In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes the research design and methodology of the multicenter multidisciplinary prospective DELIVER study which is the first large-scale study evaluating the quality and provision of primary midwifery care.Between September 2009 and April 2011, data were collected from clients and their partners, midwives and other healthcare professionals across the Netherlands. Clients from twenty midwifery practices received up to three questionnaires to assess the expectations and experiences of clients . These client data were linked to data from the Netherlands Perinatal Register and electronic client records kept by midwives. Midwives and practice assistants from the twenty participating practices recorded work-related activities in a diary for one week, to assess workload. Besides, the midwives were asked to complete a questionnaire, to gain insight into collaboration of midwives with other care providers, their tasks and attitude towards their job, and the quality of the care they provide. Another questionnaire was sent to all Dutch midwifery practices which reveals information regarding the organisation of midwifery practices, provision of preconception care, collaboration with other care providers, and provision of care to ethnic minorities. Data at client, midwife and practice level can be linked. Additionally, partners of pregnant women and other care providers were asked about their expectations and experiences regarding the care delivered by midwives and in six practices client consults were videotaped to objectively assess daily practice.In total, 7685 clients completed at least one questionnaire, 136 midwives and assistants completed a diary with work-related activities (response 100%), 99 midwives completed a questionnaire (92%), and 319 practices across the country completed a questionnaire (61%), 30 partners of clients participated in focus groups, 21 other care providers were interviewed and 305 consults at six midwifery practices were videotaped.The multicenter DELIVER study provides an extensive database with national representative data on the quality of primary care midwifery in the Netherlands. This study will support evidence-based practice in primary care midwifery in the Netherlands and contribute to a better understanding of the maternity care system. Because of the frequent (on average 13) contacts throughout pregnancy and because of their expertise, midwives are considered to be important reliable providers of pregnancy-related health education and advice for pregnant women.In the Netherlands midwives are autonomous medical practitioners, qualified to provide full maternity care on their own accountability to all women whose pregnancy and childbirth are uncomplicated including prenatal, intrapartum and postnatal care to mother and child . The firIn the Netherlands about 175,000 births occur annually. In 2009 there were 2444 registered and practising midwives (one per 1630 women within the fertile age range), of which 77% worked in a primary care setting, in just over 500 midwifery practices [Up to now, scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. It is essential to accomplish more research that evaluates the maternity care system and practice, in order to develop a better understanding of the maternity system and to provide scientific knowledge for improvement.Therefore, the Academy of Midwifery Amsterdam-Groningen (AVAG), the Netherlands Institute for Health Services Research (NIVEL), and the EMGO Institute for Health and Care Research of VU University Medical Centre initiated the national DELIVER-study. DELIVER is the Dutch acronym for data primary care midwifery (Data EersteLIjns VERloskunde).The DELIVER study aims to gain insight into the quality, organisation and accessibility of midwifery care in the Netherlands. Results of the Deliver study should further improve midwifery care in the Netherlands and contribute to evidence-based practice. This paper describes the research design and methodology of this multicenter multidisciplinary prospective study.The DELIVER study is primarily a descriptive study with the following research questions:- How is primary care midwifery organised in the Netherlands?- What is the accessibility of primary care midwifery in the Netherlands?- What is the quality of primary care midwifery in the Netherlands?Regarding the organisation of care, the DELIVER study aims to provide evidence about the referring system ('gate-keeper function' of midwives), role and responsibilities of midwives, collaboration with other care providers (e.g. continuity of care), and time expenditure of midwives. Regarding the accessibility of midwifery care, the study will assess the uptake of care , number of ethnic minority women and undocumented women under care of a midwife, and accessibility of the practice (e.g. appointment times). The quality of primary care midwifery in the Netherlands from the preconception to postnatal period will be assessed by describing communication and provision of health information , adherence to standards and guidelines, training and education of (student) midwives, experiences and satisfaction of clients (e.g. confidence in their midwife), and pregnancy outcomes. Additionally, data on midwives' attitudes towards their job and emotions, feelings, health and lifestyle of clients were collected to enable exploration of a range of secondary research questions.The DELIVER study was designed as a multicenter prospective dynamic cohort study to evaluate primary care midwifery in the Netherlands with the main focus on quality, organisation and accessibility of care. The maternity care system was assessed from the perspective of the clients as well as from the perspective of the midwives and other involved care providers. The dynamic cohort consisted of clients who completed up to three questionnaires between their first appointment in the midwifery practice and six weeks postpartum within an observation period of one calendar year. Of these clients, data were also obtained from the national Netherlands Perinatal Registry and from electronic client records kept by midwives. Data on midwifery practice were assembled by questionnaires, by recording work-related activities during one week, and by video-recordings of intake consults with clients. In addition, focus groups with client's partners evaluated their expectations, needs and experiences regarding midwifery care. Finally, interviews were held with other maternity care providers to gain insight into their experience regarding collaboration with midwives. The learning experiences of two National Surveys of General Practice, which were conducted by the NIVEL institute, were used to develop the design of the DELIVER study .Midwives and their clients were recruited from twenty midwifery practices. Purposive sampling was used to select practices, using three stratification criteria: region , level of urbanisation , and practice type . Twenty of the 519 primary care practices in the Netherlands were approached and invited to participate in this study. The approached practices received a brochure with information on the study and were visited by two members of the DELIVER research team who explained the study in further detail. If a practice declined participation, a replacement was found taking region, urbanisation and practice type into account. Ultimately, fourteen practices declined participation, mostly because of time constraints. Each participating practice signed a contract through which they gave consent to cooperate in all parts of the study, including related studies by PhD students. The twenty participating practices comprised 108 midwives and about 8200 clients per year. Midwives were instructed to provide usual care to all their clients irrespective of their participation and to refer clients with questions about the study to the research team.Of the twenty DELIVER practices, six gave permission to videotape intake consults with clients. Prior to taping, each client was asked for consent to videotape the consult.The client recruitment period at each midwifery practice was twelve months. Three practices started including patients in September 2009, two started in October 2009, thirteen in November 2009 and two in December 2009. In the first month at each practice, all clients in care were invited to participate, irrespective of their gestational age or whether they recently (maximum 6 weeks before) gave birth. The following months only new clients were invited to participate. Clients were eligible to participate if they were able to understand Dutch, English, Turkish or Arabic. The midwives were instructed to inform all eligible clients individually about the study and invite them to participate. The midwives gave all women who were interested a brochure about the study with a link to the website of the study  where thTo improve the overall response, a reminder was sent to all non-responders. In addition, five research assistants were enrolled (student midwives) to call all clients who did not complete the questionnaire within one week and invite them once more to participate.Partners of pregnant women were recruited in two midwifery practices in November and December 2010. During a consult, midwives informed the partners about the study and asked them whether they were interested. If the partners did not accompany their pregnant partner to a consult with the midwife, the midwife asked the woman whether she thought her partner might be interested in the study. Each practice sent a list of clients who were at least 28 weeks pregnant and whose partners were possibly interested in the study to a research bureau (Intomart GfK). The research bureau first sent a letter to the partners with information about the study and then phoned them to invite them to participate. One focus group was organised per practice for partners of women expecting their first child, and one for partners of women who already had at least one child. The four focus groups were undertaken and analysed by Intomart GfK.Seven categories of maternity care providers were included: clinical midwives, gynaecologists, general practitioners, maternity care assistants, paediatricians, ambulance personnel, and Obstetrics&Gynaecology (O&G) nurses. Each of the twenty DELIVER practices provided information on three of their contacts per category. The research bureau Intomart GfK executed and analysed in total 21 telephone interviews (March and April 2011): four with general practitioners, two with ambulance personnel, and three for each other category. Care providers were selected randomly, stratified by urban and rural practices.All midwives and practice assistants of the twenty participating practices were requested to keep a diary for one week sometime between February and April 2010 , and care plans  Figure .Clients received up to three questionnaires depending on their gestation at inclusion: one before 35 weeks gestation (completed on average around 20 weeks gestation), one between 35 weeks gestation and birth, one about 6 weeks postpartum. The primary aim of the questionnaires was to assess the expectations and experiences of clients regarding midwifery care. The questionnaires included validated instruments used in earlier studies  in August 2009.As the response rate of clients from ethnic minority groups was relatively low in the pilot study, a lot of effort was put into reaching such women during the main part of the study, especially women with a Turkish or Moroccan ethnic background. Primarily, the questionnaires were only offered on-line in Dutch. To enlarge participation of women from deprived areas and from ethnic minorities, written questionnaires were developed in Dutch and English . As the Midwives and research assistants tried to collect information about all non-participating clients on age, parity, ethnicity, postal code (to determine socioeconomic position), and reason for non-participation. This information can be used to check the external validity of the data.Video recordings of intake consults in primary care midwifery practices were used to gain insight into daily practice of primary care midwives, mainly on counselling regarding prenatal screening. The Roter Interaction Analysis System (RIAS) was used, which is a method of coding doctor-patient interaction during the medical visit . In addiThe research team of the DELIVER study developed a topic list which was used to evaluate the expectations, needs and experiences of partners of pregnant women regarding the care provided by midwives. The topic list comprised amongst others midwives' characteristics, counselling regarding prenatal screening, preparation for labour, the midwife's role during labour, and postnatal care.Telephone interviews were held with health care professionals that work together with primary care midwives, namely clinical midwives, gynaecologists, general practitioners, maternity care assistants, paediatricians, ambulance personnel, and O&G nurses. The main aim of these interviews was to gain insight into the number of contacts, reasons for contact, and their views on the quality of the contacts. The aim was to interview three people per profession.The midwives and practice assistants sent their completed diaries with work-related activities to the NIVEL institute where the data were (partly) analysed. The data and results were then passed on to the department of Midwifery Science of VU University Medical Center Figure .The written questionnaires that were completed by the midwives of the twenty participating practices were returned to the department of Midwifery Science. Also the questionnaires that were completed by more than half of all midwifery practices across in the Netherlands were sent to the department of Midwifery Science. Data from these questionnaires were entered into SPSS by a research assistant.Midwives received no information about study results during the course of the study to avoid bias in midwifery practice, with the exception of client response rates which were provided in order to promote further motivation in encouraging participation among their clients.Client data from written questionnaires and from telephone interviews were entered into the on-line questionnaire by research assistants. The research bureau converted all data from the client questionnaires into an SPSS database, which was transferred to the department of Midwifery Science Figure .The midwifery practices sent the data of the Netherlands Perinatal Registry and the data of the electronic client records to the NIVEL institute at the end of the study Figure . The NIVThe video tapes were analysed using a special program at the NIVEL institute. The original tapes stayed at NIVEL, but the analysed data were converted into an SPSS database and sent to the department of Midwifery Science.The focus groups with partners and the interviews with other maternity care providers were conducted and analyzed by the research bureau Intomart GfK. They processed the results of their analyses into reports which were sent to the department of Midwifery Science. Original data remained property of Intomart GfK but the anonymous transcriptions of the interviews with partners and other maternity care providers were sent to the department of Midwifery Science.Data that were entered manually (on-line or into SPSS) by someone from the research team or by a research assistant were checked by another person. A randomly selected sample of 5% of the questionnaires and client records was checked for errors and the error rate was below the maximum tolerated error rate of 1% at item level.A crucial aspect of the data collection within the framework of the DELIVER study is the possibility to link the data. The overall database consists of data at three levels: individual client, individual midwife, and midwifery practice. These data were linked by unique anonymous client identifiers and anonymous midwifery practice identifiers.n = 20) was based on experience of two National Surveys of General Practice in the Netherlands [n = 1800) it would be possible to complete all three questionnaires during the one-year study period. We aimed for a response rate of 60%, which was based on experience with the two National Surveys of General Practice.The number of included midwifery practices , because we felt that there would be considerable overlap in themes between provider groups, and that saturation would be reached with this number of interviews.The different modes of data collection require different types of data analyses, e.g. qualitative analyses for interviews and focus groups, quantitative analyses for questionnaires and diaries, and content and interaction analyses for video recordings. Subsequent publications reporting the study results will provide plans for the data analyses in detail. These subsequent publications will also report on representativeness of the clients, midwives, and midwifery practices that participated in the DELIVER study. For that purpose, characteristics of the participating midwifery practices will be compared with non-participating practices concerning region, urbanisation, and size of the practice . In order to determine whether the midwives from the twenty participating practices are comparable with all other Dutch midwives, national data will be obtained from the NIVEL Institute on age, years of experience as a midwife, and weekly working hours. Data from Statistics Netherlands will be used to assess the representativeness of the participating clients regarding age, parity, social-economic status, education, religion, and ethnicity . BecauseAs DELIVER is a descriptive study, the sample size can best be based on the width of the confidence interval around estimates. Of all women, 1890 filled in all three questionnaires. Taking clustering of data in twenty midwifery practices into account and assuming an intraclass correlation of 0.015, the effective sample size is 789. The width of the 95% confidence intervals around point estimates for continuous variables will be 0.14 times the standard deviation. For example, if we find a mean of 9 prenatal visits and a standard deviation of 2.9, the 95% confidence interval will be 8.8 to 9.2.Regarding the first research question (organisation of care), descriptive analyses will be conducted using data from midwives' diaries with work-related activities, the questionnaire they completed, and interviews with other maternity care providers. These data sources reveal information on collaboration and meetings with health care providers within and outside the practice, number of employees/associates, presence of a practice assistant, distribution of tasks, annual number of new clients and deliveries, frequency of preconception consults.For the second research question (accessibility of care), descriptive analyses will be conducted with the main variables being timing of first consult, accessibility of practice by phone, accessibility of practice by public transport, availability of consults outside office hours, and the provision of care to ethnic minority women and undocumented women.Regarding the third research question , the main variables will be satisfaction of clients and their partners, midwives' adherence to standards and guidelines, quality and content of intake consults, quality of collaboration with other maternity care providers, and pregnancy outcomes.The design and conduct of the study were offered to the Medical Ethics Committee of the VU University Medical Centre Amsterdam. Participating midwifery practices were expected to participate in all aspects of the DELIVER study. Client participation was voluntary and they could withdraw at any time.Privacy was guaranteed in accordance with Dutch legislation. Clients' and midwives' anonymity was maintained by using anonymous patient and practice identifiers.We estimated that the time investment for midwives would be about 1.5 hours per week for an average practice. Each participating midwifery practice received on average €2,000 for their input, depending on their annual number of clients. In addition, the practices received several presents during the course of the study to keep them motivated. We also tried to keep the midwives enthusiastic by sending them regular news letters with stories from midwives or researchers, tips to increase the client response rate, clients' response rates per practice, and frequently asked questions.All clients who complete at least one questionnaire received shower gel. Additionally, five coupons worth of 100 euro were raffled among all clients who completed at least two questionnaires. Client's partners who participated in one of the four focus groups received a gift certificate of 35 or 40 euro's.An overview of the collected data within the DELIVER study is given in Table n = 922) showed that 30% of them did not want to participate in this study because of an abortion or a miscarriage. If we assume that 30% of all 6733 non-responders (n = 2020) would have an abortion or a miscarriage, and therefore were not eligible for our study, the adjusted response rate is 62% (7685/12398). Data of the Netherlands Perinatal Registry could be linked to questionnaires for 5913 women, and the data of the electronic client records for 5895 women, and both registries for 5133 women.Of all 14418 invited clients, 7685 clients participated by returning at least one questionnaire and 1890 clients returned all three questionnaires. Most questionnaires were completed online, but 25% of the completed questionnaires after labour were print questionnaires. The interview bureau interviewed 183 Turkish and Moroccan clients. The overall crude client response rate was 53%. However, in this calculation women with an abortion or miscarriage were included in the denominator while these women were actually not part of our study population. Data from a part of the non-participants (p < 0.05). More specifically, the DELIVER client population comprised 4.3% Turkish and Moroccan clients, compared to 5.9% nationally (p < 0.05).For each specific research question, different client data might be included. Therefore, the representativeness of the client population will be considered for each research question separately. Overall, the distribution of participating clients over the country  was comparable with the distribution of the national population in the Netherlands. Seventeen percent of the DELIVER client population was of non-Dutch origin, compared with 25% of the national female population between 15 and 45 years of age in 2010 . All 108 midwives and 28 assistants in the twenty practices completed a diary. Regarding the questionnaire that was sent to all 521 Dutch midwifery practices, 319 practices returned the completed questionnaire (61% response rate).In six midwifery practices, 310 video recordings were made of intake consults. This concerned in total 23 different midwives.Thirty partners of pregnant women participated in one of the four focus group interviews. Twenty-one health care professionals that work together with primary care midwives were interviewed, namely four general practitioners, two ambulance personnel, and three of each of the remaining five professions .The DELIVER study is the first study evaluating the quality and provision of primary care midwifery in the Netherlands on such a large scale. The Dutch maternity care system is rather unique with a high number of homebirths and primary midwifery led births. In many countries midwives look at the Dutch system for inspiration. It is therefore crucial that the quality and characteristics of this system are described and that this information is put out in the public arena to inform people internationally about its advantages and disadvantages.The DELIVER study protocol is presented in the present paper to offer researchers the opportunity to critically review the methodological quality of this study. A discussion of the methodological issues of the DELIVER study follows below.Research into primary care midwifery can make an important contribution to the improvement of prenatal, intrapartum, and postnatal care by midwives and thus contribute to the safety and satisfaction in childbirth. Midwives are considered to be important care providers of pregnant women in the Netherlands as 78% of clients start prenatal care at the primary care level and pregnant women have frequent contacts with midwives throughout pregnancy and after childbirth . The DELBy including exhaustive information from 7685 pregnant women and 108 midwives from 20 midwifery practices plus data from 299 other primary care midwifery practices, the DELIVER study has led to a rich and substantial dataset which will allow description of various aspects of maternity care from the perspectives of midwives as well as their clients, clients' partners, and other relevant maternity care providers, making it a multidisciplinary study.Clients from ethnic minority groups were underrepresented in the pilot study, mainly because the questionnaire was only available in Dutch at that time. In the main study, many protocol adjustments and additional actions were executed to increase the response rate of this specific population: printed questionnaires were developed in Dutch and English and services of an interview bureau were enlisted to conduct telephone interviews in Turkish and Arabic. The inclusion of Dutch-speaking clients as well as non-Dutch speaking clients who could understand English, Turkish or Arabic in the main study, increased the external validity of the results because it enabled the four largest non-Western minority groups in the Netherlands to participate  as well as many other minority women who speak English.The use of on-line questionnaires, which were used for the client questionnaires, was very advantageous because built-in checks and a logical follow-up of questions led to a low rate of missing data or errors , and data could easily be uploaded to SPSS. However, in order to improve response rates for the client questionnaires, the clients were offered a choice between electronic and print questionnaires in either Dutch or English. The fact that many clients used this opportunity (25% of the completed questionnaires after labour were print questionnaires) indicates that this was a useful option to include.The video recordings that we made of 310 client consults by 23 midwives in six practices provide unique data, and this method of data collection has hardly ever been used before in midwifery care research. It is probably the optimal way to objectively evaluate the daily practice of midwives.Because not all data have been analysed yet, we cannot currently give insight in the strengths and weaknesses of the maternity care system in the Netherlands regarding the quality, organisation and accessibility of primary care midwifery. In process of time, results of the DELIVER study will describe the current level of service, which is the first step to improve midwifery care. The DELIVER study provides unique data on the activities of midwives, the variation between them and the evaluation of their care by clients and other maternity care providers. These data will enhance awareness among midwives about the care they give and this in itself may change clinical practice. For example, the results will show how many ultrasound scans women have on average and how this number varies between midwifery practices. If the variation is large, this will likely initiate a debate on when ultrasound is indicated. Secondly, the data from the client questionnaires will provide information on areas of care that could be improved. The Dutch Organisation of Midwives might use the results when developing their practice guidelines. Thirdly, if changes are introduced in midwifery practice, a repetition of the DELIVER study can show the extent to which these changes have materialised by making a comparison between the results of the first and second DELIVER study.Certainly, the DELIVER study will enhance evidence-based practice in primary midwifery care in the Netherlands. And regarding the current global discussion about the organisation of maternity care (e.g. place of birth), this study provides a reliable basis for future research.The multicenter multidisciplinary DELIVER study provides an extensive database with nationally representative data on the quality of primary care midwifery in the Netherlands. This study will support evidence-based practice in primary care midwifery in the Netherlands and will contribute to a better understanding of the maternity care system and provide scientific knowledge for improvement.The authors declare that they have no competing interests.ES, FS, and MM originated the idea for the study. ES and TK supervised the study. TK and MP recruited the midwifery practices. TW was responsible for many measurement instruments (including diaries with midwives' work-related activities) and data linkage. JM monitored the data collection. All authors participated in discussing the design of the study and developing the research protocols and questionnaires. The core research team consisted of ES, TK, FS, TW, MP, and JM. JM drafted the manuscript, and all authors read and corrected draft versions of the manuscript and approved the final manuscript.1. Abstract: Journal standard instruction for structure Abstract requires the sub-section "Background; Methods/Design; Discussion" for article type "Study protocol". Hence, "Methods" was change to "Methods/Design" sub-section heading. Please check if action taken is appropriate. Otherwise, kindly advise us on how to proceed.2. Article structure: Journal standard instruction regarding article structure requires the section "Background; Methods/Design; Discussion" for article type "Study protocol". Hence, "Methods" was change to "Methods/Design" section heading. Please check if action taken is appropriate. Otherwise, kindly advise us on how to proceed.3. Additional files: Provided additional files 1, 2 and 3 contain Tables. On the other hand, Tables 1, 2 and 4 were mentioned in the manuscript; however, no e-files were received. Hence, the additional files were captured as normal Table 1, Table 2 and Table 3. Please verify if action taken is appropriate. Otherwise, kindly advise us on how to proceed.4. References: In reference entry [The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/69/prepub


EThnicity &HEALTH) group to formulate relevant recommendations to the public authorities with a view to reducing health inequalities among ethnic minorities. This paper describes the political process and the outcomes of the ETHEALTH expert group.In Europe, progress in the development of health policies that address the needs of migrants and ethnic minorities has been slow. This is partly due to the absence of a strategic commitment by the health authorities. The Ministry of Public Health commissioned the ETHEALTH (After ten meetings, the ETHEALTH group came up with 46 recommendations, which were presented at a national press conference in December 2011. Target groups concerned by these recommendations covered both irregular migrants and migrants entitled to the national insurance coverage. Recommendations were supported by the need of combining universal approaches to health care with more specific approaches. The scope of the recommendations concerned health care as well as prevention, health promotion and access to health care. When analysing the content of the recommendations, some ETHEALTH recommendations were not fully measurable, and time-related; they were, however, quite specific and realistic within the Belgian context. The weak political commitment of an executive agency was identified as a major obstacle to the implementation of the recommendations.The ETHEALTH group was an example of scientific advice on a global health issue. It also demonstrated the feasibility of coming up with a comprehensive strategy to decrease ethnic health inequalities, even in a political context where migration issues are sensitive. Two final lessons may be highlighted at the end of the first phase of the ETHEALTH project: firstly, the combination of scientific knowledge and practical expertise makes recommendations SMART; and, secondly, the low level of commitment on the part of policymakers might jeopardise the effective implementation of the recommendations. Like other European countries, Belgium has to cope with the increasing diversity of its population. Several factors contribute to this diversity, including a long history of labour migration, the country’s colonial past, and, more recently, its strategic position in the European Union ,2. AlthoIn Belgium, the health status of migrants and ethnic minority groups (MEM) raises a paradox. On the one hand, some MEM have a lower risk of mortality, lower prevalence of some cancers, and lower alcohol consumption rates compared to Belgians . On the In the last decade, many national and international agencies have placed ethnic health equality higher on the public health agenda. The 2003 US “Unequal Treatment” report and the 2005 Bennett Report in the UK have led to proactive migrant health policies within the health services ,13. SincDespite such public advocacy, however, many European countries are still hesitating on how to come up with an explicit commitment in relation to this topic . So far,Recent events have increased the pressure on health policymakers to pay more attention to ethnic health equality in Belgium. Critical incidents – such as the failure to provide asylum applicants with adequate health care or Muslim clients refusing emergency care for gender-based reasons, and epidemiological data on the rising incidence of communicable and non-communicable diseases among MEM – have triggered more interest among public-health stakeholders. Recently, the COST HOME network has put the issue higher on the research agenda in Belgium and in Europe . The recA steering committee was commissioned by one General Director at the Ministry of Public Health. This steering committee was composed of three researchers and two civil servants from the Ministry of Public Health. The steering committee conducted the project, organised the panel meetings, invited the experts, and drafted the report. The steering committee also produced a review of the existing situation in relation to migration and health in Belgium, as well as in other countries, to provide a documentary background for the discussion.[Table 1].The steering committee invited several experts in the field of health and migration in Belgium to take part in the panel. Experts cited by the five members of the steering committee were contacted and asked to join the core group of ETHEALTH. Four experts refused to participate, either due to lack of time or because they did not consider themselves to be experts. They were replaced by other experts on the list. Twenty-one experts finally constituted the panel. The panel was made up of 8 men and 13 women. Four experts were from migrant backgrounds, 13 experts had French as their preferred national language. Table Ten panel meetings took place between June 2010 and December 2011. The first meeting agreed on the scope, target group, objectives, and disclosure of the final report. Panel sessions were also devoted to specific topics such as (1) undocumented migrants and asylum seekers; (2) cultural competence, health promotion, and prevention; and (3) monitoring and registration of data on ethnicity in relation to health issues.At each meeting, participants expressed themselves either in French or Dutch. Simultaneous interpretation was provided by professional interpreters. That service was very important to help avoid misunderstandings, first of all, between French- and Dutch-speaking stakeholders, but also to allow MEM to participate in the process. Based on the transcripts of the meetings, a first version of the report was drafted by the steering committee and sent to the members of the panel group for approval and modification. The ETHEALTH report was structured around the Priority Public Health Conditions Analytical Framework . The finWe report the outcomes concerning the general framework of the debates within the ETHEALTH group, before presenting the recommendations. We then assess how SMART the recommendations are. Finally we analyse the political process.The target group had to be defined, as the ETHEALTH group acknowledged that “migrants and ethnic minorities” encompass highly heterogeneous groups, with various histories of migration and sometimes very different needs. It was quickly admitted that nationality was no longer an appropriate term, as an important part of the migrant population living in Belgium has Belgian nationality. Accordingly, the ETHEALTH group adopted the wider approach of WHO Europe and consensually decided to use the WHO Europe concept of “Migrants and Ethnic Minorities” (MEM) .Early panel discussions quickly led to a clear distinction between legal MEM entitled to health insurance coverage and irregular MEM, whose health care coverage falls under a different legal regime. The ETHEALTH group felt that these two groups required different policy approaches, although the commissioning agency was initially not that interested in irregular migrants, because that group falls under the responsibility of a different ministry. For public health reasons, however, this group was recognised as highly vulnerable.de facto health care ghetto. In the light of this, the ETHEALTH group urged that all health care systems should be accessible to all population groups, including MEM; this requires that all health care institutions be organised in a “migrant-friendly” way in order to avoid health care ghettos and increase the accessibility and quality of care.A third debate led to an emphasis on the need to combine universal approaches to health care with more specific approaches for MEM. The ETHEALTH group noted that a small number of health care organisations, such as particular public hospitals and primary care surgeries, were increasingly attracting most MEM patients, leading to a Finally, although its initial commission focused on health care, which is the main competence of the federal Ministry of Public Health, the ETHEALTH group quickly broadened its scope to include access to health care, health promotion, and prevention.[Table . The ETHEALTH report was drafted in line with the Priority Public Health Conditions Analytical Framework [[Additional file ].The ETHEALTH group came up with 46 recommendations ,42[Tableramework ,43. ThisAt the contextual and socio-economic levels, the ETHEALTH group made the case for better data on MEM, improved coordination across the different levels of governance, and making cultural competences a licensing criterion for all health care professionals. For example, Belgium already has a National Health Survey by interview, but there is no recording of the ethnic background of the participants. An additional sample of MEM might provide more reliable estimates of the health of MEM living in Belgium (recommendation 1.2).In order to decrease differential exposure, the ETHEALTH group recommended improving equal socio-economic opportunities for MEM, fighting against discrimination, and improving preventive health care among MEM. For example, the ETHEALTH group recommended the integration of preventive activities into the primary health care services: these activities must be relevant to the neighbourhood where the health service is located (recommendation 2.5).In relation to differential vulnerability, the ETHEALTH group identified three more at-risk groups among MEM: irregular migrants and asylum seekers, MEM with mental health problems, and women. These three groups have several risk factors for having a poorer health status than the “native” population and experiencing discrimination due to the multiplication of risks. For example, in order to reduce administrative procedures and facilitate access to health services, the ETHEALTH group supported the generalisation of the “medical card” for irregular migrants. In areas where it already exists, the medical card for irregular migrants gives access to health care services for a particular period, without additional administrative procedures. For MEM with mental health problems, the ETHEALTH group advised an improvement in collaboration, including referrals of patients, between mental health services and supportive associations for MEM, such as community associations (recommendation 3.14). For women, the ETHEALTH group recommended an improvement of the management of MEM women in maternity wards, accident and emergency departments, and gynaecological services. Using interpreters, in order to avoid relying on interpretation by husbands, or cultural mediators, in order to make less likely the refusal of care by women (or their families) because of gender issues, are two concrete initiatives that could reduce the isolation of some MEM women (recommendation 3.16).In relation to health outcomes, the ETHEALTH group suggested improving the quality and accessibility of health care. Several existing initiatives were described in the report ,42. One We also assess how SMART these recommendations are, with regard to the following criteria: Specificity, Measurability, Assignability, degree of Realism, and Time-relatedness .Fourteen recommendations could be considered as universal, while 32 are specific recommendations for MEM. Among the specific recommendations, 18 concern three more vulnerable groups: irregular migrants (9 recommendations), women (3 recommendations), and MEM with mental health problems (6 recommendations). Because of specific risk factors, these three groups are considered to be at greater risk of having severe health problems or experiencing exclusion and discrimination. Universal recommendations mainly concern improvements in the accessibility and quality of care for the entire population, and not specifically for MEM. For example, recommendation 4.2 argues for free access to primary health care for all children and young people below the age of 18.A recommendation is measurable when it is possible to quantify it or at least when an indicator of progress is suggested. Actually, none of the recommendations has an indicator of progress or a measurable target. In some cases, however, the recommendation suggests a concrete action, whose measurement does not imply a quantitative measurement: this is the case with recommendation 1.2, which argues for a better sampling of MEM in the National Health Interview Survey. Moreover, recommendations 3.1 to 3.6 are extremely concrete and their adoption is likely to lead to explicit outcomes. For example, recommendation 3.6 suggests granting a temporary residence permit to irregular migrants with a contagious disease such as tuberculosis, in order to create confidence and ensure MEM follow a full course of treatment.The ETHEALTH recommendations target several stakeholders. Twenty-three recommendations target political actors : these may concern federal public authorities or regional public authorities. A total of 36 recommendations directly concern the health care sector, while 10 are addressed to non-health sectors such as the labour market . Finally, 23 recommendations require adaptations by health professionals and the health services  and no recommendation targeted the clients. Recommendations should also assign recommendation implementation to one or several agencies. However, we notice that none of the recommendations identifies the agencies responsible for implementation.Broadly, the recommendations require marginal changes. We identify three levels of change in the ETHEALTH recommendations: marginal change, enforcement of existing regulations, and radical change. Firstly, 23 recommendations require only marginal changes; these recommendations do not require legal changes or a new distribution of power. Moreover, the climate is already favourable for the implementation of some of these recommendations. Recommendation 1.6, for example, argues for the inclusion of cultural competency training in the licensing requirements for health professionals. There is currently a reform of the medical curriculum under way in Belgium that creates some momentum for the introduction of new skills into the education of medical doctors. Secondly, 14 recommendations involve the implementation of existing regulations and go on to argue for improvements in the application of these rules, for example, those that are intended to combat discrimination on the labour market (recommendation 2.1). Thirdly, 9 recommendations require more radical changes. For example, recommendation 4.2 argues for free health care for children between 0 and 18 years of age; this would require a modification of health insurance coverage, funding rules, and legislation.None of the recommendations has a deadline for implementation. Uncertainty about when the recommendations would be published may have played a role here.We now describe the role of the policy process in adopting and – possibly – implementing these recommendations within the “Shiffman and Smith” framework . This frIn relation to the cohesion of the political community, ETHEALTH group succeeded in drawing up inter-sectorial recommendations in a context of considerable political and administrative fragmentation within Belgium, where ethnicity remains a relatively neglected topic. The heterogeneity of the experts contributed to the development of a wide range of recommendations. These recommendations concerned the individual level as well as the institutional and political levels. However, implementation may still be endangered because of the high level of political, legal, and administrative fragmentation applying to health and ethnicity in Belgium. The most obvious fragmentation has to do with devolution and the North–south divide, which was particularly burning at the time. We noticed, for example, that French-speaking representatives were less keen to attend the meetings than Dutch-speaking representatives. Press coverage was also somewhat less favourable in the French-speaking media. Moreover, although the Ministry of Public Health commissioned ETHEALTH, the political context was not favourable to strong commitment: no key figure emerged to make a public commitment to the implementation of the recommendations. The “Centre for Equal Chances and Opposition to Racism” has a mandate that is somewhat closer to the objectives of ETHEALTH, but it has only an advisory role in the Belgian statutory set-up. In fact no guiding institution with a definite executive mandate currently exists in Belgium to cope with these issues. This may also jeopardise the implementation of the recommendations, as issues of ethnicity and health cut across many institutions. The absence of policymakers did, however encourage open and transparent discussion and no partisan affiliation was necessary to participate. Finally, the publication of the ETHEALTH group report led the Ministry of Public Health to call for an inter-ministerial conference, a code name in Belgium for involving federal and regional policymakers. Such conferences lay the foundations for cooperation between federal and regional authorities in order to promote more coherent planning. The ETHEALTH group also acknowledged the need to adapt the recommendations according to institutional responsibilities.Given the complexity and variety of the topics involved, the ETHEALTH group had to structure the recommendations using a wide spectrum of ideas. The steering group suggested the Priority Public Health Conditions Analytical Framework as a framework for organising the diverse recommendations and preserving the multiple perspectives highlighted by the experts . In thatThe political context was not favourable: the low level of political commitment beforehand and the absence of a federal government at the time made the whole project risky. ETHEALTH group could not assume that its recommendations would have an immediate impact and was aware that its recommendations might not be implemented. This particular situation influenced the debates and the outcomes. It was clear at the time that health care would be part of the institutional reshuffle that was expected to lead to a new devolution of responsibilities to regional authorities, which were not sitting around the table. A change in the political orientation of the Ministry of Public Health may also have impeded the diffusion of the results. Finally, the new federal government was formed just two weeks before the press conference. The day the results were presented, the federal government announced the reform of the pension system: as a consequence, the ETHEALTH recommendations were downgraded to a lower priority level both inside the government and in the media.Finally, the importance attributed to these issues was difficult to estimate, mainly because of data scarcity. Although the preliminary review of the existing data highlighted the importance of these issues, additional data are needed on migrant health in Belgium. Consequently, the first ETHEALTH recommendation concerns the need to record data on ethnic inequalities (see recommendation 1.1).The ETHEALTH recommendations were specific and, broadly, realistic within the Belgian context: they were mostly based on existing Belgian experience. Most of the recommendations require marginal changes, meaning that the potential to develop fair policies for MEM already exists in Belgium. Some recommendations were clearly defined and had a clear audience. This was particularly the case for recommendations 3.1 to 3.6, which had been discussed for a long time before ETHEALTH group was set up by a forceful advocacy group, “Kruispunt Migratie Integratie”, on behalf of irregular migrants. This example confirms the importance of having a lead agency in the field of migration and health in order to sustain the development of migrant-friendly policies.Uncertainty, however, remains when it comes to translating these recommendations into practice. The ETHEALTH recommendations were not all fully SMART . They were not formally assigned to specific stakeholders, although they suggested implicit assignment. Lack of assignation of the recommendations may lead to a dilution of responsibilities among stakeholders, with minimal commitment to implementation. Indeed, at the time, the political instability did not favour such assignability: the government had no mandate to make strong commitments and the devolution of some responsibilities to regional authorities was under discussion. Moreover, ETHEALTH group had no explicit mandate to assign the recommendations to public authorities. Similarly, the recommendations did not suggest a time schedule for implementation or indicators to assess the implementation of the recommendations. Developing an implementation plan requires a lead agency and resources to achieve it; in the field of migrant health, it is currently hard to see which agency this might be.Are the ETHEALTH recommendations consistent with similar achievements in the same field? Recently, the Council of Europe published recommendations on mobility, migration, and access to health care . It turnETHEALTH looked at a very broad spectrum, including first-generation migrants and ethnic groups, insured and non-insured migrants, and health problems, as well as upstream factors such as socio-economic inequalities or health care coverage. This differs, however, from previous European policies on migrant health. Indeed, as previously shown, most European policies tend to focus on first-generation migrants or on ethnic minorities, whereas ETHEALTH looks at all migrant groups ,50.The study had some limitations. Members of the ETHEALTH group were selected on a voluntary basis. Only 4 experts belong to an ethnic minority group and no representative of users was invited. As the MEM represent a highly heterogeneous population in Belgium, the ETHEALTH group decided against inviting users' representatives, in order to avoid an over- or underestimation of some groups in the discussion. However, the preparatory review of the existing data also looked at studies of the needs and expectations of MEM, with a view to including these in the recommendations. In future phases, ETHEALTH might consider organising discussions with representatives of users and representatives of the MEM communities, such as the Muslim Executive, in order to validate the recommendations and tailor them to the needs of clients.We also noticed that most of the experts on the panel had a patient-centred perspective on health care. None of the health experts was believed to be active in a “biomedicine” service. Experts with a patient-centred perspective may be more favourably disposed to the adaptation of health care to cultural diversity than experts without a patient-centred perspective . Some skThe ETEHALTH group was an example of “science-advising” on a global health issue. It also demonstrated the feasibility of coming up with a comprehensive strategy to decrease ethnic health inequalities, even in a political context where migration issues are sensitive. The second positive outcome of ETHEALTH has been to create a stronger community of both researchers and field workers; this may help to bring together practical experience and scientific expertise and improve the cohesion of the community.Two final lessons may be highlighted at the end of the first phase of the ETHEALTH project. Firstly, the topic for which the recommendations were the most SMART was the one for which both scientific knowledge and practical expertise were available. Secondly, a lack of commitment of policymakers might jeopardize effective implementation.aLevels displayed within the Table bIn the recommendation 3.4 : Ethnicity and Health; SMART (acronym): Specific, Measurable, Assignable, Realist and Tim-related; MEM: Migrants and Ethnic Minorities; US: United States of America; UK: United Kingdom; WHO: World Health Organisation; CSDH: Commission on Social Determinants of Health; COST HOME (acronym): European Cooperation in Sciences and Technologies–Health and Social Care for Migrants and Ethnic minorities in Europe network.The authors declare that they have no competing interests.MD carried out the analysis of the findings of the ETHEALTH group, contributed to the background review of ETHEALTH project and drafted the manuscript. VL helped to draft the manuscript and contributed to the analysis of the findings. ID and VL chaired the debates and revised the manuscript. IC and HV revised the manuscript. All authors contributed to the redaction of the ETHEALTH report and gave their approval to the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/726/prepubFigure S1. Priority Public Health Conditions Analytical Framework retrieved from Blas & Sivasankara Kurup (eds) 2010, page 7 [, page 7  (figure Click here for file


Optimal treatment gives complete relief of symptoms of many disorders. But even if such treatment is available, some patients have persisting complaints. One disorder, from which the patients should achieve complete relief of symptoms with medical or surgical treatment, is gastroesophageal reflux disease (GERD). Despite the fact that such treatment is cheap, safe and easily available; some patients have persistent complaints after contact with the health services. This study evaluates the causes of treatment failure.Twelve patients with GERD and persistent complaints had a semi-structured interview which focused on the patients' evaluation of treatment failure. The interviews were taped, transcribed and evaluated by 18 physicians,  who completed a questionnaire for each patient. The questionnaires were scored, and the relative responsibility for the failure was attributed to the patient, primary care, secondary care and interaction in the health services.Failing interaction in the health services was the most important cause of treatment failure, followed by failure in primary care, secondary care and the patient himself; the relative responsibilities were 35%, 28%, 27% and 10% respectively. There was satisfactory agreement about the causes between doctors with different specialities, but significant inter-individual differences between the doctors. The causes of the failures differed between the patients.Treatment failure is a complex problem. Inadequate interaction in the health services seems to be important. Improved communication between parts of the health services and with the patients are areas of improvement. Optimal treatment gives complete relief of many disorders. But even if such treatment is easily available, cheap and safe, some patients have persisting complaints despite contact with the health care system. One such disorder, from which the patients should achieve complete relief of symptoms with medical or surgical treatment, is gastroesophageal reflux disease (GERD). Patients with GERD followed up in meticulously performed clinical trials achieve nearly without exception symptomatic relief and normalized quality of life . In contThis study was part of a follow-up study of patients with GERD in Norway . The diaOne of the authors (HP) interviewed the patients. The interview was semi structured with an interview guide with open questions which focused on the patients' wellbeing, and their satisfaction and experience with treatment, contact with primary and secondary health care, and their opinion of reasons for the treatment failure. The interviews were taped, transcribed and evaluated by the authors who agreed upon a group of patients with persistent, significant symptoms typical of GERD.Then 18 doctors, six general practitioners, six gastroenterologists and six gastrointestinal surgeons  evaluated and interpreted the transcribed interviews and completed a questionnaire for each of the patients. The doctors were selected based on their position in the health care system, interest in and experience with GERD, and willingness. They had no interaction with the selected patients.In Norway, all patients have to contact a general practitioner in primary care who has a "gatekeeper" function. If necessary, the general practitioner refers the patient to secondary care  for further evaluation and examinations.The questionnaire completed by the doctors consisted of 31 questions regarding causes of treatment failure. Additional file The proportion of "yes" in each group of questions was calculated, i.e. three out of six "yes" answers (50%) concerning the patient had the same value as four out of eight "yes" answers (50%) concerning primary care. Because the total number of "yes" answers varied between the doctors, the scores for each doctor were adjusted to at total score of 100% divided into the four reasons for treatment failure.Descriptive statistics and ANOVA have been used for presentation of the results and comparisons between the groups respectively, and p < 0.05 has been judged as statistically significant.The project was recommended by Regional Committees for Medical and Health Research Ethics (REK), Trondheim, and Norwegian Social Science Data Services (NSD), Bergen, Norway. Written informed consent was obtained from all participants before enrolment.Twelve out of 179 patients in the follow-up study were included in this study. Figure Inadequate interaction was the main cause of treatment failure, followed by failing primary care, secondary care and the patient him/her self; the relative responsibilities for treatment failure were 35%, 28%, 27% and 10% respectively. Figure Figure The study aimed at describing how patients with persisting complaints despite contact with the health care system assessed the cause of treatment failure. The patients' presentations of their experience with the health care system were independently evaluated and interpreted by doctors with different specialities and background. Although the intention was to have the patients' own opinion about the health care system, the doctors' interpretations of the patients' statements probably have influenced the results which therefore represent a combined patient/doctor evaluation and not only the patients' own perceptions. Particularly concerning the patients' own responsibility and interaction in the health care system, the results express in large the opinion of the doctors after interpretation of the patients' statements.Treatment failure occurred in all parts of the health care system. Faulty interaction/communication between primary and secondary care and between specialists in gastroenterology and gastrointestinal surgery appears, however, to be the most important factor. The patients told that general practitioners had expressed lack of information from secondary care and uncertainty about the responsibility, and that there was disagreement upon surgical treatment. Similar communication problems are well known internationally. General practitioners lack information from the hospital concerning investigations, treatment and follow-up plans, and the referral letters from primary care to hospitals are inadequate ,8. In a The criticism against primary care was insufficient information about the disease  and treatment alternatives . Some patients felt refused or misunderstood. In addition to the same criticisms, secondary care was blamed for inaccurate diagnostics and lack of referral to other specialists. It is known that these patients have uncovered needs for health services ,3. The pThe patients themselves could not discharge from responsibility. Some had shrunken from consulting and resigned themselves to the complaints, some feared side effects of drugs and omitted drug treatment, and some were afraid of investigations (e.g. gastroscopy) and surgery.The cause of treatment failure varied between the patients. Some patients had to take the main responsibility themselves, whereas the health services were totally responsible for patients who had severe complaints despite following all recommendations.In large, groups of doctors with heterogeneous background  had concurrent evaluations, except for a minor difference concerning the patients' responsibility. It is gratifying that the groups of doctors did not tend to blame each other. There were, however, rather huge differences between the individual doctors' evaluations. The individual discrepancies are perhaps as expected, differences of opinions between doctors are well known from other topics, but the agreement between the groups was a pleasant finding.This study gives no information about the prevalence of failing treatment because the total number of patients treated for GERD in the study period is unknown, a large proportion did not answer the written inquiry or was unwilling to participate, and patients with mild or intermittent symptoms were excluded. Other studies indicate that 2/3 of the patients have some symptoms and that 3-5% have severe symptoms and reduced quality of life . NeitherA combination of qualitative and quantitative methods was used. The interviews were performed with a qualitative method and evaluated and interpreted by the doctors who scored a questionnaire. Strengths and limitations of such a method are unknown. Normally, interviews are analysed by one person or a small group who achieve consensus. In this study, the interviews were evaluated and scored by a group of independent doctors unaware of each others' evaluations. This is likely to be a strength since any bias related to one person's evaluation or consensus in a small group, is omitted. The validity is supported by the agreement between the groups of doctors, and the disagreement between individual doctors makes it likely that individual evaluations of interviews are prone to be biased. The method was chosen because we thought it might give more valid results than traditional qualitative methods do.The interviews were semi structured. An evaluation of the recordings and transcriptions could indicate that the structure was too loose and that the interviewer might to some extent have influenced the patients' opinions.The questionnaire filled in by the doctors was not formally validated. It is therefore some uncertainty regarding the completeness of the questionnaire and possible overlap of the questions.Nearly half of the patients with considerable complaints were unwilling to an interview. Although unknown, this selection has probably had insignificant effect on the external validity of the study.Treatment failure is not a simple problem easily eliminated with one intervention, it is a complex problem. Even for the individual patient there is not one single cause. Faulty interaction and communication in the health services was in this study the most important factor, followed by insufficient handling of the patients in primary and secondary care. Sometimes the patients themselves are partly responsible. The agreement of these conclusions between groups of doctors with different specialities was high and gratifying, whereas the disagreement between individual doctors was large and disquieting. The study shows that something should be done to reduce treatment failure, and hints at improved interaction and communication in the health services and with the patient  as valuable interventions.At the time when the follow-up study of patients with GERD was performed and the interviews were made (in 2003), all authors had in one way or the other been sponsored by AstraZeneca or WyethLederle, two pharmaceutical companies producing proton pump inhibitors used for the treatment of GERD. The authors have no competing interest the last five years.HP has been responsible for the follow-up study and the design of the qualitative part of this study, and has performed all the patient interviews. He has actively participated in the design of the quantitative part of the study and in writing the manuscript. PGF is the main responsible for the design and accomplishment of quantitative part of the study, the data analyses and for drafting and writing the manuscript. PGF, IB, SF, GJ and OL have together with a group of external doctors read, evaluated and scored the transcribed interviews. All authors have participated in the planning of the study, selected patients for the study based on the interviews, given valuable comments to the manuscript and approved the final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/111/prepubThe questionnaire filled in by the doctors. The doctors filled in one questionnaire for each patient based on the transcribed interview of the patient.Click here for file


Migration of non-Western women into Western countries often results in an increase in smoking prevalence among migrant women. To gain more insight into how to prevent this increase, we compared psychosocial determinants of smoking between Surinamese women in Suriname and those in the Netherlands.Data were obtained between 2000 and 2004 from two cross-sectional studies, the CVRFO study in Suriname (n = 702) and the SUNSET study in the Netherlands (n = 674). For analyses of determinants, we collected additional data in CVRFO study population (n = 85). Differences between the two groups were analysed by chi-square analyses and logistic regression analyses.As was found in other studies among migrant women, more Surinamese migrant women in the Netherlands smoked (31%) than women in Suriname (16%). More Surinamese women in the Netherlands than in Suriname had a positive affective and cognitive attitude towards smoking  and OR = 3.3 ). They perceived a positive norm within their partners and friends regarding smoking more frequently  and OR = 3.3 ).Migrant women are more positive towards smoking and perceived a more positive norm towards smoking when compared with women in the country of origin. Interventions targeted at the psychosocial determinants regarding smoking for newly migrated women, in particular the consequences of smoking and the norm towards smoking might help to prevent an increase in smoking in those populations. Smoking remains one of the major causes of cardiovascular diseases and several types of cancer. Seen as a direct health consequence of smoking, these diseases (and others) can be avoided by preventing people from smoking . In WestIn migrant populations, a multitude of determinants underlie smoking behaviour. These include broader contextual issues, socioeconomic inequalities compared to host populations, psychosocial aspects such as stress, hardship and discrimination, all of which are known to contribute to health inequalities. Finally, socio-cultural factors governing attitudes towards smoking and the process of acculturation to a 'Western' environment are also relevant -9. TheseIn order to develop interventions for preventing an increase in smoking among migrant women, insight into the underlying determinants is needed. This includes insight into changes in proximal factors such as psychosocial determinants: attitudes towards smoking, social influences regarding smoking and self-efficacy ,16. At pIn our study we had the opportunity to compare the determinants of smoking of Surinamese women in Surinam with Surinamese women in the host country, the Netherlands. Our aim was to gain insight into the differences in psychosocial determinants of Surinamese women in the Netherlands compared to those in the country of origin.Data were obtained from two cross-sectional studies, the CVRFO-study (Cardiovascular risk factor study (CardioVasculair RisicoFactor Onderzoek), in Suriname under supervision of the foundation of the advancement of Scientific Investigation Suriname; sample 1) and the SUNSET study , carried out between 2000 and 2003. Only data from women were used . Data were used from the original data collection. To gain insight into the determinants of smoking behaviour, additional data were collected among smokers from the original study in sample 1 in 2003, in order to assess differences in beliefs among women in Suriname and women in the Netherlands. We selected female smokers from the largest ethnic groups - women with a Creole, 'mixed' and Hindustani background  in order to make these data comparable with the data of the SUNSET study (sample 2). In sample 1, ethnicity was based on self-definition. In sample 2 the ethnicity of all four grandparents were asked and those who had at least 75% common in ethnic background, were assigned accordingly: the remainder was assigned as 'mixed' .In sample 1, of the 89 female smokers, 85 were willing to participate in this extra study (net response rate 95.5%). In sample 2, the data on the determinants of smoking were available for 193 women.The data for the CVRFO main study (sample 1) were collected by trained volunteers in a structured interview and physical examination held in a research location. Additional data about the women's beliefs were collected by structured telephone interviews (N = 42), conducted by one of the authors (MVvdP) as long as the respondents could speak fluent Dutch. If the respondent was not fluent in Dutch, the author carried out a face-to-face interview with an interpreter present N = 43) . Data for the SUNSET study (sample 2) were collected by structured face-to-face interviews during home visits by trained interviewers of the same ethnic background [  data from both original studies were used.Smoking behaviour was measured by the question 'Do you smoke cigarettes?' in sample 1 and by the question 'Do you smoke?' in sample 2. In this sample respondents were classified as smokers, ex-smokers and non-smokers according to WHO-standards [Attitude towards smoking can be regarded as an expected outcome associated with a particular behaviour. Cognitive and emotional advantages and disadvantages were measured by fourteen beliefs about the perceived consequences of smoking, for example,' If I smoke I have a higher risk of getting heart disease' and, 'If I smoke I think that's normal'. Using principle component analyses (varimax rotation) and reliability analyses, two sub-scales were constructed: emotional attitude towards smoking  and cognitive attitude towards the health consequences of smoking . Five items did not load on any factor and were excluded from the scales.The questionnaire used in both studies included questions on two important psychosocial determinants: attitude and social influences towards smoking. Questions were developed on the basis of the results of focus group sessions and a review of the most salient beliefs for smoking and smoking cessation among the ethnic Dutch population . AttitudSocial influences are defined as the norms that a person perceives towards a behaviour, and the perception of others who carry out that behaviour (perceived behaviour). Subjective norms were assessed by items about judgments made towards the respondent's smoking behaviour by the respondents' partner, close female family and friends, . Perceived behaviour was measured by items about the same persons mentioned above . Scales for the items regarding close family and friends were constructed separately. The internal consistencies of the scales in regard to 'subjective norm of the family', 'subjective norm of friends', 'perceived behaviour of 'family' and 'perceived behaviour of friends' were 0.81, 0.77, 0.69 and 0.73 (2 items) respectively.educational level was indicated by the highest educational level attained. Four categories were used . Financial status was assessed through answers to the question: "What is your current financial situation?" with options of - running up debts, using savings, just managing, have some savings, have a lot of savings. In addition, age in which first cigarette was smoked was measured in the SUNSET study and the additional study of the CVRFO study. In the SUNSET study, years since migration and ethnicity of friends was measured.Background characteristics were obtained from the original studies and included age (in years), educational level, marital status, financial status and number of people in the household. In both studies, Smoking prevalence in both datasets was computed with standardization for numbers of respondents per ethnicity (research question 1).Analyses of determinants of smoking were conducted among female smokers only. We compared smoking related beliefs between the two samples. Firstly, all separate beliefs were dichotomized and the scores were compared between countries and ethnicity. Differences between ethnicities or countries were considered statistically significant at p < 0.01 to adjust for multiple testing . SecondlThe samples differed significantly in their ethnic composition. In both samples, the percentage of Creole women was the highest of all subpopulations, but in the Dutch sample, more than half had a Creole background Table . The staOf the smokers in both samples, we found that the mean age was five years higher in the Dutch sample Table . The eduThe women who smoked in the Surinamese sample and the Dutch sample differed regarding most of the attitudinal beliefs Table . SurinamTable This study aims to provide more insight into the psychosocial determinants of smoking among Surinamese migrant women in the Netherlands and Surinamese women in Surinam. Of the female Surinamese smokers, those in the Netherlands were three times more likely to perceive emotional and cognitive advantages of smoking than those in Suriname. These women also perceived a positive norm of their partner and among friends regarding smoking more frequently.acculturation with health related behaviour and its determinants of immigrants in the host country, but did not compare these data with any data on people in the country of origin [As far as we know this is the first study in which the differences between the underlying psychosocial determinants between migrants and their counterparts in the country of origin have been explored. Other studies that have focused on psychosocial determinants in the context of migration, look at the changes by assessing the associations of f origin -25.Some limitations of this study need to be considered before discussing the results. Firstly, due to the cross-sectional design we are not sure whether migrant women changed their smoking behaviour after migration. It is possible that the women who migrated differ regarding smoking behaviour and beliefs about smoking from those who stayed in Suriname. However, a previous study suggests that Surinamese women in the Netherlands are in an earlier stage of the tobacco epidemic than the ethnic Dutch women . This miSecondly, we were not able to include non-smoking women in Suriname in our study, which implies that we cannot be sure that the determinants account for the differences in smoking prevalence in Surinamese women in both countries. However, as many studies have shown that these determinants are important predictors of behavioural change, our study seems to hold strong indications that the differences in determinants might contribute to the differences in smoking behaviour.Despite these limitations, our study found interesting results regarding the psychosocial determinants of smoking among female Surinamese migrants. As expected we found a higher prevalence of smoking in female Surinamese migrants in the Netherlands compared to those in the country of origin. The relatively positive attitudes and norms are in line with the differences in the prevalence. Explanations for these results can be found in the different place where the women live.In Western countries, smoking is culturally less restricted for women than in non-Western countries such as Suriname. In contrast to smoking in Suriname, in the Netherlands smoking is not regarded as shameful for women and they can smoke where they want. This seems to be reflected in the higher percentage of smokers among Surinamese women in the Netherlands. However, there is also more anti-smoking prevention available in Western countries, which might prevent a positive attitude among these women . Though,However, when we compare results of a study among Dutch students with those of the Surinamese women, we have found that the percentage of Dutch students that were aware of negative consequences of smoking for heart disease was similar with or even lower than the percentage we have found (71.2% vs. 77.9% in our study) . This maRegarding the subjective norm of family and the number of family members who smoke we have found no differences between the women in both countries. This might indicate that the norms among the family did not change after migration. It may be that, due to migration, family ties are loosening and that as a result norms in the family have less influence on smoking behaviour. The increase in smoking may be more associated with the increase of friends who smoke and a positive subjective norm towards smoking among friends and the partner in combination with a positive attitude towards smoking. As a result Surinamese women in the Netherlands are more exposed to a proximal pro-smoking social environment compared to the women in Surinam.The differences observed should be understood in the broader context of the changes that people experience after migration and which are also known to contribute to health inequalities. These include cultural changes, changes in socio-economic position, social position and perceived discrimination . With reWith regard to other contextual factors, the results of our study will be best generalisable to other migrant women who have a similar background. Regarding the Surinamese population, their colonial background, a fluency of the Dutch language and a lower socio-economic position than the ethnic Dutch are important contextual characteristics. Hence, our results may be most generalisable to migrant female groups with a colonial background from other countries, such as South Asians in the UK. However, as we see also increases in smoking behaviour among other migrant populations, similar changes might be present in other migrant groups as well.The results of this study indicate that anti-smoking interventions for migrant women should focus on the negative consequences of smoking and the prevention of a positive norm towards smoking - for example, by developing culturally targeted interventions using role modelling . These iIn conclusion, the results of this study suggest that migrant women are more positive towards smoking and perceived a more positive norm towards smoking when compared with women in the country of origin. Interventions targeted at the psychosocial determinants regarding smoking for newly migrated women, in particular the consequences of smoking and the norm towards smoking might help to prevent an increase in smoking in those populations.CVFRO: CardioVasculair RisicoFactor Onderzoek; SUNSET: SUrinamers in Nederland, Studie naar gezondheid en Etniciteit; OR: odds ratioThe authors declare that they have no competing interests.VN contributed to conception and the design, analysis and interpretation of the data and has written main parts of the manuscript, MVvdP contributed importantly to the conception and the design, carried out the additional data collection and the analysis contributed to the interpretation of the data and has been involved in drafting the manuscript, MYvE contributed to the design of the CVFRO study and the data collection and has been involved in drafting the manuscript. KS contributed to the conception and design of the SUNSET study and the additional data collection, the interpretation of the data and has been involved in drafting the manuscript. All authors approved en read the final manuscript.In 1975, almost half the population of the former Dutch colony Surinam migrated to the Netherlands. Approximately 80% of these Surinamese immigrants in the Netherlands are Hindustani  or African . Other ethnicities include Chinese and Javanese.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/397/prepub


Malaria in pregnancy has a negative impact on foetal growth, but it is not known whether this also affects the foetal nervous system. The aim of this study was to examine the effects of malaria on foetal cortex development by three-dimensional ultrasound.Brain images were acquired using a portable ultrasound machine and a 3D ultrasound transducer. All recordings were analysed, blinded to clinical data, using the 4D view software package. The foetal supra-tentorial brain volume was determined and cortical development was qualitatively followed by scoring the appearance and development of six sulci. Multilevel analysis was used to study brain volume and cortical development in individual foetuses.Cortical grading was possible in 161 out of 223 (72%) serial foetal brain images in pregnant women living in a malaria endemic area. There was no difference between foetal cortical development or brain volumes at any time in pregnancy between women with immediately treated malaria infections and non-infected pregnancies.The percentage of images that could be graded was similar to other neuro-sonographic studies. Maternal malaria does not have a gross effect on foetal brain development, at least in this population, which had access to early detection and effective treatment of malaria. Plasmodium vivax and Plasmodium falciparum malaria are associated with maternal and foetal morbidity and mortality  weeks, including one premature neonate. All anthropometric measurements in the newborn were similar between the two groups (Table Eleven (25%) women delivered at home, one (2%) underwent a caesarean section because of prolonged labour and the remaining 32 (73%) delivered in the SMRU clinic. There were no stillbirths, and all newborns appeared congenitally normal, although one infant from the non- malaria group was diagnosed with congenital heart disease later in life. Overall, the median birth weight was 2,780  grams in newborns weighted within 24 hours after delivery (n = 35), and the gestational age at delivery was 39In this study, the foetal brain volumes and foetal cortex development were compared between women with and without malaria. Although the images of this study were not primarily obtained for neuro-sonographic evaluations and 3D ultrasound exposure time was limited, seventy percent of sulci could be visualized well enough to be graded. This percentage is similar to a previous study in healthy volunteers, where ultrasound scans were performed by a neuro-sonography expert . In the The timing of malaria infection has an impact on the growth and development of the foetus . The smaIn conclusion, maternal malaria does not have a gross effect on foetal brain development, at least in this population, which had access to early detection and effective treatment of malaria.The authors declare that they have no competing interests.MJR designed the study, carried out the ultrasound scanning, performed the statistical analysis and drafted the manuscript. MCW performed the brain volume measurements and cortex grading, performed the statistical analysis and drafted the manuscript. EJHM carried out the statistical analysis and helped to draft the manuscript. SK, NK and TP performed the ultrasound scanning, organized and coordinated the study on site. GHV participated in the design of the study and revision of the manuscript. RMG participated in the design and coordination of the study, helped in the statistical analysis and revised the manuscript. FN conceived of the study and participated in the design and coordination of the study, and revised the manuscript. LRP participated in the design and analysis of the study, organized the image analysis and helped to draft and revised the manuscript. All authors read and approved the final manuscript.