Ethnicity and cardiovascular health research: pushing the boundaries by including comparison populations in the countries of origin

Chronic diseases such as cardiovascular diseases (CVD) are major health problems in most ethnic minority and migrant populations living in high income countries. By the same token, CVD is a looming threat that is creating a double burden in most of the countries where these populations originate from. The causes of the rising burden are unclear, but they are likely to be multifaceted. Traditionally, ethnicity and health research have mostly concentrated on comparing the health of ethnic minority groups with the majority populations of the countries in which they live. This is an important area of research which illuminates ethnic inequalities in health. However, a few studies on international comparisons show that a lot can be learned from comparing similar ethnic groups living in different industrialised countries. Equally, comparing ethnic minority and migrant populations to similar populations in their countries of origin will generate new knowledge about factors that predispose them to poor health outcomes. Thus, to make progress in the field of ethnicity and health research, we need a new conceptual framework that simultaneously studies migrant/ethnic groups in the country of settlement, in similar countries of settlement, and in the countries of ancestral origin. Such studies need to go beyond the commonest design of cross-sectional studies to include more cohort studies, interventions and linkage studies. This article discusses (1) the burden of CVD in ethnic minority and migrant populations; (2) approaches to understanding predisposing factors; and (3) application of the results to give insight into the potential threats that their countries of origin are likely to face.

Limited midwifery care for undocumented women in the Netherlands

BACKGROUND

Ethnic minority women in Western countries have poorer pregnancy outcomes compared to majority populations, and undocumented women are particularly vulnerable. We intended to assess whether midwives adjust their care if women are undocumented and have no health insurance.

METHODS

A retrospective matched cohort study in primary midwifery care practices in Amsterdam and Rotterdam, the Netherlands. Undocumented, uninsured women (N?=?141) were matched with documented, insured ethnic minority women (N?=?141). Information was extracted from patient records.

RESULTS

Undocumented women attended their first prenatal visit 5 weeks later in their pregnancy and received care elsewhere or disappeared from care more frequently (59.6 versus 34.3%). They frequently have an excess of 110% of the number of expected antenatal visits (32.4% versus 16.9%) and had a preterm birth more frequently (OR 4.59, 95% CI 1.43 to 14.72). Midwives were equally likely to follow referral guidelines in both groups. Undocumented women were more likely to give birth at home (OR 2.14, 95% CI 1.07?4.28) and less likely to receive maternity home care assistance (56.0 versus 79.7%).

CONCLUSION

Although referral guidelines are generally followed by midwives, undocumented women are more at risk of adverse perinatal outcomes and inadequate care than documented ethnic minority women.

Total physical activity might not be a good measure in the relationship with HDL cholesterol and triglycerides in a multi-ethnic population: a cross-sectional study

BACKGROUND

Evidence suggests that physical activity (PA) has a beneficial effect on high-density lipoprotein cholesterol (HDL) and triglycerides. However, observational studies show contrasting results for this association between different ethnic groups. It is unclear whether this is due to differences in the PA composition. The aim of this study was to assess the relationship of the total PA, along with its intensity and duration, with HDL and triglycerides in a multi-ethnic population.

METHODS

The study population was sampled from the SUNSET study and included: 502 European- Dutch, 338 Hindustani-Surinamese, and 596 African-Surinamese participants living in Amsterdam, the Netherlands. We assessed PA with the SQUASH questionnaire. We calculated age-sex-adjusted betas, geometric mean ratios (GMRs), and prevalence ratios (PRs) to assess the relationship of PA with HDL and triglycerides.

RESULTS

In the adjusted models, the highest total PA tertile compared to the lowest tertile was beneficially associated with HDL (beta: 0.08, 95% CI: 0.00, 0.16 and PR low HDL 0.59, 95% CI: 0.39, 0.88) and triglycerides (GMR: 0.93, 95% CI: 0.83, 1.03 and PR: 0.56, 95% CI: 0.29, 1.08) for the African-Surinamese. No statistically significant associations appeared for total PA among the European-Dutch and Hindustani-Surinamese. The adjusted models with the intensity score and HDL showed beneficial associations for the European-Dutch (beta: 0.06, 95% CI: 0.03, 0.10) and African-Surinamese (beta: 0.06, 0.02, 0.10), for log triglycerides for the European-Dutch (beta: -0.08, 95% CI: -0.12, 0.03), Hindustani-Surinamese (beta: -0.06, 95% CI: -0.16, 0.03), and African-Surinamese (beta: -0.04, 95% CI: -0.10, 0.01). Excepting HDL in African-Surinamese, the duration score was unrelated to HDL and triglycerides in any group.

CONCLUSIONS

Activity intensity related beneficially to blood lipids in almost every ethnic group. The activity duration was unrelated to blood lipids, while the total PA 'summary score' was associated only with blood lipids for African-Surinamese. The difference in total PA composition is the most probable explanation for ethnic differences in the total PA association with blood lipids. Multi-ethnic observational studies should include not only a measure of the total PA, but other measures of PA as well, particularly the intensity of activity.

Depressive symptoms and smoking among young Turkish and Moroccan ethnic minority groups in The Netherlands: a cross-sectional study

BACKGROUND

Although evidence indicates a strong association between depressive symptoms and smoking among host and migrant adults, less is known about this relationship among young ethnic minority groups in Europe. This paper aims to assess the relationship between depressive symptoms and smoking among young Turkish and Moroccan migrants in the Netherlands.

METHODS

Multiple logistic regression analyses was used to analyze cross-sectional data from a sample of 364 Turkish and Moroccan migrants aged 15 to 24 years. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to measure the presence of clinically significant depressive symptoms. Smoking behavior was measured by a number of questions.

RESULTS

Of the respondents, 22% were smokers and 33% had depressive symptoms. The prevalence of depressive symptoms was significantly higher in smokers (42.9%) than in nonsmokers (29.5%). Respondents with depressive symptoms had increased odds of smoking even after adjusting for socioeconomic and cultural factors (OR = 2.68, 95% CI = 1.45-4.97).

CONCLUSIONS

Depressive symptoms were significantly associated with smoking behavior in young Turkish and Moroccan migrants. In addition to other acknowledged factors, depressive symptoms should also be considered in relation to the smoking behavior of this group. Intervention programs for smoking behavior should take depressive symptoms into account for young Turkish and Moroccan migrants.

[Hypertension in Dutch and English ethnic minorities. Blood pressure better controlled in English groups than in Dutch groups]

OBJECTIVE

To compare blood pressure and the prevalence of hypertension in white Dutch and Dutch of Suriname-hindustani and Suriname-creole ethnic derivation with corresponding ethnic minority groups in England and to assess the quality of hypertension treatment in these groups.

DESIGN

Retrospective; comparison of cross-sectional studies.

METHOD

Secondary analyses were performed on data from 3 population-based studies with 13,999 participants in total of European, African of South-Asian origin from England and the Netherlands.

RESULTS

English South-Asian men and women had lower blood pressure and lower prevalence of hypertension than people of South-Asian origin in the Netherlands (Suriname-hindustani), except for systolic blood pressure in men of Indian extraction in England. There was no difference in systolic blood pressure between groups of African origin in the Netherlands and England. Diastolic blood pressure levels, however, were lower in English men and women of African origin than in people of African origin in the Netherlands (Suriname-creole). White Dutch had higher systolic blood pressure levels, but lower diastolic blood pressure levels than white English men and women. There was no difference in the prevalence of hypertension between the white groups. In persons being treated for hypertension, a substantially lower percentage of the Suriname-hindustani and Suriname-creole persons in the Netherlands had well controlled blood pressure (lower than 140/90 mmHg) than their English equivalents, with the exception of English of Indian extraction.

CONCLUSION

There were marked differences in blood pressure and prevalence of hypertension between comparable ethnic groups in England and the Netherlands. The relatively poor blood pressure control in Dutch ethnic minority groups partly explained the relatively high blood pressure levels in these groups.

Large ethnic variations in recommended physical activity according to activity domains in amsterdam, the netherlands

Purpose

The level of recommended physical activity (PA) is met less frequently by people from some ethnic minorities than others. We explored whether these differences in recommended PA between ethnic minority groups and the general population varied by domain and type of culturally-specific activity.

Methods

Participants were sampled from the population based SUNSET study and were from ethnic Dutch (n = 567), Hindustani-Surinamese (n = 370) and African-Surinamese (n = 689) descent. The validated SQUASH-questionnaire measured PA for the following domains: commuting, occupation, household, leisure time. Culturally-specific activities were added as extra question within the leisure time domain. The effect of each domain on ethnic differences in recommended PA prevalence was examined by odds-ratio (OR) analysis through recalculating recommended PA, while, in turn, excluding the contribution of each domain.

Results

In the ethnic Dutch population, more vigorous PA in commuting and leisure time was reported compared to the Surinamese groups. The Hindustani-Surinamese and African-Surinamese reported more walking as commuting activity, while the Dutch group reported cycling more frequently. Ethnic differences in recommended PA became smaller in both Surinamese groups compared with the Dutch after removing commuting activity, for example, in Hindustani-Surinamese men (OR = 0.92, 95%CI: 0.62-1.37 vs. OR = 1.33, 0.89-2.00) and women (OR = 1.61, 1.12-2.32 vs. OR = 2.03, 1.41-2.92). Removing occupational activity resulted in larger ethnic differences in both groups compared with the Dutch. Smaller effects were found for yoga and dancing, leisure time and household activities.

Conclusion

This study shows that differences in PA between ethnic minority groups and the general population vary according to the activity domain. The results indicate that including all relevant domains and activities is essential for assessment of ethnic differences in recommended PA.

Relationship between asthma and high blood pressure among adolescents in Aracaju, Brazil

BACKGROUND

Asthma has been linked to cardiovascular diseases (CVDs) and related risk factors such as hypertension in adults. It is unclear whether the relationship between asthma and hypertension found among adults is also observed in adolescents. Hence, the authors examined asthma and its association with prehypertension and hypertension among adolescents in Aracaju, Brazil.

METHODS

Data on asthma and blood pressure were collected among 1002 adolescents age 12 to 17 years old in 15 public schools, 5 municipal schools, and 10 private schools. Asthma data were ascertained by the International Study of Asthma and Allergies in Childhood (ISAAC) written questionnaire. Sex-, age-, and height-specific percentile levels were used to define prehypertension (90-94th percentile) and hypertension (>or=95th percentile).

RESULTS

The prevalence of asthma was 20.6% in boys and 27.7% in girls. Among boys, the prevalence rates of prehypertension and hypertension were 26.7% and 17.0%, respectively. Among girls, the rates of prehypertension and hypertension were 14.3% and 12.9%, respectively. There were no statistically significant associations between asthma and prehypertension, and hypertension, even after adjusting for age, social economic status, physical activity, and body mass index (BMI) in both boys (prehypertension: odds ratio [OR] = 1.35, 95% confidence interval [CI]: 0.80-2.27; hypertension: OR = 0.60, 95% CI: 0.29-1.23) and girls (prehypertension: OR = 0.71, 95% CI: 0.40-1.28; hypertension: OR = 1.07, 95% CI: 0.60-1.94).

CONCLUSIONS

These results suggest no association between asthma and high blood pressure in adolescents. More prospective studies are needed to establish whether hypertension becomes more pronounced at a specific age in asthmatics, and if so, the possible factors that may contribute to this.

The effect of neighbourhood income and deprivation on pregnancy outcomes in Amsterdam, The Netherlands

BACKGROUND

Studies suggest that the neighbourhoods in which people live influence their health. The main objective of this study was to investigate the associations of neighbourhood-level income and unemployment/social security benefit on pregnancy outcomes: preterm delivery, small for gestational age (SGA), pregnancy-induced hypertension (PIH) and miscarriage/perinatal death in Amsterdam.

METHODS

A random sample of 7883 from 82 neighbourhoods in Amsterdam. Individual-level data from the Amsterdam Born Children and their Development (ABCD) study were linked to data on neighbourhood-level factors. Multilevel logistic regression was used to estimate odds ratios and neighbourhood-level variance.

RESULTS

After adjustment for individual-level factors, women living in low-income neighbourhoods (third, second and first quartiles) were more likely than women living in high-income neighbourhoods (fourth quartile) to have SGA births: OR 1.32 (95% CI 1.04 to 1.68), 1.42 (1.11 to 1.82) and 1.62 (1.25 to 2.08) respectively. Women living in the quartile of neighbourhoods with the highest unemployment/social security benefit were more likely than those living in the quartile with the lowest unemployment/social security benefit to have SGA births 1.36 (1.08 to 1.72). The neighbourhood-level variance was significant only for SGA births. No significant associations were found between neighbourhood-level factors and other pregnancy outcomes.

CONCLUSION

The findings suggest that neighbourhood income and deprivation are related to SGA births. More research is needed to explore possible mechanisms underlying poor neighbourhood environment and pregnancy outcomes, in particular through stress mechanisms. Such information might be necessary to help improve maternal and fetal health.

A cross-national comparative study of blood pressure and hypertension between English and Dutch South-Asian- and African-origin populations: the role of national context

BACKGROUND

We compare patterns of blood pressure (BP) and prevalence of hypertension between white-Dutch and their South-Asian and African minority groups with their corresponding white-English and their South-Asian and African ethnic minority groups; and the contribution of physical activity, body sizes, and socioeconomic position (SEP); and the quality of BP treatment that may underlie differences in mean BP.

METHODS

Secondary analyses of population-based studies of 13,999 participants from the United Kingdom and the Netherlands.

RESULTS

Compared with Dutch South-Asians, all English South-Asian men and women had lower BP and prevalence of hypertension except for systolic BP in English-Indian men. Among Africans, the systolic BP did not differ, but the diastolic BP levels were lower in English-Caribbean and English- (sub-Sahara) African men and women than in their Dutch-African counterparts. English-Caribbeans had a lower prevalence of hypertension than Dutch-Africans. Compared with white-Dutch, white-English men and women had higher systolic BP levels, but lower diastolic BP levels. There were no differences in the prevalence of hypertension between the white groups. Most differences remained unchanged after adjustment for SEP, lifestyle, and body sizes in all ethnic groups. BP control rates were substantially lower among Dutch-African and Dutch South-Asian hypertensives than among their English counterparts (except Indians).

CONCLUSIONS

We found marked variations in BP and hypertension prevalence between comparable ethnic groups in England and the Netherlands. Poor BP control among Dutch South-Asians and Africans contributed to their disadvantage of the relatively high BP levels.

Tackling Africa's chronic disease burden: from the local to the global

Africa faces a double burden of infectious and chronic diseases. While infectious diseases still account for at least 69% of deaths on the continent, age specific mortality rates from chronic diseases as a whole are actually higher in sub Saharan Africa than in virtually all other regions of the world, in both men and women. Over the next ten years the continent is projected to experience the largest increase in death rates from cardiovascular disease, cancer, respiratory disease and diabetes. African health systems are weak and national investments in healthcare training and service delivery continue to prioritise infectious and parasitic diseases. There is a strong consensus that Africa faces significant challenges in chronic disease research, practice and policy. This editorial reviews eight original papers submitted to a Globalization and Health special issue themed: "Africa's chronic disease burden: local and global perspectives". The papers offer new empirical evidence and comprehensive reviews on diabetes in Tanzania, sickle cell disease in Nigeria, chronic mental illness in rural Ghana, HIV/AIDS care-giving among children in Kenya and chronic disease interventions in Ghana and Cameroon. Regional and international reviews are offered on cardiovascular risk in Africa, comorbidity between infectious and chronic diseases and cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe. We discuss insights from these papers within the contexts of medical, psychological, community and policy dimensions of chronic disease. There is an urgent need for primary and secondary interventions and for African health policymakers and governments to prioritise the development and implementation of chronic disease policies. Two gaps need critical attention. The first gap concerns the need for multidisciplinary models of research to properly inform the design of interventions. The second gap concerns understanding the processes and political economies of policy making in sub Saharan Africa. The economic impact of chronic diseases for families, health systems and governments and the relationships between national policy making and international economic and political pressures have a huge impact on the risk of chronic diseases and the ability of countries to respond to them.

An overview of cardiovascular risk factor burden in sub-Saharan African countries: a socio-cultural perspective

Background

Sub-Saharan African (SSA) countries are currently experiencing one of the most rapid epidemiological transitions characterized by increasing urbanization and changing lifestyle factors. This has resulted in an increase in the incidence of non-communicable diseases, especially cardiovascular disease (CVD). This double burden of communicable and chronic non-communicable diseases has long-term public health impact as it undermines healthcare systems.

Purpose

The purpose of this paper is to explore the socio-cultural context of CVD risk prevention and treatment in sub-Saharan Africa. We discuss risk factors specific to the SSA context, including poverty, urbanization, developing healthcare systems, traditional healing, lifestyle and socio-cultural factors.

Methodology

We conducted a search on African Journals On-Line, Medline, PubMed, and PsycINFO databases using combinations of the key country/geographic terms, disease and risk factor specific terms such as "diabetes and Congo" and "hypertension and Nigeria". Research articles on clinical trials were excluded from this overview. Contrarily, articles that reported prevalence and incidence data on CVD risk and/or articles that report on CVD risk-related beliefs and behaviors were included. Both qualitative and quantitative articles were included.

Results

The epidemic of CVD in SSA is driven by multiple factors working collectively. Lifestyle factors such as diet, exercise and smoking contribute to the increasing rates of CVD in SSA. Some lifestyle factors are considered gendered in that some are salient for women and others for men. For instance, obesity is a predominant risk factor for women compared to men, but smoking still remains mostly a risk factor for men. Additionally, structural and system level issues such as lack of infrastructure for healthcare, urbanization, poverty and lack of government programs also drive this epidemic and hampers proper prevention, surveillance and treatment efforts.

Conclusion

Using an African-centered cultural framework, the PEN3 model, we explore future directions and efforts to address the epidemic of CVD risk in SSA.

Cardiovascular disease, diabetes and established risk factors among populations of sub-Saharan African descent in Europe: a literature review

Background

Most European countries are ethnically and culturally diverse. Globally, cardiovascular disease (CVD) is the leading cause of death. The major risk factors for CVD have been well established. This picture holds true for all regions of the world and in different ethnic groups. However, the prevalence of CVD and related risk factors vary among ethnic groups.

Methods

This article provides a review of current understanding of the epidemiology of vascular disease, principally coronary heart disease (CHD), stroke and related risk factors among populations of Sub-Sahara African descent (henceforth, African descent) in comparison with the European populations in Europe.

Results

Compared with European populations, populations of African descent have an increased risk of stroke, whereas CHD is less common. They also have higher rates of hypertension and diabetes than European populations. Obesity is highly prevalent, but smoking rate is lower among African descent women. Older people of African descent have more favourable lipid profile and dietary habits than their European counterparts. Alcohol consumption is less common among populations of African descent. The rate of physical activity differs between European countries. Dutch African-Suriname men and women are less physically active than the White-Dutch whereas British African women are more physically active than women in the general population. Literature on psychosocial stress shows inconsistent results.

Conclusion

Hypertension and diabetes are highly prevalent among African populations, which may explain their high rate of stroke in Europe. The relatively low rate of CHD may be explained by the low rates of other risk factors including a more favourable lipid profile and the low prevalence of smoking. The risk factors are changing, and on the whole, getting worse especially among African women. Cohort studies and clinical trials are therefore needed among these groups to determine the relative contribution of vascular risk factors, and to help guide the prevention efforts. There is a clear need for intervention studies among these populations in Europe.

The utility of 'country of birth' for the classification of ethnic groups in health research: the Dutch experience

The relationship between ethnicity and health is attracting increasing attention in international health research. Different measures are used to operationalise the concept of ethnicity. Presently, self-definition of ethnicity seems to gain favour. In contrast, in the Netherlands, the use of country of birth criteria have been widely accepted as a basis for the identification of ethnic groups. In this paper, we will discuss its advantages as well as its limitations and the solutions to these limitations from the Dutch perspective with a special focus on survey studies. The country of birth indicator has the advantage of being objective and stable, allowing for comparisons over time and between studies. Inclusion of parental country of birth provides an additional advantage for identifying the second-generation ethnic groups. The main criticisms of this indicator seem to refer to its validity. The basis for this criticism is, firstly, the argument that people who are born in the same country might have a different ethnic background. In the Dutch context, this limitation can be addressed by the employment of additional indicators such as geographical origin, language, and self-identified ethnic group. Secondly, the country of birth classification has been criticised for not covering all dimensions of ethnicity, such as culture and ethnic identity. We demonstrate in this paper how this criticism can be addressed by the use of additional indicators. In conclusion, in the Dutch context, country of birth can be considered a useful indicator for ethnicity if complemented with additional indicators to, first, compensate for the drawbacks in certain conditions, and second, shed light on the mechanisms underlying the association between ethnicity and health.

Blood pressure and body mass index in an ethnically diverse sample of adolescents in Paramaribo, Suriname

BACKGROUND

High blood pressure (BP) is now an important public health problem in non-industrialised countries. The limited evidence suggests ethnic inequalities in BP in adults in some non-industrialised countries. However, it is unclear whether these ethnic inequalities in BP patterns in adults reflect on adolescents. Hence, we assessed ethnic differences in BP, and the association of BP with body mass index (BMI) among adolescents aged 12-17 years in Paramaribo, Suriname.

METHODS

Cross-sectional study with anthropometric and blood pressure measurements. A random sample of 855 adolescents (167 Hindustanis, 169 Creoles, 128 Javanese, 91 Maroons and 300 mixed-ethnicities) were studied. Ethnicity was based on self-reported ethnic origin.

RESULTS

Among boys, Maroons had a lower age- and height-adjusted systolic BP than Creoles, and a lower diastolic BP than other ethnic groups. However, after further adjustment for BMI, only diastolic BP in Maroons was significantly lower than in Javanese (67.1 versus 70.9 mmHg). Creole boys had a lower diastolic BP than Hindustani (67.3 versus 70.2 mmHg) and Javanese boys after adjustment for age, height and BMI. Among girls, there were no significant differences in systolic BP between the ethnic groups. Maroon girls, however, had a lower diastolic BP (65.6 mmHg) than Hindustani (69.1 mmHg), Javanese (71.2 mmHg) and Mixed-ethnic (68.3 mmHg) girls, but only after differences in BMI had been adjusted for. Javanese had a higher diastolic BP than Creoles (71.2 versus 66.8 mmHg) and Mixed-ethnicity girls. BMI was positively associated with BP in all the ethnic groups, except for diastolic BP in Maroon girls.

CONCLUSION

The study findings indicate higher mean BP levels among Javanese and Hindustani adolescents compared with their African descent peers. These findings contrast the relatively low BP reported in Javanese and Hindustani adult populations in Suriname and underscore the need for public health measures early in life to prevent high BP and its sequelae in later life.

Risk of death after first admission for cardiovascular diseases by country of birth in The Netherlands: a nationwide record-linked retrospective cohort study

OBJECTIVE

To examine differences in short- (28 days) and long-term (5 years) risk of death in patients hospitalised for the first time for various cardiovascular diseases (CVD) by country of birth and/or parental country of birth.

DESIGN

A nationwide prospective cohort of CVD patients.

SETTINGS

Entire Netherlands.

PATIENTS

118 691 patients hospitalised for the first time for various CVDs were identified through the national hospital discharge, the Dutch population and the cause-of-death registers.

MAIN OUTCOME MEASURES

Differences in short-term and long-term risk of death. Cox proportional hazard models were used to estimate the mortality hazard ratios.

RESULTS

After adjusting for age, compared with Dutch patients, Turkish, other non-Western and Western migrants had both a short- and long-term higher risk, while Suriname patients had only a long-term higher risk of total-mortality and combined-CVD mortality. These higher rates were driven mainly by an increased risk of short-term (hazard ratio 3.21; 95% CI 1.03 to 10.03) and long-term (2.29; 1.14 to 4.60) mortality following congestive heart failure (CHF) among Turkish; short-term (1.56; 1.10 to 2.20) and long-term (1.50; 1.11 to 2.01) mortality following cerebrovascular accident (CVA) among the other non-Western migrants; short-term mortality following CVA (1.10; 1.01 to 1.19) and long-tem mortality following CVA (1.10; 1.03 to 1.17), and, to a lesser extent, CHF and myocardial infarction among Western migrants; and a long-term mortality following CVA (1.29; 1.05 to 1.57) among Surinamese patients.

CONCLUSION

Higher mortality after a first episode of CVD was found in ethnic minority patients than in Dutch patients. These differences hardly changed after adjusting for possible confounders, suggesting that treatment and secondary prevention strategies may be less effective in these groups. More research is needed to explain the possible causes of these inequalities.

Educational inequalities in metabolic syndrome vary by ethnic group: evidence from the SUNSET study

BACKGROUND

Compared with Whites, many ethnic minority groups have higher prevalence of metabolic syndrome. The reasons for these ethnic inequalities in health are incompletely understood. The main objective was to examine whether socio-economic position (SEP) as measured by education was related to the prevalence of metabolic syndrome in different ethnic groups in Amsterdam, The Netherlands.

METHODS

A random sample of healthy adults aged 35-60 years. SEP was measured by educational level (secondary school and below (low), and vocational school and above (high)). Metabolic syndrome was measured according to the International Diabetic Federation guidelines.

RESULTS

Low education was negatively related to metabolic syndrome but only in White-Dutch people. Among White-Dutch men, the age adjusted prevalence ratio (95% confidence intervals) for low education was 1.46 (95% CI: 1.01-2.10) versus high education. Among White-Dutch women, the adjusted odds ratios for low education was 2.26 (95% CI: 1.39-3.68) versus high education. In both White-Dutch men and women, low education was related to several components of metabolic syndrome. Among African-Surinamese and Hindustani-Surinamese, no significant associations were found between low education and metabolic syndrome and its components.

CONCLUSION

Low education is associated with increased risk of metabolic syndrome among White-Dutch people but not among other ethnic groups. Community-based strategies to improve metabolic profiles may have to be ethnically devised. Among White-Dutch, targeting people with lower SEP may have an impact. However, among ethnic minority groups, both low and high socio-economic groups may have to be equally targeted to have an impact in reducing ethnic inequalities in health.

Environmental attributes related to walking and bicycling at the individual and contextual level

OBJECTIVE

The aim of the present paper was to give insight into the practical consequences of using either single-level or multilevel regression analyses on data from research on environmental determinants of physical activity.

METHODS

For this purpose, results from single-level and multilevel regression analyses on comparable attributes of the environment were compared using a combination of individual and aggregated data, merged at the neighbourhood level.

RESULTS

Using only individual level data, applying multilevel instead of single-level analyses did not substantially influence the results. However, ignoring the multilevel structure of our data by applying single-level in stead of multilevel analyses resulted in statistically significant associations for all the environmental attributes under study. Moreover, using information on environmental attributes at both the individual and the contextual level to adjust associations at one level for the other level showed that associated environmental attributes tend to be associated either at the individual or at the contextual level.

CONCLUSIONS

These results stress the importance for reviews and meta-analyses of recording type of measurement and type of analytical strategy used and incorporating them in the review process. Using advanced multilevel designs will still only partly solve the methodological issues involved in studying environmental attributes associated with physical activity, but it will help in disentangling this complex relationship. Therefore, it is recommended that, whenever there is a presumably relevant grouping (context; eg neighbourhoods) in a study, a multilevel approach should at least be considered.

Gender disparities in hypertension among different ethnic groups in Amsterdam, The Netherlands: the SUNSET study

BACKGROUND

Studies have consistently shown a lower prevalence of hypertension in women than in men. Obesity is an important risk factor for hypertension, and the rate of obesity is particularly high among ethnic minority women. It is therefore questionable whether the lower prevalence of hypertension in women is also true among specific ethnic minority groups in Europe. Hence, we sought to determine whether gender disparity in hypertension is consistent across different ethnic groups, and if not so, whether differences in body sizes (body mass index (BMI) and waist circumferences) explain demonstrated gender disparities in hypertension among different ethnic groups in Amsterdam, the Netherlands.

METHODS

The SUNSET study was a random sample of 1,432 people aged 35-60 years (508 White-Dutch, 591 African-Surinamese, and 333 Hindustani-Surinamese).

RESULTS

Age-adjusted hypertension rate was significantly lower in White-Dutch women than in White-Dutch men as expected--the odds ratio (95% confidence interval) was 0.35 (0.23-0.54). This difference hardly changed after adjustment for body sizes and other factors. However, among the ethnic minority groups, age-adjusted hypertension rate did not differ significantly between women and men in both African-Surinamese 0.74 (0.51-1.08) and Hindustani-Surinamese 0.80 (0.49-1.29). It was only after further adjustment for body sizes that African-Surinamese women were significantly less likely than African-Surinamese men to have hypertension 0.54 (0.36-0.81). The same pattern applied to the Hindustani-Surinamese, although less pronounced 0.59 (0.34-1.02).

CONCLUSION

Gender differences in hypertension are not consistent across ethnic groups. The lack of differences in ethnic minority groups is related to lifestyle factors particularly overweight and obesity.

The association of neighbourhood psychosocial stressors and self-rated health in Amsterdam, The Netherlands

OBJECTIVE

To investigate associations between neighbourhood-level psychosocial stressors (i.e. experience of crime, nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with the quality of green space) and self-rated health in Amsterdam, the Netherlands.

PARTICIPANTS

A random sample of 2914 subjects aged > or = 18 years from 75 neighbourhoods in the city of Amsterdam, the Netherlands.

DESIGN

Individual data from the Social State of Amsterdam Survey 2004 were linked to data on neighbourhood-level attributes from the Amsterdam Living and Security Survey 2003. Multilevel logistic regression was used to estimate odds ratios and neighbourhood-level variance.

RESULTS

Fair to poor self-rated health was significantly associated with neighbourhood-level psychosocial stressors: nuisance from neighbours, drug misuse, youngsters frequently hanging around, rubbish on the streets, feeling unsafe and dissatisfaction with green space. In addition, when all the neighbourhood-level psychosocial stressors were combined, individuals from neighbourhoods with a high score of psychosocial stressors were more likely than those from neighbourhoods with a low score to report fair to poor health. These associations remained after adjustments for individual-level factors (i.e. age, sex, educational level, income and ethnicity). The neighbourhood-level variance showed significant differences in self-rated health between neighbourhoods independent of individual-level demographic and socioeconomic factors.

CONCLUSION

Our findings show that neighbourhood-level psychosocial stressors are associated with self-rated health. Strategies that target these factors might prove a promising way to improve public health.

Prevalence and time trends in obesity among adult West African populations: a meta-analysis

The objective of this study was to determine the distribution of and trends in obesity in adult West African populations. Between February and March 2007, a comprehensive literature search was conducted using four electronic databases. Journal hand searches, citations and bibliographic snowballing of relevant articles were also undertaken. To be included, studies had to be population-based, use well-defined criteria for measuring obesity, present data that allowed calculation of the prevalence of obesity and sample adult participants. Studies retrieved were critically appraised. Meta-analysis was performed using the DerSimonian-Laird random effect model. Twenty-eight studies were included. Thirteen studies were conducted in urban settings, 13 in mixed urban/rural and one in rural setting. Mean body mass index ranged from 20.1 to 27.0 kg(2). Prevalence of obesity in West Africa was estimated at 10.0% (95% CI, 6.0-15.0). Women were more likely to be obese than men, odds ratios 3.16 (95% CI, 2.51-3.98) and 4.79 (95% CI, 3.30-6.95) in urban and rural areas respectively. Urban residents were more likely to be obese than rural residents, odds ratio 2.70 (95% CI, 1.76-4.15). Time trend analyses indicated that prevalence of obesity in urban West Africa more than doubled (114%) over 15 years, accounted for almost entirely in women. Urban residents and women have particularly high risk of overweight/obesity and obesity is rising fast in women. Policymakers, politicians and health promotion experts must urgently help communities control the spread of obesity in West Africa.

Prevalence and determinants of prehypertension among African Surinamese, Hindustani Surinamese, and White Dutch in Amsterdam, the Netherlands: the SUNSET study

BACKGROUND

Evidence suggests that prehypertension is associated with increased risk of cardiovascular mortality. Little is known about ethnic differences in prehypertension in Europe. We aimed to assess these ethnic differences and to determine the factors associated with prehypertension in Amsterdam, the Netherlands.

DESIGN

Cross-sectional study.

METHODS

Prehypertension was defined as having a blood pressure 120-139/80-89 mmHg.

RESULTS

The overall prevalence of prehypertension was 32.8% (men 37.9% and women 29.9%). The prevalence of prehypertension did not differ between the ethnic groups in men. African Surinamese and Hindustani Surinamese women, however, had a higher prevalence of prehypertension than White Dutch women. In multivariate logistic regression analysis, the odds ratios [95% confidence interval] for being prehypertensive were 2.25 (1.38-3.67; P<0.001) for African Surinamese and 2.06 (1.18-3.60; P<0.01) for Hindustani Surinamese women, compared with White Dutch women. BMI was strongly associated with prehypertension in both men and women. Total cholesterol was positively associated with prehypertension in women, whereas increased physical activity was negatively associated. The independent factors associated with prehypertension vary by ethnic group. In men, BMI was associated with prehypertension in the White Dutch, total cholesterol and low education in the African Surinamese, and fasting glucose in the Hindustani Surinamese. In women, total cholesterol was associated with prehypertension in the African Surinamese; the corresponding factor was the BMI in the Hindustani Surinamese.

CONCLUSION

Prehypertension is common in minority women. As a large proportion of people with prehypertension progress to clinical hypertension, targeting these people early with lifestyle-modification interventions aimed at weight loss, increased physical activity, and healthy dietary habits can provide important long-term benefits. The results indicate that the primary foci of such lifestyle interventions should vary between ethnic groups.

Prehypertension in the Ashanti region of Ghana, West Africa: an opportunity for early prevention of clinical hypertension

OBJECTIVE

To assess prehypertension among Ghanaian adults in the Ashanti region of Ghana, West Africa.

DESIGN

Cross-sectional study.

PARTICIPANTS

There were 1431 participants aged 18 years or more. Prehypertension was defined as blood pressure of 120-139/80-89 mmHg.

MAIN OUTCOME MEASURES

Prehypertension.

RESULTS

Overall, 31% of the study population were normotensive, 40% were prehypertensive and 29% were hypertensive. Prehypertension was more common in non-hypertensive males than non-hypertensive females (66% vs 49%, P<0.001). Prehypertension was also more common in those aged 35 years compared with those aged <35 years (P<0.001), and in overweight and obese people compared with people of normal weight (P=0.03). In a multivariate logistic regression model, male sex [odds ratio (OR) 2.36; 95% confidence interval (CI) 1.77-3.15; P<0.001], age 35-49 years (OR 1.56; 95% CI 1.12-2.18; P<0.01) and 50 years (OR 2.13; 95% CI 1.33-3.42; P=0.002)], overweight (OR 1.61; 95% CI 1.09-2.36; P=0.02) and obesity (OR 2.71; 95% CI 1.40-5.24; P=0.003) were independently associated with higher odds of prehypertension, whilst current smoking (OR 0.36; 95% CI 0.16-0.81; P=0.01) was associated with lower odds of prehypertension.

CONCLUSION

Prehypertension is very common among non-hypertensive subjects in the Ashanti region of Ghana. As a large proportion of people with prehypertension will progress to clinical hypertension, targeting these people early with lifestyle modifications such as weight reduction may provide important long-term benefits.

Ethnic differences in the effect of environmental stressors on blood pressure and hypertension in the Netherlands

BACKGROUND

Evidence strongly suggests that the neighbourhood in which people live influences their health. Despite this, investigations of ethnic differences in cardiovascular risk factors have focused mainly on individual-level characteristics. The main purpose of this study was to investigate associations between neighbourhood-level environmental stressors (crime, housing density, nuisance from alcohol and drug misuse, quality of green space and social participation), and blood pressure (BP) and hypertension among different ethnic groups.

METHODS

Individual data from the Amsterdam Health Survey 2004 were linked to data on neighbourhood stressors creating a multilevel design for data analysis. The study sample consisted of 517 Dutch, 404 Turkish and 365 Moroccans living in 15 neighbourhoods in Amsterdam, the Netherlands.

RESULTS

Amongst Moroccans, high density housing and nuisance from drug misuse were associated with a higher systolic BP, while high quality of green space and social participation were associated with a lower systolic BP. High level of nuisance from drug misuse was associated with a higher diastolic BP. High quality of green space was associated with lower odds of hypertension. Amongst Turkish, high level of crime and nuisance from motor traffic were associated with a higher diastolic BP. Similar associations were observed among the Dutch group but none of the differences were statistically significant.

CONCLUSION

The study findings show that neighbourhood-level stressors are associated with BP in ethnic minority groups but were less evident in the Dutch group. These findings might imply that the higher BP levels found in some ethnic minority groups might be partly due to their greater susceptibility to the adverse neighbourhood environment in which many ethnic minority people live. Primary prevention measures targeting these neighbourhood stressors may have an impact in reducing high BP related morbidity and mortality among ethnic minority groups.

Does the pulse pressure in people of European, African and South Asian descent differ? A systematic review and meta-analysis of UK data

The aim of this study was to assess whether the pulse pressures (PPs) in people of African and South Asian descent differ from those of the European-origin White (henceforth, White) in the UK. A systematic literature review was carried out using MEDLINE 1966-2006 and EMBASE 1980-2006. The meta-analysis was performed using Cochrane review manager software (RevMan version 4.2; Oxford, UK). Thirteen studies were examined. Results for African descent men (n=9 studies) and women (n=7) indicated that African men and women had a higher mean PP than their White counterparts. Overall weighted mean difference (WMD) in PP was 1.68 (95% confidence interval: [0.38, 2.98 mm Hg]; P=0.01) in men and 2.01 ([0.39, 3.63 mm Hg]; P<0.001) in women. South Asian men (n=7 studies) had a lower mean PP than White men (-1.94; [-3.56, -0.32 mm Hg]; P=0.02), whereas no significant difference was found between South Asian and White women (n=5 studies) (-0.40; [-3.22, 2.39 mm Hg]; P=0.77). Separate data were available for Indians (n=5 studies), Bangladeshis (n=4) and Pakistanis (n=3). Bangladeshis had a lower PP than Whites (men, -5.61; [-6.87, -4.36 mm Hg]; P<0.001) (women, -5.21; [-8.67, -1.75 mm Hg]; P=0.003). Pakistani men had a lower PP than White men (-3.33 mm Hg; [-5.67, -1.00]; P<0.001). The WMD was nonsignificantly lower in Indian men (-0.76 mm Hg), Indian women (-0.80 mm Hg) and Pakistani women (-2.06 mm Hg). The higher PP found among African descent people may contribute to their more frequent hypertension complications. However, the lower PP in South Asian populations, particularly in Bangladeshis and Pakistani men, indicates that PP is unlikely to contribute to their higher risk of cardiovascular disease in the UK.

Prevalence and management of hypertension among Turkish, Moroccan and native Dutch ethnic groups in Amsterdam, the Netherlands: the Amsterdam Health Monitor Survey

OBJECTIVE

To assess ethnic differences in the prevalence and management of hypertension among Turkish, Moroccan and native Dutch ethnic groups in Amsterdam, the Netherlands.

DESIGN

A cross-sectional survey.

PARTICIPANTS

A random sample of 1304 adults aged 18 years and over. Of these, 39.2% were Dutch, 33.2% were Turkish and 27.6% were Moroccan.

RESULTS

The prevalence of hypertension was lower in Turkish (men 25.8% and women 22.2%) and Moroccan (men 26.1% and women 19.6%) than in Dutch individuals (men 48.8% and women 35.0%). Except for Turkish women, these differences persisted after adjustment for age and body mass index: the odds ratios (95% confidence interval) for being hypertensive were 0.47 (0.30-0.74; P < 0.001) for Turkish men, 0.48 (0.30-0.76; P < 0.001) for Moroccan men and 0.51 (0.28-0.94; P = 0.03) for Moroccan women. Only Moroccan hypertensive women were less likely than Dutch women to be aware of their condition 0.31 (0.11-0.81; P < 0.01) and to be treated 0.32 (0.12-0.88; P < 0.01) for hypertension. There were no differences in hypertension control between the ethnic groups in both men and women.

CONCLUSION

The lower prevalence of hypertension among Moroccan men may contribute to the low cardiovascular disease (CVD) mortality reported among this group in the Netherlands. The differential risks in CVD mortality between Moroccan men and women may partly result from the lower hypertension awareness and treatment rates in Moroccan women. Strategies aimed at improving the detection and treatment of hypertension among Moroccan women may improve the sex disparity in cardiovascular mortality between Moroccan men and women in the Netherlands.

Factors associated with hypertension awareness, treatment and control among ethnic groups in Amsterdam, the Netherlands: the SUNSET study

We sought to determine factors associated with hypertension awareness, pharmacological treatment and control among ethnic groups in Amsterdam, The Netherlands. We analysed data on hypertensive subjects (Dutch n=130, Hindustani n=115 and African Surinamese n=225). After adjustments for important covariates, hypertension awareness was more common in Dutch people with abdominal obesity and family history of hypertension (FHH). Abdominal obesity was also associated with higher level of awareness in African Surinamese. Female sex, FHH and recent physician (general practitioner (GP)) visit were associated with higher level of awareness in both African and Hindustani Surinamese. Among the Dutch, hypertension treatment was more common in those with abdominal obesity, FHH and GP visit. Among Hindustanis, female sex, abdominal obesity and GP visit were positively associated with treatment of hypertension. Old age, female sex, FHH and GP visit were positively associated, whereas smoking was negatively associated with lower treatment in African Surinamese. High education and more physical activity were associated with better blood pressure (BP) control, whereas obesity was associated with poor BP control among the Dutch. Among African Surinamese, female sex and FHH were associated with better BP control, whereas abdominal obesity was associated with poor BP control. Only old age was associated with poor BP control in Hindustanis. In conclusion, our findings indicate that more attention is needed in promoting awareness and treatment among those with lower hypertension risk (i.e., normal body weight people and those without FHH), those without recent GP visits in all ethnic groups and African and Hindustani Surinamese men and smokers. More effort is also needed in hypertension control among Dutch people with low education, obesity and inadequate physical activity, African Surinamese men and those without FHH and old Hindustani people.

Validity of the single-item question on self-rated health status in first generation Turkish and Moroccans versus native Dutch in the Netherlands

BACKGROUND

The single-item question on self-rated health has been used in many studies as a global measure of general health. It is unclear whether ethnic minority groups in the Netherlands attach the same meaning to the single-item question as the native Dutch people do.

OBJECTIVE

To assess the validity of using the single-item question on self-rated health in comparing health status in native Dutch with first generation Turkish and Moroccan ethnic groups in the Netherlands.

METHODS

The associations between self-reported chronic illnesses and self-rated health were used to examine convergent validity, and self-rated health and health care use for predictive validity using logistic regression analysis.

RESULTS

In general, chronic illnesses were associated with fair health and poor health ratings in all the ethnic groups but there were important differences in associations between the groups. There were significant interactions between ethnicity and chronic illnesses on fair health, and poor health, independent of socio-demographical factors. There was also significant interaction between ethnicity and self-rated health on health care uses. These findings indicate that the meaning(s) attached to the single-item question differ between these ethnic groups.

CONCLUSION

The study findings suggest that the use of the single-item question on self-rated health to compare native Dutch with the first generation Turkish and Moroccan ethnic groups is not valid. These findings imply that researchers need to be cautious about the interpretation of self-rated health ratings when comparing different ethnic groups. A qualitative research is needed to find out more about how these single-item ratings are being interpreted by Turkish and Moroccan elderly in the Netherlands.

Negro, Black, Black African, African Caribbean, African American or what? Labelling African origin populations in the health arena in the 21st century

Broad terms such as Black, African, or Black African are entrenched in scientific writings although there is considerable diversity within African descent populations and such terms may be both offensive and inaccurate. This paper outlines the heterogeneity within African populations, and discusses the strengths and limitations of the term Black and related labels from epidemiological and public health perspectives in Europe and the USA. This paper calls for debate on appropriate terminologies for African descent populations and concludes with the proposals that (1) describing the population under consideration is of paramount importance (2) the word African origin or simply African is an appropriate and necessary prefix for an ethnic label, for example, African Caribbean or African Kenyan or African Surinamese (3) documents should define the ethnic labels (4) the label Black should be phased out except when used in political contexts.

Rural and urban differences in blood pressure and hypertension in Ghana, West Africa

BACKGROUND

Hypertension, once rare in traditional African societies, is rapidly becoming a major public health problem.

OBJECTIVE

To assess urban and rural differences in blood pressure (BP) and hypertension, and to determine factors associated with BP in this sub-Saharan Africa population.

STUDY DESIGN

Cross-sectional survey.

SETTING

Ashanti region of Ghana, West Africa.

PARTICIPANTS

There were 1431 participants (644 males and 787 females). Of these, 578 were from the rural setting (237 males and 341 females) and 853 from the urban setting (407 males and 446 females).

RESULTS

Age-adjusted mean systolic and diastolic BP levels were lower in rural men than in urban men (129/75 versus 133/78, P<0.001). The mean systolic and diastolic BP levels were also lower in rural women than in urban women (126/76 versus 131/80, P<0.001). After adjustments for age, the odds ratios (95% CI) for being hypertensive were 1.9 (1.3-2.9; P<0.01) for urban men and 1.9 (1.3-2.8; P<0.0001) for urban women. Urban women were more likely than rural women to be aware of their hypertensive condition (odds ratio 2.3, 95% CI, 1.2-4.2; P<0.001). Treatment and control of hypertension did not differ between the groups in either men or women. In multiple linear regression analysis, age, urban dwelling, BMI and heart rate were independently associated with systolic and diastolic BP in both men and women. Smoking and alcohol consumption were independently associated with systolic and diastolic BP but only in men.

CONCLUSION

The findings of this study demonstrate that high BP (hypertension) is an important public health burden in both urban and rural settings in this sub-Saharan African population. Cost-effective public health measures are urgently needed to prevent high BP from becoming another public health burden.

Factors associated with hypertension awareness, treatment, and control in Ghana, West Africa

Hypertension is rapidly becoming a major public health burden in sub-Saharan/Africa but awareness, treatment, and control is lagging behind. We analysed cross-sectional data from Ghana (West-Africa) to examine factors associated with awareness, treatment, and control of hypertension. The overall prevalence of hypertension was 29.4%. Of these, 34% were aware of their condition, 28% were receiving treatment, and 6.2% were controlled below SBP/DBP <140/90 mmHg. Multivariate analysis showed that old age was independently associated with higher hypertension awareness: 35-49-year-olds (odds ratio (OR) = 2.57, 95% (confidence interval) CI: 1.26-5.22), > or =50-year-olds (OR = 6.14, CI: 2.98-12.64) compared with 16-34-year-olds. Old age: > or =50-year-olds (OR: 6.25, 95% CI: 2.87-13.62), trading (OR = 2.46, 95% CI: 1.17-5.17), and overweight (OR = 1.85, 95% CI: 1.02, 3.34) were independently associated with pharmacological treatment of hypertension. Trading (OR = 2.51, 95% CI: 1.03-7.40) was independently associated with adequate blood pressure (BP) control but old age: > or =50-year-olds (OR = 0.11, 95% CI: 0.01-0.60) was independently associated with inadequate BP control. The identified factors provide important information for improving BP control among this population. Given the high cost of hypertension medication relative to income, increasing awareness and simple preventive measures such as promotion of physical activity, normalising body weight and reduction of salt intake, present the best hope for reducing the impact of hypertension on morbidity and mortality.

Prevalence, awareness, treatment, and control of hypertension among Black Surinamese, South Asian Surinamese and White Dutch in Amsterdam, The Netherlands: the SUNSET study

OBJECTIVE

To assess ethnic differences in prevalence, levels of awareness, treatment and control of hypertension among Dutch ethnic groups and to determine whether these differences are consistent with the UK findings.

DESIGN

Cross-sectional survey.

SETTING

South-east Amsterdam, The Netherlands.

PARTICIPANTS

A random sample of 1383 non-institutional adults aged 35-60 years. Of these, 36.7% were White, 42% were Black and 21.3% were South Asian people.

MAIN OUTCOME MEASURES

Prevalence of hypertension, rates of awareness, treatment, and control of hypertension.

RESULTS

The Black and South Asian subjects had a higher prevalence of hypertension compared with White people. After adjustments for age, the odds ratios (95% confidence interval) for being hypertensive were 2.2 (1.4-3.4; P < 0.0001) and 3.8 (2.6-5.7; P < 0.0001) for Black men and women, respectively, and 1.7 (1.0-2.6; P = 0.039) and 2.8 (1.8-4.5; P < 0.0001) for South Asian men and women, compared with White people. There were no differences in awareness and pharmacological treatment of hypertension between the groups. However, Black hypertensive men 0.3 (0.1-0.7; P < 0.01) and women 0.5 (0.3-0.9; P < 0.05) were less likely to have their blood pressure adequately controlled compared with White people.

CONCLUSION

The higher prevalence of hypertension found among Black and South Asian people in The Netherlands is consistent with the UK studies. However, the lower control rates and the similar levels of awareness and treatment of hypertension in Black Surinamese contrast with the higher rates reported in African Caribbeans in the UK. The rates for the South Asians in The Netherlands were relatively favourable compared to similar South Asian groups in the UK. These findings underscore the urgent need to develop strategies aimed at improving the prevention and control of hypertension, especially among Black people, in The Netherlands.

Negro, Black, Black African, African Caribbean, African American or what? Labelling African origin populations in the health arena in the 21st century

Broad terms such as Black, African, or Black African are entrenched in scientific writings although there is considerable diversity within African descent populations and such terms may be both offensive and inaccurate. This paper outlines the heterogeneity within African populations, and discusses the strengths and limitations of the term Black and related labels from epidemiological and public health perspectives in Europe and the USA. This paper calls for debate on appropriate terminologies for African descent populations and concludes with the proposals that (1) describing the population under consideration is of paramount importance (2) the word African origin or simply African is an appropriate and necessary prefix for an ethnic label, for example, African Caribbean or African Kenyan or African Surinamese (3) documents should define the ethnic labels (4) the label Black should be phased out except when used in political contexts.

Blood pressure patterns in rural, semi-urban and urban children in the Ashanti region of Ghana, West Africa

BACKGROUND

High blood pressure, once rare, is rapidly becoming a major public health burden in sub-Saharan/Africa. It is unclear whether this is reflected in children. The main purpose of this study was to assess blood pressure patterns among rural, semi-urban, and urban children and to determine the association of blood pressure with locality and body mass index (BMI) in this sub-Saharan Africa setting.

METHODS

We conducted a cross-sectional survey among school children aged 8-16 years in the Ashanti region of Ghana (West-Africa). There were 1277 children in the study (616 boys and 661 females). Of these 214 were from rural, 296 from semi-urban and 767 from urban settings.

RESULTS

Blood pressure increased with increasing age in rural, semi-urban and urban areas, and in both boys and girls. The rural boys had a lower systolic and diastolic blood pressure than semi-urban boys (104.7/62.3 vs. 109.2/66.5; p < 0.001) and lower systolic blood pressure than urban boys (104.7 vs. 107.6; p < 0.01). Girls had a higher blood pressure than boys (109.1/66.7 vs. 107.5/63.8; p < 0.01). With the exception of a lower diastolic blood pressure amongst rural girls, no differences were found between rural girls (107.4/64.4) and semi-urban girls (108.0/66.1) and urban girls (109.8/67.5). In multiple linear regression analysis, locality and BMI were independently associated with blood pressure in both boys and girls.

CONCLUSION

These findings underscore the urgent need for public health measures to prevent increasing blood pressure and its sequelae from becoming another public health burden. More work on blood pressure in children in sub-Saharan African and other developing countries is needed to prevent high blood pressure from becoming a major burden in many of these countries.

Does the white-coat effect in people of African and South Asian descent differ from that in White people of European origin? A systematic review and meta-analysis

OBJECTIVE

To assess whether the white-coat effect in people of African (Blacks) and South Asian descent differs from that of people of European origin (Whites), and if so, whether this explains demonstrated ethnic variations in blood pressure.

METHODS

A systematic literature review was carried out using Medline 1966-2003, Embase 1980-2003, and citations from references. The meta-analysis was performed using the Cochrane review manager software (RevMan version 4.2; Oxford, UK).

RESULTS

Eight studies were examined, four studies from the UK and four from the USA. The mean systolic and diastolic white-coat effect was similar in Blacks and Whites. The weighted mean difference in systolic white-coat effect was 0.31 [confidence interval 95% (CI)=-1.96, 2.57; P=0.79] and in diastolic white-coat effect was 0.18 (95% CI=-1.70, 1.35; P=0.82). Two studies reported on South Asians. Both systolic and diastolic white-coat effect was significantly lower in South Asians than in Whites; the weighted mean difference in systolic white-coat effect was -8.90 (95% CI=-13.04, -4.76; P<0.0001) and in diastolic white-coat effect was -4.66 (95% CI=-7.29, -2.03; P<0.0001).

CONCLUSION

The blood pressure differences between Blacks and Whites are unlikely to be a result of variations in white-coat effect. In contrast, the slightly lower clinic blood pressure in some South Asian populations such as Bangladeshis might be partly caused by a low white-coat effect but more studies are needed in this subject.

Does nocturnal blood pressure fall in people of African and South Asian descent differ from that in European white populations? A systematic review and meta-analysis

OBJECTIVE

To assess whether nocturnal blood pressure fall in people of African (Black) and South Asian descent differs from that of the European origin white populations (White).

METHODS

A systematic literature review was carried out using Medline 1966-2003 and Embase 1980-2003, and citations from references. The meta-analysis was performed using Cochrane review manager software (RevMan version 4.2; The Cochrane Collaboration, Oxford, UK).

RESULTS

Seventeen studies were identified; 11 studies from the USA, one from the USA and Canada, and six studies from the United Kingdom. The mean percentage systolic blood pressure (SBP) nocturnal fall was below 10% (non-dipping) in 10 of 17 studies (59%) and the diastolic blood pressure (DBP) nocturnal fall was below 10% in four of 16 studies (25%) in Blacks compared with four of 17 studies (24%) in SBP and none in DBP nocturnal falls in Whites. Compared with Whites, Blacks had a significantly lower mean percentage nocturnal fall; the overall weighted mean difference in SBP was -3.07 (95% confidence interval, -3.81, -2.33; P < 0.00001) and in DBP was -2.98 (95% confidence interval, -3.97, -2.00; P < 0.00001). Two studies on South Asians showed a higher SBP but a similar mean DBP nocturnal fall compared with Whites.

CONCLUSION

Smaller nocturnal blood pressure falls and a higher prevalence of non-dipping may contribute to the higher levels of hypertension complications seen in Black people. No such phenomenon was seen in South Asians but more research is needed to explore their higher stroke mortality.

Do variations in blood pressures of South Asian, African and Chinese descent children reflect those of the adult populations in the UK? A review of cross-sectional data

The objective of this study was to assess whether variations in BP in children of UK ethnic minority populations correspond to those seen in adults. A systematic literature review was carried out using MEDLINE 1966-2003 and EMBASE 1980-2003, supplemented by correspondence with expert informants, and citations from references. Five studies were identified. There were important differences between studies in terms of age and sex of samples, definition of ethnic minority children and methods of evaluating BP. Three studies of children of African descent reported lower mean SBP in boys from African descent compared to white boys, the differences being significant only in one study. In African descent girls, the mean SBP was significantly lower in one study, while DBP was significantly higher in one study. Four studies included children of South Asian origin. The Health Survey for England '99 reported on South Asian groups separately. Pakistani boys had a significantly higher age- and height-standardised mean SBP than the general population. The mean DBP was significantly higher in Indian and Pakistani boys than the general population. Pakistani and Bangladeshi girls had a significantly higher mean DBP than the general population. The other three studies, which combined South Asian subgroups found no significant differences in the mean BP between South Asians and white subjects. One study included children of Chinese descent and reported significantly higher mean DBP in Chinese boys and girls compared to the general population. Overall, BP across ethnic groups was similar. These similarities in BP patterns particularly in African, Bangladeshi and Pakistani descent children contrasts with those in the corresponding adult populations in the UK where BP is comparatively high in those of African descent and comparatively low in those of Bangladeshi and Pakistani descent.

Is the blood pressure of people from African origin adults in the UK higher or lower than that in European origin white people? A review of cross-sectional data

The aim of the study was to review published evidence on whether blood pressure (BP) levels and the prevalence of hypertension are higher in adult populations of African descent living in the UK as compared to the white population. A systematic literature review was carried out using MEDLINE 1966-2002 and EMBASE 1980-2002 and citations from references. In all, 14 studies were identified. Nearly all studies were carried out in the London area. The data showed important differences between studies in terms of age and sex of samples, definition of African/black and methods of evaluating BP. A total of 10 studies reported higher mean systolic BPs, while 11 studies reported higher mean diastolic BPs in men from African descent compared to white men. In women, 10 of 12 studies reported higher systolic, and 10 of 12 studies reported higher diastolic BPs. For prevalence of hypertension, eight of 10 studies reported higher rates in men from African descent; eight of nine studies showed higher rates of hypertension in women from African descent. Overall, the most representative sample and up-to-date data came from the Health Survey for England '99. Ethnic group differences in BP were not present in the younger age groups. Women of African descent had higher BP and higher body mass index (BMI). In men of African descent high BP did not coincide with higher BMI. In conclusion, the reported higher rates of hypertension in people from African descent in the UK are confirmatory of the USA African-American and white comparisons. Variations in study methods, size and body composition, and in the mix of Afro-Caribbean and West African groups explain much of the inconsistent results in the UK studies.

Is the blood pressure of South Asian adults in the UK higher or lower than that in European white adults? A review of cross-sectional data

The objective of the study was to review published evidence on whether blood pressure levels and the prevalence of hypertension are higher or lower in South Asian adults living in the UK as compared to white populations. A systematic literature review was carried out using MEDLINE 1966-2001, EMBASE 1980-2001, and citations from references. A total of 12 studies were identified. The data showed important differences between studies in terms of age and sex of samples, definition of South Asians (Indian, Pakistani and Bangladeshi) and methods of evaluating blood pressure. Seven studies reported lower mean systolic blood pressures, while seven studies showed higher diastolic pressures in South Asian men compared to white men. In women, six of nine studies showed lower systolic blood pressures, while five reported higher diastolic pressures. For prevalence of hypertension, five of 10 studies reported higher rates in South Asian men than in white men. Two of six studies showed higher prevalence rates in South Asian women. Overall, the most representative sample and up-to-date data came from the Health Survey of England 1999. Both blood pressure and the prevalence data show important differences between South Asian subgroups, yet most studies combined them. The data also showed a geographical variation between London (comparatively high blood pressure in South Asians) and the rest of the UK (comparatively low or similar blood pressure). Bangladeshis had low blood pressure and body mass index (BMI). In other South Asian subgroups, low blood pressure and the low BMI did not always coincide. To conclude, the common perception that blood pressure in South Asians is comparatively high is unreliable-the picture is complex. Overall, blood pressures are similar but there is stark heterogeneity in the South Asian groups, with slightly higher blood pressure in Indians, slightly lower blood pressure in Pakistanis, and much lower blood pressure in Bangladeshis. Variations in study methods, body shape, size and fat, and in the mix of South Asian groups probably explain much of the inconsistency in the results.