Ethnic Matters

See also: Diseases and Different Ethnic Groups.

People come from different ethnic groups and the range of diversity varies over time and between different populations. Ethnicity can have important effects on health and on uptake of health services. A knowledge and understanding of the different ethnic backgrounds of a population can help improve the healthcare of that population. The influence of ethnicity on health is a big subject and books and journals are published highlighting the many ways in which the pattern of disease and the uptake and delivery of health services are affected by aspects of ethnicity. Despite this there is a lot of misunderstanding, ignorance and prejudice about aspects of ethnicity generally but also about the effect of ethnicity on health.

Black and minority ethnic groups in the UK generally have worse health than the overall population. Some ethnic groups fare worse than others, and patterns vary between different diseases and health issues. Evidence suggests that the poorer socio-economic position of some ethnic groups is the main factor driving ethnic health inequalities. Several policies have aimed to tackle health inequalities in recent years, although to date, ethnicity has not been a consistent focus. This article aims to draw attention to some general factors and some specific problems posed by ethnicity and health.

Defining ethnicity presents problems. Ethnicity results from many aspects of difference which are socially and politically important. These Include race, culture, religion and nationality. People may identify themselves with more than one ethnic group. For example a person may identify themselves as British, Asian, Indian, Punjabi and Glaswegian. To allow data to be collected and analysed on a large scale, ethnicity is often treated as a fixed characteristic. Ethnic groups are usually classified by the methods used in the UK census, which asks people to indicate to which of 16 ethnic groups they feel they belong (see box).

Health inequalities are differences in health status that are driven by inequalities in society. Health is shaped by many different factors, such as lifestyle, material wealth, educational attainment, job security, housing conditions, psycho-social factors, discrimination and the health services. Health inequalities represent the cumulative effect of these factors. They can be passed on from one generation to the next through maternal influences on baby and child development.

Large-scale surveys like the Health Survey for England show that black and minority ethnic groups as a whole are more likely to report ill-health, and that ill-health among black and minority ethnic people starts at a younger age than in the White British. There is more variation in the rates of some diseases by ethnicity than by other socio-economic factors. However, patterns of ethnic variation in health are extremely diverse, and inter-link with many overlapping factors:¹

• Some black and minority ethnic groups experience worse health than others. For example, surveys commonly show:
  • Pakistani, Bangladeshi and Black-Caribbean people report the poorest health.
  • Indian, East African Asian and Black African people report the same health as White British.
  • Chinese people report better health.
• Patterns of ethnic inequalities in health vary from one health condition to the next. For example:
  • Black and minority ethnic groups tend to have higher rates of cardio-vascular disease than White British people.
  • Black and minority ethnic groups have lower rates of many cancers (see Box below).
• Ethnic differences in health vary across age groups, so that the greatest variation by ethnicity is seen among the elderly.
• Ethnic differences in health vary between men and women, as well as between geographic areas.
• Ethnic differences in health may vary between generations. For example, in some black and minority ethnic groups, rates of ill-health are worse among those born in the UK than in first generation immigrants.

The diversity of race, language, religion, culture and biological factors within and between people of different ethnic groups can produce inequalities in health and uptake of health services. It is important to try and understand these differences and to reduce inequalities if health and health services are to be improved across the whole population. Progress may be achieved by better understanding and education of health workers and some are even the subject of government policy and targets.

Language

Communication is fundamental and a clinician has to be certain of understanding the patient and being understood.
Even regional accents can present communication difficulties. With language differences it is sometimes necessary to use interpreters. This can present problems.

• Patient confidentiality is compromised.
• Interpretation or translation may not be faithful to the patients account or meaning.
• Translation takes time.
• It may cause embarrassment (for example between mother and son).
• There is additional cost involved.

The NHS has provided a translation service for a number of years. If a patient calls NHS direct and is able to say in English the name of the language he or she wishes to use, a consultation in that language is available.² This service has been severely criticised on two grounds. Translation services cost the NHS £55 million each year.

Culture and attitudes

These can affect many aspects of healthcare. It is necessary to understand these cultural differences and attitudes so that effective health care can be delivered in a sensitive way. Examples of such differences include:

• The patient's expectations of the doctor and of medical care generally.
• The expression of symptoms which can have cultural influences.
• Family roles and relationship differences between cultures.
• Different attitudes to sex and marriage between cultures and religions.
• Different attitudes to clinical examination which may affect what is acceptable to the patient.

Religion

There are many ways in which religious practices and beliefs have the potential to affect health and produce inequalities in health. For example:

• Influences on diet. For example:
  • Muslims and Jews have beliefs affecting the eating of meat (Halal and Kosher respectively).
  • Hindus like Buddhists are usually vegetarian.
  • Hindus have festivals (for example Navratre) involving fasting or restricted diet.
  • Islam has a fast called Ramadan that lasts for a month. The time of year varies as it is based on the lunar calendar. During the hours of daylight, that might be quite extensive in the summer, they are forbidden from ingesting anything. They are not allowed to eat, drink or smoke. It may cause problems with regard to medication or the control of diabetes. It is important to realise that Ramadan is a discipline and is not expected to make the adherent ill. Those who are ill are not expected to conform. If a Muslim patient needs to take medication including injections during the fast he should do so. Ask him to discuss it with his religious leaders if there is doubt. The following are exempt from fasting:
    • Children under the age of puberty although they may have a limited fast
    • People who are mentally incapacitated or not responsible for their actions
    • The elderly
    • The sick
    • Travellers who are on journeys of more than about fifty miles
    • Pregnant women and nursing mothers
    • Women who are menstruating
    Those who are temporarily unable to fast should make up for it later.
• Blood transfusion and organ transplantation:
  • Jehovah's Witnesses are a small sect of Christianity who maintain that the spirit is in the blood and hence it is unacceptable to perform blood transfusions and organ transplantation.
  • If parents refuse a blood transfusion for a child and the doctors maintain that it is necessary to save the child's life, it is possible to have the child made a ward of court to give the court the right to make that decision.
• Termination of pregnancy:
  • Many religions are opposed to termination of pregnancy.
  • The woman must be allowed to make up her own mind without undue pressure from others and the doctor should be very careful not to try to impose his or her own moral view.
• Contraception:
  • The Roman Catholic Church is renowned for its opposition to contraception.
  • It does allow use of the woman's menstrual cycle to permit sexual intercourse without great risk of conception but it does not permit barrier methods including condoms or caps, hormonal contraception of IUCDs. The permitted methods are often referred to as "natural contraception".³
• Circumcision may be performed for religious, hygienic or medical reasons. Examples include:
  • Jewish boys are circumcised on the 8th day of life.
  • Muslims usually circumcise between 10 and 12 years old.
  • It is often practised as a coming of age ritual in adolescent boys in sub-Sahara Africa.
  Operations are performed by the ministers of religion (surgical training is part of their theological studies). If parents want a medical practitioner to perform the operation it can be done (although only if for medical reasons in the NHS). Many doctors concerns, for example:
  • Ethical issues because the child cannot give informed consent.³
  • Risk of complications.
  Female circumcision (or more correctly female genital mutilation) involves damage or destruction of the clitoris. Complications include dyspareunia, dystocia and other psychological and physical problems. It is practised in parts of Africa, especially Sudan and Nigeria. It is estimated that there are about 132 million cases worldwide. It is discussed more fully and with references in Vulval Abnormalities and their Management.
• Other socio-cultural considerations:
  • Problems of culture and religion may make it difficult for patients to admit to such matters as homosexuality, premarital sex, alcohol abuse or even depression. Sensitivity is required.
  • Many Sikhs keep their hair short but the orthodox teaching is that they should never cut their hair or shave their beard.

Socioeconomic factors

Many ethnic minority groups experience higher rates of poverty than the White British, in terms of income, unemployment and area deprivation. Much of the variation in self-reported health between and within ethnic minority groups can be explained by differences in socioeconomic status.

Clinical and biological diversity

Biological diversity produces different diseases and susceptibility to disease. These are independent of the uptake of healthcare services and of sociocultural factors but will often make an impact on the need for health services. For example:

• Sickle cell disease occurs in people whose ancestors lived in West Africa. That may have been many generations ago but the gene persists.
• Thalassaemia is also more prevalent in people of certain races, the type and prevalence varying between places of origin.
• Diabetes is especially common amongst those whose origins are from the Indian subcontinent.
• Dark skinned people who habitually cover up may lack vitamin D in temperate climates and rickets⁴ has been reported, especially with a high consumption of chapattis that are high in phosphate.
• The race of the patient may be a consideration in deciding the best treatment for hypertension.

Both immigration and foreign travel, which for some people may mean "returning to their roots", may introduce diseases, some exotic and some more mundane. For example:

• The UK sees over 2,000 cases of malaria⁵ a year. Many are travellers who failed to take adequate prophylactic medication.
• HIV and AIDs in immigrants from Africa is responsible for a rise in the prevalence and demography of this infection in the UK.

Ethnic differences in health service delivery and the uptake of services have been reported in different parts of the NHS. For example:

• There are some positive findings such as reported equality of access in primary care.
• There is also, however, evidence of inequality of access to hospital care for ethnic minority groups. For example, South Asians have been found to have lower access to care for coronary heart disease.
• Rates of smoking cessation have been lower in Black and ethnic minority groups than in White groups.
• Rates of dissatisfaction with NHS services are higher among some Black and ethnic minority groups than in the White British population. For example South Asians report poorer experiences as hospital inpatients, according to Healthcare Commission patient surveys.

A number of recent policy developments have aimed to tackle health inequalities. Sir Donald Acheson’s Independent Inquiry into Inequalities in Health (1998) put health inequalities onto the policy agenda. It put a strong emphasis on the effects of wider inequalities, including poverty and social exclusion on health inequalities. Twelve departments signed up to cross-government work on health inequalities in the Treasury’s Tackling Health Inequalities: A Programme for Action (2003). To date, the main policy targets have focussed on socio-economic class and area deprivation, rather than ethnic inequalities (see box below).

• Policies on reducing socio-economic inequalities should consider the needs of Black and ethnic minority groups.
• Services should be sensitive to the needs of Black and ethnic minority groups and promote awareness of their health risks.
• The needs of Black and ethnic minority groups should be specifically considered in planning and providing health care.

However, ethnicity has not been a consistent focus of health inequalities policies and few policies have been specifically targeted at Black and ethnic minority groups. Two important cross-cutting factors affecting the feasibility and likelihood of action on ethnic health inequalities are the availability of data on ethnicity, and legal obligations towards racial equality.

These recommendations and the factors which inform them have important implications for doctors and others involved in the delivery of health care. Some of these are very specific, but there are some general principles to consider as well. For example doctors should:

• Be aware of the influence in general terms of race, culture and religion on the health of our patients.
• Learn about specific effects of ethnic origin on health and where appropriate seek further advice and information.
• Exercise tolerance and embrace and understand ethnic diversity.

As educated members of any community doctors might be expected to exercise tolerance and understanding and to avoid harmful bigotry and discrimination. The principle should be to follow good practice looking after the needs of every individual patient.