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 FattigdomSykdom Helse
Role of SEP in explaining ethnic differences of Health Minimal/No contribution(Wild, McKeigue 1997) Other factors – cultural/ genetic elements play larger role (Smaje 1996) Ethnic differences in health are predominately determined by Socio- economic inequalities(Navarro 1990, Sheldon&Parker 1992)
The Role of Socio-Economic position - Determinants of food take Demomographic, Nutritional and Epidemiological transition Socio-demographic characteristics Health/lifestyle Dietary environment Food beliefs Food attitudes Food preferences and taste Food availability Food Costs DIET CONSUMED Adapted from Shatenstein et al 1997
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 Førstegenerasjon249 904 Barn født i Norge 47 827 Annen innvandringsbakgrunn Adopert 13 843 Født i utlandet(en norsk foreldre) 23 143 Født i Norge(en norsk foreldre) 153 006 Født i utlandet av to norskfødte 17 827 Totalt 505 868
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 April 2002 Romsås Study (MORO 1) - All Adults from a district n= 2933 HUBRO All residents Adults n= 18747 age: 30,40,45, 59/60, 75/76 yrs Adolescents Adolescents n= 7347 age:15/16 yrs Immigrant Health Study Pakistan, Sri Lanka, Iran, Turkey & Vietnam N = 3019 Age: 30- 60 yrs January 2000/2003 May 2000 Romsås Study (MORO 2) 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 Innvandrer- HUBRO 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: www.fhi.no
Selecting Indicators of SEP Classical Class Occupation Income Education Innovative Standard of Living (Nazroo1997) Housing
Years of Education Adults aged 30-60 years In Oslo
Area of Residence Adults aged 30-60 years In Oslo
Gainful Employment Adults aged 30-60 years In Oslo
Type of Housing Adult Men aged 30-60 years In Oslo
Type of Housing Adult Women aged 30-60 years In Oslo
Mother’s Education by Ethnicity ( Youth 15-16 yrs in Oslo) P<0.001
SOCIAL CLASS BY ETHNICITY ( Youth 15-16 yrs in Oslo) P<0.001
Self reported health* by years of education Adult women 30-60 yrs in Oslo *Age adjusted
Self Reported Health* by years of education Adult Men 30-60 yrs in Oslo *Age adjusted
Self Reported Health* by Employment Status
Self Reported Health* by Area of Residence
Ethnic differences in Physical Activity among adolescents
Sedentary* during leisure time (%) * “Yes, mainly sedentary activity (reading, watching TV etc)”, 95% CI
Ethnic Differences in Physical Inactivity % % Women
Kumar et al 2003
BMI of adults from ethnic minorities Kumar et al 2003
Kumar et al 2004
Prevalece of abdominal obesity HUBRO + Innvandrer-HUBRO. Age-adjusted (Waist/hip ratio ≥ 0,85 in women)
Obesity by employment status Adults 30-60 yrs olds
Prevalence of smoking in different ethnic groups (%) Jenum 2002 %
Prevalence of Self reported Diabetes among ethnic groups(30-60 years) Percent Kumar et al 2003 N= 2740
Gestational Diabetes Mellitus - A study from a GP Clinic in Oslo - GDM detected by 2hr OGTT Basharat F et al 2004 N =167 - Indian Sub - Pakistani/Indian
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
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