Williams R, Bhopal R, Hunt K. Coronary risk in a British Punjabi population: comparative profile of non-biochemical factors. Int J Epidemiol. 1994; 23:28-37
Burholt V, Wenger GC, Shah Z. Families and Migration: Older People from South Asia.: Department for International Development (DFID) Project ESA315; 2002
Tudor Hart J. ‘The Inverse Care Law’. The Lancet. 1971; 297:405-412
Conroy SP, Mayberry JF. Patient information booklets for Asian patients with ulcerative colitis. Public Health. 2001; 115:418-420
Raynor P. Born in Bradford, a cohort study of babies born in Bradford, and their parents: Protocol for the recruitment phase. BMC Public Health. 2008; 8:327-340
Grewal N, Kaur M. Status of oral health awareness in Indian children as compared to Western children. A thought provoking situation (a pilot study). J Ind Soc Pedodentol Prevent Dent. 2007; 25:15-19
Kaur R, Kataria H, Kumar S, Kaur G. Caries experience among females aged 16–21 in Punjab, India and its relationship with lifestyle and salivary HSP70 levels. Eur J Dent. 2010; 4:308-313
Parsons S, Godson JH, Williams SA, Cade JE. Are there intergenerational differences in the diets of young children born to first-and second-generation Pakistani Muslims in Bradford, West Yorkshire, UK?. J Human Nutr Dietet. 1999; 12:113-122
Andrews L. Beakers for bottles – a health visitor oral health campaign. Comm Practitioner. 2004; 77:18-22
Mullen K, Chauhan R, Gardee R, Macpherson L. Exploring issues related to attitudes towards dental care among second generation ethnic groups. Divers Hlth Soc Care. 2006; 3:131-139
Gray M, Morris AJ, Davies J. The oral health of South Asian five-year-old children in deprived areas of Dudley compared with White children of equal deprivation and fluoridation status. Comm Dent Hlth. 2000; 17:243-245
Pitts NB, Palmer JD. The dental caries experience of 5-, 12-and 14-year-old children in Great Britain. Surveys coordinated by the British Association for the Study of Community Dentistry in 1991/92, 1992/3 and 1990/91. Comm Dent Hlth. 1994; 11:42-52
Asadi SG, Asadi ZG. Chewing sticks and the oral hygiene habits of the adult Pakistani population. Int Dent J. 1997; 47:275-278
Mattin D, Smith JM. The oral health status, dental needs and factors affecting utilisation of dental services in Asians aged 55 years and over, resident in Southampton. Br Dent J. 1991; 170:369-372
Khuwaja AK, Khawaja S, Motwani K, Khoja AA, Azam IS, Fatmi Z, Ali BS, Kadir MM. Preventable lifestyle risk factors for non-communicable diseases in the Pakistan Schools Study 1 (PASS-1). J Prevent Med Publ Hlth. 2011; 44:210-217
Bile KM, Shaikh JA, Afridi HU, Khan Y. Smokeless tobacco use in Pakistan and its association with oropharyngeal cancer. E Med Hlth J. 2010; 16:S24-30
Saeed M, Muhammad N, Khan SA, Gul F, Khuda F, Humayun M, Khan H. Assessment of potential toxicity of a smokeless tobacco product (naswar) available on the Pakistani market. Tobacco Control. 2012; 21:396-401
Ali NS, Khuwaja AK, Ali T, Hameed R. Smokeless tobacco use among adult patients who visited family practice clinics in Karachi, Pakistan. J Oral Pathol Med. 2009; 38:416-421
Basharat S, Kassim S, Croucher RE. Availability and use of Naswar: an exploratory study. J Publ Hlth. 2012; 34:60-64
Shah S, Qureshi R, Azam I. Practices and knowledge of schoolchildren regarding chhaalia/paan masala in Mahmoodabad and Chanesar Goth, Karachi. J Pakist Med Assoc. 2008; 58:678-683
Gandhi G, Kaur R, Sharma S. Chewing Pan Masala and/or Betel Quid – fashionable attributes and/or cancer menaces. J Hum Ecol. 2005; 17:161-166
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There is a substantial Panjabi community in the UK and its language is the second most common to be used in the country. As a result, it is critical that all practitioners concerned with oral health are aware of the dental practices of this community and of the increased risk of conditions such as head and neck cancer. This review assesses work published in the UK as well as in India and Pakistan. It emphasizes the need for a better understanding of cultural aspects of our care. Of course many aspects are not unique to this community but a better understanding will help with approaches to other communities. Social practices, such as paan use, can occur with greater frequencies amongst others, such as the Bangladeshi community. However, the purpose of this review is to concentrate attention on the largest minority community in the UK and, through this mechanism, to encourage interest in other groups. This interest should lead to practical approaches, such as: the development of relevant focus groups to improve clinical care; to develop outreach programmes to schools and community associations, including temples, gurdwaras and mosques; the production of appropriate literature and other media.
Clinical Relevance: This review should ensure that the reader is aware of attitudes towards dental care in the Panjabi community and of the increased frequency of a range of clinical conditions.
Article
The Panjabi community is the second largest in Britain with about 1.3 million members.1 Its language continues to be the most common one after English spoken by school children and in some homes is the language of choice.2 For many, access to healthcare is limited by both linguistic barriers and social deprivation.3 The impact of these factors on health was well summarized by Caroline Wright when she wrote for the BBC:
‘Although this is something often deemed controversial, poorer health outcomes, decreased comprehension of diagnoses and reduced satisfaction with care are all associated with limited English proficiency and cannot be ignored.4
The General Dental Council has expressed its views in Standards for Dental Professionals:
‘Promote equal opportunities for all patients. Do not discriminate against patients or groups of patients because of their sex, age, race, ethnic origin, nationality, special needs or disability, sexuality, health, lifestyle, beliefs or any other irrelevant consideration.’5
and calls on practitioners to communicate: ‘effectively with patients’5
It has not adopted the more rigorous comments of the General Medical Council which requires that practitioners: ‘must make sure, wherever practical, that arrangements are made to meet patients' language and communication needs.’6
Oral health is no exception and the need for appropriate support urgent.
This will only be effective if developed in conjunction with the community. An example is the Smile with the Prophet campaign (Bradford and Airedale PCT Smile with the Prophet: Oral Health Programme) through which young people develop an awareness of regular dental hygiene and this will contrast with the view of some older patients that the role of the dentist is to deal with acute pain or make dentures. In addition, appropriate education is needed to deal with oral tobacco and paan use, both of which are now readily available within the UK. Their use is clearly linked to the high prevalence of oral cancer in the Panjabi community.
The Panjabi community in the UK
Panjabis first came to the UK in significant numbers as a result of taking part in World War I. However, the main migrations followed World War II and the division of Panjab between Pakistan and India. In the 1950s and later, there were significant migrations from East Africa, especially Uganda, Tanzania and Kenya. A later group came from Afghanistan and work and live around Southall.6 The Muslim Panjabi community largely live in Birmingham, Bradford, Oldham and surrounding towns.7 Sikhs are commonly found in Birmingham, Ealing (Southall), Sandwell, Hounslow, Wolverhampton, Coventry, Redbridge, Leicester, Hillingdon, and Slough (Figure 1).8
Figure 1. A typical supermarket store serving the South Asian community.
Social deprivation has been reported in a number of studies amongst Panjabis in the UK, as well as in other communities. This has included: long working days, low income, crowded housing, liability to attack and perceived lack of social support for women.9,10
As postulated by the Inverse Care Law, service utilization amongst people from socially deprived communities is often poor.11 Furthermore, simply providing written information is inadequate. A study from the West Midlands has shown that fewer Panjabis can write English (41%) than speak it. Of those who can, only 63% consider their standard of written English to be good.10 Any use of literature in Panjabi needs to recognize the different scripts used by Muslim and Sikh communities, as well as the existence of distinct languages, such as Saraiki. It should be tested on patients before general release to ensure adequacy of detail and presentation.12
In the long term, understanding of the nature and magnitude of ill-health amongst the Panjabi community may be improved through programmes such as ‘Born in Bradford’.13 It promises to clarify the role of environmental, psychological and genetic factors on childhood development and subsequent adult health. It is based on a cohort of 10,000 women and their babies.
Awareness of oral health issues
In a comparative study from Amritsar of 100 Panjabi and 100 American children aged 11 to 16 years using a standardized WHO questionnaire, only 6% of those from Panjab considered the health of their teeth to be excellent. This compared with 28% of the Americans. Of the Indian children, 35% never visited a dentist. Fifteen per cent flossed regularly and 20% brushed their teeth less than once a week.14 In a population-based study from Patiala, 16% of Panjabis believed that thread-like worms caused tooth decay and 57% believed tooth loss is a natural part of ageing.15 Against such a background it is not surprising that 63% of women undergraduate students aged 16 to 21 in Panjab had caries.16 The situation was exacerbated by the fact that 75% of those taking part in the study ate some form of junk food, including chocolate, candy and soft drinks, each day. The importance of the traditional Panjabi approach to oral and dental care is underlined by a study of 226 first and second generation Pakistani Muslim mothers living in Bradford. Dietary practices were similar and independent of educational background, linguistic ability and employment status. Children's snacks consisted of crisps, biscuits and sweetened milk or tea, and this was true for first and second generation mothers.17 However, subsequent work has suggested parental views can be modified. Central to achieving such outcomes is the need to provide adequate language support and there is a clear preference for involvement of indigenous people as providers of the service.18,19 The need for such educational programmes is emphasized by a study of five-year-old children in Dudley.20 Dental caries was significantly more common amongst Asian children, once data were controlled for deprivation and fluoridation. This would reflect the findings of the British Association for the Study of Community Dentistry surveys which have repeatedly established a link between deprivation and childhood caries.21
Against this background within Panjab, only 20% use a datum or chewing stick.15 In rural areas miswaks are used by 50% of the adult population, whereas in urban areas the majority use a toothbrush. Thirty six percent of the population clean their teeth on a daily basis, the remainder less frequently, with 8% never doing so.22 The situation is complicated by the use of tobacco-containing mishiri as a tooth and gum powder. In addition, in Southampton less than 15% of South Asian adults over 55 years old attended a dentist on a regular basis. The rest saw a dentist's role as providing care when they had pain or needed new dentures.23
Use of tobacco products
In a study from schools in three Pakistani cities, 25% of pupils used some form of oral tobacco.24 Its use is widespread in Pakistan and is associated with oral cancer. This makes up almost 12% of the tumour load amongst Panjabis, with one third of cases under 40 years old.25 In the UK, it has been suggested that only 2% of Pakistani men regularly use oral tobacco, although the practice appears much commoner in older women.26 One such product is a snuff known as Naswar. In an analysis of 30 brands in Pakistan, contamination with cadmium, lead, arsenic, chromium and nickel was common, with levels well above allowable limits, and this may account for its potential role as an oral carcinogen.27 Such products can often be obtained in stores in the UK.
Smokeless tobacco use frequently starts before the age of 15 years with media advertisements responsible in 40% of cases and 31% responding to peer pressure.28 Although favoured by people of Pashtun origin, its use is spreading. Between 2001 and 2006 the import of chewing tobacco and snuff into the UK saw an increase from 9000 to 19000 kg.26 In 2012, 15 outlets in the London borough of Newham sold Naswar and users had again started at a young age and tended to have received limited education.29 Indeed, in May 2011 kHYBer nASWar BLACK SNUFF was registered as a trademark in the UK by Basit UK Ltd (No 2571405).30 This could be viewed as a positive step as 15% of such products are sold without relevant health warnings or adequate labelling.31,32
Use of paan
Paan is betel leaf on to which slaked lime is smeared and wrapped over a mixture of betel (or areca) nut and other additives such as tobacco, cardamom, aniseed, or gambeer (acacia catechu extract). It is chewed slowly and often kept in contact with the oral mucosa for several hours. The composition of nuts differs with methods of cultivation and preparation. Soaking and boiling, for instance, reduce the concentrations of tannins and alkaloids. Sliced and chewed betel nut allows direct and longer contact of the alkaloids with the buccal mucosa resulting in greater mucosal penetration.33 Paan, supari, zarda, gutkha and paan masala are all readily available in the UK (Figure 2). The brightly coloured packaging and sweet flavours, including chocolate, suggest that they are targeted at young consumers.32 In a Pakistani study of 370 students aged between 10 to 15 years, 85% were regular users of such products.34 Indeed, studies from Panjab have found that products, such as paan, pasand candy and paan masala sachets are readily available outside schools.35 In Tower Hamlets, of 700 school children, up to 92% were current users of some form of betel nut. The highest prevalence was for areca nut alone (36% boys, 43% girls), followed by mistee paan (35%, 29%), betel quid (27%, 26%) and paan masala (14%, 16%). Of current users, up to 13% used all four. Most pupils had started between ages 5 and 12 years. The frequency for each habit was between 3 and 5 episodes per week. However, boys used paan masala approximately 10 times per week.36
Figure 2. Commonly available oral refreshers which contain betel nut.1
Prevalence of oral disease
Caries and periodontitis
In a cross-sectional study of 1000 people from Ludhiana, use of smokeless tobacco, such as khaini, quid, misri or zarda, was also associated with periodontal disease. In particular, smokers with coronary artery disease showed significant periodontal disease, including calculus and loss of tooth attachment.37 Participants in the study who came from urban areas had significantly more advanced periodontal disease, with 23% showing loss of tooth attachment compared to 13% in rural residents.38 The fact that these products are used by many young people in the UK would suggest that similar results will be seen in the UK over the coming decades.
Fluorosis
During the 1960s, 46,000 children were examined in 358 villages in Panjab. The incidence of dental mottling ranged from 23 to 81% in children and from 14% to 71% in adults.39 This high incidence amongst Panjabis was first reported from Lahore by Day in 1940.40 It is likely that this will be true for new Panjabi migrants to the UK.
Oral submucosal fibrosis
Oral submucosal fibrosis as a premalignant lesion has been clearly linked to the use of betel nut.34 During recent years there has been a steady growth of oral tobacco and paan use in the UK. This has been associated with increased imports and more aggressive marketing of these products. As yet the expected increase in cases of oral submucosal fibrosis has not been seen. Case reports are appearing with more regularity and it seems probable that their numbers will continue to grow.41
Oral cancer
Between 1995 and 2002, the Karachi Cancer Registry recorded the highest incidence of cancer of the oral cavity in the world. Over the 8-year period there were 2253 cases, with 56% involving the buccal mucosa.42 In 30% of cases, the patient was under 40, with this trend increasing during the time of the study. The poor and those with low literacy were most at risk. These developments have been linked to the increased use of oral tobacco and especially paan masala.
The risk of oral cancer related to tobacco and betel nut use is summarized in Table 1.
Product
Adjusted odds ratios
Chewing Tobacco
8.3
Mishiri
3.3
Gutkha
12.8
Supari
6.6
Bidi
4.1
In her research, Yasmin Bhurgri drew attention to the importance of audio-visual educational material amongst any target population in view of this low literacy rate.42 Within the UK and the West, in general, a similar sensitivity in the provision of educational material is needed. A recent case-controlled study from Pune Cancer Institute in India has confirmed the role of a range of tobacco and betel products in the genesis of oral cancer.43
Interventions
In a study of 210 Panjabis and 168 English patients drawn from five general practices in London, bilingual staff were favoured over translators.44 The influence of communication and parental beliefs about health issues was investigated in a study from seven general practices in a multi-ethnic neighbourhood in Rotterdam, which included South Asians. Mutual understanding was often poor and led to poor adherence to prescribed therapy.45 Such findings emphasize the need to adopt a more structured community-based approach than that suggested by the British Dental Association in an Occasional Paper on Oral Screening, which was published in 2000:
Team members need to be sensitive to cultural differences of this sort;
Practice meetings could be used for sharing experiences and understandings.
Other health workers dealing with minority ethnic communities will be able to give supporting advice. Generally, people from minority ethnic groups have distinct health problems – more diseases and poorer access to services. Problems can be especially acute for women. Health authorities use ‘linkworkers’ and patients' advocates in some areas to help people access healthcare.46
A successful approach requires close collaboration between the community and the providers of healthcare. The needs of the community must be addressed and, to ensure success, the community must be involved at all stages of the programme. This means that health carers must be open and prepared for a different approach to the one they envisaged. In British Columbia, focus groups from the Panjabi community informed the design and size of posters aimed at reducing early childhood caries.47 Any new model for the care of Panjabi patients needs to bridge the gap between provider opinion and users' perceptions of the service. The best prospect for achieving this outcome is likely to be through the use of participatory meetings and research.3 This is a genuinely democratic non-coercive process whereby those to be helped determine the future of their own decisions.48 Participatory research can help:
Identify barriers which deter communities;
Facilitate greater understanding and awareness of a community's needs;
Develop relevant social skills amongst healthcare consumers and amongst health mediators and so reduce disparities in health outcomes;
Hold communities responsible for their own decisions by engaging them in defining and supporting the quality of services they want;
Providers identify and recognize root causes of problems with their services.
Participatory meetings as described, whose principles have parallels with the Alma Ata Declaration,49 will help clinicians and other healthcare providers become more aware of supportive networks in the Panjabi community. These can be based around a neighbourhood, place of origin or, perhaps most importantly, marriage. Although such networks can be supportive, they may also be watchful and controlling.50 An understanding of their local significance is critical to the development of a Panjabi patient-centred service. Its principles can be used with any minority community.
One of the few examples of a successful approach using these techniques was Smile with the Prophet. This was an oral health programme in Bradford and Airedale which attempted to link toothbrushing and other aspects with ritual and cultural aspects of hygiene. It was based around mosques and madrassas and was supported by Race for Health51 and approved by the Council for Mosques.52 It encouraged youngsters to brush their teeth daily through linking this with the teachings of the Prophet and Islam. The teaching plan had six sessions which developed oral health messages and how they fitted in with Islamic teachings, such as cleaning your teeth before prayer and not eating or drinking to excess. Pupils were given an activity book containing puzzles, drawings and a toothbrush and toothpaste.53,54 Amongst the concepts promoted by the leaflet are the following extracts: ‘Just like the Prophet I will also
Eat only the purest of food
Drink milk and water In your honour I will keep my teeth healthy by
Choosing healthy snacks between meals
Keep sugary foods and drinks to mealtimes only With strong healthy teeth I can
With the support of the local Council for Mosques the programme has also been introduced in Oldham.56 The effectiveness and general acceptability of this programme is yet to be fully assessed.
The involvement of local religious leaders, community radios and mosques, temples and gurdwaras in health campaigns is becoming more widespread. For example, the distribution of free miswaks linked to a ‘Stop smoking’ campaign during Ramadan in 2012 was received enthusiastically by the community in Leicester. The use of community partners and networks gave the campaign an effective edge, although it again awaits formal assessment.57
There are no comparable programmes directed at Hindu or Sikh Panjabi communities.
Conclusion
The Panjabi community in Britain is substantial. As yet clinicians, nurses, managers and self-help organizations in the field of oral health have failed to address the needs of Panjabi patients adequately. This includes recognition of increased frequency of certain diseases, diagnostic and therapeutic needs, as well as the role of social habits. The underlying problem is the inadequacy of communication and the answer needs to be centred around its improvement. The use of local participatory meetings will allow the emergence of community owned solutions as opposed to imposed external directives.
