Trends in educational disparities in preventive behaviours, risk perception, perceived effectiveness and trust in the first year of the COVID-19 pandemic in Germany.

BACKGROUND: Educational disparities in health and health behaviours have always been relevant in public health research and are particularly challenging in the context of the COVID-19 pandemic. First studies suggest that factors important for the containment of the COVID-19 pandemic, such as prevention behaviour, risk perception, perceived effectiveness of containment measures, and trust in authorities handling the pandemic, vary by educational status. This study builds on recent debate by examining trends in absolute and relative educational disparities in these factors in the first year of the COVID-19 pandemic in Germany. METHODS: Data stem from four waves of the GESIS Panel surveyed between March and October 2020 in Germany (15,902 observations from 4,690 individuals). Trends in absolute and relative disparities were examined for preventive behaviour, risk perception, perceived effectiveness of COVID-19 containment measures, and trust in individuals and institutions handling the COVID-19 pandemic by educational status using sex, age, residence, nationality, children under 16 living in household, family status, household size, the Big Five Inventory, and income class as control factors. Descriptive statistics as well as unadjusted and adjusted linear regression models and random effects models were performed. RESULTS: We observed an initially rising and then falling trend in preventive behaviour with consistent and significant absolute and relative disparities with a lower preventive behaviour among low educated individuals. Indication of a U-shaped trend with consistent significantly lower values among lower educated individuals was found for risk perception, whereas perceived effectiveness and trust decreased significantly over time but did not significantly vary by educational status. CONCLUSIONS: Results indicate persistent educational disparities in preventive behaviour and risk perception and a general decline in perceived effectiveness and trust in the first year of the COVID-19 pandemic in Germany. To address this overall downward trend and existing disparities, comprehensive and strategic management is needed to communicate the risks of the pandemic and the benefits of COVID-19 containment measures. Both must be adapted to the different needs of educational groups in particular in order to overcome gaps in preventive behaviour and risk perception by educational status.

Is time a healer? Course of demands during the COVID-19 pandemic in long-term care: a repeated cross-sectional survey in Germany.

In the course of the coronavirus disease 2019 pandemic, long-term nursing care facilities are faced with general and pandemic-specific demands. In our study, we examined their burden from the perspective of managers in long-term nursing care facilities and how it differed in outpatient and inpatient settings. A cross-sectional online survey of long-term care managers was conducted in April 2020 (n = 503) and December 2020/January 2021 (n = 294). Burdens have increased over the course of the pandemic especially for outpatient facilities and in terms of general demands referring to staff (e.g. (staff shortages and overload) and work organization (e.g. compliance with regulations on working hours or staffing ratio). Concerns about infections of people in need of care and of employees remain the highest burden in the course of the pandemic. This knowledge helps us to draw implications from the pandemic and to prepare for future crises.

Will the demands by the covid-19 pandemic increase the intent to quit the profession of long-term care managers? A repeated cross-sectional study in Germany.

The Corona pandemic poses major demands for long-term care, which might have impacted the intention to quit the profession among managers of long-term care facilities. We used cross-sectional data of an online survey of long-term care managers from outpatient and inpatient nursing and palliative care facilities surveyed in April 2020 (survey cycle one; n = 532) and between December 2020 and January 2021 (survey cycle two; n = 301). The results show a significant association between the perceived pandemic-specific and general demands and the intention to leave the profession. This association was significantly stronger for general demands in survey cycle two compared with survey cycle one. The results highlight the pandemic's immediate impact on long-term care. In view of the increasing number of people in need of care and the already existing scarcity of specialized nursing staff, the results highlight the need for initiatives to ensure the provision of long-term care, also and especially in such times of crisis.

Measuring social capital of healthcare organizations reported by employees for creating positive workplaces - validation of the SOCAPO-E instrument.

BACKGROUND: In highly segmented and complex healthcare organizations social capital is assumed to be of high relevance for the coordination of tasks in healthcare. So far, comprehensively validated instruments on social capital in healthcare organizations are lacking. The aim of this work is to validate an instrument measuring social capital in healthcare organizations. METHODS: This validation study is based on a cross-sectional survey of 1050 hospital employees from 49 German hospitals which specialize in breast cancer care. Social capital was assessed by a six-item scale. Reliability analyses and confirmatory factor analyses were conducted to determine the content validity of items within the theory-driven one-dimensional scale structure. The scale's associations with measures of the social aspects of the work environment (identification, social support, open communication climate) were estimated to test convergent validity. Criterion-related validity was evaluated by conducting structural equation modelling to examine the predictive validity of the scale with measures of work engagement, well-being and burnout. RESULTS: A one-dimensional structure of the instrument could be identified (CFI = .99; RMSEA = .06). Convergent validity was shown by hypothesis-consistent correlations with social support offered by supervisors and colleagues, a climate of open communication, and employee commitment to the organization. Criterion-related validity of the social capital scale was proved by its prediction of employee work engagement (R2 = .10-.13 for the three subscales), well-being (R2 = .13), and burnout (R2 = .06-.11 for the three subscales). CONCLUSIONS: The confirmed associations between social capital and work engagement, burnout as well as well-being stress the importance of social capital as a vital resource for employee health and performance in healthcare organizations. In healthcare organizations this short instrument can be used as an efficient instrument to measure the organizations' social capital.

Pflege in Zeiten von COVID-19: Onlinebefragung von Leitungskräften zu Herausforderungen, Belastungen und Bewältigungsstrategien.

Nursing care in times of COVID-19: Online survey of leaders on challenges, burdens, and coping strategies Abstract. Aim: In light of the dynamic developments and consequences of the COVID-19 pandemic for the care of people in need of long-term care the following questions arise: How do leaders of care facilities perceive the challenges, how burdened are they and how do they cope with these? METHODS: Leaders from outpatient and inpatient nursing and hospice care facilities were contacted by e-mail to participate in an online survey. Closed questions were analysed descriptively, open information was analysed by content analysis. RESULTS: From of 4,333 nursing facilities contacted, usable information was available from 525 persons. The greatest pandemic-related, interdependent challenges include concern about infections of patients and employees, procurement of protective equipment, compliance with hygiene regulations, inconsistency and lack of transparency of information and guidelines that are important for work, and loss of income and lead to a cascade of burdens. Around 40 % of respondents are uncertain whether they can cope with these. According to the respondents, the well-being and presenteeism of the leaders surveyed has deteriorated in the course of the pandemic outbreak and they appeared to be more often ill at work. Financial and structural measures, the strengthening of social cohesion and explanation were mentioned as coping strategies. CONCLUSIONS: The results show an increase in challenges and illustrate interdependent pandemic-related burdens. These are mainly met by overtime and additional effort, especially on the part of leaders. It remains unclear what long-term consequences are to be expected from the burden situation.

[DNVF-Memorandum III - Methods for Health Services Research, Part 4 - Concept and Methods for Organizational Health Services Research. Chapter 3 - Methodological Approaches for the Evaluation and Implementation of Complex Interventions in Healthcare Organizations]. / DNVF-Memorandum III ­ Methoden für die Versorgungsforschung, Teil 4 ­ Konzept und Methoden der organisationsbezogenen Versorgungsforschung. Kapitel 3 ­ Methodische Ansätze zur Evaluation und Implementierung komplexer Interventionen in Versorgungsorganisationen.

Organizational health services research is still a relatively young field of research in Germany which is of increasing interest. The German Network Health Services Research e.V. (DNVF e.V.) published in 2009 - supported by expert associations and individual members of the DNVF - a guide on "Methods for organizational health services research" of the Memorandum III, part 1 [1]. Originating from this publication and facilitated by the increasing relevance of the field, a necessity to refine the conceptual and methodological basis became evident. The update and extension of the publication from 2009 consists of three chapters: (1) Definition and concept of organizational health services research, (2) Methodological approaches in organizational health services research: indicators, data sources, data collection and data analysis, (3) Methodological approaches for the design, evaluation and implementation of complex interventions in health care organizations. The aim of the third chapter is to present methods for intervention design, evaluation of effectiveness and efficacy as well as implementation research with particular regard to the organizational context of interventions to improve health care.

[DNVF-Memorandum III - Methods for Health Services Research, Part 4 - Concept and Methods for Organizational Health Services Research: Short Version]. / DNVF-Memorandum III ­ Methoden für die Versorgungsforschung, Teil 4 ­ Konzept und Methoden der organisationsbezogenen Versorgungsforschung: Kurzfassung.

Organizational health services research in Germany is of increasing relevance. Based on the guide on methods for organizational health services research of the Memorandum III, part 1 from the year 2009, the fundamentals and standards have now been refined. The memorandum captures the theoretical framework, basic methodological approaches and methods in health services research for the design, evaluation and implementation of complex interventions in healthcare organizations.

Irritation, General and Pandemic-Related Demands, and the Importance of Workplace Health Promotion in Long-Term Care-Results From a Survey of Managers in Outpatient and Inpatient Long-Term Care Facilities in Germany.

OBJECTIVE: This study examines the association between irritation and demands of long-term care managers during the COVID-19 pandemic, as well as the role of workplace health promotion (WHP). METHODS: Findings were derived from an online survey investigating long-term care managers as part of the employees in the COVID-19 pandemic (N = 207). Data analyses were performed with linear regression and interaction analyses. RESULTS: For managers in long-term care, there was found a significant positive association between pandemic-related and general demands and irritation. The irritation level was significantly lower among managers in facilities where WHP was offered whereas the association between irritation and demands did not significantly vary by WHP. CONCLUSIONS: The presence of WHP was associated with lower average irritation levels among managers during the COVID-19 pandemic. Thus, the implementation of WHP can contribute to maintain the well-being of long-term care managers.

Complex implementation mechanisms in primary care: do physicians' beliefs about the effectiveness of innovation play a mediating role? Applying a realist inquiry and structural equation modeling approach in a formative evaluation study.

BACKGROUND: The adoption of digital health technologies can improve the quality of care for polypharmacy patients, if the underlying complex implementation mechanisms are better understood. Context effects play a critical role in relation to implementation mechanisms. In primary care research, evidence on the effects of context in the adoption of digital innovation for polypharmacy management is lacking. STUDY AIM: This study aims to identify contextual factors relevant to physician behavior and how they might mediate the adoption process. METHODS: The physicians who participated in this formative evaluation study (n = 218) were part of the intervention group in a cluster-randomized controlled trial (AdAM). The intervention group implemented a digital innovation for clinical decision making in polypharmacy. A three-step methodological approach was used: (1) a realist inquiry approach, which involves the description of a context-mechanism-outcome configuration for the primary care setting; (2) a belief elicitation approach, which involves qualitative content analysis and the development of a quantitative latent contextualized scale; and (3) a mediation analysis using structural equation modeling (SEM) based on quantitative survey data from physicians to assess the mediating role of the contextualized scale (n = 179). RESULTS: The key dimensions of a (1) context-mechanism-outcome model were mapped and refined. A (2) latent construct of the physicians' innovation beliefs related to the effectiveness of polypharmacy management practices was identified. Innovation beliefs play a (3) mediating role between the organizational readiness to implement change (p < 0.01) and the desired behavioral intent of physicians to adopt digital innovation (p < 0.01; R2 = 0.645). Our contextualized model estimated significant mediation, with a relative size of 38% for the mediation effect. Overall, the model demonstrated good fit indices (CFI = 0.985, RMSEA = 0.034). CONCLUSION: Physician adoption is directly affected by the readiness of primary care organizations for the implementation of change. In addition, the mediation analysis revealed that this relationship is indirectly influenced by primary care physicians' beliefs regarding the effectiveness of digital innovation. Both individual physician beliefs and practice organizational capacity could be equally prioritized in developing implementation strategies. The methodological approach used is suitable for the evaluation of complex implementation mechanisms. It has been proven to be an advantageous approach for formative evaluation. TRIAL REGISTRATION: NCT03430336 . First registration: 12/02/2018. CLINICALTRIALS: gov.

Effects of a Primary Care-Based Intervention on the Identification and Management of Patients with Coronary Heart Disease and Mental or Cognitive Comorbidity-A Study Protocol.

Mental and cognitive disorders (MCD) negatively affect the incidence and prognosis of coronary heart disease (CHD). Medical guidelines recommend the appropriate management of comorbid MCD in patients with CHD, yet there is evidence that the implementation in primary care is not always adequate. We present the protocol for a pilot study that aims to develop a minimally invasive intervention and evaluate its feasibility in the primary care setting to improve the identification and management of comorbid MCD in patients with CHD. The study consists of two consecutive parts and will be carried out in Cologne, Germany. Part 1 comprises the development and tailoring of the intervention, which is guided by qualitative interviews with primary care physicians (PCPs, n = 10), patients with CHD and MCD and patient representatives (n = 10). Part II focuses on the implementation and evaluation of the intervention in n = 10 PCP offices. Changes in PCP behaviour will be analysed by comparing routine data in the practice management system six months before and six months after study participation. In addition, we will explore the influence of organisational characteristics and perform a socio-economic impact assessment. The outcomes of this mixed-method study will inform the feasibility of a PCP-based intervention to improve quality of care in patients with CHD and comorbid MCD.

Considering the role of context when implementing government policies in hospitals: introduction of a prospective payment system for psychiatry.

PURPOSE: The context in which an innovation is implemented is an important and often neglected mediator of change. A prospective payment system (PPS) for psychiatric and psychosomatic facilities with major implications for inpatient psychiatric care in Germany was implemented from 2013 to 2017. This study aims to examine the determinants of implementation of this government policy using the Diffusion of Innovations theory and consider the role of context. DESIGN/METHODOLOGY/APPROACH: An exploratory case study was conducted in two wards of a psychiatric hospital in Germany: geriatric psychiatry (GerP) and general psychiatry (GenP). Fifteen interviews were conducted with different occupational groups and analyzed in-depths. Routine hospital data were analyzed for delimiting the two contexts. FINDINGS: Routine hospital data show a higher day-mix index (1.08 vs. 0.94) in the GerP context and a very different structure regarding PPS groups, indicating a higher patient complexity. Two types of factors influencing implementation were identified: Context-independent factors included social separation between nurses and doctors, poor communication behavior between the groups and a lack of conveying information about the underlying principles of the PPS. Context-dependent factors included compatibility of the new requirements with existing routines and the relative advantage of the PPS, which were both perceived to be lower in the GerP context. PRACTICAL IMPLICATIONS: Depending on the patient characteristics in the specific context, compatibility with existing routines should be ensured when implementing. Clear communication of the underlying principles and reduction of organizational and communicative barriers between professional groups are crucial success factors for implementing such innovations. ORIGINALITY/VALUE: This study shows how a diffusion process takes place in an organization even after the organization adopts an innovation. The authors could show how contextual differences in terms of patient characteristics result in different determinants of implementation from the views of the employees affected by the innovation.

A qualitative study of the adoption of Value Stream Mapping in breast cancer centers.

PURPOSE: In order to design a patient-centered discharge process, the entire process is visualized in Value Stream Mapping. The duration of the process steps and waiting times are measured and presented. As a team, health professionals discuss problems and agree on suitable solutions. METHODS: After applying Value Stream Mapping, we conducted eight interviews in 2018, four with physicians and four with breast care nurses. We used the Consolidated Framework for Implementation Research to develop the interview guide and to identify categories for content analysis. To identify the differences in attitude and experience between the occupational groups, we conducted a framework analysis. RESULTS: Each team of health professionals developed action steps to optimize the discharge process. Obstacles became apparent in the implementation of these action steps. The lack of adequate staff and complex structures were identified as the main factors. These hierarchical structures also prevented a patient-centered discharge process independent of patient-centered care by health professionals. Self-efficacy varied more among breast care nurses than physicians. The group of physicians perceives standardization in the discharge process critically and therefore assumes limitations in transferring Value Stream Mapping to hospitals. The breast care nurses were open in their attitude. Financial incentives contribute to the acceptance of the method. CONCLUSION: Value Stream Mapping is a simple way to uncover waste and develop applicable action steps. Since the implementation of the action steps was hindered by hierarchical problems and a lack of resources, management involvement and a hospital-wide approach could be beneficial.

Implementation of patient-centred care: which system-level determinants matter from a decision maker's perspective? Results from a qualitative interview study across various health and social care organisations.

OBJECTIVES: The healthcare system is characterised by a high degree of complexity and involves various actors at different institutional levels and in different care contexts. To implement patient-centred care (PCC) successfully, a multidimensional consideration of influencing factors is required. Our qualitative study aims to identify system-level determinants of PCC implementation from the perspective of different health and social care organisations (HSCOs). DESIGN: A qualitative study using n=20 semistructured face-to-face interviews with n=24 participants was carried out between August 2017 and May 2018. Interview data were analysed based on concepts of qualitative content analysis using an inductive and deductive approach. SETTING AND PARTICIPANTS: Interviews were conducted with clinical and managerial decision makers from multiple HSCOs in the model region of Cologne, Germany. Participants were recruited via networks of practice partners and cold calling. RESULTS: This study identified various determinants on the system level that are associated with PCC implementation. Decision makers described external regulations as generating an economically controlled alignment of the healthcare system. The availability and qualification of staff resources and patient-related incentives of financial resources were identified as an eminent requirement for providers to deliver PCC. Participants considered the strict separation of financing and delivery of healthcare into inpatient and outpatient sectors to be a barrier to PCC. Interorganisational collaboration and information exchange were identified as facilitators of PCC, as they enable continuous patient care cycles. CONCLUSION: The results showed the necessity of enforcing paradigm changes at the system level from disease-centredness to patient-centredness while aligning policy and reimbursement decisions directly with patient needs and values. A systematic, long-term planned strategy that extends across all organisations is lacking, rather each organisation seeks its own possibilities to implement PCC activities under external restrictions.Trial registration numberDRKS00011925.

Last Year of Life Study-Cologne (LYOL-C) (Part II): study protocol of a prospective interventional mixed-methods study in acute hospitals to analyse the implementation of a trigger question and patient question prompt sheets to optimise patient-centred care.

INTRODUCTION: The Last Year of Life Study-Cologne Part I (LYOL-C I) has identified general hospital units as the most important checkpoints for transitions in the last year of life of patients. Yet, satisfaction with hospitals, as reported by bereaved relatives, is the lowest of all health service providers. Thus, the LYOL-C Part II (LYOL-C II) focuses on optimising patient-centred care in acute hospitals for patients identified to be in their last year of life. LYOL-C II aims to test an intervention for hospitals by using a two-sided (healthcare professionals (HCPs) and patients) trigger question-based intervention to 'shake' the system in a minimally invasive manner. METHODS AND ANALYSIS: Prospective interventional mixed-methods study following a two-phase approach: phase I, individual interviews with HCPs and patient representatives to design the intervention to maximise ease of implementation and phase II, exploratory study with two arms and a prepost design with patients in their last year of life. The intervention will consist of the Surprise Question and the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for HCPs to identify patients and provide patient-centred care, plus question prompt sheets for patients, encouraging them to initiate discussions with their HCPs. Data on transitions, changes in therapy, quality of care, palliative care integration and death of patients will be analysed. Furthermore, a staff survey (pre/post) and guided interviews with staff, patients and relatives (post) will be conducted. Finally, a formative socioeconomic impact assessment to provide evidence regarding the sustainability of the intervention will be performed. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Cologne (#20-1431). Results will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: DRKS00022378.

Resource dependency and strategy in healthcare organizations during a time of scarce resources: evidence from the metropolitan area of cologne.

PURPOSE: Healthcare systems are under pressure to improve their performance, while at the same time facing severe resource constraints, particularly workforce shortages. By applying resource-dependency-theory (RDT), we explore how healthcare organizations in different settings perceive pressure arising from uncertain access to resources and examine organizational strategies they deploy to secure resources. DESIGN/METHODOLOGY/APPROACH: A cross-sectional survey of key decision-makers in different healthcare settings in the metropolitan area of Cologne, Germany, on perceptions of pressure arising from the environment and respective strategies was conducted. For comparisons between settings radar charts, Kruskal-Wallis test and Fisher-Yates test were applied. Additionally, correlation analyses were conducted. FINDINGS: A sample of n = 237(13%) key informants participated and reported high pressure caused by bureaucracy, time constraints and recruiting qualified staff. Hospitals, inpatient and outpatient nursing care organizations felt most pressurized. As suggested by RDT, organizations in highly pressurized settings deployed the most vociferous strategies to secure resources, particularly in relation to personnel development. ORIGINALITY/VALUE: This study is one of the few studies that focuses on the environment's impact on healthcare organizations across a variety of settings. RDT is a helpful theoretical foundation for understanding the environment's impact on organizational strategies. The substantial variations found between healthcare settings indicate that those settings potentially require specific strategies when seeking to address scarce resources and high demands. The results draw attention to the high level of pressure on healthcare organizations which presumably is passed down to managers, healthcare professionals, patients and relatives.

Patients' perspectives of facilitators and barriers to patient-centred care: insights from qualitative patient interviews.

OBJECTIVES: Previous studies on patient-centred care (PCC) and its facilitators and barriers usually considered specific patient groups, healthcare settings and aspects of PCC or focused on expert perspectives. The objective of this study was to analyse patients' perspectives of facilitators and barriers towards implementing PCC. DESIGN: We conducted semistructured individual interviews with chronically ill patients. The interviewees were encouraged to share positive and negative experiences of care and the related facilitators and barriers in all settings including preventive, acute and chronic health issues. Interview data were analysed based on the concept of content analysis. SETTING: Interviews took place at the University Hospital Cologne, nursing homes, at participants' homes or by telephone. PARTICIPANTS: Any person with at least one chronic illness living in the region of Cologne was eligible for participation. 25 persons with an average age of 60 years participated in the interviews. The participants suffered from various chronic conditions including mental health problems, oncological, metabolic, neurological diseases, but also shared experiences related to acute health issues. RESULTS: Participants described facilitators and barriers of PCC on the microlevel (eg, patient-provider interaction), mesolevel (eg, health and social care organisation, HSCO) and macrolevel (eg, laws, financing). In addition to previous concepts, interviewees illustrated the importance of being an active patient by taking individual responsibility for health. Interviewees considered functioning teams and healthy staff members a facilitator of PCC as this can compensate stressful situations or lack of staff to some degree. A lack of transparency in financing and reimbursement was identified as barrier to PCC. CONCLUSION: Individual providers and HSCOs can address many facilitators and barriers of PCC as perceived by patients. Large-scale changes such as reduction of administrative barriers, the expansion of care networks or higher mandatory nurse to patient ratios require political action and incentives. TRIAL REGISTRATION NUMBER: DRKS00011925.

Is Organizational Communication Climate a Precondition for Patient-Centered Care? Insights from a Key Informant Survey of Various Health and Social Care Organizations.

Health and social care organizations are under pressure of organizing care around patients' needs and preferences while complying with regulatory frameworks and constraint resources. To implement patient-centered care in health and social care organizations successfully, particular organizational preconditions need to be considered. Findings on the implementation of patient-centered care and its preconditions are rare and insufficiently account for the organizational context to explain differences. This study examines the implementation status of patient-centered care in diverse health and social care organizations and analyzes the communication climate as a precondition of successful implementation. In a cross-sectional postal key informant survey, decision makers in the highest leading positions from six different types of health and social care organizations in Cologne, Germany, were surveyed using a paper-pencil questionnaire. Patient-centered care implementation was operationalized by three categories (principles, activities, and enablers) including 15 dimensions. Organizational communication climate was operationalized by aspects of open and constructive communication, cooperation, and inclusion. Out of 1790 contacted organizations, 237 participated. In the analyses, 215 complete datasets were included. Descriptive analyses, Kruskal-Wallis test, post hoc pair-wise test, and linear regression modeling were performed. Results show that the implementation status of patient-centered care was perceived as high but differed between the various types of organizations and in terms of patient-centered care categories. Organizational communication climate was significantly associated with the implementation of patient-centered care. Especially in organizations with a higher number of employees, strategies to create a positive communication climate are needed to create a precondition for patient-centered care.

Trends in the association of different forms of precarious employment and self-rated health in Germany. An analysis with the German Socio-Economic Panel between 1995 and 2015.

BACKGROUND: Precarious employment has increased in Germany by means of labour market flexibilisation throughout the 1990s and 2000s. In this study, trends in the association of self-rated health (SRH) with different dimensions of precarious employment by gender in Germany between 1995 and 2015 were assessed considering different periods of labour market reforms and the Great Recession. METHODS: Analyses were conducted using the German Socio-Economic Panel from 1995 to 2015. All employed individuals aged 18-67 years and living in private households were considered for analysis to examine the risks of poor SRH by low wage, working poverty, non-standard working time arrangements and perceived job insecurity by gender. Predicted probabilities, adjusted risk ratio (ARR), adjusted risk difference (ARD) and trends were examined using pooled interval logistic regression with individual-clustered standard errors. RESULTS: Relative and absolute differences in SRH rose significantly over time by perceived job insecurity for men, but not for women. Working poverty appeared to be significantly associated with SRH in the Great Recession and the post-Recession period for both gender. Non-standard working time arrangements were not significantly associated with SRH for both gender, and low wage appeared to be significantly associated with SRH only for men in the post-Recession period. CONCLUSIONS: The results highlighted the relevance of labour market reforms of deregulation and flexibilisation in Germany to differences in SRH by specific forms of precarious employment and gender differences in the impact of labour market reforms on precarious employment and health.

Measuring change attitudes in health care organizations.

PURPOSE: Measuring attitudes of healthcare providers and managers toward change in health care organizations (HCOs) has been of widespread interest. The purpose of this paper is to evaluate the psychometric characteristics and usability of an abbreviated German version of the Change Attitude Scale. DESIGN/METHODOLOGY/APPROACH: The Change Attitude Scale was used in a survey of healthcare providers and managers in German hospitals after the implementation of a breast cancer center concept. Reliability analysis, confirmatory factor analysis, structural equation modeling and bivariate analysis were conducted. FINDINGS: Data from 191 key persons in 82 hospitals were analyzed. The item-scale structure produced an acceptable model fit. Convergent validity was shown by significant correlations with measures of individuals' general opinions of the breast center concept. A non-significant correlation with a scale measuring the hospital's hierarchical structure of leadership verified discriminant validity. The interaction of key persons' change attitude and hospitals' change performance through change culture as a mediator supported the predictive validity. RESEARCH LIMITATIONS/IMPLICATIONS: The study found general support for the validity and usability of a short version of the German Change Attitude Scale. PRACTICAL IMPLICATIONS: Since attitudes toward change influence successful implementation, the survey may be used to tailor the design of implementation programs and to create a sustainable culture of high readiness for change. ORIGINALITY/VALUE: This is the first study finding that a short instrument can be used to measure attitudes toward change among healthcare providers and managers in HCOs.