GHAIA: The cardiovascular risk profile and the health care seeking behaviour among Ghanaians in Amsterdam

Cardiovascular disease (CVD) is a major cause of death and the rates are even
higher in some minority populations than in European White people [1-4]. In the
Netherlands, limited epidemiological data suggest that some risk factors are
more common among some ethnic minority groups than in White-Dutch. The
preliminary results of the SUNSET study, for example, showed substantially
higher prevalence of hypertension, diabetes and obesity in African Surinamese
than in White-Dutch.

The Ghanaian population is the largest African group and the fifth largest
ethnic group in Amsterdam. The City of Amsterdam Department of Research and
Statistics (O+S) 2006 figures indicate that 10.330 registered Ghanaians live in
Amsterdam alone, the majority in South-east Amsterdam. It is estimated that an
equal number undocumented Ghanaians also reside in Amsterdam.

Essential data on CVD and risk profiles among the growing African population in
the Netherlands is limited. Information on similar ethnic minority groups such
as the African Surinamese cannot simply be extrapolated to other African
groups, such as Ghanaian population since they differ enormously in terms of
culture, socio-economic status, migration experience, and eating habits all of
which are important determinants of health. This is confirmed by our recent
report, which showed huge heterogeneity between African descent populations
living in the western world. In addition, there are indications from a small
pilot study and studies in the Department of Internal and Vascular Medicine
that the African population in Amsterdam are at an increased risk of CVD.

Recognising the importance of the growing Ghanaian population and their impact
on health services across the Amsterdam region, the AMC and the GGD have
included this group in the Academic Workplace project with the aim of
preventing obesity (and ultimately CVD) in the Amsterdam region. However, the
lack of data on cardiovascular risk profiles and their determinants among the
Ghanaian population in the Netherlands means that the essential knowledge
needed for planning effective intervention strategies is lacking among this
group. There is an urgent need to fill this gap.

The general objective of this study is to provide knowledge on CVD risk
profiles, and the perception of health care seeking behaviour among the
Ghanaian population in Amsterdam to facilitate cardiovascular prevention
efforts.

Hypotheses

We hypothesise that the Ghanaian population in the Netherlands is at increased
risk of CVD due to migration related changes in lifestyles and lower
socio-economic status, as well as issue that pertain to the access of
healthcare. In addition, we hypothesise that due to the ageing of this
population, the burden of CVD will become increasingly important.

1. To investigate the presence of risk factors for CVD (i.e. overweight/
obesity, hypertension, diabetes and dyslipidemia,) among the Ghanaian
population in Amsterdam.
a) To investigate levels of detection, treatment and control of hypertension
among the Ghanaian population in Amsterdam.
b) To determine whether socio-economic status (e.g., education and
occupation), lifestyle factors (e.g., eating habits, physical activity,
smoking, and alcohol consumption), psychosocial factors (e.g., stress) and
acculturation are associated with cardiovascular risk factors among Ghanaian
population in Amsterdam.
c) to investigate the similarities and differences with similar ethnic groups,
specifically Surinamese of African origin.
d) To explore the feasibility of conducting a large scale population-based
study within the Ghanaian population of Amsterdam. For example, in the HELIUS
study (a longitudinal study of cardiovascular disease, mental health and
infectious disease in five ethnic groups living in Amsterdam: ethnic Dutch,
Surinamese, Turkish, Moroccan and Ghanaian) which is planned to commence in the
spring of 2010.

2. To investigate the perceptions within the Ghanaian community regarding their
access to health care and to understand the health seeking behaviour among this
community.

This is an explorative study which will employ both qualitative (focus groups)
and quantitative (structured interview using questionnaire and physical
examination) study methods.
Data collection
Objective 1:
Structured interview using a questionnaire
In addition to the focus group study we will conduct a quantitative study among
a separate sample of participants. These participants will be recruited using
the methodology described in the section *Study Population*.
The interview will be based on a structured health questionnaire, and will
provide information on country of birth, parental and grand parental country of
birth, age, sex, religion, marital status, family structure, socio-economic
status and acculturation and medical history. In addition, the questionnaire
will include questions on lifestyle factors such as smoking, alcohol
consumption, physical activity, self-reported weight or weight fluctuations.
Psychosocial stress will be measured using a standardised and validated
questionnaire. Finally, information on medication used and disease history will
also be ascertained.

Physical Examination
Subsequently all participants in the structured interview will be invited to
return for a physical examination. The physical examination will be held at a
number of locations, chosen for their accessibility to the participants.
Participants will be invited to attend the examination in a fasting state
(minimum 10 hours). During the examination participants will be asked to
provide a fasting blood sample and a small sample of their urine. In addition
we will measure and record weight, height, waist and hip circumference. All
physical examinations will be conducted by trained staff, according to a
standardised protocol (see attachment, protocol lichaamelijk onderzoek). During
the examination, blood pressure will be measured with a validated oscillometric
automated digital blood pressure device (OMRON) using appropriate cuff sizes.
All results of this physical examination will be reported back to the
participant. In addition, participants who require further diagnostic
evaluation or treatment will be referred to their GP for consultation.
Participants who are not registered with a GP practice will be referred to one
of three study GPs in their local area.

Main outcome measures
Blood pressure: systolic BP, diastolic BP, prehypertension and hypertension and
use of anti-hypertensive medications.
Lipids: self-reported dyslipidemia and self-reported use of medications.
Blood parameters that are indicative of cardiovascular health, e.g. total
cholesterol, LDL-, HDL cholesterol levels, Triglyceride levels.
Diabetes mellitus: self-reported diabetes and self-reported use of insulin and
tablets.
Blood parameters indicative of diabetes, e.g. glucose, HbA1c, insulin.
Urinary values indicative of kidney function.
Anthropometrics: height, weight, BMI, waist circumference, hip circumference,
waist-hip ratio, overweight, obesity and abdominal obesity.

Objective 2: Qualitative study using focus groups
Participants for the focus groups will be invited to participate by key figures
within the Ghanaian community. The aim of the focus group discussion is to
elicit the perceptions of participants of their access to health care. Topics
to be covered in the focus groups will be loosely based on the Anderson Model
of access to health care. This includes domains such as the needs driving
health seeking behaviour, the barriers and facilitating factors in health care
access and the predisposing characteristics of individuals.

There is no direct benefit for the participants. Due to the extensive health
examination, potential benefit may be derived from early detection of
unexpected findings. Since it is an observational study, no risk is to be
expected for the participants.
The burden of participation is limited as participants are only asked for a
single data collection.
Futher, they will be interviewed at home and the physical examination will take
place in their neighbourhood, at three different locations so that participants
will have the opportunity to undergo this examination close to their home.
Arriving in a fasting state is a burden, but participants may come early in the
morning for the examination. In addition, we will draw blood first and then
offer participants something to eat. The remaining measurements will take place
last.