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Black and Minority Ethnic Groups C:/Postscript/04_HCNA3_D4.3d – 10/1/7 – 8:42 [This page: 227] 4 Black and Minority Ethnic Groups Paramjit S Gill, Joe Kai, Raj S Bhopal and Sarah Wild 1 Summary Statement of the problem/introduction This chapter provides an overview of needs assessment for the Black and Minority Ethnic Groups (BMEGs). These groups are so diverse in terms of migration history, culture, language, religion and disease profiles that in this chapter we emphasise general issues pertinent to commissioning services. This is not a systematic review of literature on all diseases affecting BMEGs –the reader is referred to other chapters in this needs assessment series for details on specific disorders. A number of general points are first provided as background to the chapter. (a) As everyone belongs to an ethnic group (including the ‘white’ population), we have restricted our discussions to the non-white ethnic groups as defined by the 1991 census question. In addition, we do not cover needs of refugees and asylum seekers, whose number is growing within the UK. (b) Principles of data interpretation are given to highlight important problems such as the interpretation of relative and absolute risk –the relative approach guides research, while the absolute approach guides commissioning. (c) In the past, data on minority groups has been presented to highlight differences rather than similarities. The ethnocentric approach, where the ‘white’ group is used as the ideal, and partial analyses are made of a limited number of disorders, has led to misinterpretation of priorities. BMEGs have similar patterns of disease and overall health to the ethnic majority. There are a few conditions for which minority groups have particular health needs, such as the haemoglobinopathies. (d) The majority of the research on health status and access and utilisation of health services has been skewed towards the South Asian and Afro-Caribbean populations, with little written on the other minority ethnic groups. (e) There is an assumption that BMEGs’ health is worse than the general population, and this is not always the case. (f) The evidence base on many issues related to minority health is small and needs to be improved. The historical and current migration patterns are important to local commissioning of services. Migration of communities from minority ethnic groups has been substantial during the latter half of the twentieth century, particularly from British Commonwealth countries such as Jamaica and India. C:/Postscript/04_HCNA3_D4.3d – 10/1/7 – 8:42 [This page: 228] 228 Black and Minority Ethnic Groups Problems of defining ethnicity, ‘race’ and culture are outlined, as they are complex concepts. Ethnicity is multi-dimensional and usually encompasses one or more of the following: ‘shared origins or social background; shared culture and traditions that are distinctive, and maintained between generations, and lead to a sense of identity in groups; and a common language or religious tradition.’ It is also used as a synonym for ‘race’ to distinguish people with common ancestral origins. Indeed, ‘race’ has no scientific value and is a discredited biological term, but it remains an important political and psychological concept. Culture is briefly defined. An individual’s cultural background has a profound influence on their health and healthcare, but it is only one of a number of influences on health –social, political, historical and economic, to name but a few. Ethnic group has been measured by skin colour, country of birth, name analysis, family origin and as self-identified on the census question on ethnic group. All these methods are problematic, but it is accepted that the self-determined census question on ethnic group overcomes a number of conceptual limitations. For local ethnic monitoring, it is good practice to collect a range of information such as religion and languages spoken. There is a marked variation in quality of ethnic minority data collection and caution is advised in interpreting such data. Further training of staff is needed, together with mandatory ethnic coding clauses within the health service contracts. Sub-categories As BMEGs are not a homogeneous group, it is not easy to categorise them using standard format as in other chapters. For pragmatic reasons, we have used the following categories in this chapter: Indian Pakistani Bangladeshi Afro-Caribbean Chinese White. Black and minority ethnic communities comprised, in 1991, 5.5% of the population of England and have a much younger age structure than the white group. It is important to note that almost half of the non-white group was born in the UK, which has important implications for future planning of services. BMEGs are also represented in all districts of Great Britain, with clustering in urban areas. Prevalence and incidence This section emphasises the importance of interpreting data on ethnic minority groups with care. One of the major issues is the comparison of health data of minority ethnic groups with those of the ethnic majority (i.e. ‘the white population’). This ethnocentric approach can be misleading by concentrating on specific issues and diverting attention from the more common causes of morbidity and mortality. For example, while there may be some differences between ethnic groups in England, cardiovascular, neoplastic and respiratory diseases are the major fatal diseases for all ethnic groups. Even in the absence of specific local data, this principle is likely to hold. C:/Postscript/04_HCNA3_D4.3d – 10/1/7 – 8:42 [This page: 229] Black and Minority Ethnic Groups 229 In this section, two approaches are combined to give the absolute and relative disease patterns. Mortality in the UK can only be analysed by country of birth, and analysis has been carried out for people born in the following countries or groups of countries: India, Pakistan, Bangladesh, China/Hong Kong/Taiwan, the Caribbean islands and West/South Africa. In addition, lifestyle and some morbidity data are provided for Indians, Pakistanis, Bangladeshis, Chinese, Afro-Caribbean and white populations. Due to the diversity and heterogeneous nature of all of the minority ethnic groups, it is not possible to give details of each specific disease by ethnic group. The top five causes of mortality (by ICD chapter) in all BMEGs are: diseases of the circulatory system (ICD 390–459) neoplasms (ICD 140–239) injury and poisoning (ICD 800–999) diseases of the respiratory system (ICD 460–519) endocrine, nutritional and metabolic diseases, and immunity disorders (ICD 240–279). Mental health and haemoglobinopathies, which are specific to a number of minority ethnic groups, are also discussed. Services available This section provides an overview of services available and their use by minority groups. It focuses upon key generic issues (such as bilingual services) and specific issues (such as the haemoglobinopathies) which are of concern to minority ethnic communities. On the whole there is no disparity in registration with general practitioner services by ethnic group except that non-registration seems to be higher amongst the African-Caribbean men. Data, from national surveys, show that –in general –minority ethnic groups (except possibly the Chinese) do not underuse either general practitioner or hospital services. After adjusting for socio-economic factors, minority ethnic respondents are equally likely to have been admitted to hospital. However, it appears that use of other community health services is lower than the general population. It is still not clear to what extent institutional racism and language and cultural barriers affect service utilisation. Even though ethnic monitoring is mandatory within the secondary sector, there still is lack of quality data for adequate interpretation. Data on cost of services for BMEGs is not available except for language provision and the haemo- globinopathies. Effectiveness of services and interventions In general, current evidence on the effectiveness and cost-effectiveness of specific services and interven- tions tailored to BMEGs is limited. As most studies have excluded individuals from the black and minority ethnic communities, there is a dearth of data on the effectiveness and cost-effectiveness in these groups. The reader is referred to other chapters for details of effectiveness and cost-effectiveness of specific services and interventions aimed at the whole population. The quality of care provided is considered generally and with reference to cardiovascular disease and the haemoglobinopathies. In addition, specific services, such as communication, health promotion and training interventions, relevant to minority groups are mentioned. C:/Postscript/04_HCNA3_D4.3d – 10/1/7 – 8:42 [This page: 230] 230 Black and Minority Ethnic Groups Models of care recommendations This section provides a generic framework for service development which includes the following points. (a) Services for BMEGs should be part of ‘mainstream’ health care provision. (b) The amended Race Relations Act should be considered in all policies. (c) Facilitating access to appropriate services by: promoting access –this will entail reviewing barriers to care and provision of appropriate information on services available providing appropriate bilingual services for effective communication education and training for health professionals and other staff appropriate and acceptable service provision provision of religious and dietary choice within meals offered in hospitals ethnic workforce issues, including addressing racial
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