The implementation of national action program diabetes in the Netherlands: lessons learned.

BACKGROUND: Over the past decade, the National Action program Diabetes (NAD) was implemented in the Netherlands. Its aim was to introduce the Care Standard (CS) for diabetes by means of a specific implementation plan and piloting in several regions. This study aimed to provide insight into the implementation of the NAD as, coupled with the introduction of the CS, it may function as an example for similar approaches in other countries. METHODS: A series of quantitative studies (participants 2010: N = 1726, participants 2013: N = 1370 & participants pilot regions 2013: N = 168) and qualitative studies (participants 2010: N = 18 and participants 2013: N = 4) was conducted among health care professionals (HCPs). In addition, two quantitative studies were conducted among type 1 and 2 patients (participants 2010: N = 573; participants 2013: N = 5056). RESULTS: Overall, positive changes in diabetes care were detected in the period 2010 - 2013. In 2013 significantly more HCPs were familiar with the CS (43.7 versus 37.6 %) and more HCPs perceived themselves to be working largely or completely in accordance with the CS (89.2 versus 79.0 %) than in 2010. A comparison of the results in specific pilot regions with the rest of the country revealed that HCPs in these regions scored significantly more positively on implementation and appreciation of the CS. This positive trend was reflected by the high levels of reported patient satisfaction and involvement in treatment. HCPs who were in possession of the CS had significantly better scores on the implementation of several elements of the CS than HCPs who were not in possession of the CS. CONCLUSION: The CS has become more prominent and embedded in daily health care practice. In retrospect the CS has provided momentum for the realization of various processes relating to the wider implementation of standards to improve the care for people with other chronic diseases in the Netherlands. Experiences with the NAD and CS underline the need to move towards an integrated multidisciplinary approach of diabetes care worldwide.

Effects of a lifestyle program in subjects with Impaired Fasting Glucose, a pragmatic cluster-randomized controlled trial.

BACKGROUND: The worldwide epidemic of type 2 diabetes (T2DM) underlines the need for diabetes prevention strategies. In this study the feasibility and effectiveness of a nurse led lifestyle program for subjects with impaired fasting glucose (IFG) is assessed. METHODS: A cluster randomized clinical trial in 26 primary care practices in the Netherlands included 366 participants older than 45 years with newly diagnosed IFG and motivated to change their lifestyle (intervention group, n = 197; usual care group, n = 169). The one-year intervention, consisting of four to five individual nurse-led consultations, was directed at improving physical activity and dietary habits. The primary outcome measure was body mass index (BMI). Linear and logistic multilevel analyses and a process evaluation were performed. RESULTS: Both groups showed small reductions in BMI at 1 and 2 years, but differences between groups were not significant. At both 1 and 2-year follow-up the number of participants physically active for at least 30 minutes at least five days a week was significantly improved in the intervention group compared to the usual care group (intervention group vs. usual care group: OR1year = 3.53; 95 % CI = 1.69-7.37 and OR2years = 1.97; 95 % CI = 1.22-3.20, respectively). The total drop-out rate was 24 %. Process evaluation revealed that participants in the intervention group received fewer consultations than advised, while some practice nurses and participants considered the RM protocol too intensive. CONCLUSIONS: This relatively simple lifestyle program in subjects with IFG resulted in a significant improvement in reported physical activity, but not in BMI. Despite its simplicity, some participants still considered the intervention too intensive. This viewpoint could be related to poor motivation and an absence of disease burden due to IFG, such that participants do not feel a need for behavioural change. Although the intervention provided some benefit, its wider use cannot be advised. TRIAL REGISTRATION: Current Controlled Trials ISRCTN41209683 , date of registration 16/10/2013h  .

A cluster-randomized controlled trial to study the effectiveness of a protocol-based lifestyle program to prevent type 2 diabetes in people with impaired fasting glucose.

BACKGROUND: Effective diabetes prevention strategies that can be implemented in daily practice, without huge amounts of money and a lot of personnel are needed. The Dutch Diabetes Federation developed a protocol for coaching people with impaired fasting glucose (IFG; according to WHO criteria: 6.1 to 6.9 mmol/l) to a sustainable healthy lifestyle change: 'the road map towards diabetes prevention' (abbreviated: Road Map: RM). This protocol is applied within a primary health care setting by a general practitioner and a practice nurse. The feasibility and (cost-) effectiveness of care provided according to the RM protocol will be evaluated. METHODS/DESIGN: A cluster randomised clinical trial is performed, with randomisation at the level of the general practices. Both opportunistic screening and active case finding took place among clients with high risk factors for diabetes. After IFG is diagnosed, motivated people in the intervention practices receive 3-4 consultations by the practice nurse within one year. During these consultations they are coached to increase the level of physical activity and healthy dietary habits. If necessary, participants are referred to a dietician, physiotherapist, lifestyle programs and/or local sports activities. The control group receives care as usual. The primary outcome measure in this study is change in Body Mass Index (BMI). Secondary outcome measures are waist circumference, physical activity, total and saturated fat intake, systolic blood pressure, blood glucose, total cholesterol, HDL cholesterol, triglycerides and behaviour determinants like risk perception, perceived knowledge and motivation. Based on a sample size calculation 120 people in each group are needed. Measurements are performed at baseline, and after one (post-intervention) and two years follow up. Anthropometrics and biochemical parameters are assessed in the practices and physical activity, food intake and their determinants by a validated questionnaire. The cost-effectiveness is estimated by using the Chronic Disease Model (CDM). Feasibility will be tested by interviews among health care professionals. DISCUSSION: The results of the study will provide valuable information for both health care professionals and policy makers. If this study shows the RM to be both effective and cost-effective the protocol can be implemented on a large scale. TRIAL REGISTRATION: ISRCTN41209683. Ethical approval number: NL31342.075.10.

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

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

Maternal depressive symptoms in relation to perinatal mortality and morbidity: results from a large multiethnic cohort study.

OBJECTIVE: To explore whether 1) maternal depressive symptoms during pregnancy are associated with preterm birth (PTB), small for gestational age (SGA), a low Apgar score and child loss; 2) maternal smoking mediates the associations; and 3) the associations differ by ethnic background. METHODS: Pregnant women in Amsterdam were approached during their first prenatal visit to participate in the Amsterdam Born Children and their Development study. They filled out a questionnaire covering sociodemographic data, life-style, and (psychosocial) health. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression scale. The baseline sample consisted of 8,052 women; the main ethnic groups were: Dutch, Creole, Turkish, and Moroccan. RESULTS: The prevalence of perinatal outcomes was: 5.4% (PTB); 12.3% (SGA); l 1.5% (low Apgar score); and 1.4% (child loss). The prevalence of high depressive symptomatology was 30.6%. After adjustment for maternal age, parity, education, ethnicity, prepregnancy body mass index, hypertension, alcohol and drug use, and a small mediation effect of maternal smoking, high versus low levels of depressive symptoms were associated with SGA (odds ratio [OR], 1.19; p = .02) and a low Apgar score (OR, 1.74; p = .01), but not with PTB (OR, 1.16; p = .18) and child loss (OR, 1.28; p = .24). Stratified analyses by ethnic background showed a tendency toward higher risks, although insignificant, among Creole women. CONCLUSIONS: Several pathways may explain the detrimental effects of maternal depressive symptomatology on perinatal health outcomes, including a psychoendocrinological pathway involving the hormone cortisol or mediation effects by maternal risk behaviors. Further research should explore the underlying pathways, in particular among ethnic subgroups.

Acculturation and use of health care services by Turkish and Moroccan migrants: a cross-sectional population-based study.

BACKGROUND: There is insufficient empirical evidence which shows if and how there is an interrelation between acculturation and health care utilisation. The present study seeks to establish this evidence within first generation Turkish and Moroccan migrants, two of the largest migrant groups in present-day Western Europe. METHODS: Data were derived from the Amsterdam Health Monitor 2004, and were complete for 358 Turkish and 288 Moroccan foreign-born migrants. Use of health services (general practitioner, outpatient specialist and health care for mental health problems) was measured by means of self-report. Acculturation was measured by a structured questionnaire grading (i) ethnic self-identification, (ii) social interaction with ethnic Dutch, (iii) communication in Dutch within one's private social network, (iv) emancipation, and (v) cultural orientation towards the public domain. RESULTS: Acculturation was hardly associated with the use of general practitioner care. However, in case of higher adaptation to the host culture there was less uptake of outpatient specialist care among Turkish respondents (odds ratio [OR] = 0.90, 95% confidence interval [CI] = 0.82-0.99) and Moroccan male respondents (OR = 0.81, 95% CI = 0.71-0.93). Conversely, there was a higher uptake of mental health care among Turkish men (OR = 0.81, 95% CI = 0.71-0.93) and women (OR = 0.81, 95% CI = 0.71-0.93). Uptake of mental health care among Moroccan respondents again appeared lower (OR = 0.74, 95% CI = 0.55-0.99). Language ability appeared to play a central role in the uptake of health care. CONCLUSION: Some results were in accordance with the popular view that an increased participation in the host society is concomitant to an increased use of health services. However, there was heterogeneity across ethnic and gender groups, and across the domains of acculturation. Language ability appeared to play a central role. Further research needs to explore this heterogeneity into more detail. Also, other cultural and/or contextual aspects that influence the use of health services require further identification.

Ethnic health care advisors: a good strategy to improve the access to health care and social welfare services for ethnic minorities?

Empirical studies indicate that ethnic minorities have limited access to health care and welfare services compared with the host population. To improve this access, ethnic health care (HC) advisors were introduced in four districts in Amsterdam, the Netherlands. HC advisors work for all health care and welfare services and their main task is to provide information on health care and welfare to individuals and groups and refer individuals to services. Action research was carried out over a period of 2 years to find out whether and how this function can contribute to improve access to services for ethnic minorities. Information was gathered by semi-structured interviews, analysing registration forms and reports, and attending meetings. The function's implementation and characteristics differed per district. The ethnicity of the health care advisors corresponded to the main ethnic groups in the district: Moroccan and Turkish (three districts) and sub-Sahara African and Surinamese (one district). HC advisors reached many ethnic inhabitants (n = 2,224) through individual contacts. Half of them were referred to health care and welfare services. In total, 576 group classes were given. These were mostly attended by Moroccan and Turkish females. Outreach activities and office hours at popular locations appeared to be important characteristics for actually reaching ethnic minorities. Furthermore, direct contact with a well-organized back office seems to be important. HC advisors were able to reach many ethnic minorities, provide information about the health care and welfare system, and refer them to services. Besides adapting the function to the local situation, some general aspects for success can be indicated: the ethnic background of the HC advisor should correspond to the main ethnic minority groups in the district, HC advisors need to conduct outreach work, there must be a well-organized back office to refer clients to, and there needs to be enough commitment among professionals of local health and welfare services.

Severity distribution of chronic obstructive pulmonary disease (COPD) in Dutch general practice.

The actual burden of chronic obstructive pulmonary disease (COPD) in terms of health care use and costs strongly depends on the distribution of disease severity. For the Netherlands, the distribution of diagnosed COPD was estimated by classifying all patients with a physician diagnosis of COPD from two different sources of general practitioners (GP)-data into mild (27%), moderate (55%), severe (15%) or very severe COPD (3%) based on their post-bronchodilator FEV1% predicted, according to the GOLD-guidelines. This distribution will most likely shift to the less severe stages when under-reporting and under-diagnosis are reduced.

Effectiveness of an education programme by a general practice assistant for asthma and COPD patients: results from a randomised controlled trial.

In this study a randomised controlled trial was carried out to investigate the effectiveness of an education programme for patients with asthma or chronic obstructive pulmonary disease (COPD). All asthma and COPD patients using medication and experiencing pulmonary symptoms were randomly assigned to the intervention (n=139) or usual-care group (n=137). The intervention consisted of taylor-made education conducted by a general practice assistant and focussing on a patients' technical skills and coping with the disease. Measurements took place at baseline, and after 1 and 2 years of follow-up. After 1 and 2 years the inhalation technique was significantly better in the intervention group compared to the usual-care group. No significant differences were observed regarding disease symptoms, health related quality of life, compliance, smoking cessation, self-efficacy, and coping. The results only support the implementation of the intervention regarding the technical skills (inhalation technique). However, given the importance of improvement of patients' coping and the need for more efficient care, we recommend further exploration of the possibilities of a more structured and intensive education programme.

Mastery and perceived autonomy support are correlates of Dutch diabetes patients' self-management and quality of life.

OBJECTIVE: The aim of this study was to assess the associations between type 2 diabetes patients' mastery and perceived autonomy support and their self-management skills and health-related quality of life (HRQOL). METHODS: A cross-sectional questionnaire survey was conducted among 3352 patients with type 2 diabetes. Key variables were assessed with validated questionnaires. RESULTS: Patients' mastery and perceived autonomy support correlated positively with their self-management skills (r=0.34, p<0.001; r=0.37, p<0.001) and HRQOL (r=0.37, p<0.001; r=0.15, p<0.001). In the linear regression analysis, mastery and perceived autonomy support were positive correlates of self-management (ß=0.23; p<0.001; ß=0.25; p<0.001). Patients with more physical or psychological complications had significantly lower scores on mastery, perceived autonomy support, self-management and HRQOL. CONCLUSION: Our results indicate the importance of mastery in relation to diabetes patients' perceived autonomy support, self-management skills and HRQOL. PRACTICE IMPLICATIONS: Since a greater sense of mastery is likely to increase patients' autonomous motivation to cope with their disease, interventions can aim to influence patients' motivational regulation. In addition, we confirmed the need for autonomy support to improve patients' self-management skills. Professionals can be trained to be autonomy-supportive, which relates to person-centered approaches such as motivational interviewing (MI).

The effectiveness of a perinatal education programme on smoking, infant care, and psychosocial health for ethnic Turkish women.

OBJECTIVE: antenatal programmes might be effective in preventing unhealthy lifestyles, poor maternal infant care practices, and poor psychosocial health in ethnic minority women, but there are few evidence-based interventions. For this reason an antenatal education programme, called 'Happy Mothers, Happy Babies' (HMHB) was systematically designed for ethnic Turkish women in the Netherlands. DESIGN: in a non-randomised trial Turkish women attending HMHB (HMHB group) were compared with those receiving care as usual (control group). SETTING: Parent-Child Centres, which provide integrated maternity and infant care. PARTICIPANTS: in both the HMHB (n=119) and the control (n=120) group, questionnaires were administered by ethnic Turkish interviewers at three (T0) and eight (T1) months of pregnancy, and two (T2) and six (T3) months after birth. FINDINGS: at baseline, women in the HMHB group had significantly lower educational levels, were less frequently in paid employment, had less knowledge about smoking, and showed more often mildly depressive symptoms. Adjusted analyses showed that HMHB was effective in improving knowledge about smoking (OR=2.73; 95% CI 1.40, 5.31), intention to engage in prevention of sudden infant death syndrome (SIDS) (OR=8.08; 95% CI 3.34, 19.56) and short-term SIDS prevention behaviour (OR=2.22; 95% CI=1.18, 4.19). However, no intervention effect was found for smoking during pregnancy, SIDS prevention behaviour on the long term, soothing behaviour, serious depressive symptoms, and parent-child attachment. KEY CONCLUSIONS: although we could not demonstrate intervention effects on all outcome measures, the HMHB programme appears to be highly welcome, and reaches an underserved minority group at increased risk for adverse perinatal outcomes. IMPLICATIONS FOR PRACTICE: the HMHB programme is one of the first systematically developed antenatal interventions for ethnic minority women. The programme can be used as a basic antenatal programme, and as a screening opportunity for women who smoke or show serious depressive symptoms.

Disease control in general practice patients with asthma.

OBJECTIVES: To examine asthma control in conjunction with medication use in asthma patients from general practice. To determine features of patients with inadequately controlled asthma. METHODS: A cross-sectional study was performed among 661 adult asthma patients recruited from general practice. Disease control was defined by: (1) respiratory symptoms; (2) forced expiratory volume in 1s (FEV(1))% predicted; (3) PEF variability; and (4) the use of beta2-agonists. Medical treatment was categorised according to the step-care therapy rules following the 1997 guideline of the Dutch College of General Practitioners (DDGP). RESULTS: Of the 661 asthma patients studied, 262 (40%) had a good disease control, 84 (13%) a mildly reduced, 235 (36%) a moderately reduced, and 80 (12%) had a poor disease control. Of the 399 patients (60%) inadequately controlled, in 292 patients (44%) adequate control might be achieved by changing treatment, in 99 patients (15%) adequate control might not completely be achieved by changing treatment, and 8 (1%) were already maximally treated. Compared to patients with a good disease control, patients inadequately controlled were usually older, less educated, younger at onset of pulmonary complaints, and in addition had more severe dyspnea and poorer health-related quality of life (HRQoL). CONCLUSION: Using our criteria, a substantial proportion of asthma patients primarily treated in general practice is not adequately controlled. Assessing patients' disease control together with the level of medical treatment may help to gain insight into the effectiveness of current disease management.

Gender differences in health-related quality of life among asthma patients.

OBJECTIVE: To identify and explain differences between men and women with asthma regarding health-related quality of life (HRQoL). METHODS: A cross-sectional study was performed among 967 asthma patients recruited from general practice. Data were collected by means of a pulmonary function assessment, a face-to-face interview, and a written questionnaire. RESULTS: Women with asthma reported lower scores on HRQoL in the age groups 16-34 and 56-75 years but not in the age group 35-55 years. In all age groups, women reported more severe dyspnea but had higher levels of pulmonary function. The poorer HRQoL reported by women could be explained by a more severe dyspnea and a higher level of medication use in women. CONCLUSIONS: The finding that women with asthma aged 16-34 and 56-75 years report poorer HRQoL than men is not due to a more severe disease state in terms of pulmonary obstruction but does seem to be related to a more severe subjective disease state in women than in men.