Ethnicity and health: Health inequalities between ethnic groups

There is reasonably extensive information on inequalities in health status between ethnic groups in the UK at a national level, much of which comes from surveys. In contrast, regional and sub-regional information is quite limited and cautious extrapolation from national information will often be the only available option. Limiting factors include lack of relevant regional and local surveys and poor recording of patients’ ethnicity by local NHS organisations.

Ethnic disparities in health at national level

In 1998, the Independent Inquiry into Inequalities in Health highlighted some of the variations between ethnic populations:

	People in Black (Caribbean, African and other) groups and Indians have higher rates of limiting long standing illness than white people. Those of Pakistani or Bangladeshi origin have the highest rates.
	There is excess mortality among men and women born in Africa and men born on the Indian sub-continent.
	Among mothers who were born in countries outside the UK, those from the Caribbean and Pakistan have infant mortality rates about double the national average. Perinatal mortality rates have also been consistently higher for babies of mothers born outside the UK. The differences between groups have not decreased over the last twenty years.

In 1999, the White Paper Saving Lives: Our Healthier Nation focused on “the main killers”: cancer, coronary heart disease and stroke, accidents, mental illness. Again, inequalities in health between ethnic groups were highlighted, e.g.:

	Death rates for coronary heart disease for those born in the Indian sub-continent are 38 per cent higher for men and 43 per cent higher for women than rates for the country as a whole.
	Stroke death rates in people born in the Caribbean and the Indian sub-continent are one and a half to two and a half times higher than for people born in this country - a differential that has persisted from the late 1970s.
	Women living in England born in India and East Africa have 40 per cent higher suicide rates than those born here.

In July 2004, the London Health Observatory published a DH-commissioned report on Ethnic Disparities in Health and Health Care which includes updated and expanded information on ethnic differentials in health status in the UK drawing on recent national surveys and other sources. A summary of ethnic differentials in health and lifestyle highlighted in the report is included as Appendix 1. Reflecting Government priorities, the report focuses on:

	coronary heart disease
	cancers
	diabetes
	mental health
	sexually transmitted infections
	communicable diseases
	population groups (older people, mothers and babies, children and young people)
	lifestyle

Questions on health were included in Census 2001. One of the question was "Over the last twelve months would you say your health has on the whole been Good, Fairly Good, Not Good". Comparisons between ethnic groups in England and Wales as a whole in terms of response to this question are presented in Table 1 below.

Table 1. Percentage of people in England and Wales rating their
health as “not good”: data from Census 2001

	Males	Females
	Age-standardised proportion	Age-standardised proportion
White British	7.8%	8.0%
White Irish	10.2%	9.3%
Other White	7.4%	7.8%
Mixed	9.8%	10.4%
Indian	8.7%	12.0%
Pakistani	13.5%	17.1%
Bangladeshi	13.9%	15.5%
Other Asian	8.7%	10.5%
Black Caribbean	10.0%	12.2%
Black African	6.8%	8.4%
Other Black	10.1%	11.9%
Chinese	5.6%	6.2%
Any other ethnic group	8.2%	8.0%
All ethnic groups	7.9%	8.2%

Source: ONS (www.statistics.gov.uk/cci/nugget.asp?id=464)

On the basis of age-standardised rates (which take account of the difference in age structures between the ethnic groups) Pakistani and Bangladeshi men and women were most likely to report their health as 'not good'. Proportions of Black Caribbean and Indian women reporting their health as “not good” were also relatively high. Chinese men and women were the least likely to report their health as 'not good'.

Reporting poor health has been shown to be strongly associated with use of health services and mortality. Thus it is not surprising, given the pattern in Table 1, that the 1999 Health Survey for England showed that Pakistani women and Bangladeshi men in England had particularly high GP contact rates compared with the general population.

Another question in Census 2001 was "Do you have any long-term illness, health problem or disability which limits your activities or the work you can do?" Comparisons between ethnic groups in England and Wales as a whole in terms of response to this question are presented in Table 2 below.

Table 2. Percentage of people in England and Wales reporting long-term illness or disability which restricts daily activities: data from Census 2001

	Males	Females
	Age-standardised proportion	Age-standardised proportion
White British	15.9%	15.3%
White Irish	17.7%	15.7%
Other White	13.7%	13.7%
Mixed	18.3%	17.8%
Indian	16.5%	19.8%
Pakistani	22.1%	25.4%
Bangladeshi	23.6%	24.9%
Other Asian	16.7%	18.6%
Black Caribbean	17.9%	19.3%
Black African	14.1%	16.7%
Other Black	18.8%	19.9%
Chinese	11.4%	12.1%
Any other ethnic group	14.7%	14.0%
All ethnic groups	16.0%	15.4%

Source: ONS (www.statistics.gov.uk/cci/nugget.asp?id=464)

Again, there were marked variations between different ethnic groups in England and Wales. After taking account of the different age structures of the groups, Pakistani and Bangladeshi men and women had the highest rates of long-term illness or disability - around 1.5 times higher than their White British counterparts. Chinese men and women had the lowest rates. In Asian and Black groups, women had higher rates than men. In the White and Mixed groups men had higher rates than women.

Ethnic disparities in health at regional and sub-regional level

Sources of information include Census 2001, EMPHO reports on specific health topics, and information provided by PCTs. Regarding the latter, each PCT in the East Midlands was invited to provide information on local work on ethnicity and health. In addition, available PCT Annual Public Health Reports were scanned for coverage of the topic.

Information on the demography of minority ethnic groups in the Region provides essential underpinning for any analysis of ethnic differentials in health in the Region. A previous EMPHO report on the Census 2001 provided basic information on the ethnic minority populations in the Region. Enhanced information is provided in Appendix 2.

Information from Census 2001

The variations between ethnic groups apparent in East Midlands data on self-reported health from Census 2001 are similar to those in England and Wales as a whole (Tables 3 and 4). For example:

	Pakistani and Bangladeshi men and women were most likely to report their health as 'not good'.
	Proportions of Black Caribbean and Indian women reporting their health as “not good” were also relatively high.
	Chinese men and women were the least likely to report their health as 'not good'.
	Pakistani and Bangladeshi men and women and Black Caribbean and Indian women had the highest rates of long-term illness or disability.

Table 3. Percentage of people in the East Midlands rating their
health as “not good”: data from Census 2001

	Males	Females
	Age-standardised proportion	Age-standardised proportion
White British	8.4%	9.6%
White Irish	10.8%	11.8%
Other White	8.6%	10.1%
Mixed	8.6%	12.0%
Indian	10.1%	15.7%
Pakistani	12.6%	19.0%
Bangladeshi	12.6%	16.3%
Other Asian	9.5%	14.3%
Black Caribbean	11.6%	15.6%
Black African	8.8%	11.5%
Other Black	9.8%	9.7%
Chinese	5.0%	7.1%
Any other ethnic group	6.5%	7.9%
All ethnic groups	8.5%	9.8%

Note : Proportions are direct age standardised (using four broad age bands)
using the entire East Midlands population at Census 2001 as the reference population.

Table 4. Percentage of people in the East Midlands reporting long-term illness or disability which restricts daily activities: data from Census 2001

	Males	Females
	Age-standardised proportion	Age-standardised proportion
White British	17.5%	19.1%
White Irish	20.2%	20.4%
Other White	16.3%	18.2%
Mixed	18.4%	21.3%
Indian	19.1%	25.8%
Pakistani	22.7%	28.3%
Bangladeshi	24.2%	25.6%
Other Asian	18.7%	23.4%
Black Caribbean	20.8%	24.7%
Black African	16.7%	21.1%
Other Black	19.7%	22.0%
Chinese	10.8%	14.6%
Any other ethnic group	13.1%	15.1%
All ethnic groups	17.5%	19.3%

Note : Proportions are direct age standardised (using four broad age bands)
using the entire East Midlands population at Census 2001 as the reference population.

Information from EMPHO Reports

Relatively few EMPHO reports include a focus on disparities in health between ethnic groups – the main reason being lack of relevant data. Recent reports on lifestyle include some pointers to ethnic variations.

	Diet
	A survey in Leicester indicated that White British respondents appeared to eat relatively more fresh fruit and vegetables - twice as many ethnic minority respondents compared to White British respondents said that they ate no portions in an average day (12% and 6% respectively).
	Physical Activity
	Analysis of Health Survey of England data for the East Midlands indicated that similar proportions of White, Black and Asian men were physically active at recommended levels. Compared to White and Asian women, the proportion of Black women who were active at recommended levels was relatively high.
	Smoking
	Analysis of data from the 2003 East Midlands Life and Work Survey indicated a substantially lower-than-average prevalence of smoking among Asian respondents. National survey data show wide variations within Asian groups with, for example, high prevalence in Bangladeshi men and low prevalence among women.

Information from PCTs
While several PCTs have used Census 2001 to profile the ethnic mix of their local populations, there appears to have been relatively little local analytical work on the comparative health status of ethnic groups within local populations.

One exception is South Leicestershire PCT which has recently published a substantial piece of work on the health needs of local minority ethnic communities. The report highlights the lack of reliable local data and emphasises the importance of developing local data collection systems.

Information from other sources
The African Caribbean Development Agency has published a report on “The Health Needs of African and Caribbean People in Nottingham” highlighting deficiencies in local data (contact: ). The report makes a number of recommendations related to maximising the use of available data and improving data collection systems for the future.