Differences in Anxiety and Depression Among Migrant and Non-Migrant Primary School Children in The Netherlands.

This is the first Dutch study investigating symptoms of five DSM-IV-classified anxiety disorders and depression in a large sample of pre-adolescent children with and without a migration background, adjusting for socioeconomic position (SEP) and social preference. Both are potential explanatory factors for differences in mental health among migrant children. We measured anxiety and depression scores with the self-report Revised Child Anxiety and Depression Scale (RCADS) in 2063 children (aged 8-13 years, 55% girls) in the Netherlands. Surinamese/Antillean, Turkish, and Moroccan children reported significantly higher anxiety scores than Dutch children. SEP and peer rejection partly explained higher anxiety scores. Surinamese/Antillean and Turkish children reported comparable depression scores to Dutch children, but Moroccan children reported lower depression scores after adjusting for SEP and peer rejection. Girls reported higher anxiety and depression levels across all four subgroups. Although differences between children with or without a migration background were small, these may increase in later life as the prevalence of anxiety and depression increases with age.

Family Empowerment (FAME): A feasibility trial of preventive multifamily groups for asylum seeker families in the Netherlands.

This study evaluated the feasibility of Family Empowerment (FAME), a preventive multifamily program for asylum seeker families in the Netherlands. FAME aims to reinforce the parent-child relationship, family functioning, and social support. We used an uncontrolled pre-test-post-test design, embedded in a mixed-methods approach. FAME was offered to 46 asylum seeker families, mostly originating from Eritrea, Armenia, or Syria. Twenty-seven parents gave consent to participate in this study. Program integrity and evaluations of participating parents and trainers were assessed. Family functioning and parental symptoms of depression and anxiety were measured pre- and post-FAME. Six participants completed all assessments. Most participants valued gathering with multiple families. Although FAME might coincide with decreases in anxiety and depression, the program had a limited impact on family functioning. Possibly, the aims of FAME did not align with some families' current needs. Lessons learned and recommendations to further improve interventions for refugee families are discussed.

Family Empowerment (FAME): study protocol for a pilot implementation and evaluation of a preventive multi-family programme for asylum-seeker families.

BACKGROUND: Families applying for asylum have often experienced multiple potentially traumatic events and continue to face stressors during their resettlement. Studies have indicated that traumatic events can negatively impact parenting behaviour and child development. A secondary preventive multi-family intervention programme, called Family Empowerment, was developed. Family Empowerment aims to strengthen parenting skills and prevent exacerbation of emotional problems in asylum-seeker families. This study protocol aims to evaluate the feasibility, acceptability, and potential effectiveness of Family Empowerment to reduce parental mental health problems and improve family functioning. METHODS: An uncontrolled pre-test-post-test design will be conducted, using a mixed-methods approach. Approximately 60 families living at asylum centres and family locations with children aged 0-18 will be included. All participants will be invited to take part in seven sessions of Family Empowerment. Measurements take place at baseline, during implementation of Family Empowerment and 1 week post-Family Empowerment. Demographic data, the quality of the parent-child interaction, family functioning, parental symptoms of depression and anxiety, and participants' feedback on progress and the therapeutic alliance will be assessed. A programme integrity list will be filled out during each session. Semi-structured interviews at baseline and post-Family Empowerment will be used to evaluate Family Empowerment. DISCUSSION: This is the first study to provide a pilot implementation and evaluation of Family Empowerment. The current study will inform us on how to improve programme elements and the implementation of Family Empowerment. Limitations are discussed. TRIAL REGISTRATION: Dutch Trial Register, TC = NTR6934. Registered on January 8 2018.

Factors facilitating dementia case management: Results of online focus groups.

To obtain insight into facilitating factors for case management in dementia care, we conducted a qualitative study with 13 online focus groups (OFGs). Participants were professionals involved in dementia case management ( N = 99). We used mind-maps and the method of constant comparison for analysis. Participants perceived OFGs as a useful tool to explore their perspectives. The perceived advantage of OFGs was the flexibility and convenience of logging in at any time or place preferred. Five facilitating factors for case management were identified in the OFGs: 1. Good cooperation between partners; 2. Organisational embedding with an independent position of case managers; 3. Structural funding; 4. Competent case managers; 5. Familiarity with case management in the region. Good cooperation was essential for successful dementia case management and should thus be a primary concern for care providers.

Sharing decisions during diagnostic consultations; an observational study in pediatric oncology.

OBJECTIVE: Children and parents need to make important decisions in the period of being informed about the diagnosis of childhood cancer. Although parents' and children's involvement is legally required, it is unclear whether oncologists involve them. This study explored which decisions families face, how oncologists involve them in shared decision-making (SDM) and which factors are associated with this process. METHODS: Forty-three families with children, starting treatment for childhood cancer, were recruited from three Dutch academic pediatric oncology clinics. Diagnostic consultations were audio-taped and coded with the OPTION. RESULTS: On average, 3.5 decisions were discussed per consultation. Most frequently discussed decisions concerned registration in a patient database (42%) and how to deal with hair loss (33%). Oncologists' assistance in SDM focused on giving information and ensuring the parents' and the child's understanding. The hospital in which children were treated (F(2,2)=5.39, p=.01) and discussing trial participation (F(1,1)=8.11, p=.01) were associated with oncologists' assistance. CONCLUSION: Decision-making during diagnostic consultations appears to focus on non-treatment related decisions. Oncologists' assistance mostly concerned sharing information, instead of SDM. PRACTICE IMPLICATIONS: Additional research is needed to provide insight in how to increase oncologists' assistance, while taking into account children's and parents' preferences concerning SDM.

A new approach to child mental healthcare within general practice.

BACKGROUND: Child and adolescent mental health problems are frequently not identified and properly treated within general practice. Politicians in the Netherlands are promoting more primary healthcare treatment for mental health problems. The current study aims to evaluate an integrated primary mental healthcare approach for child and adolescent emotional and behavioural problems. This integrated approach allows general practitioners (GPs) to comprehensively explore the request for help, followed by an informed decision to refer, offer short-term treatment within general practice or postpone a decision by asking for additional consultations with youth mental health specialists. METHOD: The study is a naturalistic evaluation of Dutch general practices with pre-test and post-test comparison with controls based on data from Electronic Medical Records (EMR). The intervention started in September 2010. EMR data of all GP contacts with children aged 4 to 18 (including diagnosis, prescriptions, referrals) from practices involved in the intervention was used from 1 January 2009 to 31 December 2012. Extra codes were added to the EMR to record aspects of the intervention. Comparable EMR data was used in control practices in 2011. RESULTS: GPs in the intervention group were able to identify more emotional and behavioural problems after the integrated service had started. They also identified more problems than GPs in the control practices. They were already reluctant to prescribe psychopharmacological medication to children before the intervention, and levels of prescription at intervention GP practices remained low for psychotropic drugs compared to control practices. Referral rates to mental healthcare remained relatively steady after the introduction of the integrated service, but referrals switched from specialized to primary mental healthcare. CONCLUSION: An integrated mental healthcare approach within general practice may lead to an increase in detected psychosocial problems among children, and these problems can mainly be treated within the primary care setting.

Factors associated with variation in urgency of primary out-of-hours contacts in the Netherlands: a cross-sectional study.

OBJECTIVES: Dutch primary out-of-hours care is provided by general practice cooperatives (GPCs). Although most GPCs use the same standardised triage system, differences between GPCs exist in the urgency assigned to patients' health problems. This cross-sectional study aims to provide insight into factors associated with the variation in assigned urgency between GPCs. DESIGN AND METHODS: Data were derived from routine electronic health records of 895 253 patients who attended 17 GPCs in 2012. Patients' gender, age, travel distance to the GPC, and the use of a computer-based decision support system for triage were investigated as possibly affecting assigned urgency. Multilevel linear regression analyses were executed for the 3 most frequently presented health problems (cystitis/other urinary infection, laceration/cut and fever). RESULTS: Variation in urgency levels between GPCs was significant for the selected health problems (p=0.00). Assigned urgency was mainly related to patient gender and age. It was not associated with the use of a computer-based decision support system, or with travel distance to the GPC. Most variation in urgency (93.4-96.7%) could be ascribed to variation in patient characteristics. CONCLUSIONS: There is significant variation in urgency levels between GPCs, even for the same health problem. This variation is mainly associated with differences in characteristics of individuals contacting the GPCs, rather than with variables such as patients' travel distance or the use of a computer-based decision support system. Since patient characteristics are likely to affect patients' clinical need, our results are an indication of the adequate functioning of the triage system.

Indicated Prevention of Childhood Anxiety and Depression: Results From a Practice-Based Study up to 12 Months After Intervention.

OBJECTIVES: We investigated whether intervention effects of FRIENDS for Life, a school-based prevention program for children with anxiety or depression symptoms, were maintained over a period of 12 months after the intervention in a naturalistic setting. METHODS: We used a quasi-experimental design, with 339 children in the intervention group and 157 in the control group (aged 8-13 years) in schools in Amsterdam, the Netherlands. We collected self-, teacher, and peer reports of anxiety and depression scores before and after intervention, and 6 and 12 months after intervention, from 2010 to 2012. RESULTS: Intervention-group children reported a continuing and significant decrease in anxiety and depression scores compared with the control group. Twelve months after the intervention, participants' anxiety and depression levels were comparable to those of the general population. Girls reported a stronger decrease in anxiety scores than did boys. Teacher reports suggested no effects. Although classmates reported increased internalizing problems in intervention-group children immediately after intervention, these effects disappeared over time. CONCLUSIONS: FRIENDS for Life, an indicated prevention program, yielded long-lasting and continuing reduction in anxiety and depression problems when implemented in daily school practice.

Structure, reliability, and validity of the revised child anxiety and depression scale (RCADS) in a multi-ethnic urban sample of Dutch children.

BACKGROUND: Although anxiety and, to a lesser extent, depression are highly prevalent in children, these problems are, difficult to identify. The Revised Anxiety and Depression Scale (RCADS) assesses self-reported symptoms of anxiety and depression in youth. METHODS: The present study examined the factor structure, internal consistency, short-term stability, and validity including sensitivity to change of the RCADS in a multi-ethnic urban sample of 3636 Dutch children aged 8 to 13 years old. RESULTS: Results indicate that the RCADS is a reliable and valid instrument. The original 6-factor structure was replicated to a fair extent in the present study (RMSEA = 0.048) and internal consistency was good (αs = 0.70-0.96). ICCs for short-term stability were 0.76 to 0.86. Girls and children who indicated wishing to participate in a program targeting anxiety and depression had higher RCADS scores. Sensitivity to change analyses showed that the RCADS can detect changes in anxiety and depression symptoms in children who participated in a preventive intervention. The study showed low agreement between teacher and self-reported internalizing problems, even for children scoring above the 90(th) percentile of the RCADS, indicating a high level of problems, emphasizing the need to also take child reports into account when screening for anxiety and depression in children. CONCLUSION: This study shows that the RCADS can yield reliable data on a diversity of anxiety disorders and depression in urban children aged 8-13 from very diverse ethnic backgrounds. TRIAL REGISTRATION: Netherlands Trial Register: NTR2397 . Registered 30 June 2010.

To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: a multilevel study.

BACKGROUND: In the Netherlands, primary out-of-hours (OOH) care is provided by large scale General Practitioner (GP) cooperatives. GP cooperatives can be contacted by patients living in the area surrounding the GP cooperative (catchment area) at hours when the patient's own general practice is closed. The frequency of primary OOH care use substantially differs between GP cooperative catchment areas. To enable a better match between supply and demand of OOH services, understanding of the factors associated with primary OOH care use is essential. The present study evaluated the contribution of sociodemographic composition of the neighbourhood in explaining differences in primary OOH care use between GP cooperative catchment areas. METHODS: Data about patients' contacts with primary OOH services (n = 1,668,047) were derived from routine electronic health records of 21 GP cooperatives participating in the NIVEL Primary Care Database in 2012. The study sample is representative for the Dutch population (for age and gender). Data were matched with sociodemographic characteristics (e.g. gender, age, low-income status, degree of urbanisation) on postcode level. Multilevel linear regression models included postcode level (first level), nested within GP cooperative catchment areas (second level). We investigated whether contacts in primary OOH care were associated with neighbourhood sociodemographic characteristics. RESULTS: The demand of primary OOH care was significantly higher in neighbourhoods with more women, low-income households, non-Western immigrants, neighbourhoods with a higher degree of urbanisation, and low neighbourhood socioeconomic status. Conversely, lower demand was associated with neighbourhoods with more 5 to 24 year old inhabitants. Sociodemographic neighbourhood characteristics explained a large part of the variation between GP cooperatives (R-squared ranging from 8% to 52%). Nevertheless, the multilevel models also showed that a considerable amount of variation in demand between GP cooperatives remained unexplained by sociodemographic characteristics, particularly regarding high-urgency contacts. CONCLUSIONS: Although part of the variation between GP cooperatives could not be attributed to neighbourhood characteristics, the sociodemographic composition of the neighbourhood is a fair predictor of the demand of primary OOH care. Accordingly, this study provides a useful starting point for an improved planning of the supply of primary OOH care.

Advantages of asynchronous online focus groups and face-to-face focus groups as perceived by child, adolescent and adult participants: a survey study.

BACKGROUND: Online focus groups (OFGs) are increasingly used as a method of data collection. Although their advantages for research have repeatedly been described, participants' opinions about OFGs have seldom been studied. We investigated OFG participants' preference for participation in an OFG or a face-to-face focus group (FTF), as well as their perceptions of the advantages of both methods. We also investigated whether any differences exist between the perceptions of child, adolescent, and adult participants. METHODS: Participants' opinions were studied by means of a questionnaire completed by 284 persons (aged 8-72 years) after their participation in one of 50 OFGs. The OFGs were conducted between December 2005 and December 2013 as part of 19 separate studies. Chi square tests with p <0.05 were used to test differences in perceived advantages of OFGs and FTFs between children, adolescents and adults. RESULTS: The most important advantage of OFGs as perceived by OFG participants was the possibility to participate at a moment most convenient to them. Adolescents and adults (90.5% and 95.9%) more often reported this as an advantage than children did (30.8%, p < 0.02). Another important perceived advantage of OFGs was the possibility to participate from home (69.1%). The most important advantage of FTFs was respondents' perception that it is easier to have a discussion with the whole group when there is personal contact with others (48.5%). This advantage was mentioned significantly more often by adults (78.4%) than by children and adolescents (4.8% and 17.7%, p < 0.02). CONCLUSIONS: Participants' perceptions of OFGs partly concur with the advantages of OFGs as a research method. Whereas respondents generally value the convenience of participating at their own time and place, the anonymity of OFGs and the increased ease to discuss personal issues were mentioned less often as advantages by the participants. An aspect that may need more attention when conducting an OFG, is the absence of a fluid discussion, which is, according to our respondents, easier to achieve in an FTF. This underlines the importance of the moderator in enabling a constructive discussion.

The association between adolescents' health and disparities in school career: a longitudinal cohort study.

BACKGROUND: Literature suggests that children's educational achievement is associated with their health status and the socioeconomic position of their parents. Few studies have investigated this association in adolescence, while this is an important period affecting future life trajectories. Our study investigates the relationship between adolescents' health and their subsequent school career, taking into account their parents' socioeconomic position. METHODS: Data of all Dutch adolescents who entered secondary education in 2003, according to the national education register, were linked to electronic health records from general practices and to data from the Dutch population register on a patient by patient basis. Secondary school career data of 2455 adolescents were available for several years, resulting in a longitudinal prospective cohort. School career was measured by the completion of secondary education within the research period. RESULTS: For most health problems, adolescents' health status at the moment of entering secondary education showed no association with the subsequent course of their school career. However, adolescents who had more frequent contact with their general practitioner for acute psychosocial problems (e.g. enuresis or overactive/hyperkinetic disorder), were less likely to complete their secondary education, also after adjustment for parental socioeconomic position. They were also less likely to complete their secondary education at the level of entry. CONCLUSIONS: Adolescents' secondary school career is negatively affected by the presence of acute psychosocial health problems, but not by the presence of physical health problems. This underlines the importance of adequately addressing mental health problems in adolescence.

Informal caregivers of people with dementia: problems, needs and support in the initial stage and in subsequent stages of dementia: a questionnaire survey.

OBJECTIVE: The ageing of the population is expected to lead to an increase in the prevalence of dementia. Providing support to informal caregivers is essential to promote their wellbeing and prevent serious caregiver burden. The aim of the study is to investigate whether differences occur between the initial and later stages of dementia in terms of (1) problems experienced by informal caregivers in the provision of care, (2) use of professional support by persons with dementia, (3) informal caregivers' needs for additional professional support. METHODS: The data were collected within the framework of the Dutch National Dementia Program, which was instigated in 2005 by the Dutch Ministry of Health, Welfare and Sport to improve integrated care for people with dementia and their informal caregivers. This paper is based on data of a questionnaire survey among 1494 informal caregivers, collected between September 2007 and December 2008. RESULTS: Most informal caregivers (98-99%) experienced problems in caring for a person with dementia, irrespective of the stage of the illness process. In later stages, informal caregivers more often experienced problems in their social networks. Most dementia patients (87-94%) received ambulatory professional support. CONCLUSIONS: Since informal caregivers indicate a need for additional professional support in all stages of dementia, professional support should be provided during the entire illness process. Informal caregivers need advice on how to cope with symptoms of dementia, how to deal with behavior problems and receive more information about (early and advanced stages of) dementia and the supply of support.

Study design of 'FRIENDS for Life': process and effect evaluation of an indicated school-based prevention programme for childhood anxiety and depression.

BACKGROUND: Anxiety disorders and depression are highly prevalent in children and affect their current and future functioning. 'FRIENDS for Life' is a cognitive-behavioural programme teaching children skills to cope more effectively with feelings of anxiety and depression. Although 'FRIENDS for Life' is increasingly being implemented at Dutch schools, its effectiveness as a preventive intervention in Dutch schools has never been investigated. The aim of the study is to evaluate the effectiveness of 'FRIENDS for Life' as an indicated school-based prevention programme for children with early or mild signs of anxiety or depression. METHODS/DESIGN: This study is a controlled trial with one pre-intervention and three post-intervention measurements (directly after, and 6 and 12 months after the end of the programme). The study sample consists of children aged 10-12 years (grades 6, 7 and 8 of Dutch primary schools), who show symptoms of anxiety or depressive disorder. Data are collected through self-report, teacher report and peer nomination. A process evaluation is conducted to investigate programme integrity (whether the programme has been executed according to protocol) and to evaluate children's and parents' opinions about 'FRIENDS for Life' using online focus groups and interviews. DISCUSSION: The present study will provide insight into the effectiveness of 'FRIENDS for Life' as an indicated school-based prevention programme for children with early or mild signs of anxiety or depression. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2397.

Child and adolescent mental health care in Dutch general practice: time trend analyses.

BACKGROUND: Because most children and adolescents visit their general practitioner (GP) regularly, general practice is a useful setting in which child and adolescent mental health problems can be identified, treated or referred to specialised care. Measures to strengthen Dutch primary mental health care have stimulated cooperation between primary and secondary mental health care and have led to an increase in the provision of social workers and primary care psychologists. These measures may have affected GPs' roles in child and adolescent mental health care. This study aims to investigate the identification and treatment of child and adolescent mental health problems in general practice over a five-year period (2004-2008). METHODS: Data of patients aged 0-18 years (N ranging from 37716 to 73432) were derived from electronic medical records of 42-82 Dutch general practices. Time trends in the prevalence of recorded mental health problems, prescriptions for psychotropic medication, and referrals to primary and secondary mental health care were analysed. RESULTS: In 2008, 6.6% of children and 7.5% of adolescents were recorded as having mental health problems; 15.2% of these children and 29.4% of these adolescents were prescribed psychotropic medication; 18.9% of these children and 22.9% of these adolescents were referred, mainly to secondary mental health care. Between 2004 and 2008, the percentages of children (chi-square: 22.06; p < 0.001) and adolescents (chi-square: 9.15; p = 0.003) who were diagnosed with mental health problems increased. An increase was also found in the percentage of children who were prescribed psychostimulants (chi-square: 8.29; p = 0.004). Prescriptions for antidepressants decreased over time in both age groups (children: chi-square: 6.80; p = 0.009; adolescents: chi-square: 13.52; p < 0.001). The percentages of children who were referred to primary (chi-square: 6.98; p = 0.008) and secondary mental health care (chi-square: 5.76; p = 0.02) increased over the years, whereas no significant increase was found for adolescents. CONCLUSIONS: Although GPs' identification of mental health problems and referrals to primary mental health care have increased, most referrals are still made to secondary care. To further strengthen primary mental health care, effective short-term interventions for child and adolescent mental health problems that can be applied in general practice need to be developed.

Benefits and problems of electronic information exchange as perceived by health care professionals: an interview study.

BACKGROUND: Various countries are currently implementing a national electronic patient record (n-EPR). Despite the assumed positive effects of n-EPRs, their overall adoption remains low and meets resistance from health care providers. This study aims to increase our understanding of health care providers' attitude towards the n-EPR, by investigating their perceptions of the benefits and problems of electronic information exchange in health care and the n-EPR in particular. METHODS: The study was conducted in three Dutch health care settings: acute care, diabetes care, and ambulatory mental health care. Two health care organisations were included per setting. Between January and June 2010, interviews were conducted with 17 stakeholders working in these organisations. Relevant themes were deduced by means of thematic qualitative analysis. RESULTS: Health care providers perceived electronic information exchange to promote the efficiency and quality of care. The problems they perceived in electronic information exchange mainly concerned the confidentiality and safety of information exchange and the reliability and quality of patient data. Many problems perceived by health care providers did not specifically apply to the n-EPR, but to electronic information exchange in general. CONCLUSIONS: The implementation of the Dutch n-EPR has mainly followed a top-down approach, thereby neglecting the fact that the perceptions and preferences of its users (health care providers) need to be addressed in order to achieve successful implementation. The results of this study provide valuable suggestions about how to promote health care providers' willingness to adopt electronic information exchange, which can be useful for other countries currently implementing an n-EPR. Apart from providing information about the benefits and usefulness of electronic information exchange, efforts should be focused on minimising the problems as perceived by health care providers. The safety and confidentiality of electronic information exchange can be improved by developing tools to evaluate the legitimacy of access to electronic records, by increasing health care providers' awareness of the need to be careful when using patient data, and by measures to limit access to sensitive patient data. Improving health care providers' recording behaviour is important to improve the reliability and quality of electronically exchanged patient data.

Communicating with child patients in pediatric oncology consultations: a vignette study on child patients', parents', and survivors' communication preferences.

OBJECTIVE: To investigate the preferences of children with cancer, their parents, and survivors of childhood cancer regarding medical communication with child patients and variables associated with these preferences. METHODS: Preferences regarding health-care provider empathy in consultations, and children's involvement in information exchange and medical decision making were investigated by means of vignettes. Vignettes are brief descriptions of hypothetical situations, in which important factors are systematically varied following an experimental design. In total, 1440 vignettes were evaluated by 34 children with cancer (aged 8-16), 59 parents, and 51 survivors (aged 8-16 at diagnosis, currently aged 10-30). Recruitment of participants took place in three Dutch university-based pediatric oncology centers. Data were analyzed by multilevel analyses. RESULTS: Patients, parents, and survivors indicated the importance of health-care providers' empathy in 81% of the described situations. In most situations (70%), the three respondent groups preferred information about illness and treatment to be given to patients and parents simultaneously. Preferences regarding the amount of information provided to patients varied. The preference whether or not to shield patients from information was mainly associated with patients' age and emotionality. In most situations (71%), the three respondent groups preferred children to participate in medical decision making. This preference was mainly associated with patients' age. CONCLUSIONS: To be able to adapt communication to parents' and patients' preferences, health-care providers should repeatedly assess the preferences of both groups. Future studies should investigate how health-care providers balance their communication between the sometimes conflicting preferences of patients and parents.

Online focus groups as a tool to collect data in hard-to-include populations: examples from paediatric oncology.

BACKGROUND: The purpose of this article is to describe and evaluate the methodology of online focus group discussions within the setting of paediatric oncology. METHODS: Qualitative study consisting of separate moderated asynchronous online discussion groups with 7 paediatric cancer patients (aged 8-17), 11 parents, and 18 survivors of childhood cancer (aged 8-17 at diagnosis). RESULTS: All three participant groups could be actively engaged over a one-week period. Respondents highly valued the flexibility and convenience of logging in at their own time and place to join the discussion. Adolescent patients and survivors emphasized that the anonymity experienced made them feel comfortable to express their views in detail. The findings indicate a strong preference for online group discussions across all participant groups. CONCLUSION: The findings show that online focus group methodology is a feasible tool for collecting qualitative data within the setting of paediatric oncology, and may offer new opportunities to collect data in other hard-to-include populations. The evaluations seem to indicate that the online group discussions have given participants an opportunity to articulate their experiences and views in a way they might not have done in a traditional group discussion.