Ethnic inequalities in access to and outcomes of healthcare: analysis of the Health Survey for England.

BACKGROUND: Ethnic/racial inequalities in access to and quality of healthcare have been repeatedly documented in the USA. Although there is some evidence of inequalities in England, research is not so extensive. Ethnic inequalities in use of primary and secondary health services, and in outcomes of care, were examined in England. METHODS: Four waves of the Health Survey for England were analysed, a representative population survey with ethnic minority oversamples. Outcome measures included use of primary and secondary healthcare services and clinical outcomes of care (controlled, uncontrolled and undiagnosed) for three conditions - hypertension, raised cholesterol and diabetes. RESULTS: Ethnic minority respondents were not less likely to use GP services. For example, the adjusted odds ratios for Indian, Pakistani and Bangladeshi versus white respondents were 1.29 (95% confidence intervals 1.07 to 1.54), 1.32 (1.10 to 1.58) and 1.35 (1.10 to 1.65) respectively. Similarly, there were no ethnic inequalities for the clinical outcomes of care for hypertension and raised cholesterol, and, on the whole, no inequalities in outcomes of care for diabetes. There were ethnic inequalities in access to hospital services, and marked inequalities in use of dental care. CONCLUSION: Ethnic inequalities in access to healthcare and the outcomes of care for three conditions (hypertension, raised cholesterol and diabetes), for which treatment is largely provided in primary care, appear to be minimal in England. Although inequalities may exist for other conditions and other healthcare settings, particularly internationally, the implication is that ethnic inequalities in healthcare are minimal within NHS primary care.

Intergenerational continuities of ethnic inequalities in general health in England.

BACKGROUND: Previous research strongly suggests that ethnic minority groups are more likely to suffer a poorer health profile compared with the overall population, although it is not clear whether these inequalities persist over generations. This study aimed to establish the degree to which ethnic inequalities in health are transmitted from the first to the second generation, and to determine the extent to which intergenerational changes in socioeconomic status and health behaviours might explain any variation that exists. METHODS: Data from the 1999 and 2004 Health Surveys for England assessed the prevalence of fair/poor general health across first (n = 4492) and second (n = 5729) generations of six ethnic minority populations. A white population was selected as reference (n = 18 407). The risk of fair/poor general health was estimated by applying logistic regression models and stepwise inclusion of demographic, socioeconomic and behavioural variables. Generational movement relative to the white baseline was assessed for all ethnic groups adjusted for age and sex. RESULTS: No significant differences in levels of reported fair/poor general health were observed between generations. After adjusting for improved socioeconomic position, the second generation became more likely to report worse health, whereas adjusting for differences in health behaviours had no effect. The Bangladeshi population showed significant intergenerational improvement in general health relative to the white reference, showing a reduction in the odds ratio (95% CI) from 2.75 (2.14 to 3.56) for the first generation to 1.58 (1.17 to 2.13) in the second generation. CONCLUSION: Ethnic minorities in England report consistent rates of fair/poor general health across generations, despite the health benefits resulting from upward social mobility. These health inequalities are unaffected by changes in health behaviours. Understanding these intergenerational pathways will have important public health policy implications as the migrant population not only ages, but also reproduces.

Behavioural characteristics and accidents: findings from the Health Survey for England, 1997.

This study analysed the relationship between major and minor accidents, and major accidents involving a moving vehicle, and behavioural and emotional factors in children, aged 4-15 years, using the Strengths and Difficulties Questionnaire (SDQ), and adjusting for demographic, socio-economic and family type factors. Data from a large representative national sample of about 6000 children were analysed using simple and multiple logistic regression. The analysis shows that the prevalence of SDQ scales, such as hyperactivity and conduct disorder were significantly higher in boys, lower social classes and step- and single-parent families. After adjusting for the demographic, socio-economic and family type factors, children who scored borderline or high for hyperactivity were almost two times more likely to report having major accidents. Children who scored high for hyperactivity and emotional symptoms were one and a half times more likely to report having minor accidents. For major accidents involving moving vehicles, the relationships with the behavioural and emotional factors were generally stronger than for major accidents in general. Hyperactivity, in particular, was significantly associated with the occurrence of major and minor accidents, and major accidents involving moving vehicles. The behavioural risk factors were significantly more common in the lower social classes, families receiving benefits and step- and single-parent families.

South Asian people and heart disease: an assessment of the importance of socioeconomic position.

OBJECTIVES: Higher rates of mortality from ischemic heart disease among South Asian people are well established and appear to be unrelated to socioeconomic position. However, traditional indicators of socioeconomic position may be inadequate when making comparisons across ethnic groups. This study investigates these issues in a British morbidity survey. METHODS: The Fourth National Survey was a British cross-sectional study conducted from 1993 to 1994. The study used a national representative community sample, consisting of 2867 white respondents, 2001 Indian respondents, and 1776 Pakistani and Bangladeshi respondents. Data on occupational class and standard of living were used to examine the contribution of socioeconomic factors to differences in rates of reported severe chest pain and diagnosed heart disease. RESULTS: White and Indian respondents had similar rates of reported indicators of heart disease, while Pakistani and Bangladeshi respondents had rates that were considerably higher. There was a clear socioeconomic gradient in reported heart disease for each ethnic group, with those who were poorer having higher rates. Controlling for occupational class made little difference to the greater risk of heart disease found in the Pakistani and Bangladeshi group; however, controlling for a more sensitive indicator of socioeconomic position-standard of living-greatly reduced their disproportionate risk. DISCUSSION: The findings suggest that South Asian people do not share a uniformly greater risk of heart disease. The more economically advantaged South Asian group, Indians, had rates that are similar to those found among white people, while the poorest groups, Pakistanis and Bangladeshis, had rates that are considerably higher. Socioeconomic position predicted risk in each ethnic group and made a key contribution to the higher risk found for Pakistani and Bangladeshi individuals. Other studies may have failed to identify the important contribution of socioeconomic position because the indicators used were too crude.

Children's emotional and behavioural well-being and the family environment: findings from the Health Survey for England.

Recent trends towards diversity in family structure have posed important challenges for traditional social theories on the family. This critical debate has not, however, had much influence on policy discussions of the impact of diverse family structures on children's psychological health, where two-parent families are presumed ideal. In 1997, the annual Health Survey for England focussed on the health of children and young people. The Strengths and Difficulties Questionnaire (SDQ), used to assess children's psychological health, was administered to the parents of 5705 children aged 4-15 using a self-completion booklet. The effect of family structure, socio-economic indicators, parental working status and parental psychological status on children's psychological health was explored using multi-variate logistic regression models. Findings indicated that the high prevalence of psychological morbidity among children of lone-mothers was a consequence of socio-economic effects. disappearing when benefits receipt, housing tenure and maternal education were taken into account. Socio-economic factors did not, however, explain the higher proportion of psychological morbidity among children with stepparents, or the strong relationship between parents' and children's psychological morbidity.

Birthweight and behavioural problems in children: a modifiable effect?

BACKGROUND: Low birthweight has been shown to predict behavioural problems in children. Less is known about the effect of birthweight, and how this may interact with the social environment in determining behaviour in a general population sample. We have examined the relationship between birthweight and social factors on childhood psychological well-being. METHODS: Cross-sectional analysis of data on 5181 children aged 4-15 years from a randomly selected household population, the 1997 Health Survey for England. The main outcome measures were behavioural problems as defined by the Strengths and Difficulties Questionnaire (SDQ) in relation to birthweight and social environmental factors. RESULTS: Birthweight was a significant predictor of total difficulties score (odds ratio [OR] = 1.27, 95% CI : 1.07, 1.49), hyperactivity in boys (OR = 1.25, 95% CI : 1.05, 1.51), and peer problems in girls (OR = 1.24, 95% CI : 0.99, 1.53). There was a strong social class gradient in the prevalence of behavioural problems for all birthweight tertiles. Bivariate analysis showed that high total difficulties score was significantly more common in lower birthweight tertiles for social classes III non-manual and III manual (P:-value for trend 0.05 and 0.03, respectively). There were smaller, non-significant effects of birthweight on the prevalence of behavioural problems in social class I and II, and IV and V. Statistical tests for an interaction between birthweight and social class were not significant. CONCLUSIONS: Early life factors, such as birthweight and social class have important influences on psychological well-being in children. The birthweight effect is influenced by social factors, with the possibility that an advantaged social environment protects against the development of behavioural problems, and a disadvantaged environment increases the risk of behavioural problems, regardless of birthweight.

Gender differences in marital support following a shared life event.

Previous work has established that women with good marriages are less at risk of depression of clinical severity following a crisis than women in poor quality relationships. Evidence for such protectiveness is less clear for men. The paper examines the relationship between marital quality, onset of depression, and gender following a severely threatening life event. The results show that good quality of marriage related to lower rates of depression for both men and women, although the overall rate for women was higher. For women with a good marital relationship, but for whom support from partner was not forthcoming at the time of the crisis (i.e. the person was "let down"), risk was increased, confirming a result from a study in Islington. The current study shows that the same set of findings holds for men. Gender differences did emerge when the subjective need for support within the marital relationship is taken into account, with women expressing greater need. However, such a desire for support was not necessarily translated into support-seeking behaviour as in a poor relationship turning to a partner was frequently inopportune. Women were also more likely to seek support outside the marriage; as in the earlier Islington research this was related to a lower risk of depression for those in a poor relationship. An unexpected finding was that men who received support outside marriage had an increased risk of depression.

Gender differences in the onset of depression following a shared life event: a study of couples.

BACKGROUND: Gender differences in clinically relevant depression are well established, appear to be greatest in childbearing years and may be the result of gender differences in social roles. METHODS: A community sample of 100 couples who had recently experienced at least one threatening life event that was potentially depressogenic for both of them was studied using a semi-structured interviewer-rated interview. Onset of depression was assessed using the Present State Examination, and, rather than assuming that a gender difference in roles existed uniformly across the couples, they were characterized according to their actual role activity and commitment. RESULTS: Women were found to have a greater risk of a depressive episode following the life event than men, and this difference was of a similar magnitude to other reports of gender differences in depression. Consistent with a role hypothesis, this greater risk was entirely restricted to episodes that followed events involving children, housing or reproductive problems. In addition, it was found that women's greater risk of a depressive episode following such events was only present among those couples where there were clear gender differences in associated roles. There was some suggestion that differences in roles on the one hand resulted in women being more likely to hold themselves responsible for such events and, on the other hand, enabled men to distance themselves from them. CONCLUSIONS: These results support the hypothesis that gender differences in rates of depression in the general population are, to a considerable extent, a consequence of role differences.