migration, ethnicity, race and health: a scottish-european perspective presentation at seventh...
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Migration, ethnicity, race and health:
a Scottish-European perspective
Presentation at seventh Quality Healthcare for Culturally Diverse Populations Conference,
Baltimore 2010by
Raj Bhopal CBE, DSc (hon), MD, MPHProfessor of Public Health, University of Edinburgh
Honorary consultant, NHS Lothian
Objectives of the presentation Share insights from an 16 year ongoing
journey trying to improve the health and healthcare of ethnic minority populations
Reflect on insights internationally, especially in a European context
Migration-key to ethnic diversification of societies Fundamentally human behaviour Reasons –
commerce, work, education, ambition, refugecuriosity & change
Europe (and USA) - progressed with migration Not shameful-for individuals or nations Lifting the stigma attached to migrants is top priority
Ethnicity-contested in Europe The group you belong to, or are perceived to belong to, because
of yourculture (language, diet, religion), ancestry, andphysical textures
In Europe, and increasingly the USA, ethnicity incorporates race, and country of birth
In several European countries the concepts of race and ethnicity are met with hostility, partly because of Nazi abuses
Immigration status is preferred This poses difficulties in talking the same language
Ethnic diversity in Europe Europe’s ethnic composition is changing dramatically.
Ethnically disaggregated European data are needed.
The challenge of delivering equitable healthcare and improvements in health status is huge.
European projects developing and testing methods, mostly within countries but sometimes across countries.
Migrating populations, 1990-2000: 175 m. in 2000 (4-fold increase cf. 1975) 230 m. predicted by 2050
Sources: Population Action International 1994, IOM 2003
Scotland’s ethnic composition-not untypical of Europe Emigration historically overshadows immigration Scotland has recently welcomed new immigration 1850-1950 Irish, Lithuanians, Jews, Italians, Poles
immigrate 1950-2000 Indians, Pakistanis, Bangladeshis,
Chinese immigrate 2001-present Asylum seekers, refugees, Eastern
Europeans, and students immigrate Still, only an estimated 4% are non-White
Country of birth of mothers of babies born in Scotland: changing the populationCountry of birth 1991 2007
United Kingdom 63702 51432
EU – pre 2004 countries
770 1100
EU – post 2004 countries
885 2388
Other 2437 3961
Forces - ethnic health inequalities Culture and lifestyle Social, educational and economic status Environment before and after migration
Early life development Generational effects Genetics
Access to and concordance with health care advice Quality and quantity of healthcare
Perceived status in society Discrimination/bias/inequity
Prioritisation given multiplicity of differences: inequity and inequality Consider whether any of the following are
inequities: The lower prevalence of smoking in Chinese
women compared to White women The higher rate of colo-rectal cancer in White
people compared to S. Asians The lower life expectancy of African Americans
compared to White Americans
What do you think?
Multiplicity of challenges for delivering equitable services-
examples varying health behaviours, beliefs and attitudes, and diseases
diagnosis, treatment, intervention, adherence to the intervention, and outcomes varying
language and cultural barriers requirements based on religion lack of information and research personal biases, stereotyped views, individual racism institutional (health system) bias, and laws against it Implementing laws requiring equal opportunities in
employment and other walks of public life
Legal Framework and Policy Consensus In 1997 EU approved the Treaty of Amsterdam Article 13 - powers to combat discrimination on
sex, racial or ethnic origin, religion or belief etc Implemented variably, sometimes vigorously The UK has:
Race Relations Amendment Act 2000 (building on 1976 act)
Public sector duty to promote equality and to demonstrate this
Unusually energetic implementation but still patchy effects
Major recent achievements in Scotland
Implementing the Race Relations Amendment Act 2001, and now Equality Act 2010
HDL (2002) 51 –Fair for All policy focused on ethnicity Energising the Organisation Demographics Access and Service Delivery-equity Human Resources-equality in employment Community Development-strengthening communities
National Resource Centre for Ethnic Minority Health (NRCEMH) 2002-2008
Major achievements in Scotland 2 Integration of the equality strands (race, religion,
age, gender, disability, sexual orientation) in NHS organisation in 2008
Information-responsibility and funding embedded in NHS agency: promotion of ethnic coding in routine information systems
Linkage of Census ethnic codes to mortality and hospitalisation databases providing health status by ethnic group
Ethnic Health Research Strategy, setting 6 priorities
Research and surveillance-health status of ethnic minorities in Scotland Ethnicity not recorded on birth and death
certificates (under consideration) Ethnic coding for in routine NHS records highly
variable So, unable to assess differences in mortality and
morbidity routinely High-level managerial activity to resolve these
problems So country of birth, name search and linkage
methods used
Using linkage methods to provide data Linkage study-heart attacks much more
common in self identified South Asians at 2001 census
More linkage derived findings awaiting publication on cardiovascular disease, cancer, maternal & child health and mental health
Anonymised Linkage of Health Databases to Census Databases:
conceptualising the procedure
Health Database Census Database
Record Linkage
Encrypted CHI Number
Personal Identifiers
Personal Identifiers
EncryptedCensusNumber
Encrypted CHI Number Encrypted Census Number
(Look-up Table)
Death & Hospitalisation from Health databases
Ethnicity and social/economic data
from Census
http://www.biomedcentral.com/1471-2458/7/142/abstract
Directly age standardised incidence ratesper thousand for first AMI (principal diagnosis)Sex/Ethnicity Person
yearsAge
adjusted rate
95% confidence
intervalFemaleNon SA 4,557,730 2.56 2.51 – 2.60SA 24,762 4.86 3.05 – 6.67
What about elsewhere in Europe? MEHO project Impossible to get pan-European perspective
Morbidity data is far behind mortality
Situation will be worse for other causes
Mapping is resource intensive
Currently data not trustworthy and difficult to standardise
Substantial inequalities still demonstrable
Country specific results may not generalise across EU
Need better information across the EU
What about risk factor data? VENI project –background and aim
Host countries’ environment may differ so project to develop methods
Aim: To develop a foundation to study internationally, starting with the Netherlands & UK, the role of lifestyle, SES and health care factors in explaining differences in risk factors between populations with broadly similar ethnic backgrounds
VENI project -Example of resultsAge-standardised current smoking by ethnic group
Fig. 1a Age-standardised prevalence of current smoking in men
46,3
32,6
22,7
54,5
36,8
28,7
52,5
28,4
35,139,3
0102030405060708090
Prev
alenc
e of
smok
ing (
%)
It seems it matters where one migrates to !
Practical activities in Scotland Interpreting and translation funded for inpatient and
outpatient services (including general practice) Spiritual services in hospital for every religion-by
creating multi-faith spaces and facilities Food in hospitals – appropriate choices Trained staff support minority patients and
communities (Minority Ethnic Health Inclusion Service-MEHIS)
Several community organisations supported to provide appropriate services
Ideas tested out using demonstration projects (Khush Dil) and trials of interventions (PODOSA)
Patient
Health Professional
Link Worker
MEHIS Link Worker Model
Some obstacles on the equitable healthcare delivery pathway-examples Implementation problems, and insufficient
monitoring Insufficient information Mainstreaming successful projects into routine
service problematic Winning hearts and minds Racial tensions and discrimination An attitude that immigrants/minorities should fit
the system, not the other way around
One example-end of life study“Policy directives aimed at improving access to
services and standards of care for ethnic minority groups in Scotland are laudable. It seems, however, that end of life services for South Asian Sikh and Muslim patients remain wanting in many key areas”.
Worth et al BMJ http://ukpmc.ac.uk/articlerender.cgi?accid=PMC2636416
Conclusions 1
Scotland’s progress incremental, incomplete and difficult, but still comparatively strong
Comparing policies to tackle ethnic inequalities in health: Belgium 1 Scotland 4
Built on partnership by a government and institutions promoting equality, and justice
Achieved within a strong NHS Underpinned by research and information Involving ethnic minority groups and individuals as
instigators, leaders, service personnel and users
Conclusions in international context 2 USA: health systems consume much more resources-despite
long recognition, equitable healthcare not yet achieved Europe: patchy progress, subject to political change. Progress
largely in service delivery, rather than governmental policy. New Zealand: innovative, and effective work in relation to
Maoris- political power and will has been instrumental Australian work on aboriginal health-challenge has been
somewhat overwhelming. Multi-ethnic countries in Middle East, China, India etc: much to
do, but issue seems mostly unrecognised
Conclusions 3: the future in Europe Health systems in our multi-ethnic
societies-challenging, interesting, with potential for great advances
Sharing experience across Europe, and between continents, means faster progress.
We must remember our ultimate goal-a healthy society
Acknowledgements
Colleagues including Rafik Gardee, Hector MacKenzie, Laurence Gruer, Aziz Sheikh, Gill Matthews, Vincent Laurent, David Ingleby
People supplying slides-Smita Grant (MEHIS, Lothian NHS) IOM for migration slide Members of the Edinburgh Ethnicity and Health Research Group The conference organisers
Further reading
Gill PS, Kai J, Bhopal RS, Wild SH. Health Needs Assessment for Black and Ethnic Minority Groups 2002 (online) and 2007 (in print) (book chapter –PDF available online at http://www.hcna.bham.ac.uk/documents/04_HCNA3_D4.pdf
Bhopal RS. Ethnicity, race, and health in multicultural societies; foundations for better epidemiology, public health, and health care. Oxford: Oxford University Press, 2007, pp 357. http://www.oup.com/uk/catalogue/?ci=9780198568179
Some URLs for organisations/policies National resource centre for ethnic minority
healthhttp://www.healthscotland.com/about/equalities/raceresources.aspx Planning and Equalities Directorate integrating equality strands
http://www.healthscotland.com/about/equalities/raceresources.aspx Information
http://www.isdscotland.org/isd/5826.html Fair for All
http://www.sehd.scot.nhs.uk/mels/HDL2002_51.pdf Ethnicity and health research strategy
http://www.healthscotland.com/documents/3768.aspx Lothian NHS board
http://www.nhslothian.scot.nhs.uk/news/documents/equalitydiversity_strategy.pdf
MEHIS http://www.saferedinburgh.org.uk/DOSDetails.cfm?ID=75
Equally connected http://www.healthscotland.com/equalities/mentalhealth/equally-connected
Comparing Belgium and Scotland policies http://eurpub.oxfordjournals.org/cgi/content/full/ckq061)