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See also separate Diseases and Different Ethnic Groups article.
Ethnicity and health - is there a problem?
Black and minority ethnic groups in the UK have worse health outcomes in many areas than the general population. Evidence suggests that the poorer socio-economic position of some ethnic groups is the main driver of ethnic health inequalities. Government policies have tried to tackle health inequalities, although ethnicity has not been a consistent focus within this.
Understanding the ethnic mix of a population can improve healthcare delivery by helping to focus resources such as screening programmes, education and resource allocation.
A need to close the health gap for ethnic minorities is recognised by the Department of Health. Since the implementation of the Race Relations Amendment Act 2000 in April 2001, a statutory duty has been laid upon the NHS and other public service agencies to 'have due regard to the need to eliminate unlawful discrimination' and to ensure that every new policy considers the implications for racial equality.
The NHS has, since April 1996, expected that all hospital trusts would record data relating to the ethnic origin of all 'admitted patients'. Although there has been steady growth in collection of this data, levels of completion remain low. This may partly be because of the perceived sensitivity of this area on the part of healthcare workers and also possibly because the information collected may be insufficiently detailed for clinical care and health service planning purposes.
Definitions of ethnic groups
Ethnicity results from many aspects of difference, including social and political influences, race, culture, religion and nationality. People may identify themselves with more than one ethnic group, although to allow data to be collected and analysed on a large scale, ethnicity is often treated as a fixed characteristic.
Ethnicity in the UK is mainly self-defined, through the ten-yearly UK population census. Ethnic groups are usually classified by the methods used in the census, which asks people to indicate to which one of 16 ethnic groups they feel they belong. This immediately gives rise to a simplification of the true picture.
- Over the last two decades England and Wales have become more ethnically diverse.
- 86% of the UK population were White (a fall from 92% in the 2001 census). Within this group, White British was the largest ethnic group at 80.5%. The group includes significant non-British White groups such as those of Irish and of Polish ethnicity.
- 91% of the population identified with at least one UK national identity (English, Irish, Scottish, Welsh).
- 7.5% of the population were Asian or Asian British.
- 3.3% were Black or Black British.
- 2.2% chose to class themselves as Mixed.
- 1% reported themselves as 'other', about half of whom were of Middle Eastern ethnicity.
- Across the English regions and Wales, London was the most ethnically diverse area and Wales the least.
- 4% of Scotland's population was from an ethnic minority group, with the majority of these being of Asian ethnicity.
- Minority ethnic populations are concentrated in urban areas, particularly in deprived areas.
- The distribution of minority ethnic groups in the UK is changing and they are becoming less geographically segregated.
- The UK is likely to become more multi-ethnic in the future.
Effects of ethnicity on healthcare
It is important to try to understand where and how ethnic differences impact on healthcare delivery if health inequalities are to be reduced across the whole population. Ethnicity may impact on healthcare and access to it at many levels, acting through factors such as:
- Differences in service uptake.
- Communication issues.
- Culture and attitudes.
- Socio-economic factors.
- Differences in disease prevalence.
These differences affect access to services and act as barriers to good healthcare.
Differences in service uptake
- There is evidence of inequality of access to hospital care for ethnic minority groups - eg, South Asians 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.
- There are some positive findings, such as reported equality of access in Primary Care.
A 2014 study of the use of NHS Direct confirmed that whilst all Mixed ethnic groups had a higher than expected uptake of NHS Direct, a lower than expected uptake was seen in Black and Asian ethnic groups.
A healthcare provider and patient need to be able to communicate as freely as possible. In the UK the vast majority of healthcare is delivered in the English language; amongst ethnic minority groups this may not be the first language or even a language of fluency. It is sometimes necessary to use interpreters. This can challenge the provision of the best care:
- Patient confidentiality can be compromised.
- The patient may be unwilling to speak on intimate matters.
- Engagement and empathy may be harder for health professionals to communicate and for patients to recognise..
- Interpretation or translation may not be faithful to the patient's account or meaning.
- Translation takes time and this may lead to superficial consulting.
- Translation using a telephone interpreter has a higher potential to be awkward and dysfunctional.
- Translation may cause embarrassment (for example, between parent and child).
- There can be additional cost involved.
Additional problems of communication include:
- Lack of interpreters and uncertainty over what language the patient speaks.
- Lack of a shared understanding of health issues and healthcare systems.
- Interpretation problems.
- Difference in understanding of health, disease and treatment.
- Different expectations.
- Patients unwilling to talk freely (eg, due to interpreter, due to fears of persecution).
- Lack of time for complex problems in the normal time frame of GP appointments.
- Extra time needed to consult with an interpreter.
It is the responsibility of healthcare professionals to ensure that consultations are understood, and we should do our best to use effective, professional translation services. It is good practice to compile a resource pack listing interpreter services which may be available locally.
- When interpretation is required, a double appointment (at least) should be made to allow sufficient time for the consultation.
- Ideally a professional interpreter is booked in advance, arrives early and may, if the patient wishes, meet the patient briefly first. The length of time an interpreter needs to be booked ahead will depend in part on how common the language is and where, geographically, your surgery is placed.
- A language identification card allows patients who can read to point to their language, enabling you to call an interpreter.
- Language Line is a useful on-the-day resource. You need to give a number of details including your organisation's PIN and the language required. They can arrange a three-way call either to your telephone or to that of the patient (if the contact is a telephone consultation). There is usually a delay of about 60 seconds before connection but, again, if the language is rare it may be wise to book in advance. It is available 24/7 on 0845 3109900. If the patient is present, using hands-free speaker mode will enable a telephone-translated consultation to proceed more easily.
- If a patient calls NHS Direct and is able to state (in English) the name of the language they wish to use, a consultation in that language is available.
- Depending on the ethnic mix of your patient population there may be services provided by the council, local hospitals, refugee support groups and other bodies. These services are often free if arranged by the patient themselves.
- Patient advocates, rather than interpreters, are provided by some Primary Care organisations and refugee organisations. They support the patient although they may add their own views and suggestions to the consultation.
- Many patients wishing to consult in a language other than English will bring a family member, friend or advocate. Family members and friends may act as interpreters, which may be a practical solution and the preference of the patient. There are many disadvantages with this approach, including confidentiality issues, embarrassment, potential conflicts and lack of good translating skills.
- You should avoid using children to interpret - this may embarrass the adults and give the child inappropriate responsibilities.
- When working with an interpreter:
- Allow extra time.
- Discuss how you will work together before you start.
- Focus on and try to maintain eye contact with the patient, not the interpreter.
- Emphasise confidentiality and address the patient as 'you' not 'he/she'.
- Speak slowly and clearly 1-2 sentences at a time and watch for non-verbal cues.
Written language materials
- The NHS Choices website 'language hub' provides links to sites offering health information in other languages.
- Google Translate may help you translate documents although the program does not cope well with colloquialisms.
- Be aware of the possible existence of culturally determined health beliefs - eg, around the significance of symptoms, or taboos around certain topics. Some patients may be reluctant to have blood taken because of views regarding its significance.
- Be aware that for some patients there may be strong taboos regarding the gender of the health professional, particularly where examination is concerned. This may also apply to interpreters.
- An ideal chaperone speaks the patient's language as well as yours; however, this is not essential.
- Referral to the local Health Inclusion Team may be helpful. Their role is to educate excluded groups in their use of health services, enabling them to improve their access to care.
Practice management approaches
- Ensure information leaflets are available to download in other languages.
- Provide clear signposting of the appointments system.
- Put up clear signage stating that racism will not be tolerated.
- Support staff dealing with stressed or angry patients and encourage tolerance on the day. Provide training for dealing with difficult patients.
- All asylum seekers are entitled to NHS treatment and GP registration. Make sure that staff are aware of this and avoid placing unnecessary barriers. The BMA website provides advice on entitlement to care for asylum seekers.
Culture and attitudes
An understanding of cultural differences and attitudes is needed for effective healthcare to be delivered appropriately. Examples of cultural and attitudinal differences which may affect health and healthcare delivery include:
- The patient's expectations.
- The expression of symptoms which have cultural or linguistic influences.
- Family roles and relationship differences between cultures.
- Different attitudes to sex and marriage between cultures and religions.
- Different attitudes to clinical examination and what is acceptable to the patient.
- Patients' preferences for doctors or nurses of particular gender.
- Different significance attached to issues such as the gender of a baby or the presence of serious abnormality detected antenatally.
- Rules around death and the timing of burial or cremation.
- Cultural and/or religious views on organ transplantation and blood transfusion.
- Assumptions regarding lack of need for immunisation or antimalarial medication when visiting relatives in at-risk countries.
- Problems of culture and religion may make it difficult for patients to admit to such matters as homosexuality, premarital sex, infidelity leading to disease or unplanned pregnancy, alcohol abuse or even depression.
Religious practices and beliefs can affect health in several ways:
- Muslims and Jews restrict or forbid the eating of certain foods.
- Hindus and Buddhists, are usually vegetarian.
- Many religious groups have festivals involving fasting or restricted diet. Ramadan lasts for a month during which Muslims are forbidden from ingesting anything in daylight hours. Those who are ill are not expected to conform but they may choose to do so. If a Muslim patient needs to take medication, including injections, during the fast, they should do so; however, many patients with diabetes will wish to adapt their regime. Some groups are exempt from fasting including
- Children under the age of puberty, who may have a limited fast.
- People who are mentally incapacitated.
- The elderly.
- The sick.
- Travellers on journeys of more than about fifty miles.
- Pregnant women and nursing mothers.
- Women who are menstruating.
- A well-described cultural effect of ethnicity of diet is the association between balti cooking, modest dress codes and vitamin D deficiency, particularly in the lower sunlight areas of the Northern hemisphere.
Smoking is the leading risk factor for disability-adjusted life-years:
- Smoking prevalence is substantially higher amongst migrants from East European countries compared with most other non-UK-born groups.
- Rates are highest in the Gypsy or Irish Traveller group.
- Across ethnic groups smoking rates are almost always higher for the UK-born than the non-UK-born population
- White and Chinese ethnic groups show a strong socio-economic gradient in smoking which is absent in the South Asian group and diminished in the Mixed and Black ethnic groups.
Blood transfusion and organ transplantation
- Jehovah's Witnesses believe that it is unacceptable to receive blood products and do not accept organ transplantation.
- Parents may refuse a blood transfusion for a child. Sometimes the courts are involved and may override the parents' view in the child's best interests.
- No religion formally forbids donation or receipt of organs, although some are discouraged from accepting transplantation from deceased donors.
Termination of pregnancy
Termination of pregnancy is unacceptable to many individuals, including some whose religious beliefs forbid it. This may be true even in extreme cases - eg, severe fetal malformation.
Where religious belief and the patient's best interests appear to be in conflict, health professionals should be very careful not to offer their own moral view but should give the patient accurate information to ensure that the decisions they take are properly informed.
See also separate Ethnocultural Issues in Contraception article.
The Roman Catholic Church opposes contraception, although it does allow use of the woman's menstrual cycle ('rhythm method') to permit sexual intercourse without great risk of conception ('natural family planning).
Male circumcision may be performed for religious, hygienic or medical reasons:
- Jewish boys are circumcised on the 8th day of life.
- There is variation in the times Muslim boys are usually circumcised.
- Circumcision is often practised as a coming of age ritual in adolescent boys in sub-Saharan Africa.
Operations are performed by the ministers of religion (surgical training is part of their theological studies). Some parents ask for a medical practitioner to perform the operation. (The NHS does not generally fund circumcision, other than when it is needed for medical reasons.)
Female genital mutilation (FGM)
- This is a procedure often involving clitoridectomy together with varying degrees of excision of the labia. It is often performed by practitioners with no degree of precision or surgical skill.
- The World Health Organization (WHO) defines it as 'all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons'.
- FGM is done for many reasons; there is no single religious basis.
- In some cultures a woman who has not undergone the procedure may be thought unmarriageable.
- Female genital cutting is a deeply rooted tradition that confers honour on a woman and her family, yet is also a traumatic experience that creates significant dermatological, gynaecological, obstetric and infectious disease complications. Complications include dyspareunia, dystocia and other psychological and physical problems.
- It is practised particularly in parts of Africa and the Middle East and there have been successful prosecutions of doctors performing such procedures in the UK.
This affects women from all ethnic groups, and there is no evidence to suggest that women from some communities are specifically at more risk than others. However, the form of the abuse may vary and in come communities domestic violence may be perpetrated by extended family members. In some cultural groups it may include forced marriage, FGM or honour killing, all of which have received significant publicity in the last few years.
Women from minority ethnic communities may be more isolated or may need to overcome religious and cultural pressures, particularly concerning the relative importance of self-assertion and protection against the community/family/perceived tradition, in order to seek help.
Many ethnic minority groups experience higher rates of poverty than the White British ethnic group, 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 socio-economic status.
Differences in disease prevalence
Biological diversity produces different diseases and susceptibility to diseases. 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. A great number of diseases have greater prevalence and impact in specific ethnic groups. For example:
- Diabetes is more prevalent amongst those whose are ethnically South Asian.
- Ethnicity may be a consideration in deciding the best treatment for hypertension.
- Sickle cell trait confers partial protection against the effects of malaria, so the sickle cell gene has been preserved in patients of West African ethnic origin, leading to significant levels of sickle cell gene carriage and sickle cell disease in this group.
- Marriage to family members (eg, first cousins) is more likely in certain ethnic groups where marriages are arranged. This leads to an increased prevalence of autosomal recessive diseases.
- Some diseases are less common in certain ethnic groups - eg, the prevalence of prostate cancer is lower in men of South Asian ethnicity than in the general population. It is, however, higher in patients of Afro-Caribbean origin.
Both immigration and foreign travel, which for some people may mean returning to their parental home or birthplace, may introduce diseases - some exotic and some more mundane. For example:
- The UK sees over 2,000 cases of malaria a year. Many are travellers who failed to take adequate prophylactic medication. Malaria is the most common imported tropical disease to the UK. Encouraging migrant travellers visiting family and friends to take prophylactic medication should be a priority - any immunity to malaria accrued by growing up in a malarious country is rapidly lost on emigration and second-generation family members will have no immunity.
- Most cases of tuberculosis (TB) in the UK are 'imported'; almost three quarters of TB cases in 2013 occurred among people born outside the UK; only 15% were recent migrants.
Most ethnic groups have poorer health than the White British group. There are wide variations in health between different ethnic groups in England and Wales. Poor health is caused by a wide range of factors, including biological determinants (age, sex, hereditary factors) and wider social determinants such as education, social position, income, local environment and experiences of racism and racial discrimination. The social determinants of health are unequally distributed across ethnic groups, leading to unjust and preventable health inequalities. For example:
- Persistent inequalities are seen in the health of Pakistani and Bangladeshi women. Their illness rates have both been 10% higher than those of White women in 1991, 2001 and 2011.
- The White Gypsy or Irish Traveller group has particularly poor health. Both men and women have twice the White British rates of limiting long-term illness.
- 50% of all men aged 65 or older reported a limiting long-term illness but 69% of Bangladeshi and White Gypsy or Irish Traveller older men reported being ill.
- The Chinese group reported persistently better health in 1991, 2001 and 2011 - half or under half the White illness rates for both men and women.
- Among younger age groups the percentage of people from ethnic minority groups who have a limiting long-term illness is not very different compared to the England and Wales total but the White Gypsy or Irish Traveller group stands out with much higher limiting long-term illness for all age groups (8% among boys aged 0-15, and 30% among men aged 16 to 64).
- There are clear regional health inequalities in England and Wales. London and other regions in the South have a better health profile than the Northern regions.
- This North-South divide in health can be mostly explained by socio-economic differences across regions.
- London is the most ethnically diverse region of England and Wales, which, together with its socio-economic profile, creates a different pattern of ethnic health inequalities as compared to the other regions. Ethnic health inequalities in London in 2011 were more severe than elsewhere in England and Wales. This is the case for most ethnic minority groups.
- For example, Bangladeshi women were more than 30% more likely to have limiting long-term illness than White British women in London, compared to 15% more likely outside London.
Ethnic health inequalities can be reduced by improvements in the social status and living conditions of disadvantaged groups.
To date, the main policy targets have focused on socio-economic class and area deprivation.
Health inequalities targets
The Health and Social Care Act 2012 places a legal duty on clinical commissioning groups (CCGs) to tackle health inequalities.
The Marmot Review examined health inequalities in England: Professor Sir Michael Marmot chaired an independent review to propose the most effective evidence-based strategies for reducing health inequalities in England. The final report, 'Fair Society Healthy Lives', was published in 2010. It found that:
- There is a pronounced socio-economic gradient in the prevalence of all major long-term conditions, in life expectancy and in disability-free life expectancy.
- Health inequalities result from social inequalities and to reduce health inequalities requires action across the social determinants of health.
- The NHS also has a pivotal contribution to make in reducing health inequalities through the way it commissions services and the way it provides healthcare.
- The conclusion of the Marmot Review was that reducing health inequalities would require action on six policy objectives:
- Give every child the best start in life.
- Enable all children, young people and adults to maximise their capabilities and have control over their lives.
- Create fair employment and good work for all.
- Ensure a healthy standard of living for all.
- Create and develop healthy and sustainable places and communities.
- Strengthen the role and impact of ill-health prevention.
In the UK, as in other countries, the growth of various ethnic communities and linguistic groups, each with its own cultural traits and health profiles, presents a complex challenge to healthcare practitioners and policy makers in terms of achieving equitable access. Ethnic differences in populations have important implications for doctors and others involved in the delivery of healthcare.
Doctors need to be aware of the influence of ethnicity, culture and religion on the health of patients in the population they serve. In particular they should consider differences in disease prevalence, possible cultural influences on health, access to and uptake of health services, and the possible barriers to good care.
Further reading and references
Szczepura A; Access to health care for ethnic minority populations. Postgrad Med J. 2005 Mar81(953):141-7.
Tobacco use, ethnicity and health; Action on Smoking and Health Scotland, June 2014
Cook EJ, Randhawa G, Large S, et al; Who uses NHS Direct? Investigating the impact of ethnicity on the uptake of telephone based healthcare. Int J Equity Health. 2014 Nov 713(1):99. doi: 10.1186/s12939-014-0099-x.
Language Identification Card; Refugee Council
Aspinall PJ, Mitton L; Smoking prevalence and the changing risk profiles in the UK ethnic and migrant minority populations: implications for stop smoking services. Public Health. 2014 Mar128(3):297-306. doi: 10.1016/j.puhe.2013.12.013. Epub 2014 Mar 4.
Bruzzone P; Religious aspects of organ transplantation. Transplant Proc. 2008 May40(4):1064-7. doi: 10.1016/j.transproceed.2008.03.049.
Tuberculosis in the UK 2014 report; Public Health England
Ethnicity and Health; Parliamentary Office of Science and Technology, Jan 2007
Which ethnic groups have the poorest health? Ethnic health inequalities 1991 to 2011; Dynamics of Diversity: Evidence from the 2011 Census: ESRC Centre on Dynamics of Ethnicity (CoDE), University of Manchester/Joseph Rowntree Foundation, Oct 2013
Fair Society Healthy Lives (The Marmot Review); UCL Institute of Health Equity, February 2010
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