Ethnic differences in health: A matter of social class

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Ethnic differences in health A matter of social
class?

• Bernadette Kumar, MD
• Research Fellow- University Of Oslo

University of Oslo, Norway
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Outline

• Relevant Concepts
• Migration to Norway
• Material and Methods
• Some salient findings
• Valuable Lessons learnt
• What this means for public policy and programmes
• Way forward /Concluding thoughts

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Defining Ethnic Minorities Heterogenous ?
Uniformly disadvantaged?
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Ethnic Differences in Health

• Growing Evidence increased documentation/
  attention over the past few decades(Marmot,
  Bhopal, Nazroo)
• Underlying factors remain contested
• (Rogers 1992, Sørlie 1992, Davey Smith 1998,
  Nazroo 1997)

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Ethnic Differences in Health

• Statistical Artefact
• Consequence of Migration
• Cultural Differences
• Racism and Discrimination
• Poorer Access to Health Care
• Material Circumstances
• Genetic or Biological Explanations
• Nazroo 1997

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Økonomisk utvikling og helsetilstand en
dobbeltspiral
Velstand
Helse
Fattigdom
Sykdom
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Role of SEP in explaining ethnic differences of
Health

• Minimal/No contribution(Wild, McKeigue 1997)
• Other factors cultural/ genetic elements play
  larger role (Smaje 1996)
• Ethnic differences in health are predominately
  determined by Socio-economic inequalities(Navarro
  1990, SheldonParker 1992)

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The Role of Socio-Economic position-
Determinants of food take
Demomographic, Nutritional and Epidemiological
transition
Socio-demographic characteristics
Health/lifestyle
Dietary environment
Food beliefs Food attitudes
Food preferences and taste
Food availability Food Costs
DIET CONSUMED
Adapted from Shatenstein et al 1997
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MIGRATION to Norway from developing counrtries a
fairly recent phenomenon with its origins in the
late sixties.
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Norway 2004 Multicultural Society ?
Population 4.6 million 7.3 immigrants Capital
Oslo 520 000 inhabitants 88,000 immigrants from
developing countries(17) 40 of all immigrants
in Oslo from the Indian Subcontinent
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INNVANDRER I NORGE

• Befolkning i alt 4 503 436
• Innvandrerbefolkningen
• Førstegenerasjon 249 904
• Barn født i Norge 47 827
• Annen innvandringsbakgrunn
• Adopert 13 843
• Født i utlandet(en norsk foreldre) 23 143
• Født i Norge(en norsk foreldre) 153 006
• Født i utlandet av to norskfødte 17 827
• Totalt 505 868

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Migration to Norway

• OSLO IMMIGRANT HEALTH STUDY included five of the
  major ethnic groups from developing countries
  living in Oslo (ie.Turkish, Pakistani, Iranian,
  Sri Lankan and Vietnamese)
• Reasons for migration vary..
• Pakistanis and Turkish have longest duration of
  stay in Oslo, are the oldest and were primarily
  labour immigrants.
• Iranians, Sri Lankans and Vietnamese were
  primarily asylum seekers and have shorter
  duration of stay in Oslo.

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Post migration - Changes in lifestyle, physical
and psycho-social changes

• Family, friends, social network
• Status/profession
• Societal norms/ rules are different

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DATA SOURCES - The HUBRO Study - Study in GP
Clinic - Other in depth studies

January 2000/2003
May 2000
April 2002
HUBRO All residents Adults n 18747 age
30,40,45, 59/60, 75/76 yrs Adolescents n
7347 age15/16 yrs
Romsås Study (MORO 1) - All Adults from a
district n 2933
Immigrant Health Study Pakistan, Sri Lanka, Iran,
Turkey Vietnam N 3019 Age 30- 60 yrs
Romsås Study (MORO 2)
HUBRO -Collaboration between NIPH, UiO and Oslo
Municipality www.fhi.no
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STUDY DESIGN METHODThe Oslo Health Study
(HUBRO) The Oslo Immigrant Health Study
(Innvandrer-HUBRO)

• Cross Sectional, population-based studies
  conducted in 2000-2001 2002
• Sample in the current analysis
• Persons aged 30-60 years attending one of the two
  studies and born in
• Norway (n9842)
• Turkey (n465)
• Iran (n649)
• Pakistan (n643)
• Sri Lanka (n1013)
• Vietnam (n567)
• Overall response rate of 47 in HUBRO and 40 in
  Innvandrer-HUBRO
• http//www.fhi.no/artikler/?id28217

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Method Data Collection

• Invitation letter with 2 sided questionnaire
  sent by post to be completed and delivered at
  clinic for the check up)
• Clinical Assessment
• Non-fasting blood samples drawn
• Blood pressure(average of three readings) and
  pulse measured
• Height and weight measured with an electronic
  scale
• Waist and hip measured with a steel tape.
• If NFBG gt6.1 respondents were requested to come
  for a fasting sample(immigrant study only)
• Questionnaire (assistance offered by translators)
• Self reported health, diseases(diabetes)
• Lifestyle factors (e.g. physical activity
  smoking)
• Biological factors(number of children)
• Socio-demographic data (e.g. education)
• 15- 16 year olds were required only to complete
  the questionnaire( they did not undergo any
  clinical examination)
• 2 reminders sent by post and the last round
  included a mobile van in different parts of the
  city.
• Translations of questionnaire availalble at
  www.fhi.no

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• Selecting Indicators of SEP
• Classical
• Class
• Occupation
• Income
• Education
• Innovative
• Standard of Living
• (Nazroo1997)
• Housing

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Years of EducationAdults aged 30-60 years In Oslo
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Area of ResidenceAdults aged 30-60 years In Oslo
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Gainful EmploymentAdults aged 30-60 years In Oslo
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Type of HousingAdult Men aged 30-60 years In Oslo
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Type of HousingAdult Women aged 30-60 years In
Oslo
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Mothers Education by Ethnicity (Youth 15-16 yrs
in Oslo)
Plt0.001
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(No Transcript)
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SOCIAL CLASS BY ETHNICITY (Youth 15-16 yrs in
Oslo)
Plt0.001
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(No Transcript)
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(No Transcript)
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Self reported health by years of
educationAdult women 30-60 yrs in Oslo
Age adjusted
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Self Reported Healthby years of educationAdult
Men 30-60 yrs in Oslo
Age adjusted
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Self Reported Health by Employment Status
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Self Reported Health by Area of Residence
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Ethnic differences in Physical Activity among
adolescents
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Sedentary during leisure time ()
Yes, mainly sedentary activity (reading,
watching TV etc), 95 CI
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Ethnic Differences in Physical Inactivity
Women


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Kumar et al 2003
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BMI of adults from ethnic minorities
Kumar et al 2003
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Kumar et al 2004
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Prevalece of abdominal obesity HUBRO
Innvandrer-HUBRO. Age-adjusted
(Waist/hip ratio 0,85 in women)
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Obesity by employment statusAdults 30-60 yrs olds
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Prevalence of smoking in different ethnic groups
()

Jenum 2002
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Prevalence of Self reported Diabetes among ethnic
groups(30-60 years)
Percent
Kumar et al 2003
N 2740
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Gestational Diabetes Mellitus - A study from a
GP Clinic in Oslo
N 167

- Indian Sub - Pakistani/Indian
Basharat F et al 2004
- GDM detected by 2hr OGTT
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BRUK AV HELSETJENESTEN

• Hyppig bruk av allemennlegen
• 29.3 menn i 40/45 aldersgruppen brukt
  allemennlegen og 37.9 i 59/60 aldersgruppen i
  motsetning til de norske 9.6 og 19.7 i
  tilsvarende grupper.

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Data Collection/Methods

• Increasing Participation
• Personal Communication- face to face is best.
• Translation is a must but is not the solution to
  all problems
• Errors and misunderstandings
• Language- use of words(cheese/paneer)
• Differing concepts sandwich spreads
• Role of food items in the diet potatoes,
  beverages
• Terminology- fatty fish
• Variation- fruits, weekends

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Kumar BN, Holmboe-Ottesen G, Wandel M 2002
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Kumar BN, Holmboe-Ottesen G, Wandel M 2002
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Limitations/ Issues of Concern

• Serious problems with crude attempts to adjust
  for SEP using conventional indicators
• Socio-economic differentials alone cannot explain
  ethnic differences
• Neither cultural practices nor biology is static
• Lifetime perspective cummulative effect?
  Intergenerational effect?
• Measuring Multiple Jeopardy( Balarajan)
• Measuring Area Effect Adds to Indiviudual SE
  disadvantage

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WHAT IS DIFFERENT?
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Lessons Learnt

• Reaching the persons
• Information viaEthnic shops,radio channels,
  newspapers
• Key persons
• Letter/ Personal contact/ Phone
• Contact with immigrant groups is important,
  involvement of resource persons from minority
  groups is essential.
• Monitor and Evaluate instruments based on
  feedback from participants and change them
  accordingly.
• Numerous sources for error and misunderstandings

TING TAR TID!!
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What can be done, and what should be done? By
whom? thats the question
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STRATEGY AND POLICY

• Reduction of unnecessary, unjust and potentially
  changeable socio-economic gradients in health is
  now identified as a goal.
• White paper on Health promotion Prescriptions
  for a Healthier Norway.A broad policy for public
  health. St.meld.nr. 16 (2002-2003).
• A campaign against smoking and the tobacco
  industry.
• Green prescription (life-style counselling by
  GPs).

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STRATEGY/POLICY

• The existence of great inequalities in health,
  particularly within Oslo - the East West
  Divide
• Differences in life expectancy between the
  districts
• Men 12 years, Women 7 years
• Strong associations between mortality and social
  class
• Strong associations between mortality and
  district SES and unhealthy behaviour (Rognerud M
  The Oslo health report Oslo 1998, Claussen B,
  Norsk Edidemiologi 2002, Jenum AK, Int J of
  Edpidem. 2001)
• Media and political awareness on social
  inequalities heightened
• Political will has been strengthened - the
  previous minister of health actively promoted
  prevention.

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CONCLUDING THOUGHTS

• Multicultural societies are here to stay!!
• Comparative studies that provide valuable
  empirical information must be pursued
• The quest for SEP indicators for across group
  comparisons is far from over.
• A need to increase the understanding of the
  interwoven influences of cultural attributes to
  health related behaviours
• Raise the potential for improving health through
  culturally appropriate interventions that are
  effective.

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FINALLY

• The genes only load the gun but it is the
  environment that pulls the trigger!!
• TAKK FOR
• OPPMERKSOMHET