"At this age, a Moroccan woman's life's work is over"-older Moroccan-Dutch migrant women's perceptions of health and lifestyle, with a focus on Ramadan experiences: qualitative research integrating education and consultation.

BACKGROUND: Older Moroccan-Dutch migrant women exhibit high rates of diabetes, hypertension, overweight and obesity which is further compounded by their high risk of multi-morbidity. Healthcare professionals' efforts to encourage this group to adopt a healthier lifestyle have little success. We ask ourselves whether the concepts used in health education and promotion relate to these women's experiences and beliefs. Today's pluralistic Dutch society requires a more differentiated and applied approach, not in an essentialist way but in awareness that translation of rather individualized concepts like health and lifestyle is not always adequate, as the meaning and interpretation of such concepts may differ and may be related to women's other (fundamental) perceptions. This can have practical consequences for health promotion and education. The aim of this explorative, qualitative research, conducted between April and September 2015 and taking an intersectional approach, was to explore older Moroccan-Dutch women's perceptions of health and lifestyle and to analyse these in a broader context, related to other fundamental forms of identity such as gender, culture and religion. METHODS: We recruited women with Moroccan backgrounds by approaching Moroccan women's organisations and using the snowballing method (chain-referral sampling). Seven 'natural' group discussions were held (amongst women who regularly meet each other, aged between 22 and 69 years), and twelve in-depth interviews and an observation day (with women from 40 to 66 years). The transcripts were then analysed using thematic content analysis. RESULTS: Five major themes were identified. Health was perceived of in the terms used in prevailing health promotion discourses in the Netherlands, but lifestyle was interpreted in a much broader sense than the current health promotion debate allows; it is not seen as an individual responsibility or as something an individual could control on their own, and the social benefits of health behaviours appear to outweigh the health benefits themselves. Lifestyle was located in three main social identities of the women: Moroccan, Muslim and mother. Finally, Ramadan played a huge and dominant role in the lifestyle experience of older Moroccan women and was central in this research. CONCLUSIONS: The finding that lifestyle is not seen as an individual responsibility but is located in social identities, can be applied to other settings that older migrant-Dutch women occupy. Further research will clarify this.

Reproductive choices: a qualitative study of Dutch Moroccan and Turkish consanguineously married women's perspectives on preconception carrier screening.

BACKGROUND: Cousin marriages, in the Netherlands most frequently between Turkish or Moroccan couples, are at higher risk of having offspring with recessive disorders. Often, these couples not perceive or accept this risk, and it is hardly considered a reason to refrain from family marriages. Preconception carrier screening (PCS) is offered to Jewish groups, and more recently in the Netherlands, to genetically isolated communities. In this study, Dutch Moroccan and Turkish women's perspectives on preconception carrier screening (PCS) and reproductive choices were explored. METHODS: Individual interviews were held with Dutch Turkish and Moroccan consanguineously married women (n = 10) and seven group discussions with Turkish and Moroccan women (n = 86). Transcripts and notes were analyzed thematically. RESULTS: All women welcomed PCS particularly for premarital genetic screening; regardless of possible reproductive choices, they prefer information about their future child's health. Their perspectives on reproductive choices on the basis of screening results are diverse: refraining from having children is not an option, in vitro fertilization (IVF) combined with pre-implantation genetic diagnosis (PGD) was welcomed, while prenatal genetic diagnosis (PND), termination of pregnancy (TOP), in vitro fertilization with a donor egg cell, artificial insemination with donor sperm (AID), and adoption, were generally found to be unacceptable. Besides, not taking any special measures and preparing for the possibility of having a disabled child are also becoming optional now rather than being the default option. CONCLUSIONS: The women's preference for PCS for premarital screening as well as their outspokenness about not marrying or even divorcing when both partners appear to be carriers is striking. Raising awareness (of consanguinity, PCS and the choice for reproductive options), and providing information, screening and counseling sensitive to this target group and their preferences are essential in the provision of effective health care.

Adapted cardiac rehabilitation programme to improve uptake in patients of Moroccan and Turkish origin in The Netherlands: a qualitative study.

AIM: To explore the treatment experiences in patients of Moroccan and Turkish origin and their rehabilitation therapists regarding an adapted outpatient cardiac rehabilitation programme. BACKGROUND: Non-native patients who participated in a cardiac rehabilitation programme at a Dutch rehabilitation centre had more difficulties to achieve the treatment aims than native Dutch patients. Therefore, an adapted programme for non-native patients, lacking proficiency in Dutch, has been instigated. The programme contains six adapted treatment modules and additional strategies: adapted education regarding (1) the heart and the vascular system and (2) the use of healthy food, with use the of (audio) visual educational materials, (3) adapted physical exercise module with explicit involvement of the patients' relatives, (4) standard use of professional interpreters, (5) increase in the number and length of consultations and (6) individual treatment instead of a group programme. DESIGN: Qualitative study. METHOD: Semi-structured, face-to-face interviews were conducted with eight patients of Moroccan and Turkish origin and five native Dutch rehabilitation therapists. By comparison, three native Dutch patients were interviewed regarding the regular programme. RESULTS: The results indicate that the patients' disease symptoms reduced and that patients adopted lifestyle changes. Therapists experienced that the number and length of the consultations, the structural use of interpreters and (audio) visual educational materials contributed to the achievement of the treatment aims. CONCLUSION: An adapted cardiac rehabilitation programme with separate modules and additional strategies for non-native patients appears to lead to satisfied patients who adopted lifestyle changes. RELEVANCE TO CLINICAL PRACTICE: The findings of this study are important as the study highlights the practical actions that may be taken by physicians and healthworkers to adjust rehabilitation treatment to the needs of patients of non-native origin.

Consanguineous marriage and reproductive risk: attitudes and understanding of ethnic groups practising consanguinity in Western society.

Consanguineous couples should be adequately informed about their increased reproductive risk and possibilities for genetic counselling. Information may only be effective if it meets the needs of the target group. This study aimed to gain more insight into: (1) attitudes of people belonging to ethnic groups in Western society towards consanguinity and their understanding of risk for offspring; and (2) their attitudes regarding reproductive information targeted at consanguineous couples. Dutch Moroccans and Turks were invited to complete an online questionnaire by snowball sampling and by placing a link on two popular Dutch Moroccan/Turkish forum websites between September and October 2011. The questionnaire was completed by 201 individuals who were, on average, neither positive nor negative towards consanguinity. Respondents with a consanguineous partner were more positive, estimated the risk for the offspring lower and were less positive about the provision of risk information to consanguineous couples when compared with respondents without a consanguineous partner. Participants of Turkish origin had a more negative attitude towards consanguinity and estimated the reproductive risk higher than Moroccan participants. More than half of the respondents thought that information should be given before marriage, whereas only 10% thought it should never be provided. The general practitioner was most often mentioned (54%) as the designated professional to inform people. Information about genetic risks related to consanguinity should be offered early, preferably before marriage. The diversity of the target population requires various strategies to disseminate information and reach consanguineous couples with the offer of genetic counselling.

Adaptations to pain rehabilitation programmes for non-native patients with chronic pain.

PURPOSE: (i) To determine whether adaptations for non-native patients have been implemented in pain rehabilitation programmes; (ii) to determine whether characteristics of the rehabilitation institute are related to having adaptations for non-native patients in place. SUBJECTS: Rehabilitation institutes and rehabilitation departments of general hospitals in The Netherlands who offer a pain rehabilitation programme. METHOD: A questionnaire was handed over in person or by e-mail to the rehabilitation physicians of the participating institutes. Twenty-seven (90%) questionnaires were returned. The questionnaire concerned programme adaptations and institute characteristics. The data were analysed by χ(2) tests or Fischer's exact tests and logistic regression analysis. RESULTS: Twelve institutes (44.4%) reported having adaptations in place for non-native patients in their pain rehabilitation programme. The most common adaptations were as follows: increased number of consultations (25.9% of the institutes); longer consultations (25.9%) and education for employees regarding cultural competency (11.1%). Institutes which treated a high percentage (≥11%) of non-native patients had implemented significantly more frequently adaptations to their rehabilitation programme (p = 0.04). The number of adaptations was neither associated with the proportion of non-native citizens in the local population nor with the number of the institutes' employees. CONCLUSION: Less than half of the institutes had implemented one or more programme adaptations for non-native patients. Institutes which had made adaptations to their rehabilitation programme treated more non-native patients.

Reasons of drop-out from rehabilitation in patients of Turkish and Moroccan origin with chronic low back pain in The Netherlands: a qualitative study.

OBJECTIVE: To explore which factors led to drop-out in patients of Turkish and Moroccan origin with chronic non-specific low back pain who participated in a rehabilitation programme. SUBJECTS: Patients of Turkish or Moroccan origin with chronic non-specific low back pain (n = 23) from 2 rehabilitation centres and 4 rehabilitation departments of general hospitals in the Netherlands. METHODS: In-depth semi-structured interviews were conducted with patients of Turkish and Moroccan origin (n = 23), rehabilitation physicians (n = 8) and rehabilitation therapists (n = 2). Interviews were transcribed or summarized and subsequently coded and analysed according to themes. RESULTS: Most patients dropped out due to expectations of a specific medical diagnosis and pain relief as the main aims of rehabilitation treatment. Other reasons for drop-out detected in the interviews were: lack of acknowledgement of the patient's complaints, lack of trust in the rehabilitation physician, contradicting views to those of the physician from the patients' country of origin with regard to the cause and treatment of pain, and communication problems. CONCLUSION: The major reason for drop-out was patients having different expectations, from those of their health providers, of the aim of treatment, as a result of a different view of the origin and treatment of low back pain.

Higher dropout rate in non-native patients than in native patients in rehabilitation in The Netherlands.

Dropout from a rehabilitation programme often occurs in patients with chronic nonspecific low back pain of non-native origin. However, the exact dropout rate is not known. The objective of this study was to determine the difference in dropout rate between native and non-native patients with chronic nonspecific low back pain participating in a rehabilitation programme in The Netherlands. A retrospective study (n = 529) of patient files was performed in two rehabilitation centres and two rehabilitation departments of general hospitals in The Netherlands. Patient files were checked for diagnosis, status of origin, sex, age and outcome, that is, reason for finishing treatment. The difference in dropout rate between patients of Dutch and non-Dutch origin was tested by chi tests and logistic regression-analysis, controlling for age, sex, type of rehabilitation institute and phase of the rehabilitation programme. Dropout occurred among one fifth (18.7%) of the total patient population. Dropout among patients of non-Dutch origin was twice as high as among native Dutch patients (P < 0.001). In regression analyses dropout was related to status of non-Dutch origin, treatment in a rehabilitation centre and the diagnostic phase of a rehabilitation programme. In conclusion, patients of non-Dutch origin drop out considerably more frequently than native Dutch patients. Dropout is higher in the diagnostic phase than in the treatment phase and in rehabilitation centres than in hospitals. Future research should clarify the reasons for the high dropout rate in patients of non-native origin.

Medical ethics and rites involving blood.

Although the discussions in the Netherlands on ritual circumcision of girls, ritual circumcision of boys and hymen construction started more than ten years ago, these discussions about rituals of blood are not connected and offer a range of very diverging views. The significance of this article is to make clear that these diverging views and separated discussions fail to make distinctions. As a result, strategies to achieve abolition of these practices are not well thought through. The objective is to connect and to deepen these discussions by a practical method, starting with the dilemmas aid workers are confronted with. The conclusion is that other issues play a role, the issue of the space we allow others to be different and the manner in which the juxtaposition of "individual versus the group" influences this issue.