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Ethnic differences in health: A matter of social class?. Bernadette Kumar, MD Research Fellow- University Of Oslo. University of Oslo, Norway. Outline. Relevant Concepts Migration to Norway Material and Methods Some salient findings Valuable Lessons learnt

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ethnic differences in health a matter of social class

Ethnic differences in health: A matter of social class?

Bernadette Kumar, MD

Research Fellow- University Of Oslo

University of Oslo, Norway

  • Relevant Concepts
  • Migration to Norway
  • Material and Methods
  • Some salient findings
  • Valuable Lessons learnt
  • What this means for public policy and programmes
  • Way forward /Concluding thoughts
ethnic differences in health
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 health5
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

konomisk utvikling og helsetilstand en dobbeltspiral
Økonomisk utvikling og helsetilstand – en ”dobbeltspiral”





role of sep in explaining ethnic differences of health
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
The Role of Socio-Economic position- Determinants of food take

Demomographic, Nutritional and Epidemiological transition




Dietary environment

Food beliefs

Food attitudes

Food preferences and taste

Food availability

Food Costs


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
Norway 2004 Multicultural Society ?


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


Førstegenerasjon 249 904

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
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
Post migration - Changes in lifestyle, physical and psycho-social changes
  • Family, friends, social network
  • Status/profession
  • Societal norms/ rules are different


- The HUBROStudy

- Study in GP Clinic

- Other in depth studies

January 2000/2003

May 2000

April 2002


All residents


n= 18747

age: 30,40,45, 59/60, 75/76 yrs


n= 7347

age:15/16 yrs

Romsås Study

(MORO 1)

- All Adults from a district

n= 2933

Immigrant Health Study

Pakistan, Sri Lanka, Iran, Turkey & Vietnam

N = 3019

Age: 30- 60 yrs

Romsås Study

(MORO 2)

HUBRO -Collaboration between NIPH, UiO and Oslo Municipality

study design method the oslo health study hubro the oslo immigrant health study innvandrer hubro
STUDY DESIGN & METHODThe 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

method data collection
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:
Selecting Indicators of SEP
  • Classical
    • Class
    • Occupation
    • Income
    • Education
  • Innovative
    • Standard of Living
    • (Nazroo1997)
    • Housing
sedentary during leisure time
Sedentary* during leisure time (%)

* “Yes, mainly sedentary activity (reading, watching TV etc)”, 95% CI


Prevalece of abdominal obesity

HUBRO + Innvandrer-HUBRO. Age-adjusted

(Waist/hip ratio ≥ 0,85 in women)

prevalence of self reported diabetes among ethnic groups 30 60 years
Prevalence of Self reported Diabetes among ethnic groups(30-60 years)


Kumar et al 2003

N= 2740

gestational diabetes mellitus a study from a gp clinic in oslo
Gestational Diabetes Mellitus - A study from a GP Clinic in Oslo

N =167

- Indian Sub - Pakistani/Indian

Basharat F et al 2004

- GDM detected by 2hr OGTT

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
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
limitations issues of concern
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
lessons learnt
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



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. 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.

The genes only load the gun but it is the environment that pulls the trigger!!