The ethnic density effect on the health of ethnic minority people in the United Kingdom: a study of hypothesised pathways

This thesis contributes to our understanding of the individual and community assets available to ethnic minority people living in areas characterised by high concentrations of co-ethnics. It has been hypothesized that positive attributes found in areas of greater concentration of ethnic minority people, or ethnic density, might provide ethnic minority residents with health promoting, or protective effects. This study explored the effect of ethnic density on the health of ethnic minority people in the UK. It proposed and tested three pathways by which ethnic density is hypothesised to operate: through a change in racism-related social norms; through buffering the detrimental effects of racism on health; and through an increase in civic-political activity. Multilevel methods were applied to three nationally representative cross sectional studies, the 1999 and 2004 Health Survey for England; the Fourth National Survey of Ethnic Minorities; and the 2005 and 2007 Citizenship Survey. Results showed a stronger ethnic density effect on psychological outcomes, as compared to that found for physical health outcomes. Effect sizes were larger when the ethnic density of specific groups was analysed, but more likely to be significant when the density of all minority groups combined was considered. Analyses conducted to test the social norms model reported a significant reduction in experienced racism among ethnic minority people living in areas of high ethnic density, as compared to their counterparts who live in areas of reduced ethnic density. Examinations of the buffering effects of ethnic density indicated a tendency for a weaker association between racism and health as ethnic density increased, although interactions were mostly non-significant. Finally, ethnic minority people were not found to report higher civic engagement as ethnic density increased, but they were found to be more satisfied with local services and to report greater community cohesion

Ethnic inequalities in multiple long-term health conditions in the United Kingdom: a systematic review and narrative synthesis

Indicative evidence suggests that minoritised ethnic groups have higher risk of developing multiple long-term conditions (MLTCs), and do so earlier than the majority white population. While there is evidence on ethnic inequalities in single health conditions and comorbidities, no review has attempted to look across these from a MLTCs perspective. As such, we currently have an incomplete understanding of the extent of ethnic inequalities in the prevalence of MLTCs. Further, concerns have been raised about variations in the way ethnicity is operationalised and how this impedes our understanding of health inequalities. In this systematic review we aimed to 1) describe the literature that provides evidence of ethnicity and prevalence of MLTCs amongst people living in the UK, 2) summarise the prevalence estimates of MLTCs across ethnic groups and 3) to assess the ways in which ethnicity is conceptualised and operationalised. We focus on the state of the evidence prior to, and during the very early stages of the pandemic. We registered the protocol on PROSPERO (CRD42020218061). Between October and December 2020, we searched ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, Web of Science, OpenGrey, and reference lists of key studies/reviews. The main outcome was prevalence estimates for MLTCs for at least one minoritised ethnic group, compared to the majority white population. We included studies conducted in the UK reporting on ethnicity and prevalence of MLTCs. To summarise the prevalence estimates of MLTCs across ethnic groups we included only studies of MLTCs that provided estimates adjusted at least for age. Two reviewers screened and extracted data from a random sample of studies (10%). Data were synthesised using narrative synthesis. Of the 7949 studies identified, 84 met criteria for inclusion. Of these, seven contributed to the evidence of ethnic inequalities in MLTCs. Five of the seven studies point to higher prevalence of MLTCs in at least one minoritised ethnic group compared to their white counterparts. Because the number/types of health conditions varied between studies and some ethnic populations were aggregated or omitted, the findings may not accurately reflect the true level of ethnic inequality. Future research should consider key explanatory factors, including those at the macrolevel (e.g. racism, discrimination), as they may play a role in the development and severity of MLTCs in different ethnic groups. Research is also needed to ascertain the extent to which the COVID19 pandemic has exacerbated these inequalities

Minority status and mental distress: a comparison of group density effects

Background It has been observed that mental disorders, such as psychosis, are more common for people in some ethnic groups in areas where their ethnic group is less common. We set out to test whether this ethnic density effect reflects minority status in general, by looking at three situations where individual characteristics differ from what is usual in a locality. Method Using data from the South East London Community Health study (n = 1698) we investigated associations between minority status (defined by: ethnicity, household status and occupational social class) and risk of psychotic experiences, common mental disorders and parasuicide. We used a multilevel logistic model to examine cross-level interactions between minority status at individual and neighbourhood levels. Results Being Black in an area where this was less common (10%) was associated with higher odds of psychotic experiences [odds ratio (OR) 1.34 95% confidence interval (CI) 1.07–1.67], and attempted suicide (OR 1.84 95% CI 1.19–2.85). Living alone where this was less usual (10% less) was associated with increased odds of psychotic experiences (OR 2.18 95% CI 0.91–5.26), while being in a disadvantaged social class where this was less usual (10% less) was associated with increased odds of attempted suicide (OR 1.33 95% CI 1.03–1.71). We found no evidence for an association with common mental disorders. Conclusions The relationship between minority status and mental distress was most apparent when defined in terms of broad ethnic group but was also observed for individual household status and occupational social class

Ethnic inequalities in age‐related patterns of multiple long‐term conditions in England: Analysis of primary care and nationally representative survey data

Little is known about the patterning of multiple long‐term conditions (MLTCs) by age, ethnicity and across conceptualisations of MLTCs (e.g. MLTCs with/without mental health conditions [MHCs]). We examined ethnic inequalities in age‐related patterns of MLTCs, and combinations of physical and MHCs using the English GP Patient Survey and Clinical Practice Research Datalink. We described the association between MLTCs and age using multilevel regression models adjusting for sex and area‐level deprivation with patients nested within GP practices. Similar analyses were repeated for MLTCs that include MHCs. We observed ethnic inequalities from middle‐age onwards such as older Pakistani, Indian, Black Caribbean and Other ethnic people had increased risk of MLTCs compared to white British people, even after adjusting for area‐level deprivation. Compared to white British people, Gypsy and Irish Travellers had higher levels of MLTCs across the age groups, and Chinese people had lower levels. Pakistani and Bangladeshi people aged 50–74 years were more likely than white people to report MLTCs that included MHCs. We find clear evidence of ethnic inequalities in MLTCs. The lower prevalence of MLTCs that include MHCs among some minoritised ethnic groups may be an underestimation due to underdiagnosis and/or inadequate primary care and requires further scrutiny

Neighbourhood ethnic density effects on behavioural and cognitive problems among young racial/ethnic minority children in the US and England: a cross-national comparison

Studies on adult racial/ethnic minority populations show that the increased concentration of racial/ethnic minorities in a neighbourhood—a so-called ethnic density effect—is associated with improved health of racial/ethnic minority residents when adjusting for area deprivation. However, this literature has focused mainly on adult populations, individual racial/ethnic groups, and single countries, with no studies focusing on children of different racial/ethnic groups or comparing across nations. This study aims to compare neighbourhood ethnic density effects on young children’s cognitive and behavioural outcomes in the US and in England. We used data from two nationally representative birth cohort studies, the US Early Childhood Longitudinal Study-Birth Cohort and the UK Millennium Cohort Study, to estimate the association between own ethnic density and behavioural and cognitive development at 5 years of age. Findings show substantial heterogeneity in ethnic density effects on child outcomes within and between the two countries, suggesting that ethnic density effects may reflect the wider social and economic context. We argue that researchers should take area deprivation into account when estimating ethnic density effects and when developing policy initiatives targeted at strengthening and improving the health and development of racial and ethnic minority children

Explaining ethnic variations in adolescent mental health: a secondary analysis of the Millennium Cohort Study

Purpose The relationship between ethnicity and adolescent mental health was investigated using cross-sectional data from the nationally representative UK Millennium Cohort Study. Methods Parental Strengths and Difficulties Questionnaire reports identified mental health problems in 10,357 young people aged 14 (n = 2042 from ethnic minority backgrounds: Mixed n = 492, Indian n = 275, Pakistani n = 496, Bangladeshi n = 221, Black Caribbean n = 102, Black African n = 187, Other Ethnic Group n = 269). Univariable logistic regression models investigated associations between each factor and outcome; a bivariable model investigated whether household income explained differences by ethnicity, and a multivariable model additionally adjusted for factors of social support (self-assessed support, parental relationship), participation (socialising, organised activities, religious attendance), and adversity (bullying, victimisation, substance use). Results were stratified by sex as evidence of a sex/ethnicity interaction was found (P = 0.0002). Results There were lower unadjusted odds for mental health problems in boys from Black African (OR 0.15, 95% CI 0.04–0.61) and Indian backgrounds (OR 0.42, 95% CI 0.21–0.86) compared to White peers. After adjustment for income, odds were lower in boys from Black African (OR 0.10, 95% CI 0.02–0.38), Indian (OR 0.40, 95% CI 0.21–0.77), and Pakistani (OR 0.49, 95% CI 0.27–0.89) backgrounds, and girls from Bangladeshi (OR 0.18, 95% CI 0.05–0.65) and Pakistani (OR 0.63, 95% CI 0.41–0.99) backgrounds. After further adjustment for social support, participation, and adversity factors, only boys from a Black African background had lower odds (OR 0.16, 95% CI 0.03–0.71) of mental health problems. Conclusions Household income confounded lower prevalence of mental health problems in some young people from Pakistani and Bangladeshi backgrounds; findings suggest ethnic differences are partly but not fully accounted for by income, social support, participation, and adversity. Addressing income inequalities and socially focused interventions may protect against mental health problems irrespective of ethnicity

Continuity of care in diverse ethnic groups: a general practice record study in England

Background: GPs and patients value continuity of care. Ethnic differences in continuity could contribute to inequalities in experience and outcomes. Aim: To describe relational continuity of care in general practice by ethnicity and long-term conditions. Design and setting: In total, 381 474 patients in England were included from a random sample from the Clinical Practice Research Datalink (January 2016 to December 2019). Method: Face-to-face, telephone, and online consultations with a GP were included. Continuity, measured by the Usual Provider of Care and Bice–Boxerman indices, was calculated for patients with ≥3 consultations. Ethnicity was taken from the GP record or linked Hospital Episode Statistics data, and long-term conditions were counted at baseline. Multilevel regression models were used to describe continuity by ethnicity sequentially adjusted for: a) the number of consultations, follow-up time, age, sex, and practice-level random intercept; b) socioeconomic deprivation in the patient’s residential area; and c) long-term conditions. Results: On full adjustment, 5 of 10 ethnic minority groups (Bangladeshi, Pakistani, Black African, Black Caribbean, and any other Black background) had lower continuity of care compared with White patients. Continuity was lower for patients in more deprived areas and younger patients but this did not account for ethnic differences in continuity. Differences by ethnicity were also seen in patients with ≥2 long-term conditions. Conclusion: Ethnic minority identity and socioeconomic deprivation have additive associations with lower continuity of care. Structural factors affecting demand for, and supply of, GPs should be assessed for their contribution to ethnic inequalities in relational continuity and other care quality domains

Ethnic inequities in the patterns of personalized care adjustments for ‘informed dissent’ and ‘patient unsuitable’: a retrospective study using Clinical Practice Research Datalink

Background In England, general practitioners voluntarily take part in the Quality and Outcomes Framework, which is a program that seeks to improve care by rewarding good practice. They can make personalized care adjustments (PCAs), e.g. if patients choose not to have the treatment/intervention offered (‘informed dissent’) or because they are considered to be clinically ‘unsuitable’. Methods Using data from the Clinical Practice Research Datalink (Aurum), this study examined patterns of PCA reporting for ‘informed dissent’ and ‘patient unsuitable’, how they vary across ethnic groups and whether ethnic inequities were explained by sociodemographic factors or co-morbidities. Results The odds of having a PCA record for ‘informed dissent’ were lower for 7 of the 10 minoritized ethnic groups studied. Indian patients were less likely than white patients to have a PCA record for ‘patient unsuitable’. The higher likelihood of reporting for ‘patient unsuitable’ among people from Black Caribbean, Black Other, Pakistani and other ethnic groups was explained by co-morbidities and/or area-level deprivation. Conclusions The findings counter narratives that suggest that people from minoritized ethnic groups often refuse medical intervention/treatment. The findings also illustrate ethnic inequities in PCA reporting for ‘patient unsuitable’, which are linked to clinical and social complexity and should be tackled to improve health outcomes for all

Radiocarbon dates for the late Pleistocene and Early Holocene occupations of Cova Rosa (Ribadesella, Asturias, Spain)

Four excavations have been performed at the archaeological site of Cova Rosa (Asturias, Cantabrian Spain): three of them in the second half of last century and the other in this decade. Although little of the archaeological material found in those excavations has been published, here we attempt the stratigraphic correlation of sections revealed by the different excavations and we present 22 new radiocarbon dates for bones and marine shells, built in a Bayesian statistical model. This has enabled the documentation of occupations that mainly took place during the Last Glacial period, in the Solutrean (middle and upper phases) and Magdalenian (archaic, lower, and upper phases), and also in the early Holocene (Mesolithic). These occupations are compared with the record at other sites in Cantabrian Spain in general and in Asturias, in particular.Introduction Cova Rosa Cave - Geographical and Geological Setting - History of Research - Stratigraphy Radiocarbon dates at Cova Rosa - Method - Validity Analysis - Results and Critical Assessment - Solutrean - Magdalenian - Mesolithic Discussion: 14C chronology of Cova Rosa Conclusion

Response of macroinvertebrates to experimental nutrient and fish additions in European localities at different latitudes

The sedimentary and plant-associated macroinvertebrate communities have been examined in a series of mesocosm experiments carried out in five locations, in Finland, Sweden, UK, Northwest Spain and Mediterranean Spain (the International Mesocosm Experiment). The experiments were designed to investigate how shallow lake ecosystems respond to the addition of nutrients and planktivorous fish along a climate gradient. Nutrient additions increased sedimentary benthos densities and total biomass to a plateau at intermediate levels of nutrients. The effect was greater in the warmest localities. Beyond the saturation point a further increase in nutrient loading had different effects depending on locality. Only in the southernmost site (in Mediterranean Spain), did it induce a shift to a turbid phase and macrophyte disappearance. Thus there are breakpoints in the relationship with nutrients, leading to alternative sediment communities subsequent to the water alternative states. Presence of fish increased the densities and biomass of sediment macroinvertebrates, more clearly in the more southern locality, where the fish Gambusia did not prey in the bottom animals. A stabilising role of macrophytes was observed by cutting them, samples taken three weeks after cutting indicated a higher effect of fish on the sediment community when macrophytes were not present. Nutrients tended also to increase densities of plant associated macroinvertebrates at low levels with a flattening of response at intermediate levels and a decline at high levels. At high fish level the numbers and biomass of plant-associated macroinvertebrates were lowered in all cases, because of increased predation. However fish addition at low level in most cases had the opposite effect, because their predation pressure was not high and regeneration of nutrients through their activities might increase food availability and control invertebrate predators. Fish influenced especially community composition, because they prey selectively. Addition of fish at low densities increased macroinvertebrate diversity. A diel migratory cycle was observed in plant-associated macroinvertebrates, but only in the southerly locations. Latitudinal influences on the structure of the macroinvertebrate communities occur but that they operate indirectly. There was a prominent effect of nutrients on these communities so that starting trophy is very important. Fish effects are layered on these and depend to a large extent on the particular range of diet of the species involved.Se ha estudiado la comunidad de macroinvertebrados bentónicos del sedimento así como la de los asociados a los macrófitos en una serie de mesocosmos concebidos para un experimento múltiple simultáneo llevado a cabo en cinco localidades europeas: Finlandia, Suecia, Reino Unido (UK), Noroeste de España y Levante Español. El experimento fue diseñado para investigar como responden los ecosistemas de lagos someros a los aportes de nutrientes y a la abundancia de peces planctívoros a lo largo de un gradiente climático. La adición de nutrientes incrementó la densidad del bentos del sedimento y su biomasa hasta estabilizarse a niveles intermedios de nutrientes, siendo este efecto mayor en las latitudes más bajas y cálidas. Más allá del punto de saturación, un aumento adicional de la carga de nutrientes tuvo efectos diferentes dependiendo de la localidad y solo en el lugar de menor latitud, (en el Levante Español) indujo el cambio hacia una fase turbia, con desaparición de los macrófitos, esto es, hay puntos de ruptura relacionados con la carga de nutrientes que conducen a comunidades alternativas en el sedimento, subsiguientes a los mencionados estados alternativos en las aguas someras. La presencia de peces aumentó la densidad y biomasa de los macroinvertebrados del sedimento, ello también más claramente en la localidad situada más al Sur, ya que el pez planctívoro ensayado (Gambusia) por lo general no depreda en los animales del sedimento. Se observó también el papel estabilizador de los macrófitos comparando las muestras tomadas antes y después de que estos fueran cortados, por ejemplo se observó un efecto mayor de los peces en las comunidades del sedimento cuando los macrófitos no estaban presentes. Los nutrientes tendieron también a incrementar las densidades de los macroinvertebrados asociados a los macrófitos cuando se aportan a bajos niveles, con una estabilización de la respuesta para los valores intermedios y un declive para los valores más altos. Cuando se adicionaron densidades altas de peces, el número y biomasa de los macroinvertebrados asociados a los macrófitos descendieron en todos los casos, como resultado del aumento de la depredación. Sin embargo, las adiciones a baja densidad de peces, en la mayoría de los casos, tuvo el efecto contrario, ya que su presión de depredación no es alta y pueden contribuir a la regeneración de los nutrientes a través de la vía detrítica que incrementa la disponibilidad de alimento, así como al control de otros invertebrados depredadores. La presencia de peces influenció especialmente la composición de la comunidad, ya que su depredación es selectiva. La adición de peces en bajas densidades aumentó la diversidad de los macroinvertebrados. También fue observado que el ciclo diario de migración en los macroinvertebrados asociados a los macrófitos, es más importante en las localidades ubicadas en las latitudes de más al Sur. Las influencias latitudinales en la estructura de las comunidades de macroinvertebrados, si bien sucede, opera indirectamente. Hay un efecto dominante de los nutrientes en estas comunidades, y el nivel trófico de las condiciones iniciales es muy importante. Los efectos de los peces se subordinan al de los nutrientes y dependen en gran medida de la dieta de las especies involucradas