*Interculturalisation: Diagnostic Evaluation with Ethnic minority patients with Low back disabilities* (IDEAL)

In march 2003, a study was instigated in the *Jan van Breemen* institution for
Rheumatology and Rehabilitation in Amsterdam with the title: *
Interculturalisation: Diagnostic Evaluation with Ethnic minority patients with
Low back disabilities (IDEAL).* This research is named the *IDEAL-project* in
short, and financed by ZonMw, the Netherlands Organisation for Health Research
and Development. This project encompasses the next set of studies.

1. A qualitative study regarding culture related factors of the dropping out of
the rehabilitation care trajectory around the time of the first consultation
(ZonMw project number 1435.0023; METC-Slz registration number 0351);
2. A quantitative study into the amount of people dropping out of the
rehabilitation care trajectory during the whole duration of the care trajectory
and defining the difference in the dropping out between rehabilitation patients
of Netherlands and non-Netherlands origin (ZonMw project number: 1435.0041);
3. A qualitative study regarding culture related factors of the dropping out of
the rehabilitation care trajectory during the whole duration of the care
trajectory, after the patients have dropped out (ZonMw project number
1435.0041).

This summary concerns the third study of the IDEAL-project, that is indicated
as the "IDEAL follow-up study".

Ethnic minority patients of Moroccan and Turkish origin with a chronic low back
disability, for which no specific physical cause can be identified, experience
barriers in the use of rehabilitation medicine, compared to patients of
Netherlands origin. The rehabilitation care trajectory of patients of
non-Netherlands origin often is ended prematurely because of a non-medical
reason, even though further rehabilitation treatment is justified (Dekker en
Post 2002; Brouwer 2005). This so called *dropping out* of the rehabilitation
trajectory (dropping out is defined as the ending of the incomplete
rehabilitation care trajectory for a non-medical reason) is twice as large
among rehabilitation patients of non-Netherlands origin, compared to patients
of Netherlands origin (Scheppers et al 2005). The precise reason for this
disparity is unclear. These barriers are most likely derived from the
differences in the patient*s and the physician*s perspective, with respect to
their background. The differences in perspective originate out of their
different cultural background. Little is known of the characteristics of these
backgrounds. This seems to suggest that the recommendation for treatment is
inadequately focussed. Because of a lack of knowledge in this area quantitative
research cannot take place, that reveals a solution to the problems.

The objective of this study is to generate knowledge about factors related to
culture, that hinder the use of rehabilitation care. This follow-up study
focuses on patients of non-Netherlands origin that are not any more under
treatment, as they have ended the incomplete rehabilitation care trajectory
because of non-medical reasons. The research question is: *Which factors that
are related to culture can possibly contribute to the premature ending of the
rehabilitation care trajectory because of non-medical reasons, among patients
of Moroccan and Turkish origin with a chronic low back pain disability for
which no specific physical cause can be identified.*

This IDEAL follow-up study is done in four rehabilitation institutions in
Amsterdam. The four institutions are: the JBI (Jan van Breemen Institution for
Rheumatology and Rehabilitation), the RCA (Rehabilitation Centre Amsterdam),
the OLVG (Onze Lieve Vrouwe Hospital) and the ZMC (Zaans Medical Centre). The
whole duration of the study adds up to 24 months (August 2007 * August 2009)
and that of the data gathering up to 15 months (Oktober 2007 * January 2009).

The IDEAL follow-up study is a qualitative and explorative study. The core
activity of this study is the semi-structured interview. After their dropping
out of the incomplete rehabilitation care trajectory is identified, the
patients and their physicians are interviewed separately. Patients are being
interviewed to reveal the non-medical reasons for their dropping out of the
care trajectory. They will be interviewed at their homes. The rehabilitation
physicians will be interviewed in their work environments. The interviews last
one to one and a half hour, on average. All respondents are interviewed twice
and the interviews will be audio recorded, transcribed and analyzed.

In the semi-structured interview, the differences in the patient*s and the
physician*s backgrounds will be explored. Semi-structured interviews are shaped
by their defined set of topics, however also topics are discussed that were not
anticipated for, at the start of the follow-up study. *Semi-structured
interviews are conducted on the basis of a loose structure consisting of open
ended questions that define the area to be explored, at least initially, and
from which the interviewer or interviewee may diverge in order to pursue an
idea in more detail* (Mays and Pope 1995).

In this study, the interview topics were generated from a literature review
(Scheppers et al 2006) and test interviews. The topics are: views on
non-medical reasons for the dropping out of the incomplete care trajectory,
views on rehabilitation, views on the differences in ethnic origin,
expectations of the health services and personnel, expectations of the patient
of non-Netherlands origin and his/ her family, the flow of the communicative
patient-physician interaction, perceptions of the illness problem (health and
illness beliefs), views on health care services and institutions, and
experiences with the health care environment (waiting lists, questionnaires and
treatment contracts). The data will be analyzed from the onset of data
collection and consists of the constant comparative analysis procedure, using
the software program Atlas-ti (Boeije 2002).

Determination of the dropping out of the rehabilitation care trajectory because
of non-medical reasons, is part of the data gathering. This is done based on
information recorded in the medical dossiers of the patients. The patient
dossiers that are studied are: (a) the dossiers of patients presently
dropping-out of the care trajectory. Their listed names are weekly provided to
the researcher by the rehabilitation physicians of the four institutions
joining the IDEAL follow-up study; (b) the dossiers of patients that formerly
have dropped out of the care trajectory and that are determined in a dossier
study carried out in the four joining institutions, during a registration
period of two years preceding the start of the data gathering of the IDEAL
follow-up study.

There is no risk involved in joining this study. The data gathering consists of
observational research activities: the research population will be interviewed
only. They will be visited twice at their homes (rehabilitation patients of
non-Netherlands origin) or in their work environments (rehabilitation
physicians). They are at any moment free to end their involvement in this study
without any consequence for their use of health services (rehabilitation
patients) or their practise of the medical profession (rehabilitation
physicians).