THE IDENTIFICATION OF ETHNIC GROUPS IN HEALTH
RESEARCH, ADDITIONAL TO THE COUNTRY OF BIRTH
CLASSIFICATION
Karien Stronks
Isik Kulu Glasgow
Niek Klazinga
Department of Social Medicine
Academic Medical Center, University of Amsterdam
Meibergdreef 15
1105 AZ Amsterdam
Tel. 020 5664892
December 2004
1
Verantwoording
Dit rapport is geschreven in opdracht van de ZonMw themacommissie ‘Cultuur en Gezondheid’.
De auteurs willen graag mw. drs. G. Stevens (Erasmus Medisch Centrum) en dr A. Hancioglu
(Hacettepe University, Ankara) bedanken voor het uitvoeren van statistische analyses en het
beschikbaar stellen van onderzoeksgegevens ten behoeve van hoofdstuk IV.
De conceptversie van dit rapport is ter toetsing voorgelegd aan de volgende deskundigen (in
alfabetische volgorde):
drs M. Alders (Centraal Bureau voor de Statistiek)
dr M. Bruijnzeels (instituut Beleid en Management Gezondheidszorg/EUR),
dr J. Dagevos (Sociaal en Cultuur Planbureau)
mw.dr M. Foets (instituut Beleid en Management Gezondheidszorg/EUR),
dr A.E. Kunst (instituut Maatschappelijke Gezondheidszorg/Erasmus MC),
dr J. Smits (KUN)
dr M. Verkuyten (ERCOMER/RUU).
Het conceptrapport is door een aantal van deze deskundigen tijdens een bijeenkomst (20 januari
2004) besproken, en door een aantal van schriftelijk commentaar voorzien. Op hoofdlijnen werd
ingestemd met de inhoud van het rapport. Meer specifiek bestond op hoofdlijnen steun voor
1. de keuze om de CBS standaardclassificatie van etnische groepen in termen van
geboorteland als uitgangspunt van dit rapport te hanteren;
2. de additionele criteria die in het onderhavige rapport worden voorgesteld voor het
onderscheiden van etnische groepen binnen één geboorteland en van de derde generatie;
3. de uiteenzetting van additionele kenmerken, die etnische groepen zoals onderscheiden op
basis van geboortelanden, verder inkleuren.
Wij willen deze experts graag voor hun constructieve commentaar bedanken.
Tenslotte zijn specifieke tekstgedeelten ter commentaar voorgelegd aan Prof. G. Oostindië (KIT)
(III.2.4) en mw. dr M. van Niekerk (IMES/UvA) (III.2.2). Ook hen danken wij voor hun opbouwende
commentaar.
2
CONTENTS
page
I.
Introduction
5
II.
Defining ethnicity, ethnic groups and related concepts
7
1.
2.
3.
3.1
3.2
3.3
III.
IV.
VI.
7
8
9
9
11
11
Indicators for the identification of ethnic groups, additional to country of birth
13
1.
2.
2.1
2.2
2.3
2.4
3.
3.1
3.2
13
16
16
19
22
23
25
25
27
A general discussion on possible additional indicators
Ethnic groups that share country of birth
Turkey
Surinam
Morocco
Dutch Antilles and Aruba
Identification of the third generation
Significance of the third generation
Indicators to identify the third generation
Associations between additional indicators for ethnic groups and health (care)
29
1.
1.1
1.2
1.3
1.4
29
29
32
34
3.
V.
Many definitions and classifications: how to cope with this diversity?
The Dutch standard of country of birth
Related concepts
Race versus ethnicity
Ethnic groups and ethnic minorities
Ethnic groups and immigrant groups
The health status of ethnic groups that share country of birth
Turkey
Surinam
Dutch Antilles and Aruba
Conclusion: differences in health between ethnic groups within
the Turkish, Surinamese and Antillean populations
Health status of the third generation
34
35
Other characteristics of ethnic groups, additional to country of birth
37
1.
2.
3.
4.
5.
38
38
39
42
43
Genetic factors
(Short-term) migration history
Cultural characterisctics
Perceived ethnic identity
Position in the host country
Conclusions and recommendations..
47
1.
2.
47
3.
Introduction
Indicators for the measurement of ethnic groups,
additional to country of birth
Other characteristics of ethnic groups, additional to ethnic origin
References
47
49
51
3
4
Chapter I
INTRODUCTION
The relationship between ethnicity, health and health care has been drawing growing attention, both
nationally and internationally. A comprehensive study of the American Institute of Medicine, for
example, addresses the issues related to ethnic disparities in the quality of health care (Smedley et
al. 2002). Also in the Netherlands, in recent years, research on ethnic disparities in health, access to
and quality of health care services has been increasing. In addition, it has become the focus of
health(care) policies (e.g. RVZ 2000).
Researchers that study the relationships between ethnicity and health (care) rarely specify what they
mean with 'ethnicity' (Ahdieh & Hahn 1996). In addition, different measures are used to
operationalise this concept, including country of birth and self-defined ethnicity. This lack of
uniformity in the identification of ethnicity and ethnic groups makes the comparison of research
results fuzzy. As stated by Afshari and Bhopal (2002, p. 1074):
“The lack of consistency in terminology and poor understanding of the concepts may [...]
hamper progress in this field and make international collaboration more difficult”.
Inversely, a common definition and the use of similar indicators might stimulate the accumulation of
knowledge in this field.
In the Netherlands, since the nineties of the previous century, the use of country of birth criteria have
been widely accepted as a basis for the identification of ethnic groups (Heeten & Verweij 1993). This
does not only apply to social and demographic but also to health (care) studies (Bruijnzeels 1999).
In this approach, people are classified into ethnic groups on the basis of their own country of birth
and that of their parents. However, it is agreed upon that in health (care) studies, country of birth as
an indicator of ethnic groups also has its drawbacks (Bruijnzeels 1999). These include the failure to
make a distinction between native Dutch people and children of the second generation immigrants,
as well as the failure to identify different ethnic groups within one country of birth (e.g. compare the
Creole and Hindu Surinamese).
These drawbacks of the current standard classification of ethnic groups are the main reasons for this
report. In view of the accumulation of knowledge, it is to be recommended that Dutch researchers in
the field of health and health care research use similar indicators to compensate for these
drawbacks. The aim of this report, written for the ZonMw research committee ‘Culture and health’, is
to propose solutions for the limitations of the country of birth criteria. The question that is central to
this report are: Given the drawbacks of the country of birth classification, which additional indicators
should be used for the identification of ethnic groups?
The target group of the report consists of researchers working in the field of ethnicity and
health(care). We limit ourselves to developing recommendations for the use of indicators for ethnic
groups in incidental studies. Issues related to the routine registration of ethnicity are outside the
scope of this report.
5
This report is structured as follows. Firstly, we will analyse the concepts of ethnicity and ethnic
groups and distinguish them from related concepts such as race and migrant status (chapter II).
Secondly, we will propose indicators for the classification of ethnic groups in Dutch health (care)
research additional to the country of birth classification (chapter III). Thirdly, we will assess whether
the additional indicators have relevance for health (care), by (empirically) assessing differences in
health (care) between ethnic groups that share country of birth, as well as between third and
first/second generation immigrants (chapter IV). Finally, we will describe additional features that can
be used to further characterise ethnic groups (chapter V). The last chapter (VI) summarizes the
recommendations.
6
Chapter II
DEFINING ETHNICITY AND RELATED CONCEPTS
II.1 Many definitions and classifications: how to cope with this diversity?
The definition of ethnicity is not simple. Although scholars agree that ethnicity has to do with group
relations and classifications of people (Verkuyten, 1999), its definition is neither precise nor
consistent. Cohen (1978) argues that only a few authors give a definition of what they mean by
ethnicity, and the rest consider its definition unnecessary. This lack of clarity on the exact definition
not only exists in social research, but also in the field of health(care) studies (Bradby 2003).
Authors that do define the term ethnicity do so in a variety of ways. Probably the most well known is
that of Weber (1968), which states that “.. We shall call ‘ethnic groups’ those human groups that
entertain a subjective belief in their common descent because of similarities of physical type or of
custom or both, or because of memories of colonization and migration”. Bhopal, one of the key
British researchers in the field of ethnicity and health, argues that the following elements are crucial
to the concept of ethnicity: “shared origins or social background, shared culture and traditions that
are distinctive, maintained between generations, and lead to a sense of identity and group, and a
common language or religious tradition” (Senior and Bhopal 1994). Berthoud (1998) emphazises the
element of heritage. He defines an ethnic group as “a community whose heritage offers important
characteristics in common between its members, and which makes it distinct from other
communities. ….. Heritage seems to be an essential ingredient …. Another important component of
ethnicity seems often to be existence of links, current or historical, with a particular geographical
area’’. The latter element is phrased by Aspinall (2001) as “a common ancestry or place of origin”.
These examples illustrate the diverse nature of the existing definitions of ethnicity. Multiple criteria
are often used, such as language, physical similarities, dressing styles, and religion. Other common
elements in the existing definitions are the reference to a common heritage, roots or ancestry.
However, there are also differences between the various definitions. This applies in particular to the
extent to which ethnicity is defined in terms of either the individual’s own identification (cf. subjective
belief, in the definition of Weber), or in terms of objective criteria that can be allocated by others,
such as a common ancestry (Aspinall 2001).
Different approaches to conceptualise ethnicity result in different classifications. If for example the
definition emphasizes the aspect of descent or common origin, ethnic groups might be distinguished
by means of researcher defined characteristics such as country of birth or language. On the other
hand, if the emphasis is on a common sense of identity, an operationalization in terms of selfassigned ethnicity might be more appropriate.
In view of the many definitions of ethnicity, might we expect researchers in different countries, or
researchers within a specific country to reach consensus on the classification of ethnic groups? This
seems unrealistic, for two reasons.
Firstly, the actual meaning of ethnicity might differ between countries. The classifications that are
currently used in different countries reflect local specificities, such as the migration history of
immigrant groups, as well as the political context, including the acceptability of making racial
distinctions (Kaplan & Bennet 2003). The categories that are used in the UK for example, including
7
ethnic groups such as the Pakistani and Irish (box 1), are useless when classifying ethnic groups in
the Netherlands, given the different composition of the population in both countries. In addition, the
actual lines of cleavages between ethnic groups might differ from place to place. In Canada for
example language is probably the most striking difference between ethnic groups, whereas different
ethnic groups in Surinam share the same language. This means that even if the same classification
is used in different countries, it is doubtful whether the outcome of these are comparable to each
other (Bradby 2003). For example Black Africans in the USA represent a completely different group
of people, in terms of migration history e.g., than the Surinamese Black African in the Netherlands.
Second, even within a specific country, it seems unrealistic to search for one ideal classification that
meets the drawbacks of all other classifications. Each of the classifications used, be it in terms of
self assigned identity or researcher assigned ethnicity, has been criticised, for different reasons.
Criticisms include the overemphasis of homogeneity within groups (such as the South Asians in the
UK), the fact that ethnicity assigned by a researcher (in terms of country of birth or language etc.)
may not coincide with the self perceived ethnic identity of an individual, and the inadequacy of crude
measures such as country of birth to capture the complexity of the real world of ethnic groups
(Bradby 2003).
In summary, it is unrealistic to strive for a classification that can do justice to the various
characteristics of ethnic groups. Instead, in practice ethnic groups are identified on the basis of
rather simple and crude criteria. In the Netherlands, ethnic groups are mostly identified on the basis
of country of birth. Information about features that further characterise these groups (in terms of
culture, language, religious and other features that were mentioned in the definitions of ethnic
groups given above), are then collected additionally.
II.2 The Dutch standard of country of birth
The Dutch standard classification of ethnic groups in terms of country of birth is the end product of a
long and intensive discussion (CBS 2000, Alders 2001). Currently, also researchers involved in
health (care) studies consider country of birth (of a person as well as his/her parents) the most
promising basis for identifying ethnic groups (cf. the conclusion of a workshop of the 'Kennisnetwerk
Cultuur en Gezondheid', which was held a few years ago, that focused on how to define ethnicity for
research purposes (Bruijnzeels 1999)).
The idea behind this country of birth classification is that, given its objective and stable character, it
allows for a uniform identification of ethnic groups. This contrasts with for example the dynamic
character of a classification in terms of perceived ethnic identity, which can hamper the
comparability of study results. In addition, it can be relatively easily applied, which is a necessary
criterion for its widespread use, and it can be defined by an outsider. Based on these considerations,
the country of birth classification is a robust measure that remains unchanged over time, thereby
promoting the accumulation of knowledge. The country of birth classification fits within the
conceptualisation of ethnicity as a common geographical origin or descent, rather than a
conceptualisation in terms of a self-perceived ethnic group (Aspinall 2001).
8
The standard definition in the Netherlands makes a distinction between a first and second
generation residents of immigrant descent. The first generation consists of persons who were born
abroad and have at least one parent who was also born abroad. The second generation consists of
persons who were born in the Netherlands and have at least one parent who was born abroad 1.
People who were born abroad or whose parents were born abroad, are frequently defined as
“allochtonen” (=Dutch residents with immigrant descent). The remaining persons, i.e. those who
were born in the Netherlands and who have parents that were both born in the Netherlands, are
classified as native Dutch (Alders 2001).
As mentioned in the introduction, the (CBS) standard classification of ethnic groups on the basis of
country of origin is the starting point for the present report2. The aim is to propose solutions for the
limitations of this approach. These include the failure to make a distinction between native Dutch
people and children of the second generation immigrants, as well as the failure to identify different
ethnic groups that share country of birth.
As already discussed, the identification of ethnic groups on the basis of country of birth of course
does not capture the complexity of all differences between ethnic groups in terms of, e.g., culture,
language and religion (Bradby 2003). There may for example be differences in language between
people that share country of origin, even though they may share a common language. An example is
the Surinamese community, here differences may be found in religion, eating habits and culture and
perceived ethnic identity. Such aspects should be considered as features that further characterise
ethnic groups (Fenton & Charsley 2000), and are as such essential in health (care) studies, not only
as a key to the explanation of ethnic differences in health (Stronks et al. 1999), but also as a basis
for making a distinction between subgroups. This will be worked out in chapter V.
II.3
Related concepts
Ethnicity has frequently been confused with race, and migrant status. In this section, the differences
between ethnicity and these related concepts will be clarified.
II.3.1 Race versus ethnicity
Although ethnicity and race have long been used as interchangeable concepts in (inter)national
health(care) research (see box 1), ethnicity should be conceptually distinguished from race.
Whereas ethnicity is commonly considered to be a social concept, the distinction between racial
groups is primarily based on biological characteristics, skin colour being the most striking (Garte
2002). At the same time, the biological significance of this concept has been seriously debated for
1
This is in fact the operational definition of the second generation. The conceptual definition states that the
second generation consists of individuals who are born in the Netherlands and have at least one parent who
belongs to the first generation. However, to determine whether someone’s parents belong to the first generation
immigrants, information is required on the country of birth of his/her grandparents. This is because someone
who was born abroad, whereas his/her parents were born in the Netherlands, would be wrongly classified as a
first generation with immigrant descent. As this information is not stored in the main Dutch registries such as the
municipal registry, the standard definition is phrased in terms of the more simple operational definition
mentioned above, based on the country of birth of a person and its parents only (Alders 2001).
2 This definition slightly differs from the approach of the ministry of Internal affairs (so-called BiZa approach),
e.g. in the sense that in the latter all people who were born in a foreign country are classified by means of their
own country of birth, irrespectively of the country of birth of their parents.
9
several decades. It has been argued that no race possesses distinct genes, and that there are more
genetic variations within races than between races (Garte 2002). Furthermore, it is claimed that
genes responsible for morphological features such as skin colour (which are the basis of racial
groupings) are few, atypical and not associated with genes responsible for diseases (Hill 1989 cited
in Senior & Bhopal 1994, Bhopal & Rankin 1999). Because of the weakness of the concept of race
as reflecting genetically different populations, the critique of “race” as a concept and a variable in
health(care) research is growing fast (Bhopal & Rankin 1999, Bhopal 2001).
Box 1
The fact that ethnicity and race are frequently mixed up is clearly illustrated by the UK Census question on
‘ethnic groups’, which is a mixture of race (white versus black) and ethnicity (in terms of country of birth).
2001 UK Census question on ethnic groups (Vidler 2001)
What is your ethnic group?
(Choose one section from (a) to (e) then tick the appropriate box to indicate your cultural background)
a) White
□ British
□ Irish
□ Any other White background
please write in
………………………………..
b) Mixed
□ White and Black Caribbean
□ White and Black African
□ White and Asian
□ Any other mixed background
please write in
………………………………………….
c) Asian or Asian British
□ Indian
□ Pakistani
□ Bangladeshi
□ Any other Asian background
please write in
…………………………………………….
d) Black or Black British
□ Caribbean
□ African
□ Any other Black background
please write in
………………………………………….
e) Chinese or other ethnic group
□ Chinese
□ Any other
please write in……………………………….
In contrast to the United Kingdom and the United States, the use of race as a concept in the
Netherlands is not very widespread, except perhaps in medical research. Caucasian, Asian and
Negroid are the categories that are mostly used in this type of studies. In the National Birth
Registration (Landelijke Verloskundigen Registratie) for example, a mixture of the race and the
country of birth of the pregnant woman is registered by the midwife (by consulting the woman, if
necessary). The possible categories where a woman can be classified are: indigenous/native (Dutch
and ethnic West-Europeans), Mediterranean (Turkish and North-African, including Moroccan), Afronon-native (Afro-allochtoon) (Surinamese, Antillean, Africans with Negroid descent), Hindu (West10
indische Indiërs), Asian (excluding Turks and Hindu’s), other European, and “Other” (Bruijnzeels
1999).
A further investigation of race as a concept, and discussions around it -whether biological or socialis of course outside the scope of this report. However, genetic factors in relation to ethnic groups are
discussed in chapter V, where these are considered as one of the “explanatory mechanisms”
between ethnicity and health.
II.3.2 Ethnic groups and ethnic minorities
The term ethnic minorities is conceptually different from ethnic groups. It refers to residents of
immigrant origin, but only those groups who are in a socio-economically adverse position. This is
why they form the focus of ethnic-minorities policy. Ethnic minority is thus a ‘policy’ term. These
groups include, in the Netherlands, people originating from Turkey, Morocco, South-European
countries (Italy, Spain, Portugal, Greece, former Yugoslavia), Surinamese, people from Dutch
Antilles and Aruba, Moluccans, invited refugees and asylum-seekers from a large number of
countries of the third world and East-Europeans, Tunisians, gypsies and “woonwagenbewoners”
(Martinez et al. 2002). In the case of invited refugees and asylum-seekers, not only the country of
origin, but also the way they have accessed the Netherlands (as a refugee or an asylum-seeker),
and their residence status are other important criteria. In a strict sense, only asylum-seekers who
have been recognised as a refugee or who have a (temporary) residence permit are included in the
ethnic minorities grouping.
II.3.3 Ethnic groups and immigrant groups
How does the term ethnic groups relate to immigrant groups? Immigrants are those who have
migrated to the ‘host country’. Thus, this concept partly overlaps with ethnic groups, i.e. in as far as
people have immigrated themselves. This applies to first generation residents of immigrant descent
(eerste generatie allochtonen), which are defined as those residents who were themselves born
abroad and have at least one parent who had also been born abroad (CBS 2000) 3. Second
generation residents of immigrant descent (tweede generatie allochtonen) consists of those who
were born in the Netherlands with at least one parent born abroad. Second generation residents with
immigrant descent are not immigrants themselves, as they were born in the Netherlands. Therefore,
the concept of “second generation (im)migrants”, is a faulty term.
3
The condition that at least one of the parents has to be born abroad excludes the possibility of including those people who
were born abroad to parents born in the Netherlands. This group is considered under “native Dutch” (autochtonen) (CBS
2000).
11
12
Chapter III
INDICATORS FOR THE IDENTIFICATION OF ETHNIC GROUPS,
ADDITIONAL TO THE COUNTRY OF BIRTH CLASSIFICATION
In chapter II the Dutch standard classification for the identification of ethnic groups has been
introduced. This defines ethnic groups in terms of their country of birth, referring to someone’s roots
or geographic origin. According to the standard definition of the Central Bureau of Statistics (2000),
a person is considered to be a resident with immigrant descent (=allochtoon), if (s)he him/herself
was born abroad and at least one of the parents was born abroad, or if someone was born in the
Netherlands with at least one of his parents born abroad.
In some cases, however, country of birth is not a valid indicator to discriminate between groups that
have a different geographic origin. Firstly, there is the problem of different ethnic groups within one
country. The Creole and Hindu Surinamese are well-known examples. Using the Dutch standard
classification, they could not be distinguished as different ethnic groups as they share country of
birth. A distinction between these groups might nevertheless be desirable, given differences in
health status. Hindustanis (for example) seem to have a relatively high diabetes prevalence,
whereas among Creoles (especially) the prevalence of hypertension seems to be extremely high
(Middelkoop 2001, Bindraban et al. 2003).
Secondly, the use of the standard classification does not allow for the definition of the third
generation. If the third generation of a certain immigrant group shows worse health status as
compared to the indigenous population, it may be desirable to have instruments that can distinguish
the third generation in health(care) research.
This chapter will explore solutions for the drawbacks of the standard classification. We will propose
indicators, additional to country of birth, that compensate for these drawbacks.
Chapter III.2 deals with the issue of different ethnic groups with a shared country of birth. We will
present country-specific recommendations for the biggest (non-Western) groups of immigrant
descent in the Netherlands (Turkey, Surinam, Morocco, Dutch Antilles and Aruba). The issue of the
third generation is dealt with in section III.3. In section III.1 we will discuss the requirements that the
additional indicators should meet.
III.1 A general discussion on possible additional indicators
Consistency seems to be the primary and most important requirement that the additional indicators
for the classification of ethnic groups should meet (Mays et al. 2003). By this we mean that the
additional criteria should be consistent with the underlying conceptual basis of ethnic groups in the
Dutch standard classification, i.e. geographic origin/roots.
Secondly, as the indicators should in principle be used to make a distinction between ethnic groups
from various countries (Surinam, Turkey, Morocco etc.), it seems desirable to develop a universal
indicator that can be applied to many different countries of birth. Although the use of different
indicators might not be a problem in a study that focuses on groups that share country of birth (e.g.
either Turkey or Surinam), this clearly is complicated in a study among populations that come from
13
different countries. In such a study, an universal criterion to further define ethnic groups that share
country of birth, is preferred.
Third, and related to the previous point, the classification system should have a flexibility to absorb
entries not yet identified. In this report, we will discuss additional indicators for the four main
immigrant groups in the Netherlands. These indicators should in principle also be applicable to other
ethnic groups, including the immigrant groups of the future.
Fourth, the indicators to be proposed should of course be measurable in a valid way.
What are potential indicators for the identification of ethnic groups additionally to country of birth,
and how should these be judged in view of these requirements?
Geographic origin of the ancestors
Given the underlying conceptualisation of the standard classification in terms of geographic origin,
the distinction of different groups within one country depends primarily on the original geographic
origins of a particular group. In practice this would mean that people would be asked about the
geographic origin of the ancestors. To distinguish the Hindustani from the Creole, for example, one
could ask whether the ancestors originate from India or Africa/Europe. Conceptually, this strategy
fits well within the country of birth approach, as it directly refers to someone’s (geographic) roots. In
practice, however, this indicator seems to have some drawbacks. Firstly, the geographic origin of
ones ancestors may not distinguish some groups sufficiently. In the case of the Turkish population
for example (see also III.2.1), the geographic origin of both the Turks and Kurds is Turkey, at least
since the 7th century. It is only before this period that the geographic origin of both groups differs.
This implies that the question on the geographic origin of the ancestors would not provide the
desired level of information, unless it is further defined by historical period. As a result the use of this
variable is complicated: Can people answer such a question? Second, the validity of this indicator
varies between different countries of birth. As mentioned previously the geographic origin of
someone’s ancestors does not seem to be a appropriate indicator for the Turkish population,
whereas in other cases it probably is (this might be the case for the Surinamese population, as the
immigration into Surinam is much more recent than in the case of the Turkish population. See also
III.2.2). This might result in the undesirable situation in which the criteria to define ethnic groups that
share country of birth might differ between countries of birth.
Language
In section III.2, it will appear that for some ethnic groups that share country of origin, language
spoken is a potential indicator to differentiate between these groups. This might then be an
(objective) proxy for making a distinction between these groups. This applies for example to the
Turks and Kurds within Turkey (see section III.2.1). As in the case of geographic origin, however,
this indicator might be applied to one country, but not to another. We will for example argue that it is
a useful indicator for the Turkish population, but not for the Surinamese (see section III.2.2). This
implies that also this indicator does not seem to be appropriate to function as a universal indicator to
identify ethnic groups.
14
Self-identified ethnic group of the respondent
A third possible indicator is self-identification of an ethnic group. Self-identification questions are
mostly read as “which ethnic group do you consider yourself belong to?”, or “according to you, which
population group do you belong to?” or “which ethnic group do you associate yourself with?”.
Compared to the drawbacks of the previous mentioned indicators, the use of self-identified ethnic
origin has the advantage of being easily applied, also in a study in which several ethnic groups are
included and in which ethnicity is one out of many variables only (implying that the room for
questions on ethnicity is limited). Moreover, it has the advantage of being applicable to all ethnic
groups, including groups from countries other than those discussed in this report. In line with these
advantages, Heeten & Verweij (1993) and others have previously recommended the use of selfidentification as an additional distinguishing indicator between ethnic groups.
However, the use of self-identification questions has some drawbacks as well. These include:

Self-identification might not be a valid indicator for the underlying concept of geographic
origin. This applies in particular if the question is phrased in terms of “belonging to”. In
that case, there is a considerable chance that people will answer that question
according to their subjective feeling or perceived ethnic identity rather than their roots
(e.g. Kurds from Turkey might answer ‘Dutch’ if they see themselves as completely
assimilated to Dutch society). Moreover, the answer on this question might depend on
the political context (e.g. the way a certain group is perceived in that specific society,
e.g. the different perceptions towards Kurds and Turkish people in the Netherlands). As
a consequence, inconsistencies would arise in the definition of ethnic groups within one
classification.

As a consequence of the operationalisation of self-identification in terms of ethnic
identity, the answers to most self-identification questions are subjective and therefore
unstable. In a study in the United States, where people had to assign themselves to an
ethnic group in two consecutive years, one-third of the population chose a different
ethnic group on the second occasion (Anonymous 1996). Another study in the United
Kingdom showed that there was a significant heterogeneity in the self-defined ethic
groups (McAuley et al. 1996). Also, it is impossible for the researcher to know what the
answer actually means. For example, considering one’s self as “Moroccan” can mean
different things for the respondent and refer to different aspects of ethnic features, and
this is problematic if the researcher uses this to define ethnic groups in addition to the
country of birth indicators.
The above implies that the wording of a question on self-identified ethnic groups is essential for the
validity of the answers. So far, this type of indicator has not been frequently applied in Dutch studies
(within or outside the health (care) sector), implying that we have not yet much experience with the
exact phrasing of this indicator. This implies that, although it seems to be the most appropriate
candidate for a universal classification system, further testing of the exact phrasing to be used is to
be recommended. This should not be limited to the sector of health (care) research. Instead, it
seems wise to explore this in close cooperation with social scientist, as they face the same problem.
15
Finally, before the additional indicators will be worked out for the four main immigrant groups in the
Netherlands, a comment should be made on the use of self-identification questions in the case of
mixed ethnic origin. Cf. a person that was born in the Netherlands, with his/her mother born in
Turkey, and father born in Morocco. Should (s)he classify him/herself as belonging to the Turkish or
to the Moroccan group? The standard definition of the Central Bureau of Statistics states that, in the
case of a person born in the Netherlands, with parents born in two different countries (not including
the Netherlands), the country of birth of the mother determines the ethnic group of that person. In
line with this approach, for people born in the Netherlands, the (self-identified) ethnic group of the
mother should be asked for. Only if the mother was born in the Netherlands, should the selfidentified ethnic group of the father be asked for. For people of the first generation, such a question
should be asked for him/herself. Considering the difficulties of applying these types of rules within
questionnaires, it is probably simpler to ask for the self-identified ethnic group of both the mother
AND father in all cases. Whether this is an adequate solution to identify the ‘mixed’ ethnic group,
needs to be tested in future studies.
III.2
Ethnic groups that share country of birth
Hindus and Creoles are well-known examples of the failure of the Dutch standard classification to
identify different ethnic groups that were born in the same country. However, there are different
groups within Morocco (Arabs and Berbers) and Turkey (among others, Turks and Kurds). Should
these also be separated in considering ethnic groups? Given the underlying conceptualisation of the
standard classification in terms of geographic origin, the distinction of different groups within one
country depends on the original geographic origins of a particular group.
This implies that, first, the historical background of different groups should be considered, in order to
explore whether the population groups living in that country have different geographic origins.
Second, it should be analysed whether groups with a different geographic origin could still be
identified as such, or that these could not be distinguished from each other anymore because of, for
example, traditionally a high percentage of ethnically mixed marriages. In the historical analyses, we
restrict ourselves to the four countries where most of the (non-Western) immigrants in the
Netherlands come from, i.e. Turkey, Surinam, Morocco, and the Dutch Antilles. Only those
population groups from these countries that are present in the Netherlands are taken into account in
these brief overviews.
III.2.1 Turkey
A recent study has shown that the Turkish population comprises some 51 ethnic groups (Andrews
1989). A nation-wide demographic survey among ever-married women show that 82% of the survey
population is of Turkish origin, 13% of Kurdish origin, 2% of Arabic origin, and the remaining 3%
belong to other ethnic groups (Koc & Hancioglu 1999).
Thus the Turks and the Kurds are the largest groups in Turkey. Should they be considered as
distinct ethnic groups? There seems to be consensus that they should. Firstly, both groups have a
different geographical origin. The Kurdish population lived in Anatolia for thousands of years prior to
16
the Turkish migration from Central Asia to the region began in the 7th century. The majority of the
Kurdish population in Turkey now lives in the (South-) eastern Anatolia, even though there is (still) a
continuing internal migration to the Western Anatolia, especially to big cities. Secondly, empirical
studies show that inter-marriage between Turks and Kurds is quite uncommon. In a resent
representative sample of women and their husbands, the percentage of ethnically mixed marriages
among the Turkish and Kurdish population appears to be rather low, ranging from approximately 1.5
% of the Turkish to 8.5 % of the Kurdish population (Gündüz-Hoşgőr & Smits 2002). This shows that
despite strong migration movements and co-residence of different ethnic groups in all regions of
Turkey, there is no strong convergence of the two groups.
Given the different geographical roots of Turks and Kurds, as well as the fact that both populations
can still be clearly distinguished from each other, we suggest that these two groups, in the country of
birth approach, be considered as separate ethnic groups.
In addition to their different geographical background, there are of course also other differences
between Turks and Kurds that might be relevant in the context of a certain study. E.g. in the case
that the researcher wants to make a further distinction by characteristics that are related to the
ethnicity concept, including culture and migration history. The majority of the Kurds in the
Netherlands has come as asylum-seekers, whereas most Turks (originally) came as labour migrants
for example. In addition, the regions where the Kurdish population in Turkey are concentrated are
socio-economically less developed and characterised by high fertility and infant mortality rates (HIPS
1994, 1999). This type of distinctions will be further worked out in chapter V.
Indicators to distinguish between Turkish and Kurds in the Turkish immigrant population
Which indicators could be used to distinguish Turks and Kurds living in the Netherlands from each
other, additional to the standard country of birth indicators?
Three options were previously mentioned for making such a distinction: geographic origin of the
ancestors, language, and self-identified ethnic group. It has been argued that a self-identification
question is the most promising indicator. It can be applied in all ethnic groups, which makes it an
attractive indicator if a study comprises different populations originating from different countries. This
indicator will therefore be worked out in the first place. Additionally, we will also explore the
possibilities of both other indicators (geographic origin of ancestors and language).
Self-identification
As mentioned before, the use of questions on self-identified ethnic group has the risk of being an
subjective and unstable indicator, which might lead to inconsistencies in the classification of ethnic
groups. Therefore such a question should be phrased as objectively as possible, in order to be sure
that the respondent reports his/her (actual) geographic descent/origin, rather than the group (s)he
feels to belong to. We propose to phrase such a question as follows:
17
“ You were born in Turkey and/or one or both of your parents were born in Turkey. As you know, there
are different population groups in Turkey, for example the Turkish, Kurdish, Arabic, Laz, Georgian,
Greek, Armenian, Hebrew etc. Turks in the Netherlands can also be divided into such groups. I would
like to know to which group your mother and your father originally belong “
(“U bent in Turkije geboren, en/of (één van) uw ouders zijn in Turkije geboren. Zoals u weet kent men
verschillende bevolkingsgroepen in Turkije, zoals Turken, Koerden, Arabieren, Laz, Georgian,
Grieken, Armeniërs, Joden enz. Tot welke van deze groepen is uw moeder/ vader oorspronkelijk
afkomstig?”)
01 Turkish
02 Kurdish
03 Arabic
04 other (specify) …………………….
As already discussed, the validity of the questions proposed here is still unknown. Its validity should
therefore be tested before the use of this specific question can be recommended in health (care)
studies.
Other indicators
As already discussed, the Turks and Kurds has lived in Turkey since the 7th century. As a
consequence of this long period, most of the Turkish ánd Kurdish people will consider Turkey as the
geographic origin of their ancestors. This implies that geographic origin of the ancestry is not a valid
indicator to make a distinction between the Turkish and Kurdish population.
In Turkey “mother tongue” of the respondent, husband, parents and parents-in-law has been used in
nationwide health and demographic surveys within the last decade, to distinguish different ethnic
groups4. This has shown to be a sufficient proxy for ethnic groups in Turkey: in one specific study
information on the mother tongue of the respondent (in that case ever-married women of ages 1549) and her husband were sufficient to determine in which ethnic group the respondent or her
husband fell into (Dündar, 1998 in Hancioglu & Koc 1999). In order to prevent people who speak
Turkish as mother tongue but whose parents have Kurdish (or dialects) as mother tongue to be
wrongly classified as Turkish, also the mother-tongue of the parents of the respondent should be
asked for (Gündüz-Hoşgőr & Smits 2002). People are classified as Turks if their own mother-tongue
as well at that of at least one parent is Turkish. People with Kurdish (or one of its dialects, such as
Kirmanc, Zaza and Soran) as their mother tongue, as well as people both of whose parents have
Kurdish (dialects) as their mother tongue are then defined as Kurdish (Gündüz-Hoşgőr & Smits
2002).
Although studies in Turkey show that mother tongue is a valid indicator of ethnic groups, for the
immigrant groups of Turkish origin living in the Netherlands, this indicator might lose its value, in
particular for later generations and younger age groups.
The questions on mother tongue could be formulated as follows:
4 Kurdish and its dialects are closely related to Old Persian and thus one of the branches of the Indo-European family of
languages. Turkish is from an entirely different family of languages, the Altaic (Altay-Ural).
18
“What is your mother-tongue?” (“Wat is uw moedertaal?”)
“What is the mother-tongue of your father/mother?” (“Wat is de moedertaal van uw
vader/moeder?”)
01 Turkish
02 Kurdish and dialects (Kurmanci, Soran, Zaza etc.)
03 Arabic
04 other (specify) …………………….
III.2.2 Surinam
The native population of Surinam are the Carib Indians, who came into contact with the Spanish, the
first colonists of Surinam, in the 15th century. The other populations of Surinam all have different
roots. These include the Creole, the Hindus, the Chinese and the Javanese.
In the second half of the 17th century Surinam was occupied by the Dutch. During this period, slaves
were imported from Africa. In Surinam, they became the ancestors of the Creoles, i.e. Surinamese
of African or of mixed European-African descent. After the abolishment of slavery in the second half
of the 19th century (1863), it was decided that the ex-slaves would work another ten years in the
plantations under state-control. After this period, the majority of the Creoles started their own smallscale agriculture. At the beginning of the 20th century, due to the failure of small-scale agriculture,
the Creoles left for urban areas in Surinam. They now live mostly in urban areas and are also
concentrated in the districts of Coronie and Para. The socio-economic status of Creoles in Surinam
is diverse (Janoenandansing & Koefoed 1991, van Niekerk 2000).
The first Hindustanis from India, which was then a British colony, arrived in Suriname in the second
half of the 19th century to work as contracted labour in the plantations, initially for five years. During
the initial phase, Hindustani labourers whose contracts had expired had to return to India. At a later
stage, it was possible to get an extension of the contract or the right to permanent stay. Due to the
relative isolation of the plantation workers, and the freedom they had outside the working hours, the
socio-cultural roots of the Hindu population grew with no obstacles. Because this group differed
strongly with respect to norms, values, religion and culture from already existing populations in
Surinam, they were initially isolated from these populations. Within a short period of time, the
Hindustanis became vital for small-scale agriculture in the rural areas, and the government offered
them permanent stay at the end of the 19th century (1895). According to the population census in
1971, they form the biggest population group in Surinam. They belong mostly to two big religious
groups: Hinduism en Islam. The majority of the Hindustanis still live in rural areas. Due to the
favourable social and economic development of the group, the isolation of the Hindustanis was
broken after the Second World War. They now participate fully in the Surinamese society. The
majority of small-trade, services, and transport companies are led by the Hindustanis
(Janoenandansing & Koefoed 1991).
The first Chinese came to Surinam in 1853 from Java. Between 1853 and 1870, more than 2000
Chinese from China (mostly North China) were contracted as labourers. After this period no more
Chinese labourers were recruited because it was expensive. However, as the original labourmigrants did not return to China but started their own living (especially in trade and in the services
19
sector), migration due to family-reunion began. The family reunion of the Chinese in Surinam still
continues; even today, an important percentage of the Chinese in Surinam has been born in China.
According to the 1971 Census, the number of Chinese in Surinam is 6400. This group is mostly
strongly oriented to the culture of the country of origin. Previously it was common that the elderly
Chinese migrated back to China, but this trend is decreasing (Janoenandansing & Koefoed 1991).
In the 19th century, there was a decline in the immigration of Hindustanis, at this time landowners
were dependent on the British who were critical to the treatment of contracted labourers from India.
This, coupled with the fact that once their contracts expired Hindus began working for themselves,
led to an acute shortage of agricultural labourers. Contracting labourers from Java, previously
“Nederlands-Indië”, was seen as an option. The first Javanese came to Surinam in 1890 and this
immigration lasted till 1939. Until 1930’s almost all were working in plantations. As a result of the
world economic crisis and the Second World War, many plantations were closed, and the Javanese
started with their own small-scale agriculture. During the Second World War and in the later period,
the Javanese also started to settle in the urban areas or in the “bauxite” industry areas. In 1971,
there were 58900 Javanese in Surinam (Janoenandansing & Koefoed 1991).
It becomes clear from this short overview, that the different population groups in Surinam all have
different roots: they have migrated to Surinam from different regions of the world. Although the
Creole are, by definition, a mixed group, and despite the fact that the different groups increasingly
mix with each other (especially among the youth), there are as many Surinamese ethnic
communities in the Netherlands as there are ethnic groups in Surinam. The Creoles, Hindustani,
Javanese and Chinese have their own organizations, events and meeting places, and can therefore
still clearly be distinguished from each other. The Creole, Hindustani etc. are therefore generally
considered as different ethnic groups (van Niekerk 2000).
Indicators to distinguish between Hindustani, Creole etc. in the Surinamese population
The size of the different Surinamese ethnic groups in the Netherlands is estimated to be as follows:
50% Hindustani origin, almost 40% Creole origin, 10% other (including 7% Javanese) (van Niekerk
2000). Which indicators could be used to distinguish these groups from each other in health(care)
research? In line with the aforementioned proposal, we will first propose a question on self-identified
ethnic groups. Secondary, we will explore the possibilities to ask for the geographic origin of a
respondent’s ancestor as well as mother tongue.
Self-identification
We recommended self-identification questions to distinguish between ethnic groups within the
Surinamese population. Again, it should be mentioned however, that such a question should be
phrased as objective as possible, in order to avoid contamination with the concept of ethnic identity.
The following phrase could be used.
20
“ You were born in Surinam and/or (one of) your parents were born in Surinam. As you know, there are
different population groups in Surinam: the Hindu, Creoles, Javanese and Chinese population and
other population groups. Surinamese people in the Netherlands can be also divided into different
population groups. I would like to know to which group your mother/your father originally belong.
(“U ben in Suriname geboren, en/of één of uw beide ouders zijn in Suriname geboren. Zoals u weet
kent men verschillende bevolkingsgroepen in Suriname: Hindoestanen, Creolen, Javanen, Chinezen
en andere groepen. Surinamers in Nederland zijn ook in verschillende bevolkingsgroepen te delen. Uit
welke van deze groepen is uw moeder/ uw vader oorspronkelijk afkomstig?” )
01
Hindustani
02
Creole/Afro Surinamese
03
Javanese
04
Chinese
05
Indians
06
Other (specify) ………………………………
Other indicators
The approach of the identification of ethnic groups within the Surinamese population that is
conceptually most consistent with the concept of ethnic origin, is to ask for the region of birth of
ancestry (voorouders). In studies in which there is room for extra questions for the identification of
ethnic groups within the Surinamese population, asking questions on the region from which the
ancestors originate might be useful. Such a question could be phrased as follows:
“Which part of the world do the ancestors of your mother / father come from?” (“Uit welk wereld deel
komen de voorouders van uw moeder /vader?”) (you might thick one more than one box/meerdere
antwoorden mogelijk)
01 Netherlands
02 Surinam
03 Europe
04 Africa
05 India
06 Java
07 China
08 North/South America (including Caribbean area)
09 Other (specify) ………………….
Although, due to the colonial past Dutch has been used as the “mother tongue” since generations
among all ethnic groups, the ‘second’ language differs between ethnic groups. This is Sranan for the
Creole, and primarily Sarnami for the Hindustani for example. Unlike the case of the Turks, however,
mother tongue is not a valid indicator to distinguish between Surinamese ethnic groups. One of the
reasons is that many young people do not speak their ‘ethnic specific’ language anymore.
Nevertheless, language is sometimes used in combination with other criteria to discriminate between
ethnic groups, e.g. in the study on Social Position and Use of Services of the SCP/EUR (Martens
1999, see also chapter IV). Such a question could be phrased as follows (SPVA 1988):
21
“What other language than the Dutch, do your parents mostly speak with family and friends?”)
(“Welke andere taal dan het Nederland, spreken uw ouders meestal met familie en
vrienden?”)
01
02
03
04
05
06
07
no other language/Dutch only
Surinaams/Sranan
Sarnami
Javanese
Chinese
Indian language
other (specify)…..
III.2.3 Morocco
Morocco was originally inhabited by Berbers who are the native population of North Africa.
References refer to them date from about 3000 B.C (www.arab.de; 28.03.2002). In the 1st century
A.D, Morocco became a province of the Roman Empire. After successive invasions, the Islam was
brought by the migration of Arabs in the 7th century (682). The Arabs and the Berbers are the largest
population groups in Morocco. The question that is central to this section is whether they should be
considered different ethnic groups.
Although both groups have different geographic origins, and the Berber and Arabic language clearly
differ from each other, there seems to be consensus that making a distinction between the Arabicspeaking Moroccans and Berber-speaking Moroccans as separate ethnic groups is problematic. The
main reason is that, during the course of centuries, the Berber and the Arabic populations in
Morocco became highly mixed with each other by internal migration and inter-ethnic marriages. In
this respect, a comparison could be made with the Dutch population with distant Belgian or French
ancestry. These are also not defined as separate ethnic groups in the Netherlands. The interaction
and mixing of the Berber- and Arabic speaking Moroccan groups have been going on since the 7th
century. This, for example, expresses itself in the fact that it is quite common that people with Arabic
ancestry speak Berber while living in Berber-speaking areas and switch back to Arabic if they move
to an Arabic-dominant region. Thus, it seems that the region of residence is the most dominant
factor in speaking a certain language or practicing certain customs, rather than where the roots of
the grandparents lie (Obdeijn e.a. 1999). This has thus led to the existence of a Moroccan culture
with Arab and Berber influences. This is why there is a tendency to consider these population
groups as different “tribes” in Morocco rather than two different ethnic groups (Otten & de Ruiter,
1991). We will therefore not propose in this report additional indicators to distinguish between both
groups.
By saying that Berber and Arabic Moroccans should not be considered as separate ethnic groups,
we do of course not want to deny that there might be differences between both groups, e.g. with
respect to culture, which could be important in understanding the health status and use of health
care of the Moroccan population in the Netherlands. Furthermore, despite the fact that, at a
population level, Arabs and Berbers could not be seen as separate ethnic groups, the Arab/Berber
distinction might be relevant for individuals who belong to that population. About 70% of the
Moroccan population come from the Rif-area, where most of the population is Berber-speaking
22
(Otten & de Ruiter 1991). Empirical studies show, among others, differences in the patterns of
bringing up children between the Arab- and Berber speaking population (Pels 1998). In addition,
evidence from Belgium shows that there are also differences in perceptions of health and attitudes
towards use of health services (de Muynck et al 1995). There are, however, also differences within
the Berber population: the Berbers living in the South of Morocco (Tashelhit speaking Berbers) have
different (cultural) characteristics than Berbers living in the North (Tarifit speaking Berbers).
III.2.4 Dutch Antilles and Aruba
The islands of Aruba, Bonaire, Curaçao, St. Maarten5, Saba and St. Eustatius in the Caribbean Sea
form the Dutch Antilles and Aruba and still form a part of the Dutch Kingdom. The Dutch Antilles lie
geographically close to Surinam, which sometimes causes the people to be classified as a single
ethnic group, even in the Netherlands (van Hulst 2000). Although these two regions were both
colonized by the Netherlands, their historical, social, economic and cultural past strongly differ from
each other. Therefore it is still advisable to make a distinction between these two groups (Narain
1991).
The first Dutch colonists settled in the Caribbean in beginning of the 17th cc., initially in Tobago,
followed by St. Maarten and Anguilla. This was followed by Curaçao, Bonaire, Aruba, and later by
St. Eustatius, Saba and St. Croix. This invasion was not permanent. During the struggle between the
colonial powers, the islands often changed hands between the Spanish, Portugese, French, English
and the Dutch. Finally the Netherlands has kept six islands. St. Eustatius was favourite among the
Europeans as a trade centre. After the settlement of the Dutch, tobacco plantations were established
in the island and until late 18th century, this island was an important trade centre. Curaçao was the
regional centre of the slave trade, while Bonaire became an important source of wood and salt. After
the abolishment of slavery in the second half of the 19th century, the Antillean economy became
oriented on trade. In 1954 the islands received an autonomous status within the Dutch Kingdom as a
political unity with their own governance. Since 1986, Aruba has separated herself from the rest of
the Dutch Antilles and has established a separate “staatsverband” with the Netherlands. The debate
over the total independence of the Dutch Antilles is still ongoing (Narain 1991).
The native population of these islands consisted of Arawak Indians. In Curaçao, the majority of the
native population was deported by the Dutch. Therefore, in this island one cannot find much of the
native Indian culture. The population of Curaçao originates to a big extent from African slaves, who
were imported later. In Aruba and to a less extent in Bonaire, the Indian-origin of the population is
relatively more dominant. In the 20th century however, there was substantial immigration from the
Dutch Windward Islands, from other Afro-Caribbean islands, and since the 1980s again from the
mestizo (mixed Indian and European continent). The current population of Aruba is consequently
formed of two major ethnic groups, one mestizo, the other Afro-Caribbean. Miscegenation between
the two is still at a modest level. This implies that the population of the two islands differ with respect
to the ethnic background of their population, as the Curaçoan population is overwhelmingly AfroCaribean (Alofs et al. 1997).
5 St. Maarten is divided into a Dutch and French region. The northern part of the island is French territory.
23
Indicators to distinguish ethnic groups within the population of the Dutch Antilles/Aruba
The majority of the migrants from the Caribbean in the Netherlands originate from Curaçao, followed
by Aruba(ns). Immigration from the other islands is minimal. According to the CBS figures, in 2001
there were about 117,000 Antilleans and Arubans in the Netherlands. Because the Dutch Antilles
and Aruba are officially still a part of the Dutch Kingdom, Antilleans and Arubans have Dutch
nationalities. They form the only ethnic minority group which can immigrate to the Netherlands
without restrictions (van Hulst 2000).
Given the different ethnic background of the Arubans on the one hand and people from Curaçao on
the other, as well as different ethnic groups from Aruba, how could both ethnic groups be
distinguished in health (care) research?
Self-identification
In line with the general recommendations that were mentioned before, the question on self-identified
ethnic group could be phrased as follows:
“You have some roots in the Dutch Antilles or Aruba. As you know, these islands comprise different
population groups: the Indian, the Afro-Caribbean etc. I would like to know which group your mother/
father originally belong”
( “U heeft een relatie met de Nederlandse Antillen of Aruba. Zoals u weet leven in dit gebied
verschillende bevolkingsgroepen, waaronder de Afro-Caribische en de Indianen. Uit welke van deze
groepen is uw moeder/vader oorspronkelijk afkomstig?”)
01. Indian
02. Afro-Caribbean
03. European
04. other (specify)
Other indicators
The inhabitants of the different islands overlap with each other (e.g. people with African ancestors
can be found in Aruba as well as Curaçao). This implies that geographic origin of a respondent’s
ancestor cannot be used to discriminate between the populations of the different islands. It can,
however, be used as an indicator of the different ethnic groups within the Aruban population. Such a
question could be phrased as follows:
“From which part of the world does the ancestry of your mother / father originally come from?”
(“Uit welk werelddeel zijn de meest verre voorouders van uw moeder / vader afkomstig?”)
01. Europe
02. Africa
03. ‘Indian’
04. Other (specify)
In spite of the colonial past it is clear that among the majority of the people of the Antilles and Aruba
Papiamentu (in the Leewards) or English (in the Windwards) has been used as the “mother tongue”
since generations. Therefore, mother tongue is a good indicator to distinguish Antilleans and
Arubans from the Dutch, but not to distinguish them among themselves.
24
III.3
Identification of the third generation
As indicated before, the CBS standard classification of ethnic groups fails to identify the third
generation of Dutch residents of immigrant descent. In this section, we will explore whether it might
nevertheless be necessary to identify the third-generation in health (care) studies (III.3.1). In
addition, we will propose indicators that can be used to make such a distinction, if necessary
(III.3.2).
III.3.1 Significance of the third generation
It is controversial among Dutch scientists and policy-makers whether the third generation of
foreigners in the Netherlands should be identified. The Dutch Central Bureau of Statistics (CBS)
does not identify the third generation of foreigners in its registrations. Those who are born in the
Netherlands to parents who are also born in the Netherlands are then defined as “Dutch”, instead of
third generation foreigners. Therefore nation-wide figures regarding the precise size of the third
generation are not available. However, the CBS has calculated estimates of the number of the third
generation for non-western population. These are based on population registers, and expressed as
an “upper” and a “lower” limit. These figures show that third generation is indeed already present in
the Netherlands (Alders & Keij 2003) (Table III.1), although the numbers are probably much smaller
than frequently suggested in debates on this issue. In addition, it is a fast growing population, as in
three years time, this population grew with more than one third (Alders & Keij 2003).
Alders and Keij (2003) estimate that at January 1st 2003, between 34,000 and 36,000 inhabitants of
the Netherlands had at least one grandparent that was born in a non-western country, and could
therefore be classified as a third generation ‘allochtoon’. Table III.1 illustrates (for the subgroup that
have all grandparents born in non-western countries) that the Surinamese comprises the largest
group among the third generation.The Turkish and Moroccan third generation is much smaller.
(http://www.staline.cbs.nl, February 2004.
Table III.1
Third generation with grandparents in Turkey, Morocco, Suriname or the Dutch Antilles and Aruba,
total, January 1, 2003
Country of birth
One or more grandparents
Two of more grandparents
Three or four grandparents
Four grand parents
Turkey
Morocco
2462
1529
655
626
1369
651
91
79
Suriname
15179
53641
480
330
Dutch
Antilles
and Aruba
6320
588
8
3
Source: CBS, Statline
Local studies provide more specific information on the size of the third generation. The Research
and Statistics Bureau for (municipality of) Amsterdam defined the third generation babies at birth for
25
the years of 1993 and 1998, based on data from the population registers. A child whose mother is a
resident with immigrant descent (allochtoon), but who himself/herself registered as Dutch is defined
as belonging to the third generation (Onderzoek en Statistiek, 2000: pp: 490-492). Figure III.1 shows
that the percentage of babies belonging to the third generation is quite low among the Turks and
Moroccans, but quite high among the South-Europeans in particular (28%). The Surinamese and
Antilleans are in between (www.onstat.amsterdam.nl;15-04-2002).
Within the context of a pilot study at the children’s outpatient department of the Academic Medical
Centrum in Amsterdam, the ethnic background of the child, parents, and grandparents was
registered. In this pilot, about 5% of the 147 children with immigrant descent (aged 0 to 16) belonged
to the third generation (Doddema 2004).
Figure III.1. Third generation ethnic minorities at birth (%): Amsterdam 1993 and 1998
source: www.onstat.amsterdam.nl; 15-04-2002
The figures presented above indicate that the number of immigrants that belong to the third
generation might be significant for specific types of studies, especially if young immigrant people are
the focus. This does not automatically imply, however, that it is always necessary to distinguish the
third generation in health(care) studies. This of course depends on the characteristics of this
generation, such as the extent of integration. There is evidence that suggests that the socioeconomic integration of at least the third generation Moluccans into the Dutch society has stagnated
(Smeets & Veenman 2000). Some take this as an indication that the integration of third-generation
of other ethnic-minority groups will also stagnate, such as that of Turkish and Moroccan groups;
while others argue that it is important to avoid generalisations (Veenman 2002).
26
In the context of health and health care, the relevance of identifying the third generation of course
also depends on the health status and use of health care of this group, as compared to that of the
first and second generation as well as the native Dutch. This issue will be dealt with in chapter IV.
III.3.2 Indicators to identify the third generation
In cases where the research questions require the identification of third generation immigrants, how
should this identification be done?
Country of birth of the grandparents
Starting from the country of birth indicators (of the respondent and his parents), the third generation
can best be identified by collecting information on country of birth for the grandparents as well. This
method is in accordance with international recommendations (Aspinall 2001). We therefore
recommend that “country of birth of grandparents” is added to the CBS standard classification for
research purposes in surveys as the most objective and valid solution to identify the third generation.
This implies that country of birth of the father/ mother of the mother of the respondent, as well as the
country of birth of the father/mother of the father of the respondent should be asked. These
questions of course need to be asked to those who were born in the Netherlands and whose parents
were also born in the Netherlands only.
We of course recognise the fact that these four questions about the country of birth of the
grandparents also introduce some complexity and extend the questionnaire in terms of time and
labour. Moreover, we do not know yet whether these questions yield valid answers (can people
really answer these questions?). Moreover, the drawback of this solution is the fact that no
distinction can be made between ethnic groups that share country of birth (such as the Hindustani
and Creole Surinamese). This implies that further questions should be added on the selfidentification of the ethnic groups the (grand)parents of people belong to. Further piloting of these
type questions is to be recommended before a final conclusion can be drawn on the validity and
applicability of the country of birth criteria for grandparents.
Self-identification
Related to the drawbacks of the country of birth criteria of the grandparents, sometimes another way
of distinguishing the third generation is recommended. In its review of the country of birth criteria, the
Institute of Social-Economic Research (ISEO) suggests to complement the current country of birth
criteria with a question on “self-identification” in order to identify the third generation (Heeten &
Verweij 1993).
The advantage of one ‘self-identification’ question instead of four extra country of birth indicators is
clear of course, although it should be realised that the recommendations of the ISEO apply to the
routine registration of ethnicity in the first place. Asking for country of birth of the grandparents might
in that context be more problematic than in the context of an incidental study.
As already discussed, the drawback of a question on self-identification is the risk of introducing the
element of (perceived) ethnic identity. Therefore, we recommend to phrase such a question as
objective as possible:
27
“ You have told us that you and your parents were born in the Netherlands. As you know, there are
different population groups in the Netherlands: native Dutch and those who originally emigrated from
other countries, such as Morocco, Turkey, Surinam, the Dutch Antilles and Aruba. I would like to know
to which group your mother/father originally belong?”
(“U heeft ons verteld dat u en uw ouders in Nederland zijn geboren. Zoals u weet kent men
verschillende bevolkingsgroepen in Nederland: autochtone Nederlanders, en mensen die uit andere
landen geëmigreerd zijn, waaronder Marokko, Turkije, Suriname, de Nederlandse Antillen en Aruba.
Uit welke van die groepen is uw moeder/vader oorspronkelijk afkomstig?”)
01. Dutch
02. Moroccan
03. Turkish:
. Turks
. Kurds
04. Dutch Antilles and Aruba:
. Indian
. Afro-Caribbean
. European
05. Surinamese:
. Hindustani
. Creole/Afro Surinamese
. Javanese
. Indians
. other Surinamese (specify)
06. Other (specify): …………………………………………….
28
Chapter IV Associations between additional indicators for ethnic origin and
health (care)
In chapter III we recommended indicators, additional to country of birth, to identify ethnic groups
within the Turkish, Surinamese and Antillean population, as well as the third generation with
immigrant descent. In this chapter, we will assess whether this further distinction of ethnic groups
has relevance for health (care). This will be done by studying whether people from different ethnic
groups within the Turkish, Surinamese and Antillean population differ in health status or use of
health care. These research question have been answered on the basis of secondary analyses of
available databases (chapter IV.1). In addition, it will be analyses whether people from the third
generation immigrants differ from the first and second generation immigrants or the native
population as far as their health and use of health care is concerned (chapter IV.2).
IV.1 The health status of ethnic groups that share country of birth
IV.1.1 Turkey
In the previous chapter, we argued that the Turkish population living in the Netherlands consists of
different ethnic groups, of which the Turks and Kurds are the largest. Self-identified ethnic origin was
recommended to make a distinction between these groups. Other possibilities include language and
geographic origin of the ancestors. Two databases were found that allow for an empirical analysis of
the relevance of this further distinction for health (care) for the Turkish population living in the
Netherlands. These include:
1. Survey on Social Position and Use of Services Among Dutch Residents with Immigrant Descent
(SPVA), 1998: a survey among the four major immigrant groups, carried out by the Erasmus
University (ISEO) and the Social and Cultural Planning Bureau (SCP).
2. Study on emotional and behavioural problems among Turkish immigrant children (a.o. BengiArslan et al. 2002).
The design and datacollection of each of these studies are described in box 1 and 2. The results of
the secondary analyses that are carried out for this report will be described below.
Box 1 Survey on Social Position and Use of Services Among Dutch Residents with Immigrant
Descent (SPVA), 1998 (Source: http://www.iseo-eur.com/ISEO/index.htm; 12 july, 2002)
Since the end of 1980’s, SPVA surveys are conducted by the Institute for Sociological-Economic
Research (ISEO) of the Erasmus University in Rotterdam. The recent surveys are conducted in
collaboration with Social and Cultural Planning Bureau. These surveys include the four biggest
ethnic minority groups in the Netherlands: Surinamese, Moroccan, Turkish, and people from the
Dutch Antilles and Aruba. The SPVA-98 contains information about 7.500 households, where more
than 1.600 Turkish, almost 1.500 Moroccan, and more than 1.800 Surinamese, and almost 1.100
Antillian and 1.500 native Dutch households have been interviewed. In addition, SPVA 1998
contains data on more than 7000 family members living in the household. The survey contains
information on the following topics: migration history, household, education, work-history, income,
housing, social contacts, fluency in Dutch language, health, contacts with neighbours, and
integration. The data on health includes the measurement of self-perceived general health (“How do
you perceive your health in general?”) and the number of contacts with the general practitioner in the
past two months.
29
Box 2 Study on psychiatric health among the parents of Turkish immigrant children
(source: Bengi-Arslan et al. 2002)
This study included 1218 Turkish children, aged 4-18, and their parents, randomly selected from
municipal registers of the Hague and Rotterdam. Of these 833 decided to participate. The data
collection took place in 1993 and 1994. It consisted of questionnaires, which were orally
administered in Turkish. These included a.o. the General Health Questionnaire (GHQ) 28-item
version, developed to detect cases of affective disorder among community and primary samples.
Ad 1. SPVA 1998
The SPVA includes two health related measurements, i.e. perceived general health status and use
of general practitioner. Those who were born in Turkey or have at least one parent born in Turkey
were classified as Turkish (n=1613). 118 of these were classified as Kurds on the basis of selfidentification (“To which population do you belong?”) as well as language. The remaining 1495
respondents were classified as Turkish.
The differences in the health indicators between Turks and Kurds have been assessed, using
logistic regression, controlling for age and sex. The results are shown in Table 1. The results
indicate no differences in self-perceived general health or use of general practitioner between the
Turks and the Kurds.
Table 1 Perceived general health and use of general practitioner by ethnic background among the
Turkish population in the SPVA, Odds Ratio and 95% Confidence Intervals (CI) a
Health indicator
Odds Ratio [95% Confidence Interval]
Turks (n=1495)
Kurds (n=118)
Perceived general healthb
1.00
1.17
Use of general practitionerc
1.00
1.05
a Results of logistic regression analysis, controlling for age and sex
b Risk of a less than good perceived general health versus (very) good
c Risk of having 2 or more contacts in the past two month versus having 0 or 1 contact.
[.76-1.80]
[.69-1.60]
Ad 2. Study on psychiatric health among the parents of Turkish immigrant children
This datacollection of this study of Crijnen et al. (Erasmus Medical Centre) took place in 1993 and
1994 among 833 Turkish children and their parents. The datacollection included the General Health
Questionnaire 28-item version, which is used to identify minor psychiatric disorders (Bengi-Arslan et
al. 2002). The GHQ consists of four seven-item scales measuring the following constructs: somatic
symptoms, anxiety/insomnia, social dysfunction and severe depression, in addition to a total score of
all items combined. As expected, most of this study population spoke Turkish, and a minority (108
respondent) had fair or (very) good fluency in Kurdish. The analyses that were carried out for the
present report show no associations between fluency in Turkish or Kurdish one the one hand, and
GHQ scores on the other hand (Table 2).
30
Table 2 Association between fluency in Turkish/Kurdish and GHQ among 833 parents of Turkish
children (results of linear regression analyses) a
Fluency in Turkishb
Fluency in Kurdishb
R-squared
p-value
R-squared
p-value
value
value
Somatic symptoms
.000
>.10
.000
>.10
Anxiety/insomnia
.000
>.10
.000
>.10
Social dysfunction
.000
>.10
.001
>.10
Severe depression
.000
>.10
.001
>.10
Total GHQ-28 score
.000
>.10
.000
>.10
a unpublished results; analyses were carried out on request by Gonneke Stevens, Erasmus MC
b categories: no, moderate, fair, good, very good.
Results of a survey among the Turkish and Kurdish population living in Turkey
The studies of which the results were shown above, carried out among Turkish people living in the
Netherlands, indicate no differences in health status between the Turks and the Kurds. Recent
studies among the Turkish and Kurdish-speaking population living in Turkey, however, do indicate
important differences in health, for a number of health indicators (Koc & Hancioglu 1999, Icduygu et
al, 1999). Table 3 shows the results of a survey among women aged 15-49 and their children
(Turkish Demographic and Health Survey) which was carried out in 1998. This survey included the
following health (care) indicators: use of antenatal care, pregnancy outcome, place of delivery,
complications of delivery, postpartum amenorrhoeic, prevalence of diarrhoea, nutritional status of
the children, breastfeeding, vaccination. For almost all of these indicators, large differences were
observed between the Turkish and the Kurdish speaking population (Table 3).
Table 3 Health indicators by ethnic background among Turkish women living in Turkey, aged 15-49a
Health indicator
Percentageb
Turkish (n7000)
Kurds (n1200)
% of women
…without prenatal care
21.9
58.8
…delivering at home
15.3
57.1
…with assistance at delivery of relative only
3.0
21.0
…with no complications of delivery
46.9
31.9
…with postpartum amenorrhoeic 7-9 months
12.6
28.8
after delivery
% of children
….stillbirths
… without breastfeeding 4-6 months after birth
… without vaccination
… height for age below 3 SD
… weight for age below 3 SD
… under 5 with diarrhoea in previous 2 weeks
1.3
27.0
1.2
3.8
.9
27.6
1.6
8.8
12.3
14.0
3.2
35.2
a
unpublished results; analyses were carried out on request by Attila Hancioglu, Associate Professor,
Hacettepe University, Institute of Population Studies, Ankara
b Unstandardized (as the Kurdish speaking women were on average younger (results not shown),
the observed worse health status of the Kurdish population could not be accounted for by age),
weighted for differences in sample size between regions.
Generally, the Kurds appear to be less healthy than the Turks and received less care than the Turks.
These associations were found in all regions in Turkey (West, South, Central, North, East) (figures
31
not shown). As the regions substantially differ with respect to socio-economic development, this
seems to suggest that the disadvantaged position of the Kurds could not entirely be traced back to
their, in general, worse socio-economic position.
Because of the differences in a.o. the health care system between Turkey and the Netherlands,
these differences among the Turkish and Kurdish population in Turkey could not automatically be
generalized to the Turkish immigrant population living in the Netherlands. If, for example, the ethnic
differences in Turkey can be largely explained by language problems, one might expect the ethnic
differences in the Netherlands to be smaller, as the language problems here apply to both ethnic
groups. We nevertheless might conclude from these results that there is a possibility that the Turkish
and Kurdish population living in the Netherland differ in health status. Further research should
provide more insight into this issue.
IV.1.2 Surinam
Two datasets were found that allow for an empirical analysis of differences in health (care) between
various ethnic groups in the Surinamese population in the Netherlands. These include:
1. Survey on Social Position and Use of Services Among Dutch Residents with Immigrant Descent
(SPVA), 1998: a survey among the four major immigrant groups, carried out by the Erasmus
University (ISEO) and the Social and Cultural Planning Bureau (SCP).
2. SUNSET-study (SUrinamese in the Netherlands: Study on EThnicity and health): an
epidemiological study of the Dept. of Social Medicine and Dept. of Internal Medicine of the
Academic Medical Centre (AMC).
Information on these datasets can be found in box 1 and box 3 respectively.
Box 3 SUNSET study: Surinamese in the Netherlands: study on health and ethnicity
(SUNSET)
SUNSET is a epidemiological study among the Surinamese population in the South East of
Amsterdam, conducted by the Department of Social Medicine of the Academic Medical Center of
University of Amsterdam (AMC), in collaboration with several Clinical departments of the AMC,
particularly Internal medicine, as well as the Amsterdam Municipal Health Service. The main aim of
SUNSET is to describe the cardiovascular risk profile of the Surinamese population in Amsterdam. It
consists of a face-to-face interview and a (complementary) physical medical check. For this study,
an a-select sample has been drawn from the municipal register, in four neighbourhoods in the
(south) east of Amsterdam. The study population consists of 1500 residents of Surinamese origin
between the ages of 15 to 60 and a reference group of 500 residents of native Dutch origin. The
face-to-face interviews contain information on the following topics: health and life-styles such as
smoking, alcohol consumption, nutrition and physical exercise. The physical medical check consists
of measurement of weight, length and blood-pressure, having a blood- and urine sample.
Ad 1. SPVA 1998
The SPVA includes two health related measurements, i.e. perceived general health status and use
of general practitioner. Those who were born in Surinam were divided into ethnic groups on the
basis of self-identification (“To which ethnic group do you belong?”) and language.
32
As can be seen in Table 4, the ethnic groups within the Surinamese population differ statistically
significantly in health status and the use of the general practitioner, with the Hindustani population
being less healthy than the other ethnic groups.
Table 4 Perceived general health and use of general practitioner by ethnic background in the
Surinamese population, SPVA 1998, Odds Ratio and 95% Confidence Intervals (CI) a
Ethnic group
Odds Ratio [95% Confidence Interval]
Perceived general
Use of general
healthb
practitionerc
Hindustani (n=659)
1.00
1.00
Creole (n=803)
.46
[.36-.60]
.64
[.50-.82]
Javanese (n=129)
.61
[.38-.97]
.53
[.32-.80]
Chinese (n=18)
.23 [.05-1.15]
.01 [.00-103.37]
Other (n=221)
.55
[.38-.81]
.47
[.31-.70]
a Results of logistic regression analysis, controlling for age and sex
b Risk of a less than good perceived general health versus (very) good
c Risk of having 2 or more contacts in the past two month versus having 0 or 1 contact.
Ad 2 SUNSET study
The main aim of the SUNSET study is to obtain insight into the cardiovascular risk profile of the
Surinamese population. The datacollection of the SUNSET study was carried out in 2001-2003,
among a representative sample of the Surinamese and native Dutch population in Amsterdam South
East, aged 15-60 years old. The Surinamese population consists of two main ethnic groups, i.e. the
Hindustani (n300), and Creoles (n700). The ethnic groups were identified by means of the
geographic origin of the ancestors of the respondent. The results of this SUNSET study indicate a
similar picture for perceived general health as the SPVA did, as far as the difference between Creole
and Hindustani is concerned. The Odds Ratio (controlling for age and sex) for Creole appeared to
be .70 (with the Hindustani as the reference category; confidence interval .52-.93). Also the
prevalence of cardiovascular risk factors such as diabetes, high blood pressure and body mass
index, differs between both populations (Table 5).
Table 5 Biomedical risk factors for cardiovascular disease by ethnic background in the Surinamese
population (35-60 years old), SUNSET study, Odds Ratios and 95% Confidence Intervals (CI) a
Health indicator
Odds Ratio [95% Confidence Interval}
Hindustani
Creole
Diabetes b
8.36 (5.30 - 13.17)
3.37 (2.16 - 5.26)
High blood pressurec
3.30
(2.33 - 4.67)
3.13 (2.29 - 4.26)
Body Mass Indexd
1.92
(1.41 - 2.61)
2.83 (2.15 - 3.71)
a Results of logistic regression analysis, controlling for age and sex
b Based on data from medical examination. Diabetes defined as fasting blood glucose >= 7.0
c Based on data from medical examination. High blood pressure defined as 90/140
d Based on data from medical examination. BMI defined as weight/length 2
In addition, ethnic differences were found in the health-related behaviour of the two Surinamese
ethnic groups. Examples are given for smoking and alcohol consumption (Table 6).
33
Table 6 Health-related behaviour by ethnic background in the Surinamese population (35-60 years
old), SUNSET study, Odds Ratios and 95% Confidence Intervals (CI)a
Health indicator
Odds Ratios [95% Confidence Intervals]
Hindustani
Creole
Smoking cigarettes
0.51 (0.38 - 0.68)
0.80
(0.63 - 1.01)
Never drink alcohol
0.08 (0.05 - 0.11)
0.23
(0.16 - 0.32)
a Results of logistic regression analysis, controlling for age and sex
.9%
IV.1.3 Dutch Antilles and Aruba
No dataset was found that allows for an empirical analysis of differences in health (care) between
various ethnic groups in the population from the Dutch Antilles and Aruba living in the Netherlands.
To our knowledge, there are only data available on the health status by geographic origin (Aruba,
Curaçao, other Antillean Islands). These data come from the Survey on Social Position and Use of
Services Among Dutch Residents with Immigrant Descent (SPVA) (1998) (see box 1). As previously
discussed, these are not a valid indicator of different ethnic groups, as for example people with
African ancestors can be found in Aruba as well as in Curaçao. As, however, people from Curaçao
more frequently have an Afro-Caribbean background as compared to those from Aruba, these data
might nevertheless give a a rough indication of potential differences.
The data in Table 6 show differences in perceived general health, with people from Curaçao and the
other Antillean islands reporting a worse health status than people from Aruba. In addition, people
from Curacao and the other Antillean islands reported a higher use of the general practitioner,
although these differences were not statistically significant.
Table 7 Perceived general health and use of general practitioner by ethnic background among the
immigrant population of the Dutch Antilles and Aruba in the SPVA, Odds Ratio and 95% Confidence
Intervals (CI)a
Ethnic group
Odds Ratio [95% Confidence Interval]
Perceived general
healthb
Use of general
practitionerc
Immigrants from ..
... Aruba (n=136)
1.00
1.00
... Curaçao (n=504)
2.07 [1.22-3.51]
1.28
... other Antillean islands (n=425)
1.90 [1.10-3.29]
1.90
a Results of logistic regression analysis, controlling for age and sex
b Risk of a less than good perceived general health versus (very) good
c Risk of having 2 or more contacts in the past two month versus having 0 or 1 contact.
[.78-2.08]
[.50-1.40]
IV.1.4 Conclusion: differences in health between ethnic groups within the Turkish,
Surinamese and Antillean populations
The number of datasets that were available to analyse differences in health between ethnic groups
within the Turkish, Surinamese and Antillean population appeared to be very limited. This is not
suprising, as the Dutch standard classification of ethnic groups in terms of country of birth does not
make this distinction. If in a specific study this distinction has been made, most of the time the
number of respondents included in these studies is too small to allow for further subanalyses. In the
‘Amsterdamse Gezondheidsmonitor’ of the Amsterdam Health Municipality for example, only about
34
30 people of the total Turkish population of approximately 1100 people considered themselves to be
Kurds.
As far as data were available, they indicate differences in health between ethnic groups within the
Surinamese population. The Hindustani seem to be less healthy than the other ethnic groups.
Among the Antillean, we could only differentiate between people with a different geographic origin.
People from Curaçao and the other Antillean islands appeared to be less healthy than people from
Aruba. No differences in health were found between the Kurds and the Turks, the two main ethnic
subgroups among the Turkish population. This is in contrast with the results of studies that have
been done in Turkey, as they indicate substantial differences in health between the Kurds and
Turks, with the Kurds being less healthy. Further studies among the Turkish living in the Netherlands
are necessary before a final conclusion can be drawn on this issue.
IV.3 Health status of the third generation
In chapter III it was argued that the number of immigrants that belong to the third generation might
be significant for specific type of studies, especially among younger age-groups. This does not
automatically imply, however, that it is always necessary to distinguish the third generation in health
(care) studies. This of course depends, among others, on the health status of this population. As
long as the populations with immigrant descent are in a disadvantaged position in terms of their
health and accessibility to health care compared to the native Dutch population, identification of third
generations might be useful. If eventually differences between further generations of Dutch residents
with immigrant descent and the native Dutch population (do) not longer exist, the identification of
further generations might become redundant.
Unfortunately, as far as we know, no data on the health status of people that belong to the third
generation are available yet. This is, of course, not surprising, given the fact that the standard
classification of ethnicity in the Netherlands, based on country of birth of a person and his/her
parents, does not allow for the identification of the third generation. However, the results of the few
studies that have been carried out in other countries, suggest that also the third generation of the
immigrant population is in a disadvantaged position in terms of their health status and the
accessibility of thealth care. A study in the UK for example shows that immigrants from Ireland living
in the UK still have a worse health status as compared to the indigenous population. Mortality
among the third generation was even higher than that among the first generation (Harding &
Balarajan 2001). A study among Hispanic and Asian adolescents shows similar results for obesity:
the difference in the prevalence obesity as compared to the white non-Hispanics was the largest for
the third generation (Popkin & Udry 1998). In addition, even in the case that the risk of a certain
disease is lower among a (non-western) immigrant population, such as the risk for breast cancer, it
appears to take many generations to reach the risk of the host population: e.g. among the third
generation of Asian women living in Hawaii, the risk of breast cancer was still lower than among the
host population (Maskarinec et al. 2001).
35
Studies from other countries thus indicate that it could not be automatically assumed that the health
status of the third generation corresponds to that of the native population. We therefore recommend
to individual researchers to make the third generation visible, as this is the only way to see whether
the results from studies in other countries apply to the immigrant groups in the Netherlands as well.
In order to do so, the number of people that belong to the third generation should of course be
substantial in a specific study.
36
Chapter V
OTHER CHARACTERISTICS OF ETHNIC GROUPS, ADDITIONAL
TO ETHNIC ORIGIN
In chapter II, it was argued that the Dutch standard definition of ethnicity conceptualises ethnicity in
terms of ethnic origin, referring to someone’s roots. Apart from their ethnic origin, ethnic groups
might differ in many other aspects, such as culture, socio-economic position and religion. In this
chapter, we will focus on these additional characteristics. It was argued in chapter II that these
aspects should not be used to define ethnic groups. In health (care) studies, it is nevertheless crucial
to have information on the additional features of ethnic groups, for several reasons:
1. We would argue that the association between ethnicity and health(care) could only be understood
if these additional features are taken into account. The reason for this is that ethnicity in itself does
not influence health (care). The fact that someone is born in Morocco does not affect health in and of
itself. Instead, people who originally come from Morocco might be less healthy because of genetic
influences, or might be healthier because of more a more favourable lifestyle. The circumstances
surrounding the migration itself may also influence health, for example, refugees from former
Yugoslavia might have a worse health status than the native Dutch as a result of their war
experiences or because they may have been separated from their families. Moreover, the higher
prevalence of diabetes among people from Surinam as compared to the native Dutch population is
more likely to be related to genetic and lifestyle factors rather than the place of birth. In other words,
the causal mechanism that might explain the association between ethnicity and health is not within
the association itself. Instead, the effect of ethnicity works through a number of other characteristics
of ethnic groups (Kaplan & Bennett 2003).
2. Related to the previous point, features that further characterise ethnic groups, such as culture and
migration history, might be relevant to differentiate between subgroups. One could e.g. think of a
situation in which the health status of an immigrant group, in general, is comparable to that of the
Dutch native population, whereas the health status of a specific subgroup is different. This might be
the case for people those who are not integrated in the Dutch society, or those who are in a (socioeconomically) disadvantaged position. In that case, restricting the study population to those who are
culturally different from the native Dutch, or those who are in a disadvantaged position, might be
more useful than including the ethnic group as a whole.
In this chapter, possible additional features that might explain the effect of ethnic background on
health or that can be used to distinguish subgroups within a certain ethnic group are discussed. The
aim is not to provide a complete and systematic overview of empirical studies in this field. This would
go beyond the aim of this chapter. Instead, the aim is to give some examples that illustrate the value
of each of these additional fatures for further characterising ethnic groups in the context of health
and health care. We will distinguish five groups of characteristics:
1.
Genetic factors (biological aspect);
2.
Short-term migration history (demographic aspect)
3.
Cultural characteristics, including religious affiliation (sociological labelling)
37
4.
Ethnic identity (self-defined ethnicity) (psychological labelling)
5.
Position in the ‘host country’, which has at least the following three dimensions:
i)
socio-economic position (socio-economic aspect)
ii)
social integration (social cultural aspect)
iii)
discrimination
Whether one or more of these factors should be taken into account, in addition to ethnic
background, depends on the specific research question. Genetic factors, for example, might have
relevance in the above-mentioned example of a higher prevalence of diabetes among some ethnic
groups, or in ethnic disparities related to the effect of a certain type of medication. Whereas if one is
interested in the ethnic disparities in health which are related to access to health care, the socioeconomic position of these ethnic groups might be more relevant.
V.1
Genetic factors
In chapter II, it has been argued that the biological significance of the concept of race is debatable.
However, this does not detract from the fact that variations in health between ethnic groups might be
partly the result of genetic factors. Examples include the higher incidence of diabetes type 1 among
Moroccan children (van Wouwe et al. 2002), the higher perinatal mortality among specific ethnic
groups (Schulpen et al. 2001), the excess prevalence of diabetes among Hindustanis (Middelkoop
2001), and the prevalence of hemoglobinopathies among Surinamese people and people with a
Mediterranean background. In the case of South Asians, it has been frequently suggested that they
have a shared evolutionary history that involved adaptation to survive under conditions of periodic
famine and low energy intake. This resulted in the development of insulin resistance syndrome,
which probably underlies South Asians’ greater risk of cardiovascular heart disease (Nazroo 1998).
In addition, genetic factors might play a role in a differential effectiveness of certain medication as for
example in the case of hypertension. Although in these and other cases the role of genetic factors is
mentioned as a possible explanation, they have seldom been studied directly as possible
explanations for ethnic variations in health. Given the growing interest in genetic factors, the interest
in identifying genetic causes for the health status of people from different ethnic origin is likely to
increase.
V.2
(Short-term) migration history
Migration history also appears to be important for the explanation of differences in health of
immigrants and the native population. Empirical studies show that refugees suffer from specific
complaints and disorders which are related to their experiences during their flight from the home
country or the asylum-seeking procedure in the host country (de Bakker et al. 2000). The possible
effects of extreme living conditions in the country of origin may also have an influence (Tjon A Ten
2001).
Elements in someone’s migration history that might be particularly relevant from a health perspective
include:
38
-
the (type of ) place (of residence) or region where one has grown up. For example, an
increase in the risk of cardiovascular disease has been observed in people who have
migrated from rural to urban areas, probably as a result of changes in lifestyle;
-
the migration itself, which might act as a source of stress;
-
the main reason for migration (e.g. family-reunion, marriage, work, study, asylum etc.),
which might affect the amount of stress experienced;
-
orientation for return-migration, which might influence (e.g.) the willingness to invest in the
process of integration in the host society;
-
the dynamics of the relationships with family in the country of origin, which again, might act
as a stressor.
V.3
Cultural characteristics
The relation between the concept of ‘culture’ on the one hand, and ‘ethnicity’ on the other, is not
simple. Culture is of course an important ‘aspect’ of ethnicity. The definitions of ethnicity that were
given in chapter II illustrate this. On the other hand defining social groups on the basis of cultural
characteristics such as dressing style or dietary habits is not specific for ethnic groups, as also social
classes, for example, often differ in culture (Anonymous 1996, Verkuyten 1999). In addition, people
within a certain ethnic group may differ in culture: some members of a group may participate in the
“Dutch” culture, whilst others hold on to their original culture. Thus although ethnicity and culture
could not be used interchangeably (Verkuyten 1999), culture is undeniably an important aspect as to
further characterise ethnic groups.
Many definitions of culture conceptualise culture as a system of shared ‘values’. One of the most
popular definitions of culture was given by Tylor in the late 19th century: “that complex whole which
includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired
by man as a member of society” (Tyler 1871, cited in Helman 2000).
In addition, culture can be seen as an inherited set of guidelines that are transmitted between
generations: “Culture is a set of guidelines (both explicit and implicit) that individuals inherit as
members of a particular society, and that tell them how to view the world, how to experience it
emotionally, and how to behave in it in relation to other people, to supernatural forces or gods and to
the natural environment. It also provides them with a way of transmitting these guidelines to the next
generation, by the use of symbols, language, art and rituals. To some extent, culture can be seen as
the “inherited lens” through which the individual perceives and understands the world that he
inhabits and learns how to live within it (Helman 2000:2)”
Ethnic groups frequently differ with respect to culture. For example people of Turkish and Moroccan
origin in the Netherlands generally differ from native Dutch people in terms of their views on issues
such as the emancipation of women, or on the acceptability of drinking alcohol. However, cultures
are never static but are often influenced by other groups around them and are in a process of
constant adaptation and change (Verkuyten 1999, Helman, 2000). This process of change under the
influence of other cultures is known as “acculturation”. Depending on the circumstances they live in,
39
people choose (certain) aspects of a culture, use them and transform them (Fay 1996 in Verkuyten
1999). Therefore, the culture of a specific group should always be seen in its particular context, as
made up of historical, economic, social, political and geographic elements.
The dynamic character of culture does not equally apply to all cultural elements, however.
Vermeulen (2001) makes a distinction between culture as a way of life and culture as a lifestyle.
Culture as a way of life, is the “internalised culture”, and is assumed to include the core values of a
cultural system, including norms and values. This is prone to change in the long-term only, in cases
where the context within which the culture is formed changes. Culture as a life-style, is on the other
hand, the use or creation of cultural symbols and artefacts to differentiate one’s self from others with
the aim of creating a “presumed community” (verbeelde gemeenschap). This includes dietary habits,
clothes etc. In this sense, culture as a life-style is prone to change more than culture as a way of life.
For example, migrant groups living in a host country can adapt themselves to the life-styles of the
host society, whereas cultural “way of life” elements may remain unchanged.
The influence of cultural factors on ethnic differences in health is often studied implicitly. By this we
mean that the association between ethnic background and health is corrected (in a statistical model)
for other possible explanations, mostly socio-economic indicators. The association that remains after
this correction is said to reflect the effect of cultural factors. This approach, however, is too
simplistic. The association between ethnic background and health is potentially affected by many
factors, not only including culture, but also socio-economic status, genetic factors etc. It is unlikely
that all relevant factors are accounted for by these kinds of studies. As a result, little is known in the
(inter)national literature about the relationship between culture and health, particularly with respect
to the cultural factors which are important for health behaviour (Foets & Denktas 2002).
Examples of a more direct way of studying culture include a recent study on influenza vaccination.
This study showed that cultural differences play an important role in explaining the higher
participation of the first generation elderly Turkish and Moroccan immigrants in the influenza
vaccination campaign (Kulu Glasgow et al. 2001). Similarly, other studies have shown that cultural
factors, such as the presence of informal care and the importance attached to it by families, played a
key role in the utilization of post-natal home care between native Dutch families and immigrant
families (El Fakiri et al. 1997). A study in Belgium among Moroccan immigrants also showed the
importance of different approaches to disease and illness in the utilization of health care services (de
Muynck et al. 1995).
In view of the scarce literature, we suggest that at least the following cultural factors might be
relevant for the explanation of ethnic disparities in health.
Norms and values
Norms and values are fundamental cultural features of ethnic groups. These norms and values can
basically govern the way of life of the members. Examples of essential differences between
populations of immigrant origin from non-western societies and western societies that might have
relevance for health, include:
40
1. structure of gender relations: Behavioural norms assigned to men and women in different ethnic
settings might differ. These norms influence father-daughter, brother-sister relations as well as
husband-wife relations. The structure of gender relations and the position of the individual therein
determines the position of the sexes within that culture. Research points out that gender relations
might play a role in the use of emergency care departments as GP posts by Moroccan families
during evening hours, when husbands get home (Bouwhuis et al. 2001).
2. attitudes and beliefs in relation to raising children: Examples include the appreciation of (higher)
education. Is there a difference in the expectations surrounding the completion of a particular level of
education according to gender? This also has an effect on the family relations and gender roles
(Vermeulen 2001) and possibly on decision-making and autonomy health-related issues, such as
utilisation of services.
3. marriage preferences and obligations: There is evidence from the Dutch literature that among
those with a Turkish and Moroccan origin, marriage preferences and obligations are rooted in the
culture as “core-values” (Esveldt et al. 1995). They are of primary importance in health-related
factors due to their link to the distribution of gene frequencies (Macbeth 2001). Marriage obligations,
such as expressed by consanguineous marriages differ between ethnic groups even within the same
country (Hancioglu & Tuncbilek 1997). There is widespread evidence that these marriages are one
of the important causes of infant mortality and morbidity (Haelst et al. 2001)
4. traditions and customs: Traditions and customs are practices often passed down through
generations. For example, feast-days, rituals around birth and death are indicators of such practices
specific to ethnic groups. They can provide an important thread of continuity with the past and are
often kept alive through practice (Giddens 2001). A recent study shows that cultural differences in
the customs and traditions around death are an important determinant of the use of terminal care by
Turkish and Moroccan residents in the Netherlands (De Graaf 2002).
5. religion (religious origin): There is a widespread recognition that religion is an important
characterising feature of ethnic groups and a strong marker of cultural differences within an ethnic
group, although this might vary between generations (Aspinall 2000, Hilton 1996). Religion and
belief may be important especially where these are expressly concerned with health and health care
(Macbeth 2001:12). In some cases, religious origin may be of influence in the application and
success of health programs, such as screening programs (breast and cervical-cancer screening).
Dietary habits may also differ between different religious groups.
Fluency in the language of the host country
One of the most important features of ethnic groups is the means/symbols by which the members
communicate among each other. Language and linguistic differences are important indicators of
means of communication. Language seems to be a crucial factor in the context of health(care) in a
host country. By this we refer to fluency in the language of the host country in particular. This is for
example closely related to utilisation of health-care services (El Fakiri et al. 1997). In addition, the
extent to which people can express themselves in the language of the host country might affect
health through many other determinants, such as the socio-economic position and the position in the
labour market.
41
Finally, it is important to realise that differences in mother language might also reflect cultural
differences in a broader sense (cf. the role of religion as a crucial marker for cultural differences).
For example, within Morocco, the Berber dialect spoken varies according to geographical region.
The “Tarifit” dialect is mostly spoken in the Rif-area, Tachelhit is spoken in the southeast of
Morocco, and Tamazight in the northeast. Distinguishing between these dialects could be useful for
studies that aim to make comparisons in the European context. The majority of the Berber
population in the Netherlands is originally from the Rif area and speaks Tarifit whereas in France the
majority of Berbers speak Tamazight and Tachelhit. As these Berber dialects are also markers for
region of origin, one can expect that there may be differences within the group Berbers in aspects
such as dietary habits or other cultural practices. These could subsequently influence health profiles.
Dietary preferences/rules
Dietary preferences or rules are an important feature of (ethnic) culture (as a life-style). They form
an important part of the scaffolding of ethnic-social relationships (Pfeffer 1998, Macbeth 2001).
Ethnicity is involved in the development of food preferences, for example, cultural/religious
influences on food choices, eating patterns (content and timing of food intake) and cuisine are
important indicators of such preferences (Macbeth 2001). Dietary preferences may have an effect on
health and therefore, are important to consider for epidemiological reasons (Macbeth 2001).
V.4
Perceived ethnic identity
Perceived ethnic identity indicates the feeling or emotional attachment of an individual towards the
ethnic group (s)he belongs to (Verkuyten 1999). In this sense, it is the “psychological labelling” that
an individual attaches to himself/herself. It reflects, in other words, the extent to which someone
feels (s)he is not only a member of a certain ethnic groups, but also considers him/herself to be part
of that group. The literature points out several components of the concept of ethnic identity, including
feeling of attachment, pride towards one’s ethnic group and historical or cultural heritage (Verkuyten
1999), ethnic loyalty (Keefe 1992), as well as ethnic consciousness (Verkuyten 1999, Vermeulen
1984, Van Heelsum 1997). Ethnic identity appears to be only slightly influenced by integration or
assimilation in the host society (Verkuyten 1999). Therefore, it seems to be less dynamic than
factors such as cultural characteristics:
‘…it is remarkable that the idea of origin and descent can stay while culturally many things
may change. People stick to their origin, what they feel as continuity with the past, while their
culture blends with others. Direct contact between different ethnic groups leads to an
interchange of different cultural characteristics and mutual adjustment therein. It however
leads to a strengthening of the feeling of being ethnically conscious and to more social
differentiation. While their culture changes, ethnic groups remain the same. In this aspect,
culture and ethnic identity are functionally independent from each other. Therefore it is quite
possible that young generations of migrants culturally become Dutch, but not ethnically.
They stay to be proud of their ethnic origin and continue to see themselves as a member of
that ethnic group’ (Verkuyten 1999:47)
42
The less variable nature of ethnic identity does not, however, mean that it is always static.
Situational changes therein may be associated with social solidarity, social distance, and personal
expediency (Barth 1969, Nagata 1974 cited in Stephan & Stephan 2000).
Ethnic identity has been shown to affect health. For example in a recent American study, ethnic
identity appeared to be a significant predictor of quality of life among African, Asian and Latino
Americans (Utsey et al. 2002). In a recent British study, however, no such relationship was found. In
addition, ethnic identity also appeared to be unrelated to specific conditions such as heart disease
and diabetes (Karlsen & Nazroo 2002). If a relationship between ethnic identity and health exists,
this might for example operate through a psychosocial mechanism, a behavioural mechanism (Barr
& Garner 2001), or social participation (Campbell & McLean 2002).
V.5
Position in the host country
Position in the host country is another characteristic by which ethnic groups can be further
described. Position in the host country seems to consist of at least the following dimensions:
-
socio-economic status
-
social integration
-
discrimination
Socio-economic position
Socio-economic position of ethnic groups in the host country is probably one of the most important
mechanisms that explain differences in health between ethnic groups. Socio-economic status is
usually indicated by educational, occupational or income level. Initially, the socio-economic
characteristics of the members of an ethnic group “immigrate” to the host country. Depending on the
context in the host society, these socio-economic characteristics can improve, stagnate, or even
worsen. The reaction of the host society to immigrants and to residents with immigrant origin are an
important determinant of these opportunities. For this reason, the relationship between the socioeconomic characteristics and health of residents with immigrant descent may differ to that in the
native population.
The relationship between socio-economic factors and ethnic disparities in health has been the
subject of numerous studies, both nationally and internationally. Empirical research shows that
ethnic disparities in health can be partly attributed to the worse socio-economic status of residents
with immigrant descent (Stronks et al. 2001, Reijneveld 1998). As with ethnic background, socioeconomic position in and of itself does not affect health and does not fully explain the association
between ethnicity and health. Instead, it influences health status through more specific explanatory
factors, including working and housing conditions and health behaviour. However, socio-economic
status remains crucial in exploring differences in health. It serves as an indicator that differences
may not be primarily the consequence of factors such as an ethnic specific culture but rather due to
a worse socio-economic position, a problem that is not unique for immigrant groups.
43
Social integration
Social contacts with the host population are seen as an essential element of the process of
acculturation of the migrant population (Berry 1992). The extent to which migrant groups have
contacts with the indigenous population might affect their health behaviour (cf. social influences on
smoking behaviour), as well as their social environment (such as social support). In addition, if
people experience conflicts between participating in the host society and being a member of the
ethnic group they originally come from, this might lead to psychosocial stress.
Another important aspect of social integration is the extent of social cohesion within a certain group,
referring to the extent of connectedness and solidarity (Kawachi & Berkman 2000). The difference in
social cohesion between Turkish and Moroccan young adults has for example been hypothesized to
explain the increased risk of the Moroccan second generation of psychotic disorders (Selten et al.
2001). Furthermore, the mechanism of social participation could also be located against the
background of the debate about the possible link between social capital and health (Kawachi &
Berkman 2000). It includes the element of community involvement, referring to the involvement of
individuals in community-based organizations and actions groups. This has been suggested to be
one of the possible strategies to reducing health inequalities between ethnic or socio-economic
groups by, among others, the World Health Organization (Rootman et al. 2001), although there is
still a lot of discussion about the relevance of this concept for health (Hawe & Shiell 2000).
To our knowledge, so far the relevance of the mechanism of social integration for ethnic differences
in health has not been studied empirically in the Netherlands.
Discrimination
As discussed above, ethnic identity refers to the self-description of one’s own ethnicity. However,
ethnicity is not only self-defined but it is also defined by other members of the society (Verkuyten
1999; Van Heelsum 1997). It is possible that the ethnic category that is assigned to a person differs
from the category that person assigns to him or herself (Verkuyten 1999). For example, Van
Heelsum (1997) points out that a Chinese Surinamer might be seen as Chinese by others while
he/she sees himself as Surinamese. Outsider defined ethnicity may be one of the important factors
which determine the status of the members of an ethnic group in a host country. It is especially
important in relation to discrimination, which can be described in the broadest sense, as the unequal
treatment of persons of different ethnic backgrounds. Within this context, the discrepancy between
how one sees one’s self and how one is defined by others becomes important to an individual’s
position in the host country (Penninx 1988).
The effects on health of ethnic minority status, outsider defined ethnicity and discrimination have,
until recently, been ignored in Dutch health(care) research. In international studies, interest in this
issue is growing. A recent study in England has shown that not only ethnic identity but also
experiences of racism, perceived racial discrimination have strong independent relationships with
health and may have influences on (especially mental) health of the ethnic minority groups (Karlsen
& Nazroo 2002). In addition, a recent study by the Institute of Medicine indicated that discrimination
is one of the essential factors that explain ethnic disparities in the access and quality of health care
services in the United States (Smedley et al. 2002). Another study, showed that discrimination was
44
related to health in Chinese Americans (Gee 2000). This applied to discrimination at an institutional
as well as an individual level.
45
46
Chapter VI
CONCLUSIONS AND RECOMMENDATIONS
VI.1 Introduction
The main reasons for this project were the drawbacks of the Dutch standard classification of ethnic
groups in terms of of country of birth, and the wish to use common additional indicators in order to
stimulate the comparability of study results. The question that was central to the report was: Taking
into account the drawbacks of the country of birth classification, which additional indicators should
be used for the identification of ethnic groups? In this chapter, we will summarize our proposals for
additional indicators.
VI.2 Indicators for the measurement of ethnic groups, additional to country of birth
The standard definition of ethnic groups in the Netherlands, defining ethnic groups on the basis of
country of birth of the respondent and his/her parents, does not allow for the identification of different
ethnic groups that share country of birth, nor for the identification of the third generation of people of
immigrant descent. Depending on their research aims and questions, Dutch researchers in the field
of health (care) might nevertheless be interested in identifying these subgroups. In chapter III we
proposed solutions for both problems, starting from the concept of ethnic origin. In chapter IV, we
assessed whether the additional indicators that were proposed have significance for health (care)
studies, by studying the association between these indicators and health (care).
Identifying different ethnic groups within one country of birth
As the Dutch standard classification of ethnicity defines ethnic groups in terms of their geographic
origin, an historical analysis of the countries of origin of the major (non-Western) immigrant groups in
the Netherlands (Turkey, Surinam, Morocco, Dutch Antilles and Aruba) was made. This in order to
determine whether in each of these populations a distinction could be made between groups with a
different geographical origin.
The historical analysis for the Moroccan population showed that no further distinction could be made
between ethnic groups. Berbers and Arabic-speaking Moroccans met each other as early as the 7th
century, and have been interacting and mixing since. This makes the differentiation of the ethnic
origin of these groups problematic, though one can make such differentiation if research questions
seek to consider the importance of cultural factors.
For the other three largest immigrant groups, i.e. the Turkish, Surinamese and the immigrant
population from the Antilles and Aruba, it was argued that a further distinction in ethnic groups could
be made, given differences in geographic origin, and given the fact that these could still be
differentiated from each other. This applies to the Turks and the Kurds among the Turkish
population, the Creoles, Hindus, Javanese, Chinese etc. among the Surinamese group, and the
Indian, Afro-Caribbean and European among the population originating from Dutch Antilles and
Aruba. The empirical analyses showed differences in health (care) between the ethnic groups in the
Surinamese population. For the Turks and Kurds living in the Netherlands, no differences were
observed. This is in contrast to what is observed in Turkey, where remarkable differences in health
and health care exist between these groups. For the population of the Antilles and Aruba, no data
47
were found that allow for making a distinction between ethnic groups. Data on the health status of
people with a different geographic origin indicated differences in health, with people from Curaçao
having the worst health status.
In addition, indicators were proposed to make a distinction between ethnic groups that share country
of birth. A question on self-identification has been recommended to distinguish between ethnic
groups. This indicator has the advantage of being applicable to all ethnic groups, independently of
country of birth. Moreover, it can be relatively easily applied, also in studies in which ethnicity is not
the main focus. It should be mentioned however, that so far little is known on the validity of
questions on self-identification. The main problem with this indicator is the wording that is used may
affect how respondents answer: does someone answer this question in terms of ethnic identity
(subjective feeling) or in terms of ethnic origin (objective). In the first case, the basis for classification
would be conceptually different from the Dutch standard classification in terms of geographic origin.
For the sake of consistency, the questions on self-identified ethnic origin should therefore be
phrased (as closely as possible) in terms of ethnic origin. A further testing of different phrasings is to
be recommended before a conclusion can be drawn as to the most valid operationalisation.
In addition to self-identified ethnic origin, we discussed two other additional options to make a
distinction between ethnic groups that share country of birth, i.e. language (in the case of the Turks
and the Kurds), and geographic origin of the ancestors (in the case of the Surinamese and Antillean
population).
Identification of the third generation in health(care) surveys:
The second-bottleneck of the use of country of birth criteria is the “invisible” third generation.
Although the identification of the third generation for registration purposes appears to be a political
decision, we argued that it could be useful to do so in health(care) surveys, as studies in other
countries indicate that the health status of the third generation still differs from that of the native
population.
In order to identify the third generation, we recommended using the same objective criteria as the
Dutch standard country of birth does. This implies that country of birth of the grandparents should be
determined for those who were themselves born in the Netherlands, and whose parents were also
born in the Netherlands. It is possible, however, that asking for the country of birth of the
grandparents does not yield valid answers (e.g. because people are not aware of the country of birth
of their grandparents). Moreover, some studies may be unable to include four extra questions due to
time restrictions. This should be further explored in future research. Self-identified ethnic background
might be a good alternative, under the condition that the questions are phrased as closely as
possible in terms of ‘ethnic origin or roots’, instead of ethnic identity (referring to the feeling of
belonging to a certain group). As already mentioned, the validity of this question should be further
tested before final recommendations can be made.
48
VI.3 Other characteristics of ethnic groups, additionally to ethnic origin
By defining ethnic groups as groups that differ in ethnic origin, it should of course not be denied that
these groups might differ in other aspects as well. These include culture, language, socio-economic
position and genetic factors. We distinguished five types of additional characteristics:
-
(perceived) ethnic identity
-
cultural characteristics, including religious affiliation
-
genetic factors
-
migration history
-
position in the host country, which has three dimensions:
i)
socio-economic position
ii)
social integration
iii)
discrimination
These factors are related to ethnic origin on the one hand, and health(care) on the other. As such,
they should be considered to be intermediary mechanisms, which can potentially explain the
association between ethnicity and health(care). In addition, they could be used to make a further
distinction between subgroups that have relevance for health(care).
49
50
REFERENCES
Afshari R, Bhopal RS. Changing pattern of use of ‘ethnicity’ and ‘race’ in scientific literature [letter].
Int J Epidemiol 2002;31:1074-6
Ahdieh L, Hahn RA. Use of the terms ‘race’, ‘ethnicity’ and ‘national origins’: a review of articles in
the American Journal of Public Health 1980-1990. Ethnicity and Health 1996;1:95-8
Alders M. Classification of the population with a foreign background in the Netherlands. Paper for
the conference ”The measure and mismeasure of Populations”. Paris, December 2001
Alders M and I Keij. Niet-westerse derde generatie in 2003. Bevolkingstrends 2003, nr 3, p. 45-49
Alofs L, Casimiri N, Carolina G, Dalhuisen L, Donk R, Hofman C, Hoogland M, Hoogstraten M,
Katelaars H, Raeven L, Rutgers W, Steegh F, Versteeg A, Walhain J. Geschiedenis van de Antillen.
Zutphen: Walburg Pers, 1997
Amersfoort, JMM van. Immigratie en minderheidsvorming. Een analyse van de Nederlandse situatie,
1945-1973. Alphen e/d Rijn, 1974
Amersfoort JMM van. Immigrant en samenleving: een terrein verkenning. In: Amersfoort JMM van,
Entzinger HB (ed.) Immigrant en samenleving, Deventer: Van Loghum Slaterus, pp: 7-29
Andrews PA. Ethnic Groups in Turkey . Ant Yayinlari, Istanbul, 1989 (in Turkish)
Anonymous. Style matters: ethnicity, race and culture: guidelines for research, audit, and
publication. BMJ 1996;312:1094-1095
Aspinall PJ. Operationalising the collection of ethnicity data in studies of the sociology of health and
illness. Sociology of health and Illness 2001;23: 829-862
Aspinall, PJ. Should a question on ‘religion’ be asked in the 2001 British census? A public policy
case in favour. Social Policy and Administration 2000;34:584-600
Aspinall PJ. The conceptual basis of ethnic group terminology and classifications. Social Science
and Medicine 1997;45:689-698
Bakker D de, Weide M, Delnoij D. Huisartsenzorg aan asielzoekers: naar een monitoring systeem.
Utrecht: Nivel 2000
Barr DT, Garner ADM. Eating concerns in East Asian immigrants: relationships between
acculturation, self-construal, ethnic identity, gender, psychological functioning and eating concerns.
51
Eat Weight Disord. 2001;6:90-8.
Barth, F. “Introduction”. In: F. Barth (ed.) Ethnic groups and boundaries. Boston: Little-Brown, pp: 938, 1969
Berghe PL van den. Ethnicity and class in Highland Peru. In: F. Barth (ed.) Ethnic groups and
boundaries. Boston: Little-Brown, pp: 71-86, 1975
Berry JW. Acculturation and adaption in a new society. Int Migration Review 1992;30:68-85
Berthoud R. Defining ethnic groups: origin or identity? Patterns of Prejudice, 32(2):53-63, 1998
Bhopal R. Ethnicity and race as epidemilological variables: centrality of purpose and context. In: H.
Macbeth and S. Prakash (eds). Health and Ethnicity. Taylor and Francis, London, pp: 21-40, 2001
Bhopal R, Rankin J. Concepts and terminology in ethnicity, race and health: be aware of the ongoing
debate. British Dental Journal, 186(10):483-484, 1999
Bhopal RS, P Phillimore, HS Kohli. Inappropriate use of the term “Asian’: an obstacle to ethnicity
and health research. Public Health Medicine 1991;13:244-246
Bindraban NR, Stronks K, Klazinga NS. Cardiovasculaire risicofactoren onder Surinamers in
Nederland: een literatuuroverzicht. NTvG 2003;147:1591-4
Blonk J, Smet J de. Registratie van allochtonen: voorstel voor het uniform registreren van
allochtonen die gebruikmaken van voorzieningen. Utrecht: NIZW, 2001
Bouwhuis CB, Kromhout MM, Twijnstra MJ, Büller HA, HA Moll. Geringe ethnische verschillen in
spoedeisende problemen bij kinderen: 10 jaar acute hulp in het Sophia Kinderziekenhuis te
Rotterdam. Ned. Tijdschr Geneeskd 2001;154:1847-1851
Bradby H. Ethnicity: not a black and white issue. A research note. Sociology of Health and Illness
1995;17:405-417
Bradby H. Describing ethnicity in health research. Ethnicity & Health 2003;8:5-13
Bruijnzeels, M. Vaststellen van de etnische herkomst van personen in onderzoek en in registraties in
de gezondheidszorg. In: ZON, Het meten van etnische herkomst, Verslag Workshop 17 november
1999, Amsterdam, pp: 27-39
52
Campbell C, McLean C. Ethnic identities, social capital and health inequalities: factors shaping
African-Caribbean participation in local community networks in the UK. Soc Sci Med 2002;55:64357.
Central Bureau of Statistics. Standaarddefinitie van allochtonen. Index, no. 10, pp: 10-13, 2000
Cohen, R. Problem and focus in anthropology. Annual Reviews of Anthropology, 7:379-403, 1978
Davies OI, Nakayama TK, JN. Martin. Current and future directions in ethnicity and methodology.
International Journal of Intercultural Relations 2000;24:525-539
Despres LA. Ethnicity and resource competition in Guyanese society. In: LA Despres (ed.) Ethnicity
and resource competition in plural societies. Mouten Publishers: The Hague, pp: 87-118, 1975
Doddema M. Registratie van etnische herkomst op de poli van een kinderziekenhuis: een pilot
[scriptie]. Amsterdam: AMC/UvA 2004
Dündar SET. Social and economic characteristics and fertility behaviour of main language groups in
Turkey. MA Thesis, Hacettepe University Institute of Population Studies, Ankara, 1998
El Fakiri F. Kulu Glasgow I, Weide MG, M Foets. Kraamzorg in allochtone gezinnen. Elsevier 1999.
Esveldt I, Kulu-Glasgow I, Schoorl J en H van Solinge. Migratiemotieven, migratienetwerken en
partnerkeuze van Turken en Marokkanen in Nederland. Den Haag:NIDI, 1995
Fenton S, Charsley K. Epidemiology and sociology as incommensurate games: accounts from the
study of health and ethnicity. Health 2000;4:403-425
Foets M, Denktaş S. Acculturation and the health of immigrant groups. Submitted.
Garte S. The racial genetics paradox in biomedical research and public health. Public Health
Reports 2002;117:421-425
Gee 2000
Giddens, A. Sociology. Polity Press, Cambridge, 2001.
Graaf FM de, Franke A. Tips voor de terminale zorg voor Turkse en Marokkaanse ouderen. Utrecht:
Nivel, 2002
Gündüz-Hoşgőr A., Smits J. Intermarriage between Turks and Kurds in Contemporary Turkey. Eur
Soc Rev 2002;18:417-32
53
Haelst M van, I Kulu Glasgow, MF Niermeijer, TWJ Schulpen. Consanguiniteit en morbiditeit bij
allochtone kinderen. Tijdschrift voor Kindergeneeskunde 2001;69:174-177
Hahn RA. Sickness and healing: an anthropological perspective. New Haven: Yale University Press,
1995
Hahn RA, BI Truman and ND Barker. Identifying ancestry: the reliability of ancestral identification in
the United States by self, proxy, interviewer, and funeral director. Epidemiology 1996;7:75-80
Hahn RA Stroup DF. Race and ethnicity in public health surveillance: criteria for the scientific use of
social categories. Public Health Reports 1994;109:7-15
Hancioglu A, Tuncbilek E. Consanguineous marriages and socio-economic characteristics. Paper
presented at the 3rd National Demographic Conference, 2-5 December, Ankara 1997 (in Turkish)
Harding S, Balarajan R. Mortality of third generation Irish people living in England and Wales:
longitudinal study. BMJ 2001;322:466-7
Harwood A. (ed.) Ethnicity and medical care. Cambridge: Harvard University Press, 1981
Hawe P, Shiell A. Social capital and health promotion: a review. Soc Sci Med 2000;51:871-885
Heelsum A van. De etnisch-culturele positie van de tweede generatie Surinamers. Amsterdam: Het
Spinhuis, 1997
Heeten J den, Verweij AO. Identificatie en registratie van etnische herkomst: een handleiding voor
registratie en beleid. Den Haag: VNG, 1993
Helman CG. Culture, health and illness. Butterworth-Heineman: Oxford, 2000
Hill AVS. Molecular markers of ethnic groups. In: Cruickshank JK, Beveers DG (eds). Ethnic factors
in health and disease. London: Wright, pp:25-31, 1989
Hilton, C. For debate: collecting ethnic group data for inpatients: is it useful? BMJ 1996;313:923-925
Hulst van H. A continuing construction of crisis. Antilleans, especially Curaçaoans, in the
Netherlands. In: Vermeulen H, Penninx R. Immigrant integration. The Dutch case. Amsterdam: Het
Spinhuis 2000
Hutchinson J and AD Smith. “Introduction”in Hutchinson and Smith (eds.) Ethnicity. Oxford OxfordNew York:University Press, 1996
54
Icduygu et al. 1999
Isajiw WW. Ethnic-identity retention. In: Breton R, Isajiw WW, Kalbach WE, Reitz JG (eds.) Ethnic
identity and equality, pp: 34-91. Toronto, Canada: University of Toronto Press, 1990.
Janoenandansing S, Koefoed G. De Surinamers. In: Ruiter JJ de (ed). Talen in Nederland: een
beschrijving van de taalsituatie van negen etnische groepen. Groningen: Wolters-Noordhoff 1991
Jenkins R. Social anthropological models of interethnic relations. In: Rex J, Mason D (eds.).
Theories of race and ethnic relations. Cambridge: Cambridge University Press, 1986
Johnson, MRD, Owen D, C Blackburn. Black and minority ethnic groups in England: the Second
health and Lifestyles Survey. London: Health Education Authority, 2000
Kaplan JB, Bennett T. Use of race and ethnicity in biomedical pulblication. JAMA 2003;289:2709-16
Karlsen S, Nazroo JY. Agency and structure: the impact of ethnic identity and racism on the health
of ethnic minority people. Sociology of Health and Illness 2002;24:1-20
Kawachi I, Berkman L. Social cohesion, social capital, and health. In: Berkman L, Kawachi I. Social
epidemiology. New York: OUP 2000
Keefe SE. Ethnic identity: the domain of perceptions of and attachment to ethnic groups and
cultures. Human Organization 1992;51: 35-41
Keesing RM. Cultural anthropology: a contemporary perspective. Holt, Rinehart and Winston, 1981
Koc, Hanciogly 1999
Kulu Glasgow I, MG Weide, DH de Bakker, GA van Essen. Wel of geen griepprik?
Verschillen tussen allochtone en autochtone ouderen. Huisarts en Wetenschap 2001;44:481-484
Kwan KLK. The internal-external ethnic identity measure: factor-analytic structures based on a
sample of Chinese-Americans. Educational and Psychological Measurement 2000;60:142-152
Levine HB. Reconstructing ethnicity. The Journal of Royal Anthropological Institute 1999; 5:165-180
Lindo F. Maakt cultuur verschil? De invloed van groepsspeciefieke gedragspatronen op de
onderwijsloopbaan van Turkse en Iberische migranten jongeren. Amsterdam: Het Spinhuis, 1996
55
Macbeth H. Defining the ethnic group: important and impossible. In: H. Macbeth and S. Prakash
(eds). Health and Ethnicity. Taylor and Francis, London, pp: 10-19, 2001
Martinez S, Groeneveld S, Kruisbergen. Integratiemonitor 2002. Rotterdam: ISEO, 2002
Martens EP. Minderheden in beeld. De SPVA-1998. Rotterdam: ISEO 1999
Martens EP, Weijers, YMR. Integratie-monitor, 2000. ISEO, Rotterdam, 2000
Mays VM, Ponce NA, Washington DL, Cochran SD. Classification of race and ethnicity: implications
for public health. Annu Rev Public Health 2003;24:83-110
McAuley J, Souza L de, Sharma V, Robinson I, Main CJ, Frank AO. Self defined ethnicity is
unhelpful. BMJ 1996;313:425-426
McKenzie KJ and Crowcroft NS. Describing race, ethnicity and culture in medical research. BMJ,
312:1054, 1996
McKenzie KJ and Crowcroft NS. Race, ethnicity, culture and science. BMJ 1984;309:286-287
Middelkoop B. Diabetes: a true trouble. Studies on cardiovascular risk, ethnicity, socio-economic
position and intervention possibilities [diss]. Amsterdam: VU, 2001
Modood T, Beishon S, Virdee S. Changing ethnic identities. Policy Studies Institute, London, 1994
Muynck A de, Verrept H, Schillemans L. De zorgvraag van Berberse en Arabische Marokkanen.
Huisarts en Research 1995;6: 228-235
Narain G. De Antilleanen en Arubanen. In: Ruiter JJ de (ed). Talen in Nederland: een beschrijving
van de taalsituatie van negen etnische groepen. Groningen: Wolters-Noordhoff 1991
Nazroo JY. Genetic, cultural or socio-economic vulnerability? Explaining inequalities in health.
Sociology of Health and Illness 1998;20:710-730
Niekerk M van. Paradoxes in paradise. Integration and social mobility of the Surinamese in the
Netherlands. In: Vermeulen H, Penninx R. Immigrant integration. The Dutch case. Amsterdam: Het
Spinhuis 2000
Obdeijn H, De Mas P, Hermans P. Geschiedenis van Marokko. Amsterdam/Leuven: Bulaaq/van
Halewyck 1999
56
Onderzoek en Statistiek. Amsterdam in Cijfers. Amsterdam: Jaarrapport, 2000
Otten R, Ruiter JJ de. De Marokkanen. In: Ruiter JJ de (ed). Talen in Nederland: een beschrijving
van de taalsituatie van negen etnische groepen. Groningen: Wolters-Noordhoff 1991
Pearlmann, J. Ethnic differences: schooling and social structure among the Irish, Italians, Jews, and
Blacks in an American city. Cambridge: Cambridge University Press 1988
Pels ..
Penninx R. Minderheidsvorming en emancipatie. Balans van kennisverwing ten aanzien van
immigranten en woonwagenbewoners. Alphen e/d Rijn: Samson, 1988
Pfeffer N. Theories of race, ethnicity and culture BMJ 1998;317:1381-1384
Phinney JS. Ethnic identity in adolescence and adulthood: a review of research. Pyschological
Bulletin 1990;108: 499-514
Polednak AP. Racial and ethnic differences in disease. NewYork: Oxford University Press, 1989
Raad voor de Volksgezondheid en Zorg. Interculturalisatie van de gezondheidszorg. Zoetermeer:
RVZ, 2000
Reijneveld SA. Reported health, life-styles and use of health-care of first generation immigrants in
the Netherlands: do socio-economic factors explain their adverse position? J Epidemiol Community
Health 1998;52:298-304
Rootman I, Goodstadt M, Hyndman B et al. Evaluation in health promotion. Principles and
perspectives. Copenhagen: WHO 2001
Schulpen JW, Steenbergen JE van, Driel HF van. Influences of ethnicity on perinatal and child
mortality in the Netherlands. Arch Dis Child. 2001;84:222-6.
Selten JP, Veen N, Feller W et al. Incidence of psychotic disorders in immigrant groups in The
Netherlands. Br J Psychiatry 2001;178:367-372
Senior PA, Bhopal R. Ethnicity as a variable in epidemiological research. BMJ 1994;309:327-330
Smedley B, Stith AY, Nelson AR (eds). Unequal Treatment: confronting racial and ethnic disparities
in health care. Washington: Institute of Medicine, National Academy Press, 2002.
57
Smeets H., Veenman J. More and more at home. Three generations of Moluccans in the
Netherlands. In: Vermeulen H, Penninx R. Immigrant integration. The Dutch case. Amsterdam: Het
Spinhuis 2000
Smith EJ. Ethnic identity development: toward the development of a theory within the context of
majority/minority status. Journal of Counseling and Development 1991;70:181-188
Sociaal en Cultureel Planbureau, Rapportage Minderheden. Den Haag: 1999
Sodowsky GR, Kwan KLK, Pannu R. Ethnic identity of Asians in the United States: conceptualisation
and illustrations. In: Ponterotto J, Casas M, Suzuki L, Alexander C (eds.). Handbook of multicultural
counselling, pp: 123-154. Newbury Park CA, Sage Publications, 1995
Stephan CW, Stephan WG. The measurement of racial and ethnic identity. International Journal of
Intercultural Relations 2000;24:541-552
Stronks K, Uniken Venema P, Dahhan N, and LJ Gunning-Schepers. Allochtoon, dus ongezond?
Mogelijke verklaringen voor de samenhang tussen etniciteit en gezondheid geïntegreerd in een
conceptueel model. TSG 1999;77:33-40
Stronks K, Ravelli ACJ, SA Reijneveld. Immigrants in the Netherlands: equal access for equal
needs? Journal of epidemiology and Community Health 2001;55:701-707
Tjon A Ten 2001
Utsey SO, Chae MH, Brown CF, Kelly D. Effect of ethnic group membership on ethnic identity, racerelated stress, and quality of life. Cultur Divers Ethnic Minor Psychol. 2002;8:366-77
Veenman J (red). De toekomst in meervoud. Perspectief op multicultureel Nederland. Assen: van
Gorcum 2002
Vermeulen H. Etnisch-culturele diversiteit als ‘feit’ en norm. Oratie. Amsterdam: Vossiuspers UvA,
2001.
Verkuyten M. Etnische identiteit: theoretische en empirische benaderingen. Het Spinhuis:
Amsterdam 1999
Vidler G. The 2001 Census of Population. Social and General Statistics Section, House of
Commons Library. Research Paper 01 / 02, March 2001.
58
Wouwe JP van, Verkerk PH, Mattiazo GF, El Mokadem N, HiraSing RA. Variation by ethnicity in
incidence of diabetes type 1 and clinical condition at onset in the Netherlands. Eur J Pediatr
2002;161:559-560
59