WHIG and DIGH

(NHG Working Group on Diversity and Global Health) The WHIG is part of the DIGH (= all Dutch GPs working in international health).

Why? The background
“The GP provides care to everyone: from young to old, and from a variety of cultural, ethnic and socio-economic backgrounds. The diversity of patients has implications for general practice due to differences in epidemiology and genetic factors.”.[1]

There are around 1.1 million people in the Netherlands who are classified as socially vulnerable. They often face a combination of problems relating to finances, housing, employment, mental and physical health, social contacts, parenting and addiction. Low literacy is often a factor.[2]  Although this problem is more common in the deprived neighbourhoods of large cities, it is certainly not confined to large cities.

There are significant health inequalities between people with a low socio-economic status (SES) and those with a high SES. On average, highly educated men live fifteen years longer in good health than men with a low level of education. These inequalities between socio-economic groups have not narrowed over the past ten years.[3] [4]Regardless of their state of health, people with a low SES are more likely to consult their GP and less likely to see a specialist. They are more likely to rate their own health as fair or poor, and they feel more restricted in their activities as a result of physical and/or emotional problems. ^3,4,[5]

In addition to low SES, ethnicity also appears to play an independent role in health inequalities.[6] Non-Western migrants are relatively more likely to suffer from chronic conditions such as diabetes, asthma and cardiovascular disease. They are also more likely to suffer from depression and anxiety disorders. There are indications that the effectiveness of healthcare for migrants and ethnic minorities is lower. There are differences in how illness is perceived and in expectations regarding healthcare.  Non-Western migrants visit their GP more frequently than other Dutch people of the same age, educational background, socio-economic status or perceived health.[7] According to estimates, by 2050 a third of the population of the Netherlands will be of non-Western origin.

General practice care for socially vulnerable patient groups is complex, given the need for specific knowledge and skills, and is often accompanied by a heavy workload and ethical dilemmas. General practitioners often feel ill-prepared to deal with these issues.[8]  In most GP training programmes, little attention is paid to cultural diversity.  Of the trainee GPs who are (very) likely to work as GPs after completing their training, the majority would prefer to have less to do with the problems associated with large cities. Forty per cent of GPs looking for a practice do not want to work in a deprived neighbourhood[9]

Conclusion:

• The Netherlands has a large group of socially vulnerable people and a growing number of migrants. GPs lack the tools they need to deal with this effectively.
• There is a great deal of knowledge and expertise in the Netherlands, but it is proving difficult to tap into and is not being utilised sufficiently in the development of guidance for GPs and NHG products.
• There is a need for a platform to optimise collaboration between the NHG, Pharos, LHV, GP training programmes, WHIG and funds for disadvantaged groups, and to share knowledge.

That is why the NHG Working Group on Diversity and Global Health (DIGH) was set up.

The WHIG is a group of general practitioners with a strong commitment to primary healthcare from an international perspective, which supports projects and activities in the fields of Family Medicine and International Health. We share an affinity with the migrant community, just as our members do. A former tropical medicine doctor will have no doubt about the added value of internationalisation, particularly upon returning to the Netherlands. Examples of this include professional expertise, such as knowledge of travel advice and imported diseases, as well as experience in intercultural communication and a broader perspective on the Dutch healthcare system.

The objectives of the WHIG are to promote the exchange of knowledge amongst general practitioners on international healthcare issues, applying that knowledge in primary healthcare in the Netherlands (e.g. travel health advice) and in other countries (e.g. supporting education), and facilitating research. These objectives align well with those of the DIGH, and we are delighted with this collaboration.

The aim of this NHG DIGH working group

• To draw on the knowledge and expertise of the participating organisations to provide GPs with the tools they need to deliver patient-centred care to everyone in the Netherlands and to reach shared decisions with each patient.
• To increase the focus on ethnic, cultural and socio-economic health inequalities and global health in GP training.
• To facilitate cooperation between the participating organisations as efficiently as possible and to bring together the knowledge and expertise available in the Netherlands.

The working group brings together representatives from the following organisations:

• AMAN – Association of Moroccan Doctors in the Netherlands,
• Arrears funds,
• EURACT – European Academy of Teachers in General Practice/Family Medicine,
• General practitioner training (Nijmegen, AMC Amsterdam, Utrecht, Maastricht and Rotterdam),
• LHV,
• LOVAH,
• NHG,
• Pharos – a centre for knowledge and advice on the health of migrants and people with low levels of education,
• Sanitas Foundation
• and the WHIG.

At the meeting on 12 November, it was decided that the following working groups will begin their work in earnest in the coming period:

• Thematic Group on Prevention, Self-Management and E-health,
• Thematic Group on Quality Standards for the Use of Interpreters,
• Thematic group on cultural competencies and global health in the general practice training programme.

We would also like to see future collaboration on setting up GP training programmes abroad (WHIG-Kenya, Nijmegen-Suriname, Leiden-Cuba, VU-Aruba).

Through our website and news updates, we keep our supporters informed about our joint activities, or join the discussion on the HAweb Group Diversity in practice.

This is an open HAweb group for GPs and GP practice nurses with an interest in ethnic and socio-economic diversity. It offers you the opportunity to ask questions and share experiences regarding the care of migrants, people with low literacy levels and socially vulnerable individuals, connect with others who have similar experiences, stay up to date with practical guidance, activities and continuing professional development, and share your expertise to help ensure that existing resources, such as guidelines, are better aligned with the increasing diversity in general practice. The establishment of this group is an initiative of the NHG DIGH (Diversity and Global Health) Working Group. Within this group, various organisations collaborate to pool knowledge and expertise on addressing ethnic and socio-economic health inequalities within general practice. Specifically, this concerns the care of migrants, people with low levels of education and socially vulnerable groups. D

Quality standards for the use of interpreters for non-native speakers in healthcare.

Providing responsible care sometimes requires the services of a professional interpreter. There are also situations where an informal interpreter, such as a family member or a neighbour, is sufficient. The quality standard on the use of interpreters, drawn up by organisations including the NHG, KNMG, LHV and various patient organisations, helps healthcare providers make this choice. To treat patients effectively, it is crucial that a healthcare provider and patient understand each other well. When a healthcare provider is dealing with a patient who speaks a different language, they will assess whether the language barrier prevents them from providing adequate care. If so, the healthcare provider will call in an interpreter. This may be an informal interpreter, but sometimes the use of a professional interpreter is necessary to provide responsible care. A range of factors play a role in making this decision. It depends on the field of practice, the circumstances and the nature of the care required. And, of course, on the patient’s wishes. Does the patient wish to bring someone along to interpret, and is this person sufficiently capable of articulating the patient’s symptoms? The quality standard sets out these kinds of considerations by means of a number of practical questions. This helps healthcare providers to manage the use of interpreters in an appropriate and effective manner. Read more on the NHG website.

“Diversity in practice”

September 2014. Work is well under way on a book about ‘Diversity in Practice’, Ethnic and socio-economic health inequalities in general practice. Following on from, for example, ‘procedures in general practice’, the aim is to create a useful reference work on these specific topics, which can often prove challenging for the average GP. This book has therefore been produced following an assessment of patients’ (migrants and those with low literacy) expectations of GPs, the questions and challenges faced by GPs and GP training programmes, and the NHG’s need for information that goes beyond standard guidelines. I will mention a few topics: communication with people with low literacy and those who speak other languages; diversity in somatic care; mental health care; ethnic differences in pharmacotherapy; prevention and self-care; and social issues. The book is likely to be published in 2015. Until then, you can also visit: www.huisarts-migant.nl

[1] NHG Position Paper: Core Values of General Practice – generalist, person-centred and continuous, 2011.

[2] Wolf, J. ‘Guidance on OGGZ under the Wmo’, Ministry of Health, Welfare and Sport and Association of Netherlands Municipalities, The Hague 2006 (www.invoeringwmo.nl).

[3] Bruggink JW. Trends in (healthy) life expectancy by level of education. Population Trends: Quarterly Statistical Journal on the Demography of the Netherlands, 2009b; 4th quarter

[4] Hoeymans N, Melse JM, Schoemaker CG (eds.). Health and determinants. Sub-report of the 2010 Public Health Future Outlook: From healthy to better. RIVM report no. 270061006. Bilthoven: RIVM, 2010

[5] Westert GP, van den Berg MJ, Zwakhals SLN, Heijink R, de Jong JD, Verkleij H. Healthcare Balance 2010. The performance of the Dutch healthcare system. Bilthoven: RIVM, 2010.

[6] Campbell JL, Ramsay J, Green J. Age, gender, socioeconomic and ethnic differences in patients’ assessments of primary health care, Qual Health Care 2001;10:90–95. Uiters E, Primary health care among ethnic minorities in the Netherlands: A comparative study [PhD thesis], Nivel, 2007

[7] Devilee 2008 Walter L.J.M. Devillé, Ellen Uiters, Gert P. Westert, Peter P. Groenewegen Perceived health and GP consultations among ethnic minorities compared with the general population in the Netherlands. In: Dutch general practice on stage: morbidity, performance and quality in an international context. Westert GP, Jabaaij L, Schellevis FG (eds). Radcliffe, Oxford, 2006.

[8] Langeveld, R. ‘Quality in Diversity’, National Association of General Practitioners and VU Medical Centre, Utrecht 2008.

[9] Hingstman L, Kenens R. Newly qualified GPs are reluctant to work in deprived neighbourhoods. Huisarts Wet: 2009, 52(11), 521