Ethnic Minoroties and Races - Case Study Example

Background: The literature regarding general health needs assessment has not yet reached a consensus as to which principles should be applied. More importantly, the theory of health needs assessment has not yet been broadly applied or focused within the context of routine collection of health information in ethnic minorities. This is vital, as it will empower health care professionals to make better use of existing health needs assessment resources to determine the particular requirements of ethnic minorities. In the discussion of ethnic minority health needs assessment, there is a wide variety of definitions encountered. Some of these definitions are more like synonyms in that they use minor differences in wording to relate a concept, while others hold underlying, unique, and important differences. The following definitions are related to ethnic minorities, and are discussed generally during the discussion of health needs studies for ethnic minorities. The specific ethnicity related to individual countries will be independently discussed at a later time. Ethnicity: Both the English and Public Health dictionaries (Oxford 2005, 2007) state the same definition for ethnicity as “the fact or state of belonging to a social group that has a common national or cultural tradition, usually it refers to group identity based on culture, religion, traditions, and customs.” Bhopal (2007), the leading scholar in UK ethnic health research, believes that this term is more associated with cultural traditions and languages rather than country of origin, race, or socio-economic status. Race: This word defines different groups of people who can be distinguished by examining their physical characteristics, e.g., the colour of their skin, the shape of their eyes and face, as well as other visible qualities such as hair texture. More importantly, the term is often discussed in association with ancestry and geographical origins of the people (Bhopal 2007). Since the Second World War, the inappropriate distinction of humans by race, i.e., that different races are deficient in some areas and others are superior, has often been noted by organizations such as UNESCO: Humans are one species, races are not biologically distinct, there is little variation in genetic composition between geographically separated groups, and the physical characteristics distinguishing races result from a small number of genes which do not relate closely to either behaviours or disease (Bhopal 2007) Some individuals and governments have decided to replace the word “race” to “ethnicity” (Bhopal 2007), as both of the terms can be often seen as synonyms, except race is often more driven by social and political interests (Coons 2006). The concept of race has further attracted great attentions between anthropologists and geneticists: traditional anthropologists believe less than 1% of the genetic making-up of human being has effectively differentiated individuals into groups of race, such as ‘Caucasian’ (white or European), Mongoloid (Asian, Chinese or Indie), Negroid (Black or African). Such “grouping” has enabled further findings on the association between racial group and diseases. One implication of racial group variations in diseases is due to region of ancestral origin. For example, sickle cell diseases tend to be occurred in African origin, or cystic fibrosis in people of European origin. However, genetics literatures have little supports for the claim, as genetic diseases are not confined to specific racial groups. The nominal racial differences in disease may just due to the differences in environmental and economic circumstances (Bhopal 2007). However, the concept of race has still been more accepted than social causes, especially when determining the population differences in health. Ethnic minority group: it is defined as “a group within a community which has different national or cultural traditions from the main population” (Oxford 2005). The concept is often regarded to non-White population or a particular identifiable group, such as gypsy travellers and Irish. Moreover, ethnic minority group has the implication of non-Christian (Bhopal 2007). The Dictionary of Public Health describes the health characteristics of ethnic minority group as following: “Members of an ethnic group share the same language have similar ways of life and a common history … often have a common genetic heritage. Ethnic groups sometimes display epidemiological patterns of disease that differ from prevailing patterns of others in the same country, which may relate to their genetic heritage, lifestyle, dietary factors, or a combination of these.” (Oxford 2007) Indigenous: The term implies a place, in which people naturally belong to or their ancestral origins were previously located. Countries, like Australia, US, China and Taiwan, often describe indigenous people as aboriginal people, who are minority population in the society. They often have modest civilisation and reside in the secluded countryside. In UK, indigenous is differently interpreted. It is seen as the alternative word of “White” and meaning the majority of the population in the society. Indigenous minority describes the indigenous people are the minority population in the society. Native: the term predominantly values more on family origins. It is often seen as the synonyms with indigenous. It occasionally refers to the people with little civilised as native. Immigrants: This word is defined as a “person who migrates to and settles in a country other than that of birthplace and upbringing. Immigrants often differ culturally and sometimes in health-related behaviour from persons born and raised in the country” (Oxford 2007). The concept of being different, such as variations in skin colours, unique attributes of specific cultures or unfamiliarity with particular behaviours, carries the implication that immigration studies are conducted largely on the basis of associated racial characteristics in comparison with the host country. It is believed that two primary features of immigrants can be identified; immigrants are often within one of the minority groups in the society, and they have dissimilar characteristics from the general population as well as from each other. General population: This is epidemiologically accepted as everyone in the population being examined. The term often indicates members of the “White” population have been included along with minorities in the ethnic health studies (Bhopal 2007). General ethnic minority: This term refers to the people within a broad ethnic minority, without including the indigenous people. Methodology The study has employed multi-clustering sampling as the sampling strategy. It consists of two stages of sampling, primary and secondary. Primary sampling In the primary sampling stage, the study has defined six major regions comprised of all the countries included in the World Health Organization’s (WHO) segmentation guideline: Africa, America, Europe, South-East Asia, the West Pacific and Eastern Mediterranean. Each region is required to classify its member countries into one of two segmentations; Group A and Group B. Group A represents the countries within the top 30 ranking assessed by the WHO Health System Assessment in the year 2000. These countries are the ones that have been considered as achieving the highest health attainments and performances through their health care systems. Conversely, Group B is made up of those countries outside of the top 30 countries in the same assessment, i.e., if a country is not in Group A, it is necessarily in Group B. These countries have failed to achieve a comparable level of health attainments and performances when compared to the Group A nations. The reason for applying this approach is that the study aims to determine a better understanding of how the health information of ethnic minorities has been collected. This type of subpopulation information is often available when the health care systems are more complete and established. In other words, if the countries have deficient health care systems, they are not only demonstrating poor collection of the health information related to the subpopulation, but also the population at large. Accordingly, any assessment that neglects a concentrated focus cannot easily distinguish the legitimate cause of ethnic minorities’ inequality. This is either attributed to poor health information collection of the general population, or insufficient information within the subpopulation groups only. In this study, countries with adequate primary, secondary and tertiary health care services, as well as those with wide health care coverage across the general population are prioritised. The study has determined that Group A, the WHO top 30 ranking countries, will be the cut-off threshold for sampling. If the cut-off threshold cannot yield a sufficiently plausible geographical spread in Group A, which is the central focus of the study, some adjustments will be needed to improve the quality and quantity of the sampling. One possible solution is to lower the cut-off threshold to include the top 50, 60, or even 100 countries in the WHO health rankings in order to include more data points and expand the sampling population of Group A. This should address all of the regions so that there are sufficient qualifying countries to yield a high enough sample population to provide statistically significant results. Problematically, the downside of this approach is not just time-consuming, but also presents another dilemma; the appropriateness of the sample countries will deteriorate in proportion to the lowering of the cut-off threshold. As the cut-off threshold is lowered to admit countries with more unfavourable rankings, such as the top 100 WHO rankings, Europe and Asia will dominate the sample population with more qualifying countries in the primary study group (Group A), thus potentially skewing the results. This effect is due to the traditional advantage held by these two regions; Europe and Asia have embraced more countries with better health care systems. Accordingly, countries like Estonia, Poland, or Latvia, which were positioned around the top 70 countries in the WHO rankings, would be qualified to be selected as participants in the Group A sampling for Europe. The likely outcome would be that the study would suffer data degradation from the less qualified sample countries and fail to properly and thoroughly assess the original hypothesis: whether the health equality of ethnic minorities under a good health care system has parity with the general population. As a result of these concerns, it was decided to continue with the original research design, and only include the WHO top 30 countries’ health rankings as the preferred cut-off threshold for the sampling. This approach should take care to balance the sample results by maximising the geographical spread of the Group A countries and focusing on appropriate sample countries. Secondary sampling In the secondary sampling, regions with more than three countries in Group A are sampled randomly to obtain three targeted countries for inclusion. The randomized approach starts with a box containing paper clips, upon which are written each Group A country’s name for a particular region. As the paper clips are randomly drawn from the box, they are not replaced. When the third paper clip of a nation within the regional Group A is drawn, the sampling of this region is then regarded as complete. This same process is repeated with the other two regions. The end result is nine targeted countries (the sum of the three sampled countries from each of three regions). For regions with less than three countries in Group A, one targeted country will be determined for further examination. The country selected will be the one that possesses the highest ranking within the WHO Health System Assessment within that categorical region. Methods In the primary sampling, six regions are defined based on the WHO segmentation. Each region has further classified its member countries into Group A and Group B. After sorting all the countries into groups, the study found that the region of Africa and South-East Asia had no qualifying countries for Group A, and the Eastern Mediterranean region had only two qualifying countries for Group A. Therefore, the three regions with more than three countries in Group A are: America, Europe and the West Pacific. The other three regions with less than three countries in Group A are: Africa, South-East Asia and the Eastern Mediterranean. In the secondary sampling, America, Europe and the West Pacific regions have randomly selected three targeted countries from each of their own regions. Africa, South-East Asia and the Eastern Mediterranean have pre-determined one targeted country through the guideline of the WHO Health System Assessment (Figure 2). All the sampled countries are listed as the following: Selection of health data The study has adopted the Health Metrics Network (HMN) approach to assess the health information of ethnic minorities. The WHO initiated the HMN in 2005 to improve national health information systems for evidence-based decision-making in developing countries. Additional clarification regarding the reasons for adopting HMN for this study are discussed below: HMN was initiated with the specific purpose of assessing the national health information collection across the globe. A total of 19 developing countries have been effectively gauged with the assessment toolkit. This has demonstrated the advantage of regional consideration rather than focusing on a single country. For example, despite the fact that the Canadian health information framework has characteristics similar to that of the HMN, the issue has only been discussed in the Canadian context, and other countries may not receive the full benefit of the assessment. Moreover, the Canadian health information framework was initiated as a result of political interest, i.e., it was begun as a result of the Canadian government’s focus on improving its health care system’s ranking after the country’s poor performance in the WHO assessment in 2000. Therefore, the accountability structure of HMN is superior to the Canadian health information framework. HMN provides detailed and rigorous guidelines for evaluation on all health information collection. Often, this has not been available or applied to other health information assessment toolkits. HMN covers a greater range of health information collection than the Canadian health information framework, as it not only aims at traditional health indicators such as determinant of health and health status, but also focuses on health information system resources, data resources and data management. In this study, health indicators and data sources are the primary focus, as other elements of health metrics require significant and broad-based coordination and support from local national health agencies. The consideration of these elements, along with the necessary coordination and support, is impractical for this study due to the time available and scarcity of resources. Moreover, the examination of health indicators and data sources is sufficient to reliably present the necessary information regarding health information collection on ethnic minorities. Health indicators There are three types of health indicators that collect health information within national health systems (Figure 2): Determinants of Health, Health System and Health Status. Each of these has subordinate indicators, which provide a broader understanding regarding health information about population health needs. For example, one subordinate indicator, called Morbidity Conditions under Health Status Indicators, collects health information on Diabetes, Body Mass Index (BMI), Low birth weight, Chronic pain, Cancer incidence and Injuries. Another indicator within the Determinants of Health section, known as Living and Working Conditions, is designed to collect information about personal income, housing affordability, the unemployment rate, and education level. Health System Indicators reveals information about the accessibility of childhood immunisation, the management of HIV and Chlamydia, those deaths due to medically-treatable diseases, and patient satisfaction. HMN has recommended a number of sample indicators that can be used to assess the population health information collection across all countries. These sample indicators can be substituted according to individual situations (WHO 2008). In this study, the substitutions made include considerations such as: The factor of general government health expenditure (GGHE) per individual is excluded, as it is not the main priority for the health needs of ethnic minorities. Workforce density has been replaced by workforce diversity. The more diverse work forces that are available in the health care service, the greater the abilities of health care services to reduce the gap incurred from social and cultural divergence. Evidence has shown that the ethnic minorities are often more vulnerable than their general population counterparts when suffering with chronic diseases. This is not only because some of the ethnic minorities are believed to have a higher likelihood to carry certain types of chronic diseases, but also as a result of the different health behaviours of ethnic minorities playing an important role. Therefore, the prevalence of diabetes has been decided as the additional indicator for the health status domain. Assessing elements The assessment has adopted the score methodology directly from the original study of the HMN, as a result of the fact that numerous elements of this study have been taken directly from the HMN. The study is made more consistent and reliable by using the original score methodology. Availability – This determines whether ethnicity is applied within the existing health information. If it is, then the distribution of the health information is available through the Internet and hardcopy sources. Read More