Service provision and utilisation in German paediatric primary care practices during public health crises: Protocol of the mixed-methods COVID-19 PedCare Study.

INTRODUCTION: Public health crises such as pandemics can cause serious disruptions to the utilisation and provision of healthcare services with negative effects on morbidity and mortality. Despite the important role of paediatric primary care in maintaining high-quality healthcare services during crises, evidence about service utilisation and provision remains limited especially in Germany. This study, therefore, explores the utilisation and provision of paediatric primary care services during the ongoing COVID-19 pandemic and their barriers and facilitators. METHODS AND ANALYSIS: The study uses a convergent mixed-methods design and comprises online surveys to parents, adolescents and primary care paediatricians (PCPs) and semistructured interviews with parents and PCPs. We recruit parents and adolescents from paediatric primary care practices and PCPs via email using mailing lists of the German Professional Association of Paediatricians and the German Society of Ambulatory Primary Care Paediatrics. The parent and adolescent surveys assess, inter alia, the utilisation of paediatric primary care services and its correlates, aspects of parental and child health as well as socioeconomic characteristics. The PCP survey investigates the provision of paediatric primary care services and its correlates, aspects of PCP health as well as sociodemographic and practice characteristics. The semistructured interviews with parents and PCPs explore several aspects of the online surveys in more detail. We use descriptive statistics and generalised linear mixed models to assess service utilisation and provision and specific correlates covered in the online surveys and apply qualitative content analysis to explore barriers and facilitators of service utilisation and provision more broadly in the semistructured interviews. We will integrate findings from the quantitative and qualitative analyses at the interpretation stage. ETHICS AND DISSEMINATION: The study was approved by the Medical Ethics Review Board of the Medical Faculty Mannheim at Heidelberg University (2020-650N). Study results will be published in journals with external peer-review.

Expanding the role of non-physician medical staff in primary care in Germany: protocol for a mixed-methods study exploring the perspectives of physicians in rural practices.

INTRODUCTION: Primary care faces substantial challenges worldwide through an increasing mismatch in supply and demand, particularly in rural areas. One option to address this mismatch might be increasing efficiency by delegation of tasks to non-physician medical staff. Possible influencing factors, motives and beliefs regarding delegation to non-physician medical staff and the potential of an expanded role, as perceived by primary care physicians, however, remain unclear. The aim of this study is to assess these factors to guide development of potential interventions for expanding the role of non-physician medical staff in delivering primary care services in rural Germany. METHODS AND ANALYSIS: This mixed-methods study based on the theoretical domains framework (TDF) consists of survey and interviews conducted sequentially. The survey, to be sent to all primary care physicians active in rural Baden-Wuerttemberg (estimated n=1250), includes 37 items: 15 assessing personal and practice characteristics, 15 matching TDF domains and 7 assessing opportunities for delegation. The interview, to be performed in a subsample (estimated n=12-20), will be informed by results of the survey. The initial interview guide consists of 11 questions covering additional TDF domains. Perspectives towards delegation will be maximised by comparing data emerging in either part of the study, seeking confirmation, disagreement or further details. ETHICS AND DISSEMINATION: The Ethics Committee of Heidelberg University approved this study (approval number: 2021-530). Written informed consent will be obtained before each interview; consent for participation in the survey will be assumed when the survey has been returned. Results will be disseminated via publications in peer-reviewed journals and talks at conferences. By combining quantitative and qualitative methods, our results will support future research for crafting potential interventions to expand the role of non-physician medical staff in rural primary care.

Estimating the potential reduction in future sickness absence from optimizing group-level psychosocial work characteristics: a prospective, multicenter cohort study in German industrial settings.

BACKGROUND: Absence from work due to sickness impairs organizational productivity and performance. Even in organizations with perfect work conditions, some inevitable baseline sickness absence exists amongst working populations. The excess sickness absence observed above this baseline rate has become the focus of traditional health promotion efforts, addressing preventable physical illness, health behavior and mental health at the personal level. However, a health and safety approach following the TOP-rule would consider work-group psychosocial work characteristics as a potential risk factor amenable to organizational measures. To date, there is a scarcity of studies relating psychosocial work characteristics to possible reduction of excess sickness-absence rates. METHODS: We aimed to estimate the potentially avoidable excess fraction of absence attributable to work-group psychosocial characteristics. We considered work-group averaged perception of psychosocial work characteristics as a proxy to the methodologically elusive objective assessment of organizational characteristics. Participants were recruited from multiple sites of a German automotive manufacturer with individuals nested within work groups. We predicted 12-month follow-up work-group sickness absence rates using data from a baseline comprehensive health examination assessing work characteristics, health behavior, and biomedical risk factors. We considered the quartile of work-groups yielding favorable psychosocial work characteristics as a realistic existing benchmark. Using the population attributable fraction method we estimated the potentially amenable sickness absence from improving work-group psychosocial characteristics. RESULTS: Data from 3992 eligible participants from 29 work groups were analyzed (39% participation rate, average age 41.4 years (SD = 10.3 years), 89.9% males and 49% manual workers.). Work-group absence rates at follow up varied from 2.1 to 8.9% (mean 5.1%, 11.7 missed days). A prediction model of seven psychosocial work characteristics at the work group level explained 70% of the variance of future absence rates. The estimated reduction from improving psychosocial work characteristics to the benchmark level amounted to 32% of all sickness absence, compared to a 31% reduction from eliminating health behavioral and medical risk factors to the benchmark target. CONCLUSIONS: Psychosocial characteristics at the work-group level account for a relevant proportion of all sickness absence. Health promotion interventions should therefore address psychosocial characteristics at the work group level.

Under regional characteristics of rural China: a clearer view on the performance of the New Rural Cooperative Medical Scheme.

The New Cooperative Medical Scheme (NCMS) was implemented in 2003 in response to the poor state of health care in rural China. Considering the substantial differences in regional socioeconomics, preferences for health care needs, and concurrent implementation of other health-related policies, the extent to which the impact of the NCMS differs in rural communities across China is unclear. The objective of this paper, therefore, was to explore the variation in the determinants of household enrolment and the impact of enrolment on health care utilization and medical expenditures in three large geographic regions in China. A quasi-experiment study was designed based on the panel data of the China Health and Nutrition Survey. The bounding approach was used to conduct a robust check of impact estimation under the assumption of unobserved bias. A major finding is that household income plays no significant role for enrolment, which indicates the equity of program coverage in income terms. However, regional circumstances matter. In the generally poorer western regions, households with a high ratio of migrant workers are less attracted to the NCMS program, and adoption of the program is related to the regional infrastructure environment variables in the eastern and western regions. The NCMS has improved medical care utilization for poor income groups and regions (western regions). The NCMS's impact on reducing the incidence of catastrophic expenditures is not shown for all regions.

Community-based efforts to promote physical activity: a systematic review of interventions considering mode of delivery, study quality and population subgroups.

OBJECTIVES: Despite the known benefits of physical activity, the majority of adults in developed countries lead sedentary lifestyles. The community setting is a promising venue for physical activity-promoting interventions. Our objectives were to investigate the effectiveness of community-based physical activity interventions by mode of delivery, study quality and to analyse intervention effectiveness in different subgroups in the population. DESIGN: We conducted a systematic literature review in Medline and other databases to identify controlled, community-based physical activity interventions published between 2001 and 2012. METHODS: We performed several post hoc subgroup comparisons for mode of delivery, study quality and selected population characteristics, using net per cent change in physical activity outcomes between baseline and follow-up as an effect measure. RESULTS: We identified 55 studies on exercise/walking sessions, face-to-face counselling, public campaigns and interventions by mail, the Internet and telephone presenting data on 20,532 participants. Overall, half of the studies reported positive physical activity outcomes (total net per cent change: 16.4%; p=0.159; net per cent change for high-quality studies, i.e. studies meeting more than 5 out of 7 quality criteria: 16.2%; p=0.010). Interventions using face-to-face counselling or group sessions were most effective (net per cent change: 35.0%; p=0.014). Net per cent change was also higher in studies exclusively tailored to women (27.7%; p=0.005) or specific ethnic groups (38.9%; p=0.034). CONCLUSIONS: This systematic review supports the effectiveness of community-based physical activity interventions in high-quality studies. Our results suggest that interventions using personal contact as well as tailored interventions are most promising.

Associations between supportive leadership and employees self-rated health in an occupational sample.

BACKGROUND: Protecting the health of the work force has become an important issue in public health research. PURPOSE: This study aims to explore potential associations between supportive leadership style (SLS), an aspect of leadership behavior, and self-rated health (SRH) among employees. METHOD: We drew on cross-sectional data from a cohort of industrial workers (n = 3,331), collected in 2009. We assessed employees' ratings of supportive, employee-oriented leadership behavior at their job, their SRH, and work stress as measured by the effort-reward model and scales measuring demands, control, and social support. Logistic regression estimated odds ratios (ORs) and corresponding 95 % confidence intervals (CIs) for the association between the perception of poor SLS and poor SRH controlling for work-related stress and other confounders. Sensitivity analyses stratified models by sex, age, and managerial position to test the robustness of associations. RESULTS: Perception of poor SLS was associated with poor SRH [OR 2.39 (95 % CI 1.95-2.92)]. Although attenuated following adjustment for measures of work-related stress and other confounders [OR 1.60 (95 % CI 1.26-2.04)], the magnitude, direction, and significance of this association remained robust in stratified models in most subgroups. CONCLUSION: SLS appears to be relevant to health in the workplace. Leadership behavior may represent a promising area for future research with potential for promoting better health in a large segment of the adult population.

Psychosocial resources and the relationship between transformational leadership and employees' psychological strain.

BACKGROUND: Leadership behavior may both serve as a supportive resource or as a source of psychological distress in the workplace. OBJECTIVE: Transformational leadership (TL), a behavior of superiors that fosters motivation, empowerment and a sense of teamness, has been associated with employee well-being, but the mechanisms that underlie these effects are unclear. We therefore explored the relationship between TL and stress by examining potential mediating roles for established organizational and personal resources. METHODS: We used cross-sectional data on TL, psychosocial resources and employee strain from a company wide survey. Linear regression and structural equation modeling assessed potential mediation following the method outlined by Baron and Kenny. RESULTS: In a convenience sample consisting of mostly white-collar employees (n=320, 42.6% male), we observed a relationship between TL and employees' perceived work-related stress that was fully mediated by protective psychosocial resources (ß =-0.33, p< 0.01). Additionally, we found that TL positively affected these resources (ß=0.61; p< 0.01) and that absence of resources led to more psychological strain (ß=-0.54, p<0.01). CONCLUSIONS: Transformational leadership seems to be associated with lower stress among employees and a perception of more available psychosocial resources. These findings indicate that TL might serve as a valuable focus for tailored interventions to improve employee health.

Anti-clockwise rotating shift work and health: would you prefer 3-shift or 4-shift operation?

BACKGROUND: We explored the association between work schedules involving nightshifts and selected measures of health and whether these associations differed among those working in either 3- or 4-shift cycles. METHODS: Employees at a German industrial company who worked on a fixed daytime schedule or on one involving nightshifts were invited to participate in this cross-sectional study. Work schedules involving a nightshift were organized into either 3 or 4 shifts rotated anti-clockwise on a weekly basis. Health characteristics included a range of clinical and physiological measures and self-reported data on stress and sleep quality. We assessed the independent association of work schedules involving any nightshift and these health characteristics in separate regression analyses, adjusting for age, gender, smoking, and alcohol consumption. RESULTS: Nightshift work (N = 133) in general and 3-shift-work (N = 53) in particular was associated with decreased sleep quality (P < 0.001). Compared to those working daytime (N = 632), employees working on a 3-shift cycle had higher adjusted odds of meeting the definition of metabolic syndrome (OR = 2.56 [1.38, 4.75]). Employees working 4-shift cycles were somewhat less likely to have metabolic syndrome (OR = 1.22 [0.73, 2.05]) and had higher parasympathetic activity measured by heart rate variability (OR = 2.20 [1.04, 4.63]). CONCLUSIONS: Our data suggest important relationships between shift schedule and a selected group of objective and subjective health measures. Additional research that further clarifies potential mechanisms underlying these relationships is needed.

Neighborhood racial residential segregation and changes in health or death among older adults.

We assessed relationships between neighborhood racial residential segregation (RRS), individual-level health declines and mortality using Health and Retirement Study data. We calculated the census-tract level Location Quotient for Racial Residential Segregation (LQRRS), and estimated adjusted relative risks (ARR) of LQRRS for declines in self-reported health or death 1992-2000, controlling for individual-level characteristics. Of 6653 adults, 3333 lived in minimal, 2242 in low, 562 in moderate, and 516 in high LQRRS tracts in 1992. Major decline/death rates were: 18.6%, 25.2%, 33.8% and 30.4% in minimal, low, moderate and high tracts, respectively. Adjusting for demographic characteristics, residence in low, moderate and high LQRRS census tracts was associated with greater likelihood of major decline/death compared to minimal LQRRS. Controlling for all variables, only moderate LQRRS predicted major decline/death, ARR=1.31 (95% CI 1.07, 1.59; p<.05).

Value of audio-enhanced handheld computers over paper surveys with adolescents.

OBJECTIVE: To examine the impact of 3 data collection modes on the number of questions answered, data quality, and student preference. METHODS: 275 urban seventh-grade students were recruited and randomly assigned to complete a paper survey (SAQ), PDA survey (PDA), or PDA survey with audio (APDA). Students completed a paper debriefing survey. RESULTS: APDA respondents completed significantly more questions compared to SAQ and PDA. PDA and APDA had significantly less missing data than did SAQ. No differences were found for student evaluation. CONCLUSIONS: Strong benefits may be gained by the use of APDA for adolescent school-based data collection.

Behavioral counseling for cardiovascular disease prevention in primary care settings: a systematic review of practice and associated factors.

Cardiovascular disease carries a substantial public health burden. Physician advice on modifying behavioral risk factors is effective, yet the practice of and factors associated with behavioral counseling in primary care have not been systematically investigated. The authors conducted a systematic review that identified 18 studies providing data on 6,338 physicians. The provision of preventive services differed by patients' individual risk. Physicians' counseling on smoking cessation was most commonly reported. The proportions of physicians counseling about nutrition and physical activity were notably lower and few physicians took further action by using more intensive counseling approaches. As studies were mainly based on self-reports, current delivery of preventive services may be overestimated. There is a need to increase the frequency of behavioral counseling in primary care settings, particularly for nutrition and physical activity, and to emphasize that counseling may also benefit individuals without cardiovascular disease risk factors.

Outcomes associated with matching patients' treatment preferences to physicians' recommendations: study methodology.

BACKGROUND: Patients often express strong preferences for the forms of treatment available for their disease. Incorporating these preferences into the process of treatment decision-making might improve patients' adherence to treatment, contributing to better outcomes. We describe the methodology used in a study aiming to assess treatment outcomes when patients' preferences for treatment are closely matched to recommended treatments. METHOD: Participants included patients with moderate and severe psoriasis attending outpatient dermatology clinics at the University Medical Centre Mannheim, University of Heidelberg, Germany. A self-administered online survey used conjoint analysis to measure participants' preferences for psoriasis treatment options at the initial study visit. Physicians' treatment recommendations were abstracted from each participant's medical records. The Preference Matching Index (PMI), a measure of concordance between the participant's preferences for treatment and the physician's recommended treatment, was determined for each participant at t(1) (initial study visit). A clinical outcome measure, the Psoriasis Area and Severity Index, and two participant-derived outcomes assessing treatment satisfaction and health related quality of life were employed at t(1), t(2) (twelve weeks post-t(1)) and t(3) (twelve weeks post-t(2)). Change in outcomes was assessed using repeated measures analysis of variance. The association between participants' PMI scores at t(1) and outcomes at t(2) and t(3) was evaluated using multivariate regressions analysis. DISCUSSION: We describe methods for capturing concordance between patients' treatment preferences and recommended treatment and for assessing its association with specific treatment outcomes. The methods are intended to promote the incorporation of patients' preferences in treatment decision-making, enhance treatment satisfaction, and improve treatment effectiveness through greater adherence.

Influenza vaccination coverage among high-risk groups in 11 European countries.

BACKGROUND: National vaccination coverage rates for individuals at increased risk of influenza-related complications represent a useful public health indicator of preparedness. We compared European countries regarding (i) vaccination coverage among high-risk groups and (ii) the likelihood that high-risk individuals reported influenza vaccination compared with those at lower risk. METHODS: We used data from the Survey of Health, Ageing and Retirement in Europe (SHARE) collected in 2004-05. Adults aged ≥ 50 years from 11 countries provided self-reports of an influenza vaccination in the previous year (n = 16,913). We defined four high-risk groups (age ≥ 65 years, presence of vascular disease, chronic lung disease or diabetes) and calculated vaccination coverage with 95% confidence intervals for each country. Country-specific multivariable logistic regression was used to estimate odds ratios (ORs) for membership in a high-risk group and vaccination. RESULTS: The Netherlands had the highest influenza vaccination coverage in high-risk groups (≥ 75% in any group) while Greece had the lowest (<27% in any group). Older age was positively associated with report of vaccination in all countries, but the strength of this association varied from an OR of <2 (Germany) to >13 (The Netherlands). The ORs for the chronic disease groups was ≥ 4 for The Netherlands and were considerably lower (and often not statistically significant) for the other countries. CONCLUSION: Influenza vaccination coverage among high-risk groups varies considerably between European countries. Our findings highlight potential opportunities for reducing influenza-related complications through support for vaccination programs that target high-risk individuals more effectively.

How Healthy is the Behavior of Young Athletes? A Systematic Literature Review and Meta-Analyses.

Participation in sports during adolescence is considered a healthy behavior. The extent to which adolescent athletes engage in other healthful (or risky) behaviors is less clear, however. We conducted a systematic literature review following the PRISMA Statement to assess the frequency of risky behaviors among athletes in this age group. We searched the PubMed, PsycINFO and SCA Sociological Abstracts databases for observational studies published in English over the last twenty years on the frequency of selected risk behaviors (alcohol consumption, smoking behavior, use of illicit drugs, unhealthy nutrition, and doping) in adolescent athletes. Two independent reviewers selected articles following the PRISMA Statement. Behavior frequency was assessed as was comparability of study design and methods. When possible, meta- analyses were performed using data from subgroups of studies in which operational indicators were comparable. Seventy-eight articles met eligibility criteria. Although report of risky behaviors varied across studies, we observed overall, that studies tend to report higher alcohol use, less smoking, less recreational drug use, and more smokeless tobacco use in (high-involved) athletes. Considerable heterogeneity was noted in study design, definition of target groups and use of operational indicators (I(2) ranged from 93.2% to 100%). Especially the higher prevalence of using alcohol and smokeless tobacco needs more attention in interventions targeted to this group. Overall, greater consensus on methods used to assess risky behaviors in adolescent athletes. Key pointsThis is the first systematic review focusing on different health related risk behaviors of adolescent athletes aged ≤ 18 years from different countries.Health related risk behaviors such as alcohol consumption are common among recreational and elite adolescent athletes.Athletes were more likely to consume alcohol, smokeless tobacco, and steroids and less likely to smoke and to use marihuana than non-athletes.Studies show high heterogeneity in the operational indicators, statistical methods, and target groups. Therefore, greater consensus around key definitions and study methods is needed to advance knowledge.

Appreciative Inquiry for quality improvement in primary care practices.

PURPOSE: To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process. METHODS: Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. RESULTS: The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. CONCLUSIONS: An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.

County-level poverty is equally associated with unmet health care needs in rural and urban settings.

CONTEXT: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. PURPOSE: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting. METHODS: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics. FINDINGS: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings. CONCLUSIONS: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.

Combining accelerometry and HR for assessing preschoolers' physical activity.

PURPOSE: With rising obesity and rapidly decreasing levels of physical activity (PA) in young children, accurate PA measurement is needed for early screening and intervention evaluation. Although the combination of accelerometry (ACC) with HR recordings is accurate in assessing PA intensity in older children, its utility in correctly classifying PA in preschoolers is unknown. METHODS: Thirty-three children (64% were boys) were recruited from four German preschools. Data included direct observation and Actiheart (CamNtech, Cambridge, UK) monitoring during 2.5 T 0.7 h (derivation data) and 1.5 T 0.3 h (validation data). Observers assessed PA using the Children's Activity Rating Scale (CARS). Moderate-to-vigorous PA (MVPA) was defined by a CARS score of 4 or 5, and sedentary behavior (SB) was defined by a CARS score of 1 or 2. Actiheart recordings were linked to CARS level, with means and 95% confidence intervals calculated for ACC and HR at each observed CARS level and for MVPA/SB. Using receiver operating characteristic analysis, gender-specific ACC and HR cutoffs for correctly classifying MVPA and SB were first determined in a derivation data set and then tested in a separate validation data set of observations. RESULTS: By combining HR and ACC cutoffs, 91% and 87% of the 15-s intervals observed as MVPA were correctly classified in girls and boys, respectively. Although generally lower, correct classification rates for SB were highest when only ACC cutoffs were applied (69% for girls and 67% for boys) rather than when combined cutoffs were used. CONCLUSIONS: Devices that combine HR and ACC data yield an accurate classification of MVPA in preschoolers but perform less well for classifying SB. These differences underscore the need to match evaluation methods with the objectives of future PA interventions.

The prevalence of current sunbed use and user characteristics: the SUN-Study 2008.

OBJECTIVES: Although sunbed use is common in many developed countries, little is known about the characteristics of sunbed users. METHODS: The SUN-Study 2008 (Sunbed-Use: Needs for Action-Study 2008) contains data on indoor tanning practices. It has a net sample size of 500 randomly selected 18-45-year-old adults living in Mannheim, Germany. RESULTS: In this sample, current sunbed users were predominantly females, employed, had completed vocational school (or an equivalent certification), were smokers, participated primarily in individual sports and had skin types III or IV. The mean overall prevalence of sun bed use was 21.0%. CONCLUSIONS: Our results highlight specific potential risk factors for intervention that should be examined in other settings among different populations.