Julika Loss

Why offered pancreases are refused in the allocation process-a descriptive study using routine data from eurotransplant.

Background The majority of pancreases, offered in allocation, are discarded. This pancreas underutilization is not well understood yet. Methods We analyzed the detailed allocation protocols of all Eurotransplant-registered German whole-pancreas donors (2005–2009; n=1758). Outcome measures included donor characteristics, number of refusals per organ, and proportion of different refusal reasons in the whole sample and subgroups. Results Thirty-seven percent of offered pancreases were transplanted; among these, 62% of pancreases were of potentially high quality (favorable donor age and pre-procurement pancreas allocation suitability score, no malignancy, n=290). A pancreas was placed after four offers (median) or withdrawn after eight offers (median). Seventy-five percent of refusal reasons were donor related (e.g., “lab results”, “age”, “macroscopy”, and “long intensive care unit [ICU] stay”). Among pancreases refused for “diabetes” or “malignancy” at least once, the proportion of transplanted organs was less than 10%; pancreases refused due to “trauma”, “age”, or “resuscitation” were later transplanted in 48%, 32%, and 28%, respectively. The impact of donor age and ICU stay on organ refusal varied substantially: organs were refused due to length of ICU stay even if donors stayed 7 days or less; some organs were transplanted without ever being refused due to ICU stay in donors who stayed 8 days or more in ICU. There were no clinically significant disparities between donors of used and unused pancreases, except age (median, 31 vs. 42 years). Discussion The loss of several pancreases seems avoidable. Many refusal reasons are not plausible, because there is no evidence supporting the refusal and because many of these organs were transplanted by other centers. This increases inefficiency in the allocation system.

Evidenzbasierung und Evaluation in der Gesundheitsförderung und Prävention am Beispiel „Gesund. Leben. Bayern.“

ZusammenfassungHintergrund:Der Ruf nach Evidenzbasierung und Evaluation ist nicht nur im Bereich der klinischen Medizin, sondern verstärkt auch im Feld der Gesundheitsförderung und Prävention zu hören. Die Evidenzgrundlagen, die Methoden zur Evaluation insbesondere von komplexen Gesundheitsförderungsmaßnahmen sowie die Kapazität und Kompetenz hierfür befinden sich derzeit in einer Phase des Aufbaus.Ziel:Im Rahmen der Gesundheitsinitiative „Gesund. Leben. Bayern.“ sollen Evidenzbasierung und Evaluation als zentrale Aspekte eines umfassenden Qualitätsmanagements von Anfang an in die Projektförderung integriert und ein Beitrag zur Schaffung neuer Evidenz im Feld der Gesundheitsförderung und Prävention geleistet werden.Ansatz:Kernstück des umfassenden Qualitätsmanagementansatzes ist ein mehrstufiges Evidenz- und Evaluationsmodell, das sowohl die Gesamtinitiative als auch die geförderten Einzelprojekte einbezieht. Dies wird unterstützt durch einen Satz miteinander kompatibler Instrumente zur Antragstellung, Berichterstattung, Evaluation und Begutachtung.Schlussfolgerung:Evidenzbasierung und Evaluation erweisen sich als zentrale Aspekte in existierenden Instrumenten zur Qualitätsförderung in der Gesundheitsförderung und Prävention. Bezeichnend für den Bayerischen Ansatz ist der umfassende, in sich stimmige Prozess „aus einem Guss“ von der Antragstellung bis hin zur Evaluation unter Berücksichtigung wissenschaftlicher und pragmatischer Gesichtspunkte.AbstractBackground:The use of evidence and evaluation is rapidly gaining importance in the field of health promotion and prevention. The evidence base, evaluation methods as well as the capacity and required competencies among practitioners are still being developed.Aims:Beyond its specific health-related targets, the health promotion initiative “Healthy Living in Bavaria” aims to integrate the use of evidence and evaluation as key components into project funding as part of a total quality management concept. Another objective is the creation of new evidence for the field of health promotion and prevention.Approach:A core element of the quality management concept is the initiatives multistage evidence and evaluation model which embraces the initiative as a whole as well as the individual projects. The model is operationalized through a set of matching instruments for application, reporting, evaluation, and appraisal.Conclusion:Nationally as well as internationally, evidence and evaluation stand out as central aspects of quality improvement instruments in health promotion and prevention. Characteristic of Bavarias quality improvement approach is the seamless process from the application to the evaluation under consideration of scientific as well as pragmatic aspects.

A systematic review on empowerment for healthy nutrition in health promotion

OBJECTIVE The present review aimed to identify and synthesize studies that used an empowerment approach within the field of healthy nutrition. DESIGN A systematic review was conducted. Studies were identified by database searching (PubMed, PsycINFO, Web of Science and Psyndex). Searching, selecting and reporting were done according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement. SETTING Health promotion including the subject of healthy nutrition. SUBJECTS Individuals from non-clinical populations. RESULTS A total of 1226 studies were screened for eligibility, eight studies were finally included. Three studies used the empowerment approach within a qualitative research paradigm and five studies within (quasi-) experimental intervention studies. Heterogeneity in settings, samples and evaluation methods was high. Most studies referred to the key message of empowerment, i.e. taking control over ones own life. However, the ways in which this key message was implemented in the interventions differed considerably. CONCLUSIONS The number of studies included was very low. Furthermore, most studies had some limitations in terms of reporting how the empowerment approach was actually applied. The empowerment approach still seems to be unfamiliar within the field of healthy nutrition.

Accept or refuse? Factors influencing the decision-making of transplant surgeons who are offered a pancreas: results of a qualitative study.

BackgroundMost offered pancreases are not transplanted. This study investigates the factors that inform and influence the transplant surgeon’s decision to select an offered pancreas.MethodsSemi-standardized interviews were conducted with 14 highly qualified transplant surgeons from all 14 German transplant centers performing > 5 pancreas transplantations per year. The interviews focused on medical and non-medical criteria on which the individual accept/refuse decision depends. Interviews were recorded, transcribed and underwent content analysis.ResultsThe interviewees agreed upon certain main selection criteria, e.g. donor age, lab results, ICU stay. However, there was no consistency in judging these parameters, and clear cut-offs did not exist. The pancreas macroscopy is a pivotal factor, as well as knowing (and trusting) the donor surgeon. 3/14 surgeons reported that they had occasionally refused a pancreas because of staff shortage. Some interviewees followed a restrictive acceptance policy, whereas others preferred to accept almost any pancreas and inspect it personally before deciding.ConclusionThe assessment of medical donor characteristics is highly inconsistent. Both very cautious as well as very permissive acceptance policies may render the allocation process less efficient. A more standardized policy should be discussed. Finally, better training for donor surgeons seems advisable, in order to increase trust and thus pancreas utilization.

Prozess- und Ergebnisevaluation des Schulprojektes „Schülerunternehmen zur gesunden Ernährung”

SummaryProcess and outcome evaluation of the school-based project „Students’ Enterprises for Healthy Nutrition”Objectives:Most food consumed in German schools is unhealthy, and evaluations of school-based interventions to improve food habits are scarce. Our study evaluates implementation and impact of „Students’ Enterprises for Healthy Nutrition”, in which students offer healthy food to their school mates.Methods:Standardised questionnaires were obtained from the supervising teachers and 923 students (grade 5–10) from the 4 intervention schools, collecting information on implementation and acceptability of the intervention (process evaluation). Data on eating habits were collected from a cohort of 475 students before and 6 months after the implementation of the Students’ Enterprises, using a modified, illustrated version of a 24-hour recall questionnaire (outcome evaluation).Results:Process: 59 % of the students appreciated the Students’ Enterprises, which varied substantially between schools, and 7–27 % regularly purchased their food there. Reasons for not using the Student’s Enterprises were food provision from home, peer pressure, and costs. Besides, there were competing sources of food supply in each school. Outcome: Data interpretation was difficult due to the heterogeneity of the Students’ Enterprises and reduced program integrity. A separate analysis of the different schools showed the reduction of sweets consumption in one school; other improvements of eating habits were not shown.Conclusions:The Students’ Enterprises represent a peer-based settings approach and were supported by the students and teachers. Further structural changes and educational means are needed to increase utilisation. Due to demand, the Enterprises’ menus risk to be extended to unhealthy food, which may be countered with innovative strategies (e. g. subsidy for healthy food).

Utilization of Prevention Services by Gender, Age, Socioeconomic Status, and Migration Status in Germany: An Overview and a Systematic Review

Background In Germany, like in other countries, there are strong associations between the individual factors gender, age, migration status, and socioeconomic status on one hand and morbidity and mortality on the other. This chapter aims to investigate if these different factors are associated with differences in the utilization of prevention services.

Probleme und ethische Herausforderungen bei der bevölkerungsbezogenen Gesundheitskommunikation

ZusammenfassungGesundheitskommunikation, zum Beispiel in Form von massenmedialen Kampagnen, Patientenbroschüren oder Internetseiten, spielt eine wichtige Rolle für Public Health. Sie trägt zum Empowerment der Bürger bei und hilft ihnen, informierte Entscheidungen in Gesundheitsbelangen zu treffen. Bevölkerungsbezogene Gesundheitskommunikation kann aber auf individueller und gesellschaftlicher Ebene zu unerwünschten Auswirkungen führen, zum Beispiel durch nicht akkurate oder einseitige Informationen, diskriminierende Botschaften, skandalisierende Berichterstattung oder unzureichende Ausrichtung auf relevante Zielgruppen. Es scheint daher sinnvoll, ethische Kriterien für Gesundheitsinformationen aufzustellen. Vorgeschlagen werden: (1) Richtigkeit, Vollständigkeit und Ausgewogenheit, (2) Transparenz, (3) Partizipation der Zielgruppe, (4) Respekt für die menschliche Würde, (5) soziale Gerechtigkeit, (6) Verhältnismäßigkeit. Es gilt zum Beispiel, rücksichtsvoll vorzugehen, um nicht bestimmte Gruppen in der gesellschaftlichen Wahrnehmung zu stigmatisieren. Zudem erfordert es viel Aufwand, die Bedeutung eines Gesundheitsverhaltens, zum Beispiel den Nutzen und die Risiken einer Früherkennungsuntersuchung, korrekt und umfassend darzustellen. Auch wenn Marketing-Prinzipien dazu anleiten, wie ein Verhalten beziehungsweise Verhaltensänderungen besser zu erreichen sind, sollten Gesundheitskampagnen die Zielpersonen nicht zu einem bevölkerungsbezogenen Gesundheitszweck manipulieren. Wie eine ethische Verantwortung von den unterschiedlichen Anbietern von Gesundheitsinformationen eingefordert werden kann, bleibt unklar.AbstractHealth communication, e.g., mass media campaigns, patient information leaflets or websites, plays an important role in public health. It contributes to citizen empowerment and helps them make informed decisions in health matters. However, public health communication can lead to adverse effects on both individual and societal level, e.g., by inaccurate or partial information, discriminatory messages, scandalizing coverage or inadequate tailoring to relevant target groups. It seems important to suggest ethical criteria for health information, e.g., (1) accuracy, completeness and balance, (2) transparency, (3) participation of the target group, (4) respect for human dignity, (5) social justice and equity, (6) appropriateness. Thoughtfulness is important in order not to stigmatize population subgroups. In addition, it is laborious to comprehensively and correctly present benefits and risks of a certain health behavior. Marketing principles guide how to ‘sell’ a certain health behavior, but health campaigns should not manipulate target persons for the sake of a population health aim. It remains unclear, however, how the different providers of health information can be held ethically responsible.

Evaluation von Empowerment : Perspektiven und Konzepte von Gesundheitsförderern. Ergebnisse einer qualitativen Studie in Australien

BACKGROUND Although the concepts of participation and empowerment are hallmarks of the WHO vision of health promotion, it is acknowledged that they are difficult to evaluate. Devising adequate study designs, indicators and methods for the assessment of participation and empowerment should take into account the experiences, concerns, working conditions and constraints of health promotion practitioners. METHODS Semi-structured interviews were conducted with 17 experienced practitioners in community-based health promotion in New South Wales, Australia. The interviews covered benefits of and barriers to the evaluation of empowerment, key indicators and methodological aspects. Interview transcripts were examined using thematic content analysis. RESULTS AND DISCUSSION The idea of evaluating empowerment is supported by health promotion practitioners, provided that empowerment is part of the programme logic and/or programme theory. The interviews highlighted the importance of a receptive environment for evaluation of empowerment and participation to take root. The resistence of health authorities towards empowerment indicators is a great challenge for funding of evaluations. Community members are to be included in the evaluation process, al-though it is not always easy to do so in a representative way and empowering approach. The best methods to capture whether empowerment has occurred in a programme are qualitative ones. The positive experiences that the interview partners made with innovative qualitative methods encourage further investment in developing new research designs.

Depression moderates the associations between beliefs about medicines and medication adherence in patients with rheumatoid arthritis: Cross-sectional study:

The ‘necessity–concerns framework’ postulates that patients’ adherence behaviour is influenced by beliefs about the necessity and the concerns patients have regarding their prescribed medicines. We hypothesized that depression moderates the associations between beliefs about medicines and medication adherence among people with rheumatoid arthritis. Using multivariate logistic regression, we observed that people experiencing more depressive symptoms showed stronger associations between necessity beliefs and adherence as well as attenuated associations between concerns and adherence, respectively, in a cross-sectional sample (N = 361). Thus, depression moderates the associations postulated in the ‘necessity–concerns framework’ in a differential way in people with rheumatoid arthritis.

Predictors of non-transplantation of adult donor organs - an observational study using routine data from Eurotransplant

BackgroundThe majority of pancreases, offered in allocation, are not transplanted. This pancreas under-utilisation is a phenomenon observed in all transplant systems in North-America and Europe. It was the aim of this study to analyse factors predictive of pancreas non-transplantation in Germany.MethodsRoutine Eurotransplant data of 3,666 deceased German donors (from 2002-2011) were used for multivariate modelling. Socio-demographic and medical factors were considered as independent variables in logistic regression models with non-transplantation as dependent variable.ResultsMale gender, advanced age, overweight/obesity, long ICU stay, a history of smoking, non-traumatic brain death, elevated levels of sodium, serum glucose, lipase/amylase and the liver not being considered for procurement were significant independent predictors of non-transplantation.ConclusionIn line with previous research, advanced age, high BMI, long ICU stay and the liver not being considered for procurement were the strongest predictors of pancreas non-transplantation in Germany. About three quarters of the variance remained unexplained, suggesting that factors not assessed or unknown may play a decisive role.