Methodological rigour in cross-cultural research.
Explore the source record for details and available documents.
Cross-Cultural Comparison↗
Biomedical subjects
D Bhugra
Publications and source records attributed to D Bhugra.
Bulimic disorders and sociocentric values in north India.
BACKGROUND: Previous studies have shown low rates of eating disorders in some developing countries. We set out to investigate the prevalence of bulimia in an all-female college population in north India and relate it to sociocentrism of the culture. METHODS: A total of 504 students in an all-girls private college in an industrial town in north India completed the Hindi translation of the Bulimia Investigatory Test, Edinburgh (BITE). A random sample of 50 students, irrespective of their scores, were interviewed using the DSM-III-R interview for eating disorders; they were also asked about qualitative aspects of their relationship with the family and their own views of their identity. RESULTS: There was no effect of age, social class, religion or height on the distribution of BITE scores. Three key factors emerged; these were related to the constructs of compulsive activity, impulsivity/sociocentric avoidance and associated attitudinal responses and depressive thinking with features of helplessness and feelings of failure. Acculturation was not related to BITE scores. Virtually all interviewees had sociocentric views of theirselves. CONCLUSIONS: Sociocentrism and impulsivity account for a significant amount of the variance. The role of sociocentrism in influencing patterns of eating deserves to be studied further.
Acculturation↗
Cross-cultural validity of the Amritsar Depression Inventory and the General Health Questionnaire amongst English and Punjabi primary care attenders.
BACKGROUND: In order to estimate the health needs of cultural groups, the cross-cultural validity of instruments requires investigation in distinct cultural rather than ethnic or racial groups. METHOD: We screened 'Punjabi' and 'English' primary care attenders in South London (UK), using the General Health Questionnaire (GHQ-12), an English origin instrument, and the Amritsar Depression Inventory (ADI), which was developed in the Punjab in India. The criterion measure was the Clinical Interview Schedule (CIS-R). We calculated the validity coefficients, optimal thresholds and the area under the 'Receive Operating Characteristic' curve to compare cross-cultural performance. We identified items on each questionnaire that contribute to performance of the instruments. RESULTS: The GHQ-12 has high validity coefficients in both cultural groups. The ADI performs as well amongst English subjects, but among Punjabis it is poorer than the GHQ-12. Among Punjabis who have been resident in the UK for over 30 years, the ADI performs no better than chance. Few items on the ADI or the GHQ are strongly predictive of case status. CONCLUSIONS: The GHQ-12 shows good validity in both cultures. Expressions of distress may change due to acculturation. 'Culturally sensitive' screening instruments need to reflect this. Further work might attend to the changing expressions of distress following migration.
Adult↗
Migration and schizophrenia.
OBJECTIVE: Since the beginning of the human race, individuals have migrated alone or in groups. This process of migration has often been considered to be an aetiological factor in the genesis of many mental disorders. METHOD: Two studies collecting rates of first onset schizophrenia in Trinidad and in London using the same assessment instruments. RESULTS: The sending countries have low rates of schizophrenia. The impact of migration itself produces high stress but rates of schizophrenia are even higher in the second generation, suggesting that that other social factors may be responsible for the increase if genetic vulnerability is excluded. CONCLUSION: Individual social factors, such as cultural identity and the impact of racism, are more likely to play a key role in the genesis of schizophrenia.
Cultural Characteristics↗
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 that 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.
Adult↗
Use of the Mental Health Act criteria in the decision-making process for compulsory admissions: a study of psychiatrists in South London.
This study investigates the decision-making process for admitting patients compulsorily under the Mental Health Act 1983 of England and Wales. We used three case-vignettes describing different clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. The vignettes were administered to a group of psychiatrists working at the Bethlem Royal and Maudsley Hospitals in South London. The psychiatrists were asked to rate 11 factors from the most to the least important in their decision to admit the individual compulsorily. Three factors resembled the criteria considered in the Mental Health Act 1983 for compulsory admission: current mental state; severity of the disease; and dangerousness to self or others. Three were other clinical features of the patient: diagnosis; psychiatric history; and likely response of the mental state to the medical treatment. The remaining five were sociodemographic features of the patient: age and gender; owning a home; occupational status; and social support available. The psychiatrists were not given the option that the patient would accept a voluntary admission to hospital. We obtained responses from 42 psychiatrists (25 males and 17 females). The most important factor for deciding to detain a patient compulsorily was perceived dangerousness to self and others. The current mental state of the patient and the severity of the illness were the next two important factors. Our results confirm that the criteria recommended by the Mental Health Act 1983 of England and Wales were applied consistently in three different hypothetical situations. The need for protection of the patient or others may take precedence over the current mental state of the patient or the severity of the illness, a finding that warrants further investigation in view of the current debate on the responsibility of psychiatrists in deciding to detain subjects affected by personality disorder.
Adult↗
Early manifestations, personality traits and pathways into care for Asian and white first-onset cases of schizophrenia.
BACKGROUND: Previous studies have shown that manifestations of symptoms and premorbid personality of patients with schizophrenia differ across cultures. However, these have only been demonstrated in cultural settings apart from each other. METHOD: We set out to compare these across different ethnic groups from a catchment area in west London. The Asian and the white group had similar inception rates of schizophrenia and we therefore decided to compare these two groups to ascertain similarities in social, demographic and personality factors and pathways into care. First-onset cases of schizophrenia were studied on a number of parameters using previously validated instruments. RESULTS: There were more similarities than differences between the two groups. When compared with the findings of a previous multicentre study in India, London Asians, like their counterparts in India, were more likely than the London white sample to present with loss of appetite, become more religious and behave as if hearing voices. However, compared to their Indian counterparts, the onset of symptoms was more likely to be insidious and alternative sources of healing were less likely to be approached. CONCLUSIONS: These findings are discussed in relation to the findings for white patients and recommendations made for future research.
Adult↗
Fertility and marital rates in first-onset schizophrenia.
BACKGROUND: Many studies have demonstrated that in schizophrenia there are decreased rates of marriage, fertility and marital fertility. However, it is not clear whether this finding occurs as a social consequence of having the illness or is an inherent part of the illness. One would expect it to vary across cultures if it were being mediated by social and cultural factors. METHOD: We investigated this by reviewing the marital and fertility data from a multi-ethnic first-contact group of patients in London with CATEGO broadly defined schizophrenia, and comparing this with similar data from a group of controls who were matched for age, gender and ethnicity. RESULTS: Our sample comprised 38 White British, 38 Caribbean and 24 Asian subjects. The Asian group were significantly older (mean age 38, P < 0.003) and had a greater percentage of females (50%). When compared to controls, the White and Caribbean patients, but not the Asians, had decreased marital and stable relationship rates. There was also decreased fertility and marital fertility as evidenced by number of children among the Whites and Caribbeans, but again significantly not among the Asians. Marital status did not predict fertility rates, particularly among the Caribbeans. Regression analysis demonstrated an effect for age on the number of children but not on marital status. CONCLUSIONS: These findings suggest that marital and reproductive behaviour are reduced in schizophrenia, but this effect may be mediated by social and cultural factors and therefore not apply consistently across ethnicity. Further research is needed to prospectively investigate populations to determine whether impairments of this nature are inherent or consequential to the illness.
Adolescent↗
The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multi-ethnic population.
BACKGROUND: African-Caribbean patients have less desirable routes of entry into the psychiatric services than other ethnic groups in Britain but this may not apply to the first contact with services. METHODS: Patients' pathways to care, type of admission or referral and sectioning details were recorded for all first contact patients presenting to south London psychiatric services over a 2-year period. We also conducted a retrospective analysis of data from the Camberwell Register, comparing rates of compulsory admission between 'Whites' and 'African-Caribbeans' for first and readmissions, over a 20-year period. RESULTS: Our first contact sample comprised 38 White, 38 African-Caribbean and 24 Asian patients with CATEGO defined broad schizophrenia. GP referral was found to be the most common mode of contact and there were no significant differences between the ethnic groups with regard to compulsory admission. Similarly, data from the Camberwell Register showed no significant difference in rates of compulsory admission between first admission White and African-Caribbean patients. However, when all readmissions were examined, African-Caribbeans were more likely to be admitted involuntarily. CONCLUSIONS: Our findings suggest that reports of less desirable routes of entry for African-Caribbean patients into the psychiatric service do not apply to their first admission but are likely to develop over time and repeated contact with the services.
Adolescent↗
Attempted suicide in west London, I. Rates across ethnic communities.
BACKGROUND: Two previous studies from the United Kingdom have suggested that rates of attempted suicide in Asian women are higher than in the native population. METHOD: Over a 1-year period we identified 434 patients presenting from one catchment area to four hospitals, after episodes of self-harm. These patients were assessed using the GHQ, CIS-R, and Life Events Inventory, and by collecting details of the attempt itself. RESULTS: Asian women had the highest overall rates; 1.6 times those in White women and 2.5 times the rate among Asian men. The rates were lowest among older women. Among younger Asian women (less than 30 years) the rates were 2.5 times those of White women and seven times those of Asian men. The rates among black groups were lower than expected. Self-poisoning was the commonest method of self-harm. CONCLUSIONS: Younger Asian women are vulnerable to increased rates of attempted self-harm and deserve to be studied further.
Adolescent↗
Attempted suicide in west London, II. Inter-group comparisons.
BACKGROUND: Previous studies of attempted suicide have suggested that cultural and social factors play a significant role in the causation of deliberate self-harm. METHOD: In order to measure elements of culture conflict two inter-group comparisons were undertaken. In the first, 27 Asian women who had presented to hospital services following attempted suicide (Asian group) were matched with a group of similar age Asian women attending GP surgeries for other reasons (Asian GP attenders group). The second comparison was between the Asian and 46 White attempters. RESULTS: On comparing Asian attempters with Asian GP attenders group the former were more likely to have a history of previous suicidal behaviour, to have a psychiatric diagnosis, and be unemployed. Their parents were more likely to have arrived in the United Kingdom at an older age. In addition, those who attempted suicide were more likely to have been in an inter-racial relationship and to have changed religions. In the second inter-group comparison, the characteristics of Asian and White suicide attempt patients were examined. White attempters were more likely to have mental illness, and were more likely to use alcohol as part of the method of attempted suicide. By contrast, Asian attempters had experienced life events pertaining to relationships, took fewer tablets and yet expressed greater regret at not succeeding in the attempt. CONCLUSIONS: Although numbers are small, social stress and other cultural factors play an important role in the act of deliberate self-harm.
Adolescent↗
Social factors and first onset schizophrenia among Asians and whites.
Previous studies from the Indian subcontinent had suggested that the onset and outcome of schizophrenia is linked with social factors. We set out to study the inception rates and social factors in whites and Asians who were presenting for the first time ever to various catchment facilities in Ealing catchment area. A total of 62 cases (38 white and 24 Asians) were diagnosed as having schizophrenia. Using well established and previously validated standardised instruments we collected information on various social factors and inception rates of schizophrenia. The inception rates and social factors were largely similar in these two groups. By and large the social factors in the two groups were broadly similar except that Asians were significantly more likely to show increased religious activity compared with their white counterparts. Contrary to previous findings Asians were more likely to have had longer duration of symptoms prior to seeking help. These findings are discussed in relation to Asian support systems and suggestions made for future research.
Adult↗
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 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 categorised as S+ (narrow) schizophrenia, giving an incidence rate of 2.8/10,000 (95% CI 1.97-3.7). The incidence rate for broad schizophrenia was calculated at 3.2/10,000 (95% CI 2.3-4.1), which is significantly lower than the comparable rate for London's African-Caribbeans of 6.6/10,000 (95% CI 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.
Adolescent↗
Racism in psychiatry: paradigm lost--paradigm regained.
Racism and psychiatry have been 'linked' in the public imagination, largely because psychiatry is seen as an instrument of social control, and racism as a different form of oppression which permeates society at large. Racism in psychiatry is often believed to be the mediating factor in cases of 'psychiatric misdiagnosis' and 'mismanagement.' Misdiagnosis includes underdiagnosis and overdiagnosis; this can account for the non-delivery of appropriate treatments because of an erroneous diagnostic label. In some instances this leads to a deferred intervention, or in some ethnic groups, help-seeking is delayed for unnecessarily long periods. Racism is not a recent phenomenon. The blunt application of the word 'racism' perpetuates conceptual confusion about what is meant by the term, what processes are taking place, how much of the processes are institutionalized or individual and to what degree individuals are aware of the impact of their actions. We propose a way of understanding racism in psychiatric practice, and suggest that within such a framework, the therapist/professional and the patient can work together towards improving patient care.
Attitude of Health Personnel↗
Should doctors reconstruct the vaginal introitus of adolescent girls to mimic the virginal state? Promiscuity is acceptable only for men.
Explore the source record for details and available documents.
Culture↗
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.
Africa↗
Common mental disorders, explanatory models and consultation behaviour among Indian women living in the UK.
Women of Indian origin are said to have a lower rate of recognized common mental disorders and a higher frequency of consultation in primary care than white British. The aim of this study was to evaluate factors, including explanatory models (patient perspectives) of illness, associated with common mental disorders and with frequency of consultation among women of Indian origin in primary care. The investigation was conducted in a general practice in West London with a large Indian population. Consecutive woman attenders of Indian descent were screened with the General Health Questionnaire-12 to identify probable cases of psychiatric morbidity. 100 patients were interviewed with the Revised Clinical Interview Schedule (CIS-R), a specific tool for the diagnosis of common mental disorders, and the Short Explanatory Model Interview, which elicits the individual's conceptualization of his or her illness. Those patients who satisfied CIS-R criteria were classified as 'cases', the others as 'controls'. Common mental disorders were documented in 30% of patients. The general practitioner's diagnosis of common mental disorders had a sensitivity of 17% and a specificity of 91%. Individuals with common mental disorders had a higher frequency of consultation (P = 0.017), were less likely to see depression as an indication for medical intervention and were more likely to withhold some of their concerns from the general practitioner. Incorrect diagnosis by the GP was most likely to occur when patients did not disclose all their complaints. These associations were all statistically significant after adjustment for possible confounders by multiple linear and logistic regression. Women of Indian origin in this sample had rates of common mental disorders similar to those in other UK populations. Differing conceptualizations of common mental disorders may contribute to their underrecognition in women of Indian origin.
Adult↗
Training and supervision in effective cross-cultural mental health services.
For mental health professionals working in areas with large black and minority ethnic populations, adequate training and continuing supervision are essential in providing culturally acceptable services. Local multidisciplinary training is the most suitable method of integrating training and supervision and developing culturally appropriate services.
Cultural Diversity↗