Participatory research in health promotion: a critical review and illustration of rationales.

In health promotion research, enthusiasm for patient and public involvement (PPI) is growing. However, a lack of conceptual clarity leads to ambiguities in participatory processes and purposes, and hampers efforts to achieve and evaluate PPI in research. This study provides an overview of its underlying reasons-or rationales-so as to better understand, guide and interpret PPI in research practice. We conducted a critical review to identify typologies of rationales for PPI. We re-categorized the different types of rationales from these typologies based on their content. We illustrated the resulting categories of rationales with examples from a case study on PPI in research on Lyme disease. Five categories of rationales for PPI were identified. The democratic rationale reflects the normative right of citizens to have a voice in research. The consumerist rationale refers to the economic right of stakeholders with interests to have a say. Rooted in social justice, the transformative rationale seeks to empower marginalized groups. The substantive rationale starts from epistemic considerations and aims to improve the quality of knowledge that research generates. The instrumental rationale is of pragmatic origin and refers to improved efficiency and effectiveness of the research. Our overview of categories of rationales can be used as a frame of reference for PPI in health promotion research. Exploring, stating explicitly and reflecting on the underlying reasons for PPI may help to define realistic purposes, select matching approaches and design appropriate evaluation studies. This might also contribute to the conceptualization of PPI.

Enthusiasm for patient and public involvement in health promotion research is growing. However, it often remains unclear why this involvement is being organized. This lack of clarity makes it difficult to implement such participatory research and to evaluate its added value. We searched for reasons that were given for starting patient and public involvement in research. We found five different reasons. The first is the right of all citizens to have a say in research that affects them. The second is the right of individuals to demand the best research. The third is the desire to involve and empower marginalized groups. The fourth aims to improve the quality of the knowledge generated by the research. The fifth is to achieve more effective and efficient research. Together, these reasons may help researchers get more clarity about why patients or the public should be involved in their studies. This may in turn help to define realistic purposes, design a good participatory process, and conduct appropriate evaluations. All in all, using these five reasons as a frame of reference might lead to a better understanding of what good participatory research in health promotion should look like.

Associations of sustained smoking and smoking cessation with work-related outcomes: a longitudinal analysis.

PURPOSE: The aim of this study was to assess the association between sustained smoking and quitting with work-related outcomes among older workers. METHODS: We categorized a sample of older employees into non-smokers, sustained smokers and quitters. Multivariable regression models were used to test longitudinal associations of sustained smoking and smoking cessation with sickness absence, productivity loss and work ability. RESULTS: We included 3612 non-smokers, 673 sustained smokers and 246 quitters. Comparing sustained smokers to non-smokers, we found higher (but not statistically significant) sickness absence for sustained smokers [1.01, 95% confidence interval (CI) - 0.16-2.17]. We did not find differences in productivity loss (OR 0.82, 95% CI 0.60-1.13) and work ability (0.05, 95% CI -0.05-0.15). For employees with a relatively high physical health at baseline, comparing quitters to sustained smokers, we found higher (but not statistically significant) productivity loss for quitters (OR 2.23, 95% CI 0.94-5.31), and no difference in sickness absence (0.10, 95% CI - 2.67-2.87), and work ability (- 0.10, 95% CI -  0.36-0.16). For employees with a relatively low physical health at baseline, comparing quitters to sustained smokers, we found a statistically significant lower work ability (- 0.31, 95% CI - 0.57-0.05), and no difference in sickness absence (2.53, 95% CI - 1.29-6.34) and productivity loss (OR 1.26, 95% CI 0.66-2.39). CONCLUSIONS: We found no evidence that sustained smokers have less favorable work-related outcomes than non-smokers or that quitters have more favorable work-related outcomes than sustained smokers. The benefits of smoking cessation for employers might take a longer time to develop.

Understanding the multitude of barriers that prevent smokers in lower socioeconomic groups from accessing smoking cessation support: A literature review.

One explanation for the increasing smoking-related health inequalities is the limited access of lower socioeconomic status (SES) smokers to smoking cessation support. In order to understand this limited access - and to eventually improve accessibility - we provide a structured overview of the barriers that lower SES smokers face in the successive phases of access to cessation support. Our literature review included 43 papers on barriers of access to cessation support for lower SES smokers, published before June 2016. We used the access to health care framework to categorize the extracted barriers into (a) either the abilities of smokers or dimensions of cessation support and (b) one of the successive phases of access to support. We found that lower SES smokers encounter many barriers. They are present in all phases of access to cessation support, and different barriers may be important in each of these phases. We also found that each phase transition is hampered by barriers related to both the abilities of smokers and the dimensions of cessation support, and that these barriers tend to interact, both with each other and with the disadvantaged living conditions of lower SES smokers. In conclusion, reducing smoking-related health inequalities by improving lower SES smokers' access to smoking cessation support requires a comprehensive approach. Our structured overview of barriers may serve as a starting point for tailoring such an approach to the multitude of barriers that prevent lower SES smokers from accessing cessation support, while simultaneously taking into account their disadvantaged living conditions.

"Like you are fooling yourself": how the "Stoptober" temporary abstinence campaign supports Dutch smokers attempting to quit.

BACKGROUND: The Stoptober temporary abstinence campaign challenges smokers to engage in a collective quit attempt for 28 days. The campaign is based on social contagion theory, SMART (i.e., Specific, Measurable, Attainable, Realistic and Time-sensitive) goal setting and PRIME (i.e., Plans, Responses, Impulses, Motives and Evaluations) theory. Although Stoptober was found to yield impressive 28-day quit rates, relapse rates remained substantial. Therefore, we examined how Stoptober supported smokers in their attempt to quit and how the campaign's effectiveness could be strengthened. METHODS: In 2016, we conducted semi-structured interviews with 23 Stoptober participants in the Netherlands. Data were analyzed thematically. RESULTS: Respondents explained how social contagion-based components had familiarized them with Stoptober, motivated them to participate, and created a pro-smoking cessation social norm. Setting SMART goals was reported as "fooling yourself", since it distracted respondents from their goal of quitting for good and helped them perceive that temporary abstinence was achievable. Respondents also illustrated the usefulness of PRIME theory. They typically used an individual selection of available supports that varied over time. To achieve long-term abstinence, respondents expressed the need for additional social network support and interactive, personalized and professional support during and after the campaign. CONCLUSIONS: Stoptober supports smokers in their attempts to quit and generally according to the campaign's theoretical principles. Added to available evidence, this finding supports the continuation and wider implementation of Stoptober, while connecting the campaign to social networks and regular smoking-cessation services to help improve long-term abstinence rates.

Implementing multiple intervention strategies in Dutch public health-related policy networks.

Improving public health requires multiple intervention strategies. Implementing such an intervention mix is supposed to require a multisectoral policy network. As evidence to support this assumption is scarce, we examined under which conditions public health-related policy networks were able to implement an intervention mix. Data were collected (2009-14) from 29 Dutch public health policy networks. Surveys were used to identify the number of policy sectors, participation of actors, level of trust, networking by the project leader, and intervention strategies implemented. Conditions sufficient for an intervention mix (≥3 of 4 non-educational strategies present) were determined in a fuzzy-set qualitative comparative analysis. A multisectoral policy network (≥7 of 14 sectors present) was neither a necessary nor a sufficient condition. In multisectoral networks, additionally required was either the active participation of network actors (≥50% actively involved) or active networking by the project leader (≥monthly contacts with network actors). In policy networks that included few sectors, a high level of trust (positive perceptions of each other's intentions) was needed-in the absence though of any of the other conditions. If the network actors were also actively involved, an extra requirement was active networking by the project leader. We conclude that the multisectoral composition of policy networks can contribute to the implementation of a variety of intervention strategies, but not without additional efforts. However, policy networks that include only few sectors are also able to implement an intervention mix. Here, trust seems to be the most important condition.

A school-based interdisciplinary approach to promote health and academic achievement among children in a deprived neighborhood: study protocol for a mixed-methods evaluation.

BACKGROUND: The large number of children that grow up in poverty is concerning, especially given the negative developmental outcomes that can persist into adulthood. Poverty has been found as a risk factor to negatively affect academic achievement and health outcomes in children. Interdisciplinary interventions can be an effective way to promote health and academic achievement. The present study aims to evaluate a school-based interdisciplinary approach on child health, poverty, and academic achievement using a mixed-method design. Generally taken, outcomes of this study increase the knowledge about effective ways to give disadvantaged children equal chances early in their lives. METHODS: An observational study with a mixed-methods design including both quantitative and qualitative data collection methods will be used to evaluate the interdisciplinary approach. The overall research project exists of three study parts including a longitudinal study, a cross-sectional study, and a process evaluation. Using a multi-source approach we will assess child health as the primary outcome. Child poverty and child academic achievement will be assessed as secondary outcomes. The process evaluation will observe the program's effects on the school environment and the program's implementation in order to obtain more knowledge on how to disseminate the interdisciplinary approach to other schools and neighborhoods. DISCUSSION: The implementation of a school-based interdisciplinary approach via primary schools combining the cross-sectoral domains health, poverty, and academic achievement is innovative and a step forward to reach an ethnic minority population. However, the large variety of the interventions and activities within the approach can limit the validity of the study. Including a process evaluation will therefore help to improve the interpretation of our findings. In order to contribute to policy and practice focusing on decreasing the unequal chances of children growing up in deprived neighborhoods, it is important to study whether the intervention leads to positive developmental outcomes in children. TRIAL REGISTRATION: ( NTR 6571 ) (retrospectively registered on August 4, 2017).

Sustainability of the good behaviour game in Dutch primary schools.

Summary: Sustainability of health promotion programs is essential to maintain their positive effects. However, few studies have examined the extent of program sustainability and the factors influencing it. We examined these issues through the Good Behaviour Game (GBG), a classroom-based program in primary schools with beneficial behavioural and health-related effects that was implemented in 2008. GBG coordinators of 17 participating schools were invited in the study 2 years after the initial program implementation. Sustainability was measured using a 20-item checklist comprised of four dimensions of routinization including: memory, adaptation, values and rules. A semi-structured interview was then completed with 16 of the GBG coordinators to discuss the checklist scores and to probe in more depth the current level of sustainability. Based on the checklist scores, sustainability of the GBG was considered 'high' in five schools, 'medium' in another five and 'weak' in six. Factors influencing sustainability identified by GBG coordinators were organizational strength, strong leadership, program championship and the perceived modifiability and effectiveness of the GBG. Also, different factors were related to different dimensions of routinization. The combination of a sustainability checklist and an interview about influential factors may help to further clarify the sustainability construct and reveal which implementation sites, routinization dimensions and influential factors should be explored to further facilitate the sustaining of programs with proven effectiveness.

Use of a knowledge broker to establish healthy public policies in a city district: a developmental evaluation.

BACKGROUND: Public health is to a large extent determined by non-health-sector policies. One approach to address this apparent paradox is to establish healthy public policies. This requires policy makers in non-health sectors to become more aware of the health impacts of their policies, and more willing to adopt evidence-informed policy measures to improve health. We employed a knowledge broker to set the agenda for health and to specify health-promoting policy alternatives. This study aimed at gaining in-depth understanding of how this knowledge broker approach works. METHODS: In the context of a long-term partnership between the two universities in Amsterdam and the municipal public health service, we employed a knowledge broker who worked part-time at a university and part-time for an Amsterdam city district. When setting an agenda and specifying evidence-informed policy alternatives, we considered three individual policy portfolios as well as the policy organization of the city district. We evaluated and developed the knowledge broker approach through action research using participant observation. RESULTS: Our knowledge brokering strategy led to the adoption of several policy alternatives in individual policy portfolios, and was especially successful in agenda-setting for health. More specifically, health became an issue on the formal policy agenda as evidenced by its uptake in the city district's mid-term review and the appointment of a policy analyst for health. Our study corroborated the importance of process factors such as building trust, clearly distinguishing the knowledge broker role, and adequate management support. We also saw the benefits of multilevel agenda-setting and specifying policy alternatives at appropriate policy levels. Sector-specific responsibilities hampered the adoption of cross-sectoral policy alternatives, while thematically designed policy documents offered opportunities for including them. Further interpretation revealed three additional themes in knowledge brokering: boundary spanning, a ripple effect, and participant observation. CONCLUSIONS: The employment of a knowledge broker who works simultaneously on both agenda-setting for health as well as the specification of health-promoting policy alternatives seems to be a promising first step in establishing local healthy public policies. Future studies are needed to explore the usefulness of our approach in further policy development and policy implementation.

Understanding the impact of area-based interventions on area safety in deprived areas: realist evaluation of a neighbour nuisance intervention in Arnhem, the Netherlands.

BACKGROUND: Area-based health inequalities may partly be explained by higher levels of area disorder in deprived areas. Area disorder may cause safety concerns and hence impair health. This study assessed how, for whom and in what conditions the intervention Meeting for Care and Nuisance (MCN) had an impact on neighbour nuisance and area safety in four deprived districts in Arnhem, the Netherlands. METHODS: Realist evaluation methodology was applied to uncover how, for whom, and under what conditions MCN was expected to and actually produced change. Expected change was based on action plans and scientific theories. Actual change was based on progress reports, media articles, interviews with district managers, and quantitative surveys. RESULTS: Three levels of impact were distinguished. At the organisational level, partly as expected, MCN's coordinated partnership strategy enabled role alignment, communication, and leadership. This resulted in a more efficient approach of nuisance households. At the level of nuisance households, as expected, MCN's joint assistance and enforcement strategy removed many of the underlying reasons for nuisance. This resulted in less neighbour nuisance. At the district level, perceptions of social control and area safety improved only in one district. Key conditions for change included a wider safety approach, dense population, and central location of the district within the city. CONCLUSIONS: This realist evaluation provided insight into the mechanisms by which a complex area-based intervention was able to reduce neighbour nuisance in deprived areas. Depending on wider conditions, such a reduction in neighbour nuisance may or may not lead to improved perceptions of area safety at the district level.

Manifestations of integrated public health policy in Dutch municipalities.

Integrated public health policy (IPHP) aims at integrating health considerations into policies of other sectors. Since the limited empirical evidence available may hamper its further development, we systematically analysed empirical manifestations of IPHP, by placing policy strategies along a continuum of less-to-more policy integration, going from intersectoral action (IA) to healthy public policy (HPP) to health in all policies (HiAP). Our case study included 34 municipal projects of the Dutch Gezonde Slagkracht Programme (2009-15), which supports the development and implementation of IPHP on overweight, alcohol and drug abuse, and smoking. Our content analysis of project application forms and interviews with all project leaders used a framework approach involving the policy strategies and the following policy variables: initiator, actors, policy goals, determinants and policy instruments. Most projects showed a combination of policy strategies. However, manifestations of IPHP in overweight projects predominantly involved IA. More policy integration was apparent in alcohol/drugs projects (HPP) and in all-theme projects (HiAP). More policy integration was related to broad goal definitions, which allowed for the involvement of actors representing several policy sectors. This enabled the implementation of a mix of policy instruments. Determinants of health were not explicitly used as a starting point of the policy process. If a policy problem justifies policy integration beyond IA, it might be helpful to start from the determinants of health (epidemiological reality), systematically transform them into policy (policy reality) and set broad policy goals, since this gives actors from other sectors the opportunity to participate.

Area-based interventions to ameliorate deprived Dutch neighborhoods in practice: does the Dutch District Approach address the social determinants of health to such an extent that future health impacts may be expected?

OBJECTIVE: We studied the local manifestation of a national procedural program that addressed problems regarding employment, education, housing and the physical neighborhood environment, social cohesion, and safety in the most deprived neighborhoods in the Netherlands. We aimed to assess if such a program, without the explicit aim to improve health, results in area-based interventions that address the social determinants of health to such an extent that future health impacts may be expected. METHODS: We used standardized questionnaires and face-to-face interviews with 39 local district managers. We analyzed the content of the area-based interventions to assess if the activities addressed the social determinants of health. We assessed the duration and scale of the activities in order to estimate their potential to change social determinants of health. RESULTS: Most districts addressed all six categories of social determinants of health central to the procedural program. Investments in broad-based primary schools, housing stock, green space, and social safety seemed to have the potential to result in district-level changes in social determinants. The scale of activities aimed at employment, income, educational attainment, and the social environment seemed too small to expect an impact at the district level. CONCLUSION: We conclude that the area-based interventions addressed the neighborhood environment to such an extent that future health impacts of the Dutch District Approach may be expected. The health effects in the long term might be more substantial when area-based interventions were devoted more to the improvement of the socioeconomic circumstances of residents.

Towards improved uptake of malaria chemoprophylaxis among West African travellers: identification of behavioural determinants.

BACKGROUND: Malaria is a potentially lethal illness for which preventive measures are not optimally used among all travellers. Travellers visiting friends and relatives in their country of origin (VFRs) are known to use chemoprophylaxis less consistently compared to tourist travellers. In this study, factors explaining the low use of chemoprophylaxis were pursued to contribute to improving uptake of preventive measures among VFRs. METHODS: Following in-depth interviews with Ghanaians living in Amsterdam, a questionnaire was developed to assess which behavioural determinants were related to taking preventive measures. The questionnaire was administered at gates of departing flights from Schiphol International Airport, Amsterdam (the Netherlands) to Kotoka International Airport, Accra (Ghana). RESULTS: In total, 154 questionnaires were eligible for analysis. Chemoprophylaxis had been started by 83 (53.9%) and bought by 93 (60.4%) travellers. Pre-travel advice had been obtained by 104 (67.5%) travellers. Those who attended the pre-travel clinic and those who incorrectly thought they had been vaccinated against malaria were more likely to use preventive measures. Young-, business- and long-term travellers, those who had experienced malaria, and those who thought curing malaria was easier than taking preventive tablets were less likely to use preventive measures. CONCLUSION: Almost half of the VFRs travelling to West Africa had not started chemoprophylaxis; therefore, there is room for improvement. Risk reduction strategies could aim at improving attendance to travel clinics and focus on young-, business and long term travellers and VFRs who have experienced malaria during consultation. Risk reduction strategies should focus on improving self-efficacy and conceptions of response efficacy, including social environment to aim at creating the positive social context needed.

Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study.

BACKGROUND: Guideline adherence in physical therapy is far from optimal, which has consequences for the effectiveness and efficiency of physical therapy care. Programmes to enhance guideline adherence have, so far, been relatively ineffective. We systematically developed a theory-based Quality Improvement in Physical Therapy (QUIP) programme aimed at the individual performance level (practicing physiotherapists; PTs) and the practice organization level (practice quality manager; PQM). The aim of the study was to pilot test the multilevel QUIP programme's effectiveness and the fidelity, acceptability and feasibility of its implementation. METHODS: A one-group, pre-test, post-test pilot study (N = 8 practices; N = 32 PTs, 8 of whom were also PQMs) done between September and December 2009. Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines' main recommendations. Determinants of adherence were measured using quantitative methods (questionnaires). Delivery of the programme and management changes were assessed using qualitative methods (observations, group interviews, and document analyses). Changes in adherence and determinants were tested in the paired samples T-tests and expressed in effect sizes (Cohen's d). RESULTS: Overall adherence did not change (3.1%; p = .138). Adherence to three quality indicators improved (8%, 24%, 43%; .000 ≤ p ≤ .023). Adherence to one quality indicator decreased (-15.7%; p = .004). Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed. Improvements were associated with the programme's multilevel approach, collective goal setting, and the application of self-regulation; unfavourable findings with programme deficits. The one-group pre-test post-test design limits the internal validity of the study, the self-selected sample its external validity. CONCLUSIONS: The QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence. To assess its value, the programme needs to be tested in a randomized controlled trial.

Gaining 'clarity through specificity' in invited patient participation: A case study of a multifaceted participatory practice in the Netherlands.

Patient participation is a highly valued principle. Yet, it remains difficult both to achieve it and to assess its added value, as participation is often started without much clarification of what it means or aims to do. In theory, patients may be invited to participate for reasons of democracy, empowerment, knowledge integration and instrumentalism. By making these rationales explicit in a participatory practice in the Netherlands, we aimed to contribute to the long-needed 'clarity through specificity' in participation. Apart from the rationales, our analytic framework included dimensions of the participatory process, reflected by questions like 'Who participates?', 'In what?' and 'With how much control?' We used this framework to conduct and analyse semi-structured interviews (n = 51) with patient participants (20), professionals (14) and researchers (17). We found that the participatory practice included all rationales and that the actual manifestation of an intended rationale very much depended on the design of the dimensions of the participatory process. We conclude that invited participation may gain in clarity by making explicit the rationales for participation. If put at the centre of attention, and made the leading factor in the design of the dimensions of the participatory process, explicit rationales may support the realisation of participation in practice and prevent it from resulting in mere window-dressing.

Effects of a brief cardiovascular prevention program by a health advisor in primary care; the 'Hartslag Limburg' project, a cluster randomized trial.

OBJECTIVE: To determine in primary care patients at high risk for a cardiovascular event, the effects on biomedical risk factors for and incidence of cardiovascular events, of a brief cardiovascular prevention program executed by a health advisor. DESIGN: cluster randomized controlled trial with 1275 patients (24 general practices) in and around Maastricht, the Netherlands (1999-2004). INTERVENTION: health advisors were to complete computerized cardiovascular risk profiles, provide multi-factorial tailored health education and advice, and communicate with GP's to optimize treatment. OUTCOME: differences in changes in risk factors between baseline and follow up at 6, 18, and 36 months and incidence of cardiovascular events at 36 months. PROCESS: Because of logistic reasons risk profiles were put on paper instead of in the computerized patient files. On average patients attended 2.3 counseling sessions. Interaction with GPs was less productive than expected. OUTCOME: Effect after six months on BMI (-0.20 kg/m(2) (95% CI -0.38 to -0.01, p=0.039), Cohen's d: -0.18), and after 18 months on HDL-cholesterol (+0.05 mmol/l (95% CI +0.01 to +0.09, p=0.014), Cohen's d: 0.14). No other (subgroup) effects were found. CONCLUSION: Given the lack of clinically meaningful effects, implementation of this intervention in its present form is not justified.

Exploring the conceptualization of program theories in Dutch community programs: a multiple case study.

Our objective was to evaluate whether the limited effectiveness of most community programs intended to prevent disease and promote health should be attributed to the quality of the conceptualization of their program theories. In a retrospective multiple case study we assessed the program theories of 16 community programs (cases) in the Netherlands (1990-2004). Methods were a document analysis, supplemented with member checks (insider information from representatives). We developed a community approach reference framework to guide us in reconstructing and evaluating the program theories. On the whole, programs did not clearly spell out the process theories (enabling the implementation of effective interventions), the program components (interventions) and/or the impact theories (describing pathways from interventions to ultimate effects). Program theories usually turned out to be neither specific nor entirely plausible (complete and valid). The limited effectiveness of most community programs should most probably be attributed to the limited conceptualization of program theories to begin with. Such a failure generally also precludes a thorough examination of the effectiveness of the community approach as such.

A 'health broker' role as a catalyst of change to promote health: an experiment in deprived Dutch neighbourhoods.

Urban social entrepreneurs have been suggested to play an essential part in the success of local health promotion initiatives. Up to now, roles like these have only been identified in retrospect. This prospective collaborative study explored the possibilities of institutionalizing a comparable role for a 'health broker' in four Dutch municipalities as an additional investment to promote health in deprived neighbourhoods. The theoretical notions of public and policy entrepreneurs as well as of boundary spanners were adopted as a reference framework. Documents produced by the collaborative project served as input for a qualitative analysis of the developments. We succeeded in implementing a 'health broker' role comparable to that of a bureaucratic public entrepreneur holding a formal non-leadership position. The role was empowered by sharing it among multiple professionals. Although positioned within one sector, the occupants of the new role felt more entitled to cross sectoral borders and to connect to local residents, compared to other within-sector functions. The 'health broker' role had the potential to operate as an 'anchoring point' for the municipal health sector (policy), public health services (practice) and/or the local residents (public). It was also possible to specify potential 'broking points', i.e. opportunities for health promotion agenda setting and opportunities to improve cross-sectoral collaboration, citizen participation and political and administrative support for health promotion efforts. The 'health broker' role we developed and implemented reflects the notion of systematic rather than individual entrepreneurship. Such a collective entrepreneurship may create additional opportunities to gradually strengthen local health promotion efforts.

Process evaluation of a multiple risk factor perinatal programme for a hard-to-reach minority group.

AIM: This article is a report of an evaluation of a multiple risk factor perinatal programme tailored to ethnic Turkish women in the Netherlands. BACKGROUND: The programme was directed at multiple risk factors and aimed at improving maternal lifestyle, infant care practices and psychosocial health during pregnancy and after delivery. The programme was carried out by ethnic Turkish community health workers in collaboration with midwives and physiotherapists. METHODS: Our multiple case study included three Parent-Child Centres providing integrated maternity and infant care. Participants (n = 119) were first and second generation pregnant ethnic Turkish women with relatively unfavourable risk profiles. Data were collected between 2005 and 2008 using mixed methods, including field notes, observations and recordings of group classes, attendance logs, semi-structured individual interviews, a focus group interview, and structured questionnaires. FINDINGS: Most participants (82%) were first generation ethnic Turkish; 47% had a low educational level; 43% were pregnant with their first child; and 34% had a minimal knowledge of the Dutch language. The community health workers' Turkish background was vital in overcoming cultural and language barriers and creating a confidential atmosphere. Participants, midwives and health workers were positive about the programme. Midwives also observed improvements of knowledge and self-confidence amongst the participants. The integration of the community health workers into midwifery practices was crucial for a successful programme implementation. CONCLUSIONS: A culturally sensitive perinatal programme is able to gain access to a hard-to-reach minority group at increased risk for poor perinatal health outcomes. Such a programme may be well received and potentially effective.

Understanding transnational healthcare use in immigrant communities from a cultural systems perspective: a qualitative study of Dutch residents with a Turkish background.

OBJECTIVES: Transnational utilisation of healthcare by people with an immigrant background carries risks, including medicalisation and adverse iatrogenic outcomes. We investigated the drivers behind such transnational healthcare use from a cultural perspective on health systems. DESIGN: Qualitative interview study (2018). SETTING: Two primary care practices in Amsterdam, the Netherlands. PARTICIPANTS: Thirteen Dutch patients of Turkish background, who had obtained healthcare in Turkey, and who in general visited the primary care practice more than once a month. RESULTS: In the respondents' stories, we observed how: (1) cross-border healthcare use was encouraged by cultural mismatches between expected and provided services and by differing explanatory models of illness upheld by patients and Dutch providers; (2) both transnationalism in patients and entitlements to insurance reimbursement facilitated the use of Turkish health services to bypass perceived barriers in the Dutch system; (3) cultural mismatches were reinforced during general practitioner consultations after the patients' return to the Netherlands, thereby inducing further service use abroad. CONCLUSIONS: Although cultural system influences are difficult to bridge, measures to reduce the unwelcome consequences of transnational healthcare use may include (1) strengthening the provision of culturally sensitive care in the country of residence and (2) restricting the reimbursement of care in the country of origin while maintaining the option to obtain care abroad.

Contextual factors that shape uptake of COVID-19 preventive measures by persons of Ghanaian and Eritrean origin in the Netherlands: A focus group study.

OBJECTIVES: To explore the contextual factors that shape uptake of COVID-19 preventive measures, in specific migrant and ethnic minority populations, with a focus on migration-related, sociocultural and socioeconomic conditions. DESIGN: A qualitative design, consisting of three online focus group discussions. SETTING: This study was conducted amongst smaller, albeit substantial, migrant and minority ethnic populations in the Netherlands. PARTICIPANTS: A total of 25 participants (12 male; 13 female) of Ghanaian and Eritrean origin, purposively sampled to ensure diversity within groups, with regards to sex, age, educational level, occupation, household size and length of stay in the Netherlands. Focus group discussions were held online, therefore, experience in the use of video conferencing software was a prerequisite. RESULTS: Participants' awareness and knowledge of COVID-19 and COVID-19 preventive measures was shaped by migration-related factors, such as limited Dutch proficiency, by access to understandable information and interference of misinformation. Participants' engagement by COVID-19 preventive measures was subject to COVID-19 threat appraisal and the ease with which complex behavioural messages could be translated to individual situations. Lastly, a strong social norm to keep with cultural and religious practices, and limited opportunity for preventive behaviour in the work and home context hinder the uptake of preventive behaviour following a decision to act according to measures. CONCLUSIONS: Migration-related, sociocultural, and socioeconomic factors shape uptake of COVID-19 preventive measures amongst persons of Ghanaian and Eritrean origin in The Netherlands. To ensure equitable uptake our results suggest the importance of timely spread of multilingual information tailored to literacy needs; as well as, education and modelling delivered through online platforms and by leading figures in respective communities; and, regulations to ensure continued access to financial and material resources to minimise negative spill-over effects and exacerbation of inequality.