Hypertension determinants among Ghanaians differ according to location of residence: RODAM study.

OBJECTIVE: Hypertension prevalence is high among African migrants, but the determinants of hypertension in migrants in Europe in relation to the population in the country of origin still needs to be elucidated. Therefore, the aim of this study was to assess the determinants of hypertension in Ghanaians residing in Ghana and Europe. METHODS: The current study used baseline data of 5659 participants, aged 25-70 years, of the Research on Obesity and Diabetes among African Migrants study. Multivariate logistic regression analysis was used to assess sociodemographic, lifestyle, psychosocial, anthropometric and health factors independently associated with hypertension in Ghanaians living in rural and urban Ghana, and Ghanaian migrants living in Europe. RESULTS: Across all sites, older age (both sexes; odds ratio 1.07, 95% confidence interval 1.06-1.08) and diabetes (females only; 2.02, 1.54-1.67) were independently associated with hypertension. The other determinants of hypertension differed between geographical locations. Higher waist circumference (1.12, 1.05-1.20) was independently associated with hypertension in rural-Ghanaian males, as was higher body mass index (1.15, 1.03- 1.28) in urban-Ghanaian males, higher waist circumference (1.04, 1.01-1.07) and diabetes (1.75, 1.17-2.63) in European-Ghanaian males. In European-Ghanaian females, high alcohol intake (1.88, 1.01 -3.53) and waist circumference (1.04, 1.02- 1.06) were associated with hypertension, whereas in rural-Ghanaian females, a higher educational level (0.28, 0.08-0.98) was inversely associated with hypertension. CONCLUSION: The current study identified several modifiable determinants of hypertension in Ghanaians, with differences between populations residing in various geographical locations. This highlights the importance of development and implementation of context-specific interventions targeting these determinants to reduce the burden of hypertension among Ghanaian migrants and nonmigrants.

Serum potassium concentration and its association with hypertension among Ghanaian migrants and non-migrants: The RODAM study.

BACKGROUND AND AIMS: Low serum potassium concentration is associated with hypertension, but whether the same association can be found in African origin populations, is unknown. We assessed serum potassium concentration, and its association with hypertension among Ghanaians living in different geographical locations. METHODS: Baseline data of 962 rural, 1420 urban, and 2947 migrant Ghanaians from the Research on Obesity and Diabetes among African Migrants study were analysed. Mean serum potassium concentration was compared between the groups, and the association between serum potassium and hypertension was assessed using multivariate regression analyses. RESULTS: Mean serum potassium concentration was higher in rural Ghana (4.28, 95% confidence interval 4.25-4.32 mmol/L) than in Ghanaians living in Amsterdam (3.90, 3.88-3.92 mmol/L) and London (4.11, 4.07-4.14 mmol/L), but lower than in Ghanaians living in urban Ghana (4.38, 4.34-4.42 mmol/L) and Berlin (4.57, 4.51-4.62 mmol/L) in both sexes. In the age-adjusted analyses, serum potassium was associated with hypertension in urban- (odds ratio 0.44, 0.23-0.82), London- (0.34, 0.17-0.64) and Amsterdam-Ghanaian males (0.41, 0.20-0.86), and in rural- (0.49, 0.28-0.84), London- (0.29, 0.17-0.49) and Amsterdam-Ghanaian females (0.33, 0.17-0.64). However, after adjustment for demographic, lifestyle, and health factors, serum potassium was associated with hypertension in Amsterdam-Ghanaian males only (0.12, 0.02-0.59). CONCLUSIONS: This study shows differences in mean serum potassium among Ghanaian populations living in different locations in Europe and Ghana, and different associations with hypertension between sites. Further research should focus on elucidating the mechanism underlying potassium handling and blood pressure regulation in African populations, in order to mitigate the burden of hypertension among these populations.

The Magnitude and Directions of the Associations between Early Life Factors and Metabolic Syndrome Differ across Geographical Locations among Migrant and Non-Migrant Ghanaians-The RODAM Study.

BACKGROUND: Early-life factors (ELFs) such as childhood nutrition and childhood socio-economic status could be the drivers of the increase in metabolic syndrome (MetSyn) among African populations, but data are lacking. This study evaluated whether markers of childhood nutritional status and childhood socio-economic status were associated with MetSyn in adulthood among migrant Ghanaians living in Europe and non-migrant Ghanaians living in Ghana. METHODS: Data from the Research on Obesity and Diabetes among African Migrants (RODAM) study, involving 2008 migrants and 2320 non-migrants aged ≥25 years, were analysed for this study. We used leg-length to height ratio (LHR), which is an anthropometric marker of childhood nutritional status, and parental education, which is a marker of childhood socio-economic status, as proxies. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated by logistic regression with adjustments for demographic and lifestyle factors. RESULTS: Parental education was higher among Ghanaians in Europe than among residents in rural and urban Ghana. The prevalence of MetSyn was 18.5%, 27.7% and 33.5% for rural, urban, and migrant residents, respectively. LHR was inversely associated with MetSyn among migrants. Compared with high paternal education, individuals with low paternal education had lower odds of MetSyn in migrants (AOR 0.71 95% CI 0.54-0.94). In contrast, compared with high maternal education, individuals with intermediate maternal education had higher odds of MetSyn in urban Ghanaians (AOR 4.53 95% CI 1.50-3.74). No associations were found among rural Ghanaians. CONCLUSION: The magnitude and direction of the associations between ELFs and MetSyn differ across geographical locations. Intermediate maternal education was positively associated with MetSyn among urban Ghanaians, while LHR and low paternal education were inversely associated with MetSyn among migrant Ghanaians. Further research into the interplay of genetics, environment and behaviour is needed to elucidate the underlying pathological mechanisms of MetSyn amongst migrants.

Associations of Serum Uric Acid Levels With Macrovascular and Renal Microvascular Dysfunction Among Individuals From Sub-Saharan Africa.

Importance: Serum uric acid (SUA) level is associated with vascular dysfunction in Eurasian populations, but little is known about this association in individuals from sub-Saharan Africa, who have a high prevalence of both relatively high SUA levels and vascular dysfunction. Objectives: To assess the associations of SUA levels with macrovascular and kidney microvascular dysfunction in individuals of sub-Saharan African ancestry and evaluate potential factors that could mediate these associations. Design, Setting, and Participants: Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes Among African Migrants study, conducted from 2012 to 2015, were performed from January to March 2021. The population included Ghanaian individuals living in Ghana and Europe. Exposure: Abnormal SUA levels. Main Outcomes and Measures: Logistic regression was used to examine the associations of SUA level quartiles with microvascular (albuminuria) and macrovascular (peripheral artery disease and coronary artery disease) dysfunction, with adjustments for age, sex, estimated glomerular filtration rate, site of residence, socioeconomic status, alcohol, smoking, diabetes, hypertension, waist-hip ratio, and total cholesterol level. Mediation analysis was performed to assess whether the association was via elevated blood pressure, hemoglobin A1c, and high-sensitivity C-reactive protein levels or via weight-hip ratio. The research questions were formulated after data collection. Results: A total of 4919 Ghanaian individuals (3047 [61.9%] women) aged 25-75 years (mean [SD], 46.26 [11.08] years) were included. There was a significant positive association between SUA quartiles and albuminuria, but not coronary artery disease or peripheral artery disease, after adjustment for covariates. After full adjustment, individuals in the fourth SUA quartile had higher odds of albuminuria (adjusted odds ratio [aOR], 1.54; 95% CI, 1.07-2.21), but not peripheral artery disease (aOR, 1.35; 95% CI, 0.87-2.08) or coronary artery disease (aOR, 1.09; 95% CI, 0.77-1.55), compared with individuals in the first quartile. After full adjustment, systolic and diastolic blood pressure significantly mediated the association between SUA concentrations and albuminuria, accounting for 19.4% of the total association for systolic and 17.2% for diastolic blood pressure; hemoglobin A1c, high-sensitivity C-reactive protein, and waist-hip ratio did not mediate this association. Conclusions and Relevance: In this cross-sectional study among a sub-Saharan African population, elevated SUA levels were significantly associated with kidney microvascular dysfunction and mediated partly through elevated blood pressure. These findings suggest that individuals from sub-Saharan Africa with elevated SUA levels may benefit from periodic screening for kidney microvascular dysfunction to aid early detection or treatment.

Body size ideals and body satisfaction among Dutch-origin and African-origin residents of Amsterdam: The HELIUS study.

OBJECTIVE: Obesity is highly prevalent among ethnic minorities and acceptance of larger body sizes may put these ethnic minorities at risk of obesity. This study aimed to examine body size ideals and body satisfaction in relation to body weight, in two Sub-Saharan African (SSA)-origin groups in the Netherlands compared to the Dutch. Additionally, in the two SSA-origin groups, this study assessed the mediating role of acculturation in the relation between ethnicity and body size ideals and body satisfaction. METHODS: Dutch, African Surinamese and Ghanaians living in Amsterdam, the Netherlands, participated in the observational HELIUS study (n = 10,854). Body size ideals were assessed using a validated nine figure scale. Body satisfaction was calculated as the concordance of current with ideal figure. Acculturation was only assessed among SSA-origin participants and acculturation proxies included age of migration, residence duration, ethnic identity and social network. Weight and height were measured using standardised protocols. RESULTS: SSA-origin women and Ghanaian men had larger body size ideals compared to the Dutch; e.g. Surinamese and Ghanaian women had 0.37 (95%CI 0.32; 0.43) and 0.70 (95%CI 0.63; 0.78) larger body size ideals compared to Dutch women. SSA-origin participants were more often satisfied with their weight compared to the Dutch. Similarly, SSA-origin participants had more than twice the odds of being satisfied/preferring a larger figure compared to the Dutch (e.g. BSurinamese men 2.44, 95%CI 1.99; 2.99). Within the two SSA-origin groups, most acculturation proxies mediated the relation between ethnicity and body size ideals in women. Limited evidence of mediation was found for the outcome body satisfaction. CONCLUSION: Public health strategies promoting a healthy weight may need to be differentiated according to sex and ethnic differences in body weight perception. Factors other than acculturation may underlie the ethnic differences between African Surinamese and Ghanaians in obesity.

Determinants of suboptimal blood pressure control in a multi-ethnic population: The Healthy Life in an Urban Setting (HELIUS) study.

Among ethnic minority groups in Europe, blood pressure (BP) control is often suboptimal. We aimed to identify determinants of suboptimal BP control in a multi-ethnic population. We analyzed cross-sectional data of the Healthy Life in an Urban Setting (HELIUS) study, including 3571 participants aged 18-70 with prescribed antihypertensive medication, of various ethnic backgrounds (500 Dutch, 1052 African Surinamese, 656 South-Asian Surinamese, 637 Ghanaian, 433 Turkish, and 293 Moroccan) living in Amsterdam, the Netherlands. 53.3% of the population had suboptimal BP control, defined as BP ≥140/90 mmHg despite prescribed antihypertensives. Using multivariate logistic regression analysis, female sex (OR 0.50, 95%CI 0.43-0.59), being married (0.83, 0.72-0.96), smoking (0.78, 0.65-0.94), alcohol intake (0.80, 0.66-0.96), obesity (1.67, 1.35-2.06), cardiovascular disease (CVD) history (0.56, 0.46-0.68), non-adherence to antihypertensives (1.26, 1.00-1.58), and family history of hypertension (1.19, 1.02-1.38) were identified to be independently associated with suboptimal BP control in the total population. In the ethnic-stratified analysis, factors associated with better BP control were female sex (all ethnic groups), smoking (Turks), and CVD history (Dutch, South-Asian Surinamese, and African Surinamese), whereas factors associated with suboptimal BP control were older age (Turks), obesity (Dutch, African Surinamese, Ghanaian, and Turks), and non-adherence to antihypertensives (Dutch). In conclusion, our analysis identifies several key determinants that are independently associated with suboptimal BP control in a multi-ethnic population, with some important variations between ethnic groups. Targeting these determinants may help to improve BP control.

Hypertension awareness, treatment and control among ethnic minority populations in Europe: a systematic review and meta-analysis.

OBJECTIVE: Ethnic minority populations (EMPs) are disproportionally affected by hypertension-mediated complications compared with European host populations (EHPs), which might be due to disparities in hypertension awareness, treatment and control. We conducted a systematic review and meta-analysis to compare awareness, treatment and control rates among EMPs with EHPs. METHODS: MEDLINE, EMBASE and Web of Science were searched from inception to 29 January 2020. Critical appraisal was performed according to methods of Hoy et al. Pooled odds ratios with corresponding 95% confidence intervals were calculated for these rates, stratified by ethnic group, using either random or fixed effect meta-analysis based on I2-statistics. Study was registered in PROSPRO (CRD42020107897). RESULTS: A total of 3532 records were screened of which 16 were included in the analysis with data on 26 800 EMP and 57 000 EHP individuals. Compared with EHPs, African origin populations were more likely to be aware (odds ratio 1.26, 95% confidence interval 1.02-1.56) and treated (1.49, 1.18-1.88) for hypertension, but were less likely to have their blood pressure controlled (0.56, 0.40-0.78), whereas South Asian populations were more likely to be aware (1.15, 1.02-1.30), but had similar treatment and control rates. In Moroccan populations, hypertension awareness (0.79, 0.62-1.00) and treatment levels (0.77, 0.60-0.97) were lower compared with EHPs, while in Turkish populations awareness was lower (0.81, 0.65-1.00). CONCLUSION: Levels of hypertension awareness, treatment and control differ between EMPs and EHPs. Effort should be made to improve these suboptimal rates in EMPs, aiming to reduce ethnic inequalities in hypertension-mediated complications.

Association between C reactive protein and microvascular and macrovascular dysfunction in sub-Saharan Africans with and without diabetes: the RODAM study.

INTRODUCTION: Although inflammation assessed by elevated C reactive protein (CRP) concentration is known to be associated with risk of cardiovascular disease, its association with microvascular and macrovascular dysfunction in diabetes and non-diabetes remains unclear. We examined the association between CRP and diabetes and associated microvascular and macrovascular dysfunction in sub-Saharan Africans with and without diabetes. RESEARCH DESIGN AND METHODS: Cross-sectional analyses of baseline data from the multicenter RODAM study (Research on Obesity and Diabetes among African Migrants) including 5248 Ghanaians (583 with diabetes, 4665 without diabetes) aged 25-70 years were done. Logistic regression analyses were used to examine the associations between CRP Z-scores and diabetes and microvascular (nephropathy) and macrovascular (peripheral artery disease (PAD)) dysfunction, with adjustments for age, sex, site of residence, smoking, body mass index, systolic blood pressure, and low-density lipoprotein cholesterol. RESULTS: In the fully adjusted models, higher CRP concentration was significantly associated with diabetes (adjusted OR 1.13; 95% CI 1.05 to 1.21, p=0.002). In participants with diabetes, higher CRP concentration was associated with PAD (1.19; 1.03 to 1.41, p=0.046) but not nephropathy (1.13; 0.97 to 1.31, p=0.120). Among participants without diabetes, higher CRP concentration was associated with higher odds of PAD (1.10; 1.01 to 1.21, p=0.029) and nephropathy (1.12; 1.04 to 1.22, p=0.004). CONCLUSIONS: In this study, higher CRP concentration was associated with higher odds of diabetes in sub-Saharan Africans. Also, higher CRP concentration was associated with higher odds of nephropathy and PAD in non-diabetes and higher odds of PAD in diabetes. CRP may be an important marker for assessment of risk of diabetes and risk for PAD and nephropathy in sub-Saharan Africans with and without diabetes.

Food consumption, nutrient intake, and dietary patterns in Ghanaian migrants in Europe and their compatriots in Ghana.

Background: West African immigrants in Europe are disproportionally affected by metabolic conditions compared to European host populations. Nutrition transition through urbanisation and migration may contribute to this observations, but remains to be characterised. Objective: We aimed to describe the dietary behaviour and its socio-demographic factors among Ghanaian migrants in Europe and their compatriots living different Ghanaian settings. Methods: The multi-centre, cross-sectional RODAM (Research on Obesity and Diabetes among African Migrants) study was conducted among Ghanaian adults in rural and urban Ghana, and Europe. Dietary patterns were identified by principal component analysis. Results: Contributions of macronutrient to the daily energy intake was different across the three study sites. Three dietary patterns were identified. Adherence to the 'mixed' pattern was associated with female sex, higher education, and European residency. The 'rice, pasta, meat, and fish' pattern was associated with male sex, younger age, higher education, and urban Ghanaian environment. Adherence to the 'roots, tubers, and plantain' pattern was mainly related to rural Ghanaian residency. Conclusion: We observed differences in food preferences across study sites: in rural Ghana, diet concentrated on starchy foods; in urban Ghana, nutrition was dominated by animal-based products; and in Europe, diet appeared to be highly diverse.

Disparities in type 2 diabetes prevalence among ethnic minority groups resident in Europe: a systematic review and meta-analysis.

Many ethnic minorities in Europe have a higher type 2 diabetes (T2D) prevalence than their host European populations. The risk size differs between ethnic groups, but the extent of the differences in the various ethnic minority groups has not yet been systematically quantified. We conducted a meta-analysis of published data on T2D in various ethnic minority populations resident in Europe compared to their host European populations. We systematically searched MEDLINE (using PUBMED) and EMBASE for papers on T2D prevalence in ethnic minorities in Europe published between 1994 and 2014. The ethnic minority groups were classified into five population groups by geographical origin: South Asian (SA), Sub-Saharan African (SSA), Middle Eastern and North African (MENA), South and Central American (SCA), and Western Pacific (WP). Pooled odds ratios with corresponding 95 % confidence interval (CI) were calculated using Review Manager 5.3. Twenty articles were included in the analysis. Compared with the host populations, SA origin populations had the highest odds for T2D (3.7, 95 % CI 2.7-5.1), followed by MENA (2.7, 95 % CI 1.8-3.9), SSA (2.6, 95 % CI 2.0-3.5), WP (2.3, 95 % CI 1.2-4.1), and lastly SCA (1.3, 95 % CI 1.1-1.6). Odds ratios were in all ethnic minority populations higher for women than for men except for SCA. Among SA subgroups, compared with Europeans, Bangladeshi had the highest odds ratio of 6.2 (95 % CI 3.9-9.8), followed by Pakistani (5.4, 95 % CI 3.2-9.3) and Indians (4.1, 95 % CI 3.0-5.7). The risk of T2D among ethnic minority groups living in Europe compared to Europeans varies by geographical origin of the group: three to five times higher among SA, two to four times higher among MENA, and two to three times higher among SSA origin. Future research and policy initiatives on T2D among ethnic minority groups should take the interethnic differences into account.

Prevalence of type 2 diabetes and its association with measures of body composition among African residents in the Netherlands--The HELIUS study.

AIMS: To compare type 2 diabetes prevalence among three ethnic groups resident in the Netherlands: Ghanaians, African Surinamese and Dutch origin. Secondly, to determine the contribution of measures of body composition to ethnic differences in type 2 diabetes. METHODS: Baseline data from Ghanaian (n=1873), African Surinamese (n=2189) and Dutch (n=2151) origin participants of the HELIUS study (aged 18-70 years) were analyzed. Type 2 diabetes was determined according to the WHO criteria. Logistic regression tested ethnic differences in type 2 diabetes and the contribution of body fat percentage and waist-to-hip ratio. RESULTS: Among men, type 2 diabetes prevalence was higher in Ghanaians (14.9%) than in African Surinamese (10.4%) and Dutch (5.0%). Among women, type 2 diabetes prevalence in Ghanaian (11.1%) was higher than in Dutch (2.3%), but similar to African Surinamese (11.5%). After adjusting for age, body fat percentage and waist-to-hip ratio, the odds ratios for having type 2 diabetes were 1.55 (95% CI: 1.12-2.15) for Ghanaian men compared with African Surinamese and 4.19 (95% CI: 2.86-6.12) compared with Dutch. Among women these odds ratios were 0.94 (95% CI: 0.70-1.26) and 4.78 (95% CI: 2.82-8.11). CONCLUSIONS: The higher prevalence of type 2 diabetes among Ghanaian compared with African Surinamese men suggests a need to distinguish between African descent populations when assessing their type 2 diabetes risk. The higher odds for type 2 diabetes among Ghanaians cannot be attributed to differences in body composition. Further research on the contribution of lifestyle factors as well as genetic and epigenetic factors is needed to identify the reasons for the observed disparities.

Determinants of adherence to treatment in hypertensive patients of African descent and the role of culturally appropriate education.

BACKGROUND: In Western countries, better knowledge about patient-related determinants of treatment adherence (medication and lifestyle) is needed to improve treatment adherence and outcomes among hypertensive ethnic minority patients of African descent. OBJECTIVE: To identify patient-related determinants of adherence to lifestyle and medication recommendations among hypertensive African Surinamese and Ghanaian patients with suboptimal treatment results (SBP≥140) living in the Netherlands and how culturally appropriate hypertension education (CAHE) influenced those determinants. METHODS: This study analysed data of 139 patients who participated in the CAHE trial. Univariate logistic regression analysis was used to measure the association between patient-related determinants (medication self-efficacy, beliefs about medication and hypertension, social support, and satisfaction with care) and treatment adherence. We also tested whether CAHE influenced the determinants. RESULTS: Medication self-efficacy and social support were associated with medication adherence at baseline. At six months, more medication self-efficacy and fewer concerns about medication use were associated with improved medication adherence. Self-efficacy was also associated with adherence to lifestyle recommendations at baseline. CAHE influenced patients' illness perceptions by creating more understanding of hypertension, its chronic character, and more concerns about the associated risks. CONCLUSION: In this high-risk population, health care providers can support medication adherence by paying attention to patients' medication self-efficacy, the concerns they may have about medication use and patients' perceptions on hypertension. The CAHE intervention improved patients' perception on hypertension.

Hypertension control in a large multi-ethnic cohort in Amsterdam, The Netherlands: the HELIUS study.

OBJECTIVE: Hypertension is a major problem among European ethnic minority groups. We assessed the current situation of hypertension prevalence and its management among a multi-ethnic population in Amsterdam, The Netherlands. METHODS: Data from the HELIUS study were used including 12,974 participants (1871 Ghanaian, 2184 African Surinamese, 2278 South-Asian Surinamese, 2277 Turkish, 2222 Moroccan and 2142 Dutch origin people), aged 18-70 years. Comparisons among groups were made using proportions and age-adjusted prevalence ratios (PRs). RESULTS: Hypertension prevalence ranged from 24% and 16% in Moroccan men and women to 52% and 62% in Ghanaian men and women. Except for Moroccan women, age-adjusted PR of hypertension was higher in all the ethnic minority groups than in Dutch. Among hypertensives, ethnic minority groups generally had higher levels of hypertension awareness and BP lowering treatment than Dutch. Moreover, prevalence rates for the prescription of more than one BP lowering drug were generally higher in African and South-Asian origin groups compared with Dutch origin people. By contrast, BP control levels were lower in all the ethnic groups than in Dutch, with control rates being significantly lower in Ghanaian men (26%, PR=0.49; 95% CI, 0.37-0.66) and women (45%, PR=0.64; 0.52-0.77), African-Surinamese men (30%, PR=0.61; 0.46-0.81) and women (45%, PR=0.72; 0.51-0.77), and South-Asian Surinamese men (43%, PR=0.77; 0.61-0.97) and women (47%, PR=0.76; 0.63-0.92) compared with Dutch men (53%) and women (61%). CONCLUSION: Our findings indicate poor BP control in ethnic minority groups despite the high treatment levels. More work is needed to unravel the potential factors contributing to the poor control in order to improve BP control in ethnic minority groups, particularly among African and South-Asian origin groups.

Diabetes self-management support for patients with low health literacy: Perceptions of patients and providers.

BACKGROUND: The aim of the present study was to explore perceptions and strategies of health care providers regarding diabetes self-management support for patients with low health literacy (LHL), and to compare their self-management support with the needs of patients with LHL and type 2 diabetes. This study serves as a problem analysis for systematic intervention development to improve diabetes self-management among patients with LHL. METHODS: This qualitative study used in-depth interviews with general practitioners (n = 4), nurse practitioners (n = 5), and patients with LHL (n = 31). The results of the interviews with health care providers guided the patient interviews. In addition, we observed 10 general practice consultations. RESULTS: Providers described patients with LHL as uninvolved and less motivated patients who do not understand self-management. Their main strategy to improve self-management was to provide standard information on a repeated basis. Patients with LHL seemed to have a different view of diabetes self-management than their providers. Most demonstrated a low awareness of what self-management involves, but did not express needing more information. They reported several practical barriers to self-management, although they seemed reluctant to use the information provided to overcome them. CONCLUSIONS: Providing and repeating information does not fit the needs of patients with LHL regarding diabetes self-management support. Health care providers do not seem to have the insight or the tools to systematically support diabetes self-management in this group. Systematic intervention development with a focus on skills-based approaches rather than cognition development may improve diabetes self-management support of patients with LHL.

Patients׳ perspectives on how treatment can impede their recovery from depression.

BACKGROUND: More than 50% of all major depressive disorder (MDD) patients experience insufficient improvement from the available treatment options. There is emerging evidence that patients׳ beliefs and experiences about MDD treatment influence treatment outcomes. The aim was to explore patients׳ perspectives on impeding characteristics of professional treatment for the recovery of MDD. METHODS: In-depth interviews in a purposive sample with 27 recovered MDD patients who had received professional treatment. Data were qualitatively analyzed using constant comparison. RESULTS: Participants׳ accounts yielded four major impeding themes: lack of clarity and consensus about the nature of the participants׳ MDD and the content of their treatment; precarious relationship with the clinician; unavailability of mental health care; and insufficient involvement of significant others. LIMITATIONS: The external generalizability may be limited due to missed other subgroups within depression. CONCLUSIONS: This study identified a comprehensive overview of impeding characteristics in MDD treatment from patients׳ perspectives. This may help clinicians to understand how patients experience MDD treatment, and to incorporate patients׳ perspectives about treatment into their joint decision-making. This can lead towards increased treatment adherence, motivation and finally success.

Culturally adapted hypertension education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: cluster-randomized trial.

OBJECTIVES: To evaluate the effect of a practice-based, culturally appropriate patient education intervention on blood pressure (BP) and treatment adherence among patients of African origin with uncontrolled hypertension. METHODS: Cluster randomised trial involving four Dutch primary care centres and 146 patients (intervention n=75, control n=71), who met the following inclusion criteria: self-identified Surinamese or Ghanaian; ≥ 20 years; treated for hypertension; SBP ≥ 140 mmHg. All patients received usual hypertension care. The intervention-group was also offered three nurse-led, culturally appropriate hypertension education sessions. BP was assessed with Omron 705-IT and treatment adherence with lifestyle- and medication adherence scales. RESULTS: 139 patients (95%) completed the study (intervention n=71, control n=68). Baseline characteristics were largely similar for both groups. At six months, we observed a SBP reduction of ≥ 10 mmHg -primary outcome- in 48% of the intervention group and 43% of the control group. When adjusted for pre-specified covariates age, sex, hypertension duration, education, baseline measurement and clustering effect, the between-group difference was not significant (OR; 0.42; 95% CI: 0.11 to 1.54; P=0.19). At six months, the mean SBP/DBD had dropped by 10/5.7 (SD 14.3/9.2)mmHg in the intervention group and by 6.3/1.7 (SD 13.4/8.6)mmHg in the control group. After adjustment, between-group differences in SBP and DBP reduction were -1.69 mmHg (95% CI: -6.01 to 2.62, P=0.44) and -3.01 mmHg (-5.73 to -0.30, P=0.03) in favour of the intervention group. Mean scores for adherence to lifestyle recommendations increased in the intervention group, but decreased in the control group. Mean medication adherence scores improved slightly in both groups. After adjustment, the between-group difference for adherence to lifestyle recommendations was 0.34 (0.12 to 0.55; P=0.003). For medication adherence it was -0.09 (-0.65 to 0.46; P=0.74). CONCLUSION: This intervention led to significant improvements in DBP and adherence to lifestyle recommendations, supporting the need for culturally appropriate hypertension care. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN35675524.

Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. a systematic review.

BACKGROUND: The importance of cultural adaptations in behavioral interventions targeting ethnic minorities in high-income societies is widely recognized. Little is known, however, about the effectiveness of specific cultural adaptations in such interventions. AIM: To systematically review the effectiveness of specific cultural adaptations in interventions that target smoking cessation, diet, and/or physical activity and to explore features of such adaptations that may account for their effectiveness. METHODS: Systematic review using MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials registers (1997-2009). INCLUSION CRITERIA: a) effectiveness study of a lifestyle intervention targeted to ethnic minority populations living in a high income society; b) interventions included cultural adaptations and a control group that was exposed to the intervention without the cultural adaptation under study; c) primary outcome measures included smoking cessation, diet, or physical activity. RESULTS: Out of 44904 hits, we identified 17 studies, all conducted in the United States. In five studies, specific cultural adaptations had a statistically significant effect on primary outcomes. The remaining studies showed no significant effects on primary outcomes, but some presented trends favorable for cultural adaptations. We observed that interventions incorporating a package of cultural adaptations, cultural adaptations that implied higher intensity and those incorporating family values were more likely to report statistically significant effects. Adaptations in smoking cessation interventions seem to be more effective than adaptations in interventions aimed at diet and physical activity. CONCLUSION: This review indicates that culturally targeted behavioral interventions may be more effective if cultural adaptations are implemented as a package of adaptations, the adaptation includes family level, and where the adaptation results in a higher intensity of the intervention. More systematic experiments are needed in which the aim is to gain insight in the best mix of cultural adaptations among diverse populations in various settings, particularly outside the US.

Barriers and enablers in the implementation of a provider-based intervention to stimulate culturally appropriate hypertension education.

OBJECTIVE: to identify barriers and enablers influencing the implementation of an intervention to stimulate culturally appropriate hypertension education (CAHE) among health care providers in primary care. METHODS: the intervention was piloted in three Dutch health centers. It consists of a toolkit for CAHE, training, and feedback meetings for hypertension educators. Data were collected from 16 hypertension educators (nurse practitioners and general practice assistants) during feedback meetings and analyzed using qualitative content analysis. RESULTS: perceived barriers to the implementation of the intervention fell into three main categories: political context (health care system financing); organizational factors (ongoing organizational changes, work environment, time constraints and staffing) and care provider-related factors (routines, attitudes, computer and educational skills, and cultural background). Few barriers were specifically related to the delivery of CAHE (e.g. resistance to registering ethnicity). Enabling strategies addressing these barriers consisted of reorganizing practice procedures, team coordination, and providing reminders and additional instructions to hypertension educators. CONCLUSION AND PRACTICE IMPLICATIONS: the adoption of a tool for CAHE by care providers can be accomplished if barriers are identified and addressed. The majority of these barriers are commonly associated with the implementation of health care innovations in general and do not indicate resistance to providing culturally appropriate care.

A cluster-randomized controlled trial evaluating the effect of culturally-appropriate hypertension education among Afro-Surinamese and Ghanaian patients in Dutch general practice: study protocol.

BACKGROUND: Individuals of African descent living in western countries have increased rates of hypertension and hypertension-related complications. Poor adherence to hypertension treatment (medication and lifestyle changes) has been identified as one of the most important modifiable causes for the observed disparities in hypertension related complications, with patient education being recommended to improve adherence. Despite evidence that culturally-appropriate patient education may improve the overall quality of care for ethnic minority patients, few studies have focused on how hypertensive individuals of African descent respond to this approach. This paper describes the design of a study that compares the effectiveness of culturally-appropriate hypertension education with that of the standard approach among Surinamese and Ghanaian hypertensive patients with an elevated blood pressure in Dutch primary care practices. METHODS/DESIGN: A cluster-randomized controlled trial will be conducted in four primary care practices in Amsterdam, all offering hypertension care according to Dutch clinical guidelines. After randomization, patients in the usual care sites (n = 2) will receive standard hypertension education. Patients in the intervention sites (n = 2) will receive three culturally-appropriate hypertension education sessions, culturally-specific educational materials and targeted lifestyle support. The primary outcome will be the proportion of patients with a reduction in systolic blood pressure >or= 10 mmHg at eight months after the start of the trial. The secondary outcomes will be the proportion of patients with self-reported adherence to (i) medication and (ii) lifestyle recommendations at eight months after the start of the trial. The study will enrol 148 patients (74 per condition, 37 per site). Eligibility criteria for patients of either sex will be: current diagnosis of hypertension, self-identified Afro-Surinamese or Ghanaian, >or= 20 years, and baseline blood pressure >or= 140/90 mmHg. Primary and secondary outcomes will be measured at baseline and at 3 1/2, 6 1/2, and eight months. Other measurements will be performed at baseline and eight months. DISCUSSION: The findings will provide new knowledge on how to improve blood pressure control and patient adherence in ethnic minority persons with a high risk of negative hypertension-related health outcomes. TRIAL REGISTRATION: ISRCTN35675524.

How Ghanaian, African-Surinamese and Dutch patients perceive and manage antihypertensive drug treatment: a qualitative study.

OBJECTIVES: To explore and compare how Ghanaian, African-Surinamese (Surinamese), and White-Dutch patients perceive and manage antihypertensive drug treatment in Amsterdam, the Netherlands. METHODS: Qualitative study was conducted using detailed interviews with a purposive sample of 46 hypertensive patients without comorbidity who were prescribed antihypertensives. RESULTS: Patients in all the ethnic groups actively decided how to manage their prescribed antihypertensive regimens. In all the groups, confidence in the doctor and beneficial effects of medication were reasons for taking prescribed antihypertensive dosage. Particularly, ethnic-minority patients reported lowering or leaving off the prescribed medication dosage. Explanations for altering prescribed dosage comprised disliking chemical medications, fear of side effects and preference for alternative treatment. Surinamese and Ghanaian men also worried about the negative effects of antihypertensives on their sexual performance. Some Ghanaians mentioned fear of addiction or lack of money as explanations for altering prescribed dosage. Surinamese and Ghanaians often discontinued medication when visiting their homeland. Some respondents from all ethnic groups preferred natural treatments although treatment type varied. CONCLUSION: Patients' explanations for their decisions regarding the use of antihypertensives are often influenced by sociocultural issues and in ethnic-minority groups also by migration-related issues. Self-alteration of prescribed medication among Surinamese and Ghanaians may contribute to the low blood pressure (BP) control rate and high rate of malignant hypertension reported among these populations in the Netherlands. This study provides new information, which can help clinicians to understand how patients of diverse ethnic populations think about managing antihypertensive drug treatment and to address ethnic disparities in medication adherence and BP control.