Learning in a real-life escape room: an explorative study on the supervisory relationship in GP residency during the COVID-19 pandemic.

BACKGROUND: The relationship between supervisors and residents plays a prominent role in the professional development of general practice (GP) residents. When disruptions occur in the normal course of healthcare, due to effects of e.g. war or emerging epidemics, we need to consider how this may affect the training of the next generation of general practitioners. As both supervisors and residents face new and unprecedented challenges that impact overall quality of the training. In this study, we examined the characteristics of the supervisory relationship in GP training during the disruptions early on during COVID-19. Our aim was to understand better how resident learning is affected in these circumstances, which is a first step in enabling supervisors, residents and faculty to anticipate disruptive situations better in the future. METHODS: We conducted a qualitative case study with a constructivist approach. Seven GP residents at the start of their second placement, and their 10 supervisors participated in this study. Participants came from a University Medical Centre in the Netherlands. Semi-structured interviews were held between September 2020 and February 2021. The subjects were (1) interviewed individually about what they had learned regarding COVID-19, and (2) they were interviewed in supervisory pairs about how they had learned. Data were iteratively analysed; thematic analysis for (1) and template analysis in (2). RESULTS: We identified notable changes in the supervisor-resident relationship attributable to COVID-19. Supervisors and residents were confronted with an all-encompassing uncertainty in the workplace, and disruptive changes in patient care and learning opportunities for residents. Supervisors and residents addressed these emerging workplace challenges through three types of collaboration, (1) getting the job done; (2) residents' learning; and (3) collective learning. Each type had a different focus and distinctive characteristics of the supervisory relationship. CONCLUSION: With the outbreak of COVID-19, supervisors and residents were faced with disruptive uncertainty. In these circumstances, learning occurred not only between residents and their supervisors, but also with non-supervising GPs and assistants in collective learning. We propose to complement collective learning in the workplace with reflection between residents and supervisors at the training institution.

"What kind of doctor do you want to become?": Clinical supervisors' perceptions of their roles in the professional identity formation of General Practice residents.

PURPOSE: Supporting the development of a professional identity is a primary objective in postgraduate education. Few empirical studies have explored professional identity formation (PIF) in residency, and little is known about supervisors' perceptions of their roles in residents' PIF. In this study, we sought to understand how supervisors perceive their roles in the PIF of General Practice (GP) residents. MATERIALS AND METHODS: Guided by principles of qualitative description, we conducted eight focus groups with 55 supervisors at four General Practice training institutes across the Netherlands. Informed by a conceptual framework of PIF, we performed a thematic analysis of focus group transcripts. RESULTS: Three themes related to how GP supervisors described their roles in supporting residents' PIF: supervising with the desired goal of GP training in mind; role modeling and mentoring as key strategies to achieve that goal; and the value of developing bonds of trust to support the process. CONCLUSIONS: To our knowledge, this study is the first to explore PIF in GP training from the perspective of clinical supervisors. The identified themes mirror the components of the therapeutic alliance between doctors and patients from a supervisor's perspective and highlight the pivotal roles of the supervisor in a resident's PIF.

Perspectives on cancer screening participation in a highly urbanized region: a Q-methodology study in The Hague, the Netherlands.

BACKGROUND: The Netherlands hosts, as many other European countries, three population-based cancer screening programmes (CSPs). The overall uptake among these CSPs is high, but has decreased over recent years. Especially in highly urbanized regions the uptake rates tend to fall below the minimal effective rate of 70% set by the World Health Organization. Understanding the reasons underlying the decision of citizens to partake in a CPS are essential in order to optimize the current screening participation rates. The aim of this study was to explore the various perspectives concerning cancer screening among inhabitants of The Hague, a highly urbanized region of the Netherlands. METHODS: A Q-methodology study was conducted to provide insight in the prevailing perspectives on partaking in CSPs. All respondents were inhabitants of the city of The Hague, the Netherlands. In an online application they ranked a set of 31 statements, based on the current available literature and clustered by the Integrated Change model, into a 9-column forced ranking grid according to level of agreement, followed by a short survey. Respondents were asked to participate in a subsequent interview to explain their ranking. By-person factor analysis was used to identify distinct perspectives, which were interpreted using data from the rankings and interviews. RESULTS: Three distinct perspectives were identified: 1). "Positive about participation", 2). "Thoughtful about participation", and 3). "Fear drives participation". These perspectives provide insight into how potential respondents, living in an urbanized region in the Netherlands, decide upon partaking in CSPs. CONCLUSIONS: Since CSPs will only be effective when participation rates are sufficiently high, it is essential to have insight into the different perspectives among potential respondents concerning partaking in a CSP. This study adds new insights concerning these perspectives and suggests several ideas for future optimization of the CSPs.

Unprofessional behaviour of GP residents and its remediation: a qualitative study among supervisors and faculty.

BACKGROUND: Lapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later practice requires timely identification and remediation. However, appropriate language to describe unprofessional behaviour and its remediation during residency is lacking. Therefore, this exploratory study aims to investigate which behaviours of GP residents are considered unprofessional according to supervisors and faculty, and how remediation is applied. METHODS: We conducted eight semi-structured focus group interviews with 55 broadly selected supervisors from four Dutch GP training institutes. In addition, we conducted individual semi-structured interviews with eight designated professionalism faculty members. Interview recordings were transcribed verbatim. Data were coded in two consecutive steps: preliminary inductive coding was followed by secondary deductive coding using the descriptors from the recently developed 'Four I's' model for describing unprofessional behaviours as sensitising concepts. RESULTS: Despite the differences in participants' professional positions, we identified a shared conceptualisation in pinpointing and assessing unprofessional behaviour. Both groups described multiple unprofessional behaviours, which could be successfully mapped to the descriptors and categories of the Four I's model. Behaviours in the categories 'Involvement' and 'Interaction' were assessed as mild and received informal, pedagogical feedback. Behaviours in the categories 'Introspection' and 'Integrity', were seen as very alarming and received strict remediation. We identified two new groups of behaviours; 'Nervous exhaustion complaints' and 'Nine-to-five mentality', needing to be added to the Four I's model. The diagnostic phase of unprofessional behaviour usually started with the supervisor getting a 'sense of alarm', which was described as either a 'gut feeling', 'a loss of enthusiasm for teaching' or 'fuss surrounding the resident'. This sense of alarm triggered the remediation phase. However, the diagnostic and remediation phases did not appear consecutive or distinct, but rather intertwined. CONCLUSIONS: The processes of identification and remediation of unprofessional behaviour in residents appeared to be intertwined. Identification of behaviours related to lack of introspection or integrity were perceived as the most important to remediate. The results of this research provide supervisors and faculty with an appropriate language to describe unprofessional behaviours among residents, which can facilitate timely identification and remediation.

Patient complaints in general practice seen through the lens of professionalism: a retrospective observational study.

BACKGROUND: Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited. AIM: To characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist. DESIGN & SETTING: A retrospective observational study in which all unsolicited patient complaints to a representative out-of-hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10-year period (2009-2019). METHOD: Complaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding. RESULTS: Out of 746 996 patient consultations (telephone, face-to-face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty-five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where ' not being taken seriously ' was mentioned most often. Forty-five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints. CONCLUSION: Most unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category.

Recruitment and retention in a 10-month social network-based intervention promoting diabetes self-management in socioeconomically deprived patients: a qualitative process evaluation.

OBJECTIVES: Socioeconomically deprived patients with type 2 diabetes often face challenges with self-management, resulting in more diabetes-related complications. However, these groups are often under-represented in self-management interventions. Evidence on effective recruitment and retention strategies is growing, but lacking for intensive self-management interventions. This study aims to explore recruitment, retention and effective intervention strategies in a 10-month group-based intervention among Dutch, Moroccan, Turkish and Surinamese patients from socioeconomically deprived neighbourhoods. METHODS: Participants were recruited through general practitioners (GPs) and participated in a 10-month social network-based intervention (10 groups, n=69): Powerful Together with Diabetes. This intervention also targeted the significant others of participants and aimed to increase social support for self-management and to decrease social influences hindering self-management. A qualitative process evaluation was conducted. Retention was measured using log books kept by group leaders. Further, we conducted 17 in-depth interviews with participants (multiethnic sample) and 18 with group leaders. Interviews were transcribed, coded and analysed using framework analyses. RESULTS: The GP's letter and reminder calls, an informational meeting and the intervention's informal nature facilitated recruitment. During the first months, positive group atmosphere, the intervention's perceived usefulness, opportunities to socialise and a reduction in practical barriers facilitated retention. After the first months, conflicting responsibilities and changes in the intervention's nature and planning hindered retention. Calls from group leaders and the prospect of a diploma helped participants overcome these barriers. CONCLUSION: To promote retention in lengthy self-management interventions, it seems important that patients feel they are going on an outing to a social gathering that is enjoyable, recreational, useful and easy to attend. However, rewards and intensive personal recruitment and retention strategies remained necessary throughout the entire intervention period. TRIAL REGISTRATION NUMBER: Dutch Trial Register NTR1886; Results.

The impact of a social network based intervention on self-management behaviours among patients with type 2 diabetes living in socioeconomically deprived neighbourhoods: a mixed methods approach.

AIMS: This paper aims to explore the effect of the social network based intervention Powerful Together with Diabetes on diabetes self-management among socioeconomically deprived patients. This 10-month group intervention targeting patients and significant others aimed to improve self-management by stimulating social support and diminishing social influences that hinder self-management. METHODS: This intervention was evaluated in a quasi-experimental study using a mixed methods approach. Of 131 socioeconomically deprived patients with suboptimal glycaemic control, 69 were assigned to the intervention group and 62 to the control group (standard diabetes education). 27 qualitative in-depth interviews with the participants and 24 with their group leaders were held to study the subjective impact of the intervention. Further, self-management behaviours (medication adherence, diet and physical activity) were assessed at baseline, 10 and 16 months. Data were analysed using framework analyses and a linear mixture model. RESULTS: Qualitative data showed that the intervention group had a better understanding of the way self-management influences diabetes. The intervention group showed more complex self-management behaviours, such as planning ahead, seeking adequate food and physical activity alternatives, and consistently taking their diabetes into consideration when making choices. In participants with complete follow-up data, we found a significant increase in physical activity in the intervention group (3.78 vs. 4.83 days) and no changes in medication adherence and diet. CONCLUSIONS: This study indicates that an intensive support group and simultaneously involving significant others might improve diabetes self-management behaviours among socioeconomically deprived patients. More studies are needed to justify further implementation of the intervention. This study is registered in the Dutch Trial Register NTR1886. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1886.

Effectiveness of a targeted lifestyle intervention in primary care on diet and physical activity among South Asians at risk for diabetes: 2-year results of a randomised controlled trial in the Netherlands.

OBJECTIVES: In South Asian populations, little is known about the effects of intensive interventions to reduce the risk of type 2 diabetes on health behaviour. We examined the effectiveness at 2 years of a culturally targeted lifestyle intervention on diet, physical activity and determinants of behaviour change among South Asians at risk for diabetes. DESIGN: Randomised controlled trial with de facto masking. SETTING: Primary care. PARTICIPANTS: A total of 536 18- to 60-year-old South Asians at risk for diabetes (ie, with impaired glucose tolerance, impaired fasting glucose or relatively high insulin resistance) were randomised to the intervention (n=283) or a control (n=253) group. Data of 314 participants (n=165 intervention, n=149 control) were analysed. INTERVENTIONS: The culturally targeted intervention consisted of individual counselling using motivational interviewing (six to eight sessions in the first 6 months plus three to four booster sessions), a family session, cooking classes and a supervised physical activity programme. The control group received generic lifestyle advice. OUTCOME MEASURES: We compared changes in physical activity, diet and social-cognitive underlying determinants between the two groups at 2-year follow-up with independent-sample t-tests, chi-square tests and Fisher's exact tests. RESULTS: At the 2-year follow-up, participants in the intervention group were more moderately to vigorously active than at baseline, but compared with changes in the control group, the difference was not significant (change min/week 142.9 vs 0.5, p=0.672). Also, no significant difference was found between the two groups in changes on any of the components of the diet or the social-cognitive determinants of diet and physical activity. CONCLUSIONS: The culturally targeted lifestyle intervention led to high drop-out and was not effective in promoting healthy behaviour among South Asians at risk for diabetes. Given the high a priori risk, we recommend to develop new strategies, preferably more acceptable, to promote healthy behaviour. TRIAL REGISTRATION: NTR1499; Results. www.trialregister.nl/trialreg/admin/rctview.asp?TC=1499.

Development of the Social Network-Based Intervention "Powerful Together with Diabetes" Using Intervention Mapping.

This article describes the development of the social network-based intervention Powerful Together with Diabetes which aims to improve diabetes self-management (DSM) among patients with type 2 diabetes living in socioeconomically deprived neighborhoods by stimulating social support for DSM and diminishing social influences hindering DSM (e.g., peer pressure and social norms). The intervention was specifically developed for patients with Dutch, Turkish, Moroccan, and Surinamese backgrounds. The intervention was developed according to Intervention Mapping. This article describes the first four steps of Intervention Mapping: (1) the needs assessment; (2) development of performance and change objectives; (3) selection of theory-based methods and strategies; and (4) the translation of these into an organized program. These four steps resulted in Powerful Together with Diabetes, a 10-month group-based intervention consisting of 24 meetings, 6 meetings for significant others, and 2 meetings for participants and their spouses. The IM method resulted in a tailored approach with a specific focus on the social networks of its participants. This article concludes that the IM method helped our planning team to tailor the intervention to the needs of our target population and facilitated our evaluation design. However, in hindsight, the intervention could have been improved by investing more in participatory planning and community involvement.

Inequalities in the Impact of National Reimbursement of Smoking Cessation Pharmacotherapy and the Influence of Injunctive Norms: An Explorative Study.

In 2011, the Dutch government reimbursed smoking cessation pharmacotherapy with behavioral therapy for quitting smokers. We investigate whether inequalities in the use of pharmacotherapy change and, if not, whether this is due to a relatively positive injunctive norm in lower socioeconomic status (SES) groups. A total of 75,415 participants aged ≥15 years from the Dutch Continuous Survey of Smoking Habits, 2009-2012, were considered with the following measures: SES (education/income), injunctive norm (mostly acceptable/neutral/mostly unacceptable), period (2011/all other years), and pharmacotherapy use (yes/no). The proportion of low SES smokers compared with high SES smokers making quit attempts with pharmacotherapy did not differ significantly. The injunctive norm of low SES smokers differed significantly from high SES smokers and nonsmokers of all SES levels. Low income smokers with mostly acceptable injunctive norms were significantly less likely to make quit attempts using pharmacotherapy than those with a neutral or less accepting injunctive norm. The significantly lower use of pharmacotherapy in quit attempts in low income smokers with a positive injunctive norm toward smoking may partly underlie the lack of uptake of reimbursed pharmacotherapy in low SES smokers.

The Uptake of Screening for Type 2 Diabetes and Prediabetes by Means of Glycated Hemoglobin versus the Oral Glucose Tolerance Test among 18 to 60-Year-Old People of South Asian Origin: A Comparative Study.

BACKGROUND: Direct comparisons of the effect of a glycated haemoglobin measurement or an oral glucose tolerance test on the uptake and yield of screening in people of South Asian origin have not been made. We evaluated this in 18 to 60-year-old South Asian Surinamese. MATERIALS AND METHODS: We invited 3173 South Asian Surinamese for an oral glucose tolerance test between June 18th 2009- December 31st 2009 and 2012 for a glycated hemoglobin measurement between April 19th 2010-November 11th, 2010. Participants were selected from 48 general practices in The Hague, The Netherlands. We used mixed models regression to analyse differences in response and participation between the groups. We described differences in characteristics of participants and calculated the yield as the percentage of all cases identified, if all invitees had been offered screening with the specified method. RESULTS: The response and participation in the glycated hemoglobin group was higher than in the group offered an oral glucose tolerance test (participation 23.9 vs. 19.3; OR: 1.30, 95%-confidence interval1.01-1.69). After adjustment for age and sex, characteristics of participants were similar for both groups. Overall, glycated hemoglobin identified a similar percentage of type 2 diabetes cases but a higher percentage of prediabetes cases, in the population than the oral glucose tolerance test. CONCLUSION: We found that glycated hemoglobin and the oral glucose tolerance test may be equally efficient for identification of type 2 diabetes in populations of South Asian origin. However, for programs aimed at identifying people at high risk of type 2 diabetes (i.e. with prediabetes), the oral glucose tolerance test may be a less efficient choice than glycated hemoglobin.

Smoking cessation behavioural therapy in disadvantaged neighbourhoods: an explorative analysis of recruitment channels.

BACKGROUND: The optimum channel(s) used to recruit smokers living in disadvantaged neighbourhoods for smoking cessation behavioural therapy (SCBT) is unknown. This paper examines the channels through which smokers participating in a free, multi-session SCBT programme heard about and were referred to this service in a disadvantaged neighbourhood, and compares participants' characteristics and attendance between channels. METHODS: 109 participants, recruited from free SCBT courses in disadvantaged areas of two cities in the Netherlands, underwent repeated surveys. Participants were asked how they heard about the SCBT and who referred them. Participant characteristics were compared between five channels, including the General Practitioner (GP), a community organisation, word of mouth, another health professional, and media or self-referred. Whether the channels through which people heard about or were referred to the service predicted attendance of ≥4 sessions was investigated with logistic regression analysis. RESULTS: Over a quarter of the participants had no or primary education only, and more than half belonged to ethnic minority populations. Most participants heard through a single channel. More participants heard about (49%) and were referred to (60%) the SCBT by the (GP) than by any other channel. Factors influencing quit success, including psychosocial factors and nicotine dependence, did not differ significantly between channel through which participants heard about the SCBT. No channel significantly predicted attendance. CONCLUSION: The GP was the single most important source to both hear about and be referred to smoking cessation behavioural therapy in a disadvantaged neighbourhood. A majority of participants of low socioeconomic or ethnic minority status heard about the programme through this channel. Neither the channel through which participants heard about or were referred to the therapy influenced attendance. As such, concentrating on the channel which makes use of the existing infrastructure and which is highest yielding, the GP, would be an appropriate strategy if recruitment resources were scarce.

Socioeconomic inequalities in smoking in The Netherlands before and during the Global Financial Crisis: a repeated cross-sectional study.

BACKGROUND: The Global Financial Crisis (GFC) increased levels of financial strain, especially in those of low socioeconomic status (SES). Financial strain can affect smoking behaviour. This study examines socioeconomic inequalities in current smoking and smoking cessation in The Netherlands before and during the Global Financial Crisis (GFC). METHODS: Participants were 66,960 Dutch adults (≥ 18 years) who took part in the annual national Health Survey (2004-2011). Period was dichotomised: 'pre-' and 'during-GFC'. SES measures used were income, education and neighbourhood deprivation. Outcomes were current smoking rates (smokers/total population) and smoking cessation ratios (former smokers/ever smokers). Multilevel logistic regression models controlled for individual characteristics and tested for interaction between period and SES. RESULTS: In both periods, high SES respondents (in all indicators) had lower current smoking levels and higher cessation ratios than those of middle or low SES. Inequalities in current smoking increased significantly in poorly educated adults of 45-64 years of age (Odds Ratio (OR) low educational level compared with high: 2.00[1.79-2.23] compared to pre-GFC 1.67[1.50-1.86], p for interaction = 0.02). Smoking cessation inequalities by income in 18-30 year olds increased with borderline significance during the GFC (OR low income compared to high income: 0.73[0.58-0.91]) compared to pre-GFC (OR: 0.98[0.80-1.20]), p for interaction = 0.051). CONCLUSIONS: Overall, socioeconomic inequalities in current smoking and smoking cessation were unchanged during the GFC. However, current smoking inequalities by education, and smoking cessation inequalities by income, increased in specific age groups. Increased financial strain caused by the crisis may disproportionately affect smoking behaviour in some disadvantaged groups.

Diabetes risk reduction in overweight first degree relatives of type 2 diabetes patients: effects of a low-intensive lifestyle education program (DiAlert) A randomized controlled trial.

OBJECTIVES: To test the efficacy of a low-intensive lifestyle education program (DiAlert) for overweight first degree relatives of type 2 diabetes patients aimed at reducing diabetes risk. METHODS: Overweight first degree relatives of type 2 diabetes patients were randomly assigned to the DiAlert intervention (N=45) or control group who received leaflets (N=51). DiAlert consists of two group sessions and newsletters. Assessments were scheduled at baseline, three and nine months, with weight loss as primary outcome. Secondary outcomes included anthropometric, metabolic, behavioral and psychological measures. Comparisons were made over time and between groups. RESULTS: Both groups showed modest weight loss with no difference between randomization groups. However, after DiAlert significantly more participants lost 5% of their weight compared to controls (P=0.03). Significant improvement of waist circumference sustained after 9 months in the intervention group (intervention: -4.33cm, P<0.01/control: -1.25cm, P=0.08). Systolic blood pressure improved within the intervention group (intervention: -8.77mmHg, P<0.01/control: -1.03mmHg, P=0.60). No effect was observed for biomedical and psychosocial outcomes. CONCLUSIONS: Our low-intensive structured lifestyle education program helps overweight relatives to improve waist circumference and supports relevant weight loss. PRACTICE IMPLICATIONS: The family approach provides opportunities to reach and engage relatives at risk in diabetes prevention education.

Is channel segmentation necessary to reach a multiethnic population with weight-related health promotion? An analysis of use and perception of communication channels.

OBJECTIVE: To explore similarities and differences in the use and perception of communication channels to access weight-related health promotion among women in three ethnic minority groups. The ultimate aim was to determine whether similar channels might reach ethnic minority women in general or whether segmentation to ethnic groups would be required. DESIGN: Eight ethnically homogeneous focus groups were conducted among 48 women of Ghanaian, Antillean/Aruban, or Afro-Surinamese background living in Amsterdam. Our questions concerned which communication channels they usually used to access weight-related health advice or information about programs and whose information they most valued. The content analysis of data was performed. RESULTS: The participants mentioned four channels - regular and traditional health care, general or ethnically specific media, multiethnic and ethnic gatherings, and interpersonal communication with peers in the Netherlands and with people in the home country. Ghanaian women emphasized ethnically specific channels (e.g., traditional health care, Ghanaian churches). They were comfortable with these channels and trusted them. They mentioned fewer general channels - mainly limited to health care - and if discussed, negative perceptions were expressed. Antillean women mentioned the use of ethnically specific channels (e.g., communication with Antilleans in the home country) on balance with general audience-oriented channels (e.g., regular health care). Perceptions were mixed. Surinamese participants discussed, in a positive manner, the use of general audience-oriented channels, while they said they did not use traditional health care or advice from Surinam. Local language proficiency, time resided in the Netherlands, and approaches and messages received seemed to explain channel use and perception. CONCLUSIONS: The predominant differences in channel use and perception among the ethnic groups indicate a need for channel segmentation to reach a multiethnic target group with weight-related health promotion. The study results reveal possible segmentation criteria besides ethnicity, such as local language proficiency and time since migration, worthy of further investigation.

Risk perception is not associated with attendance at a preventive intervention for type 2 diabetes mellitus among South Asians at risk of diabetes.

OBJECTIVE: To evaluate the association between risk perception and attendance in a diabetes prevention programme among South Asians with a high risk for diabetes. DESIGN: An observational study. We measured risk perception during the baseline interview with causal beliefs, perceived susceptibility and perceived controllability. We used logistic regression to examine the relationship between risk perception and attendance. We adjusted for relevant sociodemographic factors, screening results and psychosocial factors. SETTING: The Hague, the Netherlands. SUBJECTS: Five hundred and thirty-five Hindustani Surinamese (South Asians) aged 18-60 years from a lifestyle-versus-control intervention for the prevention of diabetes. RESULTS: In total, 68·2% attended the lifestyle or control intervention. Participants perceived lifestyle and heredity to increase the risk of diabetes and perceived increasing physical activity to decrease it. Only 44·2% of the participants perceived themselves as susceptible to diabetes and only those who perceived a family history of diabetes as a cause of diabetes appeared to be more inclined to attend. However, after adjustment for confounding, the association was not statistically significant. CONCLUSIONS: Risk perception was not significantly associated with attendance. The results suggest that increasing the risk perception alone in this South Asian population is unlikely to increase the attendance at a diabetes prevention programme.

Wanting to attend isn't just wanting to quit: why some disadvantaged smokers regularly attend smoking cessation behavioural therapy while others do not: a qualitative study.

BACKGROUND: Attendance of a behavioural support programme facilitates smoking cessation. Disadvantaged smokers have been shown to attend less than their more affluent peers. We need to gain in-depth insight into underlying reasons for differing attendance behaviour in disadvantaged smokers, to better address this issue. This study aims to explore the underlying motivations, barriers and social support of smokers exhibiting different patterns of attendance at a free smoking cessation behavioural support programme in a disadvantaged neighbourhood of The Netherlands. METHODS: In 29 smokers undertaking smoking cessation group therapy or telephone counselling in a disadvantaged neighbourhood, qualitative interviews were completed, coded and analysed. Major themes were motivations, barriers to attend and social support. Motivations and social support were analysed with reference to the self-determination theory. RESULTS: Two distinct patterns of attendance emerged: those who missed up to two sessions ("frequent attenders"), and those who missed more than two sessions ("infrequent attenders"). The groups differed in their motivations to attend, barriers to attendance, and in the level of social support they received. In comparison with the infrequent attenders, frequent attenders more often had intrinsic motivation to attend (e.g. enjoyed attending), and named more self-determined extrinsic motivations to attend, such as commitment to attendance and wanting to quit. Most of those mentioning intrinsic motivation did not mention a desire to quit as a motivation for attendance. No organizational barriers to attendance were mentioned by frequent attenders, such as misunderstandings around details of appointments. Frequent attenders experienced more social support within and outside the course. CONCLUSION: Motivation to attend behavioural support, as distinct from motivation to quit smoking, is an important factor in attendance of smoking cessation courses in disadvantaged areas. Some focus on increasing motivation to attend may help to prevent participants missing sessions.

Development of a diabetes prevention program for Surinamese South Asians in the Netherlands.

Type 2 diabetes is highly prevalent among South Asian origin groups around the world. Not only is prevalence higher than in other ethnic groups, age at presentation is lower and these groups are more likely to experience complications. Evidence suggests that lifestyle interventions may prevent or delay the onset of diabetes. However, little is known about diabetes prevention in South Asians (SA). DH!AAN is a diabetes prevention program designed for Surinamese SA in The Netherlands. In this paper, we describe the theoretical frameworks and formative research that guided the development and cultural adaptation of DH!AAN. Cultural adaptation was based on analysis of the determinants of diet and physical activity, including socio-cultural factors, within our study population. This led to the incorporation of surface and deep structure elements in the intervention. One-to-one counseling by dieticians using motivational interviewing (MI) was the basis for the intervention. Additionally, we aimed to generate social support by including family members in parts of the intervention and group sessions to address issues relating to traditional food habits. We discuss our reflections on the development process and the choices made in developing this intervention. The results of DH!AAN will provide insight into the use of MI for this population group. Moreover, DH!AAN will provide evidence regarding the feasibility of diabetes prevention among South Asian populations.

Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. a systematic review.

BACKGROUND: The importance of cultural adaptations in behavioral interventions targeting ethnic minorities in high-income societies is widely recognized. Little is known, however, about the effectiveness of specific cultural adaptations in such interventions. AIM: To systematically review the effectiveness of specific cultural adaptations in interventions that target smoking cessation, diet, and/or physical activity and to explore features of such adaptations that may account for their effectiveness. METHODS: Systematic review using MEDLINE, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials registers (1997-2009). INCLUSION CRITERIA: a) effectiveness study of a lifestyle intervention targeted to ethnic minority populations living in a high income society; b) interventions included cultural adaptations and a control group that was exposed to the intervention without the cultural adaptation under study; c) primary outcome measures included smoking cessation, diet, or physical activity. RESULTS: Out of 44904 hits, we identified 17 studies, all conducted in the United States. In five studies, specific cultural adaptations had a statistically significant effect on primary outcomes. The remaining studies showed no significant effects on primary outcomes, but some presented trends favorable for cultural adaptations. We observed that interventions incorporating a package of cultural adaptations, cultural adaptations that implied higher intensity and those incorporating family values were more likely to report statistically significant effects. Adaptations in smoking cessation interventions seem to be more effective than adaptations in interventions aimed at diet and physical activity. CONCLUSION: This review indicates that culturally targeted behavioral interventions may be more effective if cultural adaptations are implemented as a package of adaptations, the adaptation includes family level, and where the adaptation results in a higher intensity of the intervention. More systematic experiments are needed in which the aim is to gain insight in the best mix of cultural adaptations among diverse populations in various settings, particularly outside the US.