The relation between economic stressors and higher education students' mental health during the initial outbreak of the COVID-19 pandemic.

AIMS: The COVID-19 pandemic has had a large impact on the financial situation of higher education students, disproportionately affecting students with a low socioeconomic status (SES). This raises the question of whether economic stressors related to COVID-19 have aggravated existing socioeconomic inequalities in mental health. This study examined the relationship between economic stressors and students' depressive symptoms, and the role of students' SES and countries' socioeconomic conditions. METHODS: Data from the COVID-19 International Student Well-being Study was used for multilevel analyses, with depressive symptoms as dependent variable. Three indicators measured SES: educational level of the parents, ability to borrow money from their social network, and struggling with financial resources prior to COVID-19. RESULTS: Students with a low SES had more depressive symptoms, and those not able to borrow money and with parents without higher education were more exposed to a deterioration in their financial situation. Both economic stressors (reduction in working hours and a deterioration of their financial situation) were positively related to depressive symptoms. In addition, the positive relationship between a decrease in working hours and depressive symptoms was stronger in countries with a higher unemployment rate. CONCLUSIONS: We observed socioeconomic inequalities in students' mental health, which, in part, can be ascribed to a larger exposure to the economic stressors related to COVID-19 among students' with a low SES. The macroeconomic context also played a role, as the impact of a reduction in working hours on depressive symptoms was stronger in countries with poor economic conditions.

Unravelling the Belgian cascade of hypertension care and its determinants: insights from a cross-sectional analysis.

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease and all-cause mortality worldwide. Despite the widespread availability of effective antihypertensives, blood pressure (BP) control rates remain suboptimal, even in high-income countries such as Belgium. In this study, we used a cascade of care approach to identify where most patients are lost along the continuum of hypertension care in Belgium, and to assess the main risk factors for attrition at various stages of hypertension management. METHODS: Using cross-sectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Survey, we estimated hypertension prevalence among the Belgian population aged 40-79 years, and the proportion that was (1) screened, (2) diagnosed, (3) linked to care, (4) in treatment, (5) followed up and (6) well-controlled. Cox regression models were estimated to identify individual risk factors for being unlinked to hypertension care, untreated and not followed up appropriately. RESULTS: The prevalence of hypertension based on self-reported and measured high BP was 43.3%. While 98% of the hypertensive population had their BP measured in the past 5 years, only 56.7% were diagnosed. Furthermore, 53.4% were linked to care, 49.8% were in treatment and 43.4% received adequate follow-up. Less than a quarter (23.5%) achieved BP control. Among those diagnosed with hypertension, males, those of younger age, without comorbidities, and smokers, were more likely to be unlinked to care. Once in care, younger age, lower BMI, financial hardship, and psychological distress were associated with a higher risk of being untreated. Finally, among those treated for hypertension, females, those of younger age, and without comorbidities were more likely to receive no adequate follow-up. CONCLUSION: Our results show that undiagnosed hypertension is the most significant barrier to BP control in Belgium. Health interventions are thus needed to improve the accurate and timely diagnosis of hypertension. Once diagnosed, the Belgian health system retains patients fairly well along the continuum of hypertension care, yet targeted health interventions to improve hypertension management for high-risk groups remain necessary, especially with regard to improving treatment rates.

Patterns of PrEP and condom use among PrEP users in Belgium: a web-based longitudinal study.

BACKGROUND: Tailoring pre-exposure prophylaxis (PrEP) service delivery is key to scaling-up PrEP uptake. Optimal implementation of tailored services requires, among other things, insights into patterns of PrEP use, sexual behaviours and condom use over time. METHODS: Between September 2020 and January 2022, we conducted a web-based, longitudinal study among PrEP users in Belgium. In three questionnaire rounds every six-months, we assessed PrEP and condom use, and sex with steady, casual and anonymous partners in the preceding three months. Based on the patterns of PrEP use in the preceding three months, we identified distinct PrEP use categories. We investigated differences in baseline socio-demographics and sexual behaviours by PrEP use category using Fisher's exact and one-way ANOVA tests. Patterns in PrEP and condom use over time were examined using descriptive analyses and visualised in alluvial diagrams. RESULTS: In total, 326 participants completed the baseline questionnaire, and 173 completed all three questionnaires. We identified five distinct PrEP use categories: daily (≥ 90 pills), almost daily (75-89 pills), long period (> 7 consecutive days and < 75 pills) with or without additional short period use, short period (1-7 consecutive days and < 75 pills) and no PrEP use (0 pills). During the study, percentages of individuals in each PrEP use category varied, but did not change significantly over time. At baseline, daily and almost daily users were more likely to report five or more casual sex partners, ten or more anonymous sex partners and anal sex on a weekly basis with casual or anonymous partners compared to those using PrEP for long or short periods. Up to 12.6% (n = 16/127) of participants reporting anal sex with casual or anonymous partners, indicated always using condoms and PrEP with these partners. One in three (n = 23/69) participants who reported anal sex with steady partners had condomless anal sex and did not use PrEP with these partners; with casual or anonymous partners less than 3% reported this. CONCLUSIONS: Our findings show that there is little variation in PrEP use over time and that PrEP use was associated with sexual behaviours, which could be taken into account when designing tailored PrEP care.

Insights into barriers and facilitators in PrEP uptake and use among migrant men and transwomen who have sex with men in Belgium.

BACKGROUND: PrEP uptake is low among non-Belgian men and transwomen who have sex with men, although the HIV epidemic among men who have sex with men in Belgium is diversifying in terms of nationalities and ethnicity. We lack an in-depth understanding of this gap. METHODS: We conducted a qualitative study using a grounded theory approach. The data consists of key informants interviews and in-depth interviews with migrant men or transwomen who have sex with men. RESULTS: We identified four underlying determinants which shape our participants' experiences and contextualize the barriers to PrEP use. These include (1) the intersectional identities of being migrant and men and transwomen who have sex with men, (2) migration related stressors, (3) mental health and (4) socio-economic vulnerability. Identified barriers include: the accessibility of services; availability of information, social resources and providers' attitudes. These barriers influence PrEP acceptance and mediated by individual agency this influences their PrEP uptake. CONCLUSION: An interplay of several underlying determinants and barriers impacts on PrEP uptake among migrant men and transwomen who have sex with men, illustrating a social gradient in access to PrEP. We need equitable access to the full spectrum of HIV prevention and care for all priority populations, including undocumented migrants. We recommend social and structural conditions that foster exercising these rights, including adapting PrEP service delivery, mental health and social support.

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study.

BACKGROUND: Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types. METHODS: Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices. RESULTS: The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks. CONCLUSIONS: Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave.

BACKGROUND: There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence. RESULTS: Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSIONS: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Stay-at-Home: The Impact of the COVID-19 Lockdown on Household Functioning and ART Adherence for People Living with HIV in Three Sub-districts of Cape Town, South Africa.

In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV's (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019-March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June-July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

RESUMEN: En marzo de 2020, el gobierno sudafricano impuso un confinamiento generalizado para controlar la transmisión del COVID-19. Estas medidas pueden afectar la adherencia a la terapia antirretroviral de las personas con VIH. A partir de un ensayo aleatorio grupal se recopilan datos de 152 personas con VIH en los sub-distritos de Ciudad del Cabo entre octubre de 2019 y marzo de 2020 cuando el confinamiento detuvo la recopilación. Posteriormente, se realizó un seguimiento de 83 pacientes entre junio y julio de 2020. Se utilizaron modelos de efectos aleatorios para analizar: 1) los cambios en las variables entre la línea de base y de seguimiento; 2) covariables de adhesión al tratamiento. En el seguimiento se observa que aumentaron las probabilidades de estar por debajo del umbral de pobreza y disminuyeron las probabilidades de sufrir violencia. Las medidas de bienestar, funcionamiento del hogar, estigma e idoneidad en materia de VIH mejoraron entre la línea base y el seguimiento. Por otro lado, la violencia, la depresión, la inseguridad alimentaria y el estigma se asocian a una menor adherencia al tratamiento antirretroviral, mientras la mejora del bienestar se asocia a una mayor adherencia al tratamiento. De tal manera, se observa que durante situaciones de emergencia que requieran de confinamientos es recomendable que los gobiernos garanticen apoyo financiero, atención a la salud física y mental de manera continua, así como servicios especializados hacia quienes sufren violencia.

Awareness of, Willingness to Take PrEP and Its Actual Use Among Belgian MSM at High Risk of HIV Infection: Secondary Analysis of the Belgian European MSM Internet Survey.

We examined PrEP awareness, willingness to take it and early PrEP use among men who have sex with men (MSM) at increased risk of HIV acquisition in Belgium. This analysis of the Belgian EMIS online data of 2017-2018 adopts a cascade approach, with the following steps quantified as conditional probabilities: being eligible for, aware of, willing to take PrEP, and PrEP use. One out of three MSM was eligible to use PrEP according to the operationalized Belgian reimbursement criteria. PrEP awareness was lower among socioeconomically vulnerable MSM, MSM living outside large cities, MSM who were less open about their sexuality and those who did not identify as gay or homosexual. A lack of PrEP knowledge, a higher self-efficacy regarding safe sex, having a steady partner and reporting more symptoms of depression were related to unwillingness to use PrEP. Among those willing to take PrEP, less than one third were actually using PrEP. Not using PrEP was associated with living in small cities and experiencing financial problems.

The knowledge, attitude and practice of community people on dengue fever in Central Nepal: a cross-sectional study.

BACKGROUND: Since 2006, Nepal has experienced frequent Dengue fever (DF) outbreaks. Up to now, there have been no knowledge, attitude and practice (KAP) studies carried out on DF in Nepal that have included qualitative in-depth and quantitative data. Thus, we aimed to explore and compare the KAP of people residing in the lowland (< 1500 m) and highland (> 1500 m) areas of Nepal. METHODS: A cross-sectional mixed-method study was conducted in six districts of central Nepal in September-October 2018 including both quantitative (660 household surveys) and qualitative data (12 focus group discussions and 27 in-depth interviews). The KAP assessment was executed using a scoring system and defined as high or low based on 80% cut-off point. Logistic regression was used to investigate the associated factors, in quantitative analysis. The deductive followed by inductive approach was adopted to identify the themes in the qualitative data. RESULTS: The study revealed that both the awareness about DF and prevention measures were low. Among the surveyed participants, 40.6% had previously heard about DF with a significantly higher number in the lowland areas. Similarly, IDI and FGD participants from the lowland areas were aware about DF, and it's associated symptoms, hence they were adopting better preventive practices against DF. The findings of both the qualitative and quantitative data indicate that people residing in the lowland areas had better knowledge on DF compared to people in highland areas. All IDI participants perceived a higher chance of increasing future dengue outbreaks due to increasing temperature and the mobility of infected people from endemic to non-endemic areas. The most quoted sources of information were the television (71.8%) and radio (51.5%). Overall, only 2.3% of the HHS participants obtained high knowledge scores, 74.1% obtained high attitude scores and 21.2% obtained high preventive practice scores on DF. Among the socio-demographic variables, the area of residence, educational level, age, monthly income, SES and occupation were independent predictors of knowledge level, while the education level of the participants was an independent predictor of the attitude level. CONCLUSIONS: Our study found a very low level of knowledge and insufficient preventive practices. This highlights an urgent need for extensive dengue prevention programs in both highland and lowland communities of Nepal.

A cross-cultural adaptation and validation of a scale to assess illness identity in adults living with a chronic illness in South Africa: a case of HIV.

The chronic illness trajectory and its outcomes are well explained by the concept of illness identity; the extent to which ill individuals have integrated their diagnosed chronic illness into their identity or sense of self. The capacity to measure illness identity in people living with HIV (PLHIV) is still relatively unexplored. However, this is potentially useful to help us understand how outcomes for PLHIV could be improved and sustained. This paper aims to explore the cross-cultural adaptation of a Belgian developed Illness Identity Questionnaire (IIQ) and validate the instrument using a sample of South African adults living with HIV. We followed a phased scale adaptation and validation process which included an investigation of conceptual, item, semantic and operational equivalence and also examined the psychometric properties of the IIQ. The concept of illness identity with its four factors; engulfment, rejection, acceptance and enrichment in PLHIV, was found to be relevant within this context. Five items from the original IIQ were excluded from the adapted IIQ due to either semantic insufficiency and/or inadequate measurement equivalence. The mode of administration of the IIQ was changed to accommodate current study participants. The original four factor 25-item model did not fit current data, however, a better contextualized, four-factor, 20-item model was identified and found valid in the current setting. The results showed adequate statistical fit; χ2/d.f. = 1.516, RMSEA = 0.076, SRMR = 0.0893, and CFI = 0.909. Convergent and discriminant validity were also tenable. The cross-cultural adaptation and validation of the IIQ was successful, resulting in the availability of an instrument capable of measuring illness identity in PLHIV in a high HIV prevalence and resource-constrained setting. This therefore addresses the paucity of information and expands on knowledge about illness identity.

Knowledge deficit and fear of COVID-19 among higher education students during the first wave of the pandemic and implications for public health: a multi-country cross-sectional survey.

BACKGROUND: Public health measures such as physical distancing and distance learning have been implemented during the COVID-19 pandemic. COVID-19 related knowledge deficit can increase fear that leads to negative mental health and COVID-19, especially among adolescents. Therefore, our study aimed to assess COVID-19 related knowledge deficit and its association with fear among higher education (HE) students during the first wave of COVID-19. METHODS: A cross-sectional survey, COVID-19 International Students Well-being Study (C-19 ISWS) was conducted in 133 Higher Education Institutions (HEIs) in 26 countries between April 27 and July 7, 2020. A stratified convenience sampling technique was used. Descriptive, bivariate, mixed-effect logistic regression analyses were conducted using R software. RESULTS: Out of 127,362 respondents, 72.1% were female, and 76.5% did not report a previous history of confirmed COVID-19. The majority of those without the previous infection 81,645 (83.7%) were from 21 European countries while the rest 15,850 (16.3%) were from 5 non-European countries. The most frequent correct response to COVID-19 related knowledge questions among respondents was having the virus without having symptoms (94.3%). Compared to participants with good knowledge, the odds of being afraid of acquiring SARS-COV-2 infection among those with poor knowledge was 1.05 (95%CI:1.03,1.08) and the odds of being afraid of contracting severe COVID-19 was 1.36 (95%CI:1.31,1.40). CONCLUSION: COVID-19 related knowledge was independently associated with both fear of acquiring SARS-COV-2 infection as well as contracting severe COVID-19. Our findings will serve as a basis for public health response for both the current and similar future pandemics by highlighting the need for addressing the COVID-19 knowledge deficit to fight the infodemic and prevent negative mental health outcomes.

Motivational determinants of physical activity in disadvantaged populations with (pre)diabetes: a cross-cultural comparison.

BACKGROUND: Understanding motivational determinants of physical activity (PA) is essential to guide the implementation of PA at individual and population level. Knowledge about the cross-cultural generalizability of these determinants is lacking and they have mostly been studied as separate factors. This study compares a motivational process model across samples from diverse populations with, or at risk of diabetes. METHODS: Measurement invariance of barrier identified regulation, barrier self-efficacy and social support was assessed in a rural Ugandan sample (n = 712) and disadvantaged samples with high proportions of immigrants in urban South Africa (n = 566) and Sweden (n = 147). These motivational determinants were then compared through multigroup structural equation modeling. RESULTS: The studied motivational constructs showed scalar invariance. Latent mean levels of perceived social support and barrier self-efficacy were lower in South Africa and Sweden. Structural models (for different PA outcomes) were not consistent across settings except for the association between perceived social support and identified regulation. Identified regulation was only associated with vigorous PA in Uganda and with moderate PA in South Africa. The association between social support and PA outcomes ranged from weak to not significant and the association between self-efficacy and PA was not significant. Self-reported PA was highest in Uganda and lowest in Sweden. Self-reported vigorous PA was significantly related to lower hemoglobin A1c levels, while moderate PA was not. CONCLUSIONS: Findings suggest that: 1) it is feasible to compare a motivational process model across diverse settings; 2) there is lower perceived social support and self-efficacy in the urban, migrant samples; 3) identified regulation is a more promising determinant of PA than self-efficacy or social support in these populations; 4) associations between motivational determinants and PA depend on the perceived type and/or intensity of PA; 5) perceived relatedness functions as a basic psychological need across diverse settings; and 6) people's perception of the PA they perform depends on their perceived level of intensity of PA which would have major implications for health promotion.

Depressive symptoms in higher education students during the COVID-19 pandemic: the role of containment measures.

BACKGROUND: Students are a vulnerable group for the indirect impact of the COVID-19 pandemic, particularly their mental health. This paper examined the cross-national variation in students' depressive symptoms and whether this can be related to the various protective measures implemented in response to the initial stage of the COVID-19 outbreak. METHODS: Student data stem from the COVID-19 International Student Well-being Study, covering 26 countries during the first wave of the COVID-19 pandemic. Country-level data on government responses to the COVID-19 pandemic were retrieved from the Oxford COVID-19 Tracker. Multilevel analyses were performed to estimate the impact of the containment and economic support measures on students' depressive symptoms (n = 78 312). RESULTS: School and workplace closures, and stay-at-home restrictions were positively related to students' depressive symptoms during the COVID-19 pandemic, while none of the economic support measures significantly related to depressive symptoms. Countries' scores on the index of these containment measures explained 1.5% of the cross-national variation in students' depressive symptoms (5.3%). This containment index's effect was stable, even when controlling for the economic support index, students' characteristics, and countries' epidemiological context and economic conditions. CONCLUSIONS: Our findings raise concerns about the potential adverse effects of existing containment measures (especially the closure of schools and workplaces and stay-at-home restrictions) on students' mental health.

The cascade of hypertension care in Cambodia: evidence from a cross-sectional population-based survey.

BACKGROUND: Hypertension (HTN) is a leading cause of cardiovascular diseases and deaths globally. To respond to the high HTN prevalence (23.5% among adults aged 40-69 years in 2016) in Cambodia, the government (and donors) established innovative interventions to improve access to screening, care, and treatment at different public health system and community levels. We assessed the effectiveness of these interventions and resulting health outcomes through a cascade of HTN care and explored key determinants. METHODS: We performed a population-based survey among 5070 individuals aged ≥ 40 years to generate a cascade of HTN care in Cambodia. The cascade, built with conditional approach, shows the patients' flow in the health system and where they are lost (dropped out) along the steps: (i) prevalence, (ii) screening, (iii) diagnosis, (iv) treatment in the last twelve months, (v) treatment in the last three months, and (vi) HTN being under control. The profile of people dropping out from each bar of the cascade was determined by multivariate logistic regression. RESULTS: The prevalence of HTN (i) among study participants was 35.2%, of which 81.91% had their blood pressure (BP) measured in the last three years (ii). Over 63.72% of those screened were diagnosed by healthcare professionals as hypertensive patients (iii). Among these, 56.19% received treatment in the last twelve months (iv) and 54.26% received follow-up treatment in the last three months (v). Only 35.8% of treated people had their BP under control (vi). Males, those aged ≥ 40 years, and from poorer households had lower odds to receive screening, diagnosis, and treatment. Lower odds to have their BP under-control were found in males, those from poor and rich quintiles, having HTN < five years, and receiving treatment at a private facility. CONCLUSIONS: Overall, people with HTN are lost along the cascade, suggesting limited access to appropriate screening, diagnosis, and treatment and resulting poor health outcomes, especially among those who are male, aged 40-49 years, from poorer households, and visiting a private facility. Efforts to improve the quality of facility-based and community-based interventions are needed to prevent inequitable drops along the cascade of care.

Development and operationalization of a data framework to assess quality of integrated diabetes care in the fragmented data landscape of Belgium.

BACKGROUND: To assess the quality of integrated diabetes care, we should be able to follow the patient throughout the care path, monitor his/her care process and link them to his/her health outcomes, while simultaneously link this information to the primary care system and its performance on the structure and organization related quality indicators. However the development process of such a data framework is challenging, even in period of increasing and improving health data storage and management. This study aims to develop an integrated multi-level data framework for quality of diabetes care and to operationalize this framework in the fragmented Belgium health care and data landscape. METHODS: Based on document reviews, iterative working group discussions and expert consultations, theoretical approaches and quality indicators were identified and assessed. After mapping and assessing the validity of existing health information systems and available data sources through expert consultations, the theoretical framework was translated in a data framework with measurable quality indicators. The construction of the data base included sampling procedures, data-collection, and several technical and privacy-related aspects of linking and accessing Belgian datasets. RESULTS: To address three dimensions of quality of care, we integrated the chronic care model and cascade of care approach, addressing respectively the structure related quality indicators and the process and outcome related indicators. The corresponding data framework is based on self-collected data at the primary care practice level (using the Assessment of quality of integrated care tool), and linked health insurance data with lab data at the patient level. CONCLUSION: In this study, we have described the transition of a theoretical quality of care framework to a unique multilevel database, which allows assessing the quality of diabetes care, by considering the complete care continuum (process and outcomes) as well as organizational characteristics of primary care practices.

Personal, Social and Cultural Predictors of Intention to Misuse Prescription Stimulants among Medical Students: A Test of the Theory of Triadic Influence.

OBJECTIVE: The misuse of prescription stimulants among students has been identified as a public health problem. To date, most research has focused on individual-level determinants of stimulant misuse, making research on the socio-cultural context of students' misuse a priority. This study aims to test the applicability of the Theory of Triadic Influence, capturing three influence streams (personal, social and cultural) and three causational levels (ultimate, distal and proximal). METHOD: A questionnaire on stimulant misuse was distributed among all bachelor's and master's students from the five Flemish medical faculties. In total, 3159 students participated (48.99% response rate). Data were analyzed using structural equation modeling. RESULTS: Multiple personal (i.e., fear of failure, procrastination, self-perceived ADHD, sensation-seeking, academic stress, controllability), social (i.e., living situation, peer endorsement, social norm) and cultural (i.e., competitive study-environment, financial worries, positive and negative expectancies, attitude) factors were identified as risk factors of misuse intention. The strongest ultimate to distal pathway was found between self-perceived ADHD and positive expectancies, meaning that students who believed they have ADHD, although not diagnosed, were more likely to have positive expectancies about stimulants. Moreover, the strongest distal to proximal pathways were found between expectancies and attitudes toward stimulant misuse (i.e., more positive and fewer negative expectancies were associated with more favorable attitudes). Finally, attitudes were most strongly related to misuse intention. CONCLUSIONS: The current study shows that the TTI is an important framework to understand the risk factors of stimulant misuse among medical students. This study offers a strong basis for prevention initiatives.

Reduced sexual contacts with non-steady partners and less PrEP use among MSM in Belgium during the first weeks of the COVID-19 lockdown: results of an online survey.

OBJECTIVES: To examine changes in the occurrence of physical sex with non-steady partners among men who have sex with men (MSM) in Belgium during the first weeks of the COVID-19 lockdown and associations with sociodemographic factors, sexual practices, drug, alcohol and pre-exposure prophylaxis (PrEP) use. A secondary objective was to explore changes in PrEP use and the need for PrEP follow-up. METHODS: A cross-sectional online survey. The questionnaire was available in Dutch, French and English, between April 10 and 27 (2020), and disseminated via sexual health and lesbian, gay, bisexual, trans, queer or intersex organisations throughout Belgium. Eligibility criteria included being 18 years or older, not being exclusively heterosexual and living or being born in Belgium. RESULTS: The sample included 694 MSM. Physical sex with non-steady partners decreased from 59.1% to 8.9% during the first weeks of the lockdown. Those who had sex with non-steady partners were significantly more likely to be HIV positive, to use PrEP or to have engaged in sexual practices such as group sex, chemsex and sex work before the lockdown, compared with their counterparts. Among those who used PrEP before the lockdown, 47.0% stopped using PrEP, 19.7% used event-driven PrEP and 33.3% used daily PrEP during the lockdown. Almost two-thirds of PrEP users had a PrEP care appointment in the weeks before the lockdown and a minority received follow-up elsewhere or online. Some PrEP users had concerns regarding their follow-up. CONCLUSIONS: MSM in our survey substantially reduced sexual contact with non-steady partners during the first weeks of the COVID-19 lockdown, suggesting that the risk for HIV and STI transmission in this period was low. We recommend ensuring access to sexual health services, such as HIV testing and follow-up for PrEP for the small group having multiple sex partners and engaging in sexual practices such as chemsex, or group sex, even in times of a pandemic threat.

Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014.

INTRODUCTION: Cambodia has achieved significant progress in maternal health, yet remains in the group of countries with the highest maternal mortality ratio in South-East Asia. Extra efforts are needed to improve maternal health through assessing the coverage of maternal health services as a continuum of care (CoC) and identifying the gaps. Our study aims to explore the coverage level of the Optimal CoC by (1) measuring the continuity of optimal antenatal care (ANC), skilled birth attendance (SBA) and optimal post-natal care (PNC), (2) identifying the determinants of dropping out from one service to another and (3) of not achieving the complete CoC. METHOD: The study employed data from the Cambodia Demographic Health Survey 2014. We restricted our analysis to married women who had a live birth in the five years preceding the survey (n = 5678). Bi-variate and multivariate logistic regression were performed using STATA version 14. RESULTS: Almost 50% of women had achieved the complete optimal CoC, while the remaining have used only one or two of the services. The result shows that the level of women's education was positively associated with the use of optimal ANC, the continuation to using optimal PNC and achieving the complete CoC. More power of women in household decision making was also positively associated with receiving the complete CoC. The birth order was negatively associated with achieving the complete CoC, while exposure to the mass media and having health insurance increased the odds of achieving the complete CoC. Household wealth consequently emerged as an influential predictor of dropping out and not achieving the complete CoC. Receiving all different elements of ANC care improved the continuity of care from optimal ANC to SBA and from SBA to optimal ANC. CONCLUSION: The findings urge policy makers to approach maternal health care as a continuum of care with different determinants at each step. Household wealth was found to be the most influential factor, yet the study discovered also other barriers to optimal maternal health care which need to be addressed: future intervention should thus not only aim to increase wealth or health insurance coverage but also stimulate the education of women and empower women to claim power in household decision-making.

The COVID-19 International Student Well-being Study.

As a large international consortium of 26 countries and 110 higher-education institutions (HEIs), we successfully developed and executed an online student survey during or directly after the initial peak of the COVID-19 pandemic. The COVID-19 International Student Well-being Study (C19 ISWS) is a cross-sectional multicountry study that collected data on higher-education students during the COVID-19 outbreak in the spring of 2020. The dataset allows description of: (1) living conditions, financial conditions, and academic workload before and during the COVID-19 outbreak; (2) the current level of mental well-being and effects on healthy lifestyles; (3) perceived stressors; (4) resources (e.g., social support and economic capital); (5) knowledge related to COVID-19; and (6) attitudes toward COVID-19 measures implemented by the government and relevant HEI. The dataset additionally includes information about COVID-19 measures taken by the government and HEI that were in place during the period of data collection. The collected data provide a comprehensive and comparative dataset on student well-being. In this article, we present the rationale for this study, the development and content of the survey, the methodology of data collection and sampling, and the limitations of the study. In addition, we highlight the opportunities that the dataset provides for advancing social science research on student well-being during the COVID-19 pandemic in varying policy contexts. Thus far, this is, to our knowledge, the first cross-country student well-being survey during the COVID-19 pandemic, resulting in a unique dataset that enables high-priority socially relevant research.

Conceptual causal models of socioeconomic status, family structure, family functioning and their role in public health.

Social determinants of health frameworks are standard tools in public health. These frameworks for the most part omit a crucial factor: the family. Socioeconomic status moreover is a prominent social determinant of health. Insofar as family functioning is poorer in poor families and family structure and functioning are linked to health, it is critical to consider the pathways between these four constructs. In this correspondence, we reflect on how empirical studies of this conceptual nexus mirror two causal models. We conclude by reflecting on future directions for research in this field.