Understanding ethnic inequalities in mental health and the need for an intersectional approach
Reflections through the lens of the Determinants of Adolescent Social Well-being and Health (DASH) study I am a researcher in Social Epidemiology at King’s College London trying to understand how political, social, and economic processes can lead to unequal health outcomes over the life course. During the last few years, I have had the luck and opportunity to research how these processes might contribute to unequal social and health outcomes of young people from minority ethnic groups. This blog reflects my thoughts about research in ethnic inequalities in health and findings from the DASH study, a longitudinal multi-ethnic London-based study, which has highlighted better mental health for young people from ethnic minorities, and a higher likelihood of gaining a university degree than their White British peers despite common experiences of deprivation and racism. Adolescence is an especially challenging period of biological, emotional, and psychological maturation during which new identities are negotiated, independence from parental influence is growing, there are new friendship choices and an interest in intimate sexual relationships emerges. These complex maturational processes occur within specific social, cultural, and family contexts.
Despite how well-documented differences in adult mental health across ethnic groups are in the United States and the United Kingdom, the social, particularly structural, and biological determinants of ethnic inequalities in adolescent mental health are not well understood. An in-depth understanding of ethnic inequalities in mental health requires an interrogation of intersectional axes such as socioeconomic position, gender, and racism. These social structural determinants cause and operate through intermediary social determinants of health, such as housing, physical environments, social support, health behaviours — to shape health outcomes.
Different methods of understanding and measuring ethnicity across several studies have made it difficult to understand who, how and to what extent someone’s health is affected by social and economic inequalities. Assigning people to ethnic categories according to the colour of their skin, country of birth, nationality or self-reported ethnicity has been particularly problematic in that respect.
In the UK, opportunistic use of studies that were not designed to examine ethnic inequalities has resulted in studies with small sample sizes of ethnic minority adolescents and less granular groupings (e.g. White, Black, Asian, and Other) lacking in statistical power to understand the intersectional influences. This has also promoted the use of confusing terminologies such as Black, Asian, and Minority Ethnic groups (BAME), particularly evident in the COVID-19 studies. Further, a lack of studies following the same group of people over a longer period has limited our understanding of when and how inequalities in mental health problems develop in ethnic minority adolescents.
The DASH study was set up in 2001 with a theoretical emphasis on understanding the contributions of social structural influences on the development of ethnic inequalities in adolescent mental health. Initially, the study recruited ~6500 adolescents (approximately 1000 from the UK’s six main ethnic groups; White, Black Caribbean, Black African, Indian, Pakistani, and Bangladeshi, and Other) aged 11–13 years old in the most ethnically diverse London boroughs, which are also some of the poorest in the UK. The diversity of the cohort reflects the everyday diversity that young Londoners’ experience, with ~50 languages spoken in total and with parents from ~100 countries. The participants were followed up at 14–16 years old, and a subset were also followed up at 21–23 years old. Due to the detailed information on the ethnic origin of its participants (self-defined and cross-checked with the heritage of parents and grandparents) and the inclusion of rich information on social structural (including environmental), cultural and biological determinants, DASH remains a rare study worldwide to understand what contributes to ethnic differences in physical and mental health over the life course.
Consistent with previous findings, DASH has shown that ethnic minority adolescents in London had better mental health than their White British peers. Additionally, it has shown that high proportions young adults from minority ethnic groups entered higher education and completed their undergraduate degree, despite greater exposure to adversity including more socio-economic disadvantage and more racism. Statistical analyses and interviews with DASH study participants have provided a nuanced understanding of cultural diversity and adversity in everyday lives of London’s ethnic minority adolescents.
The parenting experiences of ethnic minorities varied but were generally consistent with a conservative parenting style that combined warmth and support with a disciplinary framework. Family connectedness was reflected by joint family activities such as eating a meal together, a considerable aspect of socialisation within the family as it involves repeated rituals which forge togetherness and belonging, reinforcing tradition and structure. These activities were crucial but did not fully explain this mental health advantage.
Personal faith and religious values contributed to ethnic minority mental health advantage, regardless of the extent of religious practice or attendance to religious ceremonies. When DASH participants were 21–23 years old, their reflections on their attendance to places of worship and participation in religious practices in adolescence with their parents anchored around identity formation and the embedding of morals and values.
These morals and values included an ethic of tolerance and endurance, a sense of meaning, purpose and self-worth, and positive coping strategies in the face of adversity, including racism. Several participants, particularly Africans and Muslims and those who have become parents themselves, continued regular involvement with a place of worship in adulthood. Particularly poignant from some of the narratives was the perception of a seamless boundary between family and religious life, an insight that is difficult to obtain from simply quantitative analyses.
Diversity of Friendships Cultural integration, measured in the DASH study by ethnicity of friends, was linked to greater protection in adolescent males than females. Having friends from different cultural groups increased over time and was associated with better mental health than those who reported that their friends belonged mainly to other ethnic groups than their own or to their own ethnic group. The cultural diversity of London’s neighbourhoods and schools provided many opportunities for developing ethnic, cultural, or religious solidarities and identities. The Effect of Racism
Racism has been a consistent determinant of poorer mental health in the DASH study. In a recent paper, we reported on the intersectional influence of exposure to high levels of pollution and racism. Exposure to higher concentrations of Particulate Matter (fine inhalable particles) with diameters of 2.5 micrometres and smaller, which was more prevalent among Black Caribbean and Black African adolescents, was associated with worse symptoms of conduct problems during adolescence. Adolescents who reported experiencing racism and were exposed to higher concentrations of PM2.5 also had higher symptoms of conduct problems compared to adolescents who did not experience racism. Both racism and pollution represent structural influences that cause and maintain systemic inequalities, and the effects of pollution on mental health have been also discussed before in InSPIre The Mind.
It is worth mentioning that racism has been a consistent determinant of some physical health indices such as cardio-respiratory health (e.g. lung function, pulse wave velocity) and of health behaviours (e.g. cigarette smoking). How these physical, physiological and behaviour changes interrelate with brain development and adolescent mental health is unknown but gaining increasing recognition.
DASH has enabled an in-depth understanding of the social determinants of ethnic inequalities in adolescent mental health in the UK. It has been crucial to understanding how growing up with structural adversities can harm adolescents’ mental health, and how cultural practices can buffer against adversity for ethnic minority adolescents and young adults. Importantly, it has also contributed to a now growing body of evidence which emphasises the centrality of racism to understand ethnic inequalities in mental (and physical) health in adolescence and young adulthood.
To sum up, DASH and other studies have consistently shown that racism can have a detrimental effect on lifetime opportunities of ethnic minority young people and promote intergenerational cycles of ethnic inequalities in health. Although understanding the context and processes that operate in ethnic inequalities in young people’s mental health is by no means straightforward, I believe that it is imperative that research, as well as culturally appropriate policy and practice interventions, adopt an intersectional framework that reflects the complexity of inequalities in the real world.