption that ethnicity provides a natural and fixed division between population groups. Consequently, explanations for differences tend to be reduced to ahistoric and de-contextualised genetic and cultural factors. Structural approaches generally focus on material explanations for inequalities, but there are important methodological difficulties in assessing these. We also need to consider other elements of the structural disadvantage faced by ethnic minority groups, such as their experiences of racism or concentration in particular geographical locations. Approaches that focus on ethnic identity emphasise the importance of group affiliation and culture, while acknowledging the contingent and contextual nature of ethnicity. However, despite the promise carried by identity based approaches, there has been little empirical work undertaken. These varying approaches illustrate how important ethnic inequalities in health might be to a wider understanding of mechanisms producing inequalities in health. However, a concern with mechanisms in health inequalities research can lead to a focus on technical interventions along causal pathways, with the roots of health inequalities, wider social inequalities, being ignored.

Agency and structure: the impact of ethnic identity and racism on the health of ethnic minority people

Abstract To understand ethnic inequalities in health, we must take account of the relationship between ethnic minority status, structural disadvantage and agency. So far, the direct effects of racial oppression on health, and the role of ethnicity as identity, which is in part a product of agency, have been ignored. We set out to redress this balance using data from the Fourth National Survey of Ethnic Minorities. Factor analysis suggested that dimensions of ethnic identity were consistent across the various ethnic minority groups. Initially some of these dimensions of ethnic identity appeared to be related to health, but in a multivariate model the factor relating to a racialised identity was the only one that exhibited any relationship with health. These findings suggest that ethnic identity is not related to health. Rather, the multivariate analyses presented here showed strong independent relationships between health and experiences of racism, perceived racial discrimination and class.

The buffering effects of ethnic density on experienced racism and health

Studies in the United Kingdom (UK) show a consistent inequality between the health of ethnic minorities and that of white people. This is exacerbated by the over-representation of ethnic minorities in deprived areas, which have been associated with poorer infant and child health, chronic disease, and high mortality rates. Ethnic density, defined as the proportion of ethnic minority residents in an area, is generally thought of in relation to the negative impacts of area effects on health. However, it can be considered in terms of social networks and supportive communities, possibly mitigating the detrimental impact of racism on the health of ethnic minority people. This study investigated the ethnic density effect and hypothesised that ethnic minority people who live in areas of high ethnic density would report decreased experienced racism and better health outcomes compared to their counterparts living in areas of low ethnic density. Multiple logistic regressions were conducted using data from the Fourth National Survey of Ethnic Minorities and the 1991 UK Census. Results showed a negative association between ethnic density and psychotic symptomatology, but no evidence of an association between ethnic density and general self-rated health. Findings confirm that the experience of racism is lower in places of higher ethnic density and indicate a tendency for a weaker association between racism and health as ethnic density increases.

Racial/Ethnic Discrimination and Common Mental Disorders Among Workers: Findings From the EMPIRIC Study of Ethnic Minority Groups in the United Kingdom?

OBJECTIVES We measured perceived discrimination and its association with common mental disorders among workers in the United Kingdom. METHODS We conducted a secondary analysis of a national sample of 6 ethnic groups (n=2054). Discrimination was measured as reports of insults; unfair treatment at work; or job denial stemming from race, religion, or language. The outcome assessed was presence of common mental disorders. RESULTS The risk of mental disorders was highest among ethnic minority individuals reporting unfair treatment (odds ratio [OR]=2.0; 95% confidence interval [CI]=1.2, 3.2) and racial insults (OR=2.3; 95% CI=1.4, 3.6). The overall greatest risks were observed among Black Caribbeans exposed to unfair treatment at work (OR=2.9; 95% CI=1.2, 7.3) and Indian (OR=3.1; 95% CI=1.4, 7.2), Bangladeshi (OR=32.9; 95% CI=2.5, 436.0), and Irish (OR=2.9; 95% CI=1.1, 7.6) individuals reporting insults. CONCLUSIONS Racial/ethnic discrimination shows strong associations with common mental disorders.

Racism, psychosis and common mental disorder among ethnic minority groups in England.

BACKGROUND The aim of this study was to explore the relationship between risk of psychosis, common mental disorder (CMD) and indicators of racism among ethnic minority groups in England and how this relationship may vary by particular ethnic groups. METHOD A multivariate analysis was carried out of quantitative, cross-sectional data from a nationally representative community sample of people aged between 16 and 74 years from the largest ethnic minority groups in England: those of Caribbean, Indian, Pakistani, Bangladeshi and Irish origin. RESULTS Experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of CMD and psychosis, after controlling for the effects of gender, age and socio-economic status. There was some variation in the findings when they were conducted for separate ethnic and gender groups. CONCLUSIONS An understanding of the relationship between racism and mental health may go some way towards explaining the ethnic variations found in both CMD and, particularly, psychosis.

Social and psychological impact of HPV testing in cervical screening: a qualitative study

Objective: Human papillomavirus (HPV) testing has been proposed for inclusion in the UK cervical screening programme. While testing may bring some benefits to the screening programme, testing positive for HPV, a sexually transmitted virus, may have adverse social and psychological consequences for women. The aim of this study was to examine the social and psychological impact of HPV testing in the context of cervical cancer screening. Method: In-depth interviews generating qualitative data were carried out with 74 women participating in HPV testing in England between June 2001 and December 2003. Purposive sampling was used to ensure heterogeneity in age, ethnic group, marital status, socioeconomic background, cytology, and HPV results among participants. Results: Testing positive for HPV was associated with adverse social and psychological consequences, relating primarily to the sexually transmitted nature of the virus and its link to cervical cancer. Women described feeling stigmatised, anxious and stressed, concerned about their sexual relationships, and were worried about disclosing their result to others. Anxiety about the infection was widespread, but the impact of testing positive varied. The psychological burden of the infection related to women’s relationship status and history, their social and cultural norms and practices around sex and relationships, and their understanding of key features of HPV. Conclusion: HPV testing should be accompanied by extensive health education to inform women and to de-stigmatise infection with the virus to ensure that any adverse impact of the infection on women’s wellbeing is minimised.