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Background: The assessment of primary care organizations is considered to be essential for improving care. However, the assessments' acceptability to professionals poses a challenge. Developing assessment programmes in collaboration with the end-users is a strategy that is widely encouraged to make interventions better targeted. By doing so, it can help to prevent resistance and encourage adherence to the assessment. This process, however, is rarely reported. This paper aims to fill this gap by describing the process of the co-production of an assessment programme for community health centres (CHCs) affiliated to the Federation of Community Health Centres (FCHC) in French-speaking Belgium. Methods: We conducted a documentary study on the co-production of the assessment programme before carrying out semi-structured interviews with the stakeholders involved in its development. Results: CHCs in French-speaking Belgium are increasing in number and are becoming more diverse. For the FCHC, this growth and diversification pose challenges for the meaning of CHC (an identity challenge) and what beneficiaries can expect in terms of the quality of organizations declaring themselves CHC (a quality challenge). Faced with this double challenge, the FCHC decided to develop an assessment programme, initially called Label, using participatory action research. During the co-production process, this initial programme version was abandoned in favour of a new name "DEQuaP". This new name embodies new objectives and new design regarding the assessment programme. When studying the co-production process, we attributed these changes to two controversies. The first concerns how much and which type of variety is desired among CHCs part of the FCHC. The second concerns the organization of the FCHC in its capacity as a federation. It shed light on tensions between two professional segments that, in this paper, we called "political professionalism" and "pragmatic professionalism". Conclusions: These controversies show the importance of underlying challenges behind the development of an assessment programme for CHCs. This provided information about the evolution of the identity of multidisciplinary organizations in primary care. Issues raised in the development of this assessment programme also show the importance of considering assessment methods that reflect and embody the current realities of these organizations and the way of developing these assessment methods. [ABSTRACT FROM AUTHOR]

Introduction: Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium. Methods: Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts. Findings: Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent. Conclusion: The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic immensely impacted care provision, including quality of care in general practice. This paper aimed: (1) to assess how Belgian general practices acted upon the six dimensions of quality of care during COVID-19; (2) to study differences between the three Belgian regions; and (3) to benchmark the performance of the Belgian practices against the performance in other European countries. Methods: The data collected from 479 Belgian practices during 2020–2021 using an online survey as part of the international cross-sectional PRICOV-19 study were analyzed. Hereby, descriptive statistics, chi-squared tests, and binary logistic regression analyses were performed. Thirty-four survey questions related to the six dimensions of quality of care were selected as outcome variables. The adjusted regression models included four practice characteristics as covariates: practice type, being a teaching practice for GP trainees, multidisciplinarity of the team, and payment system. Results: Belgian practices made important organizational changes to deliver high-quality care during COVID-19. Most practices (n = 259; 56.1%) actively reached out to vulnerable patients. Limitations to the practice building or infrastructure threatened high-quality care in 266 practices (55.5%). Infection prevention measures could not always be implemented during COVID-19, such as using a cleaning protocol (n = 265; 57.2%) and providing a separate doctor bag for infection-related home visits (n = 130; 27.9%). Three hundred and sixty practices (82.0%) reported at least one safety incident related to a delayed care process in patients with an urgent condition. The adjusted regression analysis showed limited significant differences between the Belgian regions regarding the quality of care delivered. Belgian practices demonstrated varied performance compared to other European countries. For example, they excelled in always checking the feasibility of isolation at home but reported more patient safety incidents related to timely care than at least three-quarters of the other European countries. Conclusions: Future studies using different design methods are crucial to investigate which country and practice characteristics are associated with delivering high-quality care. [ABSTRACT FROM AUTHOR]

Background: In Belgium, the Planning Commission for Medical Supply is responsible for monitoring human resources for health (HRH) and ultimately proposing workforce quotas. It is supported by the Planning Unit for the Supply of the Health Professions. This Unit quantifies and forecasts the workforce in the healthcare professions on the basis of a stock and flow model, based on trends observed in the past. In 2019, the Planning Unit asked the KCE (Belgian Health Care Knowledge Centre) to develop additional forecasting scenarios for the midwifery workforce, to complement the standard historical trend approach. The aim of this paper is to present the development of such forecasting scenarios. Methods: The Robust Workforce Planning Framework, developed by the Centre for Workforce Intelligence in the UK was used to develop alternative midwifery workforce scenarios. The framework consists of four steps (Horizon scanning, Scenario generation, Workforce modelling, and Policy analysis), the first two of which were undertaken by KCE, using two online surveys and five workshops with stakeholders. Results: Three alternative scenarios are proposed. The first scenario (close to the current situation) envisages pregnancy and maternity care centred on gynaecologists working either in a hospital or in private practice. The second scenario describes an organisation of midwife-led care in hospitals. In the third scenario, care is primarily organised by primary care practitioners (midwives and general practitioners) in outpatient settings. Conclusions: The Robust Workforce Planning Framework provides an opportunity to adjust the modelling of the health workforce and inform decision-makers about the impact of their future decisions on the health workforce. [ABSTRACT FROM AUTHOR]

Background: Non-pharmaceutical interventions (NPIs) were adopted in Belgium in order to decrease social interactions between people and as such decrease viral transmission of SARS-CoV-2. With the aim to better evaluate the impact of NPIs on the evolution of the pandemic, an estimation of social contact patterns during the pandemic is needed when social contact patterns are not available yet in real time. Methods: In this paper we use a model-based approach allowing for time varying effects to evaluate whether mobility and pre-pandemic social contact patterns can be used to predict the social contact patterns observed during the COVID-19 pandemic between November 11, 2020 and July 4, 2022. Results: We found that location-specific pre-pandemic social contact patterns are good indicators for estimating social contact patterns during the pandemic. However, the relationship between both changes with time. Considering a proxy for mobility, namely the change in the number of visitors to transit stations, in interaction with pre-pandemic contacts does not explain the time-varying nature of this relationship well. Conclusion: In a situation where data from social contact surveys conducted during the pandemic are not yet available, the use of a linear combination of pre-pandemic social contact patterns could prove valuable. However, translating the NPIs at a given time into appropriate coefficients remains the main challenge of such an approach. In this respect, the assumption that the time variation of the coefficients can somehow be related to aggregated mobility data seems unacceptable during our study period for estimating the number of contacts at a given time. [ABSTRACT FROM AUTHOR]

Background: The use of Electronic Health Records (EHR) data in clinical research is incredibly increasing, but the abundancy of data resources raises the challenge of data cleaning. It can save time if the data cleaning can be done automatically. In addition, the automated data cleaning tools for data in other domains often process all variables uniformly, meaning that they cannot serve well for clinical data, as there is variable-specific information that needs to be considered. This paper proposes an automated data cleaning method for EHR data with clinical knowledge taken into consideration.Methods: We used EHR data collected from primary care in Flanders, Belgium during 1994-2015. We constructed a Clinical Knowledge Database to store all the variable-specific information that is necessary for data cleaning. We applied Fuzzy search to automatically detect and replace the wrongly spelled units, and performed the unit conversion following the variable-specific conversion formula. Then the numeric values were corrected and outliers were detected considering the clinical knowledge. In total, 52 clinical variables were cleaned, and the percentage of missing values (completeness) and percentage of values within the normal range (correctness) before and after the cleaning process were compared.Results: All variables were 100% complete before data cleaning. 42 variables had a drop of less than 1% in the percentage of missing values and 9 variables declined by 1-10%. Only 1 variable experienced large decline in completeness (13.36%). All variables had more than 50% values within the normal range after cleaning, of which 43 variables had a percentage higher than 70%.Conclusions: We propose a general method for clinical variables, which achieves high automation and is capable to deal with large-scale data. This method largely improved the efficiency to clean the data and removed the technical barriers for non-technical people. [ABSTRACT FROM AUTHOR]

In recent years, the linkage of survey data to health administrative data has increased. This offers new opportunities for research into the use of health services and public health. Building on the HISlink use case, the linkage of Belgian Health Interview Survey (BHIS) data and Belgian Compulsory Health Insurance (BCHI) data, this paper provides an overview of the practical implementation of linking data, the outcomes in terms of a linked dataset and of the studies conducted as well as the lessons learned and recommendations for future links. Individual BHIS 2013 and 2018 data was linked to BCHI data using the national register number. The overall linkage rate was 92.3% and 94.2% for HISlink 2013 and HISlink 2018, respectively. Linked BHIS-BCHI data were used in validation studies (e.g. self-reported breast cancer screening; chronic diseases, polypharmacy), in policy-driven research (e.g., mediation effect of health literacy in the relationship between socioeconomic status and health related outcomes, and in longitudinal study (e.g. identifying predictors of nursing home admission among older BHIS participants). The linkage of both data sources combines their strengths but does not overcome all weaknesses. The availability of a national register number was an asset for HISlink. Policy-makers and researchers must take initiatives to find a better balance between the right to privacy of respondents and society's right to evidence-based information to improve health. Researchers should be aware that the procedures necessary to implement a link may have an impact on the timeliness of their research. Although some aspects of HISlink are specific to the Belgian context, we believe that some lessons learned are useful in an international context, especially for other European Union member states that collect similar data. [ABSTRACT FROM AUTHOR]

Background: In the organization of health care and health care systems, there is an increasing trend towards integrated care. Policy-makers from different countries are creating policies intended to promote cooperation and collaboration between health care providers, while facilitating the integration of different health care services. Hopes are high, as such collaboration and integration of care are believed to save resources and improve quality. However, policy-makers are likely to encounter various challenges and limitations when attempting to turn these great ideas into effective policies. In this paper, we look into these challenges.Main Body: We argue that the organization of health care and integrated care is of public concern, and should thus be of crucial interest to policy-makers. We highlight three challenges or limitations likely to be encountered by policy-makers in integrated care. These are: (1) conceptual challenges; (2) empirical/methodological challenges; and (3) resource challenges. We will argue that it is still unclear what integrated care means and how we should measure it. 'Integrated care' is a single label that can refer to a great number of different processes. It can describe the integration of care for individual patients, the integration of services aimed at particular patient groups or particular conditions, or it can refer to institution-wide collaborations between different health care providers. We subsequently argue that health reform inevitably possesses a political context that should be taken into account. We also show how evidence supporting integrated care may not guarantee success in every context. Finally, we will discuss how promoting collaboration and integration might actually demand more resources. In the final section, we look at three different paradigmatic examples of integrated care policy: Norway, the UK's NHS, and Belgium.Conclusions: There seems widespread agreement that collaboration and integration are the way forward for health care and health care systems. Nevertheless, we argue that policy-makers should remain careful; they should carefully consider what they hope to achieve, the amount of resources they are willing to invest, and how they will evaluate the success of their policy. [ABSTRACT FROM AUTHOR]

Background: Poor mental health is highly stigmatized and stereotyped, even more when it comes to migrant and ethnic minority groups (MEM). Belgium, which has a long history of immigration, is a good case study for analysing how the prevalence of mental illness (MI) has evolved over time and how such evolution had differed between MEM. This paper seeks to explore the prevalence of MI and potential inequalities among MEM compared to native Belgians between 1997 and 2018, shedding light on this important issue. Methods: The data set is composed of the six cross-sectional waves of the Belgian Health Interview Survey from 1997 to 2018. The 12-item General Health Questionnaire was used to assess the average level of mental health and the prevalence of MI (score ≥ 4) among five major MEM groups in Belgium (Belgian, Moroccan, Turkish, European migrants, and non-European migrants). Multivariate logistic and linear regression models were used to assess the likelihood of having a MI in the different MEM groups and survey years. The minimal clinically important difference (MID) was also calculated for the severity of MI. Results: After controlling for socioeconomic status, the average marginal effect indicated a decrease in mental health among Moroccans and Turks in Belgium between 1997 and 2018, compared to Belgians. This result was confirmed by the Chi²-test, which showed that Turkish (χ²=17.75, p < 0.001) and Moroccans respondents (χ²=4.19, p < 0.04) had a higher overall level of mental distress than Belgians. Furthermore, in 2018, even after adjusting for age, sex and education level, having a mother born in a non-EU country increased the risk of mental illness. Conclusions: Mental health inequalities between migrant and ethnic groups are on the rise in Belgium. To address this issue, particular attention should be given to the Moroccan and Turkish background populations. Specific interventions and policies must be implemented to prevent the increase of psychological distress among migrants and ethnic minorities, on the one hand, and ensure that high-quality mental health care is accessible to all, regardless of ethnicity, on the other hand. Additionally, we recommend that future research on ethnic mental healthcare includes better data collection on the country of birth of respondents and their parents. [ABSTRACT FROM AUTHOR]

Background: During the last decade, the possibility for women to cryopreserve oocytes in anticipation of age-related fertility loss, also referred to as social egg freezing, has become an established practice at fertility clinics around the globe. In Europe, there is extensive variation in the costs for this procedure, with the common denominator that there are almost no funding arrangements or reimbursement policies. This is the first qualitative study that specifically explores viewpoints on the (lack of) reimbursement for women who had considered to uptake at least one social egg freezing cycle in Belgium.Methods: To understand the moral considerations of these women, drawing from twenty-one interviews, this paper integrates elements of a symbiotic empirical ethics approach and thematic analysis.Results: We identify four themes: (1) being confronted with unclear information; (2) financial costs as ongoing concern; (3) necessity of coverage; (4) extent of reimbursement. In the first theme, we found that some women were concerned about the lack of clear information about the cost of social egg freezing. In the second theme, we report moral sentiments of injustice and discrimination which some women attributed to their struggles and needs not being recognised. The third theme illustrates diverse views on reimbursement, ranging from viewing social egg freezing as an elective treatment not appropriate for reimbursement to preferences for greater public responsibility and wider access. Finally, we describe the participants' varying proposals for partial reimbursement and the idea that it should not be made available for free.Conclusions: This research adds important empirical insights to the bioethics debate on social egg freezing, in particular by presenting (potential) users' views on the lack of reimbursement. While there is much more to say about the ethical and political complexities of the reimbursement of this procedure, our study highlighted the voices of (potential) users and showed that at least some of them would welcome the coverage of SEF through the public healthcare insurance. [ABSTRACT FROM AUTHOR]

Background: Burnout is related to huge costs, for both individuals and organizations and is recognized as an occupational disease or work-related disorder in many European countries. Given that burnout is a major problem it is important to measure the levels of burnout in a valid and reliable way. The Burnout Assessment Tool (BAT) is a newly developed self-report questionnaire to measure burnout. So far, studies concerning the psychometric properties of the original version of the Burnout Assessment Tool (BAT) including 23 items show promising results and suggest that the instrument can be used in many different settings. For various reasons there is a need of a shorter instrument. For example, burnout questionnaires are typically included in employee surveys to evaluate psychosocial risk-factors, which according to the European Occupational Safety and Health Framework Directive, should be carried out in organizations on a regular basis. The aims of this paper are to develop a shorter version of the BAT, including only 12 items (BAT12) and to evaluate its construct validity and differential item functioning regarding age, gender and country.Methods: Using data from representative samples of working populations in the Netherlands and Belgium (Flanders) a shorter version of the BAT was developed by combining quantitative (Rasch analysis) and qualitative approaches (item content analysis and expert judgements). Construct validity of the new BAT12 was evaluated by means of Rasch analysis.Results: In an iterative procedure, deleting one item from each subscale at each step, a short version of the BAT - BAT12 was developed. The BAT12 fulfils the measurement criteria according to the Rasch model after accounting for local dependency between items within each subscale. The four subscales can be combined into a single burnout score.Conclusion: The new BAT12 developed in the present study maintains the breath of item content of the original version of the BAT. The new BAT12 has sound psychometric properties. The scale works invariantly for older and younger, women and men and across two countries. A shorter version of the BAT is timesaving compared to the BAT23 and can be used in e.g. employee surveys. [ABSTRACT FROM AUTHOR]

Background: Mindfulness based stress reduction (MBSR) is increasingly being used to improve outcomes such as stress and depression in a range of long-term conditions (LTCs). While systematic reviews on MBSR have taken place for a number of conditions there remains limited information on its impact on individuals with Parkinson's disease (PD).Methods: Medline, Central, Embase, Amed, CINAHAL were searched in March 2016. These databases were searched using a combination of MeSH subject headings where available and keywords in the title and abstracts. We also searched the reference lists of related reviews. Study quality was assessed based on questions from the Cochrane Collaboration risk of bias tool.Results: Two interventions and three papers with a total of 66 participants were included. The interventions were undertaken in Belgium (n = 27) and the USA (n = 39). One study reported significantly increased grey matter density (GMD) in the brains of the MBSR group compared to the usual care group. Significant improvements were reported in one study for a number of outcomes including PD outcomes, depression, mindfulness, and quality of life indicators. Only one intervention was of reasonable quality and both interventions failed to control for potential confounders in the analysis. Adverse events and reasons for drop-outs were not reported. There was also no reporting on the costs/benefits of the intervention or how they affected health service utilisation.Conclusion: This systematic review found limited and inconclusive evidence of the effectiveness of MBSR for PD patients. Both of the included interventions claimed positive effects for PD patients but significant outcomes were often contradicted by other results. Further trials with larger sample sizes, control groups and longer follow-ups are needed before the evidence for MBSR in PD can be conclusively judged. [ABSTRACT FROM AUTHOR]

Background: Belgium was one of the countries that was struck hard by COVID-19. Initially, the belief was that we were 'all in it together'. Emerging evidence showed however that deprived socioeconomic groups suffered disproportionally. Yet, few studies are available for Belgium. The main question addressed in this paper is whether excess mortality during the first COVID-19 wave followed a social gradient and whether the classic mortality gradient was reproduced. Methods: We used nationwide individually linked data from the Belgian National Register and the Census 2011. Age-standardized all-cause mortality rates were calculated during the first COVID-19 wave in weeks 11-20 in 2020 and compared with the rates during weeks 11-20 in 2015-2019 to calculate absolute and relative excess mortality by socioeconomic and -demographic characteristics. For both periods, relative inequalities in total mortality between socioeconomic and -demographic groups were calculated using Poisson regression. Analyses were stratified by age, gender and care home residence. Results: Excess mortality during the first COVID-19 wave was high in collective households, with care homes hit extremely hard by the pandemic. The social patterning of excess mortality was rather inconsistent and deviated from the usual gradient, mainly through higher mortality excesses among higher socioeconomic groups classes in specific age-sex groups. Overall, the first COVID-19 wave did not change the social patterning of mortality, however. Differences in relative inequalities between both periods were generally small and insignificant, except by household living arrangement. Conclusion: The social patterning during the first COVID-19 wave was exceptional as excess mortality did not follow the classic lines of higher mortality in lower classes and patterns were not always consistent. Relative mortality inequalities did not change substantially during the first COVID-19 wave compared to the reference period. [ABSTRACT FROM AUTHOR]

Objective: The study of care trajectories of psychiatric patients across hospitals was previously not possible in Belgium as each hospital stores its data autonomously, and government-related registrations do not contain a unique identifier or are incomplete. A new longitudinal database called iPSYcare (Improved Psychiatric Care and Research) was therefore constructed in 2021, and links the electronic medical records of patients in psychiatric units of eight hospitals in the Antwerp Province, Belgium. The database provides a wide range of information on patients, care trajectories and delivered care in the region. In a first phase, the database will only contain information about adult patients who were admitted to a hospital or treated by an outreach team and who gave explicit consent. In the future, the database may be expanded to other regions and additional data on outpatient care may be added. Results: IPSYcare is a close collaboration between the University of Antwerp and hospitals in the province of Antwerp. This paper describes the development of the database, how privacy and ethical issues will be handled, and how the governance of the database will be organized. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Apart from a person's physical functioning, the early identification of social context indicators which affect patient outcomes - such as environmental and psychosocial issues - is key for high quality and comprehensive care at home. During a home care assessment, a person's biomedical and functional problems are typically considered. Harder to define concepts, such as psychosocial well-being or living arrangements, are not routinely documented, even though research shows they also affect functioning and health outcomes. The purpose of this study is to develop and test a concise, integrated assessment (BelRAI Social Supplement) that evaluates these social context indicators for persons receiving home care to complement existing interRAI- instruments.Methods: The development of the BelRAI Social Supplement is a multi-stage process, based upon the revised MRC-framework, involving both qualitative and quantitative research with stakeholders such as; clients, informal caregivers, care professionals and policy makers. The developmental process encompasses four stages: (I) item generation based on multiple methods and content validation by a panel of stakeholders (II) assessing feasibility and piloting methods, (III) early evaluation, and (IV) final evaluation. Stage II and III are covered in this paper.Results: During Stages I and II, a testable version of the BelRAI Social Supplement was developed in an iterative process. In Stage III, 100 care professionals assessed 743 individuals receiving home care in Flanders between December 2018 and December 2019. Using inter-item correlation matrixes, frequency distributions and regular feedback from the participants, the BelRAI Social Supplement was improved and prepared for Stage IV. The updated version of the instrument consists of four main sections: (1) environmental assessment; (2) civic engagement; (3) psychosocial well-being; and (4) informal care and support. In total, the BelRAI Social Supplement contains a maximum of 76 items.Conclusions: The BelRAI Social Supplement was reviewed and shortened in close collaboration with care professionals and other experts in Flanders. This study resulted in an instrument that documents need-to-know social context determinants of home dwelling adults. [ABSTRACT FROM AUTHOR]

Background: Immigrants make up an important share of European populations which has led to a growing interest in research on migrants' health. Many studies have assessed migrants' cancer mortality patterns, yet few have studied incidence differences. This paper will probe into histology-specific lung cancer incidence by migrant origin aiming to enhance the knowledge on lung cancer aetiology and different risk patterns among population groups.Methods: We used data on all lung cancer diagnoses during 2004-2013 delivered by the Belgian Cancer Registry individually linked with the 2001 Belgian Census and the Crossroads Bank for Social Security. Absolute and relative inequalities in overall and histology-specific lung cancer incidence have been calculated for first-generation Italian, Turkish and Moroccan migrant men aged 50-74 years compared to native Belgian men.Results: Moroccan men seemed to be the most advantaged group. Both in absolute and relative terms they consistently had lower overall and histology-specific lung cancer incidence rates compared with native Belgian men, albeit less clear for adenocarcinoma. Turkish men only showed lower overall lung cancer incidence when adjusting for education. On the contrary, Italian men had higher incidence for overall lung cancer and squamous cell carcinoma, which was explained by adjusting for education.Conclusions: Smoking habits are likely to explain the results for Moroccan men who had lower incidence for smoking-related histologies. The full aetiology for adenocarcinoma is still unknown, yet the higher incidence among Italian men could point to differences in occupational exposures, e.g. to carcinogenic radon while working in the mines. [ABSTRACT FROM AUTHOR]

Background: Out-of-pocket payments have a diverse impact on the burden of those with a higher morbidity or the chronically ill. As the prevalence of chronic diseases increases with age, older adults are a vulnerable group. The paper aims to evaluate the impact of chronic diseases on the out-of-pocket payments burden of the 50+ populations in Belgium, the Czech Republic and Germany.Methods: Data from the sixth wave of the Survey of Health, Ageing and Retirement in Europe is used. A two-part model with a logit model in the first part and a generalised linear model in the second part is applied.Results: The diseases increasing the burden in the observed countries are heart attacks, high blood pressure, cancer, emotional disorders, rheumatoid arthritis and osteoarthritis. Reflecting country differences Parkinson's disease and its drug burden is relevant in Belgium, the drugs burden related to heart attack and outpatient care burden to chronic kidney disease in the Czech Republic and the outpatient care burden of cancer and chronic lung disease in Germany. In addition, we confirm the regressive character of out-of-pocket payments.Conclusions: We conclude that the burden is not equitably distributed among older adults with chronic diseases. Identification of chronic diseases with a high burden can serve as a supplementary protective feature. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic and subsequent suppression measures have had health and social implications for billions of individuals. The aim of this paper is to investigate the risk of psychological distress associated with the COVID-19 pandemic and suppression measures during the early days of the lockdown. We compared the level of psychological distress at the beginning of that period with a pre-pandemic health survey and assessed the psychological effects of exposure to the COVID-19 pandemic and changes in social activity and support. Methods: An online survey was distributed to the general population in Belgium 3 days after the beginning of the lockdown. 20,792 respondents participated. The psychological distress of the population was measured using the GHQ-12 scale. Social activities and support were assessed using the Social Participation Measure, the Short Loneliness Scale, and the Oslo Social Support Scale. An index of subjective exposure to the COVID-19 pandemic was constructed, as well as a measure of change in occupational status. Measurements were compared to a representative sample of individuals extracted from the Belgian Health Interview Survey of 2018. Bootstrapping was performed and analyses were reweighted to match the Belgian population in order to control for survey selection bias. Results: Half of the respondents reported psychological distress in the early days of the lockdown. A longer period of confinement was associated with higher risk of distress. Women and younger age groups were more at risk than men and older age groups, as were respondents who had been exposed to COVID-19. Changes in occupational status and a decrease in social activity and support also increased the risk of psychological distress. Comparing the results with those of the 2018 Belgian Health Interview shows that the early period of the lockdown corresponded to a 2.3-fold increase in psychological distress (95% CI: 2.16–2.45). Conclusions: Psychological distress is associated with the consequences of the COVID-19 pandemic and suppression measures. The association is measurable from the very earliest days of confinement and it affected specific at-risk groups. Authorities should consider ways of limiting the effect of confinement on the mental and social health of the population and developing strategies to mitigate the adverse consequences of suppression measures. [ABSTRACT FROM AUTHOR]

Background: Faecal egg count (FEC) techniques are commonly used to detect gastrointestinal nematodes (GINs) in cattle and to determine anthelmintic efficacy/resistance through the faecal egg count reduction test (FECRT). Mini-FLOTAC is one of the techniques recommended for a standardised FEC/FECRT of helminth eggs in cattle. However, only one paper evaluated the recovery rate of GIN eggs by Mini-FLOTAC (compared to McMaster and modified-Wisconsin method) in cattle, using only a level of contamination of 200 eggs per gram (EPG) of faeces and using GIN eggs collected from goat faeces to spike faecal samples from cattle. To further study the recovery rate of GIN eggs from cattle faeces, this study was conducted in two laboratories, one in Belgium and one in Italy to evaluate the sensitivity, accuracy, precision and reproducibility of the Mini-FLOTAC and McMaster techniques (at two reading levels: grids and chambers) for the detection of GIN eggs in spiked bovine faecal samples. Methods: In both countries, spiked cattle faecal samples with five different levels of egg contamination (10, 50, 100, 200 and 500 EPG) of GINs were used. The study was performed in both laboratories by the same expert operator and using the same standard operating procedures (SOPs) for the Mini-FLOTAC and McMaster techniques. Sensitivity, accuracy and precision were calculated for each technique and for each level of contamination. Statistical analyses were performed to evaluate differences in performance between the two techniques. Results: Mini-FLOTAC had a higher sensitivity (100% at all EPG levels for Mini-FLOTAC vs 0–66.6% for McMaster chambers and grids at levels< 100 EPG), a higher accuracy (98.1% mean value for Mini-FLOTAC vs 83.2% for McMaster grids and 63.8% for McMaster chambers) and a lower coefficient of variation (10.0% for Mini-FLOTAC vs 47.5% for McMaster grids and 69.4% for McMaster chambers) than McMaster. There was no significant difference in the recovery of GIN eggs between the two studies performed in Belgium and in Italy. Conclusions: The high GIN egg recovery rate detected by Mini-FLOTAC and the similar results obtained in Belgium and in Italy indicated that the diagnostic performance of a FEC technique was not dependent on the laboratory environment. [ABSTRACT FROM AUTHOR]

Background: The clinical and economic burden of type 2 diabetes mellitus on society is rising. Effective and efficient preventive measures may stop the increasing prevalence, given that type 2 diabetes mellitus is mainly a lifestyle-driven disease. The Feel4Diabetes-study aimed to tackle unhealthy lifestyle (unhealthy diet, lack of physical activity, sedentary behaviour, and excess weight) of families with a child in the first grades of elementary school. These schools were located in regions with a relatively low socio-economic status in Belgium, Bulgaria, Finland, Greece, Hungary and Spain. Special attention was paid to families with a high risk of developing type 2 diabetes mellitus. Methods: The aim of this paper is to describe the detailed methodology of the intervention's cost-effectiveness analysis. Based on the health economic evaluation of the Toybox-study, both a decision analytic part and a Markov model have been designed to assess the long-term (time horizon of 70 year with one-year cycles) intervention's value for money. Data sources used for the calculation of health state incidences, transition probabilities between health states, health state costs, and health state utilities are listed. Intervention-related costs were collected by questionnaires and diaries, and attributed to either all families or high risk families only. Conclusions: The optimal use of limited resources is pivotal. The future results of the health economic evaluation of the Feel4Diabetes-study will contribute to the efficient use of those resources. [ABSTRACT FROM AUTHOR]

Background: The objective of this paper is to explore whether IPV 12 months before and/or during pregnancy is associated with poor psychosocial health.Methods: From June 2010 to October 2012, a cross-sectional study was conducted in 11 antenatal care clinics in Belgium. Consenting pregnant women were asked to complete a questionnaire on socio-demographics, psychosocial health and violence in a separate room. Overall, 2586 women were invited to participate and we were able to use data from 1894 women (73.2%) for analysis. Ethical clearance was obtained in all participating hospitals.Results: We found a significant correlation between IPV and poor psychosocial health: within the group of women who reported IPV, 53.2% (n = 118) had poor psychosocial health, as compared to 21% (n = 286) in the group of women who did not report IPV (P < 0.001). Lower psychosocial health scores were associated with increased odds of reporting IPV (aOR 1.55; 95% CI 1.39-1.72), with adjustments made for the language in which the questionnaire was filled out, civil/marital status, education and age. In other words, a decrease of 10 points on the psychosocial health scale (total of 140) increased the odds of reporting IPV by 55 %. When accounting for the 6 psychosocial health subscales, the analysis revealed that all subscales (depression, anxiety, self-esteem, mastery, worry and stress) are strongly correlated to reporting IPV. However, when accounting for all subscales simultaneously in a logistic regression model, only depression (aOR 0.87; 95 % CI 0.84-0.91) and stress (aOR 0.85; 95 % CI 0.77-095) remained significantly associated with IPV. The association between overall psychosocial health and IPV remained significant after adjusting for socio-demographic status.Conclusion: Our research corroborated that IPV and psychosocial health are strongly associated. Due to the limitations of our study design, we believe that future research is needed to deepen understanding of the multitude of factors involved in the complex interactions between IPV and psychosocial health. [ABSTRACT FROM AUTHOR]

Background: General practice is often recommended as an ideal setting to initiate advance care planning (ACP), but uptake of ACP in this setting is low. ACP-GP is a complex intervention to facilitate ACP for patients with chronic, life-limiting illness in Belgian general practice. It aims to increase patient ACP engagement and general practitioner (GP) ACP self-efficacy. In a cluster-randomized controlled trial, the intervention was not superior to control in increasing these outcomes. A parallel process evaluation aimed to enhance understanding of how the intervention was implemented, and which factors might have influenced trial results. Methods: We conducted a mixed-methods process evaluation following the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources include recruitment and implementation monitoring, questionnaires for patients and GPs, and semi-structured (focus group) interviews with patients and GPs. Questionnaire data were analyzed descriptively. Qualitative data were first analyzed inductively; themes were then assigned deductively to RE-AIM dimensions. Results: Thirty-five GPs and 95 patients were recruited to the trial; GP reach was low. Sixteen GPs and 46 patients provided questionnaire data at 3 months post-baseline; qualitative data were transcribed for 14 GPs and 11 patients. Adoption of intervention components was moderate to good, with the exception of the documentation template for GPs. Interviews revealed varying patient attitudes towards ACP, but patients nonetheless emphasized that conversations made them feel reassured. GPs especially valued a positive framing of ACP. When adopted, the intervention was well-implemented and participant satisfaction was high. However, intention for maintenance was moderate, with GPs raising questions of how to sustainably implement ACP conversations in the future. Conclusions: Implementing the complex ACP-GP intervention in general practice is feasible, and can be successful. However, the implementation process is challenging and the sustainability is suboptimal. Our findings will guide future research and recommendations for facilitating and implementing ACP in general practice. Trial registration: ISRCTN12995230; prospectively registered on 19/06/2020. [ABSTRACT FROM AUTHOR]

Background: Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population. Methods: We designed a qualitative study based on 1) interviews – conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers – and 2) focus groups – conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis. Results: Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile. Conclusions: Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier. [ABSTRACT FROM AUTHOR]

Background: Work hours are an important aspect of one's job and these in turn have the potential to impact people's well-being. Much research investigating the link between working hours and well-being uses cross-sectional data. Longitudinal studies, especially those studying the same subjects changing their working time, can study the impact of work time more clearly. Using panel data, this study aims to explore the impact of a reduction in working time on three domains of well-being: general well-being, job-related well-being (positive work experience) and work-family well-being (work-family conflict). In addition, our study offers insights into the role of concomitant changes in work and private circumstances of employees as we investigate whether the impact of shorter working hours for well-being is mediated by changes in the participants' and circumstances related to paid and unpaid work resources. Method: An organization of about 60 (female) employees trialed a shorter workweek for one calendar year in 2019. All full-time employees reduced their hours. The part-time working employees can be used as a control group. Panel data (survey and time-use diary data) of a 30-h workweek trial in Belgium was collected in four waves over two years in a pre- and post-intervention design. Change over time (waves) was analyzed through multilevel growth models. Result: A decrease in work-family conflict was observed during the shorter workweek. Part of this decrease is explained by concomitant changes in work and private circumstances, such as sufficiency in free time, schedule control, and satisfaction with work pressure. Positive work experience and general well-being tend to have decreased during the shorter workweek, although this could partly be explained by other organizational changes and not by the reduction in working hours per se. Schedule control helped suppress these somewhat negative effects of organizational changes on positive work experience. Conclusion: Reduced working hours have the largest and most positive impact on work-family conflict. The feeling of having enough leisure time contributes to this increased well-being. Especially for women, who were the majority in this study, a reduction in working time might be beneficial as they often bear more responsibility for household work and care tasks. Next to the duration of working time, schedule control/autonomy has an important impact on well-being. [ABSTRACT FROM AUTHOR]

Background: Taxonomic identification of wood specimens provides vital information for a wide variety of academic (e.g. paleoecology, cultural heritage studies) and commercial (e.g. wood trade) purposes. It is generally accomplished through the observation of key anatomical features. Classic methodologies mostly require destructive sub-sampling, which is not always acceptable. X-ray computed micro-tomography (µCT) is a promising non-destructive alternative since it allows a detailed non-invasive visualization of the internal wood structure. There is, however, no standardized approach that determines the required resolution for proper wood identification using X-ray µCT. Here we compared X-ray µCT scans of 17 African wood species at four resolutions (1 µm, 3 µm, 8 µm and 15 µm). The species were selected from the Xylarium of the Royal Museum for Central Africa, Belgium, and represent a wide variety of wood-anatomical features. Results: For each resolution, we determined which standardized anatomical features can be distinguished or measured, using the anatomical descriptions and microscopic photographs on the Inside Wood Online Database as a reference. We show that small-scale features (e.g. pits and fibres) can be best distinguished at high resolution (especially 1 µm voxel size). In contrast, large-scale features (e.g. vessel porosity or arrangement) can be best observed at low resolution due to a larger field of view. Intermediate resolutions are optimal (especially 3 µm voxel size), allowing recognition of most small- and large-scale features. While the potential for wood identification is thus highest at 3 µm, the scans at 1 µm and 8 µm were successful in more than half of the studied cases, and even the 15 µm resolution showed a high potential for 40% of the samples. Conclusions: The results show the potential of X-ray µCT for non-destructive wood identification. Each of the four studied resolutions proved to contain information on the anatomical features and has the potential to lead to an identification. The dataset of 17 scanned species is made available online and serves as the first step towards a reference database of scanned wood species, facilitating and encouraging more systematic use of X-ray µCT for the identification of wood species. [ABSTRACT FROM AUTHOR]

Background: Mid-March 2020, Belgium went in lockdown to combat the COVID-19-pandemic. Having to provide school-based day care and adapt to online teaching, while all social, cultural and sports events and activities were cancelled, secondary school teachers' physical activity (PA) and sedentary behaviour (SB) may have been affected considerably. This study investigates the impact of the first Belgian lockdown on PA and SB in Flemish secondary school teachers. Methods: This prospective cohort study was conducted throughout the 2019–2020 school year. PA and SB measured in March/April 2020 were compared with a pre-lockdown measurement in January/February 2020. Other pre-lockdown measurements (September/October 2019 and November/December 2019) and one other during-lockdown measurement (May/June 2020) allowed us to control for confounding. Validated questionnaires were used to assess participants' PA and SB. Generalized linear mixed models were applied in R. Results: Among 624 participants (77·2% females, 43·3 ± 10·3 years), increases were observed for total PA (+ 108 min/week; p = 0·047), moderate PA (+ 217 min/week; p = 0·001), domestic and garden PA (+ 308 min/week; p < 0·0001) and leisure-time PA (+ 131 min/week; p < 0·0001), whereas work-related PA (-289 min/week; p < 0·0001) and active transportation (-38 min/week; p =0·005) decreased. No differences were observed for walking (p = 1·0) and vigorous PA (p = 0·570). Increases were found for total SB (+ 972 min/week; p < 0·0001), work-related SB (+ 662 min/week; p < 0·0001) and leisure-time SB (+ 592 min/week; p = 0·0004), whereas transport-related SB (-290 min/week; p < 0·0001) decreased. Conclusion: During the lockdown, we found in our sample that Flemish secondary school teachers showed an increase in SB that was 9 times as high as their PA increase. As a government, education network or school, it is crucial to sensitize, promote, and facilitate sufficient MVPA and/or walking, but likewise to discourage SB during pandemic-induced lockdowns. [ABSTRACT FROM AUTHOR]

Background: In Flanders, general practitioners (GPs) were among the first ones to collect data regarding COVID-19 cases. Intego is a GPs' morbidity registry in primary care with data collected from the electronic medical records from a sample of general practices. The Intego database contain elaborate information regarding patient characteristics, such as comorbidities. At the national level, the Belgian Public Health Institute (Sciensano) recorded all test-confirmed COVID-19 cases, but without other patient characteristics. Methods: Spatio and spatio-temporal analyses were used to analyse the spread of COVID-19 incidence at two levels of spatial aggregation: the municipality and the health sector levels. Our study goal was to compare spatio-temporal modelling results based on the Intego and Sciensano data, in order to see whether the Intego database is capable of detecting epidemiological trends similar to those in the Sciensano data. Comparable results would allow researchers to use these Intego data, and their wealth of patient information, to model COVID-19-related processes. Results: The two data sources provided comparable results. Being a male decreased the odds of having COVID-19 disease. The odds for the age categories (17,35], (35,65] and (65,110] of being a confirmed COVID-19 case were significantly higher than the odds for the age category [0,17]. In the Intego data, having one of the following comorbidities, i.e., chronic kidney disease, heart and vascular disease, and diabetes, was significantly associated with being a COVID-19 case, increasing the odds of being diagnosed with COVID-19. Conclusion: We were able to show how an alternative data source, the Intego data, can be used in a pandemic situation. We consider our findings useful for public health officials who plan intervention strategies aimed at monitor and control disease outbreaks such as that of COVID-19. [ABSTRACT FROM AUTHOR]

Background: The purpose of this paper is to analyse the utilization of formal and informal home care among older patients with cancer (OCP) and to compare this with middle-aged patients with cancer (MCP) and older patients without cancer (ONC). Additionally, we examined predictors of transitions towards formal care one year after a cancer diagnosis.Methods: OCP and MCP had to be recruited within three months after a cancer diagnosis and have an estimated life expectancy over six months. ONC consisted of patients without known cancer, seen by the general practitioner. Formal and informal care were compared between the patient groups at baseline, i.e. shortly after a cancer diagnosis and changes in care were studied after one year.Results: A total of 844 patients were evaluable for formal care at baseline and 469 patients (56%) at follow-up. At baseline, about half of older adults and 18% of MCP used formal care, while about 85% of cancer patients and 57% ONC used informal care. Formal care increased for all groups after one year though not significantly in OCP. The amount of informal care only changed in MCP which decreased after one year. Cancer-related factors and changes in need factors predict a transition towards formal care after a cancer diagnosis.Conclusions: A cancer diagnosis has a different impact on the use of formal and informal care than ageing as such. The first year after a cancer diagnosis is an important time to follow-up on the patients' needs for home care. [ABSTRACT FROM AUTHOR]

Background: Overweight is a major risk factor for non-communicable diseases (NCDs) in Europe, affecting almost 60% of all adults. Tackling obesity is therefore a key long-term health challenge and is vital to reduce premature mortality from NCDs. Methodological challenges remain however, to provide actionable evidence on the potential health benefits of population weight reduction interventions. This study aims to use a g-computation approach to assess the impact of hypothetical weight reduction scenarios on NCDs in Belgium in a multi-exposure context. Methods: Belgian health interview survey data (2008/2013/2018, n = 27 536) were linked to environmental data at the residential address. A g-computation approach was used to evaluate the potential impact fraction (PIF) of population weight reduction scenarios on four NCDs: diabetes, hypertension, cardiovascular disease (CVD), and musculoskeletal (MSK) disease. Four scenarios were considered: 1) a distribution shift where, for each individual with overweight, a counterfactual weight was drawn from the distribution of individuals with a "normal" BMI 2) a one-unit reduction of the BMI of individuals with overweight, 3) a modification of the BMI of individuals with overweight based on a weight loss of 10%, 4) a reduction of the waist circumference (WC) to half of the height among all people with a WC:height ratio greater than 0.5. Regression models were adjusted for socio-demographic, lifestyle, and environmental factors. Results: The first scenario resulted in preventing a proportion of cases ranging from 32.3% for diabetes to 6% for MSK diseases. The second scenario prevented a proportion of cases ranging from 4.5% for diabetes to 0.8% for MSK diseases. The third scenario prevented a proportion of cases, ranging from 13.6% for diabetes to 2.4% for MSK diseases and the fourth scenario prevented a proportion of cases ranging from 36.4% for diabetes to 7.1% for MSK diseases. Conclusion: Implementing weight reduction scenarios among individuals with excess weight could lead to a substantial and statistically significant decrease in the prevalence of diabetes, hypertension, cardiovascular disease (CVD), and musculoskeletal (MSK) diseases in Belgium. The g-computation approach to assess PIF of interventions represents a straightforward approach for drawing causal inferences from observational data while providing useful information for policy makers. [ABSTRACT FROM AUTHOR]

Background: General practitioners (GPs) have a vital role in reaching out to vulnerable populations during and after the COVID-19 pandemic. Nonetheless, they experience many challenges to fulfill this role. This study aimed to examine associations between practice characteristics, patient population characteristics and the extent of deprivation of practice area on the one hand, and the level of outreach work performed by primary care practices (PCPs) during the COVID-19 pandemic on the other hand. Methods: Belgian data from the international PRICOV-19 study were analyzed. Data were collected between December 2020 and August 2021 using an online survey in PCPs. Practices were recruited through randomized and convenience sampling. Descriptive statistics and ordinal logistic regression analyses were performed. Four survey questions related to outreach work constitute the outcome variable. The adjusted models included four practice characteristics (practice type, being a teaching practice for GP trainees; the presence of a nurse or a nurse assistant and the presence of a social worker or health promotor), two patient population characteristics (social vulnerability and medical complexity) and an area deprivation index. Results: Data from 462 respondents were included. First, the factors significantly associated with outreach work in PCPs are the type of PCP (with GPs working in a group performing more outreach work), and the presence of a nurse (assistant), social worker or health promotor. Second, the extent of outreach work done by a PCP is significantly associated with the social vulnerability of the practice's patient population. This social vulnerability factor, affecting outreach work, differed with the level of medical complexity of the practice's patient population and with the level of deprivation of the municipality where the practice is situated. Conclusions: In this study, outreach work in PCPs during the COVID-19 pandemic is facilitated by the group-type cooperation of GPs and by the support of at least one staff member of the disciplines of nursing, social work, or health promotion. These findings suggest that improving the effectiveness of outreach efforts in PCPs requires addressing organizational factors at the practice level. This applies in particular to PCPs having a more socially vulnerable patient population. [ABSTRACT FROM AUTHOR]

Background: Older people want to age in place. Despite advancing functional limitations and their desire of aging in place, they are not always faithful to therapy that maintains independence and promotes safety. Occupational therapists can facilitate aging in place. Occupational therapy is defined as the therapeutic use of everyday life occupations with persons, groups, or populations for the purpose of enhancing or enabling participation. Aim: To describe the content a high-adherence-to-therapy and evidence-based occupational therapy intervention to optimize functional performance and social participation of home-based physically frail older adults and wellbeing of their informal caregiver, and the research activities undertaken to design this intervention. Methods: A roadmap was created to develop the occupational therapy intervention. This roadmap is based on the Medical Research Council (MRC) framework and is supplemented with elements of the Intervention Mapping approach. The TIDieR checklist is applied to describe the intervention in detail. A systematic review and two qualitative studies substantiated the content of the intervention scientifically. Results: The application of the first two phases of the MRC framework resulted in the ProMOTE intervention (Promoting Meaningful activities by Occupational Therapy in Elderly). The ProMOTE intervention is a high-adherence-to-therapy occupational therapy intervention that consists of six steps and describes in detail the evidence-based components that are required to obtain an operational intervention for occupational therapy practice. Conclusion: This study transparently reflects on the process of a high-quality occupational therapy intervention to optimize the functional performance and social participation of the home-based physically frail older adult and describes the ProMOTE intervention in detail. The ProMOTE intervention contributes to safely aging in place and to maintaining social participation. The designed intervention goes beyond a description of the 'what'. The added value lies in the interweaving of the 'why' and 'how'. By describing the 'how', our study makes the concept of 'therapeutic use-of-self' operational throughout the six steps of the occupational therapy intervention. A further rigorous study of the effect of the ProMOTE intervention on adherence, functional performance and social participation is recommended based to facilitate the implementation of this intervention on a national level in Belgium. [ABSTRACT FROM AUTHOR]

Background: Swimmer's itch, an allergic contact dermatitis caused by avian and mammalian blood flukes, is a parasitic infection affecting people worldwide. In particular, avian blood flukes of the genus Trichobilharzia are infamous for their role in swimmer's itch cases. These parasites infect waterfowl as a final host, but incidental infections by cercariae in humans are frequently reported. Upon accidental infections of humans, parasite larvae will be recognized by the immune system and destroyed, leading to painful itchy skin lesions. However, one species, Trichobilharzia regenti, can escape this response in experimental animals and reach the spinal cord, causing neuroinflammation. In the last few decades, there has been an increase in case reports across Europe, making it an emerging zoonosis. Methods: Following a reported case of swimmer's itch in Kampenhout in 2022 (Belgium), the transmission site consisting of a private pond and an adjacent creek was investigated through a malacological and parasitological survey. Results: Six snail species were collected, including the widespread Ampullaceana balthica, a well-known intermediate host for Trichobilharzia parasites. Shedding experiments followed by DNA barcoding revealed a single snail specimen to be infected with T. regenti, a new species record for Belgium and by extension the Benelux. Moreover, it is the most compelling case to date of the link between this neurotropic parasite and cercarial dermatitis. Additionally, an Echinostomatidae sp. and Notocotylus sp. were isolated from two other specimens of A. balthica. However, the lack of reference DNA sequences for these groups in the online repositories prevented genus- and species-level identification, respectively. Conclusions: The presence of T. regenti in Belgium might have severe clinical implications and its finding highlights the need for increased vigilance and diagnostic awareness among medical professionals. The lack of species-level identification of the other two parasite species showcases the barcoding void for trematodes. Overall, these findings demonstrate the need for a Belgian framework to rapidly detect and monitor zoonotic outbreaks of trematode parasites within the One Health context. [ABSTRACT FROM AUTHOR]

Background: To support self-management of chronically ill persons, innovative approaches of care practice are being developed. Unfortunately, many self-management supporting interventions struggle to achieve reliable and consistent improvements at various levels (patient, provider and healthcare system level). One possible strategy to facilitate translating theory into practice, is to consider the healthcare professionals' perspective prior to the development of new interventions. An exploration of their knowledge and opinion about barriers and facilitators is necessary before employing any self-management support (SMS) intervention. Therefore, our study aims to explore care professionals' perspectives about SMS within the Flemish primary care setting. Methods: This study used a qualitative study design to examine SMS in primary care setting. Five focus groups were conducted, grouped into three waves. Participants were healthcare professionals in Flanders representing different disciplines and settings. A maximum variation purposive sampling was used to recruit participants. For the data analysis, the framework of thematic networks by Attride-Stirling was applied. Results: A total of 34 healthcare professionals participated. Three global themes related to SMS were derived from the thematic analysis: (1) Characteristics, (2) Support strategies, (3) Barriers and facilitators. SMS was characterised as a collaboration-based and person-centred approach. A variety of supporting strategies were mentioned by the focus group participants. Most strategies consisted of informing and educating patients. Complementary to individual strategies, collaborative strategies were deemed necessary to support self-management. Regarding barriers and facilitators, different patient-related factors were identified. Additionally, competencies of healthcare providers and external factors seem to hinder the implementation of SMS in practice. Conclusions: This focus group study highlights the importance of a collaborative, person-centred approach to SMS in the context of chronic diseases. Our findings point to the need for interventions that raise awareness and address barriers associated with SMS. Since generic SMS does not exist, the road to success is a growth process in which support must be adapted to the individual patient. [ABSTRACT FROM AUTHOR]

The trajectory of COVID-19 epidemic waves in the general population of Belgium was analysed by defining quantitative criteria for epidemic waves from March 2020 to early 2023. Peaks and starting/ending times characterised nine waves numerated I to IX based on the daily reported incidence number (symbol INCID) and three "endemic" interval periods between the first four waves. The SIR compartmental model was applied to the first epidemic wave by fitting the daily prevalence pool (symbol I) calculated as the sum of the daily incidence rate and estimated number of subjects still infectious from the previous days. The basic reproductive number R0 was calculated based on the exponential growth rate during the early phase and on medical literature knowledge of the time of generation of SARS-CoV-2 infection. The first COVID-19 wave was well fitted by an open SIR model. According to this approach, dampened recurrent epidemic waves evolving through an endemic state would have been expected. This was not the case with the subsequent epidemic waves being characterised by new variants of concern (VOC). Evidence-based observations: 1) each epidemic wave affected less than a fifth of the general population; 2) the Vth epidemic wave (VOC Omicron) presented the greatest amplitude. The lack of recurrence of the same VOC during successive epidemic waves strongly suggests that a VOC has a limited persistence, disappearing from the population well before the expected proportion of the theoretical susceptible cohort being maximally infected. Fitting the theoretical SIR model, a limited persistence of VOCs in a population could explain that new VOCs replace old ones, even if the new VOC has a lower transmission rate than the preceding one. In conclusion, acquisition of potential defective mutations in VOC during an epidemic wave is a potential factor explaining the absence of resurgence of a same VOC during successive waves. Such an hypothesis is open to discussion and to rebuttal. A modified SIR model with epidemic waves of variable amplitude related not only to R0 and public health measures but also to acquisition of defective fitting in virus within a population should be tested. [ABSTRACT FROM AUTHOR]

Environmental stress represents an important burden on health and leads to a considerable number of diseases, hospitalisations, and excess mortality. Our study encompasses a representative sample size drawn from the Belgian population in 2016 (n = 11.26 million, with a focus on n = 11.15 million individuals). The analysis is conducted at the geographical level of statistical sectors, comprising a total of n = 19,794 sectors, with a subset of n = 18,681 sectors considered in the investigation. We integrated multiple parameters at the finest spatial level and constructed three categories of environmental stress through clustering: air pollution, noise stress and stress related to specific land-use types. We observed identifiable patterns in the spatial distribution of stressors within each cluster category. We assessed the relationship between age-standardized all-cause mortality rates (ASMR) and environmental stressors. Our research found that especially very high air pollution values in areas where traffic is the dominant local component of air pollution (ASMR + 14,8%, 95% CI: 10,4 – 19,4%) and presence of industrial land (ASMR + 14,7%, 95% CI: 9,4 – 20,2%) in the neighbourhood are associated with an increased ASMR. Cumulative exposure to multiple sources of unfavourable environmental stress (simultaneously high air pollution, high noise, presence of industrial land or proximity of primary/secondary roads and lack of green space) is associated with an increase in ASMR (ASMR + 26,9%, 95% CI: 17,1 – 36,5%). [ABSTRACT FROM AUTHOR]

Background: The use of medicinal plants is integral to global healthcare systems, with Sub-Saharan Africa maintaining a robust tradition of herbal medicine alongside Western-oriented healthcare. As migrant communities tend to continue traditional herbal practices after migration, documenting this use is vital to develop culturally sensitive healthcare. This study investigates plant usage and perspectives in the context of sexual and reproductive health among the Congolese community in Belgium, particularly in the Matongé quarter of Brussels. Our research questions were: (1) What is the current knowledge of medicinal plants among the Congolese community in Belgium in the context of sexual health, and what are the applications and commonly employed administration methods of these plants? (2) What role does herbal medicine play in the context of sexual health for people of Congolese descent in Belgium and how this is influenced by perceptions of sexuality? and (3) Is there a gender bias in the use of medicinal plants, and if so, can this be related to perceived gender norms? Methods: We conducted 22 semi-structured interviews with people of Congolese descent currently living in Belgium. Participants were selected using both snowball sampling and purposive sampling. Plant use in the context of sexual health was recorded through freelisting. Data on narratives, ideas, and perceptions of this plant use in the context of sexual health were collected. Interview transcripts were analyzed using thematic analysis. Results: We identified 17 plant species used for sexual health. Three overarching themes emerged from our data. Plants were used with a notable gender bias favoring male sexual potency enhancement. Men used these plants for both remedying potency issues and enhancing sexual prowess. In contrast, knowledge about plants for female sexual health was limited. Gender norms reinforced the importance of male sexual potency, while stigmatizing open discussions of female sexuality. Conclusions: The use of medicinal plants for sexual health raises health, social, and conservation concerns, underscoring the need for further research in this area. This study contributes to understanding medicinal plant use within the Congolese community in Belgium and highlights the necessity for future research on herbal practices for female sexual health in this context. [ABSTRACT FROM AUTHOR]

Usutu virus is an emerging pathogen transmitted by mosquitoes. Culex modestus mosquitoes are widespread in Europe, but their role in disease transmission is poorly understood. Recent data from a single infectious mosquito suggested that Culex modestus could be an unrecognized vector for Usutu virus. In this study, our aim was to corroborate this finding using a larger sample size. We collected immature Culex modestus from a reedbed pond in Flemish Brabant, Belgium, and reared them in the laboratory until the third generation. Adult females were then experimentally infected with Usutu virus in a blood meal and incubated at 25 °C for 14 days. The presence of Usutu virus in the saliva, head and body of each female was determined by plaque assay and quantitative real-time reverse-transcription polymerase chain reaction (qRT-PCR). The transmission efficiency was 54% (n = 15/28), confirming that Belgian Culex modestus can experimentally transmit Usutu virus. [ABSTRACT FROM AUTHOR]

Background: Day care centres (DCCs) are ideal settings for drug-resistant bacteria to emerge. Prevalence numbers of faecal carriage of antimicrobial resistant bacteria in these settings are rare. We aimed to determine the prevalence of faecal antimicrobial resistant bacteria carriage in children attending DCCs and to assess and identify infection risk factors within DCCs in The Netherlands and Belgium. Methods: A point-prevalence study was conducted in 28 Dutch (499 children) and 18 Belgian (448 children) DCCs. Stool samples were taken from the children's diapers and a questionnaire was filled in by their parents. Hygiene related to stool and toilet use, hygiene related to food, environmental contamination, hand hygiene and hygiene guidelines were assessed conform a standardized questionnaire by the infection prevention and control expert visiting the DCC. Multilevel logistical regression analyses were used to define which characteristics predicted the presence of extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-E), carbapenemase-producing Enterobacterales (CPE), vancomycin-resistant enterococci (VRE), and ciprofloxacin-resistant Enterobacterales (CipR-E). Results: The ESBL-E prevalence was 16% (n = 71) in Belgium and 6% (n = 30) in the Netherlands. The CipR-E prevalence was 17% (n = 78) in Belgium and 8% (n = 38) in the Netherlands. Antimicrobial use (RR: 0.30; 95% CI: 0.33–0.48) and hospital admissions (RR: 0.37; 95% CI: 0.25–0.54) were lower in the Netherlands. Children travelling to Asia were at higher risk of being an ESBL-E carrier. Children using antimicrobials were at higher risk of being a CipR-E carrier. Cleaning the changing mat after each use was found as a protective factor for CipR-E carriage. Conclusions: We established a significant difference in ESBL-E and CipR-E carriage and antimicrobial use and hospital admissions between the Netherlands and Belgium among children attending DCCs. The differences between both countries should be further studied to improve the policy on anti-microbial use and hospital admissions in children. [ABSTRACT FROM AUTHOR]

Background: Oral disorders are still a major global public health challenge, considering their perpetuating and chronic nature. Currently, there is no direct index to measure the quality of care on a population scale. Hence, we aim to propose a new index to measure the quality of care for oral disorders worldwide. Methods: We generated our database using the data from the Global Burden of Disease (GBD) study 2017. Among different variables such as prevalence, incidence, years lived with disability, and disability-adjusted life years, we utilised principal component analysis (PCA) to determine the component that bears the greatest proportion of information to generate the novel quality of care index (QCI) for oral disorders. Results: Global QCI for oral disorders gradually increased from 1990 to 2017 (from 70.5 to 74.6). No significant gender disparity was observed during this period, and the gender disparity ratio (GDR) was considered optimal in 1990 and 2017. Between 1990 and 2017, the age-standardised QCI for all oral disorders increased in all the SDI regions. The highest QCI for all oral disorders in 2017 belonged to high-middle SDI countries (=80.24), and the lowest YLDs rate was seen in the low SDI quintile. In 1990, the quality of care in European, Central Asian, and Central and South American countries was in the lowest quintiles, whereas the North American, East Asian, Middle Eastern, and some African countries had the highest quality of dental care. Maynmar (=100), Uganda (=92.5), Taiwan (=92.0), China (=92.5), and the United States (=89.2) were the five countries with the highest age-standardised QCI. Nicaragua (=41.3), Belgium (=40.2), Venezuela (=38.4), Sierra Leone (=30.5), and the Gambia (=30.3) were the five countries with the least age-standardised QCI values. Conclusion: The quality of care for all oral disorders showed an increasing trend on a global scale from 1990 to 2017. However, the QCI distribution was not homogenous among various regions. To prevent the exacerbation of imminent disparities in this regard, better attention to total tooth loss in high-income countries and prioritising primary healthcare provision in low-income countries are recommended for oral disorders. [ABSTRACT FROM AUTHOR]

Background: Healthcare literature suggests that leadership behavior has a profound impact on nurse work-related well-being. Yet, more research is needed to better conceptualize, measure, and analyse the concepts of leadership and well-being, and to understand the psychological mechanisms underlying this association. Combining Self-Determination and Job Demands-Resources theory, this study aims to investigate the association between engaging leadership and burnout and work engagement among nurses by focusing on two explanatory mechanisms: perceived job characteristics (job demands and resources) and intrinsic motivation. Methods: A cross-sectional survey of 1117 direct care nurses (response rate = 25%) from 13 general acute care hospitals in Belgium. Validated instruments were used to measure nurses' perceptions of engaging leadership, burnout, work engagement, intrinsic motivation and job demands and job resources. Structural equation modeling was performed to test the hypothesised model which assumed a serial mediation of job characteristics and intrinsic motivation in the relationship of engaging leadership with nurse work-related well-being. Results: Confirmatory factor analysis indicated a good fit of the measurement model. The findings offer support for the hypothesized model, indicating that engaging leadership is linked to enhanced well-being, as reflected in increased work engagement, and reduced burnout. The results further showed that this association is mediated by nurses' perceptions of job resources and intrinsic motivation. Notably, while job demands mediated the relationship between EL and nurses' well-being, the relationship became unsignificant when including intrinsic motivation as second mediator. Conclusions: Engaging leaders foster a favourable work environment for nursing staff which is not only beneficial for their work motivation but also for their work-related well-being. Engaging leadership and job resources are modifiable aspects of healthcare organisations. Interventions aimed at developing engaging leadership behaviours among nursing leaders and building job resources will help healthcare organisations to create favourable working conditions for their nurses. Trial Registration: The study described herein is funded under the European Union's Horizon 2020 Research and Innovation programme from 2020 to 2023 (Grant Agreement 848031). The protocol of Magnet4Europe is registered in the ISRCTN registry (ISRCTN10196901). [ABSTRACT FROM AUTHOR]

Introduction: Inspired by examples in low- and middle-income countries, 50 community health workers (CHWs) were introduced in Belgium to improve access to primary care for people living in socio-economically vulnerable circumstances. This article aims to explore the ways in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care. Methods: The qualitative research focuses on the first year of implementation of this pioneer nationwide CHW programme in Belgium. To respond to the research aim, thirteen semi-structured in-depth interviews were held with people living in socio-economically vulnerable circumstances. In addition, a photovoice study was conducted with fifteen CHWs comprising four phases: (1) photovoice training; (2) participatory observation with each CHW individually; (3) an individual semi-structured in-depth interview; and (4) three focus group discussions. The transcripts and the observation notes were analysed in accordance with the abductive analysis procedures described by Timmermans and Tavory. Results: The qualitative results show that the CHWs' outreaching way of working allows them to reach people living at the crossroads of different vulnerabilities that are intertwined and reinforce each other. They experience complex care needs, while at the same time they face several barriers that interrupt the continuum of access to primary care – as conceptualised in the theoretical access-to-care framework of (Levesque et al. Int J Equity Health. 12:18, 2013). Building on the theoretical access-to-care framework described by (Levesque et al. Int J Equity Health. 12:18, 2013), the conceptual model outlines first the underlying mechanisms of CHW-facilitated access to primary care: (I) outreaching and pro-active way of working; (II) building trust; (III) providing unbiased support and guidance in a culturally sensitive manner; and (IV) tailoring the CHWs' approach to the unique interplay of barriers at the individual and health system level along the access-to-care continuum as experienced by the individual. Further disentangling how CHWs provide support to the barriers in access to care across the continuum and at each step is outlined further in the process characteristics of this conceptual model. Furthermore, the qualitative results show that the way in which CHWs support people is also impacted by the broader health system, such as long waiting times and unwelcoming healthcare professionals after referral from a CHW. Discussion: The conceptual model of CHW-facilitated access to primary care developed in this article explores the way in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care in Belgium. Through their outreaching method, they play a valuable bridging role between the Belgian healthcare system and people living in socio-economically vulnerable circumstances. Highlights: - Community health workers (CHWs) reach people who live at the crossroads of different vulnerabilities. - CHWs adjust their support to the unique interplay of barriers at the individual and health system level across the access-to-care continuum. - Through their outreaching method, they play a valuable bridging role between the Belgian healthcare system and people living in socio-economically vulnerable circumstances. - The conceptual model of CHW-facilitated access to primary care explores the ways in which CHWs support people living in socio-economically vulnerable circumstances in their access to primary care in Belgium. [ABSTRACT FROM AUTHOR]

Background: Generally influenza, a contagious respiratory disease, leads to mild illness, but can present as a severe illness with significant complications for some. It entails significant health challenges and an economic burden. Annual vaccination is considered the most effective preventive measure against influenza, especially in high-risk groups. Method: Epidemiological, demographic and vaccination data of influenza from 2009-to-2019 is collected from Sciensano, the Belgian Institute for Health. Sciensano monitors influenza virus through two surveillances: the Influenza-Like Illness (ILI) surveillance in primary care and the Severe Acute Respiratory Infections (SARI) surveillance in hospital settings. Results: 49.6% [± 8.5] of all ILI-samples tested positive in this period. Influenza A was the dominant circulating type, accounting for 73.7% [± 27.5] of positive samples, while influenza B accounted for 24.3% [± 26.7]. For SARI-surveillance, the average rate of samples tested positive was 36.3% [± 9.3]. Influenza A was responsible for respectively 77.7% [± 23.8] of positive samples and influenza B for 22.2% [± 23.7]. Since 2010, epidemics typically lasted about 9.3 weeks [± 2.7]. From 2012 to 2019 the average vaccine effectiveness was 34.9% [± 15.3]. Conclusion: Influenza is quickly considered a trivial disease, but can have substantial repercussions. It remains difficult to identify the level of treat of influenza due to antigenic evolution. Measures to prevent, control and treat are needed. Vaccines that provide broader and more durable protection that can be produced more rapidly could be a potential solution. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to investigate factors influencing the uptake of first and second COVID-19 booster vaccines among adults in Belgium, particularly age, sex, region of residence and laboratory confirmed COVID-19 infection history. Results: A binomial regression model was used with having received the first or second booster as outcome and age, sex, region of residence and infection history as fixed variables. Among adults, there was generally a higher uptake to receive the first booster among older age groups compared to younger ones. Females, individuals residing in Flanders and those with no previous COVID-19 infection were more likely to receive the first booster. For the second booster, the same age trend was seen as for the first booster. Males, individuals residing in Flanders and those who tested positive for COVID-19 once after first booster were more likely to receive the second booster. Individuals with multiple positive COVID-19 tests before and after primary course or first booster were less likely to receive the subsequent booster dose compared to COVID-naïve individuals. This information could be used to guide future vaccination campaigns during a pandemic and can provide valuable insights into booster uptake patterns. [ABSTRACT FROM AUTHOR]

Background: When conducting COVID-19 contact tracing, pre-defined criteria allow differentiating high-risk contacts (HRC) from low-risk contacts (LRC). Our study aimed to evaluate whether contact tracers in Belgium followed these criteria in practice and whether their deviations improved the infection risk assessment. Method: We conducted a retrospective cohort study in Belgium, through an anonymous online survey, sent to 111,763 workers by email. First, we evaluated the concordance between the guideline-based classification of HRC or LRC and the tracer's classification. We computed positive and negative agreements between both. Second, we used a multivariate Poisson regression to calculate the risk ratio (RR) of testing positive depending on the risk classification by the contact tracer and by the guideline-based risk classification. Results: For our first research question, we included 1105 participants. The positive agreement between the guideline-based classification in HRC or LRC and the tracer's classification was 0.53 (95% CI 0.49–0.57) and the negative agreement 0.70 (95% CI: 0.67–0.72). The type of contact tracer (occupational doctors, internal tracer, general practitioner, other) did not significantly influence the results. For the second research question, we included 589 participants. The RR of testing positive after an HRC compared to an LRC was 3.10 (95% CI: 2.71–3.56) when classified by the contact tracer and 2.24 (95% CI: 1.94–2.60) when classified by the guideline-based criteria. Conclusion: Our study indicates that contact tracers did not apply pre-defined criteria for classifying high and low risk contacts. Risk stratification by contact tracers predicts who is at risk of infection better than guidelines only. This result indicates that a knowledgeable tracer can target testing better than a general guideline, asking for a debate on how to adapt the guidelines. [ABSTRACT FROM AUTHOR]

An amendment to this paper has been published and can be accessed via the original article. [ABSTRACT FROM AUTHOR]

Background: Listeriosis is a rare disease caused by the bacterium Listeria monocytogenes and mainly affects at risk people. Listeriosis can lead to sepsis, central nervous system (CNS) infections and death. The objectives of this study were to describe and quantify comorbidities and neurological sequelae underlying non-perinatal listeriosis cases and to describe the factors associated with death and CNS infections in non-perinatal listeriosis.Methods: We retrospectively collected clinical data through computerized, paper or microfilmed medical records in two Belgian university hospitals. Logistic regression models and likelihood ratio tests allowed identifying factors associated with death and CNS infections.Results: Sixty-four cases of non-perinatal listeriosis were included in the clinical case series and 84 % were affected by at least one comorbid condition. The main comorbidities were cancer, renal and severe cardio-vascular diseases. Twenty-nine patients (45 %) suffered from a CNS infection and 14 patients (22 %) died during hospitalization, among whom six (43 %) had a CNS involvement. Among surviving patients, eleven suffered from neurological sequelae (22 %) at hospital discharge; all had CNS infection. Five of these patients (45 %) still suffered of their neurological sequelae after a median follow-up of one year (range: 0.08-19). The factor associated with death during the hospitalization was the presence of a severe cardiovascular disease (OR = 4.72, p = 0.015). Two factors inversely related with CNS infections were antibiotic monotherapy (OR = 0.28, p = 0.04) and the presence of renal disease (OR = 0.18, p = 0.02).Conclusions: In a public health context these results could be a starting point for future burden of listeriosis studies taking into account comorbidity. [ABSTRACT FROM AUTHOR]

Background: The prevalence of cancer increases every year, leading to a growing population of patients and survivors in need for care. To achieve good quality care, a patient-centered approach is essential. Correct and timely detection of needs throughout the different stages of the care trajectory is crucial and can be supported by the use of screening and assessment in a stepped-care approach. The Cancer Rehabilitation Evaluation System (CARES) is a valuable and comprehensive quality of life and needs assessment instrument. For use in Flemish research and clinical practice, the CARES tool was translated for the Dutch-speaking part of Belgium (Flanders) from its original English format. This protocol paper describes the translation and revalidation of this Flemish CARES version.Methods: After forward-backward translation of the CARES into Flemish we aim to recruit 150 adult cancer patients with a primary cancer diagnosis (stage I, II or III) for validation. In this study with a combination of qualitative and a quantitative approach, qualitative data will be collected through focus groups and supplemented by two phases of quantitative data collection: i) an initial patient survey containing questions on socio-demographic and medical data, the CARES and seven concurrent instruments; and ii) a second survey administered after 1 week containing the CARES and supplementary questions to explore their impressions on the content and the feasibility of the CARES.Discussion: With this extensive data collection process, psychometric validity of the Flemish CARES can be tested thoroughly using classical test theory. Internal consistency of summary scales, test-retest reliability, content validity, construct validity, concurrent validity and feasibility of the instrument will be examined. If the Flemish CARES version is found reliable, valid and feasible, it will be used in future research and clinical practice. Comprehensive assessment with the CARES in a stepped-care approach can facilitate timely identification of cancer patients' psychosocial concerns and care needs so it can contribute to efficient provision of patient-centered quality care.Trial Registration: ClinicalTrials.gov: NCT02282696 (July 16, 2014). [ABSTRACT FROM AUTHOR]

Background: Disability and chronic conditions both have an impact on health expenditures and although they are conceptually related, they present different dimensions of ill-health. Recent concepts of disability combine a biological understanding of impairment with the social dimension of activity limitation and resulted in the development of the Global Activity Limitation Indicator (GALI). This paper reports on the predictive value of the GALI on health care expenditures in relation to the presence of chronic conditions. Methods: Data from the Belgian Health Interview Survey 2008 were linked with data from the compulsory national health insurance (n = 7,286). The effect of activity limitation on health care expenditures was assessed via cost ratios from multivariate linear regression models. To study the factors contributing to the difference in health expenditure between persons with and without activity limitations, the Blinder-Oaxaca decomposition method was used. Results: Activity limitations are a strong determinant of health care expenditures. People with severe activity limitations (5.1%) accounted for 16.9% of the total health expenditure, whereas those without activity limitations (79.0%), were responsible for 51.5% of the total health expenditure. These observed differences in health care expenditures can to some extent be explained by chronic conditions, but activity limitations also contribute substantially to higher health care expenditures in the absence of chronic conditions (cost ratio 2.46; 95% CI 1.74-3.48 for moderate and 4.45; 95% CI 2.47-8.02 for severe activity limitations). The association between activity limitation and health care expenditures is stronger for reimbursed health care costs than for out-of-pocket payments. Conclusion: In the absence of chronic conditions, activity limitations appear to be an important determinant of health care expenditures. To make projections on health care expenditures, routine data on activity limitations are essential and complementary to data on chronic conditions. [ABSTRACT FROM AUTHOR]

Background: A program supporting the initiation of insulin therapy in primary care was introduced in Belgium, as part of a larger quality improvement project on diabetes care. This paper reports on a study exploring factors influencing the engagement of general practitioners (GPs) in insulin therapy initiation (research question 1) and exploring factors relevant for future program development (research question 2). Methods: We have used semi-structured interviews to answer the first research question: two focus group interviews with GPs who had at least one patient in the insulin initiation program and 20 one-to-one interviews with GPs who were not regular users of the overall support program in the region. To explore factors relevant for future program development, the data from the GPs were triangulated with data obtained from individual interviews with patients (n = 10), the diabetes nurse educator (DNE) and the specialist involved in the program, and data extracted from meeting reports evaluating the insulin initiation support program. Results: We found differences between GPs engaged and those not engaged in insulin initiation in attitude, subjective norm and perceived behavioural control regarding insulin initiation. In general the support program was evaluated in a positive way by users of the program. Some aspects need further consideration: job boundaries between the DNE and GPs, job boundaries between GPs and specialists, protocol adherence and limited case load. Conclusion: The study shows that the transition of insulin initiation from secondary care to the primary care setting is a challenge. Although a support program addressing known barriers to insulin initiation was provided, a substantial number of GPs were reluctant to engage in this aspect of care. Important issues for future program development are: an interdisciplinary approach to job clarification, a dynamic approach to the integration of expertise in primary care and feedback on protocol adherence. Trial registration: ClinicalTrials.gov Identifier: NCT00824499 [ABSTRACT FROM AUTHOR]