[Professional health literacy among nurses in Germany: Results of a quantitative, cross-sectional survey]. / Professionelle Gesundheitskompetenz bei Pflegenden in Deutschland.

Professional health literacy among nurses in Germany: Results of a quantitative, cross-sectional survey Abstract. Background: Little is known about the professional health literacy (HL) of nurses, i.e., how well they are able to promote patients' HL. Existing studies have focused on personal HL, which does not entirely align with professional HL. Therefore, a new concept and questionnaire for professional HL have been developed and implemented for the first time. The results obtained for nurses in Germany are analysed with this article. Research question: It is asked how professional health literacy (HL) is distributed among nurses and which factors are associated with it. Methods: Data were collected through an online survey where nurses were asked about the difficulties they encounter in managing tasks in four dimensions: (1) information and knowledge management, (2) explaining and conveying information, (3) patient-centered communication, and (4) professional digital health literacy. Descriptive and multivariate, linear regression methods were used for analysis. Results: The 624 respondents rated the fourth dimension as the most difficult. The first and second dimensions were rated as similarly difficult, while the third dimension was considered least difficult. Higher professional HL is linked to better self-assessed training and framework conditions. Conclusion: Despite a relatively positive self-assessment, the results indicate areas that require improvement and should be addressed urgently.

Financing health promotion, prevention and innovation despite the rising healthcare costs: How can the new German government square the circle?

The German health system is under pressure due to increasing costs of healthcare provision and rising demand for health services. With the new coalition government, Germany has increased efforts to build a modern, innovative infrastructure for prevention and high-quality health services. The coalition agreement has a strong climate, innovation, and sustainability focus, reflecting at the same time the ambition of the new government to implement a preventive, inter-connected, and modern healthcare system in Germany. However, the agreement lacks detailed information on the achievement of the plans, especially concerning the question of how those measures should be funded in light of increasing expenditures for healthcare. Thus, the objectives of this study are to interpret the new government's plans and answer the question of how Germany in the new legislative period can ensure and fund population-based prevention programmes, health-promoting measures and innovative solutions despite the rising healthcare costs. By analysing the relevant content of the coalition agreement and drawing on an expert workshop, this paper suggests the establishment of a prevention fund and flexible remuneration model for digitalised and innovative forms of care in the new legislative period. Our findings may help identify feasible approaches to sustainable financing of health promotion, prevention and innovation in the German healthcare system.

Strengthening health system governance in Germany: looking back, planning ahead.

Health system governance has been receiving increasing attention in health system research since the 1980s. The contemporary challenges that the German health system is faced with are often closely linked to governance issues. Although Germany has the highest health expenditure as a share of Gross Domestic Product (GDP) in the European Union (EU), the spending on healthcare is out of proportion to the health outcomes of the population. The reason for this lies mainly in the complexity of the German health system which is hard to steer due to several administrative levels in the country and numerous policy actors to whom the decision-making power on healthcare provision is delegated. In this paper, we present the results of focus group discussions on governance and build upon the insights gained through the Neustart project of the Robert Bosch Foundation. Based on an internationally recognised health governance framework from the World Health Organization (WHO), experts who work in, on or for the German health system addressed health governance challenges. They provided evidence-based recommendations for the new legislative period (2021-2025) on transparency, accountability, participation, integrity and capacity of the German health system.

Priority setting and cross-country learning: the relevance of TO-REACH for primary care.

AIM: To inform the primary care community about priorities for research in primary care as came up from the European project TO-REACH and to discuss transferability of service and policy innovations between countries. BACKGROUND: TO-REACH stands for Transfer of Organizational innovations for Resilient, Effective, equitable, Accessible, sustainable and Comprehensive Health services and systems. This EU-funded project has put health systems and services research higher on the European agenda and has led to the current development of a European 'Partnership Transforming Health and Care Systems'. METHODS: To identify research priorities, both qualitative and quantitative approaches were used. Policy documents and strategic roadmaps were searched, and priorities were mapped. Stakeholders were involved through national roundtable consultations and online consultations. Regarding transferability, we carried out a review of the literature, guided by a conceptual framework, and using a snowballing approach. FINDINGS: Primary care emerged as an important priority from the inventory, as are areas that are conducive to strengthening primary care, such as workforce policies. The large variation in service organisation and policy around primary care in Europe is a huge potential for cross-country learning. However, the simple transfer of primary care service and policy arrangements from one health system to another has a big chance to fail, unless known conditions for successful transfer are taken into account and gaps in our knowledge about transfer are resolved.

Patients' attitudes toward copayments as a steering tool-results from a qualitative study in Norway and Germany.

Background: Copayments are implemented in many health care systems. The effect of copayments differs between countries. Up to now, patients' attitudes regarding copayments are mainly unknown. Objectives: Thus, the goal of our analysis was to explore adult patients' attitudes in Germany and Norway towards copayments as a steering tool. Methods: We conducted a qualitative comparative study. Episodic interviews were conducted with 40 patients in Germany and Norway. The interviews were analysed by thematic coding in the framework of grounded theory. All text segments related to copayments were analysed in depth for emerging topics and types. Results: We found three dimensions of patients' attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. The perceived steering effect consists of three types: having been influenced by copayments, not having experienced any influence and the experience of other persons to be influenced. The category comprehensibility describes that not all patients understand rules and regulations of copayments and its caps. The assessment of copayments consists of nine subcategories, three of which are rather negative and six of which are rather positive. In all three dimensions the patterns between the German and Norwegian sub-samples differ considerably. Conclusions: The results of our study point at the importance of communicating clear rules for copayments which are easily comprehensible.

A sequential model for the structure of health care utilization.

Traditional measurement models of health care utilization are not able to represent the complex structure of health care utilization. In this qualitative study, we, therefore, developed a new model to represent the health care utilization structure. In Norway and Germany, we conducted episodic interviews, participant observation and a concurrent context analysis. Data was analyzed by thematic coding in the framework of grounded theory. Consultations do very often not only have one single reason for encounter. They are usually not independent events but form part of consultation sequences. We could find structural differences between Norway and Germany regarding the flow of information between consultations and which providers are involved in health care in what way. This leads to a sequential model, in which health care utilization is seen as sequences of consultations. Such health care utilization sequences consist of nodes which are connected by edges. Nodes represent patient-provider contacts and edges depict the flow of information. Time and the level of health care providers are dimensions in the model. These sequences can be described by different measures and aggregated on population level. Thus, the sequential model can be further used in analyzing health care utilization quantitatively, e.g., by using routine data.

[Regulations of sickness certification as a factor for increased health care utilization in Germany]. / Arbeitsunfähigkeitsregelungen als Faktor für Inanspruchnahme ärztlicher Versorgung in Deutschland.

BACKGROUND: In Germany, utilization of ambulatory health care is high compared to other countries. Classical models of health care utilization cannot sufficiently explain these differences. The aim of this study was to explore relevant factors which can explain the higher health care utilization in Germany. In this article, we focus on regulations regarding sickness certification as a potential factor. METHODS: An explorative qualitative study design. We conducted episodic interviews with 20 patients in Germany and 20 patients in Norway and participant observation in four primary care practices each. Additionally, we conducted a context analysis of relevant health care system related factors which emerged during the study. Qualitative data analysis was done by thematic coding in the framework of grounded theory. RESULTS: The need for a sickness certificate was an important reason for encounter in Germany, especially regarding minor illnesses. Sickness certification is a societal topic. GPs play a double role regarding sickness certification, both as the patients' advocate and as an expert witness for social security services. In Norway, longer periods of self-administered sickness certification and more differentiated possibilities of sickness certification have been introduced successfully. CONCLUSION: Our results point to regulations regarding sickness certification as a relevant factor for higher health care utilization in Germany. In pilot studies, the effect of extended self-certification of sickness and part-time sickness certification should be further assessed.

Patients' subjective concepts about primary healthcare utilisation: the study protocol of a qualitative comparative study between Norway and Germany.

BACKGROUND: In Germany, utilisation of ambulatory healthcare services is high compared with other countries: While a study based on the process data of German statutory health insurances showed an average of 17.1 physician-patient-contacts per year, the comparable figure for Norway is about five. The usual models of healthcare utilisation, such as Rosenstock's Health Belief Model and Andersen's Behavioural Model, cannot explain these differences adequately. Organisational factors of the healthcare system, such as gatekeeping, do not explain the magnitude of the differences. Our hypothesis is that patients' subjective concepts about primary healthcare utilisation play a major role in explaining different healthcare utilisation behaviour in different countries. Hence, the aim of this study is to explore these subjective concepts comparatively, between Germany and Norway. METHODS/DESIGN: With that aim in mind, we chose a comparative qualitative study design. In Norway and Germany, we are going to interview 20 patients each with qualitative episodic interviews. In addition, we are going to conduct participant observation in four German and four Norwegian primary care practices. The data will be analysed by thematic coding. Using selected categories, we are going to conduct comparative case and group analyses. ETHICS AND DISSEMINATION: The study adheres to the Declaration of Helsinki. All interviewees will sign informed consent forms and all patients will be observed during consultation. Strict rules for data security will apply. Developed theory and policy implications are going to be disseminated by a workshop, presentations for experts and laypersons and publications.