The health of people from ethnic minority groups in England

This long read examines ethnic differences in health outcomes, highlighting the variation across ethnic groups and health conditions, and considers what’s needed to reduce health inequalities.

Key messages

In England, there are health inequalities between ethnic minority and white groups, and between different ethnic minority groups.1 The picture is complex, both between different ethnic groups and across different conditions.
Access to primary care health services is generally equitable for ethnic minority groups, but this is less consistently so, for example dental health care. However, people from some ethnic minority groups are more likely to report being in poorer health and to report poorer experiences of using health services than their white counterparts.
Before the Covid-19 pandemic, life expectancy at birth was higher among ethnic minority groups than the white and Mixed groups. The headline figures conceal significant differences between ethnic groups, for example:
- people from the White Gypsy or Irish Traveller, Bangladeshi and Pakistani communities have the poorest health outcomes across a range of indicators
- rates of infant and maternal mortality, cardiovascular disease (CVD) and diabetes are higher among Black and South Asian groups than white groups
- mortality from cancer, and dementia and Alzheimer’s disease is highest among white groups.
The Covid-19 pandemic has had a disproportionate impact on most ethnic minority communities. They experienced higher infection and mortality rates than the white population, in large part due to differences in location, occupation, deprivation, living arrangements and health conditions such as CVD and diabetes. Ethnic differences in Covid-19 mortality declined over the course of the pandemic, and by 2022 there was no excess in ethnic minority groups compared with the White British group.
In 2020, Covid-19 caused overall mortality in some ethnic minority groups to exceed that of the white population, reversing the pre-pandemic picture. However, by 2022 overall mortality rates returned to pre-pandemic patterns, with the white and Mixed groups again having the highest mortality.
Unpicking the causes of ethnic inequalities in health is difficult. Available evidence suggests a complex interplay of many factors including deprivation, environment, health-related behaviours and the ‘healthy migrant effect’2 . Most ethnic minority groups are disproportionately affected by socio-economic deprivation, a key determinant of health status in all communities.
Among ethnic minority groups structural racism can reinforce inequalities, for example, in housing, employment and the criminal justice system, which in turn can have a negative impact on health. Racism and discrimination can also have a negative impact on the physical and mental health of people from ethnic minority groups.
Covid-19 has shone a light on inequalities and highlighted the urgent need to strengthen action to prevent and manage ill health in deprived and ethnic minority communities. A cross-government strategy for reducing health inequalities (and the wider socio-economic and structural inequalities that drive them) and addressing the diverse health needs of all groups at risk of poor health and high mortality has never been more urgent.
Comprehensive, good-quality data is essential for enabling policy-makers and health care professionals to identify the specific needs of different ethnic groups, respond with tailored strategies for addressing inequalities, and track the impact of these strategies.

1The terms ‘ethnic minority’ or ‘ethnic minority groups’ refer to people belonging to ethnic groups that are in the minority in the context of the population of England.
2The ‘healthy migrant effect’ is the mortality advantage in migrants relative to the majority population in host countries that is reported in many countries. It could be due to the selective migration of healthy individuals and/or healthier lifestyles such as lower smoking and alcohol consumption.

Introduction

In the 2011 census, 15 per cent of people in England identified themselves as belonging to an ethnic minority group (see Table 1)3 . Ethnicity is a complex, multidimensional concept, defined by features such as a shared history, origins, language, and cultural traditions. Although it is a social construct often used to describe distinct populations, it is a subjective identity based on how individuals define themselves.

Health patterns differ significantly between ethnic minority groups and the white population, and between different minority groups, reflecting the diversity of demographic, socio-economic, behavioural, cultural and other characteristics between ethnic groups.

This explainer provides an overview of health outcomes and their determinants among ethnic minority groups. It focuses on selected topics where ethnic differences are significant and affect large numbers.

This is not a comprehensive review of all aspects of ethnic minority health. In particular, it does not cover mental health because of the challenges in summarising ethnic differences across diverse forms of mental illness in a short report.

3ONS estimates of population by ethnic group show the per cent non-White in England in 2018 was 16 per cent.

Table 1 Population of England by ethnic group, 2021

Ethnic group		Number	Per cent of total population
White	English, Welsh, Scottish, Northern Irish or British	41,540,790	73.5
	Gypsy or Irish Traveller	64,220	0.1
	Irish	494,255	0.9
	Roma	99,135	0.2
	Other White	3,585,000	6.3
Asian, Asian British or Asian Welsh	Bangladeshi	629,565	1.1
	Chinese	431,165	0.8
	Indian	1,843,250	3.3
	Pakistani	1,570,285	2.8
	Other Asian	952,130	1.7
Black, Black British, Black Welsh, Caribbean or African	African	1,468,475	2.6
	Caribbean	619,420	1.1
	Other Black	293,830	0.5
Mixed or multiple ethnic groups	White & Asian	474,190	0.8
	White & Black African	241,530	0.4
	White & Black Caribbean	499,310	0.9
	Other Mixed or multiple ethnic groups	454,350	0.8
Other	Arab	320,200	0.6
Other	Any other	908,950	1.6
TOTAL		56,490,050	100.0

Source: Office for National Statistics (2023)

References: References:
Office for National Statistics (2018). ‘Population denominators by ethnic group, regions and countries: England and Wales, 2011 to 2018’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/adhocs/008780populationdenominatorsbyethnicgroupregionsandcountriesenglandandwales2011to2017 (accessed on 28 January 2021).
Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).

Data on the health of ethnic minority groups

This explainer focuses on the health of ethnic minorities in England. Where articles and data sources refer to different geographies, eg, England and Wales or the UK, this is stated in the text.

The 2011 census ethnic categories are used, although sometimes data sources refer to aggregated ethnic groups when numbers are small. The categories used here are those used in the original data sources. The South Asian group refers to people from India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan. The Asian group generally also includes people from South East Asia. The Black group includes people of African and/or Caribbean origin.

Much of the data for examining ethnic differences in health comes from health records. However, its coverage and quality are imperfect. National data on mortality by ethnic group has not been available routinely because ethnicity is not recorded at death registration (although Scotland introduced this in 2012). Earlier analyses of mortality therefore used country of birth of migrants as a proxy for ethnicity, but this excludes second-generation migrants. More recently, analyses of mortality by the Office for National Statistics (ONS) and Public Health England have linked death records to secondary sources from which ethnicity is derived, eg, the 2011 Census and hospital records; these provide the best available national data on mortality by ethnicity but the results are subject to caveats. These data limitations present barriers to understanding health issues among ethnic minority groups.

Following the Covid-19 pandemic, NHS England is taking steps to improve ethnicity recording in health records and the government has said it will introduce ethnicity recording in death certificates. These data developments should facilitate a better understanding of ethnic differences in health.

References: Mathur R, Bhaskaran K, Chaturvedi N, Leon DA, van Staa T, Grundy E, Smeeth L (2013). ‘Completeness and usability of ethnicity data in UK-based primary care and hospital databases’. Journal of Public Health, vol 36, no 4, pp 684–92. Available at: https://pubmed.ncbi.nlm.nih.gov/24323951 (accessed on 11 February 2021).
NHS Digital (2021). ‘Detentions under the Mental Health Act’. GOV.UK website. Available at:
https://www.ethnicity-facts-figures.service.gov.uk/health/mental-health/detentions-under-the-mental-health-act/latest (accessed on 2 September 2021).
NHS England (2020). Implementing phase 3 of the NHS response to the Covid-19 pandemic [online]. NHS England and NHS Improvement website. Available at: ww.england.nhs.uk/publication/implementing-phase-3-of-the-nhs-response-to-the-covid-19-pandemic (accessed on 29 January 2021).
Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).
Public Health England (2020). Beyond the data: understanding the impact of Covid-19 on BAME groups [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (accessed on 29 January 2021).
Race Disparity Unit, Cabinet Office (2017). Race disparity audit summary findings from the Ethnicity Facts and Figures website [online]. GOV.UK website. Available at: www.gov.uk/government/publications/race-disparity-audit (accessed on 29 January 2021).
Race Disparity Unit, Cabinet Office (2020). Quarterly report on progress to address COVID-19 health inequalities [online]. GOV.UK website. Available at: www.gov.uk/government/publications/quarterly-report-on-progress-to-address-covid-19-health-inequalities (accessed on 29 January 2021).
Saunders CL, Abel GA, El Turabi A, Ahmad F, Lyratzopoulos (2013). ‘Accuracy of routinely recorded ethnic group information compared with self-reported ethnicity: evidence from the English Cancer Patient Experience survey’. BMJ Open, art no: e002882. Available at: https://bmjopen.bmj.com/content/3/6/e002882 (accessed on 29 January 2021).

Overall health

General health can be measured by self-reported outcomes, such as how people perceive their health, and observed outcomes such as mortality. There are differences in health between ethnic minority groups, and between ethnic minority groups and the white group; the patterns vary depending on the aspect of health being measured.

People from some ethnic minority groups (especially Pakistani and Bangladeshi groups) are more likely than White British people to report having a long-term condition and poor health, with the White Gypsy or Irish Traveller group reporting the poorest health. Health-related quality of life scores at older ages, based on responses to the GP Patient Survey, are lower among most ethnic minority groups, especially the White Gypsy or Irish Traveller, Bangladeshi and Pakistani groups. Levels of diagnosed ill health are higher in Pakistani, Bangladeshi and Black Caribbean groups than in the aggregated . Poor health co-existing with lower mortality has often been reported for migrant groups, including in the UK.

’Experimental’ ONS statistics show that in 2011–14, life expectancy at birth among people of the white group and Mixed groups was lower than in all other ethnic groups (see Figures 1a and 1b below), and that the had higher mortality from most leading causes of death. Although overall mortality declined subsequently in all ethnic groups, ethnic differences remained similar through to recent pre-pandemic years: in 2017–19 the white group had higher overall mortality than any other ethnic group.

However, the pandemic reversed the all-cause mortality advantage in some ethnic minority groups over the white group because of the significantly higher Covid-19 mortality they experienced. Ethnic differences in Covid-19 mortality declined during the course of the pandemic, and by 2022 overall mortality rates reverted to pre-pandemic patterns with the White groups again experiencing the highest mortality.

Using more granulated ethnic categories, ONS data for the 2020–22 pandemic period shows that mortality rates from all causes were highest for the White Gypsy and Irish Traveller group; the Mixed White and Black Caribbean group and White Irish group also had higher all-cause mortality rates compared with the White British group.

The ONS findings are consistent with other evidence that most ethnic minority groups and foreign-born migrants in England and Scotland had lower overall mortality than white counterparts before the Covid-19 pandemic. This could be due to many factors including the ‘healthy migrant effect’, which might mitigate some impacts of socio-economic disadvantage. Moreover, some risk factors, eg, smoking and alcohol consumption, are lower among ethnic minority groups. Studies also show that this mortality advantage among migrants is reduced over time and in UK-born descendants – possibly because cultural assimilation over time leads to lifestyle changes, eg, in diet and smoking.

A chart showing male life expectancy at birth by ethnic group, England and Wales, 2011 to 2014

Chart showing female life expectancy at birth by ethnic group, England and Wales, 2011 to 2014

Source: ONS (2021) https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/ethnicdifferencesinlifeexpectancyandmortalityfromselectedcausesinenglandandwales/2011to2014

References: Bhaskaran K, Bacon S, Evans SJ, Bates CJ, Rentsch CT, MacKenna B, Tomlinson L, Walker AJ, Schultze A, Morton CE, Grint D, Mehrkar A, Eggo RM, Inglesby P, Douglas IJ, McDonald HI, Cockburn J, Williamson EJ, Evans D, Curtis HJ, Hulme WJ, Parry J, Hester F, Harper S, Spiegelhalter D, Smeeth L, Goldacre B (2021). ‘Factors associated with deaths due to Covid-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform’. The Lancet Regional Health Europe, vol 6, art no: 100109. Available at: https://pubmed.ncbi.nlm.nih.gov/33997835/ (accessed on 24 April 2023).
Bhaskaran K, Bacon S, Evans SJW, Bates CJ, Rentsch CT, MacKenna B, Tomlinson L, Walker AJ, Schultze A, Morton CE, Grint D, Mehrkar A, Eggo RM, Inglesby P, Douglas IJ, McDonald HI, Cockburn JC, Williamson EJ, Evans D, Curtis HJ, Hulme WJ, Parry J, Hester F, Harper S, Spiegelhalter D, Smeeth L, Goldacre B (2021). ‘Factors associated with deaths due to Covid-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform’. The Lancet Regional Health Europe, no 6, art no: 100109. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC8106239/ (accessed on 2 September 2021).
Bhopal RS, Gruer L, Cezard G, Douglas A, Steiner MFC, Millard A, Buchanan D, Katikireddi SV, Sheikh A (2018). ‘Mortality, ethnicity, and country of birth on a national scale, 2001–2013: a retrospective cohort’. PLoS Med, vol 15, no 3, art no: e1002515. Available at: https://doi.org/10.1371/journal.pmed.1002515 (accessed on 29 January 2021).
Britton M, Balarajan R, Bulusu L (1990). ‘Mortality among immigrants in England and Wales, 1979-83’. In Britton M, ed. Mortality and Geography. A review in the mid 1980s. England and Wales. OPCS series DS No 9. London: HMSO.
Evandrou M, Falkingham J, Feng Z, Vlachantoni A (2016). ‘Ethnic inequalities in limiting health and self-reported health in later life revisited’. Journal of Epidemiology and Community Health, vol 70, no 7, pp 653–62. Available at: https://jech.bmj.com/content/70/7/653 (accessed on 29 January 2021).
Fischbacher CM, Steiner M, Bhopal R, Chalmers J, Jamieson J, Knowles D, Povey C (2007). ‘Variations in all cause and cardiovascular mortality by country of birth in Scotland, 1997–2003’. Scottish Medical Journal, vol 52, no 4, pp 5–10. Available at: https://pubmed.ncbi.nlm.nih.gov/18092629/ (accessed on 29 January 2021).
Gruer L, Cézard G, Clark E, Douglas A, Steiner M, Millard A, Buchanan D, Katikireddi SV, Sheikh A, Bhopal R (2016). ‘Life expectancy of different ethnic groups using death records linked to population census data for 4.62 million people in Scotland’. Journal of Epidemiology and Community Health, vol 70, no 12, pp 1251–4. Available at: https://jech.bmj.com/content/70/12/1251 (accessed on 10 February 2021).
Kennedy S, Kidd MP, McDonald JT, Biddle N (2015). ‘The healthy immigrant effect: patterns and evidence from four countries’. Journal of International Migration and Integration, no 16, pp 317–32. Available at: https://doi.org/10.1007/s12134-014-0340-x (accessed on 2 September 2021).
Marmot MG, Adelstein AM, Bulusu L (1984). Immigrant mortality in England and Wales 1970–78: causes of death by country of birth. London: HMSO.
Mathur R, Rentsch CT, Morton CE, Hulme WJ, Schultze A, MacKenna B, Eggo RM, Bhaskaran K, Wong AYS, Williamson EJ, Forbes H, Wing K, McDonald HI, Bates C, Bacon S, Walker AJ, Evans D, lesby P, Mehrkar A, Curtis HJ, DeVito NJ, Croker R, Drysdale H, Cockburn J, Parry J, Hester F, Harper S, Douglas IJ, Tomlinson L, Evans SJW, Grieve R, Harrison D, Rowan K, Khunti K, Chaturvedi N, Smeeth L, Goldacre B (2021). ‘Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform’. The Lancet, no 397, pp 1711–24. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00634-6/fulltext (accessed on 2 September 2021).
Office for National Statistics (2021). ‘Ethnic differences in life expectancy and mortality from selected causes in England and Wales: 2011 to 2014’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/ethnicdifferencesinlifeexpectancyandmortalityfromselectedcausesinenglandandwales/2011to2014 (accessed on 2 September 2021).
Office for National Statistics (2023). ‘Ethnic group by education, employment, health and housing, England and Wales: Census 2021’. ONS website. Available at: www.ons.gov.uk/releases/ethnicgroupbyeducationemploymenthealthandhousingenglandandwalescensus2021 (accessed on 24 April 2023).
Office for National Statistics (2021). ‘Mortality from leading causes of death by ethnic group, England and Wales: 2012 to 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/mortalityfromleadingcausesofdeathbyethnicgroupenglandandwales/2012to2019 (accessed on 2 September 2021).
Office for National Statistics (2021). ‘Updating ethnic contrasts in deaths involving the coronavirus (Covid-19) England: 24 January 2020 to 31 March 2021’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/24january2020to31march2021 (accessed on 2 September 2021).
Office for National Statistics (2023). ‘Updating ethnic and religious contrasts in deaths involving the coronavirus (Covid-19), England: 24 January 2020 to 23 November 2022’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/24january2020to23november2022 (accessed on 24 April 2023).
Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).
Public Health England (2019). Health-related quality of life for people aged 65 and over. Available at: www.ethnicity-facts-figures.service.gov.uk/health/physical-health/health-related-quality-of-life-for-people-aged-65-and-over/latest#data-sources (accessed on 29 January 2021).
Public Health England (2018). A review of recent trends in mortality in England [online]. GOV.UK website. Available at: www.gov.uk/government/publications/recent-trends-in-mortality-in-england-review-and-data-packs (accessed on 29 January 2021).
Public Health England (2018). Local action on health inequalities: understanding and reducing ethnic inequalities in health [online]. GOV.UK website. Available at: www.gov.uk/government/publications/health-inequalities-reducing-ethnic-inequalities (accessed on 29 January 2021).
Scott AP, Timæus IM (2013). ‘Mortality differentials 1991-2005 by self-reported ethnicity: findings from the ONS Longitudinal Study. Journal of Epidemiology and Community Health, vol 67, no 9, pp 743–50. Available at: https://pubmed.ncbi.nlm.nih.gov/23740930/ (accessed on 29 January 2021).
Wallace M (2016). ‘Adult mortality among the descendants of immigrants in England and Wales: does a migrant mortality advantage persist beyond the first generation’? Journal of Ethnic and Migration Studies, vol 42, no 9, pp 1–19. Available at: www.researchgate.net/publication/292946924_Adult_mortality_among_the_descendants_of_immigrants_in_England_and_Wales_does_a_migrant_mortality_advantage_persist_beyond_the_first_generation (accessed on 29 January 2021).
Wallace M, Darlington-Pollock F (2020). ‘Poor health, low mortality? Paradox found among immigrants in England and Wales’. Population, Space and Place, art no: e2360. Available at: https://doi.org/10.1002/psp.2360 (accessed on 2 September 2021).
Wallace M, Kulu H (2015). ‘Mortality among immigrants in England and Wales by major causes of death, 1971-2012: a longitudinal analysis of register-based data’. Social Science and Medicine, no 147, pp 209–21. Available at: https://pubmed.ncbi.nlm.nih.gov/26595089/ (accessed on 2 September 2021).
Watkinson RE, Sutton M, Turner, AJ ((2021). ‘Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey’. The Lancet Public Health. Available at: www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30287-5/fulltext (accessed on 24 April 2023).
Wild S, Mckeigue P (1997). ’Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92’. BMJ, vol 314, pp 705. Available at: www.bmj.com/content/314/7082/705 (accessed on 29 January 2021).
Wild SH, Fischbacher C, Brock A, Griffiths C, Bhopal R (2007). ‘Mortality from all causes and circulatory disease by country of birth in England and Wales 2001–2003’. Journal of Public Health, vol 29, no 2, pp 191–8. Available at: https://academic.oup.com/jpubhealth/article/29/2/191/1505208 (accessed on 29 January 2021).
Watt T, Raymond A, Rachet-Jacquet L (2022). ‘Quantifying health inequalities in England’. Health Foundation website. Available at: www.health.org.uk/news-and-comment/charts-and-infographics/quantifying-health-inequalities (accessed on 24 April 2023).
Wohland P, Rees P, Nazroo J, Jagger C (2015). ‘Inequalities in healthy life expectancy between ethnic groups in England and Wales in 2001’. Ethnicity and Health, vol 20, no 4, pp 341–53. Available at: https://doi.org/10.1080/13557858.2014.921892 (accessed on 29 January 2021).

Maternal mortality, stillbirths and infant mortality, and child health

Maternal mortality

More than one-quarter (28 per cent) of the 595,300 babies born in England in 2021 were to mothers of non-white ethnic minority origin (see Table 2).

Compared with the white group, the rate of women dying in the UK in 2018–20 during pregnancy or up to 6 weeks after the end of their pregnancy was 3.7 times higher in the Black group, and 1.7 times higher in the Asian group (although the number of such deaths is relatively low – fewer than10 a year in both the Black group and the Asian group). Deprivation and pre-existing medical problems are significant risk factors for maternal mortality.

Stillbirths and infant mortality4

Although stillbirth and infant mortality rates in England and Wales have fallen in all ethnic groups since 2007, they remain higher among ethnic minority groups. They are highest among babies from the Pakistani and Black groups (see Table 2).

The causes of infant mortality differ between ethnic groups. South Asian and Black mothers have higher proportions of premature and low birthweight babies than white mothers. Immaturity-related conditions, such as respiratory and cardiovascular disorders, contribute most to infant mortality in most ethnic groups; however, in the Pakistani and Bangladeshi groups congenital anomalies cause the most infant deaths. Babies of South Asian women have a lower rate of unexplained deaths in infancy. Explanations for these ethnic variations in infant mortality are complex, involving the interplay of environmental, physiological and socio-cultural factors. Deprivation is a significant risk factor: compared with white groups, higher proportions of mothers from ethnic minority groups, especially Black groups, live in more deprived areas.

Table 2 Live births, stillbirths and infant mortality by ethnic group, England 2021

Ethnic group	Live births	Per cent of live births	Stillbirths	Stillbirth rate per 1,000 total births	Infant deaths	Infant mortality rate per 1,000 live births
White British	349,840	58.8	1,217	3.5	1,035	3.0
White Other	72,144	12.1	280	3.9	207	2.9
Bangladeshi	9,986	1.7	39	3.9	43	4.3
Indian	22,722	3.8	116	5.1	91	4.0
Pakistani	26,745	4.5	157	5.8	175	6.5
Other Asian	15,641	2.6	65	4.1	54	3.5
Black African	20,733	3.5	146	7.0	142	6.8
Black Caribbean	5,067	0.9	34	6.7	25	4.9
Other Black	3,733	0.6	26	6.9	26	7.0
Mixed/Multiple	42,155	7.1	181	4.3	144	3.4
Other	13,817	2.3	62	4.5	43	3.1
Not stated	12,717	2.1	111	8.7	127	10.0
TOTAL	595,300	100	2,434	4.1	2,209	3.7

Source: ONS (2023)

Child health

Health and wellbeing in the early years have a significant bearing on future health. Childhood overweight and obesity rates are higher among children in , Bangladeshi and Pakistani groups (see Table 3). Some of these differences may be associated with higher levels of deprivation among ethnic minority groups, as children living in the are almost twice as likely to be obese than those in the least deprived areas. Children in Asian and Black households are more likely to live in persistent low-income households than children from white households.

Table 3 Prevalence of obesity by ethnic group, England, 2019/20

Ethnic group	Reception (4–5 years)	Year 6 (10–11 years)
White British	22.9	35.5
White Irish	22.7	38.3
Other White	20.2	38.7
Bangladeshi	22.2	47.7
Indian	14.4	38.7
Pakistani	20.2	43.7
Other Asian	19.6	42.1
Black African	30.3	49.6
Black Caribbean	26.1	48.1
Other Black	29.4	48.9
White and Asian	16.2	34.2
White and Black African	27.6	43.8
White and Black Caribbean	26.6	43.5
Other Mixed	21.6	38.7
TOTAL	22.3	37.8

Source: NHS Digital 2022

South Asian children have lower levels of physical fitness than children in white European and Black groups, and physical activity levels are lower among children from ethnic minority groups compared with white groups.

4A stillbirth is a baby born with no signs of life at or after 28 weeks' gestation. An infant death is the death of a child under one year.

References: Department for Work and Pensions (2020). ‘Persistent low income’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/work-pay-and-benefits/pay-and-income/low-income/latest (accessed on 29 January 2021).
Jardine J, Walker K, Gurol-Urganci I, Webster K, Muller P, Hawdon J, Khalil A, Harris T, van der Meulen J (2021). ‘Adverse pregnancy outcomes attributable to socioeconomic and ethnic inequalities in England: a national cohort study’. The Lancet, vol 398, no 10314, p1095–112. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01595-6/fulltext (accessed on 24 April 2023).
Knight M, Bunch K, Patel R, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (eds) (2022). 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 [online]. National Perinatal Epidemiology Unit MBRRACE-UK website. Available at: www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2022/MBRRACE-UK_Maternal_MAIN_Report_2022_v10.pdf (accessed on 24 April 2023).
Knowles RL, Ridout D, Crowe S, Bull C, Wray J, Tregay J, Franklin RC, Barron DJ, Cunningham D, Parslow RC, Brown KL (2017). ‘Ethnic and socioeconomic variation in incidence of congenital heart defects’. Archives of Disease in Childhood, vol 102, pp 496–502. Available at: https://adc.bmj.com/content/102/6/496 (accessed on 29 January 2021).
Kroll ME, Quigley MA, Kurinczuk JJ, Dattani N, Li Y, Hollowell J (2018). ‘Ethnic variation in unexplained deaths in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006-2012: national birth cohort study using routine data’. Journal of Epidemiology and Community Health, vol 72, no 10, pp 911–8. Available at: https://pubmed.ncbi.nlm.nih.gov/29973395/ (accessed on 29 January 2021).
Kroll ME, Kurinczuk JJ, Hollowell J, et al (2020). ‘Ethnic and socioeconomic variation in cause-specific preterm infant mortality by gestational age at birth: national cohort study’. Archive of Diseases in Childhood, Fetal and Neonatal Edition, 105: F56–63. Available at: https://fn.bmj.com/content/105/1/56 (accessed on 29 January 2021).
Li Y, Quigley MA, Dattani N, Gray R, Jayaweera H, Kurinczuk J, Macfarlane A, Hollowell J (2018). ‘The contribution of gestational age, area deprivation and mother's country of birth to ethnic variations in infant mortality in England and Wales: a national cohort study using routinely collected data’. PLoS One, vol 1, no 4, art no: e0195146. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5896919/ (accessed on 29 January 2021).
Li Y, Quigley MA, Macfarlane A, Jayaweera H, Kurinczuk JJ, Hollowell J (2019). ‘Ethnic differences in singleton preterm birth in England and Wales, 2006-12: analysis of national routinely collected data’. Paediatric and Perinatal Epidemiology, vol 33, no 6, pp 449–58. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6900067/ (accessed on 29 January 2021).
Love R, Adams J, Atkin A, van Sluijs E (2019). ‘Socioeconomic and ethnic differences in children's vigorous intensity physical activity: a cross-sectional analysis of the UK Millennium Cohort Study’. BMJ Open, vol 9, no 5, art no: e027627. Available at: https://pubmed.ncbi.nlm.nih.gov/31133593/ (accessed on 29 January 2021).
Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J (2020). Health equity in England: the Marmot review 10 years on [online]. The Health Foundation website. Available at: www.health.org.uk/publications/reports/the-marmot-review-10-years-on (accessed on 29 January 2021).
MBRRACE-UK (2020). Saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18 [online]. NPEU website. Available at: www.npeu.ox.ac.uk/mbrrace-uk/reports#mbrrace-uk-saving-lives-improving-mothers-care-2020-lessons-to-inform-maternity-care-from-the-uk-and-ireland-confidential-enquiries-in-maternal-death-and-morbidity-2016-18 (accessed on 29 January 2021).
National Audit Office (2020). Childhood obesity. London: National Audit Office. Available at: www.nao.org.uk/report/childhood-obesity (accessed on 2 September 2021).
NHS Digital (2020). National Child Measurement Progamme, England 2019/20 school year. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/national-child-measurement-programme/2019-20-school-year (accessed on 2 September 2021).
NHS Digital (2022). ‘National child measurement programme, England, 2021/22 school year’. NHS Digital website. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/national-child-measurement-programme/2021-22-school-year#chapter-index (accessed on 24 April 2023).
Nightingale CM, Donin AS, Kerry SR, Owen CG, Rudnicka AR, Brage S, Westgate KL, Ekelund U, Cook DG, PH Whincup (2016). ‘Cross-sectional study of ethnic differences in physical fitness among children of South Asian, black African-Caribbean and white European origin: the Child Heart and Health Study in England (CHASE)’. BMJ Open, vol 6, art no: e011131. Available at: https://bmjopen.bmj.com/content/6/6/e011131 (accessed on 29 January 2021).
Office for Health Improvement and Disparities (2023). ‘Fingertips public health data’: Data on percentage of physically active children and young people. OHID website. Available at: https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data#page/7/gid/1000042/pat/6/par/E12000004/ati/102/are/E06000015/iid/93570/age/246/sex/4/cat/-1/ctp/-1/yrr/1/cid/4/tbm/1/page-options/ine-yo-1:2020:-1:-1_ine-pt-0_ine-ct-129 (accessed on 24 April 2023).
Office for National Statistics (2021). ‘Births and infant deaths by ethnicity in England and Wales: 2007 to 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/childhealth/articles/birthsandinfantmortalitybyethnicityinenglandandwales/2007to2019 (accessed on 2 September 2021)
Office for National Statistics (2020). ‘Child and infant mortality in England and Wales: 2018’. Office for National Statistics website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2018#inequalities (accessed on 21 January 20210.
Office for National Statistics (2023). ‘Child and infant mortality in England and Wales: 2021’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/latest (accessed on 24 April 2023).
Public Health England (2016). Infant and perinatal mortality in the West Midlands [online]. GOV.UK website. Available at: www.gov.uk/government/publications/infant-and-perinatal-mortality-in-the-west-midlands (accessed on 24 April 2023).

Cardiovascular disease

Cardiovascular disease5 (CVD) is a leading cause of death nationally and in ethnic minority groups, causing 24 per cent of all deaths in England and Wales in 2019. It is a significant contributor to inequalities in life expectancy and a risk factor for poor outcomes from Covid-19. Up to 80 per cent of premature deaths from CVD are preventable through better public health and prevention of risk factors such as obesity, inadequate physical exercise and diabetes.

Prevalence of and mortality from CVD

Studies in the UK and across the Indian diaspora (eg, Europe, Fiji, Singapore, South Africa, the US and Canada) consistently show a higher incidence, prevalence and mortality from CVD in South Asian groups compared with the white group or national average. South Asian groups have the highest mortality from heart disease and also develop heart disease at a younger age. As with heart disease, stroke incidence and mortality are also higher in the South Asian population. CVD mortality is high and rising in South Asia, in contrast to the declining trend elsewhere.

These patterns are associated with a higher clustering in South Asians of risk factors6 that increase the risk of heart disease, stroke and diabetes. Although body mass index (BMI) levels are lower among South Asian groups compared with normal ranges, rates of excess abdominal fat and insulin resistance are higher. Hence National Institute for Health and Care Excellence (NICE) guidelines specify lower BMI thresholds for use by health care professionals for introducing preventive interventions in these groups. In terms of other risk factors, although smoking prevalence is lower among South Asian groups, they have low physical activity rates, especially among women. The causes of increased CVD risk among South Asian groups are multifactorial and include physiological susceptibility, environmental determinants such as deprivation, and adverse changes to lifestyle and diet following migration.

In contrast to South Asian groups, Black groups in the UK have a significantly lower risk of heart disease compared to the majority of the population, despite having a high prevalence of hypertension and diabetes (risk factors for heart disease and stroke). Lower cholesterol levels among people of African Caribbean heritage than white Europeans may protect them against heart disease. Heart disease rates are low in sub-Saharan Africa and the Caribbean.

However, Black groups have higher-than-average incidence of and mortality from hypertension and stroke, and they have strokes at a younger age. The prevalence of hypertension, a risk factor for stroke, is high in Africa and the West Indies. Obesity levels are also higher in Black groups, with NICE guidelines specifying lower BMI thresholds for them.

Care for CVD

Recent evidence suggests that greater awareness among health care providers of the CVD risk in South Asian populations, earlier diagnosis and improved management of diabetes and CVD, together with second-generation adopting healthier lifestyles than first-generation migrants, have reduced CVD mortality risks relative to white Europeans. Research also indicates that South Asian groups have equitable access to care for heart disease and better survival rates from it. Primary care audit data shows that the Asian group compares more favourably than other ethnic groups, including white groups, .

In contrast, Black groups have lower than expected rates of access to and use of cardiovascular care. Black and Mixed ethnic groups are also less likely than other ethnic groups to be prescribed drug therapy, receive regular monitoring, or reach target treatment thresholds (eg, blood pressure within target range) on various CVD measures in primary care.

5Cardiovascular disease (CVD) is the collective term for diseases affecting the circulatory system, ie, heart, arteries, blood vessels. The main forms of CVD are heart disease and stroke.
6This clustering of risk factors is called the metabolic syndrome and includes abdominal obesity, high blood pressure, high blood sugar levels, high triglyceride (fat in the blood) levels and low HDL (the ‘good’ cholesterol) levels. It is associated with obesity, physical inactivity and insulin resistance (inability to control blood sugar levels because the body doesn’t respond properly to insulin).

References: References:
Asthana S, Moon G, Dibben C, Hewson P, Bailey T, Gibson A (2018). ‘Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature’. Health and Social Care in the Community, vol 26, no 3, pp 259–72. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/hsc.12384 (accessed on 29 January 2021).
Bansal N, Fischbacher CM, Bhopal RS, Brown H, Steiner MFC, Capewell S (2013). ‘Myocardial infarction incidence and survival by ethnic group: Scottish Health and Ethnicity Linkage retrospective cohort study’. BMJ Open, vol 3, art no: e003415. Available at: https://bmjopen.bmj.com/content/3/9/e003415 (accessed on 29 January 2021).
Ben-Shlomo Y, Naqvi H, Baker I (2008). ‘Ethnic differences in healthcare-seeking behaviour and management for acute chest pain: secondary analysis of the MINAP dataset 2002-2003’. Heart, vol 94, pp 354–9. Available at: https://heart.bmj.com/content/94/3/354 (accessed on 29 January 2021).
British Heart Foundation (2010). Ethnic differences in cardiovascular disease 2010. London: British Heart Foundation. Available at: www.bhf.org.uk/informationsupport/publications/statistics/ethnic-differences-in-cardiovascular-disease-2010 (accessed on 29 January 2021).
British Heart Foundation (undated). ‘How African-Caribbean background can affect your heart health’. BHF website. Available at: www.bhf.org.uk/informationsupport/heart-matters-magazine/medical/african-caribbean-background-and-heart-health (accessed on 29 January 2021).
Cainzos-Achirica M, Comin-Colet J, McEvoy JW, Fedeli U, Sattar N, Agyemang C, Jenum AK, Murphy JD, Brotons C, Elosua R, Bilal U, Kanaya AM, Kandula NR, Martinez-Amezcua P, Pinto X (2019). ‘Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe’. Atherosclerosis, vol 286, pp 105–13.
CardioSmart American College of Cardiology (2018). ‘South Asians face increased risk for heart disease’. News article, 14 June. Cardiosmart website. Available at: www.cardiosmart.org/news/2018/6/south-asians-face-increased-risk-for-heart-disease (accessed on 29 January 2021).
Chaturvedi N (2003). ‘Ethnic differences in cardiovascular disease’. Heart, vol 89, no 6, pp 681–6. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1767706/ (accessed on 29 January 2021).
Francis DK, Bennett NR, Ferguson TS, Hennis AJM, Wilks RJ, Harris EN, MacLeish MMY, Sullivan LW (2015). ‘Disparities in cardiovascular disease among Caribbean populations: a systematic literature review’. BMC Public Health, vol 15, p 828. Available at: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2166-7 (accessed on 29 January 2021).
Public Health England (2017). Health matters: combating high blood pressure. Blog. GOV.UK website. Available at: www.gov.uk/government/publications/health-matters-combating-high-blood-pressure/health-matters-combating-high-blood-pressure (accessed on 29 January 2021).
Gunarathne A, Patel JV, Potluri R, Gammon B, Jessani S, Hughes EA, Lip GY (2008). ‘Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project’. International Journal of Clinical Practice, vol 62, no 2, pp 197–201. Available at: https://pubmed.ncbi.nlm.nih.gov/18036165/ (accessed on 29 January 2021).
Gunarathne A, Patel JV, Gammon B, Gill PS, Hughes EA, Lip GYH (2009). ‘Ischemic stroke in South Asians: a review of the epidemiology, pathophysiology, and ethnicity-related clinical features’. Stroke, vol 40, no 6, pp e415-23. Available at: www.ahajournals.org/doi/epub/10.1161/STROKEAHA.108.535724 (accessed on 29 January 2021).
Hanif W, Susarla R (2018). ‘Diabetes and cardiovascular risk in UK South Asians: an overview’. British Journal of Cardiology, vol 25, suppl 2, pp S8–13. Available at:
https://bjcardio.co.uk/2018/09/diabetes-cvd-supplement-2-diabetes-and-cardiovascular-risk-in-uk-south-asians-an-overview/ (accessed on 29 January 2021).
Johns E, Sattar N (2017). ‘Cardiovascular and mortality risks in migrant South Asians with type 2 diabetes: are we winning the battle’? Current Diabetes Reports, vol 17, art no: 100. Available at: https://doi.org/10.1007/s11892-017-0929-5 (accessed on 29 January 2021).
Lip GYH, Barnett AH, Bradbury A, Cappuccio FP, Gill PS, Hughes E, Imray C, Jolly K, Patel K (2007). ‘Ethnicity and cardiovascular disease prevention in the United Kingdom: a practical approach to management’. Journal of Human Hypertension, vol 21, pp 183–211. Available at: www.nature.com/articles/1002126 (accessed on 29 January 2021).
McKeigue PM, Miller GJ, Marmot MG (1989). ‘Coronary heart disease in south Asians overseas: a review’. Journal of Clinical Epidemiology, vol 42, no 7, pp 597–609.
Misra A, Tandon N, Ebrahim S, Sattar N, Alam D, Shrivastava U, KM Venkat Narayan, TH Jafar (2017). ‘Diabetes, cardiovascular disease, and chronic kidney disease in South Asia: current status and future directions’. BMJ, vol 357, art no: j1420. Available at: www.bmj.com/content/357/bmj.j1420 (accessed on 29 January 2021).
Nazroo JY, Falaschetti E, Pierce M, Primatesta P (2009). ‘Ethnic inequalities in access to and outcomes of healthcare: analysis of the Health Survey for England’. Journal of Epidemiology and Community Health, vol 63, no 12, pp 1022–7. Available at: https://pubmed.ncbi.nlm.nih.gov/19622520/ (accessed on 2 September 2021).
NHS Digital (2006). ‘Health survey for England – 2004, health of ethnic minorities, main report’. NHS Digital website. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/health-survey-for-england-2004-health-of-ethnic-minorities-main-report (accessed on 29 January 2021).
Office for National Statistics (2021). ‘Ethnic differences in life expectancy and mortality from selected causes in England and Wales: 2011 to 2014’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/ethnicdifferencesinlifeexpectancyandmortalityfromselectedcausesinenglandandwales/2011to2014 (accessed on 2 September 2021).
Office for National Statistics (2021). ‘Mortality from leading causes of death by ethnic group, England and Wales: 2012 to 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/mortalityfromleadingcausesofdeathbyethnicgroupenglandandwales/2012to2019 (accessed on 2 September 2021).
National Institute for Health and Care Excellence (2013). ‘BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups’. Public health guideline [46]. NICE website. Available at: www.nice.org.uk/Guidance/PH46 (accessed on 29 January 2021).
Office for National Statistics (2020). ‘Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020’. ONS: website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/deathsoccurring2marchto28july2020 (accessed on 29 January 2021).
Office for National Statistics (2020). ‘Deaths registered in England and Wales: 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2019 (accessed on 29 January 2021).
Public Health England (2017). Public Health Outcomes Framework: health equity report [online]. GOV.UK website. Available at: www.gov.uk/government/publications/health-equity-in-england (accessed on 29 January 2021).
Rana A, de Souza RJ, Kandasamy S, Lear SA, Anand SS (2014). ‘Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis’. CMAJ Open, vol 2, no 3, pp E183–91. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4183167/ (accessed on 29 January 2021).
Singh V, Prabhakaran S, Chaturvedi S, Singhal A, Pandian J (2017). ‘An examination of stroke risk and burden in South Asians’. Journal of Stroke and Cerebrovascular Diseases, vol 26, no 10, pp 2145–53.
Stroke Association (undated). Stroke and South Asian people. Stroke Association website. Available at:
www.stroke.org.uk/what-is-stroke/are-you-at-risk-of-stroke/stroke-and-south-asian-people (accessed on 1 February 2021).
Stroke Association (2018). State of the nation: stroke statistics [online]. Stroke Association website. Available at: www.stroke.org.uk/sites/default/files/state_of_the_nation_2018.pdf (accessed on 1 February 2021).
Theuri C (2016). ‘WHO: Africa has the highest rate of blood pressure in the world’. Face-2-Face website. Available at: https://face2faceafrica.com/article/africa-highest-rate-high-blood-pressure-world (accessed on 2 September 2021).
Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, Khandelwal A, Krishnan AV, Lichtman JH, Mehta LS, Patel HN, Shah KS, SH Shah, Watson KE (2018). ‘Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association’. Circulation, vol 138, no 1, pp e1-e34. Available at: www.ahajournals.org/doi/full/10.1161/cir.0000000000000580 (accessed on 1 February 2021).
Wild S, Mckeigue P (1997). ’Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92’. BMJ, vol 314, pp 705. Available at: www.bmj.com/content/314/7082/705 (accessed on 1 February 2021).
Wild SH, Fischbacher C, Brock A, Griffiths C, Bhopal R (2007). ‘Mortality from all causes and circulatory disease by country of birth in England and Wales 2001–2003’. Journal of Public Health, vol 29, no 2, pp 191–8. Available at: https://academic.oup.com/jpubhealth/article/29/2/191/1505208 (accessed on 1 February 2021).
Yusuf S, Reddy S, Ôunpuu S, Anand S (2001). ‘Global burden of cardiovascular diseases, part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies’. Circulation, vol 104, no 23, pp 2855–64. Available at: www.ahajournals.org/doi/epub/10.1161/hc4701.099488 (accessed on 1 February 2021).
Zaman MJS, Philipson P, Chen R, Farag A, Shipley M, Marmot MG, Timmis AD, Hemingway H (2013). ‘South Asians and coronary disease: is there discordance between effects on incidence and prognosis?' Heart, vol 99, pp 729–36. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3960593/ (accessed on 1 February 2021).

Diabetes

Diabetes7 is a long-term condition that can cause serious secondary complications and premature death if it is not well managed. This explainer considers type 2 diabetes. Being overweight, abdominal obesity and physical inactivity are risk factors for diabetes. The prevalence of diabetes is higher among South Asian and Black groups than in the white population and people in these groups develop the condition at a younger age.

Prevalence of and mortality from diabetes

The risk of developing diabetes is up to six times higher in South Asian groups than in white groups and South Asian groups have higher mortality from diabetes. About 400,000 people of South Asian ethnicity in the UK have diabetes, one-fifth of the UK diabetes population. High diabetes prevalence is seen also in their countries of origin and across the South Asian diaspora worldwide, eg, in Europe, the US, Canada, the Caribbean, South Africa, Fiji. South Asians with diabetes have a higher risk of developing secondary complications of cardiovascular and end-stage renal disease. However, recent studies show that excess CVD mortality in South Asians with diabetes has reduced and overall mortality is lower than in the white group.

Explanations for the high prevalence of diabetes among South Asian groups include a mix of biological, lifestyle and socio-economic factors. As with CVD, these patterns are associated with a clustering in South Asians of risk factors (see footnote 3) that increase the risk of diabetes, exacerbated by socio-economic disadvantage and changing lifestyles after migration. Even though South Asians typically have a low BMI, excess abdominal fat increases the risk of diabetes and CVD. Accordingly, NICE, the World Health Organization and several national diabetes associations recommend lower BMI thresholds for introducing preventive measures in South Asians with diabetes.

Diabetes prevalence in Black groups is up to three times higher than in the white population and they have higher mortality from diabetes; they also have a higher risk of hypertension and stroke but, unlike South Asians, are less prone to heart disease. The physiological pathways and impacts of diabetes therefore differ between ethnic minority groups. Diabetes-related co-morbidities in Black groups are similar to or lower than in white groups, except for higher rates of end-stage renal disease. Like South Asians, excess mortality associated with diabetes is lower in Blacks groups than in the white population.

Care for diabetes

One study found improved diabetes outcomes in South Asians are attributable, in part, to earlier diagnosis and risk factor management, indicating increased awareness among health care providers, equity of access and standardisation of care for long-term conditions incentivised in the Quality and Outcomes Framework for GPs. It also found little evidence of inequalities in the management of diabetes among Black patients at initial diagnosis, indicative of a wider trend of shrinking inequalities in diabetes care.

However, it is also reported that although diabetes treatment was initiated earlier in South Asian and Black groups than in white groups, they were slower to receive subsequent longer-term treatment which can contribute to worse outcomes.

7Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high. It can lead to serious secondary complications. There are two types of diabetes: type 1 diabetes when the body makes no insulin at all, and type 2 diabetes when the body doesn’t produce enough insulin or when it doesn’t react to the insulin. Some women can develop gestational diabetes during pregnancy. About 90 per cent of people with diabetes have type-2 diabetes, which is potentially preventable. This section relates to type 2 diabetes only.

References: Notes:
7. Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high. It can lead to serious secondary complications. There are two types of diabetes: type-1 diabetes when the body makes no insulin at all, and type-2 diabetes when the body doesn’t produce enough insulin or when it doesn’t react to the insulin. Some women can develop gestational diabetes during pregnancy. About 90 per cent of people with diabetes have type-2 diabetes, which is potentially preventable.
References:
Adjah ESO, Bellary S, Hanif W, Patel K, Khunti K, Paul SK (2018). ‘Prevalence and incidence of complications at diagnosis of T2DM and during follow-up by BMI and ethnicity: a matched case-control analysis’. Cardiovascular Diabetology, vol 17, no 1, pp 70. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5952414/ (accessed on 2 September 2021).
British Heart Foundation (undated). ‘Ethnicity’. BHF website. Available at: www.bhf.org.uk/informationsupport/risk-factors/ethnicity (accessed on 1 February 2021).
Cainzos-Achirica M, Comin-Colet J, McEvoy JW, Fedeli U, Sattar N, Agyemang C, Jenum AK, Murphy JD, Brotons C, Elosua R, Bilal U, Kanaya AM, Kandula NR, Martinez-Amezcua P, Pinto X (2019). ‘Epidemiology, risk factors, and opportunities for prevention of cardiovascular disease in individuals of South Asian ethnicity living in Europe’. Atherosclerosis, vol 286, pp 105–13.
Davis TME (2008). ‘Ethnic diversity in type 2 diabetes’. Diabetic Medicine, vol 25, suppl 2, pp 52–6. Available at: https://pubmed.ncbi.nlm.nih.gov/18717980/ (accessed on 1 February 2021).
Davis TME, Coleman RL, Holman RR; UKPDS Group (2014). ‘Ethnicity and long-term vascular outcomes in type 2 diabetes: a prospective observational study (UKPDS 83)’. Diabetic Medicine, vol 31, no 2, pp 200–7. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.12353 (accessed on 1 February 2021).
Goff L M (2019). ‘Ethnicity and type 2 diabetes in the UK’. Diabetic Medicine, vol 36, no 8, pp 927–38. Available at: https://doi.org/10.1111/dme.13895 (accessed on 1 February 2021).
Gujral UP, Pradeepa R, Weber MB, Narayan KMV, Mohan V (2013). ‘Type 2 diabetes in South Asians: similarities and differences with white Caucasian and other populations’. Annals of the New York Academy of Sciences, vol 1281, pp 51–63. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3715105/ (accessed on 1 February 2021).
Hanif W, Susarla R (2018). ‘Diabetes and cardiovascular risk in UK South Asians: an overview’. British Journal of Cardiology, vol 25, suppl 2, pp s8–13. Available at:
https://bjcardio.co.uk/2018/09/diabetes-cvd-supplement-2-diabetes-and-cardiovascular-risk-in-uk-south-asians-an-overview/ (accessed on 1 February 2021).
Jenum AK, Brekke I, Mdala I, Muilwijk M, Ramachandran A, Kjøllesdal M, Andersen E, Richardsen KR, Douglas A, Cezard G, Sheikh A, Celis-Morales CA, Gill JMR, Sattar N, Bhopal RS, Beune E, Stronks K, Vandvik PO, Valkengoed IGM (2019). ‘Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials’. Diabetologia, vol 62, no 8, pp 1337–48. Available at: https://link.springer.com/article/10.1007%2Fs00125-019-4905-2 (accessed on 1 February 2021).
Johns E, Sattar N (2017). ‘Cardiovascular and mortality risks in migrant South Asians with type 2 diabetes: are we winning the battle?’. Current Diabetes Reports, vol 17, no 100. Available at: https://doi.org/10.1007/s11892-017-0929-5 (accessed on 1 February 2021).
Lanting LC, Joung IMA, Mackenbach JP, Lamberts SWJ, Bootsma AH (2005). ‘Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients’. Diabetes Care, vol 28, no 9, pp 2280–8. Available at: https://care.diabetesjournals.org/content/28/9/2280 (accessed on 1 February 2021).
Mathur R, Palla L, Farmer RE, Chaturvedi N, Smeeth L (2020). ‘Ethnic differences in the severity and clinical management of type 2 diabetes at time of diagnosis: a cohort study in the UK Clinical Practice Research Datalink’. Diabetes Research and Clinical Practice, no 160. Available at: https://pubmed.ncbi.nlm.nih.gov/31923438/ (accessed on 1 February 2021).
Meeks KA, Freitas-Da-Silva D, Adeyemo A, Beune EJ, Modesti PA, Stronks K, Zafarmand MH, Agyemang C (2016). ‘Disparities in type 2 diabetes prevalence among ethnic minority groups resident in Europe: a systematic review and meta-analysis’. Internal and Emergency Medicine, vol 11, no 3, pp 327–40. Available at: https://pubmed.ncbi.nlm.nih.gov/26370238/ (accessed on 1 February 2021).
National Institute for Health and Care Excellence. (2013). BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups [online]. Public health guideline [46]. London: NICE. Available at: www.nice.org.uk/Guidance/PH46 (accessed on 1 February 2021).
NHS Digital (2019). ‘National diabetes audit 2017-18 report 2b, complications and mortality’. NHS Digital website. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-audit/report-2--complications-and-mortality-2017-18 (accessed on 1 February 2021).
Office for National Statistics (2021). ‘Ethnic differences in life expectancy and mortality from selected causes in England and Wales: 2011 to 2014’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/ethnicdifferencesinlifeexpectancyandmortalityfromselectedcausesinenglandandwales/2011to2014 (accessed on 2 September 2021).
Office for National Statistics (2021). ‘Mortality from leading causes of death by ethnic group, England and Wales: 2012 to 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/mortalityfromleadingcausesofdeathbyethnicgroupenglandandwales/2012to2019 (accessed on 2 September 2021).
Oldroyd J, Banerjee M, Heald A, Cruickshank K (2005). ‘Diabetes and ethnic minorities’. Postgraduate Medical Journal, vol 81, pp 486–90. Available at: https://pmj.bmj.com/content/81/958/486 (accessed on 1 February 2021).
Office for National Statistics (2020). ‘Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/deathsoccurring2marchto28july2020 (accessed on 1 February 2021).
Pham T M, Carpenter JR, Morris TP, Sharma M, Petersen I (2019). ‘Ethnic differences in the prevalence of type 2 diabetes diagnoses in the UK: cross-sectional analysis of the health improvement network primary care database. Clinical epidemiology, vol 11, pp 1081–8. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC6948201/ (accessed on 1 February 2021).
Piccolo RS, Subramanian SV, Pearce N, Florez JC, McKinlay JB (2016). ‘Relative contributions of socioeconomic, local environmental, psychosocial, lifestyle/behavioral, biophysiological, and ancestral factors to racial/ethnic disparities in type 2 diabetes’. Diabetes Care, vol 39, pp 1208–17. Available at: https://care.diabetesjournals.org/content/39/7/1208 (accessed on 1 February 2021).
Rana A, de Souza RJ, Kandasamy S, Lear SA, Anand SS (2014). ‘Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis’. CMAJ Open, vol 2, no 3, e183–91. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4183167/ (accessed on 1 February 2021).
Sattar N, Gill JMR (2015). ‘Type 2 diabetes in migrant South Asians: mechanisms, mitigation, and management’. Lancet, Diabetes & Endocrinology, vol 3, no 12, pp 1004–16. Available at:
www.thelancet.com/journals/landia/article/PIIS2213-8587(15)00326-5/fulltext (accessed on 1 February 2021).
Shah AD, Vittinghoff E, Kandula NR, Srivastava S, Kanaya AM (2015). ‘Correlates of pre-diabetes and type 2 diabetes in US South Asians: findings from the mediators of atherosclerosis in South Asians living in America (MASALA) study’. Annals of Epidemiology, vol 25, no 2, pp 77–83. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4306623/ (accessed on 1 February 2021).
Tillin T, Hughes AD, Godsland IF, Whincup P, Forouhi NG, Welsh P, Sattar N, McKeigue PM, Chaturvedi N (2013). ‘Insulin resistance and truncal obesity as important determinants of the greater incidence of diabetes in Indian Asians and African Caribbeans compared with Europeans’. Diabetes Care, vol 36, no 2, pp 383–93. Available at: https://doi.org/10.2337/dc12-0544 (accessed on 1 February 2021).
Wright AK, Kontopantelis E, Emsley R, Sattar N, Rutter MK, Ashcroft DM (2017). ‘Life expectancy and cause-specific mortality in type 2 diabetes: a population-based cohort study quantifying relationships in ethnic subgroups’. Diabetes Care, vol 40, pp 338–45. Available at: https://doi.org/10.2337/dc16-1616 (accessed on 1 February 2021).

Cancer

Cancer incidence

The incidence of cancer overall is generally lower among ethnic minority groups in England than in white groups. Asian, Chinese and Mixed groups have a significantly lower risk (of 20–60 per cent) of getting cancer than the white group; smoking rates are generally lower in these groups. Cancer incidence is also lower among Black women compared with white women but similar in Black and white men.

In terms of specific cancers, Asian groups have a higher incidence than the white group of cancer of the liver and mouth (females only), and a lower risk of the four major cancers (breast, prostate, lung, colorectal) and several less common cancers.

Black groups have a significantly lower incidence of three major cancers (breast, lung and colorectal) and several less-common cancers. However, the incidence of and mortality from prostate cancer is significantly higher among Black males than white males. Black men in Africa, the Caribbean and the US are also at greater risk of prostate cancer for reasons that are unclear.

Although lower breast cancer incidence in Asian and Black women is associated with a lower risk profile (such as lower alcohol consumption, breastfeeding, childbearing), cultural assimilation over time can lead to changes in health behaviours. Some evidence suggests cancer rates in South Asian groups are converging towards those in the white population.

Cancer screening

Screening is an important part of efforts to reduce cancer mortality. Screening rates for breast and cervical cancer are lower among women from ethnic minority groups, particularly South Asians. South Asians also have lower rates of bowel cancer screening.

Poorer awareness of risk factors for cancer and symptoms, and socio-cultural and practical barriers such as language, contribute to lower cancer screening rates among ethnic minority groups.

Stage at diagnosis

The stage at which cancer is diagnosed can have an impact on treatment outcomes and mortality. It may be related to a patient’s route to diagnosis, including through screening. Although data for 2012–13 showed the Black Caribbean group was more likely than White British to be diagnosed late for some cancers, 2017 data shows the proportion of early-stage cancer diagnoses among Asian and Black groups (55 per cent) was similar to the white group (52 per cent). Research has also found weak evidence of ethnic inequalities in times to cancer diagnosis and staging.

Cancer mortality

Cancer mortality rates measure cancer deaths in relation to population size, and reflect both cancer incidence (ie, the numbers who develop cancer) and the deaths from it. Overall cancer mortality rates are lower among ethnic minority groups compared with white groups. However, lung cancer mortality is higher among Bangladeshi males and prostate cancer mortality is higher among Black males.

Cancer survival measures the proportion of people with cancer who survive, and reflects many factors including deprivation, stage at diagnosis and quality of care. Cancer survival in ethnic minority groups is reported to be similar to the white population.

References: Anderson B, Marshall-Lucette S (2016). ‘Prostate cancer among Jamaican men: exploring the evidence for higher risk’. British Journal of Nursing, vol 25, no 19, pp 1046–51.
Bansal N, Bhopal RS, Steiner MFC, Brewster DH (2011). ‘Major ethnic group differences in breast cancer screening uptake in Scotland are not extinguished by adjustment for indices of geographical residence, area deprivation, long-term illness and education’. British Journal of Cancer, vol 106, pp 1361–66. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3326672/ (accessed on 1 February 2021).
Cancer Research UK. ‘Cancer incidence by ethnicity’. Cancer Research UK website. Available at: www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/ethnicity (accessed on 1 February 2021).
Chan DNS, So WKW (2017). ‘A systematic review of the factors influencing ethnic minority women’s cervical cancer screening behavior’. Cancer Nursing, vol 40, no 6, pp e1–30, Available at: doi: 10.1097/NCC.0000000000000436. Available at: https://journals.lww.com/cancernursingonline/Fulltext/2017/11000/A_Systematic_Review_of_the_Factors_Influencing.13.aspx (accessed on 1 February 2021).
Fasil Q (2018). Cancer and black and minority ethnic communities [online]. Race Equality Foundation website. Available at: https://raceequalityfoundation.org.uk/health-care/cancer-and-black-and-minority-ethnic-communities/ (accessed on 1 February 2021).
Gathani T, Ali R, Balkwill A, Green J, Reeves G, Beral V, Moser KA (2014). ‘Ethnic differences in breast cancer incidence in England are due to differences in known risk factors for the disease: prospective study’. British Journal of Cancer, vol 110, no 1, pp 224–9. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3887283/ (accessed on 1 February 2021).
Harding S, Rosato M, Teyhan A (2009). ‘Trends in cancer mortality among migrants in England and Wales, 1979-2003’. European Journal of Cancer, vol 45, no 12, pp 2168–79. Available at: https://pubmed.ncbi.nlm.nih.gov/19349162/ (accessed on 1 February 2021).
Jack RH, Møller H, Robson T, Davies EA (2014). ‘Breast cancer screening uptake among women from different ethnic groups in London: a population-based cohort study’.
BMJ Open, vol 4, no 10, art no: e005586. Available at: https://bmjopen.bmj.com/content/4/10/e005586 (accessed on 1 February 2021).
Jones ALC, Chinegwundoh F (2014). Update on prostate cancer in black men within the UK. ecancer, vol 8, art no: 455. Available at: https://ecancer.org/en/journal/article/455-update-on-prostate-cancer-in-black-men-within-the-uk (accessed on 1 February 2021).
Jones CE, Maben J, Jack RH, Davies EA, Forbes LJ, Lucas G, Ream E (2014). ‘A systematic review of barriers to early presentation and diagnosis with breast cancer among black women’. BMJ Open, vol 4, no 2, art no: e004076. Available at: https://pubmed.ncbi.nlm.nih.gov/24523424/ (accessed on 1 February 2021).
Maringe C, Li R, Mangtani P, Coleman MP, Rachet B (2015). ‘Cancer survival differences between South Asians and non-South Asians of England in 1986-2004, accounting for age at diagnosis and deprivation’. British Journal of Cancer, vol 113, pp 173–81. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4647525/ (accessed on 1 February 2021).
Marlow LAV, Wardle J, Waller J (2015). ‘Understanding cervical screening non-attendance among ethnic minority women in England’. British Journal of Cancer, vol 113, pp 833–9. Available at: https://pubmed.ncbi.nlm.nih.gov/26171938/ (accessed on 1 February 2021).
Martins T, Hamilton W, Ukoumunne OC (2013). ‘Ethnic inequalities in time to diagnosis of cancer: a systematic review’. BMC Family Practice, vol 14, art no: 197. Available at: https://doi.org/10.1186/1471-2296-14-197 (accessed on 1 February 2021).
McAllister BJ (2019). ‘The association between ethnic background and prostate cancer’. British Journal of Nursing, vol 28, no 18, pp s4–10.
Morris M, Woods L, Rogers N, O’Sullivan E, Kearins O, Rachet B (2015). ‘Ethnicity, deprivation and screening: survival from breast cancer among screening-eligible women in the West Midlands diagnosed from 1989 to 2011’. British Journal of Cancer, vol 113, pp 548–55. Available at: https://doi.org/10.1038/bjc.2015.204 (accessed on 1 February 2021).
National Cancer Intelligence Network (NCIN) (2011). ‘Ethnicity and lung cancer’. National Cancer Registration and Analysis Service website. Available at: www.ncin.org.uk/publications/data_briefings/ethnicity_and_lung_cancer (accessed on 1 February 2021).
National Cancer Intelligence Network (NCIN) (2009). Cancer incidence and survival by major ethnic group, England, 2002-2006. London: NCIN.
Niksic M, Rachet B, Warburton FG, Forbes LJL (2016). ‘Ethnic differences in cancer symptom awareness and barriers to seeking medical help in England’. British Journal of Cancer, vol 115, pp 136–44. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4931374/ (accessed on 1 February 2021).
Nimako K, Gunapala R, Popat S, O’brien MER (2013). ‘Patient factors, health care factors and survival from lung cancer according to ethnic group in the south of London, UK’. European Journal of Cancer Care, vol 22, no 1, pp 79–87.
Office for National Statistics (2021). ‘Ethnic differences in life expectancy and mortality from selected causes in England and Wales: 2011 to 2014’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/ethnicdifferencesinlifeexpectancyandmortalityfromselectedcausesinenglandandwales/2011to2014 (accessed on 2 September 2021).
Office for National Statistics (2021). ‘Mortality from leading causes of death by ethnic group, England and Wales: 2012 to 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/mortalityfromleadingcausesofdeathbyethnicgroupenglandandwales/2012to2019 (accessed on 2 September 2021).
Office for National Statistics (2020). ‘Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/deathsoccurring2marchto28july2020 (Accessed on 1 February 2021).
Price CL, Szczepura AK, Gumber AK, Patnick J (2010). ‘Comparison of breast and bowel cancer screening uptake patterns in a common cohort of South Asian women in England’. BMC Health Services Research, vol 10, art no: 103. Available at: https://pubmed.ncbi.nlm.nih.gov/20423467/ (accessed on 1 February 2021).
Public Health England (2019). ‘Early cancer diagnosis’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/physical-health/cancer-diagnosis-at-an-early-stage/latest#data-sources (accessed on 1 February 2021).
Public Health England (2018). Local action on health inequalities: understanding and reducing ethnic inequalities in health [online]. GOV.UK website. Available at:
www.gov.uk/government/publications/health-inequalities-reducing-ethnic-inequalities (accessed on 1 February 2021).
Public Health England (2018). Variation in cancer incidence by ethnicity across London in 2015. London: Public Health England.
Public Health England (2017). Public Health Outcomes Framework: health equity report - focus on ethnicity [online]. GOV.UK website. Available at: www.gov.uk/government/publications/health-equity-in-england (accessed on 1 February 2021).
Public Health England (2016). Ethnicity and stage at diagnosis [online]. NCIN website. Available at: www.ncin.org.uk/view?rid=3286 (accessed on 1 February 2021).
Public Health England (2015). Cancer and equality groups: key metrics, 2015 report. National Cancer Research and Advisory Service website. Available at:
www.ncin.org.uk/cancer_type_and_topic_specific_work/topic_specific_work/equality (accessed on 1 February 2021).
Renshaw C, Jack RH, Dixon S, Møller H, Davies EA (2010). ‘Estimating attendance for breast cancer screening in ethnic groups in London’. BMC Public Health, vol 10, art no: 157. Available at: https://pubmed.ncbi.nlm.nih.gov/20334699/ (accessed on 1 February 2021).
Szczepura A, Price C, Gumber A. ‘Breast and bowel cancer screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics’. BMC Public Health, vol 8, art no: 346. Available at: https://pubmed.ncbi.nlm.nih.gov/18831751/ (accessed on 1 February 2021).
Wallace M, Kulu H (2015). ‘Mortality among immigrants in England and Wales by major causes of death, 1971-2012: a longitudinal analysis of register-based data’. Social Science and Medicine, no 147, pp 209–21. Available at: https://pubmed.ncbi.nlm.nih.gov/26595089/ (accessed on 2 September 2021).
Wild S, Mckeigue P (1997). ’Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92’. BMJ, vol 314, pp 705. Available at: www.bmj.com/content/314/7082/705 (accessed on 1 February 2021).
Wild SH, Fischbacher CM, Brock A, Griffiths C, Bhopal R (2006). ‘Mortality from all cancers and lung, colorectal, breast and prostate cancer by country of birth in England and Wales, 2001–2003’. British Journal of Cancer, vol 94, pp 1079–85.

Covid-19

The Covid-19 pandemic had a disproportionate effect on ethnic minority groups, with Black, Asian and most other ethnic minority groups more likely to be diagnosed with Covid-19, become severely ill and die compared to the white population. Several factors contributed to these patterns.

Outcomes of Covid-19

Exposure to infection was higher among ethnic minority groups because, for example, they are more likely to work in public-facing jobs such as transport and health and social care, use public transport, and live in high-density housing, multi-generation households and urban areas where transmission is higher. People from South Asian and Black groups also have a higher prevalence of obesity and long-term conditions such as CVD, hypertension and diabetes, which increase the risk of adverse outcomes and death from Covid-19.

In the early stages of the pandemic when Covid-19 mortality was at its highest, most ethnic minority groups had significantly higher Covid-19 mortality rates than the White British group, explained in large part by ethnic differences in factors such as location, occupation, deprivation, household arrangements, pre-existing health conditions and vaccination status. Covid-19 mortality rates declined in all ethnic groups over the course of the pandemic, and by 2022 rates in ethnic minority groups were no longer higher than in the White British group. The reduction of ethnic differences in mortality risks points to the mitigating effects of public health measures including vaccination. Over the 2020–22 pandemic period as a whole, Covid-19 mortality rates were highest among Pakistani and Bangladeshi groups.

References: References:
Amnesty International (2020). Exposed, silenced, attacked: failures to protect health and essential workers during the COVID-19 pandemic [online]. Amnesty International website. Available at: www.amnesty.org/en/documents/pol40/2572/2020/en/ (Accessed on 1 February 2021).
Ayoubkhani D, Nafilyan V, White C, Goldblatt P, Gaughan C, Blackwell L, Rogers N, Banerjee A. Khunti K, Glickman M, Humberstone B, Diamond I (2021). ‘Ethnic minority groups in England and Wales - factors affecting the size and timing of elevated Covid-19 mortality: a retrospective cohort study linking Census and death records’. International Journal of Epidemiology, vol 49, no 6, pp 1951–62. Available at: https://doi.org/10.1093/ije/dyaa208 (accessed on 11 February 2020).
Bhaskaran K, Bacon S, Evans SJW, Bates CJ, Rentsch CT, MacKenna B, Tomlinson L, Walker AJ, Schultze A, Morton CE, Grint D, Mehrkar A, Eggo RM, Inglesby P, Douglas IJ, McDonald HI, Cockburn JC, Williamson EJ, Evans D, Curtis HJ, Hulme WJ, Parry J, Hester F, Harper S, Spiegelhalter D, Smeeth L, Goldacre B (2021). ‘Factors associated with deaths due to Covid-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform’. Lancet Reg Health Eur, no 6 art no 100109. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC8106239/ (accessed on 2 September 2021).
Cook T, Kursumovic E, Lennane S (2020). ‘Exclusive: deaths of NHS staff from covid-19 analysed’. HSJ website, 22 April. Available at: www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article (accessed on 1 February 2021).
Ghosh P (2020). ‘Covid studies to examine virus link with ethnicity’. BBC News website. Available at: www.bbc.co.uk/news/health-53565655?fbclid=IwAR1XXN3qBO2hoHiehjrMnuURrHwtN8gpMoD4QHXkmJ3aHqbWGMw3kxcUKss (accessed on 1 February 2021).
Haque Z, Becares L, Treloar N (2020). Over-exposed and under-protected the devastating impact of COVID-19 on black and minority ethnic communities in Great Britain [online]. Runnymede Trust website. Available at: www.runnymedetrust.org/projects-and-publications/employment-3/overexposed-and-underprotected-covid-19s-impact-on-bme-communities.html (accessed on 1 February 2021).
House of Commons Women’s and Equalities Committee (2020). Third report: Unequal impact? coronavirus and BAME people [online]. UK parliament website. Available at:
https://committees.parliament.uk/work/318/unequal-impact-coronavirus-and-bame-people/publications (accessed on 1 February 2021).
Independent Scientific Advisory Group on Emergencies (2020). Disparities in the impact of Covid-19 in black and minority ethnic populations: review of the evidence and recommendations for action [online]. Indie_SAGE website. Available at:
www.independentsage.org/disparities_bme_final_jul2020/ (accessed on 1 February 2021).
Khunti K, Platt L, Routen A, Abbas K (2020). ‘Covid-19 and ethnic minorities: an urgent agenda for overdue action’. BMJ, vol 369, art no: m2503. Available at: http://dx.doi.org/10.1136/bmj.m2503 (accessed on 1 February 2021).
Lassale C, Gaye B, Hamer M, Gale CR, Batty GD (2020). ‘Ethnic disparities in hospitalisation for Covid-19 in England: the role of socioeconomic factors, mental health, and inflammatory and pro-inflammatory factors in a community-based cohort study’. Brain, Behavior, and Immunity, vol 88, pp 44 –9. Available at: https://pubmed.ncbi.nlm.nih.gov/32497776/ (accessed on 1 February 2021).
Lawrence D (2020). An avoidable crisis: the disproportionate impact of Covid-19 on Black, Asian and minority ethnic communities: a review [online]. Lawrence Review website. Available at: www.lawrencereview.co.uk/ (accessed on 1 February 2021).
Lewis K (2020). ‘What do we know about Covid-19 inequalities among people from minority ethnic groups?’ Full fact website. Available at: https://fullfact.org/health/Covid-19-inequalities-minority-ethnicities/ (accessed on 1 February 2021).
Marmot M, Allen J, Goldblatt P, Herd E, Morrison J (2020). Build back fairer: the Covid-19 Marmot review. London: The Health Foundation and Institute of Health Equity. Available at:
www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review (Accessed on 1 February 2021).
Mathur R, Rentsch CT, Morton CE, Hulme WJ, Schultze A, MacKenna B, Eggo RM, Bhaskaran K, Wong AYS, Williamson EJ, Forbes H, Wing K, McDonald HI, Bates C, Bacon S, Walker AJ, Evans D, lesby P, Mehrkar A, Curtis HJ, DeVito NJ, Croker R, Drysdale H, Cockburn J, Parry J, Hester F, Harper S, Douglas IJ, Tomlinson L, Evans SJW, Grieve R, Harrison D, Rowan K, Khunti K, Chaturvedi N, Smeeth L, Goldacre B (2021). ‘Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform’. The Lancet, no 397, pp 1711–24. Available at: www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00634-6/fulltext (accessed on 2 September 2021).
Nafilyan V, Islam N, Mathur R, Ayoubkhani D, Banerjee A, Glickman M, Humberstone B, Diamond I, Khunti K (2021). ‘Ethnic differences in Covid-19 mortality during the first two waves of the coronavirus pandemic: a nationwide cohort study of 29 million adults in England’. medRxiv website. Available at: https://www.medrxiv.org/content/10.1101/2021.02.03.21251004v1 (accessed on 11 February 2021).
Office for National Statistics (2021). ‘Updating ethnic contrasts in deaths involving the coronavirus, England: 24 January 2020 to 31 March 2021’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/24january2020to31march2021 (accessed on 2 September 2021).
Office for National Statistics (2020). ‘Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020’. ONS website. Available at: www.ons.gov.uk/releases/explainingethnicbackgroundcontrastsindeathsinvolvingcovid19england2ndmarchto3rdjuly2020 (accessed on 1 February 2021).
Pan D, Szec S, Minhas JS, Bangash MN, Pareek N, Divall P, Williams CML, Oggioni MR, Squire IB, Nellums LB, Hanif W, Khunti K, Pareek M. ‘The impact of ethnicity on clinical outcomes in COVID-19: a systematic review’. Lancet EClinical Medicine, vol 23, art no: 100404. Available at: www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30148-6/fulltext (accessed on 1 February 2021).
Platt L, Warwick R (2020). Are some ethnic groups more vulnerable to COVID-9 than others? [online]. Institute for Fiscal Studies website. Available at: www.ifs.org.uk/inequality/chapter/are-some-ethnic-groups-more-vulnerable-to-covid-19-than-others/ (accessed on 1 February 2021).
Public Health England (2020). Analysis of the relationship between pre-existing health conditions, ethnicity and COVID-19 [online]. GOV.UK website. Available at:
www.gov.uk/government/publications/covid-19-pre-existing-health-conditions-and-ethnicity (accessed on 1 February 2021).
Public Health England (2020). Beyond the data: understanding the impact of COVID-19 on BAME groups [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (accessed on 29 January 2021).
Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).
Race Disparity Unit, Cabinet Office (2020). Quarterly report on progress to address COVID-19 health inequalities [online]. GOV.UK website. Available at: www.gov.uk/government/publications/quarterly-report-on-progress-to-address-covid-19-health-inequalities (accessed on 29 January 2021).
Raisi-Estabragh Z, McCracken C, Bethell MS, Cooper J, Cooper C, Caulfield MJ, Munroe PB, Harvey NC, Petersen SE (2020). ‘Greater risk of severe Covid-19 in Black, Asian and minority ethnic populations is not explained by cardiometabolic, socioeconomic or behavioural factors, or by 25(OH)-vitamin D status: study of 1326 cases from the UK Biobank’. Journal of Public Health, vol 2, no 3, pp 451–60. Available at: https://pubmed.ncbi.nlm.nih.gov/32556213/ (accessed on 1 February 2021).
Scientific Advisory Group for Emergencies – Ethnicity Sub-Group (SAGE) (2020). Drivers of the higher Covid-19 incidence, morbidity and mortality among minority ethnic groups, 23 September 2020 [online]. Available at: www.gov.uk/government/publications/drivers-of-the-higher-covid-19-incidence-morbidity-and-mortality-among-minority-ethnic-groups-23-september-2020 (accessed on 1 February 2021).
Vepa A, Bae JP, Ahmed F, Pareek M, Khunti K (2020). ‘Covid-19 and ethnicity: a novel pathophysiological role for inflammation’. Diabetes and Metabolic Syndrome, vol 14, no 5, pp 1043 –51. Available at: https://pubmed.ncbi.nlm.nih.gov/32640416/ (accessed on 1 February 2021).

Determinants of health

Here we examine ethnic differences in some key determinants of health, namely behavioural risk factors, access to health care services, and socio-economic factors.

Selected behavioural risk factors

Smoking, high alcohol consumption, physical inactivity and a poor diet are principal behavioural risks to health; the latter two also cause obesity. Their prevalence varies across the population, although they tend to cluster in more deprived communities.

Smoking

Smoking prevalence is lower in most ethnic minority groups than in the white group, and highest in the Mixed group (see Figure 2).

Figure 2, per cent of people aged 18 years and over who smoke: England 2021

Alcohol consumption

Adults in ethnic minority groups are less likely to drink alcohol at a hazardous, harmful or dependent level compared to white groups (see Figure 3).

Figure 3, per cent of people aged 16 and over who drink at hazardous, harmful or dependent levels, England 2014

Physical activity

Physical activity levels differ between ethnic groups and genders. People from Asian and Black groups, and women in particular, are most likely to report being physically inactive and least likely to report being active (see Figures 4a and b).

Figure 4, per cent of people aged 16 years and over who were physically active: England, 2020-21

Healthy eating

The proportion of people eating recommended portions of fruit or vegetables per day is lower in ethnic minority groups than in white groups (see Figure 5).

Figure 5, per cent of people aged 16 years and over who eat five portions of fruit or vegetables a day in England, 2018-20

Obesity

Compared with the White British group, the proportion of people who are overweight or obese is higher in Black adults and lower among most other minority groups (see Figure 6).

Figure 6, per cent of people aged 18 years and over who were overweight or obese: England, 2020-21

Access to services and patient experience

Free, universal access to health care and standardised treatment protocols have improved equity of access and outcomes across ethnic groups, especially in primary care, but less consistently across other health services. Patients from some ethnic minority groups report a poorer experience of using some health care services than the White British group. However, the patterns differ between ethnic groups and services, with no ethnic differences, from some ethnic minority groups compared with the white group, in some NHS patient surveys.

As we have shown, there are different patterns of health across different ethnic groups. Moreover, ethnic minority communities experience a higher burden of some conditions that are potentially preventable. For example, much of the excess morbidity and mortality from CVD and diabetes among Asian and Black groups is associated with modifiable risk factors. Prevention should therefore be a priority for public health and health care services. Low health literacy, potentially exacerbated by language barriers, can lead to unhealthy behaviours and poorer uptake of preventive services. Modes of disease presentation and therapeutic needs may also differ by ethnicity.

Health care services therefore need to be aware of the specific health care needs, risk factors and treatment requirements in different communities and ensure services are culturally tailored to promote adherence. For example, the incidence of diabetes among ethnic minority groups can be moderated through dietary and physical activity modifications, and culturally tailored diabetes programmes are effective at improving outcomes. Research shows that culturally adapted interventions can improve participation in cancer screening.

Socio-economic inequalities

There is a strong, systemic relationship between health and deprivation, with more deprived communities experiencing worse health and a shorter life-expectancy than less deprived groups. Deprivation levels are higher among most ethnic minority groups and these groups are over-represented in more deprived communities. In 2019, people from all ethnic minority groups except the Indian, Chinese, White Irish and White Other groups were more likely than White British people to live in the 10 per cent of neighbourhoods in England.

There are significant socio-economic differences between ethnic minority groups, and below we give some examples.

Data for 2018–21 shows that the proportion of households with a low weekly income (below £600) is highest in the Black groups. The proportion with a weekly income over £1000 is highest (about 40 per cent) in Indian and Chinese groups, and lowest in Bangladeshi (18 per cent), Black (22 per cent) and Pakistani (25 per cent) groups; this compares with 29 per cent of White British households.
In 2021 unemployment was highest in Black, Mixed, Pakistani and Bangladeshi groups, and lowest in white and Indian groups. Most ethnic minority children had higher attainment scores at Key Stage 4 (GCSE level in 2020-21 than the White British group, with the exception of White Gypsy/Roma, White Irish Traveller and Black Caribbean pupils. White pupils on free school meals had the lowest score.

Data from the 2021 census shows the following.

The proportion with a higher educational qualification is highest in Chinese and Indian followed by Black African groups, and lowest in the White Gypsy or Irish Traveller and White Roma groups.
The proportions in professional occupations (eg, doctors, teachers, lawyers) or working as managers, directors or senior officials is highest in the Chinese, Indian and White Irish groups; the proportion working in occupations requiring fewer qualifications is highest in White Gypsy or Irish Traveller and White Roma groups.
Patterns of home tenure vary significantly between ethnic groups: the proportion of people living in social rented housing is highest in Black, Mixed White-Black and White Gypsy or Irish Traveller groups, and lowest in the Indian and Chinese groups; the proportion owning their home is highest in Indian and White British groups and lowest in Black and Mixed White-Black groups; overcrowding is highest in Bangladeshi households.

Structural racism and marginalisation

The wider social context contributes to ethnic and other social inequalities. Evidence documents the prevalence of racism and discrimination in the UK, and the negative effects these can have on the physical and mental health of people from ethnic minority groups. They can also create barriers to accessing health information and health care services. Structural racism can also have an impact on health outcomes, operating via exclusionary frameworks that marginalise minority groups in, for example, the housing, employment and criminal justice systems.

References: Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K (2011). ‘Low health literacy and health outcomes: an updated systematic review’. Annals of Internal Medicine, vol 155, no 2, pp 97–107. Available at: https://pubmed.ncbi.nlm.nih.gov/21768583/ (accessed on 1 February 2021).
Buck D, Frosini F (2012). Clustering of unhealthy behaviours over time: implications for policy and practice. London: The King's Fund. Available at: www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-time (accessed on 1 February 2021).
Byrne B, Alexander C, Khan O, Nazroo J, Shankley W (eds) (2020). Ethnicity, race and inequality in the UK: state of the nation. Available at:
https://library.oapen.org/bitstream/handle/20.500.12657/22310/9781447351269.pdf?sequence=4&isAllowed=y (accessed on 1 February 2021).
Care Quality Commission (2023). ‘Maternity survey 2022’. CQC website. Available at: www.cqc.org.uk/publication/surveys/maternity-survey-2022 (accessed on 24 April 2023).
Care Quality Commission (2022). ‘Adult inpatient survey 2021’. CQC website. Available at: www.cqc.org.uk/publications/surveys/adult-inpatient-survey (accessed on 24 April 2023).
Care Quality Commission (2022). ‘Children and young people’s survey 2020’. CQC website. Available at: www.cqc.org.uk/publications/surveys/children-young-peoples-survey-2020 (accessed on 24 April 2023).
Care Quality Commission (2022). ‘Community mental health survey 2022’. CQC website. Available at: www.cqc.org.uk/publications/surveys/community-mental-health-survey (accessed on 24 April 2023).
Care Quality Commission (2022). ‘Urgent and emergency care survey 2020’. CQC website. www.cqc.org.uk/publications/surveys/urgent-emergency-care-survey-2020 (accessed on 24 April 2023).
Care Quality Commission (2020). ‘Inpatient experience during the coronavirus (Covid-19) pandemic’. CQC website. Available at: www.cqc.org.uk/publications/themed-work/inpatient-experience-during-coronavirus-covid-19-pandemic (accessed on 24 April 2023).
Creamer Attridge M, Ramsden M, Cannings-John R, Hawthorne K (2016). ‘Culturally appropriate health education for type 2 diabetes in ethnic minority groups: an updated Cochrane Review of randomized controlled trials’. Diabetic Medicine, vol 33, no 2, pp 169–83. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/dme.12865 (accessed on 1 February 2021).
Department for Digital, Culture, Media and Sport (2022). ‘Healthy eating among adults’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/diet-and-exercise/healthy-eating-of-5-a-day-among-adults/latest#download-the-data (accessed on 24 April 2023).
Department for Digital, Culture, Media and Sport (2022). ‘Physical activity’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/diet-and-exercise/physical-activity/latest (accessed on 24 April 2023).
Department for Education (2022). ‘GCSE results (Attainment 8)’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/education-skills-and-training/11-to-16-years-old/gcse-results-attainment-8-for-children-aged-14-to-16-key-stage-4/latest (accessed on 24 April 2023).
Department for Education (2019). ‘Key stage 4 and multi-academy trust performance 2018 (revised)’. GOV.UK website. Available at: www.gov.uk/government/statistics/key-stage-4-and-multi-academy-trust-performance-2018-revised (accessed on 29 January 2021).
Department for Work and Pensions (2022). ‘Household income’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/work-pay-and-benefits/pay-and-income/household-income/latest (accessed on 24 April 2023).
Department for Work and Pensions (2020). ‘Persistent low income’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/work-pay-and-benefits/pay-and-income/low-income/latest (accessed on 29 January 2021).
Escribà-Agüir V, Rodríguez-Gómez M, Ruiz-Pérez I (2016). ‘Effectiveness of patient-targeted interventions to promote cancer screening among ethnic minorities: a systematic review’. Cancer Epidemiology, vol 44, pp 22–39.
Hui A, Latif A, Chen T, Hinsliff-Smith K (2020). ‘Exploring the impacts of organisational structure, policy and practice on the health inequalities of marginalised communities: illustrative cases from the UK healthcare system’. Health Policy, vol 124, no 3, pp 298–301. Available at: https://dora.dmu.ac.uk/handle/2086/19102 (accessed on 1 February 2021).
Jenum AK, Brekke I, Mdala I, Muilwijk M, Ramachandran A, Kjøllesdal M, Andersen E, Richardsen KR, Douglas A, Cezard G, Sheikh A, Celis-Morales CA, Gill JMR, Sattar N, Bhopal RS, Beune E, Stronks K, Vandvik PO, van Valkengoed IGM (2019). ‘Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials’. Diabetologia, vol 62, no 8, pp 1337–48.
Joo JY (2014). ‘Effectiveness of culturally tailored diabetes interventions for Asian immigrants to the United States: a systematic review’. Diabetes Educator, vol 40, no 5, pp 605–15. Available at: https://pubmed.ncbi.nlm.nih.gov/24829268/ (accessed on 1 February 2021).
Karlsen S (2012). Ethnic inequalities in health: the impact of racism [online]. Race Equality Foundation website. Available at: https://raceequalityfoundation.org.uk/health-care/ethnic-inequalities-in-health-the-impact-of-racism/ (accesses on 1 February 2021).
Kelly Y, Becares L, Nazroo J (2013). ‘Associations between maternal experiences of racism and early child health and development: findings from the UK Millennium Cohort Study’. Journal of Epidemiology and Community Health, vol 67, no 1, pp 35–41. Available at: https://pubmed.ncbi.nlm.nih.gov/22760222/ (accessed on 2 September 2021).
Kreps GL, Sparks L (2008). ‘Meeting the health literacy needs of immigrant populations’. Patient Education and Counselling, vol 71, no 3, pp 328 –32. Available at: https://pubmed.ncbi.nlm.nih.gov/18387773/ (accessed on 1 February 2021).
Lagisetty PA, Priyadarshini S, Terrell S, Hamati M, Landgraf J, Chopra V, Heisler M (2017). ‘Culturally targeted strategies for diabetes prevention in minority population’. Diabetes Educator, vol 43, no 1, pp 54–77. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC5408505/ (accessed on 1 February 2021).
Lynam MJ, Cowley S (2007). ‘Understanding marginalization as a social determinant of health’. Critical Public Health, vol 17, no 2, pp 137–49. Available at: doi/10.1080/09581590601045907 (accessed on 1 February 2021).
Majeed-Ariss R, Jackson C, Knapp P, Cheater FM (2015). ‘A systematic review of research into black and ethnic minority patients’ views on self-management of type 2 diabetes’. Health Expectations, vol 18, no 5, pp 625–42.
Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J (2020). Health equity in England: the Marmot review 10 years on [online]. The Health Foundation website. Available at: www.health.org.uk/publications/reports/the-marmot-review-10-years-on (accessed on 29 January 2021).
Ministry of Housing, Communities and Local Government (2020). ‘Overcrowded households’. GIV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/housing/housing-conditions/overcrowded-households/latest (accessed on 29 January 2021).
Muennig P, Murphy M (2011). ‘Does racism affect health? Evidence from the United States and the United Kingdom’. Journal of Health Politics Policy and Law, vol 36, no 1, pp 187–214. Available at: www.researchgate.net/publication/51056666_Does_Racism_Affect_Health_Evidence_from_the_United_States_and_the_United_Kingdom (accessed on 1 February 2021).
Nazroo JY (2003). ‘The structuring of ethnic inequalities in health: economic position, racial discrimination, and racism’. American Journal of Public Health, vol 93, no 2, pp 277–84. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1447729/ (accessed on 1 February 2021).
Nazroo JY, Falaschetti E, Pierce M, Primatesta P (2009). ‘Ethnic inequalities in access to and outcomes of healthcare: analysis of the Health Survey for England’. Journal of Epidemiology and Community Health, vol 63, no 12, pp 1022–7. Available at: https://pubmed.ncbi.nlm.nih.gov/19622520/ (accessed on 1 February 2021).
NHS Digital (2020). Inpatient satisfaction with hospital care. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/patient-experience/inpatient-satisfaction-with-hospital-care/latest (accessed on 1 February 2021).
NHS Digital (2019). Patient experience of primary care: GP services. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/patient-experience/patient-experience-of-primary-care-gp-services/latest#by-ethnicity (accessed on 1 February 2021).
NHS Digital (2018). ‘Health Survey for England 2017’. NHS Digital website. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2017 (accessed on 1 February 2021).
NHS England (2022). ‘GP patient survey: national report 2022 survey’. Available at: https://gp-patient.co.uk/surveysandreports (accessed on 24 April 2023).
NHS England (2017). ‘Patient satisfaction with GP out-of-hours services’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/patient-experience/patient-satisfaction-with-gp-out-of-hours-services/latest (accessed on 1 February 2021).
Office for National Statistics (2022). ‘Adult smoking habits in the UK: 2021’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2021(accessed on 24 April 2023).
Office for National Statistics (2021). Cigarette smoking among adults [online]. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/alcohol-smoking-and-drug-use/adult-smokers/latest#data-sources (accessed on 2 September 2021).
Office for National Statistics (2023). ‘Ethnic group by education, employment, health and housing, England and Wales: Census 2021’. ONS website. Available at: www.ons.gov.uk/releases/ethnicgroupbyeducationemploymenthealthandhousingenglandandwalescensus2021 (accessed on 24 April 2023).
Office for National Statistics (2022). ‘Unemployment’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/work-pay-and-benefits/unemployment-and-economic-inactivity/unemployment/latest (accessed on 24 April 2023).
Office for National Statistics (2021). Provisional age-standardised mortality rates for all-cause mortality, deaths due to Covid-19, and deaths due to other causes by ethnic group, sex, and Index of Multiple Deprivation (IMD) quintile, England: 1 January 2020 to 31 December 2020 [online]. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/13360provisionalagestandardisedmortalityratesforallcausemortalitydeathsduetocovid19anddeathsduetoothercausesbyethnicgroupsexandindexofmultipledeprivationimdquintileengland1january2020to31december2020 (accessed on 2 September 2021).
Office for National Statistics (2021). ‘Unemployment’. GOV.UK website. Available at: https://www.ethnicity-facts-figures.service.gov.uk/work-pay-and-benefits/unemployment-and-economic-inactivity/unemployment/latest (accessed on 29 January 2021).
Pinder RJ, Ferguson J, Møller H (2016). ‘Minority ethnicity patient satisfaction and experience: results of the National Cancer Patient Experience Survey in England’. BMJ Open, vol 6, art no: e011938. Available at: https://bmjopen.bmj.com/content/6/6/e011938 (accessed on 1 February 2021).
Public Health England, UCL Institute of Health Equity (2015). Local action on health inequalities Improving health literacy to reduce health inequalities [online]. GOV.UK website. Available at: www.gov.uk/government/publications/local-action-on-health-inequalities-improving-health-literacy (accessed on 1 February 2021).
Public Health England (2020). COVID-19: understanding the impact on BAME communities [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (accessed on 1 February 2021).
Raleigh VS, Hussey D, Seccombe I, Hallt K (2010). ‘Ethnic and social inequalities in women’s experience of maternity care in England: results of a national survey’. Journal of the Royal Society of Medicine, vol 103, pp 188–98. Available at: https://journals.sagepub.com/doi/full/10.1258/jrsm.2010.090460 (accessed on 1 February 2021).
Scientific Advisory Group for Emergencies – Ethnicity Sub-Group (SAGE) (2020). Drivers of the higher COVID-19 incidence, morbidity and mortality among minority ethnic groups, 23 September 2020 [online]. Available at: www.gov.uk/government/publications/drivers-of-the-higher-covid-19-incidence-morbidity-and-mortality-among-minority-ethnic-groups-23-september-2020 (accessed on 1 February 2021).
Sport England (2023). ‘Overweight adults’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/health/diet-and-exercise/overweight-adults/latest (accessed on 24 April 2023).
Trenchard L, McGrath-Lone L, Ward H (2016). ‘Ethnic variation in cancer patients' ratings of information provision, communication and overall care’. Ethnicity and Health, vol 21, no 5, pp 515–33. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4940888/ (accessed on 1 February 2021).
Watkinson RE, Sutton M, Turner AJ (2021). ‘Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey’. The Lancet Public Health vol 6, no 3, E145–54. Available at: https://doi.org/10.1016/S2468-2667(20)30287-5 (accessed on 24 April 2023).
Zeh P, Sandhu HK, Cannaby AM, Sturt JA (2012). ‘The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review’. Diabetic Medicine, vol 29, no 10, pp 1237–52. Available at: https://pubmed.ncbi.nlm.nih.gov/22553954/ (accessed on 1 February 2021).

Conclusion

This explainer describes some ethnic inequalities in health, such as higher mortality among infants, a greater disease burden from diabetes and CVD among ethnic minority groups, and higher cancer mortality in the white group. Strategies for improving the health of England’s deprived and ethnic minority communities need to address the multiple factors that have an impact on their health.

The role of public health and NHS services: the Covid-19 pandemic has highlighted the urgent need to strengthen action to prevent and manage ill health in deprived and ethnic minority communities, with their active engagement to ensure that the planning and delivery of services takes account of their needs, experiences and expectations.
Addressing the wider determinants of health: the disproportionate impact of Covid-19 on deprived and ethnic minority groups has highlighted the urgent need for a cross-government strategy to address health inequalities and the wider socio-economic and structural inequalities that drive them, and which addresses the diverse health needs of all groups at risk of poor health and high mortality. The government, NHS organisations and local authorities have a key role to play in implementing this agenda.
Tackling structural racism: this requires action across national, local and societal levels. The NHS has a significant role to play in ensuring that health service provision is equitable and meets the needs of all communities, including ethnic minority communities.
Data: comprehensive, good-quality data is essential for enabling policy-makers and health care professionals to identify the specific needs of different ethnic minority communities, respond with tailored strategies for addressing inequalities, and track their impact.

Comments

We created videos to help reduce health inequalities between ethnic minorities. People heard what they needed to do to reduce their risk of falling, in their own language.

We have argued for decades that health status and death is significantly impacted by socio-economic and political factors. Discrimination and racism are also determinants of health/illness. Add on top of that 12 years of austerity measures. All these have significantly impacted on the health of BAME people. So how is it that white people have worse health and die more that BAME people? This given that ethnicity is only being recorded in death certificates. I suspect the finding are of very limited value.

I am 55 years born in England from Turkish and Turkish Cypriot ethnic group and ever since I can remember have always been disregarded campared to Black and Aisan groups or encouraged to be a part of this type of discussion and always felt segregated even when it comes to that label equal opportunities.

I believe the figures show that the opposite is true.

Hi Leila,

Thanks for your post. We don't have any immediate plans to write something specifically focused on mental health inequalities by ethnicity but I've passed your suggestion on to colleagues.

Thanks,

Ian

Would you consider doing a piece focused on mental health inequalities by ethnicity?

Hi Michael, in a manner of speaking. Existing analysis suggests that historically the mortality rate for non-white groups in the UK is lower than in white groups. This advantage is most associated with first generation migrants and the advantage decreases in subsequent generations. The causes of this are really complicated, one suggestion is the "healthy migrant" effect, i.e. that people who migrate tend to be in good health. The effects of assimilation are seen in subsequent generations.
Covid-19 has impacted ethnic minority mortality rates hugely and has reversed the mortality advantage in some ethnic minority groups.
Overall minority ethnic groups do have lower mortality rates, but it's a very complicated and changing picture.

Am I correct in saying that a white person will die earlier than any other race?

Brilliant article, thank you Veena! All those years of working on the NHS Outcomes Framework and it had somehow escaped me that UK Life Expectancy at birth was lower for white people than for many other ethnic groups, but that the longer they live here the worse it gets.
Hope you are well.

(Thanks for the report. It's undoubtedly useful.) Yes you are constrained by the fields in the Census. The same scheme that lumps disparate people together is about to be used in the 2021 Census, unfortunately. What I can see in the explainer is your point that "good-quality data is essential", not that BETTER quality data is essential. Nor in what way it should be better. It's up to the ONS but presumably they will carry on doing what they do unless reputable health statisticians tell them what they produce is not adequate. If it is really impossible (or is it?) to ask people to tick a box to indicate they are say Kashmiri or Somali etc., then maybe other sorts of data should be taken into account e.g. refugee or migrant status, and overlaid with income, economic activity etc.

The health of people from ethnic minority groups in England

Key messages

Introduction

Data on the health of ethnic minority groups

Overall health