[Hospice care for patients with a migration background]. / Hospicezorg voor mensen met een migratieachtergrond.

In the retrospective cohort study of Dutch hospice care by De Graaf et al., only 3% of the patients was of non-Dutch background. This seems to indicate an underrepresentation of people with a migration background in hospices, even when taking into account the low number of persons aged 70+ with a non-Dutch background. The underrepresentation can be explained by cultural differences regarding optimal palliative care and the role of family in care, by lack of knowledge about hospice care and by lack of palliative care tailored to the needs of patients with a migration background.

Person-centred care in the Dutch primary care setting: Refinement of middle-range theory by patients and professionals.

In a previous rapid realist review (RRR) of international literature insight was provided into how, why, and under what circumstances person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, by establishing a middle-range programme theory (PT), which describes the relationship between context items, mechanisms, and outcomes. Since the application of PCC in primary care in the Dutch setting is expected to differ from other countries, the objective of this study is to validate the items (face validity) resulting from the RRR for the Dutch setting by assessing consensus on the relevance of items. Four focus group discussions with patient representatives and patients with limited health literacy skills (n = 14), and primary care professionals (n = 11) were held partly combined with a Delphi-study. Items were added to refine the middle-range PT for the Dutch primary care setting. These items indicated that in order to optimally align care to the patient tailored supporting material that is developed together with the target group is important, next to providing tailored communication. Healthcare providers (HCPs) and patients need to have a shared vision and set up goals and action plans together. HCPs should stimulate patient's self-efficacy, need to be aware of the patient's (social) circumstances and work in a culturally sensitive way. Better integration between information and communications technology systems, flexible payment models, and patients access to documents, and recorded consultations should be in place. This may result in better alignment of care to the needs of patients, improved accessibility to care, improved patient's self-efficacy, and improved health-related quality of life. On the long-term higher cost-effectiveness and a higher quality of healthcare can be realised. In conclusion, this study shows that for PCC to be effective in Dutch primary care, the PT based on international literature was refined by leaving out items and adding new items for which insufficient or sufficient consensus, respectively, was found.

Migration and health: exploring healthy ageing of immigrants in European societies.

AIM: The aim is to identify important factors for immigrants' health and well-being and for their use (or non-use) of primary health care (PHC) and other non-specialised services, and for possible ways that PHC can support healthy ageing of immigrants. BACKGROUND: Older persons are an increasing share of the immigrant population in the global north, frequently in contact with various forms of health services, (PHC services most of all. Consequently, PHC services are in a particularly unique position to support healthy ageing of immigrants. METHODS: The position paper builds on five international, multi-professional and cross-disciplinary small group discussions as well as an international workshop early summer. During the discussions and the workshop, topics were arrived at as to factors related to the health situation of older immigrants, their needs, and health-seeking behaviour, and to how PHC professionals could support healthy ageing in immigrants. Those main topics in turn guided search for relevant research literature and informed the selection of the main research questions of this paper. FINDINGS: Several factors, in addition to culture and cultural differences, are important to for PHC professionals and decision-makers to take into consideration in encounters with older immigrants. The socio-economic position of the older immigrant and close relatives, inter-generational relationships within the immigrant communities, country-specific factors in the host country like health care expenditure, and communication skills in health professionals are all examples of factors playing an important role regarding the health and health-seeking behaviour of older immigrants.

Attitude and intention of migrant populations in the Netherlands regarding female genital mutilation/cutting.

BACKGROUND: Due to migration, the practice female genital mutilation/cutting (FGM/C) has become an issue of concern in high-resource countries such as the Netherlands. It was therefore of utmost importance to explore the attitude and intention of migrant populations in the Netherlands towards FGM/C, which may be leveraged to promote its elimination. Therefore, the aim of the present study was to explore the attitude and intention of migrant populations in the Netherlands regarding FGM/C. METHODS: A qualitative study design was employed using Theory of Planned Behaviour (TPB) as a framework for the analysis. Data were collected using focus-group discussions (FGDs) and individual interviews. The FGDs and individual interviews were audio-recorded and transcribed verbatim. The main topics of the interviews were based on the constructs of TPB (attitude, subjective norms, perceived behavioral control and intention). Thus, concerning the development of categories, we opted for a hybrid form using a deductive as well as an inductive approach. RESULTS: A total of 55 participants, 15 men and 40 women (9 born in the Netherlands) participated in the study. The findings showed that as a result of migration and regardless of country of origin and gender, many participants have changed their attitudes towards the abandonment of FGM/C. None of the participants intended to have FGM/C performed on their daughters. Generally, the social pressure to perform FGM/C seems to be lower in the Netherlands when compared to the country of origin. Most participants felt confident in their ability to resist social pressure. However, some participants feared that they might succumb to social pressure or feared that their daughters would undergo FGM/C without their consent. CONCLUSION: This study aimed to explore the attitude and intention of migration populations in the Netherlands regarding FGM/C. Our findings showed that the study participants had no intention to perform FGM/C on their daughters. As a consequence of acculturation process, interest in the practice of FGM/C could wane following migration. Nonetheless, some pressure to perform FGM/C still exists after migration. Newly arrived migrants and those more vulnerable to social pressure, may benefit from educational interventions that increases knowledge and awareness about various aspects of the practice, with an emphasis on empowering those individuals in facing social pressure.

Female genital mutilation/cutting (FGM/C), also known as female circumcision, is a practice which involves the cutting away of part or the whole of the external female genital organs. The practice has no health benefits, and it harms girls and women in many ways. The migration of girls and women to high-resource countries such as the Netherlands, has led to the development of programs to prevent FGM/C and to care for those affected by FGM/C.The purpose of this study was to explore the attitude and intention of migrant populations in the Netherlands towards FGM/C. The results of this study may be relevant in the development of interventional programs to promote the elimination of FGM/C. Our findings showed that the study participants had no intention to perform FGM/C on their daughters. Many participants may have changed their attitudes towards the abandonment of FGM/C. The social pressure to perform FGM/C seems to be lower in the Netherlands when compared to the country of origin, however, some pressure to perform FGM/C still exist after migration. In this regard, educational programs are necessary, with an emphasis on empowering vulnerable groups such as newly arrived migrants in facing social pressure.

The development of a culturally sensitive educational video: How to facilitate informed decisions on cervical cancer screening among Turkish- and Moroccan-Dutch women.

BACKGROUND: In the Netherlands, all women aged 30-60 years are invited to participate in the national cervical cancer screening programme, which is aimed at early detection and treatment of precancerous lesions. One fourth of the Dutch population has a migration background, with Turkish and Moroccan immigrants being the largest immigrant populations. Turkish- and Moroccan-Dutch women show lower screening participation rates and a higher incidence of cervical cancer, compared to native Dutch women. Since current information materials are not tailored to these women's needs, we developed a short culturally sensitive educational video to facilitate informed decision-making for cervical cancer screening among Turkish- and Moroccan-Dutch women. This article describes the development process of this video and the lessons learned. METHODS: Using the Entertainment-Education communication strategy, we collaborated with an interdisciplinary team of Turkish- and Moroccan-Dutch women, researchers, public health experts, and creative media professionals. We developed the video following the different stages of the Media Mapping model: Orientation, Crystallization, Design/Production, Implementation, and Dissemination. Each stage is described in the paper. RESULTS: The video was developed in Moroccan-Arabic, -Berber and Turkish, and emphasized three main themes: (1) more certainty about having cervical (pre)cancer and the possibility to prevent treatment, surgery, or premature death, and because of this, being there for the children, (2) according to the Islam, a woman should take good care of her health, and (3) anxiety, shame, and privacy. CONCLUSIONS: A short culturally sensitive educational video, delivered as part of a larger intervention together with the current information brochure, was developed based on theory and grounded in the needs of Turkish- and Moroccan-Dutch women. The value and effectiveness of this intervention to facilitate informed cervical cancer screening decisions are evaluated in a randomised controlled trial. PATIENT OR PUBLIC CONTRIBUTION: We collaborated with Turkish- and Moroccan-Dutch women during the development process of a short culturally sensitive educational video. Turkish- and Moroccan-Dutch women were also invited to watch the raw footage to verify whether the content and presentation matched their needs and requirements.

Person-centred care in primary care: What works for whom, how and in what circumstances?

This rapid realist review aims to explain how and why person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, and to construct a middle-range programme theory (PT). Peered reviewed- and non-peer-reviewed literature (Jan 2013-Feb 2021) reporting on PCC in primary care was included. Selection and appraisal of documents were based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) criteria. Data on context, mechanisms and outcomes (CMO) were extracted. Based on the extracted data, CMO configurations were identified per source publication. Configurations containing all three constructs (CMO) were included in the PT. The middle-range PT demonstrates that healthcare professionals (HCPs) should be trained and equipped with the knowledge and skills to communicate effectively (i.e. in easy-to-understand words, emphatically, checking whether the patient understands everything, listening attentively) tailored to the wishes, needs and possibilities of the patient, which may lead to higher satisfaction. This way the patient will be more involved in the care process and in the shared decision-making process, which may result in improved concordance, and an improved treatment approach. A respectful and empathic attitude of the HCP plays an important role in establishing a strong therapeutic relationship and improved health (system) outcomes. Together with a good accessibility of care for patients, setting up a personalised care plan with all involved parties may positively affect the self-management skills of patients. Good collaboration within the team and between different domains is desirable to ensure good care coordination. The coherence of items related to PCC in primary care should be considered to better understand its effectiveness.

Caring for older culturally and linguistically diverse patients with Cancer: Healthcare Providers' perceived barriers to communication.

BACKGROUND: Due to various socio-cultural and language related factors, healthcare providers experience barriers when communicating with older culturally and linguistically diverse (CALD) patients with cancer, which can lower the quality of care received by patients and negatively impact healthcare providers. Studies focusing on communication barriers of older CALD patients with cancer and a systematic comparison of those barriers between different healthcare providers have been largely missing. OBJECTIVES: In order to lay out the healthcare providers' perceived barriers to communication, the present study identified and compared communication barriers among different healthcare providers when caring for older CALD patients with cancer. METHODS: An online survey was conducted among healthcare providers in the Netherlands who identified as being involved in the care of CALD patients with cancer (N = 191), specifically; GPs (NGPs = 54), specialists (Nspecialists = 29), oncology nurses (Nnurses = 77), and pharmacists (Npharmacists = 31). Providers assessed twelve pre-specified factors on (i) importance and (ii) frequency of these factors as barriers to communication. A composite score by employing the QUOTE (Quality Of care Through the patients' Eyes) methodology was used to rank, and classify factors as either potential or influential barriers. RESULTS AND CONCLUSION: Overall, low Dutch language proficiency of older CALD patients with cancer, family interpreters providing inadequate translations, not knowing the extent of patients' informational needs, cultural differences in views about healthcare (i.e., illnesses and treatments) and family members blocking communication were found to be influential communication barriers. Healthcare providers showed several differences in what they perceived to be a potential or an influential barrier: Cultural differences in views about healthcare and patients getting treatment in their home countries were important barriers for GPs, while not knowing the patient's contact person was for pharmacists. Nurses perceived the highest number of influential barriers, while specialists perceived the least. We conclude that specific interventions that address differences in perceived barriers among providers are needed, and we highlight potential interventions that involve digital communication tools, such as the Conversation Starter.

Enhancing patient participation of older migrant cancer patients: needs, barriers, and eHealth.

OBJECTIVES: To gain insight into (1) the unfulfilled instrumental and affective needs of Turkish-Dutch and Moroccan-Dutch older cancer patients/survivors, (2) the barriers perceived by healthcare professionals in fulfilling these needs, and (3) how the Health Communicator, a multilingual eHealth tool, can support the fulfillment of patients'/survivors' needs, and decrease professionals' barriers. DESIGN: We conducted a pre-implementation study of the Health Communicator using semi-structured interviews with Turkish-Dutch (n = 10; mean age = 69.10) and Moroccan-Dutch (n = 9; mean age = 69.33) older cancer patients/survivors, and held two focus groups with general practitioners (GPs; n = 7; mean age 45.14) and oncology nurses (ONs; n = 5; mean age = 49.60). Topic list consisted of questions related to needs and perceived barriers. Analysis was based on grounded theory. The acceptance of the Health Communicator was inquired by questions based on the concepts of the Technology Acceptance Model, and analyzed deductively. RESULTS: Patients/survivors reported unfulfilled needs concerning: (1) information about cancer (treatment), (2) information about the healthcare system, (3) possibilities regarding psychosocial support, and (4) doctor-patient relationship. Among professionals, the main perceived barriers were: (1) patients'/survivors' low health literacy and language barrier, (2) cultural taboo, (3) lack of insight into patients' instrumental needs, and (4) patients'/survivors' lack of trust in Dutch healthcare. Both patients/survivors and professionals thought that implementing the Health Communicator could be effective in fulfilling most of the needs and decreasing the barriers. However, a majority of the patients/survivors were hesitant regarding the use of it, because they found it too difficult to use. Professionals showed a positive intention towards using the Health Communicator. CONCLUSIONS: To enhance patient participation among older migrant cancer patients/survivors, the Health Communicator is, under certain conditions, a promising tool for fulfilling patients'/survivors' unfulfilled instrumental and affective needs and for bridging barriers perceived by professionals.

Decision-making, barriers, and facilitators regarding cervical cancer screening participation among Turkish and Moroccan women in the Netherlands: a focus group study.

OBJECTIVES: Whether the lower Dutch cervical cancer (CC) screening participation of Turkish- and Moroccan-Dutch women is based on informed decision-making is unknown. Our aim was to explore how and why Turkish- and Moroccan-Dutch women decide to participate or not in the current Dutch CC screening programme as well as to learn their perceptions on self-sampling.DESIGN: Six focus group discussions were conducted between March and April 2019 with Turkish (n = 24) and Moroccan (n = 20) women in the Netherlands, aged 30-60 years. Questions were based on an extended version of the Health Belief Model. Discussions were transcribed verbatim and thematically analysed.RESULTS: Participants lacked knowledge about CC and its screening, and seemed to be unaware of the cons of CC screening. Perceived barriers for screening were lack of a good command of the Dutch language, having a male general practitioner, fatalism, shame and taboo, and associations of CC with lack of femininity and infertility. Other barriers were fear of the test result, cancer, suffering, death, and leaving their children behind after death. Perceived facilitators were a high perceived severity of disease, social support, and short procedure time. An additional religious facilitator included the responsibility to take care of one's own health using medical options that God provided. Participants had low self-efficacy expectations towards performing correct self-sampling.CONCLUSIONS: Although participants' informed-decision making seems to be limited, this study showed that women do not only consider factual medical information, but also practical, emotional, cultural, and religious aspects prior to deciding to screen or not. Information materials should be tailored to these aspects, as well as translated to appropriate languages due to lack of a good command of the Dutch language. Self-efficacy expectations towards performing correct self-sampling should be enhanced to promote informed CC screening participation among Turkish- and Moroccan-Dutch women.

[Refugees and mental health - what can doctors do?] / De psychische gezondheid van vluchtelingen: onze zorg.

The influx of Ukraine refugees confronts doctors with the effects of forced migration. Refugees are at risk for the development of mental health problems, due to traumatic experiences and unfavorable living circumstances post-migration (poverty, unemployment). Person-centered cultural sensitive care contributes to timely recognition and treatment of mental distress. To be effective, trust must be built through continuity of care and respectful attention to personal wishes and circumstances of the refugee. Other important aspects are the involvement of a professional interpreter, pro-active discussion of social problems and always performing a physical examination. Health education about symptoms of distress, and how to best cope with these, is helpful for refugees and families supporting refugees. For this, educational materials in different languages are available. With a little bit of extra time and effort doctors can play an important role in improving the wellbeing of refugees.

Effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to breast cancer genetic testing.

BACKGROUND: There is an underuse of genetic testing in breast cancer patients with a lower level of education, limited health literacy or a migrant background. We aimed to study the effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to genetic testing. METHODS: We conducted a multicenter study in a quasi-experimental pre-post (intervention) design. The intervention consisted of an online module and a group training for surgical oncologists and specialized nurses in three regions in the Netherlands. Six months pre- and 12 months post intervention, clinical geneticists completed a checklist with socio-demographic characteristics including the level of health literacy of each referred patient. We conducted univariate and logistic regression analysis to evaluate the effect of the training program on disparities in referral to genetic testing. RESULTS: In total, 3179 checklists were completed, of which 1695 were from hospital referrals. No significant differences were found in educational level, level of health literacy and migrant background of patients referred for genetic testing by healthcare professionals working in trained hospitals before (n = 795) and after (n = 409) the intervention. The mean age of patients referred by healthcare professionals from trained hospitals was significantly lower after the intervention (52.0 vs. 49.8, P = 0.003). CONCLUSION: The results of our study suggest that the health literacy training program did not decrease disparities in referral to genetic testing. Future research in a more controlled design is needed to better understand how socio-demographic factors influence referral to breast cancer genetic testing and what other factors might contribute.

Untangling the inter-relatedness within integrated care programmes for community-dwelling frail older people: a rapid realist review.

OBJECTIVE: To identify the relationships between the context in which integrated care programmes (ICPs) for community-dwelling frail older people are applied, the mechanisms by which the programmes do (not) work and the outcomes resulting from this interaction by establishing a programme theory. DESIGN: Rapid realist review. INCLUSION CRITERIA: Reviews and meta-analyses (January 2013-January 2019) and non-peer-reviewed literature (January 2013-December 2019) reporting on integrated care for community-dwelling frail older people (≥60 years). ANALYSIS: Selection and appraisal of documents was based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards criteria. Data on context, mechanisms, programme activities and outcomes were extracted. Factors were categorised into the five strategies of the WHO framework of integrated people-centred health services (IPCHS). RESULTS: 27 papers were included. The following programme theory was developed: it is essential to establish multidisciplinary teams of competent healthcare providers (HCPs) providing person-centred care, closely working together and communicating effectively with other stakeholders. Older people and informal caregivers should be involved in the care process. Financial support, efficient use of information technology and organisational alignment are also essential. ICPs demonstrate positive effects on the functionality of older people, satisfaction of older people, informal caregivers and HCPs, and a delayed placement in a nursing home. Heterogeneous effects were found for hospital-related outcomes, quality of life, healthcare costs and use of healthcare services. The two most prevalent WHO-IPCHS strategies as part of ICPs are 'creating an enabling environment', followed by 'strengthening governance and accountability'. CONCLUSION: Currently, most ICPs do not address all WHO-IPCHS strategies. In order to optimise ICPs for frail older people the interaction between context items, mechanisms, programme activities and the outcomes should be taken into account from different perspectives (system, organisation, service delivery, HCP and patient).

[Distinguishing people by ethnic background in healthcare]. / Onderscheid naar etnische afkomst.

Discrimination based on ethnic background and the use of terminology like 'Negro Race' in clinical practice guidelines have been criticized, also in this journal. Typical Dutch words 'allochtonen', 'non-western', 'Creools' and 'Hindostan' are unspecific or could also offend people. Nevertheless, there are health risks related to ethnic background. Healthcare improves when health professionals would consider these, contributing to person centred cultural sensitive care. Therefore, we aimed to start a discussion about which acceptable terminologies should be used to describe ethnic differences in guidelines and research. We suggest that terminologies use to describe ethnic minority groups should be as precise as possible and should not be offensive, for instance 'migration background' instead of allochtoon, and 'African-Surinamese' instead of Creool. We invite guideline developers, researchers and people of different ethnic background, to join this discussion.

Development and Evaluation of a Digital Intervention for Fulfilling the Needs of Older Migrant Patients With Cancer: User-Centered Design Approach.

BACKGROUND: Older migrant patients with cancer face many language- and culture-related barriers to patient participation during medical consultations. To bridge these barriers, an eHealth tool called Health Communicator was developed in the Netherlands. Essentially used as a digital translator that can collect medical history information from patients, the Health Communicator did not include an oncological module so far, despite the fact that the prevalence of Dutch migrant patients with cancer is rising. OBJECTIVE: This study aims to systematically develop, implement, and conduct a pilot evaluation of an oncological module that can be integrated into the Health Communicator to stimulate patient participation among older Turkish-Dutch and Moroccan-Dutch patients with cancer. METHODS: The Spiral Technology Action Research model, which incorporates 5 cycles that engage key stakeholders in intervention development, was used as a framework. The listen phase consisted of a needs assessment. The plan phase consisted of developing the content of the oncological module, namely the question prompt lists (QPLs) and scripts for patient education videos. On the basis of pretests in the do phase, 6 audiovisual QPLs on patient rights, treatment, psychosocial support, lifestyle and access to health care services, patient preferences, and clinical trials were created. Additionally, 5 patient education videos were created about patient rights, psychosocial support, clinical trials, and patient-professional communication. In the study phase, the oncological module was pilot-tested among 27 older Turkish-Dutch and Moroccan-Dutch patients with cancer during their consultations. In the act phase, the oncological model was disseminated to practice. RESULTS: The patient rights QPL was chosen most often during the pilot testing in the study phase. Patients and health care professionals perceived the QPLs as easy to understand and useful. There was a negative correlation between the tool's ease of use and patient age. Patients reported that using the module impacted the consultations positively and thought they were more active compared with previous consultations. Health care professionals also found patients to be more active than usual. Health care professionals asked significantly more questions than patients during consultations. Patients requested to see the patients' rights video most often. Patients rated the videos as easy to understand, useful, and informative. Most of the patients wanted to use the tool in the future. CONCLUSIONS: Older migrant patients with cancer, survivors, and health care professionals found the oncological module to be a useful tool and have shown intentions to incorporate it into future consultation sessions. Both QPLs and videos were evaluated positively, the latter indicating that the use of narratives to inform older, low-literate migrant patients with cancer about health-related topics in their mother tongue is a viable approach to increase the effectiveness of health care communication with this target group.

Estimates of female genital mutilation/cutting in the Netherlands: a comparison between a nationwide survey in midwifery practices and extrapolation-model.

BACKGROUND: Owing to migration, female genital mutilation or cutting (FGM/C) has become a growing concern in host countries in which FGM/C is not familiar. There is a need for reliable estimates of FGM/C prevalence to inform medical and public health policy. We aimed to advance methodology for estimating the prevalence of FGM/C in diaspora by determining the prevalence of FGM/C among women giving birth in the Netherlands. METHODS: Two methods were applied to estimate the prevalence of FGM/C in women giving birth: (I) direct estimation of FGM/C was performed through a nationwide survey of all midwifery practices in the Netherlands and (II) the extrapolation model was adopted for indirect estimation of FGM/C, by applying population-based-survey data on FGM/C in country of origin to migrant women who gave birth in 2018 in the Netherlands. RESULTS: A nationwide survey among primary care midwifery practices that provided care for 57.5% of all deliveries in 2018 in the Netherlands, reported 523 cases of FGM/C, constituting FGM/C prevalence of 0.54%. The indirect estimation of FGM/C in an extrapolation-model resulted in an estimated prevalence of 1.55%. Possible reasons for the difference in FGM/C prevalence between direct- and indirect estimation include that the midwives were not being able to recognize, record or classify FGM/C, referral to an obstetrician before assessing FGM/C status of women and selective responding to the survey. Also, migrants might differ from people in their country of origin in terms of acculturation toward discontinuation of the practice. This may have contributed to the higher indirect-estimation of FGM/C compared to direct estimation of FGM/C. CONCLUSIONS: The current study has provided insight into direct estimation of FGM/C through a survey of midwifery practices in the Netherlands. Evidence based on midwifery practices data can be regarded as a minimum benchmark for actual prevalence among the subpopulation of women who gave birth in a given year.

Female genital mutilation and women's healthcare experiences with general practitioners in the Netherlands: A qualitative study.

OBJECTIVES: While the general practitioner (GP) in the Netherlands is the first point of entry to and gatekeeper of the healthcare system, no study exists to explore the experiences of women with female genital mutilation or cutting (FGM/C) in general practice. Therefore, the aim of this study is to look into the experiences of women with FGM/C in Dutch general practice. METHODS: Semistructured interviews were held with 16 women with FGM/C. Sampling was purposeful. The interview guide and thematic analysis were based on the Illness Perception Model and Kleinman's Explanatory model. Interviews were held in English or Dutch. All data were anonymized, and recordings were transcribed verbatim. Transcripts were coded and thematically analyzed. RESULTS: The women considered FGM/C to be connected to a range of health problems, for which not all of them sought medical care. They had difficulty discussing such a sensitive topic with their GP, did not know their problems could be relieved or perceived GPs to have insufficient knowledge of FGM/C. Lack of time during consultations and overall dissatisfaction with Dutch GP care hampered trust. They strongly preferred the GP to be proactive and ask about FGM/C. CONCLUSION: There is room for improvement as most women would like their GP to discuss their health problems related to FGM/C. GPs should take a proactive attitude and ask about FGM/C. In addition, to develop the trusted relationship needed to discuss sensitive topics and provide culturally sensitive person-centered care, sufficient time during consultations is needed.

The prevalence and risk of Female Genital Mutilation/Cutting among migrant women and girls in the Netherlands: An extrapolation method.

OBJECTIVES: The aim of the study was (I) to estimate the prevalence of Female Genital Mutilation/Cutting (FGM/C) and distribution of types of FGM/C among migrant girls and women in the Netherlands, and (II) to estimate the number of migrant girls at risk of being cut in the immediate future. METHODS: National population-based survey data regarding FGM/C prevalence were applied to female migrants in the Netherlands who migrated from 29 countries with available nationally representative data on FGM/C. RESULTS: As of January 1st 2018, there were 95,588 female migrants residing in the Netherlands, originating from 29 countries with available nationally representative data on FGM/C. Our findings suggest that about 41,000 women had undergone FGM/C, of which 37% had Type III (infibulation). In total 4,190 girls are estimated to be at risk of FGM/C in the next 20 years, of whom 394 were first-generation girls. CONCLUSION: These findings show the urgency to develop appropriate strategies and policies to prevent FGM/C, to protect girls and women at risk of the practice, and to provide adequate services and support for those affected by FGM/C in the Netherlands.

Systematic development of a training program for healthcare professionals to improve communication about breast cancer genetic counseling with low health literate patients.

There is a disproportionate underuse of genetic testing in breast cancer patients from lower education or migrant background. Within these groups, communication about referral to genetic counseling appears challenging due to limited health literacy and cultural barriers. Our aim was to develop and evaluate a training program for healthcare professionals (breast surgeons and specialized nurses), to increase effective communication. We systematically developed a blended training program based on patients' and healthcare professionals' needs and preferences. Prior to the training, we assessed awareness, knowledge and self-efficacy of healthcare professionals. Acceptability and usefulness of the training program were assessed directly after the training. Healthcare professionals (n = 65) from 17 hospitals showed moderate to high awareness and knowledge about the prevalence and impact of limited health literacy. They were aware of cultural factors that influence communication. However, they did not feel confident in recognizing limited health literacy and their self-efficacy to communicate effectively with these patients was low. The training program was rated as acceptable and useful. Healthcare professionals lack confidence to effectively communicate with patients with limited health literacy or migrant background. The training program offers opportunities to improve communication about referral to breast cancer genetic counseling.

Participatory implementation research in the field of migrant health: Sustainable changes and ripple effects over time.

OBJECTIVE: This study aimed to explore whether positive impacts were sustained and unanticipated ripple effects had occurred four years after the implementation of interventions to improve cross-cultural communication in primary care. BACKGROUND: Sustaining the implementation of change using complex interventions is challenging. The EU-funded "RESTORE" study implemented guidelines and training on cross-cultural communication in five Primary Care sites in Europe, combining implementation theory (Normalisation Process Theory) with participatory methodology (participatory learning and action-PLA). There were positive impacts on knowledge, skills and clinical routines. DESIGN, SETTING AND PARTICIPANTS: Four of the five original sites (England, Ireland, Greece, The Netherlands) were available for this qualitative follow-up study. The study population (N = 44) was primary healthcare staff and migrants, most of whom had participated in RESTORE. INTERVENTION; MAIN OUTCOME MEASURES: PLA-style focus groups and interviews explored routine practice during consultations with migrants. Etic cards based on the effects of RESTORE stimulated the discussion. Deductive framework analysis was performed in each country followed by comparative data analysis and synthesis. RESULTS: Changes in knowledge, attitudes and behaviour with regard to consultations with migrants were sustained and migrants felt empowered by their participation in RESTORE. There were ongoing concerns about macro level factors, like the political climate and financial policies, negatively affecting migrant healthcare. CONCLUSION: There were sustained effects in clinical settings, and additional unanticipated positive ripple effects, due in part, from the participatory approach employed.

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

BACKGROUND: Diabetes type 2 is more prevalent in people from ethnic minorities in the Netherlands, and outcomes of care are worse compared with other Dutch people. Dieticians experience difficulties in managing these groups in self-management and adherence to dietary advice. The aim of this study was to explore the views regarding a healthy diet and dietetic care among ethnic minority type 2 diabetes patients. METHODS: Semi-structured interviews were held with 12 migrants with diabetes from Turkey, Morocco, Iraq and Curacao, who visited a dietician. Inclusion went on until saturation was reached. The interview guide was based on the Attitudes, Social influence and self-Efficacy (ASE) model and Kleinman's explanatory model of illness. Interviews were held in the language preferred by the respondent. Transcripts were coded and thematically analyzed. RESULTS: Several respondents expected a more rigorous, directive and technical approach of the dietician. All respondents acknowledged the importance of a healthy diet. What they considered healthy was determined by culturally influenced ideas about health benefits of specific foods. Important hindrances for dietary change were lack of self-efficacy and social support. Social influences were experienced both as supportive and a hindrance. CONCLUSIONS: Migrant diabetic patients' opinions about healthy food are determined by culturally influenced ideas rather than by dietary guidelines. Dutch dietary care is not tailored to the needs of these patients and should take into account migrants' expectations, cultural differences in dietary habits and specifically address the role of family.