BACKGROUND:Ethnic differences in colon cancer (CC) care were shown in the United States, but results are not directly applicable to European countries due to fundamental healthcare system differences. This is the first study addressing ethnic differences in treatment and survival for CC in the Netherlands.METHODS:Data of 101,882 patients diagnosed with CC in 1996-2011 were selected from the Netherlands Cancer Registry and linked to databases from Statistics Netherlands. Ethnic differences in lymph node (LN) evaluation, anastomotic leakage and adjuvant chemotherapy were analysed using stepwise logistic regression models. Stepwise Cox regression was used to examine the influence of ethnic differences in adjuvant chemotherapy on 5-year all-cause and colorectal cancer-specific survival.RESULTS:Adequate LN evaluation was significantly more likely for patients from 'other Western' countries than for the Dutch (OR 1.09; 95% CI 1.01-1.16). 'Other Western' patients had a significantly higher risk of anastomotic leakage after resection (OR 1.24; 95% CI 1.05-1.47). Patients of Moroccan origin were significantly less likely to receive adjuvant chemotherapy (OR 0.27; 95% CI 0.13-0.59). Ethnic differences were not fully explained by differences in socioeconomic and hospital-related characteristics. The higher 5-year all-cause mortality of Moroccan patients (HR 1.64; 95% CI 1.03-2.61) was statistically explained by differences in adjuvant chemotherapy receipt.CONCLUSION:These results suggest the presence of ethnic inequalities in CC care in the Netherlands. We recommend further analysis of the role of comorbidity, communication in patient-provider interaction and patients' health literacy when looking at ethnic differences in treatment for CC.

OBJECTIVE:Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data.DESIGN:Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate.RESULTS:Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation.CONCLUSIONS:Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.

Objective To explore the association between health literacy and the risk of cardiovascular disease (CVD), and to assess the differential effects by health literacy level of a nurse-coordinated secondary prevention program (NCPP) in patients with coronary artery disease (CAD).Methods Data were collected in two medical centres participating in the RESPONSE trial (Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists). CVD risk profiles were assessed at baseline and 12-month follow-up using the Systematic Coronary Risk Evaluation (SCORE). Health literacy was assessed by the short Rapid Estimate of Adult Literacy in Medicine (REALM-D) and the Newest Vital Sign (NVS-D); self-reported health literacy was evaluated by the Set of Brief Screening Questions (SBSQ-D).Results Among 201 CAD patients, 18% exhibited reading difficulties, 52% had difficulty understanding and applying written information, and 5% scored low on self-reported health literacy. Patients with low NVS-D scores had a higher CVD risk [ mean SCORE 5.2 (SD 4.8)versus 3.3 (SD 4.1), p < 0.01]. Nurse-coordinated care seemed to reduce CVD risk irrespective of health literacy levels without significant differences.Conclusion Inadequate health literacy is prevalent in CAD patients in the Netherlands, and is associated with less favourable CVD risk profiles. Where many other forms of CVD prevention fail, nurse- coordinated care seems to be effective among patients with inadequate health literacy.

Objective . To analyze and compare decision-relevant knowledge, decisional conflict, and informed decision-making about colorectal cancer (CRC) screening participation between potential screening participants with low and adequate health literacy (HL), defined as the skills to access, understand, and apply information to make informed decisions about health. Methods . Survey including 71 individuals with low HL and 70 with adequate HL, all eligible for the Dutch organized CRC screening program. Knowledge, attitude, intention to participate, and decisional conflict were assessed after reading the standard information materials. HL was assessed using the Short Assessment of Health Literacy in Dutch. Informed decision-making was analyzed by the multidimensional measure of informed choice. Results . 64% of the study population had adequate knowledge of CRC and CRC screening (low HL 43/71 (61%), adequate HL 47/70 (67%),p>0.05). 57% were informed decision-makers (low HL 34/71 (55%), adequate HL 39/70 (58%),p>0.05). Intention to participate was 89% (low HL 63/71 (89%), adequate HL 63/70 (90%)). Respondents with low HL experienced significantly more decisional conflict (25.8 versus 16.1;p=0.00). Conclusion . Informed decision-making about CRC screening participation was suboptimal among both individuals with low HL and individuals with adequate HL. Further research is required to develop and implement effective strategies to convey decision-relevant knowledge about CRC screening to all screening invitees.

Background: Public health workforce planning and policy development require adequate data on the public health workforce and the services provided. If existing data sources do not contain the necessary information, or apply to part of the workforce only, primary data collection is required. The aim of this study was to develop a strategy to enumerate and characterize the public health workforce and the provision of essential public health operations (EPHOs), and apply this to the environmental public health workforce in the Netherlands as an example.Methods: We specified WHO's EPHOs for environmental public health and developed an online questionnaire to assess individual involvement in these. Recruitment was a two-layered process. Through organisations with potential involvement in environmental public health, we invited environmental public health workers (n = 472) to participate in a national survey. Existing benchmark data and a group of national environmental public health experts provided opportunities for partial validity checks.Results: The questionnaire was well accepted and available benchmark data on physicians supported the results of this study regarding the medical part of the workforce. Experts on environmental public health recognized the present results on the provision of EPHOs as a reasonable reflection of the actual situation in practice. All EPHOs were provided by an experienced, highly educated and multidisciplinary workforce. 27 % of the total full-time equivalents (FTEs) was spent on EPHO 'assuring governance for health'. Only 4 % was spent on 'health protection'. The total FTEs were estimated as 0.66 / 100,000 inhabitants.Conclusions: Characterisation of the public health workforce is feasible by identification of relevant organisations and individual workers on the basis of EPHOs, and obtaining information from those individuals by questionnaire. Critical factors include the operationalization of the EPHOS into the field of study, the selection and recruitment of eligible organisations and the response rate within organisations.. When existing professional registries are incomplete or do not exist, this strategy may provide a start to enumerate the quantity and quality of the public health within or across countries.

OBJECTIVE:To assess the effect of red blood cell (RBC) transfusion on quality of life in acutely anaemic women after postpartum haemorrhage. DESIGN:Randomised non-inferiority trial. SETTING:Thirty-seven Dutch university and general hospitals. POPULATION:Women with acute anaemia (haemoglobin 4.8-7.9 g/dl [3.0-4.9 mmol/l] 12-24 hours postpartum) without severe anaemic symptoms or severe comorbidities. METHODS:Women were allocated to RBC transfusion or non-intervention. MAIN OUTCOME MEASURES:Primary outcome was physical fatigue 3 days postpartum (Multidimensional Fatigue Inventory, scale 4-20; 20 represents maximal fatigue). Non-inferiority was demonstrated if the physical fatigue difference between study arms was maximal 1.3. Secondary outcomes were health-related quality of life and physical complications. Health-related quality of life questionnaires were completed at five time-points until 6 weeks postpartum. RESULTS:In all, 521 women were randomised to non-intervention (n = 262) or RBC transfusion (n = 259). Mean physical fatigue score at day 3 postpartum, adjusted for baseline and mode of delivery, was 0.8 lower in the RBC transfusion arm (95% confidence interval: 0.1-1.5, P = 0.02) and at 1 week postpartum was 1.06 lower (95% confidence interval: 0.3-1.8, P = 0.01). A median of two RBC units was transfused in the RBC transfusion arm. In the non-intervention arm, 33 women received RBC transfusion, mainly because of anaemic symptoms. Physical complications were comparable. CONCLUSIONS:Statistically, non-inferiority could not be demonstrated as the confidence interval crossed the non-inferiority boundary. Nevertheless, with only a small difference in physical fatigue and no differences in secondary outcomes, implementation of restrictive management seems clinically justified.

Screening for prostate cancer (PC) may save lives, but overdiagnosis and overtreatment are serious drawbacks. We aimed to determine men’s preferences for PC screening, and to elicit the trade-offs they make. A discrete choice experiment (DCE) was conducted among a population-based random sample of 1000 elderly men (55–75-years-old). Trade-offs were quantified with a panel latent class model between five PC screening aspects: risk reduction of PC-related death, screening interval, risk of unnecessary biopsies, risk of unnecessary treatments, and out-of-pocket costs. The response rate was 46% (459/1000). Men were willing to trade-off 2.0% (CI: 1.6%–2.4%) or 1.8% (CI: 1.3%–2.3%) risk reduction of PC-related death to decrease their risk of unnecessary treatment or biopsy with 10%, respectively. They were willing to pay €188 per year (CI: €141–€258) to reduce their relative risk of PC-related death with 10%. Preference heterogeneity was substantial, with men with higher educational levels having a lower probability to opt for PC screening than men with lower educational levels. Men were willing to trade-off some risk reduction of PC-related death to be relieved of the burden of biopsies or unnecessary treatments. Increasing knowledge on overdiagnosis and overtreatment, especially for men with lower educational levels, is warranted to prevent unrealistic expectations from PC screening.

Prostate cancer (PC) is a major health issue. Screening for PC based on the prostate-specific antigen (PSA) test has potential to save lives, but three out of every four men who undergo a biopsy have a negative biopsy, as the PSA test lacks specificity (Schroder et al, 2009). Additionally, the PSA test is poor at discriminating between men with clinically significant cancer vs those who have little to gain (Roobol et al, 2009). The PSA test may detect small cancers that would never surface clinically during lifetime. This overdiagnosis puts men at risk of treatment complications. Current PSA screening is hence unattractive due to overdiagnosis and overtreatment. However, the decision to participate or not in any screening programme is preferably based on an individual decision-making process of weighting the test burden against the potential benefits of screening. A man will make trade-offs between what he perceives as the expected advantages and disadvantages, e.g., how negative it would be if he were to suffer from permanent erectile dysfunction due to PC screening. Patients’ preferences can have a major impact on their willingness to use health care services (Phillips et al, 2006). To improve patient-centred health care it is important to investigate men’s preferences for PC screening. Additionally, obtaining insight into these preferences is relevant to inform clinicians and policy decision makers, and for planning screening programmes. However, quantitative studies investigating men’s preferences for PC screening are lacking. We investigated the preferences of men aged 55–75 years for PC screening. We hereto used a discrete choice experiment (DCE), a quantitative approach that is increasingly used in health care (Ryan and Gerard, 2003; de Bekker-Grob et al, 2012). We used a panel latent class model. A panel latent class model accounts for the panel nature of the data as each respondent completed 16 choice tasks. In order to determine the number of classes, we selected the model with the best fit based on the AIC criterion. We tested a number of different specifications for the utility function (e.g., categorical or numerical attribute levels, two-way interactions between attributes, several attribute transformations). The optimal utility function was: where Vnsj|crepresent the observable utility that respondent n belonging to class segment c has for alternative j in choice set s; β0|crepresents an alternative-specific constant for a certain class; β1-7|care class-specific parameter weights (coefficients) linearly associated with each attribute of the DCE; β8-11|care class-specific two-way interaction effects (i.e., an effect where the influence of one attribute depends on the level of another attribute); and β12-13|care class-specific parameter weights associated with attribute transformations. In addition to the utility function, the final model allowed for several covariates (education, depressed/anxious feelings, and stated willingness to pay (WTP) for PC screening) to enter into the class assignment model (Appendix 2). The class assignment utility function for the final model was (see Equation (2)): For the class coefficients, the statistical significance of a coefficient (P-value 0.05) indicates that conditional to belonging to that class, respondents considered the attribute important in making their choices in the DCE. The sign of the coefficient reflects whether the attribute has a positive or negative effect on utility. We expected that only the attribute ‘risk reduction of PC-related death’ and one or more levels of ‘screening interval’ would have a positive effect (i.e., a positive sign) (Hol et al, 2010; van Dam et al, 2010). In terms of the class assignment parameters, statistically significant parameter estimates indicate that the associate covariate can be used to help in understanding the different segments. For example, if the depression parameter associated with a particular class in the assignment model is positive and significant, then this is indicative that people who suffer depression are more likely to belong to that particular class as given in Equation (1). While of theoretical interest, the WTP measures derived from Equation (3) are likely to be of limited relevance to the analyst. This is because the model assumes that respondents belong to all classes up to a probability (and not to just one class). It is possible however to obtain overall WTP measures by weighting the conditional WTP values by the probability that respondents belongs to a given class (given by the class assignment probability in Equation (1)). That is (see Equation (4)): In the current paper, we compute the latter marginal WTP values. We also compute the confidence intervals based on the individual-specific WTP estimates using the Krinsky and Robb procedure (Krinsky and Robb, 1986). The estimated coefficients for each latent class had the expected sign and were significant in most cases (Table 3) and showed, therefore, theoretical validity. The positive sign given to the coefficient ‘risk reduction of PC-related death’ indicated that men preferred a PC screening programme generating a higher reduction of PC-related death over a PC screening programme that generates a lower reduction of PC-related death. The negative signs for ‘risk of unnecessary treatment and biopsy’ and ‘out-of-pocket costs’ indicate that men preferred a PC screening programme with a low risk of unnecessary treatment and biopsy, and low out-of-pocket costs. All five PC screening aspects significantly influenced men’s preferences, although the preference heterogeneity was substantial. Nevertheless, irrespective of the latent class respondents belong to, risk reduction of PC death, risk of unnecessary treatment and biopsy, as well as costs, they were all important for respondents’ preferences, whereas screening interval was not. Respondents who belong to latent class 1 showed a strong preference for a shorter screening interval. Although respondents who belong to latent class 3 also showed a preference for screening every 2 years over screening every 4 years, such respondents significantly preferred screening every 4 years over screening every year. In contrary, for latent class 2 the screening interval did not have an influence on preferences for PC screening at all. Assuming a realistic PC screening programme (i.e., 20% risk reduction of PC-related death, screening interval every 4 years, 60% risk of an unnecessary biopsy, 50% risk of an unnecessary treatment, and no out-of-pocket costs) the utilities were 2.7, 4.6, and −0.6 based on latent class 1, 2, and 3 respectively (see Equation (1) and Table 3). That is, respondents belonging to latent class 1 or 2 preferred this realistic PC screening scenario over no screening (V=2.7>V=0; and V=4.6>V=0 respectively). However, respondents belonging to latent class 3 did not prefer this PC screening programme over no screening (V=−0.6<V=0). More general, assuming realistic attribute levels of PC screening, men with a lower educational level had a higher probability to prefer PC screening over no PC screening compared with men with a higher educational level, all else being equal. The same conclusion can be made for men who were willing to pay for PC screening or for men without anxiety/depressed feelings. That is, men who were willing to pay for PC screening and/or did not have anxiety/depressed feelings, had a higher probability to prefer PC screening over no PC screening compared with men who were not willing to pay for PC screening and/or had anxiety/depressed feelings, all else being equal. Risk reduction of PC-related death, screening interval, risk of unnecessary biopsies and treatments, and out-of-pocket costs, all influenced men’s preferences for PC screening. However, substantial preference heterogeneity existed. Assuming a realistic PC screening programme, men with a lower educational level had a higher probability to opt for PC screening than men with a higher educational level. This same phenomenon was found for men who were willing to pay for PC screening and/or did not have anxiety/depressed feelings. Men were willing to pay 188 per year (CI: 141–258) for each 10% reduction in their relative risk of PC-related death with 10%, or 87 per year (CI: 48–137) to get PC screening every 2 years instead of 4 years. Men were willing to trade-off 2.0% (CI: 1.6%–2.4%) or 1.8% (CI: 1.3%–2.3%) risk reduction of PC-related death to decrease their risk of unnecessary treatment or unnecessary biopsy with 10%, respectively. There are no previous DCEs investigating how characteristics of PC screening determine men’s preferences for participation in PC screening. However, a study that investigated the influence of information on preferences among men aged 50–70 years for introducing PC screening in Denmark, found that regardless of information level a PC screening programme was valued highly (Pedersen et al, 2011). These results are in line with our findings, which show that in general men had a positive attitude towards PC screening. Our finding that men were prepared to give up life expectancy to avoid side-effects of medical intervention was also found by a DCE who focused on patients’ preferences for the management of non-metastatic PC (Sculpher et al, 2004). Although PC screening intervals may differ among countries, the most widely used screening interval is screening every 4 years (Schröder et al, 2009). Our study showed that men preferred a shorter screening interval over a longer screening interval. These results are in line with other studies. In a cancer screening context, a DCE showed that people aged 50–75 years significantly preferred colorectal cancer screening intervals shorter than 10 years over a 10-year screening interval (van Dam et al, 2010). Preferring a shorter screening interval over a longer screening interval was also found in another DCE study (Wordsworth et al, 2006), where women preferred more frequent cervical cancer screening. Several studies have shown that reassurance may be a motivation for and/or a result of undergoing cancer screening (Cantor et al, 2002; Whynes et al, 2007). This stresses the importance of adequate information provided to potential screeners. Men included in our study population showed preference heterogeneity for PC screening aspects. Information about preference heterogeneity may help physicians to understand individuals’ preferences for screening. Awareness of and explicit addressing differences in personal values regarding screening in general may have a positive effect on the process and outcomes of screening initiation in individual patients. For example, our results showed that men with lower educational levels had a higher probability to prefer PC screening than men with higher educational levels. The implications are that physicians (1) should be aware that patients may overestimate their benefit of PC screening due to numeracy problems, (2) can have a role to prevent unrealistic expectations from PC screening, and (3) are able to reach an optimal shared decision-making regarding PC screening. Additionally, information about preference heterogeneity may also be useful to inform policy decisions. Tailored PC screening programmes may result in a better informed decision-making for screening. Noteworthy, as physicians and patients may differ on the desirability for PC screening, which may hamper the process and outcome of shared decision-making, further research about determining and comparing physicians’ and men’s preferences for prostate screening is recommended. The present study had several limitations. First, the response rate of 46% was higher than expected and similar to other DCE studies (Ratcliffe et al, 2002; Hundley and Ryan, 2004; Wordsworth et al, 2006; de Bekker-Grob et al, 2010b), but this response rate is still not optimal. We cannot exclude selection bias, although our respondents did not differ from non-respondents in age or marital status. Additionally, the proportions of different educational levels in our study sample were quite similar with the general population. Second, the inclusion of numbers and rates in our DCE might have caused problems with understanding the choice task. However, 93% of the respondents passed the rationality test that was included in the questionnaire, and 76% of the respondents did not find the DCE questions difficult. We hence believe that this has not influenced the results to a large extent. Finally, the current results could gain credibility if it were possible to compare the stated preferences of men with their actual behaviour in a PC screening programme. In conclusion, men are willing to trade-off some risk reduction of PC-related death to be relieved of the burden of biopsies or to avoid unnecessary treatments. Men with lower educational levels have a higher probability to prefer PC screening than men with higher educational levels. Increasing knowledge on overdiagnosis and overtreatment, especially for men with lower educational levels, is hence warranted to prevent unrealistic expectations from PC screening. where qnc represents covariates (e.g., age, income), and represents parameters to be estimated. If no covariates are included in the class assignment model, then the model can be estimated with constants only. In such a case, all respondents will have the same probability of belonging to a given class or segment. When covariates are included in the class assignment model, the class membership probability will differ depending on the covariates included in the model. For model identification, the parameters (and/or constants) for one class are required to be set to zero, such that all the remaining parameters are interpreted as being relative to this class. Note that in estimating the model, the analyst must a priori determine the number of classes to be estimated. Conditional on belonging to a given class c, the probability that individual n chooses alternative j in choice set s is given as where represent class-specific parameter estimates to be estimated and represent the attributes associated with the alternatives described within the DCE. Given Equation (iii), we use maximum likelihood estimation to locate the parameters of interest, and . We do this maximising the log-likelihood function of the model, which is given as where ynjs is an indicated variable equal to one if alternative j was observed to be chosen by respondent n in choice set s, or zero otherwise. By making use of the product of the probabilities (Equation (iii)) in the log-likelihood function (Equation (iv)), as opposed to the individual choice set probabilities (Equation (ii)), the model estimates the probability of observing sequence of choices made over the 16 choice tasks. As such, the model accounts for the pseudo panel nature of the DCE data. The parameter estimates of Equation (v) are obtained by maximising Equation (iv), given the data. Grant support for this study was from the Department of Public Health, Erasmus MC—University Medical Centre Rotterdam, The Netherlands.

Screening programs for colorectal cancer aim at reducing cancer mortality. We assessed psychological effects of being invited to an immunochemical fecal test (FIT)-based screening program.

A suggested amendment would make most epidemiological and health research impossible Legislation going through the European Parliament this summer could prohibit most epidemiological and other medical research if amendments proposed by one committee are accepted. The main goals of the legislation will be to strengthen the digital privacy rights of European citizens, improve Europe’s online economy, strengthen the free market, and end the divergence between national data protection laws of the 27 member states of the European Union. This is all well and good, as long as data protection is balanced fairly against adequate provision for legitimate data processing. The European Commission proposed last year that the EU’s 1995 Data Protection Directive 95/46/EC should be replaced by the General Data Protection Regulation.1 In line with the current directive, the draft regulation prohibits the processing of sensitive personal data, including “data concerning health.” However, the draft allows exceptions, including data processing for research and statistics. Research deserves a special position within the normative framework, not only because its focus is not on the individual, but also because it serves an important public interest—the generation of valuable knowledge for society. So far, so good. But, in December 2012, the European parliament’s Committee on Civil Liberties, Justice and Home Affairs (LIBE …

Background: Patients' preferences are important for shared decision making. Therefore, we investigated patients' and urologists' preferences for treatment alternatives for early prostate cancer (PC).Methods: A discrete choice experiment was conducted among 150 patients who were waiting for their biopsy results, and 150 urologists. Regression analysis was used to determine patients' and urologists' stated preferences using scenarios based on PC treatment modality (radiotherapy, surgery, and active surveillance (AS)), and risks of urinary incontinence and erectile dysfunction.Results: The response rate was 110 out of 150 (73%) for patients and 50 out of 150 (33%) for urologists. Risk of urinary incontinence was an important determinant of both patients' and urologists' stated preferences for PC treatment (P<0.05). Treatment modality also influenced patients' stated preferences (P<0.05), whereas the risk of erectile dysfunction due to radiotherapy was mainly important to urologists (P<0.05). Both patients and urologists preferred AS to radical treatment, with the exception of patients with anxious/depressed feelings who preferred radical treatment to AS.Conclusion: Although patients and urologists generally may prefer similar treatments for PC, they showed different trade-offs between various specific treatment aspects. This implies that urologists need to be aware of potential differences compared with the patient's perspective on treatment decisions in shared decision making on PC treatment.

Please cite this paper as: Korfage I, van Ballegooijen M, Wauben B, Looman C, Habbema J, Essink‐Bot M. Having a Pap smear, quality of life before and after cervical screening: a questionnaire study. BJOG 2012;119:936–944.Objective To assess the health‐related quality of life (HRQoL) impact of cervical cancer screening in women with normal test results.Design Questionnaire study.Setting Maastricht, the Netherlands.Population A cohort of 789 women were followed from screening invitation until after the receipt of screening results. A female age‐matched reference group (n = 567) was included.Methods Questionnaires were sent to the home address of the women before screening, after screening, and again with the screening results.Main outcome measures Generic HRQoL (SF‐12, EQ‐5D), generic anxiety (STAI‐6), screen‐specific anxiety (PCQ), and potential symptoms and feelings related to the smear‐taking procedure.Results A total of 60% of screening participants completed questionnaire 1(n = 924): 803 of these women granted permission to access their files; 789 of these 803 women had normal test results (Pap 1), and were included in the analyses. Generic HRQoL (SF‐12, EQ‐5D) and anxiety (STAI‐6) scores were similar in the study and reference groups. Before screening, after screening, and also after the receipt of test results, screening participants reported less screen‐specific anxiety (PCQ, P < 0.001) than the reference group (n = 567), with differences indicating clinical relevance. 19% of screening participants were bothered by feelings of shame, pain, inconvenience, or nervousness during smear taking, and 8 and 5% of women experienced lower abdominal pain, vaginal bleeding, discharge, or urinary problems for 2–3 and 4–7 days, respectively, following the Pap smear.Conclusion The reduced levels of screen‐specific anxiety in screening participants, possibly indicating reassurance, are worthwhile addressing in more depth. We conclude that although considerable numbers of women reported unpleasant effects, there were no adverse HRQoL consequences of cervical screening in women with normal test results.

Introduction USA studies showed an increased risk of patient safety incidents in hospital care among ethnic minorities, but in Europe ethnic disparities in patient safety have never been analysed. The present study aims to 1. Assess the risk of patient safety events in patients of non-western ethnic origin in comparison to Dutch patients 2. Analyse the determinants of the risk of adverse events in patients of non-western origin, and 3. Explore causal mechanisms in patient-provider interaction. Methods Prospective mixed methods cohort study in four hospitals. In total, 2000 patients (1000 Dutch, 1000 of any non-Western ethnic origin, age range:45–75 years) will be included. Data on explanatory variables (eg, Dutch language proficiency, health literacy, education, religion) are collected at admission. After discharge, a two-stage medical record review study, based on a Dutch record review study, is conducted by experienced reviewers to determine the incidence of adverse events. Determinants will be analysed by multilevel multivariable stepwise logistic regression. Mechanisms in the care process will be explored in qualitative interviews with patients and providers. Results Recruitment has started in December, 2010 and will continue for 24 months. Presently, 50 patients were recruited. By August, preliminary data and practical lessons from data collection will be available. Conclusion The study will quantify the risk of patient safety incidents among ethnic minority patients in hospital care, unravel the causes, and identify policy opportunities to minimise inequities in care.

Health literacy measures for use in clinical-epidemiological research have all been developed outside Europe. In the absence of validated Dutch measures, we evaluated the cross-cultural applicability of the Rapid Estimate of Adult Literacy in Medicine (REALM), the Newest Vital Sign (NVS), the Set of Brief Screening Questions (SBSQ), and the measure of Functional Communicative and Critical Health Literacy (FCCHL). Each measure was translated into Dutch following standardized procedures. We assessed feasibility, internal consistency, and construct validity among patients with coronary artery disease (n = 201) and patients with diabetes type 2 (n = 88). Patients expressed most problems in responding to the NVS-D. They were not familiar with the type of food label and had difficulties calculating in portions instead of grams. The FCCHL-D items seemed too theoretical for many patients. Cronbach's alpha was acceptable for all measures. Correlation patterns between the measures were moderately coherent with a priori hypotheses. All translated measures were able to distinguish between high- and low-educated groups of patients, with the NVS-D performing best. Despite reasonable psychometric properties as demonstrated so far, these measures need to be further developed in order to increase applicability for assessing health literacy in clinical-epidemiological research in the Netherlands.