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Among ethnic minority groups in Europe, blood pressure (BP) control is often suboptimal. We aimed to identify determinants of suboptimal BP control in a multi-ethnic population. We analyzed cross-sectional data of the Healthy Life in an Urban Setting (HELIUS) study, including 3571 participants aged 18-70 with prescribed antihypertensive medication, of various ethnic backgrounds (500 Dutch, 1052 African Surinamese, 656 South-Asian Surinamese, 637 Ghanaian, 433 Turkish, and 293 Moroccan) living in Amsterdam, the Netherlands. 53.3% of the population had suboptimal BP control, defined as BP ≥140/90 mmHg despite prescribed antihypertensives. Using multivariate logistic regression analysis, female sex (OR 0.50, 95%CI 0.43-0.59), being married (0.83, 0.72-0.96), smoking (0.78, 0.65-0.94), alcohol intake (0.80, 0.66-0.96), obesity (1.67, 1.35-2.06), cardiovascular disease (CVD) history (0.56, 0.46-0.68), non-adherence to antihypertensives (1.26, 1.00-1.58), and family history of hypertension (1.19, 1.02-1.38) were identified to be independently associated with suboptimal BP control in the total population. In the ethnic-stratified analysis, factors associated with better BP control were female sex (all ethnic groups), smoking (Turks), and CVD history (Dutch, South-Asian Surinamese, and African Surinamese), whereas factors associated with suboptimal BP control were older age (Turks), obesity (Dutch, African Surinamese, Ghanaian, and Turks), and non-adherence to antihypertensives (Dutch). In conclusion, our analysis identifies several key determinants that are independently associated with suboptimal BP control in a multi-ethnic population, with some important variations between ethnic groups. Targeting these determinants may help to improve BP control., (© 2021 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Background: Automobile car repair requires intensive activities. Several studies have described different work characteristics of automobile artisans' work. However, the effects of physical work conditions (PWC) on worker health outcomes are largely unknown., Objective: This study aimed to explore which of the PWC have high negative impact on worker's health outcomes, and whether the same conditions affected both illnesses and injuries., Methods: A cross-sectional design and a multistage method were used to randomly select 632 workers. A structured self-reported questionnaire was used to obtain information on dependent variables (illness/injuries) and independent variables (PWC). The results were analysed using the chi-square test and logistic regression analysis, while controlling for occupation., Results: Workers who manually lifted heavy items or orally sucked petrol regularly reported illnesses and injuries. Long work experience and long working hours were significantly associated with illness, whereas prolonged standing was significantly related to injuries. Contrary to our initial expectation, workers who regularly worked at 2 m or higher above the ground level tended to report less illness and injury., Conclusions: PWCs were more significantly related to work-related illnesses than injuries. Therefore, interventional programs for automobile artisans should focus on the PWC that increase worker vulnerability to work-related illnesses.

Even though informal workers in developing countries have the most hazardous jobs, there is a sheer neglect for the treatment of their occupational health problems (OHP) in practice and by policies. This qualitative study explored how informal automobile artisans from Nigeria sought care for their OHP. It focused on their choice between orthodox and traditional medicine, between self-care and professional care, and between private and public health-care providers. 43 informal automobile artisans were purposively interviewed. The treatment sought depended on the type, the severity, and the perceived cause of the OHP. The distinction between rational and non-rational explanations of the causes of OHP usually determined the treatment endpoint. The financial means of the artisans and the cost of different treatments were also important factors. The study concluded that in order to develop safer working conditions in the sector, policy makers and artisanal associations should be aware of the considerations that informed the artisans' choices on how to treat OHP ., (Copyright © 2020. Published by Elsevier Ltd.)

Background: EHealth solutions are envisaged to contribute significantly to a sustainable healthcare system. Between 2016 and 2018 the eight Dutch University Medical Centers (UMCs) received Dutch Government's funding to undertake research into the clinical impact, cost-effectiveness and ethical consideration of eHealth. The UMCs collaborated within the consortium 'Citrien fund (CF) program eHealth' and found that, in order to increase the value of eHealth in routine care, a national vision on eHealth developed by the UMCs was warranted., Objective: The objective of this paper was to elucidate the process of the 'Netherlands Federation of UMCs (NFU) eHealth vision' development by describing the results of the performed concept mapping study., Methods: A concept mapping approach was followed. Sixteen members of the steering committee of the CF program eHealth were selected as participants. First, each member selected relevant objectives from the eight individual UMC eHealth vision documents, which was to be incorporated into the overall 'NFU eHealth vision'. Second, objectives were rated for necessary to be included in the vision document and the need to achieve the objective within five years. Thereafter, the objectives were sorted into self-created thematic clusters. And finally, the concept map with the thematic clusters and corresponding objectives was discussed with the steering committee to determine the major themes of the 'NFU eHealth vision'., Results: 38 objectives were determined by the steering committee and grouped into the following 6 thematic clusters on the concept map: 'patient participation and empowerment'; 'infrastructure'; 'education and research'; 'multi-disciplinary care'; 'organisational restructuring'; and 'essential conditions for development of eHealth solutions'. After discussing the concept mapping results with the steering committee, the following five major themes were determined to be addressed in the vision document: 'patient and caregiver'; 'research and innovation'; 'education'; 'organisation of care'; and 'essential conditions for development of eHealth solutions'., Conclusion: Concept mapping was successfully applied to conceptualise the different values and opinions of the eight Dutch UMCs in order to develop a national vision on eHealth. This vision document will give direction to the development, evaluation and implementation of eHealth in the eight Dutch UMCs and their adherent healthcare providers., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: In Western countries, hypertension and hypertension-related complication are more common in ethnic minority groups of African descent than in indigenous populations. Addressing ethnic minority patients' perceptions of hypertension and its treatment through the use of cultural appropriate hypertension education (CAHE) increases adherence to medication and lifestyle recommendations. Given these effects, it seems warranted to develop a training program on how to deliver this type of patient education for Primary Care Nurse Practitioners (PCNPs)., Objective: Development and evaluation of a training program for PCNPs aimed at providing culturally appropriate hypertension patient education., Design: Prospective cohort study evaluating attitude and intended behavioral changes., Participants: Both experienced PCNPs and PCNPs in training participated in this study., Main Measures: The effects of the CAHE-training were measured by 3 different questionnaires on 1) the satisfaction with the training program, 2) the attitude towards culturally appropriate care, and 3) the commitment to change., Results: The CAHE-training program consists of 10 different components divided over two 4-hour sessions and was taught to 87 participating PCNPs. The program utilizes constructivist-learning principles and educational evidence on adult learning. The content of the program is based on the knowledge obtained from our previous studies on culturally appropriate care. The mean satisfaction-score was 7.5 (1-10 scale), with the role-play exercise with patient-actors scoring highest (8.2). We observed non-significant but positive changes in attitude. PCNPs who reported on the implementation of their intended behavior change showed significant attitude changes after three months., Conclusion: We demonstrated that our evidence based training program for PCNPs resulted in a positive learning experience with adequate intended behavioral changes in practice. Unfortunately, response rates were too low to demonstrate persistent changes in attitude.

Background: The INDEPTH Training & Research Centres of Excellence (INTREC) collaboration developed a training programme to strengthen social determinants of health (SDH) research in low- and middle-income countries (LMICs). It was piloted among health- and demographic researchers from 9 countries in Africa and Asia. The programme followed a blended learning approach and was split into three consecutive teaching blocks over a 12-month period: 1) an online course of 7 video lectures and assignments on the theory of SDH research; 2) a 2-week qualitative and quantitative methods workshop; and 3) a 1-week data analysis workshop. This report aims to summarise the student evaluations of the pilot and to suggest key lessons for future approaches to strengthen SDH research capacity in LMICs., Methods: Semi-structured interviews and questionnaires with 24 students from 9 countries in Africa and Asia were used to evaluate each teaching block. Information was collected about the students' motivation and interest in studying SDH, any challenges they faced during the consecutive teaching blocks, and suggestions they had for future courses on SDH., Results: Of the 24 students who began the programme, 13 (54%) completed all training activities. The students recognised the need for such a course and its potential to improve their skills as health researchers. The main challenges with the online course were time management, prior knowledge and skills required to participate in the course, and the need to get feedback from teaching staff throughout the learning process. All students found the face-to-face workshops to be of high quality and value for their work, because they offered an opportunity to clarify SDH concepts taught during the online course and to gain practical research skills. After the final teaching block, students felt they had improved their data analysis skills and were better able to develop research proposals, scientific manuscripts, and policy briefs., Conclusions: The INTREC programme has trained a promising cadre of health researchers who live and work in LMICs, which is an essential component of efforts to identify and reduce national and local level health inequities. Time management and technological issues were the greatest challenges, which can inform future attempts to strengthen research capacity on SDH.

Introduction: Evidence on successful quality improvement (QI) in health care requires quantitative information from randomized clinical trials (RCTs) on the effectiveness of QI interventions, but also qualitative information from professionals to understand factors influencing QI implementation., Objective: Using a structured qualitative approach, concept mapping, this study determines factors identified by cardiac rehabilitation (CR) teams on what is needed to successfully implement a web-based audit and feedback (A&F) intervention with outreach visits to improve the quality of CR care., Methods: Participants included 49 CR professionals from 18 Dutch CR centres who had worked with the A&F system during a RCT. In three focus group sessions participants formulated statements on factors needed to implement QI successfully. Subsequently, participants rated all statements for importance and feasibility and grouped them thematically. Multi dimensional scaling was used to produce a final concept map., Results: Forty-two unique statements were formulated and grouped into five thematic clusters in the concept map. The cluster with the highest importance was QI team commitment, followed by organisational readiness, presence of an adequate A&F system, access to an external quality assessor, and future use and functionalities of the A&F system., Conclusion: Concept mapping appeared efficient and useful to understand contextual factors influencing QI implementation as perceived by healthcare teams. While presence of a web-based A&F system and external quality assessor were seen as instrumental for gaining insight into performance and formulating QI actions, QI team commitment and organisational readiness were perceived as essential to actually implement and carry out these actions. These two sociotechnical factors should be taken into account when implementing and evaluating the success of QI implementations in future research., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Background: Hypertension is a highly prevalent risk factor for cardiovascular diseases in sub-Saharan Africa (SSA) that can be modified through timely and long-term treatment in primary care., Objective: We explored perspectives of primary care staff and health insurance managers on enablers and barriers for implementing high-quality hypertension care, in the context of a community-based health insurance programme in rural Nigeria., Design: Qualitative study using semi-structured individual interviews with primary care staff (n = 11) and health insurance managers (n=4). Data were analysed using standard qualitative techniques., Results: Both stakeholder groups perceived health insurance as an important facilitator for implementing high-quality hypertension care because it covered costs of care for patients and provided essential resources and incentives to clinics: guidelines, staff training, medications, and diagnostic equipment. Perceived inhibitors included the following: high staff workload; administrative challenges at facilities; discordance between healthcare provider and insurer on how health insurance and provider payment methods work; and insufficient fit between some guideline recommendations and tools for patient education and characteristics/needs of the local patient population. Perceived strategies to address inhibitors included the following: task-shifting; adequate provider payment benchmarking; good provider-insurer relationships; automated administration systems; and tailoring guidelines/patient education., Conclusions: By providing insights into perspectives of primary care providers and health insurance managers, this study offers information on potential strategies for implementing high-quality hypertension care for insured patients in SSA.

Background: In Western countries, better knowledge about patient-related determinants of treatment adherence (medication and lifestyle) is needed to improve treatment adherence and outcomes among hypertensive ethnic minority patients of African descent., Objective: To identify patient-related determinants of adherence to lifestyle and medication recommendations among hypertensive African Surinamese and Ghanaian patients with suboptimal treatment results (SBP≥140) living in the Netherlands and how culturally appropriate hypertension education (CAHE) influenced those determinants., Methods: This study analysed data of 139 patients who participated in the CAHE trial. Univariate logistic regression analysis was used to measure the association between patient-related determinants (medication self-efficacy, beliefs about medication and hypertension, social support, and satisfaction with care) and treatment adherence. We also tested whether CAHE influenced the determinants., Results: Medication self-efficacy and social support were associated with medication adherence at baseline. At six months, more medication self-efficacy and fewer concerns about medication use were associated with improved medication adherence. Self-efficacy was also associated with adherence to lifestyle recommendations at baseline. CAHE influenced patients' illness perceptions by creating more understanding of hypertension, its chronic character, and more concerns about the associated risks., Conclusion: In this high-risk population, health care providers can support medication adherence by paying attention to patients' medication self-efficacy, the concerns they may have about medication use and patients' perceptions on hypertension. The CAHE intervention improved patients' perception on hypertension.

Background: Universal health care coverage has been identified as a promising strategy for improving hypertension treatment and control rates in sub Saharan Africa (SSA). Yet, even when quality care is accessible, poor adherence can compromise treatment outcomes. To provide information for adherence support interventions, this study explored what low income patients who received hypertension care in the context of a community based health insurance program in Nigeria perceive as inhibitors and facilitators for adhering to pharmacotherapy and healthy behaviors., Methods: We conducted a qualitative interview study with 40 insured hypertensive patients who had received hypertension care for > 1 year in a rural primary care hospital in Kwara state, Nigeria. Supported by MAXQDA software, interview transcripts were inductively coded. Codes were then grouped into concepts and thematic categories, leading to matrices for inhibitors and facilitators of treatment adherence., Results: Important patient-identified facilitators of medication adherence included: affordability of care (through health insurance); trust in orthodox "western" medicines; trust in Doctor; dreaded dangers of hypertension; and use of prayer to support efficacy of pills. Inhibitors of medication adherence included: inconvenient clinic operating hours; long waiting times; under-dispensing of prescriptions; side-effects of pills; faith motivated changes of medication regimen; herbal supplementation/substitution of pills; and ignorance that regular use is needed. Local practices and norms were identified as important inhibitors to the uptake of healthier behaviors (e.g. use of salt for food preservation; negative cultural images associated with decreased body size and physical activity). Important factors facilitating such behaviors were the awareness that salt substitutes and products for composing healthier meals were cheaply available at local markets and that exercise could be integrated in people's daily activities (e.g. farming, yam pounding, and household chores)., Conclusions: With a better understanding of patient perceived inhibitors and facilitators of adherence to hypertension treatment, this study provides information for patient education and health system level interventions that can be designed to improve compliance., Trial Registration: ISRCTN47894401 .

Objectives: To evaluate the effect of a practice-based, culturally appropriate patient education intervention on blood pressure (BP) and treatment adherence among patients of African origin with uncontrolled hypertension., Methods: Cluster randomised trial involving four Dutch primary care centres and 146 patients (intervention n=75, control n=71), who met the following inclusion criteria: self-identified Surinamese or Ghanaian; ≥ 20 years; treated for hypertension; SBP ≥ 140 mmHg. All patients received usual hypertension care. The intervention-group was also offered three nurse-led, culturally appropriate hypertension education sessions. BP was assessed with Omron 705-IT and treatment adherence with lifestyle- and medication adherence scales., Results: 139 patients (95%) completed the study (intervention n=71, control n=68). Baseline characteristics were largely similar for both groups. At six months, we observed a SBP reduction of ≥ 10 mmHg -primary outcome- in 48% of the intervention group and 43% of the control group. When adjusted for pre-specified covariates age, sex, hypertension duration, education, baseline measurement and clustering effect, the between-group difference was not significant (OR; 0.42; 95% CI: 0.11 to 1.54; P=0.19). At six months, the mean SBP/DBD had dropped by 10/5.7 (SD 14.3/9.2)mmHg in the intervention group and by 6.3/1.7 (SD 13.4/8.6)mmHg in the control group. After adjustment, between-group differences in SBP and DBP reduction were -1.69 mmHg (95% CI: -6.01 to 2.62, P=0.44) and -3.01 mmHg (-5.73 to -0.30, P=0.03) in favour of the intervention group. Mean scores for adherence to lifestyle recommendations increased in the intervention group, but decreased in the control group. Mean medication adherence scores improved slightly in both groups. After adjustment, the between-group difference for adherence to lifestyle recommendations was 0.34 (0.12 to 0.55; P=0.003). For medication adherence it was -0.09 (-0.65 to 0.46; P=0.74)., Conclusion: This intervention led to significant improvements in DBP and adherence to lifestyle recommendations, supporting the need for culturally appropriate hypertension care., Trial Registration: Controlled-Trials.com ISRCTN35675524.

Purpose: The purpose of this study was to explore the sociocultural factors affecting the dietary behaviour of Dutch Surinamese patients with type 2 diabetes., Methods: In this qualitative study, 32 Surinamese primary care patients with type 2 diabetes mellitus participated in semi-structured interviews (16 African Surinamese and 16 Hindustani Surinamese). Interviews were recorded and transcripts were analysed and coded into themes using principles of grounded theory and MAXQDA software., Results: Surinamese food was eaten regularly by all respondents. Most participants were aware of the need to change their diet but reported difficulty with changing their dietary behaviour to meet dietary guidelines. Many perceived these guidelines to be based on Dutch eating habits, making it difficult to reconcile them with Surinamese cooking and eating practices. Firstly, respondents indicated that they did not choose foods based on their nutritional qualities. Instead, choices were based on Surinamese beliefs regarding 'good' (e.g., bitter vegetables) or 'bad' (e.g., spicy dishes) foods for diabetes. Secondly, respondents often perceived recommendations such as eating at fixed times as interfering with traditional values, for example hospitality. Above all, the maintenance of Surinamese cooking and eating practices was regarded as extremely important since the respondents perceived these to be a core element of their identity as Surinamese., Conclusions: For Surinamese diabetes patients, cooking and eating practices are related to deeply rooted cultural beliefs and values. The wish to maintain one's Surinamese identity may pose difficulty for patients' adherence to dietary guidelines, as these are perceived as being based on 'Dutch' habits. This suggests that immigrants with a long duration of residence in the host country like the Surinamese, who are seen as well integrated might benefit from culturally sensitive diabetes education that is adapted at surface and deep structure.

Background: Diabetes and related complications are common among ethnic minority groups. Community-based social support interventions are considered promising for improving diabetes self-management. To access such interventions, patients need to disclose their diabetes to others. Research on the disclosure of diabetes in ethnic minority groups is limited. The aim of our study was to explore why diabetes patients from ethnic minority populations either share or do not share their condition with people in their wider social networks., Methods: We conducted a qualitative study using semi-structured interviews with 32 Surinamese patients who were being treated for type 2 diabetes by general practitioners in Amsterdam, the Netherlands., Results: Most patients disclosed their diabetes only to very close family members. The main factor inhibiting disclosure to people outside this group was the Surinamese cultural custom that talking about disease is taboo, as it may lead to shame, gossip, and social disgrace for the patient and their family. Nevertheless, some patients disclosed their diabetes to people outside their close family circles. Factors motivating this decision were mostly related to a need for facilities or support for diabetes self-management., Conclusions: Cultural customs inhibited Surinamese patients in disclosing their diabetes to people outside their very close family circles. This may influence their readiness to participate in community-based diabetes self-management programmes that involve other groups. What these findings highlight is that public health researchers and initiatives must identify and work with factors that influence the disclosure of diabetes if they are to develop community-based diabetes self-management interventions for ethnic minority populations.

Background: Chronic diseases are a leading contributor to work disability and job loss in Europe. Recent EU policies aim to improve job retention among chronically ill employees. Disability and occupational health researchers argue that this requires a coordinated and pro-active approach at the workplace by occupational health professionals, line managers (LMs) and human resource managers (HRM). Little is known about the perspectives of LMs an HRM on what is needed to facilitate job retention among chronically ill employees. The aim of this qualitative study was to explore and compare the perspectives of Dutch LMs and HRM on this issue., Methods: Concept mapping methodology was used to elicit and map statements (ideas) from 10 LMs and 17 HRM about what is needed to ensure continued employment for chronically ill employees. Study participants were recruited through a higher education and an occupational health services organization., Results: Participants generated 35 statements. Each group (LMs and HRM) sorted these statements into six thematic clusters. LMs and HRM identified four similar clusters: LMs and HRM must be knowledgeable about the impact of chronic disease on the employee; employees must accept responsibility for work retention; work adaptations must be implemented; and clear company policy. Thematic clusters identified only by LMs were: good manager/employee cooperation and knowledge transfer within the company. Unique clusters identified by HRM were: company culture and organizational support., Conclusions: There were both similarities and differences between the views of LMs and HRM on what may facilitate job retention for chronically ill employees. LMs perceived manager/employee cooperation as the most important mechanism for enabling continued employment for these employees. HRM perceived organizational policy and culture as the most important mechanism. The findings provide information about topics that occupational health researchers and planners should address in developing job retention programs for chronically ill workers.

Objective: to identify barriers and enablers influencing the implementation of an intervention to stimulate culturally appropriate hypertension education (CAHE) among health care providers in primary care., Methods: the intervention was piloted in three Dutch health centers. It consists of a toolkit for CAHE, training, and feedback meetings for hypertension educators. Data were collected from 16 hypertension educators (nurse practitioners and general practice assistants) during feedback meetings and analyzed using qualitative content analysis., Results: perceived barriers to the implementation of the intervention fell into three main categories: political context (health care system financing); organizational factors (ongoing organizational changes, work environment, time constraints and staffing) and care provider-related factors (routines, attitudes, computer and educational skills, and cultural background). Few barriers were specifically related to the delivery of CAHE (e.g. resistance to registering ethnicity). Enabling strategies addressing these barriers consisted of reorganizing practice procedures, team coordination, and providing reminders and additional instructions to hypertension educators., Conclusion and Practice Implications: the adoption of a tool for CAHE by care providers can be accomplished if barriers are identified and addressed. The majority of these barriers are commonly associated with the implementation of health care innovations in general and do not indicate resistance to providing culturally appropriate care., (2010 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To investigate the effect of an educational and feedback intervention to enhance consideration of sex differences in clinical guideline development., Design: Preintervention and postintervention questionnaires in intervention and control groups. Content analysis of intervention guidelines and former versions., Setting: Guideline consultants, working-group members and guideline documents of two Dutch guideline-developing organisations., Main Outcome Measures: Attitudes of guideline developers concerning the importance of considering sex differences and the number of the sex-specific statements in the contents of guideline documents., Results: The attitude of the intervention group did not change significantly relative to the control group. Consideration of sex-related factors within the guidelines increased relative to available previous versions., Conclusion: Education and expert feedback may increase consideration of sex differences in guidelines. Further efforts are needed to implement and test these interventions.

Introduction: While Human Resource Managers (HRM) and line managers could play a significant role in the prevention of job-related problems and in promotion of early job-continuation, it is not clear wether the chronically ill workers are recognized as a group. Unlike some other groups, distinguished by gender, age or ethnicity, those with chronic illness are less distinct and may not be included in diversity management programs. The aim of this research is to address theory and evidence in literature about the topic, as well as to inquire whether chronic illness of the employees is 'visible' in practice., Methods: For desk research, we used a systematic search strategy involving medical, statistical, management, and social science databases (Web of Science, MedLine, Pub Med, Psych Info, etc.). Research results are based on case studies conducted with the managers and HRM of government and commercial organizations between March 2007 and October 2008 and between October 2008 and April 2009. These case studies were based on open interviews and focus group sessions (for human resource departments) which were consequently analyzed using thematical analysis. For group sessions, we used concept mapping to collect information from two groups of HRM professionals and managers. Secondary analysis included thematic and content analysis of 'best practice' organizations carried out by the Dutch organization Gatekeeper., Conclusions: We have discovered that the chronically ill employees are largely invisible to HRM practitioners, line managers who do not always have the right instruments for implementation of the European or national frameworks. Most practitioners are unaware of the impact of chronic illness in their organizations and in employees work life.

Background: To improve hypertension care for ethnic minority patients of African descent in the Netherlands, we developed a provider intervention to facilitate the delivery of culturally appropriate hypertension education. This pilot study evaluates how the intervention affected the attitudes and perceived competence of hypertension care providers with regard to culturally appropriate care., Methods: Pre- and post-intervention questionnaires were used to measure the attitudes, experienced barriers, and self-reported behaviour of healthcare providers with regard to culturally appropriate cardiovascular and general care at three intervention sites (N = 47) and three control sites (N = 35)., Results: Forty-nine participants (60%) completed questionnaires at baseline (T0) and nine months later (T1). At T1, healthcare providers who received the intervention found it more important to consider the patient's culture when delivering care than healthcare providers who did not receive the intervention (p = 0.030). The intervention did not influence experienced barriers and self-reported behaviour with regard to culturally appropriate care delivery., Conclusion: There is preliminary evidence that the intervention can increase the acceptance of a culturally appropriate approach to hypertension care among hypertension educators in routine primary care.

Regular physical activity (PA) can reduce blood pressure, but hypertensive patients in ethnic minority populations are often inactive. The objective of this qualitative study was to explore inhibitors and enablers of PA from the perspective of hypertensive Ghanaian, African-Surinamese and White-Dutch patients in Amsterdam, The Netherlands. In-depth individual interviews with 46 patients were analysed for thematic content, using Maxqda software. All three groups mentioned their hypertension, the presence of other health conditions, lack of priority, lack of social support, limited financial resources or access to PA facilities as inhibitors for maintaining or increasing their level of PA. Common enablers included health-related incentives, support from physicians or family and having physically demanding work. Specific inhibitors only mentioned by Ghanaians and Surinamese included inexperience with recommended 'Western' activities (cycling), little access to their habitual forms of PA, cultural preferences for large body sizes, unfamiliarity with the host country and the pressure of social demands from the Dutch society and their own communities. Specific enablers for Ghanaians and Surinamese included access to community or church-based support groups. These patient-identified inhibitors and enablers can be a useful framework for promoting PA in hypertensive patients, particularly from immigrant groups. Physicians may build their advice on the identified enablers and tackle the inhibitors.

Background: Individuals of African descent living in western countries have increased rates of hypertension and hypertension-related complications. Poor adherence to hypertension treatment (medication and lifestyle changes) has been identified as one of the most important modifiable causes for the observed disparities in hypertension related complications, with patient education being recommended to improve adherence. Despite evidence that culturally-appropriate patient education may improve the overall quality of care for ethnic minority patients, few studies have focused on how hypertensive individuals of African descent respond to this approach. This paper describes the design of a study that compares the effectiveness of culturally-appropriate hypertension education with that of the standard approach among Surinamese and Ghanaian hypertensive patients with an elevated blood pressure in Dutch primary care practices., Methods/design: A cluster-randomized controlled trial will be conducted in four primary care practices in Amsterdam, all offering hypertension care according to Dutch clinical guidelines. After randomization, patients in the usual care sites (n = 2) will receive standard hypertension education. Patients in the intervention sites (n = 2) will receive three culturally-appropriate hypertension education sessions, culturally-specific educational materials and targeted lifestyle support. The primary outcome will be the proportion of patients with a reduction in systolic blood pressure >or= 10 mmHg at eight months after the start of the trial. The secondary outcomes will be the proportion of patients with self-reported adherence to (i) medication and (ii) lifestyle recommendations at eight months after the start of the trial. The study will enrol 148 patients (74 per condition, 37 per site). Eligibility criteria for patients of either sex will be: current diagnosis of hypertension, self-identified Afro-Surinamese or Ghanaian, >or= 20 years, and baseline blood pressure >or= 140/90 mmHg. Primary and secondary outcomes will be measured at baseline and at 3 1/2, 6 1/2, and eight months. Other measurements will be performed at baseline and eight months., Discussion: The findings will provide new knowledge on how to improve blood pressure control and patient adherence in ethnic minority persons with a high risk of negative hypertension-related health outcomes., Trial Registration: ISRCTN35675524.

Background: Many recently published clinical studies report sex-specific data. This information may help to improve clinical decision-making for both sexes, but it is not easily accessible in MEDLINE. The aim of this project was to develop and validate a search filter that would facilitate the retrieval of studies reporting high quality sex-specific data on clinical questions., Methods: A filter was developed by screening titles, abstracts and Medical Subject Headings (MeSH) in a set of 80 high quality and relevant papers, 75 of which were identified through a review of clinical guidelines and five through other means. The filter, for use on OvidSP, consists of nine command lines for searching free text words in the title, abstract and MeSH of a paper. It was able to identify 74/80 (92.5%) of the articles from which it was derived. The filter was evaluated in a set of 622 recently published original studies on Alzheimer's disease and on asthma. It was validated against a reference of 98 studies from this set, which provided high quality, clinically relevant, sex-specific evidence. Recall and precision were used as performance measures., Results: The filter demonstrated 81/98 (83%) recall and 81/125 (65%) precision in retrieving relevant articles on Alzheimer's disease and on asthma. In comparison, only 30/98 (31%) recall would have been achieved if sex-specific MeSH terms only had been used., Conclusion: This sex-specific search filter performs well in retrieving relevant papers, while its precision rate is good. It performs better than a search with sex-specific MeSH. The filter can be useful to anyone seeking sex-specific clinical evidence (e.g., guideline organizations, researchers, medical educators, clinicians).

Background: Dutch guideline-developing organizations do not focus systematically on differences between men and women when developing guidelines, even though there is increasing evidence that being male or female may have an effect on health and health outcomes. In collaboration with two prominent Dutch guideline-developing organizations, we designed a training course to encourage systematic attention to sex differences in guideline development procedures., Methods: The course is targeted towards guideline developers. Its aims are to improve awareness concerning the relevance of considering sex differences in the guideline development process, as well as the competence and skills necessary for putting this into practice. The design and teaching methods of the course are based on adult learning styles and principles of changing provider behaviour. It was adjusted to the working methods of guideline organizations. The course was taught to, and evaluated by, a group of staff members from two guideline organizations in the Netherlands., Results: The course consists of five modules, each of which corresponds to a key step in the guideline development process. The participants rated the training course positively on content, programme, and trainers. Their written comments suggest that the course met its objectives., Conclusion: The training course is the first to address sex differences in guideline development. Results from the pilot test suggest that the course achieved its objectives. Because its modules and teaching methods of the course are widely transferable, the course could be useful for many organizations that are involved in developing guidelines. Follow-up studies are needed to assess the long-term effect of the course on the actions of guideline developers and its utility in other settings.

Background: Several measures have been implemented at international level to ensure that there is a greater focus on sex differences in health research. This study evaluates the effect of various formal incentives that were introduced by a Dutch financer of health research to encourage applicants to include sex differences in research proposals., Methods: We sampled 213 health research proposals submitted in 2003 to the programmes Prevention (N = 104) and Innovation (N = 109) by the Netherlands Organization for Health Research and Development (ZonMw). These proposals were analysed and categorized with regard to the expressed intention to take sex differences into consideration. Furthermore, those proposals in which such intention was absent were appraised by researchers to determine whether an intention of this kind would have been relevant., Results: We found that 23 % of proposals submitted to Prevention (incentive: programme specific instructions) and 10% of those submitted to Innovation (general set of guidelines) took account of sex differences (difference 13%; 95% CI: 3.1-22.9). Conversely, 66% of the research proposals in Prevention, and 20% in Innovation, failed to take sex differences into consideration, even though this might well have been relevant., Conclusion: There is still insufficient incentive for those submitting research proposals to ZonMw to systematically incorporate sex differences when drafting such documents. The provisions in ZonMw's policy need to be amended and better monitored. For this, we formulated some recommendations.

Background: Funding organisations and research ethics committees (RECs) should play a part in strengthening attention to gender equality in clinical research. In the research policy of European Union (EU), funding measures have been taken to realise this, but such measures are lacking in the EU policy regarding RECs., Objective: To explore how RECs in Austria, Germany, Ireland, The Netherlands and Sweden deal with gender equality issues by asking two questions: (1) Do existing procedures promote representation of women and gender expertise in the committee? (2) How are sex and gender issues dealt with in protocol evaluation?, Methods: Two RECs were selected from each country. Data were obtained through interviews with key informants and content analysis of relevant documents (regulations, guidelines and review tools in use in 2003)., Results: All countries have rules (mostly informal) to ensure the presence of women on RECs; gender expertise is not required. Drug study protocols are carefully evaluated, sometimes on a formal basis, as regards the inclusion of women of childbearing age. The reason for excluding either one of the sexes or including specific groups of women or making a gender-specific risk-benefit analysis are investigated by some RECs. Such measures are, however, neither defined in the regulations nor integrated in review tools., Conclusions: The RECs investigated in five European member states are found to pay limited attention to gender equality in their working methods and, in particular in protocol evaluation. Policy and regulations of EU are needed to strengthen attention to gender equality in the work of RECs.

Background: Clinical practice guidelines describe optimal strategies for disease prevention, diagnosis, or treatment. Increasing evidence indicates that sex-related factors may have an impact on these strategies. We examined the way in which two Dutch guideline organizations address evidence on sex factors in their guideline development methodologies. We then determined whether attention to these factors could be improved and, if so, how this could be done., Methods: We selected seven recent guidelines on four conditions: hypertension, depression, osteoporosis, and rheumatoid arthritis. We studied information obtained from interviews with members of the guideline committees and analyzed the content of the guideline documents themselves. Our findings were discussed at an expert meeting., Results: We found that all the guideline committees concerned applied an internationally accepted framework for guideline development. The proportion of male members ranged from 67% to 100%. None of the guidelines included a question (or subquestion) focusing on sex-related factors. In the literature searches no sex-specific search terms were used. Critical appraisals did not include any systematic focus on sex-related factors or effects. The number of sex-specific recommendations (relative to the total number of recommendations) ranged from 0 of 82 and 0 of 148 in the guidelines on depression to 16 of 84 in one of the guidelines on osteoporosis., Conclusions: We found that when developing guidelines, none of the committees systematically focused on sex-related factors that might be relevant to the way in which evidence is identified, appraised, or described. A number of recommendations were made with the aim to facilitate greater attention to sex-related factors in the current methods of guideline development.

Objective: To identify and compare patient and professional perspectives on what enables employees with diabetes mellitus (DM) to maintain their position in the workplace. To provide information on how professionals can help DM patients cope at work., Methods: Qualitative study using concept-mapping sessions involving 23 employees with DM and 22 health professionals (GP's, occupational physicians and specialists). All of the health professionals were experts in the field of diabetes care., Results: Patients and professionals identified five common clusters of statements on what diabetics need to enable them to cope at work: the ability to accept and cope with DM, supportive health professionals, a supportive work environment, work adaptations and good information. Patients emphasized the importance of emotional acceptance of DM and communication with colleagues, while the professionals emphasized the patient's capacity for self-care., Conclusion: The content of patient and professional perspectives on what is needed to prevent work-related problems for DM patients differed slightly. Patients rely on direct experiences in their own environment, professionals on medical knowledge accumulated in groups of patients., Practice Implications: Both perspectives were used to suggest a topic list for health professionals, which may help identify and address the occupational problems experienced by DM patients.

The aim of this study was to explore and compare explanatory models (EMs) of hypertension in native-Dutch, first-generation Ghanaian and African-Surinamese (Surinamese) hypertensives in Amsterdam, the Netherlands. Through semi-structured interviews, we elicited accounts of the nature, causes and consequences of hypertension in a purposive sample of 46 patients (aged 35-65 years, treated for hypertension in general practice >1 year). All three groups had difficulty in describing hypertension. All groups mentioned culturally specific nutritional habits as possible causes of hypertension (Dutch liquorice; Ghanaians fufu; Surinamese salty diet). Most respondents, particularly those of Ghanaian and Surinamese background, perceived stress as the main cause of hypertension and experienced symptoms of hypertension. Many Ghanaian and Surinamese respondents attributed hypertension to migration-related factors: changes in diet or climate, stress owing to adaptation to the Dutch society or obligations towards family in their homelands. Many immigrants felt a return to their homeland could cure hypertension and were concerned about the consequences of hypertension. Half of the Dutch and almost all Ghanaian and Surinamese respondents believed uncontrolled hypertension could cause immediate damage. Some Ghanaians expressed reservations sharing their concerns with community members because it might cause social stigma. Few respondents associated hypertension with obesity, even though many were overweight. Confirming findings from UK and US studies, this study reveals that EMs of hypertension in patients from three ethnic groups differ from the common medical perspective. These differences are greater for patients from migrant groups. Our findings can be useful in developing patient-centred hypertension interventions, particularly in new migrant populations.

Objective: To compare the perspectives of employees with rheumatoid arthritis (RA) with those of medical professionals regarding what persons with RA need to prevent work disability., Methods: Concept mapping was conducted in a group session with 21 employees and by mail with 17 medical professionals. Each group was asked to formulate statements on what enables employees with RA to retain their jobs. Group members scored all statements for importance and clustered them into themes. Results were statistically aggregated at the group level., Results: The concept mapping with employees yielded 59 statements, which were clustered into 7 themes. The 4 most important themes were employer support; understanding and acceptance of illness by employees themselves; suitable working conditions; and support from colleagues, health professionals, and the patient's organization. The concept mapping with medical professionals yielded 65 statements, which were clustered into 8 themes. The 6 most important themes were well-informed professionals who cooperate effectively; employees' coping capacities and commitment to work; financial regulations at the workplace; adequate social security provisions, medication, and therapy; a positive attitude on the part of employers and colleagues; and suitable working conditions., Conclusion: Factors that enable continued employment lie at different levels, including the psychosocial, practical, organizational, and social policy levels. Health professionals appear to underestimate factors that are important from the patient's perspective, especially support from employers. In discussing work with patients, health professionals need to address themes that are important from the patient's perspective.

Objectives: This study attempted to determine factors that help currently employed people with rheumatoid arthritis, diabetes mellitus or hearing loss to continue working., Methods: This was a qualitative study that used three concept-mapping sessions. Sixty-nine participants (rheumatoid arthritis 21, diabetes mellitus 23, and hearing loss 25) were recruited from the patient records of the rheumatology, diabetes, and audiology outpatients of the Academic Medical Center (AMC), Amsterdam, and referrals from occupational physicians and patient associations. An arthritis consultant, a diabetes consultant, and an audiologist screened the patients for the used illness inclusion criteria. A researcher screened the patients for the inclusion criteria of age and work., Results: The main factors enabling employees to continue working were ability to cope with the illness, support from management and colleagues, adequate work conditions, support of patient organizations and society, support of medical professionals and facilities, and benefits. The three groups of employees rated the priority of these factors differently. For the employees with rheumatoid arthritis, the support of management was the most important, followed by self-acceptance, self-efficacy, and professional advice on how to cope at work. For those with diabetes mellitus, self-acceptance, self-care, and support from management, colleagues and health professionals were the most important. For employees with hearing loss, being well informed about hearing equipment, reimbursement, and self-acceptance were the most important. A topic list was developed that can be used by health professionals as a guideline for exploring the work-related problems of patients with a chronic disease., Conclusion: The results provide an understanding of the needs chronically ill employees have at work and the areas to which health professionals need to pay attention.