Does health literacy mediate the relationship between socioeconomic status and health related outcomes in the Belgian adult population?

BACKGROUND: Health literacy (HL) has been put forward as a potential mediator through which socioeconomic status (SES) affects health. This study explores whether HL mediates the relation between SES and a selection of health or health-related outcomes. METHODS: Data from the participants of the Belgian health interview survey 2018 aged 18 years or older were individually linked with data from the Belgian compulsory health insurance (n = 8080). HL was assessed with the HLS-EU-Q6. Mediation analyses were performed with health behaviour (physical activity, diet, alcohol and tobacco consumption), health status (perceived health status, mental health status), use of medicine (purchase of antibiotics), and use of preventive care (preventive dental care, influenza vaccination, breast cancer screening) as dependent outcome variables, educational attainment and income as independent variables of interest, age and sex as potential confounders and HL as mediating variable. RESULTS: The study showed that unhealthy behaviours (except alcohol consumption), poorer health status, higher use of medicine and lower use of preventive care (except flu vaccination) were associated with low SES (i.e., low education and low income) and with insufficient HL. HL partially mediated the relationship between education and health behaviour, perceived health status and mental health status, accounting for 3.8-16.0% of the total effect. HL also constituted a pathway by which income influences health behaviour, perceived health status, mental health status and preventive dental care, with the mediation effects accounting for 2.1-10.8% of the total effect. CONCLUSIONS: Although the influence of HL in the pathway is limited, our findings suggest that strategies for improving various health-related outcomes among low SES groups should include initiatives to enhance HL in these population groups. Further research is needed to confirm our results and to better explore the mediating effects of HL.

Anxiety and depression in people with post-COVID condition: a Belgian population-based cohort study three months after SARS-CoV-2 infection.

PURPOSE: Since the onset of the COVID-19 pandemic, most research has focused on the management of the acute symptoms of the disease. Yet some people tend to experience symptoms beyond the acute phase, defined as Post-COVID-19 Condition (PCC). This study aims to assess the impact of COVID-19 and PCC on anxiety and depression. METHODS: This is a prospective longitudinal cohort study among the Belgian adult population with recent SARS-CoV-2 infection for which contact tracing was initiated. A total of 3127 people were followed-up just after their infection and three months later (from April 2021 to January 2022). Anxiety and depression were assessed at the two stages using the GAD-7 (Generalized Anxiety Disorder) and the PHQ-9 (Patient Health Questionnaire). RESULTS: Three months after infection, participants with PCC (50%) had an increased probability of having both anxiety and depressive symptoms (p < 0.001). The proportion with anxiety and depressive symptoms at three months were significantly higher in people with PCC (11% and 19%) compared to people without persistent COVID symptoms (3.8% and 4.2%) and to a matched sub-sample not infected with SARS-CoV-2 (6.5% and 4.3%). Having at least one acute COVID-19 symptom (p < 0.001), experiencing financial loss following the infection (p < 0.001), and different PCC symptoms were associated with anxiety and depressive symptoms worsening over time. CONCLUSIONS: This study showed that three months after a SARS-CoV-2 infection, one in two people suffer from PCC with significant consequences for their mental health. Follow-up on mental health must therefore have an important place in people suffering from PCC.

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study.

BACKGROUND: Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia. METHODS: Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country's income level. RESULTS: As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly. CONCLUSIONS: This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.

Unit Response and Costs in Web Versus Face-To-Face Data Collection: Comparison of Two Cross-sectional Health Surveys.

BACKGROUND: Potential is seen in web data collection for population health surveys due to its combined cost-effectiveness, implementation ease, and increased internet penetration. Nonetheless, web modes may lead to lower and more selective unit response than traditional modes, and this may increase bias in the measured indicators. OBJECTIVE: This research assesses the unit response and costs of a web study versus face-to-face (F2F) study. METHODS: Alongside the Belgian Health Interview Survey by F2F edition 2018 (BHISF2F; net sample used: 3316), a web survey (Belgian Health Interview Survey by Web [BHISWEB]; net sample used: 1010) was organized. Sociodemographic data on invited individuals was obtained from the national register and census linkages. Unit response rates considering the different sampling probabilities of both surveys were calculated. Logistic regression analyses examined the association between mode system and sociodemographic characteristics for unit nonresponse. The costs per completed web questionnaire were compared with the costs for a completed F2F questionnaire. RESULTS: The unit response rate is lower in BHISWEB (18.0%) versus BHISF2F (43.1%). A lower response rate was observed for the web survey among all sociodemographic groups, but the difference was higher among people aged 65 years and older (15.4% vs 45.1%), lower educated people (10.9% vs 38.0%), people with a non-Belgian European nationality (11.4% vs 40.7%), people with a non-European nationality (7.2% vs 38.0%), people living alone (12.6% vs 40.5%), and people living in the Brussels-Capital (12.2% vs 41.8%) region. The sociodemographic characteristics associated with nonresponse are not the same in the 2 studies. Having another European (OR 1.60, 95% CI 1.20-2.13) or non-European nationality (OR 2.57, 95% CI 1.79-3.70) compared to a Belgian nationality and living in the Brussels-Capital (OR 1.72, 95% CI 1.41-2.10) or Walloon (OR 1.47, 95% CI 1.15-1.87) regions compared to the Flemish region are associated with a higher nonresponse only in the BHISWEB study. In BHISF2F, younger people (OR 1.31, 95% CI 1.11-1.54) are more likely to be nonrespondents than older people, and this was not the case in BHISWEB. In both studies, lower educated people have a higher probability of being nonrespondent, but this effect is more pronounced in BHISWEB (low vs high education level: Web, OR 2.71, 95% CI 2.21-3.39 and F2F OR 1.70, 95% CI 1.48-1.95). The BHISWEB study had a considerable advantage; the cost per completed questionnaire was almost 3 times lower (€41 [US $48]) compared with F2F data collection (€111 [US $131]). CONCLUSIONS: The F2F unit response rate was generally higher, yet for certain groups the difference between web and F2F was more limited. Web data collection has a considerable cost advantage. It is therefore worth experimenting with adaptive mixed-mode designs to optimize financial resources without increasing selection bias (eg, only inviting sociodemographic groups who are keener to participate online for web surveys while continuing to focus on increasing F2F response rates for other groups).

Mental health, compliance with measures and health prospects during the COVID-19 epidemic: the role of health literacy.

BACKGROUND: The importance of health literacy in dealing with the COVID-19 epidemic has been emphasized but scarcely addressed empirically. In this study, the association of health literacy with mental health, compliance with COVID-19 preventive measures and health prospects was assessed in a Belgian context. METHODS: Data were extracted from the third of a series of cross-sectional online COVID-related surveys (n = 32,794). Data collection took place for 1 week starting the 28th of May 2020. People residing in Belgium and aged 18 years or older could participate. Data were collected on sociodemographic background, health literacy, multimorbidity, mental health (depression, anxiety, sleeping disorder, vitality), knowledge about COVID-19, compliance with COVID-19 measures (hygiene, physical distance, covering mouth and nose on public transport and in places where physical distance cannot be respected), and health prospects (risk for health when returning to normal life and possibility of infection). Prevalence Ratio (PR) of poor mental health, non-compliance with the measures and health prospects in relation to health literacy were calculated using Poisson regressions. RESULTS: People showing sufficient health literacy were less likely to suffer from anxiety disorders (PR = 0.47, 95% CI = [0.42-0.53]), depression (PR = 0.46, 95% CI = [0.40-0.52]) and sleeping disorders (PR = 0.85, 95% CI = [0.82-0.87]), and more likely to have optimal vitality (PR = 2.41, 95% CI = [2.05-2.84]) than people with low health literacy. They were less at risk of not complying with the COVID-19 measures (PR between 0.60 and 0.83) except one (covering mouth and nose in places where physical distance cannot be respected). Finally, they were less likely to perceive returning to normal life as threatening (PR = 0.70, 95% CI = [0.65-0.77]) and to consider themselves at risk of an infection with COVID-19 (PR = 0.75, 95% CI = [0.67-0.84]). The associations remained significant after controlling for COVID-19 knowledge and multimorbidity. CONCLUSIONS: These results suggest that health literacy is a crucial factor in managing the COVID-19 epidemic and offer a perspective for future studies that target health literacy in the context of virus outbreaks.

Mixing mixed-mode designs in a national health interview survey: a pilot study to assess the impact on the self-administered questionnaire non-response.

BACKGROUND: Many population health surveys consist of a mixed-mode design that includes a face-to-face (F2F) interview followed by a paper-and-pencil (P&P) self-administered questionnaire (SAQ) for the sensitive topics. In order to alleviate the burden of a supplementary P&P questioning after the interview, a mixed-mode SAQ design including a web and P&P option was tested for the Belgian health interview survey. METHODS: A pilot study (n = 266, age 15+) was organized using a mixed-mode SAQ design following the F2F interview. Respondents were invited to complete a web SAQ either immediately after the interview or at a later time. The P&P option was offered in case respondents refused or had previously declared having no computer access, no internet connection or no recent usage of computers. The unit response rate for the web SAQ and the overall unit response rate for the SAQ independent of the mode were evaluated. A logistic regression analysis was conducted to explore the association of socio-demographic characteristics and interviewer effects with the completed SAQ mode. Furthermore, a logistic regression analysis assessed the differential user-friendliness of the SAQ modes. Finally, a logistic multilevel model was used to evaluate the item non-response in the two SAQ modes while controlling for respondents' characteristics. RESULTS: Of the eligible F2F respondents in this study, 76% (107/140) agreed to complete the web SAQ. Yet among those, only 78.5% (84/107) actually did. At the end, the overall (web and P&P) SAQ unit response rate reached 73.5%. In this study older people were less likely to complete the web SAQ. Indications for an interviewer effect were observed as regard the number of web respondents, P&P respondents and respondents who refused to complete the SAQ. The web SAQ scored better in terms of user-friendliness and presented higher item response than the P&P SAQ. CONCLUSIONS: The web SAQ performed better regarding user-friendliness and item response than the P&P SAQ but the overall SAQ unit response rate was low. Therefore, future research is recommended to further assess which type of SAQ design implemented after a F2F interview is the most beneficial to obtain high unit and item response rates.

Contribution of chronic conditions to smoking differences in life expectancy with and without disability in Belgium.

Background: Smoking is the leading cause of premature mortality and morbidity. This study aimed at assessing the impact of smoking on life expectancy (LE) and LE with (LED) and without disability (DFLE). We further estimated the contribution of disability and mortality and their causes to differences in LED and DFLE by smoking. Methods: Data on disability, chronic conditions, and smoking from 17 148 participants of the 1997, 2001, 2004 Belgian Health Interview Surveys were used to estimate causes of disability using the attribution method. A 10-year mortality follow-up of survey participants was used. The Sullivan method was applied to estimate LED and DFLE. The contribution of disability and mortality and of causes of disability and death to smoking differences in LED and DFLE was assessed using decomposition methods. Results: Never smokers live longer than daily smokers. DFLE advantage at age 15 of +8.5/+4.3 years (y) in men/women never compared with daily smokers was the result of lower mortality (+6.2y/+3y) and lower disability (2.3y/1.3y). The extra 0.3y/1.6y LED in never smokers was due to lower mortality (+2.6y/+2.9y) and lower disability (-2.3y/-1.3y). Lower mortality from lung/larynx/trachea cancer, chronic respiratory, and ischaemic heart diseases was the main contributor to higher LED and DFLE in never smokers. Lower disability from musculoskeletal conditions in men and chronic respiratory diseases in women increased LED and DFLE in never smokers. Conclusions: Mortality and disability advantage among never smokers contributed to longer DFLE, while mortality advantage contributed to their longer LED.

Additional weighting for education affects estimates from a National Health Interview Survey.

Background: National Health Interview Surveys are used to produce country-wide results for a substantial number of health indicators. However, if some educational groups are underrepresented in the sample, estimates may be biased. This study investigated the impact of the use of post-stratification weights that adjust for the population distribution by education on estimates from the Belgian Health Interview Survey 2013. Methods: For 25 health-related indicators that match the European Core Health Indicator shortlist, estimates were computed using two different sets of post-stratification weights: one based on age group, gender and province only and the other one including also education. The Census 2011 was used as auxiliary data source. Statistical differences between the two estimates were assessed with the Delta method. Results: If education is not included as post-stratification weighting factor, low educational groups (ISCED 0-2) represent 31.1% of the total study population aged 25 years and older. If education is taken into account this proportion rises to 40.3%. The use of post-stratification weights adjusting for the population distribution by education has an impact on several survey estimates. The most pronounced effect is an increase in the estimated proportion of people with diabetes (+0.73%; 95% CI 0.19-1.27; relative increase +11.6%), asthma (+0.52%; 95% CI, 0.06-0.98; relative increase +12.4%) and difficulties to cover their health expenses (+2.31%; 95% CI, 1.52-3.10; relative increase +9.4%). Conclusions: Including education in the calculation of post-stratification weights reduces bias due to educational differences in survey participation. Auxiliary information used to calculate post-stratification weights for national health surveys should include education.

Prevalence of SARS-CoV-2 antibodies and associated factors in the adult population of Belgium: a general population cohort study between March 2021 and April 2022.

BACKGROUND: This study assessed seroprevalence trends of SARS-CoV-2 antibodies in the Belgian adult population between March 2021 and April 2022, and explored factors associated with seropositivity and seroreversion among the vaccinated and unvaccinated population. METHODS: A prospective longitudinal surveillance study was conducted within a random sample of the general population (18 + years) in Belgium, selected from the national register through a multistage sampling design. Participants provided a saliva sample and completed a survey questionnaire on three occasions: at baseline and in two follow-up waves. Outcome variables included (1) seropositivity, defined as the presence of SARS-CoV-2 antibodies, assessed with a semi-quantitative measure of anti-RBD (Receptor Binding Domain) IgG ELISA and (2) seroreversion, defined as passing from a positive to a negative antibody test between two measurements. Trends in SARS-CoV-2 antibody prevalence were assessed using binary logistic regression with contrasts applying post-stratification. Potential determinants of seropositivity were assessed through multilevel logistic regressions. RESULTS: In total 6,178 valid observations were obtained from 2,768 individuals. SARS-CoV-2 antibody prevalence increased from 25.1% in the beginning of the study period to 92.3% at the end. Among the vaccinated population, factors significantly associated with higher seropositivity rates were being younger, having a bachelor diploma, living with others, having had a vaccine in the last 3 months and having received a nucleic-acid vaccine or a combination. Lower seropositivity rates were observed among vaccinated people with a neurological disease and transplant patients. Factors significantly associated with higher seropositivity rates among the unvaccinated population were having non-O blood type and being non-smoker. Among vaccinated people, the seroreversion rate was much lower (0.3%) in those who had received their latest vaccine in the last 3 months compared to those who had received their latest vaccine more than 3 months ago (2.7%) (OR 0.13; 95%CI 0.04-0.42). CONCLUSIONS: The rapid increase in antibody seropositivity in the general adult population in Belgium during the study period was driven by the vaccination campaign which ran at full speed during this period. Among vaccinated people, seropositivity varied in function of the time since last vaccine, the type of vaccine, sociodemographic features and health status.

Household composition and suicidal behaviour in the adult population of Belgium.

PURPOSE: We aimed to estimate the prevalence of suicidal behaviours, i.e. ideation and attempt, in the adult population of Belgium, and to explore their association with household composition. METHODS: Data of 4,459 adults (25-64 years) from the 2004 Belgian Health Interview Survey were used for analyses. Bivariate and multivariate logistic regressions were used to calculate the odds of engaging in suicidal behaviours according to household type, further controlling for age, sex, income, employment status and social support. RESULTS: Lifetime prevalence of ideation and attempts was 14 and 4.7 %, respectively. Current prevalence of ideation was 4.0 % and past year prevalence of attempts was 0.5 %. Compared to other household compositions, living alone (A) and as lone parent (P) increased the odds of lifetime and current suicidal thoughts (ORA 2.3, 95 % CI 1.7-2.9 and ORP 3.8, 95 % CI 1.9-7.7) and lifetime attempts (ORA 2.3, 95 % CI 1.4-3.6 and ORP 4.5, 95 % CI 2.4-8.5). When controlling for confounders, single person and single parent households still presented increased adjusted-odds of lifetime and current suicidal thoughts (a-ORA 1.8, 95 % CI 1.1-2.9 and a-ORP 2.3, 95 % CI 1.0-5.5). The likelihood of ever attempted suicide was also higher among single parent households (a-ORP 4.5, 95 % CI 2.4-8.5) after adjustment, but not among those living alone (a-ORA 1.4, 95 % CI 0.8-2.8). CONCLUSION: Living alone or as lone parent place adults at higher risk for suicide behaviour, and this is only partly explained by lower socio-economic status or poor perceived support.

Data collection in pandemic times: the case of the Belgian COVID-19 health surveys.

BACKGROUND: Survey data were needed to assess the mental and social health, health related behaviors and compliance with preventive measures of the population during the COVID-19 pandemic. Yet, the pandemic challenged classical survey methods. Time and budgetary constraints at the beginning of the pandemic led to ad hoc recruitment of participants and easily manageable data collection modes. This paper describes the methodological choices and results in terms of participation for the COVID-19 health surveys conducted in Belgium. METHODS: The COVID-19 health surveys refer to a series of ten non-probability web surveys organized between April 2020 and March 2022. The applied recruitment strategies were diverse including, amongst others, a launch through the website and the social media of the organizing research institute. In addition, the survey links were shared in articles published in the national press and participants were requested to share the surveys in their network. Furthermore, participants were asked consent to be re-contacted for next survey editions using e-mail invitations. RESULTS: These mixed approaches allowed to reach a substantial number of participants per edition ranging from 49339 in survey 1 to 13882 in survey 10. In addition, a longitudinal component was created; a large share of the same individuals were followed up over time; 12599 participants completed at least 5 surveys. There were, however, sex, age, educational level and regional differences in participation. Post-stratification weighting on socio-demographic factors was applied to at least partly take this into account. CONCLUSION: The COVID-19 health surveys allowed rapid data collection after the onset of the pandemic. Data from these non-probability web surveys had their limitations in terms of representativeness due to self-selection but were an important information source as there were few alternatives. Moreover, by following-up the same individuals over time it was possible to study the effect of the different crisis phases on, amongst others, the mental health. It is important to draw lessons from these experiences: initiatives in order to create a survey infrastructure better equipped for future crises are needed.

Domestic violence during the COVID-19 confinement: do victims feel more socially isolated?

BACKGROUND: Since March 13th 2020, confinement measures have been introduced in Belgium to curb the spread of the coronavirus (COVID-19). These measures also have an impact on people's daily life (closure of school/businesses, teleworking, recommendation to stay at home). This can cause stress on social, economic and psychological levels and thereby can trigger domestic violence. Besides, confinement also fosters social isolation, which can complicate help seeking behaviour. The aim of this study is to determine the prevalence of domestic violence during the coronavirus crisis and to assess whether there is an association between domestic violence and social isolation. METHODS: Several online COVID-19 Health Surveys were organised among Belgian residents aged 18+ via snowball sampling. This study is based on the second (April 2020) and the sixth survey (March 2021). After excluding 1-person households and missing data, the sample size was respectively 25,251 and 12,589. Weighted prevalence of domestic violence was evaluated for the two surveys. The association (OR; 95% CI; p-value) between domestic violence and subjective social isolation was assessed with logistic regression stratified by survey and adjusted for covariates. RESULTS: In April 2020, 4.0% of the adult population reported being a victim of domestic violence (1.2% in the Health Interview Survey 2018); in March 2021, this was 6.2%. In April 2020, victims of domestic violence had higher odds of being unsatisfied with their social contacts (OR = 1.25; 95% CI: 1.08-1.44; p < .05), weak social support (OR = 2.26; 95% CI: 1.97-2.58; p < .0001) and having less confidence in health care services (OR = 1.38; 95% CI: 1.13-1.71; p < .05). In March 2021, victims had higher odds of being unsatisfied with their social contacts (OR = 1.30; 95% CI: 1.08-1.56; p < .05) and weak social support (OR = 2.41; 95% CI: 2.04-2.84; p < .0001), and social (OR = 2.64; 95% CI: 2.23-3.13; p < .0001) and emotional loneliness (OR = 2.22; 95% CI: 1.80-2.73; p < .0001). CONCLUSIONS: More people have reported domestic violence since the start of the coronavirus crisis than did in 2018. An association between domestic violence and social isolation was determined. Although confinement is needed to counteract the virus, it can put people in a dangerous situation since they do not get the help they need. Therefore, adequate support is essential.

Prevalence of Anti-SARS-CoV-2 Antibodies and Potential Determinants among the Belgian Adult Population: Baseline Results of a Prospective Cohort Study.

The prevalence of anti-SARS-CoV-2 antibodies and potential determinants were assessed in a random sample representative of the Belgian adult population. In total, 14,201 individuals (≥18 years) were invited by mail to provide saliva via an Oracol® swab. Survey weights were applied, and potential determinants were estimated using multivariable logistic regressions. Between March and August 2021, 2767 individuals participated in the first data collection. During this period, which coincided with the onset of the vaccination campaign, the seroprevalence in the population increased from 25.2% in March/April to 78.1% in July. Among the vaccinated there was an increase from 74,2% to 98.8%; among the unvaccinated, the seroprevalence remained stable (around 17%). Among the vaccinated, factors significantly associated with the presence of antibodies were: having at least one chronic disease (ORa 0.22 (95% CI 0.08-0.62)), having received an mRNA-type vaccine (ORa 5.38 (95% CI 1.72-16.80)), and having received an influenza vaccine in 2020-2021 (ORa 3.79 (95% CI 1.30-11.07)). Among the unvaccinated, having a non-O blood type (ORa 2.00 (95% CI 1.09-3.67)) and having one or more positive COVID-19 tests (ORa 11.04 (95% CI 4.69-26.02)) were significantly associated. This study provides a better understanding of vaccine- and/or natural-induced presence of anti-SARS-CoV-2 antibodies and factors that are associated with this presence.

Anxiety and Depression in Belgium during the First 15 Months of the COVID-19 Pandemic: A Longitudinal Study.

The COVID-19 pandemic and policy measures enacted to contain the spread of the coronavirus have had nationwide psychological effects. This study aimed to assess the impact of the first 15 months of the COVID-19 pandemic on the level of anxiety (GAD-7 scale) and depression (PHQ-9 scale) of the Belgian adult population. A longitudinal study was conducted from April 2020 to June 2021, with 1838 respondents participating in 6 online surveys. Linear mixed models were used to model the associations between the predictor variables and the mental health outcomes. Results showed that the prevalence of symptoms of anxiety and depression was higher in times of stricter policy measures. Furthermore, after the initial stress from the outbreak, coping and adjustment were observed in participants, as symptoms of anxiety and depression decreased during times of lower policy restrictions to almost the same level as in pre-COVID times (2018). Though time trends were similar for all population subgroups, higher levels of both anxiety and depression were generally found among women, young people, people with poor social support, extraverts, people having pre-existing psychological problems, and people who were infected/exposed to the COVID-19 virus. Therefore, investment in mental health treatment programs and supports, especially for those risk groups, is crucial.

COVID-19 and people who use drugs: Impact of the pandemic on general anxiety and depressive disorders among adults in Belgium.

BACKGROUND: During previous pandemics people who use drugs (PWUD) were categorized among the most vulnerable. In the current study, firstly, we wanted to evaluate the impact of the COVID-19 crisis on the prevalence of anxiety and depressive disorders among PWUD. Furthermore, we wanted to compare the prevalence of these disorders with that of members from the general population who did not use drugs. METHODS: We used a matched cohort design based on two separate repeated cross-sectional online surveys (April and November 2020) among PWUD and the general population. Results of GAD-7 and PHQ-9 were used as outcome variables. We calculated absolute and relative risks for matched pairs for both affective disorders, and logistic regression to compare affective disorders over both waves for PWUD. RESULTS: In April, the prevalence of affective disorders was similar for PWUD and the general population. In November, the risks for anxiety disorders increased with 64% for PWUD compared to non-PWUD (RR = 1.64, 95%CI 1.42-1.88), whereas the risks for depressive disorders more than doubled (RR = 2.29, 95%CI 1.97-2.67). Having a job and being male were protective factors for PWUD for both anxiety and depressive disorders. LIMITATIONS: As this study used self-reported data, GAD-7 and PHQ-9 give an indication of the presence of anxiety and depression which might differ from a clinician's judgement. CONCLUSIONS: PWUD might be disproportionally affected by COVID-19. Health care providers should be attentive to substance use as an indicator for increased risk of mental health problems.

Short-term impact of the COVID-19 confinement measures on health behaviours and weight gain among adults in Belgium.

BACKGROUND: In Belgium, confinement measures were introduced on the 13th of March 2020 to curb the spread of the coronavirus disease (COVID-19). These measures may affect health behaviours of the population such as eating habits, physical activity and alcohol consumption, which in turn can lead to weight gain resulting in overweight and obesity, increasing the risk of several chronic diseases, but also of severe COVID-19. The purpose of this study is to assess the impact of confinement measures on health behaviours and their associations with weight gain. METHODS: Data were derived from the second national COVID-19 health survey. Data were collected between the 16th and the 23rd of April 2020. The recruitment of participants was based on snowball sampling via Sciensano's website, invitations via e-mail and social media. The study sample includes participants aged 18 years and over with no missing data on the variables of interest (n = 28,029). The association between self-reported weight gain and health behaviour changes, adjusted for gender, age group and household composition was assessed through OR's (95% CI) calculated with logistic regression models, using post-stratification weights. RESULTS: Overall, 28.6% reported weight gain after 6 weeks of confinement. Higher odds of weight gain were observed among participants who increased or decreased their consumption of sugar-sweetened beverages (OR = 1.39 (1.15-1.68) and 1.29 (1.04-1.60), respectively), among those who increased their consumption of sweet or salty snacks (OR = 3.65 (3.27-4.07)), among those who became less physically active (OR = 1.91 (1.71-2.13)), and among those who increased their alcohol consumption (OR = 1.86 (1.66-2.08)). CONCLUSIONS: The most important correlates of weight gain during confinement were an increased consumption of sweet or salty snacks and being less physically active. These findings confirm the impact of diet and exercise on short term weight gain and plead to take more action, in supporting people to achieve healthier behaviours in order to tackle overweight and obesity, especially during the COVID-19 pandemic.

Multiple risk behaviour: increasing socio-economic gap over time?

BACKGROUND: Unhealthy behaviours often occur in combination. In this study the relationship between education and lifestyle, defined as a cluster of risk behaviours, has been analysed with the purpose to assess socio-economic changes in multiple risk behaviour over time. METHODS: Cross-sectional data from the Belgian Health Interview Surveys 1997, 2001 and 2004 were analysed. This study is restricted to persons aged ≥ 15 years with information on those health behaviours and education (n = 7431, n = 8142 and n = 7459, respectively). A lifestyle index was created based on the sum of the four unhealthy behaviours: smokers vs. non-smokers, risky versus non-risky alcohol use, sedentaryness vs. physically active and poor vs. healthy diet. The lifestyle index was dichotomized as low (0-2) vs. high (3-4). For the assessment of socio-economic inequalities in multiple risk behaviour, summary measures as Odds Ratio (OR) and Relative Index of Inequality (RII) were calculated using logistic regression, stratified by sex. RESULTS: Of the adult population, 7.5% combined three to four unhealthy behaviours. Lower educated men are the most at risk. Besides, the OR among men significantly increased from 1.6 in 2001 to 3.4 in 2004 (P = 0.029). The increase of the OR among women was less pronounced. The RII, on the other hand, did not show any gradient, neither for men nor for women. CONCLUSION: Multiple risk behaviour is more common among lower educated people. An increasing polarization in socio-economic inequalities is assessed from 2001 to 2004 among men. Therefore, health promotion programmes should focus on the lower socio-economic classes and target risk behaviours simultaneously.

Comparing web-based versus face-to-face and paper-and-pencil questionnaire data collected through two Belgian health surveys.

OBJECTIVES: Using the European Health Interview Survey (EHIS) questionnaire, a web-based survey was organized alongside a face-to-face (F2F) survey including a paper-and-pencil (P&P) questionnaire for sensitive topics. Associated with these different modes, other design features varied too (e.g., recruitment, incentives, sampling). We assessed whether these whole data collection systems developed around the modes produced equivalent health estimates. METHODS: Data were obtained from two population-based surveys: the EHISWEB (web-administered, n = 1010) and the Belgian Health Interview Survey 2018 (BHIS2018) (interviewer-administered, n = 2748). Logistic regression analyses were used to assess mode system differences while adjusting for socio-demographic differences in the net samples. RESULTS: For the P&P mode of the BHIS, significant mode system differences were detected for 2 of the 9 health indicators. Among the indicators collected via the F2F mode, 9 of the 18 indicators showed significant differences. CONCLUSIONS: Indicators collected via the web-based and P&P self-administered modes were generally more comparable than indicators collected via the web-based and F2F mode. Furthermore, fewer differences were detected for indicators based on simple and factual questions compared to indicators based on subjective or complex questions.

The Belgian health examination survey: objectives, design and methods.

BACKGROUND: In 2018 the first Belgian Health Examination Survey (BELHES) took place. The target group included all Belgian residents aged 18 years and older. The BELHES was organized as a second stage of the sixth Belgian Health Interview Survey (BHIS). This paper describes the study design, recruitment method and the methodological choices that were made in the BELHES. METHODS: After a pilot period during the first quarter of the BHIS fieldwork, eligible BHIS participants were invited to participate in the BELHES until a predefined number (n = 1100) was reached. To obtain the required sample size, 4918 eligible BHIS participants had to be contacted. Data were collected at the participant's home by trained nurses. The data collection included: 1) a short set of questions through a face-to-face interview, 2) a clinical examination consisting of the measurement of height, weight, waist circumference, blood pressure and for people aged 50 years and older handgrip strength and 3) a collection of blood and urine samples. The BELHES followed as much as possible the guidelines provided in the framework of the European Health Examination Survey (EHES) initiative. Finally 1184 individuals participated in the BELHES, resulting in a participation rate of 24.1%. Results for all the core BELHES measurements were obtained for more than 90% of the participants. CONCLUSION: It is feasible to organize a health examination survey as a second stage of the BHIS. The first successfully organized BELHES provides useful information to support Belgian health decision-makers and health professionals. As the BELHES followed EHES recommendations to a large extent, the results can be compared with those from similar surveys in other EU (European Union) member states.

Determinants of unit nonresponse in multi-mode data collection: A multilevel analysis.

BACKGROUND: Multi-mode data collection is widely used in surveys. Since several modes of data collection are successively applied in such design (e.g. self-administered questionnaire after face-to-face interview), partial nonresponse occurs if participants fail to complete all stages of the data collection. Although such nonresponse might seriously impact estimates, it remains currently unexplored. This study investigates the determinants of nonresponse to a self-administered questionnaire after having participated in a face-to-face interview. METHODS: Data from the Belgian Health Interview Survey 2013 were used to identify determinants of nonresponse to self-administered questionnaire (n = 1,464) among those who had completed the face-to-face interview (n = 8,133). The association between partial nonresponse and potential determinants was explored through multilevel logistic regression models, encompassing a random interviewer effect. RESULTS: Significant interviewer effects were found. Almost half (46.6%) of the variability in nonresponse was attributable to the interviewers, even in the analyses controlling for the area as potential confounder. Partial nonresponse was higher among youngsters, non-Belgian participants, people with a lower educational levels and those belonging to a lower income household, residents of Brussels and Wallonia, and people with poor perceived health. Higher odds of nonresponse were found for interviews done in the last quarters of the survey-year. Regarding interviewer characteristics, only the total number of interviews carried out throughout the survey was significantly associated with nonresponse to the self-administered questionnaire. CONCLUSIONS: The results indicate that interviewers play a crucial role in nonresponse to the self-administered questionnaire. Participant characteristics, interview circumstances and interviewer characteristics only partly explain the interviewer variability. Future research should examine further interviewer characteristics that impact nonresponse. The current study emphasises the importance of training and motivating interviewers to reduce nonresponse in multi-mode data collection.