Theme 1: Construction of the problem of access to health care by minority ethnic groups access to health care by minority ethnic groups

minority ethnicity

4.2.1 Theme 1: Construction of the problem of access to health care by minority ethnic groups access to health care by minority ethnic groups

• 4.2.2 Theme 24.2.2 Theme 2: Identification

of candidacy

• 4.2.3 Theme 34.2.3 Theme 3: Navigation:

Mobilising resources

• 4.2.4 Theme 44.2.4 Theme 4: Organisational issues

in navigation

• 4.2.5 Theme 54.2.5 Theme 5: Presentation, adjudication

and offers

•

4.2.6 Theme 64.2.6 Theme 6: Tractability: Policy, service developments and interventions to improve access for people of

minority ethnicity

A table of included studies can be found at Appendix 4A.

4.2.1 Theme 1: Construction of the problem of access to health care by minority ethnic groups

Our analysis suggests a meta-narrative of the inverse care law

operates in relation to ethnicity and access to health care as for

socio-NCCSDO © 2005 130 economic disadvantage. For example Bhopal (1998), in an ‘Education and Debate’ review article in the British Medical Journal (BMJ), argued that health services may offer a worse service to minority groups, an assumption also made by the NHS Plan. As with the literature on disadvantage, however, many of the assumptions rest on a relatively small body of empirical evidence, not all of it very rigorous. Much of the empirical literature reported in journals and books, though it continues to be widely cited, is quite dated, and does not reflect the changes that have occurred in recent years, particularly since key policy changes relating to discrimination and organisation of health services have been implemented. This literature also fails to make the kinds of distinctions about issues of candidacy that we identified as important in our analysis of the literature on socio-economic disadvantage and access to health care. We have organised our synthesis around the following themes generated by our analysis of the evidence:

• General practice.

• Specialist care.

• Mental health.

• Preventive services.

General practice

Like research in the area of socio-economic disadvantage, most studies of ethnic minority access to health care have focused on utilisation of health care. The picture that emerges is complex, equivocal, and beset by methodological problems.

Earlier in this report, we discussed evidence about variable supply of GPs in different parts of the country, and suggested that the

significance of this would lie in evidence that people had greater difficulties in registering with a GP, or in gaining timely access to good quality primary care. We did not identify evidence that suggests that people of minority ethnicity, other than those very recently migrated perhaps as asylum-seekers, have difficulties in registering with a GP.

As summarised by Goddard and Smith (1998), a high proportion of people from most ethnic minority groups appear to be registered with a GP, with most surveys reporting registration rates of 99-100 per cent. Indeed work cited by Chan (2000) suggests that rate of registration with a GP is higher among minority ethnic groups than among the general population, and Ahmad and Walker (1997) found that 72 per cent of people of South Asian ethnicity reported ease of contact with a GP to be ‘no problem’. Goddard and Smith’s (1998) summary suggests that a high proportion of people from many ethnic groups are registered with a GP from the same group, though this is less common among some groups, including the Chinese. Uddin et al.’s (1998) review notes that over four out of five South Asians attend a surgery with an Asian doctor. The evidence summarised by Goddard

NCCSDO © 2005 131 and Smith (1998) also suggests that people of minority ethnicity are less likely to have appointments in primary care, instead using open access surgeries, and that they wait longer in the surgery, but the currency of these findings in the light of recent policy developments is unclear.

Our analysis of the evidence suggests that there are generally high rates of GP consultation rates among people of minority ethnicity, but the impact of ethnicity on health service use varies across ethnic groups. Again, as with the literature on socio-economically

disadvantaged people, the debate has been about the extent to which higher use reflects higher need or some other variables. Evidence dating back to the early 1980s has repeatedly found higher rates of GP utilisation by South Asian groups, but these studies did not adjust for need (Balarajan et al., 1992; Balarajan et al., 1989). When attempts are made to adjust for need, rates of utilisation of GP services remain higher among South Asians generally, compared with all other ethnic groups (Gillam et al., 1989; Smaje and Le Grand, 1997). Sutton et al.’s analysis (2002) suggested that after controlling for socio-economic status and morbidity, individuals classified as Indian, Pakistani and Bangladeshi are more likely to consult, and to consult more often. Smaje and Le Grand’s (1997) analysis, adjusted for socio-economic status, found that for people aged under 45 years, people of Pakistani and Caribbean origin were higher users of GP services

compared with the white European population, but this was not consistent across gender. Caribbean women were found to consult more frequently, and Pakistani women less frequently, than their white counterparts. The effect of higher GP use is not consistent across all minority groups – Chinese people are likely to be lower users of services. Livingston et al. (2002), reporting a study of use of health and social services by immigrant elders in Islington, found that immigrants used primary and secondary care at least at the same level as older UK-born people, but that Africans and Caribbeans appear to have poorer physical health, and this excess morbidity may account for their greater contact with health and social services.

Specialist care

The evidence as regards utilisation of specialist services in secondary and tertiary care is even more equivocal, with apparent variations across ethnic groups, across different medical specialties, between men and women, and between younger and older people within

minority groups. The finding that utilisation of GP services by minority groups tends to be higher, and of specialist outpatient and inpatient services tends to be lower, has now been repeated across several studies (Saxena et al., 2002) but is not entirely consistent either across groups or medical specialities. Again, the problem in interpreting the evidence here relates to candidacy: it is not clear whether different utilisation reflects differing patterns of recognition of

Smaje and Le Grand (1997) found that outpatient consultations were lower across the range of minority groups, a finding also confirmed in Smaje’s (1998) analysis of the same data, in which he showed that there are equivalent or higher rates of GP consultation for people from most ethnic minority groups relative to whites (the Chinese population being the exception) and lower levels of outpatient utilisation. Sutton et al. (2002) reported that people of Indian, Pakistani and Bangladeshi origin have lower than expected outpatient and day case treatment, and Bangladeshi individuals have less inpatient treatment. Cooper et al. (1998) reported that South Asian children use GPs more than any other ethnic group, with the lowest rate of GP consultation among African Caribbean children, but all children and young people from minority groups were less likely to use hospital outpatients or to be hospital inpatients. White children in this study were around twice as likely to use hospital outpatients (11.3 per cent of white children compared with 6.1 per cent of Indian, five per cent of Pakistani or Bangladeshi, and seven per cent of African Caribbean children).

For asthma there is also some evidence that utilisation of secondary care is higher, bucking the overall trend for lower use of secondary care among people of minority ethnicity. Gilthorpe et al. (1999) found that age-standardised admission rates for asthma were higher in all minority ethnic groups than in the white group, irrespective of gender, and these differences could not be explained by differences in

prevalence of asthma (though again might possibly be explained by poorer control of asthma). Gilthorpe’s analysis also found that although deprivation was observed to have a significant effect on asthma admissions, ethnic differences still exist, and that it is difficult to disentangle the effects of deprivation and ethnicity as minority groups are often deprived.

There has been considerable debate about whether there are differences between South Asian and white people in the invasive management of coronary disease. Taken together, the evidence is not consistent. Gatrell et al. (2002) provided some ecological evidence that access to tertiary services may be lower from some minority groups, finding that rates of cardiac investigation (angiography) and treatment (revascularisation) are lower in wards with higher

proportion of South Asians (classified by using census data). By

contrast, a study in Leicester of people admitted to hospital with heart failure showed that South Asian patients had significantly higher age adjusted admission rates (rate ratio 3.8 for men and 5.2 for women) for heart failure compared with white patients. In the five years before admission with heart failure, 3.3 per cent (n=11 of 336 in the study) of South Asians in this study had undergone a revascularisation procedure compared with 2.1 per cent (n=105 of 5057 ) of white patients (Chi squared = 1.6; p <0.2). For the follow-up period, values

Much of the evidence in relation to cardiovascular services has been summarised by Feder et al. (2002) and by Carter et al. (2001). Feder et al. (2002) argue that most studies in the area have been affected by small sample sizes, omission of details on severity of illness,

appropriateness of procedure, and other confounding factors. Carter et al. (2001), reporting a systematic review, found that there is evidence for some variation by ethnic group in the management of coronary heart disease, with evidence for lower receipt of angiography and revascularisation for South Asians and lower recognition and

treatment of raised blood pressure in white and possibly South Asian groups. However, they comment that the studies they reviewed had small sample sizes, and did not adjust the analysis for possible differences in appropriateness of interventions between different groups. Most studies of secondary care did not adjust for demographic factors, and this could mean that variations between ethnic groups is not a function of ethnicity but of other factors such as socio-economic status. Several studies that Carter et al. review suggest that sources of variation in coronary investigation and treatment probably arise in secondary or tertiary care.

Complex debates surround issues of provision for diseases with especially high prevalence in ethnic minority populations. On the one hand, there is a reluctance to label people of minority ethnicity as having exotic or stigmatising diseases, particularly those that pose threats to public health (such as HIV and tuberculosis). On the other hand, it is argued that the distinctive health needs of different minority populations need to be recognised and served. Lack of provision of ante-natal screening for sickle cell and

haemoglobinopathies had been criticised as an example of under-provision: sickle cell anaemia has an incidence of one in 400 births among African Caribbeans (Chevannes, 1991) and about 170 babies are born annually with sickle cell disease (Anie et al., 2002). This is likely to have been ameliorated with the recent establishment of the NHS Sickle Cell and Thalassaemia Screening Programme, although such a programme will raise complex questions of ethnicity, racism, citizenship, and consumerism as well as the historical legacies of eugenics (Atkin and Ahmad, 1998).

Mental health

The picture for mental health is very distinctive, and here there is a substantial body of research summarised by Atkinson et al. (2001) showing that members of the Black population are more likely to be admitted to psychiatric units, more likely to be held in locked wards, and more likely to be sectioned under the Mental Health Act, while at the same time some types of mental health conditions, including depression and dementia, may be under-diagnosed. There is some

NCCSDO © 2005 134 evidence that minority groups tend to have higher GP consultation rates for physical problems but lower rates of consultation for mental health problems. In Bebbington et al.’s (2000) analysis of the National Survey on Psychiatric Morbidity, an odds ratio of 0.95 for black people and an odds ratio of 0.37 for South Asian people of GP consultation for a mental health problem compared with white people was reported, but there is considerable evidence pointing to much higher hospital admissions (including compulsory admissions) for black people (Bhui et al., 2003).

Bhui et al.’s (2003) recent systematic review found evidence of ethnic variations in use of specialist mental health services in the UK. The evidence most consistently suggests an excess use of inpatient

facilities by Black patients (though two studies pointed to an excess of White admissions). Of 23 papers measuring compulsory admissions, 18 showed a higher rate for Black compared with White patients. A meta-analysis of these studies gave a pooled odds ratio (Blacks compared with Whites) for compulsory admission to in-patient facilities of 4.31 (95 per cent CI 3.33-5.58).

In the previous section, we distinguished people’s attendances at health services as appearances or responses to invitations; we further distinguish compulsory admissions as ‘grabs’. We suggest that

compulsory admissions represent the forceful seizing of control over candidacy by health services. ‘Grabs’ represent one of the few

occasions when the definition and negotiation of candidacy slips wholly from the control of people and into the control of health services.

‘Grabs’ are an important example of a negative case in our emergent analysis, which has emphasised the jointly constructed nature of candidacy. It is possible to explain this negative case by referring to the very special properties of ‘grabs’, which rely on invoking statutory powers, such as those required for compulsory admission. Other examples of ‘grabs’ of control over candidacy – such as surgery in emergency situations - require simila r powers.

Preventive services

Use of preventive services also presents an inconsistent picture. A systematic review of ethnicity and health care access in London

(Atkinson et al., 2001), found that uptake of some preventive services (such as childhood immunisation) is high among ethnic minority groups, while uptake of other preventive services (such as breast and cervical screening) is relatively lower. Majeed et al. (1995) found that screening rates for breast cancer were negatively correlated with variables that measured the ethnic make-up of practice populations, and also with variables associated with social deprivations. Majeed et al. (1994) reported similar findings for uptake of cervical smears. It has also been noted that ethnic minority women have been found to be up to five times more likely to initiate antenatal care ‘late’ (after 18

Summary: Construction of the problem of access to health care by minority ethnic groups

Taken together, the evidence suggests there are important variations within and between ethnic minority groups in their utilisation of health care.

Utilisation of primary care is generally high among most ethnic minority population groups, though there are important exceptions. The studies reviewed above do not explain why: possible explanations include higher morbidity, different help-seeking behaviours and cultural orientations towards medicine, different demographics, or poorer quality consultations that lead to repeat use. The evidence on uptake of preventive services is variable. The finding that there is lower utilisation of secondary and tertiary care by people from ethnic minorities is important and interesting and it does not appear to be explained by a reluctance to seek an initial consultation with a GP. There are too few well-conducted studies to be certain of inequities or the nature of these inequities. There is a distinctive picture in re lation to utilisation of mental health care.

4.2.2 Theme 2: Identification of candidacy

As we suggest in our analysis of the literature on socio-economic disadvantage, accomplishing access to health care requires

considerable work on the part of individuals, and that the amount, complexity, and difficulty of that work may operate as barriers. For people in minority ethnic groups, there may be particular difficulties in aligning their perceptions of health and illness to those of health services, though we do not wish to overstate the distinctiveness of knowledge and beliefs among minority populations. Our synthesis is organised around the following themes, generated by our analysis of the literature:

• Recognition of health needs: People’s identification of candidacy.

• Delays and blockages in recognising or acting on candidacy.

• Identity.

• Health maintaining behaviours.

Recognition of health needs: People’s identification of candidacy

We analysed articles that examined the extent to which decisions to seek help and strategies used to cope with ill health were influenced by information, knowledge and beliefs in minority ethnic communities.

However, there is a need for caution in interpreting some of this evidence. As we showed in the general meta-ethnography, lay beliefs and knowledge take on distinctive forms that are socially and

culturally patterned: we do not wish to imply that only minority ethnic

NCCSDO © 2005 136 groups have beliefs and knowledge systems that are different from those of medicine. Many of the issues that affect minority groups in relation to beliefs and knowledge are very similar to those that affect people of all ethnicities.

Variations in cultural beliefs about the aetiology, symptomatology, and treatment of health problems are likely to explain some aspects of help-seeking behaviour. The social construction of symptoms and the significance of symptoms varies between ethnic groups. For some cultures, alternative or complementary therapies may be used in preference or instead of contact with formal health services (Chan, 2000). Goddard and Smith (1998) report evidence that the Chinese belief in health as a property of humans requiring continuing

intervention may make them less likely to view illness as episodes requiring clinical intervention. Chaturvedi et al. and Ben-Shlomo (1997) conducted a questionnaire study based on a vignette to investigate how South Asians and white Europeans would respond to anginal pain. They found that more Hindus and Sikhs than white Europeans reported that they would be concerned if they were to experience the chest pain in the case scenario, and they were twice as likely to say they would definitely seek immediate medical care.

However, paradoxically, the readiness to consult a lay network and call a GP may be counterproductive, because these actions increase the delay in administration of thrombolytic therapy. Adamson et al.

(2003) similarly found that African Caribbean people were more likely to report that they would access care immediately in response to the clinical scenarios presented in chest pain and lump scenarios, but did not report on the type of care that would be sought.

There is some evidence that medical knowledge of some diseases and conditions may be poor among some minority groups, and that this affects help-seeking. Atkinson et al.’s (2001) systematic review identified that low levels of cancer knowledge among ethnic minority populations are an important barrier to access. Problems also arise in some minority groups because Western biomedical concepts may not have their equivalents in other cultures. Davies and Webb (2000) explain that Somali culture has a concept of mental illness only in its most severe and florid form, and no concept of emotionally or

psychologically based childhood disorders in particular. Talking

therapies are unknown in Somali culture. These issues can inhibit use of child psychiatry services. Green et al. (2002) suggest that

In document Vulnerable groups and access to health care: a critical interpretive review (Page 129-140)