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Abstract 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 Patient‐reported outcome measures (PROMs) are used to assess a patient's health status at a particular point in time. They are essential in the development of person‐centred care. This paper reviews studies performed on PROMs for assessing AR and asthma control, in particular VAS scales that are included in the app MASK‐air® (Mobile Airways Sentinel networK) for asthma and rhinitis. VASs were initially developed on paper and pencil and tested for their criterion validity, cut‐offs and responsiveness. Then, a multicentric, multinational, double‐blind, placebo‐controlled, randomised control trial (DB‐PC‐RCT) using an electronic VAS form was carried out. Finally, with the development of MASK‐air® in 2015, previously validated VAS questions were adapted to the digital format and further methodologic evaluations were performed. VAS for asthma, rhinitis, conjunctivitis, work and EQ‐5D are included in the app. Additionally, two control‐medication scores for allergic symptoms of asthma (e‐DASTHMA) were validated for their criterion validity, cut‐offs and responsiveness.

Abstract Background In response to the COVID-19 pandemic, the World Health Organization established a number of key recommendations such as educational activities especially within primary care practices (PCPs) which are a key component of this strategy. This paper aims to examine the educational activities of PCPs during COVID-19 pandemic and to identify the factors associated with these practices across 38 countries. Methods A "Patient Education (PE)" score was created based on responses to six items from the self-reported questionnaire among PCPs (n = 3638) compiled by the PRICOV-19 study. Statistical analyses were performed on 3638 cases, with PCPs with missing PE score values were excluded. Results The PE score features a mean of 2.55 (SD = 0.68) and a median of 2.50 (2.16 – 3.00), with a maximum of 4.00, and varies quite widely between countries. Among all PCPs characteristics, these factors significantly increase the PE score: the payment system type (with a capitation payment system or another system compared to the fee for service), the perception of average PCP with patients with chronic conditions and the perception of adequate governmental support. Conclusion The model presented in this article is still incomplete and requires further investigation to identify other configuration elements favorable to educational activities. However, the results already highlight certain levers that will enable the development of this educational approach appropriate to primary care.

Abstract Background The mental health and well-being of GPs is a critical issue as they play a vital role in providing healthcare services to individuals and communities. Research has shown that GPs often face high levels of stress, burnout, and mental health problems due to their demanding work environment. During the COVID-19 pandemic, GPs faced additional challenges which further impacted their mental health and well-being. This study aims to investigate the impact of systemic work-related stressors on the level of well-being of GPs in Belgium during the pandemic, with a particular emphasis on identifying regional variations between Flanders, Wallonia, and Brussels-Capital. Methods Data were collected with a self-reported online questionnaire from 479 GPs Belgian practices between December 2020 and August 2021 as part of the international PRICOV-19 study that explored the organization of general practices during COVID-19 in 38 countries to guarantee safe, effective, patient-centered, and equitable care. Well-being was evaluated by the Mayo Clinic's expanded 9-item well-being index. Results The findings of this study reveal notable regional discrepancies in the degree of well-being experienced by Belgian GPs, with the Walloon region displaying the lowest level of well-being (37%) in a population highly susceptible to professional distress (57%). Among the key stressors contributing to such distress, financial difficulties among patients (p

Abstract Rationale It is unclear how each individual asthma symptom is associated with asthma diagnosis or control. Objectives To assess the performance of individual asthma symptoms in the identification of patients with asthma and their association with asthma control. Methods In this cross‐sectional study, we assessed real‐world data using the MASK‐air® app. We compared the frequency of occurrence of five asthma symptoms (dyspnea, wheezing, chest tightness, fatigue and night symptoms, as assessed by the Control of Allergic Rhinitis and Asthma Test [CARAT] questionnaire) in patients with probable, possible or no current asthma. We calculated the sensitivity, specificity and predictive values of each symptom, and assessed the association between each symptom and asthma control (measured using the e‐DASTHMA score). Results were validated in a sample of patients with a physician‐established diagnosis of asthma. Measurement and Main Results We included 951 patients (2153 CARAT assessments), with 468 having probable asthma, 166 possible asthma and 317 no evidence of asthma. Wheezing displayed the highest specificity (90.5%) and positive predictive value (90.8%). In patients with probable asthma, dyspnea and chest tightness were more strongly associated with asthma control than other symptoms. Dyspnea was the symptom with the highest sensitivity (76.1%) and the one consistently associated with the control of asthma as assessed by e‐DASTHMA. Consistent results were observed when assessing patients with a physician‐made diagnosis of asthma. Conclusions Wheezing and chest tightness were the asthma symptoms with the highest specificity for asthma diagnosis, while dyspnea displayed the highest sensitivity and strongest association with asthma control.

Abstract Background Management of unscheduled urgent care is a complex concern for many healthcare providers. Facing the challenge of appropriately dispatching unscheduled care, primary and emergency physicians have collaboratively implemented innovative strategies such as telephone triage. Currently, new original solutions tend to emerge with the development of new technologies. We created an interactive patient self-triage platform, ODISSEE, and aimed to explore its accuracy and potential factors affecting its performance using clinical case scenarios. Methods The ODISSEE platform was developed based on previously validated triage protocols for out-of-hours primary care. ODISSEE is composed of 18 icons leading to algorithmic questions that finally provide an advised orientation (emergency or primary care services). To investigate ODISSEE performance, we used 100 clinical case scenarios, each associated with a preestablished orientation determined by a group of experts. Fifteen volunteers were asked to self-triage with 50 randomly selected scenarios using ODISSEE on a digital tablet. Their triage results were compared with the experts’ references. Results The 15 participants performed a total of 750 self-triages, which matched the experts references regarding the level of care in 85.6% of the cases. The orientation was incorrect in 14.4%, with an undertriage rate of 1.9% and an overtriage rate of 12.5%. The tool’s specificity and sensitivity to advise participants on the appropriate level of care were 69% (95% CI: 64—74) and 97% (95% CI: 95—98) respectively. When combined with advice on the level of urgency, the tool only found the correct orientation in 68.4% with 9.2% of undertriages and 22.4% of overtriages. Some participant characteristics and the types of medical conditions demonstrated a significant association with the tool performance. Conclusion Self-triage apps, such as the ODISSEE platform, could represent an innovative method to allow patients to self-triage to the most appropriate level of care. This study based on clinical vignettes highlights some positive arguments regarding ODISSEE safety, but further research is needed to assess the generalizability of such tools to the population without equity issues.

Abstract Introduction Recently, the literature has promoted the use of patient‐reported outcome measures (PROMs) in clinical practice as a means to foster patient engagement. However, conditions necessary to support the use of PROMs to encourage asthma patient engagement are not clearly defined. Therefore, we sought (1) to explore the current and ideal use of PROMs by healthcare professionals (HP) in specialized asthma management centers in French‐speaking Belgium and (2) to understand under which conditions the use of PROMs contributes to patient engagement. Methods We undertook a mixed‐methods study with both anonymous online survey and in‐person qualitative semi‐structured interviews conducted with HPs to understand their perspectives on the routine use of PROMs. HPs were recruited from 16 asthma centers (French‐speaking Belgium) identified via the Belgian Respiratory Society. Results Of the 170 HPs identified from the 16 participating centers, 51 (30%) responded to the survey (n = 51) and 11 completed semi‐structured interviews. 53% (27/51) of the surveyed HPs reported using PROMs primarily for asthma monitoring and clinical research while all reported that PROMs should primarily be used in practice to facilitate communication with the patient and to address neglected aspects of the care relationship such as the psychosocial aspects of the disease. The qualitative interviews revealed avenues for moving from a medical‐centered and utilitarian use of PROMs to a use serving patient engagement. This would require HPs to go beyond their current representation of PROMs, to use instruments offering a more holistic image of the patient, to incorporate PROMs into a digital tool and to integrate PROMs in a patient education process. Conclusion The main findings of this study suggest relevant avenues for using PROMs in ways that support patient engagement.

Summary: Background: Validated questionnaires are used to assess asthma control over the past 1–4 weeks from reporting. However, they do not adequately capture asthma control in patients with fluctuating symptoms. Using the Mobile Airways Sentinel Network for airway diseases (MASK-air) app, we developed and validated an electronic daily asthma control score (e-DASTHMA). Methods: We used MASK-air data (freely available to users in 27 countries) to develop and assess different daily control scores for asthma. Data-driven control scores were developed based on asthma symptoms reported by a visual analogue scale (VAS) and self-reported asthma medication use. We included the daily monitoring data from all MASK-air users aged 16–90 years (or older than 13 years to 90 years in countries with a lower age of digital consent) who had used the app in at least 3 different calendar months and had reported at least 1 day of asthma medication use. For each score, we assessed construct validity, test–retest reliability, responsiveness, and accuracy. We used VASs on dyspnoea and work disturbance, EQ-5D-VAS, Control of Allergic Rhinitis and Asthma Test (CARAT), CARAT asthma, and Work Productivity and Activity Impairment: Allergy Specific (WPAI:AS) questionnaires as comparators. We performed an internal validation using MASK-air data from Jan 1 to Oct 12, 2022, and an external validation using a cohort of patients with physician-diagnosed asthma (the INSPIRERS cohort) who had had their diagnosis and control (Global Initiative for Asthma [GINA] classification) of asthma ascertained by a physician. Findings: We studied 135 635 days of MASK-air data from 1662 users from May 21, 2015, to Dec 31, 2021. The scores were strongly correlated with VAS dyspnoea (Spearman correlation coefficient range 0·68–0·82) and moderately correlated with work comparators and quality-of-life-related comparators (for WPAI:AS work, we observed Spearman correlation coefficients of 0·59–0·68). They also displayed high test–retest reliability (intraclass correlation coefficients range 0·79–0·95) and moderate-to-high responsiveness (correlation coefficient range 0·69–0·79; effect size measures range 0·57–0·99 in the comparison with VAS dyspnoea). The best-performing score displayed a strong correlation with the effect of asthma on work and school activities in the INSPIRERS cohort (Spearman correlation coefficients 0·70; 95% CI 0·61–0·78) and good accuracy for the identification of patients with uncontrolled or partly controlled asthma according to GINA (area under the receiver operating curve 0·73; 95% CI 0·68–0·78). Interpretation: e-DASTHMA is a good tool for the daily assessment of asthma control. This tool can be used as an endpoint in clinical trials as well as in clinical practice to assess fluctuations in asthma control and guide treatment optimisation. Funding: None.

Introduction Although asthma is a common disease, its diagnosis remains a challenge in clinical practice with both over- and underdiagnosis. Here, we performed a prospective observational study investigating the value of symptom intensity scales alone or combined with spirometry and exhaled nitric oxide fraction (FENO) to aid in asthma diagnosis. Methods Over a 38-month period we recruited 303 untreated patients complaining of symptoms suggestive of asthma (wheezing, dyspnoea, cough, sputum production and chest tightness). The whole cohort was split into a training cohort (n=166) for patients recruited during odd months and a validation cohort (n=137) for patients recruited during even months. Asthma was diagnosed either by a positive reversibility test (≥12% and ≥200 mL in forced expiratory volume in 1 s (FEV1)) and/or a positive bronchial challenge test (provocative concentration of methacholine causing a 20% fall in FEV1 ≤8 mg·mL−1). In order to assess the diagnostic performance of symptoms, spirometric indices and FENO, we performed receiver operating characteristic curve analysis and multivariable logistic regression to identify the independent factors associated with asthma in the training cohort. Then, the derived predictive models were applied to the validation cohort. Results 63% of patients in the derivation cohort and 58% of patients in the validation cohort were diagnosed as being asthmatic. After logistic regression, wheezing was the only symptom to be significantly associated with asthma. Similarly, FEV1 (% pred), FEV1/forced vital capacity (%) and FENO were significantly associated with asthma. A predictive model combining these four parameters yielded an area under the curve of 0.76 (95% CI 0.66–0.84) in the training cohort and 0.73 (95% CI 0.65–0.82) when applied to the validation cohort. Conclusion Combining a wheezing intensity scale with spirometry and FENO may help in improving asthma diagnosis accuracy in clinical practice.

Abstract MASK‐air®, a validated mHealth app (Medical Device regulation Class IIa) has enabled large observational implementation studies in over 58,000 people with allergic rhinitis and/or asthma. It can help to address unmet patient needs in rhinitis and asthma care. MASK‐air® is a Good Practice of DG Santé on digitally‐enabled, patient‐centred care. It is also a candidate Good Practice of OECD (Organisation for Economic Co‐operation and Development). MASK‐air® data has enabled novel phenotype discovery and characterisation, as well as novel insights into the management of allergic rhinitis. MASK‐air® data show that most rhinitis patients (i) are not adherent and do not follow guidelines, (ii) use as‐needed treatment, (iii) do not take medication when they are well, (iv) increase their treatment based on symptoms and (v) do not use the recommended treatment. The data also show that control (symptoms, work productivity, educational performance) is not always improved by medications. A combined symptom‐medication score (ARIA‐EAACI‐CSMS) has been validated for clinical practice and trials. The implications of the novel MASK‐air® results should lead to change management in rhinitis and asthma.

The capacity of self-assessment, to learn from experience, to make information-based decisions, and to adapt over time are essential drivers of success for any project aiming at healthcare system change. Yet, many of those projects are managed by healthcare providers' teams with little evaluation capacity. In this article, we describe the support mission delivered by an interdisciplinary scientific team to 12 integrated care pilot projects in Belgium, mobilizing a set of tools and methods: a dashboard gathering population health indicators, a significant event reporting method, an annual report, and the development of a sustainable “learning community.” The article provides a reflexive return on the design and implementation of such interventions aimed at building organizational evaluation capacity. Some lessons were drawn from our experience, in comparison with the broader evaluation literature: The provided support should be adapted to the various needs and contexts of the beneficiary organizations, and it has to foster experience-based learning and requires all stakeholders to adopt a learning posture. A long-time, secure perspective should be provided for organizations, and the availability of data and other resources is an essential precondition for successful work.

Testing strategies are crucial to prevent and control the spread of covid-19 but suffer from a lack of investment in understanding the human factors that influence their implementation. The aim of this study was to understand the factors that encourage participation and the level of engagement of nursing homes staff in a routine saliva testing programme for COVID-19 In December 2020, nursing homes (n = 571) in Wallonia (Belgium) were invited to participate in a saliva testing programme for their staff. The directors were questioned by telephone at the end of a 3-week pilot phase. 445 nursing homes took part in the evaluation questionnaire, of which 36(8%) answered that they chose not to participate in the testing programme. The average participation rate of nursing staff was 49(±25)%. Perception of the justification of the efforts required for testing and perception of practicability of the procedure were significantly associated with the adoption of the system by the nursing homes directors (OR(95%CI): 5.96(1.97-18.0), p = 0.0016); OR(95%CI): 5.64(1.94-16.4), p = 0.0015 respectively). Staff support, incentives and meetings increased the level of engagement in testing (p

Abstract Background In recent decades, asthma‐related quality of life questionnaires have joined objective clinical indicators as important outcome measures. In this study, we sought to investigate the predictors of asthma‐related quality of life in a large cohort of patients recruited from a secondary care center. Methods We conducted a cross‐sectional study on asthmatics (N = 1301) recruited from the Liège University Hospital asthma clinic (Belgium). After performing a descriptive analysis highlighting the distribution of scores from the Mini Asthma Quality of Life Questionnaire (Mini AQLQ) and its four dimensions (symptoms, activity limitation, emotional function, and environmental stimuli), we did multiple regression analysis to identify the independent predictors of AQLQ. Results Multiple regression beta analysis showed that AQLQ and its four dimensions were primarily associated with asthma control (p

While many studies have documented the intentions for the COVID-19 vaccine booster, few have explored the change from intention to final decision. This study explores the COVID-19 booster intentions and the change from intention to decision in a primo-vaccinated university population, with a distinction between staff members and students. It looks at the sociodemographic and medical characteristics, health literacy, personal COVID-19 infection and vaccination history, and attitudes/intentions regarding the booster, among the 1030 participants (64.4% staff members, 61.3% female, median age 36.0 years). Of the 8.7% who were initially hesitant, 72.7% ultimately got a booster and 27.3% did not. Another 84.2% intended to get a booster and 7.1% did not. Among the latter two groups, 88.9% maintained their intention and 11.1% changed their minds. The determinants associated with the intentions were health literacy and previous intentions regarding the COVID-19 primo-vaccination. The determinants associated with the change to non-vaccination were a previous COVID-19 infection, a past COVID-19 primo-vaccination intention, and a neutralizing antibody level. The results point to an opening for the support in decision-making, with a significant percentage of the study population potentially changing their mind between intention and final decision; this process should start early and be tailored to the individual’s COVID-19 history. A personalized approach seems necessary in order to ensure that individuals make an informed choice.

While weight-loss expectations have primarily been studied in people enrolled in weight-loss programs, the present study explores patient expectations about weight-loss and identifies related determinants in a large, non-clinical population.3916 volunteers (age > 18 years) participated in 2012 in a community-based survey in the French-speaking region of Belgium. Participants were asked to define “dream”, “goal”, “happy”, “acceptable”, and “disappointed” weights. Other self-reported measures were used to determine each participant's body mass index (BMI), body image discrepancy (BID), subjective norm (SN), weight loss activity, weight history, quality of life (QoL), and demographic and socioeconomic characteristics. The study focused on the determinants of unrealistic weight-loss “goal” (≥10% of initial weight).Results showed median weight loss targets ranged from 5 kg (“disappointed” weight loss) to 21 kg (“dreamed” weight loss). Respondents considered the recommended weight-loss target (5–10%) disappointing. Severe and morbid obesity categories are at high risk of unrealistic weight loss goal. Unrealistic weight-loss goals was associated with female gender, weight loss activity, overweight history and lower QoL in overweight and moderate obesity respondents.These findings confirm the urgent need to help patients accept more modest weight loss outcomes and the need for personalized care that considers the patient's specific profile and both weight loss expectations and determinants. Keywords: Overweight, Obesity, Population studies, Weight loss expectations

The current coronavirus disease 2019 (COVID-19) pandemic is forcing healthcare systems around the word to organise care differently than before. Prompt detection and effective triage and isolation of potentially infected and infectious patients are essential to preventing unnecessary community exposure. Since there are as yet no medications to treat or vaccines to prevent COVID-19, prevention focuses on self-management strategies, creating patient education challenges for physicians doing triage and testing. This article describes a five-step process for effectively educating, at discharge, patients who are suspected of being infectious and instructed to self-isolate at home. We are proposing the CEdRIC strategy as a practical, straightforward protocol that meets patient education and health psychology science requirements. The main goal of the CEdRIC process is to give patients self-management strategies aimed at preventing complications and disease transmission. The COVID-19 pandemic is challenging clinicians to rapidly teach their patients self-management strategies while managing the inherent pressures of this emergency situation. The CEdRIC strategy is designed to deliver key information to patients and standardize the discharge process. CEdRIC is currently being tested at triage centres in Belgium. Formal assessment of its implementation is still needed.

IntroductionThere is a pressing need for the hospitals to improve their quality and become more patient-centered. Over the last decade, several approaches were implemented to meet this demand, such as hospital accreditation or patient surveys. Many studies have addressed the patient involvement systems from the viewpoint of the factors that drive them or the achieved performance. In this study, we examined the patient involvement from the viewpoint of its function and operation rather than its performance. Following Luhmann, we reconsidered quality to be related to the absorption of uncertainty rather than improvement or innovation. The adaptation of an organization to involve patient participation can be regarded as contributing to the immune function of the organizational system.MethodsThree case studies addressing patient and family advisory councils in general hospitals were conducted in Belgium. Qualitative empirical material is retrieved from observation, documentation, and interviews.ResultsOur findings suggest that the immune function of the hospital organization operates in four main phases. First, we assess how the communicative process indicates the relevant difference that needs to be addressed. Role differentiation occurs through the depoliticization and depersonalization of criticism. Second, given the impossible realization of first-order observation of the environment, our material shows how second-order observation is organized through a dual representation. Third, we unveil how the environmental representation requires a specific organizational socialization to overcome the representation paradox. Finally, we analyze how the whole described process must fulfil the preparation of a repertoire of responses to the irritations of its environment.DiscussionThe analysis revealed that patient and family advisory councils complete a crucial immune function for organizations, far beyond the simple discussion of the “nuts and bolts” of organizational structure. These findings permit to discuss implications of the notions of participation and quality regarding to identity work of stakeholders, open organization, and change management.

Abstract 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 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 Aim To describe nursing student self‐esteem changes over time and its impacts on learning strategies. Design Existential phenomenology. Methods Interviews were conducted in Spring 2018 in a purposive sample of 39 nursing students, exploring events critical to self‐esteem and their impacts. Transcriptions were analysed descriptively and interpretatively to decipher the process that links self‐esteem, events and learning behaviour. Results What led to self‐esteem changes were “relationships with nurses during internships” and “receiving evaluations.” The students interpreted events and drew conclusions about their aptitude for nursing, which in turn prompted proactive or defensive learning behaviours. Their interpretations both depended on their self‐esteem and impacted it, in a vicious or virtuous circle. Exploring self‐esteem allows a better understanding of the importance of students' relationships with nursing teams, and of some of their defensive behaviours. Understanding the role of nursing student self‐esteem in the learning process could help improve student well‐being and competence.

Abstract Background Access to and use of digital technology are more common among people of more advantaged socioeconomic status. These differences might be due to lack of interest, not having physical access or having lower intentions to use this technology. By integrating the digital divide approach and the User Acceptance of Information Technology (UTAUT) model, this study aims to further our understanding of socioeconomic factors and the mechanisms linked to different stages in the use of Personal Health Records (PHR): desire, intentions and physical access to PHR. Methods A cross-sectional online and in-person survey was undertaken in the areas of Lorraine (France), Luxembourg, Rhineland-Palatinate and Saarland (Germany), and Wallonia (Belgium). Exploratory factor analysis was performed to group items derived from the UTAUT model. We applied linear and logistic regressions controlling for country-level heterogeneity, health and demographic factors. Results A total of 829 individuals aged over 18 completed the questionnaire. Socioeconomic inequalities were present in the access to and use of PHR. Education and income played a significant role in individuals' desire to access their PHR. Being older than 65 years, and migrant, were negatively associated with desire to access PHR. An income gradient was found in having physical access to PHR, while for the subgroup of respondents who expressed desire to have access, higher educational level was positively associated with intentions to regularly use PHR. In fully adjusted models testing the contribution of UTAUT-derived factors, individuals who perceived PHRs to be useful and had the necessary digital skills were more inclined to use their PHR regularly. Social influence, support and lack of anxiety in using technology were strong predictors of regular PHR use. Conclusion The findings highlight the importance of considering all stages in PHR use: desire to access, physical access and intention to regularly use PHRs, while paying special attention to migrants and people with less advantaged socioeconomic backgrounds who may feel financial constraints and are not able to exploit the potential of PHRs. As PHR use is expected to come with health benefits, facilitating access and regular use for those less inclined could reduce health inequalities and advance health equity.

Background: The twelve Integrated Care Program pilot projects (ICPs) created by the government plan ‘'Integrated Care for Better Health'’ aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme. Methods: A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders. Results: A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes. Discussion: The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal.

The Belgian government Integreo program (www.integreo.be) aims at a nationwide whole-system change in health and social care towards more Integrated Care (IC), by means of geographically defined integrated care projects (ICPs). Starting in early 2018, the twelve ICPs are implementing their action plan to change the organization of their regional network, covering up to 150.000 inhabitants, towards more IC. They receive limited financing: one FTE coordinator. As the final goal of the national plan is to anchor successful changes and scale-up best practices, FAITH.be (Federated consortium for Appraisal of Integrated care Teams in Health in Belgium) developed a mixed methods realist evaluation framework which aims at responding to the questions if, how, for whom and why the implementation of the ICP is successful or not so far, and learn lessons to help the ICPs to adjust their governance to support successful implementation of a whole-system change in their region. We will present preliminary insights of the implementation analysis, describing the main difficulties ICPs struggle with and how they address them. We use participative action and realist methods following RAMESES II standards (http://www.ramesesproject.org/). Data collection tools are chosen in consultation with stakeholders: coordinators, partners of and policy makers. Intermediate results are fed back and discussed with the stakeholders. Two methods are combined: qualitative enquiry for all ICPs and case study methods for three selected ICPs. Normalization Process Theory (NPT) is chosen to guide the analysis. First observations show that ICPs struggle with divergence in vision about priorities and timelines between ICPs, Governmental agencies at both federal and regional level. After postponement of crucial policy decisions and delivery of promised ICT-tools, ICPs are forced to adapt their action plan, which impedes their coherence. Moreover, due to the limited financing, ICPs are expected to pre-finance their actions towards IC, which impedes the involvement of key stakeholders, such as GPs’ and social care workers’ organisations and raises tensions between care providers, e.g. working in a fee-for service system versus those working in bundled payment systems. Hence, this hinders collective action and participation. These preliminary results will be further discussed and extended with the stakeholders. By the time of the conference, we will present the main issues for each social mechanism as described by NPT and explain why, how and for whom these difficulties occur and describe observed strategies to cope with them. First results show how the divergence of visions between policy makers and stakeholders in ICPs, hinder ICPs to implement innovative actions towards IC. Even though co-creation is considered an important pillar of the Integreo Plan, the lack of convergence of visions between policy agencies and ICPs hinders the implementation of innovative actions towards IC. The results only reflect the views of ICPs, not the policy makers. The results of the implementation analysis will be linked to the outcome and cost analysis of the ICPs

Near-death experiences (NDEs) refer to profound psychological events that can have an important impact on the experiencers' (NDErs) lives. Previous studies have shown that NDEs memories are phenomenologically rich. In the present study, we therefore aimed to extract the common themes (referred to as "features" in the NDE literature) reported by NDErs by analyzing all the concepts stored in the narratives of their experiences. A qualitative thematic analysis has been carried out on 34 cardiac arrest survivors' NDE narratives. Our results shed the light on the structure of the narratives by identifying 10 "time-bounded" themes which refer to isolated events encountered during the NDE and 1 "transversal" theme which characterizes the whole narrative and generally appears as a retrospective comment of self-reflection on the experience. The division of narratives into themes provides us with detailed information about the vocabulary used by NDErs to describe their experience. This established thematic method enables a rigorous description of the phenomenon, ensuring the inclusion of all self-reported manifestations of themes in narratives.