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Ethnic Differences in Health in Scotland: the Contrast Between Morbidity and Mortality

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Ethnic Differences in Health in Scotland: the Contrast Between Morbidity and Mortality ETHNIC DIFFERENCES IN HEALTH IN SCOTLAND: THE CONTRAST BETWEEN MORBIDITY AND MORTALITY Genevieve Cezard A Thesis Submitted for the Degree of PhD at the University of St Andrews 2020 Full metadata for this item is available in St Andrews Research Repository at: http://research-repository.st-andrews.ac.uk/ Please use this identifier to cite or link to this item: http://hdl.handle.net/10023/19578 This item is protected by original copyright Ethnic differences in health in Scotland: The contrast between morbidity and mortality Genevieve Cezard This thesis is submitted in partial fulfilment for the degree of Doctor of Philosophy (PhD) at the University of St Andrews September 2019 DECLARATIONS Candidate's declaration I, Genevieve Cezard, do hereby certify that this thesis, submitted for the degree of PhD, which is approximately 68,200 words in length, has been written by me, and that it is the record of work carried out by me, or principally by myself in collaboration with others as acknowledged, and that it has not been submitted in any previous application for any degree. I was admitted as a research student at the University of St Andrews in September 2016. I received funding from an organisation or institution and have acknowledged the funder(s) in the full text of my thesis. Date Signature of candidate Supervisor's declaration I hereby certify that the candidate has fulfilled the conditions of the Resolution and Regulations appropriate for the degree of PhD in the University of St Andrews and that the candidate is qualified to submit this thesis in application for that degree. Date Signature of supervisor Permission for publication In submitting this thesis to the University of St Andrews we understand that we are giving permission for it to be made available for use in accordance with the regulations of the University Library for the time being in force, subject to any copyright vested in the work not being affected thereby. We also understand, unless exempt by an award of an iii embargo as requested below, that the title and the abstract will be published, and that a copy of the work may be made and supplied to any bona fide library or research worker, that this thesis will be electronically accessible for personal or research use and that the library has the right to migrate this thesis into new electronic forms as required to ensure continued access to the thesis. I, Genevieve Cezard, confirm that my thesis does not contain any third-party material that requires copyright clearance. The following is an agreed request by candidate and supervisor regarding the publication of this thesis: Printed copy No embargo on print copy. Electronic copy No embargo on electronic copy. Date Signature of candidate Date Signature of supervisor iv Underpinning Research Data or Digital Outputs Candidate's declaration I, Genevieve Cezard, hereby certify that no requirements to deposit original research data or digital outputs apply to this thesis and that, where appropriate, secondary data used have been referenced in the full text of my thesis. Date Signature of candidate v vi ABSTRACT In Scotland, most minority ethnic groups live longer than the White Scottish population but whether they report better health is unclear. Similarly, the international literature on ethnicity and health is divided between a strand that highlights the overall morbidity disadvantage in ethnic minorities and another strand that is puzzled by their mortality advantage. This thesis brings the two strands together by investigating whether ethnic patterns in morbidity and mortality align, based on a unique population source. The Scottish Health and Ethnicity Linkage Study links the Scottish Census 2001 to 12 years of hospitalisation and death records and provides a considerable sample size (4.6 million people) for this research. Therefore, this thesis makes a number of methodological contributions in addition to providing key empirical evidence of an ethnic morbidity-mortality paradox in Scotland. In particular, healthy life expectancy by sex and ethnicity is calculated for the first time in the UK using a direct method. Findings highlight the shortest healthy life expectancies in the Pakistani population contrasting with their mortality advantage. Hence, the Pakistani population experiences the highest number of years in poor health in Scotland. Indeed, the Pakistani population reports poorer health than the majority population which contrasts with their mortality advantage. This contrast persists beyond socio-economic circumstances and across migrant generations. Furthermore, using interaction analyses, this research demonstrates that reporting poorer health strongly predicts higher risks of mortality in minority ethnic groups but with greater strength for particular groups. Finally, findings show higher risks of (hospitalisation-based) multimorbidity in the Pakistani population which supports their morbidity disadvantage in Scotland. Diseases underlying this disadvantage include those related to the metabolic syndrome and respiratory disease. Policy makers should aim to improve the quality of life of the Pakistani population of Scotland while future research pinpoints the root causes of this morbidity-mortality paradox. vii ACKNOWLEDGEMENTS First, I would like to thank the School of Geography and Sustainable Development at the University of St Andrews for awarding me the St Leonard’s and Geography & Sustainable Development PhD studentship. This scholarship gave me the invaluable freedom to investigate my own research project. I am extremely grateful for the guidance and support I received from my excellent supervisors. Dr Nissa Finney, Professor Hill Kulu and Dr Alan Marshall provided generous advices, insightful comments, and boundless encouragements at various stages of my PhD. They all brought their strengths to this project and contributed to my development, making me the researcher I am today. I am also very grateful for the English support I received from Mary Carr (Academic English Service of the University of St Andrews) who helped me to improve my English writing during the last phase of my PhD. I would like to thank my PhD peers and my colleagues from the Population and Health Research Group who, together, created a welcoming and supportive working environment. I would also like to give a special thanks to my colleagues from the Ladywell house office for their friendship and encouragements during my PhD. Thanks to my family and friends who encouraged me and allowed me to regularly switch off from my research. I thank my friend Cathy for reading parts of my thesis and providing an outsider perspective. I am especially grateful to Tim for his patience. His continued support made it possible for me to concentrate on my research. I thank Arthur and Claire for their great enthusiasm and, foremost, for the daily distraction they gave me. Finally, I express my gratitude to Professor Raj Bhopal and Professor Aziz Sheikh who gave me their approval to use the Scottish Health and Ethnicity Linkage Study (SHELS) for my research. I acknowledge the permission provided by National Records of Scotland, the Public Benefit and Privacy Panel for Health and Social Care and the Administrative Data Research Network for the access to the SHELS data. I also thank Dave, Robin, Carl, Greg, and Stuart for taking the time to review and clear my results. Census output is Crown copyright and is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland. The author alone is responsible for the interpretation of the data. viii TABLE OF CONTENTS DECLARATIONS ............................................................................................................................ iii ABSTRACT .................................................................................................................................... vii ACKNOWLEDGEMENTS............................................................................................................... viii TABLE OF CONTENTS .................................................................................................................... ix LIST OF TABLES ............................................................................................................................. xii LIST OF FIGURES .......................................................................................................................... xiii ABBREVIATIONS .......................................................................................................................... xiv CHAPTER 1 .................................................................................................................................... 1 1. Introduction ...................................................................................................................... 1 1.1. Introduction ....................................................................................................................... 1 1.2. Research aims and structure of the thesis ......................................................................... 5 CHAPTER 2 .................................................................................................................................... 7 2. Literature review .............................................................................................................. 7 2.1. Concepts ............................................................................................................................
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