Karien Stronks

Immigrants in the Netherlands: Equal access for equal needs?

OBJECTIVE This paper examines whether equal utilisation of health care services for first generation immigrant groups has been achieved in the Netherlands. DESIGN Survey data were linked to an insurance register concerning people aged 16–64. Ethnic differences in the use of a broad range of health care services were examined in this group, with and without adjustment for health status and socioeconomic status, using logistic regression. SETTING Publicly insured population in Amsterdam, the Netherlands. PARTICIPANTS 1422 people from the indigenous population, and 378 people from the four largest immigrant groups in the Netherlands—that is, the Surinamese, the Netherlands Antilleans, and the Turkish and Moroccan. MAIN OUTCOME MEASURES General practitioner service use (past two months), prescription drug use (past three months), outpatient specialist contact (past two months), hospital admission (past year), physiotherapist contact (past two months) and contact with other paramedics (past year). MAIN RESULTS Ethnicity was found to be associated with the use of health care after controlling for health status as an indicator for need. The use of general practitioner care and the use of prescribed drugs was increased among people from Surinam, Turkey and Morocco as compared with the indigenous population. Compared with the indigenous group with corresponding health status, the use of all other more specialised services was relatively low among Turkish and Moroccan people. Among the Surinamese population, the use of more specialised care was highly similar to that found in the Dutch population after differences in need were controlled for. Among people from the Netherlands Antilles, we observed a relatively high use of hospital services in combination with underuse of general practitioner services. The lower socioeconomic status of immigrant groups explained most of the increased use of the general practitioner and prescribed drugs, but could not account for the lower use of the more specialised services. CONCLUSIONS The results indicate that the utilisation of more specialised health care is lower for immigrant groups in the Netherlands, particularly for Turkish and Moroccan people and to a lesser extent, people from the Netherlands Antilles. Although underuse of more specialised services is also present among the lower socioeconomic groups in the Netherlands, the analyses indicate that this only partly explains the lower utilisation of these services among immigrant groups. This suggests that ethnic background in itself may account for patterns of consumption, potentially because of limited access.

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

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

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

Objective To assess ethnic differences in prevalence, levels of awareness, treatment and control of hypertension among Dutch ethnic groups and to determine whether these differences are consistent with the UK findings. Design Cross-sectional survey. Setting South-east Amsterdam, The Netherlands. Participants A random sample of 1383 non-institutional adults aged 35–60 years. Of these, 36.7% were White, 42% were Black and 21.3% were South Asian people. Main outcome measures Prevalence of hypertension, rates of awareness, treatment, and control of hypertension. Results The Black and South Asian subjects had a higher prevalence of hypertension compared with White people. After adjustments for age, the odds ratios (95% confidence interval) for being hypertensive were 2.2 (1.4–3.4; P < 0.0001) and 3.8 (2.6–5.7; P < 0.0001) for Black men and women, respectively, and 1.7 (1.0–2.6; P = 0.039) and 2.8 (1.8–4.5; P < 0.0001) for South Asian men and women, compared with White people. There were no differences in awareness and pharmacological treatment of hypertension between the groups. However, Black hypertensive men 0.3 (0.1–0.7; P < 0.01) and women 0.5 (0.3–0.9; P < 0.05) were less likely to have their blood pressure adequately controlled compared with White people. Conclusion The higher prevalence of hypertension found among Black and South Asian people in The Netherlands is consistent with the UK studies. However, the lower control rates and the similar levels of awareness and treatment of hypertension in Black Surinamese contrast with the higher rates reported in African Caribbeans in the UK. The rates for the South Asians in The Netherlands were relatively favourable compared to similar South Asian groups in the UK. These findings underscore the urgent need to develop strategies aimed at improving the prevention and control of hypertension, especially among Black people, in The Netherlands.

Cultural competence: a conceptual framework for teaching and learning

Objectives  The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework.

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

BackgroundMost European countries are ethnically and culturally diverse. Globally, cardiovascular disease (CVD) is the leading cause of death. The major risk factors for CVD have been well established. This picture holds true for all regions of the world and in different ethnic groups. However, the prevalence of CVD and related risk factors vary among ethnic groups.MethodsThis article provides a review of current understanding of the epidemiology of vascular disease, principally coronary heart disease (CHD), stroke and related risk factors among populations of Sub-Sahara African descent (henceforth, African descent) in comparison with the European populations in Europe.ResultsCompared with European populations, populations of African descent have an increased risk of stroke, whereas CHD is less common. They also have higher rates of hypertension and diabetes than European populations. Obesity is highly prevalent, but smoking rate is lower among African descent women. Older people of African descent have more favourable lipid profile and dietary habits than their European counterparts. Alcohol consumption is less common among populations of African descent. The rate of physical activity differs between European countries. Dutch African-Suriname men and women are less physically active than the White-Dutch whereas British African women are more physically active than women in the general population. Literature on psychosocial stress shows inconsistent results.ConclusionHypertension and diabetes are highly prevalent among African populations, which may explain their high rate of stroke in Europe. The relatively low rate of CHD may be explained by the low rates of other risk factors including a more favourable lipid profile and the low prevalence of smoking. The risk factors are changing, and on the whole, getting worse especially among African women. Cohort studies and clinical trials are therefore needed among these groups to determine the relative contribution of vascular risk factors, and to help guide the prevention efforts. There is a clear need for intervention studies among these populations in Europe.

A strategy for tackling health inequalities in the Netherlands

The Netherlands ministry of health has undertaken systematic research into inequalities in health. Twelve different interventions have been tried and evaluated, and from the results an independent advisory committee has devised a strategy to reduce inequalities by 2020

Prevalence of diabetes mellitus and the performance of a risk score among Hindustani Surinamese, African Surinamese and ethnic Dutch: a cross-sectional population-based study

BackgroundWhile the prevalence of type 2 diabetes mellitus (DM) is high, tailored risk scores for screening among South Asian and African origin populations are lacking. The aim of this study was, first, to compare the prevalence of (known and newly detected) DM among Hindustani Surinamese, African Surinamese and ethnic Dutch (Dutch). Second, to develop a new risk score for DM. Third, to evaluate the performance of the risk score and to compare it to criteria derived from current guidelines.MethodsWe conducted a cross-sectional population based study among 336 Hindustani Surinamese, 593 African Surinamese and 486 Dutch, aged 35–60 years, in Amsterdam. Logistic regressing analyses were used to derive a risk score based on non-invasively determined characteristics. The diagnostic accuracy was assessed by the area under the Receiver-Operator Characteristic curve (AUC).ResultsHindustani Surinamese had the highest prevalence of DM, followed by African Surinamese and Dutch: 16.7, 8.1, 4.2% (age 35–44) and 35.0, 19.0, 8.2% (age 45–60), respectively. The risk score included ethnicity, body mass index, waist circumference, resting heart rate, first-degree relative with DM, hypertension and history of cardiovascular disease. Selection based on age alone showed the lowest AUC: between 0.57–0.62. The AUC of our score (0.74–0.80) was higher than that of criteria from guidelines based solely on age and BMI and as high as criteria that required invasive specimen collection.ConclusionIn Hindustani Surinamese and African Surinamese populations, screening for DM should not be limited to those over 45 years, as is advocated in several guidelines. If selective screening is indicated, our ethnicity based risk score performs well as a screening test for DM among these groups, particularly compared to the criteria based on age and/or body mass index derived from current guidelines.

Unravelling the impact of ethnicity on health in Europe: the HELIUS study

BackgroundPopulations in Europe are becoming increasingly ethnically diverse, and health risks differ between ethnic groups. The aim of the HELIUS (HEalthy LIfe in an Urban Setting) study is to unravel the mechanisms underlying the impact of ethnicity on communicable and non-communicable diseases.Methods/designHELIUS is a large-scale prospective cohort study being carried out in Amsterdam, the Netherlands. The sample is made up of Amsterdam residents of Surinamese (with Afro-Caribbean Surinamese and South Asian-Surinamese as the main ethnic groups), Turkish, Moroccan, Ghanaian, and ethnic Dutch origin. HELIUS focuses on three disease categories: cardiovascular disease (including diabetes), mental health (depressive disorders and substance use disorders), and infectious diseases. The explanatory mechanisms being studied include genetic profile, culture, migration history, ethnic identity, socio-economic factors and discrimination. These might affect disease risks through specific risk factors including health-related behaviour and living and working conditions. Every five years, participants complete a standardized questionnaire and undergo a medical examination. Biological samples are obtained for diagnostic tests and storage. Participants’ data are linked to morbidity and mortality registries. The aim is to recruit a minimum of 5,000 respondents per ethnic group, to a total of 30,000 participants.DiscussionThis paper describes the rationale, conceptual framework, and design and methods of the HELIUS study. HELIUS will contribute to an understanding of inequalities in health between ethnic groups and the mechanisms that link ethnicity to health in Europe.

Behavioural risk factors in two generations of non-Western migrants: do trends converge towards the host population?

Migrant mortality does not conform to a single pattern of convergence towards prevalence rates in the host population. To understand better how migrant mortality develops, it is necessary to further investigate how the underlying behavioural determinants change following migration. We studied whether the prevalence of behavioural risk factors over two generations of Turkish and Moroccan migrants converge towards the prevalence rates in the Dutch population. From a random sample from the population register of Amsterdam, 291 Moroccan and 505 Turkish migrants, aged 15–30, participated in a structured interview that included questions on smoking, alcohol consumption, physical inactivity and weight/height. Data from the Dutch population were available from Statistics Netherlands. By calculating age-adjusted Odds Ratio’s, prevalence rates among both generations were compared with prevalence rates in the host population for men and women separately. We found indications of convergence across generations towards the prevalence rates in the host population for smoking in Turkish men, for overweight in Turkish and Moroccan women and for physical inactivity in Turkish women. Alcohol consumption, however, remained low in all subgroups and did not converge towards the higher rates in the host population. In addition, we found a reversed trend among Turkish women regarding smoking: the second generation smoked significantly more, while the first generation did not differ from ethnic Dutch. In general, behavioural risk factors in two generations of non-Western migrants in the Netherlands seem to converge towards the prevalence rates in the Dutch population. However, some subgroups and risk factors showed a different pattern.

Overweight and obesity among Ghanaian residents in The Netherlands: how do they weigh against their urban and rural counterparts in Ghana?

OBJECTIVE To investigate differences in overweight and obesity between first-generation Dutch-Ghanaian migrants in The Netherlands and their rural and urban counterparts in Ghana. DESIGN Cross-sectional study. SUBJECTS A total of 1471 Ghanaians (rural Ghanaians, n 532; urban Ghanaians, n 787; Dutch-Ghanaians, n 152) aged > or = 17 years. MAIN OUTCOME MEASURES Overweight (BMI > or = 25 kg/m2) and obesity (BMI > or = 30 kg/m2). RESULTS Dutch-Ghanaians had a significantly higher prevalence of overweight and obesity (men 69.1%, women 79.5%) than urban Ghanaians (men 22.0%, women 50.0%) and rural Ghanaians (men 10.3%, women 19.0%). Urban Ghanaian men and women also had a significantly higher prevalence of overweight and obesity than their rural Ghanaian counterparts. In a logistic regression analysis adjusting for age and education, the odds ratios for being overweight or obese were 3.10 (95% CI 1.75, 5.48) for urban Ghanaian men and 19.06 (95% CI 8.98, 40.43) for Dutch-Ghanaian men compared with rural Ghanaian men. Among women, the odds ratios for being overweight and obese were 3.84 (95% CI 2.66, 5.53) for urban Ghanaians and 11.4 (95% CI 5.97, 22.07) for Dutch-Ghanaians compared with their rural Ghanaian counterparts. CONCLUSION Our current findings give credence to earlier reports of an increase in the prevalence of overweight/obesity with urbanization within Africa and migration to industrialized countries. These findings indicate an urgent need to further assess migration-related factors that lead to these increases in overweight and obesity among migrants with non-Western background, and their impact on overweight- and obesity-related illnesses such as diabetes among these populations.