Views and experiences of ethnic minority diabetes patients on dietetic care in the Netherlands - a qualitative study

Background

Diabetes type 2 is more prevalent in people from ethnic minorities in the Netherlands, and outcomes of care are worse compared with other Dutch people. Dieticians experience difficulties in managing these groups in self-management and adherence to dietary advice. The aim of this study was to explore the views regarding a healthy diet and dietetic care among ethnic minority type 2 diabetes patients.

Methods

Semi-structured interviews were held with 12 migrants with diabetes from Turkey, Morocco, Iraq and Curacao, who visited a dietician. Inclusion went on until saturation was reached. The interview guide was based on the Attitudes, Social influence and self-Efficacy (ASE) model and Kleinman’s explanatory model of illness. Interviews were held in the language preferred by the respondent. Transcripts were coded and thematically analyzed.

Results

Several respondents expected a more rigorous, directive and technical approach of the dietician. All respondents acknowledged the importance of a healthy diet. What they considered healthy was determined by culturally influenced ideas about health benefits of specific foods. Important hindrances for dietary change were lack of self-efficacy and social support. Social influences were experienced both as supportive and a hindrance.

Conclusions

Migrant diabetic patients’ opinions about healthy food are determined by culturally influenced ideas rather than by dietary guidelines. Dutch dietary care is not tailored to the needs of these patients and should take into account migrants’ expectations, cultural differences in dietary habits and specifically address the role of family.

Dutch citizens of Turkish origin who utilize healthcare services in Turkey: a qualitative study on motives and contextual factors

Background

Dutch residents of Turkish origin frequently utilize healthcare in Turkey.

Methods

To investigate their motives for doing so, we conducted a qualitative study among these healthcare users using semi-structured interviews. We complemented this with informal conversations with Turkish healthcare providers and observations at the registration offices and waiting rooms of outpatient clinics in several Turkish hospitals.

Results

Respondents believed their perceived needs for referral to specialist care and diagnostic assessments to quantify their health were not being met in the Netherlands.

Conclusions

These mismatches in expectations of what constitutes “good care” led to dissatisfaction with Dutch primary care. Consequently, respondents utilized healthcare in Turkey if the opportunity arose, and were encouraged in this by their social networks. Establishing cross-border communication between healthcare providers is necessary, because there is currently no continuity of care for cross-border patients.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3026-9) contains supplementary material, which is available to authorized users.

Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide

OBJECTIVE

Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.

DESIGN

Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.

RESULTS

Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.

CONCLUSIONS

Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Quality of life assumptions determine which cervical cancer screening strategies are cost-effective

Quality-adjusted life years are used in cost-effectiveness analyses (CEAs). To calculate QALYs, a "utility" (0-1) is used for each health state induced or prevented by the intervention. We aimed to estimate the impact of quality of life (QoL) assumptions (utilities and durations of health states) on CEAs of cervical cancer screening. To do so, 12 alternative sets of utility assumptions were retrieved from published cervical cancer screening CEAs. Two additional sets were based on empirical QoL data that were integrally obtained through two different measures (SF-6D and EQ-5D) from eight groups of women (total n = 3,087), from invitation for screening to diagnosis with cervical cancer. Per utility set we calculated the number of quality-adjusted days lost (QADL) for each relevant health state in cervical cancer screening, by multiplying the study-specific assumed disutilities (i.e., 1-utility) with study-specific durations of the loss in QoL, resulting in 14 "QADL-sets." With microsimulation model MISCAN we calculated cost-effectiveness of 342 alternative screening programs (varying in primary screening test [Human Papillomavirus (HPV) vs. cytology], starting ages, and screening interval) for each of the 14 QADL-sets. Utilities used in CEAs appeared to differ largely. We found that ten QADL-sets from the literature resulted in HPV and two in cytology as preferred primary test. The SF-6D empirical QADL-set resulted in cytology and the EQ-5D one in HPV as preferred primary test. In conclusion, assumed utilities and health state durations determine cost-effectiveness of cervical cancer screening. Also, the measure used to empirically assess utilities can be crucial for CEA conclusions.

Ethnic differences in colon cancer care in the Netherlands: a nationwide registry-based study

Background

Ethnic differences in colon cancer (CC) care were shown in the United States, but results are not directly applicable to European countries due to fundamental healthcare system differences. This is the first study addressing ethnic differences in treatment and survival for CC in the Netherlands.

Methods

Data of 101,882 patients diagnosed with CC in 1996–2011 were selected from the Netherlands Cancer Registry and linked to databases from Statistics Netherlands. Ethnic differences in lymph node (LN) evaluation, anastomotic leakage and adjuvant chemotherapy were analysed using stepwise logistic regression models. Stepwise Cox regression was used to examine the influence of ethnic differences in adjuvant chemotherapy on 5-year all-cause and colorectal cancer-specific survival.

Results

Adequate LN evaluation was significantly more likely for patients from ‘other Western’ countries than for the Dutch (OR 1.09; 95% CI 1.01–1.16). ‘Other Western’ patients had a significantly higher risk of anastomotic leakage after resection (OR 1.24; 95% CI 1.05–1.47). Patients of Moroccan origin were significantly less likely to receive adjuvant chemotherapy (OR 0.27; 95% CI 0.13–0.59). Ethnic differences were not fully explained by differences in socioeconomic and hospital-related characteristics. The higher 5-year all-cause mortality of Moroccan patients (HR 1.64; 95% CI 1.03–2.61) was statistically explained by differences in adjuvant chemotherapy receipt.

Conclusion

These results suggest the presence of ethnic inequalities in CC care in the Netherlands. We recommend further analysis of the role of comorbidity, communication in patient-provider interaction and patients’ health literacy when looking at ethnic differences in treatment for CC.

Cardiovascular disease risk and secondary prevention of cardiovascular disease among patients with low health literacy

OBJECTIVE

To explore the association between health literacy and the risk of cardiovascular disease (CVD), and to assess the differential effects by health literacy level of a nurse-coordinated secondary prevention program (NCPP) in patients with coronary artery disease (CAD).

METHODS

Data were collected in two medical centres participating in the RESPONSE trial (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists). CVD risk profiles were assessed at baseline and 12-month follow-up using the Systematic Coronary Risk Evaluation (SCORE). Health literacy was assessed by the short Rapid Estimate of Adult Literacy in Medicine (REALM-D) and the Newest Vital Sign (NVS-D); self-reported health literacy was evaluated by the Set of Brief Screening Questions (SBSQ-D).

RESULTS

Among 201 CAD patients, 18% exhibited reading difficulties, 52% had difficulty understanding and applying written information, and 5% scored low on self-reported health literacy. Patients with low NVS-D scores had a higher CVD risk [mean SCORE 5.2 (SD 4.8) versus 3.3 (SD 4.1), p < 0.01]. Nurse-coordinated care seemed to reduce CVD risk irrespective of health literacy levels without significant differences.

CONCLUSION

Inadequate health literacy is prevalent in CAD patients in the Netherlands, and is associated with less favourable CVD risk profiles. Where many other forms of CVD prevention fail, nurse-coordinated care seems to be effective among patients with inadequate health literacy.

Accessibility of standardized information of a national colorectal cancer screening program for low health literate screening invitees: A mixed method study

OBJECTIVE

To explore the accessibility of standardized printed information materials of the national Dutch colorectal cancer screening program among low health literate screening invitees and to assess the effect of the information on their knowledge about colorectal cancer and the screening program.

METHODS

Linguistic tools were used to analyze the text and design characteristics. The accessibility, comprehensibility and relevance of the information materials were explored in interviews and in observations (n=25). The effect of the information on knowledge was assessed in an online survey (n=127).

RESULTS

The materials employed a simple text and design. However, respondents expressed problems with the amount of information, and the difference between screening and diagnostic follow-up. Knowledge significantly increased in 10 out of 16 items after reading the information but remained low for colorectal cancer risk, sensitivity of testing, and the voluntariness of colorectal cancer screening.

CONCLUSION

Despite intelligible linguistic and design characteristics, screening invitees with low health literacy had problems in accessing, comprehending and applying standard information materials on colorectal cancer screening, and lacked essential knowledge for informed decision-making about participation.

PRACTICE IMPLICATIONS

To enable equal access to informed decision-making, information strategies need to be adjusted to the skills of low health literate screening invitees.

Adherence to colorectal cancer screening: four rounds of faecal immunochemical test-based screening

BACKGROUND

The effectiveness of faecal immunochemical test (FIT)-based screening programs is highly dependent on consistent participation over multiple rounds. We evaluated adherence to FIT screening over four rounds and aimed to identify determinants of participation behaviour.

METHODS

A total of 23 339 randomly selected asymptomatic persons aged 50-74 years were invited for biennial FIT-based colorectal cancer screening between 2006 and 2014. All were invited for every consecutive round, except for those who had moved out of the area, passed the upper age limit, or had tested positive in a previous screening round. A reminder letter was sent to non-responders. We calculated participation rates per round, response rates to a reminder letter, and differences in participation between subgroups defined by age, sex, and socioeconomic status (SES).

RESULTS

Over the four rounds, participation rates increased significantly, from 60% (95% CI 60-61), 60% (95% CI 59-60), 62% (95% CI 61-63) to 63% (95% CI 62-64; P for trend<0.001) with significantly higher participation rates in women in all rounds (P<0.001). Of the 17 312 invitees eligible for at least two rounds of FIT screening, 12 455 (72%) participated at least once, whereas 4857 (28%) never participated; 8271 (48%) attended all rounds when eligible. Consistent participation was associated with older age, female sex, and higher SES. Offering a reminder letter after the initial invite in the first round increased uptake with 12%; in subsequent screening rounds this resulted in an additional uptake of up to 10%.

CONCLUSIONS

In four rounds of a pilot biennial FIT-screening program, we observed a consistently high and increasing participation rate, whereas sending reminders remain effective. The substantial proportion of inconsistent participants suggests the existence of incidental barriers to participation, which, if possible, should be identified and removed.

Socioeconomic Differences in Informed Decisions About Down Syndrome Screening: A Systematic Review and Research Agenda

Supporting pregnant women to make informed choices about Down syndrome screening is widely endorsed. We reviewed the literature on: (a) the association between socioeconomic position and informed choices and decision-making about Down syndrome screening, and (b) the possible mediating variables (e.g., health literacy, numeracy skills, behavioral and communication variables) that might explain the relationship. EMBASE, MEDLINE, PubMed, CINAHL, and PsycINFO were searched from January 1999 to September 2014. The methodological quality of studies was determined by predefined criteria regarding the research aims, study design, study population and setting, measurement tools, and statistical analysis. A total of 33 studies met the inclusion criteria. Women from lower socioeconomic groups experience greater difficulties making informed choices about Down syndrome screening compared to women from higher socioeconomic groups. Most studies focus on individual dimensions of informed decision-making rather than assessing elements in conjunction with one another. Few studies have explored why there are socioeconomic differences in women's ability to make informed screening decisions. Future work is needed to identify mediating variables in this pathway. Systematic evidence-based intervention development to improve communication, understanding, and decision-making about Down syndrome screening is needed to ensure that women have an equal opportunity to make an informed choice about screening regardless of their socioeconomic position.

The challenges of integrating cultural competence into undergraduate medical curricula across Europe: experience from the C2ME “Culturally competent in medical education” project

This article was migrated. The article was not marked as recommended. Providing high quality care to socially and culturally diverse populations is challenging. Many organizations concerned with quality and equity in health care have called for physician training in cross cultural communication as one strategy for ensuring patient-centered health care for all, but little is known about how to effectively and sustainably integrate such teaching into the medical school curriculum.The C2ME "Culturally Competent in Medical Education" is a European project whose aim was to contribute to the integration of cultural competence teaching in undergraduate medical curricula across Europe. In order to foster exchange among medical schools about cultural competence training, C2ME organized a symposium at the 2014 European Association for Communication in Health Care (EACH) conference. The symposium highlighted the variety of teaching approaches and methods that are used to teach cultural competence as well as the the institutional challenges that make integration of cultural competence into the curricula difficult. There is a need for greater exchange of experiences and best practices among European medical schools to overcome these challenges.

Role of relatives of ethnic minority patients in patient safety in hospital care: a qualitative study

OBJECTIVE

Relatives of ethnic minority patients often play an important role in the care process during hospitalisation. Our objective was to analyse the role of these relatives in relation to the safety of patients during hospital care.

SETTING

Four large urban hospitals with an ethnic diverse patient population.

PARTICIPANTS

On hospital admission of ethnic minority patients, 20 cases were purposively sampled in which relatives were observed to play a role in the care process.

OUTCOME MEASURES

We used documents (patient records) and added eight cases with qualitative interviews with healthcare providers, patients and/or their relatives to investigate the relation between the role of relatives and patient safety. An inductive approach followed by selective coding was used to analyse the data.

RESULTS

Besides giving social support, family members took on themselves the role of the interpreter, the role of substitutes of the patient and the role of care provider. The taking over of these roles can have positive and negative effects on patient safety.

CONCLUSIONS

When family members take over various roles during hospitalisation of a relative, this can lead to a safety risk and a safety protection for the patient involved. Although healthcare providers should not hand over their responsibilities to the relatives of patients, optimising collaboration with relatives who are willing to take part in the care process may improve patient safety.

The interpreter as co-interviewer: the role of the interpreter during interviews in cross-language health research

OBJECTIVE

Interviews with ethnic minority patients provide a rich source of data to understand their perspectives of disease and its management. Language barriers are, however, often a problem so interpreters need to be used. We explored the impact of the interpreter on cross-language interviews between researchers and respondents.

METHODS

Secondary analysis of four interviews between researchers and patients involving professional interpreters.

RESULTS

Interpreters were actively involved and influenced the interview in several ways: they assumed the interviewer's communicative role, edited information; initiated information-seeking, took over control of the interview, and took over the respondent's role. While the interpreter supported the interviewer, they posed risks to the quality of the interview.

CONCLUSION

Researchers need to be aware of the influence of interpreters. Researchers should instruct interpreters carefully about their roles though they may benefit from interpreters' strategies to support them.

[Enumerating the preventive youth health care workforce: size, composition and regional variation in the Netherlands]

OBJECTIVE

The progress in workforce planning in preventive youth health care (YHC) is hampered by a lack of data on the current workforce. This study aimed to enumerate the Dutch YHC workforce. To understand regional variations in workforce capacity we compared these with the workforce capacity and the number of children and indicators of YHC need per region.

METHODS

A national survey was conducted using online questionnaires based on WHO essential public health operations among all YHC workers. Respondents (n=3220) were recruited through organisations involved in YHC (participation: 88%).

RESULTS

The YHC workforce is multi-disciplinary, 62% had > 10 years working experience within YHC and only small regional variations in composition existed. The number of children per YHC professional varied between regions (range: 688-1007). All essential public health operations were provided. Regional differences in the number of children per YHC professional were unrelated to the indicators of YHC need.

CONCLUSION

The essential public health operations provided by the YHC workforce and the regional variations in children per YHC professional were not in line with indicators of YHC needs, indicating room for improvement of YHC workforce planning. The methodology applied in this study is probably relevant for use in other countries.

[Healthcare for teenagers: are we working together?]

There are about 1.8 million children between 10 and 18 years of age in the Netherlands in 2016. These teenagers account for approximately 10% of the total population. Teenagers are relatively healthy and do not make much use of curative care. However, they are an important group in terms of public health, because a basis for good health in later life is created in the teenage years. Good health in teenagers is also important for education, relationships and employment, and their health has an influence on the health of the next generation. Child and adolescent healthcare plays an important part in preventive care for teenagers. Better cooperation and exchange of information between paediatricians, specialists in child and adolescent healthcare and general practitioners are important in order to optimise care for teenagers.

Effect of socioeconomic status on psychosocial problems in 5- to 6-year-old preterm- and term-born children: the ABCD study

This study aimed at analysing the association between socioeconomic status (SES) and psychosocial problems in preterm- and term-born children. Scores of mothers and teachers on the Strengths and Difficulties Questionnaire (SDQ) regarding 217 preterm-born children (<37 weeks' gestation, mean 34 weeks) were compared with 4336 term-born children in the Amsterdam Born Children and their Development (ABCD) cohort at age 5-6 years. Associations between SDQ scores and SES (maternal education and perceived income adequacy) were examined with multivariate linear regression analysis. The mean mother-reported total difficulties score was significantly higher for preterm children (6.1 ± 4.7) than for term children (5.2 ± 4.1). After covariate adjustment, this difference was 0.5 (95 % CI 0.0-1.0). For preterm children 16.1 % of the mothers reported psychosocial problems compared with 10.1 % for term children. Lower maternal education and lower income adequacy were significantly related to higher SDQ scores of mothers and teachers. Differences in mothers' SDQ score between preterm and term children were larger in the high-education (Δ0.9, 95 % CI 0.2-1.5) and high-income group (Δ0.9, 95 % CI 0.3-1.6). No significant differences were found between preterm and term children in the SDQ scores reported by teachers. Low level of maternal education and inadequate income showed a much stronger association with psychosocial problems than preterm birth. No combined effect of low SES and preterm birth was found. This study corroborates the evidence for the strength of the disadvantageous effects of low SES on early psychosocial development.

[We are living longer, but are these additional years spent in good health?]

Life expectancy in western countries has increased continuously over recent years. The issue at stake is if this rise includes healthy years. The answer depends on the health indicator used, e.g., perceived health, disability, or cognitive impairment. A study by Jagger et al. (2016) provides evidence for an increase in life expectancy without cognitive impairment and an absolute compression of cognitive impairment between 1991 and 2011. Information on life expectancy without cognitive impairment is not yet available for the Netherlands. Similar to England, Dutch trends in life expectancy in excellent or good self-perceived health and in life expectancy without severe disability are favourable, although less pronouncedly so. Dutch and English data suggest that the additional years lived by the population are at least partly spent in good health.

Implications of health as 'the ability to adapt and self-manage' for public health policy: a qualitative study

BACKGROUND

To explore the implications for public health policy of a new conceptualisation of health as 'The ability to adapt and to self-manage, in the face of social, physical and emotional challenges'.

METHODS

Secondary qualitative data analysis of 28 focus group interviews, with 277 participants involved in public health and healthcare, on the future of the Dutch healthcare system. WHO's essential public health operations (EPHOs) were used as a framework for analysis.

RESULTS

Starting from the new concept of health, participants perceived health as an individual asset, requiring an active approach in the Dutch population towards health promotion and adaptation to a healthy lifestyle. Sectors outside healthcare and public health were considered as resources to support individual lifestyle improvement. Integrating prevention and health promotion in healthcare is also expected to stimulate individuals to comply with a healthy lifestyle. Attention should be paid to persons less skilled to self-manage their own health, as this group may require a healthcare safety net. The relationship between individual and population health was not addressed, resulting in little focus on collective prevention to achieve health.

CONCLUSIONS

The new concept of health as a basis for changes in the healthcare system offers opportunities to create a health-promoting societal context. However, inequalities in health within the general population may increase when using the new concept as an operationalisation of health. For public health, the main challenge is to maintain focus on the collective socioeconomic and environmental determinants of health and disease and, thereby, preserve collective prevention.

Knowledge, attitudes and beliefs regarding colorectal cancer screening among ethnic minority groups in the Netherlands - a qualitative study

BACKGROUND

Research has shown that ethnic minority groups are less likely to participate in colorectal cancer (CRC) screening than the majority population and hence less likely to be diagnosed at an early stage when treatment is potentially more successful.

OBJECTIVE

To explore knowledge, attitudes and beliefs regarding CRC and CRC screening among ethnic minority groups in the Netherlands.

DESIGN

We conducted qualitative interviews with 30 first-generation immigrants born in Turkey, Morocco and Surinam. We based the topic guide on the health belief model. Framework analysis was used to analyse our data.

RESULTS

Although knowledge of CRC and CRC screening was limited, all respondents felt susceptible to CRC. CRC screening was perceived to mainly benefit those individuals with poor health and symptoms. Although most respondents had a positive attitude towards CRC screening, knowledge about its potential harms was limited and self-efficacy to participate was low. Adult children acted as important mediators in providing access to information. The language barrier and low literacy formed serious barriers to informed participation in CRC screening.

CONCLUSION

To ensure that all eligible individuals, including ethnic minority groups, have equal opportunities to informed participation in screening, targeted communication strategies should be developed, such as oral and visual channels, and face-to-face communication in the mother tongue. This will help ethnic minority groups to make an informed decision about participation in CRC screening.

How should health service organizations respond to diversity? A content analysis of six approaches

Background

Health care organizations need to be responsive to the needs of increasingly diverse patient populations. We compared the contents of six publicly available approaches to organizational responsiveness to diversity. The central questions addressed in this paper are: what are the most consistently recommended issues for health care organizations to address in order to be responsive to the needs of diverse groups that differ from the majority population? How much consensus is there between various approaches?

Methods

We purposively sampled six approaches from the US, Australia and Europe and used qualitative textual analysis to categorize the content of each approach into domains (conceptually distinct topic areas) and, within each domain, into dimensions (operationalizations). The resulting classification framework was used for comparative analysis of the content of the six approaches.

Results

We identified seven domains that were represented in most or all approaches: organizational commitment, empirical evidence on inequalities and needs, a competent and diverse workforce, ensuring access for all users, ensuring responsiveness in care provision, fostering patient and community participation, and actively promoting responsiveness. Variations in the operationalization of these domains related to different scopes, contexts and types of diversity. For example, approaches that focus on ethnic diversity mostly provide recommendations to handle cultural and language differences; approaches that take an intersectional approach and broaden their target population to vulnerable groups in a more general sense also pay attention to factors such as socio-economic status and gender.

Conclusions

Despite differences in labeling, there is a broad consensus about what health care organizations need to do in order to be responsive to patient diversity. This opens the way to full scale implementation of organizational responsiveness in healthcare and structured evaluation of its effectiveness in improving patient outcomes.

Enumerating the preventive youth health care workforce: Size, composition and regional variation in the Netherlands

The progress in workforce planning in preventive youth health care (YHC) is hampered by a lack of data on the current workforce. This study aimed to enumerate the Dutch YHC workforce. To understand regional variations in workforce capacity we compared these with the workforce capacity and the number of children and indicators of YHC need per region. A national survey was conducted using online questionnaires based on WHO essential public health operations among all YHC workers. Respondents (n=3220) were recruited through organisations involved in YHC (participation: 88%). The YHC workforce is multi-disciplinary, 62% had >10 years working experience within YHC and only small regional variations in composition existed. The number of children per YHC professional varied between regions (range 688-1007). All essential public health operations were provided and could be clustered in an operational or policy profile. The operational profile prevailed in all regions. Regional differences in the number of children per YHC professional were unrelated to the indicators of YHC need. The essential public health operations provided by the YHC workforce and the regional variations in children per YHC professional were not in line with indicators of YHC needs, indicating room for improvement of YHC workforce planning. The methodology applied in this study is probably relevant for use in other countries.

How to characterize the public health workforce based on essential public health operations? environmental public health workers in the Netherlands as an example

Background

Public health workforce planning and policy development require adequate data on the public health workforce and the services provided. If existing data sources do not contain the necessary information, or apply to part of the workforce only, primary data collection is required. The aim of this study was to develop a strategy to enumerate and characterize the public health workforce and the provision of essential public health operations (EPHOs), and apply this to the environmental public health workforce in the Netherlands as an example.

Methods

We specified WHO’s EPHOs for environmental public health and developed an online questionnaire to assess individual involvement in these. Recruitment was a two-layered process. Through organisations with potential involvement in environmental public health, we invited environmental public health workers (n = 472) to participate in a national survey. Existing benchmark data and a group of national environmental public health experts provided opportunities for partial validity checks.

Results

The questionnaire was well accepted and available benchmark data on physicians supported the results of this study regarding the medical part of the workforce. Experts on environmental public health recognized the present results on the provision of EPHOs as a reasonable reflection of the actual situation in practice.

All EPHOs were provided by an experienced, highly educated and multidisciplinary workforce. 27 % of the total full-time equivalents (FTEs) was spent on EPHO ‘assuring governance for health’. Only 4 % was spent on ‘health protection’. The total FTEs were estimated as 0.66 /100,000 inhabitants.

Conclusions

Characterisation of the public health workforce is feasible by identification of relevant organisations and individual workers on the basis of EPHOs, and obtaining information from those individuals by questionnaire. Critical factors include the operationalization of the EPHOS into the field of study, the selection and recruitment of eligible organisations and the response rate within organisations.. When existing professional registries are incomplete or do not exist, this strategy may provide a start to enumerate the quantity and quality of the public health within or across countries.

How we developed an effective e-learning module for medical students on using professional interpreters

BACKGROUND

Language barriers may lead to poorer healthcare services for patients who do not speak the same language as their care provider. Despite the benefits of professional interpreters, care providers tend to underuse professional interpretation. Evidence suggests that students who received training on language barriers and interpreter use are more likely to utilize interpretation services.

AIMS

We developed an e-learning module for medical students on using professional interpreters during the medical interview, and evaluated its effects on students' knowledge and self-efficacy.

METHODS

In the e-learning module, three patient-physician-interpreter video vignettes were presented, with three different types of interpreters: a family member, an untrained bilingual staff member, and a professional interpreter. The students answered two questions about each vignette, followed by feedback which compared their responses with expert information. In total, 281 fourth-year medical students took the e-learning module during the academic year 2012-2013. We assessed their knowledge and self-efficacy in interpreter use pre- and post-test on 1 (lowest)-10 (highest) scale, and analysed the differences in mean scores using paired t-tests.

RESULTS

Upon completing the e-learning module, students reported higher self-efficacy in using professional interpretation. The mean knowledge score on the pre-test was 5.5 (95% confidence interval 5.3-5.8), but on the post-test this increased to 8.4 (95% CI 8.2-8.6). The difference was highly significant (p < 0.001). For self-efficacy, the mean score on the pre-test was 4.9 (95% CI 4.7-5.1), and on the post-test 7.0 (95% CI 6.8-7.1); p < 0.001.

CONCLUSION

This e-learning module improved students' knowledge and self-efficacy in using professional interpreters during the medical interview. Using such tools in medical curricula might encourage future doctors to use professional interpretation services to overcome language barriers, thereby potentially contributing to equitable healthcare services for a linguistically diverse patient population.

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.

Health changes of refugees from Afghanistan, Iran and Somalia: the role of residence status and experienced living difficulties in the resettlement process

INTRODUCTION

Worldwide, refugees show a poorer mental and physical health than the populations among which they resettle. Little is known about the factors influencing health after resettlement. We examined the development of mental and physical health of refugees. As experienced living difficulties might decrease with obtaining a residence permit, we expected this to play a central role in health improvement after resettlement.

METHODS

A two-wave study conducted in the Netherlands among a cohort of 172 recent (n = 68) and longstanding (n = 104) permit holders from Afghanistan, Iran and Somalia between 2003 and 2011. Multivariate mediation analyses were conducted for the effect of changes in living difficulties on the association between change in status and changes in health. Health outcomes were self-reported general health, number of chronic conditions, PTSD and anxiety/depression.

RESULTS

Recent permit holders had larger decreases in PTSD score (-0.402, CI -0.612; -0.192) and anxiety/depression score (-0.298, CI -0.464; -0.132), and larger improvements in self-rated general health between T1 and T2 (0.566, CI 0.183; 0.949) than longstanding permit holders. This association was not significant for changes in number of chronic conditions. Mediation analyses showed that the effect of getting a residence permit on health improvements transited through an improvement in living conditions, in particular employment and the presence of family/social support.

CONCLUSION

These results suggest that change in residence permit is beneficial for health mainly because of the change in living difficulties. These results add up to the evidence on the role of social circumstances for refugees upon resettlement, and point at labour participation and social support as key mechanisms for health improvements.

Barriers in access to home care services among ethnic minority and Dutch elderly--a qualitative study

BACKGROUND

Ethnic minority elderly have a high prevalence of functional limitations and chronic conditions compared to Dutch elderly. However, their use of home care services is low compared to Dutch elderly.

OBJECTIVES

Explore the barriers to access to home care services for Turkish, Moroccan Surinamese and ethnic Dutch elderly.

DESIGN

Qualitative semi-structured group interviews and individual interviews.

SETTING

The Netherlands.

PARTICIPANTS

Seven group interviews (n=50) followed by individual interviews (n=5) were conducted, in the preferred language of the participants.

METHODS

Results were ordered and reported according to a framework of access to health care services. This framework describes five dimensions of accessibility to generate access to health care services, from the perspective of the users: ability to perceive health needs, ability to seek health care, ability to reach, ability to pay and ability to engage.

RESULTS

This study shows that while barriers are common among all groups, several specific barriers in access to home care services exist for ethnic minority elderly. Language and communication barriers as well as limited networks and a preference for informal care seem to mutually enforce each other, resulting in many barriers during the navigation process to home care.

CONCLUSION

In order to provide equal access to home care for all who need it, the language and communication barriers should be tackled by home care services and home care nurses.

[Preterm birth and low socioeconomic status: more psychosocial problems at age 5-6?]

OBJECTIVE

Comparison of the association between socioeconomic status (SES) and psychosocial problems in preterm-born and term-born children.

DESIGN

Cohort study (Amsterdam Born Children and their Development (ABCD) cohort).

METHOD

For 217 preterm-born children (mean gestation 34 weeks), Strengths and Difficulties Questionnaire (SDQ) scores were compared with 4336 term-born children at age 5-6 years. Associations between SDQ scores and SES (maternal education and perceived income adequacy) were examined with multivariate linear regression analysis.

RESULTS

Mothers of preterm-born children often had a lower level of education. The mean SDQ total score was significantly higher for preterm-born children (6.1; SD: 4.7) than for term-born children (5.2; SD: 4.1). No significant differences were found between preterm-born and term-born children in the SDQ scores reported by teachers. For preterm-born children, 16.1% of the mothers reported psychosocial problems compared with 10.1% for term-born children. Lower maternal education and lower income adequacy were significantly related to higher SDQ scores. Differences in SDQ score between preterm-born and term-born children were most pronounced in the group with highly educated mothers (Δ0.9; 95%-CI: 0.2-1.5) and high income (Δ0.9; 95%-CI: 0.3-1.6).

CONCLUSION

There was no additional effect of preterm birth on psychosocial problems in children with a low level of maternal education or inadequate income. This study corroborates earlier evidence regarding the disadvantageous effects of low SES on psychosocial development.

Analyzing Fallacies in Argumentation to Enhance Effectiveness of Educational Interventions: The Case of Care Providers' Arguments Against Using Professional Interpretation

INTRODUCTION

Although research has shown that professional interpreters improve health care to patients who do not speak the same language as their care provider, care providers underuse professional interpretation services. To get more insight into the reasons of care providers to underuse professional interpreters, we studied fallacies in their arguments. Fallacies in reasoning may explain why care providers avoid changing their behavior even if they are aware of evidence in favor of such behavior.

METHODS

We did a secondary analysis of interviews about immigrant patients with care providers collected in two studies on in-hospital pediatric care. Interviews (N = 37) were held in 2009, in the Netherlands. Interviews were analyzed using a contextual approach to fallacious argumentation: a method that can identify fallacies as "wrong" arguments compared with the context in they are made.

RESULTS

We identified six main fallacies that care providers used to argue that they prefer not to use a professional interpreter while having free access to professional interpreters: 1) There are also some negative side effects to using professional interpreters, 2) there is no language problem, 3) it is such an enormous hassle to organize it, 4) I am a good doctor, 5) my medical information is not complex, and 6) patients do not want it.

DISCUSSION

Familiarizing care providers with these fallacies can raise their awareness of the wrong arguments to defend their underuse of professional interpreters and can be made part of their training.

Ethnic minority patients not at increased risk of adverse events during hospitalisation in urban hospitals in the Netherlands: results of a prospective observational study

OBJECTIVES

We analysed potential differences in incidence, type, nature, impact and preventability of adverse events (AEs) during hospitalisation between ethnic Dutch and ethnic minority patients, and the role of patient-related determinants. We hypothesised an increased AE incidence for ethnic minority patients.

SETTING

We conducted a prospective cohort study in four urban hospitals.

PARTICIPANTS

763 Dutch patients and 576 ethnic minority patients aged between 45 and 75, admitted for at least one night, were included in the study. All patients completed a questionnaire on patient-related determinants (eg, language proficiency).

OUTCOME MEASURES

Incidence, type (eg, diagnostic AEs), impact and nature of AEs were assessed with a two-stage medical record review. Logistic regression analysis was used to adjust for patient and admission characteristics, and to investigate the contribution of patient-related determinants to AE risk.

RESULTS

There was no significant difference in the incidence of AEs: 11% (95% CI 9% to 14%) in Dutch patients and 10% (95% CI 7% to 12%) in ethnic minority patients. Also, there was no significant difference in the incidence of preventable AEs: 3% (95% CI 1% to 4%) in Dutch patients and 1% (95% CI 0% to 2%) in ethnic minority patients. Low language proficiency, inadequate health literacy and low educational level did not increase the risk of an AE.

CONCLUSIONS

Compared with Dutch patients, ethnic minority patients were not at increased risk of AEs while receiving care in Dutch hospitals. Healthcare providers seem to have responded effectively to specific patient care needs, but we do not know whether this occurred in an ad hoc or in a systematic way.

Healthcare consumption by ethnic minority people in their country of origin

BACKGROUND

Studies from the USA, New Zealand and Denmark suggest that many ethnic minority citizens obtain healthcare in their country of origin. Their reasons for doing so and the possible consequences remain unclear.

METHODS

We used data from the Healthy Life in an Urban Setting study to investigate the magnitude, types, self-reported reasons and determinants of past-year healthcare consumption in the country of origin by ethnic minority people living in the Netherlands. Individuals of African Surinamese (n = 2059), South-Asian Surinamese (n = 1915), Ghanaian (n = 1426), Moroccan (n = 1516) and Turkish (n = 2245) origin were included (recruited 2011-2013). We performed descriptive and stepwise logistic regression analyses.

RESULTS

Respondents of Turkish origin reported the highest healthcare utilization in the country of origin (21.3%) compared with Moroccan (9.8%), Ghanaian (6.6%), African Surinamese (4.8%) and South-Asian Surinamese (3.0%) respondents. The main services used were outpatient clinics, pharmacies and health centres. The chief reported motivations were healthcare for illness, dissatisfaction with care in the residence country and seeking second opinions. Physical health status, cultural distance to the Dutch healthcare system and Turkish origin were all independently associated with healthcare use in countries of origin.

CONCLUSION

Both health status and attitudes towards services in the countries of residence and origin are significantly associated with cross-border healthcare use. Further research is needed to clarify the reasons for the relatively high rates shown by Turkish respondents and to explore the consequences for health and for healthcare utilization in the country of residence.

International application of health literacy measures: adaptation and validation of the newest vital sign in The Netherlands

OBJECTIVE

The newest vital sign assesses individual reading and numeracy skills. The aim of this study was to create a Dutch version (NVS-D) and to assess its feasibility, reliability, and validity in The Netherlands.

METHODS

We performed a qualitative study among experts (n=27) and patients (n=30) to develop the NVS-D and to assess its feasibility. For validation, we conducted a quantitative survey (n=329). Reliability was assessed by Cronbach's alpha. Construct validity was examined by analyzing association patterns. Receiver operating characteristic (ROC) curves determined optimal cut-off scores.

RESULTS

Cronbach's alpha was 0.76. In accordance with a priori hypotheses we found strong associations between NVS-D, general vocabulary, prose literacy and objective health literacy, and weaker associations between NVS-D and subjective health literacy. A score of ≥4 out of 6 best distinguished individuals with adequate versus inadequate health literacy.

CONCLUSION

The results suggest that the NVS-D is a reliable and valid tool that allows international comparable health literacy research in The Netherlands.

PRACTICE IMPLICATIONS

The NVS-D can be applied in research on the role of health literacy in health and health care, and the development of interventions. The methods can be applied in cross-cultural adaptation of health literacy measures in other countries.

A students' survey of cultural competence as a basis for identifying gaps in the medical curriculum

BACKGROUND

Assessing the cultural competence of medical students that have completed the curriculum provides indications on the effectiveness of cultural competence training in that curriculum. However, existing measures for cultural competence mostly rely on self-perceived cultural competence. This paper describes the outcomes of an assessment of knowledge, reflection ability and self-reported culturally competent consultation behaviour, the relation between these assessments and self-perceived cultural competence, and the applicability of the results in the light of developing a cultural competence educational programme.

METHODS

392 medical students, Youth Health Care (YHC) Physician Residents and their Physician Supervisors were invited to complete a web-based questionnaire that assessed three domains of cultural competence: 1) general knowledge of ethnic minority care provision and interpretation services; 2) reflection ability; and 3) culturally competent consultation behaviour. Additionally, respondents graded their overall self-perceived cultural competence on a 1-10 scale.

RESULTS

86 medical students, 56 YHC Residents and 35 YHC Supervisors completed the questionnaire (overall response rate 41%; n= 177). On average, respondents scored low on general knowledge (mean 46% of maximum score) and knowledge of interpretation services (mean 55%) and much higher on reflection ability (80%). The respondents' reports of their consultation behaviour reflected moderately adequate behaviour in exploring patients' perspectives (mean 64%) and in interaction with low health literate patients (mean 60%) while the score on exploring patients' social contexts was on average low (46%). YHC respondents scored higher than medical students on knowledge of interpretation services, exploring patients' perspectives and exploring social contexts. The associations between self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour were weak.

CONCLUSION

Assessing the cultural competence of medical students and physicians identified gaps in knowledge and culturally competent behaviour. Such data can be used to guide improvement efforts to the diversity content of educational curricula. Based on this study, improvements should focus on increasing knowledge and improving diversity-sensitive consultation behaviour and less on reflection skills. The weak association between overall self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour supports the hypothesis that measures of sell-perceived competence are insufficient to assess actual cultural competence.

Quality of primary care for resettled refugees in the Netherlands with chronic mental and physical health problems: a cross-sectional analysis of medical records and interview data

BACKGROUND

A high prevalence of mental and physical ill health among refugees resettled in the Netherlands has been reported. With this study we aim to assess the quality of primary healthcare for resettled refugees in the Netherlands with chronic mental and non-communicable health problems, we examined: a) general practitioners' (GP) recognition of common mental disorders (CMD) (depression and anxiety, and post-traumatic stress disorder (PTSD) symptoms); b) patients' awareness of diabetes type II (DMII) and hypertension (HT); and c) GPs' adherence to guidelines for CMD, DMII and HT.

METHODS

From 172 refugees resettled in the Netherlands, interview data (2010-2011) and medical records (n = 106), were examined. Inclusion was based on medical record diagnoses for DMII and HT, and on questionnaire-based CMD measures (Hopkins Symptom Checklist for depression and anxiety; Harvard Trauma Questionnaire for PTSD). GP recognition of CMD was calculated as the number of CMD cases registered in the medical record compared with those found in interviews. Patient awareness of HT and DMII was scored as the percentage of subjects diagnosed by the GP who reported their condition during the interview. GPs' adherence to guidelines for CMD, DMII and HT was measured using established indicators.

RESULTS

We identified 37 resettled refugees with CMD of which 18 (49%) had been recognised by the GP. We identified 16 refugees with DMII and 14 with HT from the medical record; 24 (80%) were aware of their condition. Thirty-five out of these 53 (66%) resettled refugees with chronic mental and non-communicable disorders received guideline-adherent treatment.

CONCLUSION

This study shows that awareness in resettled refugees of GP diagnosed DMII and HT is high, whereas GP recognition of CMD and overall guideline adherence are moderate.

A short assessment of health literacy (SAHL) in the Netherlands

Background

An earlier attempt to adapt the REALM (Rapid Estimate of Adult Literacy in Medicine) word recognition test to Dutch was not entirely successful due to ceiling effects. In contrast to REALM, the Short Assessment of Health Literacy (SAHL) assesses both word recognition and comprehension in the health domain. The aim of this study was to design, test and validate a SAHL for Dutch patients (SAHL-D).

Methods

We pretested 95 health-related terms (n = 127) and selected 33 best performing items for validation in a quantitative survey (n = 329). For each item, a correct recognition (1 point) and comprehension (1 point) contributed to the total score (scale 0–66). Internal consistency was assessed using Cronbach’s alpha. Construct validity was examined by analyzing association patterns of SAHL-D with educational level, objective and subjective health literacy, prose literacy, and vocabulary. Receiver operating characteristic (ROC) curves, with prose literacy as the reference standard, determined optimal cut-off scores.

Results

Cronbach’s alpha was 0.77 for recognition, 0.79 for comprehension, and 0.86 for the total score. Scores significantly differed substantially by educational level. Association patterns mostly confirmed a priori expectations in direction and strength, thereby supporting the construct validity of the SAHL-D. The optimal cut-off scores for differentiating between adequate and low literacy lie between 52.5 and 55.5. A shorter SAHL-D version presenting 22 terms offers a comparable prediction performance.

Conclusion

The results provide positive evidence for the reliability and validity of the SAHL-D. The SAHL-D can be applied to analyze the role of health literacy in health and healthcare, and for the development and evaluation of targeted interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-990) contains supplementary material, which is available to authorized users.

The role of health literacy in perceived information provision and satisfaction among women with ovarian tumors: a study from the population-based PROFILES registry

OBJECTIVE

To assess the association of subjective health literacy (HL) and education with perceived information provision and satisfaction.

METHODS

Women (N=548) diagnosed with an ovarian or borderline ovarian tumor between 2000 and 2010, registered in the Eindhoven Cancer Registry, received a questionnaire including subjective HL, educational level, perceived information provision, and satisfaction with the information received. Multiple linear and logistic regression analyses were performed, controlled for potential confounders.

RESULTS

Fifty percent of the women responded (N=275). Thirteen percent had low and 41% had medium subjective HL. Women with low HL reported less perceived information provision about medical tests, and were less satisfied with the information received compared to women with high HL. Low educated women reported that they received more information about their disease compared to highly educated women.

CONCLUSION

Low subjective HL among women with ovarian tumors is associated with less perceived information provision about medical tests and lower information satisfaction, whereas low education is associated with more perceived information provision about the disease.

PRACTICE IMPLICATIONS

HL should not be overlooked as a contributing factor to patients' perceived information provision and satisfaction. Health care providers may need training about recognizing low HL.

Self-rated literacy level does not explain educational differences in health and disease

BACKGROUND

Although literacy is increasingly considered to play a role in socioeconomic inequalities in health, its contribution to the explanation of educational differences in health has remained unexplored. The aim of this study was to investigate the contribution of self-rated literacy to educational differences in health.

METHODS

Data was collected from the Healthy Foundation and Lifestyle Segmentation Dataset (n = 4257). Self-rated literacy was estimated by individuals' self-reported confidence in reading written English. We used logistic regression analyses to assess the association between educational level and health (long term conditions and self-rated health). Self-rated literacy and other potential explanatory variables were separately added to each model. For each added variable we calculated the percentage change in odds ratio to assess the contribution to the explanation of educational differences in health.

RESULTS

People with lower educational attainment level were more likely to report a long term condition (OR 2.04, CI 1.80-2.32). These educational differences could mostly be explained by age (OR decreased by 27%) and could only minimally be explained by self-rated literacy, as measured by self-rated reading skills (OR decreased by 1%). Literacy could not explain differences in cardiovascular condition or diabetes, and only minimally contributed to mental health problems and depression (OR decreased by 5%). The odds of rating ones own health more negatively was higher for people with a low educational level compared to those with a higher educational level (OR 1.83, CI 1.59-2.010), self-rated literacy decreased the OR by 7%.

CONCLUSION

Measuring self-rated reading skills does not contribute significantly to the explanation of educational differences in health and disease. Further research should aim for the development of objective generic and specific instruments to measure health literacy skills in the context of health care, disease prevention and health promotion. Such instruments are not only important in the explanation of educational differences in health and disease, but can also be used to identify a group at risk of poorer health through low basic skills, enabling health services and health information to be targeted at those with greater need.

Course of post-traumatic stress disorder and health care utilisation among resettled refugees in the Netherlands

BACKGROUND

Post-traumatic stress disorder (PTSD) is a major health problem among refugees worldwide. After resettlement, the prevalence of PTSD remains high despite the fact that various PTSD treatments are known to be effective.

METHODS

We examined the course of PTSD and the role of mental health care utilisation at a 7-year interval (2003-2010) among a cohort of refugees from Iran, Afghanistan, and Somalia after resettlement in the Netherlands.

RESULTS

The unchanged high prevalence of PTSD (16.3% in 2003 and 15.2% in 2010) was attributable in part to late onset of PTSD symptoms (half of the respondents with PTSD at T2 were new cases for whom PTSD developed after 2003). The second reason concerned the low use of mental health care services at T1. Whereas the multivariate analyses showed the effectiveness of mental health care, only 21% of respondents with PTSD at T1 had had contact with a mental health care provider at that time. Use of mental health care during the first wave increased the odds of improvement in PTSD symptoms between both measurements (OR 7.58, 95% CI 1.01; 56.85).

CONCLUSIONS

The findings of this study suggest there are two possible explanations for the persistently high prevalence of PTSD among refugees. One is the late onset of PTSD and the other is the low utilisation of mental health care. Health care professionals should be aware of these issues, especially given the effectiveness of mental health care for this condition.

Interventions to enhance informed choices among invitees of screening programmes-a systematic review

BACKGROUND

Informed decision making about participation has become an explicit purpose in invitations for screening programmes in western countries. An informed choice is commonly defined as based on: (i) adequate levels of knowledge of the screening and (ii) agreement between the invitee's values towards own screening participation and actual (intention to) participation.

METHODS

We systematically reviewed published studies that empirically evaluated the effects of interventions aiming at enhancing informed decision making in screening programmes targeted at the general population. We focused on prenatal screening and neonatal screening for diseases of the foetus/new-born and screening for breast cancer, cervical cancer and colorectal cancer. The Medline, EMBASE and Cochrane databases were searched for studies published till April 2012, using the terms 'informed choice', 'decision making' and 'mass screening' separately and in combination and terms referring to the specific screening programmes.

RESULTS

Of the 2238 titles identified, 15 studies were included, which evaluated decision aids (DAs), information leaflets, film, video, counselling and a specific screening visit for informed decision making in prenatal screening, breast and colorectal cancer screening. Most of the included studies evaluated DAs and showed improved knowledge and informed decision making. Due to the limited number of studies the results could not be synthesized.

CONCLUSION

The empirical evidence regarding interventions to improve informed decision making in screening is limited. It is unknown which strategies to enhance informed decision making are most effective, although DAs are promising. Systematic development of interventions to enhance informed choices in screening deserves priority, especially in disadvantaged groups.

[Ethnic differences in uptake of professional maternity care assistance]

OBJECTIVE

To examine the ethnic differences in the uptake of professional maternity care assistance (MCA) in the Netherlands, and the factors that may explain these differences. Additionally the effect of MCA on health risk behaviour around infants is examined.

DESIGN

Questionnaire survey.

METHOD

Questionnaire data from 3967 mothers from the ABCD study (Amsterdam Born Children and their Development) included during pregnancy in 2003-2004, were used. We examined the explanatory role of ethnicity, age, socioeconomic status, mastery of the Dutch language, parity, housing situation and place of giving birth on MCA uptake, and the effect of MCA uptake on health risk behaviour around infants, such as smoking indoors, infant sleep behaviour, infant nutrition, and response to infant crying.

RESULTS

Mothers of non-Western origin less often used MCA than Dutch mothers (Ghanaian: 70%; Turkish: 75%; Moroccan: 79%; Surinamese: 81%; Dutch Caribbean: 85% vs. Dutch: 95%). Higher educational level, better mastery of the Dutch language, having a paid job and home delivery were all independently associated with the uptake of MCA, and also partially explained ethnic differences in the uptake of MCA. Mothers who received MCA more often breastfed, more often gave vitamin K when not breastfeeding, and more often lived in smoke-free homes. The protective effect of MCA was stronger for non-Western mothers than for Dutch mothers.

CONCLUSION

Mothers of non-Western origin make less use of professional MCA. Given that the use of MCA is associated with a less risk behaviour around infants, efforts should be made to improve the accessibility of professional MCA for mothers of non-Western origin.

How distressing is referral to colposcopy in cervical cancer screening?: a prospective quality of life study

OBJECTIVE

Referral for colposcopy because of abnormal Pap test results is likely to be distressing, but the extent and duration of these effects are unknown. We aimed to fill this gap.

METHODS

We conducted a prospective observational study at two departments of Obstetrics and Gynecology (an academic and a non-academic setting). Women referred for colposcopy completed questionnaires before colposcopy, and at 1, 3, and 6 months afterwards. A reference group of 706 screen participants, aged 29-60 years old, was included and completed questionnaires once. Main outcome measures were generic health-related quality of life (HRQoL), assessed through the EQ-5D and the SF-12 physical and mental scores (PCS-12 and MCS-12); anxiety as assessed by STAI-6, and screen-specific anxiety as assessed by the psychological consequences questionnaire (PCQ).

RESULTS

154 women responded to the questionnaire, of whom 132 were included in the analyses. Histological results were CIN 1 in 17/115 women (15%) and CIN 2+ in 62 (54%). In 36 women (31%) there was no histologically confirmed neoplasia. Before colposcopy physical HRQoL scores were similar or slightly better than in the reference group, while mental HRQoL (MSC-12) and (screen-specific) anxiety were worse (p<0.001). Irrespective of CIN-grades, anxiety washed out during follow-up (p<0.001), with changes being clinically relevant.

CONCLUSIONS

Referral for gynecological evaluation because of abnormal PAP-test results was distressing. Anxiety--and not the physical burden of management--seemed to be the most bothersome to women. For all CIN-grades, distress disappeared over six months following colposcopy, suggesting a reassuring effect of gynecological management.

Determinants of participation in a web-based health risk assessment and consequences for health promotion programs

Background

The health risk assessment (HRA) is a type of health promotion program frequently offered at the workplace. Insight into the underlying determinants of participation is needed to evaluate and implement these interventions.

Objective

To analyze whether individual characteristics including demographics, health behavior, self-rated health, and work-related factors are associated with participation and nonparticipation in a Web-based HRA.

Methods

Determinants of participation and nonparticipation were investigated in a cross-sectional study among individuals employed at five Dutch organizations. Multivariate logistic regression was performed to identify determinants of participation and nonparticipation in the HRA after controlling for organization and all other variables.

Results

Of the 8431 employees who were invited, 31.9% (2686/8431) enrolled in the HRA. The online questionnaire was completed by 27.2% (1564/5745) of the nonparticipants. Determinants of participation were some periods of stress at home or work in the preceding year (OR 1.62, 95% CI 1.08-2.42), a decreasing number of weekdays on which at least 30 minutes were spent on moderate to vigorous physical activity (OR_dayPA0.84, 95% CI 0.79-0.90), and increasing alcohol consumption. Determinants of nonparticipation were less-than-positive self-rated health (poor/very poor vs very good, OR 0.25, 95% CI 0.08-0.81) and tobacco use (at least weekly vs none, OR 0.65, 95% CI 0.46-0.90).

Conclusions

This study showed that with regard to isolated health behaviors (insufficient physical activity, excess alcohol consumption, and stress), those who could benefit most from the HRA were more likely to participate. However, tobacco users and those who rated their overall health as less than positive were less likely to participate. A strong communication strategy, with recruitment messages that take reasons for nonparticipation into account, could prove to be an essential tool for organizations trying to reach employees who are less likely to participate.

Informed decision-making in colorectal cancer screening using colonoscopy or CT-colonography

OBJECTIVE

To evaluate the level of informed decision making in a randomized controlled trial comparing colonoscopy and CT-colonography for colorectal cancer screening.

METHODS

8844 citizens aged 50-75 were randomly invited to colonoscopy (n=5924) or CT-colonography (n=2920) screening. All invitees received an information leaflet. Screenees received a questionnaire within 4 weeks before the planned examination, non-screenees 4 weeks after the invitation. A decision was categorized as informed when characterized by sufficient decision-relevant knowledge and consistent with personal attitudes toward participation in screening.

RESULTS

Knowledge and attitude items were completed by 1032/1276 colonoscopy screenees (81%), by 698/4648 colonoscopy non-screenees (15%), by 824/982 CT-colonography screenees (84%) and by 192/1938 CT-colonography non-screenees (10%). 1027 colonoscopy screenees (>99%) and 815 CT-colonography screenees (99%) had adequate knowledge; 915 (89%) and 742 (90%) had a positive attitude. 675 non-screenees invited to colonoscopy (97%) and 182 invited to CT-colonography (95%) had adequate knowledge; 344 (49%) and 94 (49%) expressed a negative attitude.

CONCLUSION

A large majority of screenees made an informed decision on participation. Almost half of responding non-screenees, made an uninformed decision, suggesting additional barriers to participation.

PRACTICE IMPLICATIONS

Efforts to understand the additional barriers will create opportunities to facilitate informed participation to colorectal cancer screening.

Assessing knowledge and attitudes towards screening among users of Faecal Immunochemical Test (FIT)

BACKGROUND

Informed decision making is recognized as important in screening. Invitees should be provided with relevant information, enabling them to make an informed decision. This may be more difficult in ethnic minority and low socio-economic status groups. We aimed to assess the proportion of informed decisions to participate in a faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening pilot and to explore differences in knowledge and attitude across various subgroups.

METHODS

Asymptomatic persons aged 50-74 were invited to a second round of a Dutch FIT-based pilot screening programme for CRC. An information leaflet containing all information relevant to enable informed decision making accompanied the invitation. Informed choice was assessed by a mailed questionnaire. Knowledge was elicited through 18 items and attitude towards screening through four items. Main outcome measure was the proportion of informed decision makers among participants. Differences between subgroups were evaluated using logistic regression.

RESULTS

Of 5367 screening participants, 2774 (52%) completed the questionnaire. Knowledge was adequate in 2554 (92%); 2736 (99%) showed a positive attitude towards screening. A total of 2525 persons had made an informed choice (91%); male gender, low education level, non-Dutch ethnicity and not speaking Dutch at home were negatively associated with having adequate knowledge in multivariable analysis.

CONCLUSION

In FIT-based screening for CRC, the majority of responders made an informed decision to participate. However, we did not succeed in equally providing all population subgroups with sufficient information. Future initiatives should be aimed at reaching these groups to further enable informed decision making.