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Issue 1, January 1998, pp.10-11.

Ethnicity
James Nazroo

Introduction
Most of what we know about inequalities in health in Britain comes from studies of the white population. Differences in health between ethnic groups have been described, but a shortage of data and methodological difficulties has meant that there has been very little empirical testing of possible explanations.

Ethnicity, identity and context
The 1991 Census, for the first time, included a question on ethnicity. This was relatively crude and framed in a way that allocated individuals to pre-determined groups based on a combination of skin colour and country of origin. Just over 3 million people, or about 5.5 per cent of the population, were identified as belonging to an ethnic minority group (i.e. were not identified as white). Almost half were born in the UK.

However, limitations of Census-type categorisations mean that they do not include white minority groups or explicitly identify those of mixed ethnic backgrounds. They are also unable to reflect the contextual nature of ethnicity. In fact, as well as acting as a marker for exclusion imposed on an ethnic minority group, ethnicity is part of an individual's identity, providing a connection with cultural traditions that give strength and meaning.1 But culture is not an autonomous and static feature of life. Cultural traditions are historically located, occur within particular contexts and change over time, place and person. From this perspective, ethnic identity cannot be considered as fixed.

Also, ethnicity is only one element of identity and its significance depends on context. For example, in some contexts, gender and class may be more important. People possess a range of identities that vary across contexts, so ethnic identity is neither secure nor coherent.(1) Never-the-less, although data based on Census-type categorisations are unable to reflect these elements of ethnicity, they have shed some light on the lives of ethnic minority people in Britain.(2)

Ethnic inequalities in health
Descriptions of differences in health across different ethnic groups have been limited by the quality of available data. The most frequently used national data sources are those created by combining Census information on country of birth with information from death certificates. An obvious limitation of this is that these data do not cover the large number of ethnic minority people born in the UK. Never-the-less, analyses from the last three Censuses have demonstrated important differences in mortality rates across country of birth groups.(3,4,5) For example, analyses at all three Censuses from 1971-1991 have shown that those born in South Asia are much more likely than average to die from ischaemic heart disease.

Until recently, there has only been limited nationally representative information on differences in rates of illness, rather than death rates, across ethnic groups. Now information on morbidity rates is available from the 1991 Census and two surveys that have specifically targeted ethnic minority people (the Black and Minority Ethnic Groups Health and Lifestyles Survey; and the Fourth National Survey of Ethnic Minorities (FNS).(6,7,8) There have also been numerous regional studies and studies of particular diseases, which have shown differences in health across different ethnic groups.

All of this has led to a fair amount of description of differences in the health of different ethnic groups, but there has been very little empirical investigation of the possible causes of these differences.
Socio-economic basis of ethnic inequalities in health

Given the differences in the socio-economic positions of ethnic minority and white people,(2) and our knowledge of the relationship between socio-economic position and health,(9) it would seem likely that differences in socio-economic position contribute to ethnic inequalities in health. However, analyses of mortality data suggested that differences in mortality rates by country of birth were unrelated to differences in socio-economic position.(3,5) In contrast, the FNS showed a gradient of health profiles within different ethnic groups that matched socio-economic status.(7) It also suggested that there were a range of methodological problems faced by researchers in this area, which may have contributed to these differences in findings.(7)

Methodological problems

  • Cultural background may influence the ways in which people experience and express their ill- health, making it difficult to make comparisons across different ethnic groups. There is growing evidence to support this possibility.(8,10)
  • The measures of socio-economic status typically used in health research, such as occupational class and housing tenure, were developed for use in studies of white men. They do not necessarily provide an accurate and sensitive guide to the socio-economic circumstances of ethnic minority groups (or women).(7) There is a need to develop and test new measures of socio-economic status for use when making a comparison across ethnic groups.
  • In attempting to understand the dynamic relationship between ethnicity, socio-economic status and health, we need to recognise that the ways in which people perceive and experience their ethnicity may influence both their health and socio-economic status.
  • In addition to differences in socio-economic status, researchers need to take account of a range of other factors that could contribute to ethnic inequalities in health (for example, differences in health-related behaviours across ethnic groups; differences in access to health services; factors relating to the process of migration and the accumulation of disadvantage over one's life time; other aspects of social disadvantage faced by ethnic minority groups; and genetic differences between groups).

Research in the Health Variations Programme
Two projects have been funded under Phase 1 of the Programme to tackle some of the issues raised above.
Researchers at the Universities of Bradford and Bristol and the London School of Hygiene and Tropical Medicine are conducting developmental research to investigate ethnic differences in the way people experience and talk about health, and to develop appropriate measures of socio-economic status that can be applied across different ethnic groups. The findings will be applied to quantitative surveys of ethnic inequalities in health.

At the Policy Studies Institute we are extending our work on the FNS to tackle three key issues: how far do different dimensions of socio-economic status explain ethnic inequalities in health; do ethnic differences in household structures and gender roles contribute; and do ethnic differences in geographical location make a contribution.

Central to both studies is the concern to explore the different dimensions of ethnicity and how they might be related to health.

References
1. Barot, R. (ed.) (1996) The Racism Problematic: Contemporary Sociological Debates on Race and Ethnicity, Lewiston : The Edwin Mellen Press.
2. Modood, T., Berthoud, R., Lakey, J., Nazroo, J., Smith, P., Virdee, S. and Beishon, S. (1997) Ethnic Minorities in Britain: Diversity and Disadvantage, London : Policy Studies Institute.
3. Marmot, M. G., Adelstein, A. M., Bulusu, L. and OPCS (1984) Immigrant Mortality in England and Wales 1970-78: Causes of Death by Country of Birth, London : HMSO.
4. Balarajan, R. and Bulusu, L. (1990) 'Mortality among immigrants in England and Wales, 1979-83' in M. Britton (ed.) Mortality and Geography: A Review in the Mid-1980s, England and Wales, London : OPCS.
5. Harding, S. and Maxwell, R. (1997) 'Differences in mortality of immigrants', in F. Drever and M. Whitehead (eds.) Health Inequalities: Decennial Supplement, No.15 London : HMSO.
6. Rudat, K. (1994) Black and Minority Ethnic Groups in England: Health and Lifestyles, London : Health Education Authority.
7. McKeigue, P. (1992) 'Coronary heart disease in Indians, Pakistanis and Bangladeshis: aetiology and possibilities for prevention' British Heart Journal, vol 67, pp.341-342.
8. Davey-Smith, G., Bartley, M. and Blane, D. (1990) 'The Black report on socio-economic inequalities in health 10 years on' British Medical Journal, vol 301, pp.373-377.
9. Pilgrim, S., Fenton, S., Hughes, T., Hine, C. and Tibbs, N. (1993) The Bristol Black and Ethnic Minorities Health Survey Report, Bristol : University of Bristol.
10. Nazroo, J. Y. (1997) The Health of Britain's Ethnic Minorities: Findings from a National Survey, London : Policy Studies Institute.
11. Nazroo, J. Y. (1997) Ethnicity and Mental Health: Findings from a National Community Survey, London : Policy Studies Institute.