Ethnic differences in
health: A matter of social
class?
Bernadette Kumar, MD
Research Fellow- University Of
Oslo
University of Oslo, Norway
Outline
Relevant Concepts
Migration to Norway
Material and Methods
Some salient findings
Valuable Lessons learnt
What this means for public policy and
programmes
Way forward /Concluding thoughts
Defining Ethnic Minorities –
Heterogenous ? Uniformly
disadvantaged?
Ethnic Differences in Health
Growing Evidence – increased
documentation/ attention over the
past few decades(Marmot, Bhopal,
Nazroo)
Underlying factors remain contested
(Rogers 1992, Sørlie 1992, Davey
Smith 1998, Nazroo 1997)
Ethnic Differences in Health
Statistical Artefact
Consequence of Migration
Cultural Differences
Racism and Discrimination
Poorer Access to Health Care
Material Circumstances
Genetic or Biological Explanations
Nazroo 1997
Økonomisk utvikling og helsetilstand
– en ”dobbeltspiral”
Velstand
Fattigdom
Helse
Sykdom
Role of SEP in explaining ethnic
differences of Health
Minimal/No contribution(Wild,
McKeigue 1997)
Other factors – cultural/ genetic
elements play larger role (Smaje
1996)
Ethnic differences in health are
predominately determined by Socioeconomic inequalities(Navarro 1990,
Sheldon&Parker 1992)
The Role of Socio-Economic position
- Determinants of food take
Demomographic, Nutritional and Epidemiological
transition
Socio-demographic
characteristics
Health/lifestyle
Dietary
environment
Food beliefs
Food attitudes
Food preferences and taste
Food availability
Food Costs
Adapted from Shatenstein et al
1997
DIET CONSUMED
MIGRATION to Norway from developing
counrtries a fairly recent phenomenon with
its origins in the late sixties.
Norway 2004 Multicultural
Society ?
Population:
4.6 million
7.3 % immigrants
Capital: Oslo
520 000
inhabitants
88,000 immigrants
from developing
countries(17%)
40% of all
immigrants in Oslo
from the Indian
Subcontinent
INNVANDRER I NORGE
Befolkning i alt: 4 503 436
Innvandrerbefolkningen
Førstegenerasjon
Barn født i Norge
249 904
47 827
Annen innvandringsbakgrunn
Adopert
Født i utlandet(en norsk foreldre)
Født i Norge(en norsk foreldre)
Født i utlandet av to norskfødte
Totalt
13 843
23 143
153 006
17 827
505 868
Migration to Norway
OSLO IMMIGRANT HEALTH STUDY included
five of the major ethnic groups from developing
countries living in Oslo (ie.Turkish, Pakistani,
Iranian, Sri Lankan and Vietnamese)
Reasons for migration vary..
Pakistanis and Turkish have longest duration of
stay in Oslo, are the oldest and were primarily
labour immigrants.
Iranians, Sri Lankans and Vietnamese were
primarily asylum seekers and have shorter
duration of stay in Oslo.
Post migration
- Changes in lifestyle, physical and psycho-social
changes
Family, friends,
social network
Status/professi
on
Societal norms/
rules are
different
DATA SOURCES
- The HUBRO Study
- Study in GP Clinic
- Other in depth studies
January 2000/2003
Romsås Study
(MORO 1)
- All Adults from a district
n= 2933
Romsås Study
(MORO 2)
May 2000
HUBRO
All residents
Adults
n= 18747
age: 30,40,45, 59/60,
75/76 yrs
Adolescents
n= 7347
age:15/16 yrs
April 2002
Immigrant Health
Study
Pakistan, Sri Lanka, Iran,
Turkey & Vietnam
N = 3019
Age: 30- 60 yrs
HUBRO -Collaboration between NIPH, UiO and Oslo Municipality
www.fhi.no
STUDY DESIGN & METHOD
The Oslo Health Study (HUBRO) &
The Oslo Immigrant Health Study
(Innvandrer-HUBRO)
Cross Sectional, population-based studies conducted in 2000-2001 &
2002
Sample in the current analysis:
– Persons aged 30-60 years attending one of the two studies and born in
» Norway (n=9842)
» Turkey (n=465)
» Iran (n=649)
» Pakistan (n=643)
» Sri Lanka (n=1013)
» Vietnam (n=567)
Overall response rate of 47% in HUBRO and 40% in InnvandrerHUBRO
http://www.fhi.no/artikler/?id=28217
Method – Data Collection
Invitation – letter with 2 sided questionnaire sent by post to be
completed and delivered at clinic for the check up)
Clinical Assessment
Non-fasting blood samples drawn
Blood pressure(average of three readings) and pulse measured
Height and weight measured with an electronic scale
Waist and hip measured with a steel tape.
If NFBG >=6.1 respondents were requested to come for a
fasting sample(immigrant study only)
Questionnaire (assistance offered by translators)
Self reported health, diseases(diabetes)
Lifestyle factors (e.g. physical activity & smoking)
Biological factors(number of children)
Socio-demographic data (e.g. education)
15- & 16 year olds were required only to complete the
questionnaire( they did not undergo any clinical examination)
2 reminders sent by post and the last round included a mobile van
in different parts of the city.
Translations of questionnaire availalble at:
Selecting
Indicators of SEP
Classical
Class
Occupation
Income
Education
Innovative
Standard of Living
(Nazroo1997)
Housing
Adults aged 30-60 years In Oslo
Women
Man
100
100
80
80
Country of Birth
60
Country of Birth
60
Turkey
Turkey
Sri Lanka
Sri Lanka
40
40
Iran
Iran
Pakistan
20
Vietnam
0
Norw ay
<10yrs
10-12 yrs
Years of education
>12yrs
Pakistan
20
Percent
Percent
Years of Education
Vietnam
0
Norw ay
<10yrs
10-12 yrs
Years of education
>12yrs
Area of Residence
Adults aged 30-60 years In Oslo
Men
Women
120
120
100
100
Country of birth
80
Country of Birth
80
Turkey
Turkey
60
60
Sri Lanka
Sri Lanka
Iran
40
Iran
40
Pakistan
20
Vietnam
0
Norw ay
West
Area of Residence
East
Percent
Pakistan
20
Vietnam
0
Norw ay
West
Area of residence
East
Gainful Employment
Adults aged 30-60 years In Oslo
Women
Men
100
100
80
80
Country of Birth
60
Country of Birth
60
Turkey
Turkey
Sri Lanka
Sri Lanka
40
40
Iran
Iran
Pakistan
Vietnam
0
Norw ay
Working
Not Working
Pakistan
20
Percent
20
Vietnam
0
Norw ay
Working
Not Working
Gainful Employment
Gainful Employment
Type of Housing
Adult Men aged 30-60 years In Oslo
90
80
70
60
50
Villa
Apartment
40
30
20
Other
10
0
Turkey
Sri Lanka
Iran
Pakistan
Vietnam Norw ay
Type of Housing
Adult Women aged 30-60 years In Oslo
90
80
70
60
50
40
30
20
10
0
Villa
Apartment
Other
Turkey
Iran
Vietnam
Mother’s Education by
Ethnicity (Youth 15-16 yrs in Oslo)
80
70
60
50
40
30
20
10
0
<6yrs
6-14 yrs
P<0.001
s
un
tri
e
W
Co
op
e
EE
ur
A
EN
M
SS
A
Su
b
ian
In
d
Ea
st
A
sia
<15yrs
Distribution by area of residence in Oslo
Outer West
8,8%
Inner West
3,3%
Inner East
18,7%
Outer East
69,2%
SOCIAL CLASS BY ETHNICITY
(Youth 15-16 yrs in Oslo)
Class1&2
Working
Ethnic groups
P<0.001
s
un
tri
e
W
Co
op
e
EE
ur
A
SS
A
M
EN
ian
Su
b
Not Working
In
d
Ea
st
As
ia
70
60
50
40
30
20
10
0
God eller svært god vurdering av helse og fødeland / fars fødeland.
Menn i Oslo 2000-2001(Helseprofil i Oslo)
100
90
80
Prosent
70
60
Norge
50
Vestlig
40
Ikke-vestlig
30
20
10
0
15-16 år
30 år
40+45 år
59+60 år
God eller svært god vurdering av helse og fødeland/ fars fødeland.
Kvinner i Oslo 2000-2001(Kilde:Helseprofil i oslo)
100
90
80
70
60
Norge
50
Vestlig
40
Ikke-vestlig
30
20
10
0
15-16 år
30 år
40+45 år
59+60 år
Self reported health*
by years of education
Adult women 30-60 yrs in Oslo
90
80
70
60
<10yrs
50
10-12 yrs
40
>12yrs
30
20
10
0
Turkey Sri Lanka
*Age adjusted
Iran
Pakistan Vietnam
Norway
Self Reported Health*
by years of education
Adult Men 30-60 yrs in Oslo
100
90
80
70
<10yrs
60
50
40
10-12 yrs
>12yrs
30
20
10
0
Turkey Sri Lanka
*Age adjusted
Iran
Pakistan Vietnam
Norway
Self Reported Health* by
Employment Status
100
90
80
70
WORK
60
50
40
NOTWRK
WORK
NOTWRK
30
20
10
0
Turkey Sri Lanka
Iran
Pakistan Vietnam Norway
Self Reported Health* by Area of
Residence
100
90
80
70
West
60
East
50
West
40
East
30
20
10
0
Turkey Sri Lanka
Iran
Pakistan Vietnam
Norway
Ethnic differences in Physical
Activity among adolescents
90
80
70
60
<1hr/wk
1-4hr/wk
>5hr/wk
50
40
30
20
10
0
EA
ISC
SSA
MENA
EE
WC
Sedentary* during leisure time (%)
Western
70
Indian subcontinent
60
Other immigrants
50
40
0,8349
0,8431
0,884
0,8767
30
20
10
0
Men
Women
* “Yes, mainly sedentary activity (reading, watching TV etc)”, 95% CI
Ethnic Differences in Physical
Inactivity
%
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
Turkey
Women
Men
%
Inactive%
Inactive%
Sri Lanka
Iran
Pakistan
Vietnam
Turkey
Sri Lanka
Iran
Pakistan
Vietnam
Ethnicity
East Asia
Indian
Subcontinent
Sub Saharan
Africa
North Africa/
MiddleEast
Eastern
Europe
Western
Europe
100 %
80 %
60 %
40 %
20 %
0%
Distribution of Body Mass Index among ethnic
adolescents in Oslo
8574-84
25-74
-24
Kumar et al 2003
BMI among
adults
in Oslo
BMI of adults
fromethnic
ethnic
minorities
100 %
80 %
> 30
60 %
25-29.9
18.6-24.9
40 %
< 18.5
20 %
East Asia
Indian
Subcontinent
Sub Saharan
Africa
North Africa/
MiddleEast
Eastern
Europe
Western
Europe
0%
Kumar et al 2003
Weight gain among 5 immigrant groups
100 %
80 %
> 16 kgs
60 %
Upto 15 kgs
Upto 10 kgs
40 %
No w eight gain
20 %
m
tn
a
Vi
e
Pa
kis
ta
n
n
Ira
ka
an
iL
Sr
Tr
yk
ia
0%
Kumar et al 2004
Prevalece of abdominal obesity
HUBRO + Innvandrer-HUBRO. Age-adjusted
(Waist/hip ratio ≥ 0,85 in women)
0%
10 %
20 %
30 %
40 %
50 %
Norway
Turkey
Iran
Pakistan
Sri Lanka
Vietnam
Women
60 %
Obesity by employment status
Adults 30-60 yrs olds
60
50
40
Work
Nwork
30
Work
20
NWork
10
0
Turkey
Sri Lanka
Iran
Pakistan
Vietnam
Norway
Prevalence of smoking in different
ethnic groups (%)
%
50
45
40
35
30
25
20
15
10
5
0
Men
Women
W
Jenum 2002
M
I
EA
Prevalence of Self reported Diabetes
among ethnic groups(30-60 years)
Western
East Europe
MENA
SSA
Self reported
diabetes
ISC
East Asia
0
2
Percent
N= 2740
4
6
8
10
12
Kumar et al 2003
Gestational Diabetes Mellitus
- A study from a GP Clinic in Oslo
N =167
100
90
80
70
60
50
40
30
20
10
0
GDM (IGT values)
GDM (diabetic values)
Known T2D
Norwegian
Indian Sub
- Indian Sub - Pakistani/Indian
- GDM detected by 2hr OGTT
Others
Basharat F et al 2004
BRUK AV HELSETJENESTEN
Hyppig bruk av allemennlegen
29.3% menn i 40/45 aldersgruppen
brukt allemennlegen og 37.9% i 59/60
aldersgruppen i motsetning til de
norske 9.6% og 19.7% i tilsvarende
grupper.
Data Collection/Methods
Increasing Participation
Personal Communication- face to face is best.
Translation is a must but is not the solution to all
problems
Errors and misunderstandings
Language- use of words(cheese/paneer)
Differing concepts – sandwich spreads
Role of food items in the diet –potatoes,
beverages
Terminology- fatty fish
Variation- fruits, weekends
Fig 1. Distribution of the Score of Fruit and Vegetable Index among
Norwegians and Pakistanis
Percent of the 80
sample 70
60
50
40
30
Pakistanis
20
Norwegians
10
0
Low
Moderate
High
Fruit and Vegetable Index
Kumar BN, Holmboe-Ottesen G, Wandel M 2002
Fig 2. Percentage of reported daily Fruit & Vegetable
intake using two methods among Pakistanis
50
40
30
20
FFQ
10
24 hours
recall
0
Fruit
juice
Fruits
Cooked
Veg.
Raw
Veg.
Kumar BN, Holmboe-Ottesen G, Wandel M 2002
Limitations/ Issues of Concern
Serious problems with crude attempts to adjust for
SEP using conventional indicators
Socio-economic differentials alone cannot explain
ethnic differences
Neither cultural practices nor biology is static
Lifetime perspective – cummulative effect?
Intergenerational effect?
Measuring Multiple Jeopardy( Balarajan)
Measuring Area Effect – Adds to Indiviudual SE
disadvantage
WHAT IS DIFFERENT?
Lessons Learnt
Reaching the persons
Information via:Ethnic
shops,radio channels,
newspapers
Key persons
Letter/ Personal contact/
Phone
Contact with immigrant groups is
important, involvement of resource
persons from minority groups is essential.
Monitor and Evaluate instruments
based on feedback from
participants and change them
accordingly.
Numerous sources for error and
misunderstandings
TING TAR TID!!
What can be done, and what should be done
By whom?
that’s the question……
STRATEGY AND POLICY
•
•
Reduction of unnecessary, unjust and
potentially changeable socio-economic
gradients in health is now identified as a
goal.
White paper on Health promotion:
Prescriptions for a Healthier Norway.A
broad policy for public health. St.meld.nr.
16 (2002-2003).
•
•
A campaign against smoking and the tobacco
industry.
Green prescription (life-style counselling by
GPs).
STRATEGY/POLICY
•
•
•
The existence of great inequalities in health,
particularly within Oslo - “the East – West Divide”:
• Differences in life expectancy between the
districts:
Men: 12 years, Women: 7 years
• Strong associations between mortality and
social class
• Strong associations between mortality and
district SES and unhealthy behaviour
(Rognerud M The Oslo health report Oslo
1998, Claussen B, Norsk Edidemiologi 2002,
Jenum AK, Int J of Edpidem. 2001)
Media and political awareness on social inequalities
heightened
Political will has been strengthened - the previous
minister of health actively promoted prevention.
CONCLUDING THOUGHTS
Multicultural societies are here to stay!!
Comparative studies that provide
valuable empirical information must be
pursued
The quest for SEP indicators for across
group comparisons is far from over.
A need to increase the understanding of
the interwoven influences of cultural
attributes to health related behaviours
Raise the potential for improving health
through culturally appropriate
interventions that are effective.
FINALLY…
The genes only load
the gun but it is
the environment
that pulls the
trigger!!
TAKK FOR
OPPMERKSOMHET