Implications of health as 'the ability to adapt and self-manage' for public health policy: a qualitative study.

BACKGROUND: To explore the implications for public health policy of a new conceptualisation of health as 'The ability to adapt and to self-manage, in the face of social, physical and emotional challenges'. METHODS: Secondary qualitative data analysis of 28 focus group interviews, with 277 participants involved in public health and healthcare, on the future of the Dutch healthcare system. WHO's essential public health operations (EPHOs) were used as a framework for analysis. RESULTS: Starting from the new concept of health, participants perceived health as an individual asset, requiring an active approach in the Dutch population towards health promotion and adaptation to a healthy lifestyle. Sectors outside healthcare and public health were considered as resources to support individual lifestyle improvement. Integrating prevention and health promotion in healthcare is also expected to stimulate individuals to comply with a healthy lifestyle. Attention should be paid to persons less skilled to self-manage their own health, as this group may require a healthcare safety net. The relationship between individual and population health was not addressed, resulting in little focus on collective prevention to achieve health. CONCLUSIONS: The new concept of health as a basis for changes in the healthcare system offers opportunities to create a health-promoting societal context. However, inequalities in health within the general population may increase when using the new concept as an operationalisation of health. For public health, the main challenge is to maintain focus on the collective socioeconomic and environmental determinants of health and disease and, thereby, preserve collective prevention.

[Blueprint of the 2035 specialty landscape in the Netherlands]. / Op naar een nieuw specialismenlandschap.

The Medical Specialties council of the Royal Dutch medical association (CGS) has published an innovative perspective on the future landscape of specialisms in medicine. The proposal introduces generalism as the standard of training and professional practice, which represents a fundamental change from the current system. The envisioned new structure would consist of a number of broad core specialisms, emphasizing generalist knowledge and skills, and additional subspecialties for highly complex care. This is expected to enhance healthcare efficiency and improve patient treatment. The plan meets changing healthcare needs and accommodates the preference of young doctors regarding their residency training and careers.The CGS wants to further explore the new perspective with all parties involved.

Quality Improvement with Outcome Data in Integrated Obstetric Care Networks: Evaluating Collaboration and Learning Across Organizational Boundaries with an Action Research Approach.

Introduction: Patient-reported outcome and experience measures (PROM and PREM) are used to guide individual care and quality improvement (QI). QI with patient-reported data is preferably organized around patients, which is challenging across organisations. We aimed to investigate network-broad learning for QI with outcome data. Methods: In three obstetric care networks using individual-level PROM/PREM, a learning strategy for cyclic QI based on aggregated outcome data was developed, implemented and evaluated. The strategy included clinical, patient-reported, and professional-reported data; together translated into cases for interprofessional discussion. This study's data generation (including focus groups, surveys, observations) and analysis were guided by a theoretical model for network collaboration. Results: The learning sessions identified opportunities and actions to improve quality and continuity of perinatal care. Professionals valued the data (especially patient-reported) combined with in-dept interprofessional discussion. Main challenges were professionals' time constraints, data infrastructure, and embedding improvement actions. Network-readiness for QI depended on trustful collaboration through connectivity and consensual leadership. Joint QI required information exchange and support including time and resources. Conclusions: Current fragmented healthcare organization poses barriers for network-broad QI with outcome data, but also offers opportunities for learning strategies. Furthermore, joint learning could improve collaboration to catalyse the journey towards integrated, value-based care.

Facilitating Children's Club-Organized Sports Participation: Person-Environment Misfits Experienced by Parents from Low-Income Families.

Despite the many benefits of club-organized sports participation for children, studies have shown that sports participation is lower among children from low-income families than among children from middle- or high-income families. Adopting a socioecological perspective, the main aim of our study was to identify and describe experiences of person-environment (PE) misfits in relation to parental facilitation of children's sports participation. We conducted 24 interviews with parents from low-income families. PE misfits were found in multiple behaviors related to the facilitation of children's sports participation: financing sports participation; planning and investing time; transporting children; acquiring, processing, and providing information; and arranging support. Across these PE misfits, influential attributes were found on the individual level (e.g., skills) as well as within the social, policy, physical, and information environment. In response to PE misfits experienced, parents deployed multiple strategies to reduce these PE misfits, aimed at enhancing either themselves (e.g., increasing financial capacities) or their environments (e.g., arranging social support). These results provide an insight into experienced PE misfits that took the form of multiple specific behaviors which parents found difficult while facilitating their children's sports participation. Furthermore, the results provide insight into the environmental and individual attributes that were involved in these PE misfits, and into how parents modified themselves or their environments in order to make their environments more supportive. The study contributes to future research on individual and environmental influences on parental facilitation of their children's sports participation, as well as on the development of multilevel interventions aimed at increasing sports participation among children from low-income families.

A Toolkit for Co-Designing towards Community-Based Active Ageing: Lessons Learned during Development.

It is increasingly recognized that community-based interventions for active ageing are more lasting and effective, yet the tools and methods for developing these interventions are lacking. This study investigates how to co-design community-based active ageing with older adults via the development of a toolkit to support this goal. Rapid reviews were conducted to understand (i) the effective behavioural change techniques for older adults, (ii) how to co-design with older adults for community-based interventions, and (iii) how to design tools for behaviour change that are easy to use. These reviews served as the foundation for developing a toolkit to support the co-design of community-based active ageing, which was evaluated during an interdisciplinary hackathon with older adults. Quantitative data from the surveys suggested that the confidence levels of students in developing interventions for health behaviour change and in co-designing with older adults increased after the hackathon, and the enjoyment of participating in the hackathon and of using the toolkit were statistically significant factors influencing this increase. Qualitative data from interviews and observations revealed how the toolkit was (un)used by the participants and what aspects of the toolkit can be improved. We encourage future researchers and practitioners to apply and adapt our research findings to the communities of older adults that they are working with.

[Health professionals for the climate]. / Zorgprofessionals voor het klimaat.

More than 230 medical journals have called for worldwide action against global warming and for nature restoration. They call on health professionals to actively contribute to increasing support for the radical measures necessary to maintain the health and well-being of life on our planet. This call concerns not only making one's own living and working environment greener, but above all the use of medical knowledge, expertise and authority for measures that matter worldwide. This starts with concrete advice to patients to prevent damage from climate change at an individual level. Health workers must stand up for prevention and care outside the consultation room and across national borders. After all, medical doctors have historically been in a position to speak out about these threats and to remind political leaders of their responsibility.Health professionals can lead by example by realizing greener and more sustainable care themselves.

Conceptualizing Vulnerability for Health Effects of the COVID-19 Pandemic and the Associated Measures in Utrecht and Zeist: A Concept Map.

The COVID-19 pandemic and the associated measures have impacted the health of many. Not all population groups are equally vulnerable to such health effects, possibly increasing health inequalities. We performed a group concept mapping procedure to define a common, context-specific understanding of what makes people vulnerable to health effects of the pandemic and the measures. We organized a two-step, blended brainstorming session with locally involved community members, using the brainstorm focus prompt 'What I think makes people vulnerable for the COVID-19 pandemic and the measures is…'. We asked participants to generate as many statements as possible. Participants then individually structured (sorted and ranked) these statements. The structuring data was analysed using the groupwisdomTM software and then interpreted by the researchers to generate the concept map. Ninety-eight statements were generated by 19 participants. Sixteen participants completed both structuring tasks. The final concept map consisted of 12 clusters of vulnerability factors, indicating a broad conceptualization of vulnerability during the pandemic. It is being used as a basis for future research and local supportive interventions. Concept mapping is an effective method to arrive at a vulnerability assessment in a community in a short time and, moreover, a method that promotes community engagement.

A prospective population-based multicentre study on the impact of maternal body mass index on adverse pregnancy outcomes: Focus on normal weight.

BACKGROUND: Maternal body mass index (BMI) below or above the reference interval (18.5-24.9 kg/m2) is associated with adverse pregnancy outcomes. Whether BMI exerts an effect within the reference interval is unclear. Therefore, we assessed the association between adverse pregnancy outcomes and BMI, in particular within the reference interval, in a general unselected pregnant population. METHODS: Data was extracted from a prospective population-based multicentre cohort (Risk Estimation for PrEgnancy Complications to provide Tailored care (RESPECT) study) conducted between December 2012 to January 2014. BMI was studied in categories (I: <18.5, II: 18.5-19.9, III: 20.0-22.9, IV: 23.0-24.9, V: 25.0-27.4, VI: 27.5-29.9, VII: >30.0 kg/m2) and as a continuous variable within the reference interval. Adverse pregnancy outcomes were defined as composite endpoints for maternal, neonatal or any pregnancy complication, and for adverse pregnancy outcomes individually. Linear trends were assessed using linear-by-linear association analysis and (adjusted) relative risks by regression analysis. RESULTS: The median BMI of the 3671 included women was 23.2 kg/m2 (IQR 21.1-26.2). Adverse pregnancy outcomes were reported in 1256 (34.2%). Linear associations were observed between BMI categories and all three composite endpoints, and individually for pregnancy-induced hypertension (PIH), preeclampsia, gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates; but not for small-for-gestational-age neonates and preterm birth. Within the reference interval, BMI was associated with the composite maternal endpoint, PIH, GDM and LGA, with adjusted relative risks of 1.15 (95%CI 1.06-1.26), 1.12 (95%CI 1.00-1.26), 1.31 (95%CI 1.11-1.55) and 1.09 (95%CI 1.01-1.17). CONCLUSIONS: Graded increase in maternal BMI appears to be an indicator of risk for adverse pregnancy outcomes even among women with a BMI within the reference interval. The extent to which BMI directly contributes to the increased risk in this group should be evaluated in order to determine strategies most valuable for promoting safety and long-term health for mothers and their offspring.

Risk factors for urological symptoms in a cohort of users of the HIV protease inhibitor indinavir sulfate: the ATHENA cohort.

BACKGROUND: Nephrolithiasis is a well-known complication of indinavir treatment and may result in urological symptoms ranging from renal colic to renal insufficiency. OBJECTIVE: To obtain further knowledge regarding the incidence and risk factors of urological symptoms associated with indinavir sulfate use. METHODS: This study was performed in the ATHENA (AIDS Therapy Evaluation National AIDS Therapy Evaluation Centre) cohort of patients infected with human immunodeficiency virus (HIV) receiving antiretroviral therapy in the Netherlands. The incidence rate of urological symptoms was assessed in a subcohort of 1219 patients starting HIV protease inhibitor treatment after 1996. Urological symptoms were defined as an initial report of nephrolithiasis, renal colic, flank pain, hematuria, renal insufficiency, or nephropathy. Using multivariate Cox regression analysis, risk factors for urological symptoms during indinavir treatment were subsequently studied among the subset of 644 patients who started indinavir treatment after 1996. RESULTS: The incidence of urological symptoms was 8.3 per 100 treatment-years for indinavir vs 0.8 per 100 treatment-years for other HIV protease inhibitors. Risk factors for urological symptoms during indinavir treatment were low weight (relative risk [RR], 2.1; 95% confidence interval [CI], 1.1-3.9), low lean body mass (RR, 1.7; 95% CI, 1.0-2.9), undetectable HIV-1 RNA when starting indinavir treatment (RR, 3.2; 95% CI, 1.5-6.0), prior treatment change because of intolerance (RR, 2.4; 95% CI, 1.2-5.1), indinavir regimens of 1000 mg or more twice daily (RR, 3.1; 95% CI, 1.3-8.2), and warm environmental temperatures (RR, 3.9; 95% CI, 1.7-8.8). Risk estimates were highest among patients with a low lean body mass. CONCLUSION: Increased alertness for urological symptoms is warranted for patients starting indinavir treatment, particularly among those with a low lean body mass, during indinavir regimens of 1000 mg or more twice daily, and in warm weather environments.

Enumerating the preventive youth health care workforce: Size, composition and regional variation in the Netherlands.

The progress in workforce planning in preventive youth health care (YHC) is hampered by a lack of data on the current workforce. This study aimed to enumerate the Dutch YHC workforce. To understand regional variations in workforce capacity we compared these with the workforce capacity and the number of children and indicators of YHC need per region. A national survey was conducted using online questionnaires based on WHO essential public health operations among all YHC workers. Respondents (n=3220) were recruited through organisations involved in YHC (participation: 88%). The YHC workforce is multi-disciplinary, 62% had >10 years working experience within YHC and only small regional variations in composition existed. The number of children per YHC professional varied between regions (range 688-1007). All essential public health operations were provided and could be clustered in an operational or policy profile. The operational profile prevailed in all regions. Regional differences in the number of children per YHC professional were unrelated to the indicators of YHC need. The essential public health operations provided by the YHC workforce and the regional variations in children per YHC professional were not in line with indicators of YHC needs, indicating room for improvement of YHC workforce planning. The methodology applied in this study is probably relevant for use in other countries.

Mortality and progression to AIDS after starting highly active antiretroviral therapy.

OBJECTIVES: To examine survival and progression to AIDS among HIV-infected patients after starting highly active antiretroviral therapy (HAART). METHODS: The study population consisted of 3724 patients from the ATHENA observational cohort who initiated HAART. We considered progression to either an AIDS-defining disease or death, distinguishing HIV-related and non-related (including therapy-related) deaths. A time-dependent multivariate hazards model was fitted to the patient data and 5-year survival probabilities under various therapy scenarios estimated. RESULTS: A total of 459 patients developed AIDS and 346 died during 12 503 person-years of follow-up. HIV-related mortality decreased from 3.8 to 0.7 per 100 person-years between 1996 and 2000 whereas non-HIV-related mortality did not change (0.4 and 0.9, respectively, P = 0.25). For asymptomatic and symptomatic therapy naive patients younger than 50 years with CD4 counts above 10 x 10(6) and 150 x 10(6) cells/l, respectively, predicted 5-year survival probabilities were above 90% when HAART was used continuously. This limit was 450 x 10(6) cells/l when HAART was used during 20 weeks in each 24 week-period of follow-up, and 110 x 10(6) cells/l when patients delayed initiation of HAART for 1 year after becoming eligible for treatment. CONCLUSIONS: Survival probabilities were high among HIV-infected patients initiating HAART at an early stage of infection. The best therapy strategy is therefore to start HAART at this stage of infection. However, deferring HAART in patients with high CD4 cell counts may be clinically more appropriate given toxicity and adherence problems. The lack of any change in non-HIV-related mortality suggests that toxicity has not yet become a major risk factor for death.

Determinants of recurrent toxicity-driven switches of highly active antiretroviral therapy. The ATHENA cohort.

BACKGROUND: Toxicity is the most important reason for premature switching of highly active antiretroviral therapy (HAART). In order to optimize the benefit-risk ratio of HAART, guidelines for toxicity management are needed. OBJECTIVE: An observational cohort study to estimate the incidence and identify determinants of toxicity-driven switches on second-line HAART after having switched first-line HAART despite successful viral suppression. METHODS: Patients were selected from those in the ATHENA cohort (n = 2470) who switched the initial HIV protease inhibitor (PI)-containing HAART while plasma HIV-1 RNA was

[Public healthcare occupations--insight into size and composition is limited]. / Capaciteit van de beroepsgroepen in de publieke gezondheidszorg: beperkt inzicht in omvang en samenstelling.

OBJECTIVE: To gain insight into the size and composition of the various groups of professionals operating in the Dutch public health sector in order to steer development within these groups and to improve quality and efficiency in public healthcare. DESIGN: Document analysis. METHOD: Analysis of data from 7 reports published between 2003 and 2010, focussing on descriptions of working fields, (definitions of) professions and roles and total numbers. RESULTS: By combining the data from 7 reports, we were able to estimate that the total size of all professional groups operating in the public healthcare sector is 12,000 FTE. This is an imprecise estimation because delimitation of the workforce, the occupations and roles selected and data collection methods used during the analyses was not all the same. Per analysis, the delimitation of the working fields ranged, for example, from all municipal health services to a broad selection of facilities and organisations. The roles included varied from 1 to more than 15. The only professionals for whom we could make use of data from a database for compulsory registration were the specialists in social medicine. CONCLUSION: Despite 7 reports in 7 years, we still have insufficient insight into the size and composition of the public health workforce in the Netherlands. Whether or not current capacity is sufficient in relation to the desired levels of quality and efficiency, or will be in the future, is therefore unevaluable.

Treatment failure of nelfinavir-containing triple therapy can largely be explained by low nelfinavir plasma concentrations.

The relationship between plasma concentrations of nelfinavir and virologic treatment failure was investigated to determine the minimum effective concentration of nelfinavir. Plasma samples were prospectively collected from treatment-naive patients who began taking nelfinavir, 1,250 mg BID + two nucleoside reverse transcription inhibitors (NRTIs). Nelfinavir concentration ratios were calculated by dividing each individual nelfinavir level by the time-adjusted population value. Virologic failure was defined as either no response (a detectable viral load after 6 months) or a relapse (detectable viral load after being undetectable, or an increase in viral load >1 log above nadir). Forty-eight patients were included with a median follow-up period of 8 months. The median concentration ratio of nelfinavir was 0.98 (interquartile range, 0.76-1.47). Virologic failure was observed in 29% of the patients. In a univariate analysis, the nelfinavir concentration ratio appeared to be the single determinant that was related to virologic failure (P = 0.039). Patients with a median ratio <0.90 had a relative risk of 3.0 (95% CI, 1.2-7.6) for virologic failure. Using this threshold, virologic failures were detected with 64% sensitivity and 74% specificity (P = 0.014). Virologic failure of nelfinavir-containing triple therapy can be explained, to a large extent, by low plasma levels of nelfinavir.

Low risk of treatment failure after substitution of nevirapine for protease inhibitors among human immunodeficiency virus-infected patients with virus suppression.

There is little information about the risk of treatment failure after a switch from human immunodeficiency virus (HIV) protease inhibitors (PIs) to nevirapine (Nvp) for patients with successful virus suppression. This study compared the 1-year risk of treatment failure for patients switching from a first PI-containing antiretroviral regimen to Nvp (Nvp group) with the risk for patients switching to second-line PIs (PI group) in the ATHENA (AIDS Therapy Evaluation, The Netherlands) study cohort (n=2470) whose HIV-1 RNA loads were < or = 500 copies/mL. Treatment failure was defined as measurement of HIV-1 RNA loads >500 twice or >10,000 copies/mL once or discontinuation of treatment for any reason. There were 446 eligible patients, 125 in the Nvp group and 321 in the PI group. The risk of treatment failure in the Nvp group, after data were adjusted for other risk factors, was 5-fold (95% confidence interval, 0.1-0.4) lower than the risk in the PI group, primarily because the discontinuation rate was lower. In patients with virus suppression, a switch to Nvp is more likely than a switch to second-line PIs to result in sustained virus suppression and maintenance of the new regimen.