Determinants of health

The health of women from ethnic minority groups in England

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Authors

Veena Raleigh

Key messages

1 in 4 women in England is from an ethnic minority group, of whom many are migrants. Women from ethnic minority groups experience inequalities in health, and in access to, and experience of, health care services.
The risks to health and health inequalities in women from ethnic minority groups start early and are apparent across the life course. Their specific health needs are often not fully recognised or addressed by health care services.
Women from ethnic minority groups are not a homogenous group. Patterns of health, and the determinants of health, differ significantly between and within ethnic groups.
Women from most ethnic minority groups experience lower overall mortality than women from the White British group. Women from the Chinese group have the best health outcomes overall. Mortality is highest in the White Gypsy or Irish Traveller group. The mortality advantage in most ethnic minority migrant groups, and in second UK-born generations, wanes over time due to environmental and behavioural changes resulting from cultural assimilation.
Women from South Asian and Black groups experience a higher burden of some common preventable conditions and of maternal mortality.
The causes of health inequalities across women’s life course are multifactorial and intersect. Health outcomes are shaped by the socio-economic, behavioural and wider determinants of health, and these differ significantly between and among ethnic minority groups. For example, on several socio-economic measures, women from Indian and Chinese groups compare favourably with other ethnic groups, including White British, whereas women from Pakistani, Bangladeshi and Black groups are most affected by socio-economic adversity and poverty.
Some women from ethnic minority groups face obstacles when it comes to staying healthy and accessing health care due to the way health care services are structured – this includes language barriers, lack of interpreters, services that are not culturally competent and poor health literacy.
There is a wider societal context in which deprivation and structural racism can reinforce inequalities among ethnic minority groups – for example, in education, housing and employment – which in turn can have a negative impact on health. Racism and discrimination can also impact negatively on the physical and mental health of women from ethnic minority groups and their interaction with health care services.
Policy-makers, ICBs and local partners have an important role to play in improving the health of women from ethnic minority groups and addressing the inequalities described in this long read.

Introduction

This long read describes selected health outcomes, and their determinants, in women from ethnic minority groups. It is an overview of a complex topic to help inform policy-makers, integrated care boards (ICBs), people who provide public health, the NHS and other services that support health, voluntary organisations and the public about the health of women from ethnic minority groups. The aim is to support the development and implementation of strategies to improve health and reduce inequalities among women from ethnic minority groups, and increase public awareness of the issues.

Reviews of the health of women from ethnic minority groups are sparse and often do not cover the range of health inequalities they face across the life course. This long read starts to fill that gap. It describes the barriers that women from ethnic minority groups experience in preventing ill health, accessing services, safeguarding reproductive and maternal health, managing long-term conditions and ageing well.

Note on language and data

In this long read we use the term ‘ethnic minority’ and ‘ethnic minority groups’ to refer to people belonging to ethnic groups that are in the minority in the context of the population of England. Ethnic minority groups are defined as all ethnic groups who are not White British, and includes the following White minority groups: White Gypsy or Irish Traveller, White Irish, White Roma and Other White. The terms used to describe ethnic minority groups are consistent with the principles outlined in the NHS Race and Health Observatory’s report on terminology.

Comparisons are made with the White British group where possible. In general, we refer to ethnic groups using terms consistent with the data sources and literature cited. Given the significant heterogeneity between ethnic minority groups and sub-groups in socio-economic, health and other characteristics, we use disaggregated terms where possible (eg, Black African, Black Caribbean and Other Black rather than Black). The exceptions to these general principles are where the citation refers to aggregated groups, eg, White, Black, Asian. In these circumstances, ethnic minority groups are defined as ethnic groups who are not White. South Asian is used to describe Indian, Pakistani and Bangladeshi groups collectively. Black is used to describe Black Caribbean, Black African and Other Black groups collectively.

This long read uses the term women’s health. The delivery of health care, including of women's health services, should be personalised, appropriate and inclusive for all, including for those whose gender identity differs from their sex at birth.

Where we discuss patterns for ethnic groups overall, and not separately for women, it’s because the evidence is not available by sex.

Why is the health of women from ethnic minority groups important?

Women from ethnic minority groups form a large and growing proportion of the population, and they experience inequalities in health, access to and experiences of health care. It is critically important that the health and care system identifies and addresses their health care needs. However, reviews of the health of women from ethnic minority groups are relatively sparse. It’s a complex area with significant differences in health, and its underlying determinants, between ethnic groups and sub-groups. This long read provides an introduction to the issues and discusses their implications for the NHS.

Legal requirements and policy context

Legislation requires the NHS and its partners to address equality and inequalities in health and health care.

Reducing health inequalities has long been a goal of successive governments. The Core20PLUS5 strategy for reducing health inequalities among adults in England prioritises the most deprived 20% of local populations and some clinical areas directly relevant to the health of women from ethnic minority groups – for example, maternity, early cancer diagnosis and control of high blood pressure. There are also examples of NHS guidance on equity and equality.

The Women’s Health Strategy for England published in 2022 identified inequalities, including ethnic inequalities, in women’s health, but it did not address the specific health needs of women from different ethnic minority groups and the additional challenges they face, for example due to higher levels of deprivation, language and communication barriers, racism and discrimination.¹ Some of these risks to health, such as deprivation, also impact women from the White group.

Size and composition of the female population in England

Between 2011 and 2021, the female ethnic minority population of England increased by 42%, from 5.4 million to 7.7 million people (see Figure 1), reflecting the growing ethnic diversity of the general population. 1 in 4 women is now from an ethnic minority group. In some parts of England, for example Leicester and some London boroughs (eg, Newham, Tower Hamlets, Brent), ethnic minorities comprise over half the population. Compared with the White British group, women from most ethnic minority groups are relatively young but age profiles differ significantly between groups (see Figure 1). For example, the median age of women is 16–20 years in the Other Black and some Mixed groups (who are largely UK-born second generations), 36 in the Indian group, and 45 in the Black Caribbean and White British groups.

These demographic features have significant implications for health services. The proportion of women of, or approaching, childbearing age is higher in most ethnic minority groups, and they experience inequalities in reproductive and maternal health. As these women age, their health and care needs are also changing. Services need to adapt to address the health care needs of women from ethnic minority groups throughout the life course and address any inequalities.²

Figure 1 Number of females by ethnic group, England, 2021

6 pie charts showing reflecting the growing ethnic diversity of the general population

This long read focuses on selected issues

This long read is not intended to be comprehensive. Instead, it provides an overview of some key aspects of health that disproportionately affect women from ethnic minority groups and for which data is available.

What factors affect the health of women from different ethnic groups?

The circumstances in which people grow up, live, work and age, and their lifestyles, are among the many factors that influence their health. These socio-economic, socio-cultural and behavioural factors are significant determinants of population health and health inequalities, and shape the ethnic differences in women’s health across the life course described in section on ‘What are the differences in health outcomes, access to and experience of care for women from different ethnic groups?’. Moreover, the disproportionate impact of Covid-19 on ethnic minority groups highlighted the overlapping forms of disadvantage and discrimination that drive health inequalities in minority groups, ie the intersectionality of ethnicity with social, economic, structural and other dimensions of inequality, for example gender. This intersectionality needs to be reflected in structural interventions and policies for reducing ethnic health inequalities.

Wider determinants of health

Socio-economic and socio-cultural determinants of health and health-related behaviours differ significantly between women from different ethnic groups.^3,4

Socio-economic factors

Deprivation has an adverse impact on the health of women of all ethnicities. Most ethnic minority groups are disproportionately affected by socio-economic deprivation but there are significant differences between groups (eg, Asian and Black groups) and among them (eg, among Indian, Pakistani and Bangladeshi groups, and among Black Caribbean and Black African groups).^5–10 On several socio-economic measures (see below) women from Indian and Chinese groups compare favourably with women from other ethnic groups, including White British, whereas women from Pakistani, Bangladeshi and Black groups are most affected by socio-economic adversity and poverty (see Figure 2).

For example, unemployment is higher in women from ethnic minority groups compared with the White British group (3%). However, the proportion unemployed is higher in women from Pakistani and Bangladeshi groups (11%), and Black groups (8%) compared with the Indian group (5%). Moreover, working patterns differ: the proportion of women who are economically inactive because they are looking after the home or family is under 13% in women from the White British group and several ethnic minority groups, and about 30% in women from Pakistani and Bangladeshi groups.

The proportion of households with a high weekly income is highest in Indian and Chinese groups, while the proportion with a low weekly income is highest in Black, Pakistani and Bangladeshi groups, which also have the highest levels of poverty.

Home ownership is highest in people from Indian and White British groups. In contrast, social rented housing is most common in the Black group and lowest in Indian and Chinese groups.

Compared with other ethnic groups, including the White British group, the proportion of women with higher-level educational qualifications and in managerial/senior or professional occupations is highest in the Chinese and Indian groups. The proportion with no educational qualifications is highest in the White Gypsy or Irish Traveller, White Roma, Pakistani and Bangladeshi groups.

There are also differences within the White group. Where data is available, people from the White Roma and White Gypsy or Irish Traveller groups compare poorly with other ethnic groups on several socio-economic markers.

Deprivation also impacts adversely on the health of the White British group, with the most deprived quintile having higher all-cause mortality than the most deprived quintile in other ethnic groups.

Figure 2 Socio-economic determinants of health differ significantly between women from different ethnic groups, including between ethnic minority groups

Structural and socio-cultural factorsⁱ

Several factors can have an impact on health literacy, health behaviours and access to and outcomes of health care.^11–14

For example, in Leicester and some London boroughs, English is not the main language for one-third of the population, which could hamper access to health care and information, communication with staff and treatment adherence. Language barriers, lack of interpreters and culturally competent services, stereotyping, racism and discrimination can deter effective engagement with health services. Socio-cultural perceptions may influence health behaviours, for example the negative impact of fear, embarrassment or stigma on cancer screening uptake and presentation with symptoms.^{14, 15}

Women from ethnic minority groups and recent migrants may be disadvantaged in terms of health literacy, digital proficiency and ability to navigate ‘the system’. For example, with the NHS app only available in English, language barriers and digital inclusion can be mutually reinforcing. AI and digital technology offer tremendous opportunities – such as for the management of chronic conditions such as diabetes – but also the risk of digital exclusion and/or dependency on others for assistance.

Behavioural risk factors

Smoking, excess alcohol consumption, being overweight or obese, and inadequate physical activity increase the risk of developing and dying from cardiovascular diseases (CVD), cancer, diabetes, dementia and other long-term conditions, and of adverse outcomes in pregnant women and their babies.

Smoking prevalence and excess alcohol consumption are lowest among women from most ethnic minority groups, and highest in women from White and Mixed groups (see Figure 3).

On the other hand, levels of overweight/obesity exceed 50% in women from all ethnic groups except the Chinese, and are highest in women from the Black Caribbean, Black African and Pakistani groups, with almost 3 in 4 being overweight or obese (see Figure 4). Abdominal obesity (when the waist circumference exceeds the desirable threshold for women of less than 80cm) shows similar patterns.

Moreover, physical activity levels are lower in women from Asian and Black groups, compared with the White and Mixed groups, with only about 50% meeting recommended guidelines (see Figure 4).

Use of illegal drugs is a risk factor for health. Women from White and Black groups are more likely to have used illegal drugs compared with women from Asian groups.

Figure 3 Women from ethnic minority groups have lower rates of smoking and excess alcohol consumption

Figure 4 Women from ethnic minority groups have higher rates of being overweight or obese and of very high waist circumference, and lower rates of physical activity

What are the differences in health outcomes, access to and experience of care for women from different ethnic groups?

Mortality

Despite higher deprivation levels, women from most ethnic minority groups in England and Wales have lower overall mortality than women from White and Mixed groups (see Figure 5).^17–19 The all-cause mortality advantage in most ethnic minority groups over the White British group narrowed during the Covid-19 pandemic because of their higher mortality from the virus, and in some groups with the highest Covid-19 mortality (Bangladeshi, Pakistani and Black Caribbean) it was reversed, with all-cause mortality exceeding the rate in the White British group. By 2022, the pre-pandemic pattern of lower all-cause mortality in most ethnic minority groups was apparent again. However, as shown in section 4d, mortality from some conditions is higher in ethnic minority groups.

Data for more granular ethnic categories shows that all-cause mortality is highest in the White Gypsy or Irish Traveller group; however, this ONS data is not available for all periods, including Figure 5.

Figure 5 All-cause mortality rates are lower in females from ethnic minority groups in England

Research shows that migrants to high-income countries tend to have lower mortality than host populations. This is often described as the ‘healthy migrant effect’, as healthier migrants are more likely to migrate. But this mortality advantage in migrants, and in second UK-born generations, wanes over time because of environmental and behavioural changes.^20–25 Health care systems should therefore ensure that public health messages and preventive services reach people from ethnic minority groups.

Reproductive and sexual health

The Women’s Health Strategy for England includes priorities around reproductive health, which differs by ethnicity.

Fertility: Fertility rates are not available by ethnic group of the mother, but other data indicates that women from ethnic minority groups have higher birth rates. In 2011, in England and Wales the total fertility rateⁱⁱ by mother’s country of birth was highest for mothers born in North/West/Central Africa, Pakistan and Bangladesh (3–4) compared with UK-born mothers (1.8). This is consistent with 2021 census data showing higher proportions of births and young children (0–4) in Asian and Black households.^26,27Infant mortality rates in babies of Pakistani, Bangladeshi and Black ethnicity are about double the rate in babies of White British ethnicity, reflecting ethnic differences in contributory factors such as deprivation and low birthweight.^28,29 Public health and health services should prioritise reducing these longstanding ethnic disparities in infant outcomes.

Abortion: To prevent unwanted pregnancies, women should have ready access to contraception and to abortion services when they need them. In 2022 abortions in England and Wales increased to 251,000, the highest number since records began; the increase is attributed to rising living costs and inadequate access to contraception. Compared with women from the White British group (20 per 1,000 women aged 15–44), the age-standardised abortion rate in 2022 was highest in women from Black and Mixed White-Black groups (29–42) and lowest in women from Chinese, Bangladeshi and Pakistani groups (6–13).ⁱⁱⁱ

41% of women having an abortion had had one or more previous abortions. The rate of repeat abortions is higher in women from Black groups and lower in women from Asian groups.^30–32 Compared with women from the White British group, rates of contraceptive use are lower among women from ethnic minority groups, and use of emergency contraception is higher in women from the Black Caribbean group.^33–34Considered together, these patterns point to the need for improved information about, and access to, contraception among women from ethnic minority groups.

Sexual health: Data for sexually transmitted infections (STIs) by ethnic group is not split by gender. Rates of STIs are high in people from Black and Mixed White-Black groups, and low in people from Asian groups, with differences among the sub-groups.^35–41 These patterns are influenced by underlying socio-economic factors and their role in the broader structural determinants of health, indicating that public health interventions need to be strengthened and access to contraceptive services improved in order to reduce sexual health inequalities.^42,43

Menopause: The menopause can have a significant impact on the physical and mental health of women and their ability to work, but it is often inadequately understood and addressed, including by health professionals and employers.^44,45 Women from ethnic minority groups experience inequalities in access to care and treatment for the menopause, including delayed diagnosis and lower rates of hormone replacement therapy (HRT).^46–49 Information about the menopause and access to care and support from family and employers can be especially problematic for women from some ethnic minority groups, given the language barriers, cultural sensitivities and taboos, cross-cultural communication challenges, differences in presentation and knowledge gaps in clinicians that they may encounter.^50–55Cultural attitudes to, knowledge about and symptoms of the menopause differ between women from different ethnic minority groups and sub-groups.^56–59

Maternal outcomes

About 40% of the 600,000 babies born in England and Wales in 2023 were from an ethnic minority group and about one-third of births were to non-UK born mothers. Concerns about ethnic inequalities in pregnancy outcomes (maternal mortality,^iv in particular), and women’s experiences in childbirth are longstanding and widespread.^60–64Deaths during or shortly after a pregnancy are rare ‘sentinel’ events that are considered avoidable, so it is imperative that the health and care system strengthens preventive measures for reducing these inequalities. During 2020–22, there were 240 maternal deaths in England, of whom 41 were women from Asian groups and 29 from Black groups.^{v 65}

The MBRRACE reports on confidential enquires into maternal deaths consistently report higher maternal mortality rates among women from ethnic minority groups in England. In 2020–22 the rate was about three times higher in women from the Black group and about 1.5 times higher in the Asian group compared with the White group. In 2021–23 women in the Black group had a two-fold higher rate and Asian women had a slightly higher rate. These relative risks are not adjusted for ethnic differences in the risk factors for maternal death.^vi The reports note that women who die during or shortly after a pregnancy have multiple and complex physical and mental health, social, personal and socio-economic problems, generally existing before conception. Adjustment for some risk factors, such as pre-existing conditions and obesity, reduces but doesn’t eliminate excess maternal mortality in women from Black and Asian groups.^66,67

About two-thirds of the risk of maternal death is attributable to concurrent illnesses. Women from Black and Asian groups have poorer pre-conception health and a higher prevalence of risk factors, many preventable, such as overweight/obesity, pre-existing conditions, eg, hypertension, diabetes and heart disease, and severe maternal ill health.^68–74 Women from Black groups are more likely to experience delivery complications, intensive care admissions and hospital readmissions than women of other ethnicities.^75–78

Maternal mortality is strongly associated with deprivation – the rate in women living in most deprived areas is double that in the least deprived areas.^79,80 The proportion of births to mothers living in the most deprived areas of England is higher in ethnic minority groups than White groups (53%), and highest in the Black group (83%). Late and/or insufficient engagement with antenatal care also adversely affects maternal outcomes and is higher in women from ethnic minority groups.^81–88

The confidential enquiries into maternal deaths found no ethnic differences in the causes of death and quality of care.^89,90 However, related analyses found that multiple structural (ie, health-system related) and cultural biases were identified in the care of most women from all ethnic groups, the most common being lack of multi-specialist care for clinical, social and cultural complexity (eg, multiple or uncommon conditions, lack of family/social support, symptoms dismissed by staff or women), lack of individualised care (most common in women from the Black group), and microaggressions (most common in women from the Asian group). About one-third of the women who died in 2020–22 were born overseas. Migrant women experience particular barriers with navigating maternity care pathways, timely uptake of antenatal care, language and communication barriers, inadequate access to interpreters, digital exclusion.⁹¹

Women’s experiences of maternity services

Systematic reviews and studies of women’s experiences of maternity services, including both those using quantitative or qualitative research methods, show some positive feedback from women from ethnic minority groups, but this is not the norm. Widely reported negative experiences include poor communication due to language barriers and inadequate access to interpreters; cultural insensitivity; system-level factors and the attitudes, knowledge and behaviours of health care staff; unmet needs during labour and delivery; stereotyping; racism and discrimination.^92–99

The largest quantitative evidence comes from the Care Quality Commission’s (CQCs) 2023 maternity survey which had a sample ‘boost’ of women from ethnic minority groups, who comprised 41% (about 10,000) of the 25,000 respondents in England. Mothers from Asian and Black groups, and those whose main language was not English, responded more positively than average to several questions, such as awareness of medical history, and involvement in care. However, the reverse was true for mothers from the White group and those whose main language was English. Nationally, CQC’s 2023 maternity survey showed that women's experiences of care had deteriorated in the previous five years.

Failure to meet quality and safety standards, and staff shortages, have frequently been reported for maternity services in England^100–107 and specific maternity units,^108–111 affecting women of all ethnicities. CQC’s review of maternity services in 2022–24 rated 48% as inadequate or requiring improvement, noting that poor care and being harmed in childbirth are in danger of becoming ‘normalised’.

To reduce ethnic inequalities in maternal outcomes, health care policy and practice should prioritise the reduction in pre-conceptual risks to health in women from ethnic minority groups, deliver culturally competent, personalised maternity care, and tackle structural bias and racism in health care delivery. Beyond addressing individual factors, action is also needed to tackle inequalities and structural racism in the wider socio-economic determinants of health, such as housing, education and access to healthy environments.

Key long-term conditions affecting women from ethnic minority groups

There are pronounced ethnic differences among women in the burden of some common long-term conditions (Figure 6).

Significant differences between ethnic minority groups and white british by disease area

Cardiovascular disease (CVD)^vii

CVDs are serious long-term conditions common in women of all ethnicities, but they impose a disproportionately heavy burden of ill health and mortality among people from South Asian and Black groups in the UK and elsewhere.^112–115 The prevalence of, and mortality from, heart disease is higher in South Asian (but lower in Black) groups compared with the White group (see Figure 7). Hypertension and stroke are more common in both South Asian and Black groups compared with the White group.^116–120 For example, hypertension contributes to over 20% of all deaths in women from South Asian and Black groups (see Figure 8). CVD risk factors, such as obesity and/or abdominal obesity, hypertension, pre-eclampsia, diabetes and gestational diabetes, are higher in women from South Asian and Black groups compared with the White group, contributing to adverse maternal outcomes for them and their babies.

Figure 7 Women from South Asian groups have higher mortality from heart disease in England

Figure 8 Percent of total deaths involving hypertension or diabetes is higher in women from South Asian and Black groups

People from South Asian groups have higher levels of presentation to primary care for CVD than other ethnic groups, including White groups, while Black groups have lower rates. However, despite Asian patients diagnosed with CVD having the highest rates of prescribing for cholesterol lowering drugs and controlled blood pressure and cholesterol, they have the highest mortality from heart attacks. Rates for these preventive measures are lower in Black groups, contributing to higher stroke mortality. Hospital admission rates in people with hypertension are higher in Black and Asian groups.^121,122

Sex differences in CVD diagnosis, treatment and outcomes have long been reported in the UK and elsewhere,^123–126 with women comparing unfavourably to men. For example, women at risk of, or with, CVD are less likely to be prescribed medication, more likely to be misdiagnosed, and have higher mortality than men after acute CVD events.^127–131 Biological and socio-cultural differences, and inequities in care, contribute to these inequalities.^132–137Women from ethnic minority groups are likely to face similar sex differences in the diagnosis and management of CVD. CVD awareness-raising programmes, prevention and management services should be a priority for women from South Asian and Black groups given their susceptibility to CVD, sex inequities in CVD management and outcomes, and the risks that CVD poses for maternal outcomes.

Diabetes

Diabetes^viii is a major cause of avoidable ill health, disability and mortality; if not managed well, it can lead to serious complications and premature death. The prevalence of type 2 diabetes in England (7.5%) is rising with the increasing trend in obesity, and the age at onset is falling. In the five years to 2022–23 people under 40 years, which includes women of childbearing age, diagnosed with type 2 diabetes increased by 39%. Diabetes increases the risk for mothers and babies of serious complications during pregnancy and childbirth. In 2022, women with early-onset type 2 diabetes experienced widening gaps in care and a higher rate of adverse pregnancy outcomes, such as birth defects and baby deaths: 6.6% in 2022 compared with 5.5% in 2020 and earlier years.

International evidence shows that people from South Asian and Black groups are more prone to develop type 2 diabetes.^138–140 Compared with people from the White group, diabetes prevalence in England is over twice as high in people from South Asian and Black groups, leading to significantly higher morbidity and mortality (see Figure 9).^141–145 Diabetes contributes to over one-quarter of all deaths in women from South Asian and Black Caribbean groups (see Figure 8). Moreover, diabetes develops at a younger age in people from ethnic minority groups,^146–147hence Asian and Black groups are over-represented in younger people with type 2 diabetes. In 2020–21, 32% of the England and Wales population aged 26–39 years with type 2 diabetes were from Asian groups and 7.4% from Black groups, compared with their respective proportions in the population of 11.9% and 4.3%.^148–149

Figure 9 Mortality from diabetes is higher in women from South Asian and Black groups

Over half (52.6%) of pregnant women with early-onset type 2 diabetes are from ethnic minority groups. Pre-pregnancy care (folic acid supplementation, weight management programmes, reduction in harmful medications, referral to specialist clinics, etc) is particularly inadequate in women with early-onset type 2 diabetes, and those from deprived and ethnic minority groups. It is critically important that diabetes is well managed before pregnancy to reduce the risk of adverse outcomes in mothers and babies. Women from South Asian and Black groups also have an increased risk of developing gestational diabetes and long-term health conditions subsequently.

Diabetes also impacts adversely on the health of older women from ethnic minority groups. Compared with the White group, the higher prevalence of diabetes (and hypertension and CVD) in South Asian and Black groups contributes to their higher rates of chronic kidney disease and end-stage renal failure, and they are 3–5 times more likely to start dialysis.^150–152

Given the significant adverse health impacts of diabetes on ethnic minority women and their babies, prevention and management of diabetes, including support to self-manage, should be a priority in these communities.

Cancer

The incidence of most common cancers in England (including lung, breast, cervical and ovarian), and overall cancer mortality, is lower in people from ethnic minority compared with White groups.^153–158 Similar patterns are seen elsewhere.^159–160

However, some cancers occur more frequently in ethnic minorities. People from Black groups are more likely to develop gastrointestinal and thyroid cancer, myeloma (blood cancer), cancer of the uterus in women and of the prostate in men. People from Asian groups are more likely to develop cancer of the liver, gallbladder and thyroid.^161–163 Breast cancer is the most common cancer in women of all ethnic groups.

Breast, cervical and colorectal cancer screening programmes aim to diagnose cancer early to improve the chances of successful treatment. However, screening rates in England are lower among women from ethnic minority groups, particularly South Asian groups.^164–166 Poor knowledge and awareness of cancer risk factors and symptoms, cultural beliefs, fears and stigma about cancer, language barriers and practical barriers, such as caring and work responsibilities, can contribute to lower cancer screening rates and delays in seeking help.^167–170

Human Papillomavirus (HPV) is a common virus that causes cervical cancer. The national HPV vaccination programme introduced in 2008 for girls and in 2019 for boys offers protection against the virus. Knowledge of HPV and immunisation rates for girls are lower among ethnic minority groups.^171–175 The NHS is encouraging HPV vaccination to reach its goal of eliminating cervical cancer by 2040. In the 2022–23 academic year 1 in 6 girls and 1 in 5 boys were not fully vaccinated.

Early diagnosis is vital for improving cancer survival. Overall, the proportion of cancers diagnosed early is slightly higher in ethnic minority groups than White groups. However, compared with women from the White British group, higher rates of late-stage diagnoses are reported for breast and ovarian cancer in women from Black and Asian groups, and of uterine, colon and lung cancer in women from the Black group.^176–179This contrasts with evidence showing lower rates of late-stage prostate cancer diagnoses among men from the Black group compared with White British group, possibly due to greater awareness among GPs and Black men of their higher risk, and the work of cancer charities.

Although data on cancer survival is sparse, it suggests survival is higher or similar in patients from ethnic minority groups, including women, compared with the White group.^180–183

The NHS’s annual cancer patient experience surveys monitor the experience of cancer care among people in England with a confirmed diagnosis of cancer. Patients from ethnic minority groups consistently rate their overall care less favourably than patients from the White group.^184–188

Evidence from the UK and other countries shows that through cultural assimilation and behaviour change, the prevalence of risk factors for cancer and incidence of cancer in ethnic minorities, including specifically women, rises with increasing duration of residence to approach that in the indigenous population.^189–192 This has important implications for health policies and disease prevention, because the incidence of breast, cervical and other cancers in women from ethnic minority groups could rise over time. It calls for targeted interventions to raise awareness of risk factors, symptoms, the importance of screening and early diagnosis among women from ethnic minority communities, and for health systems to address barriers to women from ethnic minority groups being seen and referred promptly.

General health and multimorbidity

Although women in England have longer life expectancy than men, they report spending more years in poor health.^193,194 A ‘paradox’ of poorer self-reported health alongside lower mortality is apparent for migrants from low and middle-income countries (South Asia and the Caribbean) compared with those born in England and Wales, especially among women.

In England in 2011–19, women from the Bangladeshi (18%), Pakistani (16%), Black Caribbean (11%) and Indian (11%) groups were more likely to report poor health compared with women from the White British group (8%), while women from the Chinese group (3%) were less likely. Self-reported rates of two or more longstanding conditions or a limiting longstanding condition^ixwere also highest in women from the Bangladeshi and Pakistani groups, and lowest in the Chinese group.

Similar patterns are apparent for diagnosed multimorbidity: overall rates of diagnosed illness in England are higher in people from Pakistani, Bangladeshi, and Black Caribbean groups than among the White population, and lower in other ethnic groups especially the Chinese. Cardiovascular multimorbidity rates (including diabetes, hypertension, heart attack or stroke) are over three times higher in adults from South Asian groups and double in adults from Black groups.

People with multiple long-term conditions have poorer health, poorer quality of life and a higher risk of dying than those in the general population. Ethnic minority groups are at higher risk of multimorbidity and of mortality from it compared with the White population.^195–198Compared with the White population (42%), early onset multimorbidity is more common among South Asian (59%) and Black (56%) groups, highlighting the need to identify, prevent and manage multimorbidity early in the life course.

Early diagnosis and management of long-term conditions can improve health and reduce or delay multimorbidity in women from ethnic minority groups, including those of working age, providing health, economic and wider societal gains.

Ageing

As women from ethnic minority groups have a younger age profile than women from the White group, over time increasing cohorts are reaching older ages – for example, between the 2011 and 2021 censuses, the number of ethnic minority women in England aged 60 and over increased by 56% (from 0.56 million to 0.87 million). The Women’s Health Strategy for England noted that the health care system doesn’t focus enough on older women’s health care needs and experiences.

In the GP patient surveys of 2014-17, health-related quality of life^x among older women (55+ years) was poorer in women from most ethnic minority groups compared with women from the White British group, especially in women from the White Gypsy and Irish Traveller, Bangladeshi and Pakistani groups. Women from the Chinese group were the exception with a higher score. These inequalities were generally greater for women than men, and widest in the self-care domain, which asks about difficulties in washing and dressing. Compared with the White British group, ethnic inequalities in health-related quality of life were accompanied by higher prevalence of long-term conditions, poor experiences of primary care, insufficient support from local services, low self-confidence in managing their own health, and deprivation.

The incidence of dementia in women in the UK is lower in the Asian group and higher in the Black group compared with the White group, consistent with a higher dementia risk in Black groups in other countries.^199,200 The lower incidence in women from the Asian group could reflect underdiagnosis, language barriers, delay in seeking help, stigma or a lower risk of developing dementia. Mortality from dementia and Alzheimer’s disease is the leading cause of death in women of all ethnic groups in England except women from South Asian groups. Compared with women from the White group, the rate is lower in all minority groups, although women from Black Caribbean and Mixed groups have higher rates than other minority groups.^201,202

Osteoporosis frequently results in fractures, for example hip fractures, which increase the risk of disability and death. More than 1 in 3 women will have an osteoporotic fracture in their lifetime and White women are at increased risk compared with other ethnic groups. Joint replacement of hips and knees is commonly performed among older people with osteoarthritis to relieve pain and improve physical function. Hip and knee replacement rates in England are lower in women from Black and Asian groups compared with the White group. There are several possible explanations for these patterns, including ethnic differences in the prevalence and severity of osteoarthritis, patient willingness to undergo surgery, and inequitable access to care.

Ensuring that older women from ethnic minority communities are informed and supported to manage long-term conditions and age well, and receive culturally competent, equitable services, is increasingly important as their numbers grow.

Footnote ii

The total fertility rate (TFR) is the average number of live children born to a group of women if they experienced the current age-specific fertility rates throughout their childbearing lifespan.
Footnote iii

We calculated age-standardised abortion rates for England and Wales by ethnic group using abortion data for 2022 and the 2021 census female population by ethnic group.
Footnote iv

Maternal deaths include the deaths of women while pregnant or within 42 days of the end of the pregnancy.
Footnote v

The maternal deaths included 38 deaths from Covid-19, over half (22) of whom were women from Asian or Black groups, who have lower Covid-19 vaccination rates. Maternal deaths related to Covid-19 have fallen and there were none in 2023.
Footnote vi

The annual MBBRACE reports present ratios of maternal mortality rates between women from ethnic minority groups and the White group. The mortality rates are ‘crude’ rates ie they are not adjusted for differences between ethnic groups in the risk factors for a maternal death such as age, parity, obesity, smoking, multiple pregnancy, pre-existing conditions, deprivation and other factors. Please note: the ratios are based on rates, and the rates (not ratios) are crude, unadjusted rates
Footnote vii

Cardiovascular disease (CVD) is a general term for conditions affecting the heart or blood vessels. Common comorbidities associated with CVD include, for example, high blood pressure, atrial fibrillation and diabetes.
Footnote viii

There are two main types of diabetes. Type 1 diabetes develops early in life and the body doesn’t produce insulin; it requires daily management with insulin injections and blood sugar monitoring. About 90% of people with diabetes have type 2 diabetes, when the body doesn’t produce enough insulin, or doesn’t respond to it; it develops in adults over many years and is associated with being overweight. Gestational diabetes can develop during pregnancy; it affects 3–5% of pregnancies in the UK and usually goes after giving birth.
Footnote ix

Longstanding conditions are those lasting, or expected to last, 12 months or more and include physical and mental health conditions. Conditions that reduce a person’s ability to carry out day-to-day activities are described as limiting longstanding conditions.
Footnote x

Health-related quality of life is measured by the EQ-5D-5L, an internationally used health status questionnaire that measures five dimensions of health: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.

What can policy-makers and integrated care boards do to improve the health of women from ethnic minority groups and reduce inequalities?

The King’s Fund has identified seven priorities for reducing health inequalities and improving health outcomes. In addition, priority areas for actions for improving the health of women from ethnic minority groups and reducing inequalities should include the following.

Analysing local data and talking to ethnic minority patients and communities to understand health outcomes and inequalities in local neighbourhoods experienced by women from ethnic minority groups.
Forming partnerships and collaborations with voluntary and community organisations, women’s groups and employers to maximise outreach to women – especially those who are socially isolated, digitally excluded or non-English speakers – build trust, ensure women from minority communities are engaged in the planning and delivery of local services, and participate in women’s health and wellbeing networks. Voluntary and community organisations have strong connections with and understanding of the needs of local communities, as was evident in the Covid-19 pandemic.
Dedicating resources to early prevention as the risks to ethnic minority women’s health, including maternal health, start early in life. Do this by strengthening culturally tailored information awareness, health literacy, health promotion, prevention and early intervention initiatives among young girls and women from ethnic minority groups, in partnership with local public health departments. Reducing risk factors such as obesity and the early onset of preventable life-long conditions such as CVD and diabetes, and improving pre-conceptual health, should be priorities.
Improving access to and provision of personalised, culturally competent and equitable services, as well as translation and interpretation services, in both primary and secondary care to address the barriers that contribute to ethnic differences in access to services, diagnosis, and management of ill health across women’s life course, including as they age.
Actions to reduce ethnic inequalities in women’s health within a broader strategy for addressing the overlapping causes and dimensions of health inequalities – including intersectionality with other characteristics such as deprivation and geography – and the role that structural racism and discrimination play in shaping and reinforcing ethnic inequalities in health.
Improving the coverage and quality of ethnicity coding in GP and NHS records by asking all women to self-report their ethnicity using recommended ethnic coding categories and reducing blanket use of ‘not known’/’not stated’ residual codes. Supporting staff and patients to understand the aims of NHS collection of ethnicity data and improving trust and confidence about personal data collection as part of care. Improving health outcomes, reducing ethnic inequalities, and planning and delivering services tailored to diverse health needs is contingent on being able to measure health care needs, access to and outcomes of health care reliably across different ethnic groups.

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The health of women from ethnic minority groups in England

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Veena Raleigh

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