Margaret Kelaher

Racism as a Determinant of Health: A Systematic Review and Meta-Analysis

Despite a growing body of epidemiological evidence in recent years documenting the health impacts of racism, the cumulative evidence base has yet to be synthesized in a comprehensive meta-analysis focused specifically on racism as a determinant of health. This meta-analysis reviewed the literature focusing on the relationship between reported racism and mental and physical health outcomes. Data from 293 studies reported in 333 articles published between 1983 and 2013, and conducted predominately in the U.S., were analysed using random effects models and mean weighted effect sizes. Racism was associated with poorer mental health (negative mental health: r = -.23, 95% CI [-.24,-.21], k = 227; positive mental health: r = -.13, 95% CI [-.16,-.10], k = 113), including depression, anxiety, psychological stress and various other outcomes. Racism was also associated with poorer general health (r = -.13 (95% CI [-.18,-.09], k = 30), and poorer physical health (r = -.09, 95% CI [-.12,-.06], k = 50). Moderation effects were found for some outcomes with regard to study and exposure characteristics. Effect sizes of racism on mental health were stronger in cross-sectional compared with longitudinal data and in non-representative samples compared with representative samples. Age, sex, birthplace and education level did not moderate the effects of racism on health. Ethnicity significantly moderated the effect of racism on negative mental health and physical health: the association between racism and negative mental health was significantly stronger for Asian American and Latino(a) American participants compared with African American participants, and the association between racism and physical health was significantly stronger for Latino(a) American participants compared with African American participants. Protocol PROSPERO registration number: CRD42013005464.

Mental health affects future employment as job loss affects mental health: findings from a longitudinal population study

BackgroundWorkforce participation is a key feature of public mental health and social inclusion policies across the globe, and often a therapeutic goal in treatment settings. Understanding the reciprocal relationship between participation and mental health has been limited by inadequate research methods. This is the first study to simultaneously examine and contrast the relative effects of unemployment on mental health and mental health on employment status in a single general population sample.MethodData were from working-age respondents (20 to 55 years at baseline) who completed nine waves of the Household, Income and Labour Dynamics in Australia (HILDA) Survey (N=7176). Cross-lagged path analyses were used to test the lagged and concurrent associations between unemployment and mental health over time, adjusting for sociodemographic characteristics.ResultsMental health was shown to be both a consequence of and risk factor for unemployment. Thus, the poorer mental health observed amongst people who are not working is attributable to both the impact of unemployment and existing mental health problems. While the strength of these two effects was similar for women, the results for men suggested that the effect of unemployment on subsequent mental health was weaker than the effect of mental health on subsequent risk of unemployment.ConclusionDisentangling the reciprocal links between mental health and workforce participation is central to the development and success of clinical goals and health and social policies that aim to promote either aspect. This study demonstrates that both effects are important and supports concurrent responses to prevent a cycle of disadvantage and entrenched social exclusion.

Successful chronic disease care for Aboriginal Australians requires cultural competence

Objective: To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice.

Use of breast cancer screening and treatment services by Australian women aged 25–44 years following Kylie Minogue's breast cancer diagnosis

OBJECTIVE To examine the effects of the publicity surrounding Kylie Minogues diagnosis with breast cancer on doctor-referred breast imaging, image-guided biopsy, and cancer excisions among a low-risk population of women in Australia. Method We examine changes in unilateral and bilateral breast imaging, image-guided breast biopsies, and surgical excisions of breast cancer before and after the announcement of Kylie Minogues diagnosis with breast cancer in May 2005. The study included procedures provided through the Australian public health system to women aged 25-44 years from October 2004 and June 2006. RESULTS The odds of women aged 25-44 years undergoing imaging procedures increased by 20% in the first and second quarters after the Minogue publicity, compared to the preceding two quarters. The volume of biopsies als increased but the biopsy rate, measured as a proportion of imaging procedures, did not change among women aged 25-34 years and decreased among women aged 35-44 years. The volume of operations to excise breast cancers did not change for either age group. Compared to the 6 month period before the publicity, there was a large and significant decrease in the odds that an excision would follow biopsy (25-34 years: OR 95% CI=0.69, 0.48-0.98; 35-44 years: OR 95% CI=0.83, 0.72-0.95). CONCLUSIONS High-publicised illnesses may affect both consumer and provider behaviour. Although they present opportunities to improve public health, they also have the potential to adversely impact the appropriateness and cost-effectiveness of service delivery.

The Transtheoretical Model and Cervical Screening: Its application among culturally diverse communities in Queensland, Australia

OBJECTIVES To apply the Transtheoretical Model of Behaviour Change (TTM) to cervical cancer screening to determine and report on the level of support required by different language and cultural groups in Queensland to enhance participation. The model consists of six stages: Pre-contemplation (no intention to be screened, no past action), Contemplation (intention to be screened, no past action), Action (intention to be screened, initial screening), Maintenance (intention to be screened, regular screening), Relapse (no intention to be screened, initial screening) and Relapse Risk (no intention to be screened, regular screening). DESIGN Focus groups and structured interviews were used to classify women in terms of the model and collect information regarding knowledge, health service contact barriers and enhancing factors and sources of information in relation to cervical cancer screening. The sample was recruited by bi-cultural workers for each community using snowball techniques. RESULTS The interview sample consisted of Australian South Sea Islanders, Chinese, German, Greek and Moslem women. There was no evidence of significant differences in TTM stage according to ethnicity. Women who intended to be screened in the future were more likely to have positive decisional balance scores and higher knowledge scores than women who did not. Women who had had Pap tests were significantly more likely to have received information from their general practitioner (GP) than women who had not had Pap tests. Women in Action and Maintenance were also more likely to have had their last Pap test by a female GP compared to women in relapse categories. Women in Pre-contemplation were more likely than women who had Pap tests to agree that they would travel a long way to see a practitioner who spoke their own language. CONCLUSION Classification based on the model was supported both by the decisional balance scale and measures of knowledge. Women in earlier stages of the model were more likely to express preferences for the provision of services in their own language and by a female. Cervical cancer screening among women in Action and Maintenance appeared to be better supported by GPs. Cervical cancer screening promotion for women of diverse cultures and ethnicities has tended to focus on Pre-contemplation and Contemplation stages, however, as most women in this sample were in Action or Maintenance, as are most Australian-born women, structuring cervical cancer screening promotion in terms of the TTM may significantly improve the effectiveness of interventions for women of diverse cultures and ethnicities.

The health of immigrant women: Queensland women from the former Yugoslavia.

A study of the social and health status of women from the former Yugoslavia was conducted in Queensland, Australia. Study participants were predominantly refugee women who had migrated to Australia between 1991 and 1996. A significant number of the women rated their health status as poor or fair. Most women did not perceive any change in health following migration, but more felt that their health had deteriorated than improved. Applying a social model of health, we explored the social contexts of countries of origin and destination that impact on womens health. We analyze how preimmigration trauma, settlement problems, health risk behaviors, and participation in screening programs affect womens health status and health needs. Data analysis indicated that government and nongovernment services can reduce the impact of preimmigration experience on health risk behaviors and poor health outcomes only to a limited degree. Since the low socioeconomic status of immigrants following immigration was identified by women as a main contributing factor to their poor health status, government support in tackling structural barriers in accessing the Australian labor market is essential to achieve positive health outcomes.

Discrimination and health in an English study

In this study we examine the relationship between education, racial discrimination and health among white (n=227), African Caribbean (n=213) and Indian and Pakistani (n=233) adults aged between 18 and 59 years living in Leeds, England, as measured in a stratified population survey. Measures of discrimination included any physical attack, verbal abuse and a combined variable, any discrimination due to race, colour, ethnicity or sex. Analyses were conducted examining the relationship between education and discrimination, discrimination and health, and discrimination and health controlling for education. People educated above secondary level were more likely than people educated to secondary level or below to report being physically attacked, verbally abused and exposed to discrimination. People from minority ethnic groups (African Caribbean and Indian Pakistani) were more likely to be verbally abused and exposed to discrimination than the white group. Ethnicity and education interacted for African Caribbeans, such that respondents with post-school qualifications were more likely to report verbal abuse or any discrimination. There was no association between having been exposed to any kind of discrimination and having fair or poor health. Physical attack and any discrimination were associated with anxiety, worry and depression. The results remained unchanged when ethnicity and education were included in the models. Education and ethnicity were associated with differences in exposure to discrimination. In turn, exposure to discrimination was associated with higher levels of anxiety, worry or depression although there was no association between discrimination and health. The results support the contention that racial discrimination may play an important role in modifying the relationship between ethnicity, socioeconomic position and health. The counter-intuitive relationship between education and levels of reported discrimination in non-minority ethnic groups highlights the value of explicitly modeling discrimination to gain a better understanding of the social determinants of health.

Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities.

Objectives: To examine experiences of racism in health settings and their impact on mental health among Aboriginal Australians.

The Impact of Different Measures of Socioeconomic Position on the Relationship Between Ethnicity and Health

PURPOSE In this study we explicitly examine the effect of using asset-based and conventional measures of socioeconomic position (SEP) on ethnic differences in health. METHODS The survey of white (n = 227), Indian and Pakistani (n = 233), and African Caribbean (n = 213) adults aged 18 to 59 years living in Leeds, United Kingdom aimed to examine the relationship between ethnicity, health, and SEP. SEP variables included perceived ability to get 10,000 pounds if needed, car ownership, level of education, and home ownership. Health variables included self-reported health status, presence of a long-term illness or disability, presence of limitations arising from a long-term illness or disability, one or more limitations in mobility, obesity, and being anxious, worried, or depressed. Logistic regression analysis was used to assess the relationship between ethnicity and SEP and health. Five models were run for each health variable so that the effects of changing the SEP measure could be ascertained. The first model included only ethnicity and the remaining 4 models tested the effects of the perceived ability to get 10,000 pounds, car ownership, level of education, and home ownership separately. RESULTS The results suggest that the statistical inclusion of asset-based SEP measures, such as car ownership and ability to obtain 10,000 pounds, which reflect an individuals ability to mobilize resources, tend to increase ethnic differences in health, whereas more conventional steady-state indicators, such as education level and home ownership, tended to have little effect or to reduce ethnic differences in health. CONCLUSIONS Overall, this study suggests that the choice of SEP measure may affect the conclusion of research on ethnicity and health and that choice of SEP measures should in turn be informed by the research problem being examined.

The Mental Health Status of Filipinas in Queensland

Objective: To determine the prevalence and investigate potential predictors of psychological distress in Filipino women living in Queensland, Australia. Methods: The sample of n = 487 women (88% response rate) was drawn from Filipino organization membership lists and supplemented by snowball sampling. Participants were interviewed in their homes or at a community event in 1996/1997. Follow-up in 1997/1998 involved n = 346 women (71% response rate) who were interviewed either in their homes or by telephone. The two surveys included measurement of demographic, immigration, physical health, satisfaction with life in Australia and life event variables. The GHQ-28 was included in the follow-up survey as a measure of psychological distress. Results: The proportion of women having an above threshold score (using the cut-off of 4/5) on the GHQ-28 was 23%. Women who were single, dissatisfied with life in Australia, had reported a major change in their financial situation, their relationship or their health in the year between surveys were significantly more likely to have an above threshold score. Conclusions: The level of mental distress among Filipinas in Queensland appears to be slightly higher than the levels reported in the general population but lower than other migrant groups. The determinants of mental distress in this population contrast with those in the general Australian population and other migrant groups. The social context of these determinants in Filipinas needs to be elicited for an understanding of these differences.