Inequity in postpartum healthcare provision at home and its association with subsequent healthcare expenditure.

BACKGROUND: Provision of postpartum care can support new families in adapting to a new situation. We aimed to determine whether various determinants of socioeconomic status (SES) were associated with utilization of postpartum care. In addition, to stress the relevance of increasing postpartum care uptake among low SES-groups, an assessment of the potential (cost-)effectiveness of postpartum care is required. METHODS: National retrospective cohort study using linked routinely collected healthcare data from all registered singleton deliveries (2010-13) in the Netherlands. Small-for-gestational age and preterm babies were excluded. The associations between SES and postpartum care uptake, and between uptake and health care expenditure were studied using multivariable regression analyses. RESULTS: Of all 569 921 deliveries included, 1.2% did not receive postpartum care. Among women who did receive care, care duration was below the recommended minimum of 24 h in 15.3%. All indicators of low SES were independently associated with a lack in care uptake. Extremes of maternal age, single parenthood and being of non-Dutch origin were associated with reduced uptake independent of SES determinants. No uptake of postpartum care was associated with maternal healthcare expenses in the highest quartile: aOR 1.34 (95% CI 1.10-1.67). Uptake below the recommended amount was associated with higher maternal and infant healthcare expenses: aOR 1.09 (95% CI 1.03-1.18) and aOR 1.20 (95% CI 1.13-1.27), respectively. CONCLUSION: Although uptake was generally high, low SES women less often received postpartum care, this being associated with higher subsequent healthcare expenses. Strategies to effectively reduce these substantial inequities in early life are urgently needed.

[Brua and psychiatry: A pilot study among Dutch-Antillean patients in the Netherlands]. / Brua en psychiatrie: een pilotstudie onder patiënten in Nederland afkomstig van de voormalige Nederlandse Antillen.

BACKGROUND: Individuals native to Aruba, Bonaire, and Curaçao, the abc islands of the former Netherlands Antilles, often attribute their complaints to brua, although they seldom discuss this with health professionals. This may have a negative influence on the therapeutic relationship and diagnostic processes.
AIM: To explore the role of brua in the illness perception of psychiatric patients in the Netherlands who were originally from the abc islands.
METHOD: A random sample of patients under treatment at Parnassia Psychiatric Institute in The Hague were interviewed with the aid of a semi-structured questionnaire.
RESULTS: Of the 18 psychiatric patients interviewed, 10 (56%) believed in brua, and 3 (17%) considered it the cause of their disease. Although none of the interviewees admitted to an active involvement in brua, 8 (44%) had been in touch with a traditional healer and 9 (50%) possessed artifacts meant to provide protection against evil. Regarding the usefulness of discussing brua with health professionals, opinions were divided.
CONCLUSION: Psychiatric patients in the Netherlands native to the abc islands are all knowledgeable of brua, with more than half of them believing in it. Despite the fear and shame that people often experience, making brua fit for discussion in clinical practice would improve the relationship between health professional and patient, yielding further opportunities for diagnosis and treatment.

Health literacy and primary health care use of ethnic minorities in the Netherlands.

BACKGROUND: In the Netherlands, ethnic minority populations visit their general practitioner (GP) more often than the indigenous population. An explanation for this association is lacking. Recently, health literacy is suggested as a possible explaining mechanism. Internationally, associations between health literacy and health care use, and between ethnicity and health literacy have been studied separately, but, so far, have not been linked to each other. In the Netherlands, some expectations have been expressed with regard to supposed low health literacy of ethnic minority groups, however, no empirical study has been done so far. The objectives of this study are therefore to acquire insight into the level of health literacy of ethnic minorities in the Netherlands and to examine whether the relationship between ethnicity and health care use can be (partly) explained by health literacy. METHODS: A questionnaire was sent to a sample of 2.116 members of the Dutch Health Care Consumer Panel (response rate 46%, 89 respondents of non-western origin). Health literacy was measured with the Health Literacy Questionnaire (HLQ) which covers nine different domains. The health literacy levels of ethnic minority groups were compared to the indigenous population. A negative binomial regression model was used to estimate the association between ethnicity and GP visits. To examine whether health literacy is an explaining factor in this association, health literacy and interaction terms of health literacy and ethnicity were added into the model. RESULTS: Differences in levels of health literacy were only found between the Turkish population and the indigenous Dutch population. This study also found an association between ethnicity and GP visits. Ethnic minorities visit their GP 33% more often than the indigenous population. Three domains of the HLQ (the ability to navigate the health care system, the ability to find information and to read and understand health information) partly explained the association between ethnicity and GP visits. CONCLUSIONS: In general, there are no differences in health literacy between most of the ethnic minority groups in the Netherlands and the indigenous Dutch population. Only the Turkish population scored significantly lower on several health literacy domains. Some domains of health literacy do explain the association between ethnicity and higher frequency of GP visits. Further research is recommended to understand the pathways through which health literacy impacts health care use.

[Validation of tools for assessing the intelligence and the functional impairment of Papiamento speaking suspects]. / Validatie van testen voor intelligentie en beperkingen in het functioneren bij Papiamentstalige verdachten.

BACKGROUND: Although Antillean suspects in the Netherlands are often diagnosed as being intellectually impaired, there are no validated tests available Papiamento (the native language) for assessing intelligence or functional impairment. AIM: To validate the use of the GIT 2 (Groninger Intelligentie Test 2) and the Barkley Functioning Impairment Scale (BFIS) for Antillean defendants detained by the Judicial Service of the Caribbean Netherlands in Bonaire. METHOD: With the approval of the publishers, the GIT 2 and the BFIS were translated in Papiamento by two independent experts. The two translations were then re-translated into Dutch by two other independent experts. Defendants with both parents born in Bonaire who had been detained for at least 18 days by the Judicial Detention Centre of the Caribbean Netherlands (JICN) in Bonaire during the period 1 January 2013 until 1 July 2014 were examined with both tests. RESULTS: The Papiamento GIT 2 and BFIS tests were taken by 23 Bonairian defendants who had been detained in the JICN in Bonaire. The internal consistency and inter-item correlation of the tests were found to be satisfactory. The IQ of 95% of the participants was reproduced as a score between 79.2 and 96.8 points. In the BFIS the question about self-care was a particularly sensitive item. The use of drugs was associated with increased functional impairment. CONCLUSION: This study seems to be a promising first step towards the validation of the GIT 2 and the BFIS. Apparently, it has now become acceptable to use written Papiamento in assessment tools.

Neutral and adaptive genomic signatures of rapid poleward range expansion.

Many species are expanding their range polewards, and this has been associated with rapid phenotypic change. Yet, it is unclear to what extent this reflects rapid genetic adaptation or neutral processes associated with range expansion, or selection linked to the new thermal conditions encountered. To disentangle these alternatives, we studied the genomic signature of range expansion in the damselfly Coenagrion scitulum using 4950 newly developed genomic SNPs and linked this to the rapidly evolved phenotypic differences between core and (newly established) edge populations. Most edge populations were genetically clearly differentiated from the core populations and all were differentiated from each other indicating independent range expansion events. In addition, evidence for genetic drift in the edge populations, and strong evidence for adaptive genetic variation in association with the range expansion was detected. We identified one SNP under consistent selection in four of the five edge populations and showed that the allele increasing in frequency is associated with increased flight performance. This indicates collateral, non-neutral evolutionary changes in independent edge populations driven by the range expansion process. We also detected a genomic signature of adaptation to the newly encountered thermal regimes, reflecting a pattern of countergradient variation. The latter signature was identified at a single SNP as well as in a set of covarying SNPs using a polygenic multilocus approach to detect selection. Overall, this study highlights how a strategic geographic sampling design and the integration of genomic, phenotypic and environmental data can identify and disentangle the neutral and adaptive processes that are simultaneously operating during range expansions.

Reef flattening effects on total richness and species responses in the Caribbean.

There has been ongoing flattening of Caribbean coral reefs with the loss of habitat having severe implications for these systems. Complexity and its structural components are important to fish species richness and community composition, but little is known about its role for other taxa or species-specific responses. This study reveals the importance of reef habitat complexity and structural components to different taxa of macrofauna, total species richness, and individual coral and fish species in the Caribbean. Species presence and richness of different taxa were visually quantified in one hundred 25-m(2) plots in three marine reserves in the Caribbean. Sampling was evenly distributed across five levels of visually estimated reef complexity, with five structural components also recorded: the number of corals, number of large corals, slope angle, maximum sponge and maximum octocoral height. Taking advantage of natural heterogeneity in structural complexity within a particular coral reef habitat (Orbicella reefs) and discrete environmental envelope, thus minimizing other sources of variability, the relative importance of reef complexity and structural components was quantified for different taxa and individual fish and coral species on Caribbean coral reefs using boosted regression trees (BRTs). Boosted regression tree models performed very well when explaining variability in total (82·3%), coral (80·6%) and fish species richness (77·3%), for which the greatest declines in richness occurred below intermediate reef complexity levels. Complexity accounted for very little of the variability in octocorals, sponges, arthropods, annelids or anemones. BRTs revealed species-specific variability and importance for reef complexity and structural components. Coral and fish species occupancy generally declined at low complexity levels, with the exception of two coral species (Pseudodiploria strigosa and Porites divaricata) and four fish species (Halichoeres bivittatus, H. maculipinna, Malacoctenus triangulatus and Stegastes partitus) more common at lower reef complexity levels. A significant interaction between country and reef complexity revealed a non-additive decline in species richness in areas of low complexity and the reserve in Puerto Rico. Flattening of Caribbean coral reefs will result in substantial species losses, with few winners. Individual structural components have considerable value to different species, and their loss may have profound impacts on population responses of coral and fish due to identity effects of key species, which underpin population richness and resilience and may affect essential ecosystem processes and services.

Disentangling trait-based mortality in species with decoupled size and age.

1. Size and age are fundamental organismal traits, and typically, both are good predictors of mortality. For many species, however, size and age predict mortality in ontogenetically opposing directions. Specifically, mortality due to predation is often more intense on smaller individuals whereas mortality due to senescence impacts, by definition, on older individuals. 2. When size-based and age-based mortality are independent in this manner, modelling mortality in both traits is often necessary. Classical approaches, such as Leslie or Lefkovitch matrices, usually require the model to infer the state of one trait from the state of the other, for example by assuming that explicitly modelled age (or stage) class structure provides implicit information on underlying size-class structure, as is the case in many species. 3. However, the assumption that one trait informs on the other is challenged when size and age are decoupled, as often occurs in invertebrates, amphibians, fish, reptiles and plants. In these cases, age-structured models may perform poorly at capturing size-based mortality, and vice versa. 4. We offer a solution to this dilemma, relaxing the assumption that class structure in one trait is inferable from class structure in another trait. Using empirical data from a reef fish, Sparisoma viride (Scaridae), we demonstrate how an individual-based model (IBM) can be implemented to model mortality as explicit, independent and simultaneous functions of individual size and age - an approach that mimics the effects of mortality in many wild populations. By validating this 'multitrait IBM' against three independent lines of empirical data, we determine that the approach produces more convincing predictions of size-class structure, longevity and post-settlement mortality for S. viride than do the trait-independent or single-trait mortality models tested. 5. Multitrait IBMs also allow trait-based mortality to be modelled either additively or multiplicatively, and individual variability in growth rates can be accommodated. Consequently, we propose that the approach may be useful in fields that may benefit from disentangling, or investigating interactions among, size-based and age-based demographic processes, including comparative demography (e.g. life-history consequences of resource patchiness) and conservation biology (e.g. impacts of invasive predators on size structure but not life span of natives).

Explanatory factors for first and second-generation non-western women's inadequate prenatal care utilisation: a prospective cohort study.

BACKGROUND: Little research into non-western women's prenatal care utilisation in industrialised western countries has taken generational differences into account. In this study we examined non-western women's prenatal care utilisation and its explanatory factors according to generational status. METHODS: Data from 3300 women participating in a prospective cohort of primary midwifery care clients (i.e. women with no complications or no increased risk for complications during pregnancy, childbirth and the puerperium who receive maternity care by autonomous midwives) in the Netherlands (the DELIVER study) was used. Gestational age at entry and the total number of prenatal visits were aggregated into an index. The extent to which potential factors explained non-western women's prenatal care utilisation was assessed by means of blockwise logistic regression analyses and percentage changes in odds ratios. RESULTS: The unadjusted odds of first and second-generation non-western women making inadequate use of prenatal care were 3.26 and 1.96 times greater than for native Dutch women. For the first generation, sociocultural factors explained 43% of inadequate prenatal care utilisation, socioeconomic factors explained 33% and demographic and pregnancy factors explained 29%. For the second generation, sociocultural factors explained 66% of inadequate prenatal care utilisation. CONCLUSION: Irrespective of generation, strategies to improve utilisation should focus on those with the following sociocultural characteristics (not speaking Dutch at home, no partner or a first-generation non-Dutch partner). For the first generation, strategies should also focus on those with the following demographic, pregnancy and socioeconomic characteristics (aged ≤ 19 or ≥ 36, unplanned pregnancies, poor obstetric histories (extra-uterine pregnancy, molar pregnancy or abortion), a low educational level, below average net household income and no supplementary insurance.

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.

Prevalence and nature of child sexual abuse in the Netherlands: ethnic differences?

In most epidemiological prevalence studies of child sexual abuse, the role of ethnicity remains unclear. This study examined the prevalence and nature of child sexual abuse in four non-Western ethnic minority groups and compared them with a native Dutch group. A sample of 3,426 young adults (aged 18-25) completed a structured, online survey on experiences of child sexual abuse. A total of 42.9% (n = 1,469) participants reported at least one form of child sexual abuse victimization before the age of 18. Surinamese and Turkish respondents' prevalence rates did not differ from the native Dutch youth. However, the Dutch Antillean respondents reported significantly higher rates of child sexual abuse on specific forms of abuse, whereas the Moroccan respondents reported lower rates compared with their native Dutch peers. With this study, we have more insight into the differences-however small they may be-between ethnic groups and native Dutch youth regarding child sexual abuse.

[Brua as an explanatory model for diseases]. / Brua als verklaringsmodel voor ziekten.

A 26-year-old woman from the island of Aruba who had been living in the Netherlands for ten years felt she was misunderstood by the various health professionals she had consulted because of her fear that she was being poisoned and would soon die. Due to her background en her belief in brua, she attributed her symptoms and her illness to 'voodoo', allegedly practiced by members of her husband's family in connection with relationship problems. A culture-sensitive approach to the patient, along with thorough psychiatric and neurological tests, yielded a surprising result. Our findings emphasise how important it is for us as health professionals to acquaint ourselves with explanatory models of the diseases of our patients, and how vital it is for us to be aware of a patient's background, particularly if the patient is of foreign descent.

The disease burden across different ethnic groups in Amsterdam, the Netherlands, 2011-2030.

BACKGROUND: Current disease burden estimates do not provide evidence across different ethnic groups. This study aims to assess the disease burden as measured by the disability-adjusted life years (DALYs) for six ethnic groups in Amsterdam, the Netherlands, for 2011 and 2030. METHODS: The DALYs were calculated by combining three components: disease-/sex-/age-specific DALYs per person; disease-specific relative risks (RRs) by ethnicity; and sex-/age-specific population sizes by ethnicity in Amsterdam in 2011 and 2030. Disease-specific DALYs were derived from the National Institute of Public Health. The RRs were obtained through a systematic review of studies published in 1997-2008. The population figures were gathered from the Statistics Netherlands and municipality of Amsterdam. RESULTS: The findings suggest that cardiovascular diseases and anxiety and depressive disorders dominate disease burden in all ethnic groups in 2011 and 2030. In most of the non-Western ethnic minorities, diabetes mellitus is the strongest contributor to the disease burden. The total disease burden will increase more strongly in non-Western ethnic minorities than ethnic Dutch. The 2030 disease burden is estimated to be highest among Surinamese and Antilleans. CONCLUSIONS: In ethnic minorities, diabetes plays an important role in the disease burden, and the total disease burden will grow stronger than ethnic Dutch, resulting in a higher total disease burden for some ethnic groups in 2030. We encourage researchers to estimate the disease burden by ethnicity so that health priorities can be set in the fields of policy, health care and research.

The integration paradox: level of education and immigrants' attitudes towards natives and the host society.

The so-called integration paradox refers to the phenomenon of the economically more integrated and highly educated immigrants turning away from the host society, instead of becoming more oriented toward it. The present study examined this paradox in the Netherlands among a large sample (N = 3,981) of immigrants, including 2 generations and 4 ethnic groups. The assumed negative relationship between level of education and attitudes toward the host society and the native population was expected to be mediated by two indicators of perceived acceptance by the native majority: discrimination and subgroup respect. Results show that higher educated immigrants perceive more discrimination and less respect for minorities, and these perceptions, in turn, relate to less positive evaluations of the native majority and the host society. This pattern of associations is quite similar for the 2 generations and for the 4 migrant groups.

Induced abortion is not associated with a higher likelihood of depression in Curaçao women.

OBJECTIVE: To investigate the risk of developing a depression after induced abortion. METHODS: A prospective cohort study conducted in Curaçao which involved 92 women having an induced abortion and 37 women delivering after an unplanned or unwanted pregnancy, who served as controls. All participants completed the Center of Epidemiological Studies Depression (CES-D) scale before and two to three weeks after the abortion or delivery. RESULTS: Following the abortion, significantly fewer women were at risk of depression (30%) as compared to when still pregnant (60%). Mean depression scores were significantly lower after- than before the procedure. The likelihood of depression post-abortum (30%) was similar to that after delivery of an unplanned/unwanted child (22%). Even though women in the abortion group more often reported having suffered from depression in the past than controls, they were not at greater risk of depression after their pregnancy had ended. CONCLUSION: Curaçao women's risk of developing a depression following an (early) induced abortion is not greater than that after carrying to term an unplanned/unwanted pregnancy. We recommend that the results of this study be taken into account in case the Curaçao government should consider legalisation of induced abortion in the near future.

Determinants of HPV vaccination intentions among Dutch girls and their mothers: a cross-sectional study.

BACKGROUND: The Dutch government recently added universal Human Papilloma Virus (HPV) vaccination for 12-year-old girls to the existing national immunization program. The participation rate for the initial catch-up campaign for girls aged 13 to 16 years in 2009 was lower (47%) than expected (70%). To inform future HPV information campaigns, this paper examines the social and psychological determinants of the HPV vaccination intentions of girls aged 13 to 16 years and their mothers who were targeted by the Dutch catch-up campaign of 2009. METHODS: A random sample of girls and their mothers was chosen from the Dutch vaccination register and received a letter inviting them to participate (n = 5,998 mothers and daughters). In addition, a random sample was recruited via an online panel by a marketing research company (n = 650 mothers; n = 350 daughters). Both groups were asked to complete a web-based questionnaire with questions on social demographic characteristics, social-psychological factors and HPV vaccination intention. Backward linear regression analyses were conducted to examine which social-psychological factors were most dominantly associated with vaccination intention. RESULTS: Data from 952 mothers (14%) and 642 daughters (10%) were available for the intended analyses. The contribution of social demographic variables to the explained variance of HPV vaccination intention was small but significant for mothers (ΔR² = .01; p = .007), but not significant for daughters (ΔR² = .02; p = .17) after controlling for HPV vaccination uptake and the sample. In addition, social-psychological determinants largely contributed to the explained variance of HPV vaccination intention of mothers (ΔR² = .35; p < .001) and daughters (ΔR² = .34; p < .001). Attitudes, beliefs, subjective norms and habit strength were significantly associated with participants' HPV vaccination intentions. CONCLUSIONS: Because of the large contribution of social-psychological variables to the explained variance of HPV vaccination intentions among the mothers and daughters, future communication strategies targeting HPV vaccination uptake should address attitudes, beliefs, subjective norms and habit strength. There is a need for longitudinal research to confirm the causality of the association between these determinants and HPV vaccination behavior indicated by this study.

Factors contributing to inconsistent condom use among heterosexual men in Curaçao.

This study explored, from a public health perspective, factors that contribute to inconsistent condom use by men in Curaçao through semi-structured face-to-face interviews with 21 heterosexual men. The findings show that there is an important disconnect between what is considered culturally appropriate sexual behaviour for men and women and condom use, that diverging from prescribed notions of masculinity and femininity in order to use condoms consistently is difficult, and that condom use is particularly problematic in the context of concurrent partnerships and sexual economic exchanges. Participants further reported that Caribbean family structures, whereby mothers assume the role as primary caregiver and fathers contribute biologically but, to a much lesser extent socially, also have an impact on condom use. Additionally, consistent condom use was reported to be impeded by a cultural taboo on talking seriously about sex and sexual health. In their totality, findings provide important input from men for the development of sexual health promotion interventions that are cognizant of the cultural context in which inconsistent condom use occurs, and that are geared not only to the individual level but also to the interpersonal and structural levels.

Characteristics of women who have repeat abortions in the Netherlands.

OBJECTIVES: To explore the demographic characteristics of women having multiple abortions, in order to identify abortion clients who might be at increased risk of repeat abortion. METHODS: On the basis of the registration data of most Dutch abortion clinics, responsible for 64% of all such procedures, women who procured a first abortion were compared to those who had one or more previously. Results of bivariate analyses and a multivariate binary logistic regression analysis are presented. RESULTS: Of all abortions, 36% were repeat abortions. Women aged over 20 were more likely to have repeat abortions, as were migrants, particularly those with a Caribbean background (from Surinam or the Netherlands Antilles) and women who had children. Effect sizes of other factors were very small. Surprisingly, women who had repeat abortions more often used contraception in the preceding six months than women who had a first abortion, but also this effect size was small as well. A multivariate logistic regression analysis led to similar results. CONCLUSIONS: Abortion clients with a Caribbean background should be targeted for the prevention of more unwanted pregnancies. Not only should the use of reliable contraception be promoted, but also compliance and continuation.

Child abuse: a common problem in Curaçao?

OBJECTIVE: To assess the prevalence of child abuse among high school students in Curacao. METHODS: A questionnaire survey among high school students up to 17 years of age was conducted. The questionnaire was based on existing literature and validated questionnaires. The questionnaire used was analysed and adapted to the situation in Curaçao by a panel of experts on child abuse. The primary objective was to gain insight into the incidence, prevalence and various forms of child abuse among students in Curaçao. Five forms of child abuse are distinguished in the literature: physical abuse, emotional abuse, sexual abuse, neglect and exploitation. Furthermore, the degree of confidence of the students in general practitioners (GPs) as care providers in the field of child abuse was explored. RESULTS: Questionnaires from 545 of the 628 respondents were included. In total, 43% of the respondents had ever-experienced an event which could be defined as (a form of) child abuse. More than one-third of the respondents reporting child abuse ever had an experience that could be interpreted as physical abuse. More than 15% of the respondents reporting child abuse had experienced sexual abuse. Girls experienced significantly more sexual abuse than boys. Emotional abuse in the last year was experienced by 3% of the respondents. One per cent of the respondents ever-experienced neglect. According to most respondents, GPs were not seen as care providers in cases of child abuse; they believed that GPs were mainly to be consulted for illnesses or physical symptoms and not for forms of child abuse. CONCLUSION: The prevalence of ever-having-experienced a form of child abuse is estimated at 431 per 1000 students. Child abuse, particularly physical abuse, is common in Curaçao, and is probably comparable to other surrounding countries. General practitioners were not seen as care providers in identifying and reporting cases of child abuse according to most respondents.

Vitamin D deficiency in risk groups living in tropical Curaçao.

OBJECTIVE: Curaçao (12 degrees 10ON, 69 degrees OW) is characterized by whole year abundant sunshine (8-10 hours/day). We challenged the automatic assumption that people living in tropical countries do not have a high risk of vitamin D deficiency, and investigated the vitamin D status in a tropical environment. METHODS: For this, we selected fifty-two elderly people with little or no exposure to direct sunlight [median 84 (60-96) years; 34females, 18 males] and who were cared for by community nurses or lived in retirement or nursing homes. Furthermore, six rehabilitating orthopaedic patients [median 72 (38-90) years; one female, five males] were included. Serum 25(OH)D, calcium, phosphate, parathyroid hormone (PTH) and creatinine were measured. Those exhibiting elevated creatinine, PTH or both had their 1,25-dihydroxyvitamin D [1,25(OH)2D] examined. RESULTS: Serum levels of 25(OH)D below 25, 50 and 75 nmol/L were detected in, respectively, seven (12%), 22 (38%) and 48 (83%) ofthe fifty-eight persons. Four persons had combined high creatinine and PTH, and low 1,25(OH)2D, which was not known by their caregivers. CONCLUSION: Abundant sunshine outdoors is no guarantee for vitamin D sufficiency. More attention is needed for vitamin D deficiency in risk groups living in tropical areas and elderly persons with poor kidney function.

Optimizing chronic HIV care in the Dutch Caribbean: a questionnaire based study on experience and perception of healthcare workers.

OBJECTIVE: Human immunodeficiency virus (HIV) infection has become a chronic disorder for which adaptation of current healthcare practices is needed. In Curaçao, a new organization of chronic HIV care is being set up based on task shifting in which healthcare workers (HCWs) will deliver HIV care more prominently within the primary healthcare system. In preparation for implementation of the proposed task-shifting model, we investigated the perception of HCWs regarding existing HIV care in Curaçao and the need for training in HIV/AIDS among HCWs. SUBJECTS AND METHODS: An in-depth questionnaire based study was used. Nineteen HCWs of seven different cadres were interviewed. The questionnaire constituted four sections: quality of existing HIV care, respondents own knowledge and willingness to be trained, need for training in HIV/AIDS and preferred educational approaches. RESULTS: Quality of existing HIV services in Curaçao is considered acceptable but needs improvement mainly to facilitate integration of chronic HIV care. All respondents indicated that training in HIV/AIDS is needed among HCWs in Curaçao, especially for nurses and general practitioners. All were willing to participate in training with varying amounts of time to be spent. Training should be tailored to the level of expertise of HCWs and to the role a HCW is expected to have in the new healthcare delivery framework. CONCLUSION: There is need for training to ensure the effective integration of chronic HIV care into the existing healthcare delivery system in Curaçao.There is a willingness and need in all cadres for training with e-learning as a preferred educational tool.