Ethnic inequalities in multiple long-term health conditions in the United Kingdom: a systematic review and narrative synthesis

Prevalence and patterns of testing for anaemia in primary care in England: a cohort study using an electronic health records database

BACKGROUND

Despite epidemiological data on anaemia being available on a global scale, the prevalence of anaemia in the UK is not well described.

AIM

To describe anaemia prevalence and testing patterns for haemoglobin and other blood parameters.

DESIGN AND SETTING

This study was a descriptive population-based cohort study using data drawn from the Clinical Practice Research Datalink Aurum database in 2019.

METHOD

Demographic data were extracted for each person who was registered at their current practice during 2019, including linked data on Index of Multiple Deprivation. Anaemia prevalence in 2019 was calculated based on World Health Organization-specified age and gender thresholds for haemoglobin. Anaemia was classified based on mean corpuscular volume and ferritin. People with anaemia were followed up for up to 1 year to investigate longitudinal testing patterns for haemoglobin.

RESULTS

The cohort contained 14 million people. Anaemia prevalence in England in 2019 was 4.1% (583 847/14 207 841) (5.1% [363 438/7 121 614] females and 3.1% [220 409/7 086 227] males). Prevalence was higher in people aged >65 years, people of Black and Asian ethnicities, and people living in areas with higher social deprivation. Only half of people with anaemia and a mean corpuscular volume of ≤100 fL had an accompanying ferritin value recorded. About half of people with anaemia had a follow-up haemoglobin test within 1 year, most of which still indicated anaemia.

CONCLUSION

Anaemia is prevalent in the UK with large disparities between levels of demographic variables. Investigation and follow-up of anaemia is suboptimal in many patients. Health interventions aimed at improving anaemia investigation and treatment are needed, particularly in the most at-risk groups.

Clusters and associations of adverse neonatal events with adult risk of multimorbidity: A secondary analysis of birth cohort data

OBJECTIVE

To investigate associations between clustered adverse neonatal events and later-life multimorbidity.

DESIGN

Secondary analysis of birth cohort data.

SETTING

Prospective birth cohort study of individuals born in Britain in one week of 1970.

POPULATION

Respondents provided data at birth (n = 17,196), age 34 (n = 11,261), age 38 (n = 9,665), age 42 (n = 9,840), and age 46 (n = 8,580).

METHODS

Mixed components analysis determined included factors, 'Birthweight'; 'Neonatal cyanosis'; 'Neonatal cerebral signs'; 'Neonatal illnesses'; 'Neonatal breathing difficulties'; and 'Prolonged duration to establishment of respiratory rate at birth', within the composite adverse neonatal event score. Log-binomial regression quantified the unadjusted and covariate-adjusted (paternal employment status and social class; maternal smoking status; maternal age; parity; cohort member smoking status and Body Mass Index) associations between the adverse neonatal event score and risk of multimorbidity in adulthood.

OUTCOME MEASURES

Multimorbidity at each adult data sweep, defined as the presence of two or more Long-Term Conditions (LTCs).

RESULTS

13.7% of respondents experienced one or more adverse neonatal event(s) at birth. The percentage reporting multimorbidity increased steadily from 14.6% at age 34 to 25.5% at age 46. A significant association was only observed at the 38 years sweep; those who had experienced two or more adverse neonatal events had a 41.0% (95% CI: 1.05 - 1.88) increased risk of multimorbidity, compared to those who had not suffered any adverse neonatal events at birth. This association was maintained following adjustment for parental confounders and adult smoking status.

CONCLUSIONS

Adverse neonatal events at birth may be independently associated with the development of midlife multimorbidity. Programmes and policies aimed at tackling the growing public health burden of multimorbidity may also need to consider interventions to reduce adverse neonatal events at birth.

Identifying predictors for food insecurity in England: a cross-sectional database analysis

BACKGROUND

Nutrition plays a significant role in non-communicable disease worldwide and is a modifiable risk factor. Food security is defined as the ability of a household or individual to afford and access sufficient healthy and nutritious food. Food insecurity rates in the UK are among the worst in Europe and rising food prices have disproportionately affected lower income households. We aimed to identify predictors for food insecurity in England using nationally representative data.

METHODS

We conducted a database analysis on data collected in the 'Food and You 2: Wave 6' public cross-sectional dataset. Data were analysed from a mixed survey, collating 3,033 responses to the United Stated Department of Agriculture Household Food Security Survey Module, which defined food security status. We calculated risk ratios (RR) for food insecurity in relation to each independent variable, including sex, respondent age group, household size, presence of children in household, income, employment status, urban/rural living status, ethnicity, chronic conditions and Index of Multiple Deprivation (IMD).

RESULTS

72.3% (n = 2,194) were food secure, 23.4% (n = 710) were food-insecure. Variables associated with increased food insecurity risk included all respondent age groups below 65 year old, household size of 5 or more, presence of children under 16 years and under 6 years, household income less than £64,000 per annum, unemployed individuals, students, Asian / Asian British and African / African British ethnicities, presence of one or more chronic conditions and IMD of 1.

CONCLUSIONS

In this analysis of nationally representative data, age, household size, presence of children, income, employment status, ethnicity and IMD were all associated with significantly increased risk for food insecurity. Further work is required to understand the relationship between these variables and food security in order to develop screening tools to identify those at highest risk of food insecurity in the population. This will help facilitate the effective provision of support to those who need it the most.

Chatbot -assisted self-assessment (CASA): Co-designing an AI -powered behaviour change intervention for ethnic minorities

BACKGROUND

The digitalisation of healthcare has provided new ways to address disparities in sexual health outcomes that particularly affect ethnic and sexual minorities. Conversational artificial intelligence (AI) chatbots can provide personalised health education and refer users for appropriate medical consultations. We aimed to explore design principles of a chatbot-assisted culturally sensitive self-assessment intervention based on the disclosure of health-related information.

METHODS

In 2022, an online survey was conducted among an ethnically diverse UK sample (N = 1,287) to identify the level and type of health-related information disclosure to sexual health chatbots, and reactions to chatbots' risk appraisal. Follow-up interviews (N = 41) further explored perceptions of chatbot-led health assessment to identify aspects related to acceptability and utilisation. Datasets were analysed using one-way ANOVAs, linear regression, and thematic analysis.

RESULTS

Participants had neutral-to-positive attitudes towards chatbots and were comfortable disclosing demographic and sensitive health information. Chatbot awareness, previous experience and positive attitudes towards chatbots predicted information disclosure. Qualitatively, four main themes were identified: "Chatbot as an artificial health advisor", "Disclosing information to a chatbot", "Ways to facilitate trust and disclosure", and "Acting on self-assessment".

CONCLUSION

Chatbots were acceptable for health self-assessment among this sample of ethnically diverse individuals. Most users reported being comfortable disclosing sensitive and personal information, but user anonymity is key to engagement with chatbots. As this technology becomes more advanced and widely available, chatbots could potentially become supplementary tools for health education and screening eligibility assessment. Future research is needed to establish their impact on screening uptake and access to health services among minoritised communities.

Comparison of mortality in people with type 2 diabetes between different ethnic groups: Systematic review and meta-analysis of longitudinal studies

AIMS

Type 2 diabetes (T2D) is more common in certain ethnic groups. This systematic review compares mortality risk between people with T2D from different ethnic groups and includes recent larger studies.

METHODS

We searched nine databases using PRISMA guidelines (PROSPERO CRD42022372542). We included community-based prospective studies among adults with T2D from at least two different ethnicities. Two independent reviewers undertook screening, data extraction and quality assessment using the Newcastle-Ottawa Scale. The primary outcome compared all-cause mortality rates between ethnic groups (hazard ratio (HR) with 95% confidence intervals).

RESULTS

From 30,825 searched records, we included 13 studies (7 meta-analysed), incorporating 573,173 T2D participants; 12 were good quality. Mortality risk was lower amongst people with T2D from South Asian [HR 0.68 (0.65-0.72)], Black [HR 0.82 (0.77-0.87)] and Chinese [HR 0.57 (0.46-0.70)] ethnicity compared to people of White ethnicity. Narrative synthesis corroborated these findings but demonstrated that people of indigenous Māori ethnicity had greater mortality risk compared to European ethnicity.

CONCLUSIONS

People with T2D of South Asian, Black and Chinese ethnicity have lower all-cause mortality risk than White ethnicity, with Māori ethnicity having higher mortality risk. Factors explaining mortality differences require further study, including understanding complication risk by ethnicity, to improve diabetes outcomes.

Paper 1: introduction to the series

OBJECTIVES

Systematic reviews hold immense promise as tools to highlight evidence-based practices that can reduce or aim to eliminate racial health disparities. Currently, consensus on centering racial health equity in systematic reviews and other evidence synthesis products is lacking. Centering racial health equity implies concentrating or focusing attention on health equity in ways that bring attention to the perspectives or needs of groups that are typically marginalized.

STUDY DESIGN AND SETTING

This Cochrane US Network team and colleagues, with the guidance of a steering committee, sought to understand the views of varied interest holders through semistructured interviews and conducted evidence syntheses addressing (1) definitions of racial health equity, (2) logic models and frameworks to centering racial health equity, (3) interventions to reduce racial health inequities, and (4) interest holder engagement in evidence syntheses. Our methods and teams include a primarily American and Canadian lens; however, findings and insights derived from this work are applicable to any region in which racial or ethnic discrimination and disparities in care due to structural causes exist.

RESULTS

In this series, we explain why centering racial health equity matters and what gaps exist and may need to be prioritized. The interviews and systematic reviews identified numerous gaps to address racial health equity that require changes not merely to evidence synthesis practices but also to the underlying evidence ecosystem. These changes include increasing representation, establishing foundational guidance (on definitions and causal mechanisms and models, building a substantive evidence base on racial health equity, strengthening methods guidance, disseminating and implementing results, and sustaining new practices).

CONCLUSION

Centering racial health equity requires consensus on the part of key interest holders. As part of the next steps in building consensus, the manifold gaps identified by this series of papers need to be prioritized. Given the resource constraints, changes in norms around systematic reviews are most likely to occur when evidence-based standards for success are clearly established and the benefits of centering racial health equity are apparent.

PLAIN LANGUAGE SUMMARY

Racial categories are not based on biology, but racism has negative biological effects. People from racial or ethnic minority groups have often been left out of research and ignored in systematic reviews. Systematic reviews often help clinicians and policymakers with evidence-based decisions. Centering racial health equity in systematic reviews will help clinicians and policymakers to improve outcomes for people from racial or ethnic minority groups. We conducted interviews and a series of four systematic reviews on definitions, logic models and frameworks, methods, interventions, and interest-holder engagement in syntheses. We found that much work remains to be done in centering racial health equity in systematic reviews. Specifically, systematic reviewers need to change who is represented on their teams, establish foundational guidance (on definitions and causal mechanisms and models, identify what interventions work to address racial health equity, strengthen method guidance, disseminate and implement results, and sustain new practices).

Ethnic inequalities in primary care experiences for people with multiple long-term conditions: Evidence from the general practice patient survey

OBJECTIVES

To examine the relationship between ethnicity and experiences of primary care for people with multiple long-term conditions (MLTCs) and assess the relative importance of demographic, practice, and area-level factors as influences on primary care experiences across ethnic groups.

STUDY DESIGN

A retrospective study using 2018-19 GP Patient Survey data linked to General Practice Workforce data and small area data published by the Office for National Statistics.

METHODS

We conducted multilevel regression analysis to assess the relationship between ethnicity and experience of accessing primary care and interacting with healthcare professionals. We built separate regression models for each outcome and included (i) each covariate separately, (ii) demographic factors and (iii) demographic, practice, and area-level factors.

RESULTS

Upon full adjustment Arab, Bangladeshi, Chinese, Indian, Pakistani, other Asian, mixed white and Asian, and other white people with MLTCs have lower levels of satisfaction with primary care access and interacting with healthcare professionals compared with white British people. The influence of demographic, practice and area-level factors is not uniform across ethnic groups; demographic factors account for the inequalities in levels of satisfaction with access to primary care between white British people and Black other, mixed other, mixed white & Black Caribbean and Gypsy & Irish Travellers. However, practice and area-level factors strengthen inequalities in the experience of accessing primary care for Bangladeshi, Indian and Pakistani people.

CONCLUSIONS

Given the link between patient satisfaction and patient-related health outcomes, the lower levels of satisfaction with accessing primary care and interacting with healthcare professionals among the aforementioned minoritised ethnic groups are concerning and require further scrutiny. Qualitative studies are required to understand and address the sources of poor experiences in primary care for minoritised people with MLTCs to improve patient-centred healthcare and outcomes.

Physical activity and sedentary behaviour interventions for people living with both frailty and multiple long-term conditions and their informal carers: a scoping review and stakeholder consultation

INTRODUCTION

This scoping review mapped evidence on physical activity (including structured exercise) and sedentary behaviour interventions (interventions to reduce sedentary behaviour) in people living with both frailty and multiple long-term conditions (MLTCs) and their informal carers.

METHODS

Ten databases and grey literature were searched from 2000 to October 2023. Two reviewers screened studies and one extracted data. Results were shared with three stakeholder groups (n = 21) in a consultation phase.

RESULTS

After screening, 155 papers from 144 studies (1 ongoing) were retained. The majority were randomised controlled trials (86, 55%). Participants' mean age was 73 ± 12 years, and 73% were of White ethnicity. MLTC and frailty measurement varied widely. Most participants were pre-to-moderately frail. Physical health conditions predominated over mental health conditions.Interventions focused on structured exercise (83 studies, 60%) or combined interventions (55 studies, 39%). Two (1%) and one (0.7%) focused solely on habitual physical activity or sedentary behaviour. Adherence was 81% (interquartile range 62%-89%) with goal setting, monitoring and support important to adherence. Carers were only involved in 15 (11%) studies. Most interventions reported positive outcomes, primarily focusing on body functions and structures.

CONCLUSIONS

A modest volume of evidence exists on multicomponent structured exercise interventions, with less focus on habitual physical activity and sedentary behaviour. Interventions report largely positive effects, but an updated systematic review is required. The field could be advanced by more rigorous characterisation of MLTCs, socioeconomic status and ethnicity, increased informal carer involvement and further evaluation of habitual physical activity and sedentary behaviour interventions.

Connected Food: First Steps for an Ambitious National Food Strategy

Background: The global food system faces growing pressure from population growth, climate change, wealth inequity, geo-political instability, and damage to the ecosystems on which our food supply depends. Fragmentation of the priorities and needs of food system stakeholders-citizens, food producers, food industries, governments-compounds the problem, with competing or misaligned interests increasing the risk of failure to adequately meet the needs of those that form, and are served, by the food system. Growing consensus on the need for transformative system level change to address the problems facing the food system is yet to be significantly reflected in strategic action. Methods: The national food strategy of the UK is offered as an exemplar to discuss the need to promote more coherent and ambitious visions of transformative change that acknowledge the complexity of the food system as a whole. We draw upon cross-sectoral experience to distil the needs, priorities, and key food system tensions that must be acknowledged to promote transformative systems change that equitably delivers healthy sustainable diets, contributes to a resilient global food system, and protects the environment. Results: Greater coherence, ambition, and consideration of the food system as a whole are needed if a UK national food strategy is to contribute to significant transformative change. Conclusions: To promote this, we advocate for (1) a food system digital twin to model and test potential food system interventions or legislation; (2) a citizens' forum to inform and co-develop a cohesive national food strategy; and (3) increased cohesion and integration of food system governance within government to drive a coherent, ambitious national food strategy.

Building a healthy generation together: parents' experiences and perceived meanings of a family-based program delivered in ethnically diverse neighborhoods in Sweden

INTRODUCTION AND AIM

Ethnically diverse neighborhoods encounter pronounced inequalities, including housing segregation and limited access to safe outdoor spaces. Residents of these neighborhoods face challenges related to physical inactivity, including sedentary lifestyles and obesity in adults and children. One approach to tackling health inequalities is through family-based programs tailored specifically to these neighborhoods. This study aimed to investigate parents' experiences and perceptions of the family-based Open Activities, a cost-free and drop-in program offered in ethnically diverse and low socioeconomic neighborhoods in Sweden.

METHODS

Researchers' engagement in 15 sessions of the Open Activities family-based program during the spring of 2022, and individual interviews with 12 participants were held. Data were analyzed using reflexive thematic analysis.

RESULTS

The analysis resulted in three main themes and seven sub-themes representing different aspects of the program's meaning to the participants as parents, their families, and communities. The main themes describe how parents feel valued by the program, which actively welcomes and accommodates families, regardless of cultural differences within these neighborhoods. The themes also show how cultural norms perceived as barriers to participation in physical activity can be overcome, especially by mothers who express a desire to break these norms and support girls' physical activity. Additionally, the themes highlight the importance of parents fostering safety in the area and creating a positive social network for their children to help them resist criminal gang-related influences.

CONCLUSIONS

The program's activities allowed parents to connect with their children and other families in their community, and (re)discover physical activity by promoting a sense of community and safety. Implications for practice include developing culturally sensitive activities that are accessible to and take place in public spaces for ethnically diverse groups, including health coordinators that can facilitate communication between groups. To enhance the impact of this program, it is recommended that the public sector support the creation of cost-free and drop-in activities for families who are difficult to reach in order to increase their participation in physical activity, outreach, and safety initiatives.

Social determinants of health and long-term conditions in people of Black African and Black Caribbean ethnicity living with HIV in London: A qualitative study

BACKGROUND

People living with human immunodeficiency virus (HIV) are disproportionately impacted by socioeconomic deprivation and are at increased risk of developing other long-term conditions (LTCs). These illnesses require transformative action to tackle the adverse effects on their health. Data on lived experiences of LTCs among people living with HIV of Black African and Black Caribbean ethnicities are sparse, and how people with LTCs are impacted by social determinants of health (SDoH).

METHODS

Through a phenomenological study design this qualitative study, conducted in 2022, comprised four focus group discussions (FGDs) with 20 people of Black ethnicities living with HIV were purposively invited from a community organisation (CO) in London, including four semistructured interviews with CO staff. Following transcription, qualitative data were analysed thematically and measures to validate the findings were implemented.

RESULTS

The findings are presented in terms of the following four levels of SDoH: (1) individual determinants (such as the impact of SDoH on lifestyle modification and self-management); (2) interpersonal determinants (such as positive experiences of accessing healthcare for LTCs); (3) clinical determinants (such as care pathway barriers) and (4) systemic determinants (such as systemic barriers related to race/ethnicity).

CONCLUSIONS

It is necessary to provide ongoing and interactive education to community members who live with HIV, focusing on risks and management of LTCs. Additionally, individuals would benefit from support to navigate increasingly complex and fragmented health services. Health Service staff require cultural competence when caring for patients of Black African and Black Caribbean ethnicities with complex health and psychosocial needs.

PATIENT OR PUBLIC CONTRIBUTION

The research team collaborated with an HIV CO in South London from the very start of the project to agree the study design and learn about the realities of their daily lived experiences. Community collaborators helped to develop the semistructured interview and FGD topic guides, and were directly involved in the data gathering, analysis and validation.

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.

Service innovations for people with multiple long-term conditions: reflections of a rapid evaluation team

Background

People living with multiple long-term conditions represent a significant concern for National Health Service policy and practice, and their care is a major theme in the 2019 National Health Service Long Term Plan. The Birmingham RAND and Cambridge Rapid Evaluation Centre team has undertaken a thematic synthesis of the 10 evaluations it has conducted from 2018 to 2023, exploring the needs, priorities and implications for people with multiple long-term conditions.

Objectives

The aims for this overarching study were to: (1) build a body of learning about service innovations in primary and community settings for people of all ages with multiple long-term conditions, focused on questions that matter most to people with multimorbidity; and (2) develop methodological insights about how rapid evaluation can be used to inform the scoping, testing and implementation of service innovations for people with multiple long-term conditions.

Design

The focus on multiple long-term conditions came from a Birmingham RAND and Cambridge Rapid Evaluation Centre prioritisation process undertaken in 2018 using James Lind Alliance methods. Cross-analysis of the findings from the 10 individual rapid evaluations was supplemented by (1) building aspects of multimorbidity into the design of later evaluations; (2) interviewing national and regional stakeholders (n=19) working in or alongside integrated care systems; (3) undertaking a rapid review of evidence on remote monitoring for people with multiple long-term conditions (19 papers included); and (4) testing overall insights with organisations representing patients and carers through a patient, public and professional engagement workshop with 10 participants plus members of the research team.

Results

While living with multiple long-term conditions is common and is the norm for people over the age of 50 using health and care services, it is not often a focus of health service provision or innovation, nor of research and evaluation activity. We discuss six themes emerging from the totality of the study: (1) our health system is mainly organised around single conditions and not multiple long-term conditions; (2) research calls and studies usually focus on single conditions and associated services; (3) building opportunities for engaged, informed individuals and carers and improved self-management; (4) the importance of measures that matter for patients and carers; (5) barriers to developing and implementing service innovations for people with multiple long-term conditions; and (6) what is needed to make patients with multiple long-term conditions a priority in healthcare planning and delivery.

Limitations

Care of people with multiple long-term conditions was not the principal focus of several of the rapid evaluations. While this was a finding in itself, it limited our learning about designing and implementing, as well as methodological approaches to evaluating, service innovations for people with multiple long-term conditions.

Conclusions

Through a thematic analysis of the portfolio of evaluations, we have deduced a set of suggested implications for how the needs of people with multiple long-term conditions can be better embedded in policy, research and practice.

Future work

Areas of uncertainty related to the care of people with multiple long-term conditions should be further explored, including developing and testing measures of patient experience of (un)co-ordinated care across settings, and interrogating the experience of health and care staff when working with people with multiple long-term conditions, to understand what works.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR134284) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 15. See the NIHR Funding and Awards website for further award information.

GIS-Based Assessments of Neighborhood Food Environments and Chronic Conditions: An Overview of Methodologies

The industrial revolution and urbanization fundamentally restructured populations' living circumstances, often with poor impacts on health. As an example, unhealthy food establishments may concentrate in some neighborhoods and, mediated by social and commercial drivers, increase local health risks. To understand the connections between neighborhood food environments and public health, researchers often use geographic information systems (GIS) and spatial statistics to analyze place-based evidence, but such tools require careful application and interpretation. In this article, we summarize the factors shaping neighborhood health in relation to local food environments and outline the use of GIS methodologies to assess associations between the two. We provide an overview of available data sources, analytical approaches, and their strengths and weaknesses. We postulate next steps in GIS integration with forecasting, prediction, and simulation measures to frame implications for local health policies.

How is ethnicity reported, described, and analysed in health research in the UK? A bibliographical review and focus group discussions with young refugees

BACKGROUND

The ethnicity data gap pertains to 3 major challenges to address ethnic health inequality: 1) Under-representation of ethnic minorities in research; 2) Poor data quality on ethnicity; 3) Ethnicity data not being meaningfully analysed. These challenges are especially relevant for research involving under-served migrant populations in the UK. We aimed to review how ethnicity is captured, reported, analysed and theorised within policy-relevant research on ethnic health inequities.

METHODS

We reviewed a selection of the 1% most highly cited population health papers that reported UK data on ethnicity, and extracted how ethnicity was recorded and analysed in relation to health outcomes. We focused on how ethnicity was obtained (i.e. self reported or not), how ethnic groups were categorised, whether justification was provided for any categorisation, and how ethnicity was theorised to be related to health. We held three 1-h-long guided focus groups with 10 young people from Nigeria, Turkistan, Syria, Yemen and Iran. This engagement helped us shape and interpret our findings, and reflect on. 1) How should ethnicity be asked inclusively, and better recorded? 2) Does self-defined ethnicity change over time or context? If so, why?

RESULTS

Of the 44 included papers, most (19; 43%) used self-reported ethnicity, categorised in a variety of ways. Of the 27 papers that aggregated ethnicity, 13 (48%) provided justification. Only 8 of 33 papers explicitly theorised how ethnicity related to health. The focus groups agreed that 1) Ethnicity should not be prescribed by others; individuals could be asked to describe their ethnicity in free-text which researchers could synthesise to extract relevant dimensions of ethnicity for their research; 2) Ethnicity changes over time and context according to personal experience, social pressure, and nationality change; 3) Migrants and non-migrants' lived experience of ethnicity is not fully inter-changeable, even if they share the same ethnic category.

CONCLUSIONS

Ethnicity is a multi-dimensional construct, but this is not currently reflected in UK health research studies, where ethnicity is often aggregated and analysed without justification. Researchers should communicate clearly how ethnicity is operationalised for their study, with appropriate justification for clustering and analysis that is meaningfully theorised. We can only start to tackle ethnic health inequity by treating ethnicity as rigorously as any other variables in our research.