Quality criteria of nature-based interventions in healthcare facilities: a scoping review

Introduction

Implementing integrated nature-based interventions that simultaneously serve human health and the restoration of biodiversity in healthcare facilities is considered a promising strategy. As an emerging field of research and practice in healthcare, identification of quality criteria is necessary to support desired outcomes related to biodiversity, human health and intervention processes. This study is part of a larger research project in collaboration with the Flemish Agency of Nature and Forest in Belgium.

Methods

A scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews, in PubMed, Medline, Web of Science and Scopus. A step-by-step tabular screening process was conducted to identify relevant studies and reviews of nature-based interventions, published in English between January 2005 and April 2023. A qualitative content analysis was conducted and the results were then presented to the project steering group and a panel of stakeholders for refinement.

Results

After filtering on the eligibility criteria, and with focus on healthcare facilities, 14 articles were included in this study. A preliminary nature-based interventions quality framework with a set of quality indicators has been developed.

Discussion

When designing integrated nature-based interventions, a needs analysis of users and the outdoor environment should be conducted. Next, the integration of a One Health and biodiversity perspective and the application of a complex intervention framework, could support the quality of the design and implementation of nature-based interventions in healthcare facilities and facilitate their assessment. In future work, more rigorous research into the design and implementation of integrated nature-based interventions is needed to test and refine the quality criteria in practice.

Non-response bias in the analysis of the association between mental health and the urban environment: a cross-sectional study in Brussels, Belgium

BACKGROUND

This paper aims at analysing the impact of partial non-response in the association between urban environment and mental health in Brussels. The potential threats of the partial non-response are biases in survey estimates and statistics. The effect of non-response on statistical associations is often overlooked and evidence in the research literature is lacking.

METHODS

Data from the Belgian Health Interview Survey 2008 and 2013 were used. The association between non-response and potential determinants was explored through logistic regressions.

RESULTS

Participants with low income, low educational levels, lower or higher age or in households with children were less likely to respond. When adjusting for socio-economic variables, non-response was higher in areas which are less vegetated, more polluted or more urbanised. Because the determinants of non-response and depressive disorders were similar, it is reasonable to assume that there will be more people with mental health problems among the non-respondents. And because more non-responses were found in low vegetation areas, the protective association between green spaces and mental health may be underestimated.

CONCLUSION

Our capacity to measure the association between the urban environment and health is affected by non-response in surveys. The non-random spatial and socio-economic distribution of this bias affects the research findings.

Differences in antibiotic prescribing quality in Belgian out-of-hours primary care services

OBJECTIVES

This study aims to compare trends in antibiotic prescribing behaviour for lower urinary tract infections among different out-of-hours primary care services.

METHODS

Cross-sectional study using routine prescription data extracted from electronic health records from six out-of-hours services. The study population included 5888 cases diagnosed with an uncomplicated lower urinary tract infection from 2016 to 2020. Prescriptions were assessed based on the national guidelines.

RESULTS

Considering the total study period, an antibiotic was prescribed in 98.9% of cases. Among these cases, 55.0% was prescribed a guideline recommended antibiotic, 21.0% was prescribed fosfomycin, 17.4% was prescribed a quinolone and 1.8% was prescribed more than one antibiotic. Guideline recommended prescribing improved substantially over time. However, there were significant differences among out-of-hours services in terms of proportion over the total study period (between 49.0% and 66.7%) as well as in terms of time-trend pattern.

CONCLUSION

Substantial differences among out-of-hours services suggest a potential for further improvement in the quality of antibiotic prescribing. Monitoring prescribing behaviour per out-of-hours primary care service can guide focused interventions.

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.

METHODS

Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.

RESULTS

The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.

CONCLUSIONS

Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

Development of a toolkit to improve interprofessional collaboration and integration in primary care using qualitative interviews and co-design workshops

Background

Despite numerous attempts to improve interprofessional collaboration and integration (IPCI) in primary care, patients, care providers, researchers, and governments are still looking for tools and guidance to do this more efficiently. To address these issues, we decided to develop a generic toolkit, based on sociocracy and psychological safety principles, to guide care providers in their collaboration within and outside their practice. Finally, we reasoned that, in order to obtain integrated primary care, different strategies should be combined.

Methods

Development of the toolkit consisted of a multiyear co-development process. Data originating from 65 care providers, through 13 in-depth interviews and five focus groups were analysed and subsequently evaluated in eight co-design workshop sessions, organised with a total of 40 academics, lecturers, care providers and members of the Flemish patient association. Findings from the qualitative interviews and co-design workshops were gradually, and inductively adapted and transformed into the content for the IPCI toolkit.

Results

Ten themes were identified: (i) awareness of the importance of interprofessional collaboration, (ii) the need for a self-assessment tool to measure team performance, (iii) preparing a team to use the toolkit, (iv) enhancing psychological safety, (v) developing and determining consultation techniques, (vi) shared decision making, (vii) developing workgroups to tackle specific (neighbourhood) problems, (viii) how to work patient-centred, (ix) how to integrate a new team member, and (x) getting ready to implement the IPCI toolkit. From these themes, we developed a generic toolkit, consisting of eight modules.

Conclusion

In this paper, we describe the multiyear co-development process of a generic toolkit for the improvement of interprofessional collaboration. Inspired by a mix of interventions from in and outside healthcare, a modular open toolkit was produced that includes aspects of Sociocracy, concepts as psychological safety, a self-assessment tool and other modules concerned with meetings, decision-making, integrating new team members and population health. Upon implementation, evaluation and further development and improvement, this compounded intervention should have a beneficial effect on the complex problem of interprofessional collaboration in primary care.

Process evaluation of the scale-up of integrated diabetes and hypertension care in Belgium, Cambodia and Slovenia (the SCUBY Project): a study protocol

INTRODUCTION

Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The 'SCale-Up diaBetes and hYpertension care' (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up.

METHODS AND ANALYSIS

A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools-including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping-were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.

Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos

BACKGROUND

General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns.

OBJECTIVES

To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record.

METHODS

We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium.

RESULTS

Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic.

CONCLUSION

We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.

Self-management support in flemish primary care practice: the development of a preliminary conceptual model using a qualitative approach

Background

Coping with a chronic disease can be really challenging. Self-management represents a promising strategy to improve daily life experiences. The role of primary healthcare professionals cannot be underestimated in supporting self-management. Due to a shortage of theory, implementation of self-management support is hindered in primary care practice. The aim of this study is to create a conceptual model for self-management support by analysing patients’ care experiences towards self-management support.

Methods

An explorative-descriptive qualitative study was conducted in Flanders, Belgium. Semi-structured interviews were performed with 16 patients and their informal caregiver (dyads) using a purposive sampling strategy and processed by an inductive content analysis, according to Graneheim and Lundman.

Results

Interviews revealed in-depth insights into patients’ care experiences. A conceptual model was developed for primary care practice, including five fundamental tasks for healthcare professionals - Supporting, Involving, Listening, Coordinating and Questioning (SILCQ) – contributing to the support of self-management of chronic patients.

Conclusions

This qualitative paper emphasises the use of the SILCQ-model to develop optimal roadmaps and hands-on toolkits for healthcare professionals to support self-management. The model needs to be further explored by all stakeholders to support the development of self-management interventions in primary care practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01652-8.

Scoping review to identify strategies and interventions improving interprofessional collaboration and integration in primary care

OBJECTIVE

To identify strategies and interventions used to improve interprofessional collaboration and integration (IPCI) in primary care.

DESIGN

Scoping review DATA SOURCES: Specific Medical Subject Headings terms were used, and a search strategy was developed for PubMed and afterwards adapted to Medline, Eric and Web of Science.

STUDY SELECTION

In the first stage of the selection, two researchers screened the article abstracts to select eligible papers. When decisions conflicted, three other researchers joined the decision-making process. The same strategy was used with full-text screening. Articles were included if they: (1) were in English, (2) described an intervention to improve IPCI in primary care involving at least two different healthcare disciplines, (3) originated from a high-income country, (4) were peer-reviewed and (5) were published between 2001 and 2020.

DATA EXTRACTION AND SYNTHESIS

From each paper, eligible data were extracted, and the selected papers were analysed inductively. Studying the main focus of the papers, researchers searched for common patterns in answering the research question and exposing research gaps. The identified themes were discussed and adjusted until a consensus was reached among all authors.

RESULTS

The literature search yielded a total of 1816 papers. After removing duplicates, screening titles and abstracts, and performing full-text readings, 34 papers were incorporated in this scoping review. The identified strategies and interventions were inductively categorised under five main themes: (1) Acceptance and team readiness towards collaboration, (2) acting as a team and not as an individual; (3) communication strategies and shared decision making, (4) coordination in primary care and (5) integration of caregivers and their skills and competences.

CONCLUSIONS

We identified a mix of strategies and interventions that can function as 'building blocks', for the development of a generic intervention to improve collaboration in different types of primary care settings and organisations.

Integration or Fragmentation of Health Care? Examining Policies and Politics in a Belgian Case Study

BACKGROUND

Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi-stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies.

METHODS

We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders' power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals' associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007-2020) through literature review was used to frame the interviews by means of a chronic care policy timeline.

RESULTS

In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform.

CONCLUSION

The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.

Clinically assessed and perceived unmet mental health needs, health care use and barriers to care for mental health problems in a Belgian general population sample

BACKGROUND

Mental health problems often remain undetected and untreated. Prior research suggests that this is mainly due to a lack of need-perception and attitudinal barriers. The aim of this study is to examine unmet mental health needs using both a clinically assessed and a self-perceived approach in a Belgian province.

METHODS

A cross-sectional survey study with a weighted representative sample of 1208 individuals aged 15 - 80 years old was carried out in 2021 in the province of Antwerp (Belgium). Mental health needs were defined as a positive symptom screening for depression (PHQ-9), anxiety (GAD-7) or alcohol abuse (AUDIT-C and CAGE), combined with experiencing significant dysfunction in daily life. Also 12-month health care use for mental health problems, self-perceived unmet mental health needs and reasons for not seeking (extra) help were assessed. Logistic regression analyses were used to explore the predictors of mental health problems, health care use, and objective and subjective unmet mental health needs.

RESULTS

One in five participants had a positive screening on one of the scales, of whom half experienced dysfunction, leading to a prevalence of 10.4% mental health needs. Among those, only half used health care for their mental health, resulting in a population prevalence of 5.5% clinically assessed unmet mental health needs. Fourteen percent of the total sample perceived an unmet mental health need. However, more women and younger people perceived unmet needs, while clinically assessed unmet needs were higher among men and older people. One in six of the total sample used health care for their mental health, most of whom did not have a clinically assessed mental health need. Motivational reasons were most often endorsed for not seeking any help, while a financial barrier was the most important reason for not seeking extra help.

CONCLUSIONS

The prevalence of unmet mental health needs is high. Assessed and perceived (unmet) mental health needs are both relevant and complementary, but are predicted by different factors. More research is needed on this discrepancy.

Validity of self-reported air pollution annoyance to assess long-term exposure to air pollutants in Belgium

In epidemiological studies, assessment of long term exposure to air pollution is often estimated using air pollution measurements at fixed monitoring stations, and interpolated to the residence of survey participants through Geographical Information Systems (GIS). However, obtaining georeferenced address data from national registries requires a long and cumbersome administrative procedure, since this kind of personal data is protected by privacy regulations. This paper aims to assess whether information collected in health interview surveys, including air pollution annoyance, could be used to build prediction models for assessing individual long term exposure to air pollution, removing the need for data on personal residence address. Analyses were carried out based on data from the Belgian Health Interview Survey (BHIS) 2013 linked to GIS-modelled air pollution exposure at the residence place of participants older than 15 years (n = 9347). First, univariate linear regressions were performed to assess the relationship between air pollution annoyance and modelled exposure to each air pollutant. Secondly, a multivariable linear regression was performed for each air pollutant based on a set of variables selected with elastic net cross-validation, including variables related to environmental annoyance, socio-economic and health status of participants. Finally, the performance of the models to classify individuals in three levels of exposure was assessed by means of a confusion matrix. Our results suggest a limited validity of self-reported air pollution annoyance as a direct proxy for air pollution exposure and a weak contribution of environmental annoyance variables in prediction models. Models using variables related to the socio-economic status, region, urban level and environmental annoyance allow to predict individual air pollution exposure with a percentage of error ranging from 8% to 18%. Although these models do not provide very accurate predictions in terms of absolute exposure to air pollution, they do allow to classify individuals in groups of relative exposure levels, ranking participants from low over medium to high air pollution exposure. This model represents a rapid assessment tool to identify groups within the BHIS participants undergoing the highest levels of environmental stress.

How accurate is telephone triage in out-of-hours care? An observational trial in real patients

OBJECTIVES

Patients in Belgium needing out-of-hours medical care have two options: the emergency department (ED) or a general practitioner (GP) on call. Currently, there is no triage system in Belgium, so patients do not know where they should go. However, patients who could be managed by a GP frequently present themselves at an ED without referral. GPs often organise themselves in a General Practitioners Cooperative (GPC). This study assesses the accuracy of a newly developed telephone triage guideline.

METHODS

Observational real-time simulation: all walk-in patients at two GPCs and three EDs were asked to call a triage telephone number with their current medical problem. The operator handling this call registered an urgency level and a resource (ED, GP or ambulance) to deploy. The treating physician's opinion was used a the gold standard for correct triage. Patients were not informed about the outcome of the triage and continued the standard care path they had chosen.

RESULTS

The overall sensitivity of the telephone triage for detecting patients who could be managed by a GP was 82% with a specificity of 53%. The correctness of the advice given by the operator according to the physicians was 71%, with 12% underestimation of urgency and 17% overestimation. At the GPC, the sensitivity for detecting patients requiring GP management/care was 91% with a specificity of 36%. At the ED, the sensitivity for detecting GP patients was 67% with a specificity of 48%.

CONCLUSION

This study evaluates a new guideline for telephone triage, showing potential overtriage for patients wanting to attend the GPC, with possible inefficiency, and potential undertriage for patients wanting to attend the ED, with possible safety issues.

The impact of COVID-19 on the well-being, education and clinical practice of general practice trainees and trainers: a national cross-sectional study

BACKGROUND

COVID-19 has changed General Practice (GP) education as well as GP clinical activities. These changes have had an impact on the well-being of medical trainees and the role of GP plays in the society. We have therefore aimed to investigate the impact that COVID-19 has had on GP trainees and trainers in four domains: education, workload, practice organization and the role of GP in society.

DESIGN

a cross-sectional study design was used.

METHODS

The Interuniversity Centre for the Education of General Practitioners sent an online survey with close-ended and open-ended questions to all GP trainees and trainers in Flanders, active in the period March - September 2020. Descriptive statistics were performed to analyze the quantitative data and thematic analysis for the qualitative data.

RESULTS

216 (response 25%) GP trainees and 311 (response 26%) trainers participated. GP trainees (63%, N = 136) and trainers (76%, N = 236) reported new learning opportunities since the COVID-19 pandemic. The introduction of telehealth consulting and changing guidelines required new communication and organizational skills. Most of the GP trainees (75%, n = 162) and trainers (71%, n = 221) experienced more stress at work and an overload of administrative work. The unfamiliarity with a new infectious disease and the fact that COVID-19 care compromised general GP clinical activities, created insecurity among GP trainers and trainees. Moreover, GP trainees felt that general GP activities were insufficiently covered during the COVID-19 pandemic for their training in GP. GP trainers and trainees experienced mutual support, and secondary support came from other direct colleagues. Measures such as reducing the writing of medical certificates and financial support for administrative and (para) medical support can help to reprioritize the core of GP care. COVID-19 has enhanced the use of digital learning over peer-to-peer learning and lectures. However, GP trainees and trainers preferred blended learning educational activities.

CONCLUSIONS

COVID-19 has created learning opportunities such as telehealth consulting and a flexible organization structure. To ensure quality GP education during the pandemic and beyond, regular GP care should remain the core activity of GP trainees and trainers and a balance between all different learning methods should be found.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care

Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care.

Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication.

Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well.

Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.

iPSYcare: the development of a linked electronic medical records database to study and optimize psychiatric care in Antwerp

Objective

The study of care trajectories of psychiatric patients across hospitals was previously not possible in Belgium as each hospital stores its data autonomously, and government-related registrations do not contain a unique identifier or are incomplete. A new longitudinal database called iPSYcare (Improved Psychiatric Care and Research) was therefore constructed in 2021, and links the electronic medical records of patients in psychiatric units of eight hospitals in the Antwerp Province, Belgium. The database provides a wide range of information on patients, care trajectories and delivered care in the region. In a first phase, the database will only contain information about adult patients who were admitted to a hospital or treated by an outreach team and who gave explicit consent. In the future, the database may be expanded to other regions and additional data on outpatient care may be added.

Results

IPSYcare is a close collaboration between the University of Antwerp and hospitals in the province of Antwerp. This paper describes the development of the database, how privacy and ethical issues will be handled, and how the governance of the database will be organized.

Operationalization of One Health Burnout Prevention and Recovery: Participatory Action Research-Design of Nature-Based Health Promotion Interventions for Employees

Burnout is, besides a global, complex phenomenon, a public health issue with negative consequences on personal, organizational, social, and economic levels. This paper outlines the co-design of a novel Nature-based Burnout Coaching intervention, called NABUCO. Due to the complexity of burnout, we propose a One Health approach in healthcare, educational and governmental pilot organizations, to deliver guidelines and protocols for prevention and recovery of burnout. We advocate the inclusion of the salutogenic and mutual healing capacity of nature connectedness, facilitating a positive impact on mental and environmental health. A transdisciplinary Participative Action Research-design resulted in an iterative adaptive cycle of co-design, implementation, and evaluation of NABUCO.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Vitamin Nature: How Coronavirus Disease 2019 Has Highlighted Factors Contributing to the Frequency of Nature Visits in Flanders, Belgium

Visiting nature is positively associated with physical and mental well-being. The role of nature became more pronounced during the coronavirus outbreak in the spring of 2020. Countries all over the world implemented confinement measures to reduce the transmission of the virus. These included but were not limited to the cancelation of public events, schools, and non-essential businesses and the prohibition of non-essential travels. However, going outside to exercise was recommended by the Belgian government. During this period, we conducted an online survey to determine if people visit nature more frequently than before and to identify the factors that contribute to this. The results are based on data from 11,352 participants in Flanders, Belgium. With the use of a bivariate and multiple regression analysis, results indicate that people visit nature more frequently than before and that nature helped to maintain social relationships during the coronavirus period. Gardens were reported to be the most popular place, followed by parks. More than half of the people experienced nature in a more positive way, and the belief that nature visits are important for general health increased. In addition, we found a positive association between nature visits and home satisfaction, as well as a positive association with subjective mental and physical health. Lastly, we identified several demographic factors contributing to the frequency of nature visits such as age, gender, and socioeconomic status. Our findings indicate the importance of nature visits for general well-being and highlight the need for nearby green infrastructure.

Association between urban environment and mental health in Brussels, Belgium

Background

Mental health disorders appear as a growing problem in urban areas. While common mental health disorders are generally linked to demographic and socioeconomic factors, little is known about the interaction with the urban environment. With growing urbanization, more and more people are exposed to environmental stressors potentially contributing to increased stress and impairing mental health. It is therefore important to identify features of the urban environment that affect the mental health of city dwellers. The aim of this study was to define associations of combined long-term exposure to air pollution, noise, surrounding green at different scales, and building morphology with several dimensions of mental health in Brussels.

Methods

Research focuses on the inhabitants of the Brussels Capital Region older than 15 years. The epidemiological study was carried out based on the linkage of data from the national health interview surveys (2008 and 2013) and specifically developed indicators describing each participant’s surroundings in terms of air quality, noise, surrounding green, and building morphology. These data are based on the geographical coordinates of the participant’s residence and processed using Geographical Information Systems (GIS). Mental health status was approached through several validated indicators: the Symptom Checklist-90-R subscales for depressive, anxiety and sleeping disorders and the 12-Item General Health Questionnaire for general well-being. For each mental health outcome, single and multi-exposure models were performed through multivariate logistic regressions.

Results

Our results suggest that traffic-related air pollution (black carbon, NO₂, PM₁₀) exposure was positively associated with higher odds of depressive disorders. No association between green surrounding, noise, building morphology and mental health could be demonstrated.

Conclusions

These findings have important implications because most of the Brussel’s population resides in areas where particulate matters concentrations are above the World Health Organization guidelines. This suggests that policies aiming to reduce traffic related-air pollution could also reduce the burden of depressive disorders in Brussels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10557-7.

Evidence-based early stage type 2 diabetes follow-up in Belgian primary care practices: Impact of multi-professional teams and care protocols

AIM

The aim of this research is to explore the current early-stage diabetes mellitus type 2 care in Belgian general practices. This, to find out if the care is provided according to the proposed evidence-based national diabetes care guideline. Additionally, this research aims to detect which person and practice characteristics can be associated with a more evidence-based care provision.

METHODS

People were included in the study if they were recently diagnosed with type 2 diabetes by the participating practice. Practice and person characteristics, and clinical parameter monitoring and lifestyle monitoring data were collected by using a questionnaire and a topic list.

RESULTS

A total of 27 general practices participated and a total of 249 people were included through their patient records. People monitored in a practice according to a self-developed protocol were 5.5 times more likely to have a better clinical parameter follow-up. Larger practices (>2000 patients), follow-up by general practitioners and practice nurses together and according to self-developed protocols were associated with a significantly better lifestyle follow-up.

CONCLUSION

Practices providing multidisciplinary diabetes care, in collaboration with practice nurses, and with diabetes care based on self-developed protocols achieved a more comprehensive follow-up.

Exploring how the urban neighborhood environment influences mental well-being using walking interviews

Mental well-being in cities is being challenged worldwide and a more detailed understanding of how urban environments influence mental well-being is needed. This qualitative study explores neighborhood factors and their interactions in relation to mental well-being. Individual semi-structured walking interviews were conducted with 28 adults living in the Brussels-Capital Region. This paper provides a detailed description of physical neighborhood factors (green-blue spaces, services, design and maintenance, traffic, cellphone towers) and social neighborhood factors (neighbor ties, neighbor diversity, social security) that link to mental well-being. A socio-ecological framework is presented to explain interactions among those neighborhood factors, and personal and institutional factors, in relation to mental well-being. The findings are linked to existing concepts and theories to better understand the mechanisms underlying the associations between the urban neighborhood environment and mental well-being. Finally, implications of the walking interview method are discussed.

The impact of COVID-19 on chronic care according to providers: a qualitative study among primary care practices in Belgium

Background

The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic.

Methods

A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. Twenty-one people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM).

Results

Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated.

Conclusion

Our findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.

Examining differences in out-of-hours primary care use in Belgium and the Netherlands: a cross-sectional study

Background

The organizational model of out-of-hours primary care is likely to affect healthcare use. We aimed to examine differences in the use of general practitioner cooperatives for out-of-hours care in the Netherlands and Belgium (Flanders) and explore if these are related to organizational differences.

Methods

A cross-sectional observational study using routine electronic health record data of the year 2016 from 77 general practitioner cooperatives in the Netherlands and 5 general practitioner cooperatives in Belgium (Flanders). Patient age, gender and health problem were analyzed using descriptive statistics.

Results

The number of consultations per 1000 residents was 2.3 times higher in the Netherlands than in Belgium. Excluding telephone consultations, which are not possible in Belgium, the number of consultations was 1.4 times higher. In Belgium, the top 10 of health problems was mainly related to infections, while in the Netherlands there were a larger variety of health problems. In addition, the health problem codes in the Dutch top 10 were more often symptoms, while the codes in the Belgian top 10 were more often diagnoses. In both countries, a relatively large percentage of GPC patients were young children and female patients.

Conclusion

Differences in the use of general practitioner cooperatives seem to be related to the gatekeeping role of general practitioners in the Netherlands and to organizational differences such as telephone triage, medical advice by telephone, financial thresholds and number of years of experience with the system. The information can benefit policy decisions about the organization of out-of-hours primary care.

Evaluating Large-Scale Integrated Care Projects: The Development of a Protocol for a Mixed Methods Realist Evaluation Study in Belgium

BACKGROUND

The twelve Integrated Care Program pilot projects (ICPs) created by the government plan 'Integrated Care for Better Health' aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme.

METHODS

A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders.

RESULTS

A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes.

DISCUSSION

The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal.

Off-label prescribing of stimulant medication to students: a qualitative study on the general practitioner perspective

Students' use of prescription stimulants to enhance study performance is increasingly under the spotlight. Medical guidelines discourage general practitioners (GPs) from prescribing stimulants to students without a diagnosis; yet a considerable proportion of students acquire them from GPs. Building on Eisenberg's theoretical framework on clinical decision-making and Conrad's sociological concept of biomedical enhancement, this study examined the social context of GPs' off-label prescribing decisions for stimulants, using data from 21 semi-structured interviews, including vignettes, undertaken with Flemish GPs. Results identified two groups of GPs: (1) hard-liners who strictly follow medical guidelines and who would only prescribe in case of an appropriate diagnosis and (2) context-dependent GPs who would prescribe stimulants depending on the patients' symptoms and extent of need. GPs' decisions depend on one-on-one doctor-patient interactions (i.e. the extent of empathy from the doctor and the extent of assertiveness from the patient); the extent to which GPs define concentration problems as medical problems; GPs' interactions with fellow health care workers; as well as GPs' interaction with the wider community. By disentangling these influences, this paper advances both theoretical and practical understanding of the sociological context in which GPs' off-label prescribing behaviour occurs.

A policy analysis of the chronic care policies in Belgium

Introduction

Chronic diseases form the largest burden of disease in European countries. Redesign of health systems towards chronic integrated care is needed, with more collaboration between first and second line, between medical and social services and support to prevention and self-management. What are the levers for change in such health systems? This study addresses this knowledge gap, through a policy analysis of barriers and facilitators for change towards chronic integrated care.

Methods

26 central level stakeholders were selected, based upon their influence in regulation and policy, financing, health care provision and community representation. Semi-structured face-to-face interviews were held covering assessment of past and current policies and implementation, barriers and opportunities for change.

Results

Reforms have taken place, such as the stimulation of local initiatives for chronic integrated care projects and the set-up of local care councils. Most stakeholders assessed the current Belgium's implementation of integrated care as low, despite a growing awareness for the need for change. A context factor often mentioned to constrain implementation was a state reform which led to a partial decentralization, fragmentation of decision power and a division of healthcare competences between federal and federated levels. Other barriers were the current financing system, the lack of investments in new models of care and the vested interests of providers.

Discussion

This analysis shows that chronic care reform in Belgium is constrained by partial decentralization of primary health care, and by the financing system and vested interests. It points to the need for coordination of health policy making and implementation. Disentangling the levels of decision-making and the financial leverage at these levels gives insights for change and change management, for the Belgium health system and other countries with a strong decentralized system.

Key messages

The current Belgium’s implementation of integrated care was assessed as low, due to different contexts factors such as division of health care competencies between different governmental levels. In a country as Belgium with a strong decentralized health care system coordination of health policy making and implementation is key in order to scale up integrated care for chronic diseases.

Validity of air pollution annoyance to assess long-term exposure to air pollution in Belgium

Background

In environmental epidemiology, air pollution exposure is often estimated at the population level. To avoid the risk of exposure misclassification, one possibility is to interpolate air pollution measures at the residence through Geographical Information Systems. However, this might imply cumbersome administrative procedures. Data on air pollution annoyance from surveys can be an alternative to assess individual exposure to air pollution. This study investigates the association between air pollution annoyance and individual air pollution exposure.

Methods

Analyses were carried out based on a linkage of data from the Belgian Health Interview Survey (HIS 2008 and 2013; >15 years; n = 9347) and annual means of air pollution concentration at the residence. Self-reported air pollution annoyance was assessed through a five-point Likert scale. Statistical analyses included Spearman correlation coefficient, analysis of variance and multivariable ordinal logistic regressions (OLR).

Results

A significant exposure-response relationship was observed between long-term air pollution exposure and self-reported air pollution annoyance. However, Spearman coefficients were low (0.18-0.24), meaning a high heterogeneity of annoyance levels for a given exposure. In multivariable OLR, the odds of being annoyed by air pollution was 2.10 (95% CI: 1.86-2.67) times higher for each Interquartile range (IQR) increase in NO2 concentration (PM2.5: 1.77 [95% CI: 1.53-2.07], PM10: 1.61 [95% CI: 1.33-1.67], black carbon: 1.45 [95% CI: 1.27-1.67]). Air pollution annoyance depended largely on individual factors especially health status.

Conclusions

Air pollution exposure has a significant influence on self-reported air pollution annoyance. However, many other factors were found to influence annoyance, independently of the exposure. We found a limited validity of self-reported air pollution annoyance to assess individual long-term exposure to air pollution.

Key messages

Significant exposure-response relationship between individual long-term air pollution exposure and self-reported air pollution annoyance. Limited validity of self-reported air pollution annoyance for assessing individual long term exposure to air pollution.

Testing a Self-Determination Theory Model of Healthy Eating in a South African Township

INTRODUCTION

The burden of type 2 diabetes is growing rapidly in sub-Saharan Africa. Healthy eating has been shown to prevent the disease but is challenging to maintain. Self-determination theory offers a motivational framework for maintaining a healthy diet based on evidence from western settings. This study aims to assess whether self-determination theory can explain healthy diet behavior in a disadvantaged urban South African population.

METHODS

Cross-sectional data from a South African township population (N = 585; pre-diabetes = 292, diabetes = 293, age 30-75) were analyzed using structural equation modeling, while controlling for socio-demographic factors. Measures included self-reported autonomous and controlled motivation, perceived competence (measured through barrier self-efficacy), perceived relatedness (measured through perceived participation of significant others) and, as indicator for healthy diet, frequency of fruit, vegetable, and non-refined starch intake.

RESULTS

Healthy eating was positively associated (β = 0.26) with autonomous motivation, and negatively associated (β = -0.09) with controlled motivation. Perceived competence and relatedness were positively associated with healthy eating (β = 0.49 and 0.37) and autonomous motivation (β = 0.65 and 0.35), and negatively associated with controlled motivation (β = -0.26 and -0.15). Autonomous motivation mediated the effect of perceived competence and relatedness on healthy eating. The model supported a negative association between controlled and autonomous motivation.

CONCLUSION

This is the first study providing evidence for self-determination theory explaining healthy eating in a disadvantaged sub-Saharan African setting among people at risk of or with diabetes type two. Our findings suggest that individuals who experience support from friends or family and who feel competent in adopting a healthy diet are more likely to become more motivated through identifying the health benefits of healthy eating as their goal. This type of autonomous motivation was associated with a healthier diet compared to individuals whose motivation originated in pressure from others or feelings of guilt or shame. Our recommendations for public health interventions include: focus on the promotion of diet-related health benefits people can identify with; encourage social support by friends or family; reinforce people's sense of competence and skills; and avoid triggering perceived social pressure or feelings of guilt.

What Motivates People With (Pre)Diabetes to Move? Testing Self-Determination Theory in Rural Uganda

Introduction

Sub-Saharan Africa is experiencing a rapid growth of type 2 diabetes (T2D) and its related burden. Regular physical activity (PA) is a successful prevention strategy but is challenging to maintain. Self-determination theory (SDT) posits that more autonomous forms of motivation are associated with more sustainable behavior change. Evidence to support this claim is lacking in sub-Saharan Africa. This study aims to explore the relationships between latent constructs of autonomous and controlled motivation, perceived competence, perceived relatedness, PA behavior, and glycemic biomarkers.

Methods

Structural equation modeling was applied to cross-sectional data from a rural Ugandan population (N = 712, pre-diabetes = 329, diabetes = 383). Outcome measures included self-reported moderate and vigorous PA, pedometer counts, and fasting plasma glucose (FPG) and glycated hemoglobin (HbA1C).

Results

Our findings support SDT, but also suggest that different types of motivation regulate different domains and intensities of PA. Higher frequency of vigorous PA – which was linked to a lower HbA1C and FPG – was predicted by autonomous motivation (β = 0.24) but not by controlled motivation (β = −0.05). However, we found no association with moderate PA frequency nor with pedometer counts. Perceived competence and perceived relatedness predicted autonomous motivation. Autonomous motivation functioned as a mediator between those needs and PA behavior.

Conclusion

This is the first study providing evidence for a SDT model explaining PA among people at risk of, or living with, T2D in a rural sub-Saharan African setting. Our findings suggest that individuals who experience genuine support from friends or family and who feel competent in doing vigorous PA can become motivated through identification of health benefits of PA as their own goals. This type of motivation resulted in a higher frequency of vigorous PA and better glycemic biomarkers. On the other hand, people who felt more motivated through pressure from others or through feelings of guilt or shame were not more engaged in PA.

Clinical Trial Registration

ISRCTN 11913581. Registered January 10, 2017.

Nature's Contributions to Human Health: A Missing Link to Primary Health Care? A Scoping Review of International Overview Reports and Scientific Evidence

Nature's contributions to human health (NCH) have gained increased attention internationally in scientific and policy arenas. However, little attention is given to the role of the health care sector in this discussion. Primary health care (PHC) is a vital backbone for linking knowledge and practice within the organization of health care. The objective of this scoping review is to evaluate how international overview reports and scientific literature on NCH address to PHC. More specifically, we extracted data on arguments, practice supporting tools and guidelines, challenges and constraints, and management approaches to integrate NCH and PHC. The scientific literature search was run in Web of Science. Two independent reviewers screened the scientific publications. Through the scientific literature search, we identified 1,995 articles of which 79 were eligible for analysis. We complemented the search with a selection of six international overview reports. Both the international overview reports and the scientific publications paid limited attention to the role of PHC regarding NCH. To cope with the current challenges and constraints to integrate NCH and PHC, more evidence on NCH, further development of PHC practice supporting tools, bottom–up integrated approaches, and closer interdisciplinary collaborations are required.

Urban environment and mental health: the NAMED project, protocol for a mixed-method study

INTRODUCTION

Mental health issues appear as a growing problem in modern societies and tend to be more frequent in big cities. Where increased evidence exists for positive links between nature and mental health, associations between urban environment characteristics and mental health are still not well understood. These associations are highly complex and require an interdisciplinary and integrated research approach to cover the broad range of mitigating factors. This article presents the study protocol of a project called Nature Impact on Mental Health Distribution that aims to generate a comprehensive understanding of associations between mental health and the urban residential environment.

METHODS AND ANALYSIS

Following a mixed-method approach, this project combines quantitative and qualitative research. In the quantitative part, we analyse among the Brussels urban population associations between the urban residential environment and mental health, taking respondents' socioeconomic status and physical health into account. Mental health is determined by the mental health indicators in the national Health Interview Survey (HIS). The urban residential environment is described by subjective indicators for the participant's dwelling and neighbourhood present in the HIS and objective indicators for buildings, network infrastructure and green environment developed for the purpose of this project. We assess the mediating role of physical activity, social life, noise and air pollution. In the qualitative part, we conduct walking interviews with Brussels residents to record their subjective well-being in association with their neighbourhood. In the validation part, results from these two approaches are triangulated and evaluated through interviews and focus groups with stakeholders of healthcare and urban planning sectors.

ETHICS AND DISSEMINATION

The Privacy Commission of Belgium and ethical committee from University Hospital of Antwerp respectively approved quantitative database merging and qualitative interviewing. We will share project results with a wide audience including the scientific community, policy authorities and civil society through scientific and non-expert communication.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium

Key messages

Innovative strategies are needed to scale up integrated chronic care for non-communicable diseases. The SCUBY project develops, implements and assesses roadmaps for the scale-up of an integrated chronic care package for hypertension and diabetes.

Caring for a frail older person: the association between informal caregiver burden and being unsatisfied with support from family and friends

BACKGROUND/OBJECTIVE

although informal caregivers (ICG) find caring for a relative mainly satisfying, it can be difficult at times and it can lead to a state of subjective burden characterised by -among others- fatigue and stress. The objective of this study is to analyse the relationship between perceived social support and subjective burden in providing informal care to frail older people.

METHODS

a descriptive cross-sectional study was conducted using data from a large nationwide longitudinal effectiveness study. Pearson correlations were calculated between the variables for support and burden. Logistic regression models were applied to determine the association between being unsatisfied with support and burden, taking into account multiple confounding variables.

RESULTS

of the 13,229 frail older people included in this study, 85.9% (N = 11,363) had at least one informal caregiver. Almost 60% of the primary informal caregivers manifested subjective burden, measured with the 12-item Zarit-Burden-Interview (ZBI-12). The percentage of informal caregivers that were unsatisfied with support from family and friends was on average 11.5%. Logistic regression analysis showed that being unsatisfied with support is associated with burden (OR1.85; 95%CI1.53-2.23). These results were consistent for the three groups of impairment level of the frail older persons analysed.

CONCLUSIONS

the association between perceived social support and subjective caregiver burden was explored in the context of caring for frail older people. ICGs who were unsatisfied with support were more likely to experience burden. Our findings underline the importance of perceived social support in relation to caregiver burden reduction. Therefore efforts to improve perceived social support are worth evaluating.

Antibiotic Prescribing Quality in Out-of-Hours Primary Care and Critical Appraisal of Disease-Specific Quality Indicators

Outpatient antibiotic use in Belgium is among the highest in Europe. The most common reason for an encounter in out-of-hours (OOH) primary care is an infection. In this study, we assessed all consultations from July 2016 to June 2018 at five OOH services. We described antibiotic prescribing by diagnosis, calculated disease-specific antibiotic prescribing quality indicators’ (APQI) values and critically appraised these APQI. We determined that 111,600 encounters resulted in 26,436 (23.7%) antibiotic prescriptions. The APQI diagnoses (i.e., bronchitis, upper respiratory infection, cystitis, tonsillitis, sinusitis, otitis media, and pneumonia) covered 14,927 (56.7%) antibiotic prescriptions. Erysipelas (1344 (5.1%)) and teeth/gum disease (982 (3.7%)) covered more prescriptions than sinusitis or pneumonia. Over 75% of patients with tonsillitis and over 50% with bronchitis, sinusitis, and otitis media were prescribed an antibiotic. Only for otitis media the choice of antibiotic was near the acceptable range. Over 10% of patients with bronchitis or pneumonia and over 25% of female patients with an acute cystitis received quinolones. The APQI cover the diagnoses for only 57% of all antibiotic prescriptions. As 5.1% and 3.7% of antibiotic prescriptions are made for erysipelas and teeth/gum disease, respectively, we propose to add these indications when assessing antibiotic prescribing quality in OOH primary care.

A study of outpatient healthcare use by ageing people with HIV

BACKGROUND

Antiretroviral treatment has turned HIV infection into a chronic condition with a near normal life expectancy and an ageing patient population. For a well-defined proportion of these patients, HIV-care could pass from specialty care to primary care, especially for prevention and treatment of additional chronic diseases. A better understanding of the complex health needs of this particular proportion is needed to determine the optimal way to integrate specialist and primary care.

OBJECTIVES

Our objective was to examine the health-seeking behaviour of ageing HIV patients. We investigated which physicians they consulted and the reasons for encounter. We also explored patients' participation in preventive healthcare activities.

METHODS

We conducted a retrospective descriptive cohort study among adults, 60 years of age or older living with HIV, who came for a routine consultation visit at the HIV clinic of the Institute of Tropical Medicine (ITM) over a period of 9 months. Those who met the inclusion criteria were offered a self-administered questionnaire. The responses were manually coded, exported into Excel and subsequently imported into SPSS for descriptive statistical analysis.

RESULTS

We analysed questionnaires from 74 patients, 11 women and 63 men. Since their last consultation visit at the ITM, 48 patients consulted their general practitioner (GP), 35 patients consulted a specialist and 7 went to the emergency department over a period of 6 months. Forty-nine patients (66%) had done a faecal occult blood test and 8 women (73% of female patients) had a screening mammography in the past 2 years, 8 women (73% of female patients) had a PAP smear in the past 3 years. Sixty-three participants (85%) declared that their vaccinations were up-to-date. Thirty-eight patients (51%) take antihypertensive medication, 35 patients (47%) cholesterol medication and 9 participants (12%) are on oral antihyperglycemic medication.

CONCLUSIONS

A large proportion of patients are seeking healthcare from their GP and specialists, other than the HIV specialist. They do so both for curative and preventive health needs. This calls for a more structured collaboration between the various care providers, whereby communication plays a pivotal role.

Comprehensive Quantitative Spatiotemporal Gait Analysis Identifies Gait Characteristics for Early Dementia Subtyping in Community Dwelling Older Adults

Background: Recent studies associated gait patterns with cognitive impairment stages. The current study examined the relation between dementia type and spatiotemporal gait characteristics under different walking conditions in pre and mild neurocognitive disorder stage.

Methods: Community-dwelling older adults (age 50+) with memory complaints consulting a memory clinic underwent, at baseline and during follow-up (every 4 months), a standard dementia assessment and a comprehensive spatiotemporal gait analysis [walking on an electronic walkway at usual pace (UP) with and without a counting-backwards (CW) or animal-reciting dual-task (AW), at fast (FP) and at slow (SP) pace]. At baseline the participants were categorized according to the Clinical Dementia Rating (CDR) scale. At the end of the study, the dementia diagnosis was used to stratify the categories in three outcome groups: developed “No-dementia,” “AD+FTD” (grouping Alzheimer's or Fronto-temporal dementia) or “VascD+LBD” dementia (grouping Vascular dementia or Lewy body dementia). The gait characteristics were compared per category in paired groups. Sub-analyzing in the ≥70-years-old participants evaluated the age effect.

Results: Five hundred and thirty-six participants, age 50-to-95-years old were followed for 31-to-41 months. In the CDR 0, no differences were seen between eventual dementia and no-dementia individuals. In the CDR 0.5, CW dual task cost (DTC) step width was larger in the imminent “AD+FTD” and AW (normalized) gait speed was slower in the future “VascD+LBD” group compared to the no-dementia participants. Slower UP (normalized) gait speed differed the future “VascD+LBD” from the “AD+FTD” individuals. In the CDR 1: Wider steps in UP, SP and CW differed the “VascD+LBD” from the “AD+FTD” group. In the ≥70-years old CDR 0 category, higher AW cycle time variability in the imminent “AD+FTD” dementia group, wider UP step width and higher AW cycle time variability in the “VascD+LBD” group differed them from the no-dementia group up to 3 years before dementia diagnosis. The distinctive gait characteristics between the no-dementia and the imminent dementia groups in CDR 0.5 and CDR 1 remained the same as in the overall group. However, no gait differences were found between “VascD+LBD” and “AD+FTD” groups in the pre-dementia stages.

Conclusion: Distinctive spatiotemporal gait characteristics were associated with specific dementia types up to 3 years before diagnosis. The association is influenced by the cognitive stage and age.

Video-recording consultations for educational purposes in out-of-hours primary care: patients and physicians are willing to participate

Background Video-recordings of consultations are used by general practitioner (GP) trainees to enable reflection on aspects of knowledge, skills and attitudes. Typically, these recordings are made during office hours in general practice, but little is known about using video-recording during out of hours (OOH) care, which is an important and distinct part of a GP's work. To be able to record consultations during OOH care (i.e. at the emergency department (ED) and at the General Practitioner Cooperative (GPC)), patients must be willing to cooperate and give informed consent. Therefore, it was of interest to investigate potential barriers in these OOH settings. Methods A questionnaire on demographics and attitudes regarding consent was administered to patients and physicians at the ED and at the GPC in Sint-Niklaas, Belgium. Results A total of 346 questionnaires were completed, 23 by physicians and 323 by patients. A majority of the patients (225/286 (79%)) would consent to video-recording the consultation, without physical examination. Almost all physicians (21/23) would agree to participate. Overall, 85% (260/323) of the patients agree when only the doctor was being recorded. Patients were neutral in recording in 79% (88/224) at the GPC and 57% (56/99) at the ED. Shyness or embarrassment was present in 32% (71/224), and 28% (28/99) at the GPC and ED, respectively. We did not find any significant differences in giving consent or feelings between patients at the GPC and ED. Conclusion A vast majority of both patients and physicians would consent to video-recording their consultation in OOH primary care settings (GPC and ED), with possible concerns about privacy, shame and discomfort.

The effects of sociodemographic factors on quality of life among people aged 50 years or older are not unequivocal: comparing SF-12, WHOQOL-BREF, and WHOQOL-OLD

Objective

The effects of sociodemographic factors on quality of life in older people differ strongly, possibly due to the fact that different measurement instruments have been used. The main aim of this cross-sectional study is to compare the associations of sex, age, marital status, education, and income with quality of life assessed with the Short-Form Health Survey (SF-12), the World Health Organization Quality of Life Questionnaire-BREF (WHOQOL-BREF), and the World Health Organization Quality of Life Questionnaire-Older Adults Module (WHOQOL-OLD).

Methods

The associations between sociodemographic factors and eleven quality of life domains were examined using a sample of 1,492 Dutch people aged ≥50 years. Participants completed the “Senioren Barometer”, a web-based questionnaire including sociodemographic factors, the SF-12, the WHOQOL-BREF, and the WHOQOL-OLD.

Results

All the sociodemographic factors together explained a significant part of the variance of all the quality of life domains’ scores, ranging from 5% to 17% for the WHOQOL-BREF, 5.8% to 6.7% for the SF-12, and 1.4% to 26% for the WHOQOL-OLD. Being a woman and being older were negatively associated with two and four quality of life domains, respectively. Being a woman, being married or cohabiting, and having higher education and a higher income were positively associated with six, six, one, and eleven quality of life domains, respectively.

Conclusion

Our study showed that the associations of sociodemographic factors and quality of life in middle-aged and older people depend on the instruments used to assess quality of life. We recommend that health care and welfare professionals focus particularly on people with a low income and carry out interventions aimed at improving their quality of life.

Practice nurse support and task suitability in a general practice: a cross-sectional survey in Belgium

Single-handed general practices and group practices are the two predominant modes of primary care provision across European countries. In Belgium, single-handed practices have been the main form of primary care provision for years, but recently a trend is emerging towards introducing more group practices where a number of primary care physicians collaborate with other health professionals such as primary care nurses. The aim of this study was to measure the current support in general practices, and to gain insight in the general practitioner attitudes towards being supported by a practice nurse. A cross-sectional study was conducted among general practitioners who were currently working in a general practice in Flanders (Belgium). 271 general practitioners filled out an online questionnaire. 30% declared to be supported by a practice nurse. The majority (>80%) of general practitioners showed positive attitudes towards collaboration with practice nurses, however the job profile and ethical framework of practice nurses remain insufficiently clear. Nurses are found most suitable to take on tasks concerning patient education and technical nursing skills. Despite the lack of governmental incentives in Belgium, general practitioners have taken the initiative to employ practice nurses - possibly - based upon an experienced necessity.

Appropriateness of transferring nursing home residents to emergency departments: a systematic review

Background

Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.

Methods

Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.

Results

Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.

Conclusions

The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

The Integration of Interlinkages Between Nature and Human Health in Primary Health Care: Protocol for a Scoping Review

Background

International overview reports and the majority of scientific publications on interlinkages between nature and human health (NHI) do not seem to focus on the role of the health care sector. Primary health care (PHC) is often the first point of contact people have with the health care system and provides comprehensive, accessible, and community-based care that meets the health needs of individuals throughout their life. PHC is a vital backbone for linking knowledge and practice within the organization of health care. This scoping review aims to focus on the potential role of PHC in relation to NHI.

Objective

The objective of this protocol is to present the method used to scope international overview reports and scientific publications on what is mentioned on the integration of NHI in PHC.

Methods

The international overview reports have been screened for keywords relating to PHC. We developed a specific search strategy to scope scientific literature on NHI in relation to PHC. The scientific literature search ran in Web of Science (WOS) and PubMed from inception to May 2017. The scientific publications are screened by 2 independent reviewers, which will result in a list of relevant publications that meet eligibility and inclusion criteria.

Results

On the basis of a first screen on the title of the first 200 results in both search engines, we decided to restrict to WOS. First insights in the international overview reports and the quantitative overview of the results in WOS give a first impression of a missing link between NHI and PHC. The findings are expected to identify knowledge gaps in the translation of evidence on NHI in PHC practices and the role of PHC regarding the application of that evidence in health care practice.

Conclusions

This is, to our knowledge, the first study that seeks to relate existing knowledge on NHI to PHC. The presentation of our method through this protocol allows researchers to build upon and improve our work in future research on the practical implementation of NIH. The findings of the scoping review are expected to guide future scientific research, international policy directives, and PHC workers to fill the gaps in the integration of NHI in PHC.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12510

The impact of cognitive impairment on the physical ageing process

BACKGROUND

Physical decline and cognitive degeneration characterise the ageing process.

AIM

Physical parameters, performance and the functional indexes were studied in relation to age in healthy and cognitively impaired older persons to understand the interactions and changes during normal ageing, cognitive decline and progression to frailty.

METHODS

Cross-sectional analysis was performed on a data registry of an ambulatory Memory Diagnosis Centre. The quantitative gait characteristics at usual pace, body composition parameters, disability scales (activity of daily living and instrumental activity of daily living) and Rockwood frailty index were compared in cognitively healthy (CHI), mild cognitively impaired, mildly and moderately demented < 80-years old and > 80-years old adults.

RESULTS

Quality of gait deteriorated with age in CHI and cognitively impaired. Skeletal muscle mass index decreased when cognitive status worsened. Disability and frailty correlated with increasing cognitive impairment. Age, gender, cognitive impairment, body composition and Rockwood's Frailty scale had a combined forecasting effect, as well as the individual effect on the gait characteristics. Disability score, Frailty index, skeletal muscle mass and skeletal muscle mass index, gait speed, normalised mean step length and swing time variability in mildly demented < 80-years old adults mirrored the parameters in the CHI > 80-years old.

CONCLUSION

Quantitative gait characteristics, muscle mass and disabilities change along with cognitive impairment, frailty and age. A more rapid physical ageing process accompanies cognitive decline. Therefore, gait characteristics should be age-referenced and studies on gait in older persons should include muscle mass, frailty and cognitive parameters.

How do general practitioners and pharmacists experience antibiotic use in out-of-hours primary care? An exploratory qualitative interview study to inform a participatory action research project

RATIONALE

Antibiotics (ABs) are one of the most prescribed medications in out-of-hours (OOH) care in Belgium. Developing a better understanding of why ABs are prescribed in this setting is essential to improve prescribing habits.

OBJECTIVES

To assess AB prescribing and dispensing challenges for general practitioners (GPs) and pharmacists in OOH primary care, and to identify context-specific elements that can help the implementation of behaviour change interventions to improve AB prescribing in this setting.

DESIGN

This is an exploratory qualitative study using semistructured interviews. This study is part of a participatory action research project.

SETTING AND PARTICIPANTS

Participants include 17 GPs and 1 manager, who work in a Belgian OOH general practitioners cooperative (GPC), and 5 pharmacists of the area covered by the GPC. The GPC serves a population of more than 187 000 people.

RESULTS

GPs feel the threshold to prescribe AB in OOH care is lower in comparion to office hours. GPs and pharmacists talk about the difference in their professional identity in OOH (they define their task differently, they feel more isolated, insecure, have the need to please and so on), type of patients (unknown patients, vulnerable patients, other ethnicities, demanding patients and so on), workload (they feel time-pressured) and lack of diagnostic tools or follow-up. They are aware of the problem of AB overprescribing, but they do not feel ownership of the problem.

CONCLUSION

The implementation of behaviour change interventions to improve AB prescribing in OOH primary care has to take these context specifics into account and could involve interprofessional collaboration between GPs and pharmacists.

TRIAL REGISTRATION NUMBER

NCT03082521; Pre-results.

Consensus study to define appropriate inaction and inappropriate inertia in the management of patients with hypertension in primary care

OBJECTIVES

To elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care.

DESIGN

A two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results.

PARTICIPANTS

14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure.

RESULTS

Inappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met.

CONCLUSION

Definitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.