Reach: contribution of ethnically specific channels
Collaboration with 13 ethnically specific organizations reached 50 mothers in total. The success of using ethnically specific channels varied between the targeted ethnic communities: 37 Ghanaians, 6 Antilleans, and 6 Surinamese mothers were reached (Table
3).
Table 3
Reach to mothers per ethnically specific channel according to ethnicity
Churches | 13 | 5 | n.a. |
Women’s organizations | 24 | n.a. | 5 |
Radio | n.a. | 1 | 1 |
Total reach
| 37 | 6 | 6 |
The differences between ethnic groups seem to be related to the organizational structure within the communities. If there were more organizations available, and if these had fixed groups that met at fixed times and places and also included young adult women (≈25–50 years of age), then more mothers with young children were reached with information about Big Move mama. We mapped many Ghanaian organizations, especially churches (n > 5), that met our criteria. Collaboration with two Ghanaian churches and two women’s organizations resulted in the 37 women reached. There were also several Surinamese organizations, but only two held regular meetings which were aimed at women 50 years and older. We collaborated with 4 Surinamese women’s organizations, of which a key figure also approached two Surinamese schools and a church, and three were involved into the employment of Surinamese radio programs/stations. This resulted in the 6 mothers reached. There were only four Antillean organizations identified, of which two collaborated. Only a church had regular meetings with fixed groups, which accounted for 5 of the 6 Antillean women reached.
Our explanation for these differences was supported and further explained by the interviews with mothers and key figures. Ghanaian key figures frexplained that the many regular gatherings of Ghanaian women, which resulted in the successful reach, stemmed from their community’s close-knit nature and retained culture and that they find the Dutch language more difficult to learn.
I: “The Ghanaian women get together quite often, in fixed groups. Why do you think this is? In your group, in churches…”
R: “In churches, yes… we love getting together, and our own things”. (Ghanaian key figure)
R: “It’s very nice, getting the women together and then giving them some information about… Dutch society. A lot of women have been here for 25, 30 years, but because they can’t read or write, they miss out on certain things”. (Ghanaian key figure)
Accordingly, the answers of the Ghanaian mothers indicated that they continue to use their own channels. They mentioned almost exclusively Ghanaian-specific channels for obtaining information about neighborhood activities (e.g., other churches, another organization, television, radio, and word of mouth within the community). Information obtained through these organizations was described as being better received than that obtained from mailings and easier to access than information obtained through a general channel (e.g., family physician). Information received through Ghanaian-specific channels was clearer because it is communicated in their own or second language (i.e., English) and their questions could be answered. Women mentioned that this clarity resulted in trust and confidence and made it easier to enroll in activities (“Then you know what to do”).
I: “Was it good that someone came [to your organization] to talk about [Big Move mama]?”
R: “Yes, then you can hear it, because sometimes… although you might want to read [it], you can’t… or you are able to read [it] but you don’t understand it very well. (…) It’s very important to me. It gives you [a] good feeling, you can trust it”. (Ghanaian mother)
In contrast, for the Antillean and Surinamese women, the Dutch language posed no problem. Furthermore, key figures described the Surinamese and Antillean women as not wanting obligations and not being very close with each other (only with their families). The latter was directly linked by these key figures to fewer regular community gatherings thus reach was seen as more difficult.
I: “We saw how the Ghanaian women got together a lot, they really got together in groups that met every two weeks. Isn’t there somewhere like that where we could reach the Antillean group all at once?”
R: “No, Antillean mothers are very different than Ghanaian mothers. You can’t compare them”.
I: “Why not?”
R: “Because the sense of solidarity among the Ghanaians is different than among the Antilleans. We’re also very close, but just with family. [With the Ghanaians,] they’re all brothers and sisters. [With us,] your immediate family is what counts, and the rest are just acquaintances”. (Antillean key figure)
Excerpts from the Antillean and Surinamese mothers echoed the explanations of the key figures. They more frequently mentioned the individual-oriented channels through which they are normally reached, most of which were not ethnically specific. For instance, Surinamese mothers mentioned social media and email. Other alternative channels they used were health care, brochures by mail, word-of-mouth communication with friends and colleagues, or possibly via Surinamese radio and television. However, the mothers who were reached via “an Antillean radio broadcast” and “Surinamese women’s organizations” were in fact reached by an immediate family member who was the leader/radio producer, or by a friend.
The interviewees, both mothers and key figures, linked the role of the available organizations to the ethnic communities’ characteristics and gave this as the final explanation for reach. Excerpts from the Ghanaian interviews showed that they see ethnically specific community organizations as a “bridge to Dutch society”. The Ghanaian gatherings provided support, help, and advice about how to deal with specifically Dutch situations. Leaders of Ghanaian women’s organizations were described as being in touch with Dutch organizations such as the Public Health Service and the local government district. They invited experts to provide information to their group, and translated that information. The organizations were the usual channels for their members to get information about important issues, such as health. The Ghanaian key figures said these are what explained high attendance at their meetings.
I: “How do you learn more about activities that take place in the neighborhood?”
R: “Umm, [our Ghanaian women’s organization] has a secretary, and she looks all over to see where we can go”.
I: “But is there also another way for you to get information?”
R: “No, she gives us all of the information, and sometimes she just puts it on the table. Should we do this? Do we want to do this?”
I: “But don’t you get a newsletter from your local government district, for example?”
R: “Sure, a newsletter, all kinds of things. [The key figure] also reads them to us and explains it to those who don’t understand Dutch. (…) She [also] usually works together with the district”. (Ghanaian mother)
I: “What struck me was that quite a few young Ghanaian women get together at [names of women’s organizations] and in churches. Why do you think this is?”
R: “The reason for this is [for example], for most women (…), the communication between them and their partner isn’t like in Ghana. One of them works in the evening and the other one in the afternoon, so then you don’t see each other. So with a group like this they have more of a chance to talk about problems and give each other advice”. (Ghanaian key figure)
The one Antillean church played the same role, providing information every week about upcoming activities. In contrast, at ad hoc informational meetings organized by Surinamese organizations, no mothers with young children were present. Furthermore, a key figure mentioned that daughters of their elderly members said they were “glad their mothers have Surinamese organizations to empower them,” but they did not seem to be interested in these organizations themselves. Surinamese mothers said they were not used to receiving information about activities like this exercise program through their churches.
Receptivity and participation: contribution of ethnically matched key figure versus ethnic Dutch health educator recruiters
If we compare expressions of receptivity and participation numbers between mothers exposed to ethnically matched recruiters with those exposed to ethnic Dutch health educators, overall, the former were better received and a larger proportion enrolled in the exercise classes. In the intervention condition, a more positive atmosphere was observed than in the comparison condition. Mothers seemed more open to and to pay more attention to the recruiter and recruitment message. The interviews with mothers supported this: they remembered the recruiter and which information she had given better if this was done by a key figure than by a health educator. Observed interaction was more positive, and the women asked more questions. Moreover, if Dutch health educators supported the information giving while key figures were involved in the recruitment, the health educator received more positive reactions, such as “A really good initiative”, “It was a very nice evening”, and “Can you please come to our church to tell about this?” In the comparison condition, by contrast, women left early or the health educator herself had to approach them.
We saw that almost all mothers who indicated they did not want to join the exercise program (or who indicated they might want to join but were not reached afterwards) had been recruited by a health educator (comparison condition; 9 of 10 mothers who refused to participate) (Table
4). There were a few more mothers in the intervention condition (12 of 35) than in the comparison condition (7 of 24) who indicated they wanted to join the exercise classes but ultimately did not. However, most mothers in the intervention condition (22 of 35) versus those in the comparison condition (7 of 24) actually started taking part in the exercise classes.
Table 4
Participation according to intervention versus comparison condition regarding recruiter
Total: intervention group - ethnically matched recruiter (I)
| 32 + 3 word of mouth/enrolled later | - | 1 (3%) | 12 (34%) | 19 + 3 (63%) |
Total: comparison group - Dutch health educator (C)
| 22 + 2 word of mouth | 4 + 1 (21%) | 4 (17%) | 7 (29%) | 7 + 1 (33%) |
Pair 1:
| | | | | |
(I) Ghanaian church 1 | 5 + 1 via another organization | - | - | 3 | 2 + 1 |
(C) Ghanaian church 2 | 7 | - | 2 | 2 | 3 |
Pair 2:
| | | | | |
(I) Ghanaian women’s organization 1 | 19 + 1 enrolled later | - | - | 5 | 14 + 1 |
(C) Ghanaian women’s organization 2 | 5 | - | - | 4 | 1 |
Pair 3:
| | | | | |
(I) Surinamese women’s organization 1 | 2 | - | - | 2 | - |
(C) Surinamese women’s organization 2 | 2 | 2 | - | - | - |
Pair 4:
| | | | | |
(I) Surinamese women’s organization 3 | - | - | - | - | - |
(C) Surinamese women’s organization 4 | +1 via mother | +1 | - | - | - |
Pair 5:
| | | | | |
(I) Surinamese radio 1 | - | - | - | - | - |
(C) Surinamese radio 2 | - | - | - | - | - |
Pair 6:
| | | | | |
(I) Antillean radio (interview) | 1 + 1 Surinamese via colleague | - | - | - | 1 + 1 |
(C) Caribbean radio | 1 | - | 1 | - | - |
Pair 7:
| | | | | |
(I) Antillean church | 5 | - | 1 | 2 | 2 |
(C) Community project | 5 + 1 via colleague | 1 | - | 1 | 3 + 1 |
(C) Immigrant organization via a school | 2 | 1 | 1 | - | - |
Excerpts of the interviewees described why they thought the ethnically matched recruiter achieved higher receptivity and participation in the intervention condition. First, the recruiter was similar and familiar to the women, which seemed to create openness, attention (e.g., better recall of the recruiter and her message), accessibility (e.g., actively approach the key figure for more information), trust, and persuasion, regardless of ethnic group. Explanations given for this had to do with the recruiter’s ethnicity and whether she was known for her expertise or activities in this area. If the recruiter was described as a close, familiar person, this was said to foster trust and persuasion.
R: “I thought the radio spot was good, too. Because everyone called me, saying, ‘[name of key figure], are you going to take part in a project?’ Because they heard my name (…)”.
I: “Ooh, okay, that’s funny, because I actually didn’t have a single response to what was on the radio. But you did, huh?”
R: “Yes, I did, I heard it, yes. But then, you’re not so well known in the Surinamese community. So I’m not too surprised. But the moment you mentioned my name. Then they say, ‘Hey [name of key figure], I heard your name on the radio. Are you taking part?’ I say, ‘Yes I am, together with Ms. [name of the health educator], we’re doing a project called Big Move mama.’” (Surinamese key figure, intervention condition)
I: “And who was the person who told you about Big Move mama? Who was that?”
R: “Er, er, [name of key figure], yeah, and also a lady, a white lady, but I forgot her name. Because [name of key figure] is… (runs her hand over her skin), so then I won’t forget, ha-ha-ha. So the other lady, she’s also white, but I forgot her name”.
I: “Well, it was also a while back. And [name of key figure], is she from the church?”
R: “Yes! The church, we have two services, one in the morning and one in the afternoon. But she goes to the morning service and I go to the afternoon service. But sometimes she comes to give us information”. (Ghanaian mother, intervention condition)
I: “And so is it also important that it’s your father [an Antillean radio producer] who’s saying this? Do you immediately take it on board then?”
R: “No (laughs), no, I don’t, but still…I have a really good relationship with my father, so as far as that goes. If he suggests something he thinks would be good for me, I’ll take it on board. That’s what I mean”. (Antillean mother, intervention condition)
Second, ethnically matched recruiters used the mother tongue to translate and explain things in a way that was relevant; this might have increased attractiveness, attention, and accessibility, although it did not seem just a matter of understanding. In fact, mothers and key figures mentioned that most Ghanaian and Antillean women could understand both English and Dutch, the languages used by the health educators. It may be, rather, the attraction to something “familiar”, as described by a key figure, and having no barrier to ask questions and interact. More positive interaction was observed when an ethnically matched recruiter used the mother tongue during recruitment, and if women approached these key figures afterwards with additional questions and for advice, they used their own language then as well. Although all women said their leader was able to translate if the Dutch health educators were the recruiters, questions were asked only in their native language if the information had also been given in this language.
I: “And I also noticed you were quick to translate it into Papiamento”.
R: “I translated it myself – it carries more feeling, the Antillean feeling. It has nothing to do with people not being able to understand Dutch or anything like that. It’s all about feeling – you feel more”. (Antillean key figure, intervention condition)
Third, mothers and key figures described, particularly, the ethnically matched recruiter as a “motivator”. The key figure was most frequently a role model, expressing a positive attitude towards exercising and the exercise program, modeling positive interaction with the health educator, and encouraging participation in the program (“Let’s go with the group”, “Take this opportunity”). Ghanaian women responded mainly with a wait-and-see attitude to the health educators’ interactive approach. When the key figure modeled positive interaction with the health educators, the whole group responded with questions and more positive reactions to the health educators afterwards. Subsequently, the availability of a role model who participated in the exercise classes herself and who could be a contact person if constraints emerged during enrollment seemed to contribute to actual participation after indicating interest. This was observed and also explained by a Ghanaian key figure:
R: “Yes, I think the information provided is good, I introduced you to the parents, you told the parents the reason, everything, and, er, you also did a good job, you talked about everything, so, er, people [responded] very enthusiastically and just signed up, and I wanted to take part too, so we had a good response (…)”.
I: “What was it that made everyone want to take part?”
R: “Because I told them it’s for our health and that it would be once a week and that we’d do it with the group. Like that, which was good. [But then later on] ‘the time is changed. So now you come from half past seven to half past eight’, I think it’s a little on the late side, but in fact I said no, I can’t complain. Because if I complain then the women will complain, too. Because everyone looks over at me (laughs)!” (Ghanaian key figure, intervention condition)
Another motivational approach was adaptation of the message by the matched recruiter, unconsciously towards cultural factors and consciously towards mothers’ characteristics and the social network. For example, an Antillean recruiter emphasized that she exercises so she can eat and also stressed the social benefits of exercising with others. Moreover, there were Antillean and Surinamese recruiters who tailored the benefits message to the mothers they knew personally and included such benefits as less back pain, exercising, and some time for oneself. Further, they were able to link people within social networks to each other to exercise together. This seemed to result in greater participation by the mothers reached, especially those mothers who at first were skeptical about the benefits of exercising.
Nevertheless, providing information was not always the best role for an ethnically matched recruiter. There were several examples where incomplete or even inaccurate information was given, which did not benefit participation and was counterproductive for receptivity. For example, in a comparison condition church, the information meeting was inaccurately presented as having a health and a healthy diet focus instead of the health benefits of exercising and an invitation for Big Move mama. Although the people listened they were not open to the information and had negative attitudes and reactions afterwards (“This wasn’t what we expected”).
Because of this, key figures generally preferred to have a health educator give the most important information about exercising and Big Move mama; the mothers also appreciated this. Only if the recruiter was a health expert herself or was known for her sport activities she felt to be capable of informing and recruiting mothers. Therefore, several key figures from the intervention condition asked the health educator to provide the information, since she was the expert. The Public Health Service of Amsterdam was perceived as a credible source – also because of collaborations with community organizations in the past – thereby creating trust in the exercise program offered. Mothers perceived the health educator as a suitable messenger, especially because she had the knowledge required and she was able to answer questions in detail. Further, the health educator was trusted because of her expertise and her involvement with the target group, her friendliness, and her patience in explaining the program. By hearing from a trusted expert, the women could assess the program for themselves and determine their own feelings about it.
R: “I think it’s good that someone from the Public Health Service does it. (…) See, to me, I just see someone from the GGD, you know, they’re not specialized in one thing, but they know a little bit of everything. [Or] she can also give you information along the lines of, ‘my colleague can help you further, ’ that kind of thing. So I do like it that it’s someone from the GGD”.
I: “And what about someone from the neighborhood?”
R: “Yes, that’s a possibility, but then I hope that person doesn’t get stuck if someone has questions they can’t answer. That comes over as rather unprofessional. So… no, I was glad she was also from the GGD”. (Surinamese mother, comparison condition)
I: “And why was it important to you that I explained things?”
R: “Well, because (…) you know more about the subject matter than I do. And the only thing I can help with is introducing you to the women. Emmm, I say a little and then, er, you can tell them about it yourself, and I always think that works the best with us, then they know that the person or the expert is getting the message across or giving the information, and then they can [ask] all of their questions (…) And the women felt much the same, they accepted it, so that was good”. (Ghanaian key figure, intervention condition)