Fred Louckx

Use of Time by Stroke Patients. A Comparison of Four European Rehabilitation Centers

Background and Purpose— Differences exist between European countries in the proportion of patients who die or become dependent after stroke. The aim of the present study was to identify differences in the use of time by stroke patients in 4 rehabilitation centers in 4 European countries. Methods— In each of the 4 centers, 60 randomly selected stroke patients were observed at 10-minute intervals using behavioral mapping. Observations took place on 30 weekdays selected at random, on equal numbers of morning, afternoon, and evening sessions. A logistic generalized estimating equation model with correction for differences in case mix and multiple testing was used for the analysis. Results— Overall time available from different professions was the highest in the United Kingdom, but patients in the United Kingdom spent on average only 1 hour per day in therapy. This was significantly less than patients in Belgium and Germany, who spent ≈2 hours, and patients in Switzerland who spent ≈3 hours per day in therapy. In all centers, patients spent less than half their time in interactions and >72% of the time in nontherapeutic activities. Conclusions— Important differences in the use of time were established, which appeared dependent on management decisions rather than the number of staff available. Patients in the Swiss and German centers spent more time in therapy, possibly because of the structured organization of rehabilitation. Further studies will verify whether this has an effect on outcome.

Motor and Functional Recovery After Stroke A Comparison of 4 European Rehabilitation Centers

Background and Purpose— Outcome after first stroke varies significantly across Europe. This study was designed to compare motor and functional recovery after stroke between four European rehabilitation centers. Methods— Consecutive stroke patients (532 patients) were recruited. They were assessed on admission and at 2, 4, and 6 months after stroke with the Barthel Index, Rivermead Motor Assessment of Gross Function, Rivermead Motor Assessment of Leg/Trunk, Rivermead Motor Assessment of Arm, and Nottingham Extended Activities of Daily Living (except on admission). Data were analyzed using random effects ordinal logistic models adjusting for case-mix and multiple testing. Results— Patients in the UK center were more likely to stay in lower Rivermead Motor Assessment of Gross Function classes compared with patients in the German center (&Dgr;OR, 2.4; 95% CI, 1.3 to 4.3). In the Swiss center, patients were less likely to stay in lower Nottingham Extended Activities of Daily Living classes compared with patients in the UK center (&Dgr;OR, 0.7; 95% CI, 0.5 to 0.9). The latter were less likely to stay in lower Barthel Index classes compared with the patients in the German center (&Dgr;OR, 0.6; 95%CI, 0.4 to 0.8). Recovery patterns of Rivermead Motor Assessment of Leg/Trunk and Rivermead Motor Assessment of Arm were not significantly different between centers. Conclusions— Gross motor and functional recovery were better in the German and Swiss centers compared with the UK center, respectively. Personal self-care recovery was better in the UK compared with the German center. Previous studies in the same centers indicated that German and Swiss patients received more therapy per day. This was not the result of more staff but of a more efficient use of human resources. This study indicates potential for improving rehabilitation outcomes in the UK and Belgian centers.

Stroke Rehabilitation in Europe What Do Physiotherapists and Occupational Therapists Actually Do

Background and Purpose— Physiotherapy (PT) and occupational therapy (OT) are key components of stroke rehabilitation. Little is known about their content. This study aimed to define and compare the content of PT and OT for stroke patients between 4 European rehabilitation centers. Methods— In each center, 15 individual PT and 15 OT sessions of patients fitting predetermined criteria were videotaped. The content was recorded using a list comprising 12 therapeutic categories. A generalized estimating equation model was fitted to the relative frequency of each category resulting in odds ratios. Results— Comparison of PT and OT between centers revealed significant differences for only 2 of the 12 categories: ambulatory exercises and selective movements. Comparison of the 2 therapeutic disciplines on the pooled data of the 4 centers revealed that ambulatory exercises, transfers, exercises, and balance in standing and lying occurred significantly more often in PT sessions. Activities of daily living, domestic activities, leisure activities, and sensory, perceptual training, and cognition occurred significantly more often in OT sessions. Conclusion— This study revealed that the content of each therapeutic discipline was consistent between the 4 centers. PT and OT proved to be distinct professions with clear demarcation of roles.

Anxiety and depression in the first six months after stroke. A longitudinal multicentre study

Purpose. To document the prevalence, severity and time course of anxiety and depression in stroke rehabilitation patients in four European countries. Method. At two, four and six months post-stroke, the prevalence and severity of anxiety and depression were determined in 532 consecutively recruited patients, using the Hospital Anxiety and Depression Scale. Time course of prevalence and severity was examined, using Cochran-Q and Friedman-tests, respectively. We identified whether the numbers of anxious/depressed patients at each time point comprised the same individuals. Results. Prevalence of anxiety ranged between 22% and 25%; depression between 24% and 30%. Median severity ranged between 4 and 5. No significant differences between centres occurred (p > 0.05). Prevalence of both disorders was not significantly different over time. Severity of anxiety decreased between four and six months; severity of depression remained stable. About 40% of the patients with initial anxiety remained anxious at six months. Some 11% and 7% of those initially not anxious became anxious at four or six months after stroke, respectively. Depression showed a similar pattern. Conclusions. Despite differences in patient profiles and intensity of rehabilitation, no significant differences occurred between centres in prevalence and severity of both disorders. Anxiety was almost as common as depression and additional patients became anxious/depressed at each time point.

Determinants of the number of antenatal visits in a metropolitan region

BackgroundAntenatal care has a positive effect on pregnancy, both clinically and psychologically, but consensus about the optimal number of antenatal visits is lacking. This study aims to provide insight into the dynamics of the number of antenatal visits a woman receives. Independent effects of predisposing, enabling and pregnancy-related determinants are examined.MethodsWomen were recruited in nine clinical centres in the Brussels Metropolitan region. Antenatal care use was measured prospectively. A Poisson regression model was applied to measure the independent effect of individual determinants on the number of antenatal visits.ResultsData on antenatal care trajectories in 333 women were collected. The multivariate analyses showed that women with a Maghreb or Turkish origin had 14% fewer visits compared with European (EU15) women. More highly educated women had 22% more visits compared with those with a low education. Women with a high income had 14% more antenatal visits compared with those with a low income. Fewer antenatal visits were observed in multiparae (15%), women initiating care after 14 weeks of gestation (31%), women without medical risks during the pregnancy (12%) and in women with a continuity of care index of 50% or more (12%). More visits were observed in delivering after week 37 (22% increase).ConclusionsPredisposing and enabling factors have to be considered when antenatal care programmes are evaluated in a metropolitan area. Variations in the number of antenatal visits show that socially vulnerable women are more at risk of having fewer visits.

Effect of socioeconomic status on functional and motor recovery after stroke: a European multicentre study

Background: Previous studies have shown an inverse gradient in socioeconomic status for disability after stroke. However, no distinction has been made between the period in the stroke rehabilitation unit (SRU) and the period after discharge. The purpose of this study was to examine the impact of education and equivalent income on motor and functional recovery for both periods. Methods: 419 consecutive patients were recruited from six SRUs across Europe. The Barthel Index (BI) and Rivermead Motor Assessment (RMA) were measured on admission, at discharge and 6 months after stroke. Ordinal logistic regression models were used, adjusting for case mix. Cumulative odds ratios (OR) were calculated to measure differences in recovery between educational levels and income groups with adjustments for case mix. Results: Patients with a low educational level were less likely to improve on the BI (OR 0.53; 95% CI 0.32 to 0.87) and the RMA arm during inpatient stay (OR 0.54; 95% CI 0.31 to 0.94). For this period, no differences in recovery were found between income groups. After discharge, patients with a low equivalent income were less likely to improve on all three sections of the RMA: gross function (OR 0.20; 95% CI 0.06 to 0.66), leg and trunk (OR 0.22; 95% CI 0.09 to 0.55) and arm (OR 0.30; 95% CI 0.10 to 0.87). No differences were found for education. Conclusions: During inpatient rehabilitation, educational level was a determinant of recovery, while after discharge, equivalent income played an important role. This study suggests that it is important to develop a better understanding of how socioeconomic factors affect the recovery of stroke patients.

Predisposing, enabling and pregnancy-related determinants of late initiation of prenatal care.

Prenatal care is important for the health and wellbeing of women and their babies. There is international consensus that prenatal care should begin in the first trimester. This study aims to analyze the effects of predisposing, enabling and pregnancy-related determinants of late prenatal care initiation. In this prospective observational study, 333 women were recruited consecutively at the beginning of their prenatal care trajectory. Data was collected on the timing of the first prenatal visit and on socio-demographic and pregnancy-related characteristics, using a semi-structured interview. A multivariate binominal logistic regression was applied to analyze independent effects on late initiation of prenatal care. Bivariately late initiation of care was associated with being inactive on the labor market, non-European origin, not having lived in Belgium since birth, low income, receiving welfare benefits, not having a regular obstetrician and experiencing difficulties getting a first appointment. When adjusting for all determinants, our multivariate analyses showed that late initiation was associated with non-European origin, low income and not having a regular obstetrician. This study shows that late initiation of prenatal care is associated with predisposing and enabling determinants. In order to ensure timely initiation of care, policy-makers should focus on encouraging women to have a regular prenatal care provider before pregnancy and taking steps in lowering out-of-pocket fees for low-income women. Future research is needed to examine whether these determinants are associated with initiation of care only or whether they play a role in the pregnancy follow-up as well.

Psychosocial working conditions and self-reported health in a representative sample of wage-earners: A test of the different hypotheses of the Demand-Control-Support model

PurposeThis paper presents an in-depth examination of the demand–control–support–model (DCS-model). Each hypothesis of the DCS-model is tested: the main effects of job demands, job autonomy, task variation and social support; the additive effects of job strain, active learning and iso-strain; and the interactive buffer-effects of job autonomy, task variation and support on job demands.MethodsData from a representative cross-sectional sample of 11,099 male and female wage-earners are investigated using log linear methods. The outcome measures are self-reported persistent fatigue, musculoskeletal complaints and emotional well-being.ResultsThere is some support for each of the hypotheses. Quantitative job demands and superior support have the strongest effects. The job autonomy and buffer hypotheses are only partially supported.ConclusionsThe strong effects of job demands, support, job strain and active learning are suggesting that a policy aimed at improving psychosocial working conditions should focus on a bearable level of job demands and the quality of social relationships at work.

Use of time by physiotherapists and occupational therapists in a stroke rehabilitation unit: A comparison between four European rehabilitation centres

Purpose. The aim of this study was to compare the time allocated to therapeutic activities (TA) and non-therapeutic activities (NTA) of physiotherapists (PT) and occupational therapists (OT) in stroke rehabilitation units in four European countries. Method. Therapists documented their activities in 15-min periods for two weeks. They recorded: activity, number of patients, number of stroke patients, involvement of other people, location and frequency of each activity. Kruskal-Wallis tests and negative binomial regression models were used to compare activities between professional groups and between units. Results. The average proportion of TA per day ranged between 32.9% and 66.1% and was higher for PT than for OT in each unit. For OT, significant differences emerged between the units in the proportion of time allocated to TA compared to NTA with British OTs spending significantly less time in TA. In the Belgian unit, three times less time was spent on patient-related co-ordination activities (e.g., administration, ward rounds) compared to the British and Swiss units. Conclusions. Time allocation differed between PT and OT and between units, affecting the time available for TA. Further investigation is necessary to study the effect of work organization in stroke rehabilitation units on the efficiency of rehabilitation regimes.

Measuring employment precariousness in the European Working Conditions Survey: The social distribution in Europe

BACKGROUND Precarious employment is becoming an increasingly important social determinant of health inequalities among workers. The way in which contemporary employment arrangements and their health consequences are addressed in empirical research is mostly based on the contract-related or employment instability dimension. A broader conceptual approach including various important characteristics of the degrading of employment conditions and relations is needed. OBJECTIVE The general objective of this paper is to empirically test a new multidimensional construct for measuring precarious employment in an existing database. Special focus is on the social distribution of precarious employment. METHODS A subsample of 21,415 participants in the EU-27 from the Fourth European Working Conditions Survey-2005 was analysed. A cross-sectional study of the social distribution of precarious employment was conducted through the analysis of proportional differences according to gender, social class and credentials for the European Union as a whole and within each country. The 8 dimensions of the employment precariousness construct were represented by 11 indicators. RESULTS In general, women, workers without supervisory authority, those with fewer credentials, and those living in Eastern and Southern European countries suffer the highest levels of precarious employment. Exceptionally, men, workers with supervisory authority and those with the highest credentials suffer the highest levels of long working hours, schedule unpredictability and uncompensated flexible working times. CONCLUSIONS This article offers the first validation for an innovative multidimensional conceptualisation of employment precariousness applied to the analysis of existing survey data, showing the unequal distribution of precarious employment across the European labour force. This set of indicators can be useful for monitoring precarious employment.