Health-related behaviours mediate the relation between ethnicity and (mental) health in the Netherlands

Objective: Ethnic minorities in the Netherlands experience worse (mental) health than Dutch natives. So far, socioeconomic factors, discrimination, and the migration process have been identified as underlying factors, neglecting the potential role of health-related behaviours. This study investigates the mediating effect of lack of physical activity, smoking and alcohol consumption on ethnic inequalities in (mental) health in the Netherlands.

Design: Data from a municipal health survey (2012) in the four largest cities in the Netherlands, including 15,633 Dutch natives, 1,297 Surinamese, 850 Turks and 779 Moroccans were analysed. Mediation analyses were performed on the associations between ethnicity and psychological distress (range 10–50) and self-rated health (range 1–5).

Results: Being from an ethnic minority was associated with higher distress and poorer self-rated health, especially for Turks (higher distress 4.69, 95%CI 4.22–5.16; poorer health 0.35, 95%CI 0.30–0.40). Moroccans and Turks were the least physically active, Turks smoked the most, and Dutch natives drank the most. Lack of physical activity partially mediated the association between Turks (6% respectively 11%) and Moroccans (13% respectively 9%) for psychological distress and self-rated health. Smoking played a mediating role (3%) in Turks.

Conclusion: Lower physical activity and smoking more cigarettes partly explained ethnic health inequalities in the Netherlands. The current findings suggest that intervening and facilitating certain ethnic groups in engaging in health behaviours could contribute to improving their health and reduce ethnic health inequalities.     

Suicidal behavior and ethnicity of young females in Rotterdam,the Netherlands: rates and risk factors

Objective. Although Western Europe is becoming increasingly multicultural, ethnic minorities are scarcely included in studies of suicidology. We investigated the prevalence of non-fatal suicidal behavior and examined risk factors in non-western female immigrant adolescents compared to majority female adolescents in the city of Rotterdam, the Netherlands.

Design. We conducted logistic regression on a dataset that consisted of self-reported health and well-being questionnaires filled out by 4527 adolescents of Dutch, South Asian-Surinamese, Moroccan, and Turkish origin. We examined whether young females of specific ethnic groups had elevated risk for attempted suicide. Well-known risk factors in suicidology of social economic class, level of education, life events, abuse, and family context were investigated to verify whether these factors are beneficial to explaining ethnic differences in suicidal behavior.

Results. We found that rates of attempted suicide among Turkish and South Asian-Surinamese young women were higher than of Dutch females, while Moroccan females had lower rates than Dutch female adolescents. Physical and sexual abuse, and an impaired family environment, as well as parental psychopathology or parental substance abuse contributed to non-fatal suicidal behavior of females across ethnicities. However, these risk factors, as well as low social economic class and of level of education, did not fully explain the vulnerability of Turkish and South Asian-Surinamese females.

Conclusion. Our findings underscored the need for developing suicide prevention for specific minority females in multicultural cities in Western Europe. Screening programs, which aim at preventing suicide attempts by young immigrant women should include risk factors in the family environment and relationship with the parents as well as physical and sexual abuse. However, the study also showed that the disproportionate risk of Turkish and South Asian-Surinamese females could not be understood by risk factors alone and transpired that the origins of ethnic disparities in suicidal behavior deserve further examination.     

Internalising and externalising behaviours in young adults: Dutch natives and Turkish migrants in the Netherlands

Objective . To compare the prevalence of internalising and externalising behaviour of Dutch and Turkish migrant young adults in the Netherlands. We will also assess associations with socio-economic position.

Method . Dutch natives (1,236) and Turkish migrants (438), age 18–28, completed the Young Adult Self-Report. Scores above the 90th percentile of the distribution of the Dutch sample were defined as deviant.

Results . Turkish migrants more often reported deviant scores than natives for internalising problems, especially for the Anxious/Depressed syndrome. For externalising problems, Turkish migrants less often had deviant scores for Intrusive Behaviour, whereas Turkish women more often had deviant scores for Aggressive and Delinquent Behaviour. Similar results were found for comparison between mean scores. After adjustment for socio-economic position, the disparities in men remained, whereas disparities in women largely disappeared.

Conclusion . Compared with Dutch young adults, Turkish migrant young adults reported more problems. Ethnic disparities were strongly associated with socio-economic disparities among women, but not among men.     

Turkish and German patients' recall of diagnosis and therapy before and following informed consent

Objective. Adequate patient knowledge is essential for good compliance, effective doctor–patient communications and is the basis for informed consent. The purpose of the study was to examine differences in recall of informed consent procedures between patients with different ethnicity and to identify potential explanatory factors.

Design. We analyzed 579 patients, attending and released from a gynecology department in Berlin, Germany, between March 1997 and October 1998. To assess actual understanding of disclosure information, Turkish and German patients' perceptions were compared with documented data of their diagnoses and therapy.

Results. Overall, patients correctly identified 69% of their diagnosis and 76% of their therapy. On discharge overall patients' recall decreased significantly. Whereas German patients' knowledge increased, Turkish patients showed significant decreases in diagnosis and therapy recall.

Conclusion. The results reflect socio‐demographic differences between ethnic groups and indicate deficiency of the informed consent process for patients belonging to an ethnic minority.

Fragestellung. Ein ausreichend gutes und adäquates Wissen der Patienten ist wichtig für eine gute Compliance, eine effektive Arzt‐Patienten‐Beziehung und stellt die Basis für den sogenannten informed consent dar. Zielstellung der Studie war die Feststellung von Unterschieden im Wissensstand von Patientinnen verschiedener Ethnizität vor und nach der Aufklärung auf einer gynäkologisch‐operativen Station und die Identifizierung von Erklärungsfaktoren für eventuelle Differenzen.

Patientinnenkollektiv und Methodik. Es wurden 579 Patientinnen in die Studie einbezogen, die zwischen März 1997 und Oktober 1998 auf einer gynäkologischen Station in Berlin behandelt und mit einem Fragebogen befragt wurden. Zur Feststellung des jeweiligen aktuellen Informationsstandes wurden die Angaben der deutschen und der türkischstämmigen Patientinnen mit den dokumentierten Daten zu Diagnose und Therapie in den Krankenakten verglichen.

Ergebnisse. Insgesamt konnten 69% aller Patientinnen ihre Diagnose und 76% die Therapie richtig wiedergeben. Der Kenntnisstand am Ende des stationären Aufenthaltes war insgesamt signifikant schlechter als am Anfang. Während die deutschen Patientinnen besser Bescheid wussten, zeigten die türkischstämmigen Patientinnen signifikante Defizite hinsichtlich ihres Wissens über ihre Diagnose und Therapie.

Zusammenfassung. Die Ergebnisse reflektieren soziodemographische Unterschiede zwischen ethnischen Gruppen und zeigen Defizite im Informationsprozess vor und während des Klinikaufenthaltes insbesondere bei den Migrantinnen auf.     

Understanding medication adherence among patients of Turkish descent with type 2 diabetes: a qualitative study

Objectives. To explore perspectives of Turkish migrants with type 2 diabetes mellitus (T2DM) on adherence to oral hypoglycaemic agents (OHA).

Design. In-depth interviews with 21 T2DM patients of Turkish descent recruited from primary care and community sources in Ghent, Belgium, using a theoretical sampling procedure. Analysis was guided by a grounded theory approach, using Nvivo 8.

Results. Respondents reported a multitude of barriers and facilitators of adherence to OHA. Some of these barriers are distinctive for T2DM patients of Turkish descent. Respondents' causal beliefs about stress and the Belgian climate often led to non-adherence during less stressful periods, like summer holidays in Turkey. Some respondents adjusted their medication use to food intake or during Ramadan fasting. Concerns about OHA were the main reason for the widespread use of herbal medicine in this sample. The religious framework used to interpret diabetes led, in combination with feelings of depression, to non-adherence in some respondents while it facilitated medication adherence in others. A potential gender effect with respect to the self-management of OHA was observed. Non-distinctive factors include: beliefs about OHA, polypharmacy, beliefs about the course of diabetes, forgetfulness, the perception of the doctor's medical expertise, feelings of depression and social support.

Conclusion. Health care providers should explore in detail and regularly patients' perspectives on illness beliefs, medication beliefs and their trust in doctors' medical expertise as this will provide useful starting points for promoting medication adherence. Whenever possible health care workers should engage with their patients in therapeutic alliances.     

The Norwegian Occupational Balance Questionnaire (OBQ11-N) – development and pilot study

Background: The concept occupational balance has been linked with health and well-being, and it is therefore viewed as an important concept for occupational therapy practice, theory and research. To operationalize and measure occupational balance, the Occupational Balance Questionnaire (OBQ) was developed in Sweden. To date, no Norwegian translations of the OBQ exists.

Aim: To describe the process of developing a Norwegian version of the 11-items Occupational Balance Questionnaire (OBQ11-N) and to evaluate its feasibility and face validity.

Methods: The development process followed a predetermined series of steps, including forward and back translation and cognitive interviews with a pilot sample.

Results: The pilot study sample (n?=?8) varied with respect to age, gender and education level. There was high level of agreement between the participants with regard to their understanding of the content of the items. Three of the items were slightly modified in terms of words and phrasing.

Conclusion: The OBQ11-N was developed according to established translation guidelines and appears to be feasible and have good face validity.

Significance: The OBQ11-N may prove useful for assessing occupational balance and associated factors in Norwegian population groups. However, more research is needed to establish the Norwegian version of the questionnaire as psychometrically valid.     

Ethnocultural predictors of postpartum infant‐care behaviours among immigrants in Canada

Objectives. To determine, among immigrants, what ethnocultural variables predict postpartum infant‐care behaviours over and above other maternal and infant characteristics.

Methods. We recruited a cohort of immigrant women on hospital postpartum units. Data on predictor variables were collected during face‐to‐face interviews in the early postpartum period. Follow‐up telephone interviews occurred at 3 months postpartum to assess infant‐care behaviours. We identified 411 women meeting our eligibility criteria, of these 77.3% agreed to participate and 94% received follow‐up interviews.

Results. In the first stage of a multiple linear regression analysis, maternal and infant predictors accounted for 24.2% of the variance in the ‘Infant‐Care Behaviours’ score. In the second stage of model building, ethnocultural variables explained an additional 5.8% of the variance.

Separate analyses for recent immigrants (resident in Canada less than 3 years) and less recent immigrants (3 or more years) yielded some differences in predictors. Among recent immigrants, worries about the infant's health, mother's education and an interaction term (current immigration status by parity) were significant predictors, explaining 23% of the variance. Among less recent immigrants, worries about the baby's health, prenatal class attendance, marital status and official language comprehension ability explained 37.7% of the variance.

Conclusions. Our results indicate that assessing ethnocultural characteristics, in addition to maternal and infant characteristics, improves the prediction of ‘Infant‐Care Behaviours’ scores.     

Alcohol use among recent immigrant Latino/a youth: acculturation,gender, and the Theory of Reasoned Action

Objective. Latino/a youth are at risk for alcohol use. This risk seems to rise with increasing US cultural orientation and decreasing Latino cultural orientation, especially among girls. To ascertain how acculturation may influence Latino/a youth alcohol use, we integrated an expanded multi-domain model of acculturation with the Theory of Reasoned Action.

Design. Participants were 302 recent Latino/a immigrant youth (141 girls, 160 boys; 152 from Miami, 150 from Los Angeles) who completed surveys at 4 time points. Youth completed measures of acculturation, attitudes toward drinking, perceived subjective norms regarding alcohol use, intention to drink, and alcohol use.

Results. Structural equation modeling indicated that collectivistic values predicted more perceived disapproval of drinking, which negatively predicted intention to drink. Intention to drink predicted elevated alcohol use.

Conclusion. Although the association between collectivistic values and social disapproval of drinking was relatively small (β = .19, p < .05), findings suggest that collectivistic values may help protect Latino/a immigrant youth from alcohol use by influencing their perceived social disapproval of drinking, leading to lower intention to drink. Educational preventive interventions aimed at reducing or preventing alcohol use in recent Latino/a immigrant youth could promote collectivistic values and disseminate messages about the negative consequences of drinking.     

Everyday life in breast cancer survivors experiencing challenges: A qualitative study

Background: Early diagnosis and treatment of breast cancer results in an increasing number of survivors, some of whom face new challenges in their transition to daily life.

Aim: Based on these experiences, the aim of this study was to describe the everyday life in breast cancer survivors experiencing challenges.

Material and method: Eleven women recruited from a follow-up study of breast cancer patients participated in qualitative interviews about their everyday occupations seven years after ending treatment. The inductive analysis revealed ten categories that were organized into five subthemes under the two main themes ‘bodily and mental loneliness’ and ‘new center of gravity in everyday life’.

Results: Findings showed how relevant information and guidance; active support to the client and their relatives; and a balance between occupations at home and at work were important matters to handle their everyday life challenges.

Conclusion and significance: By assisting these women in finding new patterns of meaningful occupations that positively affect their everyday life, the study suggests some central elements to be included in future follow-up practice for breast cancer survivors. Approaching this goal, occupational therapists should contribute to more involvement assisting cancer survivors and their partners in finding new patterns of meaningful occupations that positively affect their everyday life.     

Explanatory models of diabetes in urban poor communities in Accra,Ghana

Objectives. The objective of the study was to examine explanatory models of diabetes and diabetes complications among urban poor Ghanaians living with diabetes and implications for developing secondary prevention strategies.

Design. Twenty adults with type 2 diabetes were recruited from three poor communities in Accra. Qualitative data were obtained using interviews that run between 40 and 90 minutes. The interviews were audio-taped, transcribed and analysed thematically, informed by the ‘explanatory model of disease’ concept.

Results. Respondents associated diabetes and its complications with diet, family history, lifestyle factors (smoking, excessive alcohol consumption and physical inactivity), psychological stress and supernatural factors (witchcraft and sorcery). These associations were informed by biomedical and cultural models of diabetes and disease. Subjective experience, through a process of ‘body-listening,’ constituted a third model on which respondents drew to theorise diabetes complications. Poverty was an important mediator of poor self-care practices, including treatment non-adherence.

Conclusions. The biomedical model of diabetes was a major source of legitimate information for self-care practices. However, this was understood and applied through a complex framework of cultural theories of chronic disease, the biopsychological impact of everyday illness experience and the disempowering effects of poverty. An integrated biopsychosocial approach is proposed for diabetes intervention in this research community.     

Translating the Canadian Occupational Performance Measure to Danish,addressing face and content validity

Background: The Canadian Occupational Performance Measure (COPM) is a recognized assessment tool within Danish occupational therapy (OT), and translated versions of the COPM have been implemented in Danish OT practice. However, a rigorous translation and cross-cultural validation process has not been applied to these versions.

Aims: To produce a new Danish translation of the COPM evaluating its semantic, conceptual, operational and item equivalence while addressing its face and content validity.

Methods: An iterative, multistage translation process was undertaken with (1) forward translation involving professional translators and bilingual OTs, (2) pilot testing and cognitive debriefing interviews with 15 OTs and 37 clients which were analyzed quantitatively and qualitatively, and (3) finalization with adaptations, back translation and approval.

Results: Content validity of COPM in terms of appropriateness, acceptability, intelligibility and comprehensiveness was found in 78–100% of the cases, and its ability to ensure a client-centred focus in the assessment process was confirmed. However, issues concerning the administration and content of the COPM were identified. Subsequently, two recommendations regarding the administration of the COPM were added to the Danish version.

Conclusion: Semantic, conceptual, operational and aspects of item equivalence of the COPM into Danish were achieved and supported by face and content validity.     

The role of education for current,former and never-smoking among non-western immigrants in Norway. Does the pattern fit the model of the cigarette epidemic?

Objectives. The aim was (1) to investigate the association between education and smoking status (current, former and never-smoking) among non-western immigrants in Norway and (2) examine if these associations fit the pattern predicted by the model of the cigarette epidemic.

Design. Data came from the Oslo Health Study and the Oslo Immigrant Health study (2000–2002). The first included all Oslo citizens from seven selected birth cohorts. The second included all Oslo citizens born in Turkey, Iran, Pakistan, Vietnam and Sri Lanka. 14,768 respondents answered questions on smoking, education and relevant background variables (over-all response rate 43.3%). Two gender specific multinomial logistic regression models with smoking status [current, former or never-smoker (reference)] as dependent variable were computed and predicted probabilities of smoking status among groups with different levels of education were calculated.

Results. Smoking prevalence among men ranged from 19% among Sri Lankans to 56% among Turks. Compared to the smoking prevalence among Norwegian men (27%), smoking was widespread among Iranians (42%) and Vietnamese (36%). Higher education was associated with lower probability of current smoking among all male immigrant groups except Sri Lankans. Never having smoked was positively associated with education among Pakistani and Norwegian men. Among women, <5% smoked among Pakistanis, Vietnamese and Sri Lankans. Smoking prevalence among Turkish (28%) and Iranian (23%) women were comparable to Norwegian women (30%). The probability of smoking among Turkish and Iranian women with secondary education was higher than for other levels of education. The probability of being a never-smoker was high among Turkish and Iranian women with primary education.

Conclusions. High smoking prevalence among Turkish and Iranian men highlights the importance of addressing smoking behaviour in subgroups of the general population. Smoking was almost non-existent among Pakistani, Vietnamese and Sri Lankan women and indicates strong persistent social norms against smoking.     

Occupational therapists experiences of implementing a new complex intervention in collaboration with researchers: a qualitative longitudinal study

Background: This study was conducted in the context of a randomized controlled trial where occupational therapists (OTs) in collaboration with researchers implemented a client-centred activity of daily living intervention (CADL) for persons with stroke.

Objective: The aim was to identify and describe over time the OTs’ experiences regarding the collaboration with the researcher in their role as implementers of a new complex intervention.

Method: Focus group interviews were conducted with 33 OTs, two, six and 12 months after they had participated in a five-day workshop. The interviews were analysed using a grounded theory approach.

Results: Three categories were identified: (1) Including in the scientific world, (2) Involving as an implementer of science and (3) Integrating in a partnership. One core category emerged: The implementation of client-centred intervention enabled the fusion of practice and science. An increased experience of using CADL and support from the researchers changed the OTs’ attitudes towards engaging in research from being an outsider to the scientific world to being included and then becoming a part of the research as an implementer of science.

Conclusions: To create a context built on a collaborative partnership between practitioners and researchers enabled the fusion of practice and science.     

Alcohol use by young people from different ethnic groups: consumption, intoxication and negative consequences

Objective. To investigate alcohol consumption among mid‐adolescents from different ethnic groups and explore overall and gender variations in drinking behaviours.

Methods. A survey of alcohol use by 609 14–16 year olds recruited from three schools in an ethnically diverse area of London. Approximately 70% of the sample was of White English, White Irish, Black Caribbean or Black African ethnic origin. Self‐report information was collected via a researcher‐administered structured interview.

Results. There was a significantly lower prevalence of lifetime alcohol use among Black African respondents than among the other three ethnic groups. Black African males and males and females from the two White ethnic groups reported drinking above levels recommended by the English Department of Health. Among the recent drinkers, over half of the White Irish and White English groups and over a quarter of Black Caribbean and Black African groups had been intoxicated in the 90 days before interview. Approximately three quarters of the White English and White Irish recent drinkers, but only a half of Black Caribbean and Black African recent drinkers had experienced a negative drinking‐related consequence during the last year.

Conclusions. The survey findings suggest that while young people of White English or White Irish ethnic origin from the populations studied are more likely to drink excessively and experience negative consequences from their drinking than Black African and Black Caribbean youth, a substantial minority of Black African and Black Caribbean youth also experience alcohol‐related problems.     

Managing occupations in everyday life for people with advanced cancer living at home

Background: People with advanced cancer are able to live for extended periods of time. Advanced cancer can cause functional limitations influencing the ability to manage occupations. Although studies have shown that people with advanced cancer experience occupational difficulties, there is only limited research that specifically explores how these occupational difficulties are managed.

Objective: To describe and explore how people with advanced cancer manage occupations when living at home.

Material and methods: A sub-sample of 73 participants from a larger occupational therapy project took part in the study. The participants were consecutively recruited from a Danish university hospital. Qualitative interviews were performed at the homes of the participants. Content analysis was applied to the data.

Results: Managing occupations were manifested in two main categories; (1) Conditions influencing occupations in everyday life and (2) Self-developed strategies to manage occupations.

Significance: The findings suggest that people with advanced cancer should be supported to a greater extent in finding ways to manage familiar as well as new and more personally meaningful occupations to enhance quality of life.     

Racial discrimination,racial/ethnic segregation,and health behaviors in the CARDIA study

Objective

Racial discrimination has been associated with unhealthy behaviors, but the mechanisms responsible for these associations are not understood and may be related to residential racial segregation. We investigated associations between self-reported racial discrimination and health behaviors before and after controlling for individual- and neighborhood-level characteristics; and potential effect modification of these associations by segregation.

Design

We used data from the longitudinal Coronary Artery Risk Development in Young Adults (CARDIA) study for 1169 African-Americans and 1322 whites. To assess racial discrimination, we used a four category variable to capture the extent and persistence of self-reported discrimination between examination at years 7 (1992–1993) and 15 (2000–2001). We assessed smoking status, alcohol consumption, and physical activity at year 20 (2005–2006). Segregation was examined as the racial/ethnic composition at the Census tract level.

Results

Discrimination was more common in African-Americans (89.1%) than in whites (40.0%). Living in areas with high percentage of blacks was associated with less reports of discrimination in African-Americans but more reports in whites. After adjustment for selected characteristics including individual- and neighborhood-level socioeconomic conditions and segregation, we found significant positive associations of discrimination with smoking and alcohol consumption in African-Americans and with smoking in whites. African-Americans experiencing moderate or high discrimination were more physically active than those reporting no discrimination. Whites reporting some discrimination were also more physically active than those reporting no discrimination. We observed no interactions between discrimination and segregation measures in African-Americans or whites for any of the three health behaviors.

Conclusions

Racial discrimination may impact individuals' adoption of healthy and unhealthy behaviors independent of racial/ethnic segregation. These behaviors may help individuals buffer or reduce the stress of discrimination.     

Principles for the development of Aboriginal health interventions: culturally appropriate methods through systemic empathy

Objective. To increase Aboriginal participation in mainstream health services, it is necessary to understand the factors that influence health service usage. This knowledge can contribute to the development of culturally appropriate health services that respect Aboriginal ways of being.

Design. We used a community-based participatory approach to examine the reasons for underutilization of health services by Aboriginal Australians.

Results. Based on three focus groups and 18 interviews with Aboriginal health professionals, leaders, and community members in rural, regional, and urban settings, we identified five factors that influenced usage, including (1) negative historical experiences, (2) cultural incompetence, (3) inappropriate communication, (4) a collective approach to health, and (5) a more holistic approach to health.

Conclusion. Given that these factors have shaped negative Aboriginal responses to health interventions, they are likely to be principles by which more appropriate solutions are generated. Although intuitively sensible and well known, these principles remain poorly understood by non-Aboriginal health systems and even less well implemented. We have conceptualized these principles as the foundation of an empathic health system. Without empathy, health systems in Australia, and internationally, will continue to face the challenge of building effective services to improve the state of health for all minority populations.     

Perceived needs for attaining a ‘new normality’ after surviving myocardial infarction: A qualitative study of patients’ experience

Background: A comprehensive understanding of the various aspects of patients’ myocardial infarction (MI) experiences may help to guide these patients and their relatives through the many uncertainties they face and help them to stabilize their lives after the disruption they experienced.

Objectives: To explore MI patients’ experiences of life with MI, the challenges they face during the process of accepting their condition, and the setting and resetting of their personal goals.

Methods: Thirty semi-structured, individual interviews were conducted. The grounded theory method was used, and Atlas.ti qualitative data analysis software was used to facilitate the analysis.

Results: Three main themes and explanatory models emerged from the data analysis: a good adaptation – the ‘new normality;’ maladjustment – a continuous search for a ‘new normality;’ and perceived needs in the search for a new normality. Patients perceived several areas of need that they felt must be met before they could reach the state of a new normality. These needs included overcoming the anxiety of a possible MI recurrence; acquiring knowledge about MI in general and about ‘my MI’ in particular; the need for a timeline; for patience and steadiness; for both objective and subjective health status improvement; for taking control over the disease; and living within a supportive context.

Conclusion: When faced with a dramatic life event, most patients succeed in achieving a new normality in which they live changed but still satisfying lives. The needs experienced by patients when searching for a new normality may guide practitioners in leading patient-centred consultations.

KEY MESSAGES

• Most MI patients achieve a new normality.

• My physical identity is new: my body is different but still functional.

• My personal identity is new: I am not the same as before, the disease is part of me, but I retain parts of my previous self.