Marc Bruijnzeels

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

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

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

Hypertension is rapidly becoming a major public health burden in sub-Saharan/Africa but awareness, treatment, and control is lagging behind. We analysed cross-sectional data from Ghana (West-Africa) to examine factors associated with awareness, treatment, and control of hypertension. The overall prevalence of hypertension was 29.4%. Of these, 34% were aware of their condition, 28% were receiving treatment, and 6.2% were controlled below SBP/DBP <140/90u2009mmHg. Multivariate analysis showed that old age was independently associated with higher hypertension awareness: 35–49-year-olds (odds ratio (OR)=2.57, 95% (confidence interval) CI: 1.26–5.22), ⩾50-year-olds (OR=6.14, CI: 2.98–12.64) compared with 16–34-year-olds. Old age: ⩾50-year-olds (OR: 6.25, 95% CI: 2.87–13.62), trading (OR=2.46, 95% CI: 1.17–5.17), and overweight (OR=1.85, 95% CI: 1.02, 3.34) were independently associated with pharmacological treatment of hypertension. Trading (OR=2.51, 95% CI: 1.03–7.40) was independently associated with adequate blood pressure (BP) control but old age: ⩾50-year-olds (OR=0.11, 95% CI: 0.01–0.60) was independently associated with inadequate BP control. The identified factors provide important information for improving BP control among this population. Given the high cost of hypertension medication relative to income, increasing awareness and simple preventive measures such as promotion of physical activity, normalising body weight and reduction of salt intake, present the best hope for reducing the impact of hypertension on morbidity and mortality.

Patients’ evaluation of quality of care in general practice: What are the cultural and linguistic barriers?

OBJECTIVEnIncreased migration implies increased contacts for physicians with patients from diverse cultural backgrounds who have different expectations about healthcare. How satisfied are immigrant patients, and how do they perceive the quality of care? This study investigated which patient characteristics (such as cultural views and language proficiency) are related to patients satisfaction and perceived quality of care.nnnMETHODSnPatients (n=663) from 38 general practices in Rotterdam (The Netherlands) were interviewed. General satisfaction with the general practitioner (GP) was measured by a report mark. Perceived quality of care was measured using the Quote-mi scale (quality of care through the patients eyes-for migrants), which contains an ethnic-specific subscale and a communication process subscale. Using multilevel regression techniques, the relation between patient characteristics (ethnicity, age, education, Dutch language proficiency, cultural views) and satisfaction and perceived quality of care was analysed.nnnRESULTSnIn general, patients seemed fairly satisfied. Non-Western patients perceived less quality of care and were less satisfied than Dutch-born patients. The older the patients and the more modern cultural views they had, the more satisfied they were about the GP in general, as well as about the communication process. However, non-Western patients holding more modern views were the most critical regarding the ethnic-specific quality items. The poorer patients Dutch language proficiency, the more negative they were about the communication process.nnnCONCLUSIONnIt is concluded that next to communication aspects, especially when the patients proficiency in Dutch is poor, physician awareness about the patients cultural views is very important during the consultation. This holds especially true when the immigrant patient seems to be more or less acculturated.nnnPRACTICE IMPLICATIONSnMedical students and physicians should be trained to become aware of the relevance of patients different cultural backgrounds. It is also recommended to offer facilities to bridge the language barrier, by making use of interpreters or cultural mediators.

When cultures meet in general practice: intercultural differences between GPs and parents of child patients.

Although health care professionals in The Netherlands are increasingly confronted with diverse immigrant groups, medical counselling and treatment of these groups has not been the subject of extensive research yet. From other studies it is well known that intercultural differences can have serious consequences for health care, e.g. in terms of risk of incorrect diagnoses or non-compliance. Eighty-seven autochthonous Dutch and immigrant (mainly from Turkey and Surinam) parents of child patients and their general practitioners (GPs) were recruited to investigate the influence of cultural differences on mutual understanding and patient compliance. Analyses of questionnaires and home interviews revealed that there is a relation between the cultural background of the patient and effectiveness of communication. Communication in consultations between GPs and persons from ethnic minorities is less effective than in consultations with Dutch persons: there is more misunderstanding, and also more non-compliance. In general, mutual understanding between GP and patient proves to be a strong predictor for patient compliance. These findings hold especially true for patients living in two worlds, i.e. a mixture of traditional and western cultures. The results are discussed in terms of methodological issues and practical implications for the health care providers.

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

BackgroundHigh blood pressure, once rare, is rapidly becoming a major public health burden in sub-Saharan/Africa. It is unclear whether this is reflected in children. The main purpose of this study was to assess blood pressure patterns among rural, semi-urban, and urban children and to determine the association of blood pressure with locality and body mass index (BMI) in this sub-Saharan Africa setting.MethodsWe conducted a cross-sectional survey among school children aged 8–16 years in the Ashanti region of Ghana (West-Africa). There were 1277 children in the study (616 boys and 661 females). Of these 214 were from rural, 296 from semi-urban and 767 from urban settings.ResultsBlood pressure increased with increasing age in rural, semi-urban and urban areas, and in both boys and girls. The rural boys had a lower systolic and diastolic blood pressure than semi-urban boys (104.7/62.3 vs. 109.2/66.5; p < 0.001) and lower systolic blood pressure than urban boys (104.7 vs. 107.6; p < 0.01). Girls had a higher blood pressure than boys (109.1/66.7 vs. 107.5/63.8; p < 0.01). With the exception of a lower diastolic blood pressure amongst rural girls, no differences were found between rural girls (107.4/64.4) and semi-urban girls (108.0/66.1) and urban girls (109.8/67.5). In multiple linear regression analysis, locality and BMI were independently associated with blood pressure in both boys and girls.ConclusionThese findings underscore the urgent need for public health measures to prevent increasing blood pressure and its sequelae from becoming another public health burden. More work on blood pressure in children in sub-Saharan African and other developing countries is needed to prevent high blood pressure from becoming a major burden in many of these countries.

Ethnic specific recommendations in clinical practice guidelines: a first exploratory comparison between guidelines from the USA, Canada, the UK, and the Netherlands

Objectives: To investigate whether clinical practice guidelines in different countries take ethnic differences between patients into consideration and to assess the scientific foundation of such ethnic specific recommendations. Design: Analysis of the primary care sections of clinical practice guidelines. Setting: Primary care practice guidelines for type 2 diabetes mellitus, hypertension, and asthma developed in the USA, Canada, the UK, and the Netherlands. Main outcome measures: Enumeration of the ethnic specific information and recommendations in the guidelines, and the scientific basis and strength of this evidence. Results: Different guidelines do address ethnic differences between patients, but to a varying extent. The USA guidelines contained the most ethnic specific statements and the Dutch guidelines the least. Most ethnic specific statements were backed by scientific evidence, usually arising from descriptive studies or narrative reviews. Conclusion: The attention given to ethnic differences between patients in clinical guidelines varies between countries. Guideline developers should be aware of the potential problems of ignoring differences in ethnicity.

Validity and accuracy of interview and diary data on children's medical utilisation in The Netherlands.

STUDY OBJECTIVE: To assess the validity and accuracy of childrens medical utilisation estimates from a health interview and diary and the possible consequences for morbidity estimates. The influence of recall bias and respondent characteristics on the reporting levels was also investigated. DESIGN: Validity study, with the medical record of the general practitioner (GP) as gold standard. In a health interview and three week diary estimates of medical utilisation of children were asked and compared with a GPs medical record. SETTING: General community and primary care centre in the Netherlands. PARTICIPANTS: Parents of 1,805 children and 161 GPs. MAIN RESULTS: The sensitivity of the interview (0.84) is higher than the diary (0.72), while specificity and kappa are higher in the diary (0.96; 0.64) than in the interview (0.91; 0.5-8). Recall bias, expressed as telescoping and heaping, is present in the interview data. Prevalence estimates of all morbidity are much higher in the interview, except for skin problems. Compared with a parental diary more consultations are reported exclusively by the GP for children from ethnic minorities (OR 1.6), jobless (OR 2.3), and less educated mothers (OR 2.6). CONCLUSIONS: Estimates of medical utilisation rates of children are critically influenced by the method of data collection used. Interviews are prone to introduce recall bias, while diaries should only be used in populations with an adequate level of literacy. It is recommended that medical records are used, as they produce most consistent estimates.

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

Objective To assess whether nocturnal blood pressure fall in people of African (Black) and South Asian descent differs from that of the European origin white populations (White). Methods A systematic literature review was carried out using Medline 1966–2003 and Embase 1980–2003, and citations from references. The meta-analysis was performed using Cochrane review manager software (RevMan version 4.2; The Cochrane Collaboration, Oxford, UK). Results Seventeen studies were identified; 11 studies from the USA, one from the USA and Canada, and six studies from the United Kingdom. The mean percentage systolic blood pressure (SBP) nocturnal fall was below 10% (non-dipping) in 10 of 17 studies (59%) and the diastolic blood pressure (DBP) nocturnal fall was below 10% in four of 16 studies (25%) in Blacks compared with four of 17 studies (24%) in SBP and none in DBP nocturnal falls in Whites. Compared with Whites, Blacks had a significantly lower mean percentage nocturnal fall; the overall weighted mean difference in SBP was −3.07 (95% confidence interval, −3.81, −2.33; P < 0.00001) and in DBP was −2.98 (95% confidence interval, −3.97, −2.00; P < 0.00001). Two studies on South Asians showed a higher SBP but a similar mean DBP nocturnal fall compared with Whites. Conclusion Smaller nocturnal blood pressure falls and a higher prevalence of non-dipping may contribute to the higher levels of hypertension complications seen in Black people. No such phenomenon was seen in South Asians but more research is needed to explore their higher stroke mortality.

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

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

Incidence of Febrile Seizures in The Netherlands

To assess the incidence of febrile seizures in The Netherlands, we analyzed data from a population-based study carried out in 161 Dutch general practices. The overall incidence rate was 4.8/1,000 person-years. Considerable age and seasonal variation was found. The chance of a child suffering a febrile seizure in the course of the relevant age period (3-72 months) is 2.7%. One out of 3 children was referred to hospital. This is considerably less than in other countries. The incidence rates are similar to those found in the United States, England and Sweden, but differ from Asian studies.