| Health Survey for England - The Health of Minority Ethnic Groups '99 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
2 Self-reported health and psychosocial well-being
Lisa Calderwood and Clare Tait
This chapter covers self-reported longstanding illness (2.2) and acute sickness (2.3), self-assessed general health (2.4) and two measures of psychosocial health, the GHQ12 (2.5) and perceived social support (2.6). Several factors need to be borne in mind in considering the results. First, self-assessments of health are measures of informants' subjective views that may not necessarily correspond to medical diagnoses. Second, subjective perceptions of health and interpretations of key terms may vary between informants. In particular, informants from minority ethnic groups may interpret the questions in different ways for a variety of reasons relating to culture and language. As the results presented in this chapter are based on subjective perceptions of health and well-being, they are particularly likely to be affected by differences in interpretation between minority ethnic groups. Finally, informants may also differ both within and between groups in their willingness to report illness and ill health and in their knowledge about their own health conditions. 2.2 Self-reported longstanding illness 2.2.1 Self-reported longstanding illness by minority ethnic group All surveys in the Health Survey series since it started in 1991 have included a question on longstanding illness, that is, an illness, disability or infirmity which has affected or is likely to affect the informant over a period of time. Since 1996, an additional question has been asked to ascertain whether those with a longstanding illness are limited in their activities in any way. Longstanding illness The longstanding illness table shows the proportions of men and women
in each group who reported longstanding illness. It also shows the age-adjusted
risk ratio for each group relative to the general population.1
The most marked feature of the table is the low prevalence of longstanding illness among Chinese men and women. Chinese men and women (age-adjusted risk ratios about 0.6) were significantly less likely than the general population and all other minority ethnic groups to report longstanding illness. For both Black Caribbean and Irish men and women the prevalence of longstanding illness was at or above the general population level. Age-adjusted risk ratios among Black Caribbean men and women, relative to the general population, were 1.09 and 1.14 respectively, and among Irish men and women 1.12 and 1.09 respectively. The low observed prevalences of longstanding illness among the South Asian groups do not take account of their relatively young age distribution, and age standardisation gives a better picture of the differences. After age standardisation, the prevalence of longstanding illness among South Asian men and women was similar (risk ratios 0.94 to 1.07) to that of the general population, with the exception of Indian men, among whom it remained relatively low (risk ratio 0.82). Differences between the sexes in the prevalence of longstanding illness
were less marked than differences between the minority ethnic groups.
It should be remembered that men and women have different age distributions
(the difference varying from group to group), and that male/female comparisons
of the observed figures do not take account of this. Limiting longstanding illness Those with a longstanding illness, disability or infirmity were asked whether this condition affected their activities in any way. In the general population, 25% of men and 26% of women reported a limiting condition. Responses, like those reported above for longstanding illness, showed a marked difference between those of Chinese origin and other groups, the proportion reporting limiting longstanding illness being much lower among Chinese men and women than in other groups or in the general population.
Due to the younger age distribution of the South Asian groups, in
particular Pakistanis and Bangladeshis, the relative positions of the
groups shown in the observed percentages are changed by age standardisation.
Bangladeshi and Pakistani men and women had significantly higher risk
ratios for limiting illness than the general population (risk ratios:
1.65 and 1.44 for Bangladeshi men and women and 1.31 and 1.42 for Pakistani
men and women). The risk ratio for Indian men was 0.96, well below that
of other South Asian men, but the equivalent figure for Indian women
(1.20) was similar to other South Asian women. Irish men and Black Caribbean
women also had higher risk ratios than the general population.
The relationship between longstanding illness and limiting longstanding illness Although the observed proportion reporting longstanding illness was considerably lower among South Asian groups (ranging from 30% to 38%) than among the general population (men 44%, women 45%), the observed proportion reporting limiting longstanding illness (ranging from 21% to 30%) was closer to the general population figure (men 25%, women 26%). The probability that anyone reporting a longstanding illness would also report a limiting illness was thus higher among South Asians. Of those in the general population who reported a longstanding illness, about 57% reported a limiting illness, whereas the figures for South Asians ranged from 66% to 73% (except for Bangladeshi men, where it was 82%). Figures for Black Caribbean, Chinese and Irish were closer to those of the general population. (Table not shown.) A similar pattern has been observed elsewhere.2
One interpretation of these data is to conclude that the illness threshold
that triggers a positive response to the longstanding illness question
is higher for South Asians than for the general population. This suggests
either that South Asians are 'under-reporting' or that the general population
(over 90% of whom are white) are 'over-reporting' longstanding illness,
although the essentially subjective nature of the question makes these
concepts difficult to apply with confidence. Consequently, the longstanding
illness question may not by itself be a reliable indicator of the general
health of minority ethnic groups relative to the general population. Longstanding illness by age For the general population, both longstanding illness and limiting
longstanding illness increased with age, the increase being steeper
for limiting longstanding illness. These characteristics were shared
by the minority ethnic groups surveyed. 2.2.2 Socio-economic variations in self-reported longstanding illness Social class of head of household Among both men and women in the general population, longstanding illness and limiting longstanding illness were both associated with social class of head of household, with a higher prevalence in manual social classes, the association being stronger for limiting longstanding illness than for longstanding illness. Among men in all minority ethnic groups, the prevalence of both longstanding and limiting longstanding illness was higher in manual social classes than non-manual. However analysis of age-standardised risk ratios reveals that this difference was only significant for Bangladeshi men in relation to limiting longstanding illness. For Black Caribbean, Indian, Chinese and Irish women, the prevalence
of both longstanding and limiting longstanding illness was higher in
manual social classes than non-manual. This was also true of Bangladeshi
women in relation to longstanding illness only. The age-standardised
risk ratios show that this difference was significant for Indian and
Irish women in relation to both longstanding and limiting longstanding
illness and for Black Caribbean women in relation to limiting longstanding
illness only. Equivalised household income Longstanding illness was found to be more closely related to equivalised
household income than to social class. This was particularly true of
limiting longstanding illness. In all minority ethnic groups, informants
in the lowest income tertile had higher age-adjusted risk ratios than
informants in the highest income tertile. The risk ratios for men, including
those in the general population, are calculated relative to all men
in all income groups in the general population (and similarly for women).
a Sample base too small to report. 2.2.3 Types of longstanding illness, by minority ethnic group Informants who reported a longstanding illness were asked about the nature of their illness, disability or infirmity. These self-reported illnesses were coded by broad category and then aggregated into groups which corresponded as far as possible to the chapter headings of the Ninth Revision of the International Classification of Diseases (ICD).3 The ICD classification is mostly used to group health conditions and diseases based on their cause, whereas in the Health Survey the classification of illnesses is based solely on informants' reports. Although informants may have been told the name of their illness by their GP, the survey's classification of illness may not always correspond to a classification based on a medical diagnosis. Table 2.1 shows that in the general population well over half of those with a longstanding illness reported only one such illness. The mean number of illnesses (per person with an illness) was 1.5 for men and 1.6 for women. Similar results were found within each minority ethnic group. The types of condition reported are shown in Table 2.5. In the general population musculoskeletal conditions were the most commonly reported type of longstanding illness condition, followed by heart and circulatory system problems and respiratory system disorders. These three types of longstanding illness were also the most commonly reported by men and women in most of the minority ethnic groups, although not always in the same order. For some groups other conditions had more prominence than in the general population. For example, among Indian men and women endocrine and metabolic conditions replaced respiratory system problems as the third most common type of longstanding illness. In the general population, the different types of illnesses have different relationships with age. The 1998 Health Survey report,4 which permits more detailed age analysis because of its larger sample, shows that the prevalence of musculoskeletal problems increased progressively from an early age. The prevalence of heart and circulatory system problems also increased with age, but slowly at first and then at an accelerating pace. The prevalence of adult respiratory system problems initially declined with age before increasing again. These patterns are reflected for the general population in the 1999 survey, but are not consistently found within minority ethnic groups. For example, respiratory problems tended in most groups to increase with age, without an initial decrease. It is striking that among Black Caribbeans, the prevalence of respiratory problems decreased with age, reversing the tendency found in the other minority groups. The age gradient for musculoskeletal problems was steeper for most minority ethnic groups than in the general population. Table 2.5 shows the following:
2.3 Self-reported acute sickness 2.3.1 Self-reported acute sickness, by minority ethnic group All surveys in the Health Survey series to date have included a question on acute sickness. Respondents who had cut down on anything usually done about the house, at school/work or in their free time due to illness or injury, in the two weeks preceding the interview, were defined as having had acute sickness. In order to measure severity, respondents reporting acute sickness were asked on how many days in the last two weeks their usual activities had been affected in this way. The following table shows the proportions of men and women in each group who reported acute sickness, together with risk ratios relative to the general population.
The observed percentages appear to show that, as in the general population, women in most of the minority ethnic groups were more likely than men to report acute sickness, but this difference was significant only for Irish women. Bangladeshis were the only minority ethnic group in which men were significantly more likely than women to report acute sickness (15% compared with 11%). However, these comparisons between the sexes have not been age-standardised. After age adjustment, Chinese men (0.62) and women (0.55) were significantly less likely than the general population and all other minority ethnic groups to report acute sickness. Men and women from the other minority ethnic groups seemed to be slightly more likely to report acute sickness than the general population, but this difference was only significant for Irish women (risk ratio: 1.27). The figures for the mean number of days of sickness in Table 2.7 are based on the total sample, and thus reflect acute sickness prevalence as well as variations in the number of days' sickness per episode. It is therefore not surprising that the patterns of difference in mean days' acute sickness between the minority ethnic groups are similar to those reported for the prevalence of acute sickness. In the general population the prevalence of acute sickness increased
with age. This was the case with most minority ethnic groups, though
there were some where it was not clearly seen, notably Irish men. 2.3.2 Socio-economic variation in acute sickness Social class of head of household No relationship between acute sickness and social class of head of
household was seen in the general population (although previous evidence
has suggested there may be an association, for men in particular). No
clear social class patterns were revealed within the minority ethnic
group samples. Equivalised household income In the general population, the prevalence of acute sickness varied
inversely with equivalised household income. After age adjustment, acute
sickness risk ratios for the highest and lowest income tertiles among
men were 0.93 and 1.19 respectively, comparable figures for women being
0.91 and 1.27. Only the latter of these differences reaches statistical
significance, however. A similar association between household income
and acute sickness seems to exist for the Black Caribbean, Indian, Pakistani
and Chinese minority ethnic groups, although modest base sizes mean
this must be a tentative conclusion. Small base sizes within some of
the income tertiles prevent conclusions being drawn for the Irish and
Bangladeshi groups. 2.4 Self-assessed general health 2.4.1 Self-assessed general health, by minority ethnic group Informants were asked to classify their health in general as 'very
good', 'good', 'fair', 'bad' or 'very bad'. In the tables, which present
these separately, the 'very good' and 'good' response categories have
also been combined, as have 'bad' and 'very bad'. The two combined categories,
'good or very good' and 'bad or very bad', obviously have an inverse
relationship with each other, groups with a low prevalence of very good
or good health tending to have a high prevalence of bad or very bad
health. But owing to the presence of a middle category (fair health)
this is not necessarily always the case, and results for both categories
are therefore presented in the annexed tables. The analysis in this
commentary focuses on the (combined) prevalence of bad or very bad health.
The age-adjusted risk ratios show that Pakistanis and Bangladeshis had the worst self-assessed general health. Relative to the general population, their risk ratios for 'bad' or 'very bad' health, were 2.94 and 3.91 respectively for men, and 3.57 and 3.31 respectively for women. Risk ratios for Indian men and women (1.64 and 2.63 respectively) showed that their age-adjusted prevalences of bad or very bad health were also significantly higher than those of the general population, as was that for Black Caribbean women (1.81). In summary, Pakistanis and Bangladeshis had the worst self-assessed
health, followed by Indian men and women and Black Caribbean women.
The prevalence of bad or very bad health increased with age for the
general population and all of the ethnic minority groups, but at different
rates. The age gradient in the prevalence of bad or very bad health
was more marked in the South Asian groups. Figure 2C shows that the
proportion with bad or very bad health in those aged 16-34 was much
more similar across the various groups than the corresponding proportion
in those aged 55 and over, which was particularly high among South Asian
men and women.
2.4.2 Socio-economic variations in self-assessed general health Social class of head of household For the general population the risk ratio for reporting 'good' or
'very good' health was significantly higher for non-manual social classes
than manual social classes. Conversely, informants in manual social
classes were at more than double the risk of reporting 'bad/very bad'
health than informants in non-manual social classes (risk ratios: 1.39
compared with 0.59 for men and 1.40 compared with 0.64 for women). A
similar pattern was found for social class within all minority ethnic
groups, although the prevalence of 'bad/very bad' health seemed to discriminate
better between social classes than its converse ('good/very good' health).
In particular, Black Caribbean and Chinese men and women and Indian
and Irish women in manual social classes were more than twice as likely
to report bad/very bad health than those in non-manual social classes. Equivalised household income tertile Self-assessed general health was also associated with household income for the general population and, as with social class, this association was stronger for 'bad/very bad' health. Informants in the lowest income tertile were at a much higher relative risk of reporting 'bad/very bad' health than informants in the highest income tertile (risk ratios: 2.41 compared with 0.52 for men and 1.50 compared with 0.62 for women). There appeared to be a similar relationship between household income and self-assessed general health for the Black Caribbean, Indian, Pakistani and Chinese minority ethnic groups, although modest base sizes mean that this must be a tentative conclusion. Small base sizes within some of the income tertiles prevent conclusions being drawn for the Irish and Bangladeshi groups. 2.5 The General Health Questionnaire (GHQ12) The General Health Questionnaire (GHQ12) has been included in the Health Survey in all years except 1996, when it employed two other instruments concerned with mental health and perceptions of health (the Short-Form 36 (SF36) and EuroQol). The GHQ12 was designed to detect possible psychiatric morbidity in the general population. The questionnaire is based on twelve questions about general levels of happiness, depression, anxiety and sleep disturbance over the past four weeks. A score is constructed from the responses. As in previous Health Survey reports, a score of 4 or more was used as a threshold in the 1999 survey to identify informants with a possible psychiatric disorder,5 and is referred to as a 'high GHQ12 score'. The GHQ12 has been validated for the general population. However, its validity for specific minority groups is not automatically assured by these general population validation studies, and caution is needed in interpreting the results. The way that psychological problems are experienced or expressed by different ethnic groups is known to differ. For example, people of Asian origin are more likely to express psychological problems in terms of physical complaints.6,7 A culture-specific version of the GHQ12, called the Chinese Health Questionnaire (CHQ12),8 is available and was used among people of Chinese origin. For all Asian groups, translated versions of the questionnaire were provided where necessary. It is important to note that translations of the scale may affect outcomes as exact equivalences of the concepts and questions are difficult to achieve. Other questions may be similarly affected. 2.5.2 The prevalence of high GHQ12 scores, by minority ethnic group The following table shows the proportion of men and women in each
group who had high GHQ12 scores.
The 1999 survey confirms the finding of previous surveys that the proportion with a high GHQ12 score is higher among women than men in the general population (this difference persists even if the figures for men and women are age-standardised to adjust for the fact that there are more older women than men). Higher GHQ12 scores for women than men were also found in Black Caribbean, Indian and Chinese groups, and to a lesser extent among Pakistanis. The difference between Irish men and women was in the same direction but not significant. However, it was not found among Bangladeshis, where the proportion with high GHQ12 scores was higher for men than women. (Comparisons of sexes not age standardised.) The most marked feature of the data is the relatively low prevalence of high GHQ12 among Chinese men and women, with age-adjusted risk ratios of 0.19 for men and 0.39 for women, a far lower prevalence than for any of the other groups or the general population. Another marked feature is the relatively high proportion of Bangladeshis with high GHQ12 (age adjusted ratios 1.87 for men and 1.57 for women). Risk ratios for Pakistani men (1.34) and women (1.27) showed that they too had high GHQ12, though to a less marked degree than Bangladeshi men and women. After adjusting for age, the proportion of Black Caribbean women and
Indian women (but not men) with high GHQ12 was significantly greater
than in the general population (risk ratios 1.22 for Black Caribbean
women, 1.26 for Indian women).
In the general population, the proportion with a high GHQ12 score
did not vary much with age, but among men of South Asian origin and
Black Caribbean men, it appeared to increase with increasing age. The
relationship between age and GHQ12 score was not as clear in women.
However, the samples of each sex in the oldest age group (55 and over)
were small, and should be treated with caution. 2.5.3 Socio-economic variations in the prevalence of high GHQ12 scores There was no association between a high GHQ12 score and social class
in the general population. More detailed analysis by six social class
groups in earlier reports has also shown no systematic variation by
social class in the general population. Among the minority ethnic groups
the observed figures indicate some differences in the proportion with
high GHQ12 scores between those in manual and non-manual social classes:
however, these differences largely disappeared after age standardisation. The 1998 Health Survey report found a negative relationship between high GHQ12 and income, those in the lowest income tertile having a higher proportion with high GHQ12 than those in the highest income tertile. This is again seen in the 1999 data, both before and after age standardisation, the age-standardised relative risk varying from 1.85 among men in the lowest income tertile to 0.89 among men in the highest, and from 1.60 to 0.90 respectively in the case of women. Most but not all of the minority ethnic groups similarly showed a
decrease in the proportion with high GHQ12 from the lowest to the highest
income tertile (though with the relatively small samples of each group
not all the differences were significant). Exceptions to this pattern
were Indian men, Chinese men, Black Caribbean women and Bangladeshi
women. 2.6.1 Perceived social support, by minority ethnic group A question on perceived social support has been included in all years of the Health Survey except 1996 and 1997. The perceived social support scale, originally used in the Health and Lifestyle survey,9 asked informants about the amount of support and encouragement they received from family and friends. The scale is based on seven questions about physical and emotional aspects of social support. From these, a single scale was derived by assigning a score between one (lack of support) and three (no lack of support) for each of the seven questions. Informants with a maximum score of 21 were classified as having no lack of social support, those with a score of 18 to 20 were classified as having some lack of social support and those with a score under 18 as having a severe lack of social support. Among the general population, men (16%) were more likely than women (11%) to be classified as having a severe lack of social support. These figures are identical to those reported in the 1998 survey. This difference between the sexes was seen in all ethnic minority groups except for men and women of Indian origin. Men and women of South Asian, Chinese and Black Caribbean origin were
more likely than men and women in the general population to be classified
as having a severe lack of
social support, age-standardised risk ratios ranging from about 1.3
for Black Caribbeans to well over 2.0 for South Asians and Chinese.
Irish men and women were less likely to be classified as having a severe
lack of social support but the difference from the general population
was not significant in the case of women.
Previous surveys have not found marked age patterns in the general
population with respect to the proportion with a severe lack of social
support, and it is therefore not surprising to find no clear pattern
in the general population in 1999. Some of the minority ethnic groups
do appear to show differences by age. Among Chinese men, the proportion
with a severe lack of social support increased with increasing age from
28% at age 16-34 to 55% at age 55 and over. A similar but less marked
pattern was found among Pakistani men, but among Bangladeshi men it
appears to be reversed. The small sample sizes for these groups should
be noted. Among women there were no clear patterns by age. 2.6.2 Socio-economic variations in perceived social support 1999 survey figures for the general population, for both sexes, indicate
an association between social class and perceived social support, with
those in non-manual social classes less likely to perceive themselves
as having severe lack of social support than those in manual classes.
Except for people of Bangladeshi origin, this pattern was seen among
the minority ethnic groups. Taking into account age standardisation,
the difference between manual and non manual was significant for Indian
men and women, Pakistani men, Chinese men and Irish women. Among the general population, a clear linear association was seen
between income and perceived social support. Those in the lowest income
tertile were more likely to be classified as having a severe lack of
social support than those in the highest tertile. Across the minority
ethnic groups this pattern was seen among men and women of Black Caribbean,
Pakistani, Irish and Chinese origin. The association was most marked
among men and women of Chinese origin; 59% and 52% respectively were
classified as having a severe lack of social support in the lowest income
tertile compared to 23% and 16% in the highest income tertile. References and notes 1 It should be noted that while data for both men and women were standardised to the same general population age distribution (an aggregation of male and female), the denominators for risk ratios were the separate male and female population values. Comments on men's and women's risk ratios thus reflect their respective differences from the general population of that gender. 2 Nazroo J. The health of Britain's ethnic minorities (p.38) Policy Studies Institute, London, 1997. 3 The International Classification of Diseases and Related Health Problems (Ninth Revision),WHO, Geneva 1977. 4 Boreham R, Tait C. Self-reported health and psychosocial well-being (Chapter 6, p.235) in Erens B, Primatesta P (eds). The Health Survey for England '98: Cardiovascular disease. The Stationery Office, London, 1999. 5 Each item in the GHQ12 has four possible answers. In scoring, each item is treated as a bimodal response scale so that only pathological deviations from normal signal possession of the item. Thus each informant scores 0 or 1 on each questionnaire item, and the total possible score for the GHQ12 is 12. See Goldberg D, Williams PA. User's Guide to the General Health Questionnaire. NFER-NELSON, 1988, pp 11-12 for further discussion of the scoring method. 6 Prior L, Huat SB, Bloor M, Waller S, Rehman H. The Health Needs and Health Promotion Issues Relevant to the Chinese Community in England. School of Social and Administrative Studies, Cardiff University of Wales, 1997. 7 Rack, P. Race, Culture and Mental Disorder. Tavistock, London, 1982. 8 Cheng, TA, Williams P. The Design and Development of a Screening Questionnaire (CHQ) For Use in Community Studies of Mental Disorders in Taiwan. Psychological Medicine 1986; 16:415-422. 9 Cox BD et al. The Health and Lifestyles Survey. The Health Promotion Research Trust, London, 1987. 2.1 Longstanding illness and limiting longstanding illness, by minority ethnic group 2.2 Longstanding illness and limiting longstanding illness, by age within minority ethnic group 2.3 Longstanding illness and limiting longstanding illness, by social class of head of household within minority ethnic group 2.4 Longstanding illness and limiting longstanding illness, by equivalised household income tertile within minority ethnic group 2.5 Rate per thousand reporting longstanding illness conditions, by minority ethnic group 2.6 Rate per thousand reporting longstanding illness conditions, by age within minority ethnic group 2.7 Acute sickness, by minority ethnic group 2.8 Acute sickness, by age within minority ethnic group 2.9 Acute sickness, by social class of head of household within minority ethnic group 2.10 Acute sickness, by equivalised household income tertile within minority ethnic group 2.11 Self-assessed general health, by minority ethnic group 2.12 Self assessed general health, by age within minority ethnic group 2.13 Self-assessed general health, by social class of head of household within minority ethnic group 2.14 Self-assessed general health, by equivalised household income tertile within minority ethnic group 2.15 GHQ12 score, by minority ethnic group 2.16 GHQ12 score, by age within minority ethnic group 2.17 GHQ12 score, by social class of head of household within minority ethnic group 2.18 GHQ12 score, by equivalised household income tertile within minority ethnic group 2.19 Perceived social support, by minority ethnic group 2.20 Perceived social support, by age within minority ethnic group 2.21 Perceived social support, by social class of head of household within minority ethnic group 2.22 Perceived social support, by equivalised household income tertile within minority ethnic group
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
