The American Dental Association has identified several barriers to adequate dental care for vulnerable populations, including appropriate case management. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the dental case manager (DCM) and the effect of DCM services on their oral or overall health.We used a qualitative descriptive study design and focus groups. Twenty-five people who had received DCM services on Cape Cod, Massachusetts, attended 1 of 5 focus groups in 2009 and 2010. Digital recordings of the groups were transcribed verbatim. Textual data were categorized using directed qualitative content analysis techniques. We identified major themes and representative quotes.The following themes emerged from discussions on the DCM’s role: being available, knowledgeable about clients and insurance, and empathetic; increasing access; and providing comfort. Most participants credited their oral and overall health improvements to the DCM. All participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations, including the elderly and developmentally disabled, likely would benefit from working with a DCM.The addition of a DCM facilitated access to dental care among this sample of people living with HIV/AIDS, providing them with an advocate and resulting in self-reported improvements to oral and overall health. In 2004, the American Dental Association (ADA) cited several barriers to adequate dental care for vulnerable populations, including the lack of case management services: “[E]ven when [dental] care is available, programs often fail to provide the case management services needed to help people get to dental appointments and comply with post-treatment instructions and oral hygiene protocols” .One vulnerable population for whom access to oral health care is of particular importance is people living with HIV/AIDS (PLWHA). Approximately one-third of PLWHA have difficult-to-treat oral lesions caused by a weakened immune system. Untreated oral disease can affect the ability to eat, thus leading to weight loss and malnutrition . For PLWOne approach to improving oral health is use of a dental case manager (DCM). Like the medical case manager –9, the DSeveral studies have examined the effect of medical case managers in helping vulnerable people to find and remain in care –16. HaviLittle has been reported on the experiences of people who have DCMs or their opinions on the effect of DCM services. The objective of this study was to examine the perceptions, attitudes, and beliefs of dental patients living with HIV/AIDS on the role and value of the DCM and the effect of DCM services on their oral or overall health.Cape Cod, Massachusetts, classified as rural by the Health Resources and Services Administration, has a diverse population and a well-established gay community. The 2004 Cape Cod Community Survey  found thWe created 2 DCM positions for this study, 1 for each of 2 dental clinics associated with Harbor Health Services, Inc, which received funding from the Health Resources and Services Administration Oral Health Special Projects of National Significance. During the study period, 3 people filled the 2 positions. Two were men; 1 was Brazilian, 1 was white, and 1 was a Hispanic woman. Two were bilingual (English/Spanish and English/Portuguese). Although all had some college education, none had received medical or dental training. They were supervised by a person who had social service experience.We used focus groups to collect data. Focus groups are especially helpful in examining nuances in attitudes, beliefs, or opinions . We mailWe held 5 focus groups from December 2009 through June 2010. An experienced focus group facilitator used recommended focus group procedures  to conduDigital recordings were transcribed verbatim. Transcripts were coded and then imported into Microsoft Excel for sorting and cross-referencing. One investigator read the transcripts several times to identify emerging themes and to develop a coding scheme on the basis of the original research questions and spontaneous comments. Two investigators categorized textual data separately according to directed qualitative content analysis .This anaAlmost all (23/25) participants described themselves as non-Hispanic white; 24 were men; mean age was 49.3 years. Of the population eligible to participate, 86% were male; 85%, non-Hispanic white; 9%, non-Hispanic black . We founParticipants identified 2 major barriers to obtaining dental care before having a DCM: lack of dental coverage and lack of dental providers. One participant said, “I was always feeling that I was on my own. I didn’t have insurance that covered dental ever, so it was sort of like I was in charge of calling for a cleaning if I had the money” .Many participants discussed the need to travel several hours (4 to 6 hours round trip) to get dental care:Well, there was very little . . . it was still back then, here on Cape Cod, there was very, very little available for Ryan White [Ryan White Dental Treatment Fund pays for dental services for HIV clients who cannot otherwise afford dental care] on the Outer Cape or on the Mid Cape, so you just schlepped, you just went into the city proper, you went into Boston. When help was available, it most often came from medical case managers. That assistance, however, was often limited to making referrals and did not always result in dental care: “And if you have a medical case manager, they can help you get dental care sometimes, if they can find someone to take your insurance if you have MassHealth [Massachusetts Medicaid coverage]” .At least 1 participant in every group reported negative experiences with previous dental providers, including receiving poor care, feeling uncomfortable because of HIV status, and receiving untimely care:I went to [clinic name] in [city name] because you get a discount because you go with a student. The doctors there are teaching the students and it was a horrifying experience. I had my wisdom teeth pulled and there were like 7 people there and they didn’t anaesthetize me and my friend didn’t stay, so they had to just inject me and half of the time it was just wearing out. And the doctor was just the worst training doctor you could probably ever imagine getting and I was just like screaming, you know, and the students were looking and I’m screaming and I had to pull the doctor’s hand away and I was just “What are you doing?” Then I moved up to [city name] with my uncle and up there I couldn’t get any help whatsoever; not for HIV or anything, for absolutely anything, and I got to the point where I pretty much ended up in a nursing home. You know, I was down to 134 pounds. Participants discussed feeling uncomfortable because of their HIV status: “I can’t prove or disprove about the [HIV] status, but in past I have gotten that feeling. You get that, I don’t know how to explain it. You sort of felt, just felt uncomfortable” ; “Well, it becomes important if you feel judged. And I gotta say, that Dr [dentist name], I just don’t feel comfortable with him” .Participant descriptions of the DCM role sorted into 6 categories: 1) being accessible and available; 2) being knowledgeable about clients; 3) being knowledgeable about insurance; 4) being empathetic; 5) increasing access to care ; and 6) providing comfort . ParticiA few participants mentioned an additional potential DCM role: assisting people with travel to and from dental appointments:When I have medical appointments, I can go through the ASG [AIDS Support Group] and get the B bus. But I don’t know if that should be included in the dental [case manager role]. Let’s say, I don’t have much medical, right now it’s more focused on dental, but I still need rides to the [dental clinic] I think. Maybe, to help answer your question of what should be included, maybe that. Only 1 participant mentioned an unmet expectation: “What I’m thinking now is if my dental case manager were to ask me how happy I am with my dental providers, with my dentists” .All participants mentioned the value of the DCM; one stated, “I can’t see how a dental practice right now could function without a [dental] case manager” . Many cited previous difficulties with obtaining dental care, including the complexities of gaining access:You need someone to centrally coordinate. If you don’t know where to go or what to do, whatever the case may be, then just like you say, you go or you call when you don’t have any idea, so that one person coordinates what is going on or gives direction on what place to go, and this eases the peace of mind first of all. Another participant discussed the value of the position as the coordinator of dental care: “The [dental] case manager is like the overseer, the engineer making sure that not only are we getting the care we need now but we’re also getting the future stuff taken care of” .All participants believed that the DCM would benefit other vulnerable populations; one stated:I can’t imagine how it wouldn’t benefit. I remember when my mother was at the end of her life and when she was in her 70s, especially seniors, where there is so little. I mean, we take such bad care of our elderly. I mean, just in that aspect alone. But I think other populations of the community . . . I can’t imagine how it wouldn’t be helpful. Many participants noted changes in their oral and overall health after the DCM helped them to obtain regular dental care. Changes in oral health often involved the alleviation of pain: “Before this I had a half a mouth of teeth for a half a year before I met these dental case managers, so I was suffering, I was slowly losing weight, you know” . Another participant discussed changes not only in pain reduction but also in laboratory values:Well, it’s definitely helped me. Because when they did the top teeth, I guess I had an infection in there probably for about a year and a half. So, my T cells once this was all done jumped 100 points. So yeah, and I feel a lot better. Now that I don’t have any pain, I’ve been in pain for like, I don’t know 8 years. I was used to it, you know. Several participants mentioned the effect on their mental health and how poor oral health limited their ability to socialize:But the whole idea that like when I didn’t have teeth for a while, I couldn’t go to a restaurant, I couldn’t even have a deli sandwich. I’d sit there for 45 minutes, it would take you 20. So, has your health changed? Health, mental health, physical health, you know — everything. Overall, participants felt that their improved oral health had improved their overall health.The issues and problems of oral health access before receiving DCM services that our study’s participants described are consistent with previous findings  and highAlthough modeled after medical case managers, DCMs, as described by our study participants, may be more like community health workers (CHWs). The American Public Health Association CHW Special Interest Group defines a CHW as . . . a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. .The role of the DCM, as described by our study participants, incorporates many of these responsibilities, including being available, empathetic, and knowledgeable about their clients’ needs and providing comfort. The DCMs in our study did not have degrees in medicine, dentistry, or other health care fields; they were community members. CHWs have been effective in increasing access to medical care, particularly for vulnerable populations –29; a siThe Surgeon General in 2010 described the direct connection between oral health and general health, acknowledging the relationship between chronic oral infections and chronic diseases such as HIV/AIDS, diabetes, osteoporosis, and cardiovascular conditions . Many ofThis study has several limitations. First, because we used focus groups, which allowed us to obtain in-depth answers to open-ended questions, we had a small sample. Second, our results may reflect participation bias; the study participants may not accurately represent all dental clients receiving DCM services. Third, a study conducted in only 1 place limits generalizability. The generalizability of our data is especially limited because we collected data on only a few demographic characteristics, and these characteristics did not reflect the demographics of the overall population of interest . FourthThe addition of a DCM to 2 dental clinics on Cape Cod, Massachusetts, facilitated access to dental care and provided PLWHA with a health care advocate, resulting in self-reported improvements to oral and overall health. Participants believed that the DCM was a valuable addition to the clinic and noted that other at-risk populations  would likely benefit from working with a DCM.


Ethnic minority women from low-income countries who live in high-income countries are more physically inactive than ethnic majority women in those countries. At the same time, they can be harder to reach with health promotion programs. Targeting recruitment channels and execution to ethnic groups could increase reach and receptivity to program participation. We explored using ethnically specific channels and key figures to reach Ghanaian, Antillean, and Surinamese mothers with an invitation for an exercise program, and subsequently, to determine the mothers’ receptivity and participation.We conducted a mixed methods process evaluation in Amsterdam, the Netherlands. To recruit mothers, we employed ethnically specific community organizations and ethnically matched key figures as recruiters over Dutch health educators. Reach and participation were measured using reply cards and the attendance records from the exercise programs. Observations were made of the recruitment process. We interviewed 14 key figures and 32 mothers to respond to the recruitment channel and recruiter used. Content analysis was used to analyze qualitative data.Recruitment through ethnically specific community channels was successful among Ghanaian mothers, but less so among Antillean and Surinamese mothers. The more close-knit an ethnic community was, retaining their own culture and having poorer comprehension of the Dutch language, the more likely we were to reach mothers through ethnically specific organizations. Furthermore, we found that using ethnically matched recruiters resulted in higher receptivity to the program and, among the Ghanaian mothers in particular, in greater participation. This was because the ethnically matched recruiter was a familiar, trusted person, a translator, and a motivator who was enthusiastic, encouraging, and able to adapt her message (targeting/tailoring). Using a health expert was preferred in order to increase the credibility and professionalism of the recruitment.Recruitment for an exercise program through ethnically specific organizations seems to contribute to its reach, particularly in close-knit, highly organized ethnic communities with limited fluency in the local language. Using ethnically matched recruiters as motivator, translator, and trusted person seems to enhance receptivity of a health promotion program. An expert is likely to be needed for effective information delivery. In high-income, Western countries, non-Western ethnic minority groups have been found, on average, to be less physically active than the host population ,2. SpeciTo increase this reach, and thereby the accessibility of health promotion in the target group, employing an ethnic group’s community resources is a promising recruitment method. Examples of such resources are churches, local community leaders and organizations, ethnically specific media, networks, and events ,8. A heaHowever, not all prior studies support using ethnically specific community resources for recruitment. Formative studies among different ethnic groups have shown that some ethnic minority groups seem to rely less on ethnically specific resources than others ,12. MoreTherefore, the utility of ethnic group’s community resources for improving participation in health promotion programs is not yet clear and merits further study . Two queThis study aims to test the potential utility of targeting recruitment channels and recruiters to specific ethnic minority groups, with a particular focus on the conditions and mechanisms underlying their impact. We focused on mothers of young children because this group is at increased risk of physical inactivity ,15. The mama”. Big Move mama was an existing program that suited the shared needs of mothers from a multiethnic population. These shared needs were derived from formative research  good feeling, you can trust it”. (Ghanaian mother)R: “Yes, then you can hear it, because sometimes… although you might want to read [it], you can’t… or you In contrast, for the Antillean and Surinamese women, the Dutch language posed no problem. Furthermore, key figures described the Surinamese and Antillean women as not wanting obligations and not being very close with each other (only with their families). The latter was directly linked by these key figures to fewer regular community gatherings thus reach was seen as more difficult.I: “We saw how the Ghanaian women got together a lot, they really got together in groups that met every two weeks. Isn’t there somewhere like that where we could reach the Antillean group all at once?”R: “No, Antillean mothers are very different than Ghanaian mothers. You can’t compare them”.I: “Why not?”R: “Because the sense of solidarity among the Ghanaians is different than among the Antilleans. We’re also very close, but just with family.  they’re all brothers and sisters.  your immediate family is what counts, and the rest are just acquaintances”. (Antillean key figure)Excerpts from the Antillean and Surinamese mothers echoed the explanations of the key figures. They more frequently mentioned the individual-oriented channels through which they are normally reached, most of which were not ethnically specific. For instance, Surinamese mothers mentioned social media and email. Other alternative channels they used were health care, brochures by mail, word-of-mouth communication with friends and colleagues, or possibly via Surinamese radio and television. However, the mothers who were reached via “an Antillean radio broadcast” and “Surinamese women’s organizations” were in fact reached by an immediate family member who was the leader/radio producer, or by a friend.The interviewees, both mothers and key figures, linked the role of the available organizations to the ethnic communities’ characteristics and gave this as the final explanation for reach. Excerpts from the Ghanaian interviews showed that they see ethnically specific community organizations as a “bridge to Dutch society”. The Ghanaian gatherings provided support, help, and advice about how to deal with specifically Dutch situations. Leaders of Ghanaian women’s organizations were described as being in touch with Dutch organizations such as the Public Health Service and the local government district. They invited experts to provide information to their group, and translated that information. The organizations were the usual channels for their members to get information about important issues, such as health. The Ghanaian key figures said these are what explained high attendance at their meetings.I: “How do you learn more about activities that take place in the neighborhood?”R: “Umm, [our Ghanaian women’s organization] has a secretary, and she looks all over to see where we can go”.I: “But is there also another way for you to get information?”R: “No, she gives us all of the information, and sometimes she just puts it on the table. Should we do this? Do we want to do this?”I: “But don’t you get a newsletter from your local government district, for example?”R: “Sure, a newsletter, all kinds of things. [The key figure] also reads them to us and explains it to those who don’t understand Dutch. (…) She [also] usually works together with the district”. (Ghanaian mother)I: “What struck me was that quite a few young Ghanaian women get together at [names of women’s organizations] and in churches. Why do you think this is?”R: “The reason for this is [for example], for most women (…), the communication between them and their partner isn’t like in Ghana. One of them works in the evening and the other one in the afternoon, so then you don’t see each other. So with a group like this they have more of a chance to talk about problems and give each other advice”. (Ghanaian key figure)glad their mothers have Surinamese organizations to empower them,” but they did not seem to be interested in these organizations themselves. Surinamese mothers said they were not used to receiving information about activities like this exercise program through their churches.The one Antillean church played the same role, providing information every week about upcoming activities. In contrast, at ad hoc informational meetings organized by Surinamese organizations, no mothers with young children were present. Furthermore, a key figure mentioned that daughters of their elderly members said they were “A really good initiative”, “It was a very nice evening”, and “Can you please come to our church to tell about this?” In the comparison condition, by contrast, women left early or the health educator herself had to approach them.If we compare expressions of receptivity and participation numbers between mothers exposed to ethnically matched recruiters with those exposed to ethnic Dutch health educators, overall, the former were better received and a larger proportion enrolled in the exercise classes. In the intervention condition, a more positive atmosphere was observed than in the comparison condition. Mothers seemed more open to and to pay more attention to the recruiter and recruitment message. The interviews with mothers supported this: they remembered the recruiter and which information she had given better if this was done by a key figure than by a health educator. Observed interaction was more positive, and the women asked more questions. Moreover, if Dutch health educators supported the information giving while key figures were involved in the recruitment, the health educator received more positive reactions, such as “We saw that almost all mothers who indicated they did not want to join the exercise program (or who indicated they might want to join but were not reached afterwards) had been recruited by a health educator  Table . There wExcerpts of the interviewees described why they thought the ethnically matched recruiter achieved higher receptivity and participation in the intervention condition. First, the recruiter was similar and familiar to the women, which seemed to create openness, attention , accessibility , trust, and persuasion, regardless of ethnic group. Explanations given for this had to do with the recruiter’s ethnicity and whether she was known for her expertise or activities in this area. If the recruiter was described as a close, familiar person, this was said to foster trust and persuasion.R: “I thought the radio spot was good, too. Because everyone called me, saying, ‘[name of key figure], are you going to take part in a project?’ Because they heard my name (…)”.I: “Ooh, okay, that’s funny, because I actually didn’t have a single response to what was on the radio. But you did, huh?”mama.’” R: “Yes, I did, I heard it, yes. But then, you’re not so well known in the Surinamese community. So I’m not too surprised. But the moment you mentioned my name. Then they say, ‘Hey [name of key figure], I heard your name on the radio. Are you taking part?’ I say, ‘Yes I am, together with Ms. [name of the health educator], we’re doing a project called Big Move mama? Who was that?”I: “And who was the person who told you about Big Move R: “Er, er, [name of key figure], yeah, and also a lady, a white lady, but I forgot her name. Because [name of key figure] is… (runs her hand over her skin), so then I won’t forget, ha-ha-ha. So the other lady, she’s also white, but I forgot her name”.I: “Well, it was also a while back. And [name of key figure], is she from the church?”R: “Yes! The church, we have two services, one in the morning and one in the afternoon. But she goes to the morning service and I go to the afternoon service. But sometimes she comes to give us information”. I: “And so is it also important that it’s your father [an Antillean radio producer] who’s saying this? Do you immediately take it on board then?”R: “No (laughs), no, I don’t, but still…I have a really good relationship with my father, so as far as that goes. If he suggests something he thinks would be good for me, I’ll take it on board. That’s what I mean”. Second, ethnically matched recruiters used the mother tongue to translate and explain things in a way that was relevant; this might have increased attractiveness, attention, and accessibility, although it did not seem just a matter of understanding. In fact, mothers and key figures mentioned that most Ghanaian and Antillean women could understand both English and Dutch, the languages used by the health educators. It may be, rather, the attraction to something “familiar”, as described by a key figure, and having no barrier to ask questions and interact. More positive interaction was observed when an ethnically matched recruiter used the mother tongue during recruitment, and if women approached these key figures afterwards with additional questions and for advice, they used their own language then as well. Although all women said their leader was able to translate if the Dutch health educators were the recruiters, questions were asked only in their native language if the information had also been given in this language.I: “And I also noticed you were quick to translate it into Papiamento”.R: “I translated it myself – it carries more feeling, the Antillean feeling. It has nothing to do with people not being able to understand Dutch or anything like that. It’s all about feeling – you feel more”. Let’s go with the group”, “Take this opportunity”). Ghanaian women responded mainly with a wait-and-see attitude to the health educators’ interactive approach. When the key figure modeled positive interaction with the health educators, the whole group responded with questions and more positive reactions to the health educators afterwards. Subsequently, the availability of a role model who participated in the exercise classes herself and who could be a contact person if constraints emerged during enrollment seemed to contribute to actual participation after indicating interest. This was observed and also explained by a Ghanaian key figure:Third, mothers and key figures described, particularly, the ethnically matched recruiter as a “motivator”. The key figure was most frequently a role model, expressing a positive attitude towards exercising and the exercise program, modeling positive interaction with the health educator, and encouraging participation in the program ”.I: “What was it that made everyone want to take part?”R: “Because I told them it’s for our health and that it would be once a week and that we’d do it with the group. Like that, which was good. [But then later on] ‘the time is changed. So now you come from half past seven to half past eight’, I think it’s a little on the late side, but in fact I said no, I can’t complain. Because if I complain then the women will complain, too. Because everyone looks over at me (laughs)!” Another motivational approach was adaptation of the message by the matched recruiter, unconsciously towards cultural factors and consciously towards mothers’ characteristics and the social network. For example, an Antillean recruiter emphasized that she exercises so she can eat and also stressed the social benefits of exercising with others. Moreover, there were Antillean and Surinamese recruiters who tailored the benefits message to the mothers they knew personally and included such benefits as less back pain, exercising, and some time for oneself. Further, they were able to link people within social networks to each other to exercise together. This seemed to result in greater participation by the mothers reached, especially those mothers who at first were skeptical about the benefits of exercising.mama. Although the people listened they were not open to the information and had negative attitudes and reactions afterwards (“This wasn’t what we expected”).Nevertheless, providing information was not always the best role for an ethnically matched recruiter. There were several examples where incomplete or even inaccurate information was given, which did not benefit participation and was counterproductive for receptivity. For example, in a comparison condition church, the information meeting was inaccurately presented as having a health and a healthy diet focus instead of the health benefits of exercising and an invitation for Big Move mama; the mothers also appreciated this. Only if the recruiter was a health expert herself or was known for her sport activities she felt to be capable of informing and recruiting mothers. Therefore, several key figures from the intervention condition asked the health educator to provide the information, since she was the expert. The Public Health Service of Amsterdam was perceived as a credible source – also because of collaborations with community organizations in the past – thereby creating trust in the exercise program offered. Mothers perceived the health educator as a suitable messenger, especially because she had the knowledge required and she was able to answer questions in detail. Further, the health educator was trusted because of her expertise and her involvement with the target group, her friendliness, and her patience in explaining the program. By hearing from a trusted expert, the women could assess the program for themselves and determine their own feelings about it.Because of this, key figures generally preferred to have a health educator give the most important information about exercising and Big Move R: “I think it’s good that someone from the Public Health Service does it. (…) See, to me, I just see someone from the GGD, you know, they’re not specialized in one thing, but they know a little bit of everything. [Or] she can also give you information along the lines of, ‘my colleague can help you further, ’ that kind of thing. So I do like it that it’s someone from the GGD”.I: “And what about someone from the neighborhood?”R: “Yes, that’s a possibility, but then I hope that person doesn’t get stuck if someone has questions they can’t answer. That comes over as rather unprofessional. So… no, I was glad she was also from the GGD”. I: “And why was it important to you that I explained things?”R: “Well, because (…) you know more about the subject matter than I do. And the only thing I can help with is introducing you to the women. Emmm, I say a little and then, er, you can tell them about it yourself, and I always think that works the best with us, then they know that the person or the expert is getting the message across or giving the information, and then they can [ask] all of their questions (…) And the women felt much the same, they accepted it, so that was good”. Program recruitment through ethnically specific community channels was successful among Ghanaian mothers but less so among Antillean and Surinamese mothers. The more close-knit an ethnic community was, retaining their own culture and with poorer comprehension of the Dutch language, the better mothers were reached through ethnically specific organizations. They came together more often in organizations that had regular meetings with fixed groups and included young women; these organizations were a bridge to Dutch society and services, such as to the Public Health Service of Amsterdam and its health promotion facilities. Furthermore, regardless of ethnic group, we found that using ethnically matched recruiters resulted in higher receptivity, and, among the Ghanaian mothers in particular, greater participation. This was explained by the fact that the ethnically matched recruiter was a familiar, trusted person, a translator, and a motivator because of her enthusiasm and encouragement or message adaptation. To increase recruitment credibility and professionalism, key figures and mothers preferred the ethnic Dutch health expert.The success of using ethnically specific organizations to reach mothers seems to depend on the target community’s characteristics. Our findings reinforce previous findings in that, in the Netherlands, Ghanaians, a more close-knit community, seem to rely mainly on their own channels, while the Surinamese seemed to do this the least . This is supported by a study in England that reported differences in responses to recruitment efforts via the ethnic community that were related to the social network structure, such as how close-knit it was . This chIn addition, this study provided insight into which of the roles of the ethnically matched key figures might enhance recruitment and seemed to relate to the confidence of the individual in the role. These roles included familiar and trusted “natural helpers”, translators, and positive role models. These findings support previous results on the effectiveness of community health workers and effectiveness of their ability to provide tailored and culturally relevant messages ,29. We fThe strength of a process evaluation like this one is that it reveals underlying mechanisms through which interventions influence outcomes, for whom, why, and under which conditions . This smWe recognize that this study design does not allow us to test for statistical significance the quantitative data collected on reach and participation methods. It was our intention that the quantitative data only provide a first impression of whether these methods might contribute to reach. This impression, then, was further explained by the qualitative data, which could contradict, confirm or complement. This process of using various types of data, also known as triangulation, contributes to a better understanding of a given phenomenon  .Finally, as a consequence of the higher reach among Ghanaian mothers, we have more evidence that those key figures can contribute to higher receptivity and participation than among Surinamese and Antillean mothers. In all three ethnic groups, however, qualitative data indicated increased receptivity when key figures were involved. We cannot draw firm conclusions on whether the key figures needed to be ethnically matched. Nevertheless, some explanations for receptivity related to ethnicity-related characteristics of the key figure, skin color and language, according to Ghanaians and Antilleans. We found the strongest indications among the Ghanaian group though, since for them the ethnically specific community organizations were their main channels, and the leaders had prominent roles.Further research on ethnic minority groups that are not as close-knit, that are less organized, and that have local language proficiency is warranted to explore reach and to determine key figure characteristics that promote receptivity and participation. Furthermore, a next step would be to conduct a larger scale effectiveness study to test the actual contribution of ethnicity-based targeted recruitment approaches among close-knit ethnic communities that retain their own culture and language. In these studies the use of general audience–oriented channels would be needed along with the ethnically specific channels as a comparison group.The use of ethnically specific organizations resulted in a successful recruitment for an exercise program in close-knit, highly organized ethnic communities with limited fluency in the local language. Ethnically matched recruiters were most confident being motivators, translators, and positive role models. However, they often needed an expert  for effective information delivery. In particular the involvement of a trusted familiar key figure in combination with the expert during recruitment might have contributed to the increased receptivity and participation in the exercise program.The authors declare that they have no competing interests.MAH collected the data, performed the data extraction, analyzed the data, and drafted the manuscript. VN, SWC, KS, and APV participated in interpreting the results, and critically revised the intellectual content of the manuscript. All authors read and approved the final manuscript.We would like to thank Renée Corstjens and Gwen van Husen, health promoters of the Public Health Service, for their help in the preparation phase of this recruitment study. Thanks to Linda Boateng for her intermediary role with the Ghanaian churches, and to health educators Tamara Vincent and Chantal Goor for their help with several of the comparison groups. We are grateful to the leaders of the community organizations for their collaboration during the recruitment and input for the evaluation. Thanks to Lotte de Schouwer, Arja Schreij, and Maria Besteman for interviewing the mothers and to these mothers for participating. We would like to acknowledge Charlotte Vissenberg for her role as second coder. Finally, we acknowledge contributors of the Health Promotion and Behavioral Sciences Doctoral/Post-Doctoral Research Seminar  for their input in the final revisions of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/768/prepub


Physical fitness is one of the most important qualities in armed forces personnel. However, little is known about the association between the military environment and the occupational and leisure-time dimensions of the physical activity practiced there. This study assessed the association of rank, job stress and psychological distress with physical activity levels .This a cross-sectional study among 506 military service personnel of the Brazilian Army examined the association of rank, job stress and psychological distress with physical activity through multiple linear regression using a generalized linear model.The adjusted models showed that the rank of lieutenant was associated with most occupational physical activity ; “high effort and low reward” was associated with more occupational physical activity  and with less physical activity in sports/physical exercise in leisure ; and psychological distress was associated with less physical activity in sports/exercise in leisure .The results of this study show that job stress and rank were associated with higher levels of occupational physical activity. Moreover job stress and psychological distress were associated with lower levels of physical activity in sports/exercises. In the military context, given the importance of physical activity and the psychosocial environment, both of which are related to health, these findings may offer input to institutional policies directed to identifying psychological distress early and improving work relationships, and to creating an environment more favorable to increasing the practice of leisure-time physical activity. In modern societies, although it is established knowledge that physical activity is beneficial to physical and mental health and, in some countries, policies are in place to increase it, levels of physical activity have decreased over time both in high-income countries , and in In the past 50 years, Brazil has undergone major demographic, economic and social changes, including a rapid process of urbanization accompanied by considerable changes in traditional employment sources and work processes. The important technological advances that have occurred in various fields have contributed to changing the nature of work, including a reduction in physical demands and increased psychological demands . These cThe literature shows that physical activity, when practiced regularly, is associated with lower risk of cardiovascular disease, osteoporosis, diabetes and cancer ,8, as weA considerable number of studies show that job stress has significant impact on individual health , but fewResearchers investigating the amount of physical activity practiced sought initially to understand better how health outcomes relate to total energy expenditure in individuals’ daily activities , which can be measured directly (through equipment such as pedometers or accelerometers) and indirectly (through self-reported questionnaires) . More reThe relationship between stress at work and mental health has been subject to considerable investigation, and the literature shows that an unfavorable work environment is associated with greater prevalence of mental disorders ,21 and tPhysical activity forms an integral part of military life, because physical training is designed to improve the troop’s physical fitness, and is always encouraged and even required. Military personnel’s rank-related occupational characteristics may be associated with the occurrence of job stress and psychological distress . In thisThe Brazilian army conducts a physical fitness test, which includes evaluating cardio respiratory fitness, upper limb and trunk strength, and other physical attributes. It is applied three times a year, and the results are taken into account for career promotion purposes. Although days, times, venues and materials for military physical training are provided at the barracks, the amount of physical activity practiced by each soldier is an individual decision. During these hours, military personnel are entitled to choose what activity they will practice, for how long per session and how many times a week.The literature on the practice of physical activity in the military includes several studies focusing mainly on how factors ranging over aspects of physical fitness training and related nutritional concerns associate with cardio respiratory fitness and with physical health -36. DespThe aim of this study was to investigate how rank, job stress and psychological distress associated with physical activity among military personnel.This cross-sectional study was conducted among all the military personnel of a Brazilian army directorate and the military organizations subordinated to it. The complement was 654 service personnel, of whom 68 (10.40%) were excluded for being away from the directorate indefinitely on missions. The eligible population was 586 service personnel.The questionnaires used were self-administered, and divided into blocks by socio-economic and demographic characteristics, occupational details, and levels of physical activity, job stress and psychological distress.Level of physical activity (outcome) was evaluated using the Baecke Questionnaire  validateJob stress was evaluated using the effort-reward imbalance (ERI) model . This waThe instrument comprises 23 questions covering three facets: effort, reward and over-commitment. Effort refers to the extrinsic effort required from the employee in response to demanding aspects of the work environment; it expresses the subjective perception of workload (6 questions). Reward refers to aspects beyond financial remuneration that include job stability, career opportunities and esteem from chief/colleagues (11 questions). Over-commitment expresses whether coping strategies have been used exhaustively, and thus reflects continued and frustrated efforts, which are related to negative feelings (6 questions). The results are expressed as scores .High effort in combination with low reward in the work environment represents a reciprocity deficit between “costs” and “gains” that leads to a state of active distress and evokes negative emotions. This is the most unfavorable psychosocial situation at work. According to the methodology of the model ,42-44, qPsychological distress was measured using the validated Brazilian version  of the GRank was categorized as follows: “Superior officers and Captains” , “Lieutenants”, “Sergeant-Majors and Sergeants” and “Corporals and Privates”.The covariates were age, education, income, marital status, and lifestyle variables. Income was calculated as per capita family income, i.e., total family income divided by the number of family members living on that income, and was then categorized in Brazilian minimum wages. Lifestyle variables were alcohol consumption and smoking habits. The covariates were considered as adjustment factors for associations among the variables of interest.In order to guarantee the quality of the information in the questionnaires, pre-test, pilot, reliability and reproducibility tests were conducted on the instruments used. Levels of agreement were in excess of 70% in each of the instruments. The authors performed data collection between October 2009 and March 2010 at the directorate and at its subordinate military organizations.Exploratory and descriptive analyses were performed. Reference categories for the subsequent analysis were established as follows: for job stress the reference category, which represents a more favorable psychosocial work environment, is “low effort and high reward”; and, for psychological distress, the reference category was the absence of symptoms (“No”). In order to evaluate how job stress, psychological distress and rank associate with the physical activity scores , bivariate analysis was performed by simple linear regression via generalized linear models.To assess the associations among the variables of interest , the multiple linear regression method was used, with one model being designed for each of the scores (Model 1). The associations were adjusted for the socio-economic and demographic characteristics: age, schooling, income and marital status. For that purpose, multiple linear regression via generalized linear models (Model 2) was performed, and 95% confidence intervals (CI) were calculated to assess the accuracy of the findings. Records with missing data were excluded from the analyses.The data were input into MSAccess 2000, and the statistical analyses were performed using the R platform .All participants signed a declaration of free and informed consent. The Ethics Committee of the Institute of Social Medicine, at Rio de Janeiro State University, approved the study.Of the 586 eligible candidates, 46 (7.85%) refused to take part (their distribution showed no pattern among them). Women were withdrawn from the study because of their small number (34). The total number of participants was thus 506. Their mean age was 29 (±9.77) years. Most were single (49.8%), had per capita income of up to five minimum wages (64.4%), higher schooling (62.3%), and were childless (66.2%).Few participants failed to complete the outcome questionnaire properly, resulting in missing data by dimension as follows: OPA, 5 (0.99%); SEL, 6 (1.19%); PALL, 7 (1.38%); and TS, 8 (1.58%).Table Fifty-two percent of the directorate personnel viewed their work environment as favorable (“low effort and high reward”), and 16.2% showed signs of job stress (“high effort and low reward”).Table Table In Model 2 Table , which eAfter adjustments, job stress continued to be associated with higher levels of OPA , with no major gradient changes. The rank “corporals and privates” ceased to show an association with more OPA, while the rank of “lieutenant” continued so associated , even in the presence of the socio-economic and demographic variables. Psychological distress lost its initial association with more OPA.Job stress and psychological distress maintained their associations with lower levels of SEL  and , respectively.The rank “corporals and privates” lost its association with higher levels of PALL.This study examined the relationship between physical activity and rank, job stress  and psychological distress. The main findings were that job stress was associated with higher levels of “occupational physical activity” and lower levels of “physical activity in sports / physical exercise in leisure time”. In addition, psychological distress also displayed an association with lower levels of “physical activity in sports / physical exercise during leisure”.Siegrist  argues tPsychological distress, which initially had shown an association with “occupational physical activity”, lost that association in the multivariate model. These results suggest that mental health does not influence the amount of physical activity performed in military work routines. Kim et al.  report tThe results for SEL in Model 2 show that both “job stress” and “psychological distress” were independently associated with less “physical activity in sports/physical exercise in leisure time” after adjustment for age, schooling, income and marital status. The coefficients in Models 1 and 2 show no differences, and the statistical association continues of the same order of magnitude.The negative association found between “job stress” and “physical activity in sports/physical exercise in leisure time”, and the absence of an association with “other physical activities in leisure and locomotion”, independent of the covariates, are results that agree with the literature. A cohort study with 10-year follow-up conducted in a population sample (N = 7066) in Denmark found that individuals with high levels of stress were twice as likely to become physically inactive when compared with individuals with low levels of stress . MäkinenIn this respect, Rod et al.  explain This study investigated physical activities practiced during leisure, and the instrument used for measurement took in more detailed information about leisure-time activity types, dividing them into “sports and/or exercises in leisure time” and “other physical activities in leisure and locomotion”. Our results indicate that “job stress” was associated only with less sports activities or physical exercise, and not with other leisure time physical activities, such as walking or cycling. As “physical exercise” is a subcategory of “physical activity” that is planned, structured, repetitive, and engaged in for the purpose of improving or maintaining one or more components of physical fitness , there iThe presence of “psychological distress” was independently associated with less SEL after adjustment for the socio-economic and demographic, health and lifestyle variables, which agrees with the literature. The review study by Jones & O’Beney  noted thOur results show that “job stress”, “psychological distress” and “military rank” are not associated with total score for physical activity, or with “other physical activities in leisure and locomotion”.The exposure variables in this study  can be observed to have different effects on each of the different dimensions of physical activity. Job stress was associated, on the one hand, with higher levels of occupational physical activity (OPA) while, on the other hand, also associating with lower levels of physical activity in sports/exercise. Another important point is that psychological distress was also associated with lower levels of physical activity in sports/exercise (SEL). These findings indicate that the presence of job stress and psychological distress concomitantly would probably lead to even lower levels of such activity. The additional finding that psychosocial factors were not significantly associated with other physical activities in leisure and locomotion (PALL) may explain the lack of association with overall physical activity, which is the sum of OPA, SEL and PALL. There is limited literature available on the relationship between psychological distress and overall physical activity . The samOur findings indicate the need for more studies of the effects of psychosocial factors on the different dimensions of physical activity.The literature shows that few studies have investigated how job stress associates with levels of total, occupational and leisure-time physical activity and with mental health . This stThe first strong point of the study was the participation rate (92%), which is considered very high, and the choice of study population, which was socio-economically and demographically homogeneous, which reduced the likelihood of residual confounders. In addition, as the population sample has the same socio-economic and demographic characteristics as the Brazilian army ground forces overall , the resAnother point in favor of this study is the 1.58% information loss rate, which can be considered small and is reasonable for epidemiological studies.Another strong point is the choice of instrument used for estimating levels of physical activity, because it covers the prior 12 months , and offers important information as regards the types of physical activity, typified as “occupational physical activity”, “physical activity in sports and /or physical exercise in leisure time”, and “other physical activities in leisure and locomotion”, which permitted more detailed analysis of the dimensions that make up the set of physical activities practiced habitually, and thus more minute examination of the different aspects of physical activity and their relationships with other factors that affect health.The proportion of women among the military personnel participating in the study (census) was initially far higher (6%) than in the army overall (1.3%), which could have distorted the results and weakened their power. Accordingly, women were excluded from the analyses. Nevertheless, our findings are still comparable to the studies cited here because most of them analyzed the outcomes stratifying by gender. This methodology has been published elsewhere .One of the limitations of the study stems from its cross-sectional design, which means that temporal relationships in some associations cannot be evaluated, leaving the possibility of reverse causality. Nonetheless, our study is one of the few offering findings on the relationship of psychosocial factors with different dimensions of physical activity.The association found between “job stress” and more “occupational physical activity” suggests that the first may be related to greater effort at work, but it was not possible in this study to determine the direction of the association. The literature shows that physical activity has a beneficial impact on perception of the work environment ,57, and In conclusion, this study showed that “military rank”, “job stress” and “psychological distress” are associated with physical activity. However, this association shows different patterns related to dimensions of physical activity. For those occupying the rank of lieutenant and classified as displaying job stress there is a positive association with “occupational physical activity”, which indicates the relationship with specific occupational characteristics. Whereas “job stress” and “psychological distress” were associated with lower levels of “sports and exercise in leisure time”, rank showed no such association. “Job stress”, “rank” and “psychological distress” were not associated with “other physical activities in leisure and locomotion”. These findings are new, as the authors did not find any other study that has addressed this issue in military personnel.In line with the literature, this study showed that “job stress” and “psychological distress” are negatively associated with “sports and exercise in leisure time”. Since physical activity in sports / physical exercise is associated with physical fitness, and in the professional military context this is highly important, our results can help inform the development of institutional policies directed to early identification of psychological distress and contribute to improving work relationships, by creating an environment more favorable to increasing the practice of physical activity in sports and exercise.The authors declare that they have no competing interests.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/716/prepub


Life course theory considers events in study and work as potential turning points in deviance, including illicit drug use. This qualitative study explores the role of occupational life in cannabis use and dependence in young adults. Two and three years after the initial structured interview, 47 at baseline frequent cannabis users were interviewed in-depth about the dynamics underlying changes in their cannabis use and dependence. Overall, cannabis use and dependence declined, including interviewees who quit using cannabis completely, in particular with students, both during their study and after they got employed. Life course theory appeared to be a useful framework to explore how and why occupational life is related to cannabis use and dependence over time. Our study showed that life events in this realm are rather common in young adults and can have a strong impact on cannabis use. While sometimes changes in use are temporary, turning points can evolve from changes in educational and employment situations; an effect that seems to be related to the consequences of these changes in terms of amount of leisure time and agency . Cannabis is among the most widely used illicit drugs worldwide, with between 125 and 203 million last-year users worldwide –8.Associations between cannabis use, education, and employment have been extensively studied. Longitudinal research has shown that adolescent cannabis use is related to poor educational performance and early school dropout ; degree per se, but the commitment and stability associated with work can reduce deviance  study is part of a broader longitudinal study (CanDep) on cannabis use and transitions in cannabis dependence in young adult frequent cannabis users [see for details ]. FigureIn an additional qualitative sub-study, the dynamics underlying the changes in cannabis use and the transitions in cannabis dependence were investigated with special emphasis on study and occupational changes. We conducted life story interviews, in which users can express themselves through their narratives and thereby can improve our understanding of the processes and the context involved in these changes cf. , 29, 30], 3029, 3From each of the four trajectories at T1, 12 participants were randomly selected, stratified for gender , totaling 48 interviewees. At T2, these interviewees represented seven trajectories Table , 32].We conducted in-depth interviews, using a topic list that included questions about participants’ cannabis use career, i.e., changes in patterns of cannabis use, motives for change in cannabis use, and the occurrence of life events in various life domains. Interviewees were asked to recall changes in different life domains and in their cannabis use patterns between T0 and T1 and between T1 and T2, respectively, using detailed personal timelines cf. , 34]. On. On34)].a priori coding: , transcribed verbatim, and imported into QSR Nvivo. Transcripts were analyzed combining deductive and inductive strategies. Codes and categories were partly developed beforehand, based on the literature [ coding: ]. In add coding: ]. To guaAge of participants at baseline ranged from 18 to 30 years , for some with intervals of no use. At baseline (T0), 29 participants were (near) daily users (5–7 days per week) and the remaining 18 participants used on 3–4 days per week. During the study there was an overall decline in cannabis use frequency. At T2, 20 participants were (near)daily users, 19 participants used at least three times a week but not (near)daily, 3 participants had not used cannabis for 1 year or more and said they had quit permanently, and in the 5 remaining participants cannabis use varied from 1 day per week to less than monthly, including 3 participants who basically considered themselves as quitters, and had been using cannabis only a few times in the past year. Also quantity of cannabis used decreased, from on average 2.9 joints per using day at T0 to 2.4 at T2 (excluding three non-past year users). At T0, 24 participants were last-year cannabis dependent and 23 participants were non-dependent. At T2 this had changed to 13 dependent and 34 non-dependent participants. At baseline dependent and non-dependent interviewees were rather similar concerning mean age at initiation, mean age at baseline, gender and (near)daily use. At T2 cannabis dependent interviewees were more frequently (near)daily users than non-dependent participants, but also in NDN many participants were using (near)daily. Besides, relatively more females than males were dependent at T2.Regarding occupational status, three categories were distinguished: students, employed and neither student nor employed. At baseline, almost two-thirds of the participants (31/47) were fulltime students. At the time of the last in-depth interview some had stopped studying without a qualification, some had graduated, but most (24) were still studying. Type of study varied from a vocational training to academic studies. Most students had a job on the side; some regularly 3 days a week, others every now and then when they felt in need of money. The most popular job among these students was working in cafes or restaurants. At baseline, about a quarter of the interviewees (11/47) were in paid fulltime employment (32 or more hours weekly). At T2 more than one third was employed (18/47), all but one fulltime. By then, some interviewees still worked at the same company, and sometimes had been promoted, while others had switched work several times during these 3 years. The growing number of employed participants is partly explained by participants graduating and then starting their job career, and partly by participants quitting their study unfinished and getting employed. The employment sectors were diverse, for example some worked in bars, others in academic professions. In the course of the study, one participant became unemployed at T2. At T0, the remaining five interviewees were neither student nor employed: three defined themselves as a fulltime parent, one was on social benefits, and one was in a reintegration program (with probation). Of these participants, the one on probation had become a student at T2 and the occupational status of the other four remained unchanged. To summarize, in the course of the study the number of students dropped from 31 to 24, the number of employed  increased from 11 to 18, and the number of participants without study or work remained stable at 5.My study is somewhere on the background in my life. Of course it’s important for me to keep thinking about the future, and it plays a large role in that I have to go there a couple of times every week, and have to study for it, but if I fail a test, I fail a test, that doesn’t really bother me. (…) I’m not much of a scholar, for me the fun things in life are more important. however, most students attached goals to their study, for instance attaining their undergraduate diploma in due time, or getting high grades. some had intermediate study delays, but sooner or later commitment often grew and study became a priority.Now, my school is very important, I don’t want to do retakes, because I can’t choose another study again. My student grant ends at some time and anyhow I have to pay the next three years myself. I want to do it well and timely, not being 30 when I graduate. Imagine I’m 30 and by then I have to start my career, find a husband and possibly have kids. And that has to happen before a certain age. That’s also why I want to pass my exams in one time. In their narratives, interviewees often expressed commitment to study and work, and to strive for a steady job career. Evidently, the more important participants considered their study or job, the more effort they put into it and the more committed they felt.When I’m at work, I’m ambitious. In my last job I got promoted to supervisor within one year, and that is something I want to achieve. I have higher aspirations, and I cannot simply work somewhere for 8 hours and watch the clock. I envy people who are able to do that: have a job, do their work and that’s it. I am not like that; my work always follows me home. Yeah, I’m pretty ambitious. Although the importance that student and employed interviewees attached to their study or work varied, only a few of them felt that it was not very important and that life was more about social activities and “having fun.”Recently I finished that training, and started my own company. It goes really well. I’m much more concentrated in my work after using cannabis. And when I’m programming when I’m stoned, I’m like in the codes straight away, type everything effortlessly. Sober I start thinking about how it’s working, the syntaxes, commando’s, but stoned all of that happens fully automatic. I get into a kind of vibe to program completely uninterrupted. It makes a big difference.” “Almost all student and employed interviewees took it for granted not to use cannabis before or at school or work or when studying mainly to avoid adverse effects and/or out of responsibility.Interviewer: Why don’t you smoke cannabis at work? Interviewee: Well, it’s kind of … On the one hand I think that they wouldn’t be cool with that. I think they want to hire the sober Jacob. On the other hand: sometimes, when you have smoked a couple of joints you lose a little attention to details. And that is something that’s really important in my job, the details. So, not using cannabis at work out of feelings of responsibility, but perhaps also to distinguish work from leisure. Like: you’re not here to chill but to work. Other reasons for not using cannabis at work or at school were fear that colleagues would notice it and fear of possible consequences, such as being taken less seriously or being fired. Most interviewees said colleagues or fellow students did not know about their cannabis use. They believed that cannabis use was a private matter, and preferred to keep it to themselves. The dominant patterns in the narratives was to be rather firm in stating that it was inappropriate to be intoxicated while at work, at school or when studying. Using cannabis belonged to the leisure domain, and they reported that they only used cannabis after finishing study or work. As a result, most employed participants barely used cannabis at daytime, and more on weekends than on weekdays. With students, there was more variation, as their daily life was less structured around fixed hours throughout the week. They sometimes used cannabis at daytime, and more often during holidays. Among the participants without study and work, the three that were full time parents sometimes used cannabis at daytime when the children were at school, but more often at night when the children were asleep; they used less or not at all during school holidays.Most interviewees believed that heavy cannabis use would negatively impact their daily occupational functioning and most of them had experienced adverse effects themselves, such as difficulties getting out of bed the next day, functioning more slowly and sloppy, trouble memorizing, and postponing tasks. However, almost one in five participants (8/47) reported better functioning in some tasks when being high or stoned, mainly because they believed it improved their concentration. With cannabis, they felt like being “in a bubble” and less distracted by other people, actions or thoughts. Interestingly, all these interviewees stated to have ADHD and/or ADD , and some said that cannabis was like “natural Ritalin” or a kind of “self-medication.”I am very strict: when I have to work or go to school I don’t smoke. Well, school … occasionally, when my class begins late, at 2 PM, a friend drops by and then we’ll have a cup of coffee and smoke a joint, but not heavy. The first class is also very boring, I go stare out the window or distract others. It’s perhaps more practical not to be too stoned during lectures, but hey, occasionally it doesn’t do any harm. Sometimes, when the lecture begins at 5 PM, well, I sometimes smoke a joint at 3 PM and I think: I shouldn’t have to. I’m trying to take the study really serious, but sometimes it doesn’t work out and I think: oh well, I’ll do it tomorrow. No one is bothered by it; it doesn’t affect anyone. Despite interviewees generally holding strong views on not using cannabis before and during study or work, some did admit it had happened occasionally. While employed participants seemed to be most strict in not using when at work, students sometimes believed that study differs from work, as there is less social control at college .Not surprisingly given their stage of life, most interviewees reported life events related to study or work that had taken place in the course of our study. In total, participants reported 97 events, averaging 2.1 events per interviewee , all being study-related . Quitting a study was experienced the most ambiguously, mainly depending on whether or not this happened voluntary. In line with Rönkä et al. , we founInterviewees talked about changes in their cannabis use in terms of more use , or less use , or said their cannabis use had not changed (stable use). Negatively experienced events were most frequently associated with stable use (43%), somewhat less frequently with more use (38%), and least frequently with less use (19%). In contrast, positively experienced events were most frequently associated with stable use (72%) and much less frequently with less use (18%) or more use (10%). In more than half of the events, interviewees said that they had not impacted their cannabis use. This mainly concerned events that interviewees perceived as positive, but also as planned and not really changing their daily life, or as neutral. As Wheaton and Gotlib  stated, [about the timeline] The more demanding my study, the lesser I smoke. When I’m free, there is a peak in my use. Let’s see. In June and July I’ve used less, because I worked at a bank for 2 months, nine-to-five job, little leisure time. Then in August, an increase in use, like “long live freedom! Now I can smoke again”. After that, a normal level for a while. December slowly a decrease, because then the exams come closer. January a drop, heavy times and tough exams, 4-5 exams in one week, so then it’s 0-1 joint per day. And then February suddenly again ‘freedom!’, so daily use, 2 joints anyhow. When I have a lot of leisure time, I smoke more and sooner. When I’m busier and more serious, then I smoke less. And that is certainly a correlation, when there is an ascending line with responsibilities and working hard, there is simultaneously a descending line with cannabis use. In addition, agency came to the forefront as an important factor, most clearly in the narratives of students. Several students reported considerable delay in their study, which they all experienced as negative and some were facing a demanding last year of studies. Some expressed a low level of agency regarding their study, did not feel in control, gave up, and subsequently started to use more cannabis.I felt really bad that period. I did go out with friends, but I didn’t do much for my study and I only worked now and then. I didn’t give it my all. I smoked a lot and I started to use that, as an excuse. I had no priorities, things just happened. Life happened to me, and I sort of endorsed it… In contrast, other students chose and managed to restructure their daily life and to study hard, and, although they did not necessarily blame their study delay on cannabis, they actively reduced their cannabis use. They all stated that they were highly motivated to change their cannabis use and were convinced that they could succeed. In the course of our study, three participants reported to have quit using cannabis, giving their occupational life as the main reason, as they thought cannabis was not conducive to their functioning. They said that quitting did not occur overnight, but was a gradual process: they went from daily use to only in weekends, and step-by-step cut back. At the last interview they had not used cannabis for over a year and neither had the intention to start again.My medical study was suffering from my cannabis use. Whenever I have an exam I have to study very hard, a full week every day, spending the whole day in the library, otherwise I won’t make it. When I was using cannabis, being there at 8:30 AM was a problem anyhow, because I couldn’t wake up early. Also, after 3 PM I didn’t feel like studying anymore, no concentration, I wasn’t able to memorize things. Factual knowledge doesn’t go together with cannabis use. I always stopped using a week before the exams, but you need three days to get active and to get adjusted, and in fact you’re too late. Also, smoking cannabis at night does not go well with lectures early in the morning. I often overslept and didn’t go. All in all my study delay was one year. Last year, I decided: I don’t want to use cannabis, I want to catch up on my study. And I did! Now I do great, I pass the exams, so I shouldn’t smoke anymore. The difference between when I was smoking cannabis and now is huge.(…) I feel in control of my life now more than ever. Of the six participants who lost their job during our study, no one reported this was related to their cannabis use. While one could argue that cannabis may have affected their functioning and thus indirectly caused job loss, this did not seem the case as mostly their dismissal was due to cut-backs related to the crisis.Generally, increases or decreases in cannabis use were transient, and according to the interviewees these changes in cannabis use largely depended on changes in the amount of leisure time that went along with events or temporary changes. For instance, becoming unemployed or having a quiet study period led to more leisure time and thereby more cannabis use, whereas a new job or a busy study period led to less leisure time, and consequently to less cannabis use.per se in conjunction with events. For students such stress mainly involved study delays and exam periods, especially their final project or master thesis. For employed interviewees it was largely connected with deadlines, having to work too many hours and reorganizations or job loss. Participants without study or work perceived stress mainly related to financial problems and sometimes parenting. Stress came with ups and downs, and could have a strong impact on participants’ mood and everyday life functioning, including cannabis use. Some interviewees explained how cannabis use could be functional in dealing with stress, because it helped them to distract their mind, making it easier to relax and taking a moment for oneself. For some, smoking a joint at the end of the day was also a reward for their hard work. Consequently, it was not uncommon for interviewees to explain increases in their cannabis use by stressful and busy times.When I’m stressed, or more stressed, then I’m gonna smoke more. Just to forget a bit. It won’t solve anything, but for the moment it does, you can simply let things go. When I’m stressed, the urge to smoke increases. I don’t know if that’s positive or negative, probably not positive, but hey, it gives me some peace. By then I think: ok, now I have a break, it’s ok now. If I don’t have that break I’m a bit stuck with that frustration. Additionally, it relaxes me. Except that the next day at work I’m a little less alert and probably it’s not beneficial, but at least it relieves the evening itself. Conversely, other participants explained a decrease in their cannabis use by stressful times. Some thought that with stress cannabis use was not helpful, since it might intensify emotions and lead to more stress or worries. For some others, like Kevin, using less cannabis in times of stress was not so much because of possible unpleasant effects, but primarily a matter of time and personal choice.Interviewee: At that time I used less. See, when you’ve had a really busy day and you come home at 8 PM and you want to go to the gym and cook a meal and also have to smoke a joint and get up at 7h the next morning, no, that won’t work. Interviewer: To what extent is it about priorities? Interviewee: Yeah, it depends on your priorities, but for me it’s not cannabis, I prioritize my job. No, when I’m stressed I’m not going to smoke more, but less instead. In five participants, chronic stress ended in a situation of “burnout.” They all experienced this as very negative and it took them at least a couple of months to recover. Two of these interviewees thought their cannabis use was worsening their mental health and stopped using (one permanently and one temporarily with the intention to quit permanently). One of these interviewees remained stable in her cannabis use and two others used more cannabis during their burnout and said that this was because they had more leisure time.A recurring topic in many narratives was stress related to study or work, though not n = 12) and transitions from dependent at baseline to non-dependent at T1 and T2  being the most common trajectories , some patterns seem to become manifest. In response to occupational events, interviewees who were non-dependent at T2  mostly had not changed their use (49/75 events) or rather equally often used less (14/75) or more cannabis (12/75). Interviewees who were dependent at T2 , though they also quite often said that their cannabis use had not changed because of events (9/22 events), were somewhat more likely to use more (10/22) than less (3/22).Although numbers of participants in most trajectories are small Concerning occupational status  and trajectories some interesting patterns emerged. Firstly, many participants remained student during our study 23/47) and, although they can be found in six different trajectories, the overall tendency over time is away from cannabis dependence Secondly, all seven students who became employed, either after quitting their study (by choice or involuntary due to poor performance) or after graduation, were non-dependent at T2. Four (with stable or reduced cannabis use) showed a persistent non-dependent trajectory (NNN) and three shifted from dependent to non-dependent  in the same period as their occupational status changed from student to employed. Although this shift co-occurred with change in occupational status, it was not necessarily induced by events related to study or work. Mike (DNN), for example, said that between T0 and T1 he felt that the use of cannabis sometimes made him a bit paranoid. Therefore he decided to decrease his cannabis use, and finally he quit. In the meantime he discontinued his study and started working fulltime. Similarly, Isabel (DNN) expressed that the way she used cannabis evolved as part of a general change in lifestyle rather than specifically because of a shift in occupational status from study to work.Like with other things, you need to find a certain balance in cannabis use. For cannabis I have found that balance, I guess. I have that for a year now. Also because I live on my own now, I really got to know myself. You’re alone, there is nobody else around. It has changed me, made me more independent. Regarding the group that remained employed (10/47), no clear patterns in trajectories could be observed. These participants were represented in six different trajectories . At T0 this group included four dependent participants versus five at T2. The extent to which employed participants said that they were committed to their job varied, and also their type of job, but this did not appear to be related to their cannabis dependence status. However, sometimes change in cannabis use did not result in a dynamic trajectory, as was the case with Jonas, who stated that over time he had taken more control over his cannabis use, but was diagnosed as persistent dependent (DDD).The regularity got out of my cannabis use. I used to smoke every day, a joint before bedtime, perhaps one in the early evening and when I had a day off I could sometimes start in the afternoon. Well, that’s not really something to be proud of, and I always thought: if I want, I can stop using. It was time to prove that. It was a rude awaking [laughs]. Before, I didn’t try to control my use, I never saw the need to. But I began to feel the effects: the relatively easy college life was over, employed life was more demanding, and I had to better take care of myself. Perhaps I still don’t fully regulate my use, I sometimes have relapses. It’s difficult, because after I haven’t been smoking for a while, I think: why not smoke? I don’t have any problems with my use, I’m functioning fine, also when I smoke. I can do my job well, or quite well and my social life as well. Also in the case of the other participants (7/47) no consistent patterns could be observed in the relationship between cannabis dependence trajectories and (events in) the occupational domain. Alternatively, agency, more specifically their ability to regulate their cannabis use appears to be related to (transitions in) their dependence status. This became most clear for three participants with young children in the neither group . During our study these three mothers experienced the event of one or two children going to school for the first time, which created a considerable change in their daily time schedule. Although they all underlined not to use cannabis in presence of their children, the way they organized their cannabis use was quite different. Samantha (NNN) believed to be in control over her cannabis use. She used cannabis mainly at night, before going to sleep, and only after she had taken care of her daily responsibilities. Contrariwise, Charlotte (DDD) said that her kids often arrived too late at school, because she had difficulties getting up in the morning, and that she smoked a joint right after she had brought her children to school, even though she knew that by doing so she often postponed her daily tasks. She felt addicted, not in control over her use and in both in-depth interviews she said she would want to quit. Nathalie (NDN), on the other hand, often used cannabis after having finished her daily tasks, but between T0 and T1, when her son started to attend school, she experienced a period that she used more frequently and also in the morning. In retrospect, she believed during that time she was addicted to cannabis, and she had decided to change her use and to (successfully) retake control over it.In contrast, four of the five participants who remained student and who were dependent at T2  expressed in their narratives a lower level of agency regarding their study, e.g., reported that they did not take their study very seriously, or did not spend enough time on it.In this qualitative study we explored the role of study and work in cannabis use among a group of young adult initially frequent cannabis users. We were particularly interested in analyzing how study and work, and more specifically events related to these domains, contributed to transitions in cannabis use and dependence. We interviewed 47 young adults in-depth twice retrospectively covering a period of 3 years. All interviewees were frequent cannabis users at the start of the study (T0). During the follow-up period, there were wide variations and strong dynamics in their patterns of cannabis use, the presence of cannabis dependence, and their occupational situation. Overall, there was a declining tendency in frequency and quantity of cannabis use, including a few interviewees who had quit using cannabis altogether at the second in-depth interview. Various trajectories concerning cannabis dependence appeared. One quarter of the sample remained persistent non-dependent during the study. Some participants were persistent dependent, and others switched from a dependent to non-dependent status and vice versa, yet, at the end of the study more participants were non-dependent than at baseline .Almost two-thirds of the interviewees were students (often with a job on the side) at baseline and remained student during the total study period. Most other participants were in paid employment, and in the course of our study some students became employed as well, indicating that long-term frequent cannabis use does not necessarily restrain individuals in their professional life cf. , 38]. Mo. Mo38)].As expected in this age group (mean age 21 years), life events related to study or work were quite common, nearly all participants experienced at least one such an event. Overall, participants evaluated slightly more events as positive than negative. Similar events could be valued differently, and it was evident that agency did matter. In line with Rönkä et al. , events We also found indications for reverse causation, i.e., changes in cannabis use can lead to changes in study or work. Several interviewees, because of events such as study delays, or (expected) stressful times, gradually managed to rigorously cut back or even quit their cannabis use, which eventually was conducive to their occupational performance. Overall, interviewees, who considered their study or work as being rather important, were more committed and motivated and were more willing to rule out any possible influence of their cannabis use on their occupational functioning.Inspections on occupational events in relation to cannabis dependence (trajectories) revealed that in response to events, participants who were non-dependent at T2 mostly had not changed their use, or equally often used less or more cannabis. In contrast, interviewees who were dependent at T2 were more likely to use more rather than less in response to (negative) occupational events. Besides, interesting patterns emerged concerning occupational status . Among participants who remained student during our study, the overall tendency over time was away from cannabis dependence. The students who switched to non-dependence found their study, as it progressed and became more demanding, hard to combine with frequent cannabis use and decided for more control, through being more selective in timing and frequency of use. All students who became employed during our study were non-dependent at T2. Besides, none of the students who entered the workforce were dependent at T2, although the transition was not necessarily induced by study or work events.For other participants, including those who remained employed, no clear patterns in trajectories could be observed. Alternatively, agency, more specifically their ability to regulate their cannabis use, appeared to be related to (transitions in) their dependence status.has as well as to the amount of leisure time one creates to use cannabis. As our findings show the relationship works both ways, this provides a nuance for the debate on the “amotivational syndrome.” Our study also supports previous research stating that occupational stress can bring about an increase in drug use  and frequent cannabis use and dependence. On the one hand cannabis use and dependence impact occupational life either negatively, in terms of worsened occupational functioning, or positively, e.g., when users deliberately cut back on or stop using cannabis to improve their professional performance. On the other hand our findings support Laub and Sampson’s  line of drug use , yet, midrug use , 38] or drug use . Regardidrug use , and a pOur findings add to the growing insight into the relationship between occupational life and cannabis use of young adult cannabis users. Nonetheless several factors might limit the results of this study.An enriched sample was selected, and therefore we cannot guarantee representativeness. However, this does not necessarily mean that the sample is highly biased. Our sample includes many students, but being a student is rather common for young adults in the Netherlands. Cannabis use and occupational status in our study were quite dynamic, but to some extent this was affected by the study design. We deliberately included dynamic dependence trajectories between T0 and T1 for in-depth interviews. More generally, our sample of young adults is likely to be dynamic or even volatile in different aspects, including education and employment. From the life course theory perspective, a decline in cannabis use during young adulthood was to be expected with aging.Moreover, we investigated the process of cannabis use in the periods between interviews (T0–T1–T2), whereas cannabis dependence was dichotomously captured in diagnoses of dependence versus non-dependence, based on the presence of symptoms within a certain period. Not only could much variation underlie these diagnoses, since they refer to the time between two interviews, also the “effect” of an event related to study or work on cannabis dependence might not have been revealed, and only become apparent afterward, in a next interview. Likewise, participants who had stopped using were categorized as non-dependent, while they were actually non-users.Furthermore, it should be noted that some results presented here may not be universally replicable because they are related to the country where the study is conducted. Dutch policy officially tolerates possession and sale of small amounts of cannabis, and this may limit extrapolation of our results to countries with formal penalties. Yet, we intended to explore in-depth the role of study and work in cannabis use and dependence rather than to portray a representation of all cannabis users. Although research suggests cannabis laws have little impact on cannabis use patterns of regular users , theFinally, as mentioned before, our analyses are based on the narratives of the interviewees, and they largely create their own reconstructions of their cannabis careers and lives. Consequently, their self-perception and self-reflection formed the foundation of our analyses and interpretations. It should be noted that when interpreting the results, all data were based on self-report. We mainly looked into the subjective, not objectified, meanings of  events. Although subjective, participants’ evaluation of events often corresponded with how one would categorize them objectively (from an outsider’s perspective). Also the use of context-based timelines, including data participants (quantitatively) reported intermediately, positively contributed to the recall of their lives and cannabis use. More importantly, our approach gave novel insights in the perceptions, experiences, and attributed meanings of participants, which is reflected in the emerging importance of agency in the narratives. For example, although many interviewees stated that they had to learn by their own experience how cannabis use can impact job or study performance, most prioritized their obligations, out of personal motivations or an overall strong work ethic.How can we explain that occupational events left cannabis use largely unchanged? An explanation could be that for young adults, events such as a new study or a job switch are quite normal and part of a normal career. In fact, sometimes these events were not changing participants’ daily lives. Besides, cannabis use appeared to be primarily a leisure activity. These findings relate to the normalization thesis, which suggests that in the past decades, for many users cannabis use has become a normal part of their life, which includes clear choices about whether, where and when (not) to use , 46. CanLife course theory appeared a useful framework to explore how and why education and employment are related to cannabis use and dependence over time. Our study showed that life events in the realm of education and employment were rather common in young adults’ lives and can have a strong impact on their cannabis use. Changes in cannabis use are sometimes temporary, but turning points in cannabis use careers can evolve from events in education and employment, as became most clear for the interviewees who fully quit using cannabis. To conclude, and similar to desistance from crime, cessation of cannabis use often is a gradual process, in which agency plays a major role. Besides, regarding the occupational life of young adult cannabis users, leisure time is a (important) factor underlying changes in frequent cannabis use.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.