Moral learning through caring stories of nursing staff.

BACKGROUND: Implementing person-centred care (PCC) in nursing homes is challenging due to a gap between theory and practice. Bridging this gap requires suitable education, which focuses on learning how to attune care to the values and preferences of residents and take moral, relational, and situational aspects into account. Staff's stories about the care they provide (i.e. caring stories) may deliver valuable insights for learning about these aspects. However, there is limited research on using staff's narratives for moral learning. OBJECTIVE: This study aims to provide insight into the perspectives of nursing staff on using their caring stories to learn about PCC. RESEARCH DESIGN: In this qualitative research, we conducted two rounds of interviews with 17 participants working in nursing homes. We wanted to obtain nursing staff's perceptions of working with their caring stories and the impact on PCC. ETHICAL CONSIDERATIONS: Participation was voluntary, and participants provided written consent. The study protocol is approved by The Institutional Review Board of the Medical Ethical Committee Leiden-Den Haag-Delft. FINDINGS: Working with caring stories enables nursing staff to provide PCC and improves job satisfaction. It increases awareness of what matters to residents, fosters information rich in context and meaning, and enhances voice and vocabulary. Through in-depth team reflections, nursing staff discussed the significant moments for residents, which centralizes the discussions on the moral quality of care. DISCUSSION: Working with caring stories fosters dialogue on PCC and enhances reflection on ethical situations in daily encounters, contributing to the moral development of nursing staff. Putting nursing staff's narratives at the centre of learning suits their daily practice and intrinsic motivation. Therefore, the outcomes of this study are an addition to the existing literature about using narratives in long-term care. CONCLUSION: Using nursing staff's narratives contributes to PCC and positively impacts nursing staff. We recommend using staff's caring stories as a vehicle for moral learning in the transition to PCC.

"My Body Does Not Fit in Your Medical Textbooks": A Physically Turbulent Life With an Unexpected Recovery From Advanced Parkinson Disease After Prayer.

AIM: The purpose of this article is to enhance our understanding of prayer healing by studying a case which was described as a 'remarkable healing' by a medical assessment team at the Amsterdam University Medical Centre (UMC) in the Netherlands. METHOD: This retrospective, case-based study of prayer healing investigated numerous reported healings using both medical files and patient narratives. A medical assessment team evaluated the associated medical files, as well as any experiential data. The instances of healing could be classified as 'remarkable' or 'unexplained.' Experiential data were obtained by qualitative, in-depth interviews. The study was transdisciplinary in nature, involving medical, psychological, theological, and philosophical perspectives. The object was to understand such healings within the broader framework of the science-religion debate. RESULTS: We present the case of a female patient, born in 1959, with Parkinson disease who experienced instantaneous, nearly complete healing in 2012 after intercessory prayer. At that point the disease was at an advanced stage, rapidly progressive, with major debilitating symptoms. High doses of oral medication were required. Following this healing there was no recurrence of her former symptoms, while the remaining symptoms continued to improve. She regained all of her capacities at work, as well as in daily life. The medical assessment team described her recovery as 'remarkable.' The patient reported that she had always 'lived with God,' and that at a point when she had given up hope, 'life was given back to her.' This recovery did not make her immune to other illnesses and suffering, but it did strengthen her belief that God cares about human beings. CONCLUSION: This remarkable healing and its context astonished the patient, her family, and her doctors. The clinical course was extraordinary, contradicting data from imaging studies, as well as the common understanding of this disease. This case also raised questions about medical assumptions. Any attempt to investigate such healings requires the involvement of other disciplines. A transdisciplinary approach that includes experiential knowledge would be helpful. Against the background of the science-religion debate, we feel that the most helpful approach would be one of complementarity and dialogue, rather than stoking controversy.

Stepping outside the consultation room. On nurse-patient relationships and nursing responsibilities during a type 2 diabetes walking project.

AIMS: To examine the care practices of nurses during the organization of 20 weeks of walking sessions for people with type 2 diabetes and to reflect on implications for nurse-patient relationships and nursing responsibilities in the provision of physical activity (PA) care. DESIGN: Qualitative, ethnographic study. METHODS: Almost 70 hr of field work was completed by participant observations and informal conversations with nurses and participating patients of two different walking groups (April-October 2016). Analysis of field notes followed an inductive holistic-content approach, using both within-case and across-case analysis. RESULTS: The analysis revealed four main themes related to the nurses' care practices: (a) organizational efforts; (b) combining group and individual care; (c) stepping in- and outside the patient mode; and (d) implications back inside the consultation room. Underlying these themes was a process of relational development, both with and among patients. CONCLUSION: Stepping outside the consultation room seems to offer more space for patients' lifeworld narratives and contribute to more continuous and person-centred care. However, it also raises new questions about the provision of PA care and nursing responsibilities in this. IMPACT: Current nursing repertoires for PA counselling in type 2 diabetes care are insufficient and might be extended by organizing walking sessions for patients. Related nursing care practices impacted relationships both with and among participating patients. These have consequences for boundaries of both nursing responsibilities and care provision.

Promoting Personal and Social Recovery in Older Persons with Schizophrenia: The Case of The New Club, a Novel Dutch Facility Offering Social Contact and Activities.

Many older community-living persons with schizophrenia report unmet psychological and social needs. The Amsterdam-based New Club is a novel facility that intends to foster self-reliance and social participation in this group. To explore participants' and staff perceptions, a naturalistic qualitative study combined participant observation with interviews. The results illustrate how the New Club contributes to the personal and social recovery of its participants. At the personal level, attending the facility, activation and feeling accepted were valued positively. At the social level, engaging with others, experiencing a sense of community, and learning from one another's social skills were positive contributors. Next, various environmental factors proved important. The New Club demonstrates the feasibility of creating a facility that offers an accepting and non-demanding social environment to older community-living individuals with severe mental illnesses. It may offer a suitable alternative for the more demanding psychotherapeutic interventions offered to younger populations.

Professional competence in a health promotion program in the Netherlands.

Health promotion for senior citizens ('seniors') is an increasingly important factor in health and welfare policy, having important implications for occupational therapy. The health promotion program 'Healthy and Active Aging' originated in the US, has been modified and adapted to the Dutch context and has been implemented in community contexts. This study aimed to generate an in-depth understanding of the Healthy and Active Aging program and to use this knowledge to inform professional practice. A naturalistic case study methodology was followed, using document analysis, observations, interviews and a group interview as data gathering methods. Data were analyzed and interpreted using narrative analyses. In this specific case, a small group of women joined the program. During 10 sessions, the participants explored the meaning of everyday activities for their self-perceived health and well-being. The key experience reported by the participants and professionals related to the positive ambience within the group, the emotional recognition among the participants and the responsive guidance of the professionals. This case showed how the framework of the program can be modified and tailored to the wishes and needs of the participating seniors. The group facilitators chose a subtle, responsive manner to support and motivate the participants.

Living with end-stage renal disease: Moral responsibilities of patients.

BACKGROUND:: Living with a renal disease often reduces quality of life because of the stress it entails. No attention has been paid to the moral challenges of living with renal disease. OBJECTIVES:: To explore the moral challenges of living with a renal disease. RESEARCH DESIGN:: A case study based on qualitative research. We used Walker's ethical framework combined with narrative ethics to analyse how negotiating care responsibilities lead to a new perspective on moral issues. PARTICIPANTS AND RESEARCH CONTEXT:: One case was chosen from 20 qualitative interviews with renal patients in the Netherlands. ETHICAL CONSIDERATIONS:: Several actions have been taken to ensure the informed consent, privacy, anonymity and confidentiality of the patient in this article. More details are offered in this article. The study has been conducted in line with the recommendations of the Medical Ethical Committee of the VU Medical Center. FINDINGS:: A renal disease can force people to change their identity, relationships, values and responsibilities. The case study illustrates the moral challenges confronting renal patients. DISCUSSION AND CONCLUSION::: Moral issues can be raised by the changes to identities, relationships, values and responsibilities caused by renal disease. Support services for renal patients and their relatives should pay more attention to these issues in order to promote self-management.

Participatory Bioethics Research and its Social Impact: The Case of Coercion Reduction in Psychiatry.

In this article we address the social value of bioethics research and show how a participatory approach can achieve social impact for a wide audience of stakeholders, involving them in a process of joint moral learning. Participatory bioethics recognizes that research co-produced with stakeholders is more likely to have impact on healthcare practice. These approaches aim to engage multiple stakeholders and interested partners throughout the whole research process, including the framing of ideas and research questions, so that outcomes are tailored to the interests and context, and the type of impact stakeholders envisage. There is an emphasis on realizing social change through the conduct (not merely the results) of the research, and it is believed that the engagement of stakeholders in the research process will promote their intrinsic motivation to change their practice. Another distinctive feature of participatory bioethics research is that its central normative commitment is to reflection and dialogue, not to a particular substantive ethical approach. In reflection and dialogue there is an emphasis on inclusion and the co-production of knowledge. Furthermore, empirical and normative research are combined, and there is a deliberate attempt to give voice to otherwise marginalized positions. This provides a model of social impact which is relevant not only for bioethics research, but also for other areas of health care research. We will show the merits of a participatory approach to bioethics research with a case example. It concerns the reduction of coercion and in particular seclusion in Dutch mental healthcare.

Schema Therapy for Personality Disorders: a Qualitative Study of Patients' and Therapists' Perspectives.

BACKGROUND: Several studies have evaluated the (cost) effectiveness of schema therapy for personality disorders, but little research has been done on the perspectives of patients and therapists. AIM: The present study aims to explore patients' and therapists' perspectives on schema therapy. METHOD: Qualitative data were collected through in-depth semi-structured interviews with 15 patients and a focus group of 8 therapists. A thematic analysis was performed. RESULTS: Most patients and therapists agreed that helpful aspects in schema therapy were the highly committed therapeutic relationship, the transparent and clear theoretical model, and the specific schema therapy techniques. About unhelpful aspects, several patients and some therapists shared the opinion that 50 sessions was not enough. Furthermore, patients lacked clear advance information about the possibility that they might temporarily experience stronger emotions during therapy and the possibility of having telephone contact outside session hours. They missed practical goals in the later stage of therapy. With regard to imagery, patients experienced time pressure and they missed a proper link between the past and the present. For therapists, it was hard to manage the therapeutic relation, to get used to a new kind of therapy and to keep the treatment focused on personality problems. CONCLUSIONS: Patients and therapists found some aspects of the schema therapy protocol helpful. Their views about which aspects are unhelpful and their recommendations need to be taken into consideration when adjusting the protocol and implementing schema therapy.

How to Train Experienced Therapists in a New Method: A Qualitative Study into Therapists' Views.

BACKGROUND: Implementation of new effective treatments involves training, supervision and quality control of therapists, who are used to utilize other methods. Not much is known about therapists' views on how new psychotherapy methods should be taught. OBJECTIVE: The purpose of this study is to get insight in how experienced therapists experience the training in a new method so that training methods for experienced therapists can be improved. METHOD: Qualitative research using focus groups. For an RCT on the effectiveness of schema therapy (ST) for six personality disorders more than 80 therapists were trained in ST. They applied the ST-protocol after 4-day training, with peer supervision and limited expert supervision. Sixteen of these trained ST therapists from seven health institutions participated in the focus groups. The transcripts and records of the focus groups were analyzed on repeating themes and subthemes and in terms of higher order categories. RESULTS: Therapists appreciated didactical learning methods but particularly valued experiential learning. Especially, novice ST therapists missed role plays, feedback to learn required skills and attitudes, and attention to their resistance to new techniques (e.g., empathic confrontation and imagery). Peer supervision gave emotional recognition, but therapists lacked regular advice from an ST-expert. CONCLUSIONS: In teaching a new therapeutic method didactic teaching is necessary, but experiential learning is decisive. Experiential learning includes practicing the new therapy and reflecting on one's experiences, including resistance against new methods. Emphatic confrontation, case conceptualization, role play, peer supervision and opportunities to ask an expert supervisor during peer supervision are found to be helpful. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Especially by Eperiential learning besides didactic learning. By practicing with many role plays including feedback. By reflecting on one's experiences including resistance against ingredients of the new method. By peer supervision with opportunities to ask an expert supervisor.

Work-related change in residential elderly care: Trust, space and connectedness.

Increasing care needs and a declining workforce put pressure on the quality and continuity of long-term elderly care. The need to attract and retain a solid workforce is increasingly acknowledged. This study reports about a change initiative that aimed to improve the quality of care and working life in residential elderly care. The research focus is on understanding the process of workforce change and development, by retrospectively exploring the experiences of care professionals. A responsive evaluation was conducted at a nursing home department in the Netherlands one year after participating in the change program. Data were gathered by participant observations, interviews and a focus and dialogue group. A thematic analysis was conducted. Care professionals reported changes in workplace climate and interpersonal interactions. We identified trust, space and connectedness as important concepts to understand perceived change. Findings suggest that the interplay between trust and space fostered interpersonal connectedness. Connectedness improved the quality of relationships, contributing to the well-being of the workforce. We consider the nature and contradictions within the process of change, and discuss how gained insights help to improve quality of working life in residential elderly care and how this may reflect in the quality of care provision.

Experiences and perspectives of patients with post-polio syndrome and therapists with exercise and cognitive behavioural therapy.

BACKGROUND: Many persons affected with poliomyelitis develop post-polio syndrome (PPS) later in their life. Recently, the effectiveness of Exercise Therapy (ET) and Cognitive Behavioural Therapy (CBT) for PPS has been evaluated in a randomized controlled trial, but did not show a decrease in fatigue or improvement in secondary endpoints like Quality of Life and self-perceived activity limitations. The aim of this explorative study was to gain insight in the perceived effects and experiences of the interventions from the perspectives of the patients and therapists. METHODS: Qualitative data were collected through semi-structured interviews with 17 patients and 7 therapists. All participants were involved in the trial. A thematic analysis of the data was performed. RESULTS: Some patients experienced a short term enhanced endurance and a better use of energy during the day. However, in general patients did not experience a long lasting reduction of fatigue from the CBT or ET. Mainly patients of the CBT, but also some patients of the ET described an increase of self-esteem and self-acceptance. As a result, patients were sometimes better able to perform physical activities during the day. In contrast to the CBT, the ET was in general perceived by the patients as an intensive therapy, which was difficult to fit into their daily routine. Therapists of both the CBT and the ET struggled with a low intrinsic motivation of the patients in the study. This made it sometimes difficult for the therapists to follow the protocol. CONCLUSION: Confirming the negative quantitative study outcome, the qualitative results did not demonstrate lasting effects on fatigue. Patients did, however, experience some benefits on self-esteem and acceptance of the disease. This study showed that it is of great importance to work with feasible interventions; they should fit the patients' needs on a practical (fit into their daily routine) and mental (fit their need for support) level.

Protocol of a mixed method, randomized controlled study to assess the efficacy of a psychosocial intervention to reduce fatigue in patients with End-Stage Renal Disease (ESRD).

BACKGROUND: Patients with end-stage renal disease (ESRD) commonly suffer from severe fatigue, which strongly impacts their quality of life (QoL). Although fatigue is often attributed to disease- and treatment characteristics, research also shows that behavioural, psychological and social factors affect perceived fatigue in dialysis patients. Whereas studies on fatigue in other chronic patient groups suggest that psychological or psychosocial interventions are effective in reducing fatigue, such interventions are not yet available for ESRD patients on dialysis treatment. The objective of this study is to examine the efficacy of a psychosocial intervention for dialysis patients aimed at reducing fatigue (primary outcome) and improving QoL (secondary outcome). The intervention consists of counselling sessions led by a social worker. The implementation process and patients' and social workers' expectations and experiences with the intervention will also be evaluated. METHODS/DESIGN: This study follows a mixed-methods design in which both quantitative and qualitative data will be collected. A multi-centre, randomised controlled trial (RCT) with repeated measures will be conducted to quantitatively assess the efficacy of the psychosocial intervention in reducing fatigue and improving QoL in ESRD patients. Additional secondary outcomes and medical parameters will be assessed. Outcomes will be compared to patients receiving usual care. A sample of 74 severely fatigued dialysis patients will be recruited from 10 dialysis centres. Patients will be randomly assigned to the intervention or control group. Outcomes will be assessed at baseline, post intervention/16 weeks, and at three and six-month follow-ups. A qualitative process evaluation will be conducted parallel to/following the effectiveness RCT. Interviews and focus groups will be conducted to gain insight into patients' and social workers' perspectives on outcomes and implementation procedures. Implementation fidelity will be assessed by audio-taped and written registrations. Participatory methods ensure the continuous input of experiential knowledge, improving the quality of study procedures and the applicability of outcomes. DISCUSSION: This is the first mixed method study (including an RCT and qualitative process evaluation) to examine the effect and implementation process of a psychosocial intervention on reducing fatigue and improving QoL in ESRD patients on dialysis treatment. TRIAL REGISTRATION: NTR5366 , The Netherlands National Trial Register (NTR), registered August 26, 2015.

Nurturing Cultural Change in Care for Older People: Seeing the Cherry Tree Blossom.

There is a need for person-centred approaches and empowerment of staff within the residential care for older people; a movement called 'culture change'. There is however no single path for achieving culture change. With the aim of increasing understandings about cultural change processes and the promotion of cultural values and norms associated with person-centred practices, this article presents an action research project set on a unit in the Netherlands providing care for older people with dementia. The project is presented as a case study. This study examines what has contributed to the improvement of participation of older people with dementia in daily occupational and leisure activities according to practitioners. Data was collected by participant observation, interviews and focus groups. The results show that simultaneous to the improvement of the older people's involvement in daily activities a cultural transformation took place and that the care became more person-centred. Spontaneous interactions and responses rather than planned interventions, analysis and reflection contributed to this. Furthermore, it proved to be beneficial that the process of change and the facilitation of that process reflected the same values as those underlying the cultural change. It is concluded that changes arise from dynamic, interactive and non-linear processes which are complex in nature and difficult to predict and to control. Nevertheless, managers and facilitators can facilitate such change by generating movement through the introduction of small focused projects that meet the stakeholders' needs, by creating conditions for interaction and sense making, and by promoting the new desired cultural values.

"A Somali girl is Muslim and does not have premarital sex. Is vaccination really necessary?" A qualitative study into the perceptions of Somali women in the Netherlands about the prevention of cervical cancer.

INTRODUCTION: Participation in Human Papillomavirus (HPV) vaccination and Papanicolaou Screening (Pap smears) is low among ethnic minorities in the Netherlands and hardly any information is available about the cervical cancer prevention methods of Somali women living in the diaspora. This qualitative study, based on the Health Belief Model (HBM) and an intersectionality-based framework, explores the perceptions of Somali women living in the Netherlands regarding measures to prevent cervical cancer. METHODS: Semi-structured interviews have been conducted with young Somali women aged 17-21 years (n = 14) and Somali mothers aged 30-46 years (n = 6). Two natural group discussions have been conducted with 12 and 14 Somali mothers aged 23-66 years. The collected data has been analyzed thematically for content. RESULTS: In this study, we have identified perceived barriers to the use of preventive measures across three major themes: (1) Somali women and preventive healthcare; (2) Language, knowledge, and negotiating decisions; and (3) Sexual standards, culture, and religion. Many issues have been identified across these themes, e.g., distrust of the Dutch health care system or being embarrassed to get Pap smears due to Female Genital Mutilation (FGM) and having a Dutch, male practitioner; or a perceived low susceptibility to HPV and cancer because of the religious norms that prohibit sex before marriage. CONCLUSIONS: Current measures in the Netherlands to prevent women from developing cervical cancer hardly reach Somali women because these women perceive these kinds of preventative measures as not personally relevant. Dutch education strategies about cervical cancer deviate from ways of exchanging information within the Somali community. Teachers can provide culturally sensitive information to young Somali women in schools. For Somali mothers, oral education (e.g., poetry or theater) about the Dutch health care system and men's roles in HPV transmission may be useful. An intersectional approach, grounded in the HBM, is recommended to promote equal access to preventive health care for Somali women.

Standing out and moving up: performance appraisal of cultural minority physicians.

Despite a growing diversity within society and health care, there seems to be a discrepancy between the number of cultural minority physicians graduating and those in training for specialization (residents) or working as a specialist in Dutch academic hospitals. The purpose of this article is to explore how performance appraisal in daily medical practice is experienced and might affect the influx of cultural minority physicians into specialty training. A critical diversity study was completed in one academic hospital using interviews (N = 27) and focus groups (15 participants) with cultural minority physicians and residents, instructing specialists and executives of medical wards. Data were digitally recorded and transcribed verbatim. A thematic and integral content analysis was performed. In addition to explicit norms on high motivation and excellent performance, implicit norms on professionalism are considered crucial in qualifying for specialty training. Stereotyped imaging on the culture and identity of cultural minority physicians and categorical thinking on diversity seem to underlie daily processes of evaluation and performance appraisal. These are experienced as inhibiting the possibilities to successfully profile for selection into residency and specialist positions. Implicit criteria appear to affect selection processes on medical wards and possibly hinder the influx of cultural minority physicians into residency and making academic hospitals more diverse. Minority and majority physicians, together with the hospital management and medical education should target inclusive norms and practices within clinical practice.

User involvement in long-term care. Towards a relational care-ethics approach.

BACKGROUND: User involvement in long-term care has become official policy in many countries. Procedural and managerial approaches to user involvement have numerous shortcomings in long-term care. What is needed is a different approach that is beneficial and tuned to the needs of clients and professionals. AIM: This article presents a care-ethics approach to involvement. We illustrate this approach and its practical implementation by examining a case example of user involvement in long-term elderly care. METHODOLOGY: This case example is based on an action research project in a residential care home in the Netherlands. Seven female clients participated in the process, as well as diverse groups of professionals from this residential care home. RESULTS: The clients were concerned about meals, and collectively they became empowered and came up with ideas for improving meals. Professionals also shared the clients' experiences with meals, first in homogeneous groups and then in heterogeneous meetings with the client group. This process led to the development of partnership relations between clients and professionals. CONCLUSION: Our findings suggest that a care-ethics approach to user involvement is a means to increase resident empowerment in long-term care. Clients and professionals start sharing their experiences and values through dialogue, and they develop mutual trust and openness while doing so.

Patient involvement in research programming and implementation: A responsive evaluation of the Dialogue Model for research agenda setting.

BACKGROUND: The Dialogue Model for research agenda-setting, involving multiple stakeholders including patients, was developed and validated in the Netherlands. However, there is little insight into whether and how patient involvement is sustained during the programming and implementation of research agendas. AIM: To understand how the Dialogue Model can be optimised by focusing on programming and implementation, in order to stimulate the inclusion of (the perspectives of) patients in research. METHODS: A responsive evaluation of the programming and implementation phases of nine agenda-setting projects that had used the Dialogue Model for agenda-setting was conducted. Fifty-four semi-structured interviews were held with different stakeholders (patients, researchers, funding agencies). Three focus groups with patients, funding agencies and researchers (16 participants) were organized to validate the findings. RESULTS: Patient involvement in programming and implementation of the research agendas was limited. This was partly related to poor programming and implementation, partly to pitfalls in earlier phases of the agenda-setting. Optimization of the Dialogue Model is possible by attending to the nature of the agenda and its intended use in earlier phases. Attention should also be given to the ambassadors and intended users of agenda topics. Support is needed during programming and implementation to organize patient involvement and adapt organizational structures like review procedures. In all phases the attitude to patient involvement, stakeholder participation, especially of researchers, and formal and informal relationships between parties need to be addressed to build a strong relationship with a shared goal. CONCLUSION: Patient involvement in agenda-setting is not automatically followed by patient involvement in programming and implementation. More attention should be paid, in earlier stages, to the attitude and engagement of researchers and funding agencies.

Do not forget the professional--the value of the FIRST model for guiding the structural involvement of patients in rheumatology research.

BACKGROUND: The FIRST model describes five practical components that enable equal collaboration between patients and professionals in clinical rheumatology research: Facilitate, identify, respect, support and training. OBJECTIVE: To assess the value of this model as a framework for setting up and guiding the structural involvement of people with arthritis in health research. METHOD: The FIRST model was used as a framework during the guidance of a network of patient research partners and clinical rheumatology departments in the Netherlands. A 'monitoring and evaluation' approach was used to study the network over a period of 2 years. Data were collected using mixed methods and subjected to a directed content analysis. The FIRST components structured the data analysis. During monitoring meetings, refined and additional descriptors for each component were formulated and added if new items were found. RESULTS: The FIRST model helps to guide and foster structural partnerships between patients and professionals in health research projects. However, it should be broadened to emphasize the pivotal role of the principal investigator regarding the facilitation and support of patient research partners, to recognize the requirements of professionals for training and coaching and to capture the dynamics of collaboration, mutual learning processes and continuous reflection. CONCLUSION: FIRST is a good model to implement sustainable relationships between patients and researchers. It will benefit from further refinement by acknowledging the dynamics of collaboration and including the concept of reflection and relational empowerment. The reciprocal character of the five components, including training and support of researchers, should be incorporated.

Pulling out all the stops: what motivates 65+ year olds with depressive symptoms to participate in an outreaching preference-led intervention programme?

OBJECTIVES: Many older adults have significant depressive symptoms but few people access care for these. This study explores which personal, clinical and need factors facilitate or hinder acceptance of a new outreaching preference-led intervention programme. METHODS: From a sample of 9661 community-dwelling 65+ year olds, 244 persons with depressive symptoms according to the Patient Health Questionnaire-9 were included. Data on programme effectiveness in terms of care utilisation were collected. Associations between programme acceptance and personal, clinical and need factors were studied using quantitative (logistic regression analyses) and qualitative methods (semi-structured interviews with 26 subjects, who accepted (n = 20) or declined (n = 6) the programme). RESULTS: Fifty-six per cent (n = 137) took part in the interventions. Quantitative logistic regression analyses showed that participants were more often female, suffered from more severe depressive symptoms and perceived more loneliness. Qualitative analyses revealed that people accepting the intervention programme felt that medical terms as having a depressed mood were applicable to their situation, more often perceived their symptoms as hindering, felt lonely and more often perceived a need for care. They were more often advised by their general practitioner to participate than individuals who refused the interventions. Many participating individuals did not see a match between the intervention programme and their needs, especially with respect to meeting new people. CONCLUSION: Many older persons with depressive symptoms did not feel the need to take part in the programme. Providing support in alleviating loneliness and further adaptation to older adults' illness representations and perceptions when discussing depressive symptoms might enhance care utilisation.

Crossing cultures: health promotion for senior migrants in the Netherlands.

A health promotion programme focusing on the meaning of everyday activities was implemented and evaluated to test its usefulness for community-dwelling seniors in the Netherlands. To evaluate how senior migrants with a Surinamese-Hindustani background and professionals received the programme, and how it could be contextualized and improved in line with their values and expectations. A responsive evaluation methodology was followed to foster reflexive learning in and among stakeholders as the basis for programme contextualization. The evaluation consisted of three phases. Outcomes of former phases served as input for subsequent phases. Methods included interviews and focus groups with seniors and professionals. Open and selective coding techniques were used to analyse the interactively derived data. A. small group of women was interested and followed the programme. It was not individual concerns or daily life problems that dominated, but the wish to become well informed, to maintain functional capacities and to continue their roles in the family and community. Striking differences in perspectives between professionals and migrants related to conflict between the underlying Western values of the programme (independence, personal control and autonomy) and the values of the migrants (interdependence, predestination, rebirth and destiny). Awareness among professionals of their own cultural background and the values of the migrant seniors was enhanced, but adapting the programme to the local context and values appeared far more complicated than originally expected. Adaptation requires intensive collaboration with participants and cultural brokers in the community.