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Abstract Objective Measuring intercultural attitudes can aid in understanding and addressing persistent inequities in healthcare. Instead of creating new instruments, several sources call for a more rigorous revalidation of existing instruments towards a more broad population. As an example of such an existing instrument, the EMP-3 (Ethnic Minority Patients) focuses on the attitudes of physicians towards ethnic minority patients. Starting from a robust theoretical underpinning and a rigorous methodological setup, the present study revalidates the EMP-3 instrument for physicians towards the REMP-3 instrument for graduate healthcare practitioners. Methods We assessed the reliability and validity of the old EMP-3, which we then updated to a new REMP-3 instrument. We used structural equation modeling to model the framework of intercultural effectiveness on two waves of independent data, N 2021 = 368 and N 2022 = 390. Within this framework, we tested the new REMP-3 instrument as an operationalization of intercultural attitudes. We conducted a confirmatory factor analysis on the first wave, after which we made adaptations to the original EMP-3 instrument to obtain a new REMP-3 instrument. The new REMP-3 instrument was then cross-validated using the data of the second wave. Results The new REMP-3 instrument is a psychometric upgrade compared to the EMP-3. The REMP-3 now has a cross-validated structure, with three subscale dimensions (i.e., task perception, background perception and the perceived need to communicate) and an overarching higher-order, full-scale dimension. Both the subscales as well as the full instrument show acceptable to good internal consistency reliability, with a reduced number of items from eighteen to ten. As theoretically predicted, the REMP-3 also functions as a measure of intercultural attitudes in an intercultural competence framework. Conclusion Ultimately, the REMP-3 instrument can contribute to more equity in healthcare by concisely and reliably assessing and monitoring attitudes in healthcare practitioners. This attitude assessment represents the potential of learning new skills and knowledge to address interactions with ethnic minority patients, which is especially useful during training situations like an internship.

Abstract Background This study investigated the perceived barriers and potential facilitators for culturally sensitive care among general practitioners in Flanders. Understanding these dynamics is crucial for improving healthcare quality and equity. Methodology Twenty-one in-depth interviews were conducted with Flemish GPs. Braun and Clarke’s reflexive thematic analysis was employed to develop and interpret themes that elucidate shared underlying meanings and capture the nuanced challenges and strategies related to cultural sensitivity in healthcare. Results Two core themes were generated: GPs’ uncertainty and opposition. These themes manifest in emotional responses such as frustration, miscomprehension, and feelings of helplessness, influencing relational outcomes marked by patient disconnect and reduced motivation for cultural sensitivity. The barriers identified are exacerbated by resource scarcity and limited intercultural contact. Conversely, facilitators include structural elements like interpreters and individual strategies such as engagement, aimed at enhancing GPs’ confidence in culturally diverse encounters. A meta-theme of perceived lack of control underscores the challenges, particularly regarding language barriers and resource constraints, highlighting the critical role of GPs’ empowerment through enhanced intercultural communication skills. Conclusion Addressing GPs’ uncertainties and oppositions can mitigate related issues, thereby promoting comprehensive culturally sensitive care. Essential strategies include continuous education and policy reforms to dismantle structural barriers. Moreover, incentivizing culturally sensitive care through quality care financial incentives could bolster GP motivation. These insights are pivotal for stakeholders—practitioners, policymakers, and educators—committed to advancing culturally sensitive healthcare practices and, ultimately, for fostering more equitable care provision.

Background The COVID-19 pandemic posed severe challenges to delivery of services at Primary Care level and for achieving follow-up of patients with chronic diseases.Objectives We analysed data from the PRICOV-19 study to explore determinants of active follow-up for chronic disease patients in seven Central and Eastern European (CEE) countries during the pandemic.Methods Pricov-19 was a cross-sectional study conducted within PC (Primary Care) practices in 37 European countries. We analysed data from 7 CEE countries (Bulgaria, Czech Republic, Hungary, Poland, Moldova, Romania, Ukraine) collected between November 2020 and December 2021. Practices were recruited through random or convenience sampling and participation of practices was voluntary. We performed descriptive statistics to identify the level of follow-up of chronic disease and what health system and practice-specific factors were associated with better follow-up. We used logistic regression and meta-analysis techniques to explore associations and heterogeneity between countries.Results 67.8% out of 978 practices reported actively following up chronic patients. Positive associations were found between active follow-up and such as having more GPs (aOR = 1.18, p-value = 0.005), an above-average chronic patient population (aOR = 3.13, p-value = 0.006), adequate government support (aOR = 2.35, p-value = 0.001), and GPs having time for guideline reading (aOR = 0.008, p-value = 1.71).Conclusions Patient follow-up, was influenced by different health system and practice-specific factors. The implications suggest the need for government support to enhance PC practice organisation during crises and solutions to decrease GP workload and provide tailored care for patients with chronic disease.

Background The COVID-19 pandemic has accentuated the indispensable role of primary care. Objectives: Recognising this, the PRICOV-19 study investigated how 5,489 GP practices across 38 countries (Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kosovo*, Latvia, Lithuania, Luxembourg, Malta, Republic of Moldova, Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, and United Kingdom) adapted their care delivery during the pandemic.Methods Based on a series of discussions on the results of the PRICOV-19 study group, eight recommendations to enhance primary care’s preparedness for future crises were formulated and endorsed by EQuiP and WONCA Europe.Results The recommendations underscore the importance of recognising and sustaining the substantial strides made in patient safety within GP practices during the pandemic in current daily practices; acknowledging and supporting the pivotal role of GP practices in addressing health inequalities during crises; adopting interprofessional care models to enhance practices’ resilience and adaptability to change; supporting training practices; creating healthy working environments; investing in infrastructure that supports adequate and safe care; and increasing funding for research on patient safety and primary care quality to inform evidence-based health policies and fostering international knowledge exchange among healthcare professionals and policymakers.Conclusion Policymakers, primary care associations, and the broader healthcare system are urged to collaboratively take responsibility and increase support for GP practices to enhance their resilience, adaptability, and capacity to deliver safe and equitable healthcare during future crises.

Abstract Background Recruitment for surveys has been a great challenge, especially in general practice. Methods Here, we reported recruitment strategies, data collection, participation rates (PR) and representativeness of the PRICOV-19 study, an international comparative, cross-sectional, online survey among general practices (GP practices) in 37 European countries and Israel. Results Nine (24%) countries reported a published invitation; 19 (50%) had direct contact with all GPs/GP practices; 19 (50%) contacted a sample of GPs /GP practices; and 7 (18%) used another invitation strategy. The median participation rate was 22% (IQR = 10%, 28%). Multiple invitation strategies (P-value 0.93) and multiple strategies to increase PR (P-value 0.64) were not correlated with the PR. GP practices in (semi-) rural areas, GP practices serving more than 10,000 patients, and group practices were over-represented (P-value

Abstract Background Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload. Objectives This study aimed to investigate the association between primary care practices’ organization, and quality and safety changes during the COVID-19 pandemic. Design Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as “Only GPs”, comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and “Multiprofessional,” comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936). Results Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more “Multiprofessional” practices, whereas “Only GPs” were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic. Conclusions Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

Abstract Background The provision of diversity-sensitive care is a promising approach towards reducing health disparities. Recent criticism and a scientific gap demonstrate the need for the patient perspective on diversity-sensitive care. This systematic review aims to describe the patient perspective, including patient experiences, expectations, and satisfaction with diversity-sensitive care provided by healthcare providers. Methods In December 2022 the Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO and additionally Google Scholar were searched for original studies that described or measured patient expectations, experiences, and/or satisfaction, specifically focusing on cultural or diversity competence of healthcare providers. Analysis of the collected data was performed using a convergent mixed-methods design based on thematic synthesis. Results From initially 5,387 articles, 117 were selected for full-text screening, and ultimately, 34 articles were included in this study. The concept of diversity-sensitive care was observed to comprise three components. The first component is focused on patient-centered care and includes competencies such as clear and direct communication, shared decision-making, individualized care, empathy, and consideration. The second component centers on providing culturally tailored information, adjusting care to cultural needs, working with interpreters, allyship, community partnerships, self-awareness, and cultural knowledge, and builds upon the first component. Across the first two components of diversity-sensitive care, patients have reported experiencing dissatisfaction and encountering shortcomings in their healthcare providers, sometimes resulting in the third and final component pertaining to provider care. This component underscores the importance of linguistic, ethnic, cultural, and gender concordance in delivering quality care. Conclusion In conclusion, the patient perspective on diversity-sensitive care encompasses multiple components, from patient-centered care to concordant care. The components incorporate various competencies as communication skills, empathy, self-awareness and adjusting care to cultural needs. Patients reported experiencing dissatisfaction and shortcomings across all components of diversity-sensitive care provided by healthcare providers.

Abstract Background Culturally sensitive care is integral to effective and equitable healthcare delivery, necessitating an understanding and acknowledgment of patients’ cultural needs, preferences, and expectations. This study investigates the perceptions of cultural sensitivity among general practitioners (GPs), focusing on their intentions, willingness and perceived responsibilities in providing care tailored to cultural needs. Methods In-depth interviews were conducted with 21 Flemish GPs to explore their perspectives on culturally sensitive care. Data analysis followed a conventional qualitative content analysis approach within a constructivist framework. A coding scheme was developed to identify recurring themes and patterns in the GPs’ responses. Results Findings reveal that culturally sensitive care provision is perceived as a multifaceted process, initiated by an exploration phase where GPs inquire about patients’ cultural needs and preferences. Two pivotal factors shaping culturally sensitive care emerged: patients’ specific cultural expectations and GPs’ perceived responsibilities. These factors guided the process of culturally sensitive care towards three distinct outcomes, ranging from complete adaptation to patients’ cultural requirements driven by a high sense of responsibility, through negotiation and compromise, to a paternalistic approach where GPs expect patients to conform to GPs’ values and expectations. Three typologies of GPs in providing culturally sensitive care were identified: genuinely culturally sensitive, surface-level culturally sensitive, and those perceiving diversity as a threat. Stereotyping and othering persist in healthcare, underscoring the importance of critical consciousness and cultural reflexivity in providing patient-centered and equitable care. Conclusions This study emphasizes the significance of empathy and underscores the necessity for GPs to embrace the exploration and acknowledgement of patients’ preferences and cultural needs as integral aspects of their professional role. It highlights the importance of shared decision-making, critical consciousness, cultural desire and empathy. Understanding these nuances is essential for enhancing culturally sensitive care and mitigating healthcare disparities.

Abstract Background Patient safety is defined as the prevention of harm to patients and aims to prevent errors. This analysis explores factors associated with the reported occurrence of patient safety incidents (PSIs) in general practices in Ireland at the start of the COVID-19 pandemic. Methods The PRICOV-19 was a cross-sectional study to record the (re)organisation of care provided in general practice and changes implemented during the COVID-19 pandemic in 38 countries. Primary outcomes include three potential scenarios of PSIs: delayed care due to practice factors, delayed care due to patient factors, and delayed care due to triage. Exploratory variables included demographic and organisational characteristics, triage, collaboration, and strategies to safeguard staff members’ well-being. Results Of the 172 participating Irish general practices, 71% (n = 122) recorded at least one potential PSI. The most frequent incident was delayed care due to patient factors (65%), followed by practice (33%) and triage (30%). Multivariate analysis showed that delayed care due to patient factors was associated with changes in the process of repeat prescriptions (OR 6.7 [CI 95% 2.5 to 19.6]). Delayed care due to practice factors was associated with suburbs/small towns (OR 4.2 [1.1 to 19.8]) and structural changes to the reception (OR 3.5 [1.2 to 11.4]). While delayed care due to patient factors was associated with having a practice population of 6000–7999 patients (OR 4.7 [1.1 to 27.6]) and delayed care due to practice factors was associated with having a practice population of 2000–3999 patients (OR 4.2 [1.2 to 17.1]). No linear associations were observed with higher or lower patient numbers for any factor. Delayed care due to triage was not associated with any exploratory variables. Conclusion The COVID-19 pandemic resulted in dramatic changes in the delivery of care through general practices in Ireland. Few factors were associated with the reported occurrence of PSIs, and these did not show consistent patterns. Sustained improvements were made in relation to repeat prescriptions. The lack of consistent patterns, potentially confirms that the autonomous decisions made in general practice in response to the challenges of the COVID-19 pandemic could have benefitted patient safety (See Graphical abstract). Graphical Abstract

Abstract Background During the COVID-19 pandemic, family physicians (FPs) served as the the initial point of contact for patients potentially infected with the virus, necessitating frequent updates to treatment protocols. However, practices also faced organizational challenges in providing care to other patients who also needed their medical attention. The pressure on FPs increased and affected their well-being. The international PRICOV-19 study, titled “Primary care in times of COVID-19 pandemic,” investigated how FPs functioned during the COVID‐19 pandemic. This article examines the correlation between various organizational and structural COVID-19-related variables and the well-being of FPs in Slovenia. Methods Between October 2020 and January 2021, we conducted an online cross-sectional survey. The questionnaire was distributed to 1040 Slovenian FPs and 218 family medicine (FM) trainees. Part of the questionnaire assessed the cooperation and well-being of FPs. The Mayo Clinic Well-being Index was used for the assessment. FP’s well-being was also assessed descriptively by asking open-ended questions about maintaining mental health during the pandemic. Potential factors associated with FPs’ well-being were identified using a multivariate linear regression method. Results The final sample comprised 191 participants (response rate 14.1%). The mean value ± standard deviation of the Mayo Well-being Index was 3.3 ± 2.6 points. The FPs with the poorest well-being had 5–15 years of work experience and worked in a practice where work could not be distributed in the absence of a co-worker without compromising the well-being of colleagues. Physical activity was identified as the most common method of maintaining mental health among FPs. Conclusions The results of the study suggest that targeted interventions are needed to support FPs mid-career, increase resilience in practice, promote strong team dynamics, and prioritise physical activity in healthcare. Addressing these aspects can contribute to the well-being of individual FPs and the overall health of the healthcare workers.

Abstract Background The PRICOV-19 study aimed to assess the organization of primary health care (PHC) during the COVID-19 pandemic in 37 European countries and Israel; and its impact on different dimensions of quality of care. In this paper, we described measures taken by public PHC centers in Greece. Additionally, we explored potential differences between rural and non-rural settings. Methods The study population consisted of the 287 public PHC centers in Greece. A random sample of 100 PHC centers stratified by Health Region was created. The online questionnaire consisted of 53 items, covering six sections: general information on the PHC center, patient flow, infection prevention, information processing, communication to patients, collaboration, and collegiality. Results Seventy-eight PHC centers (78%) - 50 rural and 28 non-rural – responded to the survey. Certain measures were reported by few PHC centers. Specifically, the use of online messages about complaints that can be solved without a visit to the PHC center (21% rural; and 31% non-rural PHC centers), the use of video consultations with patients (12% rural; and 7% non-rural PHC centers), and the use of electronic medical records (EMRs) to systematically identify the list of patients with chronic conditions (5% rural; and 10% non-rural PHC centers) were scarcely reported. Very few PHC centers reported measures to support identifying and reaching out to vulnerable population, including patients that may have experienced domestic violence (8% rural; and 7% non-rural PHC centers), or financial problems (26% rural; and 7% non-rural PHC centers). Providing administrative documents to patients through postal mail (12% rural; and 21% non-rural PHC centers), or regular e-mail (11% rural; and 36% non-rural PHC centers), or through a secured server (8% rural; and 18% non-rural PHC centers) was rarely reported. Finally, providing information in multiple languages through a PHC website (12% rural PHC centers only), or an answering machine (6% rural PHC centers only), or leaflets (3% rural PHC centers only; and for leaflets specifically on COVID-19: 6% rural; and 8% non-rural PHC centers) were lacking in most PHC centers. Conclusion Our study captured measures implemented by few PHC centers suggesting potential priority areas of future improvement.

Abstract Background Primary Health Care (PHC) has been key element in detection, monitoring and treatment of COVID-19 cases in Spain. We describe how PHC practices (PCPs) organized healthcare to guarantee quality and safety and, if there were differences among the 17 Spanish regions according to the COVID-19 prevalence. Methods Cross-sectional study through the PRICOV-19 European Online Survey in PCPs in Spain. The questionnaire included structure and process items per PCP. Data collection was due from January to May 2021. A descriptive and comparative analysis and a logistic regression model were performed to identify differences among regions by COVID-19 prevalence (low

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 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 Background During the Covid-19 pandemic, family medicine practices (FMPs) changed to improve safety against new coronavirus infections for both patients and employees. Protocols for treating patients with suspected Sars-Cov-2 infections were established to protect medical staff and other patients from being infected. However, these protocols also led to increased safety risks, such as delays in treating patients with other medical conditions. This exploratory study aimed to investigate safety risks in treating patients in FMPs during the Covid-19 pandemic and to suggest improvements to prevent Covid-19 in FMPs in Slovenia. Methods A cross-sectional study was rolled out in FMPs in Slovenia as part of the international Pricov-19 study. Data collection on safety management during the Covid-19 pandemic in FMPs in Slovenia took place from November 2020 until January 2021 using a self-administered online survey for FP working in Slovenia. A chi-square test, ANOVA, independent samples t-test or bivariate correlation test was performed to explore associations regarding the safety of patients’ management variables. Results From the 191 participating family physicians (FPs) (15.2% response rate), 54.8% reported having treated patients with fever (not Covid-19) late due to the new protocols at least once, and 54.8% reported patients with urgent conditions having been seen late at least once due to not coming. In the suburbs and rural environments FPs more often reported that at least once patient with a fever (not Covid-19) was seen late due to the protocol (p = 0.017) and more often reported that at least once patient with an urgent condition was seen late due to not coming to their FP (p = 0.017). The larger the practice, the more they reported that at least once a patient with fever (not Covid-19) was seen late due to the protocol (p = 0.012) and the more they reported at least once a patient with an urgent condition was seen late due to not coming to their FP (p = 0.012). Conclusion Covid-19 affected the safety of patient management in FMP in Slovenia. The most common problem was foregone care. Therefor, protocols for chronic patient management in the event of epidemics need to be established.

Abstract Background The COVID-19 pandemic exposed the health equity gap between and within countries. Western countries were the first to receive vaccines and mortality was higher among socially deprived, minority and indigenous populations. Surprisingly, many sub-Saharan countries reported low excess mortalities. These countries share experiences with community organization and participation in health. The aim of this article was to analyse if and how this central role of people can promote a successful pandemic response. Methods This analysis was partly based on local and national experiences shared during an international and Latin American conference on person-and people-centred care in 2021. Additionally, excess mortality data and pandemic control-relevant data, as well as literature on the pandemic response of countries with an unexpected low excess mortality were consulted. Results Togo, Mongolia, Thailand and Kenya had a seven times lower mean excess mortality for 2020 and 2021 than the United States of America. More successful pandemic responses were observed in settings with experience in managing epidemics like Ebola and HIV, well-established community networks, a national philosophy of mutual aid, financial government assistance, more human resources for primary care and paid community health workers. Discussion Since trust in authorities and health needs vary greatly, local strategies are needed to complement national and international pandemic responses. Three key levers were identified to promote locally-tailored pandemic management: well-organized communities, community-oriented primary care, and health information systems. An organized community structure stems from a shared ethical understanding of humanity as being interconnected with each other and the environment. This structure facilitates mutual aid and participation in decision making. Community-oriented primary care includes attention for collective community health and ways to improve health from its roots. A health information system supports collective health and health equity analysis by presenting health needs stratified for social deprivation, ethnicity, and community circumstances. Conclusions The difference in excess mortality between countries during the COVID-19 pandemic and various country experiences demonstrate the potential of the levers in promoting a more just and effective health emergency response. These same levers and strategies can promote more inclusive and socially just health systems.

Abstract Background The COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. This paper aims to explore to what extent the COVID-19 pandemic changed the work tasks and organization of Norwegian general practice. Material and method We analysed data from the Norwegian part of the international, cross-sectional PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. In the analyses, we focused on items related to the use of alternatives to face-to-face consultations, changes in the workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices. Results There was a large and significant increase in the use of all forms of alternative consultation forms (digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities. Conclusion Norwegian GPs adapted well to the need for increased use of alternatives to face-to-face consultations, and reported a high acceptance of their increased responsibilities. However, only one in four received adequate support from the government, which is an important learning point for similar situations in the future.

Abstract Background The SARS-CoV2 pandemic as well as the implementation of public health measures to decrease the spread of the virus re-sparked the call for “virtual” health or “distance” treatments. This paper aimed to assess the use of video consultations, the up-to-dateness of practice websites, and the views of GPs on whether eHealth is a positive aspect for the future of their practices in publicly -funded primary healthcare facilities in Austria. Methods The cross-sectional online questionnaire, part of the PRICOV-19 study, was conducted from December 2020 until July 2021. We randomly recruited 176 GP practices across Austria. Descriptive statistics as well as binary logistic regression models were applied to examine the associations between telemedicine use and practice factors. Results Compared with before the pandemic (3.8%), 7.6% of publicly funded GP practices have been using video consultations since the pandemic. In line with this, 93.9% of the practices had no increase in video consultation use. Fewer than half (44.3%) had an up-to-date webpage, and 27.8% assumed that the pandemic might have been a positive driver for eHealth in their practices. Positive associations with video consultation use could be found in practices with fewer patients aged 70 years and over than the average and more patients with chronic diseases than the average. Conclusion The use of video consultations in general practice and the readiness for other telemedicine approaches are both very low in Austria. Austria has to urgently follow the example of countries with a transparent and comprehensive national digital health strategy that includes video consultation. Without a proper payment system, patient inclusion, and support with regard to administrative and organizational aspects, no substantial change will occur in spite of an increase in need due to the pandemic and changes in the patient population.

Abstract Background The COVID-19 pandemic has had an enormous impact on health systems in Europe and has generated unprecedented challenges for tertiary care. Less is known about the effects on the activities of local family doctors (FDs), who have shifted tasks and adapted their practice to accommodate the new services brought by the pandemic. The PRICOV-19 study was a multi-country survey aiming to understand the challenges posed by the pandemic in primary health care (PHC) practices around Europe. Within the framework of this study, we assessed the impact of the pandemic on PHC facilities in urban, rural, and mixed urban/rural areas in the Republic of Moldova. Methods We present the results from the PRICOV-19 questionnaire designed at Ghent University (Belgium) and distributed between January and March 2021 to PHC facilities from the 35 districts of the Republic of Moldova. This analysis presents descriptive data on limitations to service delivery, staff role changes, implementation and acceptance of COVID-19 guidelines, and incidents reported on staff and patient safety during the pandemic. Results Results highlighted the differences between facilities located in urban, rural, and mixed areas in several dimensions of PHC. Nearly half of the surveyed facilities experienced limitations in the building or infrastructure when delivering services during the pandemic. 95% of respondents reported an increase in time spent giving information to patients by phone, and 88% reported an increase in responsibilities. Few practices reported errors in clinical assessments, though a slightly higher number of incidents were reported in urban areas. Half of the respondents reported difficulties delivering routine care to patients with chronic conditions and a delay in treatment-seeking. Conclusions During the pandemic, the workload of PHC staff saw a significant increase, and practices met important structural and organizational limitations. Consequently, these limitations may have also affected care delivery for vulnerable patients with chronic conditions. Adjustments and bottlenecks need to be addressed, considering the different needs of PHC facilities in urban, rural, and mixed areas.

Abstract Background The international study PRICOV-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on German general practitioners during the second wave of the COVID-19 pandemic. This paper addresses the following research questions: (1) How were changes in tasks on primary care and patient treatment perceived by GPs?, (2) What was the role of GPs during the pandemic, and how was their wellbeing?, (3) How did GPs perceive health policy measures?, and, (4) What influenced the attitudes of GPs on health policy measures? Methods This study pursues a multi-country cross-sectional design. Data collection took place throughout Germany from 01.02. to 28.02.2021 with a quantitative online questionnaire consisting of 53 items. The questionnaire was analysed through descriptive and inferential analyses using correlation and multiple regression models. Results The response rate was 20.4% (n = 349). The respondents were mainly GPs (59.6%) in single practices (62.5%) with a mean work experience of 15 to 20 years. GPs experienced a change in their work and practice organisation (80.3%). They felt a high responsibility (70.6%) and found their work has become more meaningful to them (76%). They also saw a lack of political support (75.2%) and that the measures taken by the government overburdened the daily practice (66.4%). Not many GPs were at risk of being distressed (53.4%) but rated the health policies rather negatively (60%). The multiple regression showed, the more GPs were exposed to risk of distress, the worse they assessed the government's measures. Conclusion GPs perceived their work as relevant and felt confident they could fulfil their tasks, but noticed that health policy initially hardly supported the outpatient sector. Health policies should increase their competence in relation to primary care, ensure its needs and consider an active inclusion of GPs in preparedness plans.

Abstract Background The COVID-19 pandemic substantially magnified the inequity gaps among vulnerable populations. Both public health (PH) and primary health care (PHC) have been crucial in addressing the challenges posed by the pandemic, especially in the area of vulnerable populations. However, little is known about the intersection between PH and PHC as a strategy to mitigate the inequity gap. This study aims to assess the collaboration between PHC and PH with a focus on addressing the health needs of vulnerable populations during the COVID-19 pandemic across jurisdictions. Methods We analyzed and compared data from jurisdictional reports of COVID-19 pandemic responses in PHC and PH in Belgium, Canada (Ontario), Germany, Italy, Japan, the Netherlands, Norway, and Spain from 2020 to 2021. Results Four themes emerge from the analysis: (1) the majority of the countries implemented outreach strategies targeting vulnerable groups as a means to ensure continued access to PHC; (2) digital assessment in PHC was found to be present across all the countries; (3) PHC was insufficiently represented at the decision-making level; (4) there is a lack of clear communication channels between PH and PHC in all the countries. Conclusions This study identified opportunities for collaboration between PHC and PH to reduce inequity gaps and to improve population health, focusing on vulnerable populations. The COVID-19 response in these eight countries has demonstrated the importance of an integrated PHC system. Consequently, the development of effective strategies for responding to and planning for pandemics should take into account the social determinants of health in order to mitigate the unequal impact of COVID-19. Careful, intentional coordination between PH and PHC should be established in normal times as a basis for effective response during future public health emergencies. The pandemic has provided significant insights on how to strengthen health systems and provide universal access to healthcare by fostering stronger connections between PH and PHC.

Abstract Background General practices have adapted the practice organisation to the circumstances of the COVID-19 pandemic. In this article we describe several adjustments in general practices in the field of patient flow management, appointments, triage, referral and infection prevention. We also examined how practices relate to the policy of the government and of the professional organisations during the pandemic. Methods A cross-sectional online survey was conducted among a sample of 893 general practitioners (GPs) during February and March 2021. The response rate was 17%. Because the questionnaire concerns practices and not individual GPs, one practice owner per practice received an invitation with a link to the online questionnaire. One reminder has been sent. Results General practices adapted their organisation during the corona pandemic, partly based on information and advice from their professional organisations. The adjustments were necessary to ensure that patient care continued as much and as safely as possible, often remotely. The use of video consultations quickly increased from 6% to 65% of the practices. The cooperation with neighbouring practices improved and practices felt supported by the professional organisations. Conclusions The pandemic itself, remote care and stricter patient flow management have put pressure on the quality of care and patient safety. The accessibility of the practices was sometimes limited. In the perception of patients, this was stronger than in reality.

Abstract Background Existing evidence on the role of community health workers (CHWs) in primary healthcare originates primarily from the United States, Canada and Australia, and from low- and middle-income countries. Little is known about the role of CHWs in primary healthcare in European countries. This scoping review aimed to contribute to filling this gap by providing an overview of literature reporting on the involvement of CHWs in primary healthcare in WHO-EU countries since 2001 with a focus on the role, training, recruitment and remuneration. Methods This systematic scoping review followed the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, extension for Scoping Reviews. All published peer-reviewed literature indexed in PubMed, Web of Science, and Embase databases from Jan 2001 to Feb 2023 were reviewed for inclusion. Included studies were screened on title, abstract and full text according to predetermined eligibility criteria. Studies were included if they were conducted in the WHO-EU region and provided information regarding the role, training, recruitment or remuneration of CHWs. Results Forty studies were included in this review, originating from eight countries. The involvement of CHWs in the WHO-EU regions was usually project-based, except in the United Kingdom. A substantial amount of literature with variability in the terminology used to describe CHWs, the areas of involvement, recruitment, training, and remuneration strategies was found. The included studies reported a trend towards recruitment from within the communities with some form of training and payment of CHWs. A salient finding was the social embeddedness of CHWs in the communities they served. Their roles can be classified into one or a combination of the following: educational; navigational and supportive. Conclusion Future research projects involving CHWs should detail their involvement and elaborate on CHWs’ role, training and recruitment procedures. In addition, further research on CHW programmes in the WHO-EU region is necessary to prepare for their integration into the broader national health systems.

Abstract Background The COVID-19 pandemic had a major impact on primary care and primary care physicians (PCPs) in Israel and around the world. There is paucity of information regarding treatment of patients with COVID-19 in the community, since most research was performed in hospitals. The aim of this study was to describe the Israeli PCPs’ experience. Methods This study is a part of an international cross-sectional study, the PRICOV-19. A translated version of the questionnaire was distributed among Israeli PCPs from December 2020 to July 2021. In this study, we describe the Israeli results and compare them to the international results. Results 5,961 respondents from 29 countries answered the questionnaire, 94 from Israel, with an Israeli response rate of 16%. Israeli PCPs reported an increase in use of telemedicine from 11 to 49% during the COVID epidemic. PCPs also reported a decline in their wellbeing; absence of secured time slots for keeping updated; perception that the Ministry of Health guidelines were a threat to the staff wellbeing and organization of practice and delays in the examination of non-COVID urgent cases. Conclusions The findings of this study raise concerns regarding the PCPs experience and may form the basis for an improved process of care. Guidelines for proper usage of telemedicine, substitutes for the physical examination and procedures for minimizing delayed patient examination for urgent conditions should be developed. Government directives and clinical guidelines should be communicated in a timely manner, with secured timeslots for physicians’ self-learning or updating. Ensuring physicians’ well-being in general should be an organization priority.

Abstract Background The COVID-19 pandemic has had a disproportionately hard impact on refugees and other migrants who are often exposed to the virus with limited means to protect themselves. We tested the hypothesis that during the COVID-19 pandemic, refugees and other migrants have suffered a negative impact on mental health and have been unjustly discriminated for spreading the disease in Europe (data collection from April to November 2020). Methods Participants in the ApartTogether Survey (N = 8297, after listwise deletion of missing items final N = 3940) provided data regarding to their difficulties to adhere to preventive recommendations against COVID-19 infection (CARE), self-perceived stigmatization (SS), and psychological distress (PD). Structural Equation Modeling was used to investigate PD as a mediator in the pathway linking CARE to SS, while adjusting for the housing and residence status. To improve confidence in the findings, single hold-out sample cross-validation was performed using a train/test split ratio of 0.8/0.2. Results In the exploratory set (N = 3159) SS was associated with both CARE (B = 0.200, p

AbstractObjective To investigate practice type and location of native and immigrant general practitioners (GPs); effects of migration status concordance between GPs and patients on experiences of patients in key areas of primary care quality and discrimination.Design and setting Secondary analysis of GP and patient survey data from QUALICOPC (Quality and Costs of Primary Care), a cross-sectional study of GPs and their patients in 34 countries, performed between 2011 and 2013.Main outcome measures We explored practice type and location of native and immigrant GPs and the experiences of native patients and patients with a migration background of communication, continuity, comprehensiveness, accessibility, and discrimination, using multilevel analysis. Concordance was modelled as a cross-level interaction between migration status of GPs and patients.Results Percentages of immigrant GPs varied widely. In Europe, this was highest in England and Luxemburg (40% of GPs born abroad) and lowest in Bulgaria and Romania (1%). The practice population of immigrant GPs more often included an above average proportion of people from ethnic minorities. There were no differences in main effects of patient experiences following a visit to an immigrant or native GP, in four core areas of primary care or in discrimination. However, people from first-generation migrant background more often experienced discrimination, in particular when visiting a native GP.Conclusion Patient experiences did not vary with GPs’ migration status. Although experience of discrimination was uncommon, first-generation migrant patients experienced more discrimination. Primary care should provide non-discriminatory care, through GP awareness of unconscious bias and training to address this. Key messagesThere were large differences in percentage of migrant GPs between countries.Migrant GPs’ practices had an above average proportion of people from ethnic minorities.In general, patients’ experienced discrimination from GPs and practice staff was low, but first-generation migrant patients more often experienced discrimination.First-generation migrant patients more often experienced discrimination when they visited a native GP.

BackgroundThe international collaboration study PRICOV-19 -Primary Health Care in times of COVID-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on the subjective perceptions of general practitioners on primary health care and the impact of political measures during the second wave of the COVID-19 pandemic. Within this survey, the "open text field" of the questionnaire was utilised remarkably frequently and extensively by the respondents. It became clear that the content that was named needed to be analysed in an exploratory manner. Accordingly, this paper addresses the following question: What preoccupies general practitioners in Germany during COVID-19 that we have not yet asked them enough?MethodsThe data collection took place throughout Germany from 01.02.2021 to 28.02.2021with a quantitative online questionnaire consisting of 53 items arranged across six topics as well as an "open text field" for further comments. The questionnaire's open text field was analysed following the premises of the qualitative content analysis.ResultsThe topics discussed by the respondents were: insufficient support from health policies, not being prioritised and involved in the vaccination strategy, feeling insufficient prepared, that infrastructural changes and financial concerns threatened the practice, and perceiving the own role as important, as well as that health policies affected the wellbeing of the respondents. One of the main points was the way general practitioners were not sufficiently acknowledged for their contribution to ensuring high-quality care during the pandemic.DiscussionGerman general practitioners perceived their work and role as highly relevant during the COVID-19 pandemic. In controversy with their perception, they described political conditions in which they were the ones who contributed significantly to the fight against the pandemic but were not given enough recognition.

RESUMEN Antecedentes La creciente prevalencia de la diabetes tipo 2 resulta en una crisis mundial de salud pública, especialmente en países de ingresos bajos y medianos (PIBM) con sistemas de salud no preparados y sobrecargados, centrados principalmente en las enfermedades infecciosas y la salud materno infantil. Los estudios sobre la diabetes tipo 2 en los PIBM describen intervenciones específicas ignorando un análisis exhaustivo de los factores locales que las personas consideran influyen en su salud. Este estudio tiene como objetivo cubrir esta brecha de investigación al explorar lo que las personas con diabetes tipo 2 en Bolivia necesitan para mantener o mejorar su salud, qué tan importante perciben esas necesidades identificadas y en qué medida estas necesidades son satisfechas. Métodos De marzo a mayo de 2019, 33 personas con diabetes tipo 2 de tres municipios periurbanos del departamento de Cochabamba participaron en este estudio. Se utilizó la metodología de mapeo conceptual de Trochim, un método de lluvia de ideas cualitativo altamente estructurado, para generar y estructurar una amplia gama de perspectivas sobre lo que los participantes consideraron herramientas para su salud. Resultados La lluvia de ideas resultó en 156 enunciaciones originales condensadas en 72 necesidades y recursos conceptualmente diferentes, estructurados en nueve grupos conceptuales y cuatro dominios de acción. Estos dominios ilustrados con necesidades vitales fueron: (1) autogestión con el uso de plantas y la posibilidad de medir los niveles de azúcar periódicamente; (2) proveedores de salud con la necesidad de confiar y recibir un diagnóstico y plan de tratamiento uniforme; (3) sistema de salud con acceso oportuno a la atención y (4) comunidad con participación comunitaria en salud y seguridad, incluida el control de perros callejeros. Conclusiones Este estudio identifica principalmente factores contextuales como bajos niveles de alfabetización, problemas lingüísticos en la atención, la necesidad de articular la cosmovisión de las personas incluyendo el uso tradicional de remedios naturales con el sistema de salud boliviano y la falta de pericia en diabetes tipo 2 por parte de los proveedores de atención primaria de salud. Comprender las necesidades y estructurarlas en diferentes áreas en las que se requiere actuar, sirve como base para la planificación y evaluación de un programa de atención integral centrada en la persona para personas con diabetes tipo 2. Este método participativo sirve como una herramienta para implementar el concepto, a menudo teórico, de atención integrada centrada en las personas en el desarollo de políticas y programas de salud.

Abstract Background The Great Recession, starting in 2008, was characterized by an overall reduction in living standards. This pushed several governments across Europe to restrict expenditures, also in the area of healthcare. These austerity measures are known to have affected access to healthcare, probably unevenly among social groups. This study examines the unequal effects of retrenchment in healthcare expenditures on access to medical care for different income groups across European countries. Method Using data of two waves (2008 and 2014) of the European Union Statistics of Income and Living Conditions survey (EU-SILC), a difference-in-differences (DD) approach was used to analyse the overall change in unmet medical needs over time within and between countries. By adding another interaction, the differences in the effects between income quintiles (difference-in-difference-in-differences: DDD) were estimated. To do so, comparisons between two pairs of a treatment and a control case were made: Iceland versus Sweden, and Ireland versus the United Kingdom. These comparisons are made between countries with recessions equal in magnitude, but with different levels of healthcare cuts. This strategy allows isolating the effect of cuts, net of the severity of the recession. Results The DD-estimates show a higher increase of unmet medical needs during the Great Recession in the treatment cases (Iceland vs. Sweden: + 3.24 pp.; Ireland vs. the United Kingdom: + 1.15 pp). The DDD-estimates show different results over the two models. In Iceland, the lowest income groups had a higher increase in unmet medical needs. This was not the case in Ireland, where middle-class groups saw their access to healthcare deteriorate more. Conclusion Restrictions on health expenditures during the Great Recession caused an increase in self-reported unmet medical needs. The burden of these effects is not equally distributed; in some cases, the lower-income groups suffer most. The case of Ireland, nevertheless, shows that certain policy measures may relatively spare lower-income groups while affecting middle-class income groups more. These results bring in evidence that policies can reduce and even overshoot the general effect of income inequalities on access to healthcare.

The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems. Traditionally, structural issues with health professional education perpetuate these. COVID-19 has highlighted inequities, but may also be a disruptor, allowing positive responses and system redesign. Examples from health professional schools in high and low- and middle-income countries illustrate pro-equity interventions of current relevance. We recommend that health professional schools and planners consider educational redesign to produce a health workforce well equipped to respond to pandemics and meet future need.

Abstract The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

Abstract Background Socially excluded groups are at higher risk of low well-being and poor health. The link between social exclusion and health inequities is complex, and not being involved in society makes it difficult to be reached by standard prevention programs. Sport-for-development (SFD) programs are low-threshold and may be promising settings for inclusive actions. We explore the underlying mechanisms through which SFD might have an impact on social inclusion and examine the necessary conditions that work as a catalyst for these underlying mechanisms. Methods A realist evaluation approach was adopted. A non-profit SFD organization in a middle-large city in Flanders, Belgium, formed the setting for a single case study. Document analysis, participatory observations, interviews, and a focus group, were sources for identifying necessary context elements and essential mechanisms through which SFD could promote its participants’ health and wellbeing. Results Among the most efficient mechanisms triggered by the Foundation’s activities are learning by fun, connecting with peers (of whom some serve as role model) and engaging as a volunteer with some responsibilities. Building trust in oneself and in others is a necessary process throughout all these mechanisms. Facilitating context factors include the activities’ accessibility and unconditional approach (creating a sense of safety), the popularity of the first division football team the Foundation is associated with (leading to a sense of belonging), a steady network of social partners and a strongly positive relationship with the SFD coach(es). Conclusions Our findings demonstrate that a SFD setting may be a vehicle for engaging hard-to-reach population groups. It enhances socially vulnerable persons’ sense of competence and connectedness, leading to opportunities to improve life and work skills transferrable outside SFD settings. Based on these findings, suggestions are provided that may enhance the field and help to develop feasible (policy-led) interventions designed to promote social inclusion.

Abstract Background Health-related organisations disseminate an abundance of clinical and implementation evidence that has potential to improve health outcomes in low- and middle-income countries (LMICs), but little is known about what influences a user decision to select particular evidence for action. Knowledge brokers (KBs) play a part as intermediaries supporting evidence-informed health policy and practice by selecting and synthesising evidence for research users, and therefore understanding the basis for KB decisions, can help inform knowledge translation strategies. The Theoretical Domains Framework (TDF), a synthesis of psychological theories, was selected as a promising analysis approach because of its widespread use in identifying influences on decisions to act on evidence-based healthcare guidelines. This study explored its application in the context of KB decisions regarding evidence for use in LMICs. Methods The study analysed data collected from participants of a 2015 global maternal and newborn health conference in Mexico. A total of 324 conference participants from 56 countries completed an online survey and 20 from 15 countries were interviewed about evidence use and sharing after the conference. TDF domains and constructs were retrospectively applied and adapted during coding of qualitative data to enhance understanding of the KB decision process in selecting evidence for action. Results Application of the TDF involved challenges related to overlapping constructs, retrospective use, and complexities of global health settings and relevant knowledge. Codes needed to be added or adapted to account for how KBs’ internal reflections on external factors influenced their actions in selecting evidence to share and use, and the decisions they made during the process. Four themes of the rationale for changing the TDF were identified during analysis, namely Influences from Beyond the Organisation, Knowledge Selection as a Process, Access and Packaging of Knowledge, and Fit for Use. Conclusions Theories of individual behaviour, such as those in the TDF, can enhance understanding of the decisions made by actors such as KBs along dissemination and knowledge translation pathways. Understanding how KBs reflect on evidence and interact with their environment has the potential for improving global dissemination efforts and LMIC-to-LMIC exchange of implementation evidence.

Abstract Background People-centred health care (PCC) services are identified by the WHO as important building blocks towards universal health coverage. In 2016 the WHO formulated a comprehensive framework on integrated PCC services based on an international expert consultation. Yet, expert opinions may fail to recognize the needs of all health system stakeholders. Therefore, a consultation method that includes the health workforce and laypersons, can be instrumental to elaborate this framework more in-depth. This research sought to identify participants’ perspectives on policy options and interventions to achieve people-centred health care services from a multi stakeholder perspective. Methods Study participants, both laypersons and health professionals, were recruited in Belgium. A total of 53 participants engaged in one of the seven concept mapping workshops. In this workshop the concept mapping methodology developed by Trochim, a highly structured qualitative group method for brainstorming and idea sharing, was used to generate and structure participants´ perspectives on what is needed to achieve PCC services. The method was validated using the WHO framework. Results The seven workshops together resulted in 452 different statements that were structured in a framework forming 35 clusters and four overarching domains. The four domains with their most prominent clusters were: (1) governance & policy with intersectoral health policies and affordable health for all; (2) health workforce with excellent communication skills, appreciation of health literacy challenges and respectful attitude based on cultural self-awareness; (3) integrated health services with a greater emphasis on prevention, health promotion and the availability of health education and (4) patient, person and community empowerment and participation with support for informal care, promotion of a healthy lifestyle and contextualised health education. Additionally, this study generated ideas that fitted into every single approach described in the WHO framework. Discussion and conclusion This study shows that in order to achieve PCC a participative approach involving all stakeholders at all levels is needed. The concept mapping process is one of these approaches that brings together diverse stakeholders and foments their egalitarian and respectful participation. The framework that resulted from this study can inform future debate regarding planning, implementation and monitoring of PCC.

Abstract Background Understanding the impact of selection and medical education on practice intentions and eventual practice is an essential component of training a fit-for-purpose health workforce distributed according to population need. Existing evidence comes largely from high-income settings and neglects contextual factors. This paper describes the practice intentions of entry and exit cohorts of medical students across low and high income settings and the correlation of student characteristics with these intentions. Methods The Training for Health Equity Network (THEnet) Graduate Outcome Study (GOS) is an international prospective cohort study tracking learners throughout training and ten years into practice as part of the longitudinal impact assessment described in THEnet’s Evaluation Framework. THEnet is an international community of practice of twelve medical schools with a social accountability mandate. Data presented here include cross-sectional entry and exit data obtained from different cohorts of medical students involving eight medical schools in six countries and five continents. Binary logistic regression was used to create adjusted odds ratios for associations with practice intent. Results Findings from 3346 learners from eight THEnet medical schools in 6 countries collected between 2012 and 2016 are presented. A high proportion of study respondents at these schools come from rural and disadvantaged backgrounds and these respondents are more likely than others to express an intention to work in underserved locations after graduation at both entry and exit from medical school. After adjusting for confounding factors, rural and low income background and regional location of medical school were the most important predictors of intent to practice in a rural location. For schools in the Philippines and Africa, intention to emigrate was more likely for respondents from high income and urban backgrounds. Conclusions These findings, from a diverse range of schools with social accountability mandates in different settings, provide preliminary evidence for the selection and training of a medical workforce motivated to meet the needs of underserved populations. These respondents are being followed longitudinally to determine the degree to which these intentions translate into actual practice.

Abstract Background Patient safety is a quality indicator for primary care and it should be based on individual needs, and not differ among different social groups. Nevertheless, the attention on social disparities in patient safety has been mainly directed towards the hospital care, often overlooking the primary care setting. Therefore, this paper aims to synthesise social disparities in patient safety in the primary care setting. Methods The Databases PubMed and Web of Science were searched for relevant studies published between January 1st 2006 and January 31st 2017. Papers investigating racial, gender and socioeconomic disparities in regards to administrative errors, diagnostic errors, medication errors and transition of care errors in primary care were included. No distinction in terms of participants’ age was made. Results Women and black patients are more likely to experience patient safety events in primary care, although it depends on the type of disease, treatment, and healthcare service. The available literature largely describes gender and ethnic disparities in the different patient safety domains whilst income and educational level are studied to a lesser extent. Conclusions The results of this systematic review suggest that vulnerable social groups are likely to experience adverse patient safety events in primary care. Enhancing family doctors’ awareness of these inequities is a necessary first step to tackle them and improve patient safety for all patients. Future research should focus on social disparities in patient safety using socioeconomic indicators, such as income and education.

Background: Numerous studies have shown that during out-of-hours vulnerable patients (regarding low-education and unemployment) are more likely to seek medical help in the emergency department (ED). However, little is known about why patients seek help in the ED during daytime hours and if these reasons differ among self-referring socioeconomic groups. Objectives: To identify the reasons why patients opt for the ED during daytime hours when primary care services are available and identify possible social differences between socioeconomic groups. Methods: In 2014–2015, trained fieldworkers surveyed 723 patients visiting four EDs in Flanders using a structured interview. These quantitative data were analysed using descriptive and logistic regression analyses. Results: More than one-third of the self-referring patients reported that they attend the ED during daytime hours because they perceive their (health) problem as urgent and expect they need advanced diagnostic testing. Self-referred and low-educated patients have a 1.8 higher chance (compared to their higher-educated counterparts) of attending the ED because they expect advanced diagnostic testing. Self-referred and unemployed patients have a 3.6, 2.5 and 4.4 higher chance (compared to their employed counterparts) to opt for the ED because it is their usual source of care, family/friends refer them or they postpone care too long, respectively. Conclusion: We found sociodemographic differences in motives why self-referring patients in Flanders opt for the ED during daytime hours. In general, self-referring patients attend the ED because they perceive their condition as urgent and think they may need advanced diagnostic testing.

Unequal access to health promotion resources and early prevention services is a major determinant of health inequity among youth. Initiatives that improve the access to and adoption of health promotion messages are important undertakings, e.g., sport. Sport-for-development (SFD) programs are seen as valuable delivery tools, in which coaches are used as change agents to increase health awareness and behavior among at-risk youth. The delivery of such messages requires specific knowledge and skills that can be attained through training; however, the effectiveness of such training requires assessment. In this study, we evaluated the feasibility of such a training program for SFD coaches using process evaluation from a realist perspective, and views from multiple stakeholders, among other sources. We also clarified the inner workings of the training and investigated how context shaped the training outcomes. Increased health awareness and a sense of responsibility from acting as a role model for at-risk youth were among the perceived training outcomes. Building a safe environment for learning, engagement, and bonds of trust increased the confidence to learn, and resulted in a sense of critical self-reflection and self-development of SFD coaches towards health and prevention messages. Importantly, the unique situations (or context) of SFD coaches and SFD in general presented challenging variables, e.g., a precarious life history or living conditions, mental health issues, or low educational skills, that hampered the impact of the mechanisms put in place by the training. Here, we present a process in which the development of the 'right mind-set,' engagement and bonds of trust, in combination with the right settings are key elements for SFD coaches to learn how to convey health-promoting messages and take responsibility as role models for at-risk youth.

IntroductionMeasuring the performance of a primary care system is one of the very first steps to find out whether there is room for improvement. To obtain an objective and comprehensive view, this measurement should come from both the supply and demand sides of the system. Patients' experiences of primary care have been studied around the world, but much less energy has been invested in researching providers' perspectives. This research aims to explore how primary care physicians working at commune health centers in Vietnam evaluate their performance and their opinions on how to improve the quality of primary care services.Materials and methodsFirst, a quantitative study was conducted using the validated Vietnamese PCAT questionnaire-provider expanded version (VN PCAT PE) targeting all primary care physicians (PCPs) working at commune health centers in a province of Central Vietnam. Next, a qualitative study was carried out, consisting of in-depth interviews with PCPs, to better understand the results of the quantitative survey and gain insight on barriers of primary care services and how to overcome them.ResultsIn the quantitative portion of our study, 150 PCPs rated the quality of ongoing care and first contact in CHCs as the best (3.09 and 3.11 out of 4, respectively), and coordination as the worst performing core domain (2.53). Twenty-two PCPs also participated in our qualitative research. In regards to challenges that primary care physicians face during their daily practice, three central themes emerged: 1) patient factors such as client attitude and knowledge, 2) provider factors such as the burden of administrative work and lack of training opportunities, and 3) contextual factors such as low income and lack of resources including medicines and diagnostics. Participants recommended more health promotion campaigns in the media, increasing the number of services available at CHCs (such as being able to take blood samples), reducing the workload related to administration for CHC leaders, greater government subsidies, and providing more training courses for PCPs.ConclusionsFindings from this study offer a valuable view from the supply-side of the primary care system, specifically those who directly deliver primary care services. Along with the earlier study on consumers' evaluation of the Vietnamese primary care system, and literature from other low and middle-income countries, these findings offer emerging evidence for policymakers to improve the quality of primary care in Vietnam.

Access to healthcare is inequitably distributed across different socioeconomic groups. Several vulnerable groups experience barriers in accessing healthcare, compared to their more wealthier counterparts. In response to this, many countries use resources to strengthen their primary care (PC) system, because in many European countries PC is the first entry-point to the healthcare system and plays a central role in the coordination of patients through the healthcare system. However it is unclear whether this strengthening of PC leads to less inequity in access to the whole healthcare system. This study investigates the association between strength indicators of PC and inequity in unmet need by merging data from the European Union Statistics on Income and Living Conditions database (2013) and the Primary Healthcare Activity Monitor for Europe (2010). The analyses reveal a significant association between the Gini coefficient for income inequality and inequity in unmet need. When the Gini coefficient of a country is one SD higher, the social inequity in unmet need in that particular country will be 4.960 higher. Furthermore, the accessibility and the workforce development of a country's PC system is inverse associated with the social inequity of unmet need. More specifically, when the access- and workforce development indicator of a country PC system are one standard deviation higher, the inequity in unmet healthcare needs are respectively 2.200 and 4.951 lower. Therefore, policymakers should focus on reducing income inequality to tackle inequity in access, and strengthen PC (by increasing accessibility and better-developing its workforce) as this can influence inequity in unmet need.

Separate literatures have related volunteering to health gains and income gains. We study the association between volunteering, income and health within one statistical framework. A state-of-the-art mediation analysis is conducted on data concerning the health, volunteering and sociodemographic characteristics of 42926 individuals within 29 European countries. We find that volunteering is positively associated to self-rated health. This association is partially mediated by household income.

Background Patients with multiple chronic diseases are usually treated according to disease-specific guidelines, with outcome measurements focusing mostly on biomedical indicators (e.g. blood sugar levels or lung function). However, for multimorbidity, a goal-oriented approach focusing on the goals defined by the individual patient, may be more suitable. Despite the clear theoretical and conceptual advantages of including patient-defined goals in clinical decision-making for multimorbidity, it is not clear how patients define their goals and which aspects play a role in the process of defining them. Objective To explore goal-setting in patients with multimorbidity. Design Qualitative analysis of interviews with 19 patients diagnosed with chronic obstructive pulmonary disease and comorbidities. Results Patients do not naturally present their goals. Their goals are difficult to elicit, even when different interviewing techniques are used. Four underlying hypotheses which may explain this finding were identified from the interviews: (1) patients cannot identify with the concept of goal-setting; (2) goal-setting is reduced due to acceptation; (3) actual stressors predominate over personal goal-setting; and (4) patients may consider personal goals as selfish. Conclusions Our findings advocate for specific attention to provider skills and strategies that help patients identify their personal goals. The hypotheses on why patients may struggle with defining goals may be useful to prompt patients in this process and support the development of a clinical method for goal-oriented care.

A “Aliança DCNT” (“NCD Alliance”)1 visa colocar as doenças crônicas não transmissíveis (DCNT) na agenda global de saúde, a fim de enfrentar a chamada “crise das DCNT”. Melhorar os indicadores de morbidade e mortalidade em 2015 dependerá, em grande medida, da prevenção e controle das DCNT, especialmente nos países em desenvolvimento2. *Reprinted with permission from Elsevier (The Lancet, 2011, 6 September 2011, online first) - Reprodução autorizada do original em inglês, publicado no periódico The Lancet, detentor dos copyrights: http://dx.doi.org/10.1016/S0140-6736(11)61135-5

ABSTRACT Objective To assess the quality of the Primary Health Care services provided to children and the feasibility of using the Brazilian version of Primary Care Assessment Tool (PCAT-Brazil) as a routine quality assessment tool. Methods A cross-sectional study was carried out in Joanópolis, a small rural town in the State of São Paulo (SP), Brazil. Seven health professionals and 502 caretakers of children using the public health center were interviewed using the PCAT-Brazil, collecting data on the core and related attributes of Primary Health Care provided to children. The score of each attribute was calculated. Results Caretakers rated as good the following attributes; “degree of affiliation”, “first contact care − use of services”, “coordinated care”, and “comprehensive care − available services”. The attributes of “first contact accessibility”, “long term person care”, “comprehensive care − offered services” and “family- and community-oriented care” were scored as poor. The health professionals only rated the attribute of “first contact accessibility” as satisfactory, and considered that all other Primary Health Care attributes needed improvement. To conduct this study, at least 1,241 working hours were invested, and the estimated budget was R$12.900,00 (or U$3,953.00). Conclusion The use of the PCAT-Brazil as a routine assessment and planning tool seemed to be not feasible in the given setting due to high costs, lack of trained personnel and the huge workload. To overcome the encountered obstacles, advices are given based on field experience.