Perceived discrimination in health care in Germany- results of a population survey.

BACKGROUND: It has consistently been shown that perceived discrimination is associated with adverse health outcomes. Despite this uncontested relevance, there is a lack of research on the experiences of discrimination in health care. Therefore, the following research questions were addressed: (1) How often do people in Germany report having been discriminated in health care due to different reasons? (2) Which socio-demographic groups are most afflicted by perceived discrimination in health care? METHODS: Analyses are based on a cross-sectional online survey conducted in Germany. An adult population sample was randomly drawn from a panel which was recruited offline (N = 2,201). Respondents were asked whether they have ever been discriminated in health care due to the following reasons: age, sex/gender, racism (i.e. migration history, religion, language problems, colour of skin), health issues or disability (i.e. overweight, mental illness/addiction, disability), socio-economic status (SES, i.e. income, education, occupation). RESULTS: 26.6% of the respondents reported discrimination experiences. Perceived discrimination due to health issues or disability was most frequent (15%), followed by age (9%) and SES (8.9%). Discrimination due to racism and sex/gender was less frequently reported (4.1% and 2.5%). Younger age groups, women, and 2nd generation migrants as well as respondents with low income and low education were more likely to report any kind of discrimination in health care. Two groups were found to be at special risk for reporting discrimination in health care across different reasons: women and younger age groups. Discrimination due to racism was more prevalent among respondents who have immigrated themselves than those who were born in Germany but whose parents have immigrated. Discrimination due to SES was significantly associated with (low) income but not with education. CONCLUSIONS: More than a quarter of the adult population in Germany reported experiences of discrimination in health care. Such experiences were more frequent among lower SES groups, migrants, women, and younger people. Results underline the necessity of interventions to reduce the magnitude and consequences of discrimination in health care. Future studies should apply an intersectional approach to consider interactions between social inequality indicators regarding discrimination and to identify risk groups that are potentially afflicted by multiple discrimination.

Public knowledge and beliefs about the irritable bowel syndrome - results from the SOMA.SOC study.

BACKGROUND: Despite the epidemiological and economic relevance of the irritable bowel syndrome (IBS), there is a lack of research on what the general public knows and thinks about this condition (IBS literacy). Therefore, the aim of this study was to explore public knowledge and beliefs about IBS in Germany. Moreover, associations of knowledge and beliefs about IBS with socio-demographic characteristics as well as illness and treatment experiences were analysed. METHODS: Analyses made use of a national telephone survey (N = 1,205). A carefully developed vignette describing a person with typical symptoms of IBS was presented. Respondents were then asked to name the disease in question and beliefs about causes and treatment options were assessed. For the analyses respondents were divided into three groups: (1) people who never had IBS symptoms, (2) people who had or have IBS symptoms but never were in treatment and (3) individuals who reported to be or have been treated for IBS symptoms. RESULTS: Less than 4% of the respondents recognized IBS after presentation of the vignette. About 75% positively evaluated treatability while psychotherapy was evaluated more effective than medication. Stress and unhealthy lifestyle were the most frequently endorsed possible causes of the presented IBS symptoms. There were variations in knowledge and beliefs about IBS according to age, gender, and education. We found minor differences in beliefs and knowledge between individuals who had or have symptoms but never were in treatment and those without respective illness experience. Respondents with illness/treatment experiences rated their knowledge significantly better than those without any experiences. CONCLUSIONS: Results indicate low levels of public knowledge about IBS regarding illness recognition in Germany. A majority disagreed that they have good knowledge about IBS symptoms. Against this background, it seems reasonable to develop and test interventions to improve IBS literacy by increasing knowledge about symptoms, causes and treatment options.

Worsened self-rated health in the course of the COVID-19 pandemic among older adults in Europe.

BACKGROUND: Governments across Europe deployed non-pharmaceutical interventions to mitigate the spread of coronavirus disease 2019 (COVID-19), which not only showed clear benefits but also had negative consequences on peoples' health. Health inequalities increased, disproportionally affecting people with higher age or lower education. This study analyzed associations between social factors and worsened self-rated health of elderly people in the course of the COVID-19 pandemic, taking different stringencies of government mandates as well as infection rates into account. METHODS: Data stem from the European SHARE survey. The main outcome was a binary indicator of worsened self-rated health. Analyses included data from two waves (2020 and 2021) during the pandemic (N = 48 356 participants, N = 96 712 observations). Predictors were age, sex, education and living together with a partner, and two macro indicators that reflected the stringency of government response mandates and COVID-19 infection rates. Data were analyzed using logistic mixed-effects regression models. RESULTS: Older age [odds ratio (OR) 1.73, confidence interval (CI) 1.65-1.81] and female sex (OR 1.26, CI 1.20-1.32) were positively associated and higher education (OR 0.74, CI 0.70-0.79) was negatively associated with worsened self-rated health. Not living together with a partner showed higher odds of worsened self-rated health (OR 1.30, CI 1.24-1.36). Inequalities increased from 2020 to 2021. Associations between worsened self-rated health and government response mandates or infection rates were inconsistent. CONCLUSION: Self-rated health worsened in the course of the pandemic and health disparities increased. Possible future pandemics require targeted interventions to minimize adverse health outcomes, in particular among old, potentially isolated, and deprived people.

Multi-staged development and pilot testing of a self-assessment tool for organizational health literacy.

BACKGROUND: Until now a comprehensive, consensus-based tool that can be used by a variety of health care organizations for assessing their organizational health literacy (OHL) is not available. Therefore, we aimed to develop and test a literature- and consensus-based self-assessment tool. METHODS: The study is based on a scoping review that was previously published by the authors. For the development of the self-assessment tool, the criteria identified in the literature were synthesized with criteria gained through group discussions with representatives of different types of health care organizations (N = 27) all based in Hamburg (Germany). Consensus on the criteria was reached by conducting a Delphi process (N = 22). A review by the project's patient advisory council was included in the process. The self-assessment tool was converted into an online tool and refined by a pretest. Finally, the online survey was piloted (N = 53) and the reliability and item loadings for each scale were analyzed. RESULTS: In total, 77 criteria (items) characterizing a health literate health care organization were developed and grouped into five main categories (scales): (1) "easy access and navigation", (2) "integration, prioritization, and dissemination of OHL", (3) "qualification, quality management, evaluation, and needs assessment", (4) "communication with target groups", and (5) "involvement and support of target groups". The results of the online survey showed that the tool is suitable for assessing an organization's status quo on OHL. The psychometric analysis showed good to excellent internal consistency. Item analyses of the developed self-assessment tool was satisfactory. CONCLUSIONS: We were able to define a set of 77 items to characterize OHL, which were integrated into a new, comprehensive, and consensus-based self-assessment tool to identify areas for improvement. We found evidence that the self-assessment tool, based on the identified criteria, consists of the assumed five scales. Further research should analyze the validity of the self-assessment tool on a higher detail level.

Public depression stigma does not vary by symptom severity.

BACKGROUND: Previous studies on public depression stigma did not include different severity levels and thus, did not adequately consider the continuum notion of depressive disorders. AIMS: We address the following research questions: 1. Are there differences in public depression stigma according to different severity levels? 2. Is stigma associated with sociodemographic characteristics, experience with depressive symptoms, and symptom severity? METHODS: Computer-assisted telephone interviews were conducted in winter 2019/2020 in Germany (N = 1009). Three vignettes representing mild, moderate, and severe depressive symptoms were used. Three indicators of stigma were assessed: negative stereotypes, anger reactions, and desire for social distance. Age, sex, education, and experience with depression (own affliction, contact) were additionally introduced into multiple linear regression analyses. RESULTS: Overall, negative stereotypes, anger reactions, and desire for social distance do not significantly vary by depression symptom severity. All components of depression stigma showed positive associations with age, while anger was negatively associated with experiences. CONCLUSIONS: Our results do not indicate that public depression stigma is more pronounced when symptoms are more severe. Conclusion is ambivalent: Persons with severe depression do not seem to be additionally burdened by increased stigma, but the German public holds stigmatizing attitudes even towards individuals with mild depressive symptoms.

[Development of an online intervention on suicidality-providing knowledge and reducing suicide stigma]. / Entwicklung einer Onlineintervention zum Thema Suizidalität ­ Vermittlung von Wissen und Reduzierung von Suizidstigma.

Fear of being stigmatized by others, self-stigmatization, and inadequate information can limit those affected by suicidality from seeking help. E­mental-health interventions provide a low-threshold way to reach many individuals with information about the topic. This enables those affected to prepare themselves for personal offers of help. As part of the funding priority "Suicide Prevention (A: Destigmatization)" of the German Federal Ministry of Health, a complex intervention was developed at the University Medical Center Hamburg-Eppendorf. The development and content of this online intervention are described in this article.Following a representative telephone survey of the German general population, which investigated gaps in knowledge and stigmatization tendencies on the subject of suicide, the online intervention "8 lives - lived experience reports and facts on suicide" was developed on the basis of an Australian suicide prevention project and involved persons with a lived experience of suicide. The intervention highlighted both scientific and clinical facts about suicidality as well as a socio-cultural perspective and offered self-help options and professional support services. Video reports of persons with a lived experience of suicide were shown within the intervention. The project is currently being evaluated. A continuation is planned.The intervention is a multi-layered offer in which different perspectives on the topic of suicidality are presented. Participants are addressed on a cognitive and emotional level. Given the prevalence of suicidality and the fact that the subject is still taboo, serious, evidence-based, and low-threshold prevention and information offers seem particularly relevant.

Suicide literacy and suicide stigma - results of a population survey from Germany.

BACKGROUND: While a growing number of studies analyze the magnitude and predictors of mental health literacy, little is known about suicide-specific knowledge and beliefs ("suicide literacy"). AIMS: To examine suicide literacy among the German population and to investigate associations between suicide literacy and suicide stigma. METHODS: Telephone interviews were conducted in Germany (N = 2002, response rate: 47.3%). The literacy of suicide scale (LOSS-SF) was used covering the knowledge domains "signs," "risk factors," "causes/nature" and "treatment/prevention." In multiple regression analyses, associations between the LOSS-SF and the three dimensions "stigma," "normalization/glorification," and "depression/isolation" of the stigma of suicide scale (SOSS-SF) were examined controlling for several covariates. RESULTS: Respondents showed most knowledge concerning "treatment and prevention" (>80% correct answers). Lower suicide literacy was found in the domains "risk factors" (33-60% correct answers) and "signs for suicidal ideation" (45-53%). Suicide literacy was negatively associated with age, while it was positively associated with education, own affliction, and personal contact. Moreover, suicide literacy showed negative associations with all three dimensions of the SOSS-SF. CONCLUSIONS: There are deficits in suicide literacy in the German public that may increase suicide stigma. Addressing those deficits in information-campaigns and encouraging personal contact could help decrease suicide stigma.

Socioeconomic inequalities in primary-care and specialist physician visits: a systematic review.

BACKGROUND: Utilization of primary-care and specialist physicians seems to be associated differently with socioeconomic status (SES). This review aims to summarize and compare the evidence on socioeconomic inequalities in consulting primary-care or specialist physicians in the general adult population in high-income countries. METHODS: We carried out a systematic search across the most relevant databases (Web of Science, Medline) and included all studies, published since 2004, reporting associations between SES and utilization of primary-care and/or specialist physicians. In total, 57 studies fulfilled the eligibility criteria. RESULTS: Many studies found socioeconomic inequalities in physician utilization, but inequalities were more pronounced in visiting specialists than primary-care physicians. The results of the studies varied strongly according to the operationalization of utilization, namely whether a physician was visited (probability) or how often a physician was visited (frequency). For probabilities of visiting primary-care physicians predominantly no association with SES was found, but frequencies of visits were higher in the most disadvantaged. The most disadvantaged often had lower probabilities of visiting specialists, but in many studies no link was found between the number of visits and SES. CONCLUSION: This systematic review emphasizes that inequalities to the detriment of the most deprived is primarily a problem in the probability of visiting specialist physicians. Healthcare policy should focus first off on effective access to specialist physicians in order to tackle inequalities in healthcare. PROSPERO REGISTRATION NUMBER: CRD42019123222 .

How do care providers evaluate collaboration? - qualitative process evaluation of a cluster-randomized controlled trial of collaborative and stepped care for patients with mental disorders.

BACKGROUND: Collaborative and stepped care (CSC) models are recommended for mental disorders. Their successful implementation depends on effective collaboration between involved care providers from primary and specialist care. To gain insights into the collaboration experiences of care providers in CSC against the backdrop of usual mental health care, a qualitative process evaluation was realized as part of a cluster-randomized controlled trial (COMET) of a collaborative and stepped care model in Hamburg (Germany). METHODS: Semi-structured interviews were conducted with N = 24 care providers from primary and specialist care (outpatient psychotherapists and psychiatrists, inpatient/ day clinic mental health providers) within and outside of COMET at the trial's beginning and 12 months later. Interviews were analyzed applying a qualitative structuring content analysis approach, combining deductive and inductive category development. RESULTS: Usual mental health care was considered deficient in resources, with collaboration being scarce and mainly taking place in small informal networks. Within the COMET trial, quicker referral paths were welcomed, as were quarterly COMET network meetings which provided room for exchange and fostered mutual understanding. Yet, also in COMET, collaboration remained difficult due to communication problems, the unfavorable regional distribution of the COMET care providers and interprofessional discrepancies regarding each profession's role, competencies and mutual esteem. Ideas for improvement included more localized networks, the inclusion of further professions and the overall amelioration of mental health care regarding resources and remuneration, especially for collaborative activities. CONCLUSIONS: The process evaluation of the COMET trial revealed the benefits of creating room for interprofessional encounter to foster collaborative care. Despite the benefits of faster patient referrals, the COMET network did not fulfill all care providers' prior expectations. A focus should be set on interprofessional competencies, mutual perception and role clarification, as these have been revealed as significant barriers to collaboration within CSC models such as COMET. TRIAL REGISTRATION: The COMET trial (Collaborative and Stepped Care in Mental Health by Overcoming Treatment Sector Barriers) has been registered on July 24, 2017 under the trial registration number NCT03226743 .

Translation and psychometric evaluation of the German version of the IcanSDM measure - a cross-sectional study among healthcare professionals.

BACKGROUND: Shared decision-making (SDM) between patients and healthcare professionals (HCPs) is a key component of patient-centred care. To implement SDM in clinical practice and to evaluate its effects, it is helpful to know about HCPs' perception of SDM barriers. The measure IcanSDM was developed in Canada and assesses the perception of SDM barriers. To our knowledge, no equivalent measure exists in German. Therefore, the aim of this study was to translate and adapt the IcanSDM measure to be used by a German speaking population and evaluate its psychometric properties. METHODS: This is a cross-sectional psychometric study based on a secondary analysis of baseline data from a SDM implementation study. The original 8-item IcanSDM was translated into German using a team translation protocol. We assessed comprehensibility via cognitive interviews with n = 11 HCPs. Based on results of cognitive interviews, the translated IcanSDM version was revised. Two hundred forty-two HCPs filled out the measure. Psychometric analysis included acceptance (completion rate), item characteristics (response distribution, skewness, item difficulties, corrected item-total correlations, inter-item correlations), factorial structure (confirmatory factor analysis (CFA), model fit), and internal consistency (Cronbach's α). RESULTS: We translated and adapted the German IcanSDM successfully except for item 8, which had to be revised after the cognitive interviews. Completion rate was 98%. Skewness of the items ranged between -.797 and 1.25, item difficulties ranged between 21.63 and 70.85, corrected item-total-correlations ranged between .200 and .475, inter-item correlations ranged between .005 and .412. Different models based on CFA results did not provide a valid factorial structure. Cronbach's α ranged between .563 and .651 for different factor models. CONCLUSION: We provide the first German measure for assessing perception of SDM barriers by HCPs. The German IcanSDM is a brief measure with good acceptance. However, we found unsatisfying psychometric properties, which were comparable to results of the original scale. In a next step, the IcanSDM should be further developed and modified and predictive validity should be evaluated.

Which criteria characterize a health literate health care organization? - a scoping review on organizational health literacy.

BACKGROUND: Organizational health literacy (OHL) aims to respond to the health literacy needs of patients by improving health information and services and making them easier to understand, access, and apply. This scoping review primarily maps criteria characterizing health literate health care organizations. Secondary outcomes are the concepts and terminologies underlying these criteria as well as instruments to measure them. METHODS: The review was carried out following the JBI Manual on scoping reviews. The databases CINAHL, Cochrane Library, JSTOR, PsycINFO, PubMed, Web of Science Core Collection, and Wiley Online Library were searched in July 2020. Three researchers screened the records and extracted the data. The results were synthesized systematically and descriptively. RESULTS: The literature search resulted in 639 records. After removing duplicates, screening by title and abstract, and assessing full-texts for eligibility, the scoping review included 60 publications. Criteria for OHL were extracted and assigned to six main categories (with 25 subcategories). The most prevalent topic of organizational health literacy refers to communication with service users. Exemplary criteria regarding this main category are the education and information of service users, work on easy-to-understand written materials as well as oral exchange, and verifying understanding. The six main categories were defined as 1) communication with service users; 2) easy access & navigation; 3) integration & prioritization of OHL; 4) assessments & organizational development; 5) engagement & support of service users, and 6) information & qualification of staff. The criteria were based on various concepts and terminologies. Terminologies were categorized into four conceptual clusters: 1) health literacy in various social contexts; 2) health literate health care organization; 3) organizational behavior, and 4) communication in health care. 17 different assessment tools and instruments were identified. Only some of the toolkits and instruments were validated or tested in feasibility studies. CONCLUSIONS: Organizational health literacy includes a significant number of distinct organizational criteria. The terminologies used in the OHL literature are heterogeneous based on a variety of concepts. A comprehensive, consensus-based conceptual framework on OHL is missing.

Do multiple community-based interventions on health promotion tackle health inequalities?

BACKGROUND: Previous systematic reviews of the impact of multi-component community-based health promotion interventions on reducing health inequalities by socio-economic status (SES) were restricted to physical activity and smoking behavior, and revealed limited and rather disillusioning evidence. Therefore, we conducted a comprehensive review worldwide to close this gap, including a wide range of health outcomes. METHODS: The Pubmed and PsycINFO databases were screened for relevant articles published between January 1999 and August 2019, revealing 87 potentially eligible publications out of 2876 hits. In addition, three studies out of a prior review on the effectiveness of community-based interventions were reanalyzed under the new research question. After a systematic review process, 23 papers met the inclusion criteria and were included in the synthesis. RESULTS: More than half (56.5%) of the studies reported improvements of socially disadvantaged communities overall (i.e. reduced inequalities at the area level) in at least one health behavior and/or health status outcome. Amongst the remaining studies we found some beneficial effects in the most deprived sub-groups of residents (8.2%) and studies with no differences between intervention and control areas (34.8%). There was no evidence that any program under review resulted in an increase in health disparity. CONCLUSIONS: Our results confirm that community-based interventions may be reducing absolute health inequalities of deprived and disadvantaged populations, but their potential so far is not fully realized. For the future, greater attention should be paid to inequalities between sub-groups within communities when analyzing changes in health inequality over time.

Rationale and Design of the Hamburg City Health Study.

The Hamburg City Health Study (HCHS) is a large, prospective, long-term, population-based cohort study and a unique research platform and network to obtain substantial knowledge about several important risk and prognostic factors in major chronic diseases. A random sample of 45,000 participants between 45 and 74 years of age from the general population of Hamburg, Germany, are taking part in an extensive baseline assessment at one dedicated study center. Participants undergo 13 validated and 5 novel examinations primarily targeting major organ system function and structures including extensive imaging examinations. The protocol includes validate self-reports via questionnaires regarding lifestyle and environmental conditions, dietary habits, physical condition and activity, sexual dysfunction, professional life, psychosocial context and burden, quality of life, digital media use, occupational, medical and family history as well as healthcare utilization. The assessment is completed by genomic and proteomic characterization. Beyond the identification of classical risk factors for major chronic diseases and survivorship, the core intention is to gather valid prevalence and incidence, and to develop complex models predicting health outcomes based on a multitude of examination data, imaging, biomarker, psychosocial and behavioral assessments. Participants at risk for coronary artery disease, atrial fibrillation, heart failure, stroke and dementia are invited for a visit to conduct an additional MRI examination of either heart or brain. Endpoint assessment of the overall sample will be completed through repeated follow-up examinations and surveys as well as related individual routine data from involved health and pension insurances. The study is targeting the complex relationship between biologic and psychosocial risk and resilience factors, chronic disease, health care use, survivorship and health as well as favorable and bad prognosis within a unique, large-scale long-term assessment with the perspective of further examinations after 6 years in a representative European metropolitan population.

Effectiveness of Community-Based Health Promotion Interventions in Urban Areas: A Systematic Review.

Over the past few decades, a community-based approach was seen to be the "gold standard" for health promotion and disease prevention, especially in the field of socially deprived neighborhoods in urban areas. Up to the beginning of the 2000s, earlier reviews provide valuable information on activities in this context. However, in their conclusions they were limited to North America and Europe. Therefore, we conducted a systematic literature review on community-based health promotion and prevention programs worldwide. The Pubmed and PsycINFO databases were screened for relevant articles published between January 2002 and December 2018, revealing 101 potentially eligible publications out of 3646 hits. After a systematic review process including searching the reference lists, 32 papers met the inclusion criteria and were included in the review. Twenty-four (75.0%) articles reported improvements in at least one health behavior, health service access, health literacy, and/or a range of health status outcomes. Large-scale community-based health promotion programs, however, often resulted in limited or missing population-wide changes. Possible reasons are methodological limitations, concurrent context effects, and limitations of the interventions used. Our results confirm that community-based interventions are promising for health promotion and disease prevention but so far their potential is not fully realized. For the future, such interventions should aim at proximal outcomes and invest in community capacity building.

Medical decision making among patients with heart failure - does migration background matter?

BACKGROUND: Some studies, mainly coming from the U.S., indicate disparities in heart failure (HF) treatment according to migration/ethnicity. However, respective results are inconsistent and cannot be transferred to other health care systems. Thus, we will address the following research question: Are there differences in the diagnosis and management of HF between patients with and without a Turkish migration background in Germany? METHODS: A factorial experimental design with video vignettes was applied. In the filmed simulated initial encounters, professional actors played patients, who consulted a primary care physician because of typical HF symptoms. While the dialog was identical in all videos, patients differed in terms of Turkish migration history (no/yes), sex (male/female), and age (55 years/75 years). After viewing the video, primary care physicians (N = 128) were asked standardized and open ended questions concerning their decisions on diagnosis and therapy. RESULTS: Analyses revealed no statistically significant differences (p < 0.05), but a consistent tendency: Primary care doctors more often asked lifestyle and psychosocial questions, they more often diagnosed HF, they gave more advice to rest and how to behave in case of deterioration, they more often auscultated the lung, and more often referred to a specialist when the patient has a Turkish migration history compared to a non-migrant patient. Differences in the medical decisions between the two groups ranged between 1.6 and 15.8%. In 10 out of 12 comparisons, differences were below 10%. CONCLUSIONS: Our results indicate that are no significant inequalities in diagnosis and management of HF according to a Turkish migration background in Germany. Primary care physicians' behaviour and medical decision making do not seem to be influenced by the migration background of the patients. Future studies are needed to verify this result and to address inequalities in HF therapy in an advanced disease stage.

[Impact of COVID-19-pandemic on Clinical Care, Work Flows and Staff at a University Hospital: Results of an Interview-study at the UKE]. / Auswirkungen der COVID-19-Pandemie auf die klinische Versorgung, Arbeitsprozesse und Mitarbeitenden in der Universitätsmedizin: Ergebnisse einer Interviewstudie am UKE.

OBJECTIVES: The study investigates the impact of the COVID-19 pandemic on health services with and without specific health care of COVID-19 patients through the eyes of leading physicians at the University Medical Center Hamburg-Eppendorf (UKE). METHODS: From April 30 to May 12, 2020, four interviewers conducted 38 expert interviews via telephone, video or face-to-face by using a semi-standardized questionnaire. The standardized answers were analysed descriptively. The free text-answers were subject to a qualitative content analysis. The categories were analysed via quantitative frequency distributions. RESULTS: All chief physicians with responsibility for inpatient and outpatient health care at the UKE took part in this study (N=38). The leading physicians reported numerous changes regarding occupancy in the hospital, patient composition, work flows and diagnostic as well as therapeutic measures. Additionally, various arrangements were necessary to cover the needs of prevention, treatment and follow-up care as well as protection of staff. Measures showed, on the one hand, a strong reduction in occupancy and workload in most inpatient and outpatient clinics. On the other hand, the amount of work also increased by fundamental transitions of work flows, communication, staff structure and hygiene measures. Many respondents commented positively on the rapid and efficient setup of a digital communication structure. Partially, staff was strained by the pandemic itself and by the associated measures. CONCLUSION: The results of the study help to understand and assess the effects of the pandemic on health care, work flows and staff. The findings may support the specification and adaptation of prospective measures and processes for pandemic crisis situations. Future studies should investigate how staff beneath the highest executive level experienced and evaluated this crisis and consequences.

Development and evaluation of e-mental health interventions to reduce stigmatization of suicidality - a study protocol.

BACKGROUND: Worldwide, approximately 800,000 persons die by suicide every year; with rates of suicide attempts estimated to be much higher. Suicidal persons often suffer from a mental disorder but stigma, lack of available and suitable support, and insufficient information on mental health limit help seeking. The use of internet-based applications can help individuals inform themselves about mental disorders, assess the extent of their own concerns, find local treatment options, and prepare for contact with health care professionals. This project aims to develop and evaluate e-mental health interventions to improve knowledge about suicidality and to reduce stigmatization of those affected. In developing these interventions, a representative telephone survey was conducted to detect knowledge gaps and stigmatizing attitudes in the general population. METHODS: First, a national representative telephone survey with N = 2000 participants in Germany was conducted. Second, e-mental health interventions are developed to address knowledge gaps and public stigma detected in the survey. These comprise an evidence-based health information package about suicidality, information on regional support services, a self-administered depression test-including suicidality-and an interactive online intervention including personal stories. The development is based on a trialogical exchange of experience between persons affected by suicidality, relatives of affected persons, and clinical experts. Australian researchers who developed an e-mental health intervention for individuals affected by rural suicide were invited to a workshop in order to contribute their knowledge and expertise. Third, the online intervention will be evaluated by a mixed methods design. DISCUSSION: From representative telephone survey data, content can be developed to address specific attitudes and knowledge via the e-mental health interventions. These interventions will be easily accessed and provide an opportunity to reach people who tend not to seek professional services, prefer to inform themselves in advance and/or wish to remain anonymous. Evaluation of the online intervention will provide information on any changes in participants' self-stigma and perceived-stigma of suicidality, and any increase in participants' knowledge on suicidality or self-efficacy expectations. TRIAL REGISTRATION: German Clinical Trial Register DRKS00015071 on August 6, 2018.

Perceptions of time constraints among primary care physicians in Germany.

BACKGROUND: Time constraints during patient visits play a major role for the work stress of primary care physicians. Several studies suggest that there is a critical situation in terms of time constraints in primary care in Germany. Therefore, the following research questions are addressed: (1) What is the time allocated and needed for different types of consultations among primary care physicians in an urban area in Germany? (2) What is the extent of time stress? (3) Are there differences in time stress according to physician characteristics (gender and length of experience) and practice type (single vs. group/shared practice)? METHODS: Data stem from a face-to-face survey of primary care doctors in Hamburg and adjacent regions. A sample of 128 physicians stratified by a combination of physicians' gender and length of experience (≤15 years or > 15 years) was used. Physicians were asked about the time needed (in minutes) to provide high quality of care for patients regarding six types of consultations: (1) new patient appointment, (2) routine consultation, (3) complete physical examination, (4) symptom-oriented examination, (5) check-up, and (6) home visit (without drive). Afterwards, they were asked about the average minutes allocated for the six consultations. Time stress was measured by calculating minutes needed minus minutes available. RESULTS: Average perceived time needed was higher than time allocated for all six types of consultation. However, there were differences in the magnitude of time stress between the consultation types. Time stress was most pronounced and most prevalent in case of a new patient visit. No significant differences in time stress between male and female primary care physicians were found, while less experienced physicians reported more time stress than those with more experience (> 15 years). Physicians working in a single practice had less time stress than those working in a group or shared practice in case of a check-up visit. CONCLUSIONS: Perceived time needed is higher than time allocated for various types of consultation among primary care physicians in Germany. Time stress in primary care is particularly pronounced in case of new patient appointments. Early-career physicians are particularly affected by time stress.

[Participation in self-help groups: impact on self-management and knowledge]. / Teilnahme an Selbsthilfegruppen: Wirkungen auf Selbstmanagement und Wissenserwerb.

BACKGROUND: Self-help groups (SHGs) are an inherent part of patient involvement and play an important role in the healthcare system. Until now, however, there has been a lack of systematic investigations and quantitative data about the individual impact of self-help for patients and relatives. OBJECTIVES: This study presents the results of a comparison between members of SHGs and non-members. Thereby, the effects of self-help shall be described in terms of empowerment and self-management. The study is part of the project "Health-related Collective Self-Help in Germany" (Gesundheitsbezogene Selbsthilfe in Deutschland-SHILD) funded by the Federal Ministry of Health. MATERIALS AND METHODS: The study was conducted with patients from five therapeutic areas (diabetes mellitus type 2, prostate cancer, multiple sclerosis, tinnitus, relatives of dementia patients). Participants administered a multidimensional questionnaire (paper-and-pencil or online). Of the 2870 participants in this analysis, 49% were active members of SHGs. RESULTS: Statistical analysis showed some significant, but small differences between the two groups in five out of seven scales of the Health Education Impact Questionnaire (heiQ) in favour of the SHG members. Furthermore, SHG members performed better in specific knowledge tests. Members see the importance of their group especially in social inclusion, psychosocial relief, coping with the disease and new insights in dealing with the disease. CONCLUSIONS: With respect to the study design we cannot rule out that differences might be based on personal characteristics influencing the decision to participate in a SHG or not. But as the results are controlled for confounders, the hypothesis that SHG participation has a positive impact on the outcomes rather than vice versa seems supported.

[Clinical trial of a stepped and collaborative care model for mental illnesses and comorbidities in the Hamburg Network for Health Services Research]. / Erprobung eines integrierten und gestuften Behandlungsmodells für psychische Störungen und Komorbiditäten im Hamburger Netzwerk für Versorgungsforschung.

Healthcare for mental disorders is a big challenge for the German healthcare system. In cases of comorbid mental diseases, patients suffer from an especially high burden of disease. So far, innovative care models for collaborative and stepped care have only been investigated with respect to their effectiveness for single mental disorders.The project "Collaborative and Stepped Care in Mental Health by Overcoming Treatment Sector Barriers" (COMET), which is being carried out by the Hamburg Network for Health Services Research (HAM-NET) from 2017 until 2020, examines an innovative, guideline-based healthcare model for the improvement of healthcare for patients with mental illnesses and their potential comorbidities. In this article this new stepped and collaborative care model for patients in primary care that integrates general practitioners, psychiatrists, psychotherapists, and hospitals is presented. For the implementation and facilitation of the model, guideline-based treatment pathways, a tablet-based computer program for screening, diagnostic and guideline-based treatment recommendations, as well as a web-based transferal platform were developed.The results of this project on the effectiveness and efficacy of the model can help determine if the model can be implemented in routine healthcare. This could represent a major step towards more integrated and cross-sectoral healthcare for patients with mental illnesses.