An urgent need for primary care to engage with social and structural determinants of health
Authors: Mariam Molokhia, Seeromanie Harding
Journal: The Lancet Public Health (2021)

In The Lancet Public Health, Ruth Watkinson and colleagues1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar report on ethnic inequalities in health among older adults (ie, those aged >55 years) by use of the large, nationally representative, English cross-sectional General Practice Patient Survey (GPPS). They estimated the association between ethnicity and health-related quality of life (HRQoL) in 18 ethnic groups (including Gypsy or Irish Travellers), adjusting for age and stratifying by sex. The study showed marked ethnic and sex inequalities in health-related quality of life (HRQoL) and its domains, and in key proximal determinants of health, namely the presence of long-term conditions or multimorbidity, experience of primary care, degree of local service support provision, and patient self-confidence in management of own health. Adjustments for area-level social deprivation did not generally alter the observed ethnic and sex inequalities in HRQoL. Ethnic inequalities in mortality and morbidity have been documented for decades in the UK. Researchers have called for robust national data to fully understand how these inequalities develop within and across ethnic groups over the life course.2Smith GD Chaturvedi N Harding S Nazroo J Williams R Ethnic inequalities in health: a review of UK epidemiological evidence.Crit Public Health. 2000; 10: 377-408Crossref Scopus (151) Google Scholar The COVID-19 pandemic has drawn attention to the continued absence of robust data to understand the greater vulnerability of some groups to poorer health outcomes than others. Watkinson and colleagues1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar show the important role of diverse inequalities, with sex, ethnicity, and age being key dimensions. For example, relative to the HRQoL of their White British peers, there were larger inequalities among women than men for many ethnic groups, but in the Gypsies or Irish Travellers ethnic group, both sexes experienced large relative disadvantage, while both Chinese men and women experienced relative advantage. Younger age groups (ie, those aged 55–64 years and 65–74 years) in some ethnic groups had better relative outcomes, such as Black African men and Chinese women. Watkinson and colleagues1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar highlight an urgent need to address ethnic inequalities in the prevalence of long-term conditions, particularly diabetes and hypertension. Others have shown that cardiovascular disease mortality has been declining across most ethnic groups, but ethnic inequalities related to specific issues persist, such as low levels of diagnosis, an absence of culturally appropriate services, and poor cardiovascular risk management.3Molokhia M Okoli GN Redmond P et al.Uncoded chronic kidney disease in primary care: a cross-sectional study of inequalities and cardiovascular disease risk management.Br J Gen Pract. 2020; 70: e785-e792Crossref PubMed Scopus (2) Google Scholar, 4Saxena S Car J Eldred D Soljak M Majeed A Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study.BMC Health Serv Res. 2007; 7: 96Crossref PubMed Scopus (61) Google Scholar The prevalence of type 2 diabetes is alarmingly high in some ethnic minority groups, such as Black Caribbean and Black African groups, and is diagnosed approximately 10–12 years earlier in these groups than in White Europeans. The onset of type 2 diabetes can trigger the onset of other long-term conditions.5Ashworth M Durbaba S Whitney D Crompton J Wright M Dodhia H Journey to multimorbidity: longitudinal analysis exploring cardiovascular risk factors and sociodemographic determinants in an urban setting.BMJ Open. 2019; 9e031649Crossref PubMed Scopus (26) Google Scholar Intersectional life-course perspectives provide novel opportunities to understand inequalities in healthy ageing and premature morbidity.6Holman D Walker A Understanding unequal ageing: towards a synthesis of intersectionality and life course analyses.Eur J Ageing. 2020; (published online Oct 15.)https://doi.org/10.1007/s10433-020-00582-7Crossref PubMed Scopus (30) Google Scholar Intersectionality refers to the simultaneous experience of multiple forms of discrimination (eg, based on gender, ethnicity, and socioeconomic position). The analyses by Watkinson and colleagues1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar were limited by the absence of robust data to understand the dynamic interplay between age, sex, ethnicity, individual socioeconomic position, and area-level deprivation. Individuals from ethnic minority groups are more likely to live in deprived areas, and the concordance between individual socioeconomic position and aggregate area-level social deprivation measures, such as the Index of Multiple Deprivation score, classified by ethnicity, is not sufficiently understood. The so-called healthy migrant effect complicates interpretation of ethnic differences in health outcomes, as migrants tend to be younger and healthier than UK-born individuals from the same ethnic group. This migrant health advantage is largest among those with activity-limiting health conditions in low-skilled occupations. In addition, ecological determinants of health, such as local ethnic density and support from faith-based organisations, might influence ethnicity-specific experiences in deprived areas, including care-giving and community cohesion.7Bécares L Dewey ME Das-Munshi J Ethnic density effects for adult mental health: systematic review and meta-analysis of international studies.Psychol Med. 2018; 48: 2054-2072Crossref PubMed Scopus (42) Google Scholar Nonetheless, combining the ecological measure from the Index of Multiple Deprivation with the GPPS enhanced the value of these datasets for future analyses.1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar Given the residential patterning of ethnic minority groups, hierarchical and spatial analyses could provide nuanced insights into variations between different regions or practices in terms of area-level social deprivation, sex, and ethnicity to inform targeted policy and practice interventions. We strongly support the recommendation by Watkinson and colleagues1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar for high quality longitudinal data to increase our understanding of ethnic inequalities in health. A life-course perspective is central to understanding ageing and premature morbidity. In the UK, ethnic differences in the risk of cardiometabolic disease are present in childhood, with ethnic minority groups disproportionately exposed to cumulative and multiple adversities,8Harding S Silva MJ Molaodi OR et al.Longitudinal study of cardiometabolic risk from early adolescence to early adulthood in an ethnically diverse cohort.BMJ Open. 2016; 6e013221PubMed Google Scholar including racism.9Hicken MT Kravitz-Wirtz N Durkee M Jackson JS Racial inequalities in health: framing future research.Soc Sci Med. 2018; 199: 11-18Crossref PubMed Scopus (92) Google Scholar Such contextual factors at multiple ecological levels, together with qualitative studies on lived experiences of social and structural determinants in health, need to be incorporated into longitudinal datasets. This combination would facilitate an improved understanding of intersectional life-course influences as fundamental drivers of inequalities and would strengthen causal inferences. Despite biases, such as the absence of data on ethnicity-specific survey non-response rates and the social determinants of health, Watkinson and colleagues1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar present strong evidence of ethnic inequalities in HRQoL, the presence of long-term conditions, and poor experiences of primary care. There seems to be inadequate support from local services to manage long-term conditions in ethnic minority groups. Although constrained by the availability of granular data, the report1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar reinforces the need to consider the intersectional influences of sex and ethnicity on inequalities in healthy ageing. The findings of the study1Watkinson RE Sutton M Turner AJ Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey.Lancet Public Health. 2021; (published online Jan 28.)https://doi.org/10.1016/S2468-2667(20)30287-5Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar are important to drive transformative changes in health care that engage with the ethnic inequalities in the social and structural determinants of health. There are examples of emerging, novel, and theoretically underpinned approaches, but many community-led interventions are disconnected from primary care services.10Goff LM Moore AP Rivas C Harding S Healthy eating and active lifestyles for diabetes (HEAL-D): study protocol for the design and feasibility trial, with process evaluation, of a culturally tailored diabetes self-management programme for African-Caribbean communities.BMJ Open. 2019; 9e023733Crossref PubMed Scopus (7) Google Scholar Connecting communities to health-care and other social care systems by decision makers has the potential to ensure that communities have a say in shaping culturally accessible services for both the prevention and management of ill health. We declare no competing interests. Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional surveyWe found evidence of wide ethnic inequalities in HRQoL and five determinants of health for older adults in England. Outcomes varied between minority ethnic groups, highlighting heterogeneity in the direction and magnitude of associations. We recommend further research to understand the drivers of inequalities, together with policy changes to improve equity of socioeconomic opportunity and access to services for older adults from minority ethnic groups. Full-Text PDF Open Access