The DAWN antivirals trial: process evaluation of a COVID-19 trial in general practice.

BACKGROUND: The DAWN antivirals trial was a multicentric, randomised placebo-controlled trial evaluating antiviral medication for COVID-19 in general practice. The trial was prematurely terminated because of insufficient recruitment. AIM: To explore which factors contributed to the premature termination. DESIGN & SETTING: General practice in Belgium. METHOD: Patients were randomised to camostat or placebo (patients and physicians blinded) between June 2021 and July 2022; a third arm evaluating molnupiravir (open label) was opened in March 2022. The outcome assessor was blinded for all comparisons except for the patient reported outcomes in case of molnupiravir. The authors analysed available trial data and evaluated trial context, implementation, and mechanisms of impact based on semi-structured interviews with trial stakeholders. RESULTS: The trial recruited 44 participants; 19 were allocated to camostat (median age 55 years), 8 to molnupiravir (median age 60 years), and 17 to placebo (median age 56 years). There were no serious adverse events in either group. Most difficulties were related to the pandemic context: disruption to routine clinical services; multiple changes to the service model for COVID-19 patients; overwhelmed clinical staff; delays of trial medication; and staff shortages in the sponsor and clinical team. In addition, regulatory approval processes were lengthy and led to additional study procedures. It was felt that the trial started too late, when vaccinations had already begun. CONCLUSION: The DAWN antivirals trial was stopped prematurely. Although many barriers were related to the pandemic itself, hurdles such as a small and inexperienced sponsor and clinical teams, delays in regulatory processes, and research capacity in routine settings could be overcome by established research infrastructure and standardisation of processes.

Advance care planning among older adults in Belgium with Turkish backgrounds and palliative care needs: A qualitative interview study.

BACKGROUND: Data on advance care planning (ACP) among migrants in Europe is lacking. Research has shown that few older migrants in the United States perform ACP due to healthcare system distrust, collectivistic values and spirituality/religion. OBJECTIVES: To explore the ACP knowledge and perspectives of older Turkish-origin adults in Belgium requiring palliative care. METHOD: General practitioners (GPs) in Brussels and Antwerp recruited Turkish-origin participants aged ≥ 65 years with palliative care eligibility for this qualitative study. A GP conducted semi-structured interviews in Turkish in respondents' homes between May 2019 and February 2022 using a topic guide. Two researchers performed combined inductive/deductive thematic data analysis. RESULTS: All 15 interviewees (average age, 79 years) lacked ACP awareness and information. Some had discussed specific end-of-life preferences (e.g. care location, burial place) with family. Still, many did not feel the need to discuss future healthcare preferences, due mainly to trust in God and family for caretaking and decision-making. Some respondents viewed ACP discussions as applicable, relieving the burden on family and enabling proactive addressing of 'what if' questions. Self-identified ACP barriers were fear of making wrong decisions, 'living in the moment' and difficulty discussing death. Facilitators were obtaining sufficient ACP information and recent family illness or death. CONCLUSION: Our sample of Turkish-origin older adults in Belgium requiring palliative care lacked ACP knowledge. Our findings suggest that their lack of engagement in discussing end-of-life medical care planning was linked to their family dynamics and religion. The findings have implications for healthcare providers to ethnic-minority groups.

Advance care planning among older adults of Moroccan origin: An interview-based study.

OBJECTIVE: To explore advance care planning (ACP)-related knowledge, experience, views, facilitators and barriers among older Moroccan adults in Belgium. METHOD: General practitioners (GPs) recruited participants for semi-structured interviews. Data were analysed using the constant comparative method. RESULTS: The 25 interviewees (average age, 74 years) lacked ACP knowledge and had not discussed it with healthcare professionals. After a brief explanation, most interviewees did not find ACP useful. After more explanation with a specific example, they had fewer religious objections and were more willing to have discussions with their GPs and/or relatives. ACP barriers were a lack of knowledge, current good health, potential harm of talking about death, trust in one's children to make care decisions and fear of worrying one's children. Facilitators were GPs' information provision, children's involvement in ACP discussions and the desire to not depend on children. CONCLUSION: Many older Moroccan adults lacked familiarity, but were willing to discuss ACP after receiving understandable concrete information. GPs should facilitate ACP discussions for these patients, ideally with adult children involved, with consideration of barriers, individual preferences and generally low educational levels. PRACTICE IMPLICATIONS: GPs should provide comprehensible ACP information with case examples and consider potential barriers and facilitators in this group.

Regional Citrate Anticoagulation in Continuous Renal Replacement Therapy: Is Metabolic Fear the Enemy of Logic? A Systematic Review and Meta-Analysis of Randomised Controlled Trials.

BACKGROUND: Anticoagulation is recommended to maintain the patency of the circuit in continuous renal replacement therapy (CRRT). However, anticoagulation-associated complications can occur. We performed a systematic review and meta-analysis to compare the efficacy and safety of citrate anticoagulation to heparin anticoagulation in critically ill patients treated with CRRT. METHODS: Randomised controlled trials (RCTs) evaluating the safety and efficacy of citrate anticoagulation and heparin in CRRT were included. Articles not describing the incidence of metabolic and/or electrolyte disturbances induced by the anticoagulation strategy were excluded. The PubMed, Embase, and MEDLINE electronic databases were searched. The last search was performed on 18 February 2022. RESULTS: Twelve articles comprising 1592 patients met the inclusion criteria. There was no significant difference between the groups in the development of metabolic alkalosis (RR = 1.46; (95% CI (0.52-4.11); p = 0.470)) or metabolic acidosis (RR = 1.71, (95% CI (0.99-2.93); p = 0.054)). Patients in the citrate group developed hypocalcaemia more frequently (RR = 3.81; 95% CI (1.67-8.66); p = 0.001). Bleeding complications in patients randomised to the citrate group were significantly lower than those in the heparin group (RR 0.32 (95% CI (0.22-0.47); p < 0.0001)). Citrate showed a significantly longer filter lifespan of 14.52 h (95% CI (7.22-21.83); p < 0.0001), compared to heparin. There was no significant difference between the groups for 28-day mortality (RR = 1.08 (95% CI (0.89-1.31); p = 0.424) or 90-day mortality (RR 0.9 (95% CI (0.8-1.02); p = 0.110). CONCLUSION: regional citrate anticoagulation is a safe anticoagulant for critically ill patients who require CRRT, as no significant differences were found in metabolic complications between the groups. Additionally, citrate has a lower risk of bleeding and circuit loss than heparin.

Design and Development of Tools for Risk Evaluation of Diabetes and Cardiovascular Disease in Community Pharmacy.

There is an increasing motivation to implement pharmacist-led screening services in community pharmacies. This study aims to develop tools to support the pharmacist in the context of a diabetes and cardiovascular disease risk assessment service. Our development involved a multistep process using a user-centred approach, including a need assessment phase (14 patients, 17 pharmacists) and a creative design phase, followed by the evaluation of the materials (10 patients, 16 pharmacists). Three following themes covering educational needs emerged from stakeholders' discussions: "content", "layout", and "form", with three additional themes regarding the practical organisation: "software", "awareness", and "referral". Based on the need assessment, tools for patient education purposes and awareness campaigns were created. During the development, special attention was paid to the writing style and structure with less text and more graphical colourful elements to suit patients with different health literacy and educational levels. The evaluation phase allowed researchers to observe participants engaging with the materials. Overall, participants were satisfied with the tools. The contents were considered valuable and relevant. However, adaptations were necessary to ensure their understanding and long-term usability. Finally, future research is required to evaluate the materials' impact on patients' behaviour towards their identified risk factors and ensure their effectiveness.

Blended care to discontinue benzodiazepine receptor agonists use in patients with chronic insomnia disorder: a pragmatic cluster randomized controlled trial in primary care.

STUDY OBJECTIVES: International guidelines recommend using benzodiazepine receptor agonists (BZRA) for maximally four weeks. Nevertheless, long-term use for chronic insomnia disorder remains a common practice. This study aimed to test the effectiveness of blended care for discontinuing long-term BZRA use in general practice. METHODS: A pragmatic cluster randomized controlled superiority trial compared blended care to usual care through urine toxicology screening. In the intervention, care by the general practitioner (GP) was complemented by an interactive e-learning program, based on cognitive behavioral therapy for insomnia. Adults using BZRA daily for minimally 6 months were eligible. Participants were clustered at the level of the GP surgery for allocation (1:1). Effectiveness was measured as the proportion of patients who had discontinued at one-year follow-up. Data analysis followed intention-to-treat principles. RESULTS: In total, 916 patients in 86 clusters, represented by 99 GPs, were randomized. Primary outcome data was obtained from 727 patients (79%). At one-year follow-up, 82 patients (18%) in blended care, compared to 91 patients (20%) in usual care, had discontinued. There was no statistically significant effect for the intervention (OR: 0.924; 95% CI: 0.60; 1.43). No adverse events were reported to the research team. CONCLUSIONS: The findings did not support the superiority of blended care over usual care. Both strategies showed clinical effectiveness, with an average of 19% of patients having discontinued at one-year follow-up. Further research is important to study the effect of structurally implementing digital interventions in general practice. CLINICAL TRIAL: Big Bird trial; KCE-17016. This trial is registered at clinicaltrials.gov (NCT03937180).

Diabetes and Cardiovascular Diseases Risk Assessment in Community Pharmacies: An Implementation Study.

The implementation of a new service is often challenging when translating research findings into routine clinical practices. This paper presents the results of the implementation study of a pilot project for a diabetes and cardiovascular diseases risk-assessment service in Belgian community pharmacies. To evaluate the implementation of the service, a mixed method was used that follows the RE-AIM framework. During the testing stage, 37 pharmacies participated, including five that dropped out due to a lack of time or COVID-19-related temporary obligations. Overall, 502 patients participated, of which 376 (74.9%) were eligible for according-to-protocol analysis. Of these, 80 patients (21.3%) were identified as being at high risk for the targeted diseases, and 100 (26.6%) were referred to general practice for further investigation. We presented the limited effectiveness and the key elements influencing optimal implementation. Additional strategies, such as interprofessional workshops, a data-sharing platform, and communication campaigns, should be considered to spread awareness of the new role of pharmacists. Such strategies could also promote collaboration with general practitioners to ensure the follow-up of patients at high risk. Overall, this service was considered easy to perform and feasible in practice but would require financial and external support to ensure its effectiveness, sustainability, and larger-scale implementation.

Between Sympathy, Fascination, and Powerlessness. The Experiences of Health Professionals During the Medical Monitoring of a Hunger Strike Among Undocumented Migrants.

In 2014, a group of undocumented migrants started a hunger strike in Brussels. The medical monitoring was mainly done by young, committed health professionals with no prior experience of medical monitoring of people on hunger strike. Following the hunger strike, two focus groups were organized to assess the experiences of the health professionals during the medical monitoring of the hunger strike. Their main motivation for assisting was wanting to help the people on hunger strike but they were also curious about the living conditions among undocumented migrants and the reasons behind starting the strike. They were puzzled by the paradox of hunger strikers putting their life at risk in order to get a better life and obtain a residence permit. They felt conflicted about their own role as a caregiver: they did not know how to deal with patients who did not comply with medical advice, they struggled to build a relationship of mutual trust and feared that they would end up being instrumentalized by the hunger strikers or their environment. Afterwards, some of the health professionals were deeply touched by the experience and there were reports of symptoms of secondary traumatic stress such as re-experiencing and avoidance. During the focus group's discussions, the respondents made suggestions on how to improve the medical monitoring in the event of any future hunger strikes.

Correction: Estimation of the cardiovascular risk using world health organization/international society of hypertension risk prediction charts in Central Vietnam.

[This corrects the article DOI: 10.1371/journal.pone.0242666.].

Advance Care Planning Among Older Adults of Turkish Origin in Belgium: Exploratory Interview Study.

CONTEXT: Although conversations about future medical treatment and end-of-life care are considered to be important, ethnic minorities are much less engaged in advance care planning (ACP). OBJECTIVES: To explore ACP knowledge, experiences, views, facilitators, and barriers among older adults of Turkish origin in Belgium. METHODS: This qualitative study was based on constant comparative analysis of semistructured interview content. Participants were 33 older adults (aged 65-84 years; mean, 71.7 years; median, 74.5 years) of Turkish origin living in Belgium. RESULTS: Despite unfamiliarity with the term ACP in this sample, several participants had engaged in some ACP behaviors. Respondents considered ACP to be useful and were ready to engage in conversations about it. The most commonly mentioned facilitator was the provision of tailored information about ACP. Other facilitators included concerns about future care needs, increasing awareness among respondents' children about the advantages of ACP, and respondents' desire to avoid "burdening" their children. The most commonly mentioned barrier was respondents' lack of knowledge about ACP. Other barriers were language issues, a lack of urgency about ACP discussion, reliance on familial support, and older adults' fear of triggering negative emotions in themselves and their children. CONCLUSIONS: The provision of tailored information about ACP to older adults of Turkish origin in Belgium and the promotion of awareness about the importance of ACP among their children (when patients desire), as well as the use of professional interpreters, could facilitate ACP engagement in this population.

Estimation of the cardiovascular risk using world health organization/international society of hypertension risk prediction charts in Central Vietnam.

INTRODUCTION: Cardiovascular disease (CVD) being the leading cause of the morbidity and mortality in Vietnam, the objective of this study was to estimate the total 10-year CVD risk among adults aged 40-69 years by utilizing World Health Organization/International Society of Hypertension (WHO/ISH) risk prediction charts in Central Vietnam. MATERIALS AND METHODS: In this cross-sectional study, multi-staged sampling was used to select 938 participants from a general population aged from 40 to 69. The CVD risk factors were then collected throughout the interviews with a standardized questionnaire, anthropometric measurements and a blood test. The cardiovascular risk was calculated using the WHO/ISH risk prediction charts. RESULTS: According to the WHO/ISH charts, the proportion of moderate risk (10-20%) and high risk (>20%) among the surveyed participants were equal (5.1%). When "blood pressure of more than 160/100 mmHg" was applied, the proportion of moderate risk reduced to 2.3% while the high risk increased markedly to 12.8%. Those proportions were higher in men than in women (at 18.3% and 8.5% respectively, p-value <0.001, among the high-risk group), increasing with age. Male gender, smoking, ethnic minorities, hypertension and diabetes were associated with increased CVD risk. CONCLUSIONS: There was a high burden of CVD risk in Central Vietnam as assessed with the WHO/ISH risk prediction charts, especially in men and among the ethnic minorities. The use of WHO/ISH charts provided a feasible and affordable screening tool in estimating the cardiovascular risk in primary care settings.

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.

Assessment of the implementation fidelity of a strategy to scale up integrated care in five European regions: a multimethod study.

OBJECTIVE: The SCaling IntegRated Care in COntext (SCIROCCO) project tested a step-based scaling up strategy to explore what and how to scale up integrated care initiatives in five European regions. To gain a profound understanding of which factors influence the implementation of this strategy, the objective of this study was to assess the extent to which the SCIROCCO strategy was implemented as planned. DESIGN: Multimethod study. METHODS: The extended version of the conceptual framework for implementation fidelity was used to evaluate what factors influence the implementation of the scaling up strategy. Data were collected in the five participating European regions during the intervention period. Data collection methods included: key informant interviews, focus groups, questionnaire studies and project documents. RESULTS: All three main steps of the scaling up strategy were implemented with acceptable fidelity. Variations were observed in the duration of implementing the steps in the regions. Also, variations were observed in the coverage of experts to participate in the steps of the strategy. Several factors were observed to influence the implementation: facilitation conditions (ie, good coordination for implementation) and participant responsiveness (ie, a positive experience of participants in the organised study visits). Factors that may have moderated adherence to the original plan of the strategy were found in facilitating conditions (ie, in the flexible approach), participant recruitment factors (ie, adaptions of the procedure by the regions) and contextual factors (ie, the level of development of integrated care). CONCLUSION: This was the first study to assess implementation fidelity of a European project that used a step-based scaling up strategy in five European regions. Similar European projects that are based on collaboration between several European regions can learn from the lessons captured in SCIROCCO and can become more aware of the facilitating factors and pitfalls of implementing such projects.

Effectiveness of a blended care programme for the discontinuation of benzodiazepine use for sleeping problems in primary care: study protocol of a cluster randomised trial, the Big Bird trial.

INTRODUCTION: Problematic benzodiazepine use is a global health issue. Although the adverse side effects of long-term use of benzodiazepines are well known, it remains difficult to implement interventions for discontinuation in primary care. Considering the success of blended care for the treatment of sleeping disorders and the support of substance use disorders, evidence suggests that a blended care approach, combining face-to-face consultations with the general practitioner with web-based self-learning by the patient, is beneficial for the discontinuation of chronic benzodiazepine use for primary insomnia in general practice. Therefore, the aim of this study is to evaluate the effectiveness of such an approach for the discontinuation of benzodiazepine and zolpidem, zopiclone and zaleplon drugs ((z-)BZD) use in the long term and evaluate the implementation process. METHODS AND ANALYSIS: This study is a multicentre, pragmatic, cluster randomised controlled trial with 1200 patients, included by 120 general practitioners. Allocation to usual or blended care happens at the level of the general practice in a 1:1 ratio using a block randomisation system stratified per language. The study population consists of adult primary care patients who have been using (z-)BZD for primary insomnia on a daily basis for at least 6 months. Primary outcome measure is the proportion of patients that discontinued (z-)BZD at 12 months assessed by toxicological screening for (z-)BZD in urine. Secondary outcomes include discontinuation of (z-)BZD at 6 months, quality of life and the number of defined daily doses of (z-)BZD prescribed. Data will be collected using a study-specific online platform and analysed using the intention-to-treat approach. The process of implementing blended care will be evaluated in a nested study. ETHICS AND DISSEMINATION: This trial was approved by the Ethics Committee for Research of UZ/KU Leuven (ref. S61194). Study results will be disseminated via open-access, peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT03937180.

The transfer of knowledge on integrated care among five European regions: a qualitative multi-method study.

BACKGROUND: To examine how the knowledge transfer processes unfolded within SCIROCCO, a EU funded project (3rd Health Programme (2014-2020)) that aimed to facilitate the process of knowledge sharing across five European regions, to speed up adoption and scaling-up of integrated care initiatives. METHODS: A qualitative multi-method design was used. Data collection methods included focus groups, project documents and action plans of the regions. The data was analysed using a qualitative content-analysis procedure, which was guided by the frameworks of knowledge exchange and the why, whose, what, how framework for knowledge mobilisers. RESULTS: All five components (including the themes) of knowledge exchange could be identified in the approach developed on the knowledge transfer processes. The four questions and accompanying categories of the framework of knowledge mobilisation were also identified to a large degree. CONCLUSIONS: The observed incorporation of distinct forms of knowledge from multiple sources and the observed dynamic and fluid knowledge transfer processes both suggest that SCIROCCO developed a comprehensive knowledge transfer approach aiming to enable the adoption and scaling-up of integrated care. Overall, the multi-method qualitative nature of this research has allowed some new and practical insights in the knowledge transfer activities on integrated care between several European regions. To obtain a clear understanding of the content of the knowledge transfer approaches, which could assist the operationalising of models to support the evaluation of knowledge transfer activities, it is strongly recommended that further research of this type should be conducted in other research settings.

Five Years Later: The Impact of a Hunger Strike on Undocumented Migrant Workers in Brussels.

Five years after a hunger strike of undocumented migrant workers, participants were interviewed to find out about the long term consequences and what the post-factum evaluation of their participation was. A longitudinal observational study was set up, interviewing 46 of the 100 ex-hunger strikers and combining quantitative and qualitative research. This grassroots study shows that one out of six did not derive any benefit from their participation. Half regretted their participation, especially the ones who lost again their legal permit, mentioning health consequences and the fact that their situation hadn't improved. Given the growing number of asylum seekers around the world who are being refused legal permits, hunger strikes will remain a pressing topic. Health professionals, confronted with this possible health and life threatening action, should be informed about the long term impact of voluntary fasting on body and mind of ex-participants.

Cross-sectional study on patient-physician aggression in Belgium: physician characteristics and aggression types.

OBJECTIVES: The aim of this Belgian research study was to describe the characteristics of physicians who are at increased risk for patient-physician aggression. Second, aggression subtypes were described and data were provided on the prevalence of patient-physician aggression in Belgium. DESIGN: Cross-sectional survey. SETTING: Primary and secondary care inside and outside hospitals. PARTICIPANTS: Any physician who had worked in Belgium for the preceding 12 months was eligible to participate (n=34 648). MAIN OUTCOME MEASURES: An online, original questionnaire was used to obtain physician characteristics (eg, age, sex, native language), department, working conditions and contact with aggressive patients during their career and during the preceding 12 months. RESULTS: The questionnaire was completed by 4930 participants and 3726 (76%) were valid to take into account for statistics. During the preceding 12 months, 37% had been victims of aggression: 33% experienced verbal aggression, 30% psychological, 14% physical and 10% sexual. Multiple answers were allowed. Women and younger physicians were more likely to experience aggression. Psychiatric departments and emergency departments were the settings most commonly associated with aggression. Physicians who provided primarily outpatient care were more subject to aggression. CONCLUSION: Belgian physicians experience several forms of aggression. Those most at-risk of aggression are young and female physicians who work in outpatient, emergency or psychiatric settings.

Evolution over 11 years of the characteristics of walk-in patients at the emergency department of a university hospital in Brussels.

Walk-in patients who do not require urgent treatment at an emergency department (ED) are a known and long-standing problem. This study aims to investigate the characteristics of walk-in patients visiting the ED over time. During four days in June 2012, all walk-in patients attending the ED of the University Hospital Brussels between 8 AM and 11 PM were recorded. A similar registration took place in the same ED in June 2001. Patients completed a questionnaire about their characteristics and the reason for the encounter. Data of both study periods were compared. The mean age of the patients attending the ED was significantly lower in 2001 (40.9 years) than in 2012 (43.9 years) (p=0,02). In 2001, 81% of the participants had Belgian nationality, but in 2012 this proportion increased to 90% (p=0.008). In 2001 as well as in 2012, 21% of the participants had a referral from their family physician (FP) (p=0.9). The proportion of patients that were aware that FP could also handle some emergencies increased from 17% in 2001 to 29% in 2012 (p=0.003). More patients had complaints that begun less than 24h before they attended the ED (48% in 2001 and 58% in 2012) (p=0.03). The walk-in patients at the ED are getting slightly older and are attending the ED faster after the onset of the complaints. More patients judge their complaints as urgent. However, more patients are getting aware that FP also could handle some emergencies.

The Role of Physicians During Hunger Strikes of Undocumented Migrant Workers in a Non-Custodial Setting.

Since the beginning of the 21st century, the living conditions of undocumented migrant workers in Belgium have deteriorated drastically. In Brussels, after various social actions, undocumented people began squatting and occupying public buildings to make their struggle visible to society. Desperate, some seized the possibility of a loophole in Belgian law that permits ill persons to have access to a temporary residence permit and started hunger striking. Confronted with consecutive strikes, medical teams of voluntary health professionals faced a big dilemma. A search of the medical literature yielded information about the overall and specific tasks of health professionals during hunger strikes in custodial and hospital settings, but no scientific guidelines were found to address the specific problems the team was confronted with. Information was collected about 15 hunger strikes over a period of seven years, involving the participation of 1,158 strikers. This article describes the medical, organizational, and ethical difficulties encountered in the follow-up of hunger strikes in non-custodial settings, including those associated with the establishment of a health-care structure, operation with very limited resources, and communication with the media and other health professionals.

Assessing the maturity of the healthcare system for integrated care: testing measurement properties of the SCIROCCO tool.

BACKGROUND: The Scaling Integrated Care in Context (SCIROCCO) tool has been developed to facilitate knowledge transfer and learning about the implementation and scaling-up of integrated care in European regions. To adequately test the functionality of the tool in assessing the maturity for integrated care within regions, this study evaluated its structural validity, internal consistency and convergent validity. METHODS: Exploratory factor analysis was used to investigate the structural validity of the 12-items of the SCIROCCO tool. Hereafter, the internal consistency was assessed by calculating Cronbach's and ordinal alpha. The convergent validity was explored by testing 23 pre-hypothesized relationships between items of the SCIROCCO tool and items of an instrument measuring a similar construct. RESULTS: Factor analysis revealed a one-factor structure. Cronbach's alpha of the overall instrument was 0.92, ordinal alpha was 0.94. Only 30.34% of the hypotheses for testing the convergent validity were met. CONCLUSION: The one-factor structure is considered relevant in representing the structural validity of the SCIROCCO tool. The scale of the SCIROCCO tool shows good internal consistency. The tool (DMIC Quickscan) used to assess the convergent validity might measure a different aspect of integrated care than the SCIROCCO tool. Further research is needed to continue investigating the validity and reliability of the tool.