Understanding ethnic inequalities in mental healthcare in the UK: A meta-ethnography.

BACKGROUND: Evidence regarding the presence and persistence of ethnic inequalities in mental healthcare is well established. The reasons for these inequalities and lack of progress in diminishing them are less understood. This meta-ethnography aims to provide a new conceptual understanding of how ethnic inequalities are created and sustained; this is essential to develop effective interventions. Specifically, we sought to understand why people from ethnic minority groups are underrepresented in primary care mental health service provision and overrepresented in crisis pathways and detention. METHODS AND FINDINGS: Following eMERGe guidelines for meta-ethnographies, we searched OpenGrey, Kings Fund, CINAHL, Medline, PsycINFO, and Social Care Online databases for qualitative articles published from database inception until October 2, 2022, using broad categories of search terms relating to "ethnicity AND (mental illness/mental health/emotional distress) AND (help-seeking/service utilisation/experience/perception/view)." We included all conceptually rich articles that used qualitative methods of data collection and analysis and excluded non-UK studies and those that focused solely on causation of mental illness. Our patient, public, and practitioner lived experience advisory group provided feedback and input on key stages of the project including search terms, research questions, data analysis, and dissemination. A total of 14,142 articles were identified; 66 met the inclusion criteria. We used reciprocal, refutational, and line of argument analytical approaches to identify convergence and divergence between studies. The synthesis showed that current models of statutory mental healthcare are experienced as a major barrier to the delivery of person-centred care to those in ethnic minority groups due to the perceived dominance of monocultural and reductionist frameworks of assessment and treatment (described as "medical" and "Eurocentric") and direct experiences of racist practice. The lack of socially oriented and holistic frameworks of knowledge and understanding in medical training and services is experienced as epistemic injustice, particularly among those who attribute their mental illness to experiences of migration, systemic racism, and complex trauma. Fear of harm, concerns about treatment suitability, and negative experiences with health providers such as racist care and medical neglect/injury contribute to avoidance of, and disengagement from, mainstream healthcare. The lack of progress in tackling ethnic inequalities is attributed to failures in coproduction and insufficient adoption of existing recommendations within services. Study limitations include insufficient recording of participant characteristics relating to generational status and social class in primary studies, which prevented exploration of these intersections. CONCLUSIONS: In this study, we found that the delivery of safe and equitable person-centred care requires a model of mental health that is responsive to the lived experiences of people in ethnic minority groups. For the people considered in this review, this requires better alignment of mental health services with social and anti-racist models of care. Our findings suggest that intersections related to experiences of racism, migration, religion, and complex trauma might be more relevant than crude ethnic group classifications. Strategies to tackle ethnic inequalities in mental healthcare require an evaluation of individual, systemic, and structural obstacles to authentic and meaningful coproduction and implementation of existing community recommendations in services.

Evaluating the effectiveness and cost effectiveness of the 'strengthening families, strengthening communities' group-based parenting programme: study protocol and initial insights.

BACKGROUND: Up to 20% of UK children experience socio-emotional difficulties which can have serious implications for themselves, their families and society. Stark socioeconomic and ethnic inequalities in children's well-being exist. Supporting parents to develop effective parenting skills is an important preventive strategy in reducing inequalities. Parenting interventions have been developed, which aim to reduce the severity and impact of these difficulties. However, most parenting interventions in the UK focus on early childhood (0-10 years) and often fail to engage families from ethnic minority groups and those living in poverty. Strengthening Families, Strengthening Communities (SFSC) is a parenting programme designed by the Race Equality Foundation, which aims to address this gap. Evidence from preliminary studies is encouraging, but no randomised controlled trials have been undertaken so far. METHODS/DESIGN: The TOGETHER study is a multi-centre, waiting list controlled, randomised trial, which aims to test the effectiveness of SFSC in families with children aged 3-18 across seven urban areas in England with ethnically and socially diverse populations. The primary outcome is parental mental well-being (assessed by the Warwick-Edinburgh Mental Well-Being Scale). Secondary outcomes include child socio-emotional well-being, parenting practices, family relationships, self-efficacy, quality of life, and community engagement. Outcomes are assessed at baseline, post intervention, three- and six-months post intervention. Cost effectiveness will be estimated using a cost-utility analysis and cost-consequences analysis. The study is conducted in two stages. Stage 1 comprised a 6-month internal pilot to determine the feasibility of the trial. A set of progression criteria were developed to determine whether the stage 2 main trial should proceed. An embedded process evaluation will assess the fidelity and acceptability of the intervention. DISCUSSION: In this paper we provide details of the study protocol for this trial. We also describe challenges to implementing the protocol and how these were addressed. Once completed, if beneficial effects on both parental and child outcomes are found, the impact, both immediate and longer term, are potentially significant. As the intervention focuses on supporting families living in poverty and those from minority ethnic communities, the intervention should also ultimately have a beneficial impact on reducing health inequalities. TRIAL REGISTRATION: Prospectively registered Randomised Controlled Trial ISRCTN15194500 .

Understanding the excess psychosis risk in ethnic minorities: the impact of structure and identity.

PURPOSE: Psychotic disorders, which are associated with substantially increased morbidity and mortality, are up to five times more common in some ethnic minority groups compared with the white majority in Western countries. This long-standing and well-replicated public mental health disparity has hitherto largely eluded adequate explanation. We argue that this might have arisen in part due to the lack of attention given to theoretical work characterising the complex and multidimensional social nature of ethnicity by those epidemiological investigations that have dominated the literature. METHODS: To bridge this gap, we draw on theoretical and empirical literature from across the social sciences considering the ontological significance of ethnicity (as biology, migration, racialised structures and identity) and its relationships with psychotic disorders to illuminate probable drivers of excess psychosis risk. RESULTS: The largest gains in our theoretical understanding of excess psychosis risk among ethnic minority groups are to be made by considering ethnicity in relation to disempowerment resulting from structural and identity-based exclusion. The former is readily studied through the social gradient in health: socioeconomic disadvantage clusters in some ethnic minorities and increases the risk of poor health outcomes, including psychosis. Furthermore, limitations on identity acquisition and expression imposed by the ethnic majority can further contribute to alienate ethnic minorities and increase psychosocial disempowerment (a lack of control over one's life). CONCLUSION: We theorise that structural and identity-based exclusion act as the primary drivers shaping variation in rates of psychotic disorder by ethnic minority status.

The benefits and harms of providing parents with weight feedback as part of the national child measurement programme: a prospective cohort study.

BACKGROUND: Small-scale evaluations suggest that the provision of feedback to parents about their child's weight status may improve recognition of overweight, but the effects on lifestyle behaviour are unclear and there are concerns that informing parents that their child is overweight may have harmful effects. The aims of this study were to describe the benefits and harms of providing weight feedback to parents as part of a national school-based weight-screening programme in England. METHODS: We conducted a pre-post survey of 1,844 parents of children aged 4-5 and 10-11 years who received weight feedback as part of the 2010-2011 National Child Measurement Programme. Questionnaires assessed general knowledge about the health risks associated with child overweight, parental recognition of overweight and the associated health risks in their child, child lifestyle behaviour, child self-esteem and weight-related teasing, parental experience of the feedback, and parental help-seeking behaviour. Differences in the pre-post proportions of parents reporting each outcome were assessed using a McNemar's test. RESULTS: General knowledge about child overweight as a health issue was high at baseline and increased further after weight feedback. After feedback, the proportion of parents that correctly recognised their child was overweight increased from 21.9% to 37.7%, and more than a third of parents of overweight children sought further information regarding their child's weight. However, parent-reported changes in lifestyle behaviours among children were minimal, and limited to increases in physical activity in the obese children only. There was some suggestion that weight feedback had a greater impact upon changing parental recognition of the health risks associated with child overweight in non-white ethnic groups. CONCLUSIONS: In this population-based sample of parents of children participating in the National Child Measurement Programme, provision of weight feedback increased recognition of child overweight and encouraged some parents to seek help, without causing obvious unfavourable effects. The impact of weight feedback on behaviour change was limited; suggesting that further work is needed to identify ways to more effectively communicate health information to parents and to identify what information and support may encourage parents in making and maintaining lifestyle changes for their child.

Ethnicity and suicide in England and Wales: a national linked cohort study.

BACKGROUND: Understanding of ethnic disparities in suicide in England and Wales is poor as ethnicity is not recorded on death certificates. Using linked data, we examined variations, by sex, in suicide rates in England and Wales by ethnicity and migrant and descendant status. METHODS: Using the Office for National Statistics 2012-19 mortality data linked to the 2011 census from the Public Health Research Database, we calculated the age-standardised suicide rates by sex for each of the 18 self-identified ethnicity groups in England and Wales. We present rates by age, sex, and methods used for suicide by ethnic group. We estimated age-adjusted and sex-adjusted incidence rate ratios (IRRs) using Poisson regression models for each minority ethnic group compared with the majority population. We involved people with lived experience in the research. FINDINGS: Overall, 31 644 suicide deaths occurred over the study period, including 3602 (11%) in people from minority ethnic backgrounds, with a mean age of death of 43·3 years (SD 17·0, range 13-96). Almost all minority ethnic groups had a lower rate of suicide than the White British majority, apart from individuals who identified as being from a Mixed heritage background or White Gypsy or Irish Travellers. In females who identified as Mixed White and Caribbean, the suicide IRR was 1·79 (95% CI 1·45-2·21) compared with the White British majority; in those who identified as White Gypsy or Irish Travellers, the IRR was 2·26 (1·42-3·58). Rates in males identifying as from these two groups and those identifying as White Irish were similar to the White British majority. Compared with the non-migrant population, migrants had a lower rate of suicide regardless of ethnicity, but in the descendant population, people from a Mixed ethnicity background had a higher risk of suicide than the White British majority. INTERPRETATION: There are ethnic disparities in suicide mortality in England and Wales, but the reasons for this are unclear. The higher rate in previously overlooked minority ethnic groups warrants further attention. FUNDING: Wellcome Trust.

Principles for research on ethnicity and health: the Leeds Consensus Statement.

BACKGROUND: There is substantial evidence that health and health-care experiences vary along ethnic lines and the need to understand and tackle ethnic health inequalities has repeatedly been highlighted. Research into ethnicity and health raises ethical, theoretical and methodological issues and, as the volume of research in this area grows, so too do concerns regarding its scientific rigour and reporting, and its contribution to reducing inequalities. Guidance may be helpful in encouraging researchers to adopt standard practices in the design, conduct and reporting of research. However, past efforts at introducing such guidance have had limited impact on research practice, and the diversity of disciplinary perspectives on the key challenges and solutions may undermine attempts to derive and promote guiding principles. METHODS: A consensus building Delphi exercise--the first of its kind in this area of research practice--was undertaken with leading academics, practitioners and policymakers from a broad range of disciplinary backgrounds to assess whether consensus on key principles could be achieved. RESULTS: Ten key principles for conducting research on ethnicity and health emerged, covering: the aims of research in this field; how such research should be framed and focused; key design-related considerations; and the direction of future research. Despite some areas of dispute, participants were united by a common concern that the generation and application of research evidence should contribute to better health-care experiences and health outcomes for minority ethnic people. CONCLUSION: The principles provide a strong foundation to guide future ethnicity-related research and build a broader international consensus.

Community severance and health: what do we actually know?

Community severance occurs where road traffic (speed or volume) inhibits access to goods, services, or people. Appleyard and Lintell's seminal study of residents of three urban streets in San Francisco found an inverse relationship between traffic and social contacts. The extent of social networks predicts unhealthy behaviors, poor health, and mortality; high rather than low social integration is associated with reduced mortality, with an effect size of similar magnitude to stopping smoking. Although community severance diminishes social contacts, the implications of community severance for morbidity and mortality have not been empirically established. Based on a systematic literature search, we discuss what is actually known about community severance. There is empirical evidence that traffic speed and volume reduces physical activity, social contacts, children's play, and access to goods and services. However, no studies have investigated mental or physical health outcomes in relation to community severance. While not designed specifically to do so, recent developments in road design may also ameliorate community severance.

Investigating ethnic differences in current cigarette smoking over time using the health surveys for England.

Findings from the Health Surveys for England indicate that Bangladeshi and Black Caribbean men report higher current smoking rates than other men, while white and Black Caribbean women smoke more frequently than other women. Deprivation explains differences in current smoking rates between Bangladeshi and Black Caribbean, and white English men. The smoking rates of Pakistani men and Black Caribbean women were significantly lower than those of white English people after adjusting for socio-economic status. The smoking rates of white English, Black Caribbean and Pakistani men and Black Caribbean women appear more stable over time than those of other groups.

The relationship between maternal education and mortality among women giving birth in health care institutions: analysis of the cross sectional WHO Global Survey on Maternal and Perinatal Health.

BACKGROUND: Approximately one-third of a million women die each year from pregnancy-related conditions. Three-quarters of these deaths are considered avoidable. Millennium Development Goal five calls for a reduction in maternal mortality and the establishment of universal access to high quality reproductive health care. There is evidence of a relationship between lower levels of maternal education and higher maternal mortality. This study examines the relationship between maternal education and maternal mortality among women giving birth in health care institutions and investigates the association of maternal age, marital status, parity, institutional capacity and state-level investment in health care with these relationships. METHODS: Cross-sectional information was collected on 287,035 inpatients giving birth in 373 health care institutions in 24 countries in Africa, Asia and Latin America, between 2004-2005 (in Africa and Latin America) and 2007-2008 (in Asia) as part of the WHO Global Survey on Maternal and Perinatal Health. Analyses investigated associations between indicators measured at the individual, institutional and country level and maternal mortality during the intrapartum period: from admission to, until discharge from, the institution where women gave birth. There were 363 maternal deaths. RESULTS: In the adjusted models, women with no education had 2.7 times and those with between one and six years of education had twice the risk of maternal mortality of women with more than 12 years of education. Institutional capacity was not associated with maternal mortality in the adjusted model. Those not married or cohabiting had almost twice the risk of death of those who were. There was a significantly higher risk of death among those aged over 35 (compared with those aged between 20 and 25 years), those with higher numbers of previous births and lower levels of state investment in health care. There were also additional effects relating to country of residence which were not explained in the model. CONCLUSIONS: Lower levels of maternal education were associated with higher maternal mortality even amongst women able to access facilities providing intrapartum care. More attention should be given to the wider social determinants of health when devising strategies to reduce maternal mortality and to achieve the increasingly elusive MDG for maternal mortality.

Staying "One Step Ahead of a Racist": Expanding Understandings of the Experiences of the Covid-19 Pandemic Among People From Minoritized Ethnic Groups Living in Britain.

Covid-19 has had a disproportionate impact on those in minoritized ethnic groups. Considerable attention has been given to evidence of ethnic inequalities in rates of infection, hospitalisation, and death. But other ways in which the pandemic experience has been affected by ethnicity have received less consideration. This paper explores the lived experiences of people in different minoritized ethnic groups living in South West England, during the United Kingdom's first pandemic lockdown, using qualitative data collected from interviews and comments provided on a survey. Perceived positive opportunities for growth were offset by anxiety and stress, which were themselves compounded by an awareness of the additional risks they experienced as members of racialised groups, and a sense that this was being ignored-or intentionally exacerbated-by the British authorities. Frustration with an incompetent and corrupt national Government was intensified by concerns regarding their racist motives. Racism in wider society undermined confidence in key public institutions, such as the NHS and the police, while also producing barriers to informal local-community pandemic responses. Only through recognition of the particular ways in which the pandemic affected those in minoritized ethnic groups, including the multiple and compounding effects of current and historical racism, will it be possible to identify avenues for transformative systemic policy change and opportunities to rebuild trust and a better post-pandemic society for all.

Updated systematic review and meta-analysis of studies examining the relationship between reported racism and health and well-being for children and youth: a protocol.

INTRODUCTION: Racism is a critical determinant of health and health inequities for children and youth. This protocol aims to update the first systematic review conducted by Priest et al (2013), including a meta-analysis of findings. Based on previous empirical data, it is anticipated that child and youth health will be negatively impacted by racism. Findings from this review will provide updated evidence of effect sizes across outcomes and identify moderators and mediators of relationships between racism and health. METHODS AND ANALYSIS: This systematic review and meta-analysis will include studies that examine associations between experiences of racism and racial discrimination with health outcomes of children and youth aged 0-24 years. Exposure measures include self-reported or proxy reported systemic, interpersonal and intrapersonal racism. Outcome measures include general health and well-being, physical health, mental health, biological markers, healthcare utilisation and health behaviours. A comprehensive search of studies from the earliest time available to October 2020 will be conducted. A random effects meta-analysis will examine the average effect of racism on a range of health outcomes. Study-level moderation will test the difference in effect sizes with regard to various sample and exposure characteristics. This review has been registered with the International Prospective Register of Systematic Reviews. ETHICS AND DISSEMINATION: This review will provide evidence for future research within the field and help to support policy and practice development. Results will be widely disseminated to both academic and non-academic audiences through peer-review publications, community summaries and presentations to research, policy, practice and community audiences. PROSPERO REGISTRATION NUMBER: CRD42020184055.

Religious and ethnic differences in health: evidence from the Health Surveys for England 1999 and 2004.

OBJECTIVES: To examine the role of religion in the patterning of health inequities, and how this is related to ethnicity and socioeconomic status. DESIGN: Multivariate analyses using nationally representative data on self-assessed fair or poor health, longstanding limiting illness, diagnosed diabetes, diagnosed hypertension, waist-hip ratio, body mass index, current tobacco use and participating in no regular physical activity from 14,924 Christians, 4337 Muslims, 656 Sikhs, 1197 Hindus and 2682 people reporting not identifying with any religion with different ethnic backgrounds, who were interviewed as part of the Health Survey for England in either 1999 or 2004, adjusted for age, gender and socioeconomic status and periodicity. RESULTS: Odds ratios for general health, hypertension, diabetes, waist-hip ratio, tobacco use and physical activity speak to the importance of ethnicity in the patterning of health inequalities. But there is also evidence of an important, independent role for religion, with risks for the different health indicators varying between people with the same ethnic, but different religious, identifications. Adjusting for socioeconomic status attenuated the ethnic/religious patterning of, particularly, self-assessed health, longstanding activity-limiting illness, waist-hip ratio, body mass index and tobacco use. CONCLUSIONS: This evidence enables greater understanding of the complexities of the relationship between ethnicity, religion and health, recognising the need to understand the heterogeneity underlying both ethnic and religious group membership and the processes producing the structural disadvantage facing certain religious and ethnic groups in the mediation of the relationship between health and ethnicity/religion.

'Putting salt on the wound': a qualitative study of the impact of FGM-safeguarding in healthcare settings on people with a British Somali heritage living in Bristol, UK.

OBJECTIVES: This research documents the experiences of people with Somali heritage with female genital mutilation (FGM)-safeguarding services in healthcare and whether such services are considered appropriate by the people who encounter them. DESIGN: Six focus groups conducted with ethnic Somalis living in Bristol, during the summer of 2018, divided by gender and whether people had experienced FGM-safeguarding as adults or children.SettingParticipants experienced FGM-safeguarding in primary and secondary care. PARTICIPANTS: 30 people (21 women and 9 men), identified through local organisations or snowball sampling. All participants were of Somali heritage and aged over 18. RESULTS: Government priorities to support those who have experienced female genital cutting/mutilation (FGC/M) are being undermined by their own approaches to protect those considered at risk. Participants argued that approaches to FGM-safeguarding were based on outdated stereotypes and inaccurate evidence which encouraged health and other service providers to see every Somali parent as a potential perpetrator of FGC/M. Female participants described providers in a range of healthcare settings, including Accident and Emergency Departments (A&E), antenatal care and general practice, as 'fixated' with FGC/M, who ignored both their health needs and their experience as victims. Participants felt stigmatised and traumatised by their experience. This undermined their trust in health services, producing a reticence to seek care, treatment delays and reliance on alternative sources of care. Associated recommendations include developing more accurate evidence of risk, more appropriate education for healthcare providers and more collaborative approaches to FGM-safeguarding. CONCLUSION: All the participants involved in this study are committed to the eradication of FGC/M. But the statutory approaches currently adopted to enable this are considered ill-conceived, unnecessarily heavy-handed and ultimately detrimental to this. Recognising these common aims can enable the development of services better able to protect and support those at risk of FGC/M in ways which are culturally competent and sensitive.

Affirmative action, minorities, and public services in India: Charting a future research and practice agenda.

The National Health Policy in India mentions equity as a key policy principle and emphasises the role of affirmative action in achieving health equity for a range of excluded groups. We conducted a scoping review of literature and three multi-stakeholder workshops to better understand the available evidence on the impact of affirmative action policies in enhancing the inclusion of ethnic and religious minorities in health, education and governance in India. We consider these public services an important mechanism to enhance the social inclusion of many excluded groups. On the whole, the available empirical evidence regarding the uptake and impact of affirmative action policies is limited. Reservation policies in higher education and electoral constituencies have had a limited positive impact in enhancing the access and representation of minorities. However, reservations in government jobs remain poorly implemented. In general, class, gender and location intersect, creating inter- and intra-group differentials in the impact of these policies. Several government initiatives aimed at enhancing the access of religious minorities to public services/institutions remain poorly evaluated. Future research and practice need to focus on neglected but relevant research themes such as the role of private sector providers in supporting the inclusion of minorities, the political aspects of policy development and implementation, and the role of social mobilisation and movements. Evidence gaps also need to be filled in relation to information systems for monitoring and assessment of social disadvantage, implementation and evaluative research on inclusive policies and understanding how the pathways to inequities can be effectively addressed.

Effects of self-reported racial discrimination and deprivation on Maori health and inequalities in New Zealand: cross-sectional study.

BACKGROUND: Inequalities in health between different ethnic groups in New Zealand are most pronounced between Maori and Europeans. Our aim was to assess the effect of self-reported racial discrimination and deprivation on health inequalities in these two ethnic groups. METHODS: We used data from the 2002/03 New Zealand Health Survey to assess prevalence of experiences of self-reported racial discrimination in Maori (n=4108) and Europeans (n=6269) by analysing the responses to five questions about: verbal attacks, physical attacks, and unfair treatment by a health professional, at work, or when buying or renting housing. We did logistic regression analyses to assess the effect of adjustment for experience of racial discrimination and deprivation on ethnic inequalities for various health outcomes. FINDINGS: Maori were more likely to report experiences of self-reported racial discrimination in all instances assessed, and were almost ten times more likely to experience discrimination in three or more settings than were Europeans (4.5% [95% CI 3.2-5.8] vs 0.5% [0.3-0.7]). After adjustment for discrimination and deprivation, odds ratios (95% CI) comparing Maori and European ethnic groups were reduced from 1.67 (1.35-2.08) to 1.18 (0.92-1.50) for poor or fair self-rated health, 1.70 (1.42-2.02) to 1.21 (1.00-1.47) for low physical functioning, 1.30 (1.11-1.54) to 1.02 (0.85-1.22) for low mental health, and 1.46 (1.12-1.91) to 1.11 (0.82-1.51) for cardiovascular disease. INTERPRETATION: Racism, both interpersonal and institutional, contributes to Maori health losses and leads to inequalities in health between Maori and Europeans in New Zealand. Interventions and policies to improve Maori health and address these inequalities should take into account the health effects of racism.

Racism and health: the relationship between experience of racial discrimination and health in New Zealand.

Accumulating research suggests that racism may be a major determinant of health. Here we report associations between self-reported experience of racial discrimination and health in New Zealand. Data from the 2002/2003 New Zealand Health Survey, a cross-sectional survey involving face-to-face interviews with 12,500 people, were analysed. Five items were included to capture racial discrimination in two dimensions: experience of ethnically motivated attack (physical or verbal), or unfair treatment because of ethnicity (by a health professional, in work or when gaining housing). Ethnicity was classified using self-identification to one of four ethnic groups: Maori, Pacific, Asian and European/Other peoples. Logistic regression, accounting for the survey design, age, sex, ethnicity and deprivation, was used to estimate odds ratios (OR) and 95% confidence intervals (CI). Maori reported the highest prevalence of "ever" experiencing any of the forms of racial discrimination (34%), followed by similar levels among Asian (28%) and Pacific peoples (25%). Maori were almost 10 times more likely to experience multiple types of discrimination compared to European/Others (4.5% vs. 0.5%). Reported experience of racial discrimination was associated with each of the measures of health examined. Experience of any one of the five types of discrimination was significantly associated with poor or fair self-rated health; lower physical functioning; lower mental health; smoking; and cardiovascular disease. There was strong evidence of a dose-response relationship between the number of reported types of discrimination and each health measure. These results highlight the need for racism to be considered in efforts to eliminate ethnic inequalities in health.

The Social Functioning Questionnaire: a rapid and robust measure of perceived functioning.

BACKGROUND: The Social Functioning Questionnaire (SFQ), an eight-item self-report scale (score range 0-24), was developed from the Social Functioning Schedule (SFS), a semi-structured interview which has been used primarily with non-psychotic patients and has good test-retest and inter-rater reliability as well as construct validity. The SFQ was developed following the need for a quick assessment of perceived social function. AIMS: To give further details of old and new data sets from studies involving over 4000 subjects assessed with the SFQ illustrating its epidemiological and clinical associations. METHOD: New data were analysed from a national epidemiological study, a comparison of key-worker and subject versions of the SFQ, and reanalysis of data from three earlier clinical studies, of psychiatric emergencies, general practice psychiatric patients and those with recurrent psychotic illnesses. These data were examined further to determine their range, their relationship to other clinical measures, and change over time in clinical trials. RESULTS: The population mean score in 4164 subjects was 4.6 and the data from all studies suggested that a score of 10 or more indicated poor social functioning. Those presenting as psychiatric emergencies had the poorest social function (mean 11.4) and psychiatric patients from general practice the best function (mean 7.7) of the clinical populations. The eight item scores had a normal distribution in psychiatric populations and a skewed one in a normal population; scores were relatively stable over the short (weeks) and long-term (months), and were high in the presence of acute mental health disturbance and personality disorder, giving support to the validity of the scale. The results from a UK sample of a randomly selected population specifically weighted for ethnic minorities showed similar social function across groups.

Ethnicity, environment and health: putting ethnic inequalities in health in their place.

We set out to explore the influence of environment on ethnic inequalities in health. Studies exploring the relationship between environment and health have tended to ignore the role of ethnicity, and the health impact of the residential concentration of ethnic minority groups in disadvantaged areas. Those that have explored the role of ethnicity tend to focus on the way in which residential concentration may promote a sense of community among ethnic minority groups, and, consequently, may be protective of health (the 'ethnic density effect'). Again, they have tended to ignore the health impact of the concentration of ethnic minority groups in areas of social and economic disadvantage. We undertook a factor analysis to determine aspects of perception of 'quality' of the local environment, followed by multi-level analyses to explore the relationship between self-reported fair or poor health and individual- and ward-level characteristics among four ethnic groups (Caribbean, Indian, Pakistani and Bangladeshi, and white) in the UK. Results of the factor analysis suggested three underlying dimensions of perception of quality of the local area, related to the quality of the local environment, the provision of local amenities and local problems of crime and nuisance. These factors were entered into the multi-level models at level 2, along with indicators of ward-level ethnic density and Townsend's deprivation score, with age, gender and household social class entered at level 1. In general, there was a residual random ward-level effect suggesting an area influence on self-assessed health. However, on the whole, none of the ward-level indicators showed any statistically significant association with self-assessed health, making it difficult to precisely determine the mechanisms operating. These findings suggest, though, that there is no ethnic density effect on self-assessed health for ethnic minority groups.