© Blackwell Publishing/Editorial Board 2002

Agency and structure: ethnic identity, racism and health 1

© Blackwell Publishing/Editorial Board 2002. Published by Blackwell Publishers, 108 Cowley Road,Oxford OX4 1JE, UK and 350 Main Street, Malden MA 02148, USA.

Sociology of Health & Illness Vol. 24 No. 1 2002 ISSN 0141–9889, pp. 1–20

Agency and structure: the impact of ethnicidentity and racism on the health of ethnicminority peopleSaffron Karlsen and James Y. Nazroo

Department of Epidemiology and Public Health, University College, London

Abstract To understand ethnic inequalities in health, we must takeaccount of the relationship between ethnic minority status,structural disadvantage and agency. So far, the direct effectsof racial oppression on health, and the role of ethnicity asidentity, which is in part a product of agency, have beenignored. We set out to redress this balance using data from theFourth National Survey of Ethnic Minorities. Factor analysissuggested that dimensions of ethnic identity were consistentacross the various ethnic minority groups. Initially some ofthese dimensions of ethnic identity appeared to be related tohealth, but in a multivariate model the factor relating to aracialised identity was the only one that exhibited anyrelationship with health. These findings suggest that ethnicidentity is not related to health. Rather, the multivariateanalyses presented here showed strong independentrelationships between health and experiences of racism,perceived racial discrimination and class.

Keywords: ethnicity, identity, racism, socioeconomic, health, agency, structure

Introduction

Stripped of its dynamic social, economic, gender and historical context,culture becomes a rigid and constraining concept which is seen somehowto mechanistically determine peoples’ behaviours and actions ratherthan providing a flexible resource for living, for according meaning towhat one feels, experiences and acts to change (Ahmad 1996: 190).

Despite an increasing interest in ethnic inequalities in health in Britain, whatconstitutes being of an ethnic group, and how this is related to health, has

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remained largely unexplored (Nazroo 1998a, Smaje 1996). This is partly dueto an assumption in epidemiological research that ethnic differentials inhealth are a consequence of innate characteristics related to ‘ethnic’ or ‘racial’difference. This encourages the use of inflexible assessments of ethnicity thattreat ethnic categories as reflecting undifferentiated groups. Research findingshave often focused on, or at least implied, universal genetic and culturalexplanations for the relationship between ethnic status and health (Bhopal1997, Sheldon and Parker 1992).

More recently, research has begun to explore the possible contributionthat structural factors, particularly differences in socioeconomic position,might make to ethnic inequalities in health (Harding and Maxwell 1997,Nazroo 1997a). Such studies have found a clear class effect in the relation-ship between ethnicity and health, suggesting that the processes through whichethnic minority status leads to class disadvantage are central to understand-ing ethnic inequalities in health. However there may be other elementsof ethnicity as ‘structure’ that might also be important, and that have so farreceived little attention. In particular there is some evidence that experi-enced or perceived racism might be related to poorer health (Krieger andSidney 1996, Krieger et al. 1993, Benzeval et al. 1992).

Of course, ethnicity represents more than a position in a social structure,it also represents an identity that is at least partly a consequence of agency.The potential importance of ethnicity as identity to ethnic differences inhealth has been much discussed (Smaje 2000 and 1996, Nazroo 1998a, Ahmad1996), but has not been empirically investigated. This paper will attempt toredress this imbalance through an exploration of ethnicity as identity andits relationship with socioeconomic position, racism and health.

Structural components of ethnic differences in health

Racism may well be the key route through which structure influences ethnicinequalities in health. Racism can affect health in a number of ways (Krieger2000). It can affect health directly, through the negative physical and psycho-logical consequences of interpersonal racist victimisation and racial dis-crimination. Or indirectly, in the way that institutional racism leads to theidentification of ethnic minority groups, their reification as biologically andculturally different, and the consequent exclusion and social and economicdisadvantage that ethnic minority people experience (Miles 1989).

Recent studies have clearly shown both that socioeconomic gradientsin mortality and morbidity exist for different ethnic groups (Harding andMaxwell 1997, Nazroo 1997a, Lillie-Blanton and LaVeist 1996, Jones-Webband Snowden 1993), and the complexity of making adjustments for socio-economic position when attempting to draw comparisons across differentethnic groups (Kaufman et al. 1998, Nazroo 1998a, Nazroo 1998b, Nazroo1997a, Krieger et al. 1993). These studies suggest that conventional measures

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Agency and structure: ethnic identity, racism and health 3

of socioeconomic position may actually serve to conceal the socioeconomicdisadvantage experienced by ethnic minority groups, rather than expose it.Analysis previously undertaken on the Fourth National Survey (the datasetused here) suggests that the internal heterogeneity of traditional class group-ings, based here on the Registrar General’s measure of occupational class,masks the concentration of ethnic minority people in lower income occupa-tions, poorer quality housing and longer periods of unemployment thanwhite people in the same class (Nazroo 1997a).

In addition, the more immediate health consequences of racism have beenlargely ignored (Gillborn 1995, Krieger et al. 1993). Racism has been shownto have direct physical consequences, and such oppression can becomeinternalised, damaging self-esteem, and potentially compromising availablesocial support, which will also have consequences for health (Krieger andSidney 1996, Krieger et al. 1993, Benzeval et al. 1992). However studiesexploring the health effects of racism have so far produced inconsistentresults. Part of this inconsistency stems from the difficulties associated withassessing the extent to which individuals experience racism (Krieger 2000).In addition, the way in which an individual reacts to racism has been shownto mediate its health effects. In a study exploring rates of hypertensionamong black and white Americans, Krieger and Sidney (1996) found thatBlack Americans who said they would report and challenge racism had alower blood pressure than those who said they would tolerate but not reportit. They suggest that this negative health effect is a consequence of internal-ised anger, which was more likely among those that experienced but did notreport racial harassment.

However, while this evidence suggests that the exploration of structuralfactors is central to the understanding of ethnic inequalities in health, it isimportant to consider how they might be integrated with an understandingof agency. Here the conceptualisation of ethnicity as identity is of particularuse in understanding cultural lifestyles, as well as responses to socioeconomicdisadvantage and racial discrimination.

The role of agency: ethnic identity

Most commentators on the situation of ethnic minority people discuss anotion of ethnicity that reflects self-identification with cultural traditions thatprovide personal meaning and boundaries between groups (see, for example,the collected works in Barot 1996). Importantly, this self- and group-identification, rather than being something innate and fixed, is somethingthat is formed and perpetually transformed in relation to representation to,and reaction by, the external audience (see the opening quote from Ahmad1993). So, work on identity has suggested that an individual has a range ofdifferent ‘identities’, reflecting our age, gender, social class, ethnicity, etc,and from which it seems possible to choose – what Hall calls the ‘cultural

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supermarket’ effect (1992: 303) – and which locate us in our social context(Smaje 1996, Deaux et al. 1995).

Identity, however, is not, of course, entirely self-constructed. Jenkins (1994)defines two aspects of identity: the ‘nominal’ (the name) and the ‘virtual’(the experience). Defining who is and what it is to be a member of a partic-ular social group is seen to involve the consolidation of internal and externalprocesses: the external imposition of a characterisation, for example, willaffect the social experience of living with that identity and the self-image ofthose so defined. Further, the effect of representation is such that what it isto have a particular identity will also vary according to the external audi-ence. It is argued, therefore, that defining who we are, both by name and inexperience, is dynamic and relatively ambiguous and, while being a largelyinternal process, will be heavily influenced by wider society. In this way,the experience of racism, for example, can be seen actually to structure anindividual’s own identity, as well as affecting the way in which someonewith that identity interacts with others.

So individual decisions about who we are and our lifestyle choices, whileappearing to be unbounded and, therefore, solely a consequence of agency,are, in reality, made within social constraints, what Bourdieu terms ‘habitus’(1977). The theory of habitus explores the way in which symbolic representa-tions influence behaviour through:

a whole body of wisdom, sayings, commonplaces, ethical precepts(‘that’s not for the likes of us’) and, at a deeper level, the unconsciousprinciples of the ethos which . . . determines ‘reasonable’ and‘unreasonable’ conduct for every agent (1977: 77).

Thus Bourdieu argues that while social practice has some purpose and prac-tical intent for the individual, these goals are located within an individual’sown experience of reality, which is related to who and what they are and is,therefore, at least partially, externally defined.

Bourdieu argues that the only means of expanding this sphere of ‘reason-able’ behaviour is through increasing the lifestyle choices available, via formsof ‘capital’, which are also delimited by social position. So, attempts by socialgroups to define and appropriate their own lifestyle will also be restrainedand influenced by the social structure and wider society (see also Smaje 1996).For example, Hall (1992) discusses the way in which globalisation andsustained migration have lead to the pluralisation of national cultures andidentities. He suggests that identities may react to this by becoming moretraditional, ‘attempting to restore their former purity and recover the unitiesand certainties which are felt as being lost’ (Hall 1992: 309), or they mayadapt. He explores the notion of a translation of culture, which occurs wherepeople are obliged to come to terms with new cultures surrounding them,but also wish to retain strong links with their places of origin and associatedtraditions, and so form a new ‘hybrid’ identity with aspects of each. And, he

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argues, these changes are not restricted to minority groups. The strengtheningof local identities in the UK, for example, coincide with ‘a revamped Eng-lishness, an aggressive little Englandism, and a retreat to ethnic absolutism’(Hall 1992: 308).

So, while aspects of ethnic identity may be internally defined, and there-fore the consequence of agency, the scope of those choices will be restrictedand affected by social structure and any consideration of ethnic identityneeds to take account of this. There is also a need to consider ethnicity as a‘hybrid’ identity (Modood 1998, Hall 1992), one that is influenced by internaland external factors, locally and globally – an identity that is not just given,but which is continually changed across contexts and over time. Import-antly, this notion of ethnicity as identity emphasises the political process ofethnic affiliation at the expense of behavioural markers of ethnicity (includ-ing, of course, those behaviours relating to health) (Modood 1998). And, ofcourse, such ethnic affiliation could provide important symbolic and materialresources that are health promoting. While socioeconomic disadvantage mightcontribute to ethnic inequalities in health, there remains a cultural compon-ent to ethnicity which could also make a major contribution to differencesin health.

The demand, then, is to build on work that has investigated the impact ofstructural factors on the health of ethnic minority people to explore the roleof agency. In this paper we do this by including an assessment of the import-ance of ethnicity as identity. This is not straightforward for two reasons.First, the contextual nature of ethnic identity makes it hard to operationalisein a quantitative study. Second, the relationship between culture/identity andhealth is not likely to be straightforward. For example, while some customsmay lead to improved social support (Kelleher 1996), sociocommunal en-gagement and psychological wellbeing (Halpern and Nazroo 1999), in somecircumstances they may also lead to negative discrimination and isolation.Here we will describe one approach to exploring the relationship betweenethnic identity, structure and health: an approach that uses quantitativetechniques, but which also recognises the multi-dimensional nature of ethnicidentity.

Methods

Fourth National Survey of Ethnic MinoritiesThe findings presented in this paper are based on secondary analysis of theFourth National Survey of Ethnic Minorities (FNS). The FNS was a repres-entative survey of ethnic minority and white people living in England andWales that was undertaken in 1993 and 1994 by the Policy Studies Instituteand Social and Community Planning Research (now the National Centrefor Social Research). A sample of 5,196 people of Caribbean and Asianorigin and 2,867 white people underwent a structured face-to-face interview

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conducted by an ethnically matched interviewer in the language of therespondent’s choice. Respondents were allocated into an ethnic group onthe basis of answers to a question on their family origins. In addition tophysical (Nazroo 1997a) and mental (Nazroo 1997b) health, the questionnairecovered a comprehensive range of information on both ethnicity and otheraspects of the lives of ethnic minority people, including demographic andsocioeconomic factors. Included in this was a section on ethnic identity.However, only half of the ethnic minority sample and none of the whitesample were asked the questions on ethnic identity. (For further details ofthe methods and findings, see Modood et al. 1997.)

Across the health outcomes and in terms of sociodemographic profilesand responses to individual identity measures, analysis of the FNS datashowed great similarity between Pakistani and Bangladeshi people, on theone hand, and Indian and African Asian people on the other (Modood et al.1997, Nazroo 1997a). To overcome the problem of small numbers, thesegroups were combined for this analysis. The sample for this analysis was:591 Caribbean people; 903 Pakistani or Bangladeshi people; and 1,013Indian or African Asian people. The Chinese sample (N = 107) was toosmall to include.

Ethnic identity, occupational class and healthTo determine underlying dimensions of ethnicity that might contribute to asense of identity, a factor analysis (Kim and Mueller 1979) of these variableswas conducted. This technique is used to identify factors that can be usedto represent correlations among sets of inter-related variables. We firstconducted this for each ethnic group separately, then for all of the ethnicminority groups combined. The principal components method of factorextraction was used. This produces factors in sequence according to theamount of the total sample variance they account for. The total varianceexplained by each factor is called the eigenvalue. This analysis reports onlyfactors with an eigenvalue of 1 or over (Kim and Mueller 1979). Principalcomponents analysis was followed by oblique rotation to allow for correla-tion between the different factors identified. Cronbach’s alpha reliabilitycoefficients give results from tests of correlation between the variablesclustering under the different factors. Individual respondents were allocateda factor score for each of the factors identified, which summarised theirresponses to all of the questions included in the analysis.

The factor analysis concentrated on questionnaire items relating to descrip-tions of ancestry and ethnic affiliation, lifestyle, experience and percep-tions of racism, and social and community involvement. The factor analysisincluded questions on: aspects that would be perceived to be important ina description of the respondent given by themselves and a white person;participating in customs and behaviours which may be seen as traditional toan ethnic group; membership of ethnically-specific organisations; experience

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or recognition of racist elements in British society; and the extent to whichthe respondents saw themselves as ‘British’ and as a member of their ethnicgroup. The details of these questions will be shown in the results section.

To explore the relationship between ethnic identity, class and health, aseries of regression tests were undertaken using self-reported fair or poorhealth as the outcome variable, and the different dimensions of ethnic ident-ity, occupational class, age and gender as independent variables. Class wasassigned using the head of the household’s occupation (coded as non-manualor manual), with a third group of those with no full-time worker in thehousehold. Where it was not clear which household member was the headof household (e.g. where there was more than one working adult), classwas allocated on the basis of gender (with men’s occupations being used inpreference to women’s) and age (e.g. a father’s occupation being used inpreference to a son’s, if the father was below retirement age).

To explore associations between ethnic identity and specific health con-ditions, the analysis was repeated for probable heart disease (diagnosedangina, diagnosed heart attack or severe chest pain), diagnosed diabetes anddiagnosed hypertension.

Racial discrimination and healthTo investigate further the relationship between structural components ofethnicity and health, we performed a logistic regression test to explore therelationship between experience of racial harassment, perceptions of the extentof racial discrimination in Britain and reported fair or poor health. Variablesincluded were: occupational class, gender, age and whether the respondenthad been the victim of a racially motivated attack in the last 12 months(coded ‘none’, ‘verbal attack’ and ‘physical attack on one’s property orperson’). This analysis was repeated adding in a question asking whether therespondent felt British employers discriminated against people on the basisof race or religion (coded ‘no’, ‘a few’, ‘some’ and ‘most’), which was askedof only half the sample.

Results

Dimensions of ethnic identityAnalysis retaining all factors with an eigenvalue of one or over produced afive factor model. Half (49.1 per cent) of the total variance in the model wasexplained by these five factors. The working titles given to the five factorswere: nationality important for self description; ‘ethnicity/race’ importantfor self-description; traditional; community participation; and member of aracialised group.

The questions loading on factor 1 (nationality important for self descrip-tion) were:

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• If you were describing yourself on the phone to a new acquaintance ofyour own sex from a country you have never been to,• would your nationality tell them something important about you?• would the country your family came from tell them something

important about you?

• If a white person who knew and liked you was describing you toanother white person, would they think it important to mention:• your nationality?• the country your family came from?

(Cronbach’s alpha = 0.61)

The questions loading on factor 2 (‘ethnicity/race’ important for selfdescription) were:

• If you were describing yourself on the phone to a new acquaintance ofyour own sex from a country you have never been to,• would your skin colour tell them something important about you?• would the fact that you are Asian/Caribbean tell them something

important about you?

• If a white person who knew and liked you was describing you toanother white person, would they think it important to mention:• your skin colour?• that you are Asian/Caribbean?

(Cronbach’s alpha = 0.65)

The questions loading on factor 3 (traditional) were:

• How often do you wear Asian clothes/something that is meant to showa connection with the Caribbean or Africa?(Responses: ‘Never’; ‘At social events’; ‘At home’; ‘At work, or whileshopping’; ‘All the time’)

• ‘Who do you speak to in a language other than English?’(‘No-one’; ‘Own-age relatives’; ‘Younger relatives’; ‘Older relatives’;‘Friends outside work’; ‘Work friends’)

• ‘Would you personally mind if a close relative were to marry a whiteperson?’ (‘I wouldn’t mind’; ‘I would mind a little’; ‘I would very muchmind’)

• Do you strongly agree, agree, neither agree or disagree, disagree orstrongly disagree with these statements?:• ‘In many ways I think of myself as being British’• ‘In many ways I think of myself as being Asian/Caribbean’

(Cronbach’s alpha = 0.56)

The questions loading on factor 4 (community participation) were:

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• ‘Does your voluntary work bring you mainly into contact with peopleof your ethnic origin, mainly white people or about equally with both?’(‘Don’t volunteer’; ‘Mainly White’; ‘Both’; ‘Mainly people from myown ethnic group’)

• ‘Do your activities with this organisation bring you mainly intocontact with people of your ethnic origin, mainly white people orabout equally with both?’(‘Am not a member of an organisation’; ‘Mainly White’; ‘Both’; ‘Mainlypeople from my own ethnic group’)

(Cronbach’s alpha = 0.40)

The questions loading on factor 5 (member of a racialised group) were:

• ‘In the last twelve months, have you been a victim of a racially motiv-ated attack (verbal or physical abuse to the person or property)?’

• ‘Have you ever been treated unfairly at work or been refused a job onthe basis of race, colour or your religious or cultural background?’

• ‘How many of the employers in Britain do you think would refusea job to a person because of their race, colour, religion or culturalbackground?’(‘None’; ‘A few’; ‘About half’; ‘Most’)

(Cronbach’s alpha = 0.40)

When the factor analysis was conducted for each ethnic group separately,the results were very similar for each group.

Analysis of variance in the mean factor scores for each ethnic groupshowed no statistically significant difference between the ethnic group meansfor factors 1 (nationality important for self-description, F = 0.465, p = 0.6)or 4 (community participation, F = 0.358, p = 0.7). There was, however, astatistically significant variation between the ethnic group means for factors2 (‘ethnicity/race’ important for self description, F = 176.2, p < 0.001, with alower mean score for the Caribbean group, compared with the two SouthAsian groups), 3 (traditional, F = 406.2, p < 0.001, again with a lower meanscore for the Caribbean group) and 5 (member of a racialised group, F = 132.4,p < 0.001, with a lower mean score for the Pakistani or Bangladeshi groupand a higher mean score for the Caribbean group). These findings wouldsuggest that the dimensions of ethnic identity are consistent across differentethnic minority groups, but the nature and significance of particular dimen-sions vary markedly. (See Nazroo and Karlsen, forthcoming, for a moredetailed discussion of this and for a discussion of the relationship betweenthese dimensions of ethnic identity and socio-demographic indicators.)

Ethnic identity and healthReporting fair or poor health: Tables 1a, 1b and 1c show odds ratios of therelationship between self-reported fair or poor health, ethnic identity (using

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10 Saffron Karlsen and James Y. NazrooTable 1a Ethnic identity and risk of fair or poor health – Indian or African Asian group

Odds ratios (95% confidence intervals)

Indian or African Asian (n = 950)Model 1 Model 2 Model 3

Nationality 1.02 (0.86–1.21) 1.09 (0.91–1.31) 1.09 (0.91–1.31)Ethnicity 1.30 (1.07–1.56) 1.05 (0.86–1.29) 1.08 (0.88–1.33)Traditional 1.62 (1.32–1.99) 1.24 (1.01–1.53) 1.20 (0.97–1.50)Community 1.10 (0.93–1.29) 1.07 (0.90–1.28) 1.09 (0.91–1.31)Racialisation 1.14 (0.96–1.37) 1.33 (1.10–1.61) 1.38 (1.14–1.67)

GenderMale 1.00 1.00Female 1.58 (1.06–2.34) 1.60 (1.07–2.40)Age 1.07 (0.99–1.15) 1.08 (1.00–1.16)ClassNon-manual 1.00Manual 1.63 (1.04–2.56)No full-time worker in thehousehold 2.49 (1.56–3.97)

Chi-sq (df) 30.0 (5) 102.7 (8) 128.0 (10)p-value <0.001 <0.001 <0.001

Table 1b Ethnic identity and risk of fair or poor health – Pakistani or Bangladeshi group

Odds ratios (95% confidence intervals)

Pakistani or Bangladeshi (n = 835)Model 1 Model 2 Model 3

Nationality 1.02 (0.85–1.21) 1.10 (0.93–1.30) 1.09 (0.92–1.29)Ethnicity 1.25 (1.00–1.56) 1.04 (0.81–1.33) 1.03 (0.80–1.32)Traditional 1.76 (1.38–2.25) 1.39 (1.04–1.84) 1.34 (1.00–1.79)Community 0.94 (0.76–1.17) 1.06 (0.85–1.33) 1.13 (0.88–1.43)Racialisation 1.07 (0.85–1.33) 1.14 (0.88–1.47) 1.18 (0.91–1.52)

GenderMale 1.00 1.00Female 1.51 (0.97–2.34) 1.57 (1.00–2.47)Age 1.09 (1.00 –1.19) 1.12 (1.03–1.22)ClassNon-manual 1.00Manual 1.45 (0.74–2.84)No full-time worker in thehousehold 2.48 (1.35–4.58)

Chi-sq (df) 26.0 (5) 87.8 (8) 91.8 (10)p-value <0.001 <0.001 <0.001

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Table 1c Ethnic identity and risk of fair or poor health – Caribbean group

Odds ratios (95% confidence intervals)

Caribbean (n = 555)Model 1 Model 2 Model 3

Nationality 0.77 (0.62–0.97) 0.95 (0.74–1.23) 0.94 (0.73–1.22)Ethnicity 1.13 (0.89–1.42) 1.16 (0.90–1.49) 1.16 (0.90–1.49)Traditional 1.05 (0.81–1.37) 1.08 (0.82–1.43) 1.06 (0.81–1.40)Community 0.91 (0.74–1.12) 1.09 (0.86–1.38) 1.08 (0.85–1.37)Racialisation 0.90 (0.72–1.13) 0.94 (0.73–1.20) 0.94 (0.73–1.20)

GenderMale 1.00 1.00Female 1.81 (1.13–2.92) 1.77 (1.09–2.86)Age 0.97 (0.87–1.08) 0.99 (0.89–1.10)ClassNon-manual 1.00Manual 0.94 (0.52–1.70)No full-time worker in thehousehold 1.40 (0.80–2.45)

Chi-sq (df) 5.8 (5) 56.0 (8) 57.3 (10)p-value 0.3 <0.001 <0.001

the dimensions of ethnic identity identified using the factor analysis) andoccupational class for each ethnic group. The model was constructed in threestages: first with only self-reported health and the dimensions of identity;then with age and gender; and finally with occupational class.

Before the inclusion of age and gender, factors 1, 2 and 3 had statisticallysignificant associations with self-reported health for one or more ethnicgroups. A high score on factor 1 (importance of nationality in a self-descrip-tion) was associated with a statistically significant reduction in fair or poorhealth among Caribbean people, but had no relationship with health for theother two groups. A high score on factor 2 (importance of ‘ethnicity/race’ ina self-description) was associated with increased reports of fair or poorhealth that approached significance for the Pakistani or Bangladeshi group,and was significant for the Indian or African Asian group. A high factor 3score (traditional) was associated with a 60 to 80 per cent greater likelihoodof reporting fair or poor health for both of the South Asian groups.

After including age and gender in the models, the effects of the ethnic iden-tity factors changed. Both the reduced risk for Caribbean people associatedwith higher scores on factor 1 and the increased risk for South Asianpeople associated with higher scores on factor 2 disappeared. The effectof factor 3 for the South Asian groups remained statistically significant, but

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Table 2a Ethnic identity and risk of heart disease*

Odds ratios (95% confidence intervals)

Indian or Pakistani or CaribbeanAfrican Asian Bangladeshi

(n = 388) (n = 278) (n = 237)

Nationality 1.15 (0.79–1.66) 1.62 (1.13–2.30) 1.13 (0.69–1.86)Ethnicity 0.74 (0.51–1.09) 0.75 (0.50–1.13) 1.12 (0.76–1.65)Traditional 1.01 (0.68–1.50) 1.05 (0.64–1.71) 0.87 (0.47–1.61)Community 1.25 (0.87–1.79) 0.82 (0.48–1.42) 1.29 (0.84–1.99)Racialisation 1.32 (0.82–2.14) 0.84 (0.54–1.31) 0.90 (0.53–1.54)

ClassNon-manual 1.00 1.00 1.00Manual 1.47 (0.48–4.46) 4.98 (1.16–21.32) 0.92 (0.25–3.36)No full-time worker in thehousehold 3.06 (1.30–7.22) 6.68 (1.74–25.66) 0.98 (0.27–3.47)

* diagnosed angina, diagnosed heart attack or severe chest pain. Model also controlled for ageand gender.

the size of the association declined substantially. Entering age and genderinto the models separately suggested that it was age that accounted for thereduction in identity effects (not shown in the tables). Interestingly, afterincluding age in the models, the association between self-reported fair orpoor health and factor 5 (racialisation) increased and became statisticallysignificant for the Indian or African Asian group.

When occupational class was entered into the models, it appeared to havean effect for each ethnic group. For the two South Asian groups, the classeffect was significant and sizeable; for example, South Asian people livingin households with no full-time worker had a two-and-a-half times greaterchance of reporting fair or poor health, compared with South Asian peopleliving in non-manual-headed households. There was also an effect for theCaribbean group, but this was smaller and not statistically significant.Although the inclusion of occupational class in the model did not greatlyreduce the odds ratios for the identity factors, in the full model none of theidentity factors made a statistically significant contribution, with the excep-tion of factor 5 for the Indian or African Asian group.

Specific health outcomes: Table 2a shows associations between the fivedimensions of ethnic identity, age, gender, occupational class and heartdisease, for each ethnic group. Factor 1 was the only ethnic identity factorwhich exhibited any statistically significant effect, with a 60 per cent increasein risk of heart disease among the Pakistani or Bangladeshi group. Occupa-tional class showed a statistically significant association for both of the SouthAsian groups, with those from households with no full-time worker at

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Table 2b Ethnic identity and risk of diabetes diagnosis*

Odds ratios (95% confidence intervals)

Indian or Pakistani or CaribbeanAfrican Asian Bangladeshi

(n = 950) (n = 834) (n = 553)

Nationality 0.94 (0.66–1.33) 1.03 (0.72–1.48) 0.98 (0.60–1.61)Ethnicity 1.07 (0.69–1.64) 1.32 (0.84–2.08) 1.09 (0.72–1.65)Traditional 0.84 (0.59–1.21) 1.21 (0.79–1.85) 0.86 (0.35–2.09)Community 1.19 (0.90–1.57) 1.34 (0.96–1.86) 1.03 (0.73–1.45)Racialisation 0.99 (0.66–1.48) 0.99 (0.64–1.54) 0.85 (0.53–1.35)

ClassNon-manual 1.00 1.00 1.00Manual 1.42 (0.55–3.64) 1.95 (0.50–7.67) 0.53 (0.15–1.93)No full-time worker in thehousehold 1.65 (0.68–4.01) 2.02 (0.56–7.26) 0.95 (0.27–3.33)

* also controlled for age and gender.

between three and seven times greater risk of heart disease than those fromhouseholds headed by a non-manual worker.

None of the dimensions of ethnic identity have a statistically significantassociation with diagnosed diabetes (Table 2b). Although the odds ratiosare not statistically significant, there is a suggestion of a class effect for thetwo South Asian groups.

Factor 5 (member of a racialised group) was significantly associated withdiagnosed hypertension for the Indian or African Asian group (Table 2c).Among the Pakistani or Bangladeshi group, living in households headedby someone in a manual occupation was significantly associated with afive times greater risk of hypertension, and those from households with nofull-time worker had an almost seven times greater risk than those innon-manual occupations. There was also a suggestion of a class effect forthis outcome for the Indian or African Asian group.

The role of racism in the reporting of fair or poor healthTo explore further the health effects of racialisation that were indicated bythe findings for factor 5, we undertook a regression analysis to explore therelationship between self-reported fair or poor health, occupational classand perceived or experienced racism (Table 3). Initially models were con-structed for each ethnic group separately, but the similarity of findings acrossthe three ethnic minority groups allows us to present data for all ethnic groupscombined. There was a statistically significant relationship between occupa-tional class and self-reported fair or poor health: with those from householdsheaded by a manual worker three-fifths, and those from households with no

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Table 2c Ethnic identity and risk of hypertension diagnosis*

Odds ratios (95% confidence intervals)

Indian or Pakistani or CaribbeanAfrican Asian Bangladeshi

(n = 946) (n = 834) (n = 551)

Nationality 1.06 (0.76–1.47) 0.74 (0.55–1.00) 1.00 (0.74–1.34)Ethnicity 1.04 (0.76–1.42) 1.28 (0.92–1.77) 0.85 (0.62–1.16)Traditional 0.80 (0.58–1.10) 1.15 (0.77–1.73) 0.78 (0.54–1.13)Community 1.13 (0.86–1.49) 0.96 (0.62–1.48) 1.06 (0.82–1.36)Racialisation 1.56 (1.14–2.13) 1.16 (0.80–1.66) 1.07 (0.79–1.44)

ClassNon-manual 1.00 1.00 1.00Manual 2.07 (0.95–4.52) 5.40 (1.55–18.82) 0.95 (0.44–2.03)No full-time worker in thehousehold 1.30 (0.60–2.85) 6.78 (2.11–21.79) 1.89 (0.90–3.97)

* also controlled for age and gender.

Table 3 Racial discrimination, occupational class and risk of fair or poor health (allethnic minority groups combined)*

Odds ratios (95% confidence intervals)

All ethnic minority groupsHarassment Harassment and perceived

discrimination(n = 4106) (n = 2067)

Racially motivated attackNo attack 1.00 1.00Verbal 1.56 (1.17–2.08) 1.60 (1.09–2.35)Physical/property 2.27 (1.38–3.73) 2.23 (1.14–4.37)

British employers are racistNone 1.00A few 1.15 (0.84–1.58)Some 1.52 (1.07–2.15)Most 1.66 (1.17–2.37)

Occupational classNon-manual 1.00 1.00Manual 1.65 (1.38–1.99) 1.58 (1.22–2.05)Unemployed 1.41 (1.02–2.00) 1.39 (0.85–2.25)

Chi-sq (df) 300.6 (7) 176.2 (10)p-value <0.001 <0.001

* also controlled for age and gender.

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full-time worker two-fifths more likely to report fair or poor health thanthose from households headed by someone in a non-manual occupation.

There was a statistically significant association between reported fair orpoor health and experience of interpersonal racial harassment. Those whoreported having experienced racially-motivated verbal abuse were 60 percent more likely to report having fair or poor health compared with thosewho said they had experienced no racial harassment. Those who reportedexperience of racially-motivated assault or property damage were over twiceas likely to report fair or poor health. There was also a statistically significantassociation between a perception of British employers as discriminatingagainst people on the basis of race or religion and self-reported fair or poorhealth. Those reporting that they believed ‘some’ or ‘most’ British employersto be discriminating were between 50 and 66 per cent more likely to reportfair or poor health compared with those who believed a few, if any, Britishemployers were racist. (See Karlsen and Nazroo 2002 for further details ofthe relationship between racism, class and specific health outcomes.)

Discussion

In terms of ethnic identity, these findings are consistent with earlier worksuggesting that ethnic identity has nominal and virtual components and isinfluenced by internal and external definitions of ethnicity (Jenkins 1994).Of the dimensions of ethnic identity derived from this factor analysis, factors1 and 2 (based on nationality, country of origin and skin colour) appear tobe more closely related to the nominal components of ethnic identity. Ofcourse, giving oneself a name also requires a perception of what it is to bethat name, a perception that at least partly depends on the virtual compon-ent of ethnic identity, to which we would argue factors 3, 4 and 5 appear tobe related.

Factor 3, traditional, which combined items relating to clothes, language,attitudes to mixed marriage and perception of oneself as British and Asian/Caribbean, may operate as a boundary of inclusion, providing an internalsense of identity. The elements of it that involve presentation of a publicimage through particular behaviours and participation in customs could besimilar to what Smaje (1996) terms ‘unreflective ethnicity’, i.e. that there areaspects of behaviour that typify a particular ethnic group, while not beingculturally marked by them. If this public behaviour is unreflective, yet issignificant for identity, then it may involve some internalisation of externalattitudes and the unconscious routinisation of behaviour, reflecting thedynamic nature of what Bourdieu (1977) calls ‘bodily hexis’, where ‘politicalmythology is realised and embodied and turned into a permanent disposi-tion’ (1977: 94). However, while this would suggest some imposed internalisa-tion in the nature of this aspect of ethnic identity, it is also likely that activitieswhich are seen as traditional to an ethnic group will have been negotiated

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within the group, as well as externally influenced (see Hall’s 1992 dis-cussion of the maintenance or revitalisation of tradition as a response toglobalisation, summarised in the introduction to this paper). While aspectsof this dimension of ethnic identity may be internally defined, and thereforethe consequence of agency, the scope of those choices will be restricted andaffected by the social structure.

Factor 4, community participation, could also be considered to reflect aboundary of inclusion. Compared with factor 3, however, the perceivedneed to establish ethnically-identified groups might be more likely to reflectboth a response to exclusion by wider society and a positive celebration ofethnic group membership, a kind of politicised identity. This is one aspect ofethnicity as identity which could be construed as a ‘new social movement’(Scott 1990).

The way in which an ethnic group may develop a form of politicised oressentialist identity as a racialised group in reaction to social constraint hasbeen explored by Hall (1992). It is this dimension of identity which wouldappear to be reflected in factors 4 and 5. Factor 5, which incorporatesperceptions and experience of racism, is the most obvious indicator, amongthose dimensions explored here, of external influences on ethnic identity. Itcould be argued that those who score highly on this factor will have recog-nised their ethnic status as one that has been racialised by the ethnic majority.This factor may, therefore, carry connotations similar to the term ‘blackness’used in the 1970s and 1980s to describe the ‘expression of a common experi-ence of exclusion and of a common political identity forged through resistanceto that exclusion’ (Miles 1994: 7, see also Modood 1988). Although there wasa statistically significant difference in the distribution of scores on thisfactor for the different ethnic groups, the fact that it consistently emergedfor each, and the degree of overlap between distributions, suggests that, atleast in terms of the measures used here, there is a broad similarity in theeffects of experience of racism in relation to ethnic identity (Nazroo andKarlsen, forthcoming). This would also be consistent with work by Deauxet al. (1995) who described ‘ethnic/religious groups’ and ‘stigmatised groups’as two distinct types of social identity. This suggests that there may besimilarities in identity developed as a member of a stigmatised group, despitedifferences in (other) aspects of ‘ethnic/religious’ identity.

Indeed, in terms of the exploration of patterns of these dimensions ofethnic identity, the key finding is the similarity of factor loadings acrossthe three ethnic groups (see Nazroo and Karlsen, forthcoming). Althoughthe distribution of factor scores in some cases differed between the groups,this similarity of factor loadings across the ethnic groups would suggest thatthe basic nominal and virtual components of ethnic identity among differentethnic minority groups in Britain may be broadly similar. Indeed, differencesfor the factor that showed the largest variation between the Caribbean andSouth Asian groups, factor 3 (traditional), may be a result of Caribbeanpeople not having the same types of ‘opportunity’ as South Asian people

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to present themselves as members of an ethnic minority group (or rather toscore highly on the particular aspects of ‘traditional’ ethnic identity measuredin this analysis): for example, only a fifth of Caribbeans compared to over90 per cent of South Asian groups in this sample spoke a language otherthan English (Modood et al. 1997).

In terms of the relationship between the identified dimensions of ethnicidentity and health, initial models that did not include age or occupationalclass might have suggested that, for the South Asian groups, higher scoreson the more nominal and ‘unreflective’ elements of ethnic identity (factors 2and 3) were related to increased risk of reporting fair or poor health. Fromthis it could be hypothesised that, for more ‘unreflective’ aspects of ethnicityat least, this is related to culturally-determined health behaviours (such asdiet, exercise and smoking). But, when age was included, these effects weresubstantially reduced and in the full models, which also included occupa-tional class, they were no longer statistically significant. Dimensions ofethnic identity, as measured by the FNS, also had little association with thespecific conditions explored in this analysis: heart disease, diagnosed diabetesand diagnosed hypertension.

It seems therefore that the initial effect was spurious – largely a conse-quence of the correlation between age and both identity and health. Whilethis could be a cohort effect, earlier analysis using the FNS to explore theeffect of country of birth and migration status on health indicators andhealth-related behaviours suggested the existence of a cohort effect wasunlikely (Nazroo 1997a). So, while the existence of a cohort effect is impos-sible to rule out, it is likely that this is an age effect. Here, it is importantto acknowledge that an apparent relationship between traditional elementsof ethnic identity and health, that might be seen in a practice setting forexample, may simply be confounded by age.

Findings from the model exploring the relationship between racism, class,and self-reported health suggested that experienced harassment, perceivingBritish employers to be discriminatory and occupational class all have inde-pendent effects on self-reported fair or poor health. Independent of socialposition, as measured by our indicator of occupational class, those report-ing any experience of racial harassment had between 55 and 125 per centgreater risk of reporting fair or poor health compared with those who hadnot. Similarly, those who perceived the persistence of racist attitudes in overhalf of British employers had almost a 70 per cent increased risk of fairor poor health. These findings support earlier work suggesting a positiveassociation between experience of racism (in various forms) and experienceof poorer physical and mental health (Krieger and Sidney 1996, Kriegeret al. 1993, Benzeval et al. 1992, James et al. 1987, for further discussion seeKarlsen and Nazroo 2002). They would also seem to be supported by otherstudies suggesting a positive association between experiences of assault ingeneral and heart disease (Williams et al. 1994) and psychological distress(Williams and Hunt 1997).

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It is important to note the limitations of this study. As we pointed out ear-lier, racism and ethnic identity are multidimensional and historically locatedconcepts which can be only partially captured by a cross-sectional quantitativesurvey. Some of the factors included a small number of outcomes, which isparticularly problematic when undertaking factor analysis. These limitationscan be seen in the relatively low levels of total sample variance explained byour five factors, and the relatively low Cronbach’s alpha reliability coeffi-cients for the key variables clustering under some of the factors. Althoughthe eigenvalues give some reassurance as to the validity of our findings,these limitations would suggest a need for caution when interpreting them.

Conclusion

The evidence from the data presented here and elsewhere (Nazroo andKarlsen forthcoming, Karlsen and Nazroo 2002) suggest that ethnicity asidentity, in terms of self-description, self-presentation and behaviour, mem-bership of ethnic minority organisations, and perceptions and experiencesof racism, can be clearly and consistently identified across ethnic minoritygroups. However, our findings suggest that ethnicity as identity does notappear to influence health; rather ethnicity as structure – both in termsof racialisation and class experience – is strongly associated with health forethnic minority people living in Britain. The analysis presented here showedindependent relationships between perceptions of racial discrimination,experience of racial harassment, class indicators and health, with all threeindependent variables having a considerable impact on health. This highlightsthe limitations of current measures of structural effects used in researchexploring ethnic inequalities in health: not only do we need measures thatadequately account for the different forms of social disadvantage experiencedby ethnic minority groups, we also need to explore the various ways inwhich racism itself can impact on physical and mental health. Although fewstudies have attempted to explore the role of racism in the health experienceof people from ethnic minority groups, this would appear to be an import-ant aspect of their daily lives in Britain, and one that needs to be incorpo-rated into strategies to address ethnic inequalities in health.

Address for correspondence: Saffron Karlsen, Department of Epidemiologyand Public Health, University College London, 1–19 Torrington Place, LondonWC1E 6BTe-mail: s.karlsen@public-health.ucl.ac.uk

Acknowledgements

This paper draws on research funded by the ESRC (L128251019) under the HealthVariations Programme. The data used are drawn from the Fourth National Survey

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and thanks are due to the funders of the survey (particularly the Department ofHealth), advisory groups, colleagues at the Policy Studies Institute and the NationalCentre for Social Research, and, most importantly, the thousands of respondentswho gave of their time. We would also like to thank the anonymous reviewers fortheir very helpful comments.

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