Locating ethnicity and health: exploring concepts and contexts

Racing the Machine: Data Analytic Technologies and Institutional Inscription of Racialized Health Injustice

Recent scientific and policy initiatives frame clinical settings as sites for intervening upon inequality. Electronic health records and data analytic technologies offer opportunity to record standard data on education, employment, social support, and race-ethnicity, and numerous audiences expect biomedicine to redress social determinants based on newly available data. However, little is known on how health practitioners and institutional actors view data standardization in relation to inequity. This article examines a public safety-net health system's expansion of race, ethnicity, and language data collection, drawing on 10 months of ethnographic fieldwork and 32 qualitative interviews with providers, clinic staff, data scientists, and administrators. Findings suggest that electronic data capture institutes a decontextualized racialization within biomedicine as health practitioners and data workers rely on biological, cultural, and social justifications for collecting racial data. This demonstrates a critical paradox of stratified biomedicalization: The same data-centered interventions expected to redress injustice may ultimately reinscribe it.

Disparities by Social Determinants of Health: Links Between Long COVID and Cardiovascular Disease

Long COVID has been defined by the World Health Organisation as "continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation." Cardiovascular disease is implicated as a risk factor, concomitant condition, and consequence of long COVID. As well as heterogeneity in definition, presentation, and likely underlying pathophysiology of long COVID, disparities by social determinants of health, extensively studied and described in cardiovascular disease, have been observed in 3 ways. First, underlying long-term conditions, such as cardiovascular disease and its risk factors, are associated with incidence and severity of long COVID, and previously described socioeconomic disparities in these factors are important in exacerbating disparities in long COVID. Second, socioeconomic disparities in management of COVID-19 may themselves lead to distal disparities in long COVID. Third, there are socioeconomic disparities in the way that long COVID is diagnosed, managed, and prevented. Together, factors such as age, sex, deprivation, and ethnicity have far-reaching implications in this new postviral syndrome across its management spectrum. There are similarities and differences compared with disparities for cardiovascular disease. Some of these disparities are in fact, inequalities, that is, rather than simply observed variations, they represent injustices with costs to individuals, communities, and economies. This review of current literature considers opportunities to prevent or at least attenuate these socioeconomic disparities in long COVID and cardiovascular disease, with special challenges for research, clinical practice, public health, and policy in a new disease which is evolving.

Social cohesion and attitudinal changes toward migration: A longitudinal perspective amid the COVID-19 pandemic

The COVID-19 pandemic has impacted social interactions and coexistence around the globe in dimensions that go far beyond health issues. In the case of the Global South, the pandemic has developed along with growing South-South migratory movements, becoming another key factor that might reinforce social conflict in increasingly multicultural areas as migrants have historically served as "scapegoats" for unexpected crises as a way to control and manage diversity. Chile is one of the main destination countries for migrants from the Latin American and Caribbean region, and COVID-19 outbreaks in migrant housing have intensified discrimination. In such a context, there is a need for understanding how the pandemic has potentially changed the way non-migrants perceive and interact with migrant neighbors. Drawing on the national social cohesion panel survey study ELSOC (2016-2021, N = 2,927) the aim is to analyze the changes in non-migrants' attitudes toward migrants-related to dimensions of social cohesion-over the last years and their relation with individual status and territorial factors. We argue that social cohesion in increasingly multicultural societies is partially threatened in times of crisis. The results indicate that after the pandemic, convivial attitudes toward Latin American migrants decreased. Chileans started perceiving them more negatively, particularly those respondents with lower educational levels and who live in increasingly multicultural neighborhoods with higher rates of migrant residents.

'The filthy people': Racism in digital spaces during Covid-19 in the context of South-South migration

Notions of 'race' and disease are deeply imbricated across the globe. This article explores the historical, complex entanglements between 'race', disease, and dirtiness in the multicultural Chilean context of Covid-19. We conducted a quantitative content analysis and a discourse analysis of online readers' comments (n = 1233) in a digital news platform surrounding a controversial news event to examine Chileans' cultural representations of Haitian migrants and explore online racism and anti-immigrant discourse. Drawing on a decolonial approach, we argue that Covid-19 as a crisis has been fabricated at the expense of a constructed 'other'. We show how colonial racist logics not only endure in digital spaces, but are made viral in new ways by representing Haitian migrants as 'filthy' and 'disease carriers'. We identified two contemporary forms of racism - online cultural racism and online aggressive racism - through which people construct imaginaries of racial superiority in digital spaces.

From imperialism to inpatient care: Work differences of Filipino and White registered nurses in the United States and implications for COVID-19 through an intersectional lens

In the United States, nursing is the largest healthcare profession, with over 3.2 million registered nurses (RNs) nationwide and comprised of mostly women. Foreign‐trained RNs make up 15 percent of the RN workforce. For over half a century, the U.S. healthcare industry has recruited these RNs in response to nurse shortages in hospitals and nursing homes. Philippines‐trained RNs make up 1 out of 20 RNs in this country and continue to be the largest group of foreign‐trained nurses today. Recently, the news media has publicized the many deaths of Filipino RNs as a result of the COVID‐19 pandemic in the United States. Given the imperial historical ties between these two countries in the context of the nursing profession and the enduring labor inequities that persist, this nationally representative study is one of the few to our knowledge to not only quantitatively examine the current work differences in characteristics and experiences of Philippines‐trained RNs and U.S.‐trained white RNs practicing in the United States today, but to also do so from an intersectionality lens. The overall aim of this paper is to illuminate how these differences may serve as potential factors contributing to the disproportionate number of Filipino nurses' COVID‐19 related vulnerability and deaths in the workplace.

Experiences of everyday racism in Toronto's health care system: a concept mapping study

BACKGROUND

In Canada, there is longstanding evidence of health inequities for racialized groups. The purpose of this study is to understand the effect of current health care policies and practices on racial/ethnic groups and in particular racialized groups at the level of the individual in Toronto's health care system.

METHODS

This study used a semi-qualitative study design: concept mapping. A purposive sampling strategy was used to recruit participants. Health care users and health care providers from Toronto and the Greater Toronto Area participated in all four concept mapping activities. The sample sizes varied according to the activity. For the rating activity, 41 racialized health care users, 23 non-racialized health care users and 11 health care providers completed this activity. The data analysis was completed using the concept systems software.

RESULTS

Participants generated 35 unique statements of ways in which patients feel disrespect or mistreatment when receiving health care. These statements were grouped into five clusters: 'Racial/ethnic and class discrimination', 'Dehumanizing the patient', 'Negligent communication', 'Professional misconduct', and 'Unequal access to health and health services'. Two distinct conceptual regions were identified: 'Viewed as inferior' and 'Unequal medical access'. From the rating activity, racialized health care users reported 'race'/ethnic based discrimination or everyday racism as largely contributing to the challenges experienced when receiving health care; statements rated high for action/change include 'when the health care provider does not complete a proper assessment', 'when the patient's symptoms are ignored or not taken seriously', 'and 'when the health care provider belittles or talks down to the patient'.

CONCLUSIONS

Our study identifies how racialized health care users experience everyday racism when receiving health care and this is important to consider in the development of future research and interventions aimed at addressing institutional racism in the health care setting. To support the elimination of institutional racism, anti-racist policies are needed to move beyond cultural competence polices and towards addressing the centrality of unequal power social relations and everyday racism in the health care system.

Perspectives On Perceived Stigma And Self-Stigma In Patients With Hidradenitis Suppurativa

Objective

To review current knowledge on how patients with hidradenitis suppurativa (HS) experience stigmatization, as well as on its associations with clinical and psychosocial characteristics of the disease. A better understanding of these may help dermatologists improve screening and management for the benefit of HS patients.

Methods

A MEDLINE search using the terms stigmatization, perceived stigma, self-stigma, and HS/acne inversa.

Results

Stigmatization is common among HS patients and has a strong psychosocial impact, which is often disproportional to the extent and severity of skin involvement. Stigmatization in HS has many faces and it is more prevalent and more severe than most other skin diseases. Stigmatization of HS patients is due not only to the distressing symptoms of pain, itch malodorous discharge, and disfiguring scars but also to the lack of knowledge about HS on part of the general public.

Conclusion

Stigma is a significant contributor to the impairment of quality of life and psychiatric co-morbidities commonly seen in patients with HS. Therefore, evaluation for stigma and formulation of strategies to prevent stigmatization and treat its consequences, in the context of a multidisciplinary approach, may ameliorate considerably the lives of HS patients.

Superdiversity, population health and health care: opportunities and challenges in a changing world

OBJECTIVES

Ethno-national approaches to research public health and migrant outcomes have dominated for decades but lack efficacy in a globalised world and in view of the intractable nature of health outcome inequalities for migrant and minority groups. This article highlights some of the challenges and opportunities associated with a superdiversity perspective in public health research.

SUPERDIVERSITY AND ETHNO-NATIONAL APPROACHES

Migration patterns have changed with more people arriving from more places and the diversification of diversity meaning that the ethno-national categories utilised in public health research have reduced explanatory potential. THE EXAMPLE OF MATERNAL AND PERINATAL MORTALITY IN THE UNITED KINGDOM: Adjusting UK perinatal mortality rates by five ethnic groups based on assumptions of relationships between high levels of risk and ethnic groups masks the scale of inequality faced by groups wherein mortality rates are increasing and highlights some of the difficulties associated with using ethno-national classifications.

A SUPERDIVERSITY PERSPECTIVE

A superdiversity approach moves beyond ethno-nationalism to socially locate groups focussing on commonalities and differences across spaces and characteristics and employing intracategorical or anticategorical approaches.

CONCLUSIONS

Superdiversity brings new levels of demographic complexity and fluidity. Greater reflexivity is needed in diversity research with justification of classifications used for analysis necessary when research questions are developed.

Participation in Organized Sports and Self-Organized Physical Activity: Associations with Developmental Factors

Engagement in organized sports is associated with developmental factors, such as, healthy growth, cognitive abilities, psychological well-being and lower substance use. Research also suggest that the spontaneous free play that characterises self-organized physical activity (PA) provides young people with opportunities to learn social skills, such as self-regulation and conflict-resolution skills. We assessed associations between participation in the two activity types and several demographics along with developmental factors (e.g., body mass index (BMI)). Data was from a representative sample of 2060 students attending 38 schools in Norway (mean age (M_age) = 15.29, standard deviation (SD) = 1.51; 52% females). Results indicated that while engagement in organized sports was more related to developmental factors, relative to self-organized PA, engaging concurrently in both activities for at least an hour a week was more developmentally beneficial than engaging only in one for the same amount of time. Thus, PA programmes for students will enhance their effectiveness if they focus on structured activities but also self-organized activities where students can coordinate themselves.

Access to healthcare in superdiverse neighbourhoods

To date little attention has been focused on how the differing features of 'superdiverse' neighbourhoods shape residents' access to healthcare services. Through utilising a cross-national mixed-methods approach, the paper highlights how defining features of superdiverse neighbourhoods - 'newness', 'novelty' and 'diversity' - influence a number of neighbourhood 'domains' and 'rules of access' that regulate access to healthcare. Issues of uncertainty, affordability, compliance, transnationalism and the diversity of community and local sociability are identified as being particularly significant, but which may vary in importance according to the nationality, ethnicity and / or religion of particular individuals.

Cultural Diversity and Mental Health: Considerations for Policy and Practice

The purpose of this paper is to explore some of the key considerations that lie at the intersection of cultural diversity and mental health. Mental health providers and professionals across the world have to work with clients that are often from cultures other than their own. The differences in cultures have a range of implications for mental health practice, ranging from the ways that people view health and illness, to treatment seeking patterns, the nature of the therapeutic relationship and issues of racism and discrimination. This paper will excavate some of these considerations with a view to raising possible ways in which mental health systems and professionals can engage across cultures more equitably and sustainably.

Developing culturally adapted lifestyle interventions for South Asian migrant populations: a qualitative study of the key success factors and main challenges

OBJECTIVES

South Asian migrant populations have a high risk of non-communicable diseases, such as type 2 diabetes (T2D). The aim of this study is to provide in-depth insight into key success factors and challenges in developing culturally adapted lifestyle interventions to prevent T2D within South Asian migrant populations.

STUDY DESIGN

The study has a qualitative research design.

METHODS

In-depth interviews, using a semi-structured interview guide, were conducted with eight researchers and project leaders from five studies of culturally adapted lifestyle interventions for South Asian migrant populations. Data were analysed using a grounded theory approach.

RESULTS

Four main themes emerged as key factors for success: 'approaching the community in the right way', 'the intervention as a space for social relations', 'support from public authorities' and 'being reflexive and flexible'. Two themes emerged as challenges: 'struggling with time' and 'overemphasising cultural differences'.

CONCLUSIONS

Our findings augment existing research by establishing the importance of cooperation at the organisational and institutional levels, of fostering the creation of social networks through interventions and of acknowledging the multiplicity of identities and resources among individuals of the same ethnic origin.

Racialised prescribing: enacting race/ethnicity in clinical practice guidelines and in accounts of clinical practice

This article examines the articulation and enactment of racialised classifications in clinical practice guidelines and in accounts of clinical practice. It contributes to debates about racialisation in medicine and its consequences. The research centred on the case study of prescribing guidelines for hypertension in England and Wales, drawing on documentary sources and semi-structured expert interviews. We found that conceptual and socio-political uncertainties existed about how to interpret the designation 'Black patients' and about the practices for identifying patients' race/ethnicity. To 'close' uncertainties, and thus produce the guidelines and treat patients, respondents drew authority from disparate elements of the 'topologies of race'. This has implications for understanding processes of racialisation and for the future use of racialised clinical practice guidelines. We argue that clinical practice guidelines play a 'nodal' role in racialisation by forming an authoritative material connection that creates a path for translating racialised research into racialised healthcare practice, and that they carry with them implicit conceptual and socio-political uncertainties that are liable to create inconsistencies in healthcare practice.

Genetics of consanguinity and inbreeding in health and disease

CONTEXT

Inbreeding increases the level of homozygotes for autosomal recessive disorders and is the major objective in clinical studies. The prevalence of consanguinity and the degree of inbreeding vary from one population to another depending on ethnicity, religion, culture and geography. Global epidemiological studies have revealed that consanguineous unions have been significantly associated with increased susceptibility to various forms of inherited diseases.

OBJECTIVE

The study aimed to determine the role of consanguinity in human health and to highlight the associated risks for various diseases or disorders.

METHODS

PubMed and Google Scholar search engines were used to explore the published literature on consanguinity and its associated risks using the key words "consanguinity", "prevalence", "inbreeding depression", "coefficient of inbreeding", "child health", "mortality", "human health", "homozygosity" and "complex diseases" in different combinations. The studies were screened for eligibility on the basis of their epidemiological relevance.

RESULTS

This comprehensive assessment highlights the deleterious consequences in populations with a higher prevalence of consanguinity among different countries worldwide.

CONCLUSIONS

To avoid the inbreeding load there is the need to improve socioeconomic and educational status and to increase public awareness of reproductive health and anticipated deleterious effects. Pre-marital and pre-conception counselling of consanguineous populations should be an integral part of health policy to train people and make people aware of its harmful consequences. Furthermore, runs of homozygosity (ROH) and whole-exome sequencing (WES) are useful tools in exploring new genomic signatures for the cause of inbreeding depression.

Strong, female and Black: Stereotypes of African Caribbean women’s body shape and their effects on clinical encounters

The aim of this article is to explore how tendencies to stereotype minority ethnic groups intersect with lay discourses about them in ways that can reproduce cultural prejudices and reinforce inequalities in access to services and health outcomes. Drawing upon Black feminist and cultural studies literature, we present a theoretical examination, the stereotypes of the Black woman as ‘mammy’ and ‘matriarch’. We suggest that the influence of these two images is central to understanding the normalisation of the larger Black female body within African Caribbean communities. This representation of excess weight contradicts mainstream negative discourses of large bodies that view it as a form of moral weakness. Seeking to stimulate reflection on how unacknowledged stereotypes may shape clinical encounters, we propose that for Black women, it is the perception of strength, tied into these racial images of ‘mammy’ and ‘matriarch’ which may influence when or how health services or advice are both sought by them and offered to them. This has particular significance in relation to how body weight and weight management are/are not talked about in primary care-based interactions and what support Black women are/are not offered. We argue that unintentional bias can have tangible impacts and health outcomes for Black women and possibly other minority ethnic groups.

Evaluating a DVD promoting breast cancer awareness among black women aged 25-50 years in East London

BACKGROUND

The mean age of presentation for breast cancer among black women is substantially earlier than their white counterparts. Black women also present with adverse prognostic factors that have major clinical implications, including lower survival. To pilot the use of a 6 min DVD on breast cancer in young (under 50 years) black women, to raise awareness and examine the impact of the DVD on increased consultation and referral rates among these women.

METHODS

Two general practices (intervention practices) in the Hackney area were randomised to have the DVD mailed to all black women aged 25-50 years registered with the practices, and two practices to no intervention (control practices). EMIS data was used to compare consultation rates preintervention and postintervention, in the intervention as well as control practices. Interviews with practice staff and focus groups with patients in participating practices provided qualitative data on the study context and DVD effectiveness.

RESULTS

A trend of declining consultations for breast symptoms was observed (-22% and -31% among non-black women in the control and intervention practices, and -23% among black women in the control practice) except among the target population of black women aged 25-50 years for the DVD in the intervention practices, which saw an increase of 28% in consultations. The qualitative data indicated that the DVD was well received in the target population, and suggested further ways of disseminating awareness messages and overcoming barriers to help-seeking.

CONCLUSIONS

Pilot results suggest that the strategy of distributing the DVD may increase consultations for breast problems.

Addressing key issues in the consanguinity-related risk of autosomal recessive disorders in consanguineous communities: lessons from a qualitative study of British Pakistanis

Currently, there is no consensus regarding services required to help families with consanguineous marriages manage their increased genetic reproductive risk. Genetic services for communities with a preference for consanguineous marriage in the UK remain patchy, often poor. Receiving two disparate explanations of the cause of recessive disorders (cousin marriage and recessive inheritance) leads to confusion among families. Further, the realisation that couples in non-consanguineous relationships have affected children leads to mistrust of professional advice. British Pakistani families at-risk for recessive disorders lack an understanding of recessive disorders and their inheritance. Such an understanding is empowering and can be shared within the extended family to enable informed choice. In a three-site qualitative study of British Pakistanis, we explored family and health professional perspectives on recessively inherited conditions. Our findings suggest, firstly, that family networks hold strong potential for cascading genetic information, making the adoption of a family-centred approach an efficient strategy for this community. However, this is dependent on provision of high-quality and timely information from health care providers. Secondly, families' experience was of ill-coordinated and time-starved services, with few having access to specialist provision from Regional Genetics Services; these perspectives were consistent with health professionals' views of services. Thirdly, we confirm previous findings that genetic information is difficult to communicate and comprehend, further complicated by the need to communicate the relationship between cousin marriage and recessive disorders. A communication tool we developed and piloted is described and offered as a useful resource for communicating complex genetic information.

“Care from the heart”: older minoritised women's perceptions of dignity in care

Purpose

– Drawing findings from a large mixed-method study on perceptions of dignity, care expectations, and support in relation to older women from Black and minority-ethnic backgrounds, the purpose of this paper is to explore the interrelationships between life course events and the multiple roles adopted by women at different points in time that have shaped their perceptions of care and their care expectations in old age.

Design/methodology/approach

– In total, 32 semi-structured interviews were undertaken, allowing for the collection of data on the participants’ understanding of growing old, and the meaning and attributes of care and what care with dignity “looked and felt like”. The theoretical framework is guided by a life-course approach and grounded within an intersectionality perspective. The majority of the participants were migrants.

Findings

– Social markers such as ethnicity and cultural identity were found to influence the participants’ understanding and expectations of care with factors such as gender identity and integration in the local community also of importance. How women felt they were perceived and “recognised” by others in their everyday lives with particular focus at the time of old age with the increased potential of loss of dignity due to declining capabilities, raised the importance of the family involvement in care provision, and perceived differences in the attributes of paid and non-paid care. The notion of “care from the heart” emerged as a key attribute of care with dignity. Care with dignity was understood as a purposeful activity, undertaken with intent to show respect and to acknowledge the participants’ sense of worth and value.

Practical implications

– The implications of this study are relevant in the current debate taking place at the EU level about the lived experiences of ageing migrant groups and care expectations.

Originality/value

– The study highlights the importance of the social nature of dignity, how wider societal structures can impact and shape how care is understood for older women of migrant and minoritised backgrounds, and the need to explore migration and care across the life course.

UK Pakistani views on the adverse health risks associated with consanguineous marriages

This is a qualitative study exploring the perceptions of members from the Pakistani/Kashmiri community living in Luton, UK, on the adverse health risks associated with consanguineous marriages. Rates of stillbirths and infant mortality are higher than the national average in Luton and the existing evidence base suggests that these higher rates may be associated with consanguinity (especially first cousin marriages) in highly consanguineous populations, such as the Pakistani/Kashmiri ethnic group. This qualitative study included 9 focus groups and 10 one to one in-depth interviews (n = 58) with members from the Pakistani/Kashmiri community in Luton during 2012. Audio-recorded transcripts were analysed using framework analysis. Emerging themes included a limited knowledge, opposition to evidence and need for a more culturally sensitive health services approach. Findings from the focus group and interview discussions indicated that participants had a limited and varied understanding of genetic risk and indicated a lack of discussion within the community regarding genetic risk. They also opposed evidence that may link consanguineous marriages with infant mortality, stillbirth or genetic disorders that led to disability. The participants stressed the need for culturally sensitive and locally constructed services for information on genetic risk and services. These findings may be used to address higher rates of infant mortality and adverse health impacts associated with higher rates of consanguinity in Luton and elsewhere, through a partnership approach, improve upon current services and develop culturally appropriate services.

Cross-country differences in basal and stress-induced cortisol secretion in older adults

Objective

Several studies have emphasized the association between socioeconomic status (SES) and inadequate response of the biological stress system. However, other factors related to SES are rarely considered, such as cultural values, social norms, organization, language and communication skills, which raises the need to investigate cross-country differences in stress response. Although some studies have shown differences in cortisol levels between immigrants and natives, there is no cross-country evidence regarding cortisol levels in country-native elders. This is particularly important given the high prevalence of stress-related disorders across nations during aging. The current study examined basal diurnal and reactive cortisol levels in healthy older adults living in two different countries.

Methods

Salivary cortisol of 260 older adults from Canada and Brazil were nalyzed. Diurnal cortisol was measured in saliva samples collected at home throughout two working days at awakening, 30 min after waking, 1400 h, 1600 h and before bedtime. Cortisol reactivity was assessed in response to the Trier Social Stress Test (TSST) in both populations.

Results

Our results showed that even under similar health status, psychological and cognitive characteristics, Brazilian elders exhibited higher basal and stress-induced cortisol secretion compared to the Canadian participants.

Conclusion

These findings suggest that country context may modulate cortisol secretion and could impact the population health.

Does ethnicity affect where people with cancer die? A population-based 10 year study

Background

Ageing is a growing issue for people from UK black, Asian and minority ethnic (BAME) groups. The health experiences of these groups are recognised as a ‘tracer’ to measure success in end of life patient-preferred outcomes that includes place of death (PoD).

Aim

To examine patterns in PoD among BAME groups who died of cancer.

Material and Methods

Mortality data for 93,375 cancer deaths of those aged ≥65 years in London from 2001–2010 were obtained from the UK Office for National Statistics (ONS). Decedent's country of birth was used as a proxy for ethnicity. Linear regression examined trends in place of death across the eight ethnic groups and Poisson regression examined the association between country of birth and place of death.

Results

76% decedents were born in the UK, followed by Ireland (5.9%), Europe(5.4%) and Caribbean(4.3%). Most deaths(52.5%) occurred in hospital, followed by home(18.7%). During the study period, deaths in hospital declined with an increase in home deaths; trend for time analysis for those born in UK(0.50%/yr[0.36–0.64%]p<0.001), Europe (1.00%/yr[0.64–1.30%]p<0.001), Asia(1.09%/yr[0.94–1.20%]p<0.001) and Caribbean(1.03%/yr[0.72–1.30%]p<0.001). However, time consistent gaps across the geographical groups remained. Following adjustment hospital deaths were more likely for those born in Asia(Proportion ratio(PR)1.12[95%CI1.08–1.15]p<0.001) and Africa(PR 1.11[95%CI1.07–1.16]p<0.001). Hospice deaths were less likely for those born in Asia(PR 0.73 [0.68–0.80] p<0.001), Africa (PR 0.83[95%CI0.74–0.93]p<0.001), and ‘other’ geographical regions (PR0.90[95% 0.82–0.98]p<0.001). Home deaths were less likely for those born in the Caribbean(PR0.91[95%CI 0.85–0.98]p<0.001).

Conclusions

Location of death varies by country of birth. BAME groups are more likely to die in a hospital and less likely to die at home or in a hospice. Further investigation is needed to determine whether these differences result from patient-centred preferences, or other environment or service-related factors. This knowledge will enable strategies to be developed to improve access to relevant palliative care and related services, where necessary.

Ethnicity at work: the case of British minority workers in the long-term care sector

Purpose

– The aim of this paper is to explore the effect of ethnicity and separate this from the other dynamics associated with migration among members of the long-term care workforce in England focusing on the nature and structure of their jobs. The analysis examines interactions between ethnicity, gender, and age, and their relations with “meso” factors related to job and organizational characteristics and “macro” level factors related to local area characteristics.

Design/methodology/approach

– The paper analyses new national workforce data, the National Minimum Data Set for Social Care (NMDS-SC), n=357,869. The paper employs descriptive statistical analysis and a set of logistic regression models.

Findings

– The results indicate that labour participation of British black and minority ethnic (BME) groups in long-term care work is much lower than previously believed. There are variations in nature of work and possibly job security by ethnicity.

Research limitations/implications

– While the national sample is large, the data were not purposively collected to examine differentials in reasons to work in the care sector by different ethnicity.

Practical implications

– The analysis highlights the potential to actively promote social care work among British BME groups to meet workforce shortages, especially at a time where immigration policies are restricting the recruitment of non-European Economic Area nationals.

Originality/value

– The analysis provides a unique insight into the participation of British BME workers in the long-term care sector, separate from that of migrant workers.

The practice of hope: a longitudinal, multi-perspective qualitative study among South Asian Sikhs and Muslims with life-limiting illness in Scotland

OBJECTIVES

We explored the role of faith and religious identities in shaping end of life experiences in South Asian Muslims and Sikhs with life-limiting illnesses.

DESIGN

Secondary analysis of data from a longitudinal, multi-perspective qualitative study of the experience of life-limiting illness and access to palliative care services among South Asian Sikhs and Muslims in Scotland. Up to three semi-structured interviews were conducted with 25 participants, 15 family members and 20 health care professionals over a period of 18 months. Analysis was informed by Mattingly's theory on hope.

RESULTS

Hope emerged as a central construct in the accounts of illness constructed by the participants as they struggled to make sense of and uphold a meaningful life. Clinical encounters and, for some, religious beliefs served as sources of hope for participants. Hope unfolded as an active process that enabled them to live with the personal and in particular the social ramifications of their illness. Changing images of hope were formulated and reflected as illness progressed or treatments failed. These ranged from hoping for cure, prolonged life, the regaining of lost capabilities needed to fulfil social roles, or at times death when suffering and the consequences for the family became too hard to bear.

CONCLUSIONS

For those suffering from a life-limiting illness, sustaining hope is a complex challenge. The social character of hope is evident as it focuses on envisioning a life that is worth living, not only for oneself, but most importantly for social relations. Continuity in care at the end of life and a holistic approach is important in order to enable patients to articulate complex and changing notions of hope that at times are silenced within families, and for patients to feel confident in discussing the possible role of religious beliefs in shaping personal notions of hope.

'If you feel that nobody wants you you'll withdraw into your own': Gypsies/Travellers, networks and healthcare utilisation

Gypsies and Travellers are the unhealthiest group in British society, suffering from higher levels of physical and mental illness, lower life expectancy and with low levels of healthcare utilisation. They also continue to experience the highest level of prejudice and discrimination in society. While studies indicate that social networks play an important role in shaping health beliefs and the response to symptoms, evidence on the influence of networks on health is unclear and contradictory. This article draws on social network theory and research into the relation between discrimination and health to critically examine how networks mediate between collective experiences of racism and health-related behavior. Qualitative interviews with 39 adult Gypsies and Travellers were conducted in the South-East of England to explore the wider structural and institutional context and the influence those contexts play in shaping health beliefs and decisions whether to access formal health services. The findings indicate that the influence networks play in shaping health behaviour is dependent on the particular social context of the group and its status in relation to wider social structures, making generalization problematic.

The effect of post-natal mental distress amongst Indian and Pakistani mothers living in England on children's behavioural outcomes

BACKGROUND

Low socio-economic status (SES), post-natal mental distress and parenting impact child mental health and future well-being. There are unexplained differences in child mental health between South Asian ethnic minority groups living in the UK that may be due to variation in, and differential mediation of, these factors.

METHODS

We used multivariate multiple regression analysis of the effect of symptoms of mental distress, socio-demographic variables and warmth of parenting on child internalizing and externalizing scores at age seven (measured in 2010) in a population cohort of English children whose mothers were of Indian (n = 211) and Pakistani (n = 260) origin.

RESULTS

In the fully adjusted models the legacy of mental distress was visible for both internalizing (β coefficient 1.52, P = 0.04) and externalizing (1.68, P = 0.01) behaviour in the Pakistani children, and on the Indian children's internalizing (2.08, P = 0.008) but not externalizing (0.84, P = 0.204) behaviour. Lower SES was associated with worse behavioural scores for the Pakistani children, and warmth of parenting on Indian children's externalizing scores.

CONCLUSIONS

Symptoms of post-natal mental distress are associated with Indian and Pakistani child outcomes at age seven. The finding that warmth of parenting had a stronger association on Indian children's externalizing scores than mental distress might be explained by differences in the expression of SES on family characteristics and functioning between the two ethnic groups.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

Background

Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems.

Methods

The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis.

Results

One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms.

Conclusion

General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

Examining the family-centred approach to genetic testing and counselling among UK Pakistanis: a community perspective

WHO advice suggests a family-centred approach for managing the elevated risk of recessively inherited disorders in consanguineous communities, whilst emerging policy recommends community engagement as an integral component of genetic service development. This paper explores the feasibility of the family-centred approach in the UK Pakistani origin community. The study took place within a context of debate in the media, professional and lay circles about cousin marriage causing disability in children. Using qualitative methods, a total of six single-sex focus group discussions (n = 50) were conducted in three UK cities with a high settlement of people of Pakistani origin. Tape-recorded transcripts were analysed using framework analysis. Kinship networks within Pakistani origin communities are being sustained and marriage between close blood relatives continues to take place alongside other marriage options. Study participants were critical of what was perceived as a prevalent notion that cousin marriage causes disability in children. They were willing to discuss cousin marriage and disability, share genetic information and engage with genetic issues. A desire for accurate information and a public informed about genetic issues was articulated whilst ineffective communication of genetic risk information undermined professionals in their support role. This study suggests a community that is embracing change, one in which kinship networks are still active and genetic information exchange is taking place. At the community level, these are conditions supportive of the family-centred approach to genetic testing and counselling.

Ethnic minority women's experience of maternity services in England

OBJECTIVES

Provision for ethnic minority groups has been acknowledged as integral to good maternity care in England and ethnicity has been highlighted as an indicator of both poorer clinical outcomes and poorer experiences. Improving outcomes and services is dependent on understanding women's interaction with both service delivery and provision. The aim of this study was to explore Black and minority ethnic (BME) women's experiences of contemporary maternity care in England.

DESIGN

A UK-wide survey which investigated core aspects of maternity care sought the views of BME women about their experiences. A random sample of women were selected by the Office for National Statistics from birth registration in England and invited to complete a questionnaire three months after the birth. In a secondary analysis, text responses to open-ended questions about their maternity care were analysed using thematic analysis.

RESULTS

Sixty per cent of the 368 women who self-identified as BME responded with open text. Themes that emerged related to 'feeling cared for,' with subthemes of 'expectations of care' and 'policies, rules and organisational pressures'; 'staff attitudes and communication' with sub-themes of 'please believe me,' 'hospital as a safe place,' 'choices denied' and 'being sensitive and supportive would help,' and 'ethnicity and culture' with sub-themes of 'stereotyping' and 'improving the quality of care.'

CONCLUSION

The findings highlight issues affecting the quality of maternity care that BME women in England receive. Many issues are not unique to BME women; however, the findings reflect some seemingly enduring issues and coherence with other wider international findings, particularly in relation to post-natal care and staff attitudes. Actually being cared for and supported across their child-bearing experience are needs that women themselves identified as critical for care providers to recognise and respond to. The failures of care provision described should inform the development of services.

Does cultural context make a difference to women's experiences of maternity care? A qualitative study comparing the perspectives of breast-feeding women of Bangladeshi origin and health practitioners

Background  Maternity services struggle to provide culturally appropriate care that meets the needs of women from diverse populations. Problems include simplistic understandings of ethnicity and the role of culture in women’s lives, and stereotypes held by health practitioners.

Objective  To explore the extent to which cultural context makes a difference to experiences of breast‐feeding support for women of Bangladeshi origin and to consider the implications for the provision of culturally appropriate care.

Methods  The study comprised individual interviews with 23 women of Bangladeshi origin and four health service managers, and focus group discussions with 28 health practitioners between February and December 2008. Participants were recruited from four localities in northern England.

Results  Women’s rich descriptions of various facets of their identities were in contrast to practitioners’ representations of women of Bangladeshi origin as homogenous. Practitioners did not recognize when the needs of women of Bangladeshi origin were similar to those of the majority white population, or where cultural context made a difference to their experiences of breast‐feeding and breast‐feeding support. Some practitioners used cultural stereotypes which, combined with organizational constraints, resulted in services not meeting many of the women’s needs.

Conclusions  Implications for education, policy and practice include the need for training of health practitioners to work with diverse populations, implementing evidence‐based practice and providing an organizational context which supports practitioners to respond to diversity without using cultural stereotypes.

Canadian Punjabi Sikh men's experiences of lifestyle changes following myocardial infarction: cultural connections

OBJECTIVE

To describe how culture underlies Canadian Punjabi Sikh men's experiences of adopting lifestyle changes following myocardial infarction (MI).

DESIGN

Qualitative, interpretive design. In-depth, individual interviews were conducted with 27 Canadian Punjabi Sikh men post-MI. Data were analysed using constant comparative methods.

RESULTS

Cultural influences were identified in Punjabi Sikh men's descriptions of their experience of adopting lifestyle changes. Actions related to self-care, rehabilitation and lifestyle change post-MI were embedded in collectivist family and community contexts. Three themes, derived from the data, were found to intertwine with these contexts; they related to food consumption, physical exercise and faith and religion.

CONCLUSION AND IMPLICATIONS

These findings highlight how collectivist ideals influence Canadian Punjabi Sikh men's adoption of lifestyle changes post-MI. The content and processes by which healthcare providers deliver heart health and rehabilitation to Canadian Punjabi Sikh men might be guided, at least in part, by the collectivist cultural practices underpinning our findings.

'He's the dad isn't he?' Gender, race and the politics of prenatal screening

BACKGROUND

Men's involvement in prenatal screening is becoming increasingly important. However, despite the potentially significant role of fathers in haemoglobinopathy screening, their participation is under researched. Furthermore, the portrayal of Black and minority ethnic (BME) fathers tends to be based on persisting stereotypes of men as either absentee parents with limited roles in screening or as controlling decision-makers.

OBJECTIVE

To describe the influence of ethnicity and gender on the process of participation of men in antenatal screening for sickle cell and thalassaemia.

DESIGN

A qualitative study, using in-depth interviews and focus groups with 22 pregnant women from a range of socio-economic and ethnic backgrounds, 16 male partners and 15 midwives in a northern city in the UK.

RESULTS

Men from BME groups take a pragmatic and equitable role in screening with their partners. White British men on the other hand, while willing to participate in screening, take a more casual view of their own direct participation. Accounts from hospital midwives supported these findings.

CONCLUSIONS

While acknowledging the importance of material connections between certain BME groups and blood disorders, two key issues are raised. First, BME men's involvement contribute a challenge towards existing assumptions often made about BME fathers. Second, White British men's participation can be useful in determining the genetic status of the foetus and therefore their role should not be neglected. Screening research and practice need to broaden out their focus on issues of gender, ethnicity and screening.

The construction of ethnic differences in work incapacity risks: Analysing ordering practices of physicians in the Netherlands

Drawing from Science and Technology Studies we investigate the consequences for social differentiation of physicians' practices in Dutch illness certification. Using participant observation methods, we followed six 'Arbodienst' physicians for two weeks each. Our analysis explores whether and how the work of Dutch physicians contributes to the appearance of a category of 'problematic migrant patients'. We present how physicians, in using instruments to distinguish plausible from implausible claims for sick leave, impose order upon reality. In particular situations this ordering involves a distinction between Dutch and migrant clients. Here ethnicity appears in physicians' practice as a separate instrument to constitute order, which in the case of migrants overrules the productive instruments that are used for 'Dutch' clients. By interpreting clients' behaviour in cultural terms and making them into strangers, physicians lose their ability to fine-tune their coaching activities to the needs of these clients. As a result migrants remain work incapacitated for a longer period, which leads to a higher risk of their ending up in the disability pension program. As a consequence migrants become visible as a problematic group in the data on work incapacity and disability. The practice to categorise migrant clients with separate instruments thus results in a 'hard' category of problematic migrant clients and leads to social differentiation.

Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs' experiences

BACKGROUND

Timely antenatal sickle cell and thalassaemia (SC&T) screening for all women in primary care facilitates informed decision making, but little is known about its implementation.

AIM

To assess the feasibility of offering antenatal SC&T screening in primary care at the time of pregnancy confirmation.

DESIGN OF STUDY

Cross-sectional investigation of GPs' beliefs and perceived practices.

METHOD

Informal face-to-face interviews with 34 GPs.

SETTING

Seventeen inner-city general practices that offered antenatal SC&T screening as part of a trial.

RESULTS

GPs identified both barriers and facilitators. Organisational barriers included inflexible appointment systems and lack of interpreters for women whose first language was not English. Professional barriers included concerns about raising possible adverse outcomes in the first antenatal visit. Perceived patient barriers included women's lack of awareness of SC&T. Hence, GPs presented the test to women as routine, rather than as a choice. Organisational facilitators included simple and flexible systems for offering screening in primary care, practice cohesion, and training. Professional facilitators included positive attitudes to screening for SC&T. Perceived patient facilitators included women's desire for healthy children.

CONCLUSION

GPs reported barriers, as well as facilitators, to successful implementation but the extent to which screening could be regarded as offering 'informed choice' remained fundamental when making sense of these barriers and facilitators.

Perceived discrimination, psychological distress and health

Racism and discrimination can have significant implications for health, through complex biopsychosocial interactions. Latino groups, and particularly Puerto Ricans, are an understudied population in the United States in terms of the prevalence of discrimination and its relevance to health. Participants in our study were 45- to 75-year-old (N = 1122) Puerto Ricans. The measures were perceived discrimination, depressive symptomatology (CES-D), perceived stress (PSS), self-rated health, medical conditions, blood pressure, smoking and drinking behaviours, demographics. Our findings show that 36.9 per cent of participants had at some time experienced discrimination, with men, those with more years of education, currently employed and with higher incomes being more likely to report it. Experiences of discrimination were associated with increased levels of depressive symptoms and perceived stress. When controlling for covariates, perceived discrimination was predictive of the number of medical conditions, of ever having smoked and having been a drinker, and having higher values of diastolic pressure. Depressive symptoms are a mediator of the effect of perceived discrimination on medical conditions, confirmed by the Sobel test: z = 3.57, p < 0.001. Mediating roles of perceived stress, smoking and drinking behaviours were not confirmed. Increased depressive symptoms might be the main pathway through which perceived discrimination is associated with a greater number of medical diagnoses.

A new conceptualization of ethnicity for social epidemiologic and health equity research

Although social stratification persists in the US, differentially influencing the well-being of ethnically defined groups, ethnicity concepts and their implications for health disparities remain under-examined. Ethnicity is a complex social construct that influences personal identity and group social relations. Ethnic identity, ethnic classification systems, the groupings that compose each system and the implications of assignment to one or another ethnic category are place-, time- and context-specific. In the US, racial stratification uniquely shapes expressions of and understandings about ethnicity. Ethnicity is typically invoked via the term, 'race/ethnicity'; however, it is unclear whether this heralds a shift away from racialization or merely extends flawed racial taxonomies to populations whose cultural and phenotypic diversity challenge traditional racial classification. We propose that ethnicity be conceptualized as a two-dimensional, context-specific, social construct with an attributional dimension that describes group characteristics (e.g., culture, nativity) and a relational dimension that indexes a group's location within a social hierarchy (e.g., minority vs. majority status). This new conceptualization extends prior definitions in ways that facilitate research on ethnicization, social stratification and health inequities. While federal ethnic and racial categories are useful for administrative purposes such as monitoring the inclusion of minorities in research, and traditional ethnicity concepts (e.g., culture) are useful for developing culturally appropriate interventions, our relational dimension of ethnicity is useful for studying the relationships between societal factors and health inequities. We offer this new conceptualization of ethnicity and outline next steps for employing socially meaningful measures of ethnicity in empirical research. As ethnicity is both increasingly complex and increasingly central to social life, improving its conceptualization and measurement is crucial for advancing research on ethnic health inequities.

Occupational stress among tunnel workers in Sikkim

BACKGROUND

Job stress has been linked to a wide range of adverse effects on mental, physical and organizational health.

OBJECTIVE

The objective of this study was to determine the impact of job stress on mental, physical and social health of the underground construction workers in Sikkim.

MATERIALS AND METHODS

The study population comprised of tunnel workers and a comparable group of controls. Using the interview technique, data was collected using the SF-36 General Health Survey Questionnaire.

RESULTS

The study population comprised of individuals of whom more than half were below 40 years of age and was comparable to the group of controls. Majority reported good health, while poor health was reported by 22 % of the subjects under study Compared to their health status last year, 52% rated their health as somewhat worse. Majority reported that their physical health problems limited them in activities of daily life, viz., running, lifting heavy objects, participation in strenuous sports, climbing several flights of stairs, bending, stooping or kneeling and walking more than a mile, during the past four weeks. More than half of them had severe body ache in the past four weeks that interfered with both work outside home and housework. This was true for emotional problems also, which interfered with their normal social activities involving family, friends, neighbors or groups. The associations of occupational stress with physical, emotional and social life and with limitation of day-to-day activities among tunnel workers were found to be statistically significant.

CONCLUSION

The results emphasize the importance of assessment of the effects of job stress and of fulfilling the need of underground workers for optimum preventive measures.

'Race' or place? Explaining ethnic variations in childhood pedestrian injury rates in London

There is a substantial literature on socio-economic inequalities in injury rates, but less on ethnic differences. Using police records of road injuries to examine the relationships between pedestrian injury, area deprivation and ethnicity we found that, in London, children categorised as 'Black' had higher injury rates than those categorised as 'White' or 'Asian', and that living in less deprived areas did not protect 'Black' children from higher risk. Ethnic differences in injury rates cannot be explained by minority ethnic status or area deprivation, but are likely to result from the complex ways in which ethnicity shapes local experiences of exposure to injury risk.

Objective and perceived ethnic density and health: findings from a United Kingdom general population survey

Studies indicate an ethnic density effect, whereby an increasing proportion of persons of the same ethnicity as oneself (co-ethnics) in one's area of residence is associated with reduced risk of morbidity among ethnic minorities, though evidence is mixed. Measures of ethnic density are commonly taken from small-area census data using predefined categories of ethnicity. In a United Kingdom study, the authors compared these measures with perceived ethnic density, based on self-reported proportion of co-ethnics in the area. Using 2005 Home Office Citizenship Survey data linked to the 2001 United Kingdom Census, they found moderate-sized correlations between perceived and measured ethnic density which varied across ethnic groups (r = 0.34-0.65). Perceived ethnic density underestimated measured levels for whites and overestimated measured levels for ethnic minorities. Compared with participants in areas where less than half of residents were co-ethnics, those reporting a perceived ethnic density of more than half tended to have less limiting long-term illness (for all ethnic minorities combined, odds ratio = 0.81, 95% confidence interval: 0.63, 1.04) after adjustment for age, sex, socioeconomic position, ethnicity, area deprivation, and measured ethnic density. After adjustment for perceived ethnic density, there was no evidence of a protective association for measured ethnic density, except for Caribbeans. Perceived ethnic density may reflect individual experiences of frequency and intensity of contact with co-ethnics, which may explain why it was more consistently related to lower morbidity risk.

Racialized identity and health in Canada: results from a nationally representative survey

This article uses survey data to investigate health effects of racialization in Canada. The operative sample was comprised of 91,123 Canadians aged 25 and older who completed the 2003 Canadian Community Health Survey. A "racial and cultural background" survey question contributed a variable that differentiated respondents who identified with Aboriginal, Black, Chinese, Filipino, Latin American, South Asian, White, or jointly Aboriginal and White racial/cultural backgrounds. Indicators of diabetes, hypertension and self-rated health were used to assess health. The healthy immigrant effect suppressed some disparity in risk for diabetes by racial/cultural identification. In logistic regression models also containing gender, age, and immigrant status, no racial/cultural identifications corresponded with significantly better health outcomes than those reported by survey respondents identifying as White. Subsequent models indicated that residential locale did little to explain the associations between racial/cultural background and health and that socioeconomic status was only implicated in relatively poor health outcomes for respondents identifying as Aboriginal or Aboriginal/White. Sizable and statistically significant relative risks for poor health for respondents identifying as Aboriginal, Aboriginal/White, Black, Chinese, or South Asian remained unexplained by the models, suggesting that other explanations for health disparities by racialized identity in Canada - perhaps pertaining to experiences with institutional racism and/or the wear and tear of experiences of racism and discrimination in everyday life - also deserve empirical investigation in this context.

`Automatically you become a polygamist': `culture' and `norms' as resources for normalization and managing accountability in talk about responses to infertility

In the developing world, infertility is a serious problem. It leads to both psychological and social hardship, in part because childless marriages often result in divorce, men taking another wife or extramarital relationships. Such responses have been attributed to cultural norms that mandate procreation. However, there are theoretical, methodological and moral issues with treating cultural norms as behavioural determinants. They have been insufficiently acknowledged in health research. Therefore, I demonstrate an alternative discursive approach, which examines how people actively mobilize `culture' or `norms' in interactions, and the interpersonal functions thereby fulfilled (e.g. blaming or justifying). Analysis is presented of interviews on (responses to) infertility in Malawi. I show how respondents construct polygamy and extramarital affairs as culturally and normatively required, `automatic' and normal solutions for fertility problems and play down people's accountability for these practices. These accounts and constructions appear to facilitate engagement in affairs and polygamy when people face fertility problems, which seems problematic from a health and gender perspective. Thus, detailed analysis of how people use `culture' and `norms' in situ is important because it provides insights into its potentially undesirable consequences. Moreover, such analysis provides a starting point for culturally and gender sensitive interventions, since it highlights people's agency, and creates a space to re-construct and change practices.