Sara Willems

Wet combing versus traditional scalp inspection to detect head lice in schoolchildren: observational study

Lice infestation is a problem in local communities, probably because reservoirs remain undetected. Wet combing (combing systematically through wet, well conditioned hair with a fine toothed comb) has been presented as a cheap, ecological, self sufficient, and feasible technique for diagnosis and treatment of head lice.1-3 Compared with traditional scalp inspection it uses five elements to make living lice more visible, to better distinguish them from dandruff, and to assess the maturity of the infestation: water, conditioner, a fine toothed comb, a systematic sweep of the scalp, and a magnifying glass (10×). However, its efficacy as a diagnostic tool and as a therapeutic intervention has not been proved; hence it is not evidence based. We did an observational study comparing detection of head lice using traditional scalp inspection and wet combing. After ethical approval had been obtained, all 260 pupils, aged 2-12 years, of a primary school in a socially deprived urban area …

Tackling NCDs: a different approach is needed.

www.thelancet.com Vol 379 May 19, 2012 1873 Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/ The view by Jan De Maeseneer and colleagues that the priority in relation to non-communicable diseases (NCDs) is a health-service response is deeply fl awed. Non-governmental organisations have been struggling, in the current debate stimulated by the UN High-Level Meeting on NCDs, to shift the focus to environmental change to reduce exposure to the drivers of risk behaviours that contribute so strongly to NCDs. Do we really want to continue to live in a world where the oversupply and marketing of tobacco, alcohol, unhealthy processed foods, and soft drinks is tolerated simply to allow continuing profi ts for the shareholders of the transnational corporations producing and distributing them, while the taxpayer funds the health services and pharmaceutical response to the ensuing disease and injury?

Factors associated with medication adherence to oral hypoglycaemic agents in different ethnic groups suffering from Type 2 diabetes: a systematic literature review and suggestions for further research

Diabet. Med. 28, 262–275 (2011)

The independent impact of household- and neighborhood-based social determinants on early childhood caries - A cross-sectional study of inner-city children

This study examined the relationship between early childhood caries (ECC) and measures of socioeconomic status as environmental determinants of oral health inequalities. Dental caries and quality of oral hygiene were reported on 384 young inner-city children (24–35 months) by clinical examination. Early childhood caries was diagnosed in 18.5% of children. Ethnicity (P < 0.001) and neighborhood (P < 0.001) were the social variables significantly predictive of ECC in a logistic regression model. Living in a deprived neighborhood and the mother being of East European descent were the social variables with strongest association with ECC. These variables can be considered adequate criteria to identify groups at risk within the overall population.

Impact of selection strategies on representation of underserved populations and intention to practise: international findings

Socially accountable medical schools aim to reduce health inequalities by training workforces responsive to the priority health needs of underserved communities. One key strategy involves recruiting students from underserved and unequally represented communities on the basis that they may be more likely to return and address local health priorities. This study describes the impacts of different selection strategies of medical schools that aspire to social accountability on the presence of students from underserved communities in their medical education programmes and on student practice intentions.

Validity of self-reported utilization of physician services: a population study

BACKGROUND Health care utilization is of central interest in epidemiology, and most of the studies rely on self-report. The objectives of this study were to assess the validity of self-reported utilization of general practitioner and specialist physician by correlating self-reported utilization with registered services utilization, and to determine the factors related to that validity. METHODS The 1997 Belgian National Health Interview Survey (BNHIS) was linked with registered medical utilization data provided by the Belgian Health Insurance Funds. Valid information on general practitioner and specialist physician utilization during the past 2 months was found for 5869 participants at the BNHIS who were aged ≥25 years. Intra-class correlation coefficients were used to determine the rate of agreement, and multinomial logistic regression to model factors influencing under- and over-reporting. RESULTS The results demonstrated a substantial agreement between the self-reported and registered general practitioner contacts, and only a minor bias was found towards under-reporting. There was no significant difference between mean self-reported and registered specialist physician utilization, but the agreement was rather moderate. Gender, age, country of birth, self-rated health, number of chronic illnesses, having functional limitations and having mental health problems, were associated with under- and/or over-reporting. CONCLUSION Studies that aim to compare the utilization of different socio-demographic groups have to take into account that the reporting errors vary by respondents characteristics.

Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

BackgroundMost research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered.MethodsProcess evaluation of an action research project (2003–2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process.ResultsThe overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding.ConclusionGuided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care.Trial registration numberClinicalTrials.gov Identifier: NCT00824499

Strengthening weak primary care systems: Steps towards stronger primary care in selected Western and Eastern European countries

European health care systems are facing diverse challenges. In health policy, strong primary care is seen as key to deal with these challenges. European countries differ in how strong their primary care systems are. Two groups of traditionally weak primary care systems are distinguished. First a number of social health insurance systems in Western Europe. In these systems we identified policies to strengthen primary care by small steps, characterized by weak incentives and a voluntary basis for primary care providers and patients. Secondly, transitional countries in Central and Eastern Europe (CCEE) that transformed their state-run, polyclinic based systems to general practice based systems to a varying extent. In this policy review article we describe the policies to strengthen primary care. For Western Europe, Germany, Belgium and France are described. The CCEE transformed their systems in a completely different context and urgency of problems. For this group, we describe the situation in Estonia and Lithuania, as former states of the Soviet Union that are now members of the EU, and Belarus which is not. We discuss the usefulness of voluntary approaches in the context of acceptability of such policies and in the context of (absence of) European policies.

Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium

BackgroundDuring a four-year action research project (2003-2007), a program targeting all type 2 diabetes patients was implemented in a well-defined geographical region in Belgium. The implementation of the program resulted in an increase of the overall Assessment of Chronic Illness Care (ACIC) score from 1.45 in 2003 to 5.5 in 2007. The aim of the follow-up study in 2008 was to assess the effect of the implementation of Chronic Care Model (CCM) elements on the quality of diabetes care in a country where the efforts to adapt primary care to a more chronic care oriented system are still at a starting point.MethodsA quasi-experimental study design involving a control region with comparable geographical and socio-economic characteristics and health care facilities was used to evaluate the effect of the intervention in the region. In collaboration with the InterMutualistic Agency (IMA) and the laboratories from both regions a research database was set up. Study cohorts in both regions were defined by using administrative data from the Sickness Funds and selected from the research database. A set of nine quality indicators was defined based on current scientific evidence. Data were analysed by an institution experienced in longitudinal data analysis.ResultsIn total 4,174 type 2 diabetes patients were selected from the research database; 2,425 patients (52.9% women) with a mean age of 67.5 from the intervention region and 1,749 patients (55.7% women) with a mean age of 67.4 from the control region. At the end of the intervention period, improvements were observed in five of the nine defined quality indicators in the intervention region, three of which (HbA1c assessment, statin therapy, cholesterol target) improved significantly more than in the control region. Mean HbA1c improved significantly in the intervention region (7.55 to 7.06%), but this evolution did not differ significantly (p = 0.4207) from the one in the control region (7.44 to 6.90%). The improvement in lipid control was significantly higher (p = 0.0021) in the intervention region (total cholesterol 199.07 to 173 mg/dl) than in the control region (199.44 to 180.60 mg/dl). The systematic assessment of long-term diabetes complications remained insufficient. In 2006 only 26% of the patients had their urine tested for micro-albuminuria and only 36% had consulted an ophthalmologist.ConclusionAlthough the overall ACIC score increased from 1.45 to 5.5, the improvement in the quality of diabetes care was moderate. Further improvements are needed in the CCM components delivery system design and clinical information systems. The regional networks, as they are financed now by the National Institute for Health and Disability Insurance (NIHDI), are an opportunity to explore how this can be achieved in consultation with the GPs. But it is clear that, simultaneously, action is needed on the health system level to realize the installation of an accurate quality monitoring system and the necessary preconditions for chronic care delivery in primary care (patient registration, staff support, IT support).Trial RegistrationTrial registration number: ClinicalTrials.gov Identifier: NCT00824499

Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study

BackgroundSelf-management support is seen as a cornerstone of good diabetes care and many countries are currently engaged in initiatives to integrate self-management support in primary care. Concerning the organisation of these programs, evidence is growing that engagement of health care professionals, in particular of GPs, is critical for successful application. This paper reports on a study exploring why a substantial number of GPs was (initially) reluctant to refer patients to a self-management education program in Belgium.MethodsQualitative analysis of semi-structured face-to-face interviews with a purposive sample of 20 GPs who were not regular users of the service. The Greenhalgh diffusion of innovation framework was used as background and organising framework.ResultsSeveral barriers, linked to different components of the Greenhalgh model, emerged from the interview data. One of the most striking ones was the limited readiness for innovation among GPs. Feelings of fear of further fragmentation of diabetes care and frustration and insecurity regarding their own role in diabetes care prevented them from engaging in the innovation process. GPs needed time to be reassured that the program respects their role and has an added value to usual care. Once GPs considered referring patients, it was not clear enough which of their patients would benefit from the program. Some GPs expressed the need for training in motivational skills, so that they could better motivate their patients to participate. A practical but often mentioned barrier was the distance to the centre where the program was delivered. Further, uncertainty about continuity interfered with the uptake of the offer.ConclusionsThe study results contribute to a better understanding of the reasons why GPs hesitate to refer patients to a self-management education program. First of all, the role of GPs and other health care providers in diabetes care needs to be clarified before introducing new functions. Feelings of security and a basic trust of providers in the health system are a prerequisite for participation in care innovation. Moreover, some important lessons regarding the implementation of an education program in primary care have been learned from the study.