What works to tackle ethnic inequalities through anti-racist interventions
BMJ Open has recently published an in-depth review examining anti-racist interventions to address ethnic inequalities in healthcare. In this blog, two of the review’s authors reflect on what this means for primary care.
In the UK, we have a problem with ethnic inequalities in health care. South Asian and Black populations suffered up to five times the risk of Covid-19 deaths compared with their White counterparts [1]. Black women are four times more likely to die in childbirth compared with White women [2].
Racism is a driver of these ethnic health inequalities, operating directly through discrimination and stigma, and indirectly through the social determinants of health [3][4]. We have plenty of data on these inequalities, but we need more evidence on what works to address the problem. Looking at the published research examining anti-racist interventions in health care, we find interventions have been tested at three levels: policy level, institutional level, and community and individual level. Primary care could be a key player in reducing ethnic inequalities across these levels.
Living and working conditions
Changes at policy level can address the wider determinants of health, such as employment, nutrition and housing. Many healthcare organisations in the UK are anchor institutions, which can play a significant role in the social, economic and environmental conditions of their communities. Our review found evidence that multicomponent non-medical interventions in addition to self-management education in Type 2 Diabetes can improve access to healthy food, financial incentives and housing relocation. Non-medical interventions were more effective if integrated into medical care using the electronic medical record [5]. The trickle-down effects of policy change are clear – such as where minimum wage policies were shown to reduce HIV incidence and improve birth outcomes for black populations [6].
Health care services
Focusing the lens a little tighter at institutional level, we must have collaboration between primary care, community services and secondary care if we are to provide patient-centred care. This may include co-location of services, continuity of care and case management. In one study, co-location of primary care and mental health services not only improved mental health outcomes but also reduced disparities in initiation of care [7].
Social and community networks
At community level, primary care can address ethnic disparities by partnering with lay Community Health Workers (CHWs). Our review found these were better than broad-scale community and health system interventions, particularly when working with ethnic minority communities to improve diabetes and cardiovascular disease [8][9]. Community participation is also needed in the design, delivery and evaluation of services – we found evidence of benefit from locally recruited coalitions of ethnic minority communities working in partnership with social and health service organisations.
Individual lifestyle factors
Individual level interventions can be an important cog in the machine. Convincing evidence shows the power of culturally competent patient education in the prevention and management of long-term conditions [10][11]. Based on high quality RCTs, we recommend including multilingual, online, interactive skills-building programmes using peer support through video testimonials [12]. Harnessing patient education, and combining it with interventions to improve access and interactions with clinicians, could increase its turning force.
Interestingly, generic quality improvement activities without cultural adaptation also resulted in improved outcomes for ethnic minority groups in type 2 diabetes, cancer screening and end of life care. Activities included practice guidelines, continuing medical education, computerised decision-support tools and tracking and reminder systems [11]. This suggests that targeting clinicians in quality improvement programmes for services with higher proportions of ethnic minority populations may be an effective strategy at improving outcomes for this group.
In the course of this study, we found significant limitations in the quality of data on anti-racist interventions. We need better ethnicity data collection across services if we are to measure inequalities at baseline and monitor interventions. This includes working with communities to design appropriate ethnicity categories and training primary care staff to explain the rationale for ethnicity data collection. We also need better data coordination between primary care health records, ICSs and local authorities. This will help us bring together intelligence on health, ethnicity and wider determinants to allow for further research in this area.
In summary
Ethnic disparities abound and are driven by stigma, discrimination and the structures within society. No single organisation can address ethnic inequalities by themselves; rather, it requires a whole system approach at multiple levels. Primary care has a vital role to play in building a fairer and more equitable society.
Yip JLY, Poduval S, de Souza-Thomas L, et al. Anti-racist interventions to reduce ethnic disparities in healthcare in the UK: an umbrella review and findings from healthcare, education and criminal justice. BMJ Open 2024;14:e075711. doi:10.1136/bmjopen-2023-075711
References
1. Office for National Statistics (ONS). Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England: 8 December 2020 to 1 December 2021. Available at: Office for National Statistics 2022
2. MBRRACE-UK. Saving Lives Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2018-20. 2022. Available at: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
3. Devakumar D, Selvarajah S, Abubakar I, Kim SS, McKee M, Sabharwal NS, et al. Racism, xenophobia, discrimination, and the determination of health. Lancet. 2022;400(10368):2097-108.10.1016/S0140-6736(22)01972-9
4. Selvarajah S, Corona Maioli S, Deivanayagam TA, de Morais Sato P, Devakumar D, Kim SS, et al. Racism, xenophobia, and discrimination: mapping pathways to health outcomes. Lancet. 2022;400(10368):2109-24.10.1016/S0140-6736(22)02484-9
5. Egede LE, Walker RJ, Linde S, Campbell JA, Dawson AZ, Williams JS, Ozieh MN. Nonmedical Interventions For Type 2 Diabetes: Evidence, Actionable Strategies, And Policy Opportunities. Health Aff (Millwood). 2022;41(7):963-70. Available at: https://dx.doi.org/10.1377/hlthaff.2022.00236
6. Clark EC, Cranston E, Polin T, et al. Structural interventions that affect racial inequities and their impact on population health outcomes: a systematic review. BMC Public Health 2022;22:2162. Available at: doi:10.1186/s12889-022-14603-w
7. Lee-Tauler SY, Eun J, Corbett D, Collins PY. A systematic review of interventions to improve initiation of mental health care among racial-ethnic minority groups. Psychiatric Services. 2018;69(6):628-47. Available at: http://dx.doi.org/10.1176/appi.ps.201700382
8. Escriba-Aguir V, Rodriguez-Gomez M, Ruiz-Perez I. Effectiveness of patient-targeted interventions to promote cancer screening among ethnic minorities: A systematic review. Cancer Epidemiology. 2016;44:22-39. Available at: http://dx.doi.org/10.1016/j.canep.2016.07.009
9. Anderson LM, Adeney KL, Shinn C, Safranek S, Buckner-Brown J, Krause LK. Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations. Cochrane Database of Systematic Reviews. 2015;2015(6) (no pagination). Available at: http://dx.doi.org/10.1002/14651858.CD009905.pub2
10. Mueller M, Purnell TS, Mensah GA, Cooper LA. Reducing racial and ethnic disparities in hypertension prevention and control: What will it take to translate research into practice and policy? American Journal of Hypertension. 2015;28(6):699-716. Available at: http://dx.doi.org/10.1093/ajh/hpu233
11. Peek ME, Cargill A, Huang ES. Diabetes health disparities: A systematic review of health care interventions. Medical Care Research and Review. 2007;64(5 SUPPL.):101S-56S. Available at: http://dx.doi.org/10.1177/1077558707305409
12. Jones T, Luth EA, Lin SY, Brody AA. Advance Care Planning, Palliative Care, and End-of-life Care Interventions for Racial and Ethnic Underrepresented Groups: A Systematic Review. Journal of Pain and Symptom Management. 2021;62(3):e248-e60. Available at: http://dx.doi.org/10.1016/j.jpainsymman.2021.04.025