The idea of using serious games to effectuate better outcomes in health care has gained significant traction among a growing community of researchers, developers, and health care professionals. Many now recognize the importance of creating evidence-based games that are purposefully designed to address physical and mental health challenges faced by end users. To date, no regulatory resources have been established to guide the development of serious games for health (SGH). Developers must therefore look elsewhere for guidance. Although a more robust level of evidence exists in the research literature, it is neither structured nor is there any clear consensus. Developers currently use a variety of approaches and methodologies. The establishment of a well-defined framework that represents the consensus views of the SGH research community would help developers improve the efficiency of internal development processes, as well as chances of success. A consensus framework would also enhance the credibility of SGH and help provide quality evidence of their effectiveness.This research aimed to (1) identify and evaluate the requirements, recommendations, and guidelines proposed by the SGH community in the research literature, and; (2) develop a consensus framework to guide developers, designers, researchers, and health care professionals in the development of evidence-based SGH.A critical review of the literature was performed in October to November 2018. A 3-step search strategy and a predefined set of inclusion criteria were used to identify relevant articles in PubMed, ScienceDirect, Institute of Electrical and Electronics Engineers Xplore, CiteSeerX, and Google Scholar. A supplemental search of publications from regulatory authorities was conducted to capture their specific requirements. Three researchers independently evaluated the identified articles. The evidence was coded and categorized for analysis.This review identified 5 categories of high-level requirements and 20 low-level requirements suggested by the SGH community. These advocate a methodological approach that is multidisciplinary, iterative, and participatory. On the basis of the requirements identified, we propose a framework for developing theory-driven, evidence-based SGH. It comprises 5 stages that are informed by various stakeholders. It focuses on building strong scientific and design foundations that guide the creative and technical development. It includes quantitative trials to evaluate whether the SGH achieve the intended outcomes, as well as efforts to disseminate trial findings and follow-up monitoring after the SGH are rolled out for use.This review resulted in the formulation of a framework for developing theory-driven, evidence-based SGH that represents many of the requirements set out by SGH stakeholders in the literature. It covers all aspects of the development process  and is transparently described in sufficient detail to allow SGH stakeholders to implement it in a wide variety of projects, irrespective of discipline, health care segments, or focus. Develity data -7. To beity data . This trity data -11, has ity data ,13.Developers who intend to market their SGH interventions to clinicians and patients will also need to deliver convincing evidence of the game’s ability to safely achieve the intended outcomes if they wish to overcome the current barriers to uptake. As only a few validated tangible success stories exist, many clinicians are skeptical about the use of SGH in current health care practice. These barriers may hinder medical and scientific progress in certain fields and impact the investment risk associated with developing SGH. Although the development cost can vary greatly depending on complexity, graphical and technical design features, and the time spent on scientific substantiation and  evaluation, it typically ranges from ten to several hundred thousand dollars . When coTo create theory-driven, evidence-based SGH, developers should collect and integrate scientific evidence and data throughout the entire development life cycle—from early stage theoretical work to later stage evaluation ,7,15,16.In the absence of a regulatory framework, developers must look elsewhere for guidance on suitable approaches for developing SGH. Although a more robust level of evidence exists in the research literature, it is neither structured nor is there any clear consensus. The few resources that do exist are often focused on only a fragment of the development process, such as technology aspects or pedagogical aspects ,18. OtheThis is in fact what happens. SGH developers currently use variable frameworks, differing guidelines, and alternative methodologies in SGH development ,19. The The objective of our research was to search the literature and identify and evaluate the requirements, recommendations, and guidelines proposed by the SGH research community on the development of SGH. This included recommendations on what inputs are required to guide the development, what data should be collected, how games should be tested, which stakeholders should be engaged, and what game design approaches should be considered. On the basis of the findings, a clear and easy-to-implement consensus framework was developed to guide developers in the development of theory-driven, evidence-based SGH.A critical review of the research literature was performed in October to November 2018. The following databases were searched electronically: PubMed, ScienceDirect, Institute of Electrical and Electronics Engineers Xplore, CiteSeerX, and Google Scholar. A 3-step search strategy was used. An initial limited search was undertaken using the search strategy (game OR games) AND , where * represents a wildcard to allow for alternative suffixes. This was followed by an analysis of the text words contained in the title and abstract and an analysis of the index terms used to describe article. A second search using all identified keywords and index terms was undertaken across all above databases. Finally, the reference list of all identified reports and articles were searched for additional relevant studies. A supplemental search of guidelines from regulatory authorities was also conducted to capture the requirements of these specific stakeholders. Three researchers independently evaluated the identified articles.Included papers were empirical research studies, literature reviews, opinion pieces, preliminary research, randomized controlled trials (RCTs), theoretical models, conference proceedings, conceptual frameworks, or design documents that (1) reported on the development or evaluation of a serious game for use in a health care context, (2) were published in English, (3) were published between January 2007 and November 2018, and (4) were peer reviewed.Excluded were any articles that (1) contained abstract only, (2) reported on serious games with applications outside of health care , and (3) focused on pedagogical or psychological theory with no link to serious games.After screening, requirements relating to the development of SGH were extracted from each of the papers. These requirements were coded using the following steps, on the basis of a thematic analysis approach:Requirements of SGHs that were described, identified, or documented within the included studies were collected verbatim.Existing frameworks -5 withinThe verbatim requirements from step 1 were reviewed individually, and duplicates (variations of the same underlying requirement) were removed. Again, the resulting term was selected by 1 researcher (CB) and reviewed and agreed by the other 2 researchers.The requirements from step 3 were compared with the accepted terms from step 2 and, if deemed appropriate, the former were categorized within the latter. One researcher (CB) performed this step first and the coding was discussed and confirmed by the other 2 Researchers.The coding was performed to facilitate understanding and to address parsimony, which is threatened by nonconsensus descriptions, terminology variations, etc.Our initial search yielded 216 papers (excluding duplicates). Of these, 74 papers were included in the review. See Out of 74 articles included for review, 11 articles stress the importance of employing an evidence-based, theoretically driven approach toward developing SGH. We identified both the research methodology and game design methodology requirements. The former includes the selection of clear outcome objectives at an early stage of development, as well as an evaluation of the game’s ability to achieve those objectives at a later stage. Without considering an overarching research methodology at the outset, game developers will be challenged, or will be unable, to evaluate their games with well-designed research studies. Kato identified the following 3 questions that ought to be answered by a research methodological approach: Who is your target audience? What is the primary research goal? How can the goals be reached through gameplay (relevant theories and models) [Out of 74 articles, 21 articles advocate involving stakeholders from various disciplines in the development process. This is not surprising as SGH have emerged at the nexus of a wide variety of disciplines such as game design, software engineering, user experience design, health care, psychology, pedagogy, and clinical research. Various stakeholders were cited as relevant for inclusion in the design process, including research experts, clinical experts, regulatory authorities, and policy makers. Many acknowledge that a multidisciplinary approach poses a challenge, as individuals with differing backgrounds use differing terminology; it also highlights the importance of different elements and may be unaccustomed to working closely with those outside of their field. Nonetheless, this challenge is considered a necessary one. Importantly, 16 articles explicitly suggest also involving the target audience in the process.A participatory or user-centered design process uses input and opinion from end users to inform a game developer’s choices. Although many acknowledge this as an important criterion for development, particularly in the field of mental health ,79, therAn iterative development approach was put forward by 6 articles. By developing SGH in segments, testing, and refining along the way, various stakeholders can inform at critical points of the development cycle, and development costs may be reduced.Out of 74 articles, 7 articles highlighted the need for an approach that helps optimize the use of time and resources during development. This is particularly relevant for projects with limited development or research funding and SGH that focus on small market niches with limited potential for return on investment. There are particular challenges related to SGH that need to be managed: (1) helping multidisciplinary teams communicate and work together, (2) the slow process of research evaluation, and (3) the iterative prototyping process on the basis of user and expert feedback ,38.SGH developers increasingly use approaches inspired by Agile project management methods with SCRUM ,39,80. AOut of 74 articles, 30 articles cited the need to conduct quality evaluations and trials to validate SGH. This criterion is associated with the need to employ a high-level research methodology. The most important aspect of this criterion is likely the word quality, as there have been many trials of SGH, but only a few have reached a standard that can be considered high quality. Although it is evident that conducting a quality trial to validate SGH is a pivotal criterion, there is little consensus among the SGH community on what constitutes a quality trial. Many SGH trials only evaluate aspects, such as user experience, or technological aspects. Although this provides valuable information, it does not automatically allow for an assessment of how effective the game is at achieving the intended outcomes or the purpose for which it was designed. Drawing from the established research standards, a quality trial should include the use of a control group, participant randomization, an adequately powered trial, and objective measures of the primary and secondary outcomes.Consistent with this thinking, several articles suggest that game developers should strive to carry out RCTs. Although these types of studies may not be necessary or relevant in all cases, RCTs are the still considered the gold standard for evaluating interventions in health care. Here, it is vital for game developers to work alongside stakeholders with expertise to determine the most relevant trial that will validate their games’ claims. The elements that need to be investigated are dependent upon the development stage of SGH. For example, at an earlier stage, SGH stakeholders suggest investigating usability, user experience, and duration of play.For true evaluation, which typically occurs at a later stage of development, SGH stakeholders have identified the importance of evaluating a game’s efficacy (level to which it achieves intended objectives) in addition to its safety. The need for empirical evidence of efficacy and safety is consistent with requirements of health regulators, should SGH developers intend to have their product approved as a medical device.Mixed-methods research, where both qualitative and quantitative data are gathered, is becoming an important methodology to investigate complex health-related topics. We identified several articles that highlight the need for better integration of these methods in the SGH research -43.SGH developers should endeavor to disseminate their findings to the SGH and wider health care community. This criterion was addressed in 5 articles. Consistent with other areas of health care where researchers are urged to publish all results, even negative ones, game developers should follow suit. This provides valuable evidence to the SGH community and may inform other researchers about what did and did not work for a target audience and game design. This is particularly important in assessing the effectiveness of serious games in relation to the constructs used in the design of the game.In contrast to the high-level, or meta-level, requirements described above, the researchers also identified 20 low-level requirements from the SGH community. These requirements generally fell into 3 main categories: inputs, models and theories, and game design. Inputs represent the information and evidence that are integrated into the game from a conceptual perspective and cover the clinical or scientific content. SGH stakeholders clearly identified the importance of having a strong understanding of the target audience and their needs, clearly defining a research goal from the outset of a project. Models and theories were also identified as key requirements. This category represented the theories describing why a game would be expected to impact intended outcomes, and it also represented the associated link between these theories and game mechanics at the implementation level. SGH stakeholders suggest that without considering and integrating theories and models into SGH development, the resulting games are bound to be ineffective. The final and largest category of requirements contained all components related to the creation of the game itself. The category of game design comprised everything from defining one’s game authoring tool, engine, platform, and genre to the rules, challenges, and feedback that are integrated within the game. As identified in the models and theories categories, SGH stakeholders noted the importance of mapping the game inputs and model and theories to the game implementation choices and mechanics. Without this link, it is not possible to evaluate if the evidence and thinking captured in the former categories have been truly translated into the game.On the basis of the requirements suggested by the SGH research community, we propose a framework for developing SGH that comprises 5 distinct stages . Each stSound scientific foundations for the SGH should be established at the earliest stage of development. This will ensure that the final product is relevant, theoretically driven, and evidence based, in line with governing research methodological approaches. Although most developers tend to initiate the development process with a specific idea for an intervention in mind, the overarching objective of this stage is to assess at least conceptually and theoretically, on the basis of objective criteria, whether there is indeed a relevant medical unmet need for a clearly defined target audience who can be addressed with an SGH intervention. This stage typically comprises a topline review of the available literature on the target audience, disease status and impact, available treatment modalities, relevant clinical outcomes, psychosocial aspects (if any), and the governing health care landscape. To approach this task methodically, we propose that developers should focus on answering the following 4 questions: (1) Who is the target audience? (2) What outcome needs to be achieved? (3) How might SGH achieve this outcome? and (4) How can we evaluate whether SGH achieve the intended outcome?A first, limited profile of the intended end users should be constructed. Information can be obtained through literature review, explorations of Web materials such as patient fora and websites, or consultation with subject matter experts . At this stage, the profile should at minimum cover who the target audience is, the context in which the people function, the specific problems they face, and what their unmet needs are . On top of this, some details may be required that are game- or topic-specific. For example, if the game intends to help children with disabilities improve their motor skills, it is important to understand the disease status and specific medical needs. For a game aimed at helping patients with schizophrenia reintegrate in society, the profile should also include an overview of the other stakeholders who play a role in these patients’ lives and the relations among them . At the other end of the spectrum, a game intended to educate medical professionals on how to handle ethical dilemmas would require some level of insight into the context in which these professionals make decisions, their learner profiles, and pedagogical needs. In stage 2 of the development, this first limited profile will be broadened to also include information regarding the specific game design needs of the target audience .Outcome objectives should be clearly formulated before any creative or technical development starts. These outcomes should be  relevant, based on objective criteria. Due to the nature of SGH and their ability to educate, empower, and address multiple domains of health, we propose a biopsychosocial approach toward identifying relevant outcome objectives . This moAlthough outcome objectives may range from clinical to pedagogical, psychological, or behavioral, it is important to primarily identify a single primary outcome objective. This will steer the subsequent steps of game development and provide the greatest opportunity for success. This does not exclude a developer from identifying secondary (or even tertiary) outcome objectives as well. In fact, many cases will require the identification of various secondary outcomes that are closely linked to the primary outcome, and these need to be incorporated in the game construct as well. To give a few examples, if improved therapy compliance is the primary outcome objective, secondary outcomes may be to improve the quality of the patient’s relationships or provide a more stable home environment , or the secondary outcomes may be to overcome the patient’s misconceptions or erroneous beliefs about the therapy  ,87 or toAn often-overlooked step in SGH development is to formulate a hypothesis of how a game might achieve the intended outcome objective(s). Formulating such a hypothesis is a vital step toward the purposeful design of SGH and the evaluation of their causal effect on the outcome. First, developers should identify the outcome determinants. Outcome determinants are the underlying factors or parameters that directly or indirectly determine or influence the outcome objective. For example, if the primary outcome is to reduce peri-operative pain in children and the secondary outcome objectives are to reduce these children’s peri-operative anxiety and stress (which are closely related to the primary outcome objective), it is important to establish what underlying factors contribute to pain, anxiety, and stress in children in this situation and evaluate which of these factors a game might positively or negatively impact, and how. The literature reveals that pain has sensory, emotional, cognitive, and behavioral components that are interrelated with environmental, developmental, sociocultural, and contextual factors . One detThe identification of these determinants and relevant underlying models or theories should occur in consultation with experts from relevant disciplines. From a biopsychosocial perspective, the link between psychosocial determinants and clinical outcome also needs to be understood and integrated in the game design. In addition, the role of the target audience as well as all relevant stakeholders needs to be evaluated. As such, this step of the process is one of identifying the various factors that contribute to the problem, grouping them, charting how they relate to and impact one another, and establishing hierarchies and relative weights of impact and importance. These insights will inform the game construct, narrative scenarios, and mathematical algorithms further on in the development process.Before development starts, developers need to think ahead of how they plan to evaluate whether the game achieves the intended outcome(s). In 2012, Kato first formulated guidelines for conducting high-quality evaluations of SGH [Game evaluation should also include an evaluation of broader intervention characteristics, such as perceived relevance, user experience, and user friendliness. The particular characteristics that need to be evaluated vary depending on the objectives, and they may include satisfaction of needs , ability to engage, level of motivation, and competence autonomy. Ideally, a mixed-method methodology is used, in which both quantitative  and qualitative  data are collected for analysis and evaluation.This evaluation can be done throughout the development process through a series of iterative tests with the target audience and other stakeholders, using standard measures such as Intrinsic Motivation Inventory and Player Experience of Need Satisfaction Scale ,90.Game developers can draw from a wide range of game mechanics, design, and technological features to construct SGH. If the SGH are to achieve the intended outcomes, the choice of these game mechanics, design, and technological features should be guided by the scientific foundations established in stage 1. It is imperative to translate the theoretical basis into relevant, implementable game design elements. This stage therefore aims to answer the following 3 questions: (1) Which game mechanics are best suited to achieve the intended outcome objectives? (2) What are the design requirements? and (3) How can the game design best accommodate the evaluative trial?understanding or the acquisition of a specific skill set . Depending on the type of outcome envisaged, there may be layers of intermediate learning objectives that need to be addressed. Here, the pedagogical or behavioral intents should be mapped to a low-level game mechanic implementation. In 2015, Arnab proposed a model for translating learning objectives into learning mechanics and mapping these to relevant game mechanics [understanding and retention. Several learning mechanics address these thinking skills: exploration, repetition, and planning. Each of these learning mechanics can in turn be mapped onto one or more game mechanics, for example, story, cascading information, and strategy and planning. As such, the scientific foundations established in stage 1 can be translated into the game construct.Game mechanics are rules or methods that define the interactions and flow of a game session. They describe interactions, game conditions, and triggers in an abstract manner. The most frequently employed game mechanics in electronic health are currently rewards and feedback , but othechanics . This soAt this point, the target audience profile needs to be broadened to guide the design choices. Although the specifics will depend on the objective and scope of SGH, the objective is to gain insight into (1) the context of use and (2) the reality of the target audience. What context will the tool be used in? Will there be access to special equipment or technical support? Will the tool be used at home or in hospital? How realistic does the tool need to be (level of fidelity and immersion)? If it needs to be realistic, what characters does the target audience meet or interact with? What type of environments do they move about in? What situations or dilemmas do they typically encounter? In addition, information regarding optimal user experience for the target audience should be collected. This includes computer literacy skill levels, literacy and numeracy levels, and possible physical or mental limitations that may pose restrictions on game design . This type of information can be gathered through interviews, time-and-motion exercises , or focus groups with the target audience or relevant experts.Are there any design considerations with respect to the future evaluation of the SGH? For instance, if data need to be collected, should this data collection be included in the game design?  Will it be collected out with the game format . Does it require live feedback or investigator intervention during game play? Are there any design considerations for use in a clinical environment? Should the game design include components that can help track or assess user experience ?Once stage 2 has been completed, developers should have sufficient scientifically grounded input to guide the practical development of the game. Various approaches can be used depending on the complexity, the developer’s resources, and software and technological skills, but overall, the process comprises the selection and development of the (1) game genre, (2) game rules, (3) content, and (4) visuals and user interface. This stage ideally occurs in an iterative, participatory manner, involving key stakeholders such as clinical experts and target users to informally test and refine the tool along the way.The scientific and design foundations developed in stages 1 and 2 should now enable developers to select the most appropriate interface genre  and procedure genre  for the intended target audience and context of use. The genre chosen should facilitate the incorporation of the game mechanics and design requirements identified under stage 2.There are several authoring tools available for game development, and it is important to assess upfront which authoring tool is most suitable for the project. This will largely depend not only on the technical capabilities available in the team  but also on whether future administrators of the SGH will need to make their own modifications, such as adding new narratives or including new data measurements. Considerations should be given to open-source authoring tools versus licensed authoring platforms.Developers can now draw up a set of game rules that specifies how the player’s actions impact the game environment. Depending on the intended purpose of the tool, these rules may need to be consistent and transparent  or hidden or unpredictable (to force players to truly reflect on their choices rather than making decisions that help raise game scores). Such rules are often described in mathematical algorithms that govern the tool’s programming. When the SGH need to closely reflect reality to achieve the intended outcome objectives, for instance, through use of realistic narratives or life-like responses to in-game decision making, developers will need to translate the relations, hierarchies, impacts, and relative weights of importance of the outcome determinants, identified in stage 1, into a mathematical algorithm. This will facilitate procedurally generated narrative branching and can drive feedback and reward approaches. To stimulate flow and user engagement, developers can also build in rules that adapt game difficulty and other game-play elements to the performance or physical or mental state of the user.The amount of content required in a game will vary substantially depending on the intended objectives. Many SGH require at least some instructional content or a narrative that ties everything together. When SGH have a large pedagogical or behavioral focus, the narratives can become more elaborate, ranging from linear stories to nonlinear stories that have branching and even offer multiple endings. Within the context of health, narratives are a valuable resource to generate an understanding of the impact of an illness on the patient’s life and well-being ,92. NarrDevelopers should develop the game content in function of the intended outcomes. Linear story lines may be less time consuming, but they also tend to reduce the potential efficacy of the narrative as a persuasive mechanism as it is not responsive to the users, their state, or in-game decisions. Many SGH are designed using a one-size-fits-all approach; however, recent research shows that this approach may not be effective as different types of people are motivated by different persuasive strategies , and a sOn the basis of the specific target audience and design requirements, a theme needs to be chosen, which specifies the overall look and feel of the tool . At the same time, developers will need to assess what level of visual conceptualization will be needed. In some cases, the use of archetypical symbols or icons may be warranted to convey complex concepts either to avoid information overload or to eliminate bias ,105,106.The game has now been developed, informally tested, and refined with users, and it should be ready for  evaluation. Once the trial sites and investigators have been chosen, ethical committee or other approvals have been granted, and users have been recruited for the evaluation study, developers can commence the evaluation, analysis, and assessment of whether the tool successfully achieves the intended outcomes. This stage ideally occurs in consultation with relevant research experts who can guide and oversee the evaluation studies and support the analysis of collected data.On the basis of the findings of stage 4, developers may wish to further refine and reevaluate updated versions of the tool or proceed immediately with rollout toward the intended target audience. Regardless of the outcomes of the game evaluation studies, developers should try to disseminate the study findings to the wider SGH research community, as this will help further advance the field. Even publishing and communicating null results may provide insight on how to optimize SGH interventions and provide guidance on the best practices and pitfalls to avoid. If a game is successfully validated and implemented or marketed for the intended target audience, efforts should be made to collect user data in the field, to help monitor for adverse events (if relevant), or to further explore the validity and use of the SGH.More research should be done to identify which stakeholders should be involved in the design process, to understand how to engage them, and at what stage of the development. We propose to consider at least the following 4 stakeholders.At the earliest stage of development, subject matter experts are well placed to provide input and guidance on the 4 questions that should be answered when establishing the scientific foundations.When deciding on the level of user involvement, one should balance the need for input from users with the availability of resources such as time and funding . One shofeature creep and ensure effective use of project resources, subject matter experts can help evaluate which feedback should be prioritized. Ideally, an emphasis is placed on feedback that will help enhance user uptake and SGH effectiveness.At stage 3, end users should be actively engaged in the testing of early prototypes of the game to gather feedback on such aspects as user experience, content relevance, realism, graphic design features , and preliminary assessment of the achievability of outcome objectives. It is important to note here that not all user feedback needs to be incorporated. To avoid At stage 4, end users should be recruited into a quality trial to validate the game. End users who participate in trials should not be involved in the earlier stages of the development.Research experts should be engaged to advise on scientific approach and trial design at an early stage of development and ideally during the trial.To ensure market readiness and effectively implement and roll out the SGH to the market, a business expert should be consulted, ideally no later than stage 3.Aside from these 4 stakeholders, it may be relevant to consult with regulators, health care professionals, patient organizations, health technology assessments, and others throughout the various stages of the development process.Working with multiple stakeholders carries a specific set of challenges such as clear alignment on roles and responsibilities, finding a common language, understanding of limitations, and consensus on priorities and outcomes ,55. ThesA review of existing literature, recommendations, and guidelines on SGH development has allowed us to formulate a framework for developing theory-driven, evidence-based SGH that represents many of the requirements set out by SGH stakeholders in the research literature. The framework covers all aspects of the development process  and is transparently described in sufficient detail to allow developers to implement it in a wide variety of projects, irrespective of discipline, health care segments, or focus. Adoption of such a consensus framework by the wider SGH research community is a first step toward increasing probability of success and raising the quality of SGH by providing the necessary evidence required by stakeholders. Moreover, it would also enhance the credibility of SGH developers and allow them to achieve a sustainable market share.


What happens when citizens from societies with strong son preference culture migrate to countries in which preference for having a child of each sex prevails? Using data from Swedish population registers, we investigate the sex ratio at birth by parity and the sex composition of previous children in Sweden. Our results showed that women with Chinese, Korean, and Indian background had a substantially elevated sex ratio at the third parity if previous children were both girls. Strikingly, this skewed ratio became less pronounced after 2000, suggesting a shift for a more neutral sex preference for children among these groups in the new century. The sex ratio at birth (SRB) is defined as the number of male births per female births. Without external interventions, among newborns, there is a slight excess of boys over girls and the natural SRB lies at approximately 1.05. In some Asian societies, however, the SRB since the mid-1980s has been strongly skewed toward boys , and India, resulting in imbalances in SRB, as well as much higher parity progression ratios in families with daughters and no sons Arnold . A commoDiscrimination against girls has shifted from the postnatal discrimination mode to the prenatal discrimination mode with the availability of sex-selective technology since the mid-1980s, which sharply increases SRB in East and South Asian areas , should have higher SRB than other immigrant groups and the native-born Swedes, especially at higher order births if previous children are girls. The theory behind this hypothesis is the “cultural persistence” . The theory behind this hypothesis is that the gender egalitarian value of Swedish society and its generous welfare system may lead to more neutral parental sex preferences for children.As mentioned, the sources of immigrants to Sweden have become more diversified over time. Arriving in tandem with immigrants is their cultural capital, including language, values, ways of thinking, and their preferences for the sex of their children. Given the strong son preference culture in East and South Asia, and based on the findings regarding the elevated SRB among immigrants from these areas in different hosting contexts, we make the following hypotheses for the context of Sweden.1The data come from the Swedish population register, which is kept by the Swedish national bureau of statistics. These administrative data started to be digitalized in the 1960s and include all individuals who were registered as residents in Sweden, as well as births, deaths, and migrations  is considered a result of sex-selection of children due to preference of having a son. Previous studies for other contexts found that son-biased sex ratios are more common at third or higher order births among couples that previously only had daughters . We started the analysis from 1980 because obstetric ultrasonography and the possibility to discern the sex of a fetus became more widely available from that time onward. Nonetheless, data preparation used information on births that occurred as early as the 1960s. This step was necessary in order to construct complete birth histories. Mothers who had multiple births at any point in their lifetime were not included in the study and only live births were considered.Given that our main interest is to look into childbearing behavior after migration, only births that occurred in Sweden were used to compute our dependent variable—SRB. Births that occurred before migration were taken into account when constructing birth histories. This can help us better capture the association between the sex composition of previous child(ren) and the SRB.Children born before migration are recorded in the population register if the children immigrated to Sweden at some point in their lives. Although some births that occurred before migration to Sweden might not be included in the population register  or a son and a daughter . This general pattern provides support for the hypothesis that there is a cultural persistence of a preference for sons over daughters among mothers born in this region, even after they migrate to Sweden. In contrast, the SRBs of mothers who migrated to Sweden from other regions are closer to the natural range.To test whether the SRB of our target immigrant groups changed over calendar time, we split the observation period into two intervals: 1980–1999 and 2000–2015. Figure This pattern might also suggest a selection effect. The composition change of our target immigrant groups may help interpret the pre- and post-2000 differences in SRB. Relative to the earlier cohorts of immigrants from China, Korea, and India, the later cohorts of immigrants from the same regions are better educated  promotes sex preference similar to the Swedish society. This pattern not only reflects an adaptation to the gender-neutral preferences for children in Sweden, but also confirms a selection of the most recent cohort effect.The data administration restriction limits our ability to examine the SRB of mothers from China, Korea, and India separately, though we are aware that these three societies have various socioeconomic and cultural differences and are differently represented in Sweden.In addition, Sweden is currently a country with the largest population of international adoptees in Europe and the highest per capita rate of international adoptions in the world . In particular, we look at the SRB of immigrant mothers from China, Korea, and India, exploring whether mothers from areas with a strong son preference culture maintain their home country’s son preference culture in a universal welfare state, where a neutral sex preference for children prevails.Our results show that despite their emergent preference for having daughters , the Swedish-born women do not show any sign of sex selection of children, nor do the majority of the immigrant groups residing in the country, with the exception of women from China, Korea, and India. We find that the SRB for women with Chinese, Korean, and Indian backgrounds is substantially skewed at the third parity if previous children are both girls, confirming earlier findings for other destination countries, such as Dubuc and Coleman  and AlmoHowever, the prevailing gender egalitarian values in Sweden seem to have a direct impact on the childbearing behavior of immigrants from China, Korea, and India, which confirms hypothesis 2. Relative to their statistically significant boy-skewed SRB for the period between 1980 and 1999, their SRB for the period between 2000 and 2015 is much lower. This period change suggests that immigrant mothers from son-preference culture with the exposure to Sweden’s gender egalitarian value and universal welfare have weakened their preference to have a son in the most recent years or at least they did not resort to sex selection of the child. Similar results have also been found in Norway (Tonnessen et al. This positive effect of residing in Sweden on reducing SRB in the most recent years is also evident when we compare the SRB for Chinese, Korean, and Indian mothers in Sweden with that for women in their home countries. Women from China, Korea, and India in Sweden exhibit, for the third parity, 1.32 boys for 1 girl when they have already had 2 girls during our observation period. The same figures for their home countries were 2.25, 1.36, and 1.39, respectively (Zeng et al.


Although cervical cancer is highly preventable through regular screenings using Pap smear or human papillomavirus–deoxyribonucleic acid tests, cervical cancer remains a prevalent women's health issue across the world. Therefore, encouraging women to screen for cervical cancer is very important for the early detection of cervical cancer.The purposes of this study were to (1) assess the effectiveness of three interventions that are typically used to increase the uptake of cervical cancer screening during home visits and (2) determine the participation rate in cervical cancer screenings after invitation, the health promotion perceptions, and the cervical cancer and screening-related knowledge of women. The three interventions noted in Purpose 1 were one-on-one training accompanied by an educational brochure, providing the educational brochure only, and giving an invitation without any relevant information.This interventional study was conducted on women who were between the ages of 30 and 65 years in three Turkish provinces . Five hundred twenty home visits were made, and 356 women who did not have a Pap smear test within the previous year were invited for cervical cancer screening. Women were randomized into one of three intervention groups, and the participants in each group were invited to attend a national cervical cancer screening program and to undergo a cervical cancer screening using the related intervention type.The results showed that the interventions used during home visits and knowledge were effective in encouraging women to participate in cervical cancer screening. It was determined that the participants who had received one-on-one training accompanied by an educational brochure had a higher cervical cancer screening rate than their peers who were offered a brochure only or a verbal invitation only.Invitations to screenings that are made by providing training accompanied with a brochure were found to be effective in increasing the participation of women in cervical cancer screening. Cervical cancer is the second leading cause of cancer mortality among women worldwide, with approximately 530,000 new cases of invasive cervical carcinoma and approximately 280,000 related deaths reported each year. About 95% of the cases occur in less developed countries. The incidence of this disease is reportedly increasing, particularly in developing countries . In TurkCervical cancer is highly preventable through regular and appropriate, timely screenings . Thus, cThe participation of women in CCS is known to be inadequate in many developing countries. The sociodemographic and cultural characteristics of the women, health beliefs, their knowledge about cervical cancer and the Pap smear test, and the lack of available screening programs were all found to influence the participation rates of women in CCS . In diffNurses play a critical role in providing preventive healthcare services. Moreover, nurses who are trained in early diagnosis cancer programs in developed countries play an essential role in public health screenings and educational programs by cooperating with other healthcare professionals . The resTaking into consideration that the CCS rates of women in Turkey are below the desired level and that the most important reason that women do not participate in CCS is lack of knowledge or awareness of CCS, studies that are designed to identify activities that will increase the participation of women in CCS are genuinely needed. Therefore, this study was designed to inform women about cervical cancer, the related risk factors, and the CCS program's role in both building awareness about the services of the national cancer screening program and removing perceived barriers using various interventions. The findings of this study are hoped to help increase the participation of women in CCS.In view of the above, the primary purpose of this study was to assess the effectiveness of the three different interventions  in terms of increasing awareness about cervical cancer, related risk factors, and the CCS as well as of removing the perceived barriers of women during home visits to increase the participation of women in national CCS and the uptake of CCS. Secondarily, the level of participation in CCS after invitation, health promotion perceptions, and providing knowledge related to cervical cancer and the Pap smear test was assessed.This interventional study was performed in the three Turkish provinces of Ankara, Malatya, and Trabzon between August 2011 and April 2012. Formal approvals were obtained from the Ministry of Health of Turkey .The target population consisted of women living in the regions served by the three KETEMs—Ankara Etlik Zübeyde Hanim Women's Hospital, Malatya State Hospital, and Trabzon Fatih State Hospital.Home visits were made by the principal investigator to the women who met the inclusion criteria in each province. Those women who agreed to participate were randomly assigned to the three different interventions:(i) One-on-one training accompanied by an educational brochure (education + brochure group)(ii) An educational brochure only (brochure-only group)(iii) An invitation only, without additional information (invitation-only group)After the intervention, all participants were invited to the KETEMs for CCS. During the screening, all participants were informed about the role of the national CCS program in increasing awareness about services at the KETEMs. The principal investigator made only one home visit to each woman.The criteria for inclusion in this study were as follows: 30–65 years old ; being or having been sexually active; able to speak, read, and understand the Turkish language; and providing informed consent.Subjects were excluded from participation if theyhad gynecologic cancer;had received a hysterectomy;had received a Pap smear test during the previous year; andwere pregnant or in the 3-month postpartum period.Convenience sampling was used to select the target provinces of Ankara, Malatya, and Trabzon, which were respectively located in the northern, eastern, and middle regions to provide representative social and cultural diversity.After identifying the provinces, the sampling was made for groups that would be made available for home visits. Accordingly, a two-staged stratification sampling method was used to determine the study sample. A total of 134,704 women between the ages of 30–65 years resided in the three target provinces. Five hundred twenty women from each were calculated to be needed for the first-stage stratification. The total sample size was then stratified to each region for the second-stage stratification sampling. For this stage, it was assumed that the rate of Pap smear tests for each region was 25%, 5%, and 10%, respectively . The sample size was calculated for each region as 96 in Ankara, 147 in Malatya, and 277 in Trabzon, with a 2.5% error rate and a 97.5% confidence interval. To stratify these women by province, Equation 1 was used:After determining the sample size, the contact information for the women was obtained from the KETEM registry. The contact information of the women was numbered and ordered and then was classified by block randomization into one of the three interventions. The investigator made one home visit to each randomly selected woman to determine if they met the eligibility criteria.An educational brochure was developed to invite the women for CCS at the KETEMs and to impart knowledge of and awareness about cervical cancer, CCS with Pap smear test, and the services provided at the KETEMs. In developing the educational brochure, the key concepts to be included to inform the participants about CCS were determined and then the content relevant to these concepts were developed. A comprehensive literature review was undertaken to design the brochure . In addiThe tagline “Give yourself a chance, get regularly screened for cervical cancer” was used in the brochure to draw participants' attention. The educational brochure provided information related to “What is cervical cancer?”, “What are the causes and symptoms of cervical cancer?”, “What is a Pap smear test?”, “Why is the Pap smear test done?”, “When should the Pap smear test be done?”, and “Information about KETEMs.” In addition, the brochure invited women to participate in free CCS with Pap smear test at the KETEM in their area.Content experts included a gynecologist and a senior nurse lecturer with expertise in women's health, both of whom were consulted during the prepublication evaluation of the brochure. These individuals participated in the evaluation of the brochures before printing. The brochure content was also reviewed by KETEM management for cultural sensitivity and education level appropriateness, and modifications were made based on KETEM's feedback.The completed educational brochure was first administered by the investigator to 15 women as a pilot study to ascertain whether the content could be easily understood. The women in the pilot study were excluded from the main study.Outcome data were obtained using the following surveys: “Participant Description Questionnaire,” “Knowledge Questionnaire about Cervical Cancer and Pap Smear Test,” and “Health Belief Model Scale for Cervical Cancer and the Pap Smear Test.”The investigators developed this form based on a review of the literature. The form consists of questions that are used to determine the sociodemographic, obstetric, and gynecologic features of the women as well as Pap smear history and awareness of the available services at the KETEMs.This form consists of 10 questions that are designed to measure the basic knowledge related to cervical cancer and the Pap smear test. The questions were systemically prepared by the investigators using the same literature that was consulted in preparing the brochures. Participants were asked to mark the statements as either “true” or “false.” In the evaluation of the statements, a score of 1 was given for correct answers and 0 was given for incorrect answers. The range of total possible scores was 0–10, with higher scores indicating higher knowledge of cervical cancer and of the Pap smear test. The reliability of this questionnaire was calculated using the Kuder–Richardson 20 formula, which found a reliability coefficient of .80.The Health Belief Model (HBM) was developed by Consecutive home visits with the participants were made by the principal investigator. First, the compliance of women with the inclusion criteria was confirmed using the “Participant Description Questionnaire” during the home visit. Those who met the inclusion criteria for each group were then informed about the aim of the study and given the HBM and the “Knowledge Questionnaire about Cervical Cancer and Pap Smear Test” to complete. The participants in each intervention group were then invited to the KETEMs for CCS according to the interventions identified in the randomization table. In this regard:(1) Brochure + education group: The principal investigator conducted one-on-one training regarding the importance of cervical cancer and the Pap smear test and distributed an educational brochure to the participants in this group. The training brochure was left with the women so that they could review it at their leisure. During the training session, the following information was explained to the women:Anatomical location of the cervixPrevalence, symptoms, and risk factors of cervical cancerImportance of the Pap smear test to the early diagnosis of cervical cancerInformation about the Pap smear testHow the Pap smear test is performedHow frequently the Pap smear test should be performedWho should receive a Pap smear testIssues that need to be considered before getting a Pap smear test(2) Brochure-only group: The participants in this group were asked to read the educational brochure.(3) Invitation-only group: The participants in this group were invited to receive a CCS without receiving additional training or an educational brochure.After the intervention, the women in each intervention group were informed about the CCS services that are regularly offered by KETEMs. Moreover, they were informed that these services are offered at no cost and without prior appointment or long wait times. In addition, they were told that treatment provided at the KETEMs is free when any problem is detected as a result of screening. The women were then invited to the KETEM in their region of residence for CCS.n = 500), 71 were excluded because of reasons including having undergone a hysterectomy, being currently pregnant, having had cervical cancer, and not agreeing to the interview. Thus, 429 were interviewed. However, 73 cases were not invited to the KETEM for CCS, as they had undergone a Pap smear test within the previous year. Therefore, the final study was conducted with 356 participants, including 118 women in the education + brochure group, 119 in the brochure-only group, and 119 in the invitation-only group . The conformity of the normal distribution of data was assessed using the one-sample Kolmogorov–Smirnov test, after which it was determined that the data were not indicators of a normal distribution. Because the data did not represent a normal distribution, the chi-square (χ2), Kruskal–Wallis, and Mann–Whitney U tests were used to determine the differences among the groups. The source of differences are typically investigated using the Bonferroni-corrected Mann–Whitney U test when a difference is found using Kruskal–Wallis analysis.The study data were analyzed using SPSS Version 15.0 . The distribution of the data was expressed as counts and percentages, and descriptive statistics were presented with arithmetical mean and standard deviation . The source of the difference was investigated using the Bonferroni-corrected Mann–Whitney U test. The preintervention knowledge scores of the brochure + education group was found to be lower than the invitation-only group .Table p < .05). According to the pairwise comparisons, which were conducted to identify intervention-related differences between the groups, the postintervention knowledge scores in the brochure + education group were higher than in the invitation-only group . In addition, the postintervention knowledge scores in the brochure-only group were higher than in the invitation-only group .Furthermore, a statistically significant difference was found between the intervention groups in terms of postintervention knowledge scores  and the invitation-only group . Furthermore, the knowledge increase in the brochure-only group was higher than in the invitation-only group . All of these differences were highly significant (p < .001).When the change between the preintervention and postintervention knowledge was assessed by group, the difference in the brochure + education group was higher than in both the brochure-only group (p > .05).No statistically significant difference was found among the intervention groups in terms of the preintervention and postintervention HBM subscale scores  and the invitation-only group  in terms of the Pap smear benefits subscale scores and between the brochure + education group and brochure-only group  and between the brochure + education group and invitation-only group  in terms of the Pap smear barriers subscale scores. The perceived Pap smear benefits and the perceived Pap smear barriers among the brochure + education group participants respectively increased and decreased more than among their invitation-only group peers , number of pregnancies, age at first marriage and at first childbirth, menopausal status, preintervention awareness of KETEM, family history of cancer, and health beliefs  had no effect on screening rates. However, multiple logistic regression analysis showed that being invited with a brochure + education and a high knowledge score had a significant influence on participation in CCS after the intervention with home visit. The participation rate in CCS of the participants in the brochure + education group was 3.05 times higher than among those participants who were only given a brochure and 5.46 times higher than among those participants who were only given a personal invitation.A positive relationship was found between the postintervention knowledge score and participation in CCS. Each unit increase in knowledge score was associated with an 0.83 times increase in the likelihood of participation in CCS Table .In Turkey, as in many developing countries, the CCS rate is not yet at the desired level . This stThe sociodemographic characteristics of the women in the three groups were similar in this study, which is important in terms of showing the similarity among the groups being compared. In this study, 55.9% of the participants in the brochure + education group, 31.9% in the brochure-only group, and 25.2% in the invitation-only group went to KETEMs after the intervention and home visit to receive a CCS with Pap smear test. The participants in the brochure + education group had a higher Pap smear test rate than the those in the other intervention groups Table . In anotIn addition, the comparative effectiveness of providing a brochure + education and only giving a brochure was tested in terms of increasing knowledge of cervical cancer and the Pap smear test. Although the mean pretest knowledge score of the brochure + education group was the lowest of the three groups, the mean score for this group and the brochure-only group both significantly increased after the intervention. The highest difference in preintervention and postintervention knowledge scores was attained by the brochure + education group, whereas statistically significant increases were also found for the brochure-only and invitation-only groups Table . ConsideThe cervical-cancer and Pap-smear-test-related health beliefs of women, including perceived susceptibility, perceived seriousness, and perceived barriers, strongly influence screening behavior and participation in CCS . In thisThis study shows interventions and knowledge score to be effective in increasing the uptake of CCS after home visits, where the interventions that were used to increase the participation of women in CCS programs were evaluated. The most effective intervention for increasing participation in CCS was invitation using a brochure + education. The CCS participation rate among the participants in the brochure + education group was 3.05 times higher than among those who were only given a brochure and 5.46 times higher than among those who were only verbally invited. Moreover, a positive association was observed between knowledge scores and probability of CCS participation Table .Women's knowledge of cervical cancer and CCS after education and raised awareness plays a significant role in influencing their decision to be screened. The use of training accompanied by a brochure during home visits, the active participation of nurses during screenings, and the distribution of necessary resources to current health organizations  are highly recommended to increase the participation of women in CCS, the uptake of cervical screening, and related awareness. Furthermore, all healthcare professionals should be educated regarding the current CCS recommendations for women and be made aware of available community-based screening programs.In this study, women with high perceived barriers related to the Pap smear test  tended not to participate in CCS. Therefore, interventions that are aimed to increase participation in CCS should focus on the health beliefs and cultural norms that are specific to the women in each target community.This study found providing training accompanied by a brochure to be the most effective intervention in terms of increasing participation in CCS. These results support that interventions that are conducted to increase knowledge and awareness of cervical cancer are effective in encouraging participation in CCS.This study is affected by several limitations. First, the Cronbach's alpha value of one of the HBM subscales was lower than .70. Second, this study was limited to three provinces from three regions of Turkey. Moreover, only women currently residing in the main city in these provinces were interviewed. The effectiveness of the recommended methods in encouraging the participation of women in CCS across a broad range of areas  should be evaluated in future studies.


Semi-structured interviews with midwives providing targeted care (n = 6) were undertaken and characteristics of care were qualitatively analyzed, having the immigrant density of the facilities, the Danish ANC policy, and theories of cultural competence as the frame of reference. Six maternity wards were providing immigrant-targeted ANC. Targeted care implied longer consultations and increased attention to the individual needs of immigrant women. At these facilities, navigation in the health care system, body awareness, and use of interpreter services were key topics. The selection of women for targeted care was based on criteria (including names) that risk stigmatizing immigrant women. The arguments for not providing targeted care included that immigrant-targeted care was considered stigmatizing. Current universal care may overlook the needs of immigrant women and contribute to inequities. A strategy could be to improve dynamic cultural competencies of midwives, interpreter services, and flexibility of the care provision of the universal ANC system.Inequity in immigrants’ health during pregnancy and childbirth has been shown. We studied the Danish regional organization of public midwifery-based antenatal care (ANC) for immigrant women to assess the strengths and weaknesses of organizing ANC as either universal or immigrant-targeted. A telephone survey in 2012 to all the Danish maternity wards ( Social and ethnic disparities are documented in pregnancy and childbirth outcomes in Europe, North America, and Australia ,2. SociaThe term cultural competence has been debated, as health care providers have interpreted and used the term culture statically and simplistically . It has Around 60,000 children are born annually in Denmark and in 2012, 15% of all live-born children had immigrant mothers, a number that increased to 19% in 2018 . IncreasThe Danish ANC is regulated according to the health law , where iIn the national recommendations for ANC, immigrant women are described as a vulnerable group, with risks related to vitamin D deficiencies, anemia, hemoglobinopathy, gestational diabetes, consanguinity, infectious diseases, and fear of obstetric intervention . FurtherThe Danish ANC has been characterized as universal , however, with increasing attention to identify and help women considered to be in special need . Thus, iThe general objective of this study was to discuss the strengths and weaknesses of organizing ANC for immigrant women in targeted and universal models by analyzing the public, midwife-based ANC for immigrant women in Denmark. Specific objectives were to map where immigrant-targeted and universal care programs existed, characterize targeted care, and assess how the organization of care correlated with the immigrant density at the maternity wards. The discussion of strengths and weaknesses of targeted or universal models had the Danish ANC policy and theories cultural competence as a frame of reference.All public maternity wards in Denmark were identified from the homepage of the Danish Midwife Association . The admIf a facility provided immigrant-targeted care, the midwife conducting this service was contacted by telephone in 2013 and invited to a semi-structured interview with a focus on the midwives’ perceptions of the needs of the pregnant immigrant women, selection criteria for the targeted care, contents of the targeted care, potential challenges met in interactions with immigrant women, and the specific qualifications of the midwives. One of the respondents answered the questions by email. Answers from each maternity ward were typed and systematically summarized and open-ended questions were thematically categorized. The themes were discussed by the authors, who agreed on a line of data presentation and argumentation.The density of immigrants per maternity ward was obtained using data from the Birth Registry and Population Registry in Statistics Denmark. We obtained information on maternal origin and place of delivery for all deliveries in Denmark in 2010. A person had Danish origin if she had at least one parent who was both a Danish citizen and born in Denmark. Immigrants and descendants did not have one parent who was both born in Denmark and a Danish citizen. Immigrants were born abroad and descendants in Denmark. The study population was divided into mothers having Danish, Western, or non-Western countries of origin according to the classification by Statistics Denmark . In totaIn the discussion section of this article, we will contextualize the rationalities for providing targeted or universal care for immigrant women. The results will be analyzed in relation to the Danish national recommendations for ANC , which, The participating midwives gave their informed consent and the study was conducted following the Declaration of Helsinki. According to the Danish legislation no ethnical clearance can be given by the Danish Scientific Ethics Committee to surveys and qualitative research, however, the study was reported to the National Data Protection Agency Id. No: 514-0289/19-3000.By the end of 2012, there were 24 public maternity wards in Denmark. The midwife-based ANC was organized and managed from central administrations at the maternity ward level (department of obstetrics). Some administrative units were in charge of more than one maternity ward, giving a total of 20 administrative units. All 20 administrative midwives agreed to participate. The ANC took place at ANC clinics at different geographical locations at the community level. In Six of the 24 maternity wards had ANC clinics where immigrant-targeted ANC was provided . None ofThe selection of immigrant women to the targeted ANC differed between the facilities: At three facilities, the targeted service was mainly for women who could not speak Danish, however other women with an immigrant background could also be seen here if capacity allowed. At two other facilities, the targeted service was for all with non-Danish appearing names based on the assessment of the referring midwife, or if the GP in the woman’s file had indicated that she was an ethnic minority woman. Finally, one facility provided targeted services for women born in Somalia only.The midwives in charge of the targeted service emphasized that immigrant women constitute a very heterogeneous group. The organization of targeted service allowed more time per woman and consequently more attention to the individual needs of each woman. The midwives expressed that they had more flexibility in organizing their schedule than in the routine ANC schedule, for example, it was possible to book women more frequently or to book more time per consultation. Some facilities spent more than the double time per pregnant immigrant woman  than was the routine ANC for non-immigrant women (2 h per pregnancy).All the midwives at the targeted facilities expressed that they found the communication with ethnic minority women regarding normal, as well as acute, bodily changes during pregnancy and delivery difficult. The midwives explained this by referring to ethnic minority women having different health perceptions than the midwives. The midwives shared the perception that they needed to give more attention and time to explain the Danish ANC system: what to expect of the midwives, where to go with which symptoms, and how to establish contact with visiting nurses . At the facility targeting Somali women, special attention was given to female genital cutting, fear of cesarean section, and social vulnerability. Here they conducted group sessions bringing together pregnant women and new mothers.The midwives expressed that care provision for women, whom both had a different cultural background and language barriers, often left them with uncertainty regarding how much of their inputs were actually understood. The midwives highlighted the need for good communication and interpreter services. For example, it was mentioned that it was a very challenging and time-consuming process to obtain informed consent for recruitment to research activities.Lack of health education material in other languages than Danish was a general challenge. Some of the midwives mentioned that it was difficult to stay updated on new materials and expensive to have folders available in many different languages, so they requested for one national service that could keep track of this. Midwives at one hospital had developed a webpage with around 150 different short health education videos regarding pregnancy, birth, and the first three months after birth, which were synchronized into English, Turkish, Arabic, Urdu, and Greenlandic . The majThe midwives providing the immigrant-targeted services were all women, who had volunteered to this assignment. None of them had had special training in cultural competencies, and they characterized their care provision to be based on a ‘learning by doing’-principle. They requested more attention to, and coordination in, this field and an organizational structure for knowledge sharing with other midwives. At one administrative unit, the immigrant-targeted care was placed at four different locations, and at this unit, the midwives had biannual meetings to share experiences and support each other, which they highly appreciated.At the majority of maternity wards, no immigrant-targeted ANC was provided (18 of 24). At these wards, the proportion of non-Western immigrants ranged from 5% to 24%. Several midwives expressed that it was a deliberate decision not to single out immigrant women, as the barriers these women may face was considered to be a result of social aspects rather than aspects related to immigration, and therefore that all women should be treated according to their individual needs within universal care. At several facilities, immigrant-targeted ANC was abandoned by the end of the 1990s, as the midwives felt this was a stigmatizing practice.Regarding the delivery and post-partum period at the maternity ward, few initiatives targeting immigrants were identified. At one site, a health education leaflet in Arabic was available for distribution to the new parents, and at another site, pictograms describing the normal procedures at the nursing ward  were used.According to the national recommendation for ANC, a GP was obliged to assess an immigrant woman’s need for interpretation at first ANC visit. All managing midwives expressed that interpretation services could be arranged according to the hospital  regulations. The professional interpretation service could be in person, by telephone, or using video, however, several issues related to the interpretation services were mentioned. Often the GP did not assess the language proficiency of the women, and the midwives would then have to identify such needs, resulting in a delay in communication. At times family members did the interpretation. At several facilities it was not possible to book extra time to interpreted consultations, making it difficult to cover all elements of care, as the communication takes at least double time.Six of 24 maternity wards were providing immigrant-targeted ANC, and thus the majority of facilities did not. It was not the facilities with a high proportion of births by non-Western immigrant women that had organized immigrant-targeted care. The targeted service implied longer and more consultations, as well as increased attention to the individual needs of the women. At these six facilities, navigation in the health care system, supporting communication of body symptoms, and use of interpreter services were mentioned as crucial issues. Arguments for not providing immigrant-targeted care were that immigrant women had nothing more in common than non-immigrant women and that targeted care, therefore, was stigmatizing. The selection mechanism for immigrant-targeted care is controversial. In our study, the selection of women to immigrant-targeted care followed different criteria, using their name, language skills, or country of origin as indicators of being in special need. The process of designating vulnerable groups can have unintended effects, positive as well as negative, for both users and providers. The vulnerable group can feel that their needs are recognized and therefore creating a starting point for improved communication and patient safety. However, the categorization can also negatively bias the health professional’s perception of this group and introduce stigma . Link anConsidering a woman’s name to be related to her need for health care is a position where the diversity of immigrant women is neglected. Selection based on country of origin indicates a perception that these women belong to a distinct group. For the Somali group, this might relate to the attention this group has been given regarding, for example, female genital cutting , fear anGrouping and selecting women to targeted care according to their language skills is less problematic as the selection follows an individual assessment of each woman’s ability to engage in health care interactions.Nevertheless, targeted care also has benefits. The midwives from the immigrant-targeted consultations found the targeted model highly useful to ensure good communication, and thus identify and accommodate the individual needs of immigrant women. Especially, the increased time and flexibility were mentioned as paramount to meet the very heterogeneous needs of these women.Dubbin et al. argued that cultural and social distance between health care providers and users will cause disparities in care provision if these disparities are not well addressed. Using the Bourdieu-inspired concept of cultural health capital, they analyzed how patient-centered health care is more easily obtained by patients who share socioeconomic position and cultural understanding with the health care providers . If suchFrom this argument, it follows that in existing universally organized ANC, midwives, due to organizational barriers , fail to see and understand the needs of the ethnic minority women. In Denmark, two specialized immigrant medical clinics have been established to provide case management and coordination for complex immigrant patients where the universal health system has given up . AccordiThe midwives highlighted a need for approved and updated health education materials in different languages, an issue also highlighted among European immigrant health researchers . The midWe found that interpretation in maternal health care was not always conducted with the use of professional interpreters or supplemented with extra time, which is in correspondence with the general picture of interpreter services within the Danish health care system . HoweverFinally, it is interesting to consider why the facilities providing targeted care tended to have the lowest immigrant density. One explanation is that when meeting an immigrant woman is a rare event, procedures to deal with this event are then developed. Another explanation may be that the units with many immigrants find it too resource demanding to provide more extensive health care for up to 1:5 of their clients.This study depended on the personal answers of the administrative midwives. Some midwives gave detailed answers while others were concise. This study mapped the organizational practice and analyzed perceptions of midwives, and it could be very interesting to further study how immigrant women themselves see the balance between the recognizing and acknowledging elements of targeted care and the stigmatization issues of the selection to targeted care.Our definition of immigrant-targeted and universal ANC is novel and was chosen as it identified situations where women were actively selected to immigrant-targeted care, and therefore allowed analysis of the labeling and selection process as well as the midwives’ perceptions of the needs of immigrant women and the shortcomings of the universal ANC system. The definition could be problematic, as women should receive needs-based care within the universal Danish ANC system (differentiation of care). Some immigrant women will, for sure, receive care according to their needs within the universal system. However, if the communication barriers (including language skills) are not addressed, the differentiation of care in the universal model will not fully capture the vulnerability of some ethnic minority women, leaving their needs unaddressed. The midwives expressed that there was no monitoring of potential ethnic differences in the enrolment into differentiated care. This is problematic, as it is likely that the assessment of some immigrant women’s social and mental health needs are overlooked, as it has been suggested for refugee children in Denmark . We wantThe majority of ANC facilities in Denmark did not enroll immigrant women in targeted ANC. In the targeted models, midwives had better conditions for providing culturally competent care due to more time, increased flexibility, and more consistent interpreter services. The care provision was characterized by increased attention to individual needs, however, cross-cutting issues were: interpretation, interpersonal interaction, and communication regarding body awareness and how to navigate in the health care system. The selection of immigrant women to targeted care was based on problematic criteria (incl. names) and should be carefully considered to avoid stigma. It seems likely that the universal models of ANC overlooked the needs of vulnerable immigrant women. To reduce ethnic disparity in maternal and child health, there is a need to improve the screening tools for targeted and differentiated care and to improve the universal ANC in terms of the dynamic cultural competencies of midwives, interpreter services, and flexibility in care provision.