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PhD defence Diah Martina

Providing care that aligns with patients’ values, wishes, and preferences, also during periods of incapacity, is the foundation of patient-centered care. However, patients’ values, wishes, and preferences are not always known by healthcare professionals and their family members. Asian cultural characteristics of collectiveness where one’s health and illness are a collective matter and care for an individual is viewed mainly as a family responsibility and social harmony is often valued over individual autonomy may influence advance care planning. Particularly, in Indonesia, where faith drives many aspects of life, including healthcare decision-making in the end of life, culturally sensitive advance care planning could facilitate individual’s engagement in it. This thesis describes how to approach advance are planning with consideration of cultural aspects in Asia and Indonesia. https://epubs.ogc.nl/?epub=d.martina&k=ab577757-ecc4-43d2-8cf2-5422643d0eae

Countries worldwide are faced with the major challenge to promote sustainable employability among vulnerable groups, such as persons with poor health, with lower socioeconomic positions, and those with unfavourable working conditions.

To promote sustainable employability among vulnerable groups, information is needed on the extent to which these groups are more likely to exit the labour market or to get precarious employment, the degree to which changes in employment status affect health, and whether workers’ health could be improved through the workplace.

This dissertation demonstrated that both selection and causation mechanisms explained inequalities in health and employment, and that improvements in working conditions as well as health promotion through the workplace could provide benefits to worker’s health in general and workers in lower socioeconomic positions in particular.

The research is valuable for both policy makers and practitioners because directions are provided on how to improve sustainable employability among vulnerable groups.



Cervical cancer is an important but largely preventable health problem. Vaccination for human papillomavirus (HPV) can prevent infections that cause the majority of cervical cancers, and organised screening can detect pre-invasive lesions so that they can be treated or detect cancer at an earlier stage to improve treatment options. The health policy cycle can be used to continuously improve the balance between harms, benefits and costs of cervical cancer prevention. In this thesis we focused on the first three steps of the health policy cycle: monitoring, evaluation and barriers. We monitored the current situation by performing a systematic literature review on the effect of cervical cancer screening on cervical cancer mortality and by comparing cancer risks after different test results. We evaluated the effects of the current situation and optimized strategies for the future by applying microsimulation models to quantify the effects of cervical cancer screening and HPV vaccination, taking into account existing barriers. These models were integrated in a user-friendly web-based evaluation tool for researchers and policymakers in the EU-TOPIA project (www.eu-topia.org).



In 2020, colorectal cancer was diagnosed in approximately 1.9 million persons worldwide and caused 900,000 deaths. Screening is proven to effectively reduce colorectal cancer- related mortality by detection in an early stage and removing pre-cursors of colorectal cancer (adenomas). Therefore, a population-based colorectal cancer screening programme was implemented in 2014 in the Netherlands, biennially inviting inhabitants between 55 to 75 for a stool-based screening test, called the faecal immunochemical test (FIT). Participants with positive FIT are referred for endoscopic examination of the colon (colonoscopy).

The benefits of screening ought to outweigh the harms. This thesis aims to evaluate the benefits (yield of screening) and harms (colonoscopy complications) of FIT-based colorectal cancer screening to provide further insights in how these aspects relate to each other and how a disbalance between them can be corrected.

So far, public health research paid relatively little attention to the association of factors related to social and community networks with health outcomes. There is a need to gain a better understanding of associations between ‘social factors’ and health and wellbeing in all stages of life.

This dissertation focused on two social factors: perceived social support and loneliness. Perceived social support was examined among parents of children aged 0-8 years, living in the Netherlands. Loneliness was examined among older adults aged 70+ years, living in five European countries. Emotional and social loneliness were distinguished.

The studies presented in this dissertation provide empirical support for multiple ways in which perceived social support and loneliness are related to health and wellbeing across the lifespan. Strengthening perceived social support and reducing loneliness may be potentially promising directions to improve public health and to foster the resilience of health care systems.


If you are interested to read the thesis you can send an email to : i.fierloos@erasmusmc.nl



Health behavior interventions mostly fail to find meaningful long-term effects. A key factor in the failure of many interventions is likely an inadequate targeting of the theory-based processes that determine behavior. This study set out to address this limitation.
The objective of this thesis was threefold. Firstly, it aimed to design an innovative theory- and evidence-based mHealth intervention to reduce the risk for cardiovascular disease. Second, it set out to implement it in a manner that resonates with its intended audience. Third, it aimed to evaluate the short-term effects of the resulting intervention. Taken together, the studies presented in the current thesis provide insight into both the theory and practice of delivering cardiovascular mHealth promotion programs.

The HIV pandemic has been one of the most devastating public health threats in recent history. After emerging as a new human pathogen during the mid-20th century, the virus spread rapidly, infecting more than 79 million people worldwide, of whom 36 million have died due to its consequences. In the late 1990s, HIV related mortality peaked worldwide, with over 2 million deaths annually. The pandemic was especially severe in sub-Saharan Africa, where over 10% of the population was infected in many countries, and the high mortality rates had altogether reduced overall life expectancies. However, scientific breakthroughs coupled with an unprecedented global effort to control the pandemic have substantially expanded worldwide access to a wide range of biomedical and behavioural interventions to treat and prevent HIV infection, sparking optimism that the end of the pandemic could be in sight. Nowadays, about 75% of all people living with HIV worldwide are receiving life-saving treatment, even in the poorest countries of the world, and the number of new infections has been declining tremendously. In a landmark General Assembly on HIV and AIDS in 2016, the United Nations endorsed the ambitious commitment to end the pandemic by 2030. While progress towards this noble endeavour has been substantial, many obstacles still exist in reaching sustainable control of the pandemic. This thesis presents scientific research on the epidemiology of HIV and the potential of health systems innovations, which might contribute to overcoming some of these obstacles, and thereby help to ensure that we are truly living in the last decade of HIV.

The Last Decade of HIV? (ogc.nl)



The combination of urbanization and ageing can lead to new public health challenges, such as a higher risk of mental disorders and physical inactivity, but can also offer opportunities for the implementation of policies and interventions that promote public health. The city has therefore become a key site for the implementation of prevention and early identification policies on the trajectories of ageing and mental well-being. However, the implementation of such policies requires a good understanding of how the urban environment relates to health and well-being. The aim of this thesis is to explore the variation in urban environments and how this variation relates to physical activity and mental well-being by using data from different European cities. The studies presented in this thesis use data harmonized within the MINDMAP project. The MINDMAP project aimed to identify the opportunities and challenges posed by the urban environment for the promotion of mental health and well-being of middle-aged and older adults.
Link to the entry in the Kennisbank https://www.mulierinstituut.nl/publicaties/27287/urban-environments-physical-activity-and-mental-well-being/

Death rattle is a symptom of the dying phase. The sound is caused by the presence of mucus in the upper respiratory tract. The burden of death rattle for the patient is unknown, but the sound is disturbing for relatives and health care professionals.
Most of the studies described in this thesis were part of the research project ‘Death rattle in the dying phase: is prophylactic treatment useful?’, funded by the Netherlands Organisation for Health Research and Development (ZonMw). In this project we tried to understand the underlying causes of the various experiences of death rattle of bereaved relatives, studied the effect of prophylactically administered scopolamine butylbromide (medication that diminishes mucus) on the occurrence of death rattle, and assessed how a randomized, double-blind placebo-controlled trial in the dying phase can be feasible.

We found that death rattle can be a stressful symptom for relatives that is influenced by more factors than the intensity of the sound alone. Adequate information and communication cannot always relieve the burden for relatives. We showed that prophylactic subcutaneous scopolamine butylbromide significantly reduced the occurrence of death rattle in a hospice population. We found that the robust design and strategies to facilitate patient recruitment have resulted in a successful study with sufficient participants. According to relatives, patients’ participation in a double-blind placebo-controlled medication trial at the end of life need not be burdensome and does not interfere with the dying process.
The results are at this moment implemented in the guideline “Care in the dying phase”.

Geographical related health inequalities and inequities are of huge societal concern, especially when it comes to perinatal health and child welfare. Preventive Child Healthcare (PCHC) in the Netherlands has a unique opportunity to address vulnerable families. In this thesis the aim was to design, implement and study the effectiveness of a postnatal risk assessment in PCHC, as well as to study handover from obstetric care to PCHC and finally, to reduce child growth and developmental problems, particularly in families with a low socio-economic status.