Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆.

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

Measuring health literacy in Italy: a validation study of the HLS-EU-Q16 and of the HLS-EU-Q6 in Italian language, conducted in Florence and its surroundings.

Health literacy (HL) is the capacity of individuals, families, and communities to make sound health decisions in the context of everyday life: at home, at the workplace, and in the community, marketplace, healthcare sector, and political arena. The aim of this study, as a part of a research conducted in Florence (Italy) and its surrounding, is to validate the Italian version of the short form (HLS-EU-Q16) and of the short-short form (HLS-EU-Q6) of the HLS-EU-Q47, as a part of a research conducted to assess the level of HL in a population-based sample in Florence. Two-hundred twenty-three subjects (57% females; age: 53.7 ± 11.8 years) were interviewed. The results provided the first evidence for the reliability and validity of the HLS-EU-Q instruments (HLS-EU-Q16, HLS-EU-Q6, General-HL Index) in Italian general population. The differences in some of the results with respect to other published studies lay for specific cultural characteristics, that affect HL level and the relationships between HL, antecedents, and outcomes.

The Effect of Vaccine Literacy on Parental Trust and Intention to Vaccinate after a Major Vaccine Scandal.

Health literacy, and more specifically vaccine literacy, might be an important factor in reducing the negative effects of exposure to misleading reports on vaccination. This study explores the association between vaccine literacy and vaccination-related outcomes after misleading reports on a scandal concerning locally produced childhood vaccines had emerged in 2016 in China. Data for this study came from a cross-sectional survey, which was conducted in April 2016 in Hangzhou, China. Data were collected in kindergartens and community health centers among parents of children up to 6 years of age. Data were analyzed for 1864 participants. Binary logistic regression models showed that, after controlling for socio-demographics and children's age, parents who had better vaccine literacy (<0.05) were more likely to trust and choose domestically produced vaccines, which account for about 95% of the total vaccinations in China. This study provides evidence on a still largely understudied relationship between vaccine literacy and vaccination-related outcomes. Findings might suggest that higher literacy levels could reduce some of the negative effects of being exposed to misleading information on vaccination, eventually leading to less vaccination hesitancy.

Validity of Three Brief Health Literacy Screeners to Measure Functional Health Literacy - Evidence from Five Different Countries.

Self-reported health literacy measures have seen increased application throughout the last years, among those are the brief health literacy screeners (BHLS) developed by Chew and colleagues (2004). There has been little systematic research on the performance of these measures across different contexts, including countries and languages, to draw conclusions about their predictive power outside of the United States. This study aimed at replicating the original validation of the BHLS. Receiver operating characteristic (ROC) analysis was applied to data from Hungary, Italy, Lebanon, Switzerland, and Turkey. In addition, logistic regression models incorporating ROC analysis using BHLS as predictors were compared to models using socio-demographics only to identify individuals with inadequate and inadequate or marginal health literacy as measured with the Short Test of Functional Health Literacy in Adults. Analyses showed that in all cases the BHLS were not sufficiently able to identify individuals with different health literacy levels. Logistic regression models using socio-demographics only as predictors outperformed models using the BHLS. The findings highlight the limitations of using the BHLS outside the United States. Further, they question in how far self-reported health literacy measures are comparable across different contexts and whether thresholds for different health literacy levels are universally applicable.

Swiss Learning Health System: A national initiative to establish learning cycles for continuous health system improvement.

The health system in Switzerland is considered as one of the best in the world. Nevertheless, to effectively and efficiently meet current and future challenges, an infrastructure and culture are needed where the best evidence is systematically made available and used, and the system evolves on the basis of a constant exchange between research, policy, and practice. The Swiss Learning Health System institutionalizes this idea as a multistakeholder national initiative to ensure continuous improvement through ongoing research and implementation. This article presents the objectives and mechanisms of the Swiss Learning Health System in the context of international initiatives to strengthen health systems and improve population health through learning cycles.

Health literacy in Italy: a cross-sectional study protocol to assess the health literacy level in a population-based sample, and to validate health literacy measures in the Italian language.

INTRODUCTION: Health literacy (HL) concerns the knowledge and competences necessary for people to meet complex health demands. The aims of this study are to assess the level of HL in a sample using the Italian version of the Newest Vital Sign and the association of HL and selected antecedents with health outcomes, and to develop and validate the Italian version of the three Brief Health Literacy Screeners, two subjective numeracy items and the short form and the short-short form of the European Health Literacy Survey Questionnaire. METHODS AND ANALYSIS: The study adopts a cross-sectional design and is being conducted in Florence, with information collected through telephone interviews. The population-based sample has been randomly selected using the registries of eight general practitioners (GPs). Based on a power calculation, 480 subjects will be included. Participants have been randomly offered two different questionnaires, each containing different HL measures. Data on sociodemographics and important antecedents and consequences of HL will be collected and the distribution of HL levels calculated. The mediating role of HL will be assessed using Preacher and Hayes' model. To assess the concurrent validity of the HL scales, correlation and receiver operating characteristic analyses will be performed. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics Committee of the Area Vasta Centro. Results will be disseminated via scientific journals and conference presentations, and individual data made available to the GPs.

Low health literacy and healthcare utilization among immigrants and non-immigrants in Switzerland.

OBJECTIVE: This study aimed at investigating the association between functional health literacy and knowledge on when to seek medical help for potentially harmless (overutilization) or serious (underutilization) situations among immigrants and non-immigrants in Switzerland. METHODS: Data was collected among three immigrant groups and the native population (N=1146) in the German- and Italian-speaking part of Switzerland. Health literacy was assessed with the Short Test of Functional Health Literacy (S-TOFHLA) and three Brief Health Literacy Screeners. Over- and underutilization of healthcare services was assessed with items asking participants about when to seek medical help for minor, respectively major, physical symptoms. RESULTS: Immigrants were more likely to seek medical help when unwarranted (overutilization). Health literacy, when assessed with the S-TOFHLA, was significantly associated with over- and underutilization. Yet, once controlled for covariates, the association between health literacy and overutilization was negative. Immigration background and micro-cultural differences emerged as important predictors of utilization. CONCLUSIONS: Results suggest that functional health literacy is directly related to healthcare utilization. The effects might be amplified by (micro-)cultural differences. PRACTICE IMPLICATIONS: Healthcare providers should be aware of differences in health literacy and utilization patterns among different population groups. Communication between patients and providers should be literacy and culturally sensitive.

Does acculturation narrow the health literacy gap between immigrants and non-immigrants-An explorative study.

OBJECTIVES: To compare functional health literacy (HL) levels in three immigrant groups to those of the German- and Italian-speaking non-immigrant population in Switzerland. Moreover, to investigate whether language-independent, respectively language-dependent, functional HL and variables of acculturation were associated with self-reported health status among immigrants. METHODS: Language-independent HL was assessed with the Short Test of Functional Health Literacy (S-TOFHLA) in the respective native languages. Language-dependent HL was measured using Brief Health Literacy Screeners (BHLS) asking about participants' confidence in understanding medical information in the language of the host country. Measures of acculturation included length of stay and age when taking residency in Switzerland. RESULTS: In particular Albanian- and Portuguese-speaking immigrants had lower levels of functional HL. In unadjusted analysis "age when taking residency in Switzerland" was associated with the BHLS. Adjusted analysis showed that the BHLS were significantly associated with self-reported health among all immigrant groups (p≤0.01). CONCLUSIONS: Functional HL that is dependent on understanding of medical information in the language of the new host country is a better predictor for self-reported health status among immigrants than language-independent HL. PRACTICE IMPLICATIONS: In the clinical setting limited functional HL might be a significant obstacle to successful disease treatment and prevention in immigrants.

Causal Attribution and Coping Maxims Differences between Immigrants and Non-Immigrants Suffering from Back Pain in Switzerland.

OBJECTIVES: This study aimed at investigating the relationship between causal attributions and coping maxims in people suffering from back pain. Further, it aimed at identifying in how far causal attributions and related coping maxims would defer between immigrants and non-immigrants in Switzerland. METHODS: Data for this study came from a larger survey study that was conducted among immigrant populations in the German- and Italian-speaking part of Switzerland. Included in the analyses were native Swiss participants, as well as Albanian- and Serbian-speaking immigrants, who had indicated to have suffered from back pain within the last 12 months prior to the study. Data was analyzed for overall 495 participants. Items for causal attributions and coping maxims were subject to factor analyses. Cultural differences were assessed with ANOVA and regression analyses. Interaction terms were included to investigate whether the relationship between causal attributions and coping maxims would differ with cultural affiliation. RESULTS: For both immigrant groups the physician's influence on the course of their back pain was more important than for Swiss participants (p <.05). With regard to coping, both immigrant groups were more likely to agree with maxims that were related to the improvement of the back pain, as well as the acceptance of the current situation (p <.05). The only consistent interaction effect that was found indicated that being Albanian-speaking negatively moderated the relationship between physical activity as an attributed cause of back pain and all three identified coping maxims. CONCLUSION: The study shows that differences in causal attribution and coping maxims between immigrants and non-immigrants exist. Further, the results support the assumption of an association between causal attribution and coping maxims. However cultural affiliation did not considerably moderate this relationship.

Modular ICT-based patient empowerment framework for self-management of diabetes: Design perspectives and validation results.

INTRODUCTION: It is estimated that more than 382 million people suffer from diabetes across the globe, most of which are between the age of 40 and 59 years. ICT can play a key role in better management of diabetes and in patient empowerment. Patient empowerment involves patients to a greater extent in their own healthcare process and disease management becomes an integrated part of their daily life. Self-management opens the possibility for patients to contribute to their own healthcare as well as to be more in control of their disease. OBJECTIVES: The objective of our study was to explore the impact of an ICT-based patient empowerment framework in diabetes self-management. METHODS: A modular patient empowerment framework that fosters diabetes self-management was designed and implemented. The framework incorporates expert knowledge in the form of clinical guidelines, and it supports patients in the specification of personalized activities that are based on medical recommendations and personal goals, and in the collection of observations of daily living. The usability and usefulness of the proposed framework were assessed in a pilot study with the participation of 60 patients and 12 health professionals. RESULTS: The study revealed that a patient empowerment approach based on self-management ICT tools is useful and accepted by both the patients and the physicians. For those patients who were already disciplined in their disease management the piloted solution served as a facilitator for data logging. For the rest, it served as an incentive for better adherence to disease management principles. The ICT tools prompted many patients into becoming more physically active and into making dietary habits' adjustments. However, this impact proved to be tightly correlated with the sociocultural background of the subjects. The study also demonstrated that even in patient-centric self-management interventions the physicians still have a key role to play. However, the acceptance of such interventions by the healthcare professionals depends not only on the level of impact in their patients' disease management but also on the level of impact in their workflow. CONCLUSIONS: It is evident that a patient empowerment approach based on self-management ICT tools is useful and accepted by patients and physicians. Further, there are clear indications that ICT frameworks such as the one presented in this paper support patients in behavioral changes and in better disease management. Finally, it was realized that self-management solutions should be built around the objective not only to educate and guide patients in disease self-management, but also to assist them in exploring the decision space and to provide insight and explanations about the impact of their own values on the decision.

Health literacy in Mainland China: Validation of a functional health literacy test in simplified Chinese.

Health literacy tests in the Chinese-speaking parts of the world have been mainly developed in traditional Chinese to be used in Hong Kong or Taiwan. So far no validated tool in simplified Chinese to assess functional health literacy in Mainland China has been developed. The aim of the study was to validate the simplified Chinese version of the Short Test of Functional Health Literacy in Adults (S-TOFHLA). The traditional Chinese version was translated into simplified Chinese and 150 interviews in an outpatient department of a public hospital in Mainland China were conducted. Predictive validity was assessed by known predictors for health literacy and convergent validity by three health literacy screening questions. The Cronbach's α for the reading comprehension part was 0.94 and 0.90 for the numeracy items. Participants with lower education and men had significantly lower levels of health literacy. The reading comprehension part was significantly correlated with two of the health literacy screening questions. Our results indicate that the simplified Chinese version of the S-TOFHLA is a reliable measure of health literacy to be used in Mainland China.

The Relationship between Health Literacy and Health Disparities: A Systematic Review.

OBJECTIVES: Health literacy is commonly associated with many of the antecedents of health disparities. Yet the precise nature of the relationship between health literacy and disparities remains unclear. A systematic review was conducted to better understand in how far the relationship between health literacy and health disparities has been systematically studied and which potential relationships and pathways have been identified. METHODS: Five databases, including PubMed/MEDLINE and CINAHL, were searched for peer-reviewed studies. Publications were included in the review when they (1) included a valid measure of health literacy, (2) explicitly conceived a health disparity as related to a social disparity, such as race/ethnicity or education and (3) when results were presented by comparing two or more groups afflicted by a social disparity investigating the effect of health literacy on health outcomes. Two reviewers evaluated each study for inclusion and abstracted relevant information. Findings were ordered according to the disparities identified and the role of health literacy in explaining them. RESULTS: 36 studies were included in the final synthesis. Most of the studies investigated racial/ethnic disparities, followed by some few studies that systematically investigated educational disparities. Some evidence was found on the mediating function of health literacy on self-rated health status across racial/ethnic and educational disparities, as well as on the potential effect of health literacy and numeracy on reducing racial/ethnic disparities in medication adherence and understanding of medication intake. CONCLUSION: Overall the evidence on the relationship between health literacy and disparities is still mixed and fairly limited. Studies largely varied with regard to health(-related) outcomes under investigation and the health literacy assessments used. Further, many studies lacked a specific description of the nature of the disparity that was explored and a clear account of possible pathways tested.

Low health literacy associated with higher medication costs in patients with type 2 diabetes mellitus: Evidence from matched survey and health insurance data.

OBJECTIVE: Studies have shown that people with lower levels of health literacy create higher emergency, inpatient and total healthcare costs, yet little is known about how health literacy may affect medication costs. This cross-sectional study aims at investigating the relationship between health literacy and three years of medication costs (2009-2011) in a sample of patients with type 2 diabetes. METHODS: 391 patients from the German-speaking part of Switzerland who were insured with the same health insurer were interviewed. Health literacy was measured by a validated screening question and interview records were subsequently matched with data on medication costs. A bootstrap regression analysis was applied to investigate the relationship between health literacy and medication costs. RESULTS: In 2010 and 2011 lower levels of health literacy were significantly associated with higher medication costs (p<.05). CONCLUSION: The results suggest that diabetic patients with lower health literacy will create higher medication costs. PRACTICE IMPLICATIONS: Besides being sensitive towards patients' health literacy levels, healthcare providers may have to take into account its potential impact on patients' medication regimen, misuse and healthcare costs.

EMPOWER--pathways for supporting the self-management of diabetes patients.

Diabetes is a serious world-wide medical challenge and there is a recognised need for improved diabetes care outcomes. This paper describes results of the EMPOWER project, to foster the self-management of diabetes patients by integration of existing and new services offered to patients after having been diagnosed with diabetes. The Self-Management Pathway described in this paper helps patients in the specification of personalized activities based on medical recommendations and personal goals, as well as self-monitoring of the results. The whole process is supported by innovative ICT services that motivate patients to change their lifestyle and adhere to defined medication and activity plans. We describe the approach and present the findings of the validation phase in Germany and Turkey.

EMPOWER-support of patient empowerment by an intelligent self-management pathway for patients: study protocol.

BACKGROUND: Diabetes education together with patient empowerment has shown to be key to effective self-management behavior. When delivered through information and communication technologies (ICT), this solution has shown to lead to better health outcomes. However, the potential of ICT and their integration into the healthcare environment have not yet been fully exploited. ICT should be in particular used to facilitate communication and information exchange between patient and healthcare providers. In addition, systems should include components facilitating behavior change using empowerment approaches such as goal-setting. METHODS/DESIGN: Funded by the European Commission (FP7-ICT-2011-288209) a web/mobile based platform (EMPOWER) has been developed, which aims at supporting self-management activities of diabetes patients and their treating physicians in Germany and Turkey. The platform semantically integrates multiple information sources, such as electronic and personal health records (EHR/PHR). Patients can register patterns of daily living, record blood glucose levels, design disease management plans and set long- and short-term goals. The project actively involves the treating physician, who has the possibility to set recommendations for the patient and to monitor his/her progress on the platform. In the test-phase of EMPOWER, patients will be assigned to an intervention group and a control group. Data will be collected at baseline and three months after the intervention started. In addition, qualitative interviews will be conducted to collect extra information on usability and usefulness. Outcome measures include amongst others the Problem Areas in Diabetes questionnaire (PAID), the Summary of Diabetes Self-Care Activities and scales evaluating doctor-patient interaction. Physiological parameters, such as physical activity or blood glucose levels will be collected via the platform. Further, log files and number of logins will serve as independent variables. DISCUSSION: The interplay between multiple sources, including EHR, patients' own registered information and physicians' recommendations on one platform can have important practice implications. It might not only improve self-management activities in diabetes patients but it will also facilitate physician's work, and ultimately the physician patient relationship. TRIAL REGISTRATION: The trial has been registered with Deutsches Register Klinischer Studien (German register of clinical trials) under DRKS00007699 on January 30, 2015.

Career development for early career academics: benefits of networking and the role of professional societies.

Whilst effective networking is vitally important for early career academics, understanding and establishing useful networks is challenging. This paper provides an overview of the benefits and challenges of networking in the academic field, particularly for early career academics, and reflects on the role of professional societies in facilitating networking.