"But at a certain point, the lights literally went out": A qualitative study exploring midlife women's experiences of health, wellbeing, and functioning in relation to paid work

BACKGROUND

In the Netherlands, the fact that midlife women constitute a considerable segment of the working population is relatively new. Generally paid work contributes to midlife women's wellbeing, but they also report health challenges, such as work-related fatigue and the menopause.

OBJECTIVE

The objective of this study is to understand how midlife women themselves perceive their health, wellbeing, and functioning in relation to paid work.

METHODS

In this exploratory qualitative study, 28 women participated in five ethnically homogeneous focus group discussions (FGDs). De FGDs were recorded, transcribed verbatim, and thematically analyzed using MAXQDA.

RESULTS

We identified exhaustion as central to our analysis. During midlife, exhaustion seems to occur once a certain limit has been reached, both physically and mentally, with women feeling to have reached the end of their rope. Besides obvious physiological challenges, we identified two major themes in which we discuss challenges both in paid work and private life: (1) work environment and working conditions, and (2) burdens in private life. Participants took various measures to manage and try to reduce exhaustion, including finding a new job or negotiating different job tasks, and reducing work hours.

CONCLUSION

This study indicates that the extent to which women experience exhaustion is associated with challenges in both paid work and private life. The underlying processes do not seem to reflect individual problems, but reflect a complex set of factors at the structural level. Nevertheless, women take several individual measures to reduce their exhaustion, including reducing their participation in paid work.

Gender roles and gender norms associated with psychological distress in women and men among the Dutch general population

Women report more psychological distress than men, which may be related to both biological sex and socio-cultural gender. We tested whether associations between gender and distress differ for women and men. The cross-sectional sample consisted of 678 Dutch people (54% women). Gender roles were assessed as masculinity and femininity. A composite gender norm score was calculated by summing gendered sociodemographics. Multivariate regressions examined sex, gender, and their interaction for depressive symptoms, anxiety, and perceived stress, additionally adjusted. Women reported more psychological distress. People scoring higher on masculine gender roles, but not feminine gender roles, reported lower psychological distress. A higher gender norm score was related to more depressive symptoms and perceived stress. This association was only present in men and was explained by health-related covariates. This research shows that there is a need to further elaborate on the discrepancies between sex and gender in health psychology research to better understand individual differences.

Validation of the ARIC prediction model for sudden cardiac death in the European population: The ESCAPE-NET project: Predicting sudden cardiac death in European adults

BACKGROUND

Sudden cardiac death is responsible for 10-20% of all deaths in Europe. The current study investigates how well the risk of sudden cardiac death can be predicted. To this end, we validated a previously developed prediction model for sudden cardiac death from the Atherosclerosis Risk in Communities study (USA).

METHODS

Data from participants of the Copenhagen City Heart Study (CCHS) (n=9988) was used to externally validate the previously developed prediction model for sudden cardiac death. The model's performance was assessed through discrimination (C-statistic) and calibration by the Hosmer-Lemeshow goodness-of-fit (HL) statistics suited for censored data and visual inspection of calibration plots. Additional validation was performed using data from the Hoorn Study (N=2045), employing the same methods.

RESULTS

During ten years of follow-up of CCHS participants (mean age: 58.7 years, 56.2% women), 425 experienced SCD (4.2%). The prediction model showed good discrimination for sudden cardiac death risk (C-statistic: 0.81, 95% CI:0.79-0.83). Calibration was robust (HL statistic: p=0.8). Visual inspection of the calibration plot showed that the calibration could be improved. Sensitivity was 89.8%, and specificity was 60.6%. The positive and negative predictive values were 10.1% and 99.2%. Model performance was similar in the Hoorn Study (C-statistic: 0.81, 95% CI: 0.77-0.85 and the HL statistic: 1.00).

CONCLUSION

Our study showed that the previously developed prediction model in North American adults performs equally well in identifying those at risk for sudden cardiac death in a general North-West European population. However, the positive predictive value is low.

Contribution of type 2 diabetes to all-cause mortality, cardiovascular disease incidence and cancer incidence in white Europeans and South Asians: findings from the UK Biobank population-based cohort study

OBJECTIVE

To investigate whether the health implications of having type 2 diabetes (T2D) were different in South Asian compared with white European participants.

RESEARCH DESIGN AND METHODS

Prospective data from UK Biobank were used, and 457 935 participants of white European and 7102 of South Asian background were included. Cox proportional regression was performed to investigate the association between T2D and health outcome by ethnicity.

RESULTS

Over a mean of 7.0 years (IQR 6.3-7.6) of follow-up, 12 974 participants had died, and 30 347 and 27 159 developed cardiovascular disease (CVD) and cancer, respectively. South Asians had a higher risk for CVD mortality (HR: 1.42, 95% CI 1.07 to 1.89) and incidence (HR: 1.78, 95% CI 1.63 to 1.94), but a decreased risk for cancer mortality (HR: 0.59, 95% CI 0.41 to 0.85) and incidence (HR: 0.80, 95% CI 0.70 to 0.92) compared with white Europeans. Compared with individuals without T2D, both white Europeans and South Asians with T2D had a higher risk for all-cause mortality (1.59 (1.48 to 1.71) vs 2.83 (1.76 to 4.53)), CVD mortality (2.04 (1.82 to 2.28) vs 4.40 (2.37 to 8.16)) and CVD incidence (1.37 (1.31 to 1.44) vs 1.60 (1.31 to 1.95)), respectively. However, the magnitude of the risk was higher for South Asians than white Europeans.

CONCLUSIONS

Although T2D was associated with a higher risk for all-cause mortality and CVD incidence and mortality, in both white Europeans and South Asians, the risk experienced by South Asians with T2D was higher than their white European counterparts.

The impact of a social network based intervention on self-management behaviours among patients with type 2 diabetes living in socioeconomically deprived neighbourhoods: a mixed methods approach

AIMS

This paper aims to explore the effect of the social network based intervention Powerful Together with Diabetes on diabetes self-management among socioeconomically deprived patients. This 10-month group intervention targeting patients and significant others aimed to improve self-management by stimulating social support and diminishing social influences that hinder self-management.

METHODS

This intervention was evaluated in a quasi-experimental study using a mixed methods approach. Of 131 socioeconomically deprived patients with suboptimal glycaemic control, 69 were assigned to the intervention group and 62 to the control group (standard diabetes education). 27 qualitative in-depth interviews with the participants and 24 with their group leaders were held to study the subjective impact of the intervention. Further, self-management behaviours (medication adherence, diet and physical activity) were assessed at baseline, 10 and 16 months. Data were analysed using framework analyses and a linear mixture model.

RESULTS

Qualitative data showed that the intervention group had a better understanding of the way self-management influences diabetes. The intervention group showed more complex self-management behaviours, such as planning ahead, seeking adequate food and physical activity alternatives, and consistently taking their diabetes into consideration when making choices. In participants with complete follow-up data, we found a significant increase in physical activity in the intervention group (3.78 vs. 4.83 days) and no changes in medication adherence and diet.

CONCLUSIONS

This study indicates that an intensive support group and simultaneously involving significant others might improve diabetes self-management behaviours among socioeconomically deprived patients. More studies are needed to justify further implementation of the intervention. This study is registered in the Dutch Trial Register NTR1886. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1886.

Development of a diabetes prevention program for Surinamese South Asians in the Netherlands

Type 2 diabetes is highly prevalent among South Asian origin groups around the world. Not only is prevalence higher than in other ethnic groups, age at presentation is lower and these groups are more likely to experience complications. Evidence suggests that lifestyle interventions may prevent or delay the onset of diabetes. However, little is known about diabetes prevention in South Asians (SA). DH!AAN is a diabetes prevention program designed for Surinamese SA in The Netherlands. In this paper, we describe the theoretical frameworks and formative research that guided the development and cultural adaptation of DH!AAN. Cultural adaptation was based on analysis of the determinants of diet and physical activity, including socio-cultural factors, within our study population. This led to the incorporation of surface and deep structure elements in the intervention. One-to-one counseling by dieticians using motivational interviewing (MI) was the basis for the intervention. Additionally, we aimed to generate social support by including family members in parts of the intervention and group sessions to address issues relating to traditional food habits. We discuss our reflections on the development process and the choices made in developing this intervention. The results of DH!AAN will provide insight into the use of MI for this population group. Moreover, DH!AAN will provide evidence regarding the feasibility of diabetes prevention among South Asian populations.

A cross-national comparative study of metabolic syndrome among non-diabetic Dutch and English ethnic groups

BACKGROUND

Evidence suggests a higher prevalence of type 2 diabetes (T2D) in The Netherlands than in England, although generalized obesity prevalence is substantially lower in The Netherlands. Metabolic syndrome (MS) is more strongly associated with the risk of progression to T2D than generalized obesity. Therefore examining MS may help to better understand the differences in T2D between the two countries. We assessed whether the Dutch and English differences in T2D prevalence reflect similar differences in MS in Whites, South-Asian Indians and African-Caribbeans living in these two countries.

METHODS

Secondary analyses of population-based studies of 3010 participants aged 35-60 years. Metabolic syndrome was defined according to the International Diabetes Federation criteria. Prevalence ratios (PRs) were estimated using regression models.

RESULTS

In general, the Dutch ethnic groups had a higher prevalence of MS than their English counterparts. Adjusted PRs were 1.37[95% confidence interval (CI)1.03-1.82] and 1.52 (1.06-2.19) in White-Dutch men and women compared to White-English men and women; 2.20 (1.14-4.26) and 1.46 (0.96-2.24) in Dutch-African-Caribbean men and women compared to English-African-Caribbean men and women and 0.97 (0.74-1.27) and 1.42 (1.00-2.03) in Dutch-Indian men and women compared with their English-Indian peers, respectively. Similar patterns were also observed for some MS components, e.g. raised fasting glucose in men and central obesity in women.

CONCLUSION

The comparatively high prevalence of MS among Dutch ethnic groups may contribute to their high prevalence of T2D. The high levels of some MS components, e.g. raised fasting glucose in men and central obesity in women add to the high prevalence of MS in Dutch ethnic groups.

Social and cultural factors underlying generational differences in overweight: a cross-sectional study among ethnic minorities in the Netherlands

Background

The prevalence of overweight appears to vary in people of first and second generation ethnic minority groups. Insight into the factors that underlie these weight differences might help in understanding the health transition that is taking place across generations following migration. We studied the role of social and cultural factors associated with generational differences in overweight among young Turkish and Moroccan men and women in the Netherlands.

Methods

Cross-sectional data were derived from the LASER-study in which information on health-related behaviour and socio-demographic factors, level of education, occupational status, acculturation (cultural orientation and social contacts), religious and migration-related factors was gathered among Turkish and Moroccan men (n = 334) and women (n = 339) aged 15-30 years. Participants were interviewed during a home visit. Overweight was defined as a Body Mass Index ≥ 25 kg/m². Using logistic regression analyses, we tested whether the measured social and cultural factors could explain differences in overweight between first and second generation ethnic groups.

Results

Second generation women were less often overweight than first generation women (21.8% and 45.0% respectively), but this association was no longer significant when adjusting for the socioeconomic position (i.e. higher level of education) of second generation women (Odds Ratio (OR) = 0.77, 95%, Confidence Interval (CI) 0.40-1.46). In men, we observed a reversed pattern: second generation men were more often overweight than first generation men (32.7% and 27.8%). This association (OR = 1.89, 95% CI 1.09-3.24) could not be explained by the social and cultural factors because none of these factors were associated with overweight among men.

Conclusions

The higher socio-economic position of second generation Turkish and Moroccan women may partly account for the lower prevalence of overweight in this group compared to first generation women. Further research is necessary to elucidate whether any postulated socio-biological or other processes are relevant to the opposite pattern of overweight among men.

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.

Motivational factors mediating the association between acculturation and participation in sport among young Turkish and Moroccan women in the Netherlands

OBJECTIVE

Acculturation of migrant women has been associated with increased participation in physical activity, including participation in sport. We assessed which motivational factors mediate this association among Turkish and Moroccan migrant women in the Netherlands.

METHODS

Data were available from a cross-sectional study conducted in 2003-2004, on health-related behavior among Turkish and Moroccan ethnic groups in Amsterdam, The Netherlands. In total, we included 258 Turkish and 170 Moroccan women (aged 15-30) who participated in a structured interview including questions on participation in sport, acculturation (defined as 'the level of cultural orientation towards Dutch culture'), and motivational factors including attitudes, social influences, and self-efficacy.

RESULTS

Acculturation was strongly associated with participation in sport among Turkish women, but not among Moroccan women. Greater participation in sport among the higher acculturated Turkish women was accounted for by "culturally specific beliefs" and to a lesser extent by "perceived disadvantages" and "self-efficacy."

CONCLUSION

These results emphasize that in order to stimulate participation in sport among low acculturated Turkish women, the culturally specific beliefs should be taken into account when developing a culture-sensitive intervention. Further research is necessary to understand why acculturation leads to increased participation in sport in some ethnic groups and not in others.

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.

Risk for breast cancer among women with endometriosis

Although several risk factors are common to endometriosis and breast cancer, the results of observational studies of an association have so far been inconsistent. We evaluated the relationship between endometriosis and breast cancer on the basis of data on selected cancers and medical histories from the Danish nationwide cancer and hospital registries used in a large case-cohort study. A total of 114,327 women were included in the study of whom 1,978 women had received a diagnosis of endometriosis and 16,983 had had a diagnosis of breast cancer between 1978 and 1998. Of the women with endometriosis, 236 subsequently received a diagnosis of breast cancer. The crude overall rate ratio for breast cancer after endometriosis was 1.00 and after adjustment for reproductive factors, calendar-period, bilateral oophorectomy and benign breast disease, the rate ratio was 0.97 (95% confidence interval, 0.85-1.11). The risk for breast cancer increased with age at diagnosis of endometriosis, so that women in whom endometriosis was diagnosed at a young age (approximately <40 years) had a reduced risk for breast cancer and women in whom endometriosis was diagnosed at older ages (approximately > or =40 years) tended to have an increased risk for breast cancer. The reduced risks observed among young women may reflect their exposure to drugs with antiestrogenic effects. The increased risk associated with endometriosis among postmenopausal women may be due to common risk factors between postmenopausal endometriosis and breast cancer or an altered endogenous estrogen.

Value of self-reportable screening criteria to identify asymptomatic individuals in the general population for urogential Chlamydia trachomatis infection screening

Submission of samples from the home allows screening for Chlamydia trachomatis without preceding professional assessment of clinical risk factors. Therefore, a validation of self-reportable information for use as selective screening criteria is needed. We asked a total of 1175 women and 1033 men who participated in an in-home sampling screening study to provide information on behavior and sociodemographic characteristics. In a multivariate model, selective screening criteria were developed on the basis of information from a random part of the tested population (development group), and the validity was assessed for the remaining part of the tested population (validation group). To find all infections, 95% of the subjects had to be screened, and screening 63% of them would have detected 86% of infections. Low predictive values were found when selective screening criteria from other studies were assessed. Selective screening by means of in-home sampling strategies among men and women aged 21-23 years cannot be recommended in the area studied.