Department of Psychiatry and Behavioural Sciences, Royal Free and University Medical School, London
St Ann's Hospital, London
Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, London
Correspondence: G. Livingston, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Wolfson Building, 48 Riding House Street, London WIN 8AA, UK. Tel: 020 7530 2309; fax: 020 7530 2304; e-mail: g.livingston{at}ucl.ac.uk
Declaration of interest Part-funded by the Ethnic Health Unit, Department of Health.
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ABSTRACT |
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Aims To examine service utilisation of older immigrants compared with their UK-born counterparts and relate it to health difficulties.
Method Cross-sectional study in inner London measuring service use, mental health and disability.
Results A total of 1085 people aged 65 years were interviewed.
Independent predictors of contact with a general practitioner included being
born in Cyprus. Cypriots were the only immigrant population to report
significantly more somatic symptoms than those born in the UK
(P=0.005). Africans and Caribbeans used day care and other social
services most frequently.
Conclusions Immigrants could access services. Africans and Caribbeans appear to have poorer physical health and thus have greater contact with services. Cypriots who experience depression may present with prominent somatic symptoms. This is likely to be due to a different idiom of distress.
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INTRODUCTION |
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METHOD |
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Sampling method
We conducted the survey in Islington, a borough in inner London. The Jarman
Underprivileged Area Score is 49, which is the sixth most deprived score in
England and Wales (Jarman,
1983). We randomised enumeration districts (the smallest unit of
the census) in Islington to provide a sampling frame. The researchers visited
each household within those districts, following an introductory letter, to
ask if a person aged 65 years was present and available for interview.
Interviewers made at least three visits at different times of the day, or at
weekends, until they found the person. All residential facilities in the
selected areas were included as part of the sampling frame.
The interview
We used two standard instruments and additional direct questions during the
interview. First, we administered the shortened version of the Comprehensive
Assessment and Referral Evaluation (Short-CARE) to elicit psychiatric symptoms
and diagnoses (Gurland et al,
1984). This is a valid and reliable questionnaire for older people
in the community. It has diagnostic scales for depression and dementia and a
scale for activities of daily living (ADL), designed to identify those who
need help with day-to-day living. The diagnosis of dementia has been validated
against an outcome of deteriorating cognition or death. Validation has been
completed cross-nationally but not in specific ethnic groups. The Short-CARE
also has a symptom sub-scale measuring somatic symptoms, which records
physical symptoms associated with mental health problems, such as dizziness in
the absence of loss of consciousness and breathlessness in the absence of
exertion or diagnosed physical illness.
Next, we used the Client Service Receipt Inventory (CSRI; Beecham & Knapp, 1992), amended for use in older people. Items included gender, age, marital status, accommodation, self-designated ethnicity, country of birth, provision of health and social services and family and friends coming in to provide help in the past 3 months. To classify ethnicity, the interviewers showed the list of ethnic classification in the 1991 census and asked the participants to choose what best described them.
Finally, we asked Do you have any health problems? as a screening question for subjective health problems. If the answer was yes, a further question was asked: Can you tell me what they are? The answers were noted and a nurse or doctor categorised them for analysis (e.g. cardiovascular, psychiatric, gastrointestinal).
Analysis
For the purposes of analysis, country of birth and ethnicity were recorded
to increase the numbers in each category. The countries of birth were
aggregated into six categories: UK; Ireland; Cyprus; African and Caribbean;
other European; and others.
Owing to the large numbers of itemised health care services, we analysed service utilisation in the following areas: (a) GP; (b) hospital medical services (non-psychiatric in-patient, day patient or out-patient); (c) hospital out-patient services (non-psychiatric day patient or out-patient); (d) psychiatric contact (psychiatric in-patient, out-patient, community psychiatric nurse, domiciliary visit from psychiatrist, psychology contact); (e) non-medical health care (dietician, physiotherapist, occupational therapist or chiropodist); (f) day care services (day centre, lunch club or domiciliary respite service); (g) other social services (social worker, home care and meals on wheels); (h) informal care (non-resident family, friends or voluntary services).
We used 2 analysis to test for significant associations in
categorical data. We calculated the numbers, percentage, probability, relative
risk (RR) and 95% confidence interval (CI) of people from each country of
birth in contact with different services compared with the UK-born group. For
non-parametric data we used the Mann-Whitney U-test to examine
associations between ordinal and categorical variables.
Older immigrants from African and Caribbean countries and those born in Cyprus have raised rates of particular neuropsychiatric conditions (Livingston et al, 2001). We therefore considered the elders born in African and Caribbean countries and in Cyprus in forward logistic regression analyses, to consider whether such conditions accounted for any differential use of services within those immigrant groups. The other variables entered in the regression analyses were depression, dementia, age, gender, living alone, ADL limitation and having subjective health problems. Significant independent predictors and the odds ratio (OR) with 95% CI are reported.
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RESULTS |
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Non-participants
Of the 197 people who did not participate in the study, 153 (77.7%) refused
an interview, an interpreter was unavailable for 15 (7.6%), 11 (5.6%)
relatives refused on behalf of the older person and 2 had difficulty
communicating (1.3%); 64.3% of the non-participants were female.
Ethnicity and country of birth
Table 1 shows the
self-assigned ethnicities and countries of birth of the respondents. In total,
the respondents had 50 different countries of birth. Five people declined to
choose any of the listed ethnicities and 93 (95%) of those born in African or
Caribbean countries were Black. Because there are few differences between
country of birth and ethnicity, the remainder of the paper will report only
country of birth in order to avoid repetition.
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Morbidity
Table 2 shows morbidity
according to country of birth and ethnicity. The Cypriots were significantly
more depressed and had higher subjective morbidity than their UK-born
counterparts but were no more likely to have limitation in ADL. The number of
somatic symptoms reported by individuals ranged from 0 to 13 (2 (0.2%) and 352
(32.4%) individuals respectively). The median number of somatic symptoms
recorded was two. Cypriots were the only immigrant population to report
significantly more somatic symptoms than those born in the UK (Mann-Whitney
U=18940.500; P=0.005).
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Service utilisation
Table 3 shows the use of
services in the 3 months before interview and the association with different
countries of birth.
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General practitioner services
Both the likelihood of visiting a GP (overall 2=16.1;
P<0.006) and the frequency of visits to the GP (overall
2=88.2; P<0.0002) differed significantly according
to country of birth. Those born in the UK were least likely and Cypriot
immigrants most likely to have seen their GP (55.0% v. 74.6%) over
the 3 months prior to interview. We used logistic regression analysis to find
independent predictors of contact with the GP. These were: subjective health
problem (P<0.001; OR=3.57; 95% CI 2.46-5.19); being born in Cyprus
(P<0.05; OR=1.95; 95% CI 1.11-3.42); depression
(P<0.05; OR=1.47; 95% CI 1.04-2.06); and dementia (negative
correlation) (P<0.005; OR=0.54; 95% CI 0.35-0.83).
Hospital services
The use of secondary care medical services varied significantly according
to the country of birth. Cypriots were significantly more likely to use these
services than their UK-born counterparts. Searching for predictors of contact
with hospital medical services using logistic regression analysis, we
identified subjective health problem (P<0.001; OR=4.01; 95% CI
2.39-6.90), limitation in physical activity (P<0.001; OR=2.00; 95%
CI 1.52-2.63) and dementia (negative correlation) (P<0.001;
OR=0.39; 95% CI 0.24-0.66).
Social services
Africans and Caribbeans used day care and other social services most
frequently. We found, using logistic regression, that living alone was the
strongest predictor of the use of day services (P<0.001; OR=2.89;
95% CI 1.69-4.94), followed by having dementia (P<0.007; OR=2.57;
95% CI 1.31-5.11). Other predictors were African or Caribbean country of birth
(P<0.02; OR=2.28; 95% CI 1.16-4.44), depression
(P<0.02; OR=2.00; 95% CI 1.16-3.40), ADL limitation
(P<0.05; OR=1.75; 95% CI 1.03-3.00) and female gender
(P<0.05; OR=1.82; 95% CI 1.03-3.16). Predictors of other social
service use were ADL limitation (P<0.001; OR=11.05; 95% CI
6.74-17.84), living alone (P<0.001; OR=3.36; 95% CI 2.23-4.88),
African or Caribbean country of birth (P<0.03; OR=1.93; 95% CI
1.07-3.47) and increasing age (P<0.001; OR=1.06; 95% CI 1.03-1.09
for each year increase).
Cypriots and African and Caribbean respondents received less informal care than their UK-born counterparts. In logistic regression analyses of predictors of receipt of informal care, the only significant predictors that remained were ADL limitation (OR=5.67; P<0.001; 95% CI 4.23-7.58), subjective health problems (OR=2.50; 95% CI 1.51-4.14; P<0.0001), depression (OR=1.9; 95% CI 1.34-2.70; P<0.001) and older age (OR for 1 year increase=1.02; 95% CI 1.01-4.14; P<0.02).
Psychotropic medication
Table 4 shows those taking
psychotropic medication. This did not vary significantly according to country
of birth, although those born in Cyprus took psychotropics less than those
born in any other country. Taking psychotropic medication was associated
significantly with contact with psychiatric services: 14 (73.6%) of those in
contact with services v. 137 (14.8%) of those not
(P<0.001, RR=18.91; 95% CI 6.70-53.31). Most people (34/42) taking
antipsychotics said that they had not been in contact with psychiatric
services in the past 3 months, as did most of those taking antidementia drugs
(3/4).
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DISCUSSION |
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The Cypriot community
The highest rates of medical service use were by the Cypriot-born. This
group also was most likely to experience depression and reported most somatic
symptoms. They did not admit to using psychiatric services at all and were
least likely to be taking psychotropic medication. They had the worst
subjective health problems although they were not the most physically ill.
Neither the physical, psychiatric and subjective health problems nor the
socio-economic factors accounted for the increased contact with the GP. In
contrast, contact with hospital medical services appears to have been
accounted for by worse subjective physical health. Those born in Cyprus who
experience depression may present with prominent somatic symptoms that may be
misdiagnosed as having a physical basis (or confused with physical illness).
This is likely to be due to a different idiom of distress and to be a
culturally sanctioned presentation.
Earlier studies of morbidity in younger Greek-Cypriot immigrants in London found that this population was relatively upwardly mobile and affluent (Mavreas & Bebbington, 1987). There were higher rates of affective disorders compared with the local population but the rates were similar to those found in Athens, suggesting a cultural aetiology rather than the stress of immigration. There was, in particular, an increased rate of overall psychiatric disorders in those suffering from any physical illness. Those who had migrated more than 20 years previously had changed less and were less likely to speak English. Knowledge of English was found to protect against psychiatric disorder (Mavreas & Bebbington, 1989, 1990).
Our study confirms the pattern of high rates of depression in an older population that did not have the usual risk factors of being alone, isolated or of relatively low socio-economic status. A predominant somatic presentation has been reported in other cultures and should be considered particularly in those who are from minority immigrant groups (Patel et al, 2001).
Limitations of the study
Our study relied on participants' self-report of their contact with
services (or that of carers, if the person had dementia). Our researchers
looked at the bottles of medication and thus we were confident about what
people were taking. When psychotropic medication consumption is considered, it
suggests that there was an underreporting of contact with psychiatric
services.
The results suggest that older people were not in receipt of the appropriate psychiatric services, yet we have evidence to suggest that this is an inaccurate picture. At the time the data were gathered, local services had just started prescribing antidementia drugs and all patients should have had a 3-monthly follow-up by a psychiatrist. Despite this, most of the people taking cholinesterase inhibitors or antipsychotics reported that they had not had psychiatric contact. This under-reporting suggests that the use of psychiatric services by older people remains stigmatised.
Although our study was designed to ensure that we interviewed a representative population using instruments with appropriate psychometric properties, it was in a relatively deprived inner-city area with a relatively large immigrant population. Within inner London there is the presence of health and welfare professionals from a diverse range of ethnic and cultural backgrounds who may be expected to have an awareness of issues pertinent to these groups. We cannot therefore generalise the findings to dissimilar populations.
Informal care was measured by asking about relatives and friends coming in to help with the ADL. We did not measure what spouses and carers did for their patients because it was difficult to define care in a family context. Our measure of informal help is therefore flawed, as spouses probably provide the most care.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication June 20, 2001. Revision received January 7, 2002. Accepted for publication January 14, 2002.
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