Ursula M. Read

“I want the one that will heal me completely so it won’t come back again”: The limits of antipsychotic medication in rural Ghana

Campaigns to scale up mental health services in low-income countries emphasise the need to improve access to psychotropic medication as part of effective treatment yet there is little acknowledgement of the limitations of psychotropic drugs as perceived by those who use them. This paper considers responses to treatment with antipsychotics by people with mental illness and their families in rural Ghana, drawing on an anthropological study of family experiences and help seeking for mental illness. Despite a perception among health workers that there was little popular awareness of biomedical treatment for mental disorders, psychiatric services had been used by almost all informants. However, in many cases antipsychotic treatment had been discontinued, even where it had been recognised to have beneficial effects such as controlling aggression or inducing sleep. Unpleasant side effects such as feelings of weakness and prolonged drowsiness conflicted with notions of health as strength and were seen to reduce the ability to work. The reduction of perceptual experiences such as visions was less valued than a return to social functioning. The failure of antipsychotics to achieve a permanent cure also cast doubt on their efficacy and strengthened suspicions of a spiritual illness which would resist medical treatment. These findings suggest that efforts to improve the treatment of mental disorders in low-income countries should take into account the limitations of antipsychotic drugs for those who use them and consider how local resources and concepts of recovery can be used to maximise treatment and support families.

Ethnic differences in and childhood influences on early adult pulse wave velocity: The determinants of adolescent, now young adult, social wellbeing, and health longitudinal study

Early determinants of aortic stiffness as pulse wave velocity are poorly understood. We tested how factors measured twice previously in childhood in a multiethnic cohort study, particularly body mass, blood pressure, and objectively assessed physical activity affected aortic stiffness in young adults. Of 6643 London children, aged 11 to 13 years, from 51 schools in samples stratified by 6 ethnic groups with different cardiovascular risk, 4785 (72%) were seen again at aged 14 to 16 years. In 2013, 666 (97% of invited) took part in a young adult (21–23 years) pilot follow-up. With psychosocial and anthropometric measures, aortic stiffness and blood pressure were recorded via an upper arm calibrated Arteriograph device. In a subsample (n=334), physical activity was measured >5 days via the ActivPal. Unadjusted pulse wave velocities in black Caribbean and white UK young men were similar (mean±SD 7.9±0.3 versus 7.6±0.4 m/s) and lower in other groups at similar systolic pressures (120 mm Hg) and body mass (24.6 kg/m2). In fully adjusted regression models, independent of pressure effects, black Caribbean (higher body mass/waists), black African, and Indian young women had lower stiffness (by 0.5–0.8; 95% confidence interval, 0.1–1.1 m/s) than did white British women (6.9±0.2 m/s). Values were separately increased by age, pressure, powerful impacts from waist/height, time spent sedentary, and a reported racism effect (+0.3 m/s). Time walking at >100 steps/min was associated with reduced stiffness (P<0.01). Effects of childhood waist/hip were detected. By young adulthood, increased waist/height ratios, lower physical activity, blood pressure, and psychosocial variables (eg, perceived racism) independently increase arterial stiffness, effects likely to increase with age.

Can arterial wave augmentation in young adults help account for variability of cardiovascular risk in different British ethnic groups

Objective: Traditional cardiovascular risk factors do not fully account for ethnic differences in cardiovascular disease. We tested if arterial function indices, particularly augmentation index (AIx), and their determinants from childhood could underlie such ethnic variability among young British adults in the ‘DASH’ longitudinal study. Methods: DASH, at http://dash.sphsu.mrc.ac.uk/, includes representative samples of six main British ethnic groups. Pulse wave velocity (PWV) and AIx were recorded using the Arteriograph device at ages 21–23 years in a subsample (n = 666); psychosocial, anthropometric, and blood pressure (BP) measures were collected then and in two previous surveys at ages 11–13 years and 14–16 years. For n = 334, physical activity was measured over 5 days (ActivPal). Results: Unadjusted values and regression models for PWVs were similar or lower in ethnic minority than in White UK young adults, whereas AIx was higher – Caribbean (14.9, 95% confidence interval 12.3–17.0%), West African (15.3, 12.9–17.7%), Indian (15.1, 13.0–17.2%), and Pakistani/Bangladeshi (15.7, 13.7–17.7%), compared with White UK (11.9, 10.2–13.6%). In multivariate models, adjusted for sex, central SBP, height, and heart rate, Indian and Pakistani/Bangladeshi young adults had higher AIx (&bgr; = 3.35, 4.20, respectively, P < 0.01) than White UK with a similar trend for West Africans and Caribbeans but not statistically significant. Unlike PWV, physical activity, psychosocial or deprivation measures were not associated with AIx, with borderline associations from brachial BP but no other childhood variables. Conclusion: Early adult AIx, but not arterial stiffness, may be a useful tool for testing components of excess cardiovascular risk in some ethnic minority groups.

The effect of flexible settings on participation rates, data quality, and costs in a longitudinal study of ethnically diverse young adults: the London Determinants of young Adult Social wellbeing and Health (DASH) study

Abstract Background The loss of young and disadvantaged people in cohort studies compromises representativeness and scientific and public value. The Determinants of young Adult Social wellbeing and Health (DASH) study is a longitudinal study of young people in London, mainly from ethnic minorities, and has a social epidemiological focus. The cohort is now aged 21–23 years, an important transition phase to adulthood that influences health and wellbeing in later life. We examine the costs and benefits of different settings on motivation for participation. Methods 6643 11–13-year-olds from 51 London schools took part in the baseline survey in 2002–03 and 4781 were seen again at age 14–16 years. So far, 81% (5414 of 6643) of the cohort has been traced through friendship networks, social media, and community campaigns. A feasibility study of best practice for full follow-up was done with 400 participants between June, 2012, and August, 2013, the design of which was informed by systematic reviews. A sample of about 50 people per ethnic group (Indian, Pakistani, Bangladeshi, black Africans, black Caribbeans, white British) was chosen to give a reasonable spread by sex and socioeconomic position and across all boroughs and schools. Flexibility in settings was based on number of interview locations available (least, two; intermediate, three; most, six) and appointment times (weekdays 0900–1700 h, other). Interview locations were general practice surgeries and community pharmacies within 2 km of residential postcodes; Muslims living in east London were offered the choice of a Clinical Research Centre close to a large mosque; and central locations (Clinical Research Facility at University College Hospital and Kings College London). Participants were given GB£25 shopping vouchers and £30 vouchers if they needed childcare, and reimbursed travel expenses. A main questionnaire covered topics such as socioeconomic circumstances, social support, racism, own and parental health, and health behaviours. Dietary intake over the past 24 h was obtained in a recall questionnaire. Physical measures were done and a blood sample was also taken. The primary outcome was participation rate. Secondary outcomes were cost per participant (CPP) and quality of data. A combination of our own study team and surgery nurses was used. Interviewers were trained for 3 days and compliance to protocol was assessed by regular shadowing and analysis of data by interviewer identification code. Findings 97% (400 of 413) of those invited took part. Participation increased with flexibility in choice of interview locations (least 15%, 95% CI 11–19; intermediate 27%, 23–32; most 58%, 53–63) and was substantially boosted by weekend and evening appointments (weekday 0900–1700 h 76%, 71–80; other 24%, 17–30). CPP varied by setting from £229 (95% CI 220–239; Kings College London, 179 participants seen by study team) to £283 (276–289; Clinical Research Facility, 22 seen by their nurses). Compliance to the protocol and the quality measures were high across settings (p>0·05 for 11 of 13 measures). The CPP for those seen (40 participants) by surgery nurses was intermediate at £240 (95% CI 225–255), but the quality measures were least favourable (eg, consent for bloods 82·5%, 95% CI 70·2–94·8 vs 96·0%, 92·7–99·2 for Kings College London). Compliance to protocol was compromised by very busy environments of inner-city surgeries in deprived areas and limited familiarity with population cohorts. Interpretation Flexibility in interview locations and appointment times boosted participation rates. The use of our own study team rather than surgery nurses was associated with lower CPP and better quality data. Participants were not randomly assigned to a setting, which comprised comparisons of setting-specific participation rates. Funding The DASH study is funded by the UK Medical Research Council (MC_U130015185/MC_UU_12017/1) North Central London Research Consortium, Primary Care Research Network.

Ethnic Differences in and Childhood Influences on Early Adult Pulse Wave Velocity

Early determinants of aortic stiffness as pulse wave velocity are poorly understood. We tested how factors measured twice previously in childhood in a multiethnic cohort study, particularly body mass, blood pressure, and objectively assessed physical activity affected aortic stiffness in young adults. Of 6643 London children, aged 11 to 13 years, from 51 schools in samples stratified by 6 ethnic groups with different cardiovascular risk, 4785 (72%) were seen again at aged 14 to 16 years. In 2013, 666 (97% of invited) took part in a young adult (21–23 years) pilot follow-up. With psychosocial and anthropometric measures, aortic stiffness and blood pressure were recorded via an upper arm calibrated Arteriograph device. In a subsample (n=334), physical activity was measured >5 days via the ActivPal. Unadjusted pulse wave velocities in black Caribbean and white UK young men were similar (mean±SD 7.9±0.3 versus 7.6±0.4 m/s) and lower in other groups at similar systolic pressures (120 mm Hg) and body mass (24.6 kg/m2). In fully adjusted regression models, independent of pressure effects, black Caribbean (higher body mass/waists), black African, and Indian young women had lower stiffness (by 0.5–0.8; 95% confidence interval, 0.1–1.1 m/s) than did white British women (6.9±0.2 m/s). Values were separately increased by age, pressure, powerful impacts from waist/height, time spent sedentary, and a reported racism effect (+0.3 m/s). Time walking at >100 steps/min was associated with reduced stiffness (P<0.01). Effects of childhood waist/hip were detected. By young adulthood, increased waist/height ratios, lower physical activity, blood pressure, and psychosocial variables (eg, perceived racism) independently increase arterial stiffness, effects likely to increase with age.

Ethnic Differences in and Childhood Influences on Early Adult Pulse Wave VelocityNovelty and Significance

Early determinants of aortic stiffness as pulse wave velocity are poorly understood. We tested how factors measured twice previously in childhood in a multiethnic cohort study, particularly body mass, blood pressure, and objectively assessed physical activity affected aortic stiffness in young adults. Of 6643 London children, aged 11 to 13 years, from 51 schools in samples stratified by 6 ethnic groups with different cardiovascular risk, 4785 (72%) were seen again at aged 14 to 16 years. In 2013, 666 (97% of invited) took part in a young adult (21–23 years) pilot follow-up. With psychosocial and anthropometric measures, aortic stiffness and blood pressure were recorded via an upper arm calibrated Arteriograph device. In a subsample (n=334), physical activity was measured >5 days via the ActivPal. Unadjusted pulse wave velocities in black Caribbean and white UK young men were similar (mean±SD 7.9±0.3 versus 7.6±0.4 m/s) and lower in other groups at similar systolic pressures (120 mm Hg) and body mass (24.6 kg/m2). In fully adjusted regression models, independent of pressure effects, black Caribbean (higher body mass/waists), black African, and Indian young women had lower stiffness (by 0.5–0.8; 95% confidence interval, 0.1–1.1 m/s) than did white British women (6.9±0.2 m/s). Values were separately increased by age, pressure, powerful impacts from waist/height, time spent sedentary, and a reported racism effect (+0.3 m/s). Time walking at >100 steps/min was associated with reduced stiffness (P<0.01). Effects of childhood waist/hip were detected. By young adulthood, increased waist/height ratios, lower physical activity, blood pressure, and psychosocial variables (eg, perceived racism) independently increase arterial stiffness, effects likely to increase with age.

Ethnic Differences in and Childhood Influences on Early Adult Pulse Wave VelocityNovelty and Significance: The Determinants of Adolescent, Now Young Adult, Social Wellbeing, and Health Longitudinal Study

Early determinants of aortic stiffness as pulse wave velocity are poorly understood. We tested how factors measured twice previously in childhood in a multiethnic cohort study, particularly body mass, blood pressure, and objectively assessed physical activity affected aortic stiffness in young adults. Of 6643 London children, aged 11 to 13 years, from 51 schools in samples stratified by 6 ethnic groups with different cardiovascular risk, 4785 (72%) were seen again at aged 14 to 16 years. In 2013, 666 (97% of invited) took part in a young adult (21–23 years) pilot follow-up. With psychosocial and anthropometric measures, aortic stiffness and blood pressure were recorded via an upper arm calibrated Arteriograph device. In a subsample (n=334), physical activity was measured >5 days via the ActivPal. Unadjusted pulse wave velocities in black Caribbean and white UK young men were similar (mean±SD 7.9±0.3 versus 7.6±0.4 m/s) and lower in other groups at similar systolic pressures (120 mm Hg) and body mass (24.6 kg/m2). In fully adjusted regression models, independent of pressure effects, black Caribbean (higher body mass/waists), black African, and Indian young women had lower stiffness (by 0.5–0.8; 95% confidence interval, 0.1–1.1 m/s) than did white British women (6.9±0.2 m/s). Values were separately increased by age, pressure, powerful impacts from waist/height, time spent sedentary, and a reported racism effect (+0.3 m/s). Time walking at >100 steps/min was associated with reduced stiffness (P<0.01). Effects of childhood waist/hip were detected. By young adulthood, increased waist/height ratios, lower physical activity, blood pressure, and psychosocial variables (eg, perceived racism) independently increase arterial stiffness, effects likely to increase with age.

Health inequalities: from ethnicity to diversity

Researchers have long questioned the theoretical integrity of ethnic categories in health research (Bradby 2003), yet evidence of enduring inequalities in contexts of growing diversity means that enquiry into the causes remains of primary importance. Though research on ethnicity and health now generally includes measures of socio-economic circumstances (SEC), individual, group and contextual variables moderate this relationship, disavowing views of ethnicity as simply a proxy for disadvantage. The papers in this issue grapple with this complex intersection of ethnicity with other vectors of differentiation including migration history, age and gender, revealing differences in the ways in which these operate across diverse contexts. De Grande et al. in Belgium and Sevillano et al. in Spain, for example, explore variations in self-reported health within and between ethnic groups based on gender or migration history which was not consistently attenuated by SEC. These findings suggest limitations in overarching theories such as the ‘healthy migrant effect’ or ‘acculturation’. As in these studies, migration history is increasingly recognised as vital for a more nuanced understanding of the relationship between ethnicity and health. However, limiting this to distinguishing between ‘first’ and ‘second generation’ obscures how histories of empire and religion, as well as global and local economic and political changes, play out in dynamic patterns of migration with farreaching consequences for those who migrate and their descendants. As evidenced in Meschke et al.’s study with Hmong in the USA, the disadvantages and trauma faced by refugees and other forced migrants represent very different categories of experience from those who migrate in search of opportunities for employment or education. Focusing on young adults from ethnic minorities throws these issues into relief. At a period of significant transition, young adults engage with diverse influences from parents, peers and the wider community. Theories of convergence and acculturation suggest that the second generation will move closer to the health, lifestyle and values of the dominant culture. However, it is increasingly clear that this is not the trajectory for many. Rather identities and practices are marked by fluidity and improvisation within and between cultures (Weller 2009). Significantly, de Grande et al. and Flink et al. assign ethnicity as other than ‘Belgian’ or ‘Dutch’ where one or more parent was born abroad, highlighting the ways in which ethnic categories risk eliding such hybridity. Yet both studies reveal the challenges of negotiating this complexity and the potential impact on family relationships. Meschke et al. suggest that conflicts between parents and children arise from ‘acculturation disparity’. However, recent studies have suggested beneficial effects from access to a diverse repertoire of cultural resources in child and adolescent development (Gregory et al. 2013) which may enhance rather than erode social capital (Holland, Reynolds, and Weller 2007). Acknowledging the potential benefits of diversity should not suggest the dawn of a cosmopolitan utopia. The societies represented in these studies Ethnicity & Health, 2014 Vol. 19, No. 2, 119–121, http://dx.doi.org/10.1080/20445911.2014.887044

Spirituality and psychiatry, edited by Chris C.H. Cook, Andrew Powell and Andrew Sims

Spirituality and psychiatry, edited by Chris C.H. Cook, Andrew Powell and Andrew Sims, London, Royal College of Psychiatrists, 2009, 330 pp., £25.00 (paperback), ISBN 978-1-904671-71-8 In the Unite...