Patients' and professionals' experiences with remote care during COVID-19: a qualitative study in general practices in low-income neighborhoods.

AIM: To explore how patients and general practice professionals in low-income neighborhoods experienced the increase of remote care during COVID-19. BACKGROUND: As the GP (general practitioner) is the first point of contact in Dutch health care, there are concerns about access to remote care for patients from low-income neighborhoods. Now that general practice professionals have returned to the pre-pandemic ways of healthcare delivery, this paper looks back at experiences with remote care during COVID-19. It investigates experiences of both patients and general practice professionals with the approachability and appropriateness of remote care and their satisfaction. METHODS: In this qualitative study, 78 patients and 18 GPs, 7 nurse practitioners and 6 mental health professionals were interviewed. Interviews were held on the phone and face-to-face in the native language of the participants. FINDINGS: Remote care, especially telephone consultation, was generally well-approachable for patients from low-income neighborhoods. Contrarily, video calling was rarely used. This was partly because patients did not know how to use it. The majority of patients thought remote care was possible for minor ailments but would also still like to see the doctor face-to-face regularly. Patients were generally satisfied with remote care at the time, but this did not necessarily reflect their willingness to continue using it in the future. Moreover, there was lack in consensus among general practice professionals on the appropriateness of remote care for certain physical and mental complaints. Nurse practitioners and mental health professionals had a negative attitude toward remote care. In conclusion, it is important to take the opinions and barriers of patients and care providers into account and to increase patient-centered care elements and care provider satisfaction in remote care. Integrating remote care is not only important in times of crisis but also for future care that is becoming increasingly digitalized.

A qualitative study assessing how reach and participation can be improved in workplace smoking cessation programs.

INTRODUCTION: Randomized controlled trials have demonstrated the effectiveness of workplace smoking cessation programs. However, with low participation rates reported, it is important to understand the barriers and facilitators for the reach and participation of employees in workplace smoking cessation programs. The objective of the present study is to uncover the needs of employees regarding reach and participation when implementing a workplace program to address smoking cessation. METHODS: We carried out 19 semi-structured qualitative interviews in 2019 based on the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Framework with current and former smoking employees of organizations with ≥100 employees in the Netherlands. Some of the interviewees had experience with a cessation program. Data were analyzed using the Framework method. RESULTS: The main barriers according to employees were insufficient promotion of the cessation program, completing the program in the employee's own time and working night shifts and peak hours. Facilitators included being actively approached to participate by a colleague, positive reactions from colleagues about employee's participation in the program, providing the program on location and integrating the program as part of the organization's vitality policy. CONCLUSIONS: Effective workplace programs for smoking cessation can stimulate cessation but implementers often experience low participation rates. Our study presents recommendations to improve the recruitment and participation of employees in a workplace smoking cessation program, such as using active communication strategies, training managers to stimulate smoking employees to participate and making the program as accessible as possible by reimbursing time spent and offering the program at the workplace or nearby. Integrating the smoking cessation program into wider company vitality policy will also aid continued provision of the program.

Using the health belief model to explain COVID-19 vaccination hesitancy in Dutch urban citizens under thirty.

BACKGROUND: Worldwide the Covid-19 pandemic resulted in drastic behavioral measures and lockdowns. Vaccination is widely regarded as the true and only global exit strategy; however, a high vaccination coverage is needed to contain the spread of the virus. Vaccination rates among young people are currently lacking. We therefore studied the experienced motivations and barriers regarding vaccination in young people with the use of the health belief model. METHODS: We conducted a correlational study, based on a convenience sample. At the vaccination location, directly after vaccination, 194participants(16-30 years) who decided to get vaccinated at a pop-up location several weeks after receiving a formal invitation, filled out a questionnaire regarding their attitudes towards vaccination based on concepts defined in the health belief model. We used these concepts to predict vaccination hesitancy. RESULTS: Younger participants and participants with lower educational levels report higher levels of hesitancy regarding vaccination (low education level = 38.9%, high education level = 25.4%). Perceived severity (Mhesitancy = .23, Mno hesitancy = .37) and susceptibility (Mhesitancy = .38, Mno hesitancy = .69) were not associated with hesitancy. Health related and idealistic benefits of vaccination were negatively associated with experienced hesitancy (Mhesitancy = .68, Mno hesitancy = -.37), while individualistic and practical benefits were not associated with hesitancy (Mhesitancy = -.09, Mno hesitancy = .05). Practical barriers were not associated with hesitancy (Mhesitancy = .05, Mno hesitancy = -.01), while fear related barriers were strongly associated with hesitancy (Mhesitancy = -.60, Mno hesitancy = .29). CONCLUSIONS: Health related, and idealistic beliefs are negatively associated with experienced hesitancy about vaccination, while fear related barriers is positively associated with experienced hesitancy. Future interventions should focus on these considerations, since they can facilitate or stand in the way of vaccination in young people who are doubting vaccination, while not principally opposed to it.

Smoking Cessation Among Gender Minority Populations, Cis-women, and Cis-men: Findings From the International Tobacco Control Netherlands Survey.

INTRODUCTION: Little is known about smoking cessation among gender minority populations compared to cisgender individuals (whose gender matches their sex assigned at birth). We examined differences between smokers from gender minority populations, cis-women, and cis-men in the heaviness of smoking, quit intentions, use of cessation assistance, quit attempts (ever tried and number), and triggers for thinking about quitting. AIMS AND METHODS: We used cross-sectional data from the 2020 International Tobacco Control Netherlands Survey. Among smoking respondents, we distinguished (1) cis-women (female sex, identified as women, and having feminine gender roles; n = 670), (2) cis-men (male sex, identified as men, and having masculine gender roles; n = 897), and (3) gender minorities (individuals who were intersex, who identified as nonbinary, genderqueer, had a sex/gender identity not listed, whose gender roles were not feminine or masculine, or whose gender identity and/or roles were not congruent with sex assigned at birth; n = 220). RESULTS: Although gender minorities did not differ from cis-women and cis-men in the heaviness of smoking, plans to quit smoking, and quit attempts, they were significantly more likely to use cessation assistance (20% in the past 6 months) than cis-women (12%) and cis-men (9%). Gender minorities were also significantly more likely to report several triggers for thinking about quitting smoking, for example, quit advice from a doctor, an anti-smoking message/campaign, and the availability of a telephone helpline. CONCLUSION: Despite equal levels of quit attempts and heaviness of smoking, gender minority smokers make more use of smoking assistance, and respond stronger to triggers for thinking about quitting smoking. IMPLICATIONS: Smoking cessation counselors should be sensitive to the stressors that individuals from any minority population face, such as stigmatization, discrimination, and loneliness, and should educate their smoking clients on effective coping mechanisms to prevent relapse into smoking after they experience these stressors. Developing tailored smoking cessation programs or campaigns specifically for gender minority populations can also be useful. Based on the results of our subgroup analyses, programs or campaigns for younger gender minority smokers could focus on the availability of telephone helplines and on how friends and family think about their smoking behavior.

[Market vaccinations in Rotterdam]. / Marktvaccinaties in Rotterdam: Een voorbeeld van een campagne gestoeld op het equity-principe.

The COVID-19 vaccination rate is not evenly distributed across the Netherlands. In some neighborhoods, the vaccination rate is relatively low, causing individual health risks and a burden to the health care system. An explanation is the use of a national, general information campaign, while using a similar approach (equality approach) does not always lead to similar results. Therefore, we advocate the use of an equity approach instead, as defined by the WHO, which aims at achieving equal results by taking the specific needs of certain vulnerable groups into account. As an example, we describe an intervention that took place in Rotterdam, in which medical doctors, among which GPs, took the initiative to offer information about vaccinations and vaccination on the popular weekly markets of Rotterdam. Using interviews with medical volunteers who contributed to these market vaccinations, we outline the preconditions for successfully implementing such an outreach-based approach, and we make a number of practical recommendations.

Is smoking an independent risk factor for developing cervical intra-epithelial neoplasia and cervical cancer? A systematic review and meta-analysis.

Introduction: Cervical cancer is the fourth most common form of cancer among women. Smoking tobacco seems to be a risk factor for the development of cervical intra-epithelial neoplasia (CIN) and cervical cancer, but the exact role of smoking in the process of cervical carcinogenesis is not known. The aim of this study is to investigate the relationship between smoking and the development of CIN and cervical cancer. Areas covered: We searched Embase, Medline, Cochrane Central, Web of Science, and Google Scholar for studies on smoking and CIN and cervical cancer, published between 2009 and 2018. The following were the outcomes: CIN3 alone, CIN2 and CIN3 combined, CIN2+, CIN3+, and cervical cancer alone. We included 49 studies in our review and 45 in our meta-analyses. Expert opinion: Based on the available evidence it can be - cautiously - concluded that smoking increases the risk of cervical abnormalities. However, the high risk of bias indicates that for future studies, it will be important to adjust for relevant predictors, to separate CIN from cervical cancer as outcome measures, and to report research methods in detail.

Experiential peer support and its effects on desistance from delinquent behavior: protocol paper for a systematic realist literature review.

BACKGROUND: Experiential peers are increasingly involved in the development and delivery of interventions for individuals who are engaged in delinquent behavior. Experiential peer support, which is the provision of support to an individual engaged in delinquent behavior by someone who has previously also practiced such behavior, is one such application. Little is known, however, about its effects on desistance, or the mechanisms that explain these effects. On the basis of theoretical papers, program descriptions, and interviews with experts, we developed an initial program theory. We propose seven mechanisms that might play a role in the (potential) effects of support by experiential peers: (1) empathy and acceptance, (2) social learning, (3) social bonding, (4) social control, (5) narrative and identity formation, (6) hope and perspective, and (7) translation and connection. In addition, in this protocol paper, we describe the methods of a systematic realist literature review that will be conducted in order to investigate the evidence base for this program theory. METHODS: The study described in this protocol paper is a realist review, which is a suitable approach to study complex interventions and fits the explanatory purpose of the study. We outline the steps to be taken for the systematic realist review, including the selection and assessment of studies and the methods for synthesizing the findings. DISCUSSION: Investigating the effects and the underlying mechanisms of support by experiential peers for individuals with delinquent behavior is relevant because the forensic setting has some unique features, and the involvement of service users might create even more tension than in other settings due to stigma and perceived risks. The findings that will be reported in the realist review will contribute to the knowledge of the effects of support by experiential peers and will provide insight into which aspects remain to be studied. It might also provide formal care institutions with guidance on whether to involve experiential peers in the delivery of their services and the conditions under which these interventions are likely to lead to positive results.

Implementation of Financial Incentives for Successful Smoking Cessation in Real-Life Company Settings: A Qualitative Needs Assessment among Employers.

Randomized studies have shown that financial incentives can significantly increase the effect of smoking cessation treatment in company settings. Evidence of effectiveness alone is, however, not enough to ensure that companies will offer this intervention. Knowledge about the barriers and facilitators for implementation in the workplace is needed, in order to develop an implementation strategy. We performed a qualitative needs assessment among 18 employers working in companies with relatively many employees with a low educational level, and our study revealed priority actions that aim to improve the implementation process in these types of workplaces. First, employers need training and support in how to reach their employees and convince them to take part in the group training. Second, employers need to be convinced that their non-smoking employees will not consider the incentives unfair, or they should be enabled to offer alternative incentives that are considered less unfair. Third, the cost-effectiveness of smoking cessation group trainings including financial incentives should be explained to employers. Finally, smoking cessation should become a standard part of workplace-based health policies.

The effectiveness of shared decision-making followed by positive reinforcement on physical disability in the long-term follow-up of patients with nonspecific low back pain in primary care: a clustered randomised controlled trial.

BACKGROUND: Although the recovery of patients suffering from low back pain is highly context dependent, patient preferences about treatment options are seldom incorporated into the therapeutic plan. Shared decision-making (SDM) offers a tool to overcome this deficiency. The reinforcement by the general practitioner (GP) of a 'shared' chosen therapy might increase patients' expectations of favourable outcomes and thus contribute to recovery. METHODS: In the Netherlands, a clustered randomised controlled trial was performed to assess the effectiveness of shared decision-making followed by positive reinforcement of the chosen therapy (SDM&PR) on patient-related clinical outcomes. Overall, 68 GPs included 226 patients visiting their GP for a new episode of non-chronic low back pain. GPs in the intervention group were trained in implementing SDM&PR using a structured training programme with a focus on patient preferences in reaching treatment decisions. GPs in the control group provided care as usual. The primary outcome was the change in physical disability measured with the Roland-Morris disability questionnaire (RMD) during the six-month follow-up after the first consultation. Physical disability (RMD), pain, adequate relief, absenteeism and healthcare consumption at 2, 6, 12 and 26 weeks were secondary outcomes. A multivariate analysis with a mixed model was used to estimate the differences in outcomes. RESULTS: Of the patients in the intervention and the control groups, 66 and 62%, respectively, completed the follow-up. Most patients (77%) recovered to no functional restrictions due to back pain within 26 weeks. No significant differences in the mean scores for any outcome were observed between intervention patients and controls during the follow-up, and in multivariate analysis, there was no significant difference in the main outcome during the six-month follow-up. Patients in the intervention group reported more involvement in decision-making. CONCLUSION: This study did not detect any improvement in clinical outcome or in health care consumption of patients with non-chronic low back pain after the training of GPs in SDM&PR. The implementation of SDM merely introduces task-oriented communication. The training of the GPs may have been more effective if it had focused more on patient-oriented communication techniques and on stressing the expectation of favourable outcomes. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR) number: NTR1960. The trial was registered in the NTR on August 20, 2009.

Antidepressant prescriptions and mental health nurses: an observational study in Dutch general practice from 2011 to 2015.

PURPOSE: The purpose of this study was to investigate developments in antidepressant prescriptions by Dutch general practitioners, alongside the national introduction of mental health nurses. Antidepressant prescriptions are very common in general practice, but are often not in line with recommendations. The recent introduction of mental health nurses may have decreased antidepressant prescriptions, as general practitioners (GPs) have greater potential to offer psychological treatment as a first choice option instead of medication. MATERIAL AND METHODS: Anonymised data from the medical records of general practices participating in the NIVEL Primary Care Database in 2011-2015 were analysed in an observational study. We used multilevel logistic regression analyses to determine whether total antidepressant prescriptions and antidepressants prescribed within one week of diagnosing anxiety or depression decreased in the period 2011-2015. We analysed whether changes in antidepressant prescriptions were associated with the employment or consultation of mental health nurses. RESULTS: Antidepressants were prescribed in 30.3% of all anxiety or depression episodes; about half were prescribed within the first week. Antidepressants prescriptions for anxiety or depression increased slightly in the period 2011-2015. The employment of mental health nurses was not associated with a decreased number of prescriptions of antidepressants. Patients who had at least one mental health nurse consultation had fewer immediate prescriptions of antidepressants, but not fewer antidepressants in general. CONCLUSIONS: Antidepressant prescriptions are still common in general practice. So far, the introduction of mental health nurses has not decreased antidepressant prescriptions, but it may have a postponing effect.

Exploring the feasibility of new Dutch mental health policy within a large primary health care centre: a case study.

Background: A reform of Dutch mental health care aimed to substitute care from specialized care to general practice. Since 1 January 2014, Dutch general practitioners (GPs) are no longer allowed to refer patients without a psychiatric disorder to mental health care. Patients with non-complex psychological problems should be treated within general practice. Objective: To explore the feasibility of the Dutch mental health policy. Methods: We conducted an observational case study in a primary health care centre in 2014. The health care centre was a convenience sample; the participating GPs reorganized mental health care in line with the upcoming policy, and invited the researchers to monitor their referrals. We assessed how many patients with mental health problems (n = 408) were allocated to policy-concordant treatment. Additionally, 137 patients (33%) completed a follow up assessment on mental health problems 3 months after baseline. Results: The majority of the patients were allocated to treatment in line with the policy. Almost half of the patients (42%) were treated in a setting that was exactly policy-concordant, while the other half (47%) was treated in a setting that was even less specialized than was allowed. In general, patients showed improvement after 3 months, regardless of (non) policy-concordant treatment. Attrition rate after 3 months was high, probably due to the practical study design. Conclusion: There is potential for substitution of mental health care. Since the studied health care centre was specialized in mental health care, further research should explore if similar results can be found in other general practices.

Potential for substitution of mental health care towards family practices: an observational study.

BACKGROUND: Substitution is the shift of care from specialized health care to less expensive and more accessible primary health care. It seems promising for restraining rising mental health care costs. The goal of this study was to investigate a potential for substitution of patients with psychological or social problems, but without severe psychiatric disorders, from Dutch specialized mental health care to primary care, especially family practices. METHODS: We extracted anonymized data from two national databases representing primary and specialized care in 2012. We calculated the number of patients with and without psychiatric disorder per 1,000 citizens in three major settings: family practices, primary care psychologists, and specialized care. Family physicians recorded psychopathology using the International Classification of Primary Care, while psychologists and specialists used the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. RESULTS: Considerable numbers of patients without a diagnosed DSM-IV psychiatric disorder were treated by primary care psychologists (32.8%) or in specialized care (20.8%). Over half of the patients referred by family physicians to mental health care did not have a psychiatric disorder. CONCLUSION: A recent reform of Dutch mental health care, including new referral criteria, will likely increase the number of patients with psychological or social problems that family physicians have to treat or support. Enabling and improving diagnostic assessment and treatment in family practices seems essential for substitution of mental health care.

Applying Computerized Adaptive Testing to the Four-Dimensional Symptom Questionnaire (4DSQ): A Simulation Study.

BACKGROUND: Efficient screening questionnaires are useful in general practice. Computerized adaptive testing (CAT) is a method to improve the efficiency of questionnaires, as only the items that are particularly informative for a certain responder are dynamically selected. OBJECTIVE: The objective of this study was to test whether CAT could improve the efficiency of the Four-Dimensional Symptom Questionnaire (4DSQ), a frequently used self-report questionnaire designed to assess common psychosocial problems in general practice. METHODS: A simulation study was conducted using a sample of Dutch patients visiting a general practitioner (GP) with psychological problems (n=379). Responders completed a paper-and-pencil version of the 50-item 4DSQ and a psychometric evaluation was performed to check if the data agreed with item response theory (IRT) assumptions. Next, a CAT simulation was performed for each of the four 4DSQ scales (distress, depression, anxiety, and somatization), based on the given responses as if they had been collected through CAT. The following two stopping rules were applied for the administration of items: (1) stop if measurement precision is below a predefined level, or (2) stop if more than half of the items of the subscale are administered. RESULTS: In general, the items of each of the four scales agreed with IRT assumptions. Application of the first stopping rule reduced the length of the questionnaire by 38% (from 50 to 31 items on average). When the second stopping rule was also applied, the total number of items could be reduced by 56% (from 50 to 22 items on average). CONCLUSIONS: CAT seems useful for improving the efficiency of the 4DSQ by 56% without losing a considerable amount of measurement precision. The CAT version of the 4DSQ may be useful as part of an online assessment to investigate the severity of mental health problems of patients visiting a GP. This simulation study is the first step needed for the development a CAT version of the 4DSQ. A CAT version of the 4DSQ could be of high value for Dutch GPs since increasing numbers of patients with mental health problems are visiting the general practice. In further research, the results of a real-time CAT should be compared with the results of the administration of the full scale.

Consultations in general practices with and without mental health nurses: an observational study from 2010 to 2014.

OBJECTIVES: To investigate care for patients with psychological or social problems provided by mental health nurses (MHNs), and by general practitioners (GPs) with and without MHNs. DESIGN: An observational study with consultations recorded by GPs and MHNs. SETTING: Data were routinely recorded in 161-338 Dutch general practices between 2010 and 2014. PARTICIPANTS: All patients registered at participating general practices were included: 624 477 patients in 2010 to 1 392 187 patients in 2014. OUTCOME MEASURES: We used logistic and Poisson multilevel regression models to test whether GPs recorded more patients with at least one consultation for psychological or social problems and to analyse the number of consultations over a 5-year time period. We examined the additional effect of an MHN in a practice, and tested which patient characteristics predicted transferral from GPs to MHNs. RESULTS: Increasing numbers of patients with psychological or social problems visit general practices. Increasing numbers of GPs collaborate with an MHN. GPs working in practices with an MHN record as many consultations per patient as GPs without an MHN, but they record slightly more patients with psychological or social problems (OR=1.05; 95% CI 1.02 to 1.08). MHNs most often treat adult female patients with common psychological symptoms such as depressive feelings. CONCLUSIONS: MHNs do not seem to replace GP care, but mainly provide additional long consultations. Future research should study to what extent collaboration with an MHN prevents patients from needing specialised mental healthcare.

Equity-specific effects of 26 Dutch obesity-related lifestyle interventions.

CONTEXT: Reducing health inequalities is a policy priority in many developed countries. Little is known about effective strategies to reduce inequalities in obesity and its underlying behaviors. The goal of the study was to investigate differential effectiveness of interventions aimed at obesity prevention, the promotion of physical activity or a healthy diet by SES. EVIDENCE ACQUISITION: Subgroup analyses in 2010 and 2011 of 26 Dutch studies funded by The Netherlands Organization for Health Research and Development after 1990 (n=17) or identified by expert contact (n=9). Methodologic quality and differential effects were synthesized in harvest plots, subdivided by setting, age group, intensity, and time to follow-up. EVIDENCE SYNTHESIS: Seven lifestyle interventions were rated more effective and four less effective in groups with high SES; for 15 studies no differential effects could be demonstrated. One study in the healthcare setting showed comparable effects in both socioeconomic groups. The only mass media campaign provided modest evidence for higher effectiveness among those with high SES. Individually tailored and workplace interventions were either more effective in higher-SES groups (n=4) or no differential effects were demonstrated (n=9). School-based studies (n=7) showed mixed results. Two of six community studies provided evidence for better effectiveness in lower-SES groups; none were more effective in higher-SES groups. One high-intensity community-based study provided best evidence for higher effectiveness in low-SES groups. CONCLUSIONS: Although for the majority of interventions aimed at obesity prevention, the promotion of physical activity, or a healthy diet, no differential effectiveness could be demonstrated, interventions may widen as well as reduce socioeconomic inequalities in these outcomes. Equity-specific subgroup analyses contribute to needed knowledge about what may work to reduce socioeconomic inequalities in obesity and underlying health behaviors.

Sex differences in the latency of the late event-related potential mental rotation effect.

Sex differences in event-related potentials were examined in 23 women and 24 men during a mental rotation task. We found an early (130-400 ms) and a late (400-700 ms) ERP mental rotation effect. The late rotation effect, which is thought to indicate the onset of the cognitive process of mental rotation, emerged about 100 ms earlier in men than in women. Moreover, men showed about 100 ms shorter response latencies to the task than women. These findings suggest that the faster response in men can be explained as a result of actual mental rotation taking place earlier. Furthermore, we found increased involvement of the right hemisphere specifically in men, probably pointing at a holistic strategy in men during mental rotation.