Uptake and impact of COVID-19 preventive measures amongst migrant populations in the Netherlands

 

Uptake of preventive measures to reduce transmission of viruses such as SARS-CoV-2, is crucial in the control of pandemics. To ensure equitable uptake we explored contextual factors that shaped uptake of COVID-19 preventive measures amongst smaller, albeit substantial, migrant populations in the Netherlands. 39 persons of Eritrean, Ghanaian, Indonesian and Filipino origin, with diverse legal status and length of stay in the Netherlands, participated in five online focus group discussions. Thematic analysis of data was informed by concepts from the Precaution Adoption Process Model and Protection Motivation Theory. Awareness and knowledge of preventive measures was shaped by limited Dutch proficiency, access to understandable information and interference of misinformation. Engagement by preventive measures was subject to COVID-19 threat appraisal and the ease with which complex behavioural messages could be translated to individual situations. Perceived vulnerability of undocumented migrants in particular, motivated information-seeking. A strong social norm to keep with cultural and religious practices, and limited opportunity for preventive behaviour in work and home context hindered uptake of preventive behaviour. Preventive measures brought about job, food, and housing insecurity, and increased barriers in access to healthcare for undocumented migrants. Migration-related, sociocultural, and socioeconomic factors shape uptake of preventive measures. Preventive measures negatively impact work, housing and access to healthcare of undocumented migrants. Our results suggest importance of multilingual information tailored to literacy needs; education and modelling of behaviour; and, regulations to ensure continued access to financial and material resources to minimise negative spill-over effects. Results were incorporated in two policy briefs advising local and national government. Collaboration with municipal health services lead to multilingual public health information.

Key messages

• Migration-related, sociocultural, and socioeconomic factors shape uptake of preventive measures.

• Preventive measures negatively impact work, housing and access to healthcare of undocumented migrants.

Ethnic differences in COVID-19 deaths across various waves of Coronavirus pandemic in Netherlands

Background

It is not known how ethnic differences in COVID-19 deaths in the Netherlands evolved throughout the pandemic, especially after introduction of ethnicity-oriented COVID-19 prevention measures. We investigated associations between ethnicity and COVID-19 deaths across first wave of the pandemic, inter-wave period, and second wave in the Netherlands.

Methods

We obtained multiple registry data from Statistics Netherlands spanning from 01 March 2020 to 14 March 2021 comprising of 17.4 million inhabitants. We estimated incidence rate ratios (IRRs) for COVID-19 deaths among ethnic groups using Poisson regression models and adjusted for relevant socio-demographic factors. We used similar models to estimate IRRs for non-COVID-19 deaths among ethnic groups.

Results

Ethnic minority populations exhibited higher risk of COVID-19 deaths than the Dutch origin population throughout various study periods. The most elevated risk of COVID-19 deaths was in populations originating from low- and middle-income countries, especially those with Turkish, Moroccan, and Surinamese background. The elevated risk of COVID-19 deaths among ethnic minority groups (as compared to Dutch origin population) was higher in inter-wave period (4 times higher) and second wave (2 times higher) when compared to the first wave (1.5 times as higher). Ethnic differences in COVID-19 deaths were larger compared to non-COVID-19 deaths.

Conclusions

Ethnic differences in COVID-19 deaths persisted across first wave, inter-wave period and second wave in the Netherlands despite introduction of ethnicity-oriented prevention measures. Research on explanatory mechanisms and novel prevention measures are needed to address the ongoing differences in COVID-19 deaths across ethnic groups.

Key messages

• Ethnic differences in COVID-19 deaths persisted in the Netherlands despite introduction of ethnicity-oriented prevention measures.We therefore call for better prevention measures.

• Well known drivers of SARS-CoV-2 infection such as household wealth, did not explain our findings calling for an in-depth understanding of drivers of ethnic differences in COVID-19 deaths.

Rural and urban migration to Europe in relation to cardiovascular disease risk: does it matter where you migrate from?

OBJECTIVES

To assess whether the environmental context (i.e. rural vs urban) in which individuals in low- and middle-income countries have resided most of their lives is associated with estimated cardiovascular disease (CVD) risk after migration to a high-income country.

STUDY DESIGN

Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study were used including 1699 Ghanaian participants aged 40-79 years who had migrated to Europe from Ghana (1549 of urban origin, 150 of rural origin).

METHODS

Ten-year CVD risk was estimated using the Pooled Cohort Equation, with estimates ≥7.5% defining elevated CVD risk. Comparisons between urban and rural origin migrant groups were made using proportions and adjusted odds ratios (ORs).

RESULTS

The proportion of migrants with an elevated CVD-risk score was substantially higher among rural migrants than among urban migrants (45% vs. 37%, OR = 1.44, 95% confidence interval [CI]:1.03-2.02), which persisted after adjustment for education level, site of residence in Europe (London, Amsterdam or Berlin), length of stay in Europe, physical activity, energy intake and alcohol consumption (OR = 1.67, 95% CI: 1.05-2.67).

CONCLUSION

Our findings indicate that migrants who spent most of their lives in a rural setting before migration to Europe may have a higher CVD risk than those of urban origins. Further work is needed to confirm these findings in other migrant populations and to unravel the mechanisms driving the differential CVD risk between urban and rural migrants.

Health literacy and hypertension outcomes in a multi-ethnic population: the HELIUS study

BACKGROUND

Hypertension disproportionately affects ethnic minority groups. Although health literacy may play role in these ethnic inequalities, little is known about the extent to which health literacy affects hypertension prevalence, awareness, treatment and control in different ethnic groups. Therefore, we assessed these associations in a multi-ethnic population.

METHODS

Baseline data from the HELIUS study were used including participants of Dutch (n = 1948), South-Asian Surinamese (n = 2054) and African Surinamese (n = 1932) origin aged 18-70 years, who lived in Amsterdam, the Netherlands, were fluent in Dutch and underwent health literacy assessment through the Rapid Estimate of Adult Literacy in Medicine-Dutch (REALM-D). The REALM-D was categorized either as low (<60 sumscore) or adequate (≥60 sumscore) health literacy. Participants completed questionnaires and underwent physical examination.

RESULTS

After adjusting for confounding variables, Dutch [odds ratio (OR) 2.02; 95% confidence interval (CI), 1.11-3.64] and African Surinamese (OR 1.36; 1.03-1.79) with low health literacy were more likely than those with adequate health literacy to have hypertension, whereas in South-Asian Surinamese this association was not significant. No significant associations were found between health literacy and hypertension awareness, treatment and control in any of the ethnic groups.

CONCLUSION

Findings indicate that health literacy is associated with hypertension prevalence in selected ethnic groups, but not with hypertension awareness, treatment and control. Targeting health literacy might be an entry point for tackling ethnic inequalities in hypertension prevalence. To substantially reduce these inequalities, further research is needed to explore other factors and pathways through which health literacy may impact hypertension outcomes in different ethnic groups.

Gestational diabetes mellitus among Sub-Saharan African and Surinamese women in the Netherlands

AIM

We assessed the association between ethnicity and the risk of gestational diabetes mellitus (GDM) in the Netherlands.

METHODS

A cohort of 7815 women with known GDM status and ethnicity, including women of Sub-Saharan African ethnicity who are currently not identified as high-risk in guidelines. We compared GDM rates among participants of ethnicity to those of ethnic Dutch participants. We employed multivariable regression to correct for possible confounders, including maternal age, pre-pregnancy body mass index (BMI), and education. GDM prevalence and odds ratios based on ethnicity were the main outcome measures.

RESULTS

The prevalence rates of GDM according to ethnicity were: Dutch 0.6%, South-Asian Surinamese 6.9%, African-Surinamese 3.5%, Antillean 1.0%, Turkish 1.0%, Moroccan 1.4%, Ghanaian 6.8%, Sub-Saharan African 3.5%, other Western 0.5% and other non-Western 2.8%. After adjustment for age, pre-pregnancy BMI, and education duration, compared with the reference Dutch-ethnicity population, adjusted odds ratios (aOR) for GDM were statistically significantly higher in South-Asian Surinamese (aOR 10.9; 95% Confidence Interval (CI), 4.7-25.0), African-Surinamese (4.3; 2.0-9.2), Ghanaian (6.5; 3.0-14.5), Sub-Saharan African (5.7; 2.0-16.0), and other non-Western women (4.5; 2.2-9.0). GDM was not significantly increased among Antillean (1.4; 0.2-10.3), Turkish (1.4; 0.4-4.2), Moroccan (1.8; 0.8-4.0), and other Western women (0.8; 0.3-2.2).

CONCLUSIONS

This study shows for the first time in the Netherlands that women of Ghanaian or other Sub-Saharan African ethnicity have an increased risk of developing GDM than the Dutch. This calls for adaptation of the Dutch guidelines of screening high-risk groups for GDM and more awareness amongst obstetric caregivers.

Factors associated with suboptimal blood pressure control in a multi-ethnic population in Amsterdam

Background

Among patients using antihypertensives, blood pressure (BP) control is generally low and appears to vary between ethnicities. We aimed to identify factors associated with suboptimal BP control in a multi-ethnic population.

Methods

Cross-sectional data of the Healthy Life in an Urban Setting (HELIUS) study were used, including participants aged 18-70 years, with Dutch, African Surinamese (AS), South-Asian Surinamese (SAS), Ghanaian, Turkish or Moroccan ethnicity living in Amsterdam, the Netherlands. Suboptimal BP control was defined as BP ≥ 140/90 mmHg among participants using antihypertensives. Logistic regression analysis was performed to identify sociodemographic, lifestyle, health and psychosocial factors associated with suboptimal BP control for the total population and for each ethnic group.

Results

A total of 3,571 participants (500 Dutch, 1052 AS, 656 SAS, 637 Ghanaian, 433 Turkish, 293 Moroccan) were included in the analysis, of whom 53.3% had suboptimal BP control. Female sex (OR 0.50, 95%CI 0.43-0.59), being married (0.83, 0.72-0.96), current smoking (0.78, 0.65-0.94), obesity (1.67, 1.35-2.06), cardiovascular disease (CVD) history (0.56, 0.46-0.68), non-adherence to antihypertensives (1.26, 1.00-1.58), and family history of hypertension (1.19, 1.02-1.38) were associated with suboptimal BP control. Among ethnic subgroups, female sex was associated with lower odds of suboptimal BP control in all ethnic groups, as was current smoking (Turkish) and CVD history (Dutch, SAS, AS), whereas obesity (Dutch, AS, Turkish), older age (Turkish) and non-adherence to antihypertensives (Dutch) were associated with higher odds of suboptimal BP control.

Conclusions

Our analysis identifies several factors that are independently associated with suboptimal BP control, with only small variation between ethnic groups, suggesting that focussing on well-known determinants of suboptimal BP control is worthwhile to improve BP control rates in a multi-ethnic population.

Key messages

Several factors are associated with suboptimal blood pressure control in a multi-ethnic population, with only small variation between ethnic groups. These findings suggest that focussing on well-known determinants of suboptimal BP control is worthwhile to improve BP control rates in a multi-ethnic population.

Culture Matters in Communicating the Global Response to COVID-19

Current communication messages in the COVID-19 pandemic tend to focus more on individual risks than community risks resulting from existing inequities. Culture is central to an effective community-engaged public health communication to reduce collective risks. In this commentary, we discuss the importance of culture in unpacking messages that may be the same globally (physical/social distancing) yet different across cultures and communities (individualist versus collectivist). Structural inequity continues to fuel the disproportionate impact of COVID-19 on black and brown communities nationally and globally. PEN-3 offers a cultural framework for a community-engaged global communication response to COVID-19.

Obesity and cardiovascular disease risk among Africans residing in Europe and Africa: the RODAM study

BACKGROUND

The association between anthropometric variables and cardiovascular disease (CVD) risk among Africans is unclear. We examined the discriminative ability of anthropometric variables and estimate cutoffs for predicting CVD risk among Africans.

METHODS

The Research on Obesity and Diabetes among African Migrants (RODAM) study was a multisite cross-sectional study of Africans in Ghana and Europe. We calculated AHA/ACC Pooled Cohort Equations (PCE) scores for 3661 participants to ascertain CVD risk, and compared a body shape index (ABSI), body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), Relative Fat Mass (RFM), and Waist to Height Ratio (WHtR). Logistic regression and receiver operating curve analyses were performed to derive cutoffs for identifying high predicted CVD risk (PCE score ≥7.5%).

RESULTS

Among men, WC (adjusted Odds Ratio (aOR): 2.25, 95% CI; 1:50-3:37) was strongly associated with CVD risk. Among women, WC (aOR: 1.69, 95% CI: 1:33-2:14) also displayed the strongest association with CVD risk in the BMI-adjusted model but WHR displayed the strongest fit. All variables were superior discriminators of high CVD risk in men (c-statistic range: 0.887-0.891) than women (c-statistic range: 0.677-0.707). The optimal WC cutoff for identifying participants at high CVD risk was 89 cm among men and identified the most cases (64%). Among women, the recommended WC cutoff of 94 cm or WHR cutoff of 0.90 identified the most cases (92%).

CONCLUSIONS

Anthropometric variables were stronger discriminators of high CVD risk in African men than women. Greater WC was associated with high CVD risk in men while WHR and WC were associated with high CVD risk in women.

Factors hindering hypertension control: perspectives of front-line health professionals in rural Ghana

OBJECTIVE

Hypertension (HTN) control remains a major public health challenge in sub-Saharan Africa (SSA). Health professionals influence patient adherence and self-management practices for HTN particularly in rural and lower socio-economic communities in SSA. Contextual evidence on the reasons for the suboptimal control of HTN in clinical settings is crucial to improving health delivery practices for HTN and preventing HTN related-complications.

STUDY DESIGN

A cross-sectional qualitative study.

METHODS

Semistructured interviews were conducted among 40 purposively sampled front-line health professionals in seven health facilities in northern Ghana. Data were analysed using a thematic approach through pre-identified and evolving themes.

RESULTS

We identified three key themes underlying the poor HTN control. First, health professionals' barriers included communication difficulties, poor collaboration and referrals among health professionals and limited training on HTN and other non-communicable diseases (NCDs). Secondly, health system-related barriers included limited health personnel, drug shortages, inadequate facilities and equipment and challenges with National Health Insurance (NHIS). The third theme was patient-related barriers including non-adherence, use of traditional treatments, sociocultural factors and lack of appreciation.

CONCLUSION

A holistic public health approach, which builds upon health professionals' capacities, harnesses and integrates into existing health policy and systems structures and empowers and collaborates with communities could contribute to improving HTN control in rural settings. Health policymakers need to consider the sociocultural, economic and geographical characteristics in such settings, which influence health service delivery practices in designing and implementing HTN interventions. There is also a need for health policy to integrate NCD training and management of multiple and comorbid conditions into the training curriculum of health training institutions to build health professionals capacity to facilitate the uptake of evidence-based NCD interventions and manage the double burden of diseases.

Dyslipidaemia among Ghanaian migrants in Europe and their compatriots in Ghana: the RODAM Study

Background

Sub-Saharan African (SSA) populations are believed to have a favourable lipid profile compared to European populations. However, geographical differences in the lipid profile of a homogenous SSA population residing in different geographical locations have not yet been assessed.

Methods

We used data from the multicentre, cross-sectional RODAM study including Ghanaian adults residing in rural and urban Ghana and in London, Amsterdam and Berlin (n = 5482). Dyslipidaemias were defined based on the 2012 European Guideline on Cardiovascular Prevention. The age-adjusted prevalence of dyslipidaemias was compared between the sites using prevalence ratios (PRs) adjusted for lifestyle and dietary covariates in different models.

Results

The age-standardised prevalence rate of high total cholesterol (TC) and LDL-cholesterol (LDL-C) was lower in rural than in urban Ghana and Ghanaian migrants in Europe. Adjusted PRs of high TC and LDL-C were higher in urban Ghana (TC PR = 2.15, 95% confidence interval 1.69-2.73) and Ghanaian migrant men (TC PR = 2.03 (1.56-2.63)) compared to rural Ghana, but there was no difference between rural and Ghanaian migrant women (TC PR = 1.01 (0.84-1.22)). High triglyceride levels were as prevalent in rural Ghana (11.6%) as in urban Ghana (12.8%), but were less prevalent in Ghanaian migrant women (2.0%). In both sexes, low HDL-cholesterol was most prevalent in rural Ghana (50.1%) and least prevalent in Europe (12.9%).

Conclusions

The lipid profile of Ghanaians varied by geographical location, and differential gradients of the individual dyslipidaemias could be observed between the locations. Additional research is needed to identify factors driving these differential risks in order to assist prevention efforts.

Key messages

The lipid profile of Ghanaians in urban Ghana and Europe is less favourable compared to the lipid profile of rural Ghanaian residents. Substantial differences in lipid profiles could be observed between the geographical locations.

Association between psychosocial stress and obesity among migrant and non-migrant Ghanaians

Background

Psychosocial stress is associated with obesity in some populations, but it is unclear whether the association is related to migration.

Aim

This study explored associations between psychosocial stress and obesity among Ghanaian migrants in Europe and non-migrant Ghanaians in Ghana.

Methods

Cross-sectional data from the RODAM study were used, including 5898 Ghanaians residing in Germany, the UK, the Netherlands, rural Ghana, and urban Ghana. Perceived discrimination, negative life events and stress at work or at home were examined in relation to body mass index (BMI) and waist circumference (WC). Linear regression analyses were performed separately for migrants and non-migrants stratified by sex.

Results

Perceived discrimination was not associated with BMI and WC in both migrants and non-migrants. However, negative life events were positively associated with BMI (β = 0.78, 95% CI, 0.34 to 1.22) and WC (β = 1.96, 95% CI, 0.79 to 3.12) among male Ghanaian migrants. Among non-migrant Ghanaians, in contrast, stress at work or at home was inversely associated with BMI and WC in both males (β=-0.66, 95% CI, -1.03 to -0.28; β=-1.71 95% CI, -2.69 to -0.73, respectively) and females (β=-0.81, 95% CI, -1.20 to -0.42; β=-1.46, 95% CI, -2.30 to -0.61, respectively).

Conclusions

Negative life events are associated with increased body weight among Ghanaians in European settings, whereas stress at work or at home is associated with reduced body weight among Ghanaians in Ghana. More work is needed to understand the underlying factors driving these differential associations in order to assist prevention efforts.

Key messages

Negative life events are associated with increased body weight among Ghanaians in European settings, whereas stress at work or at home is associated with reduced body weight among Ghanaians in Ghana. More work is needed to understand the underlying factors driving these differential associations in order to assist prevention efforts.

Hyperuricemia And Estimated Cardiovascular Risk Among Migrant and non-migrant Africans

Objective

In the advent of rapid urbanization, migration and epidemiological transition, the extent to which serum uric acid (sUA) affects cardiovascular disease (CVD) risk among Africans is not well understood. We assessed differences in sUA levels and associations with estimated CVD risk among migrant Ghanaians in Europe, and non-migrant Ghanaians in rural and urban Ghana.

Methods

Baseline data from 633 rural, 916 urban and 2315 migrant RODAM study participants (40-70 years) were analyzed. Hyperuricemia was defined as sUA &gt;7mg/dl in males and &gt;6mg/dl in females. Elevated CVD risk was defined as pooled cohort equation estimates ≥ 7.5%. Logistic regressions were used to assess differences in hyperuricemia and associations with estimated CVD risk. Receiver operator curves were used to calculate sUA cut off values that maximised likelihood of elevated CVD risk.

Results

Prevalence for hyperuricemia in rural, urban and migrant participants were 17.4%, 19.1% and 31.7% for men, and 15.9%, 18.2% and 33.2% for women, respectively. Hyperuricemia was positively associated with elevated CVD risk among rural residents(adjusted OR for men 2.88, 95%CI, 1.20-6.88, 5.32, 95%CI, 2.86-9.95 for women), urban residents(1.26, 95%CI, 0.59-2.69 for men, 2.41, 95%CI, 1.56-3.73 for women) and migrants(2.39, 95%CI, 1.57-3.64) for men, 3.74, 95%CI, 2.78-5.02 for women). SUA cut-off values were 6.8mg/dl in men and 5.2mg/dl in women.

Conclusions

Our study shows variations of sUA levels in different African contexts. Hyperuricemia is associated with elevated estimated CVD risk in both migrants and non-migrants. Further studies should identify factors driving associations between SUA and CVD risk in Africans.

Key messages

Hyperuricemia is a risk factor for cardiovascular risk in both migrants and non-migrants. Cardiovascular risk is seen at low levels of serum uric acid levels in Africans.

Metabolic syndrome among Ghanaian migrants and their homeland counterparts: the RODAM study

Background

Metabolic syndrome (MetSyn) is a major risk factor for type 2 diabetes (T2D) and cardiovascular disease (CVD). T2D and CVD are a major burden among African populations both in Africa and in high-income countries. However, it is unknown whether the prevalence of MetSyn shows geographical differences between a homogenous population residing in different settings in Africa and Europe.

Methods

We used data from the cross-sectional multi-centre Research on Obesity and Diabetes among African Migrants (RODAM) study that was conducted among Ghanaians aged 25-70 years residing in rural and urban Ghana and in Amsterdam, London and Berlin (n = 5659). MetSyn was defined according to the 2009 harmonized definition. Geographical locations were compared using age-standardised prevalence rates and prevalence ratios (PRs), adjusted for age, education, physical activity and smoking.

Results

In men, the age-standardised prevalence of MetSyn was 8.3% in rural Ghana and showed a positive gradient through urban Ghana (23.6%, PR = 1.85, 95% confidence interval 1.17-2.92) to Europe, with the highest prevalence in Amsterdam (31.4%; PR = 4.45, 2.94-6.75). In women, there was a rural to urban gradient in MetSyn prevalence (rural Ghana 25%, urban Ghana 34.4%, PR = 1.38, 1.13-1.68), but small differences in MetSyn prevalence between urban Ghanaian and European Ghanaian women (Amsterdam 38.4%). The prevalence rates of the individual MetSyn components showed a positive rural-urban-Europe gradient. However, compared to their urban and European counterparts, a low HDL-C level was significantly more prevalent among rural Ghanaians.

Conclusions

MetSyn and its components are highly prevalent in Ghana as well as in Ghanaian migrants in Europe. To understand the mechanisms driving the geographical differences in MetSyn, further research is needed, thereby aiming for the reduction of T2D and CVD prevalence in SSA populations.

Key messages

Metabolic syndrome is more prevalent in urban compared to rural Ghana, and even more prevalent in Ghanaian migrants in Europe. Its components show the same positive gradient, expect for low HDL-C, which shows a negative gradient.

Associations between maternal physical activity in early and late pregnancy and offspring birth size: remote federated individual level meta-analysis from eight cohort studies

OBJECTIVE

Evidence on the impact of leisure time physical activity (LTPA) in pregnancy on birth size is inconsistent. We aimed to examine the association between LTPA during early and late pregnancy and newborn anthropometric outcomes.

DESIGN

Individual level meta-analysis, which reduces heterogeneity across studies.

SETTING

A consortium of eight population-based studies (seven European and one US) comprising 72 694 participants.

METHODS

Generalised linear models with consistent inclusion of confounders (gestational age, sex, parity, maternal age, education, ethnicity, BMI, smoking, and alcohol intake) were used to test associations between self-reported LTPA at either early (8-18 weeks gestation) or late pregnancy (30+ weeks) and the outcomes. Results were pooled using random effects meta-analyses.

MAIN OUTCOME MEASURES

Birth weight, large-for-gestational age (LGA), macrosomia, small-for-gestational age (SGA), % body fat, and ponderal index at birth.

RESULTS

Late, but not early, gestation maternal moderate to vigorous physical activity (MVPA), vigorous activity, and LTPA energy expenditure were modestly inversely associated with BW, LGA, macrosomia, and ponderal index, without heterogeneity (all: I2  = 0%). For each extra hour/week of MVPA, RR for LGA and macrosomia were 0.97 (95% CI: 0.96, 0.98) and 0.96 (95% CI: 0.94, 0.98), respectively. Associations were only modestly reduced after additional adjustments for maternal BMI and gestational diabetes. No measure of LTPA was associated with risk for SGA.

CONCLUSIONS

Physical activity in late, but not early, pregnancy is consistently associated with modestly lower risk of LGA and macrosomia, but not SGA.

TWEETABLE ABSTRACT

In an individual participant meta-analysis, late pregnancy moderate to vigorous physical activity modestly reduced birth size outcomes.

The effect of electronic reminders on risk management among diabetic patients in low resourced settings

BACKGROUND

Information technology has potential to improve health care delivery particularly among individuals with chronic diseases such as diabetes in low and middle-income countries (LMIC). Research on the usefulness of information technology to manage persons living with chronic diseases is scarce in LMIC. We sought to evaluate the effect of an electronic reminder system on cardiovascular risk factors (blood pressure, heart rate, and fasting plasma glucose) and adherence to clinical appointments among persons living with diabetes.

RESEARCH DESIGN AND METHODS

A randomized controlled design was used to recruit 200 diabetic patients (intervention n=100, control n=100) from the National Diabetes Management Research Centre, Accra. All patients received usual diabetes care. The intervention group was given electronic reminders for their clinical appointments and their physicians were prompted with abnormal laboratory results for six months.

RESULTS

Baseline characteristics were largely similar for both groups. At six months follow up, the mean reductions of all the cardiovascular risk factors in the intervention group were significantly greater than in the control group: -1.7 kg/m(2) versus -1.1 kg/m(2)(p=0.002) for BMI; -4.7 mmHg versus -2.8 mmHg (p=0.002) for SBP; -5.3 mmH versus -3.1 mmHg (p=0.001) for DBP; -1.7 bpm versus -0.1 bpm (p=0.001) for heart rate and -2.3 mmol/L versus -1.6 mmol/L (p=0.001) for fasting plasma glucose, respectively. Adherence to appointment schedules was also significantly higher in the intervention group compared with the control group (97.8% versus 89.4%, p=0.010).

CONCLUSIONS

Locally developed electronic initiatives such as this resulted in improved cardiovascular risk factors and effective compliance to clinical practices and improved quality of care for persons living with diabetes.

High diabetes risk among asylum seekers in The Netherlands

AIMS

To map the prevalence and incidence of recorded diabetes among asylum seekers according to demographic factors and length of stay in the host country.

METHODS

We used a nationwide database from the Community Health Services for Asylum Seekers. The study population included all asylum seekers aged 20-79 years who arrived in the Netherlands between 2000 and 2008. Case allocation was based on International Classification of Primary Care codes. A general practice registry was used to obtain reference data. Standardized prevalence and incidence ratios were calculated and their association with length of stay was explored with Cox regression.

RESULTS

The study included 59 380 asylum seekers among whom there were 1227 recorded cases of diabetes. The prevalence of recorded diabetes was higher among asylum seekers compared with the reference population for both men (standardized prevalence ratio=1.85, 95% CI 1.71-1.91) and women (standardized prevalence ratio=2.26, 95% CI 2.08-2.45). The highest standardized prevalence ratios were found for asylum seekers from Somalia, Sudan and Sri Lanka. The standardized prevalence ratio was higher in asylum seekers aged ≥ 30 years. Incidence rates were higher compared with the reference population for all length-of-stay intervals.

CONCLUSIONS

Asylum seekers from the majority of countries of origin were at higher risk of diabetes compared with the general population in the Netherlands. Asylum seekers from Somalia were particularly at risk. This emerging public health issue requires attention from policy-makers and care providers.

Prognosis after a first hospitalisation for acute myocardial infarction and congestive heart failure by country of birth

OBJECTIVE

To investigate differences in 28-day and 5-year mortality and 5-year readmission after a first hospitalisation for acute myocardial infarction (AMI) and congestive heart failure (CHF) between first generation ethnic minority groups (henceforth, migrants) and the ethnic Dutch population.

METHODS

Nationwide prospective cohorts of first hospitalised AMI (N=213 630) and CHF patients (N=189 069) between 1998 and 2010 were built. Differences in 28-day and 5-year mortality and in 5-year AMI/CHF readmission between migrants (Surinamese, Moroccan, Turkish, Antillean, Indonesian, Chinese and South Asian) and the ethnic Dutch population were investigated using Cox proportional hazard regression models.

RESULTS

After the first AMI hospitalisation, mortality and AMI/CHF readmission were higher in the majority of migrant groups compared with ethnic Dutch. For example, HRs (adjusted for age, sex, marital status, degree of urbanisation and year of event) with 95% CIs among Surinamese (mainly of African or South-Asian origin) were 1.16 (1.02 to 1.32) for 28-day mortality, 1.44 (1.30 to 1.60) for 5-year mortality, 1.33 (1.08 to 1.63) for AMI readmission and 2.09 (1.82 to 2.40) for CHF readmission. After a first CHF hospitalisation, mortality rates among migrants were more diverse, with lower 28-day mortality among Moroccan and Turkish migrants and higher 5-year mortality among Surinamese, Chinese and South Asians. Readmission after CHF was often higher among migrant groups.

CONCLUSIONS

Prognosis after a first AMI hospitalisation was worse among most migrant groups compared with the ethnic Dutch population. Ethnic inequalities in prognosis after a first CHF hospitalisation were more diverse. Efforts should be made to disentangle the underlying factors of the results.

Incidence of first acute myocardial infarction over time specific for age, sex, and country of birth

OBJECTIVES

To study the age- and sex-specific incidence rates of first acute myocardial infarction (AMI) among first-generation ethnic minority groups (henceforth, migrant groups) and the Dutch majority population in the Netherlands during two time periods (2000-2004 and 2005-2010).

METHODS

Through linkage of Dutch nationwide registers, first AMI events in the Dutch majority population and the major migrant groups living in the Netherlands were identified from 2000-2004 and 2005-2010. Absolute incidence rates were calculated within each age-sex-period-country of birth group.

RESULTS

Regardless of ethnic background, AMI incidence rates were higher in men than in women and increased with age. Incidence significantly declined over time among the Dutch majority population (men: -26.8%, women: -26.7%), and among most migrant groups under study. It was only in Moroccan migrants that AMI incidence significantly increased over time (men: 25.2%, women: 41.7%). Trends differed between age categories, but did not show a consistent pattern. The higher AMI incidence in Surinamese men and women and Turkish and Indonesian men compared with the Dutch majority population persisted over time, but decreased with age and became absent after 70 years of age. Moroccans had a significantly lower incidence compared with the Dutch majority population during 2000-2004, which disappeared during 2005-2010.

CONCLUSION

Primary preventive strategies should focus on Surinamese men and women and Turkish and Indonesian men below 70 years of age. Future research is necessary to unravel the factors that provoke the increasing AMI incidence over time among Moroccans.

Socioeconomic inequalities in acute myocardial infarction incidence in migrant groups: has the epidemic arrived? analysis of nation-wide data

OBJECTIVES

We assessed socioeconomic inequalities in relation to acute myocardial infarction (AMI) incidence among major ethnic groups in The Netherlands.

METHODS

A nationwide register-based cohort study was conducted (n=2 591 170) between 1 January 1998 and 31 December 2007 among ethnic Dutch and migrant groups from Suriname, Netherlands Antilles, Indonesia, Morocco and Turkey. Standardised household disposable income was used as a proxy for socioeconomic position. Cox proportional hazard models were used to estimate the socioeconomic inequalities in AMI incidence.

RESULTS

Among ethnic Dutch, the AMI incidence was higher in the low-income group than in the high-income group: adjusted HRs were 2.05 (95% CI 2.00 to 2.10) for men and 2.33 (95% CI 2.23 to 2.43) for women. Importantly, similar socioeconomic inequalities in AMI incidence were also observed in all minority groups, with the low socioeconomic group having a higher AMI incidence than the high socioeconomic group: adjusted HR ranging from 2.07 (95% CI 1.26 to 3.40) in Moroccans to 2.73 (95% CI 1.55 to 4.80) in Antilleans in men; and from 2.17 (95% CI 1.74 to 2.71) in Indonesians to 3.88 (95% CI 2.36 to 6.38) in Turks in women.

CONCLUSIONS

Our findings demonstrate socioeconomic inequalities in AMI incidence in migrant groups and suggest a convergence towards the Dutch general population. If the AMI incidence rates of the low socioeconomic group could be reduced to the level of the high socioeconomic group, this would represent a major public health improvement for all ethnic groups.

Incidence of acute myocardial infarction in first and second generation minority groups: does the second generation converge towards the majority population?

BACKGROUND

Differences in acute myocardial infarction (AMI) incidence between ethnic minority and migrant groups (henceforth, minority groups) and the majority population have been reported. Health differences may converge towards the majority population over generations. We assessed whether AMI incidence differences between minority groups living in the Netherlands and the Dutch majority population exist, and whether the incidence converges towards the majority population over generations.

METHODS

A nationwide register-based cohort study was conducted from 1997 to 2007. Using Cox Proportional Hazard Models AMI incidence differences between minorities and the majority population were estimated. When possible, analyses were stratified by generation.

RESULTS

AMI incidence differences between minorities and the majority population depended on the country of origin, and often varied between minorities originating from the same geographical region. For example, among North African and Mediterranean minorities, incidence was higher in Turkish (Hazard Ratio (HR): 1.34; 95% Confidence Interval (95% CI): 1.28-1.41), but lower in Moroccans (HR: 0.46; 95% CI: 0.40-0.52) compared with the majority population. Most minorities had a similar or lower incidence than the majority population, which remained similar or converged towards the incidence of the majority population over generations. In contrast, among minorities from the former Dutch colonies (Suriname, Indonesia, Netherlands Antilles) beneficial intergenerational changes were observed.

CONCLUSIONS

Health care professionals and policy makers should be aware of substantial AMI incidence differences between minority groups and the majority population, and the often unbeneficial change over generations. Future research should be cautious when clustering minority groups based on geographical region of the country of origin.

Downward trends in acute myocardial infarction incidence: how do migrants fare with the majority population? Results from a nationwide study

AIMS

In previous decades, a steep decline in acute myocardial infarction (AMI) incidence occurred in Western countries. We assessed whether this decline was also present in migrant groups living in the Netherlands.

METHODS AND RESULTS

Nationwide registers were linked between 1998 and 2007. Poisson regression analyses were used to calculate the biannual percentage change in AMI incidence within major non-Western migrant groups, and the differences in these changes with the Dutch majority population. Within the Dutch majority population, AMI incidence significantly declined in men (-12%) and women (-9.5%). Incidence also declined among most migrant groups under study, ranging from -12 to -4.0% in men, and from -16 to -9.5% in women. Only in Turkish women and Moroccan men the AMI incidence remained stable over time (-0.3 and 2.8%, respectively). There were no statistically significant trend differences between the Dutch majority population and the migrant groups under study. The higher AMI incidence in Turkish men and Surinamese men and women, and the lower AMI incidence in Moroccan men persisted over time.

CONCLUSIONS

There was a declining AMI incidence rate within the Dutch majority population as well as within most of the major migrant groups living in the Netherlands, except in Turkish women and Moroccan men. Trend patterns among migrant groups did not significantly differ from the Dutch majority population. To reduce ethnic inequalities, primary preventive strategies should be targeted at those migrant groups with a persisting higher incidence.

Heterogeneity in sex differences in the metabolic syndrome in Dutch white, Surinamese African and South Asian populations

AIM

To determine whether sex differences in the prevalence of the metabolic syndrome and its components differ among different ethnic groups.

METHODS

A random sample of non-institutionalized adults aged 35-60 years in Amsterdam, the Netherlands (white Dutch men n = 242, women n = 244; African-Surinamese men n = 193, women n = 399, Hindustani-Surinamese men n = 149, women n = 186). The metabolic syndrome was defined according to the International Diabetes Federation criteria.

RESULTS

In all ethnic groups, the prevalence of central obesity and reduced HDL cholesterol were higher in women than in men, but the prevalence of elevated blood pressure, fasting glucose and triglycerides were lower in women than in men. However, the magnitude of the differences varied. The sex differences in the prevalence of central obesity and reduced HDL cholesterol were particularly larger in ethnic minority groups, especially in African-Surinamese than in white Dutch. After adjustment for education, smoking, alcohol intake and physical activity, the prevalence of the metabolic syndrome was lower in white Dutch women than in white Dutch men (adjusted prevalence ratio 0.70, 95% CI 0.52-0.94). By contrast, the prevalence of the metabolic syndrome was higher in African-Surinamese women than in African-Surinamese men (adjusted prevalence ratio 1.56, 95% CI 1.12-2.18). Among Hindustani-Surinamese, men and women had a similar prevalence of the metabolic syndrome (adjusted prevalence ratio 1.00, 95% CI 0.76-1.31).

CONCLUSIONS

Our findings suggest different patterns in sex differences in the metabolic syndrome among the ethnic groups. The relatively high prevalence of central obesity in African-Surinamese women may underlie their higher prevalence of the metabolic syndrome. Strategies to improve metabolic profiles among African-Surinamese and white Dutch people need to take sex differences into account.

A review of population-based studies on hypertension in Ghana

BACKGROUND

Hypertension is becoming a common health problem worldwide with increasing life expectancy and increasing prevalence of risk factors. Epidemiological data on hypertension in Ghana is necessary to guide policy and develop effective interventions.

METHODS

A review of population-based studies on hypertension in Ghana was conducted by a search of the PUBMED database, supplemented by a manual search of bibliographies of the identified articles and through the Ghana Medical Journal. A single reviewer extracted data using standard data collection forms.

RESULTS

Eleven studies published on hypertension with surveys conducted between 1973 and 2009 were identified. The prevalence of hypertension was higher in urban than rural areas in studies that covered both types of area and increased with increasing age (prevalence ranging from 19.3% in rural to 54.6% in urban areas). Factors associated with high blood pressure included increasing body mass index, increased salt consumption, family history of hypertension and excessive alcohol intake. The levels of hypertension detection, treatment and control were generally low (control rates ranged from 1.7% to 12.7%).

CONCLUSION

An increased burden of hypertension should be expected in Ghana as life expectancy increases and with rapid urbanisation. Without adequate detection and control, this will translate into a higher incidence of stroke and other adverse health outcomes for which hypertension is an established risk factor. Prevention and control of hypertension in Ghana is thus imperative and any delays in instituting preventive measures would most likely pose a greater challenge on the already overburdened health system.