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The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link. Healthcare professionals (HCPs) have a pivotal role in optimising patient care and should be familiar with Complementary and Alternative Medicines (CAM). The aim of the study was to explore UK based HCPs personal and professional opinions and experiences of herbal medicines (HMs). An online questionnaire was distributed via social media to recruit (n=112) a range of HCPs from across the UK. HCPs from primary and secondary care, the private sector and academia took part. A large proportion of participants (62%) said they did not personally use any HMs, while 38% did use HMs. HCPs who had personally used HMs had a positive impression of HMs and were more likely to recommend HMs to patients than those who had not used HMs themselves. Participants were given the opportunity to share their perceptions on the safety and efficacy of HMs and their experiences with patients reporting adverse drug reactions to HMs and herb-drug interactions. HCPs identified their lack of knowledge on HMs and insufficient training which made them unable to advise patients on the safe use of HMs. More education on HMs would help improve HCPs knowledge of HMs and help them make better informed decisions when considering patients pharmaceutical care plans.

Background To describe how using a combined approach of community-based participatory research and intervention mapping principles could inform the development of a tailored complex intervention to improve management of asthma for South Asian (SA) children; Management and Interventions for Asthma (MIA) study. Methods A qualitative study using interviews, focus groups, workshops, and modified intervention mapping procedures to develop an intervention planning framework in an urban community setting in Leicester, UK. The modified form of intervention mapping (IM) included: systematic evidence synthesis; community study; families and healthcare professionals study; and development of potential collaborative intervention strategies. Participants in the community study were 63 SA community members and 12 key informants; in-depth semi-structured interviews involved 30 SA families, 14 White British (WB) families and 37 Healthcare Professionals (HCPs) treating SA children living with asthma; prioritisation workshops involved 145 SA, 6 WB and 37 HCP participants; 30 participants in finalisation workshops. Results Two key principles were utilised throughout the development of the intervention; community-based participatory research (CBPR) principles and intervention mapping (IM) procedures. The CBPR approach allowed close engagement with stakeholders and generated valuable knowledge to inform intervention development. It accounted for diverse perceptions and experiences with regard to asthma and recognised the priorities of patients and their families/caregivers for service improvement. The ‘ACT on Asthma’ programme was devised, comprising four arms of an intervention strategy: education and training, clinical support, advice centre and raising awareness, to be co-ordinated by a central team. Conclusions The modified IM principles utilised in this study were systematic and informed by theory. The combined IM and participatory approach could be considered when tailoring interventions for other clinical problems within diverse communities. The IM approach to intervention development was however resource intensive. Working in meaningful collaboration with minority communities requires specific resources and a culturally competent methodology.

Background The incidence of dementia in Black, Asian and minority ethnic (BAME) groups is increasing in the UK, with concern about underdiagnosis and late presentation. Aims By reviewing referrals to memory clinics from Leicester City we examined whether the following differed by ethnicity: the proportion with a diagnosis of dementia, type of dementia and severity at presentation. Method We examined referrals between 2010 and 2017: all those whose ethnicity was recorded as Black (n = 131) and a random sample of 260 Asian and 259 White British referrals. Severity of dementia was assessed by record review. Odds ratios (ORs) were adjusted for general practice, age, gender and year of referral. Results A diagnosis of dementia was recorded in 193 (74.5%) White British, 96 (73.3%) Black and 160 (61.5%) Asian referrals. Compared with Asians, White British had twice the adjusted odds of a dementia diagnosis (OR = 1.99 (1.23–3.22). Of those with dementia, Alzheimer's disease was more common in White British (57.0%) than in Asian (43.8%) and Black referrals (51.0%): adjusted OR White British versus Asian 1.76 (1.11–2.77). Of those with dementia, the proportion with moderate/severe disease was highest in White British (66.8%), compared with 61.9% in Asian and 45.8% in Black groups. The adjusted OR for the White versus Black groups was 2.03 (1.10–3.72), with no significant difference between Asian and White British groups. Conclusions Differences in confirmed dementia suggest general practitioners have a lower threshold for referral for possible dementia in some BAME groups. Unlike other centres, we found no evidence of greater severity at presentation in Asian and Black groups.

Migrant South Asian communities in the UK have brought with them their own traditional forms of medicine, yet little is known about their current use of herbal medicines (HMs) in the UK. The aim of the study was to explore the origins, use and transmission of knowledge of traditional HMs used by diasporic South Asian communities in the UK. A researcher-administered questionnaire was used for data collection (n = 192). An opportunity sampling technique was used to recruit participants across several locations in Birmingham and Leicester. Two thirds of participants (n = 126) stated they used HMs to maintain their health and to treat various health conditions such as digestive problems, skin conditions and diabetes. Almost 2000 actively used HMs were documented including 123 plant species that were identified. Participants imported HMs from abroad as well as sourcing them locally and even growing some of their own plants. Up to 82% (n = 87) of participants who took prescription medicines did not tell their healthcare professionals about any HMs they consumed; this raises concerns about people's knowledge of herb-drug interactions, compliance and effect on prescribed medicine regimens. Similar studies to explore the use of HMs by other ethnic groups are imperative to help optimise pharmaceutical care of patients. Copyright © 2017 John Wiley & Sons, Ltd.

A crucial element in any intercultural activity, particularly when the use of language is a crucial element of diagnosis, treatment (“talking therapies”) or ensuring concordance (“compliance”) with a treatment regime, or indeed, “informed consent”, is that the language used is understood equally on both sides of the dyadic transaction—or conversation. As this volume notes in its introduction, language while crucial to communication can also present a barrier: “Overcoming these barriers requires certain competencies such as working with a qualified interpreter”. This chapter, drawing on the personal experience of an experienced interpreter and trainer of interpreters, and her doctoral research into the use of interpreters in psychiatric interviews [1] uses a number of vignettes or observations of the interpretation process, alongside reflection of the interpreter’s experience, to suggest ways in which those working with interpreters may better understand the process, and the situation of the interpreter as a person as well as language-translation “machine”. Frequently, the interpreter has only a linguistic knowledge of the languages used in a conversational transaction, and possibly some understanding of the technical issues involved in that discussion, but may be unfamiliar with any other aspect of the experiences of either of the two principal “actors” in that conversation or the technical languages they are using. In relation to mental health especially, the interpreter needs to be advised to attempt to convey the “style” or paralinguistics of the language used as well as the meaning, since often mental distress or some specific conditions may be indicated by particular formulations or departure from “standard” speech patterns.

Background and aims Childhood asthma places a significant physical, financial, and psychological burden on patients, families, communities and the healthcare system. Current research indicates certain minority ethnic groups, especially South Asian children, encounter inequalities in asthma management and outcomes. Furthermore, children’s views and aspirations are infrequently evaluated. We report here the process of encouraging children’s participation in a multiphase participatory the Management in Asthma (MiA) study. The aim of this study was to explore the perceptions and experiences of asthma and its management in British South Asian (BSA) and White British (WB) children, using adapted qualitative methods. Methods Two qualitative methods were used: semi-structured interview and prioritisation workshop, adapted to encourage children’s participation (table 1). 14 themes for optimising asthma management identified from the semi-structured interviews and were used in the ranking exercises. Children ranked these themes by linear (LI, non-equal ranking), diamond (DA, equal ranking permitted) and budget pie (BP, ranking by funds allocation). Results Semi-structured interviews with children, with or without parents/guardian present (33 BSA and 14 WB children with asthma aged 5–12-years-old) revealed considerable similarities in experiences of asthma, notably inadequate holistic approach to asthma management amongst healthcare professionals and the role of schools and peers in children’s asthma perception and management. Barriers to health information provision existed in both groups. Consistently, WB children’s perception of asthma aetiology was different from BSA children. In all the ranking methods, children (21 BSA and 1 WB child aged 5––12-years-old) highly prioritised acute attacks according to their perceived health importance. ‘Strength of opinion’ was demonstrated in BP, as acute attack received £1430 in total, whilst the 2nd place theme only received £610. Conclusion Future intervention in children with asthma may wish to focus on managing acute attacks by a holistic approach, by involving schools, families and healthcare professionals. Furthermore, ethnospecific divergent beliefs about asthma aetiology can be tackled by a targeted educational programme.

BackgroundCommunication may be an influential determinant of inequality of access to, engagement with and benefit from psychiatric services.AimsTo review the evidence on interventions designed to improve therapeutic communications between Black and minority ethnic patients and clinicians who provide care in psychiatric services.MethodSystematic review and evidence synthesis (PROSPERO registration: CRD42011001661). Data sources included the published and the ‘grey’ literature. A survey of experts and a consultation with patients and carers all contributed to the evidence synthesis, interpretation and recommendations.ResultsTwenty-one studies were included in our analysis. The trials showed benefits mainly for depressive symptoms, experiences of care, knowledge, stigma, adherence to prescribed medication, insight and alliance. The effect sizes were smaller for better-quality trials (range ofd0.18–0.75) than for moderate- or lower-quality studies (range ofd0.18–4.3). The review found only two studies offering weak economic evidence.ConclusionsCulturally adapted psychotherapies, and ethnographic and motivational assessment leading to psychotherapies were effective and favoured by patients and carers. Further trials are needed from outside of the UK and USA, as are economic evaluations and studies of routine psychiatric care practices.

SUMMARY Adaptation of health interventions has garnered international support across academic disciplines and among various health organizations. Through semi-structured interviews, we sought to explore and understand the perspectives of 26 health researchers and promoters located in the USA, UK, Australia, New Zealand and Norway, working with ethnic minority populations, specifically African-, South Asian- and Chineseorigin populations in the areas of smoking cessation, increasing physical activity and healthy eating, to better understand how adaptation works in practice. We drew on the concepts of intersectionality, representation and context from feminist, sociology and human geography literature, respectively, to help us understand how adaptations for ethnic groups approach the variable of ethnicity. Findings include (i) the intersections of ethnicity and demographic variables such as age and gender highlight the different ways in which people interact, interpret and participate in adapted interventions; (ii) the representational elements of ethnicity such as ancestry or religion are more complexly lived than they are defined in adapted interventions and (iii) the contextual experiences surrounding ethnicity considerations shape the receptivity, durability and continuity of adapted interventions. In conclusion, leveraging the experience and expertise of health researchers and promoters in light of three social science concepts has deepened our understanding of how adaptation works in principle and in practice for ethnic minority populations.

Context Adapting behavior change interventions to meet the needs of racial and ethnic minority populations has the potential to enhance their effectiveness in the target populations. But because there is little guidance on how best to undertake these adaptations, work in this field has proceeded without any firm foundations. In this article, we present our Tool Kit of Adaptation Approaches as a framework for policymakers, practitioners, and researchers interested in delivering behavior change interventions to ethnically diverse, underserved populations in the United Kingdom.

This paper presents the findings of a qualitative study exploring White and British Indian informal stroke carers' experiences of caring, factors contributing to their stress, and strategies used to overcome stress.A qualitative approach involving in-depth interviews was used to explore informal carers' experiences of caring for stroke survivors and the stress of caring at one and three to six months from the onset of stroke. Interviewers bilingual in English and Gujarati or Punjabi conducted interviews with carers. Socio-demographic data of carers and stroke survivors were collected at one, and three to six months by dedicated stroke research nurses.A total of 37 interviews with carers caring for stroke survivors with a wide range of physical and mental impairments were completed. A majority of carers had assumed the task of caring within a few weeks of the stroke. Irrespective of ethnicity, carers' emotional and physical well-being was undermined by the uncertainty and unpredictability of caring for stroke survivors, and meeting their expectations and needs. The strain of managing social obligations to care was common to all carers irrespective of gender and ethnicity, but the higher levels of anxiety and depression reported by Indian British female carers appeared to stem from the carers' pre-existing physical ailments, their cultural and religious beliefs, and household arrangements. Carers' strain in extended households was exacerbated by the additional responsibility of caring for other dependent relatives.Since the role of carers is clearly indispensable in the successful rehabilitation of survivors, it is vital to ensure that their well-being is not undermined by a lack of information and training, and that their need for professional support is prioritised.

AIMS Previous research in the UK has established the difficulty of recruiting and collecting information from individuals whose main language is spoken and does not have an agreed written form. The aims of this study were (i) to develop culturally competent translations of two questionnaires measuring diabetes self-care in languages with no written form and to establish their face validity and (ii) to develop acceptable methods of delivery with the potential for providing valid and reliable data for use in research studies. METHODS Adults with Type 2 diabetes from two minority ethnic groups whose main language is spoken (Sylheti and Mirpuri) were recruited via the Birmingham Heartlands hospital diabetes centre. Participants were invited to attend five focus groups to consider the content and method of delivery of two questionnaires measuring knowledge of diabetes and confidence in diabetes self-care. Delivery methods were (i) pen and paper self-completion in Bengali/Urdu, (ii) pen and paper assisted completion in spoken language, (iii) partially-assisted completion in spoken language, (iv) independent audio delivery in spoken language. RESULTS Culturally competent content was achieved for both questionnaires in both languages. The Mirpuri men and women's groups preferred assisted or partially assisted completion in spoken language. The Sylheti groups' preference was for independent audio delivery in spoken language. CONCLUSIONS The face validity of two questionnaires measuring diabetes self-care is established for Sylheti and Mirpuri, in four alternative delivery formats. The questionnaires are now ready for psychometric testing in minority ethnic populations and the methods available for use by researchers to establish within-study feasibility.

This paper reviews the literature on “public” perceptions of the practice of gamete (egg and sperm) donation in the treatment of infertility. Despite regular “consultation” exercises in the UK on the manner in which infertility treatments should be regulated, there is little sense of how a range of public groups respond to developments in this area. The key themes from thirty-three articles, chapters and reports are discussed. The review reveals the limited nature of our current knowledge of public understandings of and attitudes towards gamete donation as a form of infertility treatment which has been readily available and widely practiced for many years. The review is critical of the methodological and epistemological basis of much of the work in this area and argues that there is a strong case for social scientific research to attempt to capture the perceptions of a wider range of people who are rarely included in formal public consultations and often similarly excluded from research studies.

DNA barcoding, a technique used to identify species based on short regions of DNA [1], can discriminate between different species, and identify contaminants and adulterants. Ocimum tenuiflorum L., commonly known as holy basil or tulsi, is native to Asia. Three types of tulsi are recognised in the Hindu culture (figure 1); Raam and Shyam (Krishna) are varieties of O. tenuiflorum, whilst Vana tulsi is O. gratissimum L. [2]. Following migration, tulsi plants are widely grown in South Asian (SA) households across the UK. The aim of this research is to use DNA barcoding techniques to identify tulsi plants collected from SA families, using ITS and trnH-psbA regions. A variety of tulsi samples were collected for authentication: community samples from SA families in the UK, commercial samples, and vouchered specimens. DNA analyses discovered that samples described as Shyam tulsi collected from communities in the UK were O. tenuiflorum, but Raam tulsi samples were O. gratissimum. Commercial samples proved to be recalcitrant to DNA extraction; this could be because the DNA had been degraded during manufacturing processes. Vouchered specimen obtained were used to create reference DNA barcodes which were not available in the current DNA databases. Both ITS and trnH-psbA regions were successfully used to distinguish between O. tenuiflorum and O. gratissimum samples. The plastid trnH-psbA primers were more efficient for amplification and sequence analysis than the ITS region. The results exemplify how with the transmission of traditions from one country to another, confusion of species is occurring. Both the ITS and trnH-psbA regions had their strengths and limitations which reinforces the importance of using multiple primers for species authentication.

Regular readers of this journal will know that we take a very broad view of diversity and equality issues: we are interested in gender, learning disability, living with long-term conditions such as poor mental health, race, ethnicity and inequalities in care. However, a recent leader in The Economist (Berkeley 2015) suggests that there is yet another kid on the block and a highly neglected one at that: working class men. The reactions have been, predictably, both vitriolic and patronising, for example, blaming women for working outside the home and blaming the American people for their failure to elect Senator George Wallace as President in 1968. At first glance it is difficult to see what the problem is. Men, especially white men, occupy the majority of positions of privilege throughout the world. Most political leaders are male: at the beginning of this year there were only ten female heads of state and fourteen governments led by women (UN Women http://www.unwomen.org). Men also dominate business: of the top 500 US companies listed by Fortune magazine, only 25 have female CEOs (Gallagher 2015). Only 20% of FTSE 100 companies have female CEOs (Groom 2015). Men also dominate all the major world religions as well as the sciences, legal systems and the arts. In every society patriarchy still flourishes and is still considered by many to be normal. It is “so universal, it cannot be the product of some vicious circle that was kick-started by a chance occurrence. .....It is far more likely that even though the precise definition of ‘man’ and ‘woman’ varies between cultures, there is some universal biological reason why almost all cultures valued manhood over womanhood. We do not know what this reason is” (Hariri 2011:153-4).

BackgroundBlack and minority ethnic (BME) people using psychiatric services are at greater risk of non-engagement, dropout from care and not receiving evidence-based interventions than white British people.ObjectivesTo identify effective interventions designed to improve therapeutic communications (TCs) for BME patients using psychiatric services in the UK, to identify gaps in the research literature and to recommend future research.ParticipantsBlack African, black Caribbean, black British, white British, Pakistani and Bangladeshi patients in psychiatric services in the UK, or recruited from the community to enter psychiatric care. Some studies from the USA included Hispanic, Latino, Chinese, Vietnamese, Cambodian and African American people.InterventionsAny that improve TCs between BME patients and staff in psychiatric services.Data sourcesThe published literature, ‘grey’ literature, an expert survey, and patients' and carers’ perspectives on the evidence base. Databases were searched from their inception to 4 February 2013. Databases included MEDLINE, Applied Social Sciences Index and Abstracts, The Cochrane Library, Social Science Citation Index, Allied and Complementary Medicine Database, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE, The Campbell Collaboration and ProQuest for dissertations.Review methodsStudies were included if they reported evaluation data about interventions designed to improve therapeutic outcomes by improving communication between BME patients and psychiatric professionals. Qualitative studies and reports in the grey literature were included only if they gave a critical evaluative statement. Two members of the team selected studies against pre-established criteria and any differences were resolved by consensus or by a third reviewer, if necessary. Data were extracted independently by two people and summarised in tables by specific study designs. Studies were subjected to a narrative synthesis that included a thematic analysis contrasting populations, countries and the strength of evidence for any intervention. The components of the interventions were compared. Patient perspectives on acceptability were considered alongside quality scores and methodological strengths and weaknesses.ResultsTwenty-one studies (19 from the published literature and two from the grey literature) met the inclusion criteria. There were 12 trials, two observational quantitative studies, three case series, a qualitative study and three descriptive case studies. Only two studies, one a pilot trial and one a case series, included economic data; in both, a favourable but weak economic case could be made for the intervention. The trials tested interventions to prepare patients for therapeutic interventions, variable levels of ethnic matching (of professional to patient), cultural adaptation of therapies, and interventions that included social community systems in order to facilitate access to services. Empowering interventions favoured by patients and carers included adapted cognitive–behavioural therapy, assessments of explanatory models, cultural consultation, ethnographic and motivational interviews, and a telepsychiatry intervention.LimitationsStudies tended to have small sample sizes or to be pilot studies, and to use proxy rather than direct measures for TCs.ConclusionsEmpowering interventions should be further researched and brought to the attention of commissioners. Several promising interventions need further evaluative research and economic evaluations are needed.Study registrationThe study is registered as PROSPERO CRD42011001661.FundingThe National Institute for Health Research Health Technology Assessment programme.

There has been little work on ethnicity related to pressure ulcers in general and little or nothing specific to South Asians, and the Pakistani ethnic group in particular.To explore the relevance of ethnicity in pressure ulcers.All admissions over a 5-year period to a District General Hospital in Burton, United Kingdom (UK) were considered where data were present on Waterlow Score, ethnicity and pressure sore status. Logistic regression analysis was conducted using ethnicity and other variables to predict ulcer formation. RESULTS; Age is predictive, but ethnicity was not found to be a significant predictor.There is no evidence that members of the Pakistani ethnic minority are at higher risk than the majority White population in Burton, with respect to pressure ulcers.

This paper briefly outlines the housing careers of Vietnamese households since their arrival in the UK in the late 1970s and draws on a series of focus groups to examine the role that ethnicity has...

Background: There is a growing body of evidence supporting lifestyle interventions for the prevention of chronic disease. However, it is unclear to what extent these evidence-derived recommendations are applicable to ethnic minority populations. We sought to assess the degree of consideration of ethnicity in systematic reviews and guidelines for lifestyle interventions. Methods: Two reviewers systematically searched seven databases to identify systematic reviews (n = 111) and UK evidence-based guidelines (n = 15) on smoking cessation, increasing physical activity and promoting healthy diet, which were then scrutinized for ethnicity-related considerations. Evidence statements were independently extracted and thematically analysed. Results: Forty-one of 111 (37%) systematic reviews and 12 of 15 (80%) guidelines provided an evidence statement relating to ethnicity; however, these were often cursory and focused mainly on the need for better evidence. Five major themes emerged: (i) acknowledging the importance of diversity and how risk factors vary by ethnicity; (ii) noting evidence gaps in the effectiveness and cost-effectiveness of interventions for ethnic minorities; (iii) observing differential effects of interventions where these have been trialled with ethnic minority populations; (iv) suggesting adaptation of interventions for ethnic minority groups; (v) proposing improvements in research on interventions involving ethnic minority populations. Conclusions: Despite increasing recognition of the challenges posed by ethnic health inequalities, there remains a lack of guidance on the extent to which generic recommendations are applicable to, and how best to promote lifestyle changes in, ethnic minority populations. These important evidence gaps need to be bridged and tools developed to ensure that equity and population context is appropriately considered within evidence syntheses.

Increasing ethnic or cultural diversity in the population served by healthcare services requires improved competence and updated provision. Both individual staff and institutions need to reflect on and prepare to meet new challenges. Three key elements—reflective self-awareness, knowledge of others, and skills in managing difference—must be developed. Recognition of diversity and a database of appropriate information are essential for both workers and management of organisations. Above all, some preparedness for continual change and learning is essential. This article provides some suggestions and examples to assist with this.

Editor, Diversity and Equality in Health and Care; Professor of Nursing, Faculty of Health, Birmingham CityUniversity, Birmingham, UKThe last few months have seen a succession of mem-orials and funerals for some icons of our age, fromMadiba Mandela to Pete Seeger, who gave the earlieryearsofstruggleforequalityanddiversitytheirsongs,catchphrases,cheerleadersandrecognisablefaces,andmuch of their energy. We also mark the passing ofProfessor Stuart Hall, the West-Indian-born sociologistwhodidmuchtoestablishantiracisminsocialscience,and who was very clear about the distinction betweenpositive factors such as differences, differentiation anddiversity and the negativity of discrimination.Thestrugglecontinues.Regularreaderswillbeawarethat one of our major concerns is violence and dis-crimination aimed at women, particularly when boundup in and accentuated by ‘ethnic’ or ‘cultural’ con-siderations that militate against criticism. It wastherefore good to see how communities and activistscametogethertosupport internationalEndFGM day(Tuesday6February2014).Thiswasahighlysuccess-fulcampaignthatatonestagegarneredtwosignaturesasecondonapetitiontourgeBritishschoolstotacklethis issue through education and vigilance. The Twitterhashtag#EndFGMrapidlybecameatrendingaddress,and is worth a visit to find what is still ongoing withregardtothisissue.ItnowseemsthattheUKSecretaryof State for Education has in fact bowed to pressureand will be writing to all schools to alert them to thisissue. Only by constant organisation and pressure,often through such websites as www.change.org, canwe bring about improvement and challenge the pro-cess that Stuart Hall termed ‘othering’ by making the‘other’ part of ‘us.’The papers in this issue have a lot to say about‘othering’ and exclusion. The ‘other’ is useful to andmaythusbetoleratedbythe‘norm’butneverbecomeapartofit.The‘other’isandcontinuestobedifferent.No matter how well acculturated, there will always bethat moment when a curtain passes between the‘other’ and the majority group, an indefinable some-thing that separates and excludes and which neitherside can remove. This may be most acute for first-generationmigrants.Thereistheexpectationthatthesecond generation will be more acculturated, find iteasiertofitin,and speakthe languagelike ‘oneofus’,butintimetheytoomayfind,oftenbecause ofvisibledifferences, the subtle ways in which discriminationfunctions,belowtheradar.Onecanfeellikeaninsiderwithan‘accessallareas’passatapopconcert,butstillfind that there are dual worlds and rooms that onecannot access without extra privilege. Even when onehas the privilege accorded to fame or position, dis-crimination can continue. Indeed, it can hurt even byassociation when one feels that others of one’s owngrouparebeingdiscriminatedagainst,whichmayleadthe famous to show their solidarity with the struggle.Few of us can write songs like Pete Seeger or speecheslikeMadibaMandela,whogaveavoicetothevoicelessand dispossessed, but thisjournaluses such academicprivilegeandpowerasitcantoensurethatatleastthescientific evidence for equality is there for those whoneedandseektouseit.Wealsocommentonandexposethose situations where evidence exists and action isnot taken, as some of the papers in this issue seem todemonstrate an institutional slowness to learn fromprevious experience, research and campaigning.

Research into communication in health has so far had a low priority. What there is, has been targeted at immediate perceived problems; that is, attention has been focused on where there is prima facie evidence of a barrier to communication which might be attributable to, for example, language or culture. Clearly, most health professionals do not see themselves as being different from those they care for and serve. However, even when skin colour, language, religion and place of upbringing are identical, there will still remain differences of imagination, of class, and of experience. While the following paper draws primarily on the research literature of communication with minorities, it should be read as having a wider applicability. The model of ethnicity (which, fortunately, has replaced the more positivist, absolutist and normalising model of `race') can be applied to any community or group which shares close common interests.

Objective Existing smoking cessation interventions tend to be under utilized by ethnic minority groups. We sought to identify smoking cessation interventions that have been adapted to meet the needs of African-, Chinese- and South Asian-origin populations, to increase understanding of the approaches used to promote behavior change, to assess their acceptability to the target populations, and to evaluate their effectiveness. Methods Two reviewers independently searched for, identified, critically appraised and extracted data from studies identified from 11 databases (January 1950–April 2013). Study quality was assessed using validated instruments (EPHPP and STROBE). Adaptations were independently coded using an established typology, and findings descriptively summarized and thematically synthesized. Results 23 studies described interventions adapted for African-Americans, and five for Chinese-origin populations. No intervention adapted for South-Asian populations was identified. Six studies directly compared a culturally adapted versus a non-adapted intervention. Adapted interventions were more acceptable to ethnic minority groups, but this did not translate into improvements in smoking cessation outcomes. Conclusions Given the evidence of greater acceptability of adapted interventions, it may be ethically preferable to use these. There is, however, no clear evidence of the effectiveness of adapted interventions in promoting smoking cessation in ethnic minority groups.

Background: We aimed to validate the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) among English\ud speaking adults representing two of the minority ethnic groups living in the UK, self-identified as Chinese or\ud Pakistani by background, in a mixed methods study.\ud Methods: Quantitative data were collected in two cities in the West Midlands, UK. Item response, dimensionality,\ud internal consistency, and construct validity of the WEMWBS were assessed in Chinese and Pakistani groups\ud separately, using data from both cities combined.\ud Qualitative data were collected in the first city in eight focus groups of different ages recruited by the community\ud workers. Three mixed sex Chinese and five single sex Pakistani groups discussed ease of completion and\ud comprehension of items, together with overall reactions to the scale and underlying concept.\ud Results of quantitative and qualitative analysis were examined for commonalities and differences.\ud Results: Item completion and item total correlations were satisfactory in both groups. In the Chinese data,\ud Exploratory Factor Analysis showed a single factor with loadings ranging from 0.60 to 0.82 for all 14 items. In the\ud Pakistani data, three factors reached statistical significance; however, a substantial drop in eigenvalues between the\ud first and second factors and the limited variance explained by the second and third factors supported a one-factor\ud model. All items loaded on this factor from 0.51 to 0.83.\ud In the Chinese and Pakistani data respectively, Cronbach’s alpha was 0.92 (0.89 – 0.94) and 0.91 (0.88 – 0.94);\ud Spearman’s correlation with GHQ-12 was - 0.63 (−0.73 to −0.49) and −0.55 (−0.70 to −0.36), and with the WHO-5\ud 0.62 (0.46-0.75) and 0.64 (0.50 to 0.76).\ud Qualitative analysis revealed good comprehension and ease of completion of almost all items. Some culturally\ud determined differences in understanding of mental well-being, which varied both between and within\ud communities, emerged.\ud Conclusions: The WEMWBS was well received by members of both Pakistani and Chinese communities. It showed\ud high levels of consistency and reliability compared with accepted criteria. Data were sufficiently strong to\ud recommend the WEMWBS for use in general population surveys.\ud

Twenty first century globalisation has been influenced by the emergence of discourse, migration patterns and the movement of ideologies across traditional national borders. In the context of healthcare, this necessitates traversing beyond the boundaries of the traditional medical model of practice. There is an urgent imperative to actively seek and include patients’ perception of their illness and attitudes to medical care, in order to provide optimum personalised healthcare - one of the aspirations of current NHS policy. A challenge for globalisation is an understanding at a deeper level of the nexus between culture, health and illness. Globalisation and multiculturalism require revisiting the current delivery of health care. This editorial proposes that the key to the success of this ideal is cultural competence at the levels of individual practitioners, organisations and policymakers. The clinical features and epidemiology of musculoskeletal disease in minority ethnic groups have been addressed relatively sparsely in the medical literature. A comprehensive review of all conditions is beyond the scope of this editorial. However, we shall emphasise key issues germane to musculoskeletal healthcare in minority populations by eliciting three exemplars: rheumatoid arthritis (“rheumatoid”), systemic lupus erythematosus (“lupus”) and low serum levels of vitamin D (“hypovitaminosis D”).

BackgroundThere is now a considerable body of evidence revealing that a number of ethnic minority groups in the UK and other economically developed countries experience disproportionate levels of morbidity and mortality compared with the majority white European-origin population. Across these countries, health-promoting approaches are increasingly viewed as the long-term strategies most likely to prove clinically effective and cost-effective for preventing disease and improving health outcomes in those with established disease.ObjectivesTo identify, appraise and interpret research on the approaches employed to maximise the cross-cultural appropriateness and effectiveness of health promotion interventions for smoking cessation, increasing physical activity and improving healthy eating for African-, Chinese- and South Asian-origin populations.Data sourcesTwo national conferences; seven databases of UK guidelines and international systematic reviews of health promotion interventions aimed at the general population, including the Clinical Evidence, National Institute for Health and Clinical Excellence and Scottish Intercollegiate Guidelines Network databases (1950–2009); 11 databases of research on adapted health promotion interventions for ethnic minority populations, including BIOSIS, EMBASE and MEDLINE (1950–2009); and in-depth qualitative interviews with a purposive sample of researchers and health promoters.Review methodsTheoretically based, mixed-methods, phased programme of research that involved user engagement, systematic reviews and qualitative interviews, which were integrated through a realist synthesis. Following a launch conference, two reviewers independently identified and extracted data from guidelines and systematic reviews on the effectiveness of interventions for the general population and any guidance offered in relation to how to interpret this evidence for ethnic minority populations. Data were thematically analysed. Reviewers then independently identified and critically appraised studies of adapted interventions and summarised data to assess feasibility, acceptability, equity, clinical effectiveness and cost-effectiveness. Interviews were transcribed, coded and thematically analysed. The quantitative and qualitative data were then synthesised using a realist framework to understand better how adapted interventions work and to assess implementation considerations and prioritise future research. Our preliminary findings were refined through discussion and debate at an end-of-study national user engagement conference.ResultsInitial user engagement emphasised the importance of extending this work beyond individual-centred behavioural interventions to also include examination of community- and ecological-level interventions; however, individual-centred behavioural approaches dominated the 15 relevant guidelines and 111 systematic reviews we identified. The most consistent evidence of effectiveness was for pharmacological interventions for smoking cessation. This body of work, however, provided scant evidence on the effectiveness of these interventions for ethnic minority groups. We identified 173 reports of adapted health promotion interventions, the majority of which focused on US-based African Americans. This body of evidence was used to develop a 46-item Typology of Adaptation and a Programme Theory of Adapted Health Promotion Interventions. Only nine empirical studies directly compared the effectiveness of culturally adapted interventions with standard health promotion interventions, these failing to yield any consistent evidence; no studies reported on cost-effectiveness. The 26 qualitative interviews highlighted the need to extend thinking on ethnicity from conventional dimensions to more contextual considerations. The realist synthesis enabled the production of a decision-making tool (RESET) to support future research.LimitationsThe lack of robust evidence of effectiveness for physical activity and healthy-eating interventions in the general population identified at the outset limited the comparative synthesis work we could undertake in the latter phases. Furthermore, the majority of studies undertaking an adapted intervention were conducted within African American populations; this raises important questions about the generalisability of findings to, for example, a UK context and other ethnic minority groups. Lastly, given our focus on three health areas and three populations, we have inevitably excluded many studies of adapted interventions for other health topics and other ethnic minority populations.ConclusionsThere is currently a lack of evidence on how best to deliver smoking cessation, physical activity and healthy eating-related health promotion interventions to ethnic minority populations. Although culturally adapting interventions can increase salience, acceptability and uptake, there is as yet insufficient evidence on the clinical effectiveness or cost-effectiveness of these adapted approaches. More head-to-head comparisons of adapted compared with standard interventions are warranted. The Typology of Adaptation, Programme Theory of Adapted Health Promotion Interventions and RESET tool should help researchers to develop more considered approaches to adapting interventions than has hitherto been the case.FundingThe National Institute for Health Research Health Technology Assessment programme.

BACKGROUND: There is increasing international concern about the persistent under-representation of ethnic minority patients in research. AIMS: We aimed to explore strategies being employed by US and UK researchers when attempting to recruit minority ethnic participants into research with a view to increasing participation by South Asians in UK asthma research. METHODS: Qualitative interviews with 36 asthma-interested researchers. RESULTS: Key themes were: the need to build long-term trusting relationships; ensuring that the procedures and practices used were respectful; paying attention to logistic considerations with respect to funding, the location of the research and taking proactive steps to overcome language-related barriers; and the importance of effective dissemination of results to, amongst others, the minority ethnic groups under study. The use of financial incentives or “co-payments” was reported as being a successfully-employed strategy in the US context, which could be considered for use in the UK. CONCLUSIONS: There is a need for funders and researchers to take proactive steps to develop longer-term relationships built on trust and respect with the populations they wish to study. Attention to the location of research, language considerations, financial reimbursement and appropriate dissemination of results are all likely to translate into improved recruitment of these “hard-to-reach” populations.

This study evaluated the experiences of joint appointees within a school of nursing and midwifery. The nature of joint appointments has evolved, particularly since nurse education moved from the NHS into higher education institutions. Anecdotal evidence suggests that joint appointments are viewed as a bridge between clinical services and university teaching. Although joint clinical and academic appointments are the norm within medical schools, they form a minority of the appointments within most nursing schools. The general findings were that joint appointees need to be committed to the role, flexible, open to new working cultures, independent and self-supporting. The benefits to the individual and the organizations were perceived as very positive. Staff recruited into current joint appointment posts need to be clinically experienced, professionally aware, socially sensitive and politically astute.

Background Previous health research has often explicitly excluded individuals from minority ethnic backgrounds due to perceived cultural and communication difficulties, including studies where there might be language/literacy problems in obtaining informed consent. This study addressed these difficulties by developing audio-recorded methods of obtaining informed consent and recording data. This report outlines 1) our experiences with securing recruitment to a qualitative study investigating alternative methods of data collection, and 2) the development of a standardised process for obtaining informed consent from individuals from minority ethnic backgrounds whose main language does not have an agreed written form. Methods Two researchers from South Asian backgrounds recruited adults with Type 2 diabetes whose main language was spoken and not written, to attend a series of focus groups. A screening tool was used at recruitment in order to assess literacy skills in potential participants. Informed consent was obtained using audio-recordings of the patient information and recording patients' verbal consent. Participants' perceptions of this method of obtaining consent were recorded. Results Recruitment rates were improved by using telephone compared to face-to-face methods. The screening tool was found to be acceptable by all potential participants. Audio-recorded methods of obtaining informed consent were easy to implement and accepted by all participants. Attrition rates differed according to ethnic group. Snowballing techniques only partly improved participation rates. Conclusion Audio-recorded methods of obtaining informed consent are an acceptable alternative to written consent in study populations where literacy skills are variable. Further exploration of issues relating to attrition is required, and a range of methods may be necessary in order to maximise response and participation rates.

Abstract This paper presents a knowledge review, undertaken to identify potential barriers affecting the recruitment of British South Asian people into the nursing profession. The review identified eleven studies, which explored attitudes and levels of knowledge towards nursing within the British South Asian population. Many of these studies, although providing useful insights, have methodological limitations. Studies highlighted perceptions among the South Asian population of nursing as a low status and stressful occupation with unsociable working hours and low pay. Nursing members of the opposite sex was not acceptable to some individuals on religious grounds. Others, however, had no problem with this. The review highlights both similarities and differences in attitudes towards nursing amongst the British South Asian population and the majority white population. Factors such as the lack of exposure to positive role models and limited opportunities to gain an insight into the work of nurses suggest that South Asian people might be less likely to consider nursing as a career than their white counterparts. To gain a better understanding of views held towards nursing within this population however, more comparative studies are needed to take an account of diversity in terms of social class, gender, ethnicity and religion.

Aim: The study set out to explore the perceptions and knowledge of drug use of the Bangladeshi origin population in Leicester through local Mosques and community and resource centers for recruiting subjects. Setting and Design: A triangulated methodology was used for this research. A review of all available literature was carried out to establish if there was evidence of a drug problem among the Bangladeshis in the UK along with questionnaires and interviews. Materials and Methods: A triangulated methodology was used for this research. A review of all available literature was carried out along with questionnaires as well as semi-structured interviews using self-designed questionnaires. Results and Conclusions: Only 66 questionnaires (16.5%) were returned (46 males and 20 females). These and qualitative exploratory interviews with a small number of community leaders confirmed that drug-related problems exist among the Bangladeshi community, especially in the younger age group and are recognized as such but help seeking is often problematic. An understanding of the perceptions of the Bangladeshi population is useful in developing culturally appropriate services for this group.

Research and development in the field of sight loss and provision for visual impairment among black and minority ethnic groups in Britain is poorly developed. There are real and inexcusable inequalities in access to services for people from minority ethnic communities, and a distinct lack of knowledge about the issues involved among both sight-loss service-providing bodies who are relatively uninformed about ethnic and cultural diversity, and among black and minority ethnic communities in respect of sight loss and provision to meet the needs of visually impaired people. The article, based on systematic review of published and ‘grey’ literature and action research, describes some key issues which might be taken into account to ensure that the gulf between these two silos of information and experience may be bridged, and insists that so-called ‘colour-blind practice’ is not acceptable.

This paper presents key findings from the first major study of the provision of infertility services to South Asian communities in the UK. The research aimed to explore the social meanings of infertility and to examine the experiences of couples receiving fertility treatment. Focus groups with people from Pakistani, Bangladeshi and Indian communities (n = 93) revealed a strongly pro-natalist ideology and a relatively limited knowledge of infertility and treatments. Interviews with 50 participants from the same communities revealed a general satisfaction with secondary level infertility services. However, a minority felt inadequately informed about their condition, tests undertaken and treatment options; only one-third were given any written information about treatment; many were concerned about delays and waiting times; a minority felt that staff could be more sympathetic in their response to 'failed' treatment and several couples suggested that additional emotional support would be helpful. No information or resources were available in any South Asian language and the arrangements for communication support for non-English speakers were generally less than adequate. There was little evidence of the use of data on ethnic or religious background in infertility clinics. Recommendations for policy and practice are proposed.

We have conducted a research review of visual impairment in ethnic minorities in the UK to make recommendations for future research strategies. In the UK ethnic minorities represent about 6% of the population, but locally they may form a third or more of certain city totals. The age profile is relatively young, so that there are fewer older people, and thus less age-related blindness. The incidence of ethnically specific disease patterns has implications for service providers. Some are recognised, although there is less knowledge about the implications for eyesight. More common diseases, notably hypertension and diabetes show ethnic variation (specifically, raised prevalence). There are raised levels of glaucoma (in African-Caribbean groups) and cataract (in Asians), and possibly lower levels of myopia. Visual impairment may have a greater functional impact on minorities because they have worse levels of health and outcomes, and that other forms of social exclusion combine to result in worse quality of life. We conclude that: there is a need for greater cultural sensitivity in the provision of services and information; there is a need for more training and awareness of ethnic diversity among service providers; low levels of registration and apparent under-utilisation of preventive, rehabilitation and support services by black and minority ethnic groups should be studied; more research is needed into the contrast between interest and health issues and willingness to prevent ill-health, and low levels of knowledge among minority groups; and there is a need for greater sophistication in ethnic categorisation in research.

Religious and spiritual beliefs and their associated ritual or behavior play a major role in the lives of many people, and their observance can have critical impact on health care. Membership in a faith group provides an identity as well as support and may suggest acceptable patterns of behavior. This article discusses ways in which understanding of the underlying nature of religious belief and behavior may assist the clinician. Practices that are fundamentally similar among different religions and which may constrain treatment plans are compared. Guidelines are provided, and pointers given on key religious observances among major faith groups, while noting that levels of adherence and observance are highly personal.

Effective communication is intrinsic to the delivery of satisfactory health care. It is necessary to recognize that even when using a common language, serious communication problems may arise when cultures and their inherent understandings of meaning differ. This article points out instances where a common understanding of language is crucial.

The NHS and its clinical workforce are committed to evidence-based practice, which requires quality evidence to assist and justify change. Such evidence can be used to inform best practice and to create new standards. The risk is that where needs are under-researched, developments - and resources - can be delayed until relevant research is conducted and completed to adequate standards. New research governance regulations have spelled out what these standards should be. However, black and minority ethnic communities, and individuals, express a high level of 'research fatigue', feeling that they have been the objects of much previous research and experimentation. They therefore question whether there is any reason for delays in the implementation of change. The problem is that 'validated' research often excludes their experiences, while that which includes them is rarely 'best practice' or 'peer-reviewed' research. Nevertheless, it does create evidence, and often the research generated by, or based within, communities holds considerable detail and insight. However, it is not 'owned' in turn by the NHS and the scientific establishment. The research governance regulations provide a framework that might lead to new understandings of best practice in research, create ownership, and generate more inclusive, equitable research with greater validity in a multi-cultural society. Researchers are urged to consider what would assist them to ensure that their studies meet this ideal and comply with scientific and community-based moral standards.

Background Osteomalacia is a significant population health risk that preferentially affects darker skinned people where English may not be the first language. Objectives We were interested to develop an e-based interactive, multi language tool, based on the Mind-Map and giving information in an accessible layered fashion suitable for people with poor English language skills. Methods The Mind-Map wasused as the “home” page. Hyperlinks gave the user options to link to more detailed information. It was possible to take any route through the information and to return from any screen to the original Mind-Map screen. The tool was designed to give the user information in layers. The first layers of the tool are the basic knowledge the user requires to make informed decisions and choices. Further layers lead the user to more in depth information and links to the internet. Only the first layer of the tool was translated into Urdu. The translation was reviewed by a panel of six educated Urdu speakers in the UK to ensure that the translation was correct. A focus group of 10 Urdu speakers from Stourbridge was used to test the tool. A presentation using the tool was performed and their reactions to it recorded. The participants were given the DVD to take away with them. Two months later the group was reconvened and the discussion recorded and transcribed. Results All participants felt that they had learned a lot about Osteomalacia. There was a feeling that this was a very important issue and they were surprised how little they knew about it. The content was judged to be of appropriate detail. It was felt that only the first layer would be used in a presentation but some users may be interested in having more information. It was also suggested that presenting it in English to encourage people to speak enough English to interact with healthcare professionals would be helpful. There were suggestions on how this should be used with presentations in communities but also in schools. They felt that this was a community tool rather than just hospital based. One participant had already given presentations to their community and reported very good informal feedback. Conclusions We have produced a bi-lingual interactive tool to educate people about Osteomalacia and its treatment. Initial reactions show it to be suitable for the intended audience. We now intend to study this for knowledge transfer and change of behaviour. Acknowledgements We would like to acknowledge the contribution of the focus group from Stourbridge Birmingham. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.4424

Carers of stroke survivors face significant burdens, and increased carer strain has negative implications for both the stroke survivor and the carer. There are limited data on carer strain in the British Indian UK population. In a prospective cohort of White British and British Indian stroke survivors and their carers, we report the incidence of carer strain in each ethnicgroup, describe patient and carer characteristics, and identify predictors of increased carer strain. Forty-nine participants and their carers were of White British origin and 24 of Indian ethnic origin, whose first language was Gujarati or Punjabi.Multidimensional outcome measures were used to assess the physical and cognitive function in stroke survivors at one month and 3–6 months (final follow-up) from stroke onset. Levels of carer strain were assessed at the same time points using the Carer Strain Index and the Hospital Anxiety and Depression Scale. Statistical significance for difference in patient and carer characteristics between White British and British Indian groups was assessed. Logistic regression models were used to identify predictors of carer strain. British Indian stroke survivors had poorer scores on cognitive assessment (Mini Mental State Examination median 21, IQR 10.5–26.5 in British Indian, versus median 28.5, IQR 20–30, p=0.001) at one month. British Indian carers were younger, and reported higher levels of anxiety and depression at one month (medianHospital Anxiety and Depression Scale subscore depression 3.5 in White British, versus 7 in British Indian, P=0.002, median hospital anxiety and depression score total 10, versus 14, P=0.012). Twenty-four percent of all carers showed evidence of elevated carer strain (CSI>6) at one month, and 30% at final follow-up. There were no differences in levels of carer strain between the two ethnic groups. These findings will inform future research, and in turn, may help to guide population-targeted interventions aimed at reducing carer strain.

Open Access article Background In the UK, people of South Asian origin with asthma experience excess morbidity, with hospitalisation rates three times those of the majority White population and evidence suggests that South Asian children with asthma are more likely to suffer uncontrolled symptoms and hospital admissions with acute asthma compared to White British children. This paper draws on data from The Management and Interventions for Asthma (MIA) study to identify the operation of barriers to optimal care and good asthma control for South Asian children. Methods The MIA study followed a multi-phase, iterative, participatory design, underpinned by the socio-ecological model. Findings presented here are from face-to face, semi-structured interviews with South Asian (Indian, Pakistani and Bangladeshi origin) parents and carers of a child with asthma (n=49). Interviews were conducted in English or relevant South Asian languages using specially trained community facilitators. Data were transcribed verbatim and analysed according to the principles of interpretive thematic analysis, facilitated by the use of NVivo. Results Seven dimensions of candidacy are identified: identification of candidacy; navigation; the permeability of asthma services; appearances at health services; adjudications; offers and resistance and operating conditions in the local production of candidacy. The analysis demonstrates several ways in which a potential lack of alignment between the priorities and competencies of British South Asian families and the organization of health services combine to create vulnerabilities and difficulties in effectively managing childhood asthma. Conclusions Healthcare systems have a responsibility to develop services that are sensitive and appropriate to the needs of their communities. In South Asian communities, further efforts are required to raise awareness of symptoms and effectively communicate how, when and where to seek help for children. There is a need for improved diagnosis and consistent, effectively communicated information, especially regarding medication. Parents made several suggestions for improving services: presentations about asthma at easily accessible community venues; an advice centre or telephone helpline to answer queries; opportunities for sharing experiences with other families; having information provided in South Asian languages; longer GP appointments; extended use of asthma nurses; and better education for healthcare professionals to ensure consistency of care and advice.

Background: Black and Minority Ethnic (BME) groups in receipt of specialist mental health care have reported higher rates of detention under the mental health act, less use of psychological therapies, and more dissatisfaction. Although many explanations have been put forward to explain this, a failure of therapeutic communications may explain poorer satisfaction, disengagement from services and ethnic variations in access to less coercive care. Interventions that improve therapeutic communications may offer new approaches to tackle ethnic inequalities in experiences and outcomes.\ud Methods: The THERACOM project is an HTA-funded evidence synthesis review of interventions to improve therapeutic communications between black and minority ethnic patients in contact with specialist mental health services and staff providing those services. This article sets out the protocol methods for a necessarily broad review topic, including appropriate search strategies, dilemmas for classifying different types of therapeutic communications and expectations of the types of interventions to improve them. The review methods will accommodate unexpected types of study and interventions. The findings will be reported in 2013, including a synthesis of the quantitative and grey literature.\ud Discussion: A particular methodological challenge is to identify and rate the quality of many different study types, for example, randomised controlled trials, observational quantitative studies, qualitative studies and case studies, which comprise the full range of hierarchies of evidence. We discuss the preliminary methodological challenges and some solutions. (PROSPERO registration number: CRD42011001661).\ud Keywords: Interventions, Therapeutic communications, Black and minority ethnic patients, Psychiatric services\ud