Development and content validity of an application to assess 24-hour movement behaviors in 0-4-year-old children involving end-users and key stakeholders: the My Little Moves app

BACKGROUND

Recently, research focus has shifted to the combination of all 24-h movement behaviors (physical activity, sedentary behavior and sleep) instead of each behavior separately. Yet, no reliable and valid proxy-report tools exist to assess all these behaviors in 0-4-year-old children. By involving end-users (parents) and key stakeholders (researchers, professionals working with young children), this mixed-methods study aimed to 1) develop a mobile application (app)-based proxy-report tool to assess 24-h movement behaviors in 0-4-year-olds, and 2) examine its content validity.

METHODS

First, we used concept mapping to identify activities 0-4-year-olds engage in. Parents (n = 58) and professionals working with young children (n = 21) generated a list of activities, sorted related activities, and rated the frequency children perform these activities. Second, using multidimensional scaling and cluster analysis, we created activity categories based on the sorted activities of the participants. Third, we developed the My Little Moves app in collaboration with a software developer. Finally, we examined the content validity of the app with parents (n = 14) and researchers (n = 6) using focus groups and individual interviews.

RESULTS

The app has a time-use format in which parents proxy-report the activities of their child, using eight activity categories: personal care, eating/drinking, active transport, passive transport, playing, screen use, sitting/lying calmly, and sleeping. Categories are clarified by providing examples of children's activities. Additionally, 1-4 follow-up questions collect information on intensity (e.g., active or calm), posture, and/or context (e.g., location) of the activity. Parents and researchers considered filling in the app as feasible, taking 10-30 min per day. The activity categories were considered comprehensive, but alternative examples for several activity categories were suggested to increase the comprehensibility and relevance. Some follow-up questions were considered less relevant. These suggestions were adopted in the second version of the My Little Moves app.

CONCLUSIONS

Involving end-users and key stakeholders in the development of the My Little Moves app resulted in a tailored tool to assess 24-h movement behaviors in 0-4-year-olds with adequate content validity. Future studies are needed to evaluate other measurement properties of the app.

A Longitudinal Study in Worrisome Sexual Behavior Following Sexual Abuse in Infancy or Early Childhood: The Amsterdam Sexual Abuse Case

Worrisome sexual behavior (WSB) is often described as an outcome specific to child sexual abuse (CSA). Therefore, it is highly relevant to study WSB in relation to sexual abuse, especially in very young children, as it is hard to recognize sexual abuse in children who have limited verbal capacities of disclosing. Over time, literature describing WSB following CSA has gradually broadened. However, a gap remains regarding the long-term development of WSB in children who were sexually abused during infancy or very early childhood. To our knowledge, our study is the first to examine developmentally-related sexual behavior versus sexual abuse-specific behavior longitudinally in children who were sexually abused at a very young age. In total, we examined the sexual behavior, as reported by parents of 45 children who experienced early-age sexual abuse for a period of more than five years. Overall, we found that WSB is likely to be a CSA-specific and potentially long-term outcome for children who were sexually abused at a very young age. Despite the decrease in sexual abuse-specific behavior over time, the level of this behavior was still significantly high 8 years after the sexual abuse. This finding supports long-term monitoring and assessment and intervention for WSB over time. Despite these findings, it is important to note that WSB does not serve as proof of sexual abuse in children; likewise, when a child does not present with WSB, it does not indicate the absence of a substantiated history of sexual abuse.

Developing a digital informed consent app: opportunities and challenges of a new format to inform and obtain consent in public health research

BACKGROUND

Informed consent procedures for large population-based cohort studies should be comprehensive and easy-to-use. This is particularly challenging when participants from different socio-economic groups and multicultural ethnic backgrounds are involved. Recently, more and more studies have tried to use multimedia in informed consent procedures. We describe the development and testing of a digital informed consent app and elaborate on whether this may contribute to a comprehensive and practical procedure to obtain informed consent for public health research.

METHODS

In a sample of parents with young children, we used a mixed method approach to study the user experience of an informed consent app and evaluate whether it can be used to adequately inform people and register their consent. Through semi-structured interviews we investigated participants' experiences with and opinions about the app, with a special focus on comprehensibility of the content and the usability of the app. Information retention questions were asked to evaluate to what extent participants could recall key aspects of the provided study information.

RESULTS

The 30 participants in this study used the app between 4 and 15 min to give their consent. Overall, they found the app well-designed, informative and easy to use. To learn more about the study for which informed consent is asked, most of the participants chose to watch the animated film, which was generally found to convey information in a clear manner. The identification process was met with mixed reactions, with some feeling it as a secure way to give consent, while for others it contradicted their view of using data anonymously. Information retention questions showed that while all participants remembered various aspects of the study, fewer than half answered all four questions satisfactorily.

CONCLUSION

Our study shows that a well-designed informed consent app can be an effective tool to inform eligible participants and to record consents. Still, some issues remain, including trust barriers towards the identification procedure and lack of information retention in some participants. When implementing consent procedures that incorporate digital formats, it may be beneficial to also invest in a complementary face-to-face recruitment approach.

The ENCOMPASS framework: a practical guide for the evaluation of public health programmes in complex adaptive systems

Background

Systems thinking embraces the complexity of public health problems, including childhood overweight and obesity. It aids in understanding how factors are interrelated, and it can be targeted to produce favourable changes in a system. There is a growing call for systems approaches in public health research, yet limited practical guidance is available on how to evaluate public health programmes within complex adaptive systems. The aim of this paper is to present an evaluation framework that supports researchers in designing systems evaluations in a comprehensive and practical way.

Methods

We searched the literature for existing public health systems evaluation studies. Key characteristics on how to conduct a systems evaluation were extracted and compared across studies. Next, we overlaid the identified characteristics to the context of the Lifestyle Innovations Based on Youth Knowledge and Experience (LIKE) programme evaluation and analyzed which characteristics were essential to carry out the LIKE evaluation. This resulted in the Evaluation of Programmes in Complex Adaptive Systems (ENCOMPASS) framework.

Results

The ENCOMPASS framework includes five iterative stages: (1) adopting a system dynamics perspective on the overall evaluation design; (2) defining the system boundaries; (3) understanding the pre-existing system to inform system changes; (4) monitoring dynamic programme output at different system levels; and (5) measuring programme outcome and impact in terms of system changes.

Conclusions

The value of ENCOMPASS lies in the integration of key characteristics from existing systems evaluation studies, as well as in its practical, applied focus. It can be employed in evaluating public health programmes in complex adaptive systems. Furthermore, ENCOMPASS provides guidance for the entire evaluation process, all the way from understanding the system to developing actions to change it and to measuring system changes. By the nature of systems thinking, the ENCOMPASS framework will likely evolve further over time, as the field expands with more completed studies.

A sexual abuse case series of infants and toddlers by a professional caregiver: A qualitative analysis of parents' experiences during the initial crisis period post-discovery

BACKGROUND

The discovery that one's child has been sexually abused may be one of the worst events a parent can experience. The importance of parental support for the recovery of child sexual abuse (CSA) victims emphasizes the need to gain insight in difficulties parents face after disclosure.

OBJECTIVE

To improve crisis intervention by exploring how parents of very young, mostly male CSA victims involved in a large unique CSA case, look back on their initial reactions after disclosure, the impact of media coverage, and their experiences with service responses during the immediate aftermath of CSA discovery.

PARTICIPANTS AND SETTING

We conducted 18 qualitative interviews with 21 parents enrolled in the longitudinal Amsterdam Sexual Abuse Case (ASAC) study.

METHODS

We used thematic analysis, combining a deductive and inductive approach.

RESULTS

We identified four themes regarding parents' initial experiences after disclosure: shock, uncertainty, roller coaster and survival mode. Four themes emerged regarding the impact of media coverage: vulnerable to exposure, fear that the child would recognize the suspect, no escape possible, and burden versus acknowledgement. Parents' experiences regarding the actions of professionals also generated four themes: stressful and confronting, need for support, need for information, and need for professional competence.

CONCLUSIONS

Disclosure of extrafamilial CSA left parents in shock, affecting their sense of control. Media coverage exacerbated stress for many parents, although some also drew support from it. Actions of professionals defined by parents as helpful included: being supportive, compassionate, accessible, and competent, providing information, and promoting autonomy. Implications for professionals are discussed.

Developing the logic framework underpinning a whole-systems approach to childhood overweight and obesity prevention: Amsterdam Healthy Weight Approach

BACKGROUND

Whole-systems approaches (WSAs) are well placed to tackle the complex local environmental influences on overweight and obesity, yet there are few examples of WSAs in practice. Amsterdam Healthy Weight Approach (AHWA) is a long-term, municipality-led program to improve children's physical activity, diet, and sleep through action in the home, neighborhood, school, and city. Adopting a WSA, local political, physical, social, educational, and healthcare drivers of childhood obesity are viewed as a complex adaptive system. Since 2013, AHWA has reached >15,000 children. During this time, the estimated prevalence of 2-18-year-olds with overweight or obesity in Amsterdam has declined from 21% in 2012 to 18.7% in 2017. Declining trends are rarely observed in cities. There is a need to formally articulate AHWA program theory in order to: (i) inform future program evaluation which can interpret this decline within the context of AHWA and (ii) contribute a real-life example of a WSA to the literature.

METHODS

This study aimed to formally document the program theory of AHWA to permit future evaluation. A logic framework was developed through extensive document review and discussion, during program implementation.

RESULTS

The working principles of the WSA underpinning AHWA were made explicit in an overarching theory of change, articulated in a logic framework. The framework was operationalized using an illustrative example of sugar intake.

CONCLUSIONS

The logic framework will inform AHWA development, monitoring, and evaluation and responds to a wider need to outline the working principles of WSAs in public health.

The Amsterdam Sexual Abuse Case: What Scars did it Leave? Long-Term Course of Psychological Problems for Children Who have been Sexually Abused at a Very Young Age, and their Parents

Longitudinal research of CSA in infancy and early childhood is scarce. The current study examined the long-term course of psychological outcomes (PTSD, dissociation and internalizing and externalizing behavioral problems) in children who were sexually abused in the early childhood. Additionally, we looked into the outcomes for their parents by assessing PTSD symptoms and negative emotional reactions towards the sexual abuse of their child. We examined the outcomes for five consecutive years in a sample of children (n = 45) who were sexually abused at a very young age (0-3) and their parents (n = 42), included in the Amsterdam Sexual Abuse Case-study. We found that outcomes following CSA in early childhood go beyond PTSD symptoms and can manifest in atypical symptoms such as behavioral problems. Parents experienced persistent PTSD in the years following CSA disclosure. CSA in very young children warrants long-term monitoring, as negative outcomes still present 8 years later.

Sarphati Amsterdam: a dynamic research infrastructure

Sarphati Amsterdam is a collaboration between the city of Amsterdam and four Amsterdam research institutions, focusing on innovative multidisciplinary research beneficial to preventing non-communicable diseases effectively and sustainably. With the Sarphati Cohort, Sarphati Amsterdam has established a dynamic cohort study that systematically monitors growth and its determinants from birth until adulthood, in order to 1) identify causes of overweight and 2) evaluate interventions to combat overweight.

Data collection is linked to routine Youth Health Care consultations with all ∼150,000 Amsterdam children (0-18y). Thus, making selected care data on growth and development available for research. After informed parental consent, anonymised data can be used to systematically monitor children. Additional data is collected through age-specific questionnaires. The sub-cohort structure facilitates more extensive data collection in subpopulations, including interviews, observations, and biosamples.

Up until March 2020 over 5,130 children enrolled. The continuous inclusion of new-borns gives the Sarphati Cohort its dynamic character. This enables the incorporation of innovative research designs to evaluate interventions.With over 170 different nationalities Amsterdam has a highly diverse population, both in terms of cultural and socio-economic background. The data collection strategies and tailored tools are developed to meet the level of adaptability this design requires.

Embedding research in this manner enriches it way beyond clinical settings and provides an unparalleled depth and breadth of data. With the Sarphati Cohort, Sarphati Amsterdam facilitates innovative research in the field of obesity that will contribute to the ambitious policy objectives of the city of Amsterdam to promote healthy behaviour and improve the quality of life of young people.

School-Based Physical Activity Interventions in Prevocational Adolescents: A Systematic Review and Meta-Analyses

PURPOSE

Literature detailing the effectiveness of school-based physical activity promotion interventions in prevocational adolescents was reviewed to identify effective intervention characteristics.

METHODS

The search strategy assessed studies against inclusion criteria study design, study population, school setting, language, and construct. The risk of bias of the included studies was assessed, and extractions were made of the physical activity (PA) level outcome measures and intervention characteristics regarding organizational, social, and content features. A meta-analysis was conducted to determine the overall effect of the interventions on the PA level. Identification of effective intervention characteristics was done by subgroup analyses. Meta-regression analysis was performed with PA level as dependent variable and intervention characteristics as covariates.

RESULTS

A total of 40 eligible studies was included for meta-analyses. Among the included studies, the overall intervention effect on increasing the PA level of prevocational adolescents was weak (standardized mean difference [SMD] .19, 95% confidence interval [CI] .12-.27). Intervention characteristics that improve the effect size to a moderate level were intracurricular PA (SMD .43, 95% CI .19-.68), involving school staff in an intracurricular intervention (SMD .37, 95% CI .16-.58) and a tailored intracurricular intervention (SMD .35, 95% CI .13-.58). Meta-regression analysis confirmed PA as a positive predictor.

CONCLUSIONS

The effect of a school-based PA intervention was small to moderate. A sensible choice in the assembly of a multicomponent school-based PA intervention increases the effectiveness considerably. Physical education teachers, school administrators, and policy makers should consider organizational (intracurriculum, short and medium duration), personal (tailoring, participation), social (school staff) and content (PA) determinants.

A Descriptive Mixed-Methods Analysis of Sexual Behavior and Knowledge in Very Young Children Assessed for Sexual Abuse: The ASAC Study

Child sexual abuse (CSA) is a worldwide problem with serious consequences. We hypothesized that worrisome sexual behavior and knowledge would frequently be reported in children assessed after CSA. We therefore investigated (A) what types of sexual behaviors and knowledge were reported by parents of young children assessed for CSA; (B) in what cases such behaviors and knowledge were worrisome; and (C) how such children responded verbally and non-verbally during child interviews. We conducted a mixed-methods study, including qualitative inductive content analysis and quantitative analysis. It included 125 children (76 boys, 60.8%; median age 3.3 years, age range 0–11), all involved in the Amsterdam sexual abuse case (ASAC) and examined for highly suspected (n = 71) or confirmed CSA (n = 54). We identified themes from (1) the parent reports: sexual behavior (e.g., self-stimulation, touching others, imitation of sexual acts), fears and anxiety with regard to sexuality, and sexual utterances (sexual slang, references to sexual acts); and (2) the child interviews: behavioral reactions (avoidance, distractive behaviors), emotional reactions (anger, aggression), and verbal reactions (conspicuous utterances, refusal to talk about specific subjects). In 37% of the children the sexual behavior was deemed worrisome or very worrisome. Clinicians who assess children for CSA are advised to focus in particular on sexual behavior problems and inappropriate sexual knowledge.

The effect of a preconception care outreach strategy: the Healthy Pregnancy 4 All study

Background

Preconception care has been acknowledged as an intervention to reduce perinatal mortality and morbidity. However, utilization of preconception care is low because of low awareness of availability and benefits of the service. An outreach strategy was employed to promote uptake of preconception care consultations. Its effect on the uptake of preconception care consultations was evaluated within the Healthy Pregnancy 4 All study.

Methods

We conducted a community-based intervention study. The outreach strategy for preconception care consultations included four approaches: (1) letters from municipal health services; (2) letters from general practitioners; (3) information leaflets by preventive child healthcare services and (4) encouragement by peer health educators. The target population was set as women aged 18 to 41 years in 14 Dutch municipalities with relatively high perinatal morbidity and mortality rates. We evaluated the effect of the outreach strategy by analyzing uptake of preconception care consultations between February 2013 and December 2014. Registration data of applications for preconception care as well as participant questionnaires were obtained for analysis.

Results

The outreach strategy led to 587 applications for preconception care consultations. The majority of applications (n = 424; 72%) were prompted by the invitation letters (132,129) from the municipalities and general practitioners. The effect of the municipal letter seemed to fade out after 3 months.

Conclusions

Outreach strategies amongst the general population promote uptake of preconception care consultations, although on a small scale and with a temporary effect.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3882-y) contains supplementary material, which is available to authorized users.

Ethnicity and socioeconomic status are related to dietary patterns at age 5 in the Amsterdam born children and their development (ABCD) cohort

BACKGROUND

Health inequalities are already present at young age and tend to vary with ethnicity and socioeconomic status (SES). Diet is a major determinant of overweight, and studying dietary patterns as a whole in relation to overweight rather than single nutrients or foods has been suggested. We derived dietary patterns at age 5 and determined whether ethnicity and SES were both related to these dietary patterns.

METHODS

We analysed 2769 validated Food Frequency Questionnaires filled in by mothers of children (5.7 ± 0.5y) in the Amsterdam Born Children and their Development (ABCD) cohort. Food items were reduced to 41 food groups. Energy adjusted intake per food group (g/d) was used to derive dietary patterns using Principal Component Analysis and children were given a pattern score for each dietary pattern. We defined 5 ethnic groups (Dutch, Surinamese, Turkish, Moroccan, other ethnicities) and 3 SES groups (low, middle, high, based on maternal education). Multivariate ANOVA, with adjustment for age, gender and maternal age, was used to test potential associations between ethnicity or SES and dietary pattern scores. Post-hoc analyses with Bonferroni adjustment were used to examine differences between groups.

RESULTS

Principal Component Analysis identified 4 dietary patterns: a snacking, full-fat, meat and healthy dietary pattern, explaining 21% of the variation in dietary intake. Ethnicity was related to the dietary pattern scores (p < 0.01): non-Dutch children scored high on snacking and healthy pattern, whereas Turkish children scored high on full-fat and Surinamese children on the meat pattern. SES was related to the snacking, full-fat and meat patterns (p < 0.01): low SES children scored high on the snacking and meat pattern and low on the full-fat pattern.

CONCLUSIONS

This study indicates that both ethnicity and SES are relevant for dietary patterns at age 5 and may enable more specific nutrition education to specific ethnic and low socioeconomic status target groups.

Sexual abuse in very young children: a psychological assessment in the Amsterdam Sexual Abuse Case study

Background: Child sexual abuse (CSA) is a worldwide problem affecting children of all ages and socioeconomic backgrounds. A knowledge gap exists regarding the psychological outcomes for children, boys in particular, who are abused during their early lives. Objective: To provide a descriptive psychological profile of children who experienced sexual abuse as infants or toddlers from a male daycare worker and babysitter, and to assess the psychopathological impact on their parents. Method: Parents of children involved in the Amsterdam Sexual Abuse Case (41 parents; 44 children, age range 3-11 years, 30 boys, 14 girls) completed measures on post-traumatic stress disorder (PTSD), dissociation, sexual and non-sexual behaviour problems, and attachment insecurity in their children, as well as on parental psychological well-being, 3 years after disclosure. Sexual abuse characteristics were obtained from police records. Results: We found that 3% of confirmed child victims had PTSD, 30% sexual behaviour problems, 24% internalizing problems, 27% attachment insecurity, and 18% any psychiatric disorder (including PTSD); 39% were asymptomatic. In parents, we found feelings of guilt, shame, and anger about the abuse of their child; 19% showed PTSD symptoms and 3% showed avoidant and 8% anxious attachment problems in their intimate relationship. Parental symptomatology was related to child symptomatology, except for child sexual behaviour problems. One-quarter of confirmed child victims and 45% of parents had received psychological treatment. Conclusions: Three years after disclosure, extrafamilial CSA in very young children was associated with sexual and non-sexual behaviour problems and attachment insecurity, but rarely with PTSD or dissociation. For parents it was associated with PTSD symptoms and emotional reactions. Assessments and interventions should focus on the wide spectrum of problems that follow CSA, as well as on parental psychopathology and the parent-child relationship. Future follow-up assessments in our longitudinal study should provide insights into longer-term outcomes.

Psychosocial symptoms in very young children assessed for sexual abuse: A qualitative analysis from the ASAC study

Child sexual abuse (CSA) is a worldwide problem with serious consequences. No recognizable symptom pattern for suspected CSA has yet been identified in very young children. We aim to investigate psychosocial symptoms in a sample of children with confirmed or strongly suspected CSA and the interpretations given to such symptoms by independent clinical experts. Secondly we examined whether experts were able to identify confirmed victims of severe CSA. A qualitative study including inductive content analysis of medical files and focus group discussions with independent experts on the interpretation of psychosocial symptoms was conducted. We included 125 children (76 boys, 60.8%, and 49 girls, 39.2%; median age 3.3 years; age range 0-11) who were involved in the Amsterdam sexual abuse case (ASAC) and had been examined for strongly suspected CSA. We identified four themes among the psychosocial symptoms: problems concerning emotions, behavior, toilet training, and development, whether or not associated with the daycare center or the perpetrator. Clinical experts identified signs of posttraumatic stress disorder (PTSD), regression in continence skills (not otherwise explained), and problems triggered by exposure to the perpetrator or the abuse location as concerning symptoms for CSA. Less concerning symptoms were designated as worrisome if they were numerous and there was no clear explanation for these symptoms. A clear symptom pattern was lacking and about half of the confirmed severe victims of CSA did not display any psychosocial problems. Therefore, it is difficult for experts to identify confirmed CSA victims. Thus, the assessment of suspected CSA should be over time and multidisciplinary.

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative.

CONCLUSION

Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is needed. What is known • Child sexual abuse (CSA) affects many children on both the short and the long term but remains unrecognized in most cases. • So far, there is a lack of studies on symptom patterns of CSA in male, preschool children. What is new • None of the children showed CSA-specific findings at physical and anogenital examination; STIs were not found in the confirmed victims of CSA. • The most prominent finding was the deviant behavioral response of the children examined, especially in children who experienced anal/vaginal penetration; therefore, precise observation of a child's behavior during physical examination is a crucial part of the evaluation of suspected CSA.

Diabetes risk reduction in overweight first degree relatives of type 2 diabetes patients: effects of a low-intensive lifestyle education program (DiAlert) A randomized controlled trial

OBJECTIVES

To test the efficacy of a low-intensive lifestyle education program (DiAlert) for overweight first degree relatives of type 2 diabetes patients aimed at reducing diabetes risk.

METHODS

Overweight first degree relatives of type 2 diabetes patients were randomly assigned to the DiAlert intervention (N=45) or control group who received leaflets (N=51). DiAlert consists of two group sessions and newsletters. Assessments were scheduled at baseline, three and nine months, with weight loss as primary outcome. Secondary outcomes included anthropometric, metabolic, behavioral and psychological measures. Comparisons were made over time and between groups.

RESULTS

Both groups showed modest weight loss with no difference between randomization groups. However, after DiAlert significantly more participants lost 5% of their weight compared to controls (P=0.03). Significant improvement of waist circumference sustained after 9 months in the intervention group (intervention: -4.33cm, P<0.01/control: -1.25cm, P=0.08). Systolic blood pressure improved within the intervention group (intervention: -8.77mmHg, P<0.01/control: -1.03mmHg, P=0.60). No effect was observed for biomedical and psychosocial outcomes.

CONCLUSIONS

Our low-intensive structured lifestyle education program helps overweight relatives to improve waist circumference and supports relevant weight loss.

PRACTICE IMPLICATIONS

The family approach provides opportunities to reach and engage relatives at risk in diabetes prevention education.

Overweight and obesity in young Turkish, Moroccan and Surinamese migrants of the second generation in the Netherlands

OBJECTIVE

To examine differences in overweight and obesity of second-generation Turkish, Moroccan and Surinamese migrants v. first-generation migrants and the ethnic Dutch. We also studied the influence of sociodemographic factors on this association.

DESIGN

Data were collected in 2008 in a cross-sectional postal and online health survey.

SETTING

Four major Dutch cities.

SUBJECTS

In the survey 42 686 residents aged 16 years and over participated. Data from Dutch (n 3615) and second/first-generation Surinamese (n 230/139), Turkish (n 203/241) and Moroccan (n 172/187) participants aged 16-34 years were analysed using logistic regression with overweight (BMI ≥ 25·0 kg/m²) and obesity (BMI ≥ 30·0 kg/m²) as dependent variables. BMI was calculated from self-reported body height and weight. Sociodemographic variables included sex, age, marital status, educational level, employment status and financial situation.

RESULTS

After controlling for age, overweight (including obesity) was more prevalent in most second-generation migrant subgroups compared with the Dutch population, except for Moroccan men. Obesity rates among second-generation migrant men were similar to those among the Dutch. Second-generation migrant women were more often obese than Dutch women. Ethnic differences were partly explained by the lower educational level of second-generation migrants. Differences in overweight between second- and first-generation migrants were only found among Moroccan and Surinamese men.

CONCLUSIONS

We did not find a converging trend for the overweight and obesity prevalence from second-generation migrants towards the Dutch host population. Therefore, preventive interventions should also focus on second-generation migrants to stop the obesity epidemic.

A process evaluation: does recruitment for an exercise program through ethnically specific channels and key figures contribute to its reach and receptivity in ethnic minority mothers?

Background

Ethnic minority women from low-income countries who live in high-income countries are more physically inactive than ethnic majority women in those countries. At the same time, they can be harder to reach with health promotion programs. Targeting recruitment channels and execution to ethnic groups could increase reach and receptivity to program participation. We explored using ethnically specific channels and key figures to reach Ghanaian, Antillean, and Surinamese mothers with an invitation for an exercise program, and subsequently, to determine the mothers’ receptivity and participation.

Methods

We conducted a mixed methods process evaluation in Amsterdam, the Netherlands. To recruit mothers, we employed ethnically specific community organizations and ethnically matched key figures as recruiters over Dutch health educators. Reach and participation were measured using reply cards and the attendance records from the exercise programs. Observations were made of the recruitment process. We interviewed 14 key figures and 32 mothers to respond to the recruitment channel and recruiter used. Content analysis was used to analyze qualitative data.

Results

Recruitment through ethnically specific community channels was successful among Ghanaian mothers, but less so among Antillean and Surinamese mothers. The more close-knit an ethnic community was, retaining their own culture and having poorer comprehension of the Dutch language, the more likely we were to reach mothers through ethnically specific organizations. Furthermore, we found that using ethnically matched recruiters resulted in higher receptivity to the program and, among the Ghanaian mothers in particular, in greater participation. This was because the ethnically matched recruiter was a familiar, trusted person, a translator, and a motivator who was enthusiastic, encouraging, and able to adapt her message (targeting/tailoring). Using a health expert was preferred in order to increase the credibility and professionalism of the recruitment.

Conclusions

Recruitment for an exercise program through ethnically specific organizations seems to contribute to its reach, particularly in close-knit, highly organized ethnic communities with limited fluency in the local language. Using ethnically matched recruiters as motivator, translator, and trusted person seems to enhance receptivity of a health promotion program. An expert is likely to be needed for effective information delivery.

Ethnic differences in the association between cardiovascular risk factors and psychological distress in a population study in the Netherlands

BACKGROUND

There is growing body of evidence of an association between cardiovascular risk factors and depressive and anxiety symptoms. The purpose of this study was to investigate whether these associations are similar in ethnic minority groups.

METHODS

A random urban population sample, aged 18+, stratified by ethnicity (484 native Dutch subjects, 383 Turkish-Dutch subjects, and 316 Moroccan-Dutch subjects), in Amsterdam, the Netherlands, was interviewed with the Kessler Psychological Distress scale (K10) in combination with measurements of several cardiovascular risk factors. The association of psychological distress (defined as a K10 score above cut-off of 20) with cardiovascular risk factors (obesity, abdominal obesity, hypertension, hypercholesterolemia, low HDL cholesterol levels or diabetes), ethnicity and their interaction was analyzed using logistic regression analyses, stratified by gender and adjusted for age.

RESULTS

Cardiovascular risk factors were not significantly associated with psychological distress in any of the gender/ethnic groups, with the exception of a positive association of obesity and hypertension with psychological distress in native Dutch women and a negative association of hypertension and psychological distress in Turkish men. Interaction terms of cardiovascular risk factors and ethnicity were approaching significance only in the association of obesity with the K10 in women.

CONCLUSION

In this cross-sectional multi-ethnic adult population sample the majority of the investigated cardiovascular risk factors were not associated with psychological distress. The association of obesity with psychological distress varies by gender and ethnicity. Our findings indicate that the prevention of obesity and psychological distress calls for an integrated approach in native Dutch women, but not necessarily in Turkish-Dutch and Moroccan-Dutch women, in whom these problems may be targeted separately.

DiAlert: a prevention program for overweight first degree relatives of type 2 diabetes patients: results of a pilot study to test feasibility and acceptability

Background

Prevalence of type 2 diabetes mellitus is increasing due to lifestyle changes, particularly affecting those genetically at risk. We developed DiAlert as a targeted group-based intervention aimed to promote intrinsic motivation and action planning for lifestyle changes and weight loss in first degree relatives of patients with type 2 diabetes mellitus.

The main objective of the pilot of the DiAlert intervention was to assess fidelity, feasibility and acceptability prior to starting the randomized controlled trial.

Methods

Individuals with a family history of type 2 diabetes mellitus were self-identified and screened for eligibility. DiAlert consists of two group sessions. Feasibility, fidelity, acceptability and self-reported perceptions and behavioral determinants were evaluated in a pre-post study using questionnaires and observations. Determinants of behavior change were analyzed using paired-samples t tests and Wilcoxon signed rank tests.

Results

DiAlert was delivered to two groups of first degree relatives of patients with type 2 diabetes mellitus (N = 9 and N = 12). Feasibility and fidelity were confirmed. Overall, the DiAlert group sessions were positively evaluated (8.0 on a scale of 1 to 10) by participants. The intervention did not impact perceived susceptibility or worry about personal diabetes risk. Action planning with regard to changing diet and physical activity increased.

Conclusions

DiAlert proved feasible and was well-accepted by participants. Positive trends in action planning indicate increased likelihood of actual behavior change following DiAlert. Testing the effectiveness in a randomized controlled trial is imperative.

Trial registration

Netherlands National Trial Register (NTR): NTR2036

Comorbidity of anxiety and depressive disorders: a comparative population study in Western and non-Western inhabitants in the Netherlands

BACKGROUND

Overlap of depressive and anxiety symptoms is supposedly more common in non-Western populations. This can lead to diagnostic uncertainity and undertreatment.

AIMS

The aim of this study was to assess cross-cultural differences regarding the comorbidity of anxiety and depressive disorders in a comparative population study.

METHODS

In a random urban population sample, stratified for descent, in Amsterdam, the Netherlands, diagnostic interviews were held by bilingual interviewers. Diagnoses of anxiety and depressive disorders, based on the Composite International Diagnostic Interview, were obtained for 307 native Dutch subjects, 205 Turkish-Dutch subjects and 186 Moroccan-Dutch subjects.

RESULTS

The prevalence rate of comorbid anxiety and depressive disorders was higher in Turkish-Dutch (9.8 %) and Moroccan-Dutch (3.8%) subjects compared to native Dutch subjects (2.3%). However, this could be explained by differences in baseline prevalence rate and level of severity of the separate disorders. The onset order of anxiety disorders and depressive disorders was comparable in each ethnic group.

CONCLUSIONS

The high prevalence rate of comorbid anxiety and depressive diorders in non-Western immigrants in the Netherlands necessitates assesssment and treatment of both disorders. There was no indication of a - culturally influenced - stronger overlap between anxiety and depressive disorders in non-Western immigrants in the Netherlands.

Obesity and cardiovascular disease risk among Turkish and Moroccan migrant groups in Europe: a systematic review

Migrants from Turkey and Morocco are among the largest ethnic minority groups in several European countries. In this review, we aimed to systematically search, assess and describe the available literature on cardiovascular disease (CVD), obesity and other endogenous cardiovascular risk factors among these groups. Although the number of publications covering this topic among Turkish and Moroccan migrants has increased in the past decades, studies among these groups, especially the Moroccan, are still limited. There is a particular lack of information on CVD mortality and morbidity rates. Furthermore, studies are often hampered by low participation rates, small sample sizes and self-reported data. This further complicates drawing sound conclusions on CVD and risk factors among these migrant groups. The results with regard to CVD morbidity and mortality rates are inconclusive. With regard to CVD risk factors, we tentatively conclude that obesity and diabetes are more common among Turkish and Moroccan migrant groups in Europe than the western European population. In the Turkish population there is also a fair amount of evidence for unfavourable high-density lipoprotein cholesterol levels. However, more research on this topic among these major ethnic minorities is of high importance.

Changing the odds. What do we learn from prevention studies targeted at people with a positive family history of type 2 diabetes?

People with a positive family history of type 2 diabetes (T2DM) are at high risk of developing diabetes. We set out to review the literature reporting on the development and/or evaluation of lifestyle interventions specifically aimed at prevention of T2DM in this group. Targeting people with a positive family history of T2DM seems so far an underutilized prevention strategy. They can and should be approached with the aim to raise risk awareness and promote healthy eating, weight loss and physical activity, thereby reducing their risk of developing diabetes.

DiAlert: a lifestyle education programme aimed at people with a positive family history of type 2 diabetes and overweight, study protocol of a randomised controlled trial

Background

Family history is a known risk factor for type 2 diabetes (T2DM), and more so in the presence of overweight. This study aims to develop and evaluate the effectiveness of a new lifestyle education programme 'DiAlert' targeted at 1st degree relatives of people with T2DM and overweight. In view of the high risk for diabetes and cardiovascular disease in immigrants from Turkish origin living in Western Europe, a culturally appropriate Turkish version of DiAlert will be developed and tested.

Methods/design

In this RCT, 268 (134 Dutch and 134 Turkish) overweight 1st degree relatives of patients with T2DM will be allocated to either the intervention or control group (leaflet). The intervention DiAlert aims to promote intrinsic motivation to change lifestyle, and sustain achieved behaviour changes during follow-up. Primary outcome is weight loss. Secondary outcomes include biological, behavioural and psychological indices, along with process indicators. Measurements will take place at baseline and after 3 and 9 months. Changes in outcomes are tested between intervention and control group at 3 months; effects over time are tested within and between both ethnic groups at 3 and 9 months.

Discussion

The DiAlert intervention is expected to be more effective than the control condition in achieving significant weight loss at 3 months, in both Dutch and Turkish Dutch participants.

Trial registration

Netherlands National Trial Register (NTR): NTR2036

Ethnic differences in systemic inflammation: an investigation of C-reactive protein levels among Moroccan, Turkish and Dutch groups in the Netherlands

OBJECTIVE

C-reactive protein (CRP) is a sensitive, non-specific systemic marker for inflammation and tissue damage in the human body and independently associated with incident cardiovascular disease (CVD) and traditional CVD risk factors. The aim of this study is to describe and analyse ethnic differences in CRP levels between Turkish, Moroccan and ethnic Dutch groups.

METHODS

Data were collected in the setting of a general health survey, in Amsterdam, the Netherlands, in 2004. From 1219 adults information on physical and psychological health, lifestyle and demographic background was obtained via health interviews. In a physical examination, measurements of anthropometry and blood pressure were performed. Blood samples were collected and high-sensitive CRP was determined.

RESULTS

Mean CRP levels, excluding acute inflammation, were higher among Turkish migrants (men: 2.1mg/l; women: 2.9mg/l) and Moroccan women (2.9mg/l) compared to the Dutch (men: 1.7mg/l; women: 2.3mg/l). 'High CVD risk' CRP levels (3mg/l≥CRP≥10mg/l) were also more prevalent in these groups. Ethnic differences in mean CRP levels persisted after controlling for sex, age, BMI and smoking. Ethnic differences in 'high CVD risk' CRP levels were attenuated by controlling for traditional CVD risk factors in men, but not in women.

CONCLUSION

Their relatively high CRP levels put Turkish and female Moroccan migrants at higher risk of future cardiovascular events, especially women. Known determinants cannot explain ethnic differences in mean CRP levels. Traditional CVD determinants account for ethnic differences in 'high CVD risk' CRP levels among men, but not women.

Acculturation and psychological distress among non-Western Muslim migrants--a population-based survey

BACKGROUND

Political and social developments point at increasing marginalization of Muslim migrants, but little is known about its consequences for the mental health of this particular group.

AIM

To explore the relationship between acculturation and psychological distress among first-generation Muslim migrants from Turkey and Morocco in the Netherlands.

METHODS

A cross-sectional study. Respondents were interviewed in their preferred language. Acculturation was measured with the Lowlands Acculturation Scale (LAS) and psychological distress with the Kessler Psychological Distress Scale (K10). Data were complete for 321 subjects and analyzed with multivariate linear regression.

RESULTS

Less skills for living in Dutch society was associated with distress (p = 0.032). Feelings of loss were related to distress among Moroccans (p = 0.037). There was an interaction between traditionalism and ethnic background (p = 0.037); traditionalism was related to less distress among Moroccans (p = 0.020), but not among Turkish. Finally, there was an interaction by gender among Turks (p = 0.029); conservative norms and values seemed to be related to distress among men (p = 0.062), not women.

CONCLUSION

Successful contact and participation in Dutch society, and maintenance of heritage culture and identity were moderately associated with less psychological distress. Improving mastery of the dominant language in host societies, and allowing migrants to preserve their traditions, might be effective measures in improving the mental well-being of migrants.

[Differences in perinatal mortality between districts of Amsterdam]

OBJECTIVE

To study the effect of district on perinatal mortality in Amsterdam, the Netherlands, taking into account various risk factors including ethnicity and social economic status (SES).

DESIGN

Cohort study.

METHOD

The investigation related to 73,661 singleton births in Amsterdam, Diemen and Ouder-Amstel recorded in the Netherlands Perinatal Registry over the years 2000-2006. Logistic regression analysis was used to determine if perinatal mortality differed by district, taking into account various risk factors.

RESULTS

Each year in Amsterdam an average of 10,525 singleton children were born of whom 114 infants died (10.8 per 1,000 births (‰)). National perinatal mortality was 9.9 ‰. In three districts, perinatal mortality was 1.5-2 times higher than the national average: Zuidoost (21‰), Slotervaart (14‰) and Zeeburg (14‰). However, mortality in the districts of ZuiderAmstel (5‰), Oud-Zuid (7‰), Centrum and Osdorp (8‰) was 20-50% lower. The high risk of perinatal mortality in the Zuidoost district (odds ratio: 2.1; 95% CI: 1.9-2.6) was explained by the high prevalence of women with higher risk factors; African or South Asian Surinamese ethnicity, low SES and preterm birth. The effects of parity and ethnicity on perinatal mortality differed by district. In Zeeburg increased effect for higher parity and for Turkish/Moroccan ethnicity was seen. In Slotervaart the perinatal mortality risk was increased (odds ratio: 1.8; 95% CI: 1.3-2.5), but this was not explained by the risk factors studied.

CONCLUSION

Amsterdam had districts with both highly elevated and reduced perinatal mortality rates. The prevalence of risk factors differed by district and the effects of ethnicity and parity were not homogenous. Therefore, tailored policy and research by district is necessary.

Obesity and body fat distribution: ethnic differences and the role of socio-economic status

OBJECTIVE

This study investigates differences in overweight and body fat distribution between Turkish and Moroccan migrants and the ethnic Dutch population, and the contribution of socio-economic status to their higher obesity prevalence.

METHODS

Data were collected as part of a general health survey, in Amsterdam, the Netherlands (2004). From 1,285 adults information on physical and psychological health, lifestyle and demographic background was obtained through health interviews. In a physical examination body height and weight as well as waist and hip circumference were measured.

RESULTS

Overweight was more common among Turkish migrants and Moroccan migrant women as compared to their Dutch counterparts. Obesity prevalence rates were more than twice as high among Turkish (39.6%) and Moroccan (39.1%) women than among Dutch women (16.5%). Controlling for level of education and unemployment attenuated ethnic differences in overweight. Abdominal obesity was more common among Turkish and Moroccan than among Dutch women. After controlling for BMI, migrant men had a relatively low waist circumference compared to Dutch men.

CONCLUSION

Overweight is relatively common among Turkish and Moroccan migrants, especially women. Education and employment are relevant in explaining ethnic differences in overweight. Compared to Dutch men, migrant men seem to have a more favourable fat distribution with less abdominal fat.

Ethnic differences in total and HDL cholesterol among Turkish, Moroccan and Dutch ethnic groups living in Amsterdam, the Netherlands

Background

High total cholesterol and low HDL (high-density lipoprotein) cholesterol are important determinants of cardiovascular disease. Little is known about dyslipidemia among Turkish and Moroccan migrants, two of the largest ethnic minority groups in several European countries. This study examines ethnic differences in total and HDL cholesterol levels between Dutch, Turkish and Moroccan ethnic groups.

Methods

Data were collected in the setting of a general health survey, in Amsterdam, the Netherlands, in 2004. Total response rate was 45% (Dutch: 46%, Turks: 50%, Moroccans: 39%). From 1,220 adults information on history of hypercholesterolemia, lifestyle and demographic background was obtained via health interviews. In a physical examination measurements of anthropometry and blood pressure were performed and blood was collected. Total and HDL cholesterol were determined in serum.

Results

Total cholesterol levels were lower and hypercholesterolemia was less prevalent among the Moroccan and Turkish than the Dutch ethnic population. HDL cholesterol was also relatively low among these migrant groups. The resulting total/HDL cholesterol ratio was particularly unfavourable among the Turkish ethnic group. Controlling for Body Mass Index and alcohol abstinence substantially attenuated ethnic differences in HDL cholesterol levels and total/HDL cholesterol ratio.

Conclusions

Total cholesterol levels are relatively low in Turkish and Moroccan migrants. However part of this advantage is off-set by their relatively low levels of HDL cholesterol, resulting in an unfavourable total/HDL cholesterol ratio, particularly in the Turkish population. Important factors in explaining ethnic differences are the relatively high Body Mass Index and level of alcohol abstinence in these migrant groups.

Ethnic health care advisors: a good strategy to improve the access to health care and social welfare services for ethnic minorities?

Empirical studies indicate that ethnic minorities have limited access to health care and welfare services compared with the host population. To improve this access, ethnic health care (HC) advisors were introduced in four districts in Amsterdam, the Netherlands. HC advisors work for all health care and welfare services and their main task is to provide information on health care and welfare to individuals and groups and refer individuals to services. Action research was carried out over a period of 2 years to find out whether and how this function can contribute to improve access to services for ethnic minorities. Information was gathered by semi-structured interviews, analysing registration forms and reports, and attending meetings. The function’s implementation and characteristics differed per district. The ethnicity of the health care advisors corresponded to the main ethnic groups in the district: Moroccan and Turkish (three districts) and sub-Sahara African and Surinamese (one district). HC advisors reached many ethnic inhabitants (n = 2,224) through individual contacts. Half of them were referred to health care and welfare services. In total, 576 group classes were given. These were mostly attended by Moroccan and Turkish females. Outreach activities and office hours at popular locations appeared to be important characteristics for actually reaching ethnic minorities. Furthermore, direct contact with a well-organized back office seems to be important. HC advisors were able to reach many ethnic minorities, provide information about the health care and welfare system, and refer them to services. Besides adapting the function to the local situation, some general aspects for success can be indicated: the ethnic background of the HC advisor should correspond to the main ethnic minority groups in the district, HC advisors need to conduct outreach work, there must be a well-organized back office to refer clients to, and there needs to be enough commitment among professionals of local health and welfare services.

Acculturation and use of health care services by Turkish and Moroccan migrants: a cross-sectional population-based study

BACKGROUND

There is insufficient empirical evidence which shows if and how there is an interrelation between acculturation and health care utilisation. The present study seeks to establish this evidence within first generation Turkish and Moroccan migrants, two of the largest migrant groups in present-day Western Europe.

METHODS

Data were derived from the Amsterdam Health Monitor 2004, and were complete for 358 Turkish and 288 Moroccan foreign-born migrants. Use of health services (general practitioner, outpatient specialist and health care for mental health problems) was measured by means of self-report. Acculturation was measured by a structured questionnaire grading (i) ethnic self-identification, (ii) social interaction with ethnic Dutch, (iii) communication in Dutch within one's private social network, (iv) emancipation, and (v) cultural orientation towards the public domain.

RESULTS

Acculturation was hardly associated with the use of general practitioner care. However, in case of higher adaptation to the host culture there was less uptake of outpatient specialist care among Turkish respondents (odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.82-0.99) and Moroccan male respondents (OR = 0.81, 95% CI = 0.71-0.93). Conversely, there was a higher uptake of mental health care among Turkish men (OR = 0.81, 95% CI = 0.71-0.93) and women (OR = 0.81, 95% CI = 0.71-0.93). Uptake of mental health care among Moroccan respondents again appeared lower (OR = 0.74, 95% CI = 0.55-0.99). Language ability appeared to play a central role in the uptake of health care.

CONCLUSION

Some results were in accordance with the popular view that an increased participation in the host society is concomitant to an increased use of health services. However, there was heterogeneity across ethnic and gender groups, and across the domains of acculturation. Language ability appeared to play a central role. Further research needs to explore this heterogeneity into more detail. Also, other cultural and/or contextual aspects that influence the use of health services require further identification.

Psychometric properties of an interviewer-administered version of the Kessler Psychological Distress scale (K10) among Dutch, Moroccan and Turkish respondents

The Kessler Psychological Distress scale (K10) is an instrument that is widely used to screen for mental disorders, but information is lacking on its psychometric qualities in non-Western samples. This study used a population-based sample (N = 725) to assess the reliability and validity of the K10 across ethnic groups in an urban area. The results were generally supportive of the K10 as a reliable and valid instrument to screen for anxiety and depression in all three groups. Cronbach's alpha was high (0.93) and the results indicated the existence of a solid single factor structure. Item bias in relation to ethnic background was minor. In each group, there was good criterion validity with respect to one-month DSM-IV diagnosis for depressive and/or anxiety disorder. The results nevertheless highlight the importance of cross-cultural validation, as we found different cut-off values for ethnic subgroups to obtain optimal sensitivity and specificity for detecting depressive and/or anxiety disorders.

Uptake of health services for common mental disorders by first-generation Turkish and Moroccan migrants in the Netherlands

Background

Migration and ethnic minority status have been associated with higher occurrence of common mental disorders (CMD), while mental health care utilisation by non-Western migrants has been reported to be low compared to the general population in Western host countries. Still, the evidence-base for this is poor. This study evaluates uptake of mental health services for CMD and psychological distress among first-generation non-Western migrants in Amsterdam, the Netherlands.

Methods

A population-based survey. First generation non-Western migrants and ethnic Dutch respondents (N = 580) participated in structured interviews in their own languages. The interview included the Composite International Diagnostic Interview (CIDI) and the Kessler psychological distress scale (K10). Uptake of services was measured by self-report. Data were analysed using weighting techniques and multivariate logistic regression.

Results

Of subjects with a CMD during six months preceding the interview, 50.9% reported care for mental problems in that period; 35.0% contacted specialised services. In relation to CMD, ethnic groups were equally likely to access specialised mental health services. In relation to psychological distress, however, Moroccan migrants reported less uptake of primary care services (OR = 0.37; 95% CI = 0.15 to 0.88).

Conclusion

About half of the ethnic Dutch, Turkish and Moroccan population in Amsterdam with CMD contact mental health services. Since the primary purpose of specialised mental health services is to treat "cases", this study provides strong indications for equal access to specialised care for these ethnic groups. The purpose of primary care services is however to treat psychological distress, so that access appears to be lower among Moroccan migrants.

Diabetes prevalence and risk factors among ethnic minorities

BACKGROUND

Ethnic minorities living in Western societies may have a higher prevalence of diabetes. We investigated whether the prevalence of diabetes among Turkish and Moroccan migrants differs from the indigenous urban population in the Netherlands, and whether these differences can be explained by differences in risk factors.

METHODS

In 2004 a general health survey, stratified by ethnicity and age, was carried out among the population of Amsterdam. The current study included 375 Turkish, 314 Moroccan and 417 Dutch individuals aged 18-70 years. Participants underwent a physical examination and a health interview. Diabetes was based on self-report, the use of anti-diabetic medicine, blood glucose levels and HbA1c.

RESULTS

The prevalence of diabetes in the Amsterdam population was significantly higher in Turkish (5.6%) and Moroccan (8.0%), compared to Dutch individuals (3.1%). These differences, which were much larger after adjustment for age, were only partly explained by the lower socioeconomic status and higher frequency of obesity among ethnic minorities. The difference between Dutch and Moroccan individuals remained significant even after adjustments for multiple risk factors. The typical age of onset of diabetes in both Turks and Moroccans is respectively one and two decades younger than in the indigenous population.

CONCLUSION

Diabetes is more prevalent among Turkish and Moroccan migrants as compared to the indigenous population. Only part of this difference can be explained by differences in demographic and lifestyle risk factors.

Depressive and anxiety disorders in different ethnic groups: a population based study among native Dutch, and Turkish, Moroccan and Surinamese migrants in Amsterdam

INTRODUCTION

To explore ethnic differences in psychopathology, this study examined the prevalence of depressive and anxiety disorders among different ethnic groups in Amsterdam and determined whether ethnic differences can be explained by socio-demographic differences.

METHODS

A population-based sample of 321 Dutch, 231 Turkish, 191 Moroccan, 87 Surinamese/Antilleans was interviewed by well-trained bilingual interviewers, using the CIDI 2.1. Educational level and income were used as indicators of socio-economic status.

RESULTS

The weighed 1-month prevalence of depressive and/or anxiety disorders was 6.6% (Dutch), 18.7% (Turkish), 9.8% (Moroccans) and 1.2 % (Surinamese/Antilleans). Among Moroccans, the prevalence of affective disorders seemed higher in men than in women, among the Turkish the opposite was observed. Ethnic differences in prevalence could not be explained by socioeconomic differences.

CONCLUSION

Turkish women and men and Moroccan men in Amsterdam seem to have a higher risk of current affective disorders. Ethnicity is an independent predictor of common mental disorders in the Netherlands.

Depression in first generation labour migrants in Western Europe: the utility of the Center for Epidemiologic Studies Depression Scale (CES-D)

OBJECTIVE

The number of elderly migrants from Turkish and Moroccan descent in Western Europe will increase sharply in the coming decades. Identifying depressed elderly migrants necessitates a screening instrument that is both acceptable and has good psychometric properties. This study examines the utility of Turkish and Arabic translations of the Center for Epidemiologic Studies Depression Scale (CES-D) among elderly labour migrants from Turkish and Moroccan descent in the Netherlands.

METHOD

The data were derived from a community based health survey among 304 native Dutch, 330 Turkish and 299 Moroccan migrants, aged 55-74 years, living in Amsterdam, the Netherlands. Acceptability, reliability, convergent and construct validity were studied.

RESULTS

Acceptability of the CES-D was satisfactory, although Moroccan migrants and Turkish females had difficulty answering one or more of the (interpersonal) items from the CES-D. Translated versions of the CES-D proved to be highly internal consistent and have good convergent validity in both Turkish and Moroccan elderly. Depressed and somatic items were much more intermingled in Turkish and Moroccan elderly compared to earlier studies and native Dutch elderly. This fits to the hypothesis that Turkish and Moroccan elderly migrants tend to somatize their depressive symptoms much more than native Western elderly.

CONCLUSION

The utility of the CES-D for elderly migrants of Turkish and Moroccan descent was found to be satisfactory.

[Travel advice on the prevention of infectious diseases insufficiently obtained by indigenous and non-native inhabitants of Amsterdam, the Netherlands]

OBJECTIVE

To determine the travel behaviour of inhabitants of Amsterdam, the Netherlands, with respect to age and ethnicity, as well as the impact of travel advice, in particular regarding hepatitis A vaccination of Turkish and Moroccan children.

DESIGN

Descriptive.

METHOD

In a sample of 2000 inhabitants of Amsterdam, a survey was carried out during the period October 1999-November 2000 on seeking medical advice prior to travelling. In addition, 429 Turkish and Moroccan parents were questioned about hepatitis A vaccination of their children when travelling to their country of origin.

RESULTS

In the three years preceding the survey one third of the Amsterdam population travelled to a country where infectious diseases such as malaria and hepatitis A were endemic. Many travellers (18%) went to Asia, Central or Latin America and Africa. Others (12%) travelled to the Middle-East or North Africa. One third of the travellers had sought advice from the Municipal Public Health Service of Amsterdam. Other travellers were advised by their general practitioner (10%). A large group (38%) did not seek any advice at all. Almost one third of the travellers went to their country of origin, particularly Turkish and Moroccan inhabitants of Amsterdam. Seventy percent of Turkish and Moroccan travellers had not sought travel advice. More than half the Turkish and Moroccan parents did not have their children vaccinated against hepatitis A when travelling to their country of origin.

CONCLUSION

One fifth of the indigenous Dutch population received no travel advice. More than half of Turkish and Moroccan children travelling to their country of origin were not vaccinated against hepatitis A.

Life expectancy and mortality differences between migrant groups living in Amsterdam, The Netherlands

There is an apparent contradiction between the high level of morbidity and the low level of mortality observed in certain groups of migrants living in Europe. This observation should have some consequences for health policy development and the targeting of resources in a city like Amsterdam. In this paper a number of hypotheses to explain the low mortality in migrant groups are discussed. An analysis is made of mortality in Amsterdam using data from the civil registry as to mortality according to age, sex and nationality group of the deceased. Standard demographic techniques such as the standardised mortality ratio (SMR) and life table analysis were employed. Life table analysis shows that life expectancy in Amsterdam is lowest among residents of Dutch descent (73.3 yr for males and 79.1 yr for females) and highest among those of Mediterranean origin (77.6 yr for males and 86.1 yr for females). This appears to contradict previous research based on the SMR, which showed high mortality in migrant groups. To find the cause of this contradiction, the SMR and risk ratios by age are studied. The conclusion of this paper is that on the basis of life table analysis it appears that some immigrant groups living in Amsterdam have a remarkably high life expectancy. Since the SMR is sensitive to demographic differences between groups compared, questions can be raised about previous studies using the SMR. It has been suggested that the high life expectancy in migrant groups is not really caused by good health but by 'spurious' phenomena, such as problems in mortality registration. However, in view of the available data it seems likely that some migrant groups do in fact have high life expectancy, although the morbidity in these groups can be quite high. These findings should inform health-related policy.

[Increased proportion of elementary school children with asthmatic symptoms in the Netherlands, 1984/85-1994/95; a literature review]

OBJECTIVE

To investigate whether the prevalence of asthmatic symptoms among children in the Netherlands has changed.

DESIGN

Literature study.

METHOD

Investigations into the prevalence of children with asthmatic symptoms were collected from Medline, Embase and various libraries if they had been performed between 1984/'85 and 1994/'95 and had used the so-called WHO or Region list. 23 studies were selected with data on 76,353 elementary school pupils. Linear regression analysis, weighed for the number of children, was used to determine if the proportions of children with asthmatic symptoms had increased over the years.

RESULTS

In 10 years the prevalence of recent shortness of breath had increased by 107% (from 4.16 to 8.63%), that of recent wheeze by 16% (from 10.64 to 12.35%), that of recent attacks of breathlessness with wheezing by 17% (from 5.29 to 6.19%), and for chronic cough by 259 (from 1.05 to 3.77%) to 272% (from 3.14 to 11.68%). The prevalence of doctor-diagnosed asthma had increased by 120% (from 2.82 to 6.19%).

CONCLUSION

There had been a pronounced increase in the percentage of primary schoolchildren with asthmatic symptoms between 1984/'85 and 1994/'95. The prevalence of doctor-diagnosed asthma increased faster then did key symptoms of asthma.

Health risk assessment of fungi in home environments

LEARNING OBJECTIVES

Reading this article will enable the readers to recognize the public health importance of fungi in the home environment. In view of the recognized impact of fungi on human health, the large population being exposed to fungi, and the large population risk for developing allergic diseases, there is a need to establish guidelines for allowable exposure to fungi based on a health risk assessment. The aim of this study was to evaluate the status of the data on the relationship between exposure to fungi in the home environment and allergic health effects with respect to the development of such guidelines.

DATA SOURCES

The past 10 years of peer-reviewed literature focused on the relationships between respiratory disease and exposure to fungi in indoor environments was examined, Indexing terms included mold, fungi, allergy, asthma, and indoor environment, among others. Each study was evaluated on the following criteria: aim and design of the study, methods for assessing exposure and health effects, and data analysis.

STUDY SELECTION

Nine population based studies were identified that examined the relationship between allergy and the presence of fungi in the home environment. These studies included quantitative measures of fungal presence in either air or dust.

RESULTS

One or more positive associations were found between fungal levels and health outcomes in seven of the nine cross-sectional studies identified.

CONCLUSIONS

Despite these positive associations it remains impossible to set guidelines for fungi in home environments based on health risk assessment. This is in part because of the cross-sectional study designs, and inconsistency and inadequate validation of the measures used to evaluate exposure and health effects. Future research designed to generate data that can be used for the development of health risk assessment based guidelines for fungi in home environments should focus on susceptible populations, and use measures that accurately represent exposure and adverse health effects.

Cockroach allergen in house dust

The cockroach allergen (Bla g 1) content was determined in the floor dust of 46 homes with recent cockroach extermination in Amsterdam, The Netherlands. IgE antibodies to Blattella germanica, house-dust mite, cat dander, dog dander, and a mixture of molds were determined in venous blood samples of 46 children (4-12 years) and one of their biologic parents (24-54 years). Specific IgE to cockroach was also determined in a sample of the general population studied in a previous case-control study, one group (n = 20) with three groups (n =76) without history of cockroach infestation of the home. Cockroach allergen was detected in floor dust from 44% of the homes, with levels up to 3899 ng Bla g 1/g. Seven of the 46 adults and only one of the 46 children studied had positive RAST to cockroach. Geometric mean cockroach allergen concentrations in living room and master bedroom of sensitized adults were similar to those of nonsensitized adults. In the groups of children without a history of cockroach infestation of the home, positive RAST against cockroach was observed in 16% of the children with respiratory symptoms, in 4% of the children without respiratory symptoms, and in 48% of the children with two or more positive RAST to other allergens. Of the 18 children with positive RAST against cockroach, only one had a history of cockroach infestation of the home and 16 (89%) had also positive RAST against house-dust mite.

Air pollution and daily mortality in Amsterdam

Few data are available on the association between the present low levels of air pollution in Western Europe and mortality. Daily mortality counts and the concentrations of black smoke, inhalable particles (PM10), sulfur dioxide (SO2), carbon monoxide (CO), and ozone (O3) were available for Amsterdam from 1986 to 1992. We used Poisson regression analysis to control for seasonal and other long-term temporal patterns. Black smoke and PM10 were positively associated with increased risk of mortality. The relative risk for a 100-micrograms per m3 increase in black smoke on the same day was 1.19 [95% confidence interval (CI) = 1.02-1.38], and that for a 100-micrograms per m3 increase in PM10 was 1.06 (95% CI = 0.99-1.14). The relative risk for individuals over 64 years of age was higher. We found no consistent association between the levels of SO2 or CO and daily mortality, but ozone lagged 2 days was positively associated with daily mortality. The effect of particulates on acute mortality was independent of these pollutants. The results of the present study are consistent with the relation reported between particulate air pollution and daily mortality in other communities in Europe and the United States.

Infant respiratory symptoms in relation to mite allergen exposure

The relationship between the Dermatophagoides pteronyssinus (Der p) I content of house dust and the respiratory symptoms reported for young infants was studied. One hundred and four infants, aged 3-15 months, were selected during July-September 1993 through the Dutch postnatal health care service, using a short screening questionnaire to identify mothers with respiratory allergy to house dust and/or pets. Forty-eight were selected from this group of mothers ("high risk" infants) and 56 infants were selected when neither of the parents reported allergy or chronic respiratory symptoms ("low risk" infants). All homes were visited in October 1993. Dust samples were collected from the infant's mattress and from other places in the home, and the Der p I content was measured in dust extracts. The results indicate that on more than half of the mattresses, the Der p I level was over 2,000 ng.g-1, the level suggested to be associated with an increased risk of sensitization. Information on respiratory symptoms ("wheeze" and "prolonged cough") experienced since birth was obtained by questionnaire from one of the parents on the dust sampling day. The occurrence of respiratory symptoms in the infants appeared to be positively related to the Der p I concentration of the dust. Although no objective measurements of respiratory symptoms were available, the results of this study suggest that exposure to mite allergen in early life may lead to respiratory symptoms that are suggestive of airway obstruction in the first year of life.

Der p I concentrations in mattress surface and floor dust collected from infants' bedrooms

BACKGROUND

Allergen exposure in early childhood is thought to be important for sensitization and subsequent development of asthma. Not much is known, however, about exposure of young children to allergens in the home.

OBJECTIVES

This study was designed to document dust mite allergen exposure in young children, and to determine whether infants from atopic mothers (= 'high-risk' infants) are exposed to lower concentrations of house dust mite allergen than infants from non-atopic parents (= 'low-risk' infants).

METHODS

Dust samples were taken in the homes of 104 infants (48 'high-risk' and 56 'low-risk' infants, selected by questionnaire) aged 3-15 months, from floors in different rooms and from the child's mattress surface.

RESULTS

The majority of the infants were found to be exposed to Der p I concentrations of more than 2000 ng/g in dust collected from the surface of their mattresses. Lower Der p I concentrations were found in mattress surface dust from the beds of infants from atopic mothers than of infants from non-atopic parents. Also, lower Der p I concentrations were found in floor dust from the homes of infants from atopic mothers. Infant beds equipped with new mattresses, new blankets and top plastic sheeting had significantly lower Der p I concentrations than beds equipped with used mattresses and blankets, without top plastic sheeting.

CONCLUSIONS

Young children in the Netherlands are exposed to significant concentrations of Der p I in mattress surface dust. Allergic parents appear to provide their children with environments somewhat less rich in mite allergen than non-allergic parents.

The exposure of cyclists, car drivers and pedestrians to traffic-related air pollutants

Volunteers provided with personal air sampling (PAS) equipment covered concurrently, by car or bicycle, various selected routes. These comprised two inner city routes in Amsterdam (ICR 1 and 2) as well as a route including a tunnel on a busy highway (TR) and a rural route just south of Amsterdam (RR). A third inner city route, a busy narrow street, was subsequently also selected, and covered by bicycle or walking (ICR 3). Each run lasted about 1 h; the sampling time on the TR route was approximately 30 min. The sampling periods in January and May lasted 2 weeks with four sampling days per week. In August only ICR 3 was covered, this sampling period lasted 2 days. CO, NO2, benzene, toluene and xylenes were measured in the personal air samples. A monitoring vehicle covered the routes concurrently and measured CO, NO2 and pm10 (semi) continuously. Lead and PAH content in pm10 was determined. The ventilation of the volunteers was measured while they were using a car or a bicycle. The route and the type of transport influenced (P < 0.001) the concentrations of CO, benzene, toluene and xylenes. The daily average temperature was positively associated with the exposure of car drivers and cyclists to most compounds measured. A volunteer exhaled on average 2.3 times more air as a cyclist than as a car driver. Despite the much higher concentrations in the personal air samples of car drivers, the uptake of CO, benzene, toluene and xylenes of cyclists sometimes approached that of the car drivers. The uptake of NO2 of cyclists was clearly higher than that of car drivers.

Damp housing and childhood respiratory symptoms: the role of sensitization to dust mites and molds

In 1990, a case-control study was conducted in the Netherlands into the association between damp housing, childhood respiratory symptoms, and sensitization to house dust mites and mold allergens. In this study, 259 children with chronic respiratory symptoms and 257 control children were involved. Total serum immunoglobulin E (IgE) and specific IgE against house dust mites and a mixture of molds were determined. A visual inspection for signs of home dampness was performed in all homes. A questionnaire was given to the parents of the children to elicit information about the presence of signs of dampness in the previous 2 years and about risk factors for childhood respiratory disease. In the case group, 94 children had elevated serum IgE levels to house dust mites and 24 children to the mixture of molds. In the control group, house dust mite allergy was found in 31 children and mold allergy in two children. In a crude analysis, cases were slightly more likely to have been living in homes where damp or mold was reported or observed than were the controls. In cases as well as controls, home dampness was associated with increased sensitization to dust mites and molds. There was no relation between home dampness and case-control status after stratification for sensitization, however. Restriction of the analysis to cases with elevated serum IgE levels against dust mites and/or molds, and to controls without elevated serum IgE, increased the odds ratios, and several became significant at p < 0.05. This supports a connection between damp housing and sensitization to dust mites and/or molds and childhood respiratory symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

House dust mite allergen (Der p I) and respiratory symptoms in children: a case-control study

The association between house dust mite allergen in house dust and childhood respiratory symptoms was investigated in a case-control study of 259 children with reported chronic respiratory symptoms and 257 control children without reported respiratory symptoms. The Der p I concentration in floor dust of the living room and bedroom and in mattress dust was determined using an enzyme immunoassay. Venous blood samples were taken from all children for serum IgE determination against house dust mite (Dermatophagoides pteronyssinus) by radioallergosorbent assay (RAST). A questionnaire was administered to the parents of the children to elicit information about the home, about changes made to the home in the past in relation to respiratory symptoms, and about a number of risk factors for childhood respiratory disease. In 83% of the dwellings of cases and 89% of those of controls, Der p I concentrations higher than 2000 ng/g were found, and in 54% of the dwellings of cases and 57% of those of controls, the concentrations exceeded 10,000 ng/g dust. In a crude analysis, cases were generally exposed to lower Der p I concentrations than controls. Restriction of the analysis to cases sensitized to dust mites, and non-sensitized controls, taking the type of floor covering into account, showed not significantly higher Der p I concentrations in bedroom floor dust of cases. However, restriction of the analysis to cases sensitized to dust mites and cases not sensitized to house dust mites--adjusting for allergen avoidance measures taken in the past--revealed a positive association between the Der p I concentrations in bedroom floor dust and mattress dust and sensitization.(ABSTRACT TRUNCATED AT 250 WORDS)

Mite antigen in house dust: relationship with different housing characteristics in The Netherlands

As part of a case-controlled study on the relationship between home dampness and respiratory symptoms of children, the concentration of the major allergen of Dermatophagoides pteronyssinus (Der p I) in floor dust and mattress dust in 516 dwellings in the Netherlands was measured. A checklist, completed by the investigators, was used to obtain information on home and occupant characteristics, which may have an impact on the Der p I concentration in house dust. The geometric mean mite antigen concentrations were 2370 ng Der p I/g floor dust for the living room, 2201 ng Der p I/g floor dust for the bedroom and 5075 ng Der p I/g mattress dust. In 86% of the houses the maximum concentration was higher than 2000 ng Der p I/g dust, that is regarded as representing a risk for genetically predisposed individuals for the development of specific IgE to house dust mite allergen. In 55% of the houses the maximum concentration exceeded 10,000 ng Der p I/g dust, regarded as a risk factor for acute attacks of asthma for mite allergic patients. The Der p I concentrations in dust from carpeted floors were six to 14 times higher than in dust from floors with a smooth floor covering. Higher Der p I concentrations in floor dust were also significantly associated with increasing age of the dwelling and of the floor covering, with an increasing number of occupants, and with the absence of floor insulation. For mattress dust, the age of the mattress, the presence of an outer cavity wall and mechanical ventilation were important factors. Older mattresses had higher levels, and mattress dust from bedrooms with solid brick outer walls had higher levels than that from bedrooms with outer cavity walls. Mattresses in homes with continuous mechanical ventilation had almost twice lower levels than mattresses in homes with natural ventilation. There was a tendency towards higher Der p I concentrations in dust in homes with reported or observed signs of dampness. The Der p I concentrations in dust from carpeted bedroom floors and mattresses were positively associated with the average relative humidity in the bedroom over a period of 3-6 weeks in a subset of the homes where relative humidity was measured. Similar results were obtained using the concentrations of Der p I in ng/m2 instead of ng/g dust. The results obtained in this study are of importance for planning and evaluating allergen avoidance measures advised to mite allergic patients.