Bcares, Laia May 2007 THE EFFECT OF ETHNIC DENSITY ON HEALTH Abstract Studies in the United Kingdom show

a consistent inequality between the health of ethnic minorities and that of White people, with differences reported on health outcomes such as overall self-reported health, limiting long-standing illness, heart disease, and hypertension, among others. Further, it has been shown that ethnic minorities are over-represented in deprived and segregated areas, which have been correlated with high mortality rates, infectious diseases and teenage childbearing. However, albeit ethnic density is generally thought of in terms of the negative impacts of segregation, it can also be considered in terms of social networks and supportive communities, mitigating socioeconomic effects and the detrimental impact of racism on the health of ethnic minority people. Several studies in both the UK and the US have studied the protective properties of ethnic density on the health of ethnic minorities, but existent evidence is unreliable due to statistical and measurement problems, leaving the question of whether ethnic density is protective on the health of ethnic minorities unanswered. The proposed study consists of an investigation of the hypothesised protective effects that ethnic density has on the health of its ethnic minority residents. It aims to improve current knowledge and methodological gaps by using a novel multilevel approach that will analyse data from three large nationally representative surveys: the 1999 and 2003 Health Survey for England, the 2003 and 2005 Home Office Citizenship Survey, and the Fourth National Survey of Ethnic Minorities, all of which will be linked to the 2001 UK Census. Introduction Although the transformation of Great Britain into the multi-ethnic society of today began in the 1550s with the arrival of a small number of Africans as Britain became involved in the slave trade,

Bcares, Laia May 2007 notable migration to Great Britain didnt start until the early nineteenth century, with an influx and efflux of Irish people who came to either settle permanently, or worked temporarily and eventually returned back to Ireland. The latter part of the nineteenth century greeted an initial wave of Eastern European Jews, who migrated to Britain escaping poverty or persecution, with a second wave migrating during World War II. Ethnic minority populations in the UK increased significantly during the second half of the 20th century as a result of high rates of immigration in the 1950s and 1960s. It was during that time that people from the West Indies were recruited to fill low paying jobs in urban areas, which were of low appeal to local residents. Around that same time the peak of Indian migration occurred, with people from the Indian subcontinent settling in Britain for educational and economic purposes. About a decade later, Britain welcomed Ugandan refugees from the Idi Admins government, and in the 1980s open entrance to the United Kingdom started to close, with a change in immigration laws limiting the numbers of people allowed to migrate1. Despite the commonality of arriving to the same host country, ethnic minority groups residing in the UK differ greatly by their reasons for immigration, settlement patterns, and age structure, among other factors which inevitably affect their health and socioeconomic status. Health Inequalities among Ethnic Groups Although the collection of ethnic data in the United Kingdom began in the late 1970s, the 1991 Census was the first to classify the British population by ethnic group1. The 1991 Census reported that approximately 5.5% of people residing in the UK (over 3 million) were from an ethnic minority background. By the 2001 census, the percentage of ethnic minorities had grown to 7.9%, an increase of 53% from 19911. As of the latest census, Indians were the largest UK ethnic minority group (22.7%), followed by Pakistanis (16.1%), individuals of mixed ethnic backgrounds (14.6%), black Caribbeans (12.2%), black Africans (10.5%), and Bangladeshis (6.1%). Inequalities in health

Bcares, Laia May 2007 among ethnic groups in the United Kingdom have been extensively documented, with studies on health disparities showing a consistent discrepancy between the health of Bangladeshi, Pakistani and Caribbean people compared to that of White and Chinese people2-6. Analyses on the Fourth National Survey on Ethnic Minorities indicate that Caribbeans are more likely than Whites to describe their health as fair, poor or very poor, and that Pakistani and Bangladeshi people, who fare worse than all other ethnic groups, are 50% more likely than White people to report fair, poor, or very poor health5. Similar patterns of health disparities have been observed in other health outcomes, including longstanding illness limiting ability to work, heart disease, and hypertension, where ethnic minorities report higher rates of disease than those reported by White people. In some cases, as in diabetes amongst Pakistani and Bangladeshi people, rates of ill health are over five times that of Whites5. Possible explanations of health disparities have fallen on socio-economic inequalities among ethnic groups, and analyses on socio-economic position and health have demonstrated a steady relationship among ethnic groups7. However, despite sound and replicated studies on ethnic inequalities in health2-4;6;7, a core problem on the quality of data remains. Studies often use broad categories of ethnicity (lumping together South Asians, for example), or crude levels of socioeconomic data, which do not reflect actual income gradients between ethnic groups. Moreover, the majority of studies are cross-sectional and collect socioeconomic data on current position, rather than across the life course6. Despite these flaws, important socio-economic effects have been found. However, after accounting for socio-economic status large differences remain among ethnic groups, providing evidence for the possibility that socio-economic factors are not the sole explanation behind ethnic disparities in health5. The impact of socioeconomic disadvantages experienced by ethnic minorities must be studied within a wider framework, encompassing their migrant history and disadvantaged place in society. More importantly, the explanation of ethnic inequalities in health must take into

Bcares, Laia May 2007 consideration health-shaping daily experiences of ethnic minorities in the UK, such as events of racial harassment and discrimination experienced by ethnic minority groups6. Furthermore, the number of epidemiological studies collecting data on experiences of racial harassment and discrimination remains fairly limited6. Racial Discrimination and Health Racism or racial discrimination has been examined by recent studies as a possible cause of the health gap among ethnic minority groups, reporting correlations between interpersonal ethnic discrimination and higher levels of stress, anxiety, and high blood pressure, among other health outcomes8-12. Racial discrimination can be enacted through two different, although not mutually exclusive paths: interpersonally and/or institutionally. Interpersonal discrimination refers to discriminatory interactions between individuals13; institutionalised discrimination, on the other hand, is embodied in discriminatory policies embedded in organizational13, and can discern itself as inherited disadvantage, such as racial residential segregation. The existence of interpersonal discrimination in the UK has been clearly established in several studies. For example, in an analysis of the Fourth National Survey on Ethnic Minorities, Karlsen and Nazroo13 found that in the year previous to the survey, 3% of the respondents believed that they or their property had been physically attacked for reasons to do with their ethnicity; 12% reported experiencing racially motivated verbal abuse; and 64% believed that some British employers would refuse someone a job on the grounds of race, colour, religion, or cultural background13. Discrimination has been suggested to impact on mental health by leading to affective reactions such as sadness, through shaping an individuals appraisal of the world14, by reinforcing secondary status and impacting on ones self esteem15, and by internalising negative stereotypes16. Despite this information, the exact pathways by which racism and discrimination impact on health have not been

Bcares, Laia May 2007 clearly defined yet; nonetheless, several studies have linked experiences of discrimination to poor health. For example, Karlsen and Nazroo found that respondents who reported experiences of verbal abuse were approximately 50% more likely than those who did not report such events to describe their health as fair or poor, and those who reported being physically attacked or having their property vandalized were over 100% more likely than those who did not to report fair or poor health13. Although the direct association between interpersonal discrimination and health has been established8-13, the ways in which the processes and mechanisms of institutional discrimination, such as racial residential segregation, impact on health are not yet fully understood, and in the UK there is currently a dearth of research examining the relationship between racial segregation and health outcomes. Racial Residential Segregation Residential segregation has been defined as the spatial differentiation and distribution of majority and minority ethnic groups across a metropolitan area and its neighbourhoods17;18, and has been referred to as a social manifestation of individual prejudices and institutional discrimination, and as one of the mechanisms by which racism operates17;19-21. Processes shaping residential segregation include distrust and fear caused by generalised racism and the experience of continuous discrimination of exclusion along ethnic lines22. In the UK, studies have suggested that racism is a major factor affecting the residential choices and housing tenure adopted by early migrants, as private landlords and public housing allocation have restricted ethnic minority groups to areas of low-quality housing23. Segregation has been stated to concentrate poverty, dilapidation, and social problems in ethnic minority neighbourhoods24;25, resulting in under-funded and ineffective institutions in these communities25. Wards with high proportions of ethnic minorities have been shown to be more

Bcares, Laia May 2007 densely populated, with more social housing, lower proportion of households with cars and central heating, and lower proportions of unemployment and individuals in professional and managerial occupations26. Pathways linking segregation to health Residential segregation can impact on health either directly, if the mere fact of living in a deprived neighbourhood is deleterious to health, or indirectly, through a broad range of pathogenic residential conditions, such as the availability and accessibility of health services, lack of healthy foods or recreational facilities, environmental pollution, access to transportation, normative attitudes towards health, and social support17;27-30. A review by Picket and Pearl28 found negative neighbourhood effects to be associated with an increased risk of all-cause mortality31-38; infant and child health39-41; chronic disease among adults32;37;42-48; and health behaviour42;45;46;49-51. Despite comprising a minority of the overall UK population, ethnic minority groups are overrepresented in specific geographic areas, accounting for a majority of the neighbourhood resident population; over thirty percent of the total ethnic minority population live in neighbourhoods where minorities account for over 50% of the residents52. For example, albeit only accounting for 0.55% of the general UK population, Bangladeshis constitute more than a third of the residents of the London borough of Tower Hamlets52. In addition, the ethnic minority population is not evenly distributed among all wards. An indication of the degree of ethnic concentration in the UK is that 31.2% of the total ethnic minority population live in wards where minorities account for over 50% of the population, and that the top 10% of wards by ethnic minority density contain around 64% of all minority residents52. Within greater London, which contains 45% of the ethnic minority population, and only 10.3% of the overall population5, several residential areas have been associated with

Bcares, Laia May 2007 specific ethnic groups, so that, for example, Ugandans, Ghanaians and Nigerians are usually clustered in south London, and most Somalis reside in east London53. Existing neighbourhood studies show that Caribbean, Pakistani, Bangladeshi, and to some extent Indian people are more likely than White people to reside in disadvantaged wards54, which, as previously mentioned, are characterised by poor social and material infrastructure, including low quality and quantity of leisure facilities, transport, housing, physical environment, food shopping opportunities, and primary and secondary health services27. Moreover, living in a deprived neighbourhood has been associated with an increased risk of poor-rated physical and mental health27;55, and given that ethnic minorities have been found to reside in deprived areas, it is possible that they are being disproportionately affected by detrimental area effects on health. However, despite the evidence on the deleterious effect that residential segregation has on socioeconomic standing and health, areas with high levels of ethnic concentrations have been hypothesized to provide its residents with an information network highly valuable in social interactions and economic activities, such as expenditures and employment opportunities56. In the case of new migrants, living in areas with high concentrations of co-ethnics provides them with location-specific human capital acquired by neighbourhood residents (longer term migrants or natives of the same origin), including information obtained directly and indirectly through established networks56. Further, regional and national associations fostering social networks are closely linked with the clustered settlement process53. For example, ethnic minority people have been found to perceive the amenities in their neighbourhood in a more favourable manner than White people, even after accounting for area deprivation54, possibly reflecting their investment in the facilities, either commercial or civic, established for their communities57. Furthermore, it is has been hypothesized

Bcares, Laia May 2007 that the concentration of ethnic minorities in a particular geographical area, or ethnic density, might provide its residents with protective effects on health, through the ethnic density effect. Ethnic Density Researchers in several disciplines have investigated the properties of the ethnic density effect on different outcomes, including education, health, and economic mobility54;58-64. Hypotheses of the ethnic density effect in health research have been coined stipulating that as the size of an ethnic minority group increases, their health complications will decrease60;65. It has been stated that ethnic density may aid in the development of positive roles64, and it may facilitate increased political mobilisation and material opportunities, as well as encourage healthy behaviour54. Moreover, theoretical frameworks behind the ethnic density effect articulate that positive health outcomes are attributed to the protective and buffering effects that enhanced social cohesion, mutual social support and a stronger sense of community and belongingness provide from the direct or indirect consequences of discrimination and racial harassment1;53;64;65. Hypothesised pathways for the relationship between ethnic density and health Social capital, a key domain of social cohesion66, defined as the features of social life such as networks, norms and trust, that enable participants to act together more effectively to pursue shared objectives67, has been linked to several health outcomes and measures of well-being68, and has been argued to generate positive social outcomes69. Social capital has been described to be either bonding (inward looking) or bridging (outward looking); thus, whereas bridging social capital includes people across diverse social divisions, bonding social capital is centred on relationships and networks of trust and reciprocity that reinforce bonds and connections within groups70. Ethnicity has been referred to as a form or source of social capital because ethnic group membership is often a basis for networks of social relations71, and because social capital obtained through resources found

Bcares, Laia May 2007 in ethnic minority networks is considered the leading factor in improving the chances of upward educational mobility among ethnic minorities72, and a source of economic and moral support for second generations73. Besides the well-established pathway of social support, which has been associated with a decrease in morbidity and mortality74-77, this study hypothesises that social capital will impact on the health of ethnic minorities through two individual, although not mutually exclusive pathways that will counterbalance or reduce the harmful effects of racism. These mechanisms, encompassed within ethnic density effect, are described below: 1) Buffering effect: The buffering model posits that social support "buffers (protects) persons from the potentially pathogenic influence of stressful events75, such as racial harassment and discrimination. The buffering properties found in the ethnic density effect are expected to counteract the detrimental effects of racism through two different, yet not mutually exclusive mechanisms: a) a change in the appraisal process of a stressful event such as interpersonal racial harassment, and b) the recognition and discussion of experienced discrimination with other ethnic minority people. The first mechanism, a change in the appraisal process, is based on the premise that racial harassment is usually perceived and internalised by ethnic minority people as evidence of their own flaws and subordinate status9, rather than as an act perpetrated from a discriminatory and prejudicial stance. However, it is hypothesised that living among co-ethnics and other ethnic minority people will bestow upon the person subjected to interpersonal racial harassment a different perspective, based on the likelihood that the discriminatory event experienced it is not due to an internalized individual flaw, but rather to an isolated assault by aberrant perpetrator. It is hypothesised that this outlook will be the consequence of greater involvement and participation in the community, found in areas of high ethnic density. Community involvement, or civic participation, has been shown to be lower in ethnic- or income-heterogenic areas78;79, thus it is likely that areas of high ethnic density will be

Bcares, Laia May 2007 characterised by higher rates of community involvement, including participation in political parties, trade unions, PTA, neighbourhood associations, and informal social contact with neighbours among others. It is then expected that participation in the community will generate positive role models64, a stronger sense of community and belongingness1 and enhanced social cohesion64, which are hypothesised to provide ethnic minorities with the notion that an interpersonal racist event experienced is the oddity of one individual, not a normative behaviour and a consequence of being an ethnic minority. This cognitive process, in turn, is hypothesised to decrease self-stigmatisation and stress, which have been related to overall health and mental health31;80;81. The second mechanism, the recognition and discussion of experienced discrimination with other ethnic minority people, emerges from the indication that an individuals social support and social networks, such as those found in neighbourhoods and residential communities, may permit an ethnic minority individual to recognize and discuss experiences of racism with others, which may mediate the association between racism and health82. Further, studies have shown that among people who report having experienced discrimination, those who do something about it, such as reporting the event or talking about it, have better health outcomes than those who do not9. 2) Social norms: The existence of social norms, a characteristic of social capital83, is hypothesised to decrease the likelihood that an ethnic minority person living in an ethnically dense neighbourhood will experience racial harassment. Through the enforcement of informal social control exerted over deviant behaviour84 and low tolerance against discrimination, it is expected that racist harassment and discriminatory events will be less frequent in ethnically dense neighbourhoods.

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Bcares, Laia May 2007 In conjunction with its buffering effects, the existence of social norms carries out the hypothesised protective effects of ethnic density against the detrimental impact of racism, illustrated in Figure 1. Figure 1. Hypothesised protective mechanisms of the ethnic density effect (model adapted from Cohen and Wills, 1985)
Enforcement of social norms and low tolerance against racism
Reduced incidence

Racial harassment or interpersonal discriminatory event(s)

Community involvement leading to: Positive role models, sense of belonging, increased social cohesion

Appraisal process
Buffering effect

Discussion of events with peers

Event(s) perceived as stressful. Internalised oppression.

Event(s) perceived as oddity of individual, not as evidence of own flaws

Buffering effect

Emotionally linked physiological response

Health outcome

Existent studies on the relationship between ethnic density and health Studies that have examined the effects of ethnic density on health have yielded mixed results; whereas several analyses have been able to demonstrate the protective effect of ethnic density63;65;8592

, others have not54;93-95. This discrepancy in the findings can be attributed to the fact that studies

have used different health outcomes, different definitions of ethnic groups, different levels of geographical measurement, and most importantly, weak methodological approaches. It is also 11

Bcares, Laia May 2007 possible that other variables in the relationship between ethnicity, neighbourhood and health are overshadowing the effect of ethnic density, masking its protective effect on health. For example, Karlsen and colleagues54 refer to the interplay between socio-economic status and health, indicating that the concentration of ethnic minorities in socio-economically deprived neighbourhoods might disguise the protective effects of ethnic density through the negative health impact of living in deprived areas. Studies supporting and contradicting ethnic density are characterised by methodological and measurement limitations, making the results unreliable. Such limitations include: 1. The collection of ethnic data as an observer-assigned characteristic63. 2. The combination of ethnic groups into one non-white group or several large heterogeneous ethnic groups, such as the classification of South Asians for Bangladeshis, Pakistanis and Indians63;85-87;89;91-95. 3. The measurement of ethnic density as either own-group residential concentration or overall minority concentration, failing to test whether the ethnic density effect is group-specific or the result of living among other ethnic minorities, regardless of specific ethnic group. Moreover, several studies have been inconsistent in the definition of ethnicity, measuring ethnic group specifically (e.g., black) but defining ethnic density as general minority concentration (e.g., non-white)85-87;91-95. 4. The use of statistical analyses that do not account for the nested nature of the data, hindering the identification of independent effects of the individual and the area on health, and not allowing for the clustering of individuals within areas63;87;89;91;93-95.

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Bcares, Laia May 2007 5. The use of data collected in few and similar areas in close proximity (e.g., boroughs in south east London), which does not allow for generalisation of the effects of ethnic density to other areas and/or ethnic groups63;86;87;89-91;93;94. 6. The failure to test and control for confounders and mediators in the relationship between ethnic density and health, concealing possible effects of ethnic density, and failing to provide insight into pathways linking the ethnic density effect to health outcomes63;85;87;89-97. 7. The use of rigid categories of ethnic density, making difficult the detection of an ethnic density effect, a possible threshold, and/or testing the linearity of the association between ethnic density and health54;85;91. 8. The use of different measures of ethnic density (i.e., percentage minority people vs. segregation indices), limiting the possibility of comparing results across studies87. Therefore, in order to correct limitations from previous research and accurately measure the impact of the ethnic density effect on health, future studies must be designed appropriately, ensuring the use of: a) a self-assigned ethnicity variable, divided into ethnic groups as specific as possible; b) a measure of ethnic density categorised as both specific-ethnicity density for each ethnic group and overall ethnic minority density, measured through different methodology (e.g., percentage ethnic minority people, Index of Dissimilarity, and Index of Isolation) and recoded as both a continuous and categorical variable; c) individual-level markers of social participation and social networks, socioeconomic status, experiences of discrimination and racism, health and wellbeing, as well as area geomarkers of deprivation; d) multilevel methodology that allows for the clustering of individuals within census areas; and e) precise and clearly defined area measures that will be able to capture local group concentrations with accuracy88;98.

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Bcares, Laia May 2007 The use of the analytical and measurement considerations described above are expected to warrant a stronger confidence in the results found for the association between ethnic density and health. These improvements, however, will not provide a clear explanation regarding the pathways linking exposure and outcome variables, underlying the need to test for the hypothesised mediator variables and explanatory pathways explaining the association. Figure 2 represents this studys hypothesised relationships between residential segregation, ethnic density and health. Residential segregation, a social manifestation of individual and institutionalised discrimination17, has been shown to impact negatively on health through the different area and individual-level variables listed inside boxes 1 and 2 (red-coloured), including area deprivation, social isolation from political and economic power, poor social norms and inferior social services. While residential segregation has been shown to be deleterious to health, its ethnic density attribute has also been hypothesised to provide some protective effects to ethnic minority residents, buffering the detrimental impact of residential segregation through the social support variables enumerated in box number 3 (light orange), which include enhanced social cohesion, mutual social support, and stronger sense of community, among others. More specifically, it is hypothesised that ethnic density is protective of the harmful effects of discriminatory insults on health through two different, although not mutually exclusive, processes (described in detail in figure 1): 1) a buffering effect produced by a change in the appraisal process of a discriminatory event and the possibility of discussing the event with peers, and 2) a reduced incidence of racial harassment due to enforced social norms and low tolerance for racism. In summary, this study hypothesises that the health of ethnic minorities living in ethnically dense areas will be better than that of their counterparts residing in areas of less ethnic concentration,

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Bcares, Laia May 2007 due to ethnic densitys protective effects of enhanced social networks and buffered experiences of discrimination. More specifically, the study hypothesises that: I. The health of ethnic minority people residing in areas with high ethnic density will be better than the health of ethnic minority people residing in less ethnically dense areas after controlling for area deprivation and individual socio-economic and demographic characteristics. II. The relationship between ethnic density and health will follow a non-linear path where the buffering effects of ethnic density will significantly impact on ethnic minorities health after a certain percentage of co-ethnics living in an area. III. Ethnic minority people living in areas of high ethnic density will have greater community involvement than their counterparts living in areas of low ethnic density. IV. Reported experiences of racism will be fewer in areas with higher concentrations of ethnic minority people as compared to areas of less ethnic density. V. The impact of discrimination will be less among ethnic minority people living in areas of high ethnic density as compared to their counterparts living areas of less ethnic density. These hypotheses will be tested by asking the following research questions: 1. 2. Is there an association between ethnic density and health? What is the strength of the relationship between ethnic density and health after controlling for the following factors? a. b. c. d. Neighbourhood deprivation Gender Age Individual socioeconomic position

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Bcares, Laia May 2007 e. f. g. h. i. English language fluency Immigrant generation (1st generation vs. British born, and migration cohort) Religion Household composition Neighbourhood clustering (ethnic minority neighbourhoods right next to each other as compared to ethnic neighbourhoods surrendered by non-ethnic neighbourhoods). 3. What are the mechanisms by which ethnic density impacts on health? Is there an association between: a. b. c. 4. Ethnic density and increased community involvement Increased community involvement and health Ethnic density and experienced discrimination

Amongst individuals reporting experiences of racism and discrimination, does ethnic density moderate the effect of racism and discrimination on health?

5.

Is there a certain proportion of ethnic density that is beneficial for health and a threshold in which ethnic density becomes detrimental?

6.

Is there a difference in the ethnic density effect in: a. b. White residents in ethnic minority neighbourhoods Ethnic minority residents from the same ethnic background as the majority of ethnic minority residents populating the neighbourhood (e.g. Bangladeshi people in a neighbourhood with high Bangladeshi concentration)?

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Bcares, Laia May 2007 c. Ethnic minority residents from a different ethnic background than that populating the neighbourhood (e.g. Black Caribbean people in a Bangladeshi neighbourhood)? In order to conduct these research questions, this study will analyse data from three large national surveys (the 2003 and 2005 Home Office Citizenship Survey, the 1999 and 2004 Health Survey for England, and the Fourth National Survey on Ethnic Minorities); the variables contained in these five datasets will ensure that the different hypotheses and research questions can be adequately tested. This study will build on previous literature and improve the current gaps in the methodology by using detailed and precise ethnic groups, two definitions (specific and general to ethnic minority status) and two values of ethnic density (continuous and categorical) to test for a threshold effect and the linearity of the relationship. Moreover, in order to test the hypothesised pathways linking ethnic density to health, the study will include variables on individual-level markers of social participation and social networks, socioeconomic status, and experiences of discrimination and racism, employing multilevel methodology to allow for the clustering of individuals within geographical areas.

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Figure 2. Hypothesised Pathways between Residential Segregation, Ethnic Density and Health
1

Bcares, Laia Area-Level Consequences of Residential Segregation Detrimental effects on health

- Poor quality of primary health care services and discriminatory practices among service providers - Poor Collective Resources such as services and job opportunities - Increased crime and victimisation - Poor Housing Conditions (dampness, overcrowding, etc) - Economic Deprivation (concentrated poverty and unemployment)

Buffering Effects of Ethnic Density

Residential Segregation

- Enhanced social cohesion - Mutual social support - Stronger sense of community and belongingness - Development of positive roles - Increased political mobilisation and employment opportunities - Encouragement towards healthy behaviour - Lower exposure to racial harassment and discrimination - Recognition and discussion of experienced discrimination with co-ethnics

Ethnic Density

Racism

Protective Effects on Health

Health

Individual-Level Consequences of Residential Segregation - Lack of social integration thorough limited contact with successful members of the white or ethnic minority community leading to isolation from economic power - Poor Social Norms regarding work ethic, devalued academic success, de-stigmatisation of imprisonment and unemployment

Detrimental effects on health

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Bcares, Laia May 2007

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