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Ethnic inequalities in healthEthnic inequalities in health
James NazrooJames Nazroo
University College LondonUniversity College London
www.ucl.ac.uk/epidemiology
Why is there an interest in ethnic inequalities in health?Why is there an interest in ethnic inequalities in health?
Aetiological investigations
Monitoring
Access to appropriate treatment
Investigating inequalities in health
Concern with ethnic disadvantage, racialisation and social inequalities: health as a component of wider disadvantage
Reported fair or bad health by ethnic Reported fair or bad health by ethnic group and agegroup and age
0%
20%
40%
60%
80%
100%
2-5 5-9 10-12 13-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-60 61-70 > 70
Caribbean Indian Pakistani Bangladeshi Chinese White minority White English
Health Survey for England 1999
Reported fair or bad healthReported fair or bad health
Age adjusted odds ratio compared with white English
0.5
1
1.5
2
2.5
3
3.5
4
Caribbean Indian Pakistani Bangladeshi Chinese Whiteminority
Od
ds
ra
tio
(a
nd
95
% C
.I.)
Health Survey for England: Nazroo 2004
Explaining ethnic inequalities in healthExplaining ethnic inequalities in health
Statistical artifact
Migration
Differences in genetic risk
Culture and lifestyle
Material disadvantage
Ecological effects
Racism: exclusion and harassment
Paradigms in research on ethnic differences in health (1)Paradigms in research on ethnic differences in health (1)
Un-theorised’ ethnicity Appears to be empirically driven Carries an implicit theory of fixed genetic and cultural difference Explanations are often reduced to racialised stereotypes
Avoiding premature coronary deaths in AsiansAvoiding premature coronary deaths in Asians Asians’ evolutionary history involved adaptation ‘to survive under conditions
of periodic famine’ leading to a high prevalence of insulin resistance.
Central obesity may also develop as a consequence of lifestyle (culture): ‘a diet rich in saturated fats and energy (including ghee) and a sedentary lifestyle’.
“Well Asian clinics” should be set up to address the low use of medical services.
Community leaders should increase awareness of risk factors.
Survivors should relay their experiences to members of their community.
Dietary advice should be given and Asians should be encouraged to increase regular physical activity.
Gupta et al. 1996
Paradigms in research on ethnic differences in health (2)Paradigms in research on ethnic differences in health (2)
Un-theorised’ ethnicity Appears to be empirically driven Carries an implicit theory of fixed genetic and cultural difference Explanations are often reduced to racialised stereotypes
Ethnicity as structure Notions of fixed difference are used to justify exclusionary practices Racism Socioeconomic disadvantage
Ethnic differences in occupational positionEthnic differences in occupational position
20171141282430IV/V
30242839332627IIIm
161416 7141419IIInm
34464513253623I/II
RG class of head of household
75726746596958
Male employment rates
White English
White minority
ChineseBangl-adeshi
PakistaniIndianCaribbean
Health Survey for England 1999
Per cent
Ethnic differences in equivalised Ethnic differences in equivalised household incomehousehold income
48% 45%
69%
90%
41%
27% 31%
0%
20%
40%
60%
80%
100%
Caribbean Indian Pakistani Bangladeshi Chinese Whiteminority
WhiteEnglish
Bottom tertile Middle tertile Top tertile
Health Survey for England 1999
Experiences of racism and discriminationExperiences of racism and discrimination
One in 8 ethnic minority people experience racial harassment in a year.
Repeated racial harassment is a common experience.
25% of ethnic minority people say they are fearful of racial harassment.
Modood et al. 1997
Experiences of racism and discriminationExperiences of racism and discrimination
One in 8 ethnic minority people experience racial harassment in a year.
Repeated racial harassment is a common experience.
25% of ethnic minority people say they are fearful of racial harassment.
20% of ethnic minority people report being refused a job for racial reasons, and almost 3/4 of them say it has happened more than once.
20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.
Modood et al. 1997
Experiences of racism and discriminationExperiences of racism and discrimination
One in 8 ethnic minority people experience racial harassment in a year.
Repeated racial harassment is a common experience.
25% of ethnic minority people say they are fearful of racial harassment.
20% of ethnic minority people report being refused a job for racial reasons, and almost 3/4 of them say it has happened more than once.
20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.
White people freely report their own prejudice: One in four say they are prejudiced against Asian people; One in five say they are prejudiced against Caribbean people.Modood et al. 1997
Equivalised income and fair or bad healthEquivalised income and fair or bad health
0%
10%
20%
30%
40%
Caribbean Indian Pakistani Bangladeshi Chinese Whiteminority
WhiteEnglish
Bottom Tertile Middle Tertile Top Tertile
Health Survey for England 1999
Socioeconomic effects and fair or bad healthSocioeconomic effects and fair or bad health
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Caribbean Indian Pakistani Bangladeshi Chinese White minority
Ln
Od
ds
rati
o c
om
par
ed w
ith
wh
ite
En
glis
h
Not adjusted for socioeconomic effects Adjusted for socioeconomic effects
Health Survey for England 1999
Racism, discrimination, occupational class and healthRacism, discrimination, occupational class and health
Predicted per cent reporting fair or poor health
0
10
20
30
40
50
None Verbal Physical orproperty
No or afew
Some ormost
Nonmanual Manual
(Karlsen and Nazroo 2002)
Racial harassment Do employers discriminate? Class
Paradigms in research on ethnic differences in health (3)Paradigms in research on ethnic differences in health (3)
Un-theorised’ ethnicity Appears to be empirically driven Carries an implicit theory of fixed genetic and cultural difference Explanations are often reduced to racialised stereotypes
Ethnicity as structure Notions of fixed difference are used to justify exclusionary practices Racism Socioeconomic disadvantage
Ethnicity as identity Identification with cultural traditions Provides guidelines for action and psychological and material resources Both historical and immediate context influence identity – hybrid identities
Tobacco use*Tobacco use*
Men
0
10
20
30
40
50
60
Cigarettes Any tobacco product
*Use of chewing tobacco products was only asked of the South Asian groups
Women
0
10
20
30
40
50
60
Black
Carib
bean
India
n
Pakista
ni
Bangladesh
i
Chinese
Irish
General p
opulatio
n
Health Survey for England 1999
Typologies of sexual lifestyleTypologies of sexual lifestyle
Multiple partnerships/encounters interleaved with monogamous relationships alongside primary relationships no primary/monogamous relationships
Serial monogamy within marriages only within and/or outside of marriage
Single mongamy since before marriage/outside of marriage within marriage
Pre-coitarchy
Jamaican
African
South
Asian
Sexual History
ExES: Elam et al. 1999
Women looking after the homeWomen looking after the home
0%
20%
40%
60%
80%
BlackCaribbean
Indian Pakistani Bangladeshi Chinese Irish Generalpopulation
Smoking among South Asian PeopleSmoking among South Asian People
0%
5%
10%
15%
20%
25%
30%
35%
Family Origin Age on Migration Gender Class
Pakistani
Bangladeshi
Indian
Manual
No FT worker
Non-manual11 years or older
< 11 yearsMale
Female
Nazroo 1998
Ethnicity as a social identityEthnicity as a social identity
race and ethnicity are intrinsically forms of collective social identity ... Identity confers a sense of personal location, and provides a stable core of individuality. But it is also about social relationships ... In exploring the dynamics of identity, we therefore need to understand the way in which identity grows out of and is transformed by action and struggle, and to ask:
Who is constructing the categories and defining the boundaries?
Who is resisting these constructions and definitions?
What are the consequences of being written into or out of particular categories?
What happens when subordinate groups seek to mobilize along boundaries drawn for the purposes of domination?
What happens to individuals whose multiple identities may be fragmented and segmented by category politics?
Solomos 1998
Ethnic making situationsEthnic making situations
Enslavement of Africans leading to post-slavery societies – post slavery minorities.
Colonial rule and post-colonial states – indigenous minorities, urban minorities (migrant worker populations) and ‘multi-cultural’ plural societies.
Western capitalism and the formation of nation states – proto-nations (people who make a claim to be nations).
Concluding commentsConcluding comments
Diversity of experiences across ethnic groups, classes, gender and generations.
Ethnicity is a form of personal identity.
Ethnicity/race is also an externally imposed identity.
Ethnic identity is historically and socially contingent/constructed.
Central role of social disadvantage in determining the pattern of ethnic inequalities in health.