Racism as the fundamental cause of ethnic inequities in COVID-19 vaccine hesitancy: A theoretical framework and empirical exploration using the UK Household Longitudinal Study

Saunders

Bécares

2022

Preprint

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Background Having multiple long-term conditions has been associated with a higher treatment burden, reduced quality of life and a higher risk of mortality. Epidemiological evidence suggests that people from minoritised ethnic groups have a higher prevalence of multiple long-term conditions (MLTCs) but questions remain regarding the patterning of MLTCs by age, how this varies for different ethnic group populations, and across conceptualisations of MLTCs (for example, MLTCs with and without mental health conditions). The aim of this study is to examine ethnic inequalities in age-related patterns of MLTCs, and combinations of physical and mental health conditions. Methods We analysed data from the English GP Patient Survey (GPPS) 2015-2017, and Clinical Practice Research Datalink (CPRD) Aurum from 2016, to give us insight into self-reported and primary care recorded long-term conditions in people aged 18 years and above. We described the association between two or more long-term conditions and age using multilevel regression models adjusting for sex and area-level deprivation with patients nested within GP practices. Similar analyses were repeated for MLTCs that included a mental health condition. Findings For both self-reported and primary care recorded LTCs, people from most minoritised ethnic groups had a lower prevalence of MLTCs at younger ages compared to their white counterparts. We observed ethnic inequalities from middle age onwards such that in later life, Pakistani, Indian, Black Caribbean and people of Other ethnicity were at an increased risk of having MLTCs compared to white British people. These trends remained after adjusting for area-level deprivation. Compared to white British people, Gypsy and Irish Travellers had higher levels of MLTCs across the age groups, and Chinese people had lower levels. Pakistani and Bangladeshi people aged 50-74 years were more likely than white British people to report two or more LTCs that included a mental health condition. People from other minoritised ethnic groups were less likely to report this compared to white British people. Conclusion We find clear evidence of ethnic inequalities in MLTCs. It is imperative for health systems to recognise and respond to the higher prevalence of MLTCs that develop by middle age for many minoritised ethnic group people. The lower prevalence of MLTCs that include a mental health condition among some minoritised ethnic group people may be an underestimation due to underdiagnosis and/or inadequate care in primary care and requires further scrutiny.

Section: Discussionmentioning

confidence: 99%

Section: Possible Mechanismsmentioning

confidence: 99%

Ethnic inequalities in age-related patterns of multiple long-term conditions in England: analysis of primary care and nationally representative survey data

Saunders

Bécares

2022

Preprint

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“…In this review, we included studies published up until 2020 and identified three studies where COVID19 was the index condition. Whilst we do not consider COVID19 a long-term condition to be captured by definitions of multimorbidity [1,3], we acknowledge that the pandemic has exacerbated ethnic inequalities in healthcare [128]. Our decision to focus mainly on studies published before 2020 ensures that the review sets a benchmark and provides an overview of studies that examined ethnic inequalities in the prevalence of MLTCs prior to the pandemic.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Ethnic inequalities in multiple long-term health conditions in the United Kingdom: a systematic review and narrative synthesis

Bécares

2023

BMC Public Health

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Indicative evidence suggests that minoritised ethnic groups have higher risk of developing multiple long-term conditions (MLTCs), and do so earlier than the majority white population. While there is evidence on ethnic inequalities in single health conditions and comorbidities, no review has attempted to look across these from a MLTCs perspective. As such, we currently have an incomplete understanding of the extent of ethnic inequalities in the prevalence of MLTCs. Further, concerns have been raised about variations in the way ethnicity is operationalised and how this impedes our understanding of health inequalities. In this systematic review we aimed to 1) describe the literature that provides evidence of ethnicity and prevalence of MLTCs amongst people living in the UK, 2) summarise the prevalence estimates of MLTCs across ethnic groups and 3) to assess the ways in which ethnicity is conceptualised and operationalised. We focus on the state of the evidence prior to, and during the very early stages of the pandemic. We registered the protocol on PROSPERO (CRD42020218061). Between October and December 2020, we searched ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, Web of Science, OpenGrey, and reference lists of key studies/reviews. The main outcome was prevalence estimates for MLTCs for at least one minoritised ethnic group, compared to the majority white population. We included studies conducted in the UK reporting on ethnicity and prevalence of MLTCs. To summarise the prevalence estimates of MLTCs across ethnic groups we included only studies of MLTCs that provided estimates adjusted at least for age. Two reviewers screened and extracted data from a random sample of studies (10%). Data were synthesised using narrative synthesis. Of the 7949 studies identified, 84 met criteria for inclusion. Of these, seven contributed to the evidence of ethnic inequalities in MLTCs. Five of the seven studies point to higher prevalence of MLTCs in at least one minoritised ethnic group compared to their white counterparts. Because the number/types of health conditions varied between studies and some ethnic populations were aggregated or omitted, the findings may not accurately reflect the true level of ethnic inequality. Future research should consider key explanatory factors, including those at the macrolevel (e.g. racism, discrimination), as they may play a role in the development and severity of MLTCs in different ethnic groups. Research is also needed to ascertain the extent to which the COVID19 pandemic has exacerbated these inequalities.

“…clinical examinations, organ transplantation, blood transfusion, antenatal screening and immunisations) resulting in differential health outcomes and healthcare delivery. 16 Notwithstanding that such explanations ignore upstream processes which can influence how patients from minoritised ethnic groups make decisions regarding their health, including institutional racism which has fostered mistrust of institutions, 17 our findings suggest that they broadly accept and are compliant with the incentivised treatment. 7…”

Section: Discussionmentioning

confidence: 70%

“…The aim of this study is to assess whether there are ethnic inequities in PCA reporting. We focus on two PCA reasons: ‘patient unsuitable’ (exempted by a GP for a range of reasons including failure to respond to maximum dose of treatment, adverse reaction to treatment, extreme frailty or supervening condition 17,18 ) and ‘informed dissent’ (where patients do not agree to treatment or medical investigation). This will give us insight into the clinical judgments made by GPs and patient choice.…”

Section: Introductionmentioning

confidence: 99%

Ethnic inequities in the patterns of Personalised Care Adjustments for ‘Informed Dissent’ and ‘Patient Unsuitable’: A retrospective study using Clinical Practice Research Datalink

Ashworth

Hughes

et al. 2022

Preprint

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Objectives To examine patterns of PCA reporting for Informed Dissent and Patient Unsuitable, how they vary by ethnic group, and whether ethnic inequities can be explained by socio-demographic factors or comorbidities. Design A retrospective study using routinely collected electronic health records. Setting Individual patient data from Clinical Practice Research Datalink collected from UK general practice. Participants Patients with at least one of the 12 Quality and Outcomes Framework (QOF) conditions which had PCA coding options from a random sample of 690,00 patients aged 18+ years on the 1st of Jan 2016. Main outcomes measures The associations between ethnicity and two PCA reasons (Informed Dissent and Patient Unsuitable) were examined using logistic regressions after adjustment for age, sex, multiple QOF conditions and area-level deprivation. Results The association between ethnicity and the two PCA reasons were in opposite directions. After accounting for age, gender, multiple QOF conditions and area-level deprivation, people of Bangladeshi [OR: 0.69, 95% CI: 0.55 to 0.87], Black African [OR: 0.70, 95% CI: 0.61 to 0.81] , Black Caribbean, OR: 0.67, 95% CI: 0.58 to 0.76], Indian [OR: 0.74, 95% CI: 0.66 to 0.83], mixed [OR: 0.86, 95% CI: 0.74 to 0.99], other Asian [OR: 0.74 95% CI: 0.64 to 0.86] and other ethnicity [OR: 0.66, 95% CI: 0.55 to 0.80] were less likely to have a PCA record for Informed Dissent than people of white ethnicity. Only people of Indian ethnicity were significantly less likely than people of white ethnicity to have a PCA record for Patient Unsuitable in fully adjusted models [OR: 0.80, 95% CI: 0.67 to 0.94]. We found ethnic inequities in PCA reporting for Patient Unsuitable among people of Black Caribbean, Black other, Pakistani, and other ethnicity, but these attenuated after adjusting for multiple QOF conditions and/or area level deprivation. Conclusion Study findings counter the narratives that suggest that people from minoritised ethnic groups often refuse medical intervention. They illuminate the complex relationship between Informed Dissent and (dis)empowerment which requires further scrutiny. They also show ethnic inequalities in PCA reporting for Patient Unsuitable that are linked to clinical and social complexity and should be tackled to improve health outcomes for all.