The experience sampling methodology as a digital clinical tool for more person-centered mental health care: an implementation research agenda.

This position paper by the international IMMERSE consortium reviews the evidence of a digital mental health solution based on Experience Sampling Methodology (ESM) for advancing person-centered mental health care and outlines a research agenda for implementing innovative digital mental health tools into routine clinical practice. ESM is a structured diary technique recording real-time self-report data about the current mental state using a mobile application. We will review how ESM may contribute to (1) service user engagement and empowerment, (2) self-management and recovery, (3) goal direction in clinical assessment and management of care, and (4) shared decision-making. However, despite the evidence demonstrating the value of ESM-based approaches in enhancing person-centered mental health care, it is hardly integrated into clinical practice. Therefore, we propose a global research agenda for implementing ESM in routine mental health care addressing six key challenges: (1) the motivation and ability of service users to adhere to the ESM monitoring, reporting and feedback, (2) the motivation and competence of clinicians in routine healthcare delivery settings to integrate ESM in the workflow, (3) the technical requirements and (4) governance requirements for integrating these data in the clinical workflow, (5) the financial and competence related resources related to IT-infrastructure and clinician time, and (6) implementation studies that build the evidence-base. While focused on ESM, the research agenda holds broader implications for implementing digital innovations in mental health. This paper calls for a shift in focus from developing new digital interventions to overcoming implementation barriers, essential for achieving a true transformation toward person-centered care in mental health.

Strategies, processes, outcomes, and costs of implementing experience sampling-based monitoring in routine mental health care in four European countries: study protocol for the IMMERSE effectiveness-implementation study.

BACKGROUND: Recent years have seen a growing interest in the use of digital tools for delivering person-centred mental health care. Experience Sampling Methodology (ESM), a structured diary technique for capturing moment-to-moment variation in experience and behaviour in service users' daily life, reflects a particularly promising avenue for implementing a person-centred approach. While there is evidence on the effectiveness of ESM-based monitoring, uptake in routine mental health care remains limited. The overarching aim of this hybrid effectiveness-implementation study is to investigate, in detail, reach, effectiveness, adoption, implementation, and maintenance as well as contextual factors, processes, and costs of implementing ESM-based monitoring, reporting, and feedback into routine mental health care in four European countries (i.e., Belgium, Germany, Scotland, Slovakia). METHODS: In this hybrid effectiveness-implementation study, a parallel-group, assessor-blind, multi-centre cluster randomized controlled trial (cRCT) will be conducted, combined with a process and economic evaluation. In the cRCT, 24 clinical units (as the cluster and unit of randomization) at eight sites in four European countries will be randomly allocated using an unbalanced 2:1 ratio to one of two conditions: (a) the experimental condition, in which participants receive a Digital Mobile Mental Health intervention (DMMH) and other implementation strategies in addition to treatment as usual (TAU) or (b) the control condition, in which service users are provided with TAU. Outcome data in service users and clinicians will be collected at four time points: at baseline (t0), 2-month post-baseline (t1), 6-month post-baseline (t2), and 12-month post-baseline (t3). The primary outcome will be patient-reported service engagement assessed with the service attachment questionnaire at 2-month post-baseline. The process and economic evaluation will provide in-depth insights into in-vivo context-mechanism-outcome configurations and economic costs of the DMMH and other implementation strategies in routine care, respectively. DISCUSSION: If this trial provides evidence on reach, effectiveness, adoption, implementation and maintenance of implementing ESM-based monitoring, reporting, and feedback, it will form the basis for establishing its public health impact and has significant potential to bridge the research-to-practice gap and contribute to swifter ecological translation of digital innovations to real-world delivery in routine mental health care. TRIAL REGISTRATION: ISRCTN15109760 (ISRCTN registry, date: 03/08/2022).

Associations between self-rated health, mental health problems and physical inactivity among urban adolescents.

Background: Self-rated health is a valid and reliable subjective indicator of general health. We aimed to assess the associations between self-rated health, mental health problems, physical activity, sedentary behaviour and BMI among Slovak urban adolescents. Methods: Data were collected within the EU-FP7: EURO-URHIS 2 (The European Health Indicator System Part 2) project in two largest Slovak cities: Bratislava and Kosice. Sample included 1111 adolescents (response rate 73.7%, mean age 14.32 ± 0.48 years, 52.8% boys). Self-rated health was measured with the first item from the Short Form Health Survey 36 questionnaire, mental health problems were assessed by the Strengths and Difficulties Questionnaire and for physical activity and sedentary behaviour questions from the WHO HBSC questionnaire were used. Logistic regression was performed to determine the associations between self-rated health and the independent variables. Results: Self-rated health was found to be significantly associated with mental health problems, sedentary behaviour and BMI. However, the strongest association was found with engagement in physical activity every day (OR 8.0; 95% CI 1.6-39.9). Conclusions: Previous research revealed that self-rated health was associated with various mental health problems. Our findings add to these results by showing that physical activity and sedentary behaviour are also very important additional factors related to self-rated health. Better understanding of these associations can help in developing more effective public health intervention programmes for adolescents.

Elderly from lower socioeconomic groups are more vulnerable to mental health problems, but area deprivation does not contribute: a comparison between Slovak and Dutch cities.

Background: Little is known about factors associated with mental health problems (MHP) of the elderly in socioeconomically deprived neighbourhoods, and comparisons between Central European and Western European countries on this topic are lacking. We examined whether MHP occurred more frequently in deprived neighbourhoods and among deprived people. Next, we examined whether the association of MHP with area deprivation differed by country and whether this could be explained by the socioeconomic (SE) characteristics of the residents. We obtained data on non-institutionalized residents aged 65 years and above from the EU-FP7: EURO-URHIS 2 project from Slovak ( N = 665, response rate 44.0%) and Dutch cities ( N = 795, response rate 50.2%). An elevated score on General Health Questionnaire-12 (≥2) indicated MHP. Education and household income with financial strain were used as measures of individual SE status. We employed multilevel logistic regression. Overall rates of MHP were significantly higher in Slovakia (40.6%) than in the Netherlands (30.6%). The neighbourhood unemployment rate was not associated with the mental health of elderly in either country. Rates of MHP were significantly higher among elderly with low and medium income [odds ratio (OR) = 1.75, 95% confidence interval (CI) = 1.16-2.62; OR = 1.64, 95% CI = 1.12-2.41, respectively] and financial strain (OR = 2.26, 95% CI = 1.56-3.28) when compared with those with high income and no strain, respectively. Individual-level SE characteristics explained differences between the two countries. The risk of MHP among the elderly is associated with their individual-level SE position but not with neighbourhood deprivation in both Slovakia and the Netherlands.

Are area-level and individual-level socioeconomic factors associated with self-rated health in adult urban citizens? Evidence from Slovak and Dutch cities.

Background: Evidence shows that living in disadvantaged areas is associated with poor health. This may be due to the socioeconomic (SE) characteristics of both these residents and the areas where they live. Evidence regarding this on Central European (CE) countries is scarce. Our aim was to assess whether the prevalence of poor self-rated health (SRH) was higher in deprived urban areas, whether this can be explained by individual SE status (SES) and whether this differed between Slovakia and the Netherlands per age group. We examined the association of urban-level data and individual-level SE factors from different urban areas in different countries (Slovakia, the Netherlands) using comparable urban health indicators and area indicators. We also obtained unique data from the EU-FP7 EURO-URHIS 2 project. Multilevel logistic regression showed that poor SRH was associated with area deprivation in both countries. Regarding age by country, poor SRH occurred more frequently in the more deprived areas for the younger age group (≤64) in the Netherlands but for the older age group (≥65 years) in Slovakia. Moreover, Slovak citizens reported poor SRH significantly more often than Dutch residents. Individual SES was significantly associated with poor SRH in both age groups and both countries for most area-level SE measures. Individual SES is associated with SRH more strongly than area deprivation. Therefore, it is important to account for relative deprivation at an individual level when considering health-enhancing activities. Moreover, the effect of urban-area deprivation seems to differ between CE and WE countries.

The effect of neighbourhood unemployment on health-risk behaviours in elderly differs between Slovak and Dutch cities.

BACKGROUND: Health-risk behaviours (HRB) increase the risk of disability and chronic diseases at an older age. This study aimed to compare Slovakia and the Netherlands regarding differences in the prevalence of HRB by neighbourhood and individual deprivation and to determine whether area differences could be explained by the socio-economic position (SEP) of the residents. METHODS: We obtained data on non-institutionalized residents aged ≥ 65 years from the EU-FP7: EURO-URHIS 2 project from Slovak (N = 665, response rate 44.0%) and Dutch cities (N = 795, response rate 50.2%). HRB concerned daily smoking, binge drinking, physical activity, consumption of fruits and vegetables and body mass index. Area deprivation was measured by the neighbourhood unemployment rate. Individual SEP was measured by education and household income with financial strain. We used multilevel logistic regression. RESULTS: In Slovakia, no HRB was associated with either neighbourhood unemployment or individual SEP. The elderly in the Netherlands from the least favourable neighbourhoods were more likely to be daily smokers [odds ratio (OR) 2.32; 95% confidence interval (CI) 1.25, 4.30] and overweight (OR 1.84; 95% CI 1.24, 2.75) than residents from the most favourable ones. For the Dutch elderly the gradients varied per HRB and per individual-level SEP indicator. Individual SEP explained country differences in the association of area unemployment with smoking and lack of physical activity but not that with overweight. CONCLUSION: Countries differed in the associations with HRB of both neighbourhood unemployment and individual SEP among the elderly urban residents. The local importance of socio-economic factors on both levels should be considered when developing health-promotion activities for the elderly.

Trends in multiple recurrent health complaints in 15-year-olds in 35 countries in Europe, North America and Israel from 1994 to 2010.

BACKGROUND: Health complaints are a good indicator of an individual's psychosocial health and well-being. Studies have shown that children and adolescents report health complaints which can cause significant individual burden. METHODS: Using data from the international Health Behaviour in School-aged Children study, this article describes trends in multiple recurrent health complaints (MHC) in 35 countries among N = 237 136 fifteen-year-olds from 1994 to 2010. MHC was defined as the presence of two or more health complaints at least once a week. Logistic regression analysis was performed to evaluate trends across the five survey cycles for each country. RESULTS: Lowest prevalence throughout the period 1994-2010 was 16.9% in 1998 in Austria and highest in 2006 in Israel (54.7%). Overall, six different trend patterns could be identified: No linear or quadratic trend (9 countries), linear decrease (7 countries), linear increase (5 countries), U-shape (4 countries), inverted U-shape (6 countries) and unstable (4 countries). CONCLUSION: Trend analyses are valuable in providing hints about developments in populations as well as for benchmarking and evaluation purposes. The high variation in health complaints between the countries requires further investigation, but may also reflect the subjective nature of health complaints.

Facilitators and barriers to behavior change in overweight and obesity management using the COM-B model.

Introduction: Increasing overweight and obesity rates represent one of the global public health challenges. COM-B is a theoretical model used to identify areas to target to achieve behavior change. It identifies three factors that are needed for any behavior to occur: capability, opportunity, and motivation. We aimed to assess the potential facilitators and barriers to behavior change in weight management using the COM-B. Methods: The study included 139 people with overweight and obesity (mean age 48.81 ± 14.49 years; 64.5% female; body mass index 32.64 ± 6.51 kg/m2; waist-to-height ratio 0.62 ± 0.10) from primary care settings. All participants completed the Brief Measure of Behavior Change (COM-B), the General Self-Efficacy Scale (GSE), the Rosenberg Self-esteem Scale (RSE), and the Overall Evaluation of Health (OEH). Multiple linear regression was performed to analyse the data. Results: The associations between sociodemographic and clinical variables and COM-B domains attenuated or were no longer significant when psychological resources were added to the regression models. Self-efficacy was identified as a stronger facilitator of health behavior change (p < 0.001) when compared to self-esteem (p < 0.05). No associations between automatic motivation and psychological resources were identified, however. Automatic motivation was found to be associated with higher age, being in a relationship, and better health. Discussion: Behavioral interventions for weight management should specifically target different components of COM-B. Self-efficacy and self-esteem may play a significant role in individual capabilities, opportunities, and reflective motivation and should be included in tailored public health interventions. Health programs targeting younger and single people, and people with chronic conditions may help to promote sustainable behavior change.

A comparison of social prescribing approaches across twelve high-income countries.

BACKGROUND: Social prescribing connects patients with community resources to improve their health and well-being. It is gaining momentum globally due to its potential for addressing non-medical causes of illness while building on existing resources and enhancing overall health at a relatively low cost. The COVID-19 pandemic further underscored the need for policy interventions to address health-related social issues such as loneliness and isolation. AIM: This paper presents evidence of the conceptualisation and implementation of social prescribing schemes in twelve countries: Australia, Austria, Canada, England, Finland, Germany, Portugal, the Slovak Republic, Slovenia, the Netherlands, the United States and Wales. METHODS: Twelve countries were identified through the Health Systems and Policy Monitor (HSPM) network and the EuroHealthNet Partnership. Information was collected through a twelve open-ended question survey based on a conceptual model inspired by the WHO's Health System Framework. RESULTS: We found that social prescribing can take different forms, and the scale of implementation also varies significantly. Robust evidence on impact is scarce and highly context-specific, with some indications of cost-effectiveness and positive impact on well-being. CONCLUSIONS: This paper provides insights into social prescribing in various contexts and may guide countries interested in holistically tackling health-related social factors and strengthening community-based care. Policies can support a more seamless integration of social prescribing into existing care, improve collaboration among sectors and training programs for health and social care professionals.

Programmes and calls for public health research in European countries.

INTRODUCTION: Public health research, at population and organizational level, needs to be identified independently within 'health' research from biomedicine and life sciences. In PHIRE (Public Health Innovation and Research in Europe), we investigated the extent and character of public health research calls and programmes in European countries. METHODS: Country respondents, identified through national member associations of the European Public Health Association completed a standardized recording instrument. Public health research was defined, and the call period limited to the latest full year (2010). Of the 30 countries included (EU 27 plus Iceland, Norway and Switzerland), there were reports for 25 countries A simple classification of the calls was developed. RESULTS: There were 75 calls and programmes included. Of these, 41 (55%) together were in France and the UK, and 34 in a further 14 countries, while 9 countries reported there were no calls or programmes opened in 2010. Calls were categorized across diseases, behaviours, determinants, services and methodologies. Some calls were broad, while others--particularly in the countries with several calls--were more detailed towards specific issues. Levels of funding varied markedly and were difficult to define. Where stated, in 32 responses, 19 calls were only open to national applicants and 13 from abroad. CONCLUSIONS: Most European countries have competitive programmes and calls relevant for public health research, but they are poorly identified. Only a minority of countries present a wide range of topics and specific fields. Effort is needed to develop classifications for public health programmes and calls for public health research, improve information (including financial) collection to enable systematic comparisons and build greater recognition of public health research within research communities, with national and European research funding organizations, and for practitioners and policymakers.

Competitive funding and structures for public health research in European countries.

INTRODUCTION: The European Union is giving increasing emphasis to research as a driver for innovation and economic development. The European collaborative study PHIRE (Public Health Innovation and Research in Europe) investigated the funding and structures of public health research at national level in European countries. METHODS: Background materials were prepared for national public health associations of European countries to hold workshops or discussions with research and policy stakeholders on their public health research systems. The reports, supplemented from internet sources for 23 EU countries (four did not contribute), provided information for framework analysis. RESULTS: All countries have public funding and administrative structures for research, but structures for public health research are more varied. In most countries, competitive health research funding is controlled by the Ministry of Science, with little input from the Ministry of Health. In four countries, Ministries of Health provide competitive funding alongside Ministries of Science, and in two countries there is a single health research council. There is no comparative reporting of public health research funding, and little connection with European public health research programmes. CONCLUSION: Europe needs a comprehensive picture of national and regional systems of public health research, in order to critically assess them and better adapt to changes and challenges, and to achieve a European Research Area for public health.

Impact of innovations in national public health markets in Europe.

BACKGROUND: Social innovations can contribute to health and wellbeing. PHIRE (Public Health Innovation and Research in Europe) investigated the impacts at national level of innovation projects funded by the European Union Public Health Programme. METHODS: Through the European Public Health Association, experts assessed the uptake of the eight public health projects, for 30 European countries. Their reports were assembled by country and, thereafter, national public health associations reviewed the reports. Following stakeholder workshops, or internal and external consultations, 11 national reports were produced which included discussion on the impacts of the public health innovations in national product markets. RESULTS: In 11 countries, there were reports on the eight innovations for 45 (51%) of the possible public health markets. The innovations contributed positively to policy, practice and research, across different levels and in different ways, in 35 (39%) market, while competing innovation activities were recorded in 10 (11%) markets. The workshops also discussed contributing factors and limitations in dissemination and timing for policy cycles. CONCLUSIONS: The impacts of European Union social innovations in public health markets can be identified through national discussions. Further attention should be given to understanding drivers and incentives for successful public health innovations.

Civil society engagement in innovation and research through the European Public Health Association.

BACKGROUND: The European Public Health Association (EUPHA) proposed and led PHIRE (Public Health Innovation and Research in Europe), with co-financing by the European Commission, to assess public health innovation and research at national level in Europe. PHIRE was also designed to promote organizational development and capacity building of EUPHA. We assess the success and limitations of using EUPHA's participative structures. METHODS: In total, 30 European countries were included-27 EU countries, Iceland, Norway and Switzerland. EUPHA thematic section presidents were asked to identify country informants to report, through a web-based questionnaire, on eight public health innovations. National public health associations (EUPHA member organizations) were requested to identify their national public health research programmes and calls, review the health research system, coordinate a stakeholder workshop and provide a national report. The section and national reports were assessed for responses and completeness. RESULTS: Half of the final responding CIs were members of EUPHA sections and the other half gained from other sources. Experts declined to respond for reasons including lack of time, knowledge of the innovation or funding. National public health associations held PHIRE workshops with Ministries of Health in 14 countries; information for 10 countries was gained through discussions within the national association, or country visits by PHIRE partners. Six countries provided no response. Some national associations had too weak organizational structures for the work or insufficient financial resources or criticism of the project. CONCLUSION: EUPHA is the leading civil society organization giving support to public health research in Europe. PHIRE created new knowledge and supported organizational development. EUPHA sections gained expert reports on public health innovations in European countries and national public health associations reported on national public health research systems. Significant advances could be made if the European Commission worked more directly with EUPHA's expert members and with the national public health associations.

Social support, positive caregiving experience, and caregiver burden in informal caregivers of older adults with dementia.

Introduction: Dementia is currently one of the major causes of disability and dependency among older adults worldwide. Cognitive dysfunction, neuropsychiatric symptoms, somatic complaints, and functional impairment fundamentally affect not only a person living with dementia (PLwD), but also his/her informal caregiver(s), often resulting in a high caregiver burden. A number of variables, including the caregiver's sociodemographic characteristics, the clinical characteristics of PLwD, social support, and the caregiver's personal resources determine the caregiver's burden. Objectives: The aim of this study was to investigate the associations of caregiver burden in informal caregivers of PLwD with perceived social support, positive caregiving experience, and applying therapeutic communication methods. Methods: The data were collected from September 2021 to February 2022 among 115 "PLwD-informal caregiver" dyads in the community settings in Slovakia. Measures included the Zarit Burden Interview (ZBI-12), the Oslo Social Support Scale (OSSS-3), the Positive Aspects of Caregiving Scale (PACS), and two questions on applying therapeutic communication methods-reminiscence and validation according to Naomi Feil. The Short IQCODE was used for assessing cognitive decline in PLwD. Pearson's and Spearman's correlations, t-tests, Chi-square, ANOVA, and linear multiple regression analyses were used to analyze the data (IBM SPSS 27). Results: The mean age of informal caregivers was 54 ± 12.4 years (81.7% of women) and the mean caregiving duration was 4.8 ± 4.8 years. The mean age of PLwD was 80.5 ± 8.3 years (73.0% of women) and their Short IQCODE mean score was 4.1 ± 1.0. Lower caregiving burden was significantly associated with higher perceived social support (ß = 0.33, p < 0.01), with higher positive caregiving experience (ß = 0.33, p < 0.01), and higher caregiving intensity (ß = 0.24, p < 0.05) among informal caregivers of PLwD. The associations between caregiver burden and applying two therapeutic communication methods were not significant. Conclusions: Implementing psycho-social and educational public health interventions focused on strengthening social support and maintaining positive perceptions of caregiving can help reduce the increased risk of caregiver burden in informal caregivers of older adults with dementia.

Public health research priorities in Europe seen by non-governmental organizations.

BACKGROUND: Public health research is concerned with population health, determinants of health, health systems research, health promotion, environmental health, health protection, disease prevention and research in other fields of public health. During the last decades, non-governmental organisations (NGOs) are more often entering the field of public health research. This paper presents results of work within SPHERE (Strengthening Public Health Research in Europe), a European Commission funded study aimed to gather information and produce knowledge on the state of public health research in Europe. METHODS: A questionnaire survey was developed and conducted among NGOs enrolled in a database held by the European Public Health Alliance (EPHA). There were 80 replies, and the response rate for NGOs that were members of EPHA was 53%. RESULTS: There were no significant statistical differences in the responses when analysed for three European groups ['old' member states (EU 15), accession members states in 2004 (EU 10) and EU-associated countries]. The NGOs reported a relatively large international experience, expressed by participation in international public health research, and more often practice work. The main research priorities reported were general public health, environmental health, ADHD, obesity, nutrition, tobacco control. NGOs showed low correlation between their work field and their proposed public health research priorities. CONCLUSION: There are growing numbers of NGOs in Europe concerned with public health. This survey indicates their interest also in public health research priorities.

Health-risk behaviours in deprived urban neighbourhoods: a comparison between Slovak and Dutch cities.

OBJECTIVES: International comparisons of the associations of area-level socioeconomic position (SEP) and health-risk behaviours (HRBs) are for the most part lacking. The aims of this study were to compare Slovakia and the Netherlands regarding differences in the prevalence of HRBs by neighbourhood and individual deprivation, and to determine whether area differences could be explained by the SEP of residents. METHODS: We obtained data on residents aged 19-64 from Slovak and Dutch cities from the FP7 EURO-URHIS2 project and employed multilevel logistic regression. RESULTS: The association between neighbourhood-level unemployment and HRBs differed between countries. In the Netherlands, the prevalence of almost all HRBs was higher in deprived areas, except for the consumption of fruits and vegetables. These area effects diminished after controlling for individual-level SEP. In Slovakia, no area effects were observed, although Slovak residents showed a higher risk for most HRBs. At the individual level, an inverse SE gradient was found for almost all HRBs in both countries. CONCLUSIONS: Local analyses of small area health differences and health determinants are critical for efficient implementation of neighbourhood-based interventions.

The effect of urban-area unemployment on the mental health of citizens differs between Slovak and Dutch cities.

Conclusive evidence on the association of mental health problems (MHP) with area unemployment is lacking in regard to Central European cities. We obtained data on residents aged 19-64 from Slovak and Dutch cities from the FP7 EURO-URHIS 2 project. Multilevel logistic regression showed that the association between MHP (GHQ-12-total score ≥2) and area unemployment was strong in the Netherlands, but absent in Slovakia. Slovak citizens from the most favourable neighbourhoods had nearly double the risk of MHP than their Dutch counterparts. Individual-level socioeconomic characteristics did not explain area differences. The effect of urban-area unemployment seems to differ between Central European and Western European countries.