Has psychological distress among UK South Asians been under-estimated? A comparison of three measures in the west of Scotland population

Falling on deaf ears: interpreters as cultural brokers in mental healthcare

Communication is the cornerstone of mental healthcare. In the UK, many people who will need access to mental health services do not possess English as their first language. In this editorial, we seek to examine current policy and guidance with respect to interpreting in mental healthcare, and explore the benefits and challenges of interpretation and the ethical implications to consider. We focus on how mental health services could better engage with interpreters as cultural brokers to understand cultural expressions of distress. We conclude by suggesting an education and research agenda which could decrease ethnic disparities in mental healthcare.

Mental health of patients from different cultures in Germany

Background

Empirical studies on migration and mental health of migrants are still rare. In Germany they are often characterised by low sample sizes and are limited to certain diseases and geographical areas (old federal states). The comparability of their results is limited. Nonetheless, the assessment of migrants’ health is necessary for adequate medical and psychosocial care for this target group.

Aim

To provide data on mental health of migrants from Poland and from Vietnam in Germany. Methods: We have assessed a random sample of migrants from Poland (n=140) and from Vietnam (n=88) using the Giessen Subjective Complaints List – 24 (GSCL-24) and the Hospital Anxiety and Depression Scale (HADS). Additionally we asked migrants about their knowledge of health care institutions in case of psychosocial problems, their demands and the existing barriers to health care utilisation.

Results

Migrants from Poland and Vietnam have a higher general score of complaints of physical ill-health and higher anxiety and depression values than Germans. Psychosocial and medical institutions are visited less.

Conclusion

Further analytical studies are needed to clarify health differences between these groups. Migrants are a heterogeneous group and only group-specific investigations will clarify associations between countries of origin, health status and use of health care institutions.

An Integrated Approach to Bias in a Longitudinal Survey in the United Kingdom: Assessing Construct, Method, and Item Bias in the General Health Questionnaire (GHQ-12)

Construct, method, and item bias are three levels of measurement bias (i.e., internal bias) essential for valid group comparisons. While many studies often focus on only one level of bias, an integrated perspective on bias is still missing, especially in longitudinal designs. The aim of this study is to address bias in an integrated manner, using four waves of data in the U.K. Longitudinal Household Panel Survey. Responses to the General Health Questionnaire (GHQ-12) from natives and two generations of immigrants were used to analyze the three levels of bias. While the basic structure of the GHQ-12 was stable across groups and time, item and method bias decreased with repeated administrations. Results were confirmed with a sensitivity test. The integrated results allowed for a distinction between temporal sources of bias that became smaller over time and sources affecting valid comparisons persistently. We discuss the implications for mental health assessment.

Investigating the Dynamics of Migration and Health in Australia: A Longitudinal Study

There have been few longitudinal studies investigating the immigrant health and changes in their health with longer residency in the host country. Additionally, the pathways and mechanisms by which transition of health over time occurs are poorly understood, limiting the ability to implement policies that will result in improved health for all, including immigrants. We assessed differences in health outcomes among foreign-born people from English speaking countries and non-English speaking countries relative to native-born Australians over a 10-year period using a large representative longitudinal dataset. We also explored English language proficiency, socio-economic factors and health behaviour factors as possible mechanisms through which health outcomes change over time post-migration. Conventional multilevel mixed and hybrid regression models were used to evaluate health outcomes in 9558 native-born and 3067 foreign-born people from the Household, Income and Labour Dynamics in Australia survey. There were clear differences in physical health, mental health and self-assessed health between foreign-born subgroups in comparison with native-born Australians. Foreign-born people from English speaking countries typically had a health advantage relative to native-born people, and foreign-born people from non-English speaking countries had a health disadvantage with respect to native-born people for all health outcomes. There was no evidence that these differences changed by duration of residence except for self-assessed health amongst foreign-born people from non-English speaking countries when duration of residence exceeded 20 years. English language proficiency mediated the relationship between duration of residence and health for foreign-born people from non-English speaking countries.

Searching for a Screener: Examination of the Factor Structure of the General Health Questionnaire in Malaysia

Although mental health program development and service delivery have progressed in Malaysia since its independence in 1957, a shortage of mental health professionals remains a main barrier to mental health care ( Haque, 2005 ). Stigma and cultural beliefs about mental illness may further impede psychological help-seeking. An easy-to-use mental health screener such as the 12-item General Health Questionnaire (GHQ-12) could be used to streamline mental health service delivery and to facilitate integration into primary health care settings. In this study, we conducted a Multigroup Confirmatory Factor Analysis (MGCFA) across English and Chinese language versions for the GHQ-12 to examine the fit of existing factor structures for the GHQ-12. Participants were Malaysian college students of diverse ethnicities attending 2 schools in Malaysia who completed English or Chinese versions of the GHQ-12 (English subsample, n = 151, Chinese subsample, n = 127). Results suggested that an eight-item version of Ye’s (2009) model provided the best fit for both language versions. However, some items on the Chinese version appear to underestimate general psychological distress compared with the English version, thus potentially limiting its utility. Possible reasons for differential item performance and implications of the study are discussed.

South Asian older adults with memory impairment: improving assessment and access to dementia care

OBJECTIVE

With increasing international migration, mental health care of migrants and ethnic minorities is a public health priority. South Asian older adults experience difficulties in accessing services for memory impairment, dementia and mental illness. This review examines barriers and facilitators in the pathway to culturally appropriate mental health care.

METHODS

Web of Knowledge, Pubmed and Ovid databases were searched for literature on South Asian older adults or their family carers, their understandings of mental illness and dementia and their pattern of service use. Dates were from 1984 to 2012. Abstracts were assessed for relevance, followed by detailed reading of salient papers. Three researchers rated the quality of each included study. A narrative synthesis was undertaken of extracted and charted data.

RESULTS

Eighteen studies met the eligibility criteria for the review. South Asians and health professionals highlighted several difficulties which deterred help seeking and access to care: a lack of knowledge of dementia and mental illness, and of local services; stigma; culturally preferred coping strategies; and linguistic and cultural barriers in communication and decision making.

CONCLUSIONS

To improve access for these groups, service users and providers need to be better informed; services need to be more culturally tailored, sometimes employing staff with similar cultural backgrounds; and health professionals can benefit from dementia education and knowledge of local services. These factors are key to the delivery of the National Dementia Strategy in England.

Does mortality vary between Asian subgroups in New Zealand: an application of hierarchical Bayesian modelling

The aim of this paper was to see whether all-cause and cause-specific mortality rates vary between Asian ethnic subgroups, and whether overseas born Asian subgroup mortality rate ratios varied by nativity and duration of residence. We used hierarchical Bayesian methods to allow for sparse data in the analysis of linked census-mortality data for 25-75 year old New Zealanders. We found directly standardised posterior all-cause and cardiovascular mortality rates were highest for the Indian ethnic group, significantly so when compared with those of Chinese ethnicity. In contrast, cancer mortality rates were lowest for ethnic Indians. Asian overseas born subgroups have about 70% of the mortality rate of their New Zealand born Asian counterparts, a result that showed little variation by Asian subgroup or cause of death. Within the overseas born population, all-cause mortality rates for migrants living 0-9 years in New Zealand were about 60% of the mortality rate of those living more than 25 years in New Zealand regardless of ethnicity. The corresponding figure for cardiovascular mortality rates was 50%. However, while Chinese cancer mortality rates increased with duration of residence, Indian and Other Asian cancer mortality rates did not. Future research on the mechanisms of worsening of health with increased time spent in the host country is required to improve the understanding of the process, and would assist the policy-makers and health planners.

Migration and Pacific mortality: estimating migration effects on Pacific mortality rates using Bayesian models

Pacific people living in New Zealand have higher mortality rates than New Zealand residents of European/Other ethnicity. The aim of this paper is to see whether Pacific mortality rates vary by natality and duration of residence. We used linked census-mortality information for 25- to 74-year-olds in the 2001 census followed for up to three years. Hierarchical Bayesian modeling provided a means of handling sparse data. Posterior mortality rates were directly age-standardized. We found little evidence of mortality differences between the overseas-born and the New Zealand-born for all-cause, cancer, and cardiovascular disease (CVD) mortality. However, we found evidence for lower all-cause (and possibly cancer and CVD) mortality rates for Pacific migrants resident in New Zealand for less than 25 years relative to those resident for more than 25 years. This result may arise from a combination of processes operating over time, including health selection effects from variations in New Zealand's immigration policy, the location of Pacific migrants within the social, political, and cultural environment of the host community, and health impacts of the host culture. We could not determine the relative importance of these processes, but identifying the (modifiable) drivers of the inferred long-term decline in health of the overseas-born Pacific population relative to more-recent Pacific migrants is important to Pacific communities and from a national health and policy perspective.

Psychological distress during pregnancy in a multi-ethnic community: findings from the born in Bradford cohort study

PURPOSE

Antenatal anxiety and depression are predictive of future mental distress, which has negative effects on children. Ethnic minority women are more likely to have a lower socio-economic status (SES) but it is unclear whether SES is an independent risk factor for mental health in pregnancy. We described the association between maternal mental distress and socio-demographic factors in a multi-ethnic cohort located in an economically deprived city in the UK.

METHODS

We defined eight distinct ethno-language groups (total N = 8,454) and classified a threshold of distress as the 75th centile of within-group GHQ-28 scores, which we used as the outcome for univariate and multivariate logistic regression for each ethnic group and for the sample overall.

RESULTS

Financial concerns were strongly and independently associated with worse mental health for six out of the eight ethnic groups, and for the cohort overall. In some groups, factors such as working status, education and family structure were associated with worse mental health, but for others these factors were of little importance.

CONCLUSIONS

The diversity between and within ethnic groups in this sample underlines the need to take into consideration individual social, migration and economic circumstances and their potential effect on mental health in ethnically diverse areas.

Latin-American Immigrant Women and Mental Health: Differences according to their Rural or Urban Origin

Spain is one of the EU countries that receive most immigrants, especially from Latin America. The process of migration implies a high level of stress what may have repercussions for the mental health of immigrants. The purposes of this study were: (a) to determine whether the degree of mental health of immigrant women differs according to their rural or urban origin, (b) to compare the mental health of immigrant women with that of the female normative sample of host population (Spain). A sample of 186 Latin American immigrant women (142 from urban areas and 44 from rural areas) was recruited in Barcelona by means of a consecutive case method. A structured interview and the SCL-90-R were administered. The results indicated that the immigrant women from rural origin reported higher levels of psychological symptomatology than those from urban areas. Immigrants reported higher levels of psychological symptomatology than the native female population and in most of the psychological symptoms exceeded 90% of the native Spanish population. Migration is a powerful stressor which may lead to psychological distress. Being female of rural origin and being in an illegal situation is related with an increase in symptomatology.

Epidemiology of depression in diabetes: international and cross-cultural issues

INTRODUCTION

This paper reviews the most up-to-date epidemiological evidence of the relationship between depression and diabetes, and considers the risk factors for the development of depression and the consequences of depression in diabetes with an emphasis on international and cross-cultural data. The difficulties that researchers face when epidemiological studies require assessment of psychological phenomena, such as depression, across different cultural settings are explored.

METHODS

Relevant papers were sought on the epidemiology of diabetes and depression in people with diabetes by undertaking a literature search of electronic databases including MEDLINE, Psych-INFO, CINAHL and EMBASE. These papers were assessed by the authors and a narrative review of the relevant literature was composed.

RESULTS

Systematic reviews of the prevalence of depression in people with diabetes have focused on studies conducted in English speaking countries and emerging data suggest that there may be international variations in prevalence and also in how symptoms of depression are reported. There appears to be a bi-directional relationship between depression and diabetes, with one influencing the other; however, research in this area is further complicated by the fact that potential risk factors for depression in people with diabetes often interact with each other and with other factors. Further research is needed to elucidate the causal mechanisms underlying these associations.

LIMITATIONS

Data from non-English speaking countries remain scarce and so it is difficult to come to any firm conclusions as to the international variation in prevalence rates of co-morbid diabetes and depression in these countries until further research has been conducted.

CONCLUSION

It is important to take a culture-centered approach to our understanding of mental health and illness and consider the key issues related to the development of culturally sensitive depression screening tools. In order to come to any firm conclusions about the international variation in prevalence of co-morbid diabetes and depression, issues of culture and diversity must be taken into account prior to conducting international epidemiological studies.

Measuring psychological well-being in South Asians with diabetes; a qualitative investigation of the PHQ-9 and the WHO-5 as potential screening tools for measuring symptoms of depression

BACKGROUND

People from South Asian backgrounds living in the UK have a greatly increased risk of developing Type 2 diabetes. Whether or not this patient group also experience high rates of depressive symptoms (known to be the case in Caucasian populations with diabetes) remains unknown, partly because it is unclear whether the screening tools used are culturally relevant. The aim of this study was to develop culturally competent translations (in both written and audio formats) of two screening tools used to measure symptoms of depression in languages with no written form and establish their face validity.

METHODS

Adults with Type 2 diabetes from two South Asian minority ethnic groups (from Bangladesh and Pakistan) whose main language is only spoken (Sylheti and Mirpuri) were recruited via the Birmingham Heartlands Hospital Diabetes Centre. Participants attended two focus group meetings to consider the content and method of delivery of two questionnaires measuring symptoms of depression, the Patient Health Questionnaire (PHQ-9) and the World Health Organization Well-being Index (WHO-5).

RESULTS

Culturally equivalent content was achieved for both questionnaires in both languages. The Mirpuri men and women groups did not indicate a clear preference for either mode of questionnaire delivery; however, the Sylheti groups' preference was for independent audio-delivery in their spoken language.

CONCLUSIONS

The face validity of the PHQ-9 and the WHO-5 was established for Sylheti and Mirpuri in an audio delivery format. Psychometric testing is now needed among minority ethnic populations so that the feasibility of wider use can be determined.

Mood and anxiety disorders and the use of services and psychotropic medication in an immigrant population: findings from the Israel National Health Survey

OBJECTIVE

Using the Israel National Health Survey (INHS), we compared immigrants' 12-month prevalence of mental disorders and the use of services and psychotropic drugs with that of the general population.

METHODS

A representative sample of noninstitutionalized residents, aged 21 years and older, was drawn from the National Population Register. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorders were assessed using a revised version of the Composite International Diagnostic Interview. Respondents were asked to report any health service and psychotropic drug use in the past 12 months.

RESULTS

During the 12 months preceding the INHS, immigrants and Israelis (that is, those born in Israel or those who emigrated to Israel before 1989) were equally likely to have a common mental disorder (OR 0.9; 95% CI 0.7 to 1.1) and to use health services (OR 0.9; 95% CI 0.7 to 1.2). However, among respondents who did not meet the DSM-IV criteria for a specific mental disorder, the immigrants reported markedly more use of psychotropic drugs than the Israelis, in particular more anxiolytics, mood stabilizers, and hypnotics.

CONCLUSION

The results suggest that the common mental disorders and mental health service use among the immigrants are no higher than that among their Israeli counterparts. The higher use of psychotropic drugs by immigrants may be an indirect indicator of a higher level of psychological distress symptoms, such as anxiety, depression, and sleep disorders.

Overweight status and psychological well-being in adolescent boys and girls: a multilevel analysis

Background: Psychological distress and high body mass index (BMI) are linked in adults, especially in females. Effects of social position and behaviour, and whether obesogenic environments affect adolescents and adults equally are unresolved. The aim was to examine associations between psychological distress and being overweight in adolescents, by sex, accounting for social, lifestyle and contextual factors. Correlation of area-level variation in overweight status in adolescents and adults was investigated. Methods: Height, weight, General Health Questionnaire 12 (GHQ12) of psychological distress, physical activity, smoking, alcohol consumption, area deprivation and social class were available on 635 male and 618 female adolescents (13–15 years) from two cross-sectional population health surveys conducted in Scotland in 1998–99/2003–04. Multilevel logistic regression modelled overweight (including obese) status accounting for intraclass correlation of adolescents in households within postcode sector areas in health board regions. Univariable analysis examined effects of high (4 or more) GHQ12 score; multivariable analysis further allowed for covariates. Adult data were used to assess the importance of correlation between adolescent and adult area-level variation. Results: Univariably, there was significantly increased risk of being overweight associated with high GHQ12 score for girls but not boys; adolescent and adult area-level variation correlation did not impact. Results remained significant for girls in multivariable analyses (OR = 2.44, 95% confidence interval (CI): 1.33–4.50) and non-significant for boys (OR = 1.31, 95% CI: 0.56–3.05). Conclusions: Findings indicate being overweight is associated with psychological distress in adolescent girls, but not boys. Effects are not mediated by social, lifestyle or contextual factors.

Contextualising experiences of depression in women from South Asian communities: a discursive approach

The aim of this paper is to present an interpretation of the accounts of depression provided by women from South Asian communities. The paper presents the findings from a qualitative study, conducted in the UK, which explored women from South Asian communities and their experiences of depression. It is argued here, through examples of women's accounts of their experiences, that depression is 'embodied', that is, grounded in the materiality of the body which is also immersed in subjective experiences and in the social context of women's lives. Qualitative data were collected from four focus groups and ten individual interviews with women. The analysis involved a discursive approach. Analysis revealed how women made strategic choices in how they presented their symptoms as legitimate and for gaining access to what they perceived to be appropriate healthcare. This is not to argue that this is a culturally specific phenomenon but one which is a feature of all healthcare negotiations.

Organizational barriers and ethnicity in the Scottish NHS

The NHS faces a crisis in terms of staffing and recruitment. Many of the ethnic minority GPs in inner city areas throughout the UK are coming up to retirement age, and there is an insufficient supply of trainees to fill estimated vacancies. Over 2,000 nursing vacancies exist across the UK, and recruitment to the profession and retention within the profession are poor. Nurses have been recruited from overseas for the past 40 years, and are currently being recruited from Finland, Malaysia, and the West Indies, whilst doctors are being sought in India, Pakistan and Africa. Overseas recruitment is not a new phenomenon, and numerous studies have been carried out to examine equal opportunities and racial discrimination within the NHS. The aim of this paper was to examine ethnicity and equal opportunities within the Scottish NHS and record the levels of organisational awareness of ethnicity and equal opportunities' issues. The paper also examines the link between health service delivery to ethnic minorities and internal cultural attitudes to staff.

Preliminary study of non-psychotic disorders in people from the Indian subcontinent living in the UK and India

OBJECTIVE

The prevalence of anxiety and depressive disorders in people of South Asian origin in the UK is not accurately known.

METHOD

A population-based study of UK residents from the Indian subcontinent was screened for anxiety and depressive disorders with the Self-Rating Questionnaire (SRQ) and for life events using the brief list of threatening life events. Similar measures were administered to siblings in India.

RESULTS

The UK sample included 223 Sikhs, 100 Hindus and 49 Muslims. Elevated SRQ scores were recorded in 5%, 13% and 23%, respectively, of men from these groups and in 16%, 27% and 57%, respectively, of females. Subjects reporting one or more threatening life events (most commonly unemployment and financial problems) also had raised SRQ scores. A total of 117 siblings in India reported similar SRQ scores to their index subjects in the UK, but reported more threatening life events, notably deaths and illness in the family and financial problems.

CONCLUSION

This preliminary study indicates that psychiatric disorder in ethnic groups varies across religious groups. The prevalence may be high in some religious groups in association with social difficulties. The patterns of stress in India and the UK are different.

Minority ethnic community participation in needs assessment and service development in primary care: perceptions of Pakistani and Bangladeshi people about psychological distress

OBJECTIVES: To promote community participation in exploring perceptions of psychological distress amongst Pakistani and Bangladeshi people, in order to develop appropriate services. DESIGN: Training and facilitation of resident community members (as community project workers), to define and conduct qualitative research involving semistructured interviews in their own communities, informing primary care led commissioning and service decision making. Setting A socio-economically disadvantaged inner-city locality in the UK. Participants One-hundred and four South Asian people (49 of Pakistani and 55 of Bangladeshi origin), interviewed by 13 resident community members. RESULTS: All community project workers completed training leading to a National Vocational Qualification, and successfully executed the research. Most study respondents located their main sources of stress within pervasive experience of racism and socio-economic disadvantage. They were positive about 'talking' and neutral listening as helpful, but sought strategies beyond non-directive counselling services that embraced practical welfare advice and social support. The roles of primary health care professionals were believed to be restricted to physical ill health rather than personal distress. The importance of professionals' sex, age, ethnicity and social status were emphasized as affecting open communication. Practical recommendations for the re-orientation and provision of services were generated and implemented in response to the findings, through dialogue with a primary care commissioning group, Health and Local Authority, and voluntary agencies. CONCLUSIONS: The work illustrates the feasibility and value of a community participation approach to research and service development in addressing a challenging and neglected area of minority ethnic health need. It offers one model for generating responsive service change in the context of current health policy in the UK, whilst also imparting skills and empowering community members. The study findings emphasize the need to recognize the social contexts in which distress is experienced and have implications for effective responses.

Social class and health: the puzzling counter-example of British South Asians

British South Asians (with ancestry from the Indian subcontinent) provided a puzzling exception to the British class gradient in mortality during the 1970s. On the assumption that class gradients in health are produced mainly by gradients in standard of living, this might be due to a break in the relation of class to standard of living (change in class structure), or by a break in the relation of standard of living to patterns of health behaviour and health risk (change in class lifestyles). Data on these characteristics are available from the West of Scotland Twenty-07 Study, where 159 South Asians aged 30-40 (mean age 35) were sampled alongside 319 of the general population in Glasgow. As regards changes in class structure, results indicate that the underclass thesis, which suggests that ethnic minorities are forced into less eligible jobs or into a separate labour market or into unemployment, resulting in a standard of living below that of the general population, still holds good for British South Asians in categories from social class III non-manual downwards. It does not hold good for owners of small businesses, where Sikhs and Hindus in particular have a standard of living equivalent to general population counterparts. However, prosperity is not predictable from levels of education in the subcontinent and from this and other signs it appears that a wholesale redistribution of class chances is occurring among British South Asians, disrupting inter-and intra-generational continuities in the relation between class and standard of living. There is little sign of change in class lifestyles, i.e. in the relation between standard of living and health behaviour or health risk. As yet, though, the new distribution of standard of living is affecting patterns of health behaviour and health risk more strongly than symptom experience or chronic illness, suggesting that a class gradient in health will re-emerge.

Generational continuity and change in British Asian health and health behaviour

OBJECTIVES

To trace patterns of health and health behaviour in those with ancestry in the Indian subcontinent (British Asians) compared with the general population of their age (1) in the younger generation age 14-15 mainly born in the UK and (2) in the older mainly migrant generation.

DESIGN

Cross sectional random sample surveys of two age groups in Glasgow.

SAMPLES

334 British Asians (86% born in the UK) and 490 non-Asians, all aged 14-15; 173 British Asians aged 30-40 (mean age 35, 93% born abroad), and 344 general population aged 35.

MEASURES

Health: self assessed health/fitness, longstanding/limiting illness, chronic phlegm, accidents, symptoms, tooth loss. Health behaviour: smoking, alcohol, drugs, exercise.

RESULTS

At age 14-15, compared with non-Asian counterparts: fewer British Asian girls reported limiting illness (p < 0.05) or chronic phlegm (p < 0.01), fewer boys reported accidents (p < 0.01), and fewer of both sexes had lost second teeth (p < 0.05); more of both sexes reported not smoking, drinking alcohol, or using drugs (p < 0.01 or below), fewer reported frequent exercise (p < 0.05 or below). Smoking patterns were consistently related to ethnic differences in chronic phlegm, and patterns of alcohol consumption to those in accidents. In health, British Asian girls aged 14-15 generally compared more favourably with non-Asian counterparts than did those aged 30-40. The reverse was true for British Asian male subjects. In health behaviour, British Asians of both sexes aged 14-15 showed strong continuities with those aged 30-40.

CONCLUSIONS

Favourable health behaviour has brought a health advantage to young British born Asians, even though this was not the case in the migrant generation. Female health disadvantage is also much less marked than in migrants aged 30-40, but may re-emerge between ages 15-30. Migrant Asian male subjects may have had misleadingly high respiratory health levels because of positive selection.