Umar Z. Ikram

The contribution of perceived ethnic discrimination to the prevalence of depression

BACKGROUND European research on the association between perceived ethnic discrimination (PED) and health is importantly lacking. It is also unknown how much PED contributes to disease prevalence. In this study, we quantified the contribution of PED to depression in five ethnic groups in a middle-size European city. METHODS We used cross-sectional data from the HELIUS study (Healthy Life in an Urban Setting), collected from January 2011 to June 2013 in Amsterdam, The Netherlands. We included a random sample of 1753 ethnic Dutch, 1143 South-Asian Surinamese, 1794 African Surinamese, 1098 Ghanaians and 850 Turks, aged 18-70 years. PED was assessed using the Everyday Discrimination Scale. Patient Health Questionnaire-9 was used for assessing depressive symptoms and major depressive disorder (MDD). We used logistic regression and calculated the contribution of PED to depressive symptoms and MDD using the population attributable fractions. RESULTS Depressive symptoms and MDD were most common in Turks and South-Asian Surinamese, and lowest in ethnic Dutch. PED had a positive association with depressive symptoms and MDD in only the ethnic minority groups. The contributions of PED to depressive symptoms and MDD were around 25% in both the Surinamese groups, and Turks, and ∼15% in Ghanaians. CONCLUSION We conclude that PED contributes considerably to depression in ethnic minority groups in a European context. As such, ethnic inequalities in depression could be reduced substantially if ethnic minority groups would not perceive any ethnic discrimination. We encourage more European research on the health impact of PED.

Association between Integration Policies and Immigrants' Mortality: An Explorative Study across Three European Countries

Background To integrate immigrants into their societies, European countries have adopted different types of policies, which may influence health through both material and psychosocial determinants. Recent studies have suggested poorer health outcomes for immigrants living in countries with poorly rated integration policies. Objective To analyse mortality differences of immigrants from the same country of origin living in countries with distinct integration policy contexts. Methods From the mortality dataset collected in the Migrant Ethnic Health Observatory (MEHO) project, we chose the Netherlands (linked data from 1996-2006), France (unlinked; 2005-2007) and Denmark (linked; 1992-2001) as representatives of the inclusive, assimilationist and exclusionist policy models, respectively, based on the Migrant Integration Policy Index. We calculated for each country sex- and age-standardized mortality rates for Turkish-, Moroccan- and local-born populations aged 20-69 years. Poisson regression was used to estimate the mortality rate ratios (MRRs) for cross-country and within-country comparisons. The analyses were further stratified by age group and cause of death. Results Compared with their peers in the Netherlands, Turkish-born immigrants had higher all-cause mortality in Denmark (MRR men 1.92; 95% CI 1.74-2.13 and women 2.11; 1.80-2.47) but lower in France (men 0.64; 0.59-0.69 and women 0.58; 0.51-0.67). A similar pattern emerged for Moroccan-born immigrants. The relative differences between immigrants and the local-born population were also largest in Denmark and lowest in France (e.g., Turkish-born men MRR 1.52; 95% CI 1.38-1.67 and 0.62; 0.58-0.66, respectively). These patterns were consistent across all age groups, and more marked for cardiovascular diseases. Conclusions Although confounders and data comparability issues (e.g., French cross-sectional data) may affect the findings, this study suggests that different macro-level policy contexts may influence immigrants’ mortality. Comparable mortality registration systems across Europe along with detailed socio-demographic information on immigrants may help to better assess this association.

Perceived Discrimination and Health among Immigrants in Europe According to National Integration Policies.

Background: Discrimination harms immigrants’ health. The objective of this study was to analyze the association between perceived discrimination and health outcomes among first and second generation immigrants from low-income countries living in Europe, while accounting for sex and the national policy on immigration. Methods: Cross-sectional study including immigrants from low-income countries aged ≥15 years in 18 European countries (European Social Survey, 2012) (sample of 1271 men and 1335 women). The dependent variables were self-reported health, symptoms of depression, and limitation of activity. The independent variables were perceived group discrimination, immigrant background and national immigrant integration policy. We tested for association between perceived group discrimination and health outcomes by fitting robust Poisson regression models. Results: We only observed significant associations between perceived group discrimination and health outcomes in first generation immigrants. For example, depression was associated with discrimination among both men and women (Prevalence Ratio-, 1.55 (95% CI: 1.16–2.07) and 1.47 (95% CI: 1.15–1.89) in the multivariate model, respectively), and mainly in countries with assimilationist immigrant integration policies. Conclusion: Perceived group discrimination is associated with poor health outcomes in first generation immigrants from low-income countries who live in European countries, but not among their descendants. These associations are more important in assimilationist countries.

Perceived Ethnic Discrimination and the Metabolic Syndrome in Ethnic Minority Groups: The Healthy Life in an Urban Setting Study.

Objective Ethnic differences in the metabolic syndrome could be explained by perceived ethnic discrimination (PED). It is unclear whether PED is associated with the metabolic syndrome. We assessed this association and quantified the contribution of PED to the metabolic syndrome. Methods Baseline data were used from the Healthy Life in an Urban Setting study collected in the Netherlands from 2011 to 2014. The population-based sample included South-Asian Surinamese, African Surinamese, Ghanaian, Turkish, and Moroccan participants (aged 18 to 70 years). PED was measured using the Everyday Discrimination Scale. The metabolic syndrome was determined according to the harmonized definition of the International Diabetes Federation, American Heart Association, and others. Logistic regression was used for analysis. population-attributable fraction was used to calculate the contribution of PED. Results PED was positively associated with the metabolic syndrome in South-Asian Surinamese, African Surinamese, and Moroccan participants (odds ratio [95% confidence interval] = 1.13 [0.99–1.30], 1.15 [1.00–1.32], and 1.19 [1.03–1.38], respectively) after adjusting for potential confounders and mediators. No significant association was observed among Ghanaian and Turkish participants. For the individual components, the associations were statistically significant for blood pressure, fasting glucose, and waist circumference among Surinamese participants. PED was associated with dyslipidemia in Moroccan participants. The population-attributable fractions were 5% for South-Asian Surinamese and Moroccan participants, and 7% for African Surinamese participants. Conclusions We found a positive association of PED with the metabolic syndrome in some ethnic groups, with PED contributing around 5% to 7% to the metabolic syndrome among Surinamese and Moroccans. This suggests that PED might contribute to ethnic differences in the metabolic syndrome.

The disease burden across different ethnic groups in Amsterdam, the Netherlands, 2011–2030

BACKGROUND Current disease burden estimates do not provide evidence across different ethnic groups. This study aims to assess the disease burden as measured by the disability-adjusted life years (DALYs) for six ethnic groups in Amsterdam, the Netherlands, for 2011 and 2030. METHODS The DALYs were calculated by combining three components: disease-/sex-/age-specific DALYs per person; disease-specific relative risks (RRs) by ethnicity; and sex-/age-specific population sizes by ethnicity in Amsterdam in 2011 and 2030. Disease-specific DALYs were derived from the National Institute of Public Health. The RRs were obtained through a systematic review of studies published in 1997-2008. The population figures were gathered from the Statistics Netherlands and municipality of Amsterdam. RESULTS The findings suggest that cardiovascular diseases and anxiety and depressive disorders dominate disease burden in all ethnic groups in 2011 and 2030. In most of the non-Western ethnic minorities, diabetes mellitus is the strongest contributor to the disease burden. The total disease burden will increase more strongly in non-Western ethnic minorities than ethnic Dutch. The 2030 disease burden is estimated to be highest among Surinamese and Antilleans. CONCLUSIONS In ethnic minorities, diabetes plays an important role in the disease burden, and the total disease burden will grow stronger than ethnic Dutch, resulting in a higher total disease burden for some ethnic groups in 2030. We encourage researchers to estimate the disease burden by ethnicity so that health priorities can be set in the fields of policy, health care and research.

Inequalities by immigrant status in depressive symptoms in Europe: the role of integration policy regimes

PurposeWe aimed to study whether country integration policy models were related to inequalities by immigrant status in depressive symptoms in Europe.MethodsThis is a cross-sectional study using data from 17 countries in the sixth wave of the European Social Survey (2012), comparing subjects born either in the country of residence (non-immigrants, N = 28,333) or in a country not classified as “advanced economy” by the IMF (immigrants, N = 2041). Depressive symptoms were assessed with the eight-item version of the Center for Epidemiologic Studies Depression scale. Countries were grouped into three integration policy regimes (inclusive, assimilationist, and exclusionist). Linear regressions were fitted adjusting first by age, sex, and education level, then sequentially by citizenship, perceived discrimination, and socio-economic variables.ResultsIn all integration regimes, immigrants report significantly more depressive symptoms than non-immigrants. The gap is the largest in exclusionist countries (immigrants score 1.16, 95% CI 0.65–1.68, points higher than non-immigrants in the depression scale), followed by assimilationist countries (0.85 and 0.57–1.13) and inclusive countries (0.60 and 0.36–0.84). Financial strain explains all the associations in inclusive countries, most of it in assimilationist countries, but only a small part in exclusionist countries.ConclusionsAcross most European countries, immigrants seem to experience more depressive symptoms than the population born in the country, mostly reflecting their poorer socio-economic situation. Inequalities are larger in countries with more restrictive policies. Despite some limitations, this study adds new evidence to suggest that immigrants’ health is shaped by integration policies in their host country.

Ethnic Variations in Prognosis of Patients with Dementia: A Prospective Nationwide Registry Linkage Study in The Netherlands

BACKGROUND Data on dementia prognosis among ethnic minority groups are limited in Europe. OBJECTIVE We assessed differences in short-term (1-year) and long-term (3-year) mortality and readmission risk after a first hospitalization or first ever referral to a day clinic for dementia between ethnic minority groups and the ethnic Dutch population in the NetherlandsMethods: Nationwide prospective cohorts of first hospitalized dementia patients (N = 55,827) from January 1, 2000 to December 31, 2010 were constructed. Differences in short-term and long-term mortality and readmission risk following hospitalization or referral to the day clinic between ethnic minority groups (Surinamese, Turkish, Antilleans, Indonesians) and the ethnic Dutch population were investigated using Cox proportional hazard regression models with adjustment for age, sex, and comorbidities. RESULTS Age-sex-adjusted short-term and long-term risks of death following a first hospitalization with dementia were comparable between the ethnic minority groups and the ethnic Dutch. Age- and sex-adjusted risk of admission was higher only in Turkish compared with ethnic Dutch (HR 1.57, 95% CI,1.08-2.29). The difference between Turkish and the Dutch attenuated and was no longer statistically significant after further adjustment for comorbidities. There were no ethnic differences in short-term and long-term risk of death, and risk of readmission among day clinic patients. CONCLUSION Compared with Dutch patients with a comparable comorbidity rate, ethnic minority patients with dementia did not have a worse prognosis. Given the poor prognosis of dementia, timely and targeted advance care planning is essential, particularly in ethnic minority groups who are mired by cultural barriers and where uptake of advance care planning is known to be low.

Parental Smoking and Adult Offspring’s Smoking Behaviors in Ethnic Minority Groups: An Intergenerational Analysis in the HELIUS Study

Introduction To understand smoking behaviors among ethnic minority groups, studies have largely focused on societal factors, with little attention to family influences. Yet studies among majority groups have identified parental smoking as an important risk factor. It is unknown whether this applies to ethnic minority groups. We investigated the association between parental smoking and adult offsprings smoking behaviors among ethnic minority groups with an immigrant background. Methods We used data from the Healthy Life in an Urban Setting study from Amsterdam (the Netherlands) from January 2011 to December 2015. The sample consisted of 2184 parent-offspring pairs from South-Asian Surinamese, African Surinamese, Turkish, Moroccan, and Ghanaian origin. We collected self-reported smoking data: current status, duration of exposure to parental smoking, number of daily cigarettes, heavy smoking ( > 10 cigarettes/day), and nicotine dependency (using the Fagerström Test). Analyses were stratified by offsprings age, cohabitation with parent, education (parent/offspring), offsprings cultural orientation, and gender concordance within pairs. Logistic regression was used. Results Overall, parental smoking was associated with offsprings smoking behaviors (eg, current smoking: odds ratio 2.33; 95% confidence interval 1.79-3.03), with little ethnic variation. We found dose-response associations between exposure to parental smoking and offsprings smoking. The associations were similar across different strata but stronger in gender-concordant pairs (3.16; 2.12-4.51 vs. 1.73; 1.15-2.59 in gender-discordant pairs; p-value for interaction .017). Conclusions Parental smoking is associated with offsprings smoking behaviors in ethnic minority groups across different strata but particularly in gender-concordant pairs. Similar to majority groups, family influences matter to smoking behaviors in ethnic minority groups. Implications Our findings have deepened our understanding of smoking behaviors among ethnic minority groups. Future studies should simultaneously consider societal factors and parental influences, to comprehensively understand their impact on smoking among ethnic minority groups. Also, smoking patterns among family members should be addressed in individual counselling, irrespective of ethnicity.

Association of perceived ethnic discrimination with general and abdominal obesity in ethnic minority groups: the HELIUS study

Background Discrimination is associated with obesity, but this may differ according to the type of obesity and ethnic group. This study examines the association of perceived ethnic discrimination (PED) with general and abdominal obesity in 5 ethnic minority groups. Methods We used cross-sectional data from the HELIUS study, collected from 2011 to 2015. The study sample included 2297 Ghanaians, 4110 African Surinamese, 3021 South-Asian Surinamese, 3562 Turks and 3868 Moroccans aged 18–70 years residing in Amsterdam, the Netherlands. Body mass index (BMI) was used as a measure for general obesity, and waist circumference (WC) for abdominal obesity. PED was measured using the Everyday Discrimination Scale. We used linear regression models adjusted for sociodemographics, psychosocial stressors and health behaviours. In additional analysis, we used standardised variables to compare the strength of the associations. Results In adjusted models, PED was significantly, positively associated with BMI in the South-Asian Surinamese (β coefficient 0.338; 95% CI 0.106 to 0.570), African Surinamese (0.394; 0.171 to 0.618) and Turks (0.269; 0.027 to 0.510). For WC, a similar pattern was seen: positive associations in the South-Asian Surinamese (0.759; 0.166 to 1.353), African Surinamese (0.833; 0.278 to 1.388) and Turks (0.870; 0.299 to 1.440). When stratified by sex, we found positive associations in Surinamese women, Turkish men and Moroccan men. The strength of the associations with BMI and WC was comparable in the groups. Among the Ghanaians, no significant associations were observed. Conclusions Ethnic and sex variations are observed in the association of PED with both general and abdominal obesity. Further research on psychosocial buffers and underlying biological mechanisms might help in understanding these variations.

The relationship between ethnic composition of the residential environment and self-reported health among Turks and Moroccans in Amsterdam

BackgroundPrevious studies from the US and UK suggest that neighbourhood ethnic composition is associated with health, positive or negative, depending on the health outcome and ethnic group. We examined the association between neighbourhood ethnic composition and self-reported health in these groups in Amsterdam, and we aimed to explore whether there is spatial variation in this association.MethodsWe used micro-scale data to describe the ethnic composition in buffers around the home location of 2701 Turks and 2661 Moroccans. Multilevel regression analysis was used to assess the association between three measures of ethnic composition (% co-ethnics, % other ethnic group, Herfindahl index) and three measures of self-reported health: self-rated health, Physical and Mental Component Score (PCS, MCS). We adjusted for socioeconomic position at individual and area level. We used geographically weighted regression and spatially stratified regression analyses to explore whether associations differed within Amsterdam.ResultsEthnic heterogeneity and own ethnic density were not related to self-rated health for both ethnic groups. Higher density of Turks was associated with better self-rated health among Moroccans at all buffer sizes, with the most significant relations for small buffers. Higher heterogeneity was associated with lower scores on PCS and MCS among Turks (suggesting worse health). We found spatial variation in the association of the density of the other ethnic group with self-rated health of Moroccans and Turks. We found a positive association for both groups, spatially concentrated in the sub-district Geuzenveld.ConclusionsOur study showed that the association of ethnic composition with self-reported health among Turks and Moroccans in Amsterdam differed between the groups and reveals mainly at small spatial scales. Among both groups, an association of higher density of the other group with better self-rated health was found in a particular part of Amsterdam, which might be explained by the presence of a relatively strong sense of community between the two groups in that area. The study suggests that it is important to pay attention to other-group density, to use area measurements at small spatial scales and to examine the spatial variation in these associations. This may help to identify neighbourhood characteristics contributing to these type of area effects on urban minority health.