Explaining ethnic differences in late antenatal care entry by predisposing, enabling and need factors in The Netherlands. The Generation R Study.

Despite compulsory health insurance in Europe, ethnic differences in access to health care exist. The objective of this study is to investigate how ethnic differences between Dutch and non-Dutch women with respect to late entry into antenatal care provided by community midwifes can be explained by need, predisposing and enabling factors. Data were obtained from the Generation R Study. The Generation R Study is a multi-ethnic population-based prospective cohort study conducted in the city of Rotterdam. In total, 2,093 pregnant women with a Dutch, Moroccan, Turkish, Cape Verdean, Antillean, Surinamese Creole and Surinamese Hindustani background were included in this study. We examined whether ethnic differences in late antenatal care entry could be explained by need, predisposing and enabling factors. Subsequently, logistic regression analysis was used to assess the independent role of explanatory variables in the timing of antenatal care entry. The main outcome measure was late entry into antenatal care (gestational age at first visit after 14 weeks). With the exception of Surinamese-Hindustani women, the percentage of mothers entering antenatal care late was higher in all non-Dutch compared to Dutch mothers. We could explain differences between Turkish (OR = 0.95, CI: 0.57-1.58), Cape Verdean (OR = 1.65. CI: 0.96-2.82) and Dutch women. Other differences diminished but remained significant (Moroccan: OR = 1,74, CI: 1.07-2.85; Dutch Antillean OR 1.80, CI: 1.04-3.13). We found that non-Dutch mothers were more likely to enter antenatal care later than Dutch mothers. Because we are unable to explain fully the differences regarding Moroccan, Surinamese-Creole and Antillean women, future research should focus on differences between 1st and 2nd generation migrants, as well as on language barriers that may hinder access to adequate information about the Dutch obstetric system.

Sleep duration differences between children of migrant and native origins.

AIM: To explore whether primary school children of migrant and native Dutch origins differ regarding their sleep duration per night, a risk for overweight and obesity, and to determine to what degree differences in parenting styles contribute to these differences. SUBJECTS AND METHODS: A cross-sectional survey, including 1,943 children aged 8-9 years old and their primary caregivers, was performed. Data were collected from primary schools in cities and adjacent municipalities in The Netherlands: Eindhoven and Rotterdam. The outcome measure was mean sleep duration per night. The main independent variable was migrant background, based on the country of birth of the parents. A possible mediating variable was parenting style (rejecting, neglecting, permissive, authoritarian, authoritative). Age and sex of the child as well as parental socioeconomic status, as indicated by educational level, were added as confounders. RESULTS: Dutch children have the highest sleep duration: more than 11 h (mean = 670.1; SD = 27.7). All migrant children show less than 11 h of sleep per night. Migrant children of non-Western origin, especially Turkish and Moroccan children, show the lowest sleep duration per night. Parenting styles do not contribute to these differences. CONCLUSION: Migrant background is associated with sleep duration. As children of migrant origin are, in general, at higher risk for overweight and obesity and sleep duration is regarded as a risk factor for overweight and obesity, further investigation of this association is needed.

Which chronic conditions are associated with better or poorer quality of life?

The objective of the present study is to compare the QL of a wide range of chronic disease patients. Secondary analysis of eight existing data sets, including over 15,000 patients, was performed. The studies were conducted between 1993 and 1996 and included population-based samples, referred samples, consecutive samples, and/or consecutive samples. The SF-36 or SF-24 were employed as generic QL instruments. Patients who were older, female, had a low level of education, were not living with a partner, and had at least one comorbid condition, in general, reported the poorest level of QL. On the basis of rank ordering across the QL dimensions, three broad categories could be distinguished. Urogenital conditions, hearing impairments, psychiatric disorders, and dermatologic conditions were found to result in relatively favorable functioning. A group of disease clusters assuming an intermediate position encompassed cardiovascular conditions, cancer, endocrinologic conditions, visual impairments, and chronic respiratory diseases. Gastrointestinal conditions, cerebrovascular/neurologic conditions, renal diseases, and musculoskeletal conditions led to the most adverse sequelae. This categorization reflects the combined result of the diseases and comorbid conditions. If these results are replicated and validated in future studies, they can be considered in addition to information on the prevalence of the diseases, potential benefits of care, and current disease-specific expenditures. This combined information will help to better plan and allocate resources for research, training, and health care.

Measuring morbidity of children in the community: a comparison of interview and diary data.

BACKGROUND: Little is known about the validity of estimates of morbidity experienced at home. METHODS: In the Dutch National Survey of Morbidity and Interventions in General Practice mothers of 1630 children answered a health interview and kept a health diary for 3 weeks (only the first 2 weeks were used). Children's symptoms were recorded during the interview using a check list and monitored in the health diary through open-ended questions. RESULTS: In the interview parents reported symptoms for 65% of their children and in the diary for 54% of children. Ear problems, colds, fever and weakness and anxiety were reported more often in the interview. Mother's mental health was assessed by the General Health Questionnaire; those scoring >4 were assessed as having impaired mental health and these parents reported symptoms for more children in the interview (81%) than in the diary (65%). For similar reference periods, the least educated mothers reported fewer children with symptoms in the diary (45%) than in the interview (66%). More highly educated mothers reported similarly in the diary (67%) and the interview (70%). CONCLUSION: Both data collection methods yield different estimates of community morbidity. Explanations such as telescoping, the seriousness of the symptoms, the amount of psychological distress of the respondent, forgetfulness and literacy limitations are discussed. We recommend that diaries should not be used in less educated populations.

Epilepsy patients: health status and medical consumption.

OBJECTIVE: To study the health status and medical consumption of outpatients with active epilepsy in comparison with the general population. DESIGN: Descriptive population study (multi-stage random sample). SETTING: Structured questionnaire. PATIENTS: Thirty-nine epilepsy patients compared with a general population of 12,975. RESULTS: Epilepsy patients revealed poorer health, a higher mean complaint score (5.3 versus 3.7, P < 0.05), a higher score on the General Health Questionnaire (P < 0.05), a somewhat higher score on the bio-logical problem list (BIOPRO) (1.8 versus 1.4, P > 0.05), less active sports engagement (16% versus 39%, P < 0.01), more fatigue (46 vs 29%, P < 0.05), dizziness (33 vs 10%, P < 0.01), nervousness (28 vs 18%, P > 0.05), sleep disturbance (23 vs 15%, P > 0.05) and excitability (33 vs 15%, P < 0.01) when compared with the general population. The BIOPRO showed problems in epilepsy patients on specific items related to self-confidence (P < 0.001) Epileptic patients do not show more absence due to illness, from work, school or at home (15 vs 18%, P > 0.05) and/or more problems at work or in the family when compared with the general population. Almost half of epilepsy patients had consulted a specialist in the past 2 months (46 vs 23% of the general population, P < 0.001). Epilepsy patients consulted the family physician slightly more often than other responders (3.0 versus 2.3, P > 0.05) and contacted the family physician's assistant considerably more often (2.3 versus 0.7, P < 0.001). One-third of epilepsy patients consulted an alternative healer in the past 5 years versus 14% in the general population (P < 0.001). CONCLUSIONS: The study shows an excess of psychosocial problems and medical consumption in epilepsy patients, but not more absence from work or problems at work or in the family. Further development of a quality of life instrument specific to epilepsy is advised.

Validity and accuracy of interview and diary data on children's medical utilisation in The Netherlands.

STUDY OBJECTIVE: To assess the validity and accuracy of children's medical utilisation estimates from a health interview and diary and the possible consequences for morbidity estimates. The influence of recall bias and respondent characteristics on the reporting levels was also investigated. DESIGN: Validity study, with the medical record of the general practitioner (GP) as gold standard. In a health interview and three week diary estimates of medical utilisation of children were asked and compared with a GP's medical record. SETTING: General community and primary care centre in the Netherlands. PARTICIPANTS: Parents of 1,805 children and 161 GPs. MAIN RESULTS: The sensitivity of the interview (0.84) is higher than the diary (0.72), while specificity and kappa are higher in the diary (0.96; 0.64) than in the interview (0.91; 0.5-8). Recall bias, expressed as telescoping and heaping, is present in the interview data. Prevalence estimates of all morbidity are much higher in the interview, except for skin problems. Compared with a parental diary more consultations are reported exclusively by the GP for children from ethnic minorities (OR 1.6), jobless (OR 2.3), and less educated mothers (OR 2.6). CONCLUSIONS: Estimates of medical utilisation rates of children are critically influenced by the method of data collection used. Interviews are prone to introduce recall bias, while diaries should only be used in populations with an adequate level of literacy. It is recommended that medical records are used, as they produce most consistent estimates.

Health care use by diabetic patients in the Netherlands: patterns and predicting factors.

AIMS: Diabetic patients require care from a variety of health care providers, but little is known about their actual use of health care. Aims of this study were to (1) obtain information on health care use by diabetic patients in the Netherlands, (2) distinguish patterns of health care utilisation among these patients, and (3) develop insight into the factors predicting these patterns. METHOD: Data on 388 diabetic patients were extracted from a nationally representative database of patients with chronic disease. Data on health care utilisation and background variables were collected in 1998 by means of a survey. Patients' GPs registered information about medical diagnosis, illness duration and co-morbidity. Analysis included descriptive statistics, as well as cluster and logistic analysis. RESULTS: Diabetic patients use a wide range of services, but large differences exist. Four patterns of health care utilisation could be distinguished: a pattern of low consumption, one of moderate consumption with a central role for internal medicine, one of more extensive diabetes care consumption, and one of high medical and home care consumption. Type 1 diabetes appeared to be an important determinant of the moderate, mainly internal medicine pattern and the more extensive diabetes care pattern. The pattern of high medical and home care was not predicted by diabetes type, but by the presence of co-morbidity and by poor self-rated health. CONCLUSION: Despite the fact that diabetic patients use a wide range of health care services, there seems to be a problem of under utilisation, especially among type 2 diabetic patients.

The Primary Health Care Project in Belgium: a survey on the utilization of health services.

The article consists of two major parts. In the Introduction a general overview is given of the Primary Health Care Project, carried out in Belgium from 1975 to 1978 in the broader framework of a large National Project in the Social Sciences. An explanation is given of the scope of the study, its method and sampling. Since the very broad study design, it was decided to make a selection of interesting results. An overview is given of the most relevant data with respect to the utilization of health care services and of medicines. After a short clarification of the concept of utilization behaviour, some data are presented in order to describe the use of medical services and the consumption of medicines. Secondly an attempt is made to explain utilization behaviour. For the explanatory model used in this project, the WHO-model functioned as an important source of inspiration. In this way it surmounted the limitations of much previous research. This model included variables on the level of the individual-perceived morbidity, predisposing factors and enabling factors-as well as system variables--such as degree of urbanization, proximity and the way of functioning of the medical supply. The research results have successfully shown that: there is a strong relationship between perceived presence and perceived seriousness of morbidity on the one hand, utilization behaviour on the other hand; the health perspective (including medical knowledge, values and attitudes) seems to have a differential influence on utilization behaviour, depending on age and social background of the respondent; the inclusion of socio-structural variables is an innovation in the Belgian health care research. The hypothetical character of the relationships found here is largely supported by the research simultaneously conducted in the French-speaking region of Belgium; accessibility and socialization are factors having a clear influence on the use of general practice services. The importance of the presence and the organization of the supply in the explanation of utilization behaviour is partly confirmed.

An orientation toward help-seeking for emotional problems.

In recent years, many researchers tried to explain the social selection in use of mental health care services. A modest role is attributed to the orientation toward help-seeking. This article studies this orientation. Our research-population consisted of 10,171 Dutch persons, aged 18 and older. Analysis showed that most people are prone to seek help for one or more emotional problems. People who are more prone to seek help are younger, have had more education and have a higher family income. They have more often acquaintances working in mental health care. People who are more prone to seek help do not see chance as the locus of control of health. These people are less dependent on their GP for common disorders and are more open about mental health matters. The results of discriminant analysis are not satisfactory, but when we try to distinguish the groups of people who are and who are not willing to seek help, we see that the best discriminating factor is their help-seeking attitude for common disorders. People who have high expectations from the GP for common disorders, clearly do have a preference to seek help for the emotional problems. The groups of people who are more willing to seek help from the GP compared to mental health professionals cannot be distinguished by these expectations. Here the level of education discriminates fairly well: people who are more prone to seek help from a GP have a lower educational level. Future research should be focussed on the testing of a theoretical model that explains the orientation toward help-seeking for emotional problems and selection in help-seeking with longitudinal data.

Social support and stressful events in two dimensions: life events and illness as an event.

Previous research on the buffering effects of social support focused mainly on life events as stressors, and mental illness as outcome. Furthermore, the question as to why support influences illness has not been subjected to theoretical or empirical study much. In this article we develop a hypothesis on the basis of the theory of social capital. We hypothesize that specific types of social resources are more relevant to the consequences of some events than of others. We test this hypothesis in two ways: (1) by taking life events as stressor and occurrence of illness as outcome, and, which is somewhat unusual, (2) by taking illness as stressor and duration and disabilities of illness as the outcome. Analyses of a representative sample of the Dutch population (N = 10,110) reveal that receiving specific types of support does not lead to better health or less illness in cases of stress. On the contrary, people who are under stress and receive more support, also appear to report more illness, more disabilities and a longer duration. We suggest that in an open sample like ours, the disease level measured is not severe enough to assess buffer effects of social support.

Patients with irritable bowel syndrome: health status and use of health care services.

BACKGROUND: The reason for consulting a physician is more related to illness behaviour than to the severity of complaints. Yet, little is known about the course of complaints, the health care seeking behaviour, and psychosocial factors influencing these items in patients with irritable bowel syndrome (IBS) attending the general practitioner (GP). AIM: To study health status, lifestyle, and use of health care services of patients with IBS in order to indicate problem areas accessible for intervention strategies. METHOD: Structured interviews of 53 patients with IBS aged 15 years and older compared with a general population of 12,975 in the same age range, all drawn from the Dutch National survey of Morbidity and Intervention in General Practice. RESULTS: Patients with IBS revealed a lower grade of education (P < 0.001), poorer health (P < 0.001), a higher mean complaint score (8.3 versus 4.0, P < 0.001), a higher score on the General Health Questionnaire (P < 0.001), a higher score on the biographic problem list (BIOPRO, 2.3 versus 1.4, P < 0.001), and more absence from work (32% versus 18% in two months, P < 0.01). Patients with IBS consulted the family physician (1.6 versus 0.8 in three months, P < 0.001), the physical therapist (30% versus 15% in one year, P < 0.001), and the alternative therapist (32% versus 15% in five years, P < 0.001) more often than those without. CONCLUSIONS: The study shows an excess of comorbidity, psychosocial problems, use of health care services, and absence owing to disease in patients with IBS. Special guidelines and training of GPs to apply a more integral approach may reduce the cost of health care and may lead to a more favourable course in patients with IBS.

Everyday symptoms in childhood: occurrence and general practitioner consultation rates.

BACKGROUND: Fewer than 20% of all illnesses that occur in the home require the attention of a general practitioner (GP). Whether specific illnesses in children are more likely to need the attention of a GP is poorly understood, as is the influence of various other factors. Health diaries are the most suitable method of collecting comprehensive information about children's health problems at home and in general practice simultaneously. AIM: To investigate the occurrence of, and consultation rates for, specific symptoms in childhood in relation to age, sex, birth order, and place of residence of the child, and season of the year. METHOD: The parents of 1805 children kept a health diary over three weeks and recorded symptoms and consultation behaviour. The symptoms were later combined into illness episodes. RESULTS: Over three weeks, colds/flu (157/1000 children) and respiratory symptoms (114/1000 children) occurred most frequently. More young children (0-4 years) suffered from illness generally. Eleven per cent of all illness episodes required the attention of a GP. Consultation rates differed greatly according to symptoms. A GP was consulted most often for ear (36%) and skin (28%) problems, and least often for headaches (2%) and tiredness (1%). Regardless of symptoms, young children (0-4 years) were taken to a GP twice as often as older children (10-14 years). CONCLUSIONS: This study emphasizes the enormous amount of illness that occurs in children and the fact that more than 80% of all illnesses are dealt with by parents without reference to the professional health care system.

Trends in HIV-related consultation in Dutch general practice.

New medicine against AIDS and a possible changing attitude towards AIDS will affect the role of the general practitioner (GP). We aim to explore and assess the changing role of the GP in preventing and detecting AIDS, which will be done by providing insight into the changing numbers and content of HIV-related consultations in the general practice. Since 1988 a representative sample of 63 Dutch GPs have participated in a network. They recorded all face-to-face consultations with non HIV-infected patients in which the subject of AIDS was brought up. Timetrend analysis is used to investigate variations over time in the number and content of the consultations, GPs' actions and patients' characteristics. The influence of a rural or urban setting and the characteristics of the patients who are involved are also taken into account. Until 1994 a significant increase was found in the number of consultations. In highly urban areas the number of consultations is higher and still growing, whereas physicians in rural areas see fewer patients every year. The most important topic of conversation was the request for an HIV test (74%). This figure grew over the years, as did the number of tests performed. GPs became less passive and restrictive in advising tests. The group of patients has also changed, e.g. patients do not mostly belong to traditional risk groups anymore, and are significantly younger. AIDS seems to have become more familiar to patients and doctors. A lot of general information is available from different sources. Because of this change in attitude and knowledge of patients, the GPs' role as it relates to AIDS is becoming more specific in tracing infected patients and giving customized information to individuals. Patients visit their physicians less often because of concerns about AIDS, but the GP continues to fulfil a very important role in the prevention and detection of AIDS.

Stress in chronic disease: do the perceptions of patients and their general practitioners match?

OBJECTIVE: To compare the stressors accompanying chronic disease as perceived by patients and their GPs and to explore how incongruence in patients' and GPs' ideas influences patients' health status and use of health care. METHOD: A total of 580 patients with a diagnosis of diabetes or osteoarthritis and their GPs were interviewed by questionnaire about the stressors accompanying a patient's illness. In addition, information was obtained from each patient on health status and use of health care. RESULTS: The results show that patient and GP diverge in the way they think about chronic illness. Incongruence was larger in the case of osteoarthritis. In both diabetes and osteoarthritis, incongruence between patient and GP was associated with a worse health status of the patient and an increase in health-care use, although the pattern of correlation differed by type of disease. CONCLUSIONS: A chronic disease requires an ongoing relationship between patient and GP over years. Therefore, it is especially important that providers recognize the problems with which chronic disease patients are faced. Too often, providers are one-sided focused on the medical aspects of disease, neglecting the personal impact that a chronic disease has on the patient's life. In this way, successful treatment is complicated.

Sex differences among recipients of benzodiazepines in Dutch general practice.

OBJECTIVE: To analyse sex differences among recipients of benzodiazepines in Dutch general practice. DESIGN: Study of consultations and associated interventions as recorded in the Dutch national survey of general practice. SETTING: Practices of 45 general practitioners monitored during 1 April to 30 June 1987. SUBJECTS: 61,249 patients (29,035 (47.4%) men in the age groups 19-44, 45-64, and 65 years and over. MAIN OUTCOME MEASURES: Symptoms among recipients of repeat as well as new benzodiazepine prescriptions stratified by sex and age. RESULTS: Prescriptions for benzodiazepines were found to be significantly more common among women than among men, (a) after correcting for the sex distribution of the total patient population, and (b) in the two oldest age groups after correcting for the number of consultations. Of all prescriptions for benzodiazepines, 89% (6055/6777) were repeats and 70% (4759/6777) requests. Only 9% (439/4759) of these were authorized by the general practitioner, the rest being issued by the general practitioner's assistant after he or she had referred to the diagnosis in the patient's record. In contrast, only three (1%) of the 492 first time recipients of benzodiazepines had requested a prescription and were not seen by the general practitioner. Women (43/96; 45%) aged 45-64 years received their first prescription for benzodiazepines almost twice as often as men (15/63; 24%) without symptoms or a diagnosis being an indication (female to male relative risk 1.88 (95% confidence interval 1.15 to 3.08)). CONCLUSIONS: The sex difference among first time recipients of benzodiazepines seems to be due to general practitioners being less stringent when prescribing this drug for women. The difference continues in repeat prescriptions, physicians failing to check adequately the need for these.

[Migrants in family practice: their symptoms and diagnoses differ from the Dutch]. / Migranten in de huisartspraktijk: andere klachten en diagnosen dan Nederlanders.

OBJECTIVE: To determine to what extent Turks, Moroccans and Surinamese differ from the Dutch in health problems, while taking the impact of relevant background characteristics into account. DESIGN: Secondary analysis. SETTING: Dutch Institute for health care research, Utrecht, the Netherlands. PATIENTS AND METHODS: In 1987/'88, 161 general practitioners and their assistants in 103 general practices recorded all patient contacts during three months in four consecutive periods for the Dutch National Survey on Morbidity and Interventions in General Practice. Data on 1165 Turkish, 853 Moroccan, 1355 Surinamese and 1471 Dutch persons (a 1% sample) between 18 and 65 years of age were used. Differences in health problems (complaints and diagnoses) between groups were tested by means of logistic regression analysis. Sex, age, educational level, working situation, marital status, health insurance, region and urbanisation were included in the analyses as covariates, for which the data were corrected. RESULTS: The pattern of complaints and diagnoses of ethnic minorities agreed with that of the Dutch in many respects, but there were also clear differences. Surinamese differed the most. Digestive problems, acute and chronic, eye problems, acute musculoskeletal problems, especially muscle pain or fibrositis, respiratory infections and eczema occurred more often in all three minority groups. Surinamese had more diagnoses in the categories of blood and endocrine/metabolic disorders (diabetes mellitus), Moroccanshad fewer diagnoses of the circulatory system (hypertension). Turks and Surinamese had more general and social problems, while Surinamese also had more psychological problems. CONCLUSION: In some areas ethnic minorities have more health problems than Dutch patients who are comparable with them in background characteristics. This clearly suggests an 'ethnic' factor.

[Multiple sclerosis in family practice]. / Multipele sclerose in de huisartspraktijk.

OBJECTIVE: To study the family physician's role in the diagnosis and treatment of multiple sclerosis (MS) patients. DESIGN: Descriptive. SETTING: Nederlands Instituut voor Onderzoek van de Gezondheidszorg, Utrecht, The Netherlands. METHOD: In the Dutch National survey of morbidity and intervention in general practice, data were collected by 161 general practices throughout the Netherlands (161 family physicians) regarding contacts with patients during three months. These data were examined for contacts which resulted in the diagnosis of MS and for comorbidity. RESULTS: MS patients (n = 118) had 4.3 encounters per 3 months with their family physician and (or) the practice assistant. In 5 patients MS was diagnosed for the first time. Apart from neurological complaints characteristic of MS the family physician was consulted most frequently for sleeping disorders, urinary tract infections and urine incontinence. One-third of patients depended on social security and 26% had a paid job. CONCLUSION: The family physician was consulted relatively frequently by MS patients. Apart from sleeping disorders remarkably few psychic complaints were noted.

[Little recognition of mental problems in children by parents and family physicians]. / Weinig herkenning van psychische problemen bij kinderen door ouders en huisartsen.

OBJECTIVE: To determine the prevalence of psychic problems in children in the Dutch GP-practice and to determine how often parents and general practitioners (GPs) recognize psychic problems in children. DESIGN: Descriptive. SETTING: World Health Organisation Collaborating Centre for Primary Health Care (NIVEL) and Academic Hospital, Department of Child and Adolescent Psychiatry, Utrecht, the Netherlands. METHOD: In 810 children presence or absence of emotional and behavioural problems was studied by means of the Child Behaviour Checklist (CBCL) filled out by a parent at the moment of contact with a GP. The GPs findings in these were also recorded. RESULTS: 7.7% of all children obtained a total CBCL score indicating presence of emotional and behavioural problems (> P90). These children had problems at school, had repeated a school year, and followed special education more often. Nevertheless most of their parents (86%) did not experience problems with their children and 40% of the parents did not report any psychic problem in the preceding 2 weeks. Only 15% of these children were completely free of signs and symptoms, however, as against 40% of children with low scores. The percentages of children with high scores consulting a GP, social work or mental health care agency were somewhat higher than the percentages of children without these problems, but only the last-mentioned difference was significant. Children saw the GP rarely because of psychosocial problems (n = 7; less than 1%; 1 had a high CBCL score). Regardless of the presence of emotional and behavioural problems, as assessed by the CBCL, the GP seldom diagnosed psychological or social problems in children (n = 11; 1.4%; 2 had a high CBCL score) and rarely suspected the complaints had a psychosocial background. CONCLUSION: Children with a high CBCL score did not visit their GPs more often. The perception by the parent appears to be crucial in the help-seeking process. In many children in whom the screening instrument indicated the presence of emotional and behavioural problems, parents did not consider their children as problematic and did not seek the help of a GP.

[Management of psoriasis in family practice is now in closer agreement with the guidelines of the Netherlands Society of Family Physicians]. / Beleid bij psoriasis in de huisartspraktijk nu meer in overeenstemming met de standaard van het Nederlands Huisartsen Genootschap.

OBJECTIVE: To assess changes in incidence of psoriasis and to study changes in the management of psoriasis in general practice after the sending of guidelines on management of psoriasis to general practitioners (GPs) by the NHG. DESIGN: Secondary data analysis. SETTING: Netherlands Institute for Health Care Research (NIVEL), Utrecht, the Netherlands. METHOD: Data on the incidence of psoriasis and its management by general practitioners were collected from a file predating the publication of the NHG guideline 'Psoriasis' in 1994, namely the 'Dutch National Survey of General Practice' (NS; 1987/'88), and from a subsequent file, the 'Registration Network Groningen' (RNG; 1995). RESULTS: In the NS there were 106 new patients with psoriasis (incidence: 1.3/1000/year; 95% confidence interval (95% CI): 1.2-1.4) while in the RNG there were 24 (incidence: 1.2/1000/year; 95% CI: 0.7-1.9). In all, there were 466 psoriasis patients in the NS and 125 in the RNG. The number of referrals to dermatologists was halved in 1995 (7.2%) compared with 1987/'88 (14.4%; p < 0.05). The most frequently prescribed dermatologica in psoriasis was in 1995 corticosteroid group 3 (32.8%; in 1987/'88: 28.5%), but the rise was stronger in corticosteroid group 2 (29.6%; in 1987/'88: 16.0%; p < 0.001) and group 4 (16.0%; in 1987/'88: 8.8%; p < 0.05). CONCLUSION: The incidence of psoriasis in general practice had not changed between 1987/'88 en 1995. Referral pattern and prescription shifted towards the guidelines issued by the NHG.

The use of outpatient mental health care services of migrants vis-a-vis Dutch natives: equal access?

BACKGROUND: Although the use of outpatient mental health care services by migrants in the Netherlands has increased in recent years, whether it aligns with the need for care is unclear. AIMS: To investigate ethnic-related differences in utilization in outpatient mental health care, taking need into account, and to examine whether socio-economic or cultural barriers explain such differences. METHODS: Data for the native population was taken from the second Dutch National Survey of General Practice (N = 7,772). An additional random sample was drawn (N = 1,305) from four migrant groups (Surinamese, Dutch Antilleans, Moroccans and Turks) living in the Netherlands. Participants were surveyed on mental health care utilization, indicators of need, educational level, proficiency in Dutch and acculturation. RESULTS: Use of outpatient mental health care was about 5% for the indigenous population. Among migrants, percentages of use ranged from 6.5% (Moroccans) to 9.0% (Turks). Corrected for need, however, all non-Dutch groups had a lower chance of service utilization than the native group. Acculturation predicted utilization but did not explain all ethnic-related differences; proficiency in Dutch and health beliefs were not explanatory factors. CONCLUSIONS: In non-Dutch-speaking migrant groups, utilization is about half the level of the native Dutch, suggesting that a substantial gap exists. Our study found that acculturation only partially explains the differences.