Implementation of an integrated community approach in deprived neighbourhoods: a theory-based process evaluation using the Consolidated Framework for Implementation Research (CFIR).

BACKGROUND: We investigated the implementation process of an Integrated Community Approach (ICA) applied in four low socio-economic status neighbourhoods in Maastricht, the Netherlands. The ICA is a Population Health Management initiative and aims to improve population health, quality of care, professional's satisfaction and decrease costs of care. This study addresses the facilitators and barriers for implementing the ICA from a stakeholder perspective, including steering group members, professionals and citizens. METHODS: We conducted a mixed-methods study using a triangulation of methods to investigate the implementation from 1 December 2016 to 31 December 2020. The Consolidated Framework for Implementation Research guided data collection and data-analysis for evaluating the implementation process. In total, 77 interviews, 97 observations, seven focus groups, 65 collected documents and two surveys with open-ended questions were conducted. RESULTS: Facilitators for implementation were the use of citizen science to bring residents' needs into sharp focus, the integration of the ideology of Positive Health into the working routines of the professionals and leadership at the steering group level to overcome barriers in the ICA. The existing accounting and financial infrastructure obstructed combining budgets at neighbourhood level. CONCLUSIONS: Engaging citizens and professionals at an early stage is an important facilitator for implementation. The use of a shared vision on health also worked as a facilitator since it created a shared language among professionals, which is important in Population Health Management initiatives where multiple professionals are expected to collaborate. TRIAL REGISTRATION: NTR 6543; registration date, 25 July 2017.

Collaborative governance at the start of an integrated community approach: a case study.

BACKGROUND: We studied collaborative governance at the start of an integrated community approach aiming to improve population health, quality of care, controlling health care costs and improving professional work satisfaction. Our objective was to investigate which characteristics of collaborative governance facilitate or hamper collaboration in the starting phase. This question is of growing importance for policymakers and health initiatives, since on a global scale there is a shift towards 'population health management' where collaboration between stakeholders is a necessity. In addition, it is crucial to investigate collaborative governance from the beginning, since it offers opportunities for sustainability of collaboration later on in the process. METHODS: We performed a qualitative case study in four deprived neighbourhoods in the city of Maastricht, the Netherlands. An integrated community approach was implemented, involving various stakeholders from the public and private health sectors and provincial and local authorities. Data was collected from December 2016 to December 2018, with a triangulation of methods (50 observations, 24 interviews and 50 document reviews). The Integrative Framework for Collaborative Governance guided data collection and analysis. RESULTS: We focused on the dynamics within the collaborative governance regime, consisting of principled engagement, shared motivation and capacity for joint action. We found that shared goalsetting, transparency, being physically present, informal meetings, trust and leadership are key aspects at the start of collaborative governance. An extensive accountability structure can both hamper (time-consuming which hinders innovation) and facilitate (keep everybody on board) collaboration. The characteristics we found are of significance for policy, practice and research. Policymakers and practitioners can use our lessons learned for implementing similar (population health) initiatives. This case study contributes to the already existing literature on collaborative governance adding to the knowledge gap on the governance of population health approaches. TRIAL REGISTRATION: NTR6543 , registration date; 25 July 2017.

Preferences of people with Type 2 diabetes for diabetes care: a discrete choice experiment.

AIMS: Limited knowledge exists on the preferences of people with Type 2 diabetes towards diabetes care. Consequently, these care preferences cannot yet be considered in the development of tailored diabetes care approaches. Therefore, this study aimed to assess care preferences and their determinants in people with Type 2 diabetes. METHODS: A discrete choice experiment was conducted to elicit people's preferences. People with Type 2 diabetes, treated in 30 Dutch primary care practices, were asked to choose repeatedly between two hypothetical diabetes care packages, which differed in six attributes: role division in daily diabetes care planning, lifestyle education method, type of medication management support, consultation frequency, emotional support and time spend on self-management. A mixed-logit model was used to estimate the relative importance of the included attributes. Preference heterogeneity among people with different person- and disease-related characteristics was investigated. RESULTS: In total, 288 participants completed the experiment. They preferred to plan their daily diabetes care together with a healthcare provider, to receive individual lifestyle education, medication and emotional support from a healthcare provider, one consultation visit every 3 months and to spend less time on self-management. Participants did not prefer to receive emotional support from a psychologist. Heterogeneity in preferences could partly be explained by differences in sex, education level and glucose-lowering drug use. CONCLUSION: People with Type 2 diabetes show a preference for traditional care models. Emotional support was identified by participants as the most important attribute. It is therefore important to adequately guide them when changes in diabetes care organization are implemented.

Positive Health beyond boundaries in community care: design of a prospective study on the effects and implementation of an integrated community approach.

BACKGROUND: High healthcare expenditures due to population ageing and chronic complex health complaints are a challenge on a global scale. To improve the quality of healthcare, population health, and professionals' work satisfaction and to reduce healthcare costs (Quadruple Aim), the Dutch Ministry of Health, Welfare and Sport designated nine pioneer site regions across the Netherlands. One of these pioneer sites is the integrated community approach (ICA) known as 'Blue Care'. This article describes the design of a prospective study investigating the effects of Blue Care ICA on Quadruple Aim outcomes and a process evaluation focussing on its implementation in deprived neighbourhoods. METHODS: A mixed-methods approach, combining both quantitative and qualitative research methods, is applied to yield an enriched understanding of the various processes that will take place in the neighbourhoods. A prospective, quasi-experimental study is conducted within a natural experiment. Blue Care ICA is being implemented between 2017 and 2020 and research activities are taking place parallel to the implementation process. Effects of Blue Care ICA are measured at T0 (baseline), T1 (after 1 year), T2 (after 2 years) and at T3 (after 3 years) using a questionnaire. The primary outcome measure is health-related quality of life (SF-12v2), secondary outcomes are health status (EQ-5D-5 L), resilience (RS-Scale), Positive Health (Spiderweb diagram) and quality of care (grade 0-10). As part of the process evaluation, the Consolidated Framework for Implementation Research guided the formulation of process evaluation questions. Participant observations, interviews and focus groups with all stakeholders active in the Blue Care ICA will be conducted during the whole implementation period (2017-2020). DISCUSSION: The evaluation takes into account the interconnections between content, application, context and outcomes to understand how the Blue Care ICA unfolds over time in a complex, dynamic setting. Results of the effect and process evaluation will become available in 2020. TRIAL REGISTRATION: NTR 6543 , registration date; 25 July 2017.

Prevention of tick bites: an evaluation of a smartphone app.

BACKGROUND: Lyme borreliosis (LB) is the most common reported tick-borne infection in Europe, and involves transmission of Borrelia by ticks. As long as a vaccine is not available and effective measures for controlling tick populations are insufficient, LB control is focused on preventive measures to avoid tick bites. To inform citizens about the risk of ticks, motivate them to check for tick bites, and encourage them to remove any attached tick as quickly as possible, a mobile app called 'Tekenbeet' (Dutch for 'tick bite') was developed and released. The aim of this study was to evaluate the usage and user satisfaction of the 'Tekenbeet' app and to investigate whether it affects users' knowledge, perceived severity, perceived susceptibility, self-efficacy, response efficacy, current behavior and intention to comply with preventive measures. METHODS: Usage of the app was evaluated with data obtained from Google Analytics. A survey among the Dutch general adult population with two data collection periods evaluated the usage, user satisfaction and its influence on abovementioned outcomes. RESULTS: Data obtained from Google Analytics showed the app was downloaded almost 40,000 in the 20 months following the launch. The 'tick radar' and 'tick diary' screens were viewed most often. In addition, a total of 554 respondents completed an online survey. The mean user satisfaction score was 7.44 (on a scale of 1-10) and 90.9% of respondents would recommend the app to others. On average, survey respondents who downloaded the app (n = 243) recorded significantly more often higher knowledge scores (OR 3.37; 95% CI 2.02-5.09) and had a higher intention to comply with preventive measures (OR 2.47; 95% CI 1.22-5.85) compared to respondents who did not download the app (n = 311). CONCLUSIONS: The 'Tekenbeet' app is a frequently used and well-appreciated educational tool to increase public knowledge of ticks and tick bites. It also helps to improve the user's intention to apply preventive measures. The use of smartphones and apps is now commonplace in the Netherlands; the 'Tekenbeet' app feeds into this trend and thereby offers a modern day alternative to established formats such as an information leaflet and information provision on the Internet.

Education on tick bite and Lyme borreliosis prevention, aimed at schoolchildren in the Netherlands: comparing the effects of an online educational video game versus a leaflet or no intervention.

BACKGROUND: Lyme disease or Lyme borreliosis (LB) is the most common tick-borne disease both in the United States and Europe. Children, in particular, are at high risk of contracting LB. Since child-specific educational tools on ticks, tick bites and LB are lacking, we developed an online educational video game. In this study, we compared the effectiveness of an online educational video game versus a newly developed leaflet aimed to improve prevention of tick bites and LB among Dutch schoolchildren. METHODS: A total of 887 children, aged 9-13 years and attending the two final years of primary schooling, were recruited from 25 primary schools in June and July 2012. They were assigned through cluster randomization to one of three intervention groups: 'game' (22.4%), 'leaflet' (35.6%) or 'control' (41.9%). Prior to and directly following intervention, the children were asked to complete a short questionnaire. The main outcome measures were knowledge, perception (perceived susceptibility and importance) and preventive behavior in relation to tick bites and LB. Generalized linear mixed models were used to analyze the data. RESULTS: In the game group, the leaflet group and the control group, knowledge about ticks and tick bites improved significantly. The game was also an effective tool for improving preventive behavior; the frequency of checking for ticks increased significantly. However, there were no significant differences in knowledge improvement between the interventions. The game outperformed the leaflet in terms of improving preventive behavior, whereas the frequency of tick checks increased significantly. But this frequency didn't increase more than in the control group. CONCLUSIONS: The positive knowledge effects observed in the control group suggests the presence of a mere measurement effect related to completion of the questionnaire. The game did not outperform the leaflet or control group on all outcome measures. Therefore, the game may be of value as a complementary role, in addition to other media, in child-specific public health education programs on ticks and LB. This trial was retrospectively registered on October 21, 2016 (trial registration number: ISRCTN15142369).

[Inter-sectoral costs and benefits arising from mental health (disorders)]. / Intersectorale kosten en baten van geestelijke (on)gezondheid.

BACKGROUND: Mental health disorders may bring costs and benefits to areas and sectors lying outside the health care system. However, little is known about these inter-sectoral costs and benefits (ICBs) in spite of the increasing interest in societal cost-benefit analyses (SCBA) that attempt to quantify all costs and benefits involved.
AIM: To present a first inventory of ICBs relating to mental health care and to describe the relation between ICBs and SCBA.
METHOD: We reviewed the literature and conducted a secondary analysis of the results of a previous study.
RESULTS: We found that at least eight mental health disorders were reported to have a (financial) impact on at least three sectors outside the health care system.
CONCLUSION: Further research into ICBs is needed so that future inter-sectoral policy can be better directed and targeted more efficiently.

Citizen science in the community: Gaining insight in community and participant health in four deprived neighbourhoods in the Netherlands.

The aim of this study was to examine if citizen science contributes to gaining insight into community health and to the health of the citizen scientists themselves. Therefore, thirteen citizens in four deprived neighbourhoods were trained as citizen scientists to conduct research in their own communities. Results showed that the citizen scientists identified forty (health related) themes in their communities. The citizen scientists reported an increase in their overall self-perceived health which, however, was not significantly demonstrated in the prequestionnaire and postquestionnaire.

[Substitution of care: what do we know, what should we know, and what should we do?] / Substitutie van zorg.

In order to contain rising healthcare expenditure, the Dutch minister of Health, Welfare, and Sport has agreed with various stakeholders to shift care as much as possible from the expensive specialised care sector to the cheaper primary care sector. Such a shift is only desirable if it constitutes a permanent shift to the primary care sector thereby reducing costs while simultaneously increasing quality of care and the health of the population. In order to prove the success of substitution initiatives, their effects must be compared with the national trend at population level. Longitudinal research is necessary as substitution constitutes a transitional process that requires continuous monitoring and interaction between patients, healthcare providers, insurers, and scientists.

Is the incidence of diabetes increasing in all age-groups in The Netherlands? Results of the second study in the Dutch Sentinel Practice Network.

OBJECTIVE: To assess possible changes in the incidence of diabetes in all age-groups in The Netherlands during a 10-year period (1980-1983/1990-1992). RESEARCH DESIGN AND METHODS: Since 1970, a network of sentinel stations (the Dutch Sentinel Practice Network) consisting of approximately 1% of the Dutch population has been in operation to gain insight into the morbidity patterns of the Dutch population as recorded by general practitioners. One of the items recorded from 1990 to 1992 was the incidence of diabetes. The first study with a similar design that registered the incidence of diabetes was conducted from 1980 to 1983. RESULTS: The overall incidence of diabetes increased significantly by 12.1% in the period between the two studies. This overall increase can largely be attributed to a statistically significant increase in the age-group 45-64 years (30.5%). Although not statistically significant, the 36% increase of diabetes in the age-group 0-19 years is in accordance with the increase of type I diabetes based on the first and second nationwide retrospective studies covering the total Dutch population. CONCLUSIONS: There is a marked increase in the incidence of diabetes in the age-group 45-64 years. This selective increase is probably not due to a real rise caused by changes in exposure to risk factors but to an earlier recognition of symptoms and signs of diabetes followed by blood glucose measurements and/or to more intensive case finding in general practice.

Trends in hospital admissions among children aged 0-19 years with type I diabetes in The Netherlands.

OBJECTIVE: To determine the number and duration of hospital admissions due to diabetes in children aged 0-19 years between 1980-1991. RESEARCH DESIGN AND METHODS: Secondary analysis of data collected by the SIG Health Care Information was based on the 9th revision of the International Classification of Diseases. The subjects were all children in The Netherlands, aged 0-19 years. The main outcome measures were number and duration of hospital admissions due to type I diabetes (ICD 9 code 250.0-250.9). RESULTS: The hospital admission rate due to diabetes decreased > 30%. This decrease was statistically significant in all age subgroups. The total number of days in hospital due to diabetes decreased dramatically: from 24,961 in 1980 to 11,305 in 1991. The average duration of hospital stay length due to diabetes decreased as well from 14.5 days in 1980 to 11.9 days in 1991. CONCLUSIONS: The hospital admission rate and the length of hospital stay for diabetes in children aged 0-19 years have decreased, in spite of an increasing incidence. The hospital admission rate may decrease still further if more children with newly diagnosed diabetes can be adequately managed by team management at home in the initial phase.

Increasing incidence of type I diabetes in The Netherlands. The second nationwide study among children under 20 years of age.

OBJECTIVE: A nationwide retrospective study was conducted to assess the incidence of type I diabetes in The Netherlands among children < 20 years of age in 1988-1990. The first study with a similar design covered 1978-1980. RESEARCH DESIGN AND METHODS: The capture-recapture census method was chosen for analysis of the data. A questionnaire was sent to all Dutch pediatricians and internists, and for the ascertainment, a similar questionnaire was sent out separately to members of the Dutch Diabetes Association, which is the national patient association. RESULTS: The average achieved ascertainment rate was 81%. The ascertainment-adjusted annual incidence was 13.2/100,000 for 0- to 19-year-old children, indicating an increase of 23% compared with the 1978-1980 survey; for 0- to 14-year-olds, the increase amounted to 17%. CONCLUSIONS: This study suggests a sustained increase of type I diabetes in The Netherlands because the cumulative incidence studied previously in the 1960-1970 birth cohorts of male army conscripts 18 years of age was also found to rise. In contrast to Northern European countries, an increase in incidence for the age category 0-4 years could not be found.

Causes and consequences of comorbidity: a review.

A literature search was carried out to identify and summarize the existing information on causes and consequences of comorbidity of chronic somatic diseases. A selection of 82 articles met our inclusion criteria. Very little work has been done on the causes of comorbidity. On the other hand, much work has been done on consequences of comorbidity, although comorbidity is seldom the main subject of study. We found comorbidity in general to be associated with mortality, quality of life, and health care. The consequences of specific disease combinations, however, depended on many factors. We recommend more etiological studies on shared risk factors, especially for those comorbidities that occur at a higher rate than expected. New insights in this field can lead to better prevention strategies. Health care workers need to take comorbid diseases into account in monitoring and treating patients. Future studies on consequences of comorbidity should investigate specific disease combinations.

Diabetes monitoring system in The Netherlands.

Under the aegis of the European Regional Offices of the World Health Organization (WHO) and the International Diabetes Federation (IDF) a joint action programme to contest the growing burden of diabetes has been drawn up. The St. Vincent Declaration (1980) specifies targets for diabetes care, the reduction of complications, the integration into society and the education of the diabetic individual. The WHO/IDF have drawn up a data set to monitor progress in reaching the targets of the St. Vincent Declaration. The objective of the project Diabetes Monitoring System is to examine the possibilities for implementing a longitudinal-based and standardised diabetes monitoring system in the Netherlands. Although computerised recording systems for diabetes are seldom used and the agreement with the WHO/IDF data set varies substantially, the willingness of physicians to participate is clearly sufficient. This principally explorative project will hopefully lead to the implementation of a monitoring system in which a widely accepted data set is recorded to establish improvements in quality of care and to perform epidemiological research.

Disease-staging for modelling current and future health-care impact of disease: illustrations for diabetes mellitus and AIDS.

This paper addresses the economic relevance of appropriately staging progression of disease for cost assessment and projection. Illustrations are drawn from two Dutch cost-of-illness studies for Diabetes Mellitus (DM) and AIDS. Our disease-staging specifies a separate late stage to capture terminal high-intensity care for end-stage complications. Data are used from a registration of national hospital resource utilization for DM and from a detailed database on AIDS hospital care and costs. In particular, differences in average length of hospital stay for several potential DM end-stage complications are compared with non-DM patients. Neglecting the separation of a specific late stage is estimated to possibly miscalculate 15-20% of the hospital bed needs for DM and AIDS in the Netherlands. In particular, confidence intervals of future projections for AIDS hospital beds--using respectively staged and non-staged models--do not overlap. AIDS hospital costs are overprojected by almost 11% in the non-staged model. Our estimation of DM hospital bed needs raises the percentage in total Dutch hospital beds from 1.7% (neglecting a specific late stage) to 2.0%. For DM and AIDS an appropriate disease-staging averts structural biases in estimations of bed needs and costs, and therefore benefits the planning of hospital care facilities. Obviously, gathering comparable information and developing similar methodology on other diseases, such as respiratory disease, cardiovascular disease and cancer, is needed and could benefit planning in these fields.

['Public health status and perspectives' 1997. I. Introduction]. / 'Volksgezondheid toekomst verkenning' 1997. I. Introductie.

The 'Public health status and forecasts' 1997 presents a comprehensive and integrated overview of health, disease and health care in the Netherlands, to which more than 250 experts contributed. On the basis of the findings, policy recommendations are formulated regarding target groups, planning, prevention, health care, monitoring and research.

The governance of quality management in dutch health care: new developments and strategic challenges.

This article gives a brief sketch of quality management in Dutch health care. Our focus is upon the governance of guideline development and quality measurement. Governance is conceptualized as the structure and process of steering of quality management. The governance structure of guideline development in the Netherlands can be conceptualized as a network without central coordination. Much depends upon the self-initiative of stakeholders. A similar picture can be found in quality measurement. Special attention is given to the development of care standards for chronic disease. Care standards have a broader scope than guidelines and take an explicit patient perspective. They not only contain evidence-based and up-to-date guidelines for the care pathway but also contain standards for self-management. Furthermore, they comprise a set of indicators for measuring the quality of care of the entire pathway covered by the standard. The final part of the article discusses the mission, tasks and strategic challenges of the newly established National Health Care Institute (Zorginstituut Nederland), which is scheduled to be operative in 2013.

Projecting utilization of hospital in-patient days in The Netherlands: a time-series analysis.

The object was to model and project utilization of hospital in-patient days for selected diseases in The Netherlands. We used sex- and age-specific standardized monthly utilization of hospital in-patient days during 1980-90 for lung cancer, diabetes, coronary heart disease, stroke, and pneumonia. These data were supplied by the Health Care Information Centre (Stichting Informatiecentrum voor de Gezondheidszorg). We applied Box-Jenkins time-series analysis seasonal autoregressive integrated moving-average (SARIMA) models. Estimated models are tested by considering the Portmanteau test and the Akaike information criterion. SARIMA models give an adequate representation of hospital-in-patient-days utilization for the major sex and age classes of most selected diseases. Poor modelling results are obtained for diabetes in all sex and age groups and in elderly women with coronary heart disease or with stroke. Seasonality is an important factor in most of the models that we have estimated, particularly for utilization of pneumonia and stroke patients. The major trends in standardized in-patient days are downward, and projected 1995 levels of standardized utilization are below the 1990 levels for all the selected diseases. Population-based projections for 1995 are lower than the 1990 projections only for lung cancer and diabetes. The adequacy of the SARIMA models appears to be sensitive with respect to the parameter in the Portmanteau test. We discuss two possible explanatory developments for in-patient-days utilization: (i) developments in the provision of hospital care, and (ii) epidemiological developments. The selected diseases showed a decreasing mean duration of stay in 1980-90. Only for coronary heart disease did a rise in discharges in the same period outweigh this trend. We assessed contrasts between published epidemiological developments and the trends in in-patient-days utilization. Possible explanations concern shifts from in-patient to out-patient care and changes in treatment. Finally, complementary to our SARIMA models, the investigation of future in-patient days utilization by means of scenario analytic approaches remains important.

Forecasting the number of diabetic patients in The Netherlands in 2005.

OBJECTIVES: There is evidence from past decades that the number of diabetic patients has increased independently of changes in demography. A static model that takes into account only demographic changes is therefore unable to forecast the expected number of diabetic patients correctly. METHODS: We developed a dynamic model in which actual incidence, prevalence, and life expectancy data are used and alternative assumptions about future trends in these parameters can be incorporated. RESULTS: This dynamic model forecasts higher numbers of diabetic patients than the less sophisticated static model. According to the dynamic model, a 46% increase in the number of diabetic patients in The Netherlands can be expected, from 244,000 in 1990 to 355,000 in 2005 (about 2.5% annually). The static model forecasts a 22% increase. CONCLUSIONS: Diabetes mellitus will become a more serious public health problem than can be expected from demographic changes only. In planning future health care, monitoring of trends in incidence, prevalence, remission, and mortality or life expectancy is a necessary prerequisite.

The burden of mortality of diabetes mellitus in The Netherlands.

Our objective was to estimate the excess mortality and the reduction in life expectancy related to diabetes mellitus. We developed a life table to describe the Dutch population in two states, diabetic and non-diabetic, using age- and sex-specific prevalence of diabetes mellitus and risks of dying for diabetic subjects. We compared the calculated excess deaths with registered deaths. The cause-of-death registration practice underestimates diabetes-related mortality. The method used in this study, combining mortality data with data from epidemiologic studies, provides an assessment of the impact of diabetes on the Dutch population.