Racism triggers smoking in British ethnic minority adolescents: evidence from the determinants of young adult social wellbeing and health (DASH) longitudinal study

OBJECTIVE: Racism may have a negative impact on the health behaviours in adolescence, however there were few longitudinal studies. We examined the impact of perceived racism on smoking in an ethnically diverse sample of adolescents in the UK, and potential modifying factors. DESIGN AND METHODS: In 2002/03, 6643 11-13 year olds in London, ~80% ethnic minorities, participated in the baseline survey. In 2005/06 4,782 were followed-up. In 2012-14 665 took part in a pilot follow-up aged 21-23y, including 42 qualitative interviews. Measures of socio- economic and psychosocial factors and health were collected. RESULTS: Ethnic minority adolescents were more likely to report racism compared with White British, but smoking was generally lower. Reported racism in adolescence was associated with having ever smoked (e.g. males Odds Ratio 2.20, 95% CI 1.59-3.02), and with smoking initiation (males 4.09, 2.45-6.83). Smoking initiation was greatest among Black Caribbeans. Attendance to a place of worship, being a Muslim and a good parent-child relationship were independent protective factors. Qualitative interviews supported evidence for reported racism as well as protective factors including increasing ethnic diversity, a sense of identity and belonging, supportive parenting, high aspirations, and religious faith. CONCLUSIONS: This is the first UK study to show the negative impact of racism on smoking in adolescence, regardless of ethnic origin. Religious involvement and parenting may provide social support and reinforce cultural and religious values which may prevent the uptake of harmful health behaviours such as smoking. This has implications for health promotion among young people of all ethnicities.

Factors in the onset of schizophrenia: a comparison between London and Trinidad samples

Objective: Sociodemographic factors play an important role in the genesis of mental disorders. High rates of unemployment and other social factors have been reported previously among African-Caribbeans with schizophrenia in London. The aim of the present study was to compare these factors in Trinidad with London African-Caribbeans. METHOD: Using internationally-defined criteria, patients with first-onset schizophrenia were recruited in both countries, and information on the onset of symptoms, help-seeking, pathways into care, premorbid personality and educational and employment status were collected. These two samples are compared on a number of these factors. A total of 56 cases of first-onset of psychosis coming into contact with psychiatric services in Trinidad were studied. Of these, 46 cases were diagnosed as having schizophrenia using the CATEGO program. Over a period of 2 years, 38 African-Caribbean patients with schizophrenia were recruited in London. RESULTS: African-Caribbean patients with schizophrenia in London were more likely to be admitted for perceived threat to others and to have shown loss of interest and serious neglect and to have assaulted others. A lower proportion were admitted via a psychiatrist and a higher proportion by the police. The unemployment rate among the London sample of African-Caribbeans was much higher than in the general population, whereas this was not the case for the Trinidad patients. CONCLUSION: These findings are discussed in the context of culture and aetiology of schizophrenia, and suggestions with regard to future research are made. (AU)

First-contact incidence rate of schizophrenia on Barbados

BACKGROUND: The incidence rate for broad schizophrenia among second-generation African-Caribbean people in the United Kingdom has been reported as high. Ethnicity, migration and psychosocial stressors have been suggested as causal factors. AIMS: To determine the incidence of schizophrenia for the whole population of Barbados using an identical methodology to two previous studies in Trinidad (Bhugra et al, 1996) and London (Bhugra et al, 1997). METHOD: A 12-month study of all persons in the 18-54-year age group presenting with a psychosis for the first time was carried out on the population of Barbados. Information was collected using the World Health Organization screening and measurement instruments. RESULTS: On an island of just over a quarter of a million, 40 out of the 53 patients that met the inclusion criteria were categorized as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10,000 (95 percent Cl 1.97 - 3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10,000 (95 percent Cl 2.3 - 4.1), which is significantly lower than the comparable rate for London's African-Caribbeans of 6.6/10,000 (95 percent Cl 4.5 - 8.7). CONCLUSIONS: The very high rate for broad schizophrenia among African-Caribbean people in the UK is probably due to environmental factors. (AU)

Social environment and substance misuse: a study of ethnic variations among inner London adolescents

OBJECTIVES: To explore ethnic variations in drug, tobacco and alcohol use and their correlation with other factors which operate through peer, familial and religious influences. DESIGN: Semi-structured interviews with 132 12-13-year-old young people from four ethnic groups attending secondary schools in two inner London boroughs and a follow-up interview completed approximately 17 months later. RESULTS: The data was analysed using chi-square and McNemar tests. Familial, religious and peer influence closely correlated with ethnicity. Bangladeshi young people showed lower levels of peer and higher levels of religious and familial involvement and lower levels of substance use. White young people reported higher levels of peer, lower levels of religious and familial involvement, and a higher level of substance use. Black African and Black Caribbean young people lay between the two extremes. CONCLUSION: The findings suggest that young people with lower levels of familial and religious influence, or higher levels of peer influence, have higher levels of substance consumption than other young people. Health education initiatives need to promote personal decision-making skills within the context of the young people's individual culture. Cultural diversity should be recognised within local health education needs assessment.(Au)

The development of the Short Explanatory Model Interview (SEMI) and its use among primary-care attenders with common mental disorders

BACKGROUND: Recent anthropological studies have documented the importance of understanding the relation of culture to the experience of mental illness. The use of interviews that elicit explanatory models has facilitated such research, but currently available interviews are lengthy and impractical for epidemiological studies. This paper is a preliminary report on the development of a brief instrument to elicit explanatory models for use in field work. METHOD: The development of the SEMI, a short interview to elicit explanatory models is described. The interview explores the subject's cultural background, nature of presenting problem, help-seeking behaviour, interaction with physician/healer and beliefs related to mental illness. RESULTS: The SEMI was employed to study the explanatory models of subjects with common mental disorders among Whites, African-Caribbean and Asians living in London and was also used in Harare, Zimbabwe. Data from its use in four different ethnic groups is presented with the aim of demonstrating its capacity to show up differences in these varied settings. CONCLUSIONS: The simplicity and brevity of the SEMI allow for its use in field studies in different cultures, data can be used to provide variables for use in quantitative analysis and provide qualitative descriptions.(Au)

Prevalence of antibodies to HTLV in antenatal clinic attenders in south east London

The prevalence of antibodies to HTLV in women attending a south east London antenatal clinic between October 1990 and July 1992 was determined using sera referred for rountine rubella antibody testing. Samples were screened for HTLV antibody using a modified Fujirebio gel particle agglutination test and reactive sera confirmed by ELISA (Abbott Laboratories, North Chicago, IL) and two commercial Western blots (Cambridge Biotech Inc., Rockville, MD, and Diagnostic Biotechnology, Genelab Diagnostics, Louvaine, Belgium). This strategy confirmed the presence of HTLV-1 antibodies in 12 out of 6,289 sera (0.19 percent, 95 percent confidence limits 0.083 percent to 0.30 percent) and HTLV-2 antibodies in 2 (0.03 percent) sera. Specimens from 8 to 821 (0.97 percent, 95 percent confidence limits 0.42 percent to 1.9 percent). Afro-Caribbean women, three of 1,136 (0.26 percent, 95 percent confidence limits 0.055 percent to 0.78 percent). African women, and one of 3,049 (0.033 percent, 95 percent confidence limits 0.006 percent to 0.18 percent). Caucasian women were positive for HTLV-1 antibodies. Sera from Afro-Caribbean women born in the Caribbean were 7.6 times more likely to be HTLV-1 antibody positive than sera from Afro-Caribbean women born in the UK (P = 0.012). Selective testing of Afro-Caribbean and African antenatal clinic attenders, in this setting, would have identified 11 of the 12 HTLV-1 infections at an estimated cost of prevention of HTLV-1 associated disease of 100,000 pounds per case which is considerably less than the 1.3 million pounds which has been estimated to prevent a case by universal screening of UK blood donors.(AU)

Afro-Caribbean and Asian Subjects living in the UK may be susceptible to atypical Parkinsonism

INTRODUCTION: Although the prevalence and pattern of parkinsonism in white caucasian population have been reported, little is known about the pattern and prevalence of parkinsonism in black and Asian patients (from the Indian subcontinent). We recently reviewed this topic and felt that contrary to popular belief parkinsonism may be commoner in UK. Furthermore, the pattern of parkinsonism appears to be different in this group. METHODS AND RESULTS: Based on this observation we have now set up a worldwide and British study involving Afro-Caribbean and India (patients originating from the Indian subcontinent) subjects. In the first leg of this study, we carried out a door to door knocking assessment for Parkinsonism in one electoral ward in London with a high Afro-Caribbean population and identified three cases of atypical parkinsonism. We have subsequently been reviewing the case files of over 150 patients attending Movement Disorders clinical in areas of London with a high population of the Afro-Caribbean and Indian population. So far, we have identified 18 cases of Parkinsonism in patients of Afro-Caribbean and Asian origin. Fourteen out of 18 cases show non familial atypical parkinsonism with signs of progressive supranuclear palsy in five, probable striato nigral degeneration in four, and a levodopa unresponsive progressive parkinsonism which falls but no dystonia in three, spino-cerebellar atrophy type three in one and autopsy proven Pick's disease in 1.4. High field Magnetic resonance imaging and CT brain scanning have been remarkable apart from non-specific cortical atrophy and signs of vascular disease in some. CONCLUSIONS: Our observations suggest that parkinsonism is probably more common than realized in the Afro-Caribbean and Asian populations and these patients may be more susceptible to atypical parkinsonism. The reason for this is unclear and may reflect genetic or environmental factors as has been postulated in relation to higher incidence of diabetes and ischaemic heart disease in migrant Asian population in UK. Further epidemiological studies addressing this issue are in progress. (AU)

Black Skin Disease in South East London

Skin disease in black patients can present a diagnostic challenge both because of variations in clinical appearance and because certain disorders appear unique to black skin. The majority of dermatology text books and atlases concentrate mainly on white skinned patients. Our hospital serves a cosmopolitan local community in whom 40 percent of the population is black. We recorded the diagnosis made in 461 consecutive black (African, Afro-Caribbean and mixed-race) patients who attended a general dermatology new patient clinic in South East London. The aim of the study was to document the spectrum of skin disease seen in black patients and to highlight these disorders. 187 children and 274 adults were studied. In the black children atopic eczema was diagnosed in 38 percent, tinea capitis 26.7 percent, pityriasis alba 3.7 percent, viral warts 3.2 percent, keloids 2.7 percent, others 25.7 percent. Diseases recorded which are not seen in the white children included Facial Afro-Caribbean Childhood Eruption (FACE) and infantile acropustulosis. Of the 274 adults assessed, acne was diagnosed in 14.6 percent, eczema 10.2 percent, psoriasis 5.1 percent, pityriasis versicolor 4.0 percent, alopecia areata 3.3 percent, dermatofibroma 2.9 percent, urticaria 1.8 percent, pityriasis rosea 1.8 percent, cutaneous sarcoid 1.5 percent, discoid lupus 1.1 percent. Diseases more commonly seen in black skin were acne nuchae keloidalis/scalp folliculitis 14.6 percent, keloids 4.4 percent, post inflammatory pigmentation 3.6 percent and traction alopecia 1.1 percent; other disorders were seen in 30 percent. Normal variants recorded were dermatosis papulosa nigra, linear nail pigmentation and palmar pits. As the UK population becomes increasingly cosmopolitan, familiarity with skin disorders in both black and white skin is increasingly relevant to our practice. (AU)

Gonorrhoea in inner London: the hidden epidemic

BACKGROUND: Very little is known about local variations in the distribution of sexually transmitted infections in Great Britain. In the United States of America, rates of gonorrhoea are approximately ten times higher amongst African-Americans than whites. This study was designed to estimate population-based incidence rates of gonorrhoea in an inner London area and to examine their relationship with age, ethnic group and socioeconomic deprivation. DESIGN: Cross-sectional study. SETTING: Eleven Departments of Genitourinary Medicine in South and Central London. SUBJECTS: 1,978 first episodes of gonorrhoea diagnosed in 1994 and 1995 in residents of 73 electoral wards in the boroughs of Lambeth Southwark and Lewisham who attended any of the Departments of Genitourinary Medicine. MAIN OUTCOME MEASURES: Age-, sex- and ethnic-specific rates of gonorrhoea per 100,000 population aged 15 - 59 years per year. Rate ratios (95 percent confidence intervals) for the effects of age and ethnic group on gonorrhoea rates on women and men, before and after adjustment for confounding factors. RESULTS: Overall incidence rates of gonorrhoea in residents of Lambeth, Southwark and Lewisham were 138.3 per 100,000 per year for women and 291.9 per 100,000 per year for men aged 15-59 years. Inconsistencies in the coding of ethnicity, race, or nationality between Departments meant that cases in those from all black minority ethnic groups had to be considered in a single category. At all ages gonorrhoea rates were higher in members of black than white ethnic groups. After taking deprivation score and age into account women from black minority groups were 10.5 (8.6 - 12.8) times as likely and men 11.0 (9.7 - 12.6) times as likely as whites to experience gonorrhoea. Rate ratios for the effect of age, adjusted for ethnic group and privilege, were 15.2 (11.6 - 19.7) for women and 2.0 (1.7 - 2.5) for men aged 15 -19 years compared to those over 30 years. CONCLUSIONS: Gonorrhoea rates on Lambeth, Southwark and Lewisham in 1994-95 were six to seven times higher than for England and Wales one year earlier. The presentation of national trends thus hides the disproportionate contribution of ongoing endemic transmission in this area. Teenage women and young adult men, particularly those from black minority ethnic groups were the most heavily affected, even after socioeconomic underprivilege is taken into account. (AU)

Oral Health related behaviours of a Caribbean group living in South London

According to the 1991 census there are approximately 3 million people from minority ethnic groups residing in England and Wales, which constitutes 6 percent of the total population. The Black Caribbean group are the second largest ethnic group living in England and Wales today, however there is little dental research aimed towards this group when compared to other ethnic groups. It is essential to gain an understanding in the way ethnic groups live and behave as all are inherently different and therefore can not be seen as homogenous, especially when planning services and implementing policy. This piece of research aimed to look at a number of oral health related practices of Caribbean groups living in the South London area in order to gain an understanding and insight into this particular group. Community groups were used as a starting point to gain access. The method of data collection used was quantitative. Group leaders were willing to participate once the aims of the research had been explained. The majority of the sample, 64.7 percent cleaned their teeth twice a day. There was an even split between those who regularly attended the dentist, 23 percent and those who only attended when in pain, 25 percent. When asked "where they last went for treatment in the UK." 60 percent said they went to an N.H.S dentist, 16 percent reported "never" attending the dentist. The majority of respondents had not experienced any problems with their teeth in the last month, however bleeding gums was reported most frequently in this particular ethnic group. When asked if the respondents were "satisfied" or "not satisfied" with their teeth, 60 percent felt satisfied. Concern relating to dissatisfaction was attached to colour, fillings and size of teeth. The research points to areas of concern amongst this ethnic group. Despite claiming to clean their teeth on a regular basis their dental attendance was very poor, only attending when in pain. Therefore oral hygiene appeared to be high but did not match their attendance patterns. Irregular attendance could be due to factors such as access and lack of information. It is apparent that research of this nature is essential in order to gain a clearer understanding of attitudes and behaviour of different ethnic groups. (AU)

South London Community stroke register (SLSR): Stroke incidence in the first two years of the register (1995-1996)

The aim of this project is to determine whether whether there are ethnic differences in the incidence of first-ever stroke and in the frequencies of different subtypes of stroke. SETTING: An inner-city population of 234,533 residents of Lambeth, Brixton and North Southwark, of which 72 percent are Caucasian, 21 percent are Black (11 percent Afro-Caribbean, 7.5 percent West African, and 2.5 percent Black mixed), and 3 percent are Asian, Bangladeshi and Pakistani. METHODS: Using a multi-source, prospective community stroke register, data on incidence and stroke subtype were collected. Ethnic origin was self-reported by the patient or carer using the standardized OPCS census classification of the group. Stroke subtype was classified using brain radiology (computerized tomography or magnetic resonance imaging) or necropsy data. Strokes without pathological confirmation of stroke subtype using either of these methods were unclassified. RESULTS: A total of 596 strokes were registered in 1995-1996 giving a mean overall annual incidence rate of 1.3 strokes per 1,000 population per year (95 percent C.I. 1.1 -1.4). Incidence of stroke was significanlty higher in all ages in blacks compared with whites (p>0.0001), and the mean age of stroke was significantly lower in blacks compared wih whites (63.5 years, 95 percent C.I. 60.1 - 66.9, and 73.9 years. 95 percent C.I. 74.7 - 72.6, respectively, and p>0.0001). Of the first 500 patients registered, classifications of stroke subtype using information from brain radiology or necroscopy was possible in 441 patients (88.2 percent). There were signfificant ethnic differences in the frequencies of the subtypes of stroke between blacks and whites (p 0.015), with an increased proportion of strokes due to intracranial haemorrhage and lacunar infarction in the blacks (28.4 percent and 29.6 percent) compared with whites (16.4 percent and 24.8 percent), and an increased proportion of non-lacunar infarction in the whites compared with blacks (45.5 percent and 36.4 percent respectively). CONCLUSION: These results suggest important ethnic differences in stroke incidence which probably reflect differences in risk factors for stroke between ethnic groups. These need to be examined further in order to develop effective strategies for stroke prevention in multi-ethnic communities.(AU)

Neonatal Screening for Haemoglobinopathies in South East London: findings and comparisons with Jamaica

INTRODUCTION: Neonatal screening for sickle cell disorders has been shown to reduce mortality and morbidity. Methods of screening vary but in 1994, the local Health Authority funded universal neonatal screening across the whole of Lambeth, Southwark and Lewisham. This paper will report the findings of the first three years of operation of the programme and compare findings with the screening programme currently operating in Jamaica. METHOD: since May 1994 dried bloo[d] spots of all infants have been screened at King's College Hospital and screen positive cases followed up by counsellors. Infants are followed up at four sites (Guy's, King's, Lewisham and St.Thomas') according to parental preference. Minimum standards for follow-ups have been agreed by clinicians across all four sites and information of the success in achieving these standards is now being collected. RESULTS: Overall there have been 122 affected infants detected in the first two years 10 months of the programmes operation. This is made up of 83 HbSS, 35 HbSC, 4HbSBThal. This gives a birth preference of 23.4 per 1000 total population (2.3HbSS, 1.0 HbSC). Allowing for a termination rate of 20 percent this indicates that the expected birth prevalence in the district would be 4.2 per 1000 births. This compares with birth prevalence of of 0.3 per 1000 for congenital hypothyroidism, 06. per 1000 for cystic fibrosis and 0.1 for phenylketonuria. The distribution of the births is unevem with 57 in Southwark, 40 in Lambeth and 25 in Lewisham. The paper will report on the follow-up and outcome of care provided for this population to date. Discussion: South East London has the highest prevalence of sickle cell disorders of any district in the UK. Sickle cell disorder is now as common in South East London as it is in Jamaica. The follow-up arrangements established in South East London provide an opportunity for colloboration with the West Indies which may help to determine some of the reasons for differences in the natural course of the disease in these populations. The population based approach established should allow monitoring of the impact of community education and antenatal screening programmes on the birth prevalence over time. (AU)

The findings of a London wide needs assessment for sickle cell dis orders

The size of the population in London with Sickle cell disorders has increased markedly in the past 20 years and it is now one of the commonest reasons for admission of children to hospital in inner London. This paper presents the findings of a London Wide Needs assessment for sickle cell disorders.It reviews Health and Local Authorities response to the needs of their populations in terms of the development of strategy and services. It also considers reasons for the failures to develop appropriate services[AU]

A Comprehensive approach to needs assessment of sickle cell services: The value of seeking service users' views

The recent `Fair Shares for London' study used multiple methods to carry out a needs assessment of services for sickle cell disorders in Greater London. This paper reported on one of these, a series of focus group discussions with users of services for sickle cell disorders. The aims of the focus groups were as follows: 1. To investigate and record service users' experiences, perceptions and opinions about current service provision for people with sickle cell disorders. 2. To structure the discussions so as to cover the same range of services investigated by the questionnaire surveys. Three focus groups, each consisting of 6-8 people, were conducted at different locations in London. The results of the focus groups reflect those of the questionnaire survey, indicating that service users recognise some recent improvements in service delivery, but that many aspects of services for sickle cell disorders in Greater London remain inadequate. Improvements most often mentioned included ambulance services and some aspects of acute care. Significant problems persist in the delivery of community services and education, housing and social services. Some examples of good practice in primary care were highlighted. However the majority of participants made little or no use of GP services due to previous negative experiences. The Fair Shares for London study shows how the use of qualitative methods in needs assessment can enhance and validate results. The focus group discussions made an important contribution to the overall findings, complementing and elucidating the results of the questionnaire survey of purchasers and providers, as well as identifying areas for further research.(AU)

Experience of human lymphotropic virus type 1 (HTLV-I) in an East London hospital

We describe the experience of The Royal London Hospital with human T-cell lymphotropic virus type 1 (HTLV-1 related disease. Twelve patients presented from 1988-1993, nine of them in 1993. None were born in the U.K. and 11 were of West Indian origin. Ten had overt lymphomas, one tropical spastic paraparesis/HTLV-1 associated myelopathy (TSP/HAM) and one typical lymphocytosis and strongyloidiasis. Five presented acutely ill to casualty and three died shortly after presentation. Four had been referred to rheumatologists and five had predominantly gastrointestinal symptoms. The population of Caribbean origin served by the hospital is 23,700 and one would only expect one or two cases of lymphoma and one or two of TSP/HAM per year. Overall the spectrum of clinical disease at presentation was varied. Suspicion of HTLV-1 infection is merited in patients of West Indian origin between the ages of 30 - 65 years, who present with a sarcoid-like illness, gastrointestinal symptoms, leukaemia/lymphoma, myelopathy or myositis like-illness. (AU)

Psychosis with good prognosis in Afro-Caribbean people now living in the United Kingdom

OBJECTIVES - to compare the course and outcome of psychotic illness in a group of Afro-Caribbean patients resident in the United Kingdom and a group of white British patients. DESIGN - cohort study of consecutive admissions followed up for four years. SUBJECTS - 113 patients with psychotic illness of recent onset admitted to two south London hospitals. MAIN OUTCOME MEASURES - course of illness, history of self harm, social disability, treatment received, and hospital use adjusted for socioeconomic origin. RESULTS - the Afro-Caribbean group spent more time in a recovered state during the follow up period (adjusted odds ratio 5.0; 95 percent confidence interval 1.7 10 14.5), were less likely to have had a continuous illness (0.3; 0.1 to 0.8), were less at risk of self harm (0.2; 0.1 to 0.8), and were less likely to have been prescribed antidepressant treatment (0.3; 0.1 to 0.9). There were no differences in hospital use, but the Afro-Caribbean group had more involuntary admissions (8.9; 2.1 to 35.6) and more imprisonments over the follow up period (9.2; 1.6 to 52.3). CONCLUSIONS - Afro-Caribbean patients in the United Kingdom have a better outcome after psychiatric illness than do white people. The combination of high incidence and more benign course of illness of psychotic illness in this group may be due, at least in part, to a greater exposure to precipitants in the social environment. (AU)

Incidence of psychotic illness in London: comparison of ethnic groups

The objective is to compare annual incidences of psychosis in people from different ethnic groups as defined in the 1991 census. The setting was the catchment area of district psychiatric hospital. The design included all people aged 16 to 54 years who made contact with a wide range of community and hospital services between 1 July 1991 and 30 June 1992 were screened for psychotic symptoms. Patients with such symptoms were interviewed face to face to collect information on demography, ethnic group, psychiatric history and symptoms, drug use, and how care had been sought. A key informant, usually a close relative, was also interviewed. The main outcome measures entailed age standardised incidence of schizophrenia and non-affective psychosis according to the ninth edition of the International Classification of Diseases in each ethnic group. The results showed that ninety three patients took part, of whom 38 were assigned a certain or very likely diagnosis of schizophrenia (15 in white population, 14 in black, seven in Asian, and two in others). The age standardised annual incidence of schizophrenia was 2.2 (95 percent confidence 1.5 to 2.9) per 10,000 of the population. The incidence ratio for schizophrenia in all ethnic minority groups compared with the white population was 3.6 (1.9 to 7.1); the corresponding figure fon non-affective psychosis was 3.7 (2.2 to 6.2). The conclusions were that raised incidences of schizophrenia were not specific to the African Caribbeans, which suggests that the current focus on schizophrenia in this population is misleading. Members of all ethnic groups minority groups were more likely to develop a psychosis but not necessarily schizophrenia. The personal and social pressures of belonging to any ethnic minority group in Britain are important determinants in the excess of psychotic disorders found (AU)