The challenges of health and healthcare in multicultural societies Men’s Health Forum 2007 Raj Bhopal CBE, DSc (hon) Professor of Public Health, University.
Post on 02-Jan-2016
218 Views
Preview:
Transcript
The challenges of health and healthcare in
multicultural societies
Men’s Health Forum 2007
Raj Bhopal CBE, DSc (hon)Professor of Public Health, University of Edinburgh &
Chairman, Steering Committee of the National Resource Centre for Ethnic Minority Health
Lecture contents
Migration Human species Definitions of race and ethnicity Assessing ethnicity and race Relative and absolute approaches in interpreting
variations-some examples in practice and research Forces generating inequalities and inequities Race, clinical medicine and genetics Challenges and potential Example: prevention of diabetes Conclusions and directions
Migration-key to understanding The driving force creating multi-ethnic societies Fundamental human behaviour Permitted humans to leave Africa Reasons –
trade and commerce, demand for work, demand for workers, education, personal aspirations, political refugecuriosity
All are worthy and important
Human species
What is a species? Were there several human species on Earth at any
point? How many human species are there on the earth
today? How do we know?
All humans on the earth now are Homo sapiens: race and ethnicity define subgroups. This was not always so
Race
The group a person belongs to, or is perceived to belong to because of-
physical features reflecting ancestry
Increasingly concept emphasises a common social and political heritage
The concept is largely discredited in Europe, where it is displaced by ethnicity
Ethnicity
The group a person belongs to, or is perceived to belong to, because of-
culture, language, diet, religion, ancestry,
and
physical textures Ethnicity subsumes race
Assessing ethnicity: three approaches 3 main approaches i.e.
self-assessment
assessment by another using data assessment by another by observation.
However you do it, you need to create a classification-difficult
UK has taken the task seriously only in the last 20 years or so
England: Comparison of the 1991 and 2001 Census ethnic groupings
1991 Census 2001 Census
White British, Irish, Any other white background
Black Caribbean, Black African, Black other
Caribbean, African, Any other Black background
Indian, Pakistani, Bangladeshi Indian, Pakistani, Bangladeshi any other Asian background
Chinese Chinese
Any other ethnic group Any other ethnic group
No ‘Mixed’ category White and Black Caribbean, White and Black African, White and Asian, Any other mixed background
Assessing variations by ethnic group Absolute risk approach: examine patterns
within each group (primary). Then compare with other ethnic groups-the
relative risk approach (secondary). The interpretation will be different. Maximise value by doing both.
Newcastle Heart Project: Smoking prevalence (%)
Indian Pakistani Bangladeshi European
Men
(S. Asian combined, 33%)
14 32 57 33
Women
(S. Asian combined, 3%)
1 5 2 31
Standardpopulation
Bangladeshi men
SMR for stroke(ICD 10 I60-69)
100 249
(213-292)
Mortality for stroke given as standardized mortality ratios (95% confidence interval) in Bangladeshi born men in England and Wales, around 2001 census
Forces generating ethnic health inequalities Culture and lifestyle Social, educational and economic status Environment before and after migration
Early life development Generational effects Genetics
Access to and concordance with health care advice
Question: Are ethnic inequalities inequities i.e. injustices?
Equity and inequality
Consider whether the following are inequities: The lower prevalence of smoking in Sikh Indian
compared to White men The higher rate of colo-rectal cancer in White
people compared to S. Asians The lower life expectancy of African Americans
compared to White Americans
What do you think? One deep problem is racism.
Racism, prejudice and inequity
Why might ethnic minority patients get worse care in a health setting?
Might racism and prejudice play a part? What kinds of racism have you seen? What experiences of racism have you, and
close friends or relatives experienced?
The continuing promotion of Hitlerian Views
TABERNACLE OF THE PHINEHAS PRIESTHOOD / ARYAN NATIONS
PLEDGE: I will conduct myself at all times as a gentleman (or woman) reflecting the superiority of the Aryan Race.
http://www.aryan-nations.org/about.htm (accessed 24th of Feb. 2005)
Race: Ashley Montagu
“…. the race problem.. seems to have grown more troubling than ever.…”
his formula and analysis of the problem: “race” = the physical appearance (genetic) of the individual + intelligence of the individual + ability of the group to which the individual belongs to achieve a high civilization.
“Nothing could be more unsound, for there is no genetic linkage whatever between these three variables.”
Ashley Montagu, Man’s Most Dangerous Myth, p31
Pharmacological variations by ethnic group: BiDil
Finding of the efficacy of isosorbide dinitrate plus hydralazine (BiDil) in black patients (Taylor, N Engl J Med 2004, 351 p 2055)
FDA approval for populations describing themselves as black (unique and controversial decision)
The race, medicine and genetics debate is wide open
Health-care challenges for a multi-ethnic world
Responding to varying health behaviours, beliefs and attitudes differences in the pattern of diseases differences in diagnosis, treatment and outcome language and cultural barriers calls for a service sensitive to cultural differences personal biases, stereotyped views, individual
racism, and institutional racism laws requiring equal opportunities in employment
and promotion
Medicine and diversity
In an increasingly diverse society, which serves to enrich our lives and experiences, doctors must learn to value ethnic diversity to deliver effective health care. In doing so, they will bring mutual benefits for their patients and themselves.J Kai et al. Medical Education 1999 p622
The future for health professionalsMy vision of a future health professional:
learns about the unity yet diversity of humanity.
engages in studies emphasising ethnicity, religion and language that includes bedside teaching.
Grasps opportunities for learning about ethnic diversity with a strong focus on how people maintain their heath in different cultures.
The future 2
takes special interest in the health beliefs and attitudes of one or more ethnic minority populations
integrates relevant ideas into the advice on healthy living for all patients and populations.
makes sure that there is a reason for mentioning the patient's ethnic group, and explains it.
The future 3 takes pride that the health service’s policy makers
and peers seek his/her advice on improving services for ethnic minorities.
finds that these roles and skills are appropriately recognised in the awards and promotions committees.
Doing things: the evidence based approach-PODOSA A major national project, set in Glasgow and
Edinburgh Object-contribute to worldwide efforts to
control the epidemic of diabetes About 20% of adult South Asians in the UK
have got diabetes compared to about 5% in the population as a whole
Why?
Stemming the epidemicStemming the epidemic
Tackle the causesTackle the causes Tackle intermediate states e.g. impaired Tackle intermediate states e.g. impaired
glucose tolerance (the focus today and to-glucose tolerance (the focus today and to-date)date)
Tackle the diseaseTackle the disease
Da Qing, China Study 42 percent reduction in the incidence of Da Qing, China Study 42 percent reduction in the incidence of diabetes over six yearsdiabetes over six years
Finnish Diabetes Prevention Study -58 percent reduction in three Finnish Diabetes Prevention Study -58 percent reduction in three yearsyears
Diabetes Prevention Programme Study, USA- 58% reduction in Diabetes Prevention Programme Study, USA- 58% reduction in three yearsthree years
Indian Diabetes Prevention Programme, Chennai, India - 30 Indian Diabetes Prevention Programme, Chennai, India - 30 percent reduction in three yearspercent reduction in three years
We have been inspired!We have been inspired!
It can be done!It can be done!
NewNewTrial in Edinburgh and Trial in Edinburgh and Glasgow-Glasgow-
Primary prevention of Primary prevention of diabetes and obesity in South diabetes and obesity in South Asians (PODOSA)Asians (PODOSA)
www.podosa.org/index.htmlwww.podosa.org/index.html
Principal research questionPrincipal research question
does a family-based weight loss and does a family-based weight loss and physical activity programme reduce the physical activity programme reduce the incidence of type 2 diabetes in South incidence of type 2 diabetes in South Asians?Asians?
adapt existing interventions culturallyadapt existing interventions culturally apply in families with diabetesapply in families with diabetes Focus on reducing weight and increasing physical activity in Focus on reducing weight and increasing physical activity in
adults with IGTadults with IGT 300 families will be randomised into two groups (600 people with 300 families will be randomised into two groups (600 people with
IGT in total)IGT in total) One group of 300 will receive 15 contacts over three yearsOne group of 300 will receive 15 contacts over three years one group of 300 will have 4 contactsone group of 300 will have 4 contacts
Trial summary
Intervention GoalsIntervention Goals
weight loss of at least 3.5 kg (5% minimum)weight loss of at least 3.5 kg (5% minimum) increase in moderate physical activity to at least 30 increase in moderate physical activity to at least 30
minutes dailyminutes daily BMI to less than or equal to 25 or preferably 23BMI to less than or equal to 25 or preferably 23 reduce waist size to less than 90 cm for men, and reduce waist size to less than 90 cm for men, and
less than 80 cm for womenless than 80 cm for women
TimescalesTimescales
Participant recruitment-July 2007 through to Participant recruitment-July 2007 through to June 2008June 2008
Follow-up through to 2010/11Follow-up through to 2010/11 Trial concludes July/August 2011Trial concludes July/August 2011
Results so farResults so far
Trial staff are in place (Anne Douglas, Alex Trial staff are in place (Anne Douglas, Alex Cellini, Harpreet Bains, Sunita Wallia, Ruby Cellini, Harpreet Bains, Sunita Wallia, Ruby Bhopal, Anu Sharma, Alyson Grubb)Bhopal, Anu Sharma, Alyson Grubb)
So far:So far:About 150 people screenedAbout 150 people screened
Many with possible diabetes they did not know aboutMany with possible diabetes they did not know about
Quite a few with possible IFGQuite a few with possible IFG
about 16people with IGTabout 16people with IGT
Advice and help needed from professional colleagues
How to gain referrals into the trial:people with IFGpeople with IGTpeople with a family historypeople at high risk
please send them our way Key contact telephone number: Anne Douglas, trial manager,
650-3213, Anne.Douglas@ed.ac.uk People can sign up on our website
Conclusions International migration and exchange are creating multi-
ethnic global societies. The concept of ethnicity can improve public health,
health care, and clinical care, and advance science The greatest goal is that people should be long-lived,
free of disease and disability, brimming with energy, creative and full of ideas.
Ethnicity can contribute to this goal. In doing so, we improve the health and healthcare of the
entire population
Further reading for such a professional
Gill PS, Kai J, Bhopal RS, Wild SH. Health Needs Assessment for Black and Ethnic Minority Groups 2002 (book chapter - in press, available online at http://hcna.radcliffe-oxford.com/bemgframe.htm
Bhopal RS. Ethnicity, race, and health in multicultural societies; foundations for better epidemiology, public health, and health care. Oxford: Oxford University Press, 2007, pp 357. http://www.oup.com/uk/catalogue/?ci=9780198568179
top related