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Aims This process evaluation aims at identifying the facilitators and inhibitors that influenced the successful uptake of a nurse-led triage system streaming low-risk patients from an emergency department (ED) to the general practitioner (GP). Design & Methods Semi-structured interviews with ED nurses (n = 12), ED doctors (n = 6) from the ED of a Belgian general hospital and GPs (n = 5) affiliated with the adjacent GP cooperative (GPC). The process evaluation ran in parallel with the TRIAGE trial that started in March 2019 and ended 31st of December 2019. The first set of interviews was conducted in June 2019 and the second set in January 2020. Data were analysed based on grounded theory. Results Through a deductive framework, facilitators and inhibitors could be identified on three levels: the organisational, group and individual level. Main inhibitors are the degree of risk aversion of individual nurses, possible language barriers during delivery of the triage advice and the non-adapted ED infrastructure. Training on both the use of the triage protocol and effective delivery of the triage advice, in combination with periodical feedback from the GPC were the most important facilitators. Conclusion Based on the process evaluation we can conclude that a consensus exists among stakeholders that the ED Nurses are considered ideally positioned to perform the triage of walk-in patients, although a certain degree of experience is necessary. Although the extended triage protocol and GPC referral increases the complexity and duration of triage and entails a higher workload for the triage nurses, ED nurses found it did lead to a lower (perceived) workload for the ED in general.

Non-take-up of means-tested benefits is a widespread phenomenon which undermines the effectiveness and fairness of social policies. The digitalisation of the welfare state creates new opportunities for proactively contacting people who are potentially entitled to benefits, but do not take up their social rights. In this study, we report on how new data flows were used to reach out to potential beneficiaries of the Increased Reimbursement of health care, a programme targeted at low-income households in Belgium. By randomizing the period in which potential beneficiaries were contacted, we were able to identify a three- to four-fold increase in take-up among those contacted as a result of the outreaching activities. Households that did not respond to the intervention, the never takers, have lower pre-intervention healthcare expenditures. This suggests that non-take-up was reduced primarily among those who would expect to benefit most from receiving the Increased Reimbursement. Exploiting the combination of rich administrative data with experimental evidence, we also find that early responders are mostly older and have higher historic health expenditures than late responders. Furthermore, results point to the need for balancing well the inclusiveness of the intervention with an increased number of applications by ineligible people.

Background During the TRIAGE trial, emergency nurses diverted 13.3% of patients with low-risk complaints from a Belgian emergency department (ED) to the adjacent general practitioner cooperative (GPC). We examined the effects of this diversion on the total cost, insurance costs and patient costs, as charged on the invoice. Changes in the cost composition and the direct impact on revenues of both locations were examined as a secondary objective. Methods The differences in costs between intervention and control weekends were tested with two-sample t-tests and Kolmogorov-Smirnov (KS) tests. For the main outcomes an additional generalised linear model was created. Proportions of patients charged with certain costs were examined using Pearson's chi-square tests. Average revenues per weekend were compared using pooled t-tests. Results During intervention weekends, total costs increased by 3% (€3.3). The costs decreased by 8% (€2.2) for patients and increased by 6% (€5.5) for insurance, mainly driven by differences in physician fees. More patients were charged a consultation fee only (25% vs. 19%, p-value

Objective Adolescent vaccination coverage under a system of non school-based vaccination is likely to be suboptimal, but might be increased by targeted encouragement campaigns. We analysed the effect on human papillomavirus (HPV) vaccination initiation by girls aged 1218 of two campaigns set up in Flanders (Belgium) in 2007 and 2009: a personal information campaign and a combined personal information and financial incentive campaign. Methods We analysed (objective) data on HPV vaccination behaviour from the National Alliance of Christian Mutualities (NACM), Flanders largest sickness fund. We used z-scores to compare the monthly proportion of girls initiating HPV vaccination over time between carefully selected intervention and control groups. Separate analyses were done for older and younger girls. Total sample sizes of the intervention (control) groups were 221 (243) for the personal information campaign and 629 (5,322) for the combined personal information and financial incentive campaign. Results The personal information campaign significantly increased vaccination initiation, with older girls reacting faster. One year after the campaign the percentages of vaccination initiation for the oldest girls were 64.6 and 42.8 % in the intervention and control group, respectively (z = 3.35, p = 0.0008); for the youngest girls the percentages were 78.4 and 68.1 % (z = 1.71, p = 0.09). The combined personal information and financial incentive campaign increased vaccination initiation among certain age groups. One year after the campaign the difference in percentage points for HPV vaccination initiation between intervention and control groups varied between 18.5 % (z = 3.65, p = 0.0002) and 5.1 % (z = 1.12, p = 0.26). Conclusion Under a non school-based vaccination system, personal information and removing out-of-pocket costs had a significant positive effect on HPV vaccination initiation, although the effect substantially varied in magnitude. Overall, the obtained vaccination rates remained far below those realised under school-based HPV vaccination.

We exploit a comprehensive new panel dataset on retailbank branch locations in 233 neighborhoods (local markets) in the metropolitan area of Antwerp to describe (i) how between 1991 and 2006 the patterns of bank presence, entry, exit and choice deeply evolve and (ii) whether and how changes in these “on the ground” patterns systematically diverge across Antwerp’s different, highly segregated neighborhoods. We show that over the 15-year period under study entry and exit dynamics substantially intensify, the level change in branch desert grows significantly, and bank choice markedly declines; and that between 1996 and 2001, these changes are robustly associated with the neighborhood average income. In doing so, we advance a new technique for generating spatial measures that both minimize the discretization bias and can be reliably linked to neighborhoods. We demonstrate that the resulting measures are indeed more precise than traditional count measures.

We present evidence from a randomized A–eld experiment explictly designed to shed light on the role of standard information, goal framed information, and decision task complexity in individualsA­ choice of payment method. The experiment encouraged 19,707 Clients of the Belgian National O¢ ce for Family BeneA–ts to change from benefit payment by check to payment via direct transfer via a one-time mailing. The direct mailings multiplied the switching rate of these treated individuals (relative to the controls) by more than four times, showing that simply providing information can result in a very large behavioural change. Interestingly, foreigners were much more reponsive to the direct mailings than Belgians. Furthermore, simple, lowcost supplements to the standard information can amplify the magnitude of the behavioural responses. Adding both a flyer and a specific plan supplement to the standard letter not only yielded the largest effects on individuals' method of payment choice, but also appeared to speed up the decision to switch. We provide a simple, behavioural economics' interpretation to account for our results.

School-based, free HPV vaccination for girls in the first year of secondary school was introduced in Flanders (Belgium) in 2010. Before that, non school-based, co-payment vaccination for girls aged 12-18 was in place. We compared vaccination coverage, age-specific coverage and socio-economic inequalities in coverage -3 important parameters contributing to the effectiveness of the vaccination programs - under both vaccination systems. We used retrospective administrative data from different sources. Our sample consisted of all female members of the National Alliance of Christian Mutualities born in 1995, 1996, 1998 or 1999 (N=66,664). For each vaccination system we described the cumulative proportion HPV vaccination initiation and completion overtime. We used life table analysis to calculate age-specific rates of HPV vaccination initiation and completion. Analyses were done separately for higher income and low income groups. Under non school-based, co-payment vaccination the proportions HPV vaccination initiation and completion slowly rose over time. By age 17, the proportion HPV vaccination initiation/completion was 0.75 (95% CI 0.74-076)/0.66 (95% CI 0.65-0.67). The median age at vaccination initiation/completion was 14.4 years (95% CI 14.4-14.5)/15.4 years (95% CI 15.3-15.4). Socio-economic inequalities in coverage widened over time and with age. Under school-based, free vaccination rates of HPV vaccination initiation were substantially higher. By age 14,the proportion HPV vaccination initiation/completion was 0.90 (95% CI 0.90-0.90)/0.87(95% CI 0.87-0.88). The median age at vaccination initiation/completion was 12.7 years (95% CI 12.7-12.7)/13.3 years (95% CI 13.3-13.3). Socio-economic inequalities in coverage and in age-specific coverage were substantially smaller. (C) 2015 Published by Elsevier Ltd.

This chapter focuses on the determinants of a number of immunization programme outcomes in Flanders (Belgium), such as vaccine initiation and uptake, completion of the vaccination schedule and compliance to official validity criteria. These were assessed in both infant and adolescent age groups. Three main groups of potential influencing factors are looked at: (1) individual background variables; (2) family level variables; (3) external factors such as the governmental vaccination programme and other initiatives to promote vaccination. Data on parental willingness to pay for and willingness to accept multiple concomitant injections and their determinants are discussed as well. Exploring relationships between vaccination programme outcomes and influencing factors can give important information to optimize vaccination programme performance.

De manier waarop een vaccinatieprogramma georganiseerd en gefinancierd wordt heeft een grote invloed op het vaccinatiegedrag van mensen en op de mate waarin bepaalde doelgroepen bereikt worden. Aan de hand van terugbetalingsgegevens van vaccins voor humaan papillomavirus (HPV) bij de Landsbond der Christelijke Mutualiteiten (LCM) maken we een inschatting van de vaccinatiegraad in de periode voor de gratis universele HPV-vaccinatie via een collectief georganiseerd systeem (2007-2010). In deze periode vond HPV-vaccinatie plaats op initiatief van de meisjes zelf of van hun arts, en diende er remgeld betaald te worden. We laten zien dat aan twee voorwaarden voor een doeltreffend vaccinatiebeleid niet voldaan was. Ten eerste zijn er aanwijzingen dat zonder bijkomende inspanningen (zoals informatiecampagnes) de vaccinatiegraad zou afnemen over de tijd heen. Ten tweede werden bepaalde prioritaire doelgroepen, die een hoger risico hebben op baarmoederhalskanker, niet bereikt: mensen uit gezinnen met lagere inkomens en dochters van vrouwen die niet deelnemen aan screening voor baarmoederhalskanker. Gratis vaccinatie via een georganiseerd systeem (via de schoolgezondheidszorg, de huisarts, de pediater of de gynaecoloog) kan waarschijnlijk aan deze tekortkomingen tegemoetkomen. Daarnaast is het belangrijk het HPV-vaccinatiebeleid, samen met het beleid voor baarmoederhalskankerscreening, te integreren in een globale strategie ter bestrijding van baarmoederhalskanker.

Objective We investigated whether and to what extent the uptake of the Human Papillomavirus (HPV) vaccine by girls aged 12–18 was related to the cervical cancer screening history of age-appropriate older female household members (assumed to be their mothers) in Flanders (Belgium). Methods We studied administrative records on 127,854 female members of the National Alliance of Christian Mutualities, which is the largest health insurance fund in Flanders. Reimbursement data for HPV vaccination of girls for the period 2007–2009 were linked with reimbursement data for cervical cancer screening of their mothers in the three preceding years. A multilevel logit model was used to study associations between both preventive behaviors. In the model we controlled for both the girl's and the mother's age, the province of residence and the socio-economic background of the family. Results A clear association between a mother's history of participation in cervical cancer screening and her daughter's HPV vaccination initiation was found. The conditional odds of HPV vaccination initiation were more than 4 times higher for girls whose mother had one Pap test than for girls whose mother had none (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 3.5–5.9). For girls whose mother had three or more Pap tests, the conditional odds were 16 times higher than for girls whose mother did not have any pap tests ([OR] = 16.0; 95% [CI] = 12.1–21.2). The effect of screening (having received 1 pap smear as compared to none) was larger for girls living in neighborhoods with the lowest median income ([OR] = 6.0, 95% [CI] = 3.6–10.1). Conclusion In a situation where both cervical cancer screening and HPV vaccination are opportunistic, we found evidence that these preventive behaviors cluster within families.

We examine the effects of bank deregulation on the spatial dynamics of retail-bank branching, exploiting, much like a quasi-natural experiment, the context of intense liberalization reforms in Belgium in the late nineties. Using .ne-grained data on branch network dynamics within the metropolitan area of Antwerp and advancing novel spatial econometric techniques, we show that these liberalization reforms radically shifted and accelerated branch network dynamics. Entry and exit dynamics substantially intensified, the level change in financial void grew significantly, and bank choice markedly declined. Moreover, all these changes consistently extended (even with greater intensity) after the liberalization peak. However, the immediate and longer-term spatial ramifications of the financial sector liberalization were very distinct. All immediate changes systematically, differentially impacted the poorer and wealthier neighborhoods, disenfranchising the poorer neighbourhoods and favoring their wealthier counterparts. The longer-term effects on spatial patterns of change no longer exhibited this systematic relationship with neighborhood income. We draw out the policy implications of our findings.