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Ethnic differences in health: A matter of social class?

Ethnic differences in health: A matter of social class?. Bernadette Kumar, MD Research Fellow- University Of Oslo. University of Oslo, Norway. Outline. Relevant Concepts Migration to Norway Material and Methods Some salient findings Valuable Lessons learnt

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Ethnic differences in health: A matter of social class?

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  1. Ethnic differences in health: A matter of social class? Bernadette Kumar, MD Research Fellow- University Of Oslo University of Oslo, Norway

  2. 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

  3. Defining Ethnic Minorities – Heterogenous ? Uniformly disadvantaged?

  4. 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)

  5. 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

  6. Økonomisk utvikling og helsetilstand – en ”dobbeltspiral” Velstand Helse Fattigdom Sykdom

  7. 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, Sheldon&Parker 1992)

  8. 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

  9. MIGRATION to Norway from developing counrtries a fairly recent phenomenon with its origins in the late sixties.

  10. 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

  11. 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

  12. 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.

  13. Post migration - Changes in lifestyle, physical and psycho-social changes • Family, friends, social network • Status/profession • Societal norms/ rules are different

  14. DATA SOURCES - The HUBROStudy - 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 age:15/16 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

  15. 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 (n=9842) • Turkey (n=465) • Iran (n=649) • Pakistan (n=643) • Sri Lanka (n=1013) • Vietnam (n=567) • Overall response rate of 47% in HUBRO and 40% in Innvandrer-HUBRO http://www.fhi.no/artikler/?id=28217

  16. 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 >=6.1 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

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

  18. Years of EducationAdults aged 30-60 years In Oslo

  19. Area of ResidenceAdults aged 30-60 years In Oslo

  20. Gainful EmploymentAdults aged 30-60 years In Oslo

  21. Type of HousingAdult Men aged 30-60 years In Oslo

  22. Type of HousingAdult Women aged 30-60 years In Oslo

  23. Mother’s Education by Ethnicity (Youth 15-16 yrs in Oslo) P<0.001

  24. SOCIAL CLASS BY ETHNICITY (Youth 15-16 yrs in Oslo) P<0.001

  25. Self reported health* by years of educationAdult women 30-60 yrs in Oslo *Age adjusted

  26. Self Reported Health*by years of educationAdult Men 30-60 yrs in Oslo *Age adjusted

  27. Self Reported Health* by Employment Status

  28. Self Reported Health* by Area of Residence

  29. Ethnic differences in Physical Activity among adolescents

  30. Sedentary* during leisure time (%) * “Yes, mainly sedentary activity (reading, watching TV etc)”, 95% CI

  31. Ethnic Differences in Physical Inactivity Women % %

  32. Kumar et al 2003

  33. BMI of adults from ethnic minorities Kumar et al 2003

  34. Kumar et al 2004

  35. Prevalece of abdominal obesity HUBRO + Innvandrer-HUBRO. Age-adjusted (Waist/hip ratio ≥ 0,85 in women)

  36. Obesity by employment statusAdults 30-60 yrs olds

  37. Prevalence of smoking in different ethnic groups (%) % Jenum 2002

  38. Prevalence of Self reported Diabetes among ethnic groups(30-60 years) Percent Kumar et al 2003 N= 2740

  39. 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

  40. 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.

  41. 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

  42. Kumar BN, Holmboe-Ottesen G, Wandel M 2002

  43. Kumar BN, Holmboe-Ottesen G, Wandel M 2002

  44. 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

  45. WHAT IS DIFFERENT?

  46. Lessons Learnt • Reaching the persons • Information via:Ethnic 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!!

  47. What can be done, and what should be done? By whom? that’s the question……

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