Health literacy: What lessons can be learned from the experiences and policies of different countries?

BACKGROUND: Adequate levels of health literacy (HL) are crucial to ensure good quality of health, social life and wellbeing. HL is a mediating factor in health disparities. Low HL hampers interaction with healthcare. HL is a shared responsibility of individuals and the healthcare system. Multi-dimensional programs and policies should be set up. AIM: To learn from current HL policies and action plans and to identify elements to consider for the development of national HL plans. METHOD: Transversal analysis of HL policies in six countries, based on a preliminary scoping review. A combination of document analysis and key informant approach. Local experts validated and completed information for their country. A transversal comparison was performed. RESULTS: Several approaches were identified, often influenced by contextual factors, healthcare reforms and existence of centers of expertise. Some governments developed full-fledged, standalone plans, while others developed broader plans covering the entire health and care sector. Some took a conceptually driven, high level approach. Others took a pragmatic approach. And some did not have a governmental plan at all. CONCLUSION: Policy makers should analyse their state structure and health system, and search for local 'pockets of excellence', to develop a well-planned, substantiated HL approach for their country.

Difficulties encountered by long COVID patients in the Belgian health system / Difficultés rencontrées par les patients COVID long dans le système de santé belge

INTRODUCTION: After contracting COVID-19, many people have continued to experience various symptoms for several weeks and months, even after a mild acute phase. These people with ‘long COVID’ faced difficulties when confronted with the healthcare system. PURPOSE OF RESEARCH: In order to better understand their experience, we supplemented the information obtained in an online survey with a mixed qualitative approach based on 33 individual interviews and discussions with 101 participants in a forum in March 2021. RESULTS: Several shortcomings were identified in the contacts of ‘long’ COVID patients with the health care system, such as the lack of listening or empathy of some health care professionals, the lack of a systematic or proactive approach during the diagnostic assessment, or the lack of interdisciplinary coordination. Patients feel misunderstood and are forced to develop their own strategies, whether for diagnosis or treatment. Patients’ discomfort has led them to question the value of medicine and to resort to unconventional therapies to alleviate their symptoms, sometimes at great cost. CONCLUSIONS: Better informing the medical profession about the manifestation of the disease and the possible treatments, including the possibilities of reimbursement, would raise awareness and give them the tools to respond to the needs of ‘ long’ COVID patients. A comprehensive assessment of the patient through an “interdisciplinary assessment” seems necessary.

Introduction: Suite à une infection COVID-19, bon nombre de personnes ont ressenti divers symptômes pendant plusieurs semaines et mois, et ce, même après une phase aiguë légère. Ces personnes atteintes de « COVID long ¼ se sont trouvées confrontées au système de soins de santé, non sans difficultés. But de l'étude: Afin de mieux comprendre leurs expériences, nous avons complété les informations obtenues via une enquête en ligne par une approche qualitative mixte, comprenant 33 entretiens individuels et les discussions de 101 participants à un forum durant le mois de mars 2021. Résultats: Plusieurs lacunes ont été mises en évidence lors des contacts des patients « COVID long ¼ avec le système de santé, comme l'absence d'écoute ou d'empathie de certains professionnels de la santé, d'approche systématique ou proactive lors du bilan diagnostique, ou encore l'absence de coordination interdisciplinaire. Les patients se sentent incompris et se voient obligés de développer leurs propres stratégies afin d'établir un diagnostic ou un traitement. Le malaise des patients les ont amenés à remettre en question la valeur de la médecine et à recourir à des thérapies non conventionnelles afin de soulager leurs symptômes, parfois à un prix élevé. Conclusions: Mieux informer le corps médical quant à la manifestation de la maladie et aux prises en charge possibles, y compris les possibilités de remboursement, permettrait de le sensibiliser et de lui donner les outils pour répondre aux besoins des patients « COVID long ¼. Évaluer de manière globale le patient via un « bilan interdisciplinaire ¼ est nécessaire.

Developing an agency's position with respect to patient involvement in health technology assessment: the importance of the organizational culture.

OBJECTIVES: The objective of this study was to map the PI culture at KCE in the context of the development of organization-wide supported position statements about PI. METHODS: A nominal group technique was used to measure the PI culture at KCE. Arguments for and against PI and conditions for PI in different phases of the HTA process were collected. A literature review and interviews fed the draft position statements, for which support was assessed by means of a two-round Delphi process. RESULTS: Arguments in favor of PI in HTA related to the relevance of the scope, expertise with data collection, bringing in fresh ideas for study design, access to survey participants, validation of data analyses, adherence to recommendations. Disadvantages and risks included the lack of scientific knowledge of involved patients, resources requirements, conflicts of interest, and heterogeneity within patient populations. Conditions for meaningful PI referred to measures mitigating the identified disadvantages. Eighteen position statements supported by KCE could be formulated. CONCLUSION: The KCE culture seems predominantly positive toward PI, although attitudes vary between HTA researchers. KCE recognizes the potential value of PI in HTA, but considers the level of involvement to be contingent on the topic and phase in the HTA process.

Acceptability and Perceived Benefits and Risks of Public and Patient Involvement in Health Care Policy: A Delphi Survey in Belgian Stakeholders.

BACKGROUND: In systems with public health insurance, coverage decisions should reflect social values. Deliberation among stakeholders could achieve this goal, but rarely involves patients and citizens directly. OBJECTIVES: This study aimed at evaluating the acceptability, and the perceived benefits and risks, of public and patient involvement (PPI) in coverage decision making to Belgian stakeholders. METHODS: A two-round Delphi survey was conducted among all stakeholder groups. The survey was constructed on the basis of interviews with 10 key stakeholders and a review of the literature on participation models. Consensus was defined as 65% or more of the respondents agreeing with a statement and less than 15% disagreeing. Eighty stakeholders participated in both rounds. They were defined as the Delphi panel. RESULTS: Belgian stakeholders are open toward PPI in coverage decision processes. Benefits are expected to exceed risks. The preferred model for involvement is to consult citizens or patients, within the existing decision-making structures and at specific milestones in the process. Consulting citizens and patients is a higher level of involvement than merely informing them and a lower level than letting them participate actively. Consultation involves asking nonbinding advice on (parts of) the decision problem. According to the Delphi panel, the benefits of PPI could be increasing awareness among members of the general public and patients about the challenges and costs of health care, and enriched decision processes with expertise by experience from patients. Potential risks include subjectivity, insufficient resources to participate and weigh on the process, difficulties in finding effective ways to express a collective opinion, the risk of manipulation, and lobbying or power games of other stakeholders. CONCLUSIONS: PPI in coverage decision-making processes is acceptable to Belgian stakeholders, be it in different ways for different types of decisions. Benefits are expected to outweigh risks.

Association of burnout and intention-to-leave the profession with work environment: A nationwide cross-sectional study among Belgian intensive care nurses after two years of pandemic.

BACKGROUND: Intensive care unit (ICU) nurses are at an increased risk of burnout and may have an intention-to-leave their jobs. The COVID-19 pandemic may increase this risk. OBJECTIVE: The objective of this study was to describe the prevalence of burnout risk and intention-to-leave the job and nursing profession among ICU nurses and to analyse the relationships between these variables and the work environment after two years of the COVID-19 pandemic. DESIGN: A national cross-sectional survey of all nurses working in Belgian ICUs was conducted between December 2021 and January 2022 during the 4th and 5th waves of the COVID-19 pandemic in Belgium. The Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to measure the work environment, intention-to-leave the hospital and/or the profession was assessed. The risk of burnout was assessed using the Maslach Burnout Inventory scale including emotional exhaustion, depersonalisation, and reduced personal accomplishment. SETTING: Nurses in 78 out of 123 Belgian hospital sites with an ICU participated in the survey. PARTICIPANTS: 2321 out of 4851 nurses (47.8%) completed the entire online survey. RESULTS: The median overall risk of burnout per hospital site (high risk in all three subdimensions) was 17.6% [P25: 10.0 - P75: 28.8] and the median proportion of nurses with a high risk in at least one subdimension of burnout in Belgian ICUs was 71.6% [56.7-82.7]. A median of 42.9% [32.1-57.1] of ICU nurses stated that they intended-to-leave the job and 23.8% [15.4-36.8] stated an intent-to-leave the profession. The median overall score of agreement with the presence of positive aspects in the work environment was 49.0% [44.8-55.8]. Overall, nurses working in the top 25% of best-performing hospital sites with regard to work environment had a statistically significant lower risk of burnout and intention-to-leave the job and profession compared to those in the lowest performing 25% of hospital sites. Patient-to-nurse ratio in the worst performing quartile was associated with a higher risk for emotional exhaustion (OR = 1.53, 95% CI:1.04-2.26) and depersonalisation (OR = 1.48, 95% CI:1.03-2.13) and intention-to-leave the job (OR = 1.46, 95% CI:1.03-2.05). CONCLUSIONS: In this study, a high prevalence of burnout risk and intention-to-leave the job and nursing profession was observed after two years of the COVID-19 pandemic. Nevertheless, there was substantial variation across hospital sites which was associated with the quality of the work environment. TWEETABLE ABSTRACT: "Burnout & intention to leave was high for Belgian ICU nurses after 2 years of COVID, but wellbeing was better with high quality work environments and more favourable patient to nurse ratios".

Barriers to Somatic Health Care for Persons With Severe Mental Illness in Belgium: A Qualitative Study of Patients' and Healthcare Professionals' Perspectives.

BACKGROUND: A huge and still growing mortality gap between people with severe mental illness (SMI) and the general population exists. Physical illnesses, mainly cardiovascular diseases, substantially contribute to the high mortality rates in patients with SMI. Disparities in somatic health care access, utilisation, and provision contribute to these poor physical health outcomes. METHODS: A qualitative study, using semi-structured interviews, was set up to explore SMI patients' and healthcare professionals' perspectives on somatic health care in different psychiatric settings of the three Belgian regions (Flanders, Brussels, Wallonia). Interviews were digitally recorded and transcribed prior to qualitative inductive thematic analysis, using Nvivo software. The COnsolidated criteria for REporting Qualitative research (COREQ) were used for reporting methods and findings. RESULTS: Collaboration and information flows between psychiatric healthcare professionals, non-psychiatric healthcare professionals, and persons with SMI were troublesome. This seemed to be mainly due to stigma and prejudice and challenging communication and data transfer. Lack of sufficient training and experience to identify and treat somatic health problems in people with SMI (for psychiatrists and psychiatric nurses) and lack of psychiatric knowledge and feeling or sensitivity for psychiatric patients (for non-psychiatric healthcare professionals) further complicated adequate somatic health care. Finally, optimal somatic follow-up of patients with SMI was hampered by organisational problems (unavailability of equipment, unadapted infrastructure, understaffing, hospital pharmacy issues, and insufficient health promotion/lifestyle interventions), patient-related issues (unawareness of physical problems, non-adherence, need for accompaniment) and financial barriers. CONCLUSION: There is an urgent need for integrated somatic and mental healthcare systems and a cultural change. Psychiatrists and primary care providers continue to consider the mental and physical health of their patients as mutually exclusive responsibilities due to a lack of sufficient training and experience, poor or absent liaison links, time constraints and organisational and financial barriers. Modifying these aspects will improve the quality of somatic health care for these vulnerable patients.

A multi-criteria decision approach for ranking unmet needs in healthcare.

Early temporary reimbursement (ETR) schemes for new interventions targeting high unmet needs are increasingly applied in pharmaceutical policy. Crucial for these schemes is the assessment of unmet healthcare needs of patients and society. This study develops and tests a multi-criteria decision approach (MCDA) for assessing therapeutic and societal needs. The Belgian unmet needs commission, responsible for creating a list of unmet needs for the ETR programme, has tested this methodology to assess the needs in eight health conditions. For therapeutic need, three criteria were included (impact of the condition on quality of life and on life expectancy and inconvenience of current treatment); for societal need two criteria (condition-related healthcare expenditures per patient, prevalence). The results show that the proposed MCDA is feasible and acceptable for the unmet needs commission. Clear definitions of the criteria and regular repetition of these is needed to avoid variable interpretation of the criteria by the commission members. Quality assessment of the evidence is desired. Rankings resulting from the application have face validity. Considering therapeutic need separately from societal need is considered appropriate. Policy makers should consider the use of MCDA in assessing healthcare needs. MCDA improves the transparency and accountability of the decision making processes and is practical and feasible.

What Does the Public Want? Structural Consideration of Citizen Preferences in Health Care Coverage Decisions.

Background. Multi-criteria decision analysis can improve the legitimacy of health care reimbursement decisions by taking societal preferences into account when weighting decision criteria. This study measures the relative importance of health care coverage criteria according to the Belgian general public and policy makers. Criteria are structured into three domains: therapeutic need, societal need, and new treatments' added value. Methods. A sample of 4,288 citizens and 161 policy makers performed a discrete choice experiment. Data were analyzed using multinomial logistic regression analysis. Level-independent criteria weights were determined using the log-likelihood method. Results. Both the general public and policy makers gave the highest weight to quality of life in the appraisal of therapeutic need (0.43 and 0.53, respectively). The general public judged life expectancy (0.14) as less important than inconvenience of current treatment (0.43), unlike decision makers (0.32 and 0.15). The general public gave more weight to "impact of a disease on public expenditures" (0.65) than to "prevalence of the disease" (0.56) when appraising societal need, whereas decision makers' weights were 0.44 and 0.56, respectively. When appraising added value, the general public gave similar weights to "impact on quality of life" and "impact on prevalence" (0.37 and 0.36), whereas decision makers judged "impact on quality of life" (0.39) more important than "impact on prevalence" (0.29). Both gave the lowest weight to impact on life expectancy (0.14 and 0.21). Limitations. Comparisons between the general public and policy makers should be treated with caution because the policy makers' sample size was small. Conclusion. Societal preferences can be measured and used as decision criteria weights in multi-criteria decision analysis. This cannot replace deliberation but can improve the transparency of health care coverage decision processes.

Experiences of hospital-based multidisciplinary team meetings in oncology: An interview study among participating general practitioners.

BACKGROUND: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients' care. General practitioners (GPs) are invited to join, but their participation is minimal. OBJECTIVES: Aim of this study is to explore participating GPs' perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings. METHODS: In May to June 2014, semi-structured interviews (n = 16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles. RESULTS: Attendance of an MDT meeting is perceived as part of the GP's work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP's perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP's intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics. CONCLUSION: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.

Peer, family integration and other determinants of cannabis use among teenagers.

Cannabis consumption is on the rise in the French-speaking Community of Belgium, especially among teenagers. The physical and mental harms related to that drug prompted us to search for factors associated with cannabis consumption. The aim of this paper is thus to identify a series of potential predictors of teenager's cannabis use and particularly the influence of peer and family integration. The data analyzed were taken from the 1998 data bank "Health Behavior in School-Aged Children", an international quantitative cross-national study, which takes place every four years. The variables investigated were peer and family integration and the habit of drug consumption (tobacco, alcohol or a narcotic other than cannabis) as potential determinants of the experimentation, current usage of cannabis (at least once a month) and regular usage (at least once a week). Apart from the socio-demographic variables, these predictors were investigated by univariate and multivariate analysis (logistic regression). The analyses covered 744 students in Catholic high schools. Results showed that 30.2% of students had tried to smoke cannabis and 50% of them continued to smoke it at least during the previous month. Age, number of income in the family, strong peer group integration [OR 7.7; CI 95% (3.5;17.3)] and drug-consumption habit [for example, tobacco use: OR 7.4; CI 95% (4.8;11.32)] were associated with cannabis experimentation. Age, gender, nationality, average family integration [OR 2.13; CI 95% (1.1;4.1)] and other drugs use as addiction to nicotine [OR 9.5; CI 95% (5.6;16.3)] determined the current consumption of the substance. Preventive action should aim at improving the teenager's integration into the family circle in order to prevent the trial and consumption of cannabis. In addition, prevention should include the consumption of (addictive) substances in general.