Research Report

Transcription

Research Report

Research Report - Salú Kòrsou
Project group members
Mirjam Achtereekte 10079564
Wim Bennink 10076867
Pauline Bulk 10052100
Lisette Grootscholten 10063889
Carla Mensonides 10062556
Tutor Ilsa Meeldijk - Tutorgroup 1 - Class vdco3
Code VD-H610-12 PROJECT 1 - Course 3.2 2012/2013 - The Hague 18 January 2013
The Hague University of Applied sciences
Academy of Health - Nutrition and Dietetics
Research Report - Salú Kòrsou
Overall assignment: ‘Go Global’
Tutor Ilsa Meeldijk
Tutorgroup 1
Class vdco3
Project group members
Mirjam Achtereekte 10079564
Wim Bennink 10076867
Pauline Bulk 10052100
Lisette Grootscholten 10063889
Carla Mensonides 10062556
Code VD-H610-12 PROJECT 1
Course 3.2 2012/2013
The Hague 18 January 2013
The Hague University of Applied sciences
Academy of Health - Nutrition and Dietetics
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Preface
‘Go Global’ is an organisation which advises public health experts, who are planning to work abroad.
‘Go Global’ organizes meetings to inform health professionals. In the present case, the dieticians
decided to go for Curacao. The complete report, consisting of two parts is intended for the health
professionals who are interesting in working with other cultures in The Netherlands and in present
case, Curacao.
To actually help patients/clients abroad, to change their lifestyle and eating habits in a positive way,
the dietician should be very well prepared. Besides information about Curaçao, the second report
contains informati on about the dietary habits and cultural rituals of Antillean people,
in The Netherlands. After extensive research and various activities, there will be presented a
thorough report, as a tool for dieticians.
Certain issues could not be found and the knowledge derived from contacts with a dietician, an
intern on Curaçao and teachers. For this we would like to thank Mrs. F. Eijndhoven, Ms. H. Van Haren
(mail contacts abroad) and the teachers of HHS: A. Rotteveel and G. Foendoe-Aubel and of course
our tutor I. Meeldijk.
Summary
This report contains all necessary information for the dietician that works with other cultures in The
Netherlands and in Curacao. Communication with foreign people could very well be an occurring
problem. The report is written in commission by the expat agency ‘Go Global’. To contribute to the
reduction of disease and complications from overweight and obesity, requires more than a regular
preparation. The dietician’s preparation should include a thorough knowledge of culture, population,
history, dietary habits and the healthcare system. Mutual relations, to work together with other
disciplines abroad can be instructive. The culture shock is discussed because it is important for the
dietician to become aware and be prepared for the situation. A suitable tool is the model of
Hofstede. It is very important to be aware of the role attitudes play. It is important for the foreign
dietician to be aware of her own attitude in another culture. Dietary habits, history of food, local
products and Antillean cuisine result in an extraordinary high intake of carbohydrates and saturated
fats. It will lead to many different diseases like obesities and Diabetes mellitus type 2 and others.
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The healthcare costs have risen and seem to be a threat to economy. Therefore it is important to be
aware of the economic and psychological aspects, in order to show understanding as and empathize
for the patient/client. Positive developments like projects for preventing obesity and dietary
information campaigns for diabetes patients are present. The Government is working on a basic
Insurance, so people can choose a private dietician. Before that’s possible, it will take about one
year. There is a food legislation of the former Netherlands Antilles that currently applies to all food
products on Curaçao. The dieticians are trained to be active in all health care settings as well as in the
commercial sector. Most of the people that are certified dieticians on this island, have obtained a
Dutch education in dietetics. One of the questions will be: What kind of roles do dieticians play in
Curacao and what are the possibilities in the future? Because it is such a small island, there are not
many opportunities to put all different roles of a dietician into practice. It also depends on the
initiatives of the dietician herself. The above-mentioned items are explained in this thorough
research report.
In part two will be mentioned what effective substantiation training is for the part of the Antillean
population, living in the Netherlands, with an objective BMI under 25 by means of a healthier
lifestyle? To find out, the lifestyle of the Antillean people living in the Netherlands will be described.
Also, the best way to inform en stimulates Antillean people to a healthier lifestyle will be mentioned
in this part of the research report. The way to do this is a cooking workshop for and with Antillean
people. During this workshop the dietician learns from the participants and the participants even
learn more from the dietician.
Eventually the conclusion can be that the preparation must be thorough on all issues mentioned, to
achieve a positive result to everyone’s satisfactory. Also the environmental factors determine the
local situation.
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Index
1. Introduction
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1.1 Research questions, Research report part 1:
1.2 Sub question, Research report part 1:
1.3 Research questions, Research report part 2:
2. Methods
3. Results
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3.1 Research report part 1 The dieticians
3.1.1 Sociological and Cultural aspects
3.1.2 Economics
3.1.3 Food and dietary habits
3.1.4 Food legislation
3.1.5 Health Problems
3.1.6 Health care
3.1.7 Dietary information campaigns
3.1.8 Roles, education, and vacancies
3.1.9 Attitude, image and position
3.2 Research report part 2 The people
3.2.1 Introduction
3.2.2 Background
3.3.3 Education information
3.3.4 Topics for the workshop
3.3.5 Evaluation
4. Conclusions
5. Discussion
6. Advices
7. References and literature
Annex 1
Annex 2
Annex 3
Annex 4
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1. Introduction
1.1 Research question, Research report part 1:
What characteristics concerning food and health of the population of Curaçao are relevant for a
nutritionist?
In order to answer the question above, the following sub questions functioned as a guideline.
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To what extent does culture affect health?
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How can differences in culture be used in a dietician – patient situation?
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Which religious values are important for a dietician?
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Is the model of Hofstede useful?
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What is the economic situation on Curaçao?
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How are the dietary habits of the people living in Curaçao?
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Is healthy food available and affordable?
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How is food legislation regulated in Curaçao?
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What are the most common health problems and their main causes on Curaçao?
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Are the Antillean people motivated to eat healthy because of their general health situation?
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How is the health care system organized in Curaçao?
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What can be told about the dietary information campaigns on the Island?
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In which professional role and professional field are they most needed?
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What is the educational level of the dieticians of Curaçao, and in what way are they registered
and united?
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What is the image and position of the dietician in Curaçao?
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What kind of professional attitude does a dietician need to have?
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1.3 Research question, Research report part 2:
What is an effective education for the part of the Antillean population with an
objective BMI under 25 by means of a healthier lifestyle?
1.4 Sub questions, Research report part 2:
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How do the Antillean people live in the Netherlands?
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What is the prevalence of overweight and obesity comparing Dutch and Antillean people?
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What’s the best way to inform en stimulate Antillean people to a healthy lifestyle?
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Do they feel the need for healthy eating or is the explanation of great importance, so the
Antillean people consider it seriously?
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What food do they prefer and what are their dietary habits?
2. Methods
Evidence-based literature research was started initially this delivered no recent scientific informative.
For example The “Curacao Health Study” dates from 1996. After discussing our doubts it was decided
that multiple other sources had to be used. This was done by asking questions by mail to a local
dietician mrs. F van Eijndhoven, she is also chairman of the NAVD (Nederlands Antilliaanse
Vereniging van Dietisten), and to Hélène van Haren, the current intern on Curacao.
On the internet there are found useful news articles, websites for instance of the Pan American
Health Organisation, and of the Volksgezondheidinstituut Curacao.
In the Netherlands there are interviewed several Antilleans, a visit has been payed to a social
meeting of Antillean ladies and the “Haagse Markt”.
Food legislation on Curaçao is difficult to trace. Our teacher of Food Science, A. Rotteveel contacted
Gwendell Foendoe-Aubel, he provided the correct information through his contacts in Curaçao.
Articles and links on blackboard were a good source of information as well.
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3. Results
3.1 Part 1 The dieticians:
3.1.1 Sociological and Cultural aspects
To gain insight into the cultural differences and their consequences, Sociology uses a model created
by Hofstede. In sociology the word culture is used to describe the total of expectations, standards
and values that people have acquired as a member of the society (Hendrix, 2006).
Hofstede distinguishes five cultural dimensions. When talking about the cultural dimensions of a
country he refers to the customs, standards and values used by the majority of the people in that
country (Hofstede, 2011).
The first dimension of national culture: power distance.
Power distance is the level of acceptation by the less powerful people that the division of power is
not equal. In countries with a small power distance the people with less power are less dependent on
the people with more power, they are equal. In countries with a larger distance of power the docility
is greater and the people are more passive.
In Curacao the distance of power is almost the same as in the Netherlands. Compared to other
countries, the Dutch score low on the power distance scale (Example of countries with large power
distance: Malaysia, Russia, Morocco) (Hofstede G. , 2005) (Hendrix, 2006).
The second dimension of national culture: collectivism versus individualism
Collectivism is when, from birth on, individuals are included in strong, close groups which provide
protection in exchange of unconditional loyalty.
Individualism is when ties between the individuals are loose and everyone has to look after oneself
and their closest family. This is similar to the “we” and “I” cultural differences (Hendrix, 2006). The
Netherlands is a society based on the individualism cultural dimension. One of the consequences is
that if you don’t live according the rules you should feel guilty.
In the collectivism cultural dimension, the members of the group are ashamed of the faults made by
individuals. Respect and social control within the group is essential, avoiding public failure is very
important. The group thinks for you, meaning that you don’t have to take responsibility for your
actions. (Hofstede G. , 2005).
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Bearing the above in mind, a counsellor using the individual approach when
treating a client from a collectivism culture, will surely fail. If you don’t see this as
counsellor, unnecessary communication problems will occur and will affect the relation with your
client (Becker-Woudstra, 2008).
The third dimension of national culture: masculinity versus femininity
A society is called masculine when the division of the sexes is strictly separated. Men are expected
to be assertive, tough and pursue materialistic success. Women are expected to be modest and focus
on the quality of life. Example of a masculine society: doctors are male and nurses are female
(Hofstede G., 2005). In a more feminine society the roles have a bigger overlap, both sexes are more
equal. Curacao has a more masculine culture. Women were subordinate for a long time. Men left the
island for study or work in other countries, especially in the Netherlands, leaving the women behind
to look after the children, but without financial support of the fathers (Antillen, 2010).
A counsellor with a feminine cultural background will surely experience the differences between the
sexes in Curacao. Nowadays the government tries to change this situation and make the position of
the sexes more equal (Wikipedia, 2012).
The fourth dimension of national culture: uncertainty avoidance
Avoiding threats, uncertain and unknown situations are what this cultural dimension is about.
The Netherlands scores high compared to Curacao, resulting in less decisiveness.
In Curacao religion is stable at the moment. The majority is Roman Catholic (87%). Politically
however it has been unstable since 2010. Corruption and interference by the Dutch government
have created a situation that no new government has been installed yet after the latest elections
(Wikipedia, 2012). One of the consequences is that there is no money budgeted for health.
In 2012 preparations were made to create a basic Insurance for all residents of Curacao. But this is
not effective yet. Which is a pity, because a number of consultations to a dietetic practice will be
included (KkCuraçao, 2012). This political instability makes investors reluctant to invest in new
projects in this country. And with no new investments, another uncertainty is created:
unemployment (Dryger, 2012).
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The fifth dimension of national culture: long-term versus short-term orientation
In long-term oriented cultures there is a strong tendency to save and invest, thriftiness, and
perseverance in achieving results. A short-term culture characterizes a focus on achieving quick
results and consumption (Hofstede, 2011). The Dutch culture is based on a long-term orientation,
unlike Curacao where the overall spending is based on short-term orientation (Hofstede G. , 2005).
3.1.2 Economics
Tourism is the main source of income. On the island 38% of the people work in the tourism industry
(Landenkompas, 2011).
Another big source of income is the oil refinery, which is leased by the government to Petreoleos, a
Venezuelan company. Financial services are also a source of income. Being a tax paradise, a lot of
trade houses and banks have their offices on this island. Access to Latin America is much easier this
way. This situation enhances employment and commercial traffic, another advantage for the island.
The Curacao’s Central Bureau of Statistics (CBS.CW, 2012) reports that Curacao’s economy grew by
0,6% in 2011 (2010 had a growth of 0,1%).
This economic growth also has a positive impact on health care. There is an agreement between the
general practitioners and the Minister of Health (Leidel-Schenk, 2012). Prevention of overweight is
also included in this agreement. As a result, there are more opportunities for dieticians.
Despite of the economic growth the socioeconomic status is often very low, perhaps partly due to
the fact that higher educated people left the island.
3.1.3 Food and dietary habits
During the history, many different foods and eating habits have come together on the one Island
Curaçao. Food is very important on Curaçao. The local food (Krioyo) on the other Caribbean islands
is similar (Narin, 2004). The main Nutrition products, are corn flour, beans, cassava, sweet potatoes,
hot peppers and saltwater fish. There is an abundance of papayas, mangos, coconut, pumpkins,
avocados and plantains (Haren, 2012).
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Various local dishes :

delicious seafood,

meats and side dishes.
The cuisine of Curaçao, Krioyo, is pronounced ‘Criollo’, which is Spanish for "Creole". Creole cuisine
means a blend of flavours and techniques of the Caribbean and Latin American cuisine.
On Bonaire and Curaçao a hot sauce called Pika is used (diced onions, vinegar, and hot peppers), to
enhance local dishes. Pika is delicious, but also rich in calories. Kabritu Stoba (stew of goat meat) is a
favourite local specialty. Plantains (fried bananas) are usually served as vegetables or as side dishes.
Keshi Yena is also very delicious and means "filled cheese"; the cheese is stuffed with mainly chicken,
raisins and beans. Funchi is another specialty and is made out of corn; it's similar to corn bread and is
usually fried like french fries. Typical side dishes are rice with beans, white rice, french fries, or baked
potatoes. Dradu (local Mahi-Mahi), lobster and keshi-yena (filled cheese). Exotic specialties are
iguana soup or stew, and the flower of cactus trees. On both Curaçao and Aruba people eat also
Sòpitu, a mix of cooked fish in coconut milk, salted meat and other ingredients.
Pastechi (fried pastry filled with cheese, tuna, ham, or ground meat),is used as breakfast or snack.
By the supply of fresh fruit and vegetables from Venezuela nowadays, unlike the past, people also
eat some vegetables.
Fruit is expensive (Wikipedia, 2011). The only way to make it feasible for local people to consume
fruits and vegetables, is the emergence of local agriculture, which must be stimulated by the
Government. Currently there is a shortage of farmers because farming equipment is expensive and
working hard in this climate, with long-lasting drought, is no option (Haren, 2012).
People on Curaçao eat at lunchtime a warm meal at the so called “Truck di pan”, at the side of the
roads. The trucks are open till late at night, so people take an additional meal or snack in the late
evening. At festive occasions on Curaçao one often finds a variety of so-called "Kos dushi"(traditional
sweets): kokada, coconut candies, also ko'i Lehi, sweet condensed milk and sugar, and tentalaria,
peanut candies. On Curaçao there’s also much fried food (Chenette, 2011).
The Blue Curaçao liqueur is indeed produced on Curaçao. The island also has many Chinese
restaurants that serve not only Indonesian dishes such as nasi goreng and egg rolls, but also Dutch
specialties such as croquettes and pancakes.
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The local food and dietary habits on Curaçao will inevitably lead
to the fact that the population on Curaçao gets due to their basic
nutrition and local, cultural habits within, too many of the following nutrients: carbohydrates,
unsaturated fats, sugars. This is an excess intake of energy. This also leads irrevocably to diseases like
high blood pressure, cholesterol, diabetes, heart diseases, overweight and obesity in itself, which will
be described in the following part (Haren, 2012).
Quotation for example “Antillean women live to eat". In their experience, the benefits of healthier
eating do not outweigh the disadvantages.
This hampers these women to eat healthier, according to the survey conducted by LEI, part of
Wageningen UR, which is funded by the Ministry of Agriculture (Wijk-Jansen, 2010).
3.1.4 Food legislation
According to the Ministry of Health, Environment and Nature of Curaçao, legislation of the former
Netherlands Antilles currently is applicable to all food products on Curaçao. The website
www.overheid.nl has an option for the "regulation of provinces, municipalities, water boards, BES
and former Netherlands Antilles". Furthermore, much of the legislation in Curaçao is very dated and
not digitally available. So there is a specific legislation for food products on Curaçao and it is excluded
from the Dutch food legislation. Exact details regarding food legislation can be found on the internet
site www.overheid.nl (Overheid.nl, 1997)(Foendoe-Abel G., by e-mail, 2013).
Curaçao is affiliated with The Pan American Health Organization (PAHO, 2012). PAHO is an
international public health agency and exists almost 110 years. It serves as Regional Office for the
World Health Organization. PAHO is internationally recognized as part of the United Nations system.
The PASB is the secretariat of the PAHO. The PASB ensures that all the people of the Americas enjoy
optimal health and contribute to the well-being of their families and communities. To ensure
cooperation among Member States and partners, to promote the ability in health, to control
diseases, and to improve the quality of, and lengthen, the lives of the people of the Americas (PAHO,
2012).
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3.1.5 Health problems
Hypertension, hypercholesterolemia and dyslipidaemia and a combination
of these diseases are frequently present. These dysfunctions will lead to related cardiovascular
disorders. The most important issues are the presence of obesity, diabetes mellitus and overweight
itself. Also cancer is a common disease. The unhealthy poor dietary habits and lack of exercise as well
as a high consumption of alcohol and tobacco are risk factors for chronic diseases (Haren, 2012).
Poverty in Curaçao is often not visible. Agnes Cobelens, president of the Foundation for Acute
Poverty Relief (SANA), mentions that poverty is inherited. Mylene Testing, president of the Foodbank
in Curaçao said that the vicious circle in which many people are, is hard to be broken. The Foodbank
has been around for 30 years. "Poverty is no priority for the government in Curaçao." One of the
major problems with poverty, is access to healthy food and thus nutrient inadequacy like for example
iron shortage. The reason simply is that healthy food is too expensive. Culture of shame is big on
Curaçao, so people are too proud to admit that they need help from charity. This iron inadequacy is
leading to lack of concentration in children. Sometimes the children do not finish their education
(RNW, 2012). The contacts on Curaçao are unaware of iron deficiency especially in Curaçao.
According to them, the iron deficiency on Curaçao may be as widespread as in the Netherlands. One
possible reason may be that the people often eat chicken instead of meat (Haren, 2012).
Obesity
The obesity epidemic is also one of the biggest causes of death in the Caribbean. The number one
cause of death is diabetes mellitus due to obesity. But obesity also leads to non-communicable
diseases (NCD’s) such as diabetes, hypertension, stroke, heart diseases and some forms of cancers.
Like obesity itself there is not one simple intervention that can prevent obesity or other related
diseases, because so many psychological, cultural, economic and environmental factors are involved.
The financial consequences of obesity, high expenses, will mainly be felt in the healthcare sector, but
obesity will eventually threaten economic development of the Caribbean islands. The government
should act on the social and environmental conditions. Several sectors must be involved, so people
can make healthier choices in food and active lifestyle (Henry, 2011).
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Diabetes mellitus type 2
Increasingly, the population of Curaçao are faced with diabetes mellitus.
Not only increasingly, but people are getting younger diabetic even at the age of 35.
In some cases It even happens among children. Precise data about the amount, circumstances or risk
groups of diabetes patients on the Island, are lacking. A research that gives specific information is
necessary for a targeted government policy. This is written by Diabetes Association Sokudi (AmigoeSokudi, 2012).
There should be more and better cooperation in the form of a multidisciplinary consultation and
"network administrative organization" (NAO), which will control the business and policies of the
government (Diabeteszorg op Curaçao, 2009). The Public Health Department (GGD) estimates the
number of diabetics in Curaçao between 20,000 and 30,000. That means that between 14 and 21% of
the Curaçao, Sokudi is aware of the fact that there are still not enough initiatives for prevention.
Sokudi helps people to improve their lifestyle in an physical and mental way (Hewitt, 2010).
3.1.6 Health care
The GGD, including the Department of Nutrition and Dietetics , is responsible for the health care of
the people of Curaçao and the securing of a sanitary environment. A new single regional public
health organization, the Caribbean Public Health Agency (CARPHA), has been created by the
Caribbean Community with support from the Pan American Health Organization/World Health
Organization (PAHO/WHO) and some international partners.
CARPHA will replace and build on the work of the Caribbean Community's five Regional Health
Institutions like the Caribbean Food and Nutrition Institute (CFNI). The CARPHA becomes operational
in January 2013 (Caribbean News Now!, 2012).
Hospitals:
Secondary health care is provided in hospitals. There are 7 on Curaçao, with a total of 1.187 beds
(Pan American Health Organisation, 2012). In 2015 a new general hospital will be opened on Curaçao
(VIC, 2012).
Medical specialists:
Most of the specialists on Curaçao are educated en accredited in the Netherlands, and mainly Dutch
protocols are being used (VIC, 2012).
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The Dietician:
Until now dieticians work mostly on recovery of patients and on
prevention of diseases. Especially the prevention task deserves more
attention. On Curaçao The main task of the dieticians working with obese
patients and/or diabetes (VIC, 2012). Some dieticians have their own practice
and some work part-time in different places like a hospital, or at a general practioner
(Haren, 2012).
Cost:
Like anywhere in the world the costs of healthcare are increasing due to the growing amount of
elderly people, technological developments, and an unhealthy lifestyle with more and more chronic
diseases. Less income of more economically inactive inhabitants leads to rising costs of health per
person. SVB is the largest health insurance company of Curaçao, about 2.6% of the population of
Curaçao is not insured (VIC, 2012). Everyone with a job receives health care through the social
insurance bank or through their work provider. The retired and unemployed people are also entitled
to healthcare (Haren, 2012).
3.1.7 Dietary information campaigns
Past and Present:
The Foundation “Hulp aan Curaçao” provided, through the project "Foodbank", since 1982 free food
to those who are financially unable or barely able to meet their livelihood. The composition of the
packages is also considered a good representation of all nutritional groups. The Foundation started
further more in 2005 the project Tutti Frutti - Fruit. Fresh fruit is provided to children going to an
(unsubsidized) after school (Voedselbank Curaçao).
Another foundation is Fundashon Kome Salu, Salu Pensa, Biba Salu (Foundation Eat, Think and Live
healthy) founded in 1987. So there are several foundations that are committed to a healthy Curaçao
(Roos, 2012). Financial resources can be obtained through donations or through AMFO.
As a result of the termination of the subsidy to AMFO, the organization phase out its activities in the
course of 2013. One of the projects is about diabetes (AMFO, 2008).
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Initiatives such as Move Your Act!, Ban Move and 'kaminata's'
(walks) motivates the population literally to more exercise and health
promotion. Diabetes Association Sokudi motivates the population through
courses concerning healthy living. Sokudi has a yearly Diabetes day (Monart, 2010).
The subproject 1: “Obesity prevention on Curaçao” is an initiative of the GGD of Curaçao. It is
important to tackle obesity and overweight in Curaçao preventively in a systematic, comprehensive
and structured manner. Ahead of obesity prevention plans are already some initiatives to promote
“awareness” (agenda setting and awareness). For example activities with the waist ribbon at the
annual Fatum run, open day at the diabetes association, a health bus (healthy areas) to a yearly
symposium and workshops.
Further attention is for the primary prevention of obesity among youth. Called subproject 2:
"Nutrition education in primary and secondary education”. Besides nutrition education, intensifying
physical education is very important and not to forget the involvement of parents and teachers (GGD
Curaçao, 2008).
Skol Salu has started in 2010 at the Department of Public Schools in Curaçao. Besides the nutritional
component, other themes picked up including physical exercise , education and welfare. The themes
are based on the UK concept of the Healthy Schools (Sommers & Velden, 2011).
An official food guide for the English speaking Caribbean is existing. 70% Of the daily intake of all the
food guides consists of carbohydrates (Food and Agriculture Organization of the United Nations,
2007).
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Most of the dieticians working in Curaçao, finished their study in
the Netherlands. So they all have the same knowledge as a dietician in
the Netherlands, including the knowledge of the dietary information
campaigns that are available in the Netherlands, like “Gezond eten en bewegen” of
the Voedingscentrum. Nutritional guidelines, such as the “schijf van vijf”, can be used in Curaçao,
when the Dieticians give different food options to choose from. Curaçao has not only products from
the Netherlands, but also many products imported from (north and south) America. American
products predominate in the stores. So when the Dieticians give a variation lists consisting of a mix of
different (healthy) brands combined, this can still be based on the “schijf van vijf” (Haren, 2012).
Future
The Strategic Plan of Action (2011 – 2015) for the Prevention and Control of Chronic Non-Communicable Diseases in the Countries of the Caribbean Community is intended to provide a plan for action
and resource mobilization at both the regional and national level to form. Goals are:
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Healthy eating (including, trans fat, fat, sugar)
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Salt reduction
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Integrated Programmes, especially at school, at work, and faith-based setting (Pan American
Health Organization, 2011).
The Millennium Development Goals (MDGs) report for Curaçao and Sint Maarten is the first to be
produced and is mainly a baseline study on the status of progress in the direction of the MDGs in
these islands from 2001 to 2010. To achieve the goals and objectives in 2015, the aim about food is:
“Eradicate extreme poverty and hunger” (Governments of Curaçao and Sint Maarten, 2011).
The Caribbean Public Health Agency (CARPHA) will serve as the lead agency for coordinating panCaribbean action in areas including disease surveillance, health promotion and communication,
development of human resources for health, emergency preparedness and response, and policy
development. The merger of five institutions into one regional health agency will allow for more
effective investments and action to protect and promote public health (Pan American Health
Organization, 2012).
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3.1.8 Roles, education and vacancies
The role of a dietician on Curaçao doesn’t differ much from the one in the Netherlands. Information
on all six roles of a nutritionist/dietician is hard to find.
Practitioner
Because it is such a small island, there are not many opportunities to put all different roles of a
dietician into practice. “All the people on the island (that I know of) are dieticians in the role
practitioner and have their own practice.” According to Hélène van Haren, a student of the Hague
University of Applied sciences who does her internship on Curaçao (Haren, 2012).
Information officer
Sosiedat Kurasoleño di Diabétiko (Sokudi), the association for diabetes patients, organises annually
meetings in order to inform about lifestyle habits to prevent diabetes or diabetes related problems.
Sokudi does this together with local dieticians in the role of information officer (Amigoe, 2011).
Marketing manager
Dieticians in the role of international marketing manager live on Curaçao to work for the Nutricia
company. From Curaçao other islands and countries in South-America are easier to reach by plain
than from Europe (Visser, 2012).
Education
The Curaçao educational system includes schools for elementary, secondary, technical, higher and
limited university education. Recently a Medical university and a general University have settled on
the island (Live in Curaçao). Every year about 300 students come from Curaçao or one of the other
former Dutch islands to the Netherlands, for more opportunities and to study (Entzinger & Toubourg,
2011). All people living on Curaçao speak Dutch and they have a Dutch passport, what makes it
possible to go to the Netherlands to further their studies on a grant. Most of the people that are
certified dieticians on this island, have obtained a Dutch education in dietetics. They are associated in
the NAVD. Mrs. van Eijnhoven is one of the few Antillean dieticians enrolled in Dutch Quality
Register. To Curacao such a system would be good, but it is impossible to offer affordable and highly
qualified training courses, because of the small number of dieticians on the island (Eijndhoven,
2012).
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Vacancies
Curaçao is a small Island, so the vacancies are rare, according to Hélène
van Haren. Nowadays every dietician would have less work, than they would
like. A part of the population (30.000 people) only can choose one dietician. The Government is
working on a basic Insurance, so people can choose a private dietician. Before that’s possible, it will
take about one year. Due to the average age of the so-called private dietician of 58, there will
become jobs available in the coming years. As stated in her answers, Mrs. Eijndhoven mentions that
dieticians from abroad can’t work on Curaçao, only dieticians that are born there or have their roots
on Curaçao (‘Landskinderen’) have the possibility to work on the Island (Eijndhoven, 2012).
3.1.9 Attitude, Image and position
Imago and position
It depends on the initiatives of the dietician herself to cooperate in committees with other
healthcare attendants, or to achieve a position that is important to her. The population will only visit
the dietician if it is prescribed by the doctor and they will not visit at their own initiative. A part of the
patients with a prescription will not even pay a visit to the dietician, or they postpone their visit
(Eijndhoven, 2012).
Attitude
Working as a dietician in a new culture can be thrilling, personally satisfying, and intellectually
stimulating. It can also be frustrating. Participation in Curacao provides a rare chance for you to begin
to know another society from within. You need to adapt one's behaviour to the customs and
expectations of Curacao. This is not to deny your own culture but to respect that of others. You have
to be open to similarities and differences, to learn rather than to judge. The problems that you
experience as you integrate into Curacao can be a result of what is termed “culture shock”.
Attitudes come in a wide variety of species, ranging from cultural to personal attitudes. You take
attitudes with you to Curacao, and those you form once there, will have such a great effect upon
your perception of the people and ways of Curacao, it is very important for you to be aware of the
role attitudes play.
"Culture shock" is caused by the aforementioned mismatch of cultural attitudes. And it's easily seen
by people who do not keep an open mind, and omit to invest any effort trying to understand a
foreign culture, and the tendency to judge something that is different as inferior. It is important to be
open toward the culture of Curacao, to try to discard stereotypes (Study Abroad Center).
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3.2 Research report part 2 The people
3.2.1 Introduction
What is an effective substantiation training for the part of the Antillean
population, living in the Netherlands, with an objective BMI under 25 by means of a healthier
lifestyle? To find out, the lifestyle of the Antillean people living in the Netherlands will be described.
Also, the best way to inform en stimulates Antillean people to a healthier lifestyle will be in the
spotlight.
Literature, results of the questions of Food Science and interviews will be used in order to form a
clear and reliable image.
3.2.2 Background
Prevalence
There’s a high prevalence of overweight amongst Antillean people. 20% of the Antilleans in the age
of 18-70 years struggle with obesity (BMI ≥ 30). Among women, this percentage is 25%. These figures
are shocking but the figures of the Antilleans living on Curacao are even higher. Overweight is
alarmingly high. According to the data of the Curaçao Health Study of 1996, 56% of men and 68% of
women suffering from overweight (BMI ≥ 25).Furthermore, 18.7% of men and 36.2% of the women
have obesity (BMI ≥ 30) on Curaçao (Nationaal kompas volksgezondheid, 2012).
The prevalence of overweight and obesity are lower in the Netherlands, however these figures still
rise. Almost 12% of the Dutch population suffers from obesity, 36% of the Dutch population is
overweight (CBS, 2012).
Obesity among adults
30
27
25
20
%
20
15
12
10
Dutch population
Antilleans living in The
Netherlands
Antilleans living on the
Antilles
5
0
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When there no action (such as: dietary information
campaigns and education) will be taken, the figures will
rise further. The tipping point comes within range when good
dietary information campaigns and education has been implemented. The annual direct costs of
health care as a result of overweight and obesity will decrease (RIVM, 2012).
Antilleans living in Netherlands
Population submitted by the Antilles are also called non-Western immigrants. The number of
Antilleans is estimated at approximately 135,000 (0.8%). However, these figures are not completely
reliable because there are many unregistered Antilleans living in the Netherlands (CBS, Statline
2009). Most of the Antilleans live in the capital cities; Amsterdam, Rotterdam and The Hague. The
target group also is represented reasonable in the province of Flevoland as well.
Social economic status
About 3,500 to 4,000 people with an Antillean background in the Netherlands in 2011 are higher
education students. Many of them are born and/or raised in the Netherlands, but also every year a
250 to 300 students come directly from Curaçao or the other Antillean islands to study. The
Netherlands now offers more choice in vocational and University courses than Curaçao and the other
Antillean islands.
Health problems
Overweight and obesity have a major influence on the quality of life. People with overweight/obesity
face a greater risk of getting chronic diseases such as; type 2 diabetes mellitus, cardiovascular
disease, some forms of cancer and reduced mobility. In addition, overweight/obesity can lead to
psychological and social complaints, in particular with children (Rijksoverheid, 2012).
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3.3.3 Education information
Prevention for Antillean people
Prevention aimed at Antilleans focuses on the approach of
overweight and the far-reaching consequences of this. Diabetes mellitus and
cardiovascular diseases can be reduced with a healthy lifestyle including a healthy diet. The aim is to
improve the health status and quality of life. It is also shown that overweight and obesity and related
diseases are an enormous cost for the society. Figures indicate that the direct impact of overweight
and obesity costs society approximately 505,4 million each year on medical care. The indirect
consequences of obesity cost an estimated 2 billion euro’s each year (Nationaal kompas, 2010). On
prevention, information for promoting a healthy weight and a healthy diet, is spended approximately
13 million euro’s in 2007in the Netherlands. A small amount compared to the medical cost savings.
Only with an intensive approach of overweight and obesity, people’s behaviour at the long-term can
be changed. Research shows that overweight with 1 to 3 percentage points can decrease (RIVM,
2005).
Organisations
Prevention and health promotion focused on immigrants are achieved by active institutions that also
have the general population as a target group. This applies, for example, to home care institutions,
local health authorities and health promoting interventions. These institutions expanded their activeties in an increasing multicultural society. Some institutions are specifically focused on immigrants,
they organise also preventing activities by specific channels towards the target groups directly.
Immigrant organisations themselves and neighbourhood homes are increasingly important
distribution points for information material about health.
Attention is focused on interventions for specific health problems among Antilleans. These include
overweight, obesity, and the consequences like diabetes mellitus and cardiovascular disease.
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Ways to learn
An important factor when choosing a form of education is, what and
how do people remember?
Significant are following percentages. We remember: 50% of what we hear and see, 70% of what we
discuss with others, 80% of what we evaluate and discuss with others and 90% of what we explain.
There for the education will take place in the higher percentages of the way people remember.
The way we like to do this, is a cooking workshop for and with Antillean people. During this workshop
the dietician learns from the participants and the participants even learn more from the dietician.
Antillean ladies meet each other and cook together in The Hague. Our workshop in general is given
for club members who lead the meetings normally, these ladies are also from the Antilles and know
how and when problems can occur. So the Antilleans will be informed to inform other Antilleans. In
this way the participants will adopt the information faster because they may trust someone from
their own culture better.
3.3.4 Topics for the workshop
The workshop will consist of three meetings and will be organised once every two weeks. This way
there is enough time at the first meeting for acquaintance, explanation and expectations. During the
first meeting there will also be a presentation by power point, which will also be distributed, because
the participants must be able to read the explanations and information afterwards. The group
discusses with each other and tells from their own point of view what their attitude is towards a
healthy lifestyle and what they think themselves to be able to do.
The expectation is that the group during the first meeting, according to the stages of changes model
of Prochaska, will be in phase one (pre-contemplation) or phase two (contemplation). The workshop
is adapted to phase 3 (action). At the end of the course the aim is to activate the participant towards
phase 4(maintenance).
During the second and third meeting the participants will cook with guidance of the dietician. The
dishes are prepared and afterwards, enjoyed collectively.
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Food products and dietary habits
All gathered information about food and dietary habits, is
described in the research report part one, chapter 3.1.3. In The Hague the
Antillean people especially buy there groceries on “De Haagse markt”. Really all ingredients which
are used in the Antillean cuisine are for sale.
Lifestyle
In the perception of women with Antillean roots the benefits of healthier eating and lifestyle do not
outweigh the disadvantages (interview, 2012).
Among Antillean women there’s more acceptance of an above average body weight than indigenous
Dutch people. The main drawback of healthier eating is that eating less means; less tastefully food to
enjoy. The women don’t expect much support from their social environment for a healthier diet, or
for weight loss.
For a better understanding of overweight and obesity in women with an Antillean background, the
workshop will highlight the health benefits of healthier foods. There is an explanation why it does not
have to be necessarily expensive, difficult, less tasteful and cosy (Wageningen UR).
Exercise
The importance of sufficient exercise also will be mentioned, the rule that will be implied is; working
out is fine, physical activity is required for a minimum period of two times 30 minutes each day.
Physical activity means climbing stairs, dancing, hiking, cycling and so on.
Healthy nutrition directives
Healthy nutrition directives are the foundation of the workshops. The “Schijf van vijf” will be used
during the cooking workshops, and has in consultation with the ladies to be adjusted in a proper way.
Special attention will be paid to portion sizes. Antilleans are probably accustomed to large servings
and will fill their plates multiple times. Breakfast, lunch, dinner and two or three (the maximum)
times a day a snack will be the advised guideline.
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Carbs
There are too few vegetables in the daily menu. Also the fact that
potatoes and legumes often are seen as vegetables, causes misconceptions. In the case of type 2
diabetes, it is important to divide the carbs evenly over the day. Therefore explanation about
vegetable’s and which products are rich in carbohydrates is necessary.
Fat
Antillean people have the tendency to fry there food often. So when they prepare meats or fish, they
usually fry this in oil. Witch chronic disease it is of interest to bring the saturated fat percentage
down. Vegetable oil use is definitely a very good choice, use of this should be emphasised, therefore.
However, it is just as important to bring the total fat content down.
Salt
Antillean menu contains overall much salt. Because of the higher risk of getting chronic diseases such
as; type 2 diabetes mellitus and cardiovascular disease, salt intake is particularly important. This will
be discussed in all three meetings.
Easy, accessible and affordable
Cost can be covered from the health insurance, they compensate three consult hours each year. This
will not be enough but there is often from municipalities a request funding for this types of activities.
The houses in the neighbourhood houses are already often equipped with sufficient space and
spacious kitchens. Schools and care institutions can often be partly rented for not too very high costs.
The participants themselves will bring their one groceries as only payment for the workshops.
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3.3.5 Evaluation
Evaluation process
After the cooking workshop, during the meal,
the workshop becomes verbally evaluated. What are the findings, what was easy to apply and what
problems were encountered? The prepared dishes are photographed, along with the recipes,
method of preparation and nutritional value table. The dietician combines it into a cooking booklet.
Evaluation product
Healthy nutrition directives are the foundation of the workshops. Therefore de participants will be
screened whether they comply with the healthy nutrition directives during the first workshop. The
expectation is that no one will. After two months the participants will be screened again and the aim
is that 50% of them will come up to expectations.
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4. Conclusions
A lot happens on Curaçao regarding to food,
health, economy and prevention. Religion is important
on Curaçao, but with no significant influence on dietary habits.
Dietary habits, history of food, local products and Antillean cuisine result in an extraordinary high
intake of carbohydrates and saturated fats. It will lead to many different diseases like obesities and
diabetes mellitus type 2 and others. The healthcare costs have risen and seems to be a threat to
economy. Positive developments are rising, although still a great deal should be achieved. The
dietician consults are in the basic Insurance for a few hours, so more people receive the opportunity
of personal advice. People also need to be motivated, because they clamp on to their food culture.
Poverty must be tackled, so everyone can afford healthy products. The government should invest in
automation of agriculture, to improve the local situation. Aid agencies and regional GGD would set
up projects, in which major barriers are contested. There are plenty of dietary and physical activity
campaigns, but just education is not enough to achieve significant change in behaviour. Foreign
dieticians will have to take into account the cultural differences. The population acts according to
certain patterns, and it’s a task of the dietician to be open to differences in culture, so she can
empathize with patients/clients.
New younger dieticians should boost the image and take initiatives to set up activities which will lead
to behavioural change. Practical nutrition advice and multidisciplinary collaboration are important
items. There is sufficient work to be done now and in the future. Unfortunately it is not noticeable in
the number of vacancies. The Government must be able to intervene in the automation of
agriculture, that will probably be one of the few options for a positive change. Investments in
agriculture will potentially lead to new jobs.
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Discussion
Within this project there was only one discussion
point: which country/culture will be chosen.
Our first choice was the Netherlands Antilles, but this was not
supported by all project members. It was decided to narrow it down to one of the islands because
the cultures on each of the islands were different and they had become separate states.
Aruba had been independent for a longer time than the others and had a more American culture
because of the American tourists. Because of the American influence less people had immigrated to
the Netherlands than before, so the group of the Arubans in the Netherlands was not so big.
Bonaire is an independent municipality of the Netherlands and a lot of Dutch people live there (86%).
This culture is similar to the Dutch culture.
The most interesting island of the Netherlands Antilles is Curacao. Its culture is different from the
Dutch. A large number of people have emigrated to the Netherlands and there are Dutch companies
who have expatriates on Curacao. Despite the many differences in culture there are many ties to the
Netherlands. This is why this island was interesting for our project. There were not many scientific
articles about the culture of Curacao, but after consultation with our Tutor there are also other, not
scientifically based articles, used
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5. Advices
To achieve successful integration when changing your
work area to Curacao, our report advises the following:

Be prepared for a culture shock. The new culture has its own norms
and values that are present without noticing them. After a while you will miss your own culture,
and lose the certainties of your own culture. Be aware that this can happen and prepare yourself
by reading as much as possible about this new culture and the social consequences.
An appropriate tool for this can be the model of Hofstede.

Eat the local food, experience the traditions, the local products and customs. It is essential that
you empathize in the eating culture in order to gain expertise, a prerequisite when working in
the nutrition field. This will enable you to find alternatives within the eating culture that will be
accepted by the people who prepare the food, so they will implement these alternatives. This
trust is not something you gain in a day, this will take time.

The street scene of Curacao is different. The Dutch are generally thinner than most people on
Curacao. In the beauty culture of Curacao it is accepted that people are fat, you will not find
many people who are slim and thin. This fatness creates health problems, but these problems
are often not recognized as being caused by being fat. As dietician it is very important that you
take this into account. The image that people have of themselves is different and the problems
this overweight creates are experienced differently by the Curacao people.

On Curacao dieticians mostly work as practitioners. They work as independent dieticians with
their own practice, but also in combination with a physiotherapist or in a health centre. This line
of work has to suit you; there are fewer opportunities in other professional dietetic roles on the
island.

To make your own practice profitable, there are possibilities to qualify for money coming from
projects of the health promotion campaigns. It is recommended to research the possibilities in
advance. There are several existing health care activities that complement nutritional
information.
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Annex 1
A comparison of the countries Venezuela, Suriname and Jamaica with the Netherlands concerning
the five cultural dimensions of Hofstede.
This is differentiated from countries in the region of Curaçao, because Curaçao was not included in
the list of models to compare countries.
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Annex 2
Questions and answers intern H. van Haren, Curacao.
Are the people motivated to work on their health situation, or do they understand the reasons why it
is important? Because being slim is not that important for appearance in their culture.
I think they do understand that eating healthy is important, but some have the wrong idea of what a
healthy diet contains. For example, they might think there being healthy, because they’re eating
lettuce, but on the lettuce they put dressing and don’t realize that this contains allot of calories. But I
think this is all over the world, that people don’t have the right information what good nutrition really
is. But there are more and more lectures being given on the island about good nutrition. With doing
this they try to make the people more aware.
Once there diagnosed with a disease the people are motivated to work on their health. They are
revered to a dietician to get there health issue under control . When that is not the case, they don’t
really have a big enough reason to work hard on their health, so then there not that motivated. Being
overweight here is normal, nobody looks at you differently, so they don’t really feel pressure or the
need to lose weight and give up their way of eating.
Is it true that there is a higher prevalence of anaemia due to cow's milk in children’s nutrition? Can
you explain this?
From interview has emerged that anaemia under the Antillean women is common. Can you explain
what is caused this and how often this occurs. We found out that there is more frequent congenital
deficiency but not that this is the case for all women.
I had a hard time finding an answer to these questions.
All I can say is that people here eat allot of meat, so I don’t understand why anemia would be
common here. So in any case, I don’t think the nutrition is to blame. But I wouldn’t know the other
cause.
Imago dietician
What do you know about the image of the dietician on the island of Curacao? What opinion has the
population about the function of dietician? How is the collaboration with other health care
attendants?
Dieticians don’t have a bad image. Just like doctors etc., they are there to help with health problems.
From my experiences during consultations, I did notice that the patients think that the dieticians will
do all the work for them, as if there is some magic diet they can take and all their health problems will
be resolved. They don’t realize in the beginning how much work they actually have to put in it
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themselves. This is very confronting to them. I have seen patients going from being very happy at the
beginning when they explain how much they eat, to being very quiet when they’re confronted with
what they have to change in their way of living and diet.
The collaboration with other health care attendants is good. They work with Physiotherapist,
Cardiologists, Internist, Diabetes Miletus nurses, Doctors.
Vacancies/ possibilities
Are there enough jobs for the professional role practitioner or is the market sufficiently represented?
What are the opportunities in various roles as a practitioner, officer in prevention, nutrition
manager, or an independent business (commercial) with products for sale in Curacao?
In the report I already explained this.
Health care
Is everyone insured for the costs of healthcare, in specific the cost from a dietician? Are there many
people without insurance? Do people have to deal with a high amount of own risk?
This is also in the report.
Are many of the dieticians in curacao their own entrepreneur or do they work for one of the
hospitals, or maybe a combination of both?
A combination of both. Some work part-time at different places, for example at a hospital and at a
general practitioner.
And some have their own practice.
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Annex 3
Questions and answers Dietician Mrs. F. Eijndhoven from Curaçao.
Food / Food habits
Do people nowadays eat more fruits and vegetables, from Venezuela, or is it too expensive for the
population? Are there any ways to change that? They are still not eating much vegetables and fruits,
they aren’t used to it. And still it is expensive. In town there are coming small ships from Venezuela
and also the supers are buying fruits and vegetables from Venezuela as also from America and
Europe. The Government shall abolish the tax on fruit and vegetables.
Health problems
Is it true that the main diseases obesity and diabetes mellitus are most common in curacao or is
there another important issue that we overlooked? That depends how you look at it. When you count
the causes of death is no 1 heart disease. DM is about 10-15% of the population, but HT is more than
20%. Obesity is very common, bur I only have date from 20 years ago, and there is a difference
between obesity and adiposities. What does the government at the moment? The government is busy
with a program of multidisciplinary approach for DM that will be implemented soon. Are there any
interventions?
Are the people motivated to work on their health situation, or do they understand the reasons why it
is important? Because being slim is not that important for appearance in their culture. ???? People
are more motivated to change their lifestyle if there they have DM or HT or dyslipidaemia, then when
they have only too much weight. But that is not typical for Curacao.
Is it true that there is a higher prevalence of anaemia due to cow's milk in children’s nutrition? I am
nota ware of that? How did you get this information? Can you explain this?
From interview has emerged that anaemia under the Antillean women is common. Can you explain
what is caused this is it more common than e.g in Holland? They are eating not much vegetables, but
veggie’s aren’t an important source of Fe. Perhaps they eat more chicken and how often this occurs
no data I have.. We found out that there is more frequent congenital deficiency but not that this is
the case for all women.
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Food legislation
Can you tell us something about the food legislation in Curacao? Is the Codex Alimentarius used
when necessary? Or perhaps by reference from you to a particular authority who can tell us more
about. Curacao is connected with PAO
Imago dietician
What do you know about the imago of the dietician on the island of Curacao? I do not know the
difference with other countries, but I have the feeling when a doctor is proposing to go to a dietician,
only part are directly going, part are postponing there first consultation, and part never comes. I have
no data. What opinion has the population about the function of dietician? How is the collaboration
with other health care attendants? That depends of the dietician his/herself. I myself am in different
commissions with other caretakers. What is the position of the dietician that depends of the dietician
his/herself?
Vacancies/ possibilities
Are there enough jobs for the professional role practitioner or is the market sufficiently represented?
What are the opportunities in various roles as a practitioner, officer in prevention, nutrition
manager, or an independent business (commercial) with products for sale in Curacao?
At the moment every dietician can have some more work, due to the fact that part of the population
(30.000 people) only can go to 1 dietician. Within a year I think every dietician can treat them, and
then a lot of people can go to the private dietician.
The average age of the private dictations is around 58, so in the near future there will be jobs vacant.
Government is busy with a basic insurance, and the dietician will be in that for several hours a year.
The role as prevention is low. There is not done much wit hit, except the dieticians how are doing
prevention in their one practice.
With professional we are starting to reduce the problems with elderly people.
The former GGD (GMN now) is doing prevention with kids, and adolescents.
DM, I discussed above.
It is not possible for dictations from abroad to work over here, only for “landskinderen” people that
are born here or have their roots here.
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Annex 4
Questionnaire Healthy nutrition directives
These recommendations can be specified for the adult population.
Do you apply to the next questions?
-
at least five – but preferably on all days of the week at least half an hour – moderately strenuous
physical activity in the form of, for example, brisk walking, cycling or gardening
-
use daily 150-200 grams and 200 grams of vegetables fruit
use a diet with daily 30-40 grams fibre, especially from vegetable, fruit and whole grain cereal
products
-
use two servings of fish per week (à 100-150 grams), of which at least a portion of oily fish
limit the use of saturated fatty acids to less than 10% and energy of single trans-unsaturated
fatty acids to less than 1% of energy
-
limit the use of foods and beverages with easily fermentable sugars and drinks with a high
content of food acids to 7 food/drink moments per day (including main meals)
-
limit the intake of salt up to 6 grams per day
If one drinks alcoholic consumptions, limit this than to two standard glasses (men) or one
standard glass (women) per day.
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Research Report

Transcription

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