Program managers' perspectives on using knowledge to support population health management initiatives in their development towards health and wellbeing systems: a qualitative study.

BACKGROUND: Population health management (PHM) initiatives are more frequently implemented as a means to tackle the growing pressure on healthcare systems in Western countries. These initiatives aim to transform healthcare systems into sustainable health and wellbeing systems. International studies have already identified guiding principles to aid this development. However, translating this knowledge to action remains a challenge. To help address this challenge, the study aims to identify program managers' experiences and their expectations as to the use of this knowledge to support the development process of PHM initiatives. METHODS: Semi-structured interviews were held with program managers of ten Dutch PHM initiatives. These Dutch PHM initiatives were all part of a reflexive evaluation study and were selected on the basis of their variety in focus and involved stakeholders. Program managers were asked about their experiences with, and expectations towards, knowledge use to support the development of their initiative. The interviews with the program managers were coded and clustered thematically. RESULTS: Three lessons for knowledge use for the development of PHM initiatives were identified: (1) being able to use knowledge regarding the complexity of PHM development requires (external) expertise regarding PHM development and knowledge about the local situation regarding these themes; (2) the dissemination of knowledge about strategies for PHM development requires better guidance for action, by providing more practical examples of actions and consequences; (3) a collective learning process within the PHM initiative is needed to support knowledge being successfully used for action. CONCLUSIONS: Disseminating and using knowledge to aid PHM initiatives is complex due to the complexity of the PHM development itself, and the different contextual factors affecting knowledge use in this development. The findings in this study suggest that for empirical knowledge to support PHM development, tailoring knowledge to only program managers' use might be insufficient to support the initiatives' development, as urgency for change amongst the other involved stakeholders is needed to translate knowledge to action. Therefore, including more partners of the initiatives in knowledge dissemination and mobilization processes is advised.

How to collaborate for health throughout the project timeline - a longitudinal study reflecting on implemented strategies in three projects for a healthy living environment.

BACKGROUND: When improving the health of local and regional populations, cross-sector collaboration between different policy domains, non-governmental organisations and citizens themselves is needed. Previously, enabling factors and strategies have been identified to improve cross-sector collaboration for health. However, few longitudinal studies have been conducted to understand how the implementation of strategies for cross-sector collaboration changes throughout the collaboration process. The aim of this study is therefore to learn more about the different strategies that were implemented throughout three cross-sector collaboration projects for a healthy living environment. METHODS: The realist evaluation approach was used to understand how the implemented strategies worked, in which context, why and with what outcomes. Project partners were asked to reflect on their implemented strategies at two different moments in the project timelines, and quarterly updates with project leaders were held. In addition two reference panels were organised for data triangulation. RESULTS: Three key insights for successful cross-sector collaboration throughout projects for a healthy living environment were identified, namely 1. Investing in trust among the partners and faith in the project has a positive influence on continuing the collaboration throughout the project; 2. Making stakeholders actively participate throughout the project requires additional strategies after the onset of the project, and 3. Defining roles, tasks, and other prerequisites at the start of the project helps in pursuing the project over time, but needs re-examination throughout the project. These key insights were based on multiple examples of implemented strategies, linked to context, mechanisms and outcomes. CONCLUSIONS: This study shows the different strategies that can be employed as the collaboration in projects for a healthy living environment progresses. We found that 'trust' does not merely include the relationships built between the partners, but at the onset of projects can also be based on faith in the project itself. In addition, as it can be difficult to foresee the right investments and strategies at the onset of the project, frequent reflection moments to choose fitting strategies might benefit regional partners in their cross-sector collaboration for health.

[High and intensive care three years later; an evaluation of the experiences of patients and employees and the effect on coercive measures in psychiatry]. / Drie jaar high en intensive care; evaluatie van ervaringen van cliënten en medewerkers en effect op gebruik van dwang en drang.

BACKGROUND: As part of the national campaign against the use of coercive measures in psychiatry, the Mental Health Service in Eindhoven set up the first modern high and intensive care centre (HIC) in Eindhoven in 2012. AIM: To study the progress of the numbers on coercive measures, and to evaluate the experiences of patients and treatment team members after working for three years according to the HIC model. METHOD: We analysed the registration data, carried out a short survey and conducted interviews. RESULTS: We found that the number of coercive measures used between 2012 and 2015 had declined by 42%. Patients generally had a positive attitude to the treatment they had received. They appreciated the role played by the team and were pleased to have had access to modern technology. Team members had a positive attitude to working with the HIC model. CONCLUSION: The main goals of working according to the new HIC model have been achieved. However, it should be possible to increase cooperation with mobile teams, develop more links with patients' next-of-kin and make wider use of modern technology.

Redesigning mental healthcare delivery: is there an effect on organizational climate?

OBJECTIVE: Many studies have investigated the effect of redesign on operational performance; fewer studies have evaluated the effects on employees' perceptions of their working environment (organizational climate). Some authors state that redesign will lead to poorer organizational climate, while others state the opposite. The goal of this study was to empirically investigate this relation. DESIGN: Organizational climate was measured in a field experiment, before and after a redesign intervention. At one of the sites, a redesign project was conducted. At the other site, no redesign efforts took place. SETTING: Two Dutch child- and adolescent-mental healthcare providers. PARTICIPANTS: Professionals that worked at one of the units at the start and/or the end of the intervention period. INTERVENTION: The main intervention was a redesign project aimed at improving timely delivery of services (modeled after the breakthrough series). MAIN OUTCOME MEASURES: Scores on the four models of the organizational climate measure, a validated questionnaire that measures organizational climate. RESULTS: Our analysis showed that climate at the intervention site changed on factors related to productivity and goal achievement (rational goal model). The intervention group scored worse than the comparison group on the part of the questionnaire that focuses on sociotechnical elements of organizational climate. However, observed differences were so small, that their practical relevance seems rather limited. CONCLUSIONS: Redesign efforts in healthcare, so it seems, do not influence organizational climate as much as expected.

Model fidelity of assertive community treatment for clients with first-episode psychosis: a target group-specific application.

Assertive community treatment (ACT) is described as a team treatment model designed to provide assertive, outreaching, comprehensive, community-based, rehabilitation-oriented and supportive psychiatric services for people with severe mental illness as reported by Drake et al. (Psychiatr Serv 52: 179-182, 2001) and Teague et al. (Psychiatr Serv 68: 216-232, 1998). This study explores variations in the way the original components of ACT are implemented for the target group of clients with a first-episode psychosis, and establishes whether these variations lead the treatment model to a higher, more valuable, outcome level. The study also describes how to achieve this optimally effective application of target group-specific treatment services.

[Assertive Community Treatment for patients with a first episode psychosis. Model fidelity and specific adaptations for particular target groups]. / Assertive Community Treatment bij patiënten met een eerste psychose. Modelgetrouwheid en doelgroepspecifieke aanpassingen.

BACKGROUND: Assertive Community Treatment (ACT) is an evidence-based treatment model, which has been frequently discussed and investigated and which has been used mainly with patients suffering from 'severe mental illness'. It is a pro-active type of treatment involving a multidisciplinary team who provide outreaching and intensive care (treatment, rehabilitation and support). Increasingly, the act model is being used with other target groups such as patients with a first episode psychosis. Frequently act is not being implemented strictly in accordance with the original model. As a result, various combinations of elements of act are being presented. AIM: Primarily to find out whether the original components of act can be varied in such a way that it combines the best possible treatment procedures for the target group of patients suffering from a first episode psychosis. METHOD: Model fidelity was measured and patients and their carers were asked to state to what extent the care provided met their care requirements. The results were used for adaptations of the original model. However, it was assumed from the outset that any variations on the essential elements of the act model could undermine the fundamental principles of act and affect its efficacy. We therefore adhered to the original model as strictly as possible, looking particularly at the care requirements of patients and carers and examining which elements of the model could be used to improve the care of patients with a first episode psychosis. RESULTS AND CONCLUSION: Results show that it is possible to implement the original act model successfully and that patients and caregivers are satisfied with the model. There is strong evidence that the implementation of elements of the act in specific combinations can increase the efficacy of the act when it is applied to special groups of patients, such as those with a first episode psychosis. However, considerable care and caution are called for when act is being adapted in this way for use with special groups of patients.

Communalization of health care: how to do it properly. Criteria for a just communalization of health care applied to the Dutch situation.

Communalization of health care refers to the increasing responsibility of citizens to look after their ill or handicapped fellow members of society and to provide care to them. Governments in Western Europe more and more develop health care policies directed at communalization of health care. The article discusses the care responsibilities of individuals based on the views of the philosophers Buber, Levinas, and Ricoeur and on the views of the family therapist Nagy. The care responsibilities of states are discussed in terms of the views of the political philosophers Rawls and Daniels and these are linked to right liberal, left liberal, and Christian-democrat views on care responsibilities of states. Thereupon, four criteria for a proper communalization of health care are proposed and different forms of health care policies with respect to communalization of care are assessed. In the last section, we look closely at several measures in the just reformed Dutch health care system and discuss how far these measures meet our criteria for a proper communalization. We focus in this section on the effects of these measures on family care because more and more family care plays an important role in good functioning of the health care system.

Key concepts of demand-driven health care; an approach based on client's needs.

In most European countries we are witnessing a shift from supply-driven to demand-driven approaches in health care. According to these approaches, health care should contribute to the fulfillment of health-care-related needs of individuals and, therefore, to their perceived quality of life. The purpose of this study is to develop a conceptual framework for research in this new view of health care. The authors conclude that the 'felt need' should be the foundation of demand-driven care. The second part of the study is based on a widely used behavioral model resulting in a conceptual framework for research, policy and practice. This study makes a start at providing information about fundamental concepts that are at the heart of the demand-driven approach. In order to contribute to quality of life, health care providers should explore the underlying needs while developing services in order to fit the demand-driven approach.

The development of alcohol consumption and problem drinking in Rotterdam 1980-1994: more problem drinking amongst the young and the middle aged.

In 1980/1981 and in 1994, two surveys on problem drinking were conducted in the city of Rotterdam. This article presents data on changes in alcohol consumption and alcohol-related problems between 1981 and 1994. Special attention has been paid to possible shifts in groups at risk and to shifts in the kind of problems experienced. It was found that, in 1994, compared to 1981, problem drinking had become more prevalent amongst the young and the middle aged.

Comparing the diagnostic accuracy of carbohydrate-deficient transferrin, gamma-glutamyltransferase, and mean cell volume in a general practice population.

In certain populations, the biological alcohol marker carbohydrate-deficient transferrin (CDT) is known to have a high diagnostic accuracy. The aim of this study was to compare the diagnostic accuracy of CDT, gamma-glutamyltransferase (gamma-GT), and mean cell volume (MCV) in a general practice population; more specifically, to ascertain whether CDT is a better tool than gamma-GT and MCV for (early) recognition of excessive alcohol use. To represent the general practice situation as realistically as possible, three different drinking patterns are defined: irregular excessive, regular excessive, and very excessive. From a sample of 524 men from seven general practices, sensitivity, specificity, and predictive values of the three markers for the three drinking patterns were compared, and receiver-operating characteristic analysis was used to compare differences between the markers. The results indicate that drinking patterns do influence the (difference in) diagnostic accuracy. CDT has a higher diagnostic accuracy for all three drinking patterns than gamma-GT and higher predictive values for hazardous [(ir)regular excessive] drinking patterns than MCV. However, receiver-operating characteristic analyses failed to demonstrate a significant difference between these patterns. It is concluded that the performance of all tests is too low to be useful for screening procedures in a general population; however, some tests may be useful for case finding. CDT seems to be the best alcohol marker available, although the difference between CDT and MCV is small.

Drinking patterns and attitudes toward drinking in the late-middle-aged.

The main objective of this study was to gain insight into attitudes toward drinking, drinking patterns and the relationship between attitudes and drinking patterns in the population in the age range 55 to 69. Respondents over 55 years of age were compared to those below 55. The former ones were more likely to be abstainers and less tolerant toward others' drinking. Being tolerant toward others' drinking was negatively associated with abstaining from alcohol. Some differences were observed between being tolerant toward drinking patterns of men, women, or relatives, and own drinking behavior.

Alcohol consumption, alcohol-related problems, problem drinking, and socioeconomic status.

In general, a lower socioeconomic status (SES) is related to a lower health status, more health problems, and a shorter life expectancy. Although causal relations between SES and health are unclear, lifestyle factors play an intermediate role. The purpose of the present study was to obtain more insight into the relation between SES, alcohol consumption, alcohol-related problems, and problem drinking, through a general population survey among 8000 people in Rotterdam. Odds ratios were calculated using educational level as independent, and alcohol consumption, alcohol-related problems, and problem drinking as dependent variables. Abstinence decreased significantly by increasing educational level for both sexes. For men, excessive drinking, and notably very excessive drinking, was more prevalent in the lowest educational group. For women, no significant relation between educational level and prevalence of excessive drinking was found. After controlling for differences in drinking behaviour, among men the prevalence of 'psychological dependence' and 'social problems' was higher in intermediate educational groups, whereas prevalence of 'drunkenness' was lower in intermediate educational groups. For women, a negative relation was found between educational level and 'psychological dependence'; prevalence of 'symptomatic drinking' was higher in the lowest educational group. Prevalence of problem drinking was not related to educational level in either sex. It is concluded that differences exist between educational levels with respect to abstinence, but only limited differences were found with respect to excessive drinking. Furthermore, there is evidence for higher prevalences of alcohol-related problems in lower educational levels, after controlling for differences in drinking behaviour, in both sexes.

Aggregate comparisons of self-reported versus nonself-reported drinking in a general population survey.

Insight is gained into the validity of self-reported drinking in the general population by comparing self-reports and nonself-reports on the aggregate level. Married and cohabiting respondents of a general population survey (N = 2,169) were asked about both their own and their spouses' drinking behavior. It was found that on the aggregate level, distribution of "moderate" drinking and usual frequency of drinking is similar between self- and nonself-reports. Self-reported "heavy" drinking, however, is lower than nonself-reported "heavy" drinking among women in general, older women, and women with a lower education. Among men in general and older men in particular, however, self-reported occasional "heavy" drinking was found to be higher. The similar distribution of "moderate" drinking and usual frequency of drinking between self- versus nonself-reports gives reassurance about the validity of self-reported drinking behavior. The discordance in self-reported versus nonself-reported "heavy" drinking, however, raises questions about the validity. Interpretation of the discordance is not conclusive: more research (experimental and qualitative) has to be done to disentangle this issue.

The specificity of the CDT assay in general practice: the influence of common chronic diseases and medication on the serum CDT concentration.

Early recognition of alcohol problems by general practitioners might be enhanced by the use of better alcohol markers. Several studies have revealed promising results for the carbohydrate-deficient transferrin (CDT) assay in certain populations. The aim of our study was to examine the specificity of the CDT assay in a general practice population. The main research question was whether common chronic diseases and/or the accompanying prescribed drugs have a negative influence on the specificity of the CDT assay. The 524 men who participated were selected from seven general practices and were suffering from one or more of the following diseases: hypertension, asthma/bronchitis, diabetes mellitus, adipositis/lipid metabolism disorder, angina pectoris, depression, and disorders of the digestive tract. None of the studied diseases or of the accompanying prescribed drugs had an influence on the specificity of the CDT assay. The overall specificity in this general practitioner population was 0.92. It can be concluded that the studied diseases do not bear an influence on the serum CDT concentration, and that, therefore, the CDT assay is a highly specific instrument for use in assessing alcohol consumption in general practice patients.

Mode effects on self-reported alcohol use and problem drinking: mail questionnaires and personal interviewing compared.

OBJECTIVE: Much attention is paid to the influence of different data collection methods on the quality of self-reported drinking behavior estimates. Thus far, however, the findings show inconsistencies. Therefore, a comprehensive study was conducted to compare data on alcohol use and alcohol-related problems obtained by mail survey and personal interviews. METHOD: A general population survey on alcohol was conducted among a random sample of 8,000 Dutch inhabitants of Rotterdam aged 16 to 69. A small sample (n = 500) of the total sample (N = 8,000) was personally interviewed and the others (n = 7,500) received a mailed questionnaire. The response rate was 44% (N = 3,537). Respondents of the mail survey and personal interviews are compared on overall response rate, item-nonresponse rate, background factors, self-reported alcohol use, alcohol-related problems and problem drinking. RESULTS: No notable differences in self-reported alcohol use, alcohol-related problems or problem drinking were found by data collection mode. This holds for both the total general population and for men and women separately. The overall response rate was somewhat higher for the personal interviews. No important significant differences were found in item nonresponse or background factors. CONCLUSIONS: The absence of notable differences in estimated self-reported drinking behavior by mail survey and personal interviews indicates that both data collection methods yield comparable results. This is true for both the total population and for men and women separately.

Social climate on alcohol in Rotterdam, The Netherlands: public opinion on drinking behaviour and alcohol control measures.

Research was undertaken regarding the Dutch climate on alcohol in 1994 and results were compared with earlier findings. It was found that the social climate on alcohol in The Netherlands can be characterized by 'moderation'. Over the years, drinking without problems has become more acceptable (and is even encouraged at times) whereas excessive drinking and consequent problems still meet strong disapproval. Opinions concerning alcohol control measures mirror this attitude. Measures such as the restriction of drinking in public places and raising the age limits are endorsed by the public. However, more people are now against restrictions on the general availability of alcohol. Although drink-driving has decreased over the years, its prevalence is still high, especially among those who are most at risk.

Gender differences in alcohol-related problems: controlling for drinking behaviour.

AIMS: Two hypotheses were tested to explain a high prevalence of alcohol-related problems among women relative to their low prevalence of excessive drinking: (1) At a given level of drinking, women may report more problems of any type than do men. (2) At a given level of drinking, the number of problems or the severity of the reported problems may be lower among women than among men. DESIGN: General population survey. SETTING: Rotterdam, The Netherlands. PARTICIPANTS: 3537 Dutch respondents within the age range 16-69 years. MEASUREMENTS: Alcohol-related problems were measured in five problem areas: psychological dependence, symptomatic drinking, social problems, health problems/accidents and frequent drunkenness/hangovers. A problem index was formed by adding up the scores in the five separate problem areas. Alcohol use was measured by the Quantity-Frequency-Variability index. FINDINGS: For the same level of drinking, women were as likely as men to report alcohol-related problems except that women light drinkers were actually less likely to report problems than men. Men tended to have a greater accumulation of different types of problems within drinking categories than women. Overall problem severity, however, did not differ between men and women. The apparent excess prevalence of alcohol problems in women relative to drinking level appears to be due to presence of problems even among light drinkers and a greater preponderance of light drinkers in women than men. CONCLUSIONS: The first hypothesis was rejected; drinking levels being the same, the level of alcohol problems is the same or even lower for women than for men. As hypothesized, men tend to have a greater accumulation of different kinds of problems than women. However, the severity of the reported problems does not differ between men and women.

Alcohol use and problem drinking: prevalences in the general Rotterdam population.

Research was done on the distribution of abstinence, excessive drinking, alcohol-related problems, and problem drinking among the general population of Rotterdam, Netherlands in 1994. Prevalences are assessed among the total population and subpopulations defined by sex, age, marital status, educational level, daily activities, and income. A general population survey was conducted among a random sample of 8,000 Dutch inhabitants of Rotterdam in the 16-69 age range. The response rate was 44% (N = 3,537). The majority of the respondents were "light" or "moderate" drinkers. Prevalences of excessive drinking, alcohol-related problems (1 or more), and problem drinking in the total population were 8, 28, and 9%, respectively. It is shown that women tend to report many alcohol-use-related problems considering their relatively low consumption pattern; young men have a high prevalence of problem drinking; being single, being unemployed, and being declared unfit to work are associated with problematic drinking. The results found for socioeconomic status appear to be inconsistent.

Socio-economic differences in general practitioner and outpatient specialist care in The Netherlands: a matter of health insurance?

Equal treatment for equal needs, irrespective of socio-economic position, is a major issue in many countries. Although in the Netherlands differences in utilization of health care between population groups are less pronounced than in most other countries, some differences by socio-economic position do exist. Controlling for health status, individuals with a high socio-economic status have a higher probability of outpatient contacts with a specialist, but a lower probability of general practitioner contacts, compared with those with a low socioeconomic status. In this cross-sectional study, we studied whether socio-economic differences in GP and outpatient specialist care utilization that exist after health status is taken into account could be explained by different aspects of health insurance. The study population, in which people with asthma and chronic obstructive pulmonary disease (COPD), diabetes mellitus, severe back complaints, and heart diseases are overrepresented, consists of 2867 respondents. Multivariate analyses show that the socio-economic differences in outpatient specialist contacts cannot be explained by differences in health insurance, whereas differences in general practitioner contacts can partially be explained by the fact that individuals with higher socio-economic status more often have a private (instead of public) insurance. This is not owing to differences in deductible or insurance coverage between public and private insurance, but is more likely to be caused by differences in regulatory aspects between these two insurance schemes (such as the stronger gate-keeper role of the general practitioner in the public insurance scheme.