This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

Transcultural communication and health care practice:

Towards an epidemiology of diversity: Ethnic minority demography, disease patterns and pathways to care

Author: Mark R D Johnson

© Crown copyright material is reproduced with the permission of the Controller of HMSO and the Queen’s Printer for Scotland.


This module is intended to complement the other modules of the course. It deliberately adopts a more clinical and ‘factual’ approach in some respects, and may appear at times to reflect a ‘medical model’ of health, rather than the social approach. However, we insist that a ‘social model’ should underpin all consideration of epidemiology, since many of the factors considered are socially constructed. However, we need also to recognise that people do have real illnesses and require clinical treatment using medicine and surgery. This module intends to help the practitioner to consider some of the clinical issues with which he or she may be faced. Illness, or the ‘sick role’, like other disabilities, can be socially constructed. Therefore, you should always be critical of the facts presented to you. Like every other section of the course, we begin with some definitions, including consideration of the meaning of ‘ethnicity’ and ‘race’. Those we present here may differ in some ways from those in use in other modules that is not to say that we consider the others as wrong or less useful. However, for the discussion we are having, these may be helpful in this context. The reflective and alert practitioner must be prepared to balance different definitions of key concepts like these!

Exercise 0.1 Reflection activity

Consider why different authors in this course, or in different contexts, might find it acceptable, necessary or useful to use different definitions of such key concepts or variables.

Suggestions for exercise 0.1:

  • Some concepts or terms are ‘socially constructed’ and therefore will differ according to the society and members of the group using them.
  • When we are talking about health and disease, we may need to accentuate different causative factors or elements which affect people’s needs and response to treatment.
  • Everybody has their own agenda: there is no single truth.  By using our own definition, we are setting the limits of the discussion and highlighting what we see as relevant.

Aims and learning objectives

After completing this module you should have a better understanding of how ethnic diversity in the population is related to health needs and the planning of health care. In particular, you should have achieved the following aims:


  • recognise that the various components of ethnic diversity affect disease patterns, expression of disease, and access to health care, and understand some of the ways in which this process operates.
  • understand how patterns of diversity may affect the burden of disease in the population, and hence the case mix and the services that will be required.
  • gain insight into the ways in which ethnicity, culture and institutional racism may affect people’s access to the health care services they need
  • explore ethnic differences in pathways to care.

As a result, you should understand the value of ethnic monitoring in the planning and delivery of health care, and the necessity to ask patients about their family background and culture. You may also have learned more about your own learning needs in terms of clinical knowledge and cultural competence.

It is important to recognise that many places in Britain have very small numbers of people from identifiable minority ethnic backgrounds that is, who are ‘visible minorities’. Nurses, doctors, allied health professions and other clinical care workers may well be working in settings where they rarely encounter a service user from one of the minority ethnic groups described in the statistics presented here. However, that is not a reason for ignoring this information: we have to learn about rare medical conditions and care needs in order to qualify, in case we encounter them in later practice. The principles which are applied are universal and in exactly the same way, an understanding of ‘ethnicity’ and ‘diversity’ will make the practitioner better prepared for all sorts of variation, whether in culture, language, religion, diet or ‘custom’, and hence more able to move between settings or places, and between service users. Everyone has some ‘ethnic origin’ and personal, local or family culture. Using the approach laid out in the first section, and understanding how this may affect peoples’ health needs, will prepare you to practice anywhere and may make life easier for the person from a minority ethnic group when they enter a clinic or hospital where they are the only one from their background. Imagine that you are on holiday in a faraway country, and you meet someone who speaks a little of your language, or knows the town where you come from, and can prepare food the way you like it!

Background or preparatory reading

Some of these may be available in your library. Don't try to read everything, but do read the introduction and some key chapters of at least one of them. Note, before you start, the date on which they were published. Think what difference this might make to your reading of them now.

  • Acheson D (Chair) 1998 Independent Inquiry into Inequalities in Health London: Stationery Office
  • Ahmad WIU (Ed) 2000 Ethnicity, Disability and Chronic Illness Buckingham: Open University Press
  • Ahmad WIU (Ed) 1993 ‘Race’ and Health in Contemporary Britain Buckingham: Open University Press
  • Culley L and Dyson S 2001 Ethnicity and Nursing Practice Palgrave
  • Gill P S, Kai J, Bhopal R S and Wild S Health Care Needs Assessment: Black and Minority Ethnic Groups hcna.radcliffe-online.com/bemgframe.htm
  • Hopkins A and Bahl V (Eds) 1993 Access to health care for people from black and ethnic minorities London: Royal College of Physicians
  • Johnson MRD, Owen D, Blackburn C, Rehman H and Nazroo J 2000 Black and Minority Ethnic Groups in England: The second health & lifestyles survey London: Health Education Authority
  • Kai J (Ed) 2000 Ethnicity, Health and Primary Care Oxford University Press
  • Nazroo JY 1997 The Health of Britain’s Ethnic Minorities London: PSI
  • Department of Health 1999 Health Survey for England: The Health of Minority Ethnic Groups DoH: www.doh.gov.uk/public/england/htm
  • London Health Observatory website: www.lho.org.uk/hil/bme.htm

Exercise 0.2 A preparatory task

Think about your community or family, and the diseases that you have come across in them. How do these patterns of ill health (or death) compare with the diseases you have learned about on your course so far?

Do they seem to reflect the ‘priorities’ of ‘Our Healthier Nation’ (the White Paper that sets the objectives for the New NHS)?  If you can, get together with other students and see if their home communities or families suffer from the same diseases or if they know of illnesses you have not seen.

Our Healthier Nation can be found on following website: www.ohn.gov.uk

Prompt for exercise 0.2:

  • the Government priorities of Our Healthier Nation were:
  • coronary Heart Disease and Stroke
  • cancer(s)
  • mental Illness
  • HIV/AIDS and sexual health
  • accidents
  • each local health district was also encouraged to set its own ‘local priority’ many chose ‘Teenage Pregnancy’.
  • more recently, Inequalities have also been highlighted as a priority issue.

(Reference: White Paper: Saving Lives, Our Healthier Nation 1999)

Note: Another way of setting priorities has been the publication of ‘National Strategic Frameworks (NSFs) for key diseases (such as Cancer) and conditions (such as Old Age). Examine which publications came first, and which diseases were chosen.  You will find these documents on the Department of Health website.


In epidemiology, we have to compare the health of different groups of people in the populations. To do this, we make use of many statistical terms and different ways of calculating ‘rates’ to make those comparisons on a fair (comparable) basis.


The study of the spread of disease with a view to finding means of control and prevention. It includes all forms of disease relating to environment and lifestyle as well as communicable (infectious) diseases.


A measure of the impact of disease on society expressed as a rate ‘point prevalence’ refers to the number of people with a disease at any given time (expressed usually as number of people with the disease, per thousand in the total population), or episodes of sickness per thousand people over a given period (period prevalence).


Another measure of the impact of disease (morbidity), or the risk of catching that disease, which is usually expressed as the number of new cases (per thousand people) in a given period of time.


The state of being diseased usually expressed as a rate of numbers of cases per hundred thousand or million people. This may be given as a prevalence rate (qv) or as an annual incidence rate (qv).


Dying. The mortality rate for a specific disease is the risk of dying from that cause (as a percentage or per thousand, of the population concerned. (see SMR).

PMR: Proportional Mortality Rate

A way of expressing the relative risk of dying from a disease (see Relative Risk, SMR). It is calculated in slightly different ways from the SMR, but the essential meaning of the statistic is the same: expressed as a ratio, with 100 as the ‘standard’, a value of 200 would imply double the risk in the group concerned, compared to the overall population.

SMR: Standardised Mortality Rate

A measure of mortality that takes into account the fact that some causes of death are more common at different ages, and so the rate is adjusted for the specific age-bands (or total population age profile) being considered. It might also be given as an Age and Sex specific Mortality Rate for a particular cause.


The number of people in the population ‘at risk’ (i.e. the population for which the comparison of a rate is being calculated). So, to calculate the risk for women having an accident while playing golf, we need to know the number of women who play that game. To calculate a perinatal mortality rate, we need to know the number of births in the period for which we have the number of deaths.


The number of people with a specific condition (which is divided by the denominator to reach a ‘rate’).

Relative risk

The ratio between rates of risk for two groups of people. If both groups have the same risk of dying, for example, the relative risk would be 1.0 but if men were twice as likely as women to be killed by a fall, their relative risk for that cause would be 2.0.

Information Or Knowledge About Diversity:

A Health Warning

A little knowledge is a dangerous thing - and the risk of stereotypes is that they are all at least partly true. The problem for the nurse is that they may meet people from any cultural background, and from any ethnic group. Even so, knowing all there is to know about (say) Islam, and the genetic makeup of people from the specific country (say, Sweden), they will still not be in a position to know whether the particular client they are working with fits all the knowledge they have! Just as many Christians or Jews may describe themselves as ‘lapsed’ or ‘non-observant’, there are degrees of observance in people from all religious groups, and many small differences between regions and families. Epidemiology is a science of averages. It only provides a basis from which you can begin to ask intelligent, well-informed, questions about the needs of your patient. If in doubt ask. If you are certain without asking, ask again.