Superdiversity, population health and health care: opportunities and challenges in a changing world.

OBJECTIVES: Ethno-national approaches to research public health and migrant outcomes have dominated for decades but lack efficacy in a globalised world and in view of the intractable nature of health outcome inequalities for migrant and minority groups. This article highlights some of the challenges and opportunities associated with a superdiversity perspective in public health research. SUPERDIVERSITY AND ETHNO-NATIONAL APPROACHES: Migration patterns have changed with more people arriving from more places and the diversification of diversity meaning that the ethno-national categories utilised in public health research have reduced explanatory potential. THE EXAMPLE OF MATERNAL AND PERINATAL MORTALITY IN THE UNITED KINGDOM: Adjusting UK perinatal mortality rates by five ethnic groups based on assumptions of relationships between high levels of risk and ethnic groups masks the scale of inequality faced by groups wherein mortality rates are increasing and highlights some of the difficulties associated with using ethno-national classifications. A SUPERDIVERSITY PERSPECTIVE: A superdiversity approach moves beyond ethno-nationalism to socially locate groups focussing on commonalities and differences across spaces and characteristics and employing intracategorical or anticategorical approaches. CONCLUSIONS: Superdiversity brings new levels of demographic complexity and fluidity. Greater reflexivity is needed in diversity research with justification of classifications used for analysis necessary when research questions are developed.

Evolution of atherogenic diets in South Asian and Italian women after migration to a higher risk region.

BACKGROUND: To identify differences in the evolution of the diets of South Asian and Italian migrants, a cross-sectional, multiethnic study was undertaken in Glasgow, Scotland. METHODS: Five groups of women aged 20-42 years comprising general population (n = 35), South Asian migrants (n = 35) British-born controls (n = 37), Italian migrants (n = 30) and British-born (n = 38) participated in an interviewer administered structured questionnaire on issues relating to health, diet and food selection. Anthropometric measurements were made and subjects completed a 7-day weighed diet inventory. RESULTS: Compared with the general population, dietary differences were greatest amongst first generation migrant groups. There were major differences between the two migrant groups. South Asian migrants tended to display a more atherogenic profile (fat 42.4% energy, saturated fat 15.0% energy, vitamin C 5.1 mg per 1000 kJ) than the general population (fat 39.1% energy, saturated fat 13.5% energy, vitamin C 6.8 mg per 1000 kJ), and Italian migrants (fat 35.7% energy, saturated fat 12.1% energy, vitamin C 10.9 mg per 1000 kJ). However, South Asian groups had higher intakes of polyunsaturated fatty acids which may be cardioprotective. CONCLUSIONS: South Asian migrants to Scotland appear to develop adverse dietary elements in the first generation, which are modified in subsequent generations, whereas Italians' diets remain cardioprotective in the migrant generation but deteriorate in subsequent generations.

Ethnic differences in anthropometric and lifestyle measures related to coronary heart disease risk between South Asian, Italian and general-population British women living in the west of Scotland.

AIMS: To compare anthropometric measurements and to define their behavioural associations in migrant and British-born South Asians (who have increased cardiovascular risk) or Italians (who have reduced cardiovascular risk), and in the general population of British women living in the west of Scotland. STUDY DESIGN: Cross-sectional survey of women aged 20-42 y, selected mainly from birth registration data, which included 63 migrant South Asians, 56 British-born South Asians, 39 migrant Italians, 51 British-born Italians, and 50 subjects representative of the general population of women, all resident in the west of Scotland. MEASUREMENTS: Height, weight, body mass index (BMI), and waist and hip circumferences. RESULTS: With age adjustment, migrant South Asians (0.88) had greater waist-to-hip ratio than British-born South Asians (0.84; P<0.05), while there was no difference between migrant (0.81) and British-born (0.79) Italian groups. Both migrant (P<0.001) and British-born South Asian (P<0.05) groups had higher waist-to-hip ratio and were about 3 cm shorter than Italian groups and the general population. Neither weight nor BMI were different between ethnic groups. Waist and hip circumferences were not different between migrant and British-born ethnic minority groups. Migrant South Asians (86.8 cm) had significantly (P<0.05) larger waist circumference than the general population (78.6 cm). British-born Italian women (103.0 cm) had larger hip circumference than the general population of women (96.4 cm), while other groups had similar hip circumferences. Additional adjustments for physical activity, smoking, alcohol consumption and parity reduced the differences in anthropometric measurements: only waist-to-hip ratio of migrant South Asians remained significantly (P<0.01) higher than that of the general population women. CONCLUSIONS: The adverse anthropometric indicators of cardiovascular risk in migrant South Asian women are substantially explained by their lifestyle factors and parity. British-born South Asian women are more similar to the general population women. Anthropometric differences between migrant or British-born Italians and the general population women are small.

Behaviours and expectations in relation to sexual intercourse among 18-20 year old Asians and non-Asians.

OBJECTIVES: To begin to map the reported behaviours and attitudes of young Britons of south Asian origin that may have implications for sexual health. "South Asian" refers to people able to trace their ancestry from the Indian subcontinent (that is, India, Pakistan, and Bangladesh), henceforth referred to as "Asian". DESIGN: A cross sectional study of sexual behaviour using self report measures in a self complete section of a social survey administered by trained interviewers in 1996. SETTING: Greater Glasgow, Scotland. SUBJECTS: Sample (n = 824) originally recruited aged 14-15 in 1992 in secondary schools in Greater Glasgow and subsequently traced through general practitioner registration for 1996 survey. 492 Asians and non-Asians aged 18-20 years old eventually interviewed in their own homes. MAIN OUTCOME MEASURES: Self reported experience of sexual intercourse, age at first intercourse, and contraceptive practice over year before interview. METHODS: Measures of sexual behaviour and attitudes were elicited through a self complete questionnaire filled out in the presence of, and returned to, a trained social interviewer. RESULTS: Asians, and particularly Asian women, were far less likely to report having had heterosexual intercourse. Those Asian women who had had intercourse were likely to do so for the first time at an older age, and with an older partner, than the non-Asian women. Asian women were less likely to report using the pill than non-Asian women, irrespective of their marital status, and Asian men were less likely than non-Asian men to report using condoms. Asian sexual abstinence was reported to be for religious reasons, which were not important for non-Asians. In contrast with non-Asians, Asians saw themselves as likely to be married with children within the next 5 years. Asian men considered the ideal age to marry for men and women to be younger than the non-Asian men's average estimate. Asian and non-Asian women suggested a similar ideal age for men to marry, but Asian women considered a younger age appropriate for women than did non-Asian women. CONCLUSIONS: The higher level of sexual abstinence among Asians, and particularly women, has implications for the delivery of sexual health services to the minority who are sexually active before marriage. The underreporting of condom use by Asian men compared with their non-Asian counterparts, suggests a failure of the existing sexual health education and health services to reach minority ethnic young men which may be remedied by collaborative work with institutions currently used by the Asian community.

Prevention of rebleeding from oesophageal varices: two-year follow up of a prospective controlled trial of propranolol in addition to sclerotherapy.

A prospective randomised trial comparing propranolol and sclerotherapy to sclerotherapy alone was conducted over a 2-year follow up in a district hospital setting of unselected patients. Rebleeding and survival were analysed. Thirty-nine patients were randomised to propranolol plus sclerotherapy and 34 to sclerotherapy alone. The two groups were clinically comparable. There was no significant difference in the cumulative percent of patients free of rebleeding; 54% of the sclerotherapy group rebled compared to 52% of the group treated with propranolol plus sclerotherapy (Hazard ratio 1.09 (0.54-2.22) and p = 0.81, NS). Two-year actuarial survival was also not significantly different, with 77% of the propanolol plus sclerotherapy group surviving, compared to 74% of sclerotherapy alone (Hazard ratio 1.08 (0.35-2.22) and p = 0.79, NS). The mean time to eradication of varices was not significantly different between the two groups (propranolol plus sclerotherapy 222 days, sclerotherapy alone 243 days), nor did the rate of variceal recurrence differ (72.7 vs 72 days). This study did not show long-term improvement in rebleeding or survival using propranolol in addition to a regular sclerotherapy programme.

Rapid intravenous low-dose diazepam as sedation for upper gastrointestinal endoscopy.

One hundred patients for endoscopy, aged, between 18 and 74 years were randomly allocated to two equal groups. Group A received 10 mg diazepam intravenously rapidly over 2-4 s; Group B received diazepam intravenously over 1-2 min, titrated to provide a satisfactory level of sedation (mean dose 15.9 mg). Patient co-operation during endoscopy was similar in both groups, but one patient in Group A developed respiratory depression. Tests of psychomotor function after endoscopy showed greater impairment 30 min following injection for Group B, compared with Group A (P less than 0.02). Total or partial amnesia for endoscopy was present in 62% of Group A, and 90% in Group B (P less than 0.005). However, postal follow-up showed that endoscopy was acceptable to 96% of Group A and 98% of Group B. Delayed sedation later in the day was reported by 26% of Group A compared with 48% of Group B.

Bile diversion after total gastrectomy.

A method for studying bile reflux into the oesophagus after total gastrectomy is described using 99Tcm-HIDA and an external imaging system. Two reconstructions were studied: oesophagojejunostomy with a diverting entero-anastomosis (omega reconstruction 6 studies) and Roux-en-Y reconstruction (20 studies). The incidence of reflux on scanning correlated well with the incidence of oesophagitis, and the finding of reflux was almost always associated with severe symptoms. The omega procedure was unsuccessful in diverting bile in 5 patients despite an entero-anastomosis as wide as 12 cm. The Roux-en-Y reconstruction was unsuccessful in diverting bile in 5 patients all of whom had a diverting limb 35 cm in length; none of the 9 patients with a diverting limb longer than 35 cm refluxed (range 40--50 cm).