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Rapid Responses: Rapid Responses published:
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Tobacco and anxiety disorders
- Antonio E Nardi (10 January 2004)
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Getting it right in multi-cultural research
- Mark RD Johnson, Gary S Collins (14 January 2004)
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Information regarding lifestyle factors in ethnic minority groups should not be undervalued
- Miranda J Pallan, Sam Ramaiah, Director of Public Health, Walsall Teaching Primary Care Trust, Walsall WS1 1TE (22 January 2004)
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Further observations on cross-cultural comparability of questionnaires: a pilot study with bengali speakers
- Raj S Bhopal, Sushmita Weibe, Amanda Vettini, Lisa Hanna, Sonja Hunt. Amanda Amos (6 February 2004)
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Antonio E Nardi, Associate Professor Federal University of Rio de Janeiro R. Visconde de Piraja, 407/702. Rio de Janeiro. 22410-003. Brazil
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Bhopal et al (1) assessed the adequacy of cross cultural adaptations of survey questions on self reported tobacco and alcohol consumption in the United Kingdom. The comparison of prevalence data the surveys showed some important discrepancies, greater for tobacco than for alcohol. Perhaps the surveys have not followed best practice in relation to measurement of risk factors in cross cultural settings. The authors concluded that research is still needed to help achieve linguistic equivalence of survey questions in cross cultural investigations. The influence of smoking among psychiatric patients has many theoretical and clinical implications. Smoking can improve cognition, mood, and anxiety (2) but by the multiplicity of positive reinforcing effects of nicotine and nicotine withdrawal can exacerbate these symptoms (2). Smokers with an anxiety disorder are less likely to stop smoking (2,3).There is good evidence for a closer relationship between smoking and anxiety disorder (4) and a possible causal relationship between smoking and the first panic attack (3). Lopes et al. (4) investigated the prevalence of cigarette smoking among 262 mood or anxiety disorder (DSM-IV) outpatients. Among them, 26.3% (n=69) were smokers, 23.7% (n=62) were former smokers, and 50.0% (n=131) were nonsmokers. The prevalence of nicotine dependence (DSM-IV) among smokers was 59.0%. The social anxiety disorder patients were the heaviest smokers (75.0%), with more unsuccessful attempts to stop smoking (89.0%). The panic disorder patients had an ambiguous relationship with the tobacco. Some patients recognize that the cigarette smoking decrease their anxiety. On the other hand they have difficulties in stopping smoking as they cannot distinguish some of the abstinence symptoms from an imminent panic attack and the impossibility of leaving an important cause of death – tobacco – increases their suffering with hypochondriac worries. A biological marker that sheds light on the relationship between anxiety disorders and tobacco is a dopaminergic pathway of action related to nicotine (5). Smoking has been linked to greater dopamine activity in the human basal ganglia (5). Nicotine increases the release of dopamine in the smoker’s striatum and consequently stimulates the presynaptic dopamine synthesis (5). Social anxiety disorder has been associated with low dopamine D2 receptor binding potential in the striatum and the development of nicotine dependence may be associated with increased dopamine activity in the basal ganglia (5). Cognitive and respiratory factors may also be associated in panic attack and tobacco smoking (3). Tobacco smoking causes several clinical pathologies such as lung cancer and chronic obstructive pulmonary disease and passive smoking causes the deaths of thousands of nonsmokers and morbidity in children and other relatives of smokers (2). Research and public campaign are extremely useful to draw attention to all the groups and subgroups susceptible to a higher risk of dependence and difficulties to withdrawal from tobacco. References: 1.Bhopal R, Vettini A, Hunt S, Wiebe S, Hanna L, Amos A. review of prevalence data in, and evaluation of methods for cross cultural adaptation of, UK surveys on tobacco and alcohol in ethnic minority groups. BMJ 2004; 328: 76-80. 2.Hughes JR, Fiester S, Goldstein M, Resnick M, Rock N, Ziedonis D. Treatment of patients with nicotine dependence. In: American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Compendium 2000. 1st edition. American Psychiatric Press, Washington, DC. 3.Valença AM, Nascimento I, Nardi AE. Smoking and panic disorder. Psychiatric Services 2001; 52: 1105-1106. 4.Lopes FL, Nascimento I, Zin WA, Valença AM, Mezzasalma MA, Figueira I, Nardi AE. Smoking and psychiatric disorders: a comorbidity survey. Braz J Med Biol Res 2002; 35: 961-967. 5.Salokangas RK, Vilkman H, Ilonen T, Taiminen T, Bergman J, Haaparanta M, Solin O, Alanen A, Syvalahti E, Hietala J. High levels of dopamine activity in the basal ganglia of cigarette smokers. Am J Psychiatry 2000; 157: 632- 634. Competing interests: None declared |
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Mark RD Johnson, Director, Mary Seacole Research Centre 266 London Road, Leicester LE2 1RQ, Gary S Collins
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Bhopal and colleagues (1) raise important issues. As a sometime member of the team which developed one of the earliest methodologies for surveying schoolchildren's smoking (2), and a researcher conducting a systematic review on the cultural sensitivity of treatment outcome measures, we share their concerns. The need to make research 'culturally competent (or as the new Zealanders would say, 'culturally safe') becomes increasingly important as we cope with globalisation, transnational research (3) and the implications in UK of the Race Relations Amendment Act for evidence-based practice. It is to be regretted that Bhopal's team were unable to find studies or examples of good practice outside the 'quality of life' field - this is not exactly a new issue (4). They also refer to the HEA study (their reference 14 - the 'BMEG2' survey) (5) which was analysed by our team. Unfortunately, we did not design the questionnaire for that, and did not receive Bhopal's team's request for information. We have tried to ensure that work we are involved in does use standardised, validated questions and when talking about 'smoking' actually refer to tobacco use instead (some people use pipes and cigars, as well as paan). This is only one of several issues that need attention when conducting research relating to ethnic or cultural diversity (6). Now that the Health Survey for England 2004 is already in the field, it is too late to affect its methodology (and its authors will speak for themselves, but they may be expected to have taken these factors on board). We shall, however, welcome the start of a debate and the sharing of validated, cross-culturally sensitive questions on all aspects of minority ethnic health, and offer our Centre as a point of reference and deposit in England to complement the work north of the border! Sincerely, (Prof) Mark R D Johnson
Dr Gary S Collins
1: Bhopal R, Vettini A, Hunt S, Wiebe S, Hanna L, Amos A 2004 'review of prevalence data in and evaluation of methods for cross cultural adaptation of, UK surveys on tobacco and alcohol in ethnic minority groups' British Medical Journal 328 :76-80 2: Murray M, Bewley B, Johnson MRD et al 1982 ‘Social class, parents, children and smoking’ Bulletin of the International Union against Tuberculosis 57, pp258-262 3: Collins GS, Efficace F 2002 'Cross-Cultural Issues in Assessing Quality of Life in Cancer Clinical Trials' Expert Review of Pharmacoeconomics & Outcomes Research, 2(3): 261—267 4: Johnson MRD, Cross M 1984 Surveying Service Users in Multi-Racial areas Coventry: RUER/Centre for Research in Ethnic Relations, Warwick University 5: Johnson MRD, Owen D, Blackburn C, 2000 Black and Minority Ethnic Communities - Health & Lifestyles London: Health Education Authority 6: Johnson MRD 2003 ‘Research Governance and Diversity: Quality standards for a multi-ethnic NHS’ NT Research 8,1 :2-10 Competing interests: The Mary Seacole Research Centre and Centre for Evidence in Ethnicity health & Diversity are funded to conduct 'cross-cultural' health research. Johnson has worked in 'smoking', 'alcohol' and drugs research. Collins is funded by an NHS Health Technology Assessment grant to evaluate the use of outcome measures in multi-ethnic populations. |
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Miranda J Pallan, Specialist Registrar in Public Health Walsall Teaching Primary Care Trust, Walsall WS1 1TE, Sam Ramaiah, Director of Public Health, Walsall Teaching Primary Care Trust, Walsall WS1 1TE
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EDITOR- Bhopal et al. clearly demonstrate the need for high quality, validated survey methods when researching behaviours in ethnic minority groups (1). This has implications for future research design, however, policy makers in the short term have to base their decisions on the data currently available. While it is important to take into account the limitations of the data available, it is also important not to disregard potentially valuable data unnecessarily. In Walsall, two Asian lifestyle surveys were undertaken in 1995 and 2000, employing the same survey design and method of administration (using trained interviewers). These surveys highlighted the importance of issues such as the high proportion of Bangladeshis reporting that they smoked in both surveys (24% and 23% compared to 11% and 10% of all South Asians in the 1995 and 2000 surveys respectively) (2,3). Although deficiencies in survey design may make these proportions inaccurate in absolute terms, valuable information can be gained from comparisons over time and between the groups included in the surveys. As Bhopal et al. clearly stated, difficulties arise when attempting to compare across surveys of ethnic minority groups, either local or national. This accepted, until more rigorous survey design in this area provides us with more accurate data, policy makers should be careful not to undervalue data currently available. References 1. Bhopal R, Vettini A, Hunt S, Weibe S, Hanna L, Amos A. Review of prevalence data in, and evaluation of methods for cross cultural adaptation of, UK surveys on tobacco and alcohol in ethnic minority groups. BMJ 2004; 328: 76-80. 2. Walsall Health Authority Department of Public Health Medicine 1995. The health and lifestyle of Walsall’s Asian community aged 16 to 65. 3. Walsall Health Authority Department of Public Health Medicine 2001. Walsall’a Asian health and lifestyle survey 2000. Competing interests: None declared |
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Raj S Bhopal, Professor, Public Health Sciences Public Health Sciences, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9PQ, Sushmita Weibe, Amanda Vettini, Lisa Hanna, Sonja Hunt. Amanda Amos
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Further to the comments by Johnson and Collins (1) on the paper by Bhopal et al (2) we should like to develop the theme of cultural sensitivity and translation procedures. In a pilot study following the analysis reported by Bhopal et al. ten Bengali speakers were recruited and asked to comment on translations into Bengali of key questions from tobacco and alcohol surveys. Through a bi-lingual research associate (SW) they were asked to note any problems of understanding, naturalness of the wording and the cultural appropriateness of the items. There were 5 men and 5 women in the age range 21-66 years. Where relevant they were asked to suggest alternative translations to the ones given. This exercise revealed that many translations were in too ‘high’ or formal a form of Bengali which would pose a particular problem for people from Bangladesh. Some translations were regarded as too literal. For example, the translation. “do you ever smoke cigarettes?’ used the word for ‘smoke’ in Bengali. However, it was pointed out that the correct usage would be “Do you eat/ consume cigarettes?” The word ‘regularly’ as in the question, ‘Do you smoke cigarettes regularly?’had been translated using a term which had the connotation of some beneficial activity in the sense of disciplined regularity, such as taking medicine and thus was not at all appropriate for smoking. The use of terms such as ‘weekend’ and ‘weekday’ was judged inappropriate for this community. As one respondent noted “There is no word for weekend. The question should be related to days off or holidays”. Since many Bangladeshis work in the catering and restaurant business the notion of a weekend in the English sense is not necessarily shared. The practice of rolling cigarettes is not common in the Bengali community. It was remarked that asking questions about alcohol to people who are devout Muslims could be very offensive. The term ‘homebrew’ was regarded as not salient as the idea of making one’s own alcohol was was thought to be an alien concept . The use of festivals such as ‘Christmas’ and ‘New Year’ in questions designed to assess drinking habits was regarded as insensitive.The concept of a ‘hangover’ was said not to exist. It is clear that there were problems with the translations both with respect to linguistic equivalence and cultural relevance. An important finding is that although some translations were perfectly adequate and understandable, the question itself was culturally inappropriate. This tendency of translators to focus on linguistic issues at the expense of relevance and salience has been noted elsewhere (3). This pilot study involved only ten Bengali speakers and cannot be taken to be in any way representative of the Bengali-speaking community in general. One problem is that people have varying degrees of familiarity with Bengali and the language takes different forms according to the region from which people come. In Edinburgh the main variant is Syllheti. Most men from Bangladesh are fluent in Bengali but females may be more familiar with Syllheti. Among older people from Bangladesh not more than about 20% read or write Bengali and people with minimal education may speak only Syllheti. Those with some formal education may understand both Bengali and Syllheti but the majority of people from Bangladesh are said not to understand the ‘higher’ forms of Bengali. This is a phenomenon which also occurs in translations of English into European languages and is a consequence of relying upon highly educated professional translators (4). An obvious question arising from this small exercise is that of why the translators do not apprise the researchers of the cultural inappropriateness of some items. Is it due to them being thoroughly Westernised? Is it not seen as part of the task? Are they too removed from the situation? Are translators merely given a questionnaire or interview schedule to translate and meet but briefly, if at all, with the researchers? If so there may be no discussion of the intent and conceptual basis of the item and no opportunity for the translators to point out anomalies. Where the researcher(s) are not familiar with the languages in question they have no control over what is being asked and may assume that sensitive items are being dealt with by the translator. There is a need for much greater attention to be paid to the intricacies of translation as well as the cultural moraes of ethnic minority communities. Researchers and translators should work in close collaboration, preferably involving monolingual speakers of the language(s) in question. Sushmita Weibe, Former Research Associate, Public Health Sciences,
University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9PQ.
1:Johnson MRD, Collins GS 2004 ‘Getting it right in multi-cultural research’. British Medical Journal 328: 76. 2:Bhopal R, Vettini A, Hunt S, Wiebe S, Hanna L, Amos A 2004 'Review of prevalence data in and evaluation of methods for cross cultural adaptation of, UK surveys on tobacco and alcohol in ethnic minority groups' British Medical Journal 328 :76-80 3. Hunt SM Cross-cultural aspects of the measurement of quality of life in randomized clinical trials. In M. Staquet, R. Hays & P. Fayers (eds) Quality of Life Assessment in Clinical Trials: Methods and Practice. Oxford University Press. 1998: 4. Hunt SM, McEwen J, McKenna S 1986 Measuring Health Status. Croom Helm.Cheltenham. Competing interests: None declared |
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